Mitchell, Medicaid Recession-Related FMAP Increases (R46346) (CRS R46346, 2020-05-07)
Summary
Congressional Research Service report R46346, "Medicaid Recession-Related FMAP Increases," by Alison Mitchell, Specialist in Health Care Financing, dated May 7, 2020. The report describes the federal medical assistance percentage (FMAP), the federal government's share of most Medicaid expenditures, and says Medicaid is a countercyclical program. It compares three recession-related FMAP increases: the Jobs and Growth Tax Relief Reconciliation Act of 2003 (P.L. 108-27), the American Recovery and Reinvestment Act of 2009 (P.L. 111-5), and the Families First Coronavirus Response Act (P.L. 116-127). The report states that the Families First Coronavirus Response Act added a temporary FMAP increase of 6.2 percentage points beginning January 1, 2020.
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Medicaid Recession-Related FMAP Increases
Alison Mitchell
Specialist in Health Care Financing
May 7, 2020
Congressional Research Service
7-....
www.crs.gov
R46346
SUMMARY
R46346
Medicaid Recession-Related FMAP Increases
May 7, 2020
Medicaid is jointly financed by the federal government and the states. States incur
Medicaid costs by making payments to service providers (e.g., for doctor visits) and Alison Mitchell
performing administrative activities (e.g., making eligibility determinations), and the Specialist in Health Care
federal government reimburses states for a share of these costs. The federal Financing
-re-acte--@crs.loc.gov
government’s share of a state’s expenditures for most Medicaid services is called the
federal medical assistance percentage (FMAP). The FMAP varies by state and is For a copy of the full report,
inversely related to each state’s per capita income. For FY2020, FMAP rates range from please call 7-.... or visit
50% (13 states) to 77% (Mississippi). www.crs.gov.
Medicaid is a countercyclical program, which means that the rate of growth for Medicaid enrollment tends to
accelerate when the economy weakens and tends to slow when the economy gains strength. During recessions,
growth in the unemployment rate results in an increase in the rate of growth for Medicaid enrollment, which
increases the rate of growth for Medicaid expenditures at the same time that state revenues decline. Reduced state
revenues can make it difficult for states to continue financing their Medicaid program, especially with the
recession-related growth in Medicaid enrollment.
Federal fiscal relief to states is provided during recessions through adjustments to the FMAP rate because this
process for getting federal Medicaid funding to states is already in place. Many states have indicated that past
FMAP increases allowed the states to prevent further reductions to their Medicaid programs and other portions of
their state budgets.
The federal government provided states with temporary FMAP rate increases to provide states with fiscal relief on
two past occasions: in response to the 2001 recession through the Jobs and Growth Tax Relief Reconciliation Act
of 2003 (JGTRRA; P.L. 108-27) and in response to the Great Recession through the American Recovery and
Reinvestment Act of 2009 (ARRA; P.L. 111-5, as amended by P.L. 111-226). The JGTRRA FMAP increase
provided a 2.95 percentage point increase to FMAP rates for the last two quarters of FY2003 and the first three
quarters of FY2004. The ARRA FMAP increase provided an across-the-board increase, along with an
unemployment-related increase for eligible states. The ARRA across-the-board increase was a 6.2 percentage
point FMAP increase, starting in the first quarter of FY2009 and lasting through the first quarter of FY2011; the
increase phased down to 3.2 and 1.2 percentage points for the second and third quarters of FY2011, respectively.
Most recently, the Families First Coronavirus Response Act (FFCRA; P.L. 116-127) added a temporary Medicaid
FMAP increase of 6.2 percentage points beginning January 1, 2020, and continuing through the Coronavirus
Disease 2019 (COVID-19) public health emergency period. Although the country had not officially entered into a
recession at the time FFCRA was enacted, a recession with significant increases in the unemployment rate was
expected in the near term.
The recession-related FMAP increases have similar components, but there are differences. Similarities of all three
of these recession-related FMAP increases include across-the-board FMAP increases; requirements to maintain
Medicaid eligibility standards that are no more restrictive than they were prior to the FMAP increases; and
requirements to ensure that states do not increase the percentage that local governments contribute to Medicaid
expenditures.
However, there are differences in how the recession-related FMAP increases were determined. For instance, the
JGTRRA and ARRA FMAP increases included hold-harmless provisions that kept the states’ regular FMAP rates
from declining, and these increases excluded certain Medicaid expenditures from the FMAP increases. The ARRA
FMAP increase had an unemployment-related increase that the JGTRRA and FFCRA increases did not have.
Also, the JGTRRA FMAP increase did not have additional requirements for states, but ARRA and FFCRA have
differing sets of additional requirements for states to adhere to in order to qualify for the FMAP increases.
