The Medicaid and CHIP (Children’s Health Insurance Program) Payment and Access Commission (MACPAC) June 15 released its June 2019 Report to Congress on Medicaid and CHIP. The commission made recommendations on the treatment of third-party payments in the disproportionate share hospital (DSH) definition of Medicaid shortfall, as well as prescription drug coverage, among other topics.
MACPAC also recommends that Congress change the definition of Medicaid shortfall in the Social Security Act to exclude costs and payments for all Medicaid-eligible patients for whom Medicaid is not the primary payer. The recommendation addresses an issue caused by a court ruling that allowed hospitals to receive DSH payments for costs that were paid by other, non-Medicaid payers.
Currently, states are generally required under the Medicaid drug rebate program to cover participating manufacturers’ products once they have been approved by the Food and Drug Administration and enter the market. By contrast, Medicare Part D and exchange plans have up to 180 days after a new drug enters the market to make a coverage determination.
MACPAC recommends that Congress also amend the Social Security Act to allow states to exclude or otherwise restrict coverage of a covered outpatient drug for 180 days after a new drug or formulation enters the market. Additionally, the Medicaid drug rebate is currently capped at 100% of the drug’s average manufacturer price, but MACPAC recommends that Congress amend the Social Security Act to remove the cap on Medicaid drug rebates.