Editor’s Note: Since this post was published, CCF submitted formal comments on both the Medicaid Access and Managed Care proposed rules.
Just a few months ago, we urged Medicaid advocates to consider leveraging their state Medicaid advisory committees to help improve their Medicaid programs. But now we’re happy to report that exciting changes may be coming to Medicaid advisory committees across the country!
CMS recently issued new proposed regulations on access and managed care in Medicaid, and the proposed access regulations include a significant update to the Medicaid advisory committee structure and requirements. (You can learn more about the two new regulations here.) The improvements to the Medicaid advisory committee system have the potential to transform the operation of state Medicaid programs, making them more attuned and responsive to the lived experiences of enrollees.
Let’s start with the basics about the new structure. Currently, every state is required to operate a singular Medical Care Advisory Committee (MCAC), that convenes various Medicaid stakeholders, including beneficiaries, to provide recommendations to the state agency. First, the proposed regulation would change the MCAC name to “Medicaid Advisory Committee,” which is more consistent with the names states currently use for their MCACs. Second, the proposed regulation would create a new Beneficiary Advisory Group (BAG), comprised entirely of individuals with lived experience in Medicaid, that will provide direct feedback to the state Medicaid agency and participate in the MAC. Below are some details about the top changes.
The bulk of the requirements set out in the proposed regulation apply to both the MAC and BAG, but we’ll start with some design details that are specific to each entity.
MAC Composition and Report
CMS’s proposed rule does a lot more than change the name of MCACs. While current regulations require some consumer stakeholder participation, there is no established minimum composition. The proposed regulation would require that 25% of the MAC committee be from the BAG. In addition, the proposed rule requires the MAC include at least one stakeholder from each of several categories, including a beneficiary advocacy organization category. The rule also requires participation from at least one other state agency that serves Medicaid enrollees (in an ex-officio role), which could facilitate Medicaid coordinating with agencies addressing a variety of health-related social needs, such as housing, education, or nutrition.
BAG Design Details
The state must form and support a BAG comprised of Medicaid enrollees (past and present) and Medicaid enrollee family or caregivers. The role of the BAG is to advise the state on the operation of its Medicaid program. The BAG must meet separately in advance of MAC meetings, allowing BAG members the opportunity to provide direct input to the state and help prepare for the MAC meeting (which some BAG members will participate in). At least one member of the state agency executive staff must be present at the BAG (and MAC) meetings.
New Requirements for Both MACs and BAGs
The existing regulations for MCACs have limited details and requirements for state MCAC function, which results in wide variation in MCAC operation and quality across states. The proposed regulation includes many new requirements and standards to ensure that both MACs and BAGs truly achieve their purpose.
A major problem with the current MCAC system in any given state is that few people know about it, and even fewer know how it works. The proposed regulation would add numerous transparency requirements, to make sure that MAC and BAG operations are known to the public. The state must: develop and publish processes to recruit and appoint committee members; develop bylaws for committee governance; and publish committee member lists, the meeting schedule, and past meeting minutes and attendee lists.
Currently, a state could convene its MCAC only once a year (not nearly enough to provide meaningful advice) yet not be out of compliance with the MCAC regulations. The proposed regulation would require that MACs and BAGs must meet at least quarterly, and additionally as needed. At least two of the MAC meetings per year must be open to the public, offering the public a chance to speak, while BAGs can decide whether their meetings should be public. States must take reasonable steps to make meetings accessible to people with disabilities and limited English proficiency, and allow participation virtually or by phone. States also must select meeting times and locations to maximize attendance.
The proposed regulations also expand on the mission of MCACs. Current regulations only require the state to rely on the MCAC for advice on “health and medical care services,” which could be construed quite narrowly to only allow input on services. The proposed regulation expands the role of the MAC and BAG to provide recommendations on all elements of state Medicaid programs, including services, eligibility and enrollment processes, communications, and quality of care, among other policy development topics. One thing the proposed regulation could be more explicit about is clarifying that policy development means consulting with the MAC and BAG prior to making major decisions and changes, as opposed to just seeking after the fact feedback. We don’t want states shooting first and asking the MAC and BAG questions later. CMS could also be more explicit about what other statutory processes (such as designing content of Medicaid applications and notices) could or should be linked to MAC and BAG input – either as a best practice now or, more ideally, by future rulemaking.
One of the greatest flaws in the current MCAC system is that, while enrollee participation is at least generally required, enrollees often lack the supports needed to meaningfully participate. The current regulations do generally require Medicaid staff assistance and necessary financial arrangements to support beneficiary participation. The proposed regulation fleshes this out for MACs and BAGs, adding requirements to support for recruitment of members, planning of meetings, producing meeting minutes, and to provide information and research. It would be great if CMS’s final regulation went one step further by considering how the BAG members might have independent (i.e., not state agency staff) policy experts or counsel to support them in developing their policy recommendations or might even be compensated for their time.
Finally, the proposed regulation also requires a new annual report from the MAC. The MAC will develop an annual report on activities and recommendations made that year, which the state must review and include responses to the recommendations, as well as a summary of BAG recommendations and responses to those, and then the MAC would do a final review before the report is finalized.
Closing Thoughts
The proposed regulation is a home run for beneficiaries. It creates clear standards, processes, and transparency where before there were almost none. This will meaningfully improve consumer participation in the lowest performing states – consumers will actually know about MACs and BAGs, participate in them, and do so more effectively. State Medicaid programs will finally benefit from the lived experience of Medicaid enrollees who understand when and how and why the system breaks down. These improvements are long overdue, and kudos to CMS for finally getting it done – or at least proposing to do it. Let’s hope the final regulations reflect the simple principle that we ought to listen more to the people who rely on Medicaid day-in and day-out.
