The document summarizes the results of the 16th Annual Survey of Medicaid Directors conducted by Health Management Associates for the Kaiser Family Foundation. Some key findings from the survey include: - Total Medicaid spending and enrollment growth has slowed in recent years for both expansion and non-expansion states. - Nearly all states have implemented delivery system initiatives like patient-centered medical homes, and many have expanded these initiatives in recent years. - States are focused on strategies to address the opioid epidemic and control pharmacy costs, particularly for specialty drugs. Most are also expanding community-based long-term services and supports.

1. 16th Annual Survey
of Medicaid Directors
Conducted by HMA for
Kaiser Family Foundation

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2

3. 3
SURVEY AREAS COVERED
 Medicaid Enrollment &
Spending Growth
 Expansion Growth
 Changes in Payments
 Changes in Benefits
 Areas of State Focus
 LTSS
 MCO Expansion
 Quality Initiatives
 Delivery System Initiatives
 Looking Ahead
Available at: www.kff.org or www.healthmanagement.com

4. 4.7%
6.8%
8.7%
10.4%
12.7%
8.5%
7.7%
6.4%
1.3%
3.8%
5.8%
7.6%
6.6%
9.7%
-4.0%
3.2%
6.8%
10.5%
5.9%
4.5%
-1.9%
0.4%
3.2%
7.5%
9.3%
5.6%
4.3%
3.2%
0.2%
-0.5%
3.1%
7.8%7.2%
4.8% 2.3%
1.5%
5.3%
13.2%
3.9%
3.3%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Proj.
Total Medicaid Spending Medicaid Enrollment
Annual Percentage Changes, FY 1998 – FY 2017
NOTE: For FY 1998-2013, enrollment percentage changes are from June to June of each year. FY 2014-2016 reflects growth in average monthly enrollment. Spending growth
percentages refer to state fiscal year. FY 2017 data are projections based on enacted budgets.
SOURCE: Kaiser Family Foundation, Medicaid Enrollment & Spending Growth: FY 2016 & FY 2017; October 2016, available at: http://kff.org/health-reform/press-release/50-
state-survey-finds-slower-growth-in-total-medicaid-spending-nationally-in-fy-2016-and-projected-for-fy-2017-as-earlier-increases-from-the-affordable-care-acts-coverage-
expansions-taper-off/
RECESSIONS AND THE IMPLEMENTATION OF THE ACA RESULTED IN
PEAKS IN TOTAL MEDICAID SPENDING AND ENROLLMENT
1

5. 19.3%
4.8%
2.6%
10.3%
7.1%
4.2%3.9%
1.1% 1.2%
2.2%
3.8% 3.5%
2015 2016 2017 Proj 2015 2016 2017 Proj
Expansion States Non-Expansion States
Median Rates of Growth
NOTE: Percentages reflect the median percent change for each group of states for each year. FY 2017 growth reflects projections in enacted budgets. In FY 2016, Alaska and
Montana moved and in FY 2017, Louisiana moved to the expansion state group.
SOURCE: Kaiser Family Foundation, Medicaid Enrollment & Spending Growth: FY 2016 & FY 2017; October 2016, available at: http://kff.org/health-reform/press-release/50-
state-survey-finds-slower-growth-in-total-medicaid-spending-nationally-in-fy-2016-and-projected-for-fy-2017-as-earlier-increases-from-the-affordable-care-acts-coverage-
expansions-taper-off/
MEDICAID ENROLLMENT & TOTAL SPENDING GROWTH: SLOWING IN FY
2016 AND FY 2017, FOR BOTH EXPANSION & NON-EXPANSION STATES
Medicaid Enrollment Total Medicaid Spending
2

