Insights

On December 11, 2025, the Medicaid and CHIP Payment and Access Commission (MACPAC) met for their December meeting. The Commissioners examined strategies for implementing the community engagement requirements which were signed into law under the One Big Beautiful Bill Act.

CONSIDERATIONS FOR IMPLEMENTING COMMUNITY ENGAGEMENT REQUIREMENTS: FINDINGS FROM STAKEHOLDER INTERVIEWS

MACPAC staff began by reviewing the community engagement requirements and current clarifications before sharing their findings from stakeholder interviews. The interviews were conducted between June and August of 2025 and included stakeholders such as CMS officials, state Medicaid directors, representatives of national advocacy organizations, and think tank staff.

One of the largest concerns raised by interview participants was how states will access community engagement data. For example, while free data sources are available, they are often not updated in a timely manner or provide aggregated data, making it difficult for state Medicaid agencies to comply with verification requirements. Paid data sources can be timelier but are also expensive. For example, it was reported that North Carolina’s contract with Equifax for its data set doubled from 2022 to 2025. Stakeholders have requested that Centers for Medicare and Medicaid Services (CMS) provide guidance on free data sources or enter into agreements to reduce costs for paid data sources.

Another major concern raised by stakeholders is the cost of IT infrastructure changes. These infrastructure changes are needed to adequately meet reporting requirements but can cause administrative budgets to balloon. For instance, Georgia recently saw 90% of administrative spending go towards IT infrastructure upgrades.

During Commissioner discussion, there continued to be concerns raised about the cost and requirements of implementing new IT structures. One Commissioner verified that state funds were still being matched at a rate of 10 to 90 for IT upgrades. There was also concern about how to best report verification data, especially for populations that may not have access to technology or digital tools. One suggestion was to look for ways to track and manage data that does not put the impetus on the individual to prove their exemption status or continued eligibility.

The opportunities for managed care organizations were also discussed, with multiple Commissioners highlighting how they have previously been critical to successful engagement with their members. Commissioners discussed continuing to explore how other similar partners could increase engagement, especially in maintaining timely data and finding a framework for effective monitoring.

One Commissioner emphasized the importance of understanding and comparing infrastructure and policy decisions across states to gain a clearer picture of how each state is managing the rollout. The Commissioner noted that this would become more important if some states see enrollment numbers drop drastically, and that it is important to pause and intervene to prevent large population segments from losing their health care coverage.

The Chair concluded the session by suggesting that the Commission should reexamine some rules and regulations regarding managed care plans and their role in helping individuals remain eligible.

EXPERT PANEL ON IMPLEMENTING COMMUNITY ENGAGEMENT REQUIREMENTS

MACPAC invited Lindsay Browning, Deputy Executive Director of Programs, National Association of Medicaid Directors, and Caprice Knapp, Principal Deputy, Center for Medicaid and CHIP Services, to answer questions from MACPAC staff and Commissioners.

The panel opened with questions from MACPAC staff. The first topic focused on what Ms. Browning and Ms. Knapp were hearing from states, as well as the deeper policy questions states have been grappling with. Ms. Knapp answered that CMS is seeing a lot of alignment with the responses MACPAC staff have reported from stakeholders, with the greatest emphasis on timelines and IT infrastructure. Deeper policy questions have related to how best to convert the data states can access into acceptable formats and how to partner with the respective Departments of Education. She emphasized that questions can be sent to medicaidreforms@cms.hhs.gov. Ms. Browning also noted alignment with interviews conducted by MACPAC staff, in which states emphasized concerns about member engagement. She also said she has been receiving policy questions about differential impacts of the community work requirements between states and how states can best show a clear paper trail for future audits.

When asked about which areas state agencies are seeking additional federal guidance, Ms. Browning emphasized the need for states to receive early signals from CMS about future guidance. More clarity on where CMS will be specific or flexible with implementation requirements, what the minimum product looks like for IT solutions, and data reporting expectations were also of interest. Ms. Knapp did not provide a clear answer on what additional guidance states could expect from CMS before June 2026. She did highlight the monthly informational calls and all state calls that CMS intends to continue as good sources of information and early signaling.

Ms. Browning was also asked about what lessons from the recent unwinding of the Public Health Emergency (PHE) could be applied to the rollout of the community engagement requirements, Ms. Browning made it clear that while there are similarities, the new community engagement requirements are not an established body of policy that can be examined; instead, decisions are being made now and in the future. That said, she feels that the increased automation of eligibility policies and the advancement of community engagement structures in the unwinding were helpful. Ms. Knapp emphasized the importance of outreach and vendor and managed care plan engagement for being successful.

