Chapter 1:
Engaging
Beneciaries through
Medical Care
Advisory Committees
to Inform Medicaid
Policymaking
Chapter 1: Engaging Beneciaries through MCACs to Inform Medicaid Policymaking
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March 2024
Engaging Beneciaries through Medical
Care Advisory Committees to Inform
Medicaid Policymaking
Recommendations
1.1 In issuing guidance and in providing technical assistance to states on engaging beneciaries in Medical Care
Advisory committees (MCACs) under Section 42 CFR 431.12, the Centers for Medicare & Medicaid Services should
address concerns raised by states related to beneciary recruitment challenges, strategies to facilitate meaningful
beneciary engagement in Medicaid MCAC meetings, and clarify how states can provide nancial arrangements to
facilitate beneciary participation.
1.2 In implementing requirements in 42 CFR 431.12(d)(2) that Medicaid Medical Care Advisory Committee (MCAC)
membership include beneciaries, state Medicaid agencies should include provisions in their MCAC bylaws that
address diverse beneciary recruitment and develop specic plans for implementing policies to recruit beneciary
members from across their Medicaid population, including those from historically marginalized communities.
1.3 In implementing requirements in 42 CFR 431.12(e) to increase the participation of beneciary members in Medicaid
Medical Care Advisory Committees (MCACs), state Medicaid agencies should develop and implement a plan to
facilitate meaningful beneciary engagement and to reduce the burden on beneciaries in engaging in MCACs by
streamlining application requirements and processes, and by addressing logistical, technological, nancial, and
content barriers.
Key Points
•
Beneciaries have much to oer state Medicaid programs in the development and implementation of Medicaid
policies and can provide feedback to policymakers on the issues that aect their access and use of Medicaid-
covered services.
•
Federal rules require each state Medicaid agency to establish a Medical Care Advisory Committee (MCAC) that
consists of beneciaries or consumer group representatives, along with other stakeholders, to advise on the
Medicaid program and policies (§ 1902(a)(4) of the Social Security Act, 42 CFR 431.12).
•
MACPAC examined federal and state policies on beneciary participation in MCACs and how states use beneciary
input to inform programs, policies, and operations. This work focused on how states engage groups that are often
excluded from the decision making process.
•
States have varied MCAC policies and implementation approaches, and the majority of state MCACs have
beneciary vacancies.
•
States identied specic areas related to beneciary inclusion in MCACs for which they need guidance and
technical assistance, such as approaches for increasing beneciary recruitment and diverse beneciary
representation, use of nancial arrangements to encourage beneciary participation, and strategies to support
beneciary engagement in discussions.
•
Beneciaries participating in MCACs generally described their experience as positive. However, they also cited
challenges to participating on MCACs, such as the application and appointment process, meeting attendance
requirements, and diculty contributing to certain complex policy discussions.
•
In May 2023, the Centers for Medicare & Medicaid Services released a notice of proposed rulemaking that would
rename and expand the scope and use of states’ MCACs; require states to make MCAC materials publicly available;
and establish a beneciary-only group consisting of Medicaid beneciaries, their family members, and their caregivers.
•
MACPAC’s recommendations focus on the need for federal guidance and technical assistance to states to address
beneciary recruitment challenges, state eorts to strengthen the diversity of representation of beneciary members,
and state eorts to reduce burden on beneciaries while participating in MCACs.
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Report to Congress on Medicaid and CHIP
CHAPTER 1: Engaging
Beneciaries through
Medical Care Advisory
Committees to Inform
Medicaid Policymaking
Medicaid beneciaries can oer state Medicaid
programs their unique insight and feedback on how
programs and policies are meeting their needs,
challenges in accessing care, and opportunities
for improvement. Policymakers can engage with
beneciaries to develop a deeper understanding
of the issues that aect their access to care, co-
create solutions, and anticipate potential unintended
consequences of policies that would negatively
aect the people served by the program. Sustained
beneciary engagement can help build trust between
the community and the state Medicaid agency and
promote accountability to beneciaries (Skelton-Wilson
et al. 2021). In addition, research shows that engaging
people with lived experience is one strategy government
ocials can use to advance health equity (Allen et al.
2021, Zhu et al. 2021). However, beneciaries are not
often included in policymaking decisions that aect their
coverage and health outcomes (Coburn et al. 2021).
As a way to include those with lived experience with
the Medicaid program in state Medicaid agencies’
policymaking process, federal rules require each state
Medicaid agency to establish a Medical Care Advisory
Committee (MCAC) that includes beneciaries or
consumer group representatives along with other
stakeholders (§ 1902(a)(4) of the Social Security Act,
42 CFR 431.12). These rules grant states exibility
in implementing their MCACs to t the needs of their
state. As such, states have adopted varied approaches
to structuring and running their MCACs. To establish
more explicit expectations for including beneciary
perspectives in MCACs, in May 2023, the Centers
for Medicare & Medicaid Services (CMS) proposed
a rule on ensuring access to Medicaid services that
also revises the MCAC regulations. This proposed
rule is the rst change to MCAC regulations since
CMS established them in 1978. The proposed rule
emphasizes beneciary engagement and increases
transparency between the Medicaid agency and
beneciaries (CMS 2023).
Historically, little information has been reported publicly
about state implementation or use of MCACs, the
eectiveness of MCACs in bringing the beneciary
voice to Medicaid programs, or the experience of
states or beneciaries with MCACs. The Commission
signaled that additional research should be done to
learn more about current state practices for engaging
beneciaries of color, incorporating beneciary input
into program policies and operations, and promoting
greater participation (MACPAC 2022a). To address
gaps in knowledge about MCACs, MACPAC contracted
with RTI International (RTI) to examine how states use
MCACs to engage beneciaries, particularly those
from historically marginalized communities, to inform
programs, policies, and operations. RTI conducted
a policy scan of state statute and regulations as
well as publicly available bylaws, charters, member
lists, and websites for all 50 states and the District of
Columbia to understand state rules for MCACs.
1
RTI
analyzed MCAC membership requirements, including
requirements for engaging beneciaries from historically
marginalized populations, current MCAC composition,
supports oered for beneciary participation, frequency
of meetings, beneciary recruitment practices, and
policy areas in which states require MCACs’ input.
Our analytic approach helped identify how each
state’s MCAC is established and conducted. MACPAC
and RTI interviewed a CMS ocial from the Center
for Medicaid and CHIP Services as well as state
Medicaid ocials, beneciaries, and consumer
group representatives who participate in the advisory
committee meetings in six states.
2
These interviews
explored the barriers to beneciary participation as
well as approaches to overcome these barriers. The
majority of our research concluded before the release
of the proposed rule from CMS.
