States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address Long-Standing Issues: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2021 and 2022

KFF commissioned Health Management Associates (HMA) to survey Medicaid directors in all 50 states and the District of Columbia to identify and track trends in Medicaid spending, enrollment, and policy making. This is the 21st annual survey, each conducted at the beginning of the state fiscal year (FY) from FY 2002 through FY 2022. Additionally, nine mid-fiscal year surveys were conducted during state fiscal years 2002-2004, 2009-2013, and 2021 when a large share of states were considering mid-year Medicaid policy changes due to state budget and revenue shortfalls. Findings from previous surveys are referenced in this report when they help to highlight current trends. Archived copies of past reports are available on the following page.¹

The KFF/HMA Medicaid survey on which this report is based was sent to state Medicaid directors in June 2021. The survey instrument (in Appendix A) was designed to document policy actions in place in FY 2021 and implemented or planned for FY 2022 (which began for most states on July 1, 2021).² The survey captures information consistent with previous surveys, particularly for provider payment rates, benefits, and managed care, to provide some trend information. Each year, questions are added or revised to address current issues. This year, in light of the ongoing COVID-19 pandemic, a number of questions were added to capture information regarding state actions taken or planned in response to the pandemic.

Medicaid directors and staff provided data for this report in response to a written survey and a follow-up telephone interview. Overall, 47 states responded in mid-summer of 2021, though response rates for specific questions varied.³ Forty-three states participated in a follow-up telephone interview, conducted between July and August 2021.⁴ The telephone discussions are an important part of the survey to ensure complete and accurate responses and to record additional context for and complexities of state actions.

The survey does not attempt to catalog all Medicaid policies in place for each state. This report highlights certain policies in place in state Medicaid programs in FY 2021 and policy changes implemented or planned for FY 2022; we also highlight state experiences with policies adopted in response to the COVID-19 pandemic. Experience has shown that adopted policies are sometimes delayed or not implemented for reasons related to legal, fiscal, administrative, systems, or political considerations, or due to delays in approval from CMS. Policy changes under consideration without a definite decision to implement are not included in the survey. States completed this survey in mid-summer of 2021, following increased vaccination rates and declining COVID-19 cases but just prior to a new wave of COVID-19 infections, hospitalizations, and deaths driven by the highly contagious Delta variant. Given differences in the financing structure of their programs, the U.S. territories were not included in this analysis.