How the Pandemic Continues to Shape Medicaid Priorities: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2022 and 2023
Executive Summary
FMAP = Federal Medicaid Assistance Percentage.
State fiscal years begin on July 1 except for these states: New York on April 1; Texas on September 1; Alabama, Michigan, and District of Columbia on October 1.
Arkansas and Georgia did not respond to the 2022 survey. In some instances, we used publicly available data or prior years’ survey responses to obtain information for these states. However, unless otherwise noted, these states are not included in counts throughout the survey.
Introduction
Centers for Medicare & Medicaid Services (CMS), National Health Expenditure Data Fact Sheet: Table 4, National Health Expenditures by Source of Funds and Type of Expenditure: Calendar Years 2011-2018 (CMS, March 2020), https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.html.
States must provide continuous coverage to Medicaid enrollees until the end of the month in which the PHE ends to receive enhanced federal funding.
Arkansas and Georgia did not respond to the 2022 survey. In some instances, we used publicly available data or prior years’ survey responses to obtain information for these states. However, unless otherwise noted, these states are not included in counts throughout the survey. Among responding states, one state (Texas) did not participate in a follow-up telephone interview.
State fiscal years begin on July 1 except for these states: New York on April 1; Texas on September 1; Alabama, District of Columbia, and Michigan on October 1.
Delivery Systems
Center for Health Care Strategies, Medicaid Accountable Care Organizations: State Update, (Hamilton, NJ: Center for Health Care Strategies, February 2018), https://www.chcs.org/media/ACO-Fact-Sheet-02-27-2018-1.pdf
Michael Wilson et al., “The impacts of accountable care organizations on patient experience, health outcomes, and cost: a rapid review,” Journal of Health Services Research & Policy 25 no. 2 (April 2020): 130-138, https://journals.sagepub.com/doi/full/10.1177/1355819620913141
Office of the Assistant Secretary for Planning and Evaluation (ASPE), Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Evaluation of Outcomes of Selected Health Home Programs Annual Report - Year Five, (Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, May 2017), https://aspe.hhs.gov/basic-report/evaluation-medicaid-health-home-option-beneficiaries-chronic-conditions-evaluation-outcomes-selected-health-home-programs-annual-report-year-five
Office of the Assistant Secretary for Planning and Evaluation (ASPE), Report to Congress on the Medicaid Health Home State Plan Option, (Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, May 2018), https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-home-information-resource-center/downloads/medicaidhomehealthstateplanoptionrtc.pdf
Kevin Grumbach, Thomas Bodenheimer, and Paul Grundy, “The Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Cost from Recent Prospective Evaluation Studies, August 2009,” (Washington DC: Patient-Centered Primary Care Collaborative, August 2009), https://pcmh.ahrq.gov/sites/default/files/attachments/The%20Outcomes%20of%20Implementing%20
Patient-Centered%20Medical%20Home%20Interventions.pdfConnecticut does not have capitated managed care arrangements, but does carry out many managed care functions through ASO arrangements that include payment incentives based on performance, intensive care management, community workers, educators, and linkages with primary care practices.
Vermont runs a public, non-risk bearing prepaid health plan delivery model under its Section 1115 Global Commitment to Health waiver.
Idaho’s Medicaid-Medicare Coordinated Plan has been recategorized by CMS as an MCO but is not counted here as such since it is secondary to Medicare. Publicly available data used to verify status of two states that did not respond to the 2022 survey (Arkansas and Georgia).
Includes the Arizona Indian Medical Home Program, conducted under PCCM authority and in place since 2017, that was not counted in prior year reports as a PCCM program.
For purposes of this report, states contracting with “PCCM entities” are also counted as offering a PCCM program. In addition to furnishing basic PCCM services, PCCM entities also provide other services such as intensive case management, provider contracting or oversight, enrollee outreach, and/or performance measurement and quality improvement. 42 CFR §438.2.
Oklahoma Health Care Authority, “OHCA to Transition to New Health Care Model News Release,” May 26, 2022: https://oklahoma.gov/ohca/about/newsroom/2022/may/ohca-to-transition-to-new-health-care-model.html
A previously planned managed care transition was struck down, in June 2021, by the Oklahoma Supreme Court which ruled that the Oklahoma Health Care Authority did not have the authority to implement the program without legislative approval.