Answers to questions about monitoring implementation and data collection emphasized minimizing the burden on states by clarifying what needs to be reported and creating a list of a reasonable number of measures. Building on existing systems and adopting a collaborative approach with CMS were listed as strategies for long-term implementation success.

The floor was then opened for Commissioners to ask questions directly, starting with what states are seeing as initial priorities. Ms. Knapp shared that, in her experience, states are seeking guidance on the minimum viable product for data reporting and clarification on qualifying events and medical fragility exemptions. Ms. Browning reported that states are most concerned with verifying employment, income, and education, with discussions about expanding to the volunteering category to take place later.

A couple of Commissioners raised concerns about how CMS will evaluate whether states are prepared to roll out the new requirements. Ms. Knapp assured questioners that both IT and policy readiness review parameters are in place. CMS is also working with states that are choosing to start implementation early, allowing them to avoid disenrolling individuals through a hold-harmless period. CMS can also step in and put a state on pause if there are unexpected events, such as large numbers of disenrollments.

When asked how MACPAC can be helpful to states and CMS during the lead-up to January 2027, Ms. Browning emphasized recommendations on outcome measurement, specifically identifying a small set of meaningful measures to best monitor and track eligibility requirements. Other recommendations about member outreach were also suggested.

The cost of IT infrastructure procurement was also discussed, with Commissioners wondering how states can keep costs down. Ms. Knapp emphasized that Administrator Oz was meeting with vendors to figure out solutions to high procurement costs, especially for systems that multiple states would be interested in. Ms. Browning raised the need for continued evaluation of data source costs, specifically for states finding high-value data from lower-cost sources.

On December 10, 2025, the Senate Committee on Homeland Security Subcommittee on Investigations held a hearing on principles to fix healthcare. Democratic Senators focused on the need to extend the enhanced Advance Premium Tax Credits (APTCs) while Republicans were firm that the Affordable Care Act (ACA) needs a complete overhaul.

OPENING STATEMENTS

• Chairman Ron Johnson (R-WI)

WITNESS TESTIMONY

• Mr. Christopher Briggs, Obamacare Enrollee – Testimony
• Mr. Nick Stehle, Obamacare Enrollee – Testimony
• Mr. Joel White, President, Council for Affordable Health Coverage – Testimony
• Mr. Tarren Bragdon, President and Chief Executive Officer, Foundation for Government Accountability – Testimony
• Mr. Dan Jacobs, Small Business Owner and ACA Marketplace Enrollee – Testimony
• Mr. Aaron Lehman, Farmer and ACA Marketplace Enrollee – Testimony

MEMBER DISCUSSION

Sen. Rick Scott (R-FL) stated he understands how important it is for people to have access to health care they can afford, which is why he has introduced S.3264, a bill that would establish HSA-style accounts through which individuals could purchase health care. Mr. White was in support of the bill, indicating that it will help the small business market. Mr. Bragdon was also in support of the bill, stating, “putting money in patients’ pockets is transformative.”

Sen. Bernie Moreno (R-OH) stated that only a small percentage of Americans are affected by the expiration of APTCs, and therefore, said more work needs to be done to reduce costs for all Americans. Some ideas he shared were increased transparency in health care costs, the use of association health plans, and reforms of certain practices by pharmacy benefit managers (PBMs).

Sen. Elissa Slotkin (D-MI) shared that while the ACA is not perfect, it did provide affordable coverage for people with pre-existing conditions. She also said she is not willing to take away enhanced ATPCs while Congress considers other policies to improve the affordability of health care.

Ranking Member Richard Blumenthal (D-CT) asked Mr. Lehman to share his recent experience shopping for a health care plan. Mr. Lehman indicated that seeing the rise in premiums resulted in intense sticker shock, which has made him and other farmers he represents nervous about how they will afford coverage. Ranking Member Blumenthal asked Mr. Jacobs how not extending APTCs would affect his business. Mr. Jacobs expressed concern about how the rise in premiums will lead to less consumer spending, especially in the service industry, and he is expecting many small businesses to close as a result. Ranking Member Blumenthal indicated that he would like to tackle additional health care challenges, but APTC extension is on a tight timeline that needs to be addressed immediately.

