State Medicaid Programs Respond to Meet COVID-19 Challenges: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2020 and 2021

Introduction

Like all other aspects of the American health landscape, the COVID-19 pandemic and subsequent public health emergency (PHE) declaration¹ have dramatically impacted state Medicaid programs, requiring states to rapidly adapt to meet the changing needs of their Medicaid beneficiaries and providers. Nationwide, Medicaid provides health insurance coverage to about one in five Americans² and accounts for nearly one-sixth of all U.S. health care expenditures.³ Prior to the pandemic, the Medicaid program had a history of constantly evolving to react to changes in federal and state policies, the economy, and other state budget and policy priorities. The current pandemic, however, has generated both a public health crisis and an economic crisis with increased unemployment, which contributes to growth in Medicaid enrollment and spending at the same time state tax revenues may be falling.

In response to the pandemic, Congress has authorized changes to Medicaid through the Families First Coronavirus Response Act (FFCRA)⁴ and Coronavirus Aid, Relief, and Economic Security (CARES) Act,⁵ including a 6.2 percentage point increase in federal Medicaid matching funds (FMAP) (retroactive to January 1, 2020) available to states that meet five “maintenance of eligibility” (MOE) conditions that ensure continued coverage for current enrollees as well as coverage of coronavirus testing and treatment.⁶ This fiscal relief is in place until the end of the quarter in which the PHE ends, which means it is currently slated to expire at the end of March 2021. Beginning early in the pandemic, states have adopted Medicaid policies to respond to COVID-19 through a variety of emergency authorities (Disaster-Relief State Plan Amendments (SPAs), traditional SPAs, other administrative authorities, HCBS waiver Appendix K, Section 1115 demonstration waivers, and Section 1135 waivers).⁷ The beginning and end dates for these actions vary by authority and many are tied to the PHE.⁸

This report draws upon findings from the 20th 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.⁹) This year’s survey instrument was modified to focus on policy changes planned for FY 2021 and policies adopted in response to the pandemic, and was sent to each state Medicaid director in June 2020. Overall, 43 states¹⁰ responded by mid-August 2020, although response rates for specific questions varied. Given differences in the financing structure of their programs, the U.S. territories were not included in this analysis. An acronym glossary and the survey instrument are included as appendices to this report.

This report highlights policy changes in place or planned for FY 2021 (which began for most states on July 1, 2020).¹¹ Key findings, along with state-by-state tables, are included in the following sections:

• Eligibility and Enrollment
• Provider Rates and Taxes
• Delivery Systems
• Long-Term Services and Supports
• Benefits, Cost-Sharing, and Telehealth
• Pharmacy Cost Containment Actions
• Challenges and Priorities in FY 2021 and Beyond Reported by Medicaid Directors