For purposes of this report, the following two states are not counted here as PCCM states: Connecticut uses PCCM authority to reimburse medical home-related costs and South Carolina uses PCCM authority to provide care management services to medically complex children.
Arkansas did not respond to the 2022 survey. Therefore, its dental services PHP status was confirmed via publicly available data.
Mississippi reported a total MCO penetration rate of 46.2% in the 2022 survey compared to 99.4% in the 2021 survey (and 76.3% in the 2020 survey), noting that to contain costs during the pandemic, MCO enrollees with no utilization were shifted to FFS unless they elected to stay enrolled with an MCO.
In order of Medicaid enrollment size, the 10 states are: California, New York, Texas, Florida, Pennsylvania, Illinois, Ohio, Michigan, Arizona, and Georgia.
Centers for Medicare and Medicaid Services (CMS), “Medicaid & CHIP Monthly Application, Eligibility Determinations, and Enrollment Reports,” last updated August 2022, https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/monthly-reports/index.html
For this section regarding MCO penetration rates, 2021 survey data were used for the two states that did not respond to the 2022 survey (Arkansas and Georgia) and for two states (North Carolina and Virginia) that did not provide complete data for the MCO penetration rate question. Also, data for Washington is based on our own calculations using July 2022 data reported on the Apple Health Client Eligibility dashboard.
NC Medicaid, “Fact Sheet: Standard Plan Overview, County Playbook: Medicaid Managed Care,” November 15, 2021, https://medicaid.ncdhhs.gov/media/10407/download?attachment
NC Medicaid, “Enrollment Overview Dashboard,” accessed October 12, 2022, https://medicaid.ncdhhs.gov/reports/dashboards#enroll
NC Medicaid, “Tailored Plan Information for Beneficiaries, Five Things You Need to Know About North Carolina’s Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plans,” https://medicaid.ncdhhs.gov/media/10862/download?attachment
In FY 2022, California will transition several non-dual-eligible populations into mandatory managed care, including individuals in the following aid categories: Trafficking and Crime Victims Assistance Program; accelerated enrollment; Child Health and Disability Prevention infant deeming; Pregnancy-related Medi-Cal (Pregnant Women only, 138–213 percent of the federal poverty level (FPL)), beneficiaries with other health coverage and those residing in certain formerly excluded rural zip codes.
California Department of Health Care Services, “Section 1915(b) Waiver Proposal for California Advancing and Innovating Medi-Cal (CalAIM),” updated December 16, 2021 with technical corrections incorporated January 2022, https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-17-apprvd-app.pdf
Dual-eligible beneficiaries in the seven Coordinated Care Initiative (CCI) counties (Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, Santa Clara) participating in California’s Financial Alignment Demonstration and the County Organized Health System counties are already required to enroll in managed care.
New York Department of Health, “Transition of Children placed in Foster care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care Effective July 1, 2021,” July 2021 presentation, https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/
foster_care_transition_overview_7_30_21.pdfMissouri Department of Social Services, “News Release: DSS announces new Specialty Health Plan, awards contract to Home State Health,” June 2, 2022, https://dss.mo.gov/press/06-02-2022-new-specialty-health-plan.htm
Ohio Medicaid Managed Care, “OhioRISE (Resilience through Integrated Systems and Excellence),” https://managedcare.medicaid.ohio.gov/managed-care/ohiorise
California Department of Health Care Services, “CalAIM Long-Term Care Carve-In Transition,” upated October 17, 2022, https://www.dhcs.ca.gov/provgovpart/Pages/Long-Term-Care-Carve-In-Transition.aspx
Maine Department of Health and Human Services, “Primary Care Plus (PCPlus),” https://www.maine.gov/dhhs/oms/providers/value-based-purchasing/primary-care
NC Medicaid, “Fact Sheet: Eastern Band of Cherokee Indians Tribal Option Overview, County Playbook: NC Medicaid Managed Care,” December 21, 2021, https://medicaid.ncdhhs.gov/media/8154/download
Washington State Health Care Authority, “Primary care case management entities (PCCMe) State Plan Amendment,” https://www.hca.wa.gov/about-hca/who-we-are/tribal-relations/primary-care-case-management-entities-pccme-state-plan-amendment
The state intent of this change is to reduce member transitions between programs and gaps in case, simplify provider contracting and credentialing processes, and streamline the administration of the program.