The ndings from the policy scan and stakeholder
interviews identied several challenges with recruitment
of beneciaries, particularly those representing
historically marginalized communities, and barriers
to meaningful beneciary engagement. Examples
of engagement barriers include beneciary feelings
of intimidation, reacting to proposed policy versus
informing the policymaking process, or inconvenient
meeting times. The ndings also identied potential
approaches to addressing these challenges, such as
Chapter 1: Engaging Beneciaries through MCACs to Inform Medicaid Policymaking
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March 2024
partnering with community-based organizations to
recruit individuals or hosting premeeting sessions with
beneciaries to help increase their understanding of and
comfort with complex policy topics.
As CMS works to nalize the rule on MCACs, the
federal government and states can continue their
eorts to improve beneciary engagement. States
have identied specic areas related to engaging
beneciaries in MCACs for which they need guidance
and technical assistance. Beneciaries have also
cited challenges to participating on MCACs, such as
the application process. Addressing challenges to
beneciary engagement in MCACs is likely to require
ongoing state focus. However, our work identied steps
CMS and states can now take to address challenges
raised by state ocials and beneciaries. The
Commission makes three recommendations to improve
beneciary engagement on MCACs:
1.1 In issuing guidance and in providing technical
assistance to states on engaging beneciaries
in Medical Care Advisory Committees (MCACs)
under Section 42 CFR 431.12, the Centers for
Medicare & Medicaid Services should address
concerns raised by states related to beneciary
recruitment challenges, strategies to facilitate
meaningful beneciary engagement in Medicaid
MCAC meetings, and clarify how states can
provide nancial arrangements to facilitate
beneciary participation.
1.2 In implementing requirements in 42 CFR
431.12(d)(2) that Medicaid Medical Care Advisory
Committee (MCAC) membership include
beneciaries, state Medicaid agencies should
include provisions in their MCAC bylaws that
address diverse beneciary recruitment and
develop specic plans for implementing policies
to recruit beneciary members from across
their Medicaid population, including those from
historically marginalized communities.
1.3 In implementing requirements in 42 CFR 431.12(e)
to increase the participation of beneciary
members in Medicaid Medical Care Advisory
Committees (MCACs), state Medicaid agencies
should develop and implement a plan to facilitate
meaningful beneciary engagement and to
reduce the burden on beneciaries in engaging in
MCACs by streamlining application requirements
and processes, and by addressing logistical,
technological, nancial, and content barriers.
This chapter begins by providing background on the
importance of beneciary engagement, challenges
to beneciary engagement, and state approaches
to address these challenges. Next, we review the
federal statute and regulations related to MCACs and
recent proposed changes to these regulations. Then
we discuss key ndings about state approaches to
MCAC beneciary recruitment, meeting structure,
and beneciary engagement from the policy scan
and the interviews. This section of the chapter
highlights the barriers to beneciary recruitment and
engagement and examples of state strategies to
address these challenges as well as how CMS plans
to address certain challenges in the proposed rule.
The chapter then concludes with the Commission’s
recommendations and its rationales.
The Importance of
Beneciary Engagement
Beneciary engagement ensures that those being
served by the health system have a voice in
how policies and programs are both created and
implemented, which can support states’ eorts to
advance health equity. The Centers for Disease
Control and Prevention (CDC), which helped develop
the principles of community engagement for federal
health agencies, stated that the goals of community
engagement are to “build trust, enlist new resources
and allies, create better communication, and improve
overall health outcomes as successful projects
evolve into lasting collaborations” and to engage the
community in policymaking (NIH 2011, CDC 1997).
Community engagement research notes that those
most aected by programs and policies often have
the solutions on how to improve them, which is why
it is important to codevelop strategies (Agonafer et
al. 2021).
Eorts to engage meaningfully with beneciaries
should be mindful of historic distrust of health care
systems and other institutions and the factors that
aect beneciaries’ ability to provide feedback
(MACPAC 2022a). This distrust from Medicaid
beneciaries, particularly those from marginalized
communities, is the product of decades-long
Chapter 1: Engaging Beneciaries through MCACs to Inform Medicaid Policymaking
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Report to Congress on Medicaid and CHIP
structural inequities (Agonafer et al. 2021).
3
A 2022
U.S. Department of Health and Human Services
report stated that such inequities stem from racism,
ableism, and other systems of oppression and require
sustained institutional changes to overcome them.
This report notes individuals who experience these
inequities mistrust institutions with power, such as
government agencies. Trust building consists of
acknowledging the systemic barriers and validates
the experiences of those harmed by such systems
(Ramirez et al. 2022). Often beneciaries are either
excluded from discussions of the policies that aect
their health and coverage or are asked to react to
policies after decisions have been made (Coburn et
al. 2021, Zhu et al. 2021). Lack of trust in government
systems and programs and uncertainty about
whether feedback will be taken into account may also
discourage beneciaries from sharing their views
(Musa et al. 2009).
BOX 1-1. Other State Strategies to Engage Beneciaries
State Medicaid agencies use varying methods for incorporating beneciary input into policy and program
decision making outside of Medical Care Advisory Committees (MCACs). States are required to provide
public notice and oer the public the opportunity to submit comments or provide input before proposed
program changes are submitted to the federal government. States can also solicit feedback from beneciary
surveys. Additional strategies for obtaining beneciary feedback include the following:
Member-only advisory councils. Several states convene member-only advisory councils to make
the engagement opportunities more accessible. In one study, states reported more robust consumer
participation in beneciary-only subcommittees compared to the committees in which other stakeholders
participate (Zhu et al. 2021). For example, Pennsylvania has a beneciary-only subcommittee that focuses
on members’ needs. This group is facilitated by a consumer advocacy group and meets separately from the
MCAC meeting. The objective of the subcommittee is to initiate consumer-focused policy ideas and provide
input on state policy initiatives. This subcommittee holds the agency accountable and elevates issues to
gain greater attention (Zhu and Rowland 2020).
Tribal council consultation. State Medicaid agencies are required to consult with American Indian and
Alaska Natives (AIAN) tribes and be responsive to their issues and concerns when making changes to the
Medicaid program that have tribal implications (CMS 2015). Section 5006 of the American Recovery and
Reinvestment Act of 2009 (P.L. 111-5) requires states to consult with tribes, designees of Indian health
programs, and urban Indian organizations on matters related to Medicaid and the State Children’s Health
Insurance Program (CHIP) that aect the populations. States are required to consult with tribes before
submitting Section 1115 waiver requests to CMS (42 CFR 431.408(b)).
Town halls. State Medicaid ocials can host town hall meetings to provide beneciaries the opportunity
to share their experiences with the Medicaid program. For example, state ocials in Nebraska host town
hall listening sessions every six months in various locations around the state. These town halls allow for
beneciaries to directly share areas of concern as well as suggest policy and programmatic changes to
improve the program.