6. 8.4%
9.9%
12.9%
5.5% 4.9%
10.1%
3.0% 4.0%
5.7%
-10.9%
-4.9%
16.1%
20.1%
10.0%
2.6% 3.8% 2.9% 4.4%
8.7%
10.4%
12.7%
8.5% 7.7%
6.4%
1.3%
3.8%
5.8%
7.6% 6.6%
9.7%
-4.0%
3.2%
6.8%
10.5%
5.9%
4.5%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Proj
State Medicaid Spending Growth Total Medicaid Spending Growth
NOTE: FY 2017 projections based on enacted budgets. State spending for FY 2000-2015 includes all non-federal spending. State Medicaid spending for FYs 2016 - 2017 refers to
state spending, largely general fund.
SOURCE: Kaiser Family Foundation, Medicaid Enrollment & Spending Growth: FY 2016 & FY 2017; October 2016. www.kff.org
GROWTH IN TOTAL AND STATE SHARE OF MEDICAID SPENDING IS GENERALLY
PARALLEL, EXCEPT WHEN STATUTORY CHANGES IMPACT FMAP
ARRA Enhanced FMAP
(2009 – 2011)
Enhanced FMAP / Federal
Fiscal Relief (2003-2005)
100% ACA Enhanced
Match (2014 – 2016)
Expiration of
ARRA FMAP
3

7. 22
16
10
5
8
5 6
26
3
2 1
FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 Adopted FY
2017
Other Eligibility Expansions ACA Medicaid Expansion
SOURCE: Kaiser Commission on Medicaid and the Uninsured Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2016.
http://kff.org/medicaid/report/implementing-coverage-and-payment-initiatives-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2016-and-2017/
SINCE 2014, 32 STATES ADOPTED THE ACA MEDICAID EXPANSIONS, PLUS A
FEW STATES MADE TARGETED ELIGIBILITY CHANGES
4

8. NOTES: Restrictions include rate cuts for any provider or freezes for nursing facilities or hospitals. FY 2017 rates were not set for MCOs in Florida or Minnesota
at the time of the survey. Illinois did not provide a response for FY 2017 rates as a budget for FY 2017 had not been enacted at the time of the survey. SOURCE:
KCMU Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2016.
STATES WERE MOST LIKELY TO INCREASE PAYMENT RATES FOR MCOS AND
NURSING FACILITIES, AND TO FREEZE HOSPITAL RATES
20
32
26
18 17 15 1315
32
25
14 11 8 9
Inpatient
Hospitals
Nursing
Facilities
MCOs Outpatient
Hospital
Primary Care
Physicians
Specialist
Physicians
Dentists
FY 2016 Adopted FY 2017
31
19
4 6
2 1 1
36
19
6 4 6 4 4
5 1Cuts
Freezes
States with Rate Increases
States with Rate Restrictions
3 4
5

9. NOTES: States reported benefit restrictions, eliminations, enhancements, and additions in FY 2016 and FY 2017. Excluded from these changes are the implementation of
alternative benefit plans for the Medicaid expansion group. Home and community-based services (HCBS) and pharmacy benefit changes are also excluded. SOURCE: Kaiser
Commission on Medicaid and the Uninsured Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2016.
BENEFIT ENHANCEMENTS IN FY 2016 & FY 2017 MOST COMMON FOR
BEHAVIORAL HEALTH, SUBSTANCE USE, TELE-HEALTH, & DENTAL SERVICES
16
19
15 15
13
19
24
21
24
21 20
FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
(adopted)
Number of States Reporting Benefit Enhancements/ Additions
6
3
10
20 18 18
8
4
1 3 4
Number of States Reporting Benefit Restrictions/ Eliminations
6

10. 10
AREAS OF STATE FOCUS
States are focused on pharmacy cost-containment,
and also strategies to address the opioid epidemic.
✚ 31 states in FY 2016 and 23 in FY 2017 reported
implementing or plans to implement pharmacy cost
containment efforts.
 Targeted to specialty and high cost Rx
✚ Most states with MCOs carve drugs into capitation
payments.
✚ Nearly all states reported specific opioid-focused
pharmacy management policies.
 Quantity limits, Use of prior authorization
 Required use of Prescription Drug Monitoring
Programs
 Expanded access to naloxone
SOURCE: Kaiser Commission on Medicaid and the Uninsured Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2016.
http://kff.org/medicaid/report/implementing-coverage-and-payment-initiatives-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2016-and-2017/