Virginia Medicaid, “Cardinal Care: A Program for All Medicaid Members,” https://www.dmas.virginia.gov/for-members/cardinal-care/
Virginia Medicaid, “Cardinal Care Transition: What Providers Should Know,” https://www.dmas.virginia.gov/for-providers/cardinal-care-transition/
Ohio Medicaid Managed Care, “PNM & Centralized Credentialing,” https://managedcare.medicaid.ohio.gov/managed-care/centralized-credentialing
Ohio Medicaid Managed Care, “Fiscal Intermediary,” https://managedcare.medicaid.ohio.gov/managed-care/fiscal-intermediary
We asked states to indicate whether the following specified delivery system and payment reform initiatives were in place as of July 1, 2022: patient-centered medical home (PCMH); Health Home (under ACA section 2703); Accountable Care Organization (ACOs); episode of care; and all-payer claims database.
Arkansas and Georgia did not respond to the 2022 survey; 2021 survey data and publicly available data were used to identify delivery system and payment reform initiatives in place for these states.
Publicly available data was used to verify PCMH program of two states that did not respond to the 2022 survey (Arkansas and Georgia).
Building off the experience of Health Homes and California’s Whole Person Pilots, the goal of this new benefit is to bring a whole person focus to the care of certain high-need Medi-Cal beneficiaries, e.g., children/youth with complex physical, behavioral, developmental, and oral health needs, individuals who are homeless or at risk of homelessness, among other target populations, to address both their clinical and non-clinical needs. For more information, see:
State of California – Health and Human Services Agency, CalAIM Enhanced Care Management Policy Guide, Sacramento, CA: State of California – Health and Human Services Agency, September 2021, https://www.dhcs.ca.gov/Documents/MCQMD/ECM-Policy-Guide-September-2021.pdf
Health Equity
The NCQA distinction in Multicultural Health Care is in the process of being updated to the more comprehensive Health Equity Accreditation.
NCQA, “Current Multicultural Healthcare Customers,” https://www.ncqa.org/current-multicultural-healthcare-customers/
Eighteen states reported “other” strategies to improve completeness of REL data: Alaska, Arizona, Colorado, Connecticut, Kansas, Louisiana, Maryland, Massachusetts, Minnesota, New Jersey, New Mexico, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Washington, and Wisconsin.
The NCQA distinction in Multicultural Health Care is in the process of being updated to the more comprehensive Health Equity Accreditation.
NCQA, “Current Multicultural Healthcare Customers,” https://www.ncqa.org/current-multicultural-healthcare-customers/
Benefits
42 C.F.R. Section 440.230(b).
American Rescue Plan Act of 2021, Pub. L. No. 117-2 (March 11, 2021), https://www.congress.gov/117/plaws/publ2/PLAW-117publ2.pdf
Bipartisan Safer Communities Act, Pub. L. No. 117-159 (June 25, 2022), https://www.congress.gov/117/plaws/publ159/PLAW-117publ159.pdf
Inflation Reduction Act of 2022, Pub. L. No. 117-169 (August 16, 2022), https://www.congress.gov/bill/117th-congress/house-bill/5376/text
National Suicide Hotline Designation Act of 2020, Pub. L. No. 116-172 (October 17, 2020), https://www.congress.gov/116/plaws/publ172/PLAW-116publ172.pdf
Consolidated Appropriations Act, 2021, Pub. L. No. 116-260 (December 27, 2020), https://www.congress.gov/116/plaws/publ260/PLAW-116publ260.pdf
In a few instances throughout this section, we rely on publicly available data (e.g. Section 1115 waiver documents or Medicaid State Plan Amendment documents) to supplement reported state benefit changes.
