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A View from the States: Key Medicaid Policy Changes

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A View from the States: Key Medicaid Policy Changes October 2019 A View from the States: Key Medicaid Policy Changes Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020 Prepared by: Kathleen Gifford, Eileen Ellis, Aimee Lashbrook, and Mike Nardone Health Management Associates and Elizabeth Hinton, Robin Rudowitz, Maria Diaz, and Marina Tian Kaiser Family Foundation Acknowledgements Pulling together this report is a substantial effort, and the final product represents contributions from many people. The combined analytic team from the Kaiser Family Foundation and Health Management Associates (HMA) would like to thank the Medicaid directors and Medicaid staff in all 50 states and the District of Columbia. In a time of limited resources and challenging workloads, we truly appreciate the time and effort provided by these dedicated public servants to complete the survey, to participate in structured interviews, and to respond to our follow-up questions. Their work made this report possible. We also thank the leadership and staff at the National Association of Medicaid Directors (NAMD) for their collaboration on this survey. We offer special thanks to Jim McEvoy at HMA who developed and managed the survey database and whose work is invaluable to us. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020 ii Table of Contents Executive Summary ...................................................................................................................................... 1 Introduction.................................................................................................................................................... 7 Eligibility and Premiums ................................................................................................................................ 8 Changes to Eligibility Standards ................................................................................................................ 9 Births Financed by Medicaid .................................................................................................................... 14 Premiums ................................................................................................................................................. 14 Coverage Initiatives for the Criminal Justice Population ......................................................................... 15 Table 1: Changes to Eligibility Standards in all 50 States and DC, FY 2019 and FY 2020 .................... 17 Delivery Systems ........................................................................................................................................ 18 Managed Care ......................................................................................................................................... 19 Populations Covered by Risk-Based Managed Care .............................................................................. 19 Services Covered Under MCO Contracts ................................................................................................ 22 Managed Care (Acute and LTSS) Quality, Contract Requirements, and Administration ........................ 23 PCCM and PHP Program Changes ......................................................................................................... 28 Social Determinants of Health ................................................................................................................. 30 Criminal Justice-Involved Populations ..................................................................................................... 33 Emerging Delivery System and Payment Reforms ................................................................................. 34 Table 2: Share of the Medicaid Population Covered Under Different Delivery Systems in all 50 States and DC, as of July 1, 2019 ...................................................................................................................... 39 Table 3: Enrollment of Special Populations Under Medicaid Managed Care Contracts for Acute Care in all 50 States and DC, as of July 1, 2019.................................................................................................. 40 Table 4: Behavioral Health Services Covered Under Acute Care MCO Contracts in all 50 States and DC, as of July 1, 2019.............................................................................................................................. 41 Table 5: Select Medicaid Managed Care Quality Initiatives in all 50 States and DC, In Place in FY 2019 and Actions Taken in FY 2020 ................................................................................................................. 42 Table 6: Select Delivery System and Payment Reform Initiatives in all 50 States and DC, In Place in FY 2019 and Actions Taken in FY 2020 ........................................................................................................ 43 Benefits and Cost-Sharing .......................................................................................................................... 44 Benefit Changes ...................................................................................................................................... 45 Cost-Sharing ............................................................................................................................................ 47 Pharmacy Cost Containment Actions in FY 2019 and FY 2020 .............................................................. 48 Strategies to Address Opioid Use Disorder ............................................................................................. 50 Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020 iii Institutions for Mental Disease (IMD) Flexibilities .................................................................................... 54 Table 7: Benefit Changes in all 50 States and DC, FY 2019 and FY 2020 ............................................. 56 Table 8: Medicaid FFS Pharmacy Benefit Management Strategies for Opioids in all 50 States and DC, in Place in FY 2019 and Actions Taken in FY 2020 ................................................................................ 57 Table 9: New IMD Service Authorities and Actions Taken or Planned by States ................................... 58 Long-Term Services and Supports ............................................................................................................. 59 Managed Long-Term Services and Supports (MLTSS) .......................................................................... 64 Table 10: Long-Term Care Actions to Serve More Individuals in Community Settings in all 50 States and DC, FY 2019 and FY 2020 ............................................................................................................... 68 Table 11: Capitated MLTSS Models in all 50 States and DC, as of July 1, 2019 ................................... 69 Provider Rates and Taxes ........................................................................................................................... 70 Provider Rates ......................................................................................................................................... 70 Provider Taxes and Fees ......................................................................................................................... 74 Table 12: Provider Rate Changes in all 50 States and DC, FY 2019 ...................................................... 76 Table 13: Provider Rate Changes in all 50 States and DC, FY 2020 ...................................................... 77 Table 14: Provider Taxes in Place in all 50 States and DC, FY 2019 and FY 2020 ............................... 78 Challenges and Priorities in FY 2020 and Beyond Reported by Medicaid Directors.................................. 79 Conclusion................................................................................................................................................... 81 Methods....................................................................................................................................................... 82 Appendix A: Acronym Glossary .................................................................................................................. 83 Appendix B: Survey Instrument .................................................................................................................. 86 Endnotes ..................................................................................................................................................... 96 Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020 iv Executive Summary Medicaid covers one in five Americans, accounts for one in six dollars spent on health care in the United States, and makes up more than half of all spending on long-term services and supports.1 Medicaid is a state budget driver as well as the largest source of federal revenue to states. The program is constantly evolving in response to federal policy changes, the economy, and state budget and policy priorities. As states began state fiscal year (FY) 2020, the economy in most states was strong. With fewer budget pressures, many states reported expansions or enhancements to provider rates and benefits. As several states implemented, adopted, or continued to debate the ACA Medicaid expansion, a number of states also continued to pursue
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