Managed care organization (MCO) member advisory committees. Given that managed care is the
predominant delivery system in Medicaid, MCOs can play a role in engaging beneciaries and encouraging
them to share their perspectives on the Medicaid program in addition to their views on the MCOs’
operations. Some states require MCOs to have member advisory committees (Bailit Health 2023). For
example, Oregon’s Medicaid beneciaries are enrolled in coordinated care organizations; each organization
must have at least one community advisory council, and more than half of the council’s voting members
must include representatives of the community (ORS § 414.575). Medicaid ocials can attend MCO
beneciary meetings to engage directly with beneciaries.
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Equitable engagement strategies consist of
understanding the strengths that exist within
communities, including members of communities that
are most impacted by systemic injustices; dedicating
resources to ensure engagement is done in culturally
meaningful ways; providing the adequate orientation,
background, or preparatory materials for eective
participation; and oering supports that ensure
participation for those with varied abilities and access
needs (Ramirez et al. 2022).
Community engagement research highlights the
importance of establishing continuous and sustained
bidirectional feedback loops even if every concern
cannot be addressed or recommendation made.
Experts in the eld of community engagement stress
the need to create meaningful opportunities for input,
such as engaging people as early as possible in the
decision making process and being realistic with
beneciaries about timelines to help set expectations.
Research also indicates that regular communication
with beneciaries about how the state uses and
applies their input is particularly important to building
trust and their continued engagement (Roman et al.
2023, Ramirez et al. 2022). One study of MCACs
found that not all states could identify instances in
which the advisory committee’s recommendations
aected policymaking. However, states dened
success as building relationships between agency
leaders and beneciaries (Zhu et al. 2021).
Federal Statute and
Requirements
Section 1902(a)(4) of the Social Security Act, as
implemented in 42 CFR 431.12, requires states to
have an MCAC to advise the state Medicaid agency
on health and medical care services and participate
in policy development and program administration.
Federal regulations describe requirements for the
appointment and composition of the committee
members, the scope of topics for committee
discussion, and the support committee members can
receive from the Medicaid agency. The state Medicaid
director or a higher authority in the state must appoint
MCAC members on a rotating and continuous basis
(42 CFR 431.12 (c)). MCACs must include (at a
minimum) board-certied physicians and other health
professionals who are familiar with the medical
needs of low-income population groups, Medicaid
beneciaries and members of other consumer
organizations, and the director of the public welfare
department or the public health department (42 CFR
431.12(d)). In addition, federal rules require states to
make nancial arrangements, if necessary, to support
the participation of beneciaries in MCACs and provide
states exibility in determining such arrangements
(42 CFR 431.12(f)). Federal funding is available at
50 percent to cover committee expenditures (42 CFR
431.12(g)). The main purpose of MCACs is to provide
a bidirectional feedback loop between the state
Medicaid agency and the individuals who provide, pay
for, or use Medicaid services (Davidson et al. 1984).
Proposed rule
CMS released a notice of proposed rulemaking
(NPRM) in May 2023 to increase the two-way
communication between state Medicaid agencies
and stakeholders and to promote transparency
and accountability by state Medicaid agencies to
committee members.
4
CMS’s intent is to make MCAC
requirements more robust to ensure all states are
using these committees optimally by informing the
program with the experiences of beneciaries, their
caretakers, and other stakeholders (CMS 2023).
The NPRM would add specicity to the rules for MCAC
structure and operations to create more meaningful
engagement opportunities for Medicaid beneciaries.
The proposed rule, if nalized, would rename
MCACs to Medicaid Advisory Committees (MACs)
and expand the scope of topics to be addressed by
MACs.
5
The state has discretion to identify topics
the MAC will address, such as services that address
health-related social needs, coordination of care,
beneciary communications from the Medicaid agency,
grievances, consumer experience survey ratings, or
design of a new program.
The proposed rule, if nalized, would also require
that state Medicaid agencies establish a Beneciary
Advisory Group (BAG), that would meet separately
from the MAC, with crossover membership with the
MAC. Specically, BAG members would constitute at
least 25 percent of the MAC membership. The BAG
would include Medicaid beneciaries, their family
members, and their caregivers. Other members of the
Chapter 1: Engaging Beneciaries through MCACs to Inform Medicaid Policymaking
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Report to Congress on Medicaid and CHIP
MAC would include representatives from consumer
groups, clinical providers or administrators, Medicaid
managed care plans, and other state agencies. The
NPRM proposes minimum requirements for making
information on the MAC and BAG activities publicly
available. Specically, states must post MAC and
BAG membership lists, meeting schedules, meeting
minutes, bylaws, recruitment processes, and an
annual report on MAC activities and how the state
used MAC and BAG feedback on its website. If
the rule is nalized, states would have one year to
implement these requirements (CMS 2023). CMS
has indicated that it will issue a nal rule and future
guidance on meaningful beneciary engagement and
transparency, but it is unclear when this would occur.
State Implementation
of MCACs
Though federal regulations require beneciary
representation on MCACs, little research has explored
MCAC implementation, outcomes, and state strategies
for beneciary engagement on MCACs, particularly
with those from historically marginalized communities.
One study found that MCAC beneciary engagement
varies state by state; states appreciated beneciary
input in regard to identication and overcoming
implementation challenges for agency programs and
faced barriers when it came to authentic and sustained
engagement (Zhu et al. 2021).
Our analysis also found that substantial variation exists
in how states have implemented MCACs with respect
to beneciary and consumer group membership
requirements and meeting participation requirements.
In implementing MCACs, states experience many of
the challenges with engaging beneciaries described
in community engagement research. This section
highlights state approaches for MCAC beneciary
representation and recruitment, nancial arrangements
to encourage beneciary participation, and beneciary
engagement, drawn from our policy scan and
stakeholder interviews.
Beneciary representation and
recruitment
State rules for beneciary representation on MCACs
and approaches to recruiting beneciaries vary. CMS
defers to states on how to structure their MCAC
composition and recruit beneciaries onto their MCAC.
Given this exibility, our analysis found that each
state’s MCAC composition is dierent.
Beneciary and consumer group membership.
In our review of publicly available information for 44
state MCACs and the District of Columbia, 38 states
explicitly describe requirements for beneciary or
consumer group representation in their state policy
documents. Publicly available information related to
MCAC membership requirements in the remaining
states was not found. Of the states that had these
requirements publicly available, there was variation
in committee composition and specic requirements
for representation.
6
Only 14 states explicitly require
beneciary representation (i.e., Medicaid recipients,
their family members, or caregivers of Medicaid
recipients) in the MCAC, and
13 of these 14 states
also require consumer group representation.
7
Twenty-three states and the District of Columbia
require representation from either consumer group
members or beneciaries.
8
Some states do not
specify the number of beneciary members, while
Utah and Nebraska specify that at least 51 percent of
MCAC members should be beneciaries, beneciary
representatives, or consumer groups.
Interviewees noted that beneciary members of
MCACs may feel uncomfortable participating during
meetings if they make up a small proportion of the
membership relative to other types of members. In
addition to consumer groups and beneciaries, MCAC
membership can include state Medicaid ocials,
ocials from other state government agencies, health
care providers, and hospital and plan representatives.
State ocials from two states noted that they
had reconstituted their MCACs so that committee
membership is weighted more equally between
Medicaid beneciaries and consumer group members
relative to providers and plan representatives.
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States are not federally required to have beneciary
representation from historically marginalized
communities on their MCACs, but some have
adopted fairly narrow, state-specic requirements.
For example, Connecticut, Oregon, and Wisconsin
require representation of persons with disabilities.
Connecticut and Wisconsin also require
representation of dually eligible beneciaries or older
adults. Minnesota requires tribal representation on
its MCAC. No state requires specic beneciary
representation by race or gender. A few states
have requirements for consumer group member
representation. For example, Idaho requires
representation from legal aid providers and clergy.
Kentucky requires consumer group representation
of persons reentering society after incarceration,
children and youth, women, and minorities.
Diverse representation of beneciaries can provide
state Medicaid agencies with access to a broad range
of perspectives on how the Medicaid program is
meeting their needs and challenges with the program.
As previously mentioned, meaningful engagement can
help the state Medicaid agency establish trust with
these communities and advance state health equity
eorts by providing opportunities for beneciaries
and other MCAC members to codevelop solutions
to beneciaries’ challenges. It is also a way for state
Medicaid agencies to demonstrate commitment to the
individuals being served, and it increases program
accountability (Allen et al. 2021).
The NPRM retains current rules about beneciary
representation and does not add requirements around
diverse representation. Instead, CMS encourages
states to consider diverse representation as part of
their member selection of Medicaid beneciaries.
The proposed rule encourages states to consider
geographical diversity, tribal communities, people
older than age 65, or people with disabilities.
These considerations for states are consistent with
CMS’s strategic plan for advancing health equity for
underserved populations (CMS 2023).
9
Beneciary member recruitment. State Medicaid
agencies use dierent strategies to recruit
beneciaries. States advertised openings for
beneciary representation on the MCAC through
announcements on their state Medicaid websites.
The policy scan found that 12 states published
information on their MCAC website to actively
recruit MCAC members. Our interview ndings
suggest that publishing information on the MCAC
website alone is insucient to recruit beneciary
members. Beneciaries conrmed they did not learn
about MCAC position openings through such a
public posting. States may partner with community-
based organizations to identify individuals or recruit
beneciaries directly from town halls and other public
meeting forums. Another common approach is to
recruit beneciaries who serve on other state advisory
committees or managed care organization beneciary
committees. Alaska, Maryland, and Utah require state
Medicaid ocials to contact consumer, provider, or
community organizations for recommended beneciary
members. In Virginia, the state Medicaid agency
works with community-based stakeholders to identify
potential committee members and also sends letters to
randomly selected Medicaid enrollees with information
on how to apply to the committee.
States often recruit consumer group members to
represent Medicaid beneciary perspectives and to
speak to issues beneciaries experience. This strategy
can be benecial because consumer group members
may be easier to recruit than beneciaries, can
represent a broader community perspective, may have
more familiarity with technical Medicaid topics, and
may face fewer barriers to participation. For example,
one state Medicaid ocial stated that they rely
heavily on consumer groups to gain beneciary input.
However, one consumer group member shared that
although consumer group representation is important,
these advocates do not necessarily provide the same
perspectives as beneciaries who have more intimate
experience with the program.
The policy scan and interviews revealed little
information about how MCACs recruit from historically
marginalized communities. Most of the interviewed
beneciaries and consumer group representatives
were unaware of MCAC eorts to recruit beneciaries
from historically marginalized communities. In Utah,
the MCAC bylaws state that the MCAC should ensure
that individuals from underrepresented groups,
communities, or identities are aware of opportunities to
participate on the MCAC.
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Report to Congress on Medicaid and CHIP
Beneciary recruitment challenges. State Medicaid
agencies note diculties in nding beneciaries willing
to participate in MCACs, which can lead to beneciary
vacancies. The analysis of publicly available
membership lists found that the majority of states had
beneciary vacancies. Only 11 states had beneciaries
listed as part of their MCACs. One state ocial noted
that because of challenges related to nding new
beneciary members, the same beneciary has been a
member of the MCAC for nearly two decades.
Our research shows that state educational eorts
regarding MCACs is limited. Thus, beneciaries may
be unaware that their state has an advisory group
that seeks their participation and input, the purpose
of the MCAC, or how to apply. By increasing outreach
and education about the MCAC and beneciary
opportunities to participate, states may be able
to increase the number of beneciaries choosing
to participate.
State ocials noted their intent and eorts to increase
the number of beneciaries on the MCACs but that
doing so was dicult. Although our ndings suggest
that using other Medicaid-related committees to recruit
members is a helpful tactic in nding beneciaries,
Medicaid ocials also commented that this strategy
can create challenges when multiple agencies and
committees seek the same beneciaries’ input. Most
state ocials acknowledge that Medicaid beneciaries,
such as those who work during traditional business
hours or those who are parents, have responsibilities
that aect their ability to participate in MCAC meetings.
Recruiting individuals from marginalized communities
requires additional eort, so some states have focused
on community-based approaches to implement this
tailored approach. A Nebraska state ocial reported
that MCAC community listening sessions held
in dierent locations around the state have been
an eective tool for recruiting diverse beneciary
members. An Oregon Medicaid ocial described
sharing recruitment information in Spanish and
has oered to translate these materials into other
languages to attract beneciaries who do not speak
English as their rst language. Most Medicaid ocials
described a word-of-mouth approach in collaboration
with beneciary members from diverse communities
whose terms were ending soon. Other states noted
challenges with recruiting beneciaries in general
and were not yet focused on targeted recruitment of
beneciaries from historically marginalized groups.
There has been no federal guidance or technical
assistance on how to recruit and retain members from
historically marginalized groups.
The NPRM proposes that states develop their
recruitment and appointment processes for both MAC
and BAG member recruitment and appointment and
publish the processes on their state websites. This
information would need to be easily accessible to the
public. CMS indicates that guidance about recruitment
strategies is forthcoming.
State use of nancial arrangements for
beneciaries
States have adopted strategies that address logistical
barriers that limit beneciary participation in MCACs.
Examples of logistical barriers include the inability
to take time o work and the availability and cost of
transportation and childcare. Some state Medicaid
agencies are beginning to host more virtual MCAC
meetings to eliminate transportation barriers (Coburn
et al. 2021). Other strategies to increase participation
include hosting MCAC meetings outside of traditional
work hours, providing food during meetings, or
providing transportation to and from meetings (Allen
et al. 2021).
Most states oer at least one type of nancial
arrangement to facilitate beneciary participation on
MCACs, but either most beneciaries are unaware
of these supports or the supports are underused.