Three states reported addition of CCBHCs in FY 2022 or FY 2023: Kansas, New Mexico, and West Virginia. The Medicaid Certified Community Behavioral Health Center (CCBHC) Medicaid demonstration program aims to improve the availability and quality of ambulatory behavioral health services and to provide coordinated care across behavioral and physical health. CCBHCs provide a comprehensive range of nine types of services. The CCBHC demonstration program was first established by the Protecting Access to Medicare Act of 2014; more recently, the 2022 Bipartisan Safer Communities Act allocated funds for additional planning grants to states to participate in the demonstration.
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation and Office of Behavioral Health, Disability, and Aging Policy, Certified Community Behavioral Health Clinics Demonstration Program: Report to Congress, 2019 (U.S. Department of Health and Human Services, September 2020),
https://aspe.hhs.gov/sites/default/files/migrated_legacy_files/196036/CCBHCRptCong19.pdfProtecting Access to Medicare Act of 2014, Pub. L. No. 113-93 (April 1, 2014), https://www.congress.gov/113/statute/STATUTE-128/STATUTE-128-Pg1040.pdf
Bipartisan Safer Communities Act, Pub. L. No. 117-159 (June 25, 2022),
https://www.congress.gov/117/plaws/publ159/PLAW-117publ159.pdfThree states reported adoption of the CoCM model in FY 2022 or FY 2023: Illinois, Texas, and Wisconsin. Collaborative care models are evidence-based and generally include care coordination, care management, monitoring and treatment, and regularly scheduled psychiatric review and consultation for patients who do not show improvement.
Jürgen Unützer et al., The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes, (Center for Health Care Strategies and Mathematica Policy Research, May 2013): https://www.chcs.org/media/HH_IRC_Collaborative_Care_Model__052113_2.pdf
American Psychiatric Association, “Learn About the Collaborative Care Model,” https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/learn
The 10 states are: California, Colorado, Kansas, Maine, Maryland, Montana, Nevada, Ohio, Oregon, and South Carolina. The American Rescue Plan Act provided a new option for states to provide community-based mobile crisis intervention services, with 85% federal matching funds for these services for the first three years. On September 12, 2022, Oregon became the first state to receive CMS approval of this new Medicaid option.
U.S. Department of Health and Human Services Press Office, “HHS Approves Nation’s First Medicaid Mobile Crisis Intervention Services Program, To Be Launched in Oregon,” September 12, 2022, https://www.hhs.gov/about/news/2022/09/12/hhs-approves-nations-first-medicaid-mobile-crisis-intervention-services-program-to-be-launched-in-oregon.html
CMS, State Plan Amendment (SPA) OR 22-0012 (September 12, 2022), https://www.medicaid.gov/medicaid/spa/downloads/OR-22-0012.pdf
Wash. Admin. Code § 182-550-4550, https://casetext.com/regulation/washington-administrative-code/title-182-health-care-authority/washington-apple-health/chapter-182-550-hospital-services/section-182-550-4550-effective1012022administrative-day-rate-and-swing-bed-day-rate
CMS, State Plan Amendment (SPA) WA-21-0032 (June 2, 2022), https://www.medicaid.gov/medicaid/spa/downloads/WA-21-0032.pdf
West Virginia Department of Health & Human Resources, “Pilot Program for Treatment for Pregnant and Postpartum Women Awarded to WV,” August 27, 2021, https://dhhr.wv.gov/News/2021/Pages/Pilot-Program-for-Treatment-for-Pregnant-and-Postpartum-Women-Awarded-to-WV.aspx
CMS, State Plan Amendment (SPA) WV-22-0003 (September 7, 2022), https://www.medicaid.gov/medicaid/spa/downloads/WV-22-0003.pdf
The 7 states are: Arizona, Colorado, Illinois, Nebraska, New York, Ohio, and Utah. In addition, Louisiana began covering skin substitutes for chronic diabetic lower extremity ulcers (FY 2022) and Nevada plans to provide a limited dental benefit to adults with diabetes, if approved by CMS (FY 2023).
Federal financial participation is not available to state Medicaid programs for room and board except in certain medical institutions. Federal financial participation is generally available under certain housing-related supports and services that promote health and community integration. These include home accessibility modifications, one-time community transition costs, and housing tenancy supports. These depend on the individual’s disability and/or health status and are not used for generality utilities in the home.