Congressional Research Service
Medicaid Recession-Related FMAP Increases
Contents
The FMAP Rate ............................................................................................................................... 1
Medicaid and Recessions ................................................................................................................ 3
Growth in Medicaid Enrollment ............................................................................................... 3
Medicaid Enrollment Growth During Recent Recessions .................................................. 4
Potential Impact of Medicaid Expansion on Enrollment Growth ....................................... 4
Medicaid Expenditures and State Revenues ............................................................................. 5
After Recessions........................................................................................................................ 6
Recession-Related FMAP Increases ................................................................................................ 6
JGTRRA FMAP Increase .......................................................................................................... 9
ARRA FMAP Increase ............................................................................................................ 10
FFCRA FMAP Increase .......................................................................................................... 13
Conclusion ..................................................................................................................................... 15
Tables
Table 1. Comparison of Medicaid Recession-Related FMAP Increase Provisions ......................... 7
Table A-1. FY2003 and FY2004 Regular FMAP Rates and JGTRRA FMAP Rates .................... 16
Table B-1. FMAP Rate Increase Under ARRA and Extended by P.L. 111-226 ............................ 20
Table B-2. Calculation of Increased FMAPs Under ARRA for the Second Quarter of
FY2010 ....................................................................................................................................... 23
Table C-1. FY2020 Regular FMAP Rates and Regular Rates Plus 6.2 Percentage Points
for the FFCRA FMAP Increase .................................................................................................. 27
Appendixes
Appendix A. Jobs and Growth Tax Relief Reconciliation Act of 2003 FMAP Increase ............... 16
Appendix B. American Recovery and Reinvestment Act of 2009 FMAP Increase ...................... 19
Appendix C. Families First Coronavirus Response Act FMAP Increase ...................................... 27
Contacts
Author Contact Information .......................................................................................................... 29
Congressional Research Service
Medicaid Recession-Related FMAP Increases
edicaid is a means-tested entitlement program that finances the delivery of primary and
M acute medical services, as well as long-term services and supports.1 Historically,
Medicaid eligibility generally has been limited to low-income children, pregnant
women, parents of dependent children, the elderly, and individuals with disabilities. Since 2014,
however, states have had the option to cover nonelderly adults with income up to 133% of the
federal poverty level (FPL)2 under the Patient Protection and Affordable Care Act (ACA; P.L.
111-148, as amended) Medicaid expansion.
Medicaid is jointly financed by the federal government and the states.3 The federal government’s
share of most Medicaid expenditures is called the federal medical assistance percentage (FMAP).
The remainder is referred to as the state share.
Medicaid is a countercyclical program, meaning the rate of growth for Medicaid enrollment tends
to accelerate when the economy weakens and tends to slow when the economy gains strength.
During recessions, the rate of growth for Medicaid enrollment increases, which also increases the
rate of growth for Medicaid expenditures at the same time that state revenues are decreasing.
The federal government provided states with fiscal relief through temporary FMAP rate increases
in response to the 2001 recession (March 2001 through November 2001) and the Great Recession
(December 2007 through June 2009).4 The Families First Coronavirus Response Act (FFCRA;
P.L. 116-127), enacted on March 18, 2020, recently added a temporary Medicaid FMAP increase,
beginning January 1, 2020, and continuing through the Coronavirus Disease 2019 (COVID-19)
public health emergency period.5
This report begins with an overview of the FMAP rate. Then, it discusses the recession-related
impact on the Medicaid program based on the experiences of the 2001 recession and the Great
Recession. The final section of this report describes the three recession-related FMAP increases
and compares them according to their various aspects, such as time periods for the FMAP
increases, the amounts of the increases, and the requirements for states to receive the increases.
The FMAP Rate
The FMAP rate generally is determined annually and varies by state according to each state’s per
capita income relative to the U.S. per capita income.6 The formula provides higher FMAP rates,
1 For more information about the Medicaid program, see CRS Report R43357, Medicaid: An Overview.
2 For more information about the federal poverty level (also referred to as the poverty guidelines), see
https://aspe.hhs.gov/poverty-guidelines.
3 For more information about Medicaid financing, see CRS Report R42640, Medicaid Financing and Expenditures.
4 The time periods for the recessions are from National Bureau of Economic Research (NBER), “US Business Cycle
Expansions and Contractions,” at https://www.nber.org/cycles.html. To determine when the nation is in a recession,
NBER examines and compares various measures of broad economic activity, including gross domestic product,
economy-wide employment, and income.
5 The public health emergency period is defined in paragraph (1)(B) of §1135(g) of the Social Security Act (SSA) as a
public health emergency declared by the Secretary of the Department of Health and Human Services (HHS) pursuant to
§319 of the Public Health Service Act. This refers to the public health emergency declared by the HHS Secretary on
January 31, 2020, with respect to the Coronavirus Disease 2019 (COVID-19) outbreak. The determination was made
retroactive to January 27, 2020.
