MACPAC Report to Congress: June 2013

Rachel B. Morgan RN, BSN 10/23/2013

The Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) submitted a report to Congress in June examining key policy issues related to eligibility and coverage for maternity services, the newly implemented increase in Medicaid physician payment for primary care services, access to care for persons with disabilities, the availability of Medicaid and CHIP data that can be used by the Congress for oversight and program monitoring, and improving the effectiveness of program integrity activities. MACPAC is a nonpartisan federal agency charged with providing policy and data analysis to Congress on Medicaid and CHIP, and for making recommendations to the Congress and the secretary of the U.S. Department of Health and Human Services (HHS), and the states on a wide range of issues affecting these programs. The commission conducts independent policy analysis and health services research on key Medicaid and CHIP topics, including but not limited to: 

  • Eligibility, enrollment and benefits
  • Payment
  • Access to care
  • Quality of care
  • Interactions of Medicaid and CHIP with Medicare and the health care system generally
  • Data development to support policy analysis and program accountability

The commission’s reports are intended to provide Congress with a better understanding of the Medicaid and CHIP programs, their roles in the U.S. health care system, and key policy and data issues. Much of this research may also be beneficial to states as they consider legislative actions pertaining to Medicaid. Here are some additional details from the June report:

Maternity Services: Examining Eligibility and Coverage in Medicaid and CHIP

In their latest report, MACPAC found that almost half, about 1.8 million hospital births, were paid for by Medicaid or CHIP programs. In examining state data, the report found that all but nine states have extended coverage to pregnant women above 133 percent of the federal poverty level (FPL). The Affordable Care Act (ACA) mandates maternity care for those covered by health insurance exchange plans and requires coverage of other pregnancy-related services. States will continue to have considerable discretion as to how they cover pregnant women above 138 percent FPL and may have the option to transition these individuals to exchange coverage. The continuance of a separate eligibility pathway however may cause women to cycle among Medicaid, CHIP, and private coverage available through exchanges, or to uninsured status.

The report examines the potential effects of this “churning” and how it may affect the health care of the individual and increase the administrative burden on states, providers, and the plans. The report also details some of the efforts to improve outcomes and reduce costs. For example, almost one-third of Medicaid deliveries were by cesarean section (c-section). C-section deliveries are more costly than vaginal deliveries, approximately $5,000 as opposed to an uncomplicated vaginal delivery at $3,000, and c-sections often result in a higher percentage of adverse outcomes. Many state programs have initiated protocols that reduce elective c-sections and nonmedically indicated induced deliveries before 39 weeks gestation.

American Academy of Pediatrics Report: Fact Sheet: Medicaid and Children

Medicaid Primary Care Physician Payment Increase

A provision in the ACA requires state Medicaid agencies to increase to Medicare levels the payment rates of primary care services furnished by primary care physicians in 2013 and 2014. The provision applies to services delivered by physicians paid under fee-for-service arrangements and by Medicaid managed care organizations (MCOs). The federal government is funding the full cost of the difference between the state’s Medicaid fees as of July 1, 2009, and Medicare fees in 2013 and 2014. (Additional information on the ACA provider payment requirements.)

There is some concern that access to care for current Medicaid beneficiaries and the newly eligible population through the expansions will be hampered becauseof a low rate of primary physician participation. MACPAC conducted semi-structured interviews with six states and the District of Columbia in late 2012 and early 2013 to gain a greater understanding of the operational and policy issues. These interviews brought to light several issues, including some concerns about the time allotted to implement the provision and about the difficulty of identifying eligible providers.

Delays due to complex system modifications, completion of necessary provider and MCO contract amendments, as well as the limited effective period would lessen the positive impact an increase would have. A critical question for policymakers is how the payment increase will affect physician participation and enrollee access to care. Since a complete analysis is not likely to be available until after the provision expires in 2014, the commission will continue to monitor the implementation, and analyze claims data to examine changes. 


The commission also publishes MACStats which includes state-specific information about program enrollment, spending, eligibility levels, optional Medicaid benefits covered, and the federal medical assistance percentage (FMAP), as well as an overview of cost-sharing permitted under Medicaid and the dollar amounts of common FPLs used to determine eligibility for Medicaid and CHIP.