See: Centers for Medicare & Medicaid Services, Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH), Baltimore, MD: Department of Health and Human Services, January 2021, https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf
The 12 states are: AZ, CA, CT, DC, ME, MA, NC, NH, OR, UT, WA, and WI.
The CalAIM demonstration and its various components are authorized under Section 1115, Section 1915(b), and through state plan amendments.
California Department of Health Care Services, Medi-Cal Community Supports, or In Lieu of Services (ILOS), Policy Guide (August 2022), https://www.dhcs.ca.gov/Documents/MCQMD/DHCS-Community-Supports-Policy-Guide.pdf
Centers for Medicare and Medicaid Services, Letter to Jacey Cooper, Chief Deputy Director, Health Care Programs, California Department of Health Care Services, from Deputy Administrator and Director, Daniel Tsai (December 29, 2021), https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-calaim-ext-appvl-12292021.pdf
Centers for Medicare and Medicaid Services, Letter to Amanda Cassel Kraft, Assistant Secretary, MassHealth, from CMS Administrator, Chiquita Brooks-LaSure (September 28, 2022), https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ma-masshealth-ca1.pdf
Centers for Medicare and Medicaid Services, Letter to Dana Hittle, Interim Medicaid Director, Oregon Health Authority, from CMS Administrator, Chiquita Brooks-LaSure (September 28, 2022), https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/or-health-plan-09282022-ca.pdf
Centers for Medicare and Medicaid Services, Letter to Jami Snyder, Director, Arizona Health Care Cost Containment System, from Deputy Administrator and Director, Daniel Tsai (October 14, 2022), https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/az-hccc-ca-10142022.pdf
Connecticut Department of Social Services, “Connecticut Housing Engagement and Support Services (CHESS) Initiative,” updated September 2, 2021, https://portal.ct.gov/DSS/Health-And-Home-Care/Connecticut-Housing-Engagement-and-Support/Connecticut-Housing-Engagement-and-Support-Services---CHESS
Connecticut Medical Assistance Program, Provider Bulletin 2022-52, July 2022, https://portal.ct.gov/-/media/DPH/Injury-Prevention/CTVDRS/Connecticut-Medical-Assistance-Program_Community-Violence-Prevention-Services.pdf
Wisconsin Department of Health Services, “Housing Support Services,” updated May 11, 2022, https://www.dhs.wisconsin.gov/medicaid/housing-supports.htm
Leah Ramirez, Wisconsin Department of Health Services, “Housing Support Services,” https://publicmeetings.wi.gov/download-attachment/204ce20a-8a6b-4b3f-9520-783bc417e027
The 9 states are: Hawaii, Iowa, Kentucky, Maryland, Maine, New Hampshire, Oklahoma, Tennessee, and Virginia.
Nevada Department of Health and Human Services, Section 1115 Demonstration Waiver Application: Expansion of Dental Services for Adults with Diabetes (July 2022): https://dhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Board/1115_Dental_Waiver_NV
_Oral_Health_Section.pdfThe 3 states adding coverage of SDF are: California, Rhode Island, and Utah.
American Dental Association, “Silver Diamine Fluoride,” updated July 19, 2021, https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/silver-diamine-fluoride
CMS, State Plan Amendment (SPA) MT-22-005 (June 23, 2022), https://www.medicaid.gov/medicaid/spa/downloads/MT-22-0005.pdf
CMS, State Plan Amendment (SPA) OK-21-0022-A (September 24, 2021), https://www.medicaid.gov/Medicaid/spa/downloads/OK-21-0022-A
Consolidated Appropriations Act, 2021, Pub. L. No. 116-260 (December 27, 2020), https://www.congress.gov/116/plaws/publ260/PLAW-116publ260.pdf
Center for Medicare and Medicaid (CMS), SMD #21-005, “UPDATED: Mandatory Medicaid Coverage of Routine Patient Costs Furnished in Connection with Participation in Qualifying Clinical Trials,” April 13, 2022, https://www.medicaid.gov/federal-policy-guidance/downloads/smd21005.pdf
42 CFR 438.3(e)(2).
42 CFR § 438.3 (e)(2)(iv).
California Department of Health Care Services, Medi-Cal Community Supports, or In Lieu of Services (ILOS), Policy Guide (August 2022), https://www.dhcs.ca.gov/Documents/MCQMD/DHCS-Community-Supports-Policy-Guide.pdf
Telehealth
State Telehealth Medicaid Fee-For-Service Policy: A Historical Analysis of Telehealth: 2013-2019 (Center for Connected Health Policy, January 2020), https://www.cchpca.org/2021/04/Historical-State-Telehealth-Medicaid-Fee-For-Service-Policy-Report-FINAL.pdf
Rose C. Chu, Christie Peters, Nancy De Lew, and Benjamin D. Sommers, State Medicaid Telehealth Policies Before and During the COVID-19 Public Health Emergency (Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, July 19, 2021), https://aspe.hhs.gov/sites/default/files/2021-07/medicaid-telehealth-brief.pdf
Centers for Medicare and Medicaid (CMS), “Medicaid and CHIP and the COVID-19 Public Health Emergency: Preliminary Medicaid and CHIP Data Snapshot,” June 2022, https://www.medicaid.gov/state-resource-center/downloads/covid-19-medicaid-data-snapshot-01312022.pdf
MACPAC, Medicaid and Rural Health (Washington, DC: MACPAC, June 2021), https://www.macpac.gov/wp-content/uploads/2021/04/Medicaid-and-Rural-Health.pdf
Government Accountability Office, Medicaid: CMS Should Assess Effect of Increased Telehealth Use on Beneficiaries’ Quality of Care (Washington, DC: Government Accountability Office, March 2022), https://www.gao.gov/assets/gao-22-104700.pdf
The 28 states that newly added audio-only coverage are: AL, CO, CT, DC, IA, IL, IN, KS, LA, MD, MI, MO, NC, ND, NE, NH, NY, OH, OK, OR, PA, RI, SC, SD, TX, VT, WI, and WV.
The 19 states that expanded existing audio-only coverage are: AK, CA, DE, FL, HI, ID, KY, MA, ME, MN, MS, MT, NJ, NM, NV, TN, UT, VA, and WA.
Centers for Medicare and Medicaid (CMS), “Medicaid and CHIP and the COVID-19 Public Health Emergency: Preliminary Medicaid and CHIP Data Snapshot,” June 2022, https://www.medicaid.gov/state-resource-center/downloads/covid-19-medicaid-data-snapshot-01312022.pdf
The 37 states are: AK, AL, AZ, CA, CT, DC, HI, IA, ID, IN, KS, KY, MA, MD, ME, MI, MN, MO, MS, MT, NC, NE, NH, NM, NV, NY, OH, OK, OR, RI, SC, UT, VA, VT, WI, WV, and WY.
The 4 states are: Louisiana, New Jersey, Pennsylvania, and Texas.
The 6 states are: Colorado, Iowa, Nevada, New Hampshire, North Carolina, and Utah. North Carolina noted that overall telehealth utilization among rural populations has grown to be equivalent to utilization among urban populations; however, telehealth utilization for specialized services is higher among urban populations.
Government Accountability Office, Medicaid: CMS Should Assess Effect of Increased Telehealth Use on Beneficiaries’ Quality of Care (Washington, DC: Government Accountability Office, March 2022), https://www.gao.gov/assets/gao-22-104700.pdf
The 3 states are: California, Kansas, and Ohio.
The 5 states are: Indiana, Iowa, Michigan, North Carolina, and Rhode Island.
The 6 states are: California, Indiana, Nevada, New York, Rhode Island, and Tennessee.
Government Accountability Office, Medicaid: CMS Should Assess Effect of Increased Telehealth Use on Beneficiaries’ Quality of Care (Washington, DC: Government Accountability Office, March 2022), https://www.gao.gov/assets/gao-22-104700.pdf
Bipartisan Safer Communities Act, Pub. L. No. 117-159 (June 25, 2022), https://www.congress.gov/117/plaws/publ159/PLAW-117publ159.pdf
State of Arizona and Health Services Advisory Group, 2021 ACC Adult and Child CAHPS Summary Report (January 2022), https://www.azahcccs.gov/Resources/HPRC/Downloads/2021_CAHPS_ACC_Report-ForPosting.pdf
Specifically, Arizona, Maine, and Nebraska reported plans to use enhanced ARPA HCBS funding. ARPA also included funding to invest in affordable high-speed internet and connectivity.
The White House, “FACT SHEET: Biden-Harris Administration Announces Over $25 Billion in American Rescue Plan Funding to Help Ensure Every American Has Access to High Speed, Affordable Internet,” June 7, 2022, https://www.whitehouse.gov/briefing-room/statements-releases/2022/06/07/fact-sheet-biden-harris-administration-announces-over-25-billion-in-american-rescue-plan-funding-to-help-ensure-every-american-has-access-to-high-speed-affordable-internet/
Ohio Administrative Code 5160-1-18 (July 15, 2022), https://codes.ohio.gov/ohio-administrative-code/rule-5160-1-18
South Carolina Healthy Connections Medicaid, “Update on Telehealth Flexibilities Issued During the COVID-19 Public Health Emergency,” April 29, 2022, https://www.scdhhs.gov/press-release/update-telehealth-flexibilities-issued-during-covid-19-public-health-emergency
Alaska House Bill 265 (July 14, 2022), https://legiscan.com/AK/text/HB265/id/2479085
Texas Medicaid & Healthcare Partnership, “Telemedicine and Telehealth Services Provided by Rural Health Clinics,” February 28, 2022, https://www.tmhp.com/news/2022-02-28-telemedicine-and-telehealth-services-provided-rural-health-clinics
Rhode Island House Bill 6032 (July 6, 2021), https://legiscan.com/RI/bill/H6032/2021
Rhode Island Executive Order 20-06 (March 18, 2020), https://health.ri.gov/publications/exec-orders/ExecOrder20-06.pdf
Provider Rates and Taxes
Social Security Act Section 1902(a)(30)(A) and 42 CFR Section 447.204.
Federal regulations permit only the following exceptions that allow states to make payments directly to providers or direct managed care plan expenditures for plan-covered services: state directed payments and permissible pass-through payments that comply with the requirements at 42 C.F.R. § 438.6, and provider payments required by federal law or regulation, for example, prospective payment system rates required for federally qualified health centers (FQHCs).
Alex Zorn, “Nursing Homes Score Win With 17.5% Medicaid Increase in Pennsylvania for 2023,” Skilled Nursing News, July 11, 2022, https://skillednursingnews.com/2022/07/nursing-homes-score-win-with-17-5-medicaid-increase-in-pennsylvania-for-2023/
The total number of states responding to this question in the prior surveys was 51 in the 2019 survey, 43 in the 2020 survey, and 47 in the 2021 survey.
Government Accountability Office, Medicaid: CMS Needs More Information on States’ Financing and Payment Arrangements to Improve Oversight (Washington, DC: Government Accountability Office, December 2020), https://www.gao.gov/assets/gao-21-98.pdf
Throughout the Provider Taxes section, we use 2021 survey data for Arkansas and Georgia because these states did not respond to the 2022 survey.
The Deficit Reduction Act of 2005 amended the federal Medicaid provider tax law to restrict the use of MCO taxes effective July 1, 2009. Prior to that date, states could apply a provider tax to Medicaid MCOs that did not apply to MCOs more broadly and could use that revenue to match Medicaid federal funds. Since 2009, several states have implemented new MCO taxes that tax member months rather than premiums and that meet the federal statistical requirements for broad-based and uniform taxes. In addition to the 12 states reporting implemented MCO taxes, some states have implemented taxes on health insurers more broadly that generate revenue for their Medicaid programs.
10 states reported having an ambulance tax in place in FY 2022: CA, KY, LA, MA, MI, MO, OK, TN, UT, and VT. MA was still awaiting CMS approval at the time of the survey but planned to implement the tax retroactively to FY 2022.
11 states reported planned increases to one or more provider taxes in FY 2023: AZ, CA, CO, IL, KS, LA, MA, NC, OK, PA, and WV. These increases were most commonly for taxes on hospitals.
7 states reported planned decreases to one or more provider taxes in FY 2023: California, Colorado, Hawaii, Idaho, Missouri, Rhode Island, and Washington.
