黑料不打烊

Ohio Medicaid is no stranger to change. Over the last several years, there have been several broad policy changes, from a new managed care system, to new programs like OhioRISE, to an expansion of MyCare Ohio. And, during this time, there have been complicating factors like the covid-19 public health emergency and the resultant impact of inflation on the basic delivery of services and care. Now, as the Trump administration comes in for the second time, questions arise as to what to expect in Medicaid policy and how it may impact Ohio.

While it鈥檚 often overlooked, federal rule making has a significant impact on the operations of states. Just in the last couple of years, the Biden Administration has implemented policies including:

• 罢丑别听, such as the 80/20 policy, implementation timelines, and other questions regarding Home and Community Based Services waivers that states and certain stakeholders elevate to the Centers for Medicare & Medicaid Services (CMS).
• 罢丑别听, which聽addresses Medicaid聽managed care聽access, financing, and quality, including strengthening standards for timely access to care and states鈥� monitoring and enforcement efforts.
• The Long-Term Care Facility (聽requires minimum聽聽for nursing facilities.
• Two rules streamline Medicaid enrollment and renewal processes for the聽聽(MSP) and for聽. Each rule is expected to increase Medicaid enrollment by about one million people.

These rules are set to be implemented over several years. The Trump Administration could delay implementation of certain provisions, which would eliminate regulations while rolling back enrollee protections, payment transparency, and improved access. Alternatively, the Trump Administration could adjust their enforcement strategy or issue new regulations that would undo or augment these final regulations.

Beyond regulation, there is still the potential for fundamental policy change to the program鈥檚 financing. Notably, the concept of block grants or per-capita caps has reemerged as a potential option, where states would no longer receive federal 鈥渕atch鈥�, but rather a fixed amount based on historical averages. In fact, Energy and Commerce as an area of active conversation in the House Republican Caucus.

Making a fundamental, national change in the financing arrangement of Medicaid would require an act of Congress. Many think this movement away from a traditional reimbursement structure was one of the main reasons for the failure to repeal the Affordable Care Act during the first Trump administration. Notably, as Ohio is a 鈥渞ecipient鈥� state, meaning it receives more in federal taxes than it provides for the Medicaid program, this could significantly impact the long-term financial stability in future state budgets. Often, this challenge is why block granting is usually associated with additional state powers around curbing enrollment, services and coverage, so states may more easily cut the program to accommodate tighter financing.

Depending on how all of these changes would unfold, Medicaid programs, including Ohio鈥檚 may have to adopt their systems to accommodate. However, the Trump administration may also pursue greater flexibility for states to design and innovate in Medicaid in ways that are consistent with their goals. This could include greater flexibility to limit covered services, raise cost-sharing requirements, limit enrollment or require more frequent determination of eligibility. There may also be programmatic refocusing away from initiatives which center health equity and expanded coverage, including alternatives to 鈥淢edicaid expansion鈥�, as well as a fundamental reorientation of the use of waivers.

Speaking of waivers, there is likely going to be a dramatic change in the way waivers are applied and executed. This can include, but is not limited to, waivers that test new policies the prioritize cost-cutting measures over access and coverage, including waivers which change how the Medicaid expansion group is managed in states. Included in this are 鈥淲ork Requirement鈥� waivers, something . While examples from other states have shown that such waivers are , the Trump administration and many policymakers see these requirements as a way to ensure labor force participation. Though there is evidence to suggest

As Ohio providers, plans and policymakers gear up for the next state budget, the landscape of Medicaid policy will be something to pay attention to. While Medicaid represents nearly 48% of the total state budget, . What鈥檚 more, nearly 1 in 3 Ohioans rely on the program, disproportionately in rural communities, and it supports Ohio鈥檚 second largest industry in healthcare. Make sure you stay on top of the latest updates to the program in Ohio and beyond and sign up for 黑料不打烊s Weekly Roundup.