Chairman Johnson was strongly opposed to extending APTCs, repeating that now the subsidies are returning to the rates that were originally set in the ACA. He is in support of returning to the high-risk pool model for individuals with pre-existing conditions, feeling that it provides a good option to receive health insurance. Chairman Johnson asked Mr. White about the rise in insurance company’s stock prices and how to drive down health care costs. Mr. White shared that the increase in the stock price was directly correlated with the increase in the premium price. Mr. White indicated that the only way to decrease costs was to bring consumerism back to health care. Mr. Bragdon also supported the statement, saying that without consumerism, there is no incentive to reduce costs.

Chairman Johnson asked Mr. Lehman and Mr. Jacobs what percentage of their income an individual pays for health insurance before a subsidy should begin to apply. Mr. Lehman did not have an exact figure in mind, and Mr. Jacobs responded that he “is not a policy maker” and is “a bad person to ask” because he “would rather pay more so people who make less can have better health care.”

On December 4 and 5, 2025, the Medicare Payment Advisory Commission (MedPAC) met to discuss recommendations for the March 2026 Report to Congress. Many of the sessions during this two-day meeting focused on evaluating payment rates for physicians, inpatient services, outpatient services, home health services, and services provided in institutions such as skilled nursing facilities (SNFs). There was also discussion about the quality of care Medicare beneficiaries receive across different settings, including hospitals, outpatient settings, other facilities, and at home.

PHYSICIAN AND OTHER HEALTH PROFESSIONAL SERVICES RATES

MedPAC staff offered a comprehensive view of current spending and service use under the Medicare

Physician Fee Schedule (PFS), followed by a discussion of access-to-care and quality-of-care metrics. There was a change in the provider mix, with more advanced practice nurses (APRNs) and physician associates (PAs) providing care. MedPAC staff found that Medicare Economic Index (MEI) growth outpaced PFS updates, and suggested that increasing compensation rates is not necessary to maintain wide access to care. The Chair’s draft recommendation is for Congress to increase payment rates by 0.5% more than current law, resulting in a 1.25% increase for advanced alternative payment model (A-APM) clinicians and a 0.75% increase for other clinicians.

The Commissioners expressed widespread support for the Chair’s recommendation. One Commissioner was unsupportive, indicating that, due to inflation, the proposed increase in payment would result in a net decrease of 2.2%. A few other Commissioners acknowledged this point but felt that increasing the rate more would lead to ballooning costs. There was sentiment that the reimbursement policy needs an overhaul, as the current system is squeezing providers and not benefiting either providers or patients.

Some Commissioners suggested that staff begin taking a closer look at the effects of concierge care and at how to quantify its use. There was also strong support for crafting new survey questions to measure quality of care, as the Merit-based Incentive Payment System (MIPS) is flawed. One Commissioner also noted that comparison data between private insurance options and Medicare is helpful, but if the comparison group is worsening, that does not automatically mean Medicare access and quality are improving.

HOSPITAL INPATIENT AND OUTPATIENT SERVICE RATES

MedPAC staff found hospital supply and availability were relatively steady for fiscal year 2024 (FY24), with Medicare inpatient stays and outpatient services increasing in 2024. Hospital margins increased slightly but remained low. Relatively efficient hospitals’ margins also increased from -2% to -1% in 2024. MedPAC staff also said that the Medicare Safety-Net Index (MSNI) remained a better predictor of hospitals’ all-payer operating margins than other metrics. The Chair’s draft recommendation for 2027 payments is to update the 2026 Medicare base payment rates by the amount specified in current law, and to implement MSNI as described in the March 2023 report, adding $1 billion to the MSNI pool.

There was general support for the recommendations, with many Commissioners specifically mentioning strong support for the MSNI contribution. Two Commissioners expressed reservations about supporting the recommendation because they wanted separate Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS) measures and recommendations.

The Commissioners were very interested in the efficient hospital model and in how it has been previously validated. There was also general interest in how the model is used; however, the Chair pushed for the committee to remain on the topic of recommendations and suggested revisiting the conversation at a later date. A few Commissioners asked how $1 billion was determined as the amount to contribute. The staff and the Chair clarified that it was about 0.5% of a rate increase and that additional information on the expected effects of the contribution would be provided.

