Amid Unwinding of Pandemic-Era Policies, Medicaid Programs Continue to Focus on Delivery Systems, Benefits, and Reimbursement Rates: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2023 and 2024
Executive Summary
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.
Florida, Minnesota, and South Carolina did not respond to the 2023 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
Florida, Minnesota, and South Carolina did not respond to the 2023 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, four states (Alabama, New Hampshire, New Jersey, and Washington) 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
Medicaid and CHIP Payment And Access Commission, “Medicaid Managed Care Capitation Rate Setting,” March 2022; https://www.macpac.gov/wp-content/uploads/2022/03/Managed-care-capitation-issue-brief.pdf.
Connecticut 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 Washington and three other states that did not respond to the 2023 survey (Florida, Minnesota, and South Carolina).
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.
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.
Oklahoma Health Care Authority, “OHCA Selects Organizations to Assist in Serving Oklahoma Medicaid”, June 8, 2023; https://oklahoma.gov/ohca/about/newsroom/2023/june/ohca-selects-organizations-to-assist-in-serving-oklahoma-medicaid.html
Florida did not respond to the 2023 survey. Therefore, the status of its dental services PHP was confirmed via publicly available data. Dental PHPs in Arkansas and New Hampshire and New Jersey’s NEMT PHP were also confirmed via publicly available data.
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).
The Managed Care Access, Finance, and Quality (“Managed Care” NPRM), would require states to submit an annual payment analysis comparing certain managed care provider rates to Medicare rates.
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 2022 survey data for Florida, Maryland, Minnesota, New Hampshire, South Carolina, Washington, and Wisconsin.
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.
Twenty-one states reported planned increases to one or more provider taxes in FY 2024: Arizona, California, Colorado, Georgia, Hawaii, Iowa, Idaho, Illinois, Kansas, Louisiana, Missouri, Mississippi, North Carolina, Nevada, Ohio, Oklahoma, Pennsylvania, Tennessee, Utah, Vermont, and West Virginia. These increases were most commonly for taxes on hospitals.
Benefits
42 C.F.R. Section 440.230(b).
In a few instances throughout this section, publicly available data (e.g., Section 1115 waiver documents or Medicaid State Plan Amendment documents) is used to supplement reported state benefit changes.
Utah Department of Health and Human Services, “Medicaid Information Bulletin,” February 2023: https://medicaid.utah.gov/Documents/manuals/pdfs/February2023Interim-MIB.pdf
Texas Medicaid & Healthcare Partnership, “Texas Medicaid Provider Procedures Manual,” September, 2023: https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2023/2023-09-september/2_04_Childrens_Services_0.pdf
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.pdf
Protecting 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.pdf
The 12 states that reported expanding behavioral health and related services for children and youth are: Delaware, Hawaii, Idaho, Illinois, Louisiana, Maine, Missouri, Montana, Nebraska, New Mexico, New York, and Ohio.
The 13 states that reported expanding coverage of doula services are: Colorado, Delaware, District of Columbia, Illinois, Kansas, Massachusetts, Michigan, Nevada, New Hampshire, New York, Ohio, Oklahoma, and Pennsylvania.
Beginning October 1, 2023, Section 11405 of the Inflation Reduction Act (IRA) requires Medicaid coverage for approved adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and their administration, without cost sharing.
The 4 states that reported coverage of services provided by pharmacists are: Illinois, Oklahoma, Pennsylvania, and Wyoming.
Chidinma A. Ibe, Debra Hickman and Lisa A. Cooper, “To Advance Health Equity During COVID-19 and Beyond, Elevate and Support Community Health Workers,” JAMA Health Forum 2, no.7 (July 2021), https://doi.org/10.1001/jamahealthforum.2021.2724.
Sonia Ahmed, et al. “Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice,” International Journal for Equity in Health 21, no. 49 (April 2022), https://doi.org/10.1186/s12939-021-01615-y.
Miya L. Barnett, et al. “Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review” Administration and Policy in Mental Health and Mental Health Services Research 45, (July 2017), https://doi.org/10.1007/s10488-017-0815-0.
California previously reported the addition of Traditional Healers and Natural Helpers to deliver culturally appropriate care for AI/AN individuals with SUD in the FY 2022-2023 Annual KFF survey of state Medicaid officials. The California Health Care Services’ CalAIM Behavioral Health Initiative link indicates this proposed policy change is still pending.
Currently, traditional healing benefits are available as a covered Specialized Therapy under New Mexico’s Self-Directed Community Benefit (CB) program for individuals who are elderly or disabled and meet a nursing facility level of care. They may also be reimbursed by MCOs as a value-added service. Source: https://www.hsd.state.nm.us/wp-content/uploads/Tribal-Meetings.pdf
Washington State Health Care Authority, “Washington Medicaid Transformation Project (MTP 2.0),” September 14, 2023, https://www.spokanecounty.org/DocumentCenter/View/50550/Washington-Medicaid-Transformation-Project-MTP-20_09152023
Pharmacy
Texas and Louisiana noted coverage of only Orlistat/Xenical in their survey response; publicly available data sources used to verify coverage status in South Carolina.
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
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
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.
Florida, Minnesota, and South Carolina did not respond to the 2023 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, four states (Alabama, New Hampshire, New Jersey, and Washington) did not participate in a follow-up telephone interview.