A View from the States: Key Medicaid Policy Changes: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020

Introduction

Medicaid provides health insurance coverage to one in five Americans and accounts for nearly one-sixth of all U.S. health care expenditures.1 The Medicaid program constantly evolves due to changes in federal and state policies, the economy, and other state budget and policy priorities, and has become a significant driver of innovation in the broader health care sector. Unlike 2018 when only two states had not enacted a budget as of July 1, seven states in 2019 did not have a fully completed budget at the beginning of their fiscal year. Budget impasses, however, were driven by various policy disagreements rather than by a weak fiscal environment.2,3 In fact, strong revenue performance in the spring of 2019 enabled most states to finalize their FY 2020 budgets with increased spending for priority programs and more dollars directed to state rainy day funds at the beginning of FY 2020 when this survey was conducted.4

Report findings are drawn from the 19th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Family Foundation (KFF) and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors (NAMD). (Previous reports are archived here.5) This year’s KFF/HMA Medicaid budget survey was conducted from June through September 2019 via a survey sent to each state Medicaid director in June 2019 and then a follow-up telephone interview. An acronym glossary and the survey instrument are included as appendices to this report.

The District of Columbia is counted as a state for the purposes of this report; the counts of state policies or policy actions that are interspersed throughout this report include survey responses from the 51 “states” (including DC). All 50 states and DC participated in the survey which typically includes completion of the survey instrument and a follow-up telephone interview discussions between July and September 2019.6 Given differences in the financing structure of their programs, the U.S. territories were not included in this analysis.

This report examines Medicaid policies in place or implemented in FY 2019, policy changes implemented at the beginning of FY 2020, and policy changes for which a definite decision has been made to implement in FY 2020 (which began for most states7 on July 1, 2019). Policies adopted for the upcoming year are occasionally delayed or not implemented for reasons related to legal, fiscal, administrative, systems, or political considerations, or due to delays in approval from CMS. Key findings of this survey, along with state-by-state tables, are included in the following sections of this report:

Executive Summary Eligibility and Premiums