Insights

On April 11, 2025, the Medicare Payment Advisory Commission (MedPAC) held the second day of its April 2025 public meeting, which was also the final day of the 2024-2025 cycle of public meetings. Today’s sessions focused on access to hospice care and other services under the Medicare hospice benefit and nursing home quality for Medicare beneficiaries. Today’s sessions were more informative, and no recommendations were presented to or voted on by Commissioners. That said, both topics are clearly of interest to Commissioners, and we expect them to be features of future public meeting sessions.

ACCESS TO HOSPICE AND OTHER SERVICES

The first session focused on access to hospice and certain specialized services for beneficiaries participating in Medicare’s hospice benefit. Specifically, the session focused on four specialized services: dialysis for beneficiaries with end-stage renal disease (ESRD), radiation, blood transfusions, and chemotherapy for beneficiaries with cancer. MedPAC staff shared that the motivation for examining this topic comes from findings that hospice use is substantially lower for decedents with ESRD compared to the overall population. Another motivation for the focus on this topic came from concerns that Medicare beneficiaries may not understand the policy for covering these specialized services, and concerns that the cost of providing these services is higher than the daily hospice payment rate. To examine these concerns, MedPAC conducted a literature review, analyzed available Medicare claims data, and conducted interviews with clinicians, hospice providers, dialysis providers, and family caregivers.

MedPAC staff began the review of their work by providing an overview of the role of these specialized services within the hospice benefit. They shared that Medicare permits, but does not require, hospices to offer these services if they are used for palliative purposes. Staff noted that these decisions are made at the facility level and are dependent on a facility’s governing philosophy on what services fit under the category of palliative care. MedPAC staff also noted that Medicare generally does not have data on how often hospice providers furnish certain services, and there is no data on the costs to provide these services. MedPAC did compare the hospice routine home care (RHC) rate with the average fee-for-service (FFS) payment for dialysis, transfusion, and radiation to patients not enrolled in hospice. They found the average FFS payments for these services generally exceeded the Medicare hospice benefit daily payment rate. MedPAC staff ended their presentation by presenting some potential policy considerations for Commissioners, including the potential for enhanced data reporting, changes to the hospice payment system to address possible disincentives to providing certain services, and developing a program to help beneficiaries transition into hospice care.

MedPAC staff began the review of their work by providing an overview of the role of these specialized services within the hospice benefit. They shared that Medicare permits, but does not require, hospices to offer these services if they are used for palliative purposes. Staff noted that these decisions are made at the facility level and are dependent on a facility’s governing philosophy on what services fit under the category of palliative care. MedPAC staff also noted that Medicare generally does not have data on how often hospice providers furnish certain services, and there is no data on the costs to provide these services. MedPAC did compare the hospice routine home care (RHC) rate with the average fee-for-service (FFS) payment for dialysis, transfusion, and radiation to patients not enrolled in hospice. They found the average FFS payments for these services generally exceeded the Medicare hospice benefit daily payment rate. MedPAC staff ended their presentation by presenting some potential policy considerations for Commissioners, including the potential for enhanced data reporting, changes to the hospice payment system to address possible disincentives to providing certain services, and developing a program to help beneficiaries transition into hospice care.

During the questions and discussion period, some Commissioners asked if comparing the hospice daily payment with the average FFS payments for non-hospice beneficiaries made sense, given how costs under the Medicare hospice benefit tend to be higher at certain times during the course of care. Other Commissioners discussed the uniqueness of dialysis among the services featured in MedPAC’s analysis, since it is critical for keeping ESRD patients alive. There was an agreement among several Commissioners that this could cause a beneficiary to delay entry into hospice. Other Commissioners wanted MedPAC to examine the rationale for why the hospice benefit is carved out of Medicare Advantage and paid for by FFS Medicare. Commissioners also debated having a system where access to specialized services is so dependent on the facility a beneficiary goes to. Some Commissioners expressed concerns that this system leaves many beneficiaries unable to access services that would help ease their suffering. Others countered that the current system allows for flexibility and individualized care and that Medicare should not dictate which services are offered.

MedPAC staff noted that this session will not be a topic in the June 2025 Report to Congress, but they expect it to be a continued topic of interest. The Chairman of MedPAC confirmed that the Commission will continue to look at this issue.

REGULATIONS, STAR RATINGS, AND FFS MEDICARE POLICIES TO IMPROVE NURSING HOME QUALITY

The final session of the April 2025 public meeting focused on a topic that MedPAC has long been interested in improving nursing home quality. MedPAC staff gave an overview of the different regulations and programs promulgated to address concerns about this issue. These include the inspection and certification requirements that nursing homes must meet to participate in Medicare, the star rating system, the skilled nursing facility value-based purchasing (SNF VBP) program, and a Center for Medicare and Medicaid Innovation demonstration aimed at improving nursing home quality. MedPAC staff summarized their findings that there is limited evidence that these regulations and programs have worked. Specifically, staff noted various government and academic studies to support this point.