The nancial support can be reimbursements for
unspecied incurred expenses, per diems, or can
be provided on a case-by-case basis determined by
the state Medicaid agency. Among the states with
published policies, travel supports was the most
common. Twenty-two states oer travel expense
reimbursement. All six states interviewed reimburse
for beneciary MCAC members’ travel costs (which
may include reimbursement of transportation and hotel
expenses) to attend in-person meetings. Despite these
nancial arrangements for travel, some beneciaries
and consumer group members noted that individuals
may experience challenges that are not addressed by
available supports. For example, some beneciaries
may not be able to attend in-person meetings because
they do not have a car or have limited access to
alternative transportation options.
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Few states oer other types of nancial arrangements
to support beneciary MCAC participation. Three
states oer childcare or dependent care expense
reimbursement. Four states oer reimbursement for
personal assistance. Vermont is unique in that it limits
its per diem, reimbursement for travel and childcare
expenses, and personal assistance services to MCAC
members whose income does not exceed 300 percent
of the federal poverty level.
Beneciaries often cite the lack of compensation
and lost income from having to take time o work as
barriers to participation in MCAC meetings (Zhu and
Rowland 2020). Community engagement researchers
note that other experts are often compensated for
providing their expertise and posit that beneciaries,
who are experts in their lived experience, should
be treated similarly. Adequately compensating
beneciaries for their time and expertise demonstrates
that the state Medicaid agency values their input
(Roman et al. 2023, Allen et al. 2021).
Challenges in using nancial arrangements. Of
states providing nancial arrangements, 19 states oer
nancial compensation; however, little information is
provided on their availability or how to access them.
Seven states provide nancial arrangements “if
needed,” and ve oer reimbursements for “necessary
expenses,” but no further information was provided
in publicly available documentation. Oregon passed
legislation in 2022 that oers certain MCAC members
$166 per day for when they are performing MCAC-
related duties, such as preparing for and attending
meetings (ORS § 292.495).
10
Some beneciary interviewees expressed that they do
not use nancial arrangements because they fear it
may aect either their Medicaid eligibility or status with
other entitlement programs.
11
During the interviews,
state Medicaid ocials asked for more clarication
from CMS about the appropriate nancial support for
beneciaries that does not aect their eligibility. States
also sought more information about the appropriate
forms of reimbursement, such as gift cards or checks.
CMS has not indicated publicly whether it will issue
further guidance about how states can oer nancial
support without aecting beneciaries’ eligibility.
Eorts to support beneciary
engagement in MCAC discussions
Some states provide supports to better engage
beneciaries during MCAC meetings, but most
consumer group members and beneciaries identied
this as an area for improvement. Some interviewees
identied examples of helpful supports that state
ocials may provide, such as sharing information with
committee members in advance of MCAC meetings,
providing background information for agenda items,
working with beneciaries to cocreate the meeting
agenda, and hosting premeeting question-and-
answer sessions to help increase beneciaries’
understanding of complex policy topics. Maryland
provides sta assistance specically for beneciaries
to review meeting materials. Some states also provide
interpretation services to enable participation by
beneciaries with limited English prociency.
States may also use subcommittees as a strategy
to obtain input in specic areas that are important
to beneciaries. Twenty-three states use topic-
based MCAC subcommittees or beneciary-only
subcommittees as ways to solicit beneciary input
on specic topics. Common subcommittees include,
for example, special health populations, long-term
services and supports, consumer-focused groups, or
managed care.
State resource challenges limit additional
engagement eorts. Meaningful engagement eorts
to strengthen the relationship between the Medicaid
agency and beneciaries is time and labor intensive,
and states face diculty balancing this investment
with other priorities. State ocials agreed on the
need to improve beneciary engagement practices
but acknowledged sta capacity as a key limitation
to such eorts. State Medicaid ocials suggested
providing additional federal funding to states for
the time and work state Medicaid agencies put in
to organize and run MCAC meetings. State ocials
indicated such funding could help support state eorts
to engage beneciaries in meeting proceedings, such
as preparing beneciaries for each meeting. Under
current and proposed federal MCAC rules, federal
match for Medicaid administrative activities is available
for expenditures related to MCAC and, in the future,
MAC and BAG activities.
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Beneciary Experience
Participating in MCACs
Beneciaries participating in MCACs generally
described their experience as a positive collaboration
between the state Medicaid agency and MCAC
members. Beneciaries agreed that beneciary voice
on MCACs was important because it is an opportunity
for policymakers to learn from the beneciaries’ lived
experiences to inform current and future policies
and improve program administration. At the same
time, beneciaries identied several challenges that
hindered their ability to participate in MCACs. These
include the application and appointment process,
participation requirements, and engagement in
discussions.
Application and appointment
processes
In some states, the MCAC application and
appointment processes, which are designed and
implemented by states, can hinder new beneciary
participation. Some beneciaries described the
application to join their state’s MCAC as long,
complex, overly formal, and similar to a job application.
Current federal regulations require appointments to
an MCAC be made by either a state Medicaid director
or higher state authority but does not prescribe the
application process.
Challenges with completing the application.
Some state ocials noted that overly complicated
MCAC applications could deter potential beneciary
members, especially those with lower educational
attainment and less experience with formal job
applications. For example, in one state, MCAC
applicants must create a prole on an online job
application platform. The application requires a
resume, short personal biography, and background
check. Applicants must disclose potentially sensitive
information, such as past bankruptcy lings or criminal
charges. Although sharing this information does not
automatically disqualify applicants, these questions
may dissuade potential applicants. In contrast, the
Nebraska MCAC application is simpler and asks
applicants two open-ended questions: their aliation
with the Nebraska Medicaid program and the reason
for wanting to serve on this committee. One strategy
used by state Medicaid ocials is to assist potential
new members with the MCAC application. This help
includes previewing the application questions with
potential applicants, translating the application into
Spanish, and oering assistance in completing and
submitting the MCAC application.
Challenges with appointment process. Some states
require MCAC members be nominated and appointed
by the governor. Interviewees from these states noted
that this process is tedious because it requires several
rounds of vetting candidates. Others noted that some
beneciaries may assume that they will not receive
governor approval due to personal reasons (e.g.,
having a dierent political aliation than the governor
or a prior legal record). One consumer group member
who tried to recruit more beneciaries noted that
beneciaries who were previously incarcerated were
hesitant to apply, thinking they would be disqualied,
which is untrue.
MCAC participation requirements
MCAC requirements for member term length vary
by state, with three years as the most common
term length. Current federal rules require that after
committee members complete their terms, the state
will appoint a new member to ensure that membership
rotates continuously. State ocials indicated that it can
be dicult to nd beneciaries willing to participate
in a multiyear commitment. Interviewees also noted
that one benet of longer terms is gaining a deeper
knowledge of the state’s Medicaid program, but they
acknowledged that the downside could be a lack of
new voices on the MCAC, particularly from potentially
diverse populations.