6 For more information about the Medicaid federal medical assistance percentage (FMAP), see CRS Report R43847,
Medicaid’s Federal Medical Assistance Percentage (FMAP).
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Medicaid Recession-Related FMAP Increases
or federal reimbursement rates, to states with lower per capita incomes, and it provides lower
FMAP rates to states with higher per capita incomes.
FMAP rates have a statutory minimum of 50% and a statutory maximum of 83%. For a state with
an FMAP of 60%, the state gets 60 cents back from the federal government for every dollar the
state spends on its Medicaid program. In FY2020, FMAP rates range from 50.00% (13 states) to
76.98% (Mississippi).7
The FMAP formula relies on each state’s per capita personal income in relation to the U.S.
average per capita personal income. The national economy is basically the sum of all state
economies. As a result, the national response to an economic change is the sum of the state
responses to economic change. If more states (or larger states) were to experience an economic
decline, the national economy would reflect this decline to some extent. However, the extent of
the total decline would be offset by states with small decreases or even increases (i.e., states with
growing economies). The U.S. per capita personal income, because of this balancing of positive
and negative, usually has only a small percentage change each year. Because the FMAP formula
compares state changes in per capita personal income (which can have large changes each year)
with changes in the U.S. per capita personal income, states’ FMAP rates often change from year
to year. For most of the states experiencing annual FMAP rate changes, the change has been be
less than one percentage point—but that can translate to a significant dollar amount.
The FMAP rate is used to reimburse states for the federal share of most Medicaid expenditures,
but exceptions to the regular FMAP rate have been made for certain states (e.g., the District of
Columbia and the territories), situations (e.g., during economic downturns), populations (e.g.,
ACA Medicaid expansion population and certain women with breast or cervical cancer),
providers (e.g., Indian Health Service facilities), and services (e.g., family planning and home
health services).
The FMAP is also used to determine the federal share of other federal programs. For instance, it
is used to determine the federal share of spending for foster care maintenance, adoption
assistance, and guardianship assistance payments authorized by Title IV-E of the Social Security
Act.8 The FMAP rate is also used to determine the relative federal and state shares of the
“mandatory matching funds” provided by the Child Care Entitlement to States.9 In addition, it
determines the federal share of funding under the Temporary Assistance for Needy Families
(TANF) Contingency Funds and the federal share of collections under the Child Support
Enforcement program.10
Separate from the regular FMAP rate, the enhanced FMAP (E-FMAP) rate is provided for
services and administration under the State Children’s Health Insurance Program (CHIP), subject
7 HHS, “Federal Financial Participation in State Assistance Expenditures; Federal Matching Shares for Medicaid, the
Children’s Health Insurance Program, and Aid to Needy Aged, Blind, or Disabled Persons for October 1, 2019
Through September 30, 2020,” 83 Federal Register 611577, November 28, 2018.
8 For more information, see CRS Insight IN11297, Federal Medical Assistance Percentage (FMAP) Increase Available
for Title IV-E Foster Care and Permanency Payments; and CRS Report R42792, Child Welfare: A Detailed Overview
of Program Eligibility and Funding for Foster Care, Adoption Assistance and Kinship Guardianship Assistance under
Title IV-E of the Social Security Act.
9 The Child Care Entitlement to States is authorized in §418 of the SSA. For more information, see CRS In Focus
IF10511, Child Care Entitlement to States.
10 For more information about the Temporary Assistance for Needy Families (TANF) Contingency Funds, see CRS
Report RL32748, The Temporary Assistance for Needy Families (TANF) Block Grant: A Primer on TANF Financing
and Federal Requirements.
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Medicaid Recession-Related FMAP Increases
to the availability of funds from a state’s federal allotment for CHIP. The E-FMAP rate is
calculated by reducing the state share under the regular FMAP rate by 30%.11
Medicaid and Recessions
Medicaid expenditures are influenced by a number of economic, demographic, and programmatic
factors. Economic factors include health care prices, unemployment rates, and individuals’
wages. Demographic factors include population growth and the age distribution. Programmatic
factors include changes to eligibility and benefits or other program changes. Other factors include
the number of eligible individuals who enroll and their utilization of covered services.
Medicaid is a countercyclical program. During recessions, growth in the unemployment rate
results in an increase in the rate of growth for Medicaid enrollment, which increases the rate of
growth for Medicaid expenditures at the same time that state revenues decline. Reduced state
revenues can make it difficult for states to continue financing their Medicaid programs, especially
with the recession-related growth in Medicaid enrollment.12 The effect of recessions on Medicaid
enrollment, Medicaid expenditures, and state tax revenues are generally not isolated to the
recession period and can continue after the recession has officially ended.13
Growth in Medicaid Enrollment
Individuals and their dependents may become eligible for Medicaid because they experience
reductions in their incomes due to reduced hours or job loss. During economic downturns, the
number of individuals with reduced hours or job losses increases, and the rate of job losses are
considerably higher among low-income workers.14 This increases the number of individuals
eligible for Medicaid.