11. 42
19
23
14
46
41
18 18
9
47
HCBS Waiver or SPA
Expansions
Building Balancing
Incentives into
MLTSS
PACE Expansions Close/Downsize
Institution
Total States with
HCBS Expansions
Implemented in FY 2016 Adopted for FY 2017
NOTES: "HCBS Waiver or SPA Expansion" includes increases to the number of Section 1915(c) waiver slots, serving more people under existing waiver caps, or the addition of
Section 1915(i) or Section 1915(k) state plan options to serve more individuals. SOURCE: Kaiser Commission on Medicaid and the Uninsured Survey of Medicaid Officials in 50
states and DC conducted by Health Management Associates, October 2016.
ALMOST EVERY STATE IS EXPANDING COMMUNITY-BASED LONG TERM
SERVICES AND SUPPORTS
8

12. 52 2
4
9
9
3
3
8
28
34
25
32
13
All Beneficiary Groups
39 states
Children
39 states
ACA Expansion Adults
27 states
All Other Adults
39 states
Elderly and
Disabled
39 states
Excluded <25% 25-49% 50-74% 75+%
1
1 1
1
NOTES: Limited to 39 states with MCOs in place on July 1, 2016. Of the 32 states that had implemented the ACA Medicaid expansion as of July 1, 2016, 27 had MCOs in
operation. SOURCE: Kaiser Commission on Medicaid and the Uninsured Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates,
October 2016.
IN 2016, AT LEAST 75% OF ALL MEDICAID BENEFICIARIES ARE IN AN MCO
IN 28 STATES (UP FROM 21 STATES IN 2015)
1
1
9

13. 11
7
11
7
17
12
9 10
7
17
Pay for
Performance
28 states
Public Reporting
of Quality
Metrics
22 states
Adult and Child
Measures
32 states
Other Quality
Initiatives
12 states
Any of Select
Quality
Initiatives
36 states
New/Expanded in FY 2016 New/Expanded in FY 2017
NOTES: States with MCOs indicated if selected quality initiatives were in place in FY 2015, new or expanded in FY 2016 or FY 2017. SOURCE: KCMU Survey of Medicaid Officials
in 50 states and DC conducted by Health Management Associates, October 2016.
17 OF THE 39 MCO STATES EXPANDED OR IMPLEMENTED NEW QUALITY
INITIATIVES IN MCOS IN FY 2016; 17 ALSO IN FY 2017
In Place
in FY
2015:
10

14. 11
6 5
3 4
21
13
7
11
7
5
25
PCMH
29 states
ACA Health
Homes
20 states
ACO Initiative
7 states
Episode of Care
2 states
DSRIP
7 states
Any Delivery
System
Initiatives
36 states
New/Expanded in FY 2016 New/Expanded in FY 2017
NOTES: Expansions include rollouts of existing initiatives to new areas or groups, and other increases in enrollment or providers.
SOURCE: KCMU Survey of Medicaid Officials in 50 states and DC conducted by HMA, October 2016. www.kff.org
42 STATES NOW HAVE DELIVERY SYSTEM INITIATIVES; NEW INITIATIVES IN 21
STATES IN FY 2016 AND 25 STATES IN FY 2017
In Place in FY
2015:
11

15. Strategies
Integration Physical and
Behavioral Health
Opioid Harm Reduction
Value Based Purchasing
Focus on Social Needs
Managed Long-Term Care
ACO, Episode of Care, Health
Homes, DSRIP
Populations
Seriously Mentally Ill
Criminal Justice Involved
Elderly and Disabled
Duals
Goals
Cost Containment
Increase Access
Improved Outcomes
Improved Population Health
SOURCE: Kaiser Commission on Medicaid and the Uninsured Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2016.
LOOKING AHEAD, MEDICAID PRIORITIES FOCUSED ON IMPROVING CARE AND
OUTCOMES FOR HIGH NEED POPULATIONS
12

16. CONTACT ME
JEFF SMITH
Managing Principal
20860 N Tatum Blvd
Suite 300
Phoenix, AZ 85050
602.363.7232
jeffsmith@healthmanagement.com
www.healthmanagement.com