MCAC meeting frequency ranges from monthly to
annually, though most MCACs meet quarterly. Our
review found that in 44 states and the District of
Columbia, MCACs have met at least once in the past
two years. In addition to scheduled meetings, 18
states allow the MCAC chair, governor, state Medicaid
director, or other members to schedule additional
meetings as needed. Interviewees noted that
increasing the frequency of meetings can strengthen
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the connections between the state Medicaid agency
and the MCAC members as well as provide beneciary
members greater opportunity to provide regular
feedback. State ocials mentioned that the transition
to virtual or hybrid meetings, due to the COVID-19
pandemic, had a positive eect. Hybrid meetings had
greater attendance than in-person-only meetings
because they were more accessible for participants.
However, some consumer group members described
a lack of closeness with their peers when joining
meetings only virtually.
Challenges with attending meetings. The time
commitments and inconvenient meeting times can
be barriers to beneciary engagement. Across
all interviewee types, most stakeholders agreed
that time commitments for traveling and attending
MCAC meetings can be a barrier to participation.
Beneciaries may have jobs, childcare responsibilities,
or other obligations that may preclude them from
joining meetings during the business day. The
beneciary experience stands in contrast to that
of consumer group and other members (e.g., state
agency ocials, health plan representatives) who
attend these meetings as part of their jobs. Some
states move their MCAC meeting locations around
the state, such as hosting some meetings on tribal
reservations, in rural parts of the state, or in public
locations such as libraries and schools, to make them
accessible for diverse populations.
Engagement in MCAC discussion
Beneciaries and other individuals, such as some
consumer group members, who do not have a
background in health policy may feel hesitant about
participating in MCAC meetings due to the complexity
and specialization of the topics. States require MCACs
to discuss and provide input on a wide variety of policy
topics, including program administration, covered
services, quality of care, access to care, managed
care, quality assurance strategies, eligibility, and
enrollment. Beneciaries tend to feel more qualied
to participate in MCAC discussions on topics that
directly apply to their lived experience (e.g., provider
networks, covered services, and enrollment) than
with other Medicaid technical topics, such as provider
payments or managed care contracting. When the
latter topics are discussed, interviewees noted that
beneciaries may be less likely to speak up as they
have not had experience with these issues. Given the
range of topics within the purview of MCACs, it may be
unrealistic to expect that beneciary members will be
able to contribute equally to them all.
Most beneciaries interviewed reported that they
received little to no orientation, training, resources, or
supports to familiarize them with the MCAC or provide
background information on policy topics discussed.
To clarify areas in which beneciary feedback is
most needed, three states dene specic areas for
beneciaries’ input, such as beneciary use of services
and gaps in service, design of outreach programs, and
dissemination of accessible information.
Some beneciaries noted that they did not always
receive timely responses to questions or follow-
through on requested information on MCAC matters.
Beneciaries stated that they have to be persistent
with the Medicaid ocials to have these questions
addressed and noted that not all beneciaries feel
comfortable doing this.
Uncertainty around the use of beneciary input.
Beneciaries and consumer group members across all
six study states indicated that they had experienced
the Medicaid agency sta listening to their input
on Medicaid policy and program topics, but some
were uncertain whether their feedback led to real
change. Beneciaries indicated that they would like
information from their state Medicaid programs about
how their feedback leads to program improvements to
demonstrate that their participation is not a pro forma
activity by the state. For example, one beneciary
noted that they do not always feel like their voice has
equal power compared to that of other state ocials
or participating providers. Another beneciary noted
that it is unclear how much authority the MCAC has to
eect change and wondered if the Medicaid agency is
obligated to act on their recommendations. The state’s
MCAC bylaws do not address this. Other beneciary
and consumer group members commented that
oftentimes, MCAC meetings are solely updates from
the state with little opportunity to provide input and
collaboration early in the policymaking process.
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Report to Congress on Medicaid and CHIP
Beneciary-only subcommittees
Some state MCACs convene beneciary-only
subcommittees without the presence of other
stakeholders. Beneciaries and consumer
group members described feeling intimidated or
discouraged from participating if certain MCAC
members, such as government ocials, providers,
or plan representatives, dominated the discussion.
Additionally, consumer group representatives
cautioned how overrepresentation of certain MCAC
members in meetings compared to beneciaries
can lead to an unbalanced power dynamic and
limit beneciary participation. Beneciary-only
subcommittees can help provide a less intimidating
meeting environment that is more conducive to
beneciary participation. One consumer group
member stated that their state’s beneciary-only
group has more representation from marginalized
populations and that there is more robust participation
by beneciaries than in other state advisory groups.
The NPRM would mandate each state establish a
BAG consisting of beneciaries, family members of
beneciaries, or caretakers.
Subcommittee challenges. Although beneciary-
only subcommittees may provide a less daunting
environment for some members, the subcommittees
may experience challenges to beneciary engagement
similar to those of MCACs generally unless steps are
taken to address them. For example, beneciaries
may still feel unprepared to discuss certain topics
without advanced briengs or preparation support.
Depending on how the beneciary-only subcommittee
is structured, there may be an imbalanced ratio of
Medicaid sta to beneciaries, which may hamper
conversation. In addition, beneciary members may
experience challenges with the time commitment
associated with preparing for and attending meetings,
especially if the member is expected to participate
in both the subcommittee meetings and the MCAC
meetings. One consumer advocate who chairs a
beneciary-only subcommittee noted the importance
of ensuring that information and perspectives shared
during subcommittee meetings are considered in
MCAC and state Medicaid agency policy and program
deliberations and acted upon. The consumer advocate
noted that this has not always been the case.
Commission
Recommendations
MACPAC’s recommendations to improve beneciary
engagement on MCACs aim to address key
challenges that emerged during our examination of
state use of MCACs. The recommendations focus
on the need for more federal guidance and technical
assistance to states to address beneciary recruitment
challenges, eorts to strengthen the diversity of
representation of beneciary members, and eorts to
reduce the burden on beneciaries while participating
in MCACs. In conjunction with ongoing work at the
federal and state levels to address these challenges,
these recommendations may facilitate improvements
in beneciary recruitment and participation on MCACs.
Recommendation 1.1
In issuing guidance and in providing technical
assistance to states on engaging beneciaries in
Medical Care Advisory Committees (MCACs) under
Section 42 CFR 431.12, the Centers for Medicare &
Medicaid Services should address concerns raised by
states related to beneciary recruitment challenges,
strategies to facilitate meaningful beneciary
engagement in Medicaid MCAC meetings, and clarify
how states can provide nancial arrangements to
facilitate beneciary participation.
Rationale
The states in our study described specic topics for
which they need guidance and technical assistance
from CMS to leverage the expertise and experience
of beneciary MCAC members in their program
policies and operations. CMS has indicated plans to
issue guidance on beneciary recruitment and model
practices for facilitating beneciary participation in
MACs and BAGs following the issuance of nal rules.