There was broad agreement among Commissioners that current efforts to address nursing home quality have not been enough to make meaningful improvements. A few Commissioners expressed concerns that part of the star rating system for nursing home quality is based on the results of inspections of facilities, saying that those are really to ensure nursing homes are meeting the minimum standards of quality. There was also support for the standing MedPAC recommendation that the star rating system should include a category to measure beneficiary satisfaction. Other Commissioners highlighted their view that staffing, which is currently a category measured by the star rating system, was an important measurement. The recently vacated nursing home staffing mandate did not come up very much, which is unsurprising given that a federal court recently vacated it. One Commissioner expressed that she was reconsidering her opposition to staffing ratio mandates. However, another Commissioner countered that MedPAC should follow the lead of Congress, which he argued has shown interest in repealing the rule.

Regarding positive recommendations to improve nursing home quality, several Commissioners praised institutional special needs plans (I-SNPs) and high-need accountable care organizations (ACOs) for their record on improving nursing home quality. A few Commissioners also expressed an interest in considering a separate long-term care benefit under traditional Medicare to improve nursing home quality. However, another Commissioner opposed that idea, and others thought it was unlikely to be adopted as a recommendation from Congress in the current environment. The session ended with the MedPAC Chairman stating that although the Commission should be responsive to Congress, it should not shape its work based on what Congress wants to hear. He also said that MedPAC will need to consider whether improving nursing home quality will require more money and ways to improve the system without spending money.

Material from this session will be included, along with previous MedPAC work on this topic, in the June 2025 Report to Congress.

On April 11, 2025, the Medicaid and CHIP Payment and Access Commission (MACPAC) held the second day of its April meeting. The meeting agenda included votes on recommendations for children and youth with special health care needs for the June report to Congress, as well as discussions on Medicaid payment policies to support the home- and community based services (HCBS) workforce, health care access for children in foster care, appropriate access to residential treatment for behavioral health needs for children in Medicaid, and Medicare-Medicaid Plan (MMP) transition.

VOTES ON RECOMMENDATIONS

Due to one vacant seat, the total number of votes was 16. The votes were as follows:

• Recommendation 1.1 – Congress should require that all states develop and implement a strategy for transitions from pediatric to adult care for children and youth with special health care needs, including but not limited to, children enrolled in Medicaid through Supplemental Security Incomerelated eligibility pathways and the Katie Beckett pathway for children with disabilities, those eligible for Medicaid under The Tax Equity and Fiscal Responsibility Act, and children who qualify to receive an institutional level of care. The strategy should address the development of an individualized transition of care plan, and describe (1) the entity responsible for developing and implementing the individualized transition of care plan, (2) the transition of care timeframes, including the age when the individualized transition of care plan is developed, and (3) the process for making information about the state’s strategy and beneficiary resources related to transitions of care publicly available. Vote 16-0 in favor.
• Recommendation 1.2 – The Secretary of the U.S. Department of Health and Human Services should direct the Centers for Medicare & Medicaid Services to issue guidance to states on existing authorities for covering transition of care services for children and youth with special health care needs, including but not limited to, children enrolled in Medicaid through Supplemental Security Income-related eligibility pathways and the Katie Beckett pathway for children with disabilities, those eligible for Medicaid under The Tax Equity and Fiscal Responsibility Act, and children who qualify to receive an institutional level of care. Vote 16-0 in favor.
• Recommendation 1.3 – The Secretary of the U.S. Department of Health and Human Services should direct the Centers for Medicare & Medicaid Services (CMS) to require states to collect and report to CMS data to understand (1) which beneficiaries are receiving services to transition from pediatric to adult care, (2) utilization of services that support transitions of care, (3) and receipt of an individualized transition of care plan. Additionally, CMS should direct states to assess and report to CMS beneficiary and caregiver experience with transitions of care. Vote 16-0 in favor.
• Recommendation 1.4 – The Secretary of the U.S. Department of Health and Human Services should direct the Centers for Medicare & Medicaid Services to amend 42 CFR 431.615(d) to require that inter-agency agreements (IAAs) between state Medicaid and Title V agencies specify the roles and responsibilities of the agencies in supporting CYSHCN transitions from pediatric to adult care. The roles and responsibilities of the state Medicaid agency described in the IAA should reflect the agency’s strategy for transitions of care. Vote 16-0 in favor.