Individuals and their dependents also may lose access to employer-sponsored health insurance.
When individuals have reduced hours or experience job loss, they may lose the health insurance
coverage they had through their employer for themselves and their dependents. These individuals
may be eligible for the Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation
coverage, which provides temporary access to a former employer’s health insurance. However,
employers are not required to pay for the cost of COBRA coverage, which may be more
expensive than an individual’s prior cost of insurance.15
11 For more information about financing for the State Children’s Health Insurance Program (CHIP), see CRS Report
R43949, Federal Financing for the State Children’s Health Insurance Program (CHIP).
12 John Holahan and A. Bowen Garrett, Rising Unemployment, Medicaid and the Uninsured, Kaiser Commission on
Medicaid and the Uninsured, June 2009, at https://www.kff.org/wp-content/uploads/2013/03/7850.pdf (hereinafter
cited as Holahan and Garrett, Rising Unemployment, Medicaid and the Uninsured, June 2009).
13 U.S. Government Accountability Office (GAO), Medicaid: Improving Responsiveness of Federal Assistance to
States during Economic Downturns, GAO-11-395, March 2011, at https://www.gao.gov/new.items/d11395.pdf
(hereinafter cited as GAO-11-395, Medicaid: Improving Responsiveness).
14 GAO-11-395, Medicaid: Improving Responsiveness; Laura Snyder and Robin Rudowitz, Trends in State Medicaid
Programs: Looking Back and Looking Ahead, Kaiser Commission on Medicaid and the Uninsured, June 21, 2016, at
https://www.kff.org/report-section/trends-in-state-medicaid-programs-section-1-medicaid-spending-and-enrollment-
trends/; Henry S. Farber, “Job Loss in the Great Recession Historical Perspective from the Displaced Workers Survey,
1984-2010,” National Bureau of Economic Research, May 2011, at https://www.nber.org/papers/w17040; Holahan and
Garrett, Rising Unemployment, Medicaid and the Uninsured, June 2009.
15 Holahan and Garrett, Rising Unemployment, Medicaid and the Uninsured, June 2009.
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Medicaid Recession-Related FMAP Increases
Some individuals, or their dependents, might already be Medicaid eligible and have employer-
sponsored health insurance. During economic downturns, employers may lower the amount they
contribute to the cost of health benefits or decide to no longer provide health insurance coverage
to these employees. This increase in the cost of or loss of employer-sponsored health insurance
may result in these individuals enrolling for Medicaid coverage.
As discussed below, there is a relationship between the unemployment rate and Medicaid
enrollment. The ACA Medicaid expansion, which was implemented after the last recession, is
expected to increase the effects of a recession on Medicaid enrollment.
Medicaid Enrollment Growth During Recent Recessions
Medicaid enrollment follows economic cycles, with enrollment growth increasing at a faster rate
during economic downturns and Medicaid enrollment growth increasing at a slower rate when
economic conditions improve.16
The U.S. Government Accountability Office (GAO) analyzed federal Medicaid enrollment data
during the 2001 recession and the Great Recession. GAO found that during the 2001 recession,
the national unemployment rate increased from 4.3% to 5.5%, and total Medicaid enrollment
increased by approximately 2 million (or 5.6%). GAO also found that during the Great Recession,
the national unemployment rate grew from 5.0% to 9.5%, and Medicaid enrollment rose by
nearly 4.3 million (or 9.7%).17
Potential Impact of Medicaid Expansion on Enrollment Growth
The ACA Medicaid expansion that went into effect in 2014 is expected to increase the effects of a
recession on Medicaid enrollment.18 As there has not been a recession since states have had the
option to implement the Medicaid expansion, there is no experience available to quantify the
impact.19
During the Great Recession, Medicaid eligibility in most states was not available to many of the
individuals who lost their jobs. This is because nonelderly adults without dependent children were
not eligible for Medicaid. Prior to the Medicaid expansion, Medicaid eligibility for nonelderly
adults, in most states, was limited to individuals with disabilities, pregnant women, and parents of
poor children. Also, states’ Medicaid income eligibility thresholds for parents were significantly
lower than the income eligibility level for the Medicaid expansion of up to 133% of FPL.20
As a result of the Medicaid expansion, the percentage of adults eligible for Medicaid during
future periods of high unemployment is expected to be larger than in the past.21 An increase in the
rate of enrollment growth for the Medicaid expansion in response to an increase in the
unemployment rate would have less of an impact on state budgets than an increase in the rate of
16 Holahan and Garrett, Rising Unemployment, Medicaid and the Uninsured, June 2009.
17 GAO-11-395, Medicaid: Improving Responsiveness.
18 Paul D. Jacobs, Steven C. Hill, and Salam Abdus, “Adults Are More Likely To Become Eligible For Medicaid
During Future Recessions If Their State Expanded Medicaid,” Health Affairs, vol. 36, no. 1 (January 2017) (hereinafter
cited as Jacobs, Hill, and Abdus, “Adults Are More Likely To Become Eligible For Medicaid During Future
Recessions”).
