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.