Ohio Health Policy Snapshots

Sign up for Ohio Health Policy Snapshots delivered right to your inbox

This week, our In Focus highlights the 24th annual Medicaid Budget Survey conducted by the Kaiser Family Foundation (KFF) and 黑料不打烊, Inc. (黑料不打烊), in collaboration with the National Association of Medicaid Directors (NAMD). Survey results were released on October 23, 2024, in two new reports:  and . 

The sections below review results and share key takeaways. On November 12, during NAMD鈥檚 2024 Fall Conference, KFF experts and state Medicaid directors will delve into survey findings on policies in place or planned for fiscal year (FY) 2024 and FY 2025, including state experiences with reduced state revenues and the unwinding of the pandemic-related continuous enrollment provision.  

Several of 黑料不打烊鈥檚 former Medicaid directors and Medicaid experts will be in attendance at the NAMD meeting to provide additional context and address questions about FY2025 Medicaid policies in the post-election landscape. Visit our Medicaid team at our exhibit hall booth, where we will have executive summaries on hand.

Medicaid Enrollment and Spending Growth 

During the COVID-19 pandemic, Medicaid enrollment reached record highs as a result of the Families First Coronavirus Response Act, which authorized a 6.2 percentage point increase in the federal match rate, also known as the or Federal Medical Assistance Percentage until the public health emergency ended, provided that states did not disenroll people with Medicaid coverage. During this time, Medicaid and Children鈥檚 Health Insurance Program (CHIP) enrollment rose to 94 million in April 2023 from 71 million in February 2020. In FY 2024 and into FY 2025, states are concluding their Medicaid unwinding eligibility redeterminations. 

Medicaid enrollment declined by 7.5 percent year over year in FY 2024 and is expected to further decline by 4.4 percent in FY 2025. However,鈥痭et Medicaid enrollment remained above pre-pandemic levels. Total Medicaid spending growth slowed to 5.5 percent in FY 2024 and is expected to slow further to 3.9 percent in FY 2025. State shares of spending, however, rose by 19.2 percent in FY 2024 and is estimated to slow to 7 percent in FY 2025. According to FY 2025 enacted budgets, most states anticipate revenue growth will continue to flatten and expect state general fund spending growth to slow. More than half of responding states anticipated a state revenue shortfall to some degree (see Figure 1). 

Figure 1. Percent Change in Medicaid Spending and Enrollment, FY 1998鈭�2025 

Source: FY 2024鈭�2025 spending data and FY 2025 enrollment data are derived from the annual KFF survey of state Medicaid officials conducted by 黑料不打烊, October 2024. All 50 states submitted survey responses by October 2024; state response rates varied across questions. FY 2025 projections based on enacted budgets. Historic data reflects growth across all 50 states and DC and comes from various sources.

Managed Care and Provider Rates 

Capitated managed care remains the predominant delivery system for Medicaid in most states. Specifically: 

• A total of 46 states operated some form of Medicaid managed care (managed care organizations [MCOs] and/or primary care case management [PCCM]). 
• 42 states contracted with risk-based MCOs. 

States use a variety of鈥痳isk mitigation tools鈥痶o ensure appropriate payment levels for MCOs, including risk-sharing arrangements, risk and acuity adjustments, medical loss ratios, or incentive and withhold arrangements (see Figure 2). 

• Of the 41 responding MCO states, 25 reported seeking approval from the Centers for Medicare & Medicaid Services (CMS) for a capitation rate amendment to address shifts in the average risk profile of MCO members in FY 2024 and/or FY 2025 because of the unwinding.  
• Separate from the KFF report, 黑料不打烊 tracks state Medicaid managed care rate certifications. In addition, Wakely, an 黑料不打烊 Company,  a paper summarizing approaches taken by actuaries in 27 states, and considerations for how they relate to the biggest enrollment shift in Medicaid since the implementation of the Affordable Care Act. 