19 For more information about the Medicaid expansion, see CRS In Focus IF10399, Overview of the ACA Medicaid
Expansion; and CRS Report R43564, The ACA Medicaid Expansion.
20 Jacobs, Hill, and Abdus, “Adults Are More Likely To Become Eligible For Medicaid During Future Recessions.”
21 Jacobs, Hill, and Abdus, “Adults Are More Likely To Become Eligible For Medicaid During Future Recessions.”
Congressional Research Service 4
Medicaid Recession-Related FMAP Increases
enrollment growth for the traditional Medicaid populations because the federal matching rate for
the Medicaid expansion is 90%, which is higher than the regular FMAP rate.22 Although the state
share of the Medicaid expansion is 10% of the expenditures, the increase in the enrollment for the
Medicaid expansion during economic downturns could contribute to states’ budget pressures.
Medicaid Expenditures and State Revenues
Increases in Medicaid enrollment growth during economic downturns generally result in an
increased rate of growth for total Medicaid expenditures.23 As with Medicaid enrollment, when
the economic conditions improve, Medicaid expenditure growth tends to slow.
At the same time that unemployment rate increases during economic downturns cause Medicaid
enrollment and expenditures to increase at a faster rate, states general revenues are negatively
affected.24 During the 2001 recession, states experienced a 4.2% decline in state tax revenue from
state FY2001 to state FY2002.25
In the study described in the “Medicaid Enrollment Growth During Recent Recessions” section,
GAO also looked at the impact of the Great Recession on total state tax revenues. Nationally,
GAO found that the Great Recession led to a 10.2% decline in state tax revenues from the fourth
quarter of 2007 to the fourth quarter of 2009.26 The impact of the Great Recession on state tax
revenue varied significantly from state to state.27 Although state tax revenue for most states (44
states and the District of Columbia) decreased, these revenue decreases ranged from 1% in Iowa
to 23% in Arizona.28
Medicaid accounts for almost 20% of state general fund expenditures, and it is the second largest
category of general fund expenditures for states.29 The reduction in state tax revenue during
economic downturns can make it difficult for states to finance the state share of Medicaid,
especially while Medicaid enrollment and expenditures are increasing.30 Since most states are
required to balance their budgets, the reduced state tax revenues and increased Medicaid
expenditures, among other budget pressures, may lead states to increase taxes, reduce
expenditures—including for the Medicaid program—or both.31
22 For more information about the Medicaid matching rate for the Medicaid expansion, see CRS In Focus IF10399,
Overview of the ACA Medicaid Expansion.
23 Centers for Medicare & Medicaid Services (CMS), Office of the Actuary, 2016 Actuarial Report on the Financial
Outlook for Medicaid, 2017.
24 GAO-11-395, Medicaid: Improving Responsiveness.
25 This is based on data that state legislative fiscal officers provided to the National Conference for State Legislatures
(NCSL). Todd Haggerty, “Weakcovery”: State General Fund Revenues, Economic Downturns & Recoveries, NCSL,
January 2013, at https://www.ncsl.org/research/fiscal-policy/state-revenues-downturns-and-recoveries.aspx.
26 GAO-11-395, Medicaid: Improving Responsiveness.
27 GAO-11-395, Medicaid: Improving Responsiveness.
28 GAO-11-395, Medicaid: Improving Responsiveness.
29 Elementary and secondary education is the largest category of general fund expenditures for states. National
Association of State Budget Officers, 2019 State Expenditure Report: Fiscal Years 2017-2019, November 2019, at
https://www.nasbo.org/reports-data/state-expenditure-report.
30 GAO-11-395, Medicaid: Improving Responsiveness.
31 Kaiser Commission on Medicaid and the Uninsured, Rising Unemployment Medicaid and the Uninsured: A Multi-
Year Snapshot of State Financing Effects, January 2009, at https://www.kff.org/wp-content/uploads/2013/03/
7850_fs.pdf; Holahan and Garrett, Rising Unemployment, Medicaid and the Uninsured, June 2009.
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Medicaid Recession-Related FMAP Increases
In response to the 2001 recession, 34 states reduced Medicaid expenditures by freezing or
reducing provider payments, eliminating coverage for optional services, increasing premiums,
and increasing copayments for prescription drugs.32 As a result of the Great Recession, 31 states
froze or reduced Medicaid provider rates or increased Medicaid provider taxes,33 and other states
reduced prescription drug costs and limited or eliminated coverage for optional services, such as
mental health or dental care.34
After Recessions
The impacts of recessions on Medicaid enrollment, Medicaid expenditures, and state tax revenues
have continued even after the recessions have officially ended. For example, the 2001 recession
officially ended in November 2001, but state tax revenue continued to decline through the second
quarter of 2002, and the national unemployment rate remained above prerecession levels through
June 2003. Medicaid enrollment increased at higher than average rates of growth through 2003.
Although the Great Recession officially ended in June 2009, 25 states continued to experience
unemployment rates above 9%, until at least December 2010.35 Some states were still feeling the
effects of the recession in 2011 and 2012.36 The timing and duration of the continued impact of
national recessions on states have varied according to the economic conditions and revenue
structures of each state, along with the mix of each state’s industries and resources.37
Recession-Related FMAP Increases
In the past, two laws have provided states with fiscal relief through temporary FMAP rate
increases due to recessions: the Jobs and Growth Tax Relief Reconciliation Act of 2003
(JGTRRA; P.L. 108-27) and the American Recovery and Reinvestment Act of 2009 (ARRA; P.L.
111-5, as amended by P.L. 111-226). In addition, the Families First Coronavirus Response Act
(FFCRA; P.L. 116-127) recently provided a temporary FMAP increase during the COVID-19
public health emergency period.
As noted by GAO, “the FMAP is a readily available mechanism for providing temporary
assistance to states because assistance can be distributed quickly, with states obtaining funds on a
quarterly basis through Medicaid’s existing payment system.”38 The increased FMAP rates help
states maintain their Medicaid programs during economic downturns. Also, the increased FMAP
rates effectively reduce the state share of Medicaid expenditures for states, allowing states to use
the state funding that would have been used for the state share of Medicaid—if there were not a
recession-related FMAP rate—for non-Medicaid state budget needs.39
32 GAO-11-395, Medicaid: Improving Responsiveness.
33 For more information about Medicaid provider taxes, see CRS Report RS22843, Medicaid Provider Taxes.
34 GAO-11-395, Medicaid: Improving Responsiveness.
35 GAO-11-395, Medicaid: Improving Responsiveness.
36 CMS, Office of the Actuary, 2012 Actuarial Report on the Financial Outlook for Medicaid, 2013; GAO-11-395,
Medicaid: Improving Responsiveness.
37 GAO-11-395, Medicaid: Improving Responsiveness.
38 GAO-11-395, Medicaid: Improving Responsiveness.
39 GAO-11-395, Medicaid: Improving Responsiveness; Gabriel Chodorow-Reich, et al., “Does State Fiscal Relief
During Recessions Increase Employment? Evidence from the American Recovery and Reinvestment Act,” American
Economic Journal: Economic Policy, vol. 4, no. 3 (August 2012) (hereinafter cited as Chodorow-Reich, et al., “Does
State Fiscal Relief Increase Employment? Evidence from ARRA,” August 2012).
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Medicaid Recession-Related FMAP Increases
As shown in Table 1, the recession-related FMAP increases have similar components, but there
are differences. All three recession-related FMAP increases had across-the-board increases to the
regular FMAP rates as their main component. The JGTRRA across-the-board increase of 2.95
percentage points was lower than the 6.2 percentage point across-the-board increases for ARRA
and FFCRA. The ARRA across-the-board increase phased out at the end of the time period for the
FMAP increase, but the other two increases do not phase down. In addition, the JGTRRA and
ARRA FMAP increases included hold-harmless provisions that kept states’ regular FMAP rates
from declining, and these increases did not apply to certain Medicaid expenditures that use the
regular FMAP rate. The FFCRA FMAP increase, however, does not exclude Medicaid
expenditures that use the regular FMAP rate. Also, the ARRA FMAP increase included an
unemployment-related additional increase to the FMAP, but the JGTRRA and FFCRA FMAP
increases do not. JGTRRA and FFCRA applied the FMAP increases to the territories and
provided the territories additional federal Medicaid funding, but ARRA gave the territories a
choice of the across-the-board FMAP increase, along with increased funding or a larger increase
in funding without an FMAP increase.
All three of the recession-related FMAP increases have requirements for states in order to qualify
for the FMAP increase. For example, all three FMAP increases require states to maintain
Medicaid eligibility standards that are no more restrictive than those that were in effect on a
certain date. All three also prohibit states from increasing the percentage local governments are
required to contribute to the state share of Medicaid.40 The JGTRRA FMAP increase did not have
additional requirements for states, but the ARRA and FFCRA FMAP increases include differing
sets of additional requirements for states, which are listed in Table 1.
Table 1. Comparison of Medicaid Recession-Related FMAP Increase Provisions
JGTRRA FMAP Increase ARRA FMAP Increase FFCRA FMAP Increase
Time Period for Last two quarters of First quarter of FY2009 Starting January 1, 2020,
Increase FY2003 and the first three through the third quarter of through the last day of the
quarters of FY2004. FY2011. calendar quarter in which
the Coronavirus Disease
2019 (COVID-19) public
health emergency period
ends.a
Funding Limit Limited to $10 billion. None. None.
States 50 states, the District of 50 states and the District of 50 states, the District of
Columbia, and the Columbia. Columbia, and the
territories. territories.b
Hold-Harmless Yes. Yes. No.
Provision
Across-the-Board 2.95 percentage points. 6.2 percentage points 6.2 percentage points.
FMAP Increase phased down to 3.2 and
then 1.2 for the last two
quarters, respectively.
Unemployment- None. Three-tier unemployment- None.
Related Increase related increase.
40 Some states require local governments to finance part of the nonfederal (i.e., state) share of Medicaid costs. Because
a temporary FMAP rate increase would reduce a state’s nonfederal share, a local government required to contribute a
specified dollar amount (or some other amount that is not a fixed percentage of the nonfederal share) could pay a larger
percentage of the nonfederal share than it otherwise would have without the FMAP rate increase.
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Medicaid Recession-Related FMAP Increases
JGTRRA FMAP Increase ARRA FMAP Increase FFCRA FMAP Increase
Medicaid Did not apply to Medicaid Did not apply to the None.
Payments DSH payments and Medicaid following Medicaid
Excluded payments matched using the expenditures: (1) DSH
E-FMAP. payments, (2) Medicaid
payments matched using the
E-FMAP, and (3) most
expenditures for individuals
who were eligible for
Medicaid because of a state
expansion of eligibility
implemented after July 1,
2008.
Application to None. None. Community First Choice
FMAP services.d
Exceptionsc FMAP exceptions calculated
based on the regular FMAP
are indirectly increased.e
Maintenance of Medicaid eligibility is no Medicaid “eligibility Medicaid “eligibility
Effort for more restrictive than what standards, methodologies, standards, methodologies,
Eligibility was in effect on September and procedures” are no and procedures” are no
2, 2003. more restrictive than what more restrictive than what
was in effect on July 1, 2008. was in effect on January 1,
2020.
Restriction of Ensure that local Ensure that local Ensure that local
Requirement for governments were not governments were not governments are not
Local Funding required to pay a larger required to contribute a required to contribute a
percentage of the state’s larger percentage of the larger percentage of the
nonfederal Medicaid state’s nonfederal Medicaid state’s nonfederal Medicaid
expenditures than expenditures or Medicaid expenditures or Medicaid
otherwise would have been DSH payments than DSH payments than
required on April 1, 2003. otherwise would have been otherwise would have been
required on September 30, required on March 11,
2008. 2020.
Other None. States were also required to States are also required to
Requirements do the following: (1) comply (1) not impose premiums
with requirements for exceeding the amount in
prompt payment of health place as of January 1, 2020f;
care providers under (2) provide continuous
Medicaid; (2) not deposit or coverage of Medicaid
credit the additional federal enrollees during the public
funds paid as a result of the health emergency period;
increase to any reserve or and (3) provide coverage
rainy day fund; and (3) (without the imposition of
submit a report to the HHS cost sharing) for testing
Secretary regarding how the services and treatments for
additional federal funds paid COVID–19) (including
as a result of the temporary vaccines, specialized
FMAP increase were equipment, and therapies).
expended.
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Medicaid Recession-Related FMAP Increases
JGTRRA FMAP Increase ARRA FMAP Increase FFCRA FMAP Increase
Territories Increase of 5.9% in the Choice of 6.2 percentage Increases the additional
Specific federal Medicaid annual points FMAP increase along federal Medicaid funding
Provisionsg capped funding. with a 15% increase in available for each territory
annual capped funding or in FY2020 and FY2021.h
regular FMAP rate along
with a 30% increase in its
cap.
Sources: American Recovery and Reinvestment Act of 2009 (ARRA; P.L. 111-5, as amended by P.L. 111-226);
Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA; P.L. 108-27); Families First Coronavirus
Response Act (FFCRA; P.L. 116-127); and Centers for Medicare & Medicaid Services (CMS), Families First
Coronavirus Response Act – Increased FMAP FAQs, March 24, 2020(updated April 13 2020), at
https://www.medicaid.gov/state-resource-center/downloads/covid-19-section-6008-faqs.pdf; CMS, Families First
Coronavirus Response Act (FFCRA), P.L. 116-127 Coronavirus Aid, Relief, and Economic Security (CARES) Act, P.L. 116-
136 Frequently Asked Questions (FAQs), April 13, 2020, at https://www.medicaid.gov/state-resource-center/
downloads/covid-19-section-6008-CARES-faqs.pdf.
