How the Pandemic Continues to Shape Medicaid Priorities: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2022 and 2023
Introduction
The COVID-19 pandemic public health emergency (PHE), in place for more than two and a half years at the time of this report, has had profound impacts on the ongoing operations of state Medicaid programs, requiring states to rapidly adapt to meet the changing needs of Medicaid enrollees and providers. Nationwide, Medicaid provided health insurance coverage to about one in four Americans in 2020 and accounted for nearly one-sixth of all U.S. health care expenditures in 2020.1 Total Medicaid/CHIP enrollment grew to 89.4 million in June 2022, an increase of 18.2 million (25.6%) from February 2020, right before the pandemic, when enrollment began to steadily increase. Beginning early in the pandemic, states and the federal government implemented numerous Medicaid emergency authorities to enhance state capacity to respond to the emerging public health and economic crises. In addition, Congress authorized changes to Medicaid through the Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security (CARES) Act, including a 6.2 percentage point increase in federal Medicaid matching funds (FMAP) (retroactive to January 1, 2020). This “enhanced FMAP” is available to states that meet “maintenance of eligibility” (MOE) conditions which ensure continued coverage for current enrollees as well as coverage of coronavirus testing and treatment. All of these changes (the emergency policy actions, the fiscal relief, and the MOE) are tied to the duration of the PHE. The PHE is currently set to end in mid-January, and the Biden Administration has indicated it will provide states with 60-day notice before it ends (i.e., in mid-November if the PHE is not extended again).
When the PHE ends, states will begin processing redeterminations and millions of people could lose coverage if they are no longer eligible or face administrative barriers despite remaining eligible.2 Current CMS guidance indicates states must initiate all renewals and other outstanding eligibility actions within 12 months after the PHE ends. Medicaid emergency authorities related to the PHE expire at different times, but states can choose to continue some of these changes even after the PHE ends. Some unwinding of PHE emergency authorities is already completed or underway. The temporary 6.2 percentage point increase in federal matching funds will expire at the end of the quarter in which the PHE ends.
This report draws upon findings from the 22nd annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by KFF and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors (NAMD). (Previous reports are archived here.) This year’s KFF/HMA Medicaid budget survey was conducted from June through September 2022 via a survey sent to each state Medicaid director in June 2022 and then a follow-up telephone interview. Overall, 49 states responded by September 2022,3 although response rates for specific questions varied. The District of Columbia is counted as a state for the purposes of this report. Given differences in the financing structure of their programs, the U.S. territories were not included in this analysis. The survey instrument is included as an appendix to this report.
This report examines Medicaid policies in place or implemented in FY 2022, policy changes implemented at the beginning of FY 2023, and policy changes for which a definite decision has been made to implement in FY 2023 (which began for most states on July 1).4 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 CMS approval delays. Key findings, along with state-by-state tables, are included in the following sections: