Annual Survey of Medicaid Directors Finds States Continue to Adopt Policies to Respond to the Pandemic and Are Addressing Issues Related to Social Determinants of Health and Health Equity

More than 18 months into the COVID-19 pandemic, state Medicaid programs around the country continue to reshape policy in response to the public health emergency and at the same time advance broader initiatives and priorities, including efforts to address the social determinants of health and health equity, finds a new KFF survey.

The 21st annual KFF survey of Medicaid directors in states and the District of Columbia highlights policies in place and changes implemented or planned for the current fiscal year (which for most states runs from July to June). It also reviews state experiences with policies adopted in response to the COVID-19 pandemic. A companion survey report provides a look at state Medicaid directors’ spending and enrollment projections and expectations beginning the current fiscal year, including preparations for the eventual unwinding of the COVID-19 public health emergency (PHE) and the return to a new normal of operations.

The pandemic has profoundly affected Medicaid program spending, enrollment, and policy, challenging state Medicaid agencies, providers, and enrollees in a myriad of ways, the survey shows.

States report a variety of activities offered by Medicaid managed care plans aimed at promoting the take-up of COVID-19 vaccinations, for instance. These include member and provider incentives, member outreach and education, provider engagement, assistance with vaccination scheduling and transportation coordination, and partnerships with state and local organizations.

In state fiscal years (FY) 2021 and FY 2022 more states were implementing or planning provider rate increases compared to restrictions, and the majority of reporting states indicated that provider payment changes were related to COVID-19. The most common of these were rate increases for nursing facilities and providers of home and community-based services. While most states rely on capitated arrangements with managed care organizations to deliver Medicaid services to most Medicaid enrollees, fee for service rates remain important benchmarks for managed care payments in many states, often serving as the state-mandated payment floor.

Over half of responding states report that the pandemic prompted them to expand programs to address social determinants of health, especially related to housing. Also, three-quarters of responding states reported initiatives in place or planned to address racial and ethnic disparities in health, with many focusing on disparities in specific health outcomes including maternal and infant health, behavioral health, and COVID-19 outcomes and vaccination rates.

Policy-related survey findings appear across five sections of the report: delivery systems, benefits and telehealth, social determinants of health, provider rates and taxes, and pharmacy. Among the other key findings:

  • Twenty-two states reported new or enhanced benefits in FY 2021, and 29 states are adding or enhancing benefits in FY 2022. Many states are focused on expanding behavioral health services, care for pregnant and postpartum women, dental benefits, and housing-related supports. A large majority of states also cited the value of telehealth in maintaining or expanding access to care during the pandemic, particularly for behavioral health. Post-pandemic telehealth coverage and reimbursement policies are being evaluated in most states, with states weighing expanded access against quality concerns, especially for audio-only telehealth.
  • Most states that contract with managed care organizations (36 of 41 states) reported that 75 percent or more of their Medicaid beneficiaries were enrolled in MCOs as of July 1, 2021. Children and adults (particularly Medicaid expansion adults) are much more likely to be enrolled in Medicaid managed care than elderly individuals with disabilities.
  • Two-thirds of states that include Medicaid pharmacy benefits in managed care contracts reported prohibiting spread pricing in managed care organization subcontracts with their pharmacy benefit managers. This reflects a significant increase in state Medicaid agency oversight of these arrangements, in which a pharmacy benefit manager charges a Medicaid managed care organization more than it pays a pharmacy for a prescription drug and then pockets the difference.

In the companion report, KFF researchers analyze Medicaid enrollment and spending trends for state fiscal years 2021 and 2022.

The survey found that states expected Medicaid enrollment growth to slow to 4.5 percent in FY 2022 (down from 10.3% in FY 2021); total federal and state Medicaid spending to grow by 7.3 percent (down from 11.4% in FY 2021); and state Medicaid spending to grow by 14 percent (up from 4% in FY 2021).

The recent federal extension of the PHE to mid-January 2022 will likely reshape states’ projections and delay anticipated changes in enrollment and spending trends further into or beyond FY 2022. How long the PHE remains in place is pivotal, because enhanced federal Medicaid money is tied to it, as are the “maintenance of eligibility” requirements which have ensured continuous coverage for Medicaid enrollees. However, much uncertainty remains about the duration of the public health emergency and the progression of the pandemic.

When the short-term federal financial support related to the pandemic eventually ends, states are likely to face pressures to contain growth in state spending tied to enrollment, even as they work to overcome challenges with systems and staffing to ensure that eligible individuals remain covered by Medicaid or transition to other sources of coverage.

KFF researchers conducted the survey over the summer with analysts from Health Management Associates.

The full survey reports are:

For more data and analyses about Medicaid, visit kff.org

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