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MACPAC Shares Directed Payment Recommendations, Commitment to Health Equity

Julie Kozminski
June 20, 2022

In its June 2022 report to Congress, the Medicaid and CHIP Payment and Access Commission (MACPAC) provides recommendations for oversight of managed care directed payments and examines Medicaid’s role in advancing health equity.

MACPAC states the use of directed payments has grown substantially since 2016. Approved directed payment arrangements increased from 65 directed payments arrangements in 23 states in August 2018 to 230 distinct arrangements in 37 states by December 2020. Commissioners are concerned about the oversight and transparency of these payments given the limited information available about them.

MACPAC recommends:

  • publishing directed payment approval documents, managed care rate certifications, and evaluations for directed payments on Medicaid’s website;
  • making provider-level data on directed payment amounts publicly available in a standard format that enables analysis;
  • requiring states to quantify how directed payment amounts compare to prior supplemental payments and clarify whether these payments are necessary for health plans to meet network adequacy requirements and other existing access standards;
  • requiring states to develop rigorous, multiyear evaluation plans for directed payment arrangements that substantially increase provider payments above the rates described in the Medicaid state plan; and
  • ensuring the Department of Health and Human Services (HHS) clarifies roles and responsibilities for states, actuaries, and divisions of CMS involved in the review of directed payments and the review of managed care capitation rates.

In the report’s health equity chapter, MACPAC commits itself to examining how it can best contribute to combatting structural racism and addressing racial disparities. The commission reviews the racial and ethnic demographics of Medicaid beneficiaries and federal efforts to improve health equity.

MACPAC also outlines approaches states can take, including improved data collection; commitment of state leadership to the issue; and removing systemic barriers to coverage, delivery system levers, and a diverse workforce. MACPAC plans to incorporate other historically marginalized beneficiaries into future inequities analyses.

The report also includes chapters on monitoring access to care for Medicaid beneficiaries, access to vaccines, adoption of health information technology among behavioral health providers, and integrating care for beneficiaries dually eligible for Medicaid and Medicare.

Contact Director of Policy Rob Nelb, MPH, at or 202.585.0127 with questions.

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