In issuing such guidance, CMS should ensure that it
addresses the topics identied by states.
Our work highlights a number of such areas, including
approaches for recruitment and retention of beneciary
members from historically marginalized groups. States
experience recruitment and retention challenges for
MCAC members in general, and many appear to have
relatively little experience conducting outreach and
Chapter 1: Engaging Beneciaries through MCACs to Inform Medicaid Policymaking
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March 2024
describing the need and opportunities for beneciary
participants in MCACs to certain historically
marginalized communities. CMS is also well positioned
to help state-to-state learning on approaches to elicit
beneciary participation during MCAC meetings.
Beneciaries indicated that it can be challenging to
fully engage in MCAC discussions on certain topics,
and states have noted a need for information on how
to assist beneciaries. For example, some states have
adopted strategies, such as providing an orientation
for new beneciary MCAC members, facilitating
premeeting briengs, collaborating on the agenda
setting, and creating bidirectional feedback loops, to
help beneciaries prepare for MCACs, which may be
useful for other states. In addition, there may be other
areas in which guidance and technical assistance
could be useful to states, such as approaches for
demonstrating the ways beneciary input has aected
program policy.
In addition, states seek clarication on the rules for
providing nancial arrangements to help beneciaries
participating in MCACs, including, specically, how to
oer nancial support without aecting beneciaries’
eligibility. State Medicaid ocials indicated a need
for clarication from CMS on permissible forms
and amounts of nancial arrangements to facilitate
beneciary participation.
At the time of publication of this report, it is unclear
when the rule will be nalized or when CMS guidance
on MCACs will be issued. In addition to changing
the structure of MCACs, the proposed rule includes
many other changes to Medicaid, which we expect
will also necessitate federal guidance and technical
assistance. Given the importance of beneciary
MCAC participation in lifting up the experience of
beneciaries, the Commission urges CMS to issue
guidance as described above as expeditiously
as possible. It is the Commission’s view that the
challenges states and beneciaries experience
with MCAC participation and engagement under
current rules are likely to persist under the proposed
restructured MACs and BAGs, if nalized. Thus, timely
issuance of guidance on the topics described in this
chapter is needed.
Implications
Federal spending. The Congressional Budget Oce
estimates this recommendation would not have a
direct eect on federal Medicaid and CHIP spending.
CMS would have to dedicate resources to develop the
guidance and provide technical assistance to states
as it indicated it would. This guidance and technical
assistance will provide further clarity to the federal
requirements.
States. Federal guidance could assist states with
their eorts to engage beneciaries on MCACs in
a way that promotes their voice and contributes
to policymaking decisions. States may be able to
strengthen beneciary participation and engagement
in MCACs and benet from the beneciary feedback
about issues related to the Medicaid program and the
services it covers. This bidirectional feedback loop
ensures that the program operates eciently and as it
was designed to operate.
Enrollees. When states increase meaningful
engagement, beneciaries may have a more positive
experience, and they may be able to make greater
contributions to the MCAC discussions. This would
provide them the opportunity to have an input on
policymaking.
Plans and providers. There would be no direct eect
on plans and providers.
Recommendation 1.2
In implementing requirements in 42 CFR 431.12(d)
(2) that Medicaid Medical Care Advisory Committee
(MCAC) membership include beneciaries, state
Medicaid agencies should include provisions in
their MCAC bylaws that address diverse beneciary
recruitment and develop specic plans for
implementing policies to recruit beneciary members
from across their Medicaid population, including those
from historically marginalized communities.
Chapter 1: Engaging Beneciaries through MCACs to Inform Medicaid Policymaking
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Report to Congress on Medicaid and CHIP
Rationale
States serve a diverse array of Medicaid beneciaries,
including those who are too often marginalized
due to factors such as their race and ethnicity, age,
disability, sex, gender identity, sexual orientation,
and geography. The current federal regulations
require state Medicaid agencies to include Medicaid
beneciaries but do not speak to their diversity. This
recommendation directs states to include a diverse
range of voices reective of their Medicaid population
as part of operationalizing this existing requirement.
Some states will need to revise their bylaws and other
policy documents to implement this recommendation.
If the BAG is included in the nal rule, states should
also include diverse representation within this group.
Engaging beneciaries from historically marginalized
backgrounds allows them to share their unique
experiences and concerns. It is the Commission’s
view that there should be diverse representation of
Medicaid beneciaries participating in policymaking
decisions, including beneciaries of color and
individuals with disabilities, who can share their
experiences with Medicaid (MACPAC 2022b).
Intentional and continuous eort is required to engage
people who have historically been excluded from
the decision making process related to the design,
implementation, and operationalization of Medicaid
policies and programs.
Implications
Federal spending. The Congressional Budget Oce
estimates this recommendation would not have a
direct eect on federal Medicaid and CHIP spending.
States. States will have to invest resources to develop
strategies and policies for recruiting beneciaries from
communities that are marginalized due to factors such
as their race and ethnicity, age, disability, sex, gender
identity, sexual orientation, and geography. States may
face resource constraints given other programmatic
needs.
Enrollees. Under this recommendation, beneciaries
from historically marginalized communities may
increase participation in MCACs, providing them an
avenue to share their perspectives and experiences to
help improve program policy and administration.
Plans and providers. There would be no direct eect
on plans and providers. State Medicaid agencies may
work with plans and providers to recruit beneciaries
from diverse communities to participate in MCACs.
Recommendation 1.3
In implementing requirements in 42 CFR 431.12(e)
to increase the participation of beneciary members
in Medicaid Medical Care Advisory Committees
(MCACs), state Medicaid agencies should develop and
implement a plan to facilitate meaningful beneciary
engagement and to reduce the burden on beneciaries
in engaging in MCACs by streamlining application
requirements and processes, and by addressing
logistical, technological, nancial, and content barriers.
Rationale
Beneciaries have noted challenges that can prevent
their participation in MCACs. One such diculty in
some states is a burdensome application process.
Application processes involving long applications or
applications asking sensitive questions about issues
that are unlikely to aect beneciaries’ ability to
provide input and their perspective on the Medicaid
program may dissuade individuals from participating.
Complex applications also can hinder some
beneciaries from applying if they nd the application
overwhelming. In addition, application processes
that require a nomination or referral from high-level
state government leaders may in eect disqualify
beneciaries willing to participate. Eliminating such
requirements and streamlining the application could
make MCACs more accessible to and reduce the
burden on the individuals willing to serve on MCACs.
Addressing logistical and other barriers may also
make it more feasible for beneciaries to participate
in MCACs. Logistical barriers that hamper beneciary
participation include inconvenient meeting times,
particularly for those Medicaid beneciaries working
in jobs from which it can be hard to get time o or in
which taking time o results in lost income. Certain
Chapter 1: Engaging Beneciaries through MCACs to Inform Medicaid Policymaking
16
March 2024
meeting locations may be inconvenient, particularly for
beneciaries residing in rural regions or for those without
reliable transportation. Other beneciaries can face
nancial barriers, such as the cost of childcare or public
transportation, gas, or parking associated with attending
meetings. Greater state use of nancial arrangements
under 42 CFR 431.12(f) could help address some of
these nancial barriers.