MEDICAID PAYMENT POLICIES TO SUPPORT HCBS WORKFORCE

The session focused on how Medicaid payment policies can better support the HCBS workforce by outlining current HCBS rate-setting practices, emphasizing that wages are the largest cost driver, yet reliable wage data remains limited. Most states rely on Bureau of Labor Statistics (BLS) data, which lack specificity for Medicaid HCBS roles. The CMS “Access Rule” will improve some data transparency, but it doesn’t require states to report or publish average wages. MACPAC proposed a policy requiring states to publicly report, biannually, the average hourly wages paid to HCBS workers—disaggregated by service type and worker classification—to help states set more accurate and competitive rates. The recommendation is intended to give states access to more granular wage data without imposing significant new burdens, as it builds on existing reporting obligations.

Commissioner discussion centered on a proposed policy requiring states to report average hourly wages for HCBS workers, with mixed reactions from commissioners. Several expressed strong support for the concept, viewing it as a rational and important step toward addressing workforce adequacy and helping states set more appropriate rates. Others emphasized the need to consider broader factors—such as health insurance, full-time employment, rural vs. urban dynamics, and managed care environments—that impact workforce stability. Some commissioners raised concerns about feasibility, data accuracy, and administrative burden, particularly how averages would be calculated and who would bear the cost. While many acknowledged the value of improved wage data, there was debate over whether this policy would truly address workforce challenges or simply add complexity.

HEALTH CARE ACCESS FOR CHILDREN IN FOSTER HOMES

The next session highlighted the complex health care needs of children in foster care, emphasizing how trauma, placement instability, and fragmented data systems negatively impact access to care. It noted that while some states are improving collaboration between Medicaid and child welfare agencies—often through workgroups or specialty managed care plans—there are no federal requirements mandating such coordination or data sharing. Children in foster care may have better physical health outcomes when care coordination is strong, but access to behavioral and oral health services remains a challenge due to workforce shortages. States using specialized managed care organizations (MCOS) report reduced administrative burdens and better population-specific outcomes. The study underscored the need for improved interagency collaboration, data sharing, and tailored delivery models to better support this vulnerable population.

All commissioners agreed that there is an urgent need to prioritize health care for children in foster care, particularly regarding their heightened behavioral health needs. Commissioners discussed the potential of specialty managed care programs to address these needs, questioning how widely they are used and how they differ across states. There was interest in identifying best practices, including the use of foster care liaisons and formal agreements between agencies and health plans. Concerns were raised about the long-term challenges faced by youth aging out of foster care and the importance of designing policies that account for their unique circumstances. Overall, commissioners called for deeper analysis of managed care models, data on outcomes, and cross-sector collaboration to improve care for this vulnerable population.

APPROPRIATE ACCESS TO RESIDENTIAL TREATMENT FOR BEHAVIORAL HEALTH NEEDS FOR CHILDREN

The following session outlined gaps in federal data, variation in state practices, and challenges such as limited in-state facility capacity, lack of home- and community-based alternatives, and workforce shortages. It highlighted how out-of-state placements often result from insufficient local resources, and how payment structures may incentivize such placements. The report also addressed the need for improved coordination among federal agencies and called attention to disparities in assessment requirements and data availability. The draft will be finalized for MACPAC’s June 2025 report to Congress. Commissioners pointed out the absence of information on bed shortages, workforce limitations, and challenges related to discharging children from psychiatric residential treatment facilities (PRTFs), particularly when homebased resources are lacking. There was a call to acknowledge how the residential setting itself can become a barrier to appropriate care. Others emphasized the need for future work on quality and safety, especially in light of increasing out-of-state placements and the role of private investor-owned facilities. Additionally, there was a suggestion to include tracking of children with disabilities in ongoing and future research.

MMP TRANSITION: PROCUREMENT, IT, AND ENROLLMENT

The final session of the day outlined Medicaid coverage policies, referral sources, and challenges such as inconsistent data, limited in-state capacity, and financial incentives that encourage out-of-state placements. The presentation highlighted barriers including lack of HCBS workforce shortages, institution for mental diseases (IMD) exclusion rules, and gaps in facility and outcome data. The presentation also emphasized the need for improved guidance, interagency collaboration, and data infrastructure to ensure effective, high-quality care. Final recommendations will be included in MACPAC’s June 2025 report to Congress. Commissioners focused on the challenges and considerations involved in transitioning from current Medicaid managed care models to Dual Eligible Special Needs Plans (D-SNPs). Commissioners emphasized the importance of understanding how protest timelines and blackout periods impact state transitions, as well as the need for continuity of care and technical support, especially regarding member access under MCOs. Concerns were raised about communication with beneficiaries during plan changes, the overlap of organizational roles, and the need for better insight into state experiences. There was also discussion about the structure of CMS and plan contracts, with calls for greater transparency and potential separation of contracts to support smoother transitions.