POST ACUTE CARE: TRENDS AND KEY ISSUES

This presentation was suggested to evaluate, holistically, post-acute care facilities’ use and payment. The differences in eligibility requirements, benefits, and cost-sharing requirements make it difficult to conduct a one-to-one comparison of quality outcomes, but preliminary results indicate possible inefficient care. There are plans for future work to evaluate the new case-mix systems, monitor the TEAM alternative payment model, compare Medicare Advantage and fee-for-service (FFS) use of post-acute care, and examine Medicare Advantage’s impact on the financial performance of SNFs and inpatient rehabilitation facilities (IRFs).

The largest discussion thread was the desire for more data to support future recommendations. Measures such as patient experiences and outcomes, as well as how providers select facilities, were among the suggestions. There was discussion on the 3-midnight rule and the inclusion of observation status for post-acute care facilities. MedPAC previously recommended that observation be included, but there have been no further changes. Another large topic of commentary was understanding geographic locations of each type of post-acute care facility and how location may influence patient placement.

While the presentation stated that there are no guidelines for patient placement, one Commissioner responded that the rehabilitative specialties do have guidelines, along with their clinical judgement, for evaluating patients. This led to the suggestion that these guidelines be collected and examined to understand how they are used, and that the reports be reformatted as needed.

SKILLED NURSING FACILITIES RATES

The MedPAC presentation on SNFs suggested that SNF access has remained stable for Medicare beneficiaries, as the number of SNFs decreased while occupancy rates increased. Quality measures were also noted as being stable, but there are gaps in quality data since patient experience data is not uniformly collected. Margins for freestanding SNFs were high in 2024, averaging 24.4%. The Chair’s draft recommendation for 2027 rates is to reduce 2026 Medicare base payment rates for SNFs by 4%. The expected implications are a decrease in spending relative to the current law, but no adverse effect on access to care.

The design of nursing home star ratings was evaluated, and an alternative approach was proposed that would equally weight each domain. The idea is that it would increase the weight of the staffing rating. It was also suggested that the change in approach could provide a more complete picture of quality and compliance for SNFs.

There was broad support for the recommendation, with some saying that it is a conservative reduction in payment due to the high margins SNFs experience. There was commentary on ways to more accurately reflect SNF star ratings by changing domain weights, with some Commissioners suggesting a higher staffing weighting and others arguing that the other domains are equally necessary. It was also suggested that CMS overhaul the measures used to evaluate quality and compliance. More long-term thinking about paying for outcomes and care was raised as an avenue for the commission to explore.

HOME HEALTH CARE SERVICES RATES

MedPAC staff provided an overview of home health care services and spending, showing that access to care has remained adequate. They also highlighted that the overall use of home health services has declined by 1%, but Los Angeles, California, has seen rapid growth in the area. This has led to a usage rate of about twice the national average and has been accompanied by a rapid rise in costs. While some tools have been used to address program concerns, use remains high. Quality of care has also remained stable, and home health margins have remained high, averaging 21.2%. The Chair’s draft recommendation for 2027 is for Congress to reduce the 2026 Medicare base payment rate for home health services by 7%. The expected implications would be to decrease spending with no adverse effect on access to care.

A few Commissioners asked MedPAC staff whether what was being seen in California represented the start of a larger trend and requested a closer look at the differences in California’s usage rates. There was interest in whether the higher home health usage was offset by lower usage of other post-acute care settings, such as SNFs and IRFs. One Commissioner, who practices in Los Angeles County, offered some commentary he believed could explain the differences. In his opinion, low property tax rates encourage older populations to age in place and choose home health services over other types of care. Another possibility is the availability of remote home monitoring equipment, which makes it easier for patients and providers to feel comfortable with home health programs. The Commissioner encouraged MedPAC staff to examine discharge-to-home rates in Los Angeles County compared to the rest of the country to understand if the high usage of home health services results in lower emergency department readmission rates.

Other discussion topics revealed that Medicare FFS is the preferred payer for home health services, above both Medicare Advantage and private health insurance. A better understanding of the payer mix is a topic that multiple Commissioners expressed interest in revising. Other data points that future work could examine include utilization rates, especially comparisons between rural and urban communities, as well as utilization by living status.

Overall, there was broad support for the Chair’s draft recommendation. The only hesitation was why a 7% rate cut was chosen over similar rates, especially when compared with other draft recommendations. The Chair explained that the Commission is trying to preserve access and quality while signaling the feeling that rates need to be lowered. Some long-term planning to examine whether a single large rate cut or a series of smaller rate cuts over a longer period was preferred was suggested.