Addressing the content barriers that beneciaries
experience would also assist their engagement during
MCAC meetings. Medicaid beneciaries are experts in
their own experience but are not necessarily Medicaid
policy or health services experts and can experience
diculty contributing to MCAC discussions. States
should take steps to help beneciaries prepare for
MCAC meetings, particularly if topics are technical in
nature, to ensure that beneciary points of view are
considered in those areas.
Implications
Federal spending. The Congressional Budget Oce
estimates this recommendation would not have a direct
eect on federal Medicaid and CHIP spending.
States. States would need to dedicate resources to
assessing current barriers to beneciary participation and
developing a plan for addressing them. States may face
resource constraints given other programmatic needs.
Enrollees. Streamlining the MCAC application process
and addressing logistical, nancial, and content-related
concerns for beneciaries would reduce key barriers
to their participation. By doing so, the willingness of
beneciaries to participate in MCACs could increase.
Plans and providers. There would be no direct eect on
plans and providers.
Endnotes
1
RTI conducted the policy scan in the fall of 2022. RTI was
unable to nd publicly available MCAC documentation for
four states: Arkansas, Missouri, Tennessee, and Wyoming.
RTI was unable to conrm an active committee (one that has
met within the past two years) for California and New York. In
the spring of 2023, California launched a Medicaid member
advisory committee (DHCS 2023).
2
Interviewees included state Medicaid ocials,
beneciaries, and consumer group representatives
from Kentucky, Maryland, Nebraska, North Carolina,
Oregon, and Virginia. The state Medicaid ocials
identied beneciary members and consumer group
representatives on the MCACs for the interview process.
3
Marginalized communities consist of groups that
are excluded from involvement in decision making
processes or policies due to factors such as to race,
gender identity, sexual orientation, age, physical ability,
language, geography, or socioeconomic status (Pratt
and Fowler 2022).
4
In addition to promoting beneciary engagement, the
proposed rule also includes a number of provisions
designed to meet the statutory obligations to ensure
that Medicaid provides access to services, such as
increasing payment rate transparency and standardizing
reporting (CMS 2023).
5
For this chapter, MACPAC sta will continue to use the
term “MCAC” unless discussing the proposed rule.
6
The total membership requirement ranges from 9
members to 48 members, while most MCACs require
between 15 and 20 members.
7
The 14 states that explicitly require beneciary
member representation are Alabama, Connecticut,
Florida, Kentucky, Maine, Maryland, Minnesota,
Mississippi, New Hampshire, North Carolina, Oregon,
Pennsylvania, Vermont, and Wisconsin. Mississippi is
the only state from this list that does not also explicitly
require consumer group representation.
8
The 23 states are Alaska, Arizona, Delaware, Georgia,
Hawaii, Idaho, Illinois, Indiana, Iowa, Louisiana,
Massachusetts, Michigan, Montana, Nebraska, Nevada,
North Dakota, Ohio, Oklahoma, South Dakota, Texas,
Utah, Washington, and Wyoming.
9
In 2021, CMS announced a strategic plan to apply
a health equity lens across all its programs to achieve
equitable outcomes through high-quality, aordable,
person-centered care (Brooks-LaSure and Tsai 2021).
10
Any member of a state board or commission, including
those on MCACs, who earns less than $50,000 per year
qualies for this per diem (ORS § 292.495). The amount
is tied to the legislative per diem.
Chapter 1: Engaging Beneciaries through MCACs to Inform Medicaid Policymaking
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11
According to the Internal Revenue Service, for any
additional compensation received that is at least $600 during
one calendar year, a 1099 tax form must be completed, and
the amount must be reported for tax purposes (IRS 2023).
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Medicaid and CHIP Payment and Access Commission
(MACPAC). 2022a. Chapter 6: Medicaid’s role in advancing
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(MACPAC). 2022b. Panel discussion: Beneciary
engagement and elevating consumer voices in Medicaid
policymaking. Presentation before MACPAC, January
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Chapter 1: Engaging Beneciaries through MCACs to Inform Medicaid Policymaking
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Commission Vote on Recommendations
19
Report to Congress on Medicaid and CHIP
Commission Vote on Recommendations
In its authorizing language in the Social Security Act (42 USC 1396), Congress requires MACPAC to review
Medicaid and CHIP program policies and make recommendations related to those policies to Congress, the
Secretary of the U.S. Department of Health and Human Services, and the states in its reports to Congress, which
are due by March 15 and June 15 of each year. Each Commissioner must vote on each recommendation, and the
votes for each recommendation must be published in the reports. The recommendations included in this report,
and the corresponding voting record below, fulll this mandate.
Per the Commission’s policies regarding conicts of interest, the Commission’s conict of interest committee
convened prior to the vote to review and discuss whether any conicts existed relevant to the recommendations.
It determined that, under the particularly, directly, predictably, and signicantly standard that governs its
deliberations, no Commissioner has an interest that presents a potential or actual conict of interest.
The Commission voted on these recommendations on December 15, 2023.
_________________________________________________________________________________________
Engaging Beneciaries through Medical Care Advisory Committees to Inform
Medicaid Policymaking
1.1 In issuing guidance and in providing technical assistance to states on engaging beneciaries in Medical
Care Advisory Committees (MCACs) under Section 42 CFR 431.12, the Centers for Medicare & Medicaid
Services should address concerns raised by states related to beneciary recruitment challenges, strategies
to facilitate meaningful beneciary engagement in Medicaid MCAC meetings, and clarify how states can
provide nancial arrangements to facilitate beneciary participation.
1.2 In implementing requirements in 42 CFR 431.12(d)(2) that Medicaid Medical Care Advisory Committee
(MCAC) membership include beneciaries, state Medicaid agencies should include provisions in their MCAC
bylaws that address diverse beneciary recruitment and develop specic plans for implementing policies
to recruit beneciary members from across their Medicaid population, including those from historically
marginalized communities.
1.3 In implementing requirements in 42 CFR 431.12(e) to increase the participation of beneciary members
in Medicaid Medical Care Advisory Committees (MCACs), state Medicaid agencies should develop and
implement a plan to facilitate meaningful beneciary engagement and to reduce the burden on beneciaries
in engaging in MCACs by streamlining application requirements and processes, and by addressing logistical,
technological, nancial, and content barriers.
1.1-1.3 voting
results # Commissioner
Yes 17 Allen, Bella, Bjork, Brooks, Duncan, Gerstor, Giardino, Heaphy, Hill,
Ingram, Johnson, Killingsworth, McCarthy, McFadden, Medows, Snyder,
Weno