Pharmacy
State policymakers remain concerned about Medicaid prescription drug spending growth and the entry of new high-cost drugs to the market, like Aduhelm, which could cost states anywhere from $230 to $695 million and states report developing strategies and policies to address these drugs is a priority.
Inflation Reduction Act of 2022, Pub. L. No. 117-169 (August 16, 2022), https://www.congress.gov/bill/117th-congress/house-bill/5376/text
2021 survey data were used for the two states that did not respond to the 2022 survey (Arkansas and Georgia).
Ohio is “unbundling” many components of pharmacy benefit administration from MCO responsibilities and will contract with a single PBM instead. It is also contracting with a Pharmacy Pricing and Audit Consultant (PPAC) who will provide operational and consulting support in the areas of pharmacy reimbursement, benefit design, oversight, and auditing. Additional information about the program change is available at Ohio Medicaid Managed Care, “Ohio Medicaid Single Pharmacy Benefit Manager (SPBM),” https://managedcare.medicaid.ohio.gov/wps/portal/gov/manc/managed-care/single-pharmacy-benefit-manager
In New York, effective April 1, 2023, the pharmacy benefit will be transitioned from managed care to FFS. This was previously scheduled for implementation on April 1, 2021 but was delayed for two years by the state legislature.
Kentucky Cabinet for Health and Family Services, Provider Bulletin “Kentucky Managed Care Organization Single Pharmacy Benefit Manager Announcement,” April 1, 2021, https://chfs.ky.gov/agencies/dms/dpo/ppb/Documents/ProviderMailingApril2021Final.pdf
Mississippi is conducting an MCO procurement and plans to move to processing pharmacy claims through a single pharmacy benefits administrator beginning in FY 2024. See https://medicaid.ms.gov/coordinated-care-procurement/ for more information.
Arizona, Colorado, Massachusetts, Michigan, and Oklahoma are exploring adding additional VBAs.
The 16 states are AK, CT, ID, IL, IN, MS, MT, ND, NV, NY, OR, PA, SC, TN, TX, and VT.
The 6 states are: Alaska, Indiana, Montana, North Dakota, Vermont, and Texas. Arizona, a state that already has a VBA in place, also indicated that it would evaluate national-level VBA arrangements that become available.
See Medicaid Drug Rebate Program Notice, Release No. 189, March 23, 2022, Technical Guidance - Value-Based Purchasing (VBP) Arrangements for Drug Therapies using Multiple Best Prices; State Reporting of VBP Supplemental Rebate Agreements; accessed at https://www.medicaid.gov/prescription-drugs/downloads/state-rel-189-vbp.pdf. This notice provides: “Beginning July 1, 2022, manufacturers will be able to report varying “best price” points (i.e., multiple best prices) for a covered outpatient drug to the Medicaid Drug Rebate Program (MDRP) if associated with a value-based purchasing (VBP) arrangement that meets the definition of such an arrangement at 42 CFR § 447.502, and that arrangement is offered to all states.”
These states are: Alaska, District of Columbia, Maine, Mississippi, Nevada, and Virginia.
Maine is implementing a preferred drug list specific to physician administered drugs, while other states reported making changes to utilization management practices, clinical policy, or reimbursement of physician administered drugs.
Spread pricing refers to the difference between the payment the PBM receives from the MCO and the reimbursement amount it pays to the pharmacy. In the absence of oversight, some PBMs have been able to keep this “spread” as profit.
The 4 states that reported recently implemented or planned policies to prohibit spread pricing are: Florida, Kentucky, Massachusetts, and Maryland.
The 2 states that reported recently implemented or planned policies to require pass through pricing in MCO contracts with PBMs are: Nebraska and Nevada.
The 4 states are: Connecticut, District of Columbia, Mississippi, and Texas.
Methods
State fiscal years begin on July 1 except for these states: New York on April 1; Texas on September 1; Alabama, District of Columbia, and Michigan on October 1.
Arkansas and Georgia did not respond to the 2022 survey. In some instances, we used publicly available data or prior years’ survey responses to obtain information for these states. However, unless otherwise noted, these states are not included in counts throughout the survey.
Among responding states, one state (Texas) did not participate in a follow-up telephone interview.