Figure 2. States Seeking Capitation Rate Amendments to Address Acuity Shifts Resulting from the Unwinding for the Rating Periods Beginning in FY 2024 and/or FY 2025 

States also are implementing a range of fee-for-service (FFS) rate increases across provider types. More than half of states reported increasing both inpatient and outpatient hospital FFS base rates in FY 2024. States reported rate increases for nursing facilities and home and community-based service providers more often than for other provider categories, reflecting ongoing staffing challenges for long-term services and supports (LTSS).鈥疢ost states also reported rate increases for outpatient behavioral health providers, primary care professionals, and dentists. 

Social Determinants of Health and Reducing Health Disparities 

States are increasingly addressing social determinants of health (SDOH) and associated health-related social needs (HRSN) using several types of Medicaid authorities. For example: 

• A total of 39 states reported leveraging Medicaid MCO contracts to promote at least one strategy to address SDOH, including screening enrollees for behavioral health or social needs, providing referrals to social services, partnering with community-based organizations, and requiring providers to capture SDOH data and employ community health workers. See Figure 3 for details. 

Figure 3. MCO Contract Requirements Related to SDOH, FY 2024鈭�25 

• Nearly all states also had least one specified MCO requirement related to reducing racial and ethnic health disparities in FY 2025. 黑料不打烊 one-third of states reported at least one MCO financial incentive tied to reducing racial/ethnic disparities in place in FY 2024, most commonly linking capitation withholds or pay for performance incentives to improving health disparities. 
• Medicaid Section 1115 demonstrations are also being used to expand flexibilities by adding HRSN services and supports, including coverage of rent/temporary housing, utilities, and meal support. CMS has approved ten states under the new HRSN Section 1115 framework. 

叠别苍别蹿颈迟蝉听

In all, 41 states reported new or enhanced benefits in FY 2024, and 38 states reported plans to add or enhance benefits in FY 2025. Benefit enhancements continue to outpace benefit cuts. 

• States especially continue to expand behavioral health benefits, particularly for mental health and substance use disorder services. 
• A total of 11 states reported benefit actions related to the addition or expansion of crisis services, including mobile crisis responses and crisis services for youth. 

Prescription Drugs 

Rising prescription drug鈥痗osts鈥痑re an ongoing concern for states and nearly three-quarters of states reported at least one new or expanded initiative to contain prescription drug costs in FY 2024 or FY 2025. 

• Efforts to implement or expand value-based arrangements with pharmaceutical manufacturers were the most frequently mentioned cost-containment initiative across states. 
• Weight-loss prescription drugs also are a hot topic in the states; 13 states now cover GLP-1s (glucagon-like peptide-1s) prescribed to treat obesity. Most state Medicaid programs reported that cost was a key factor contributing to their decisions. 

Key Opportunities, Challenges, and Priorities in FY 2025 and Beyond 

Medicaid directors are focused on behavioral health, LTSS, and key initiatives related to SDOH or reentry services for justice-involved populations in FY 2025 and beyond. In addition, state-reported priorities included鈥痬aternal and child health, rural initiatives, school-based services, continuous coverage for children, value-based payment and quality initiatives, and network monitoring and oversight. 

Budget pressures and workforce shortages are among the main challenges for Medicaid. States noted adequate staffing and systems are obstacles for compliance with recently promulgated federal regulations, particularly the access and managed care rules, which present new reporting, oversight, and beneficiary protection responsibilities for states. Many states also reported a notable increase in per enrollee costs due to the greater healthcare needs of enrollees who retained coverage during the unwinding, adding pressure to budgets. 

Connect with Us 

The KFF Medicaid budget report provides important policy insights for federal and state government decisionmakers and Medicaid stakeholders. 黑料不打烊鈥檚 Medicaid experts know the impact and planning needed to navigate these policies and to inform new decisions in 2025 and beyond. For more information about the key takeaways from the KFF report and 黑料不打烊鈥檚 Medicaid solutions, contact our experts below.