Notes: FMAP = federal medical assistance percentage; E-FMAP = enhanced federal medical assistance
percentage; DSH = disproportionate share hospital; HHS = Department of Health and Human Services.
a. The public health emergency period is defined as paragraph (1)(B) of Section 1135(g) of the Social Security
Act, which is a public health emergency declared by the HHS Secretary pursuant to Section 319 of the
Public Health Service Act. This is referring to the public health emergency declared with respect to the
COVID-19 outbreak by the HHS Secretary on January 31, 2020. The determination was made retroactive
to January 27, 2020.
b. The regular FMAP rates for the territories are statutorily set at 55%. However, for the remainder of
FY2020 and FY2021, the FMAP rates for the territories are increased to 83% for American Samoa,
Commonwealth of the Northern Mariana Islands, Guam, and the U.S. Virgin Islands and to 76% for Puerto
Rico. The FFCRA FMAP increase is added to the FMAPs for FY2020 and FY2021 (i.e., 83% and 76%,
respectively).
c. The FMAP rate is used to reimburse states for the federal share of most Medicaid expenditures, but
exceptions to the regular FMAP rate have been made for certain states, situations, populations, providers,
and services.
d. Expenditures for the Community First Choice services receive both the six percentage point FMAP increase
under section 1915(k) of the Social Security Act and the FFCRA FMAP increase, if the expenditures
otherwise qualify.
e. FMAP exceptions calculated based on the regular FMAP use the regular FMAP plus the FFCRA FMAP
increase for the calculation. These FMAP exceptions are for individuals eligible on the basis of breast and
cervical cancer, Certified Community Behavioral Health Clinics, and Money Follows the Person.
f. Section 3720 of the Coronavirus Aid, Relief, and Economic Security Act (P.L. 116-136) delays the
application of the premium requirement until 30 days after March 18, 2020 (i.e., the date of enactment for
FFCRA).
g. Federal Medicaid funding to the states and the District of Columbia is open-ended, but the Medicaid
programs in the territories are subject to annual federal capped funding. The permanent source of federal
Medicaid funding for the territories is the annual federal capped funding, and this funding has been
supplemented since July 1, 2011, with additional Medicaid funding. For more information about Medicaid
funding for the territories, see CRS In Focus IF11012, Medicaid Funding for the Territories.
h. Section 6009 of FFCRA.
The following sections provide summaries of the recession-related FMAP rate increases from
JGTRRA, ARRA, and FFCRA, as well as the time period for the FMAP increases, the amount of
the increases, and the requirements for states to receive them.
JGTRRA FMAP Increase
As part of the state fiscal relief for FY2003 and FY2004 included in JGTRRA, FMAP rates for
the 50 states, the District of Columbia, and the territories were held harmless and increased in the
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Medicaid Recession-Related FMAP Increases
last two quarters of FY2003 and the first three quarters of FY2004.41 This provision was
statutorily limited to $10 billion.42 Table A-1 shows JGTRRA FMAP increases for the 50 states,
the District of Columbia, and the territories.
The FMAP rates were increased by an across-the-board 2.95 percentage points for each state (i.e.,
the 50 states, the District of Columbia, and the territories). The FMAP increase did not apply to
Medicaid disproportionate share hospital (DSH) payments and Medicaid payments that were
matched using the E-FMAP (e.g., breast and cervical cancer treatment).
The hold-harmless provision kept the FMAP rates from declining during that period. Specifically,
for FY2003, if a state’s FY2002 FMAP rate was higher than the FY2003 rate (without the 2.95
percentage point increase), then the FY2002 rate was substituted for the FY2003 rate for the last
two quarters of FY2003. Similarly in FY2004, if a state’s FY2003 FMAP rate was higher than the
FY2004 rate (without the 2.95 percentage point increase), then the FY2003 rate was substituted
for the FY2004 rate for the first three quarters of FY2004.
To qualify for the JGTRRA FMAP increase, a state could not have had a Medicaid plan with
more restrictive eligibility rules than the plan in effect on September 2, 2003. If a state restored
program eligibility to the levels in effect on September 2, 2003, then the state would have
qualified for the increased FMAP rate for the entire quarter in which eligibility was reinstated.
States also needed to ensure that local governments were not required to contribute a larger
percentage of the state’s nonfederal Medicaid expenditures than otherwise would have been
required on April 1, 2003, for the last two quarters of FY2003 and the first three quarters of
FY2004.
In addition to the JGTRRA FMAP increase, JGTRRA increased the federal Medicaid funding
available for each of the territories by 5.9%.43
The JGTRRA FMAP increase was provided to states in FY2003 and FY2004, well after the
recession ended in November 2001. All states received the same FMAP increase, and the increase
was not based on need using measures such as unemployment rates or state tax revenues.44
States indicated that the JGTRRA FMAP increase prevented states from making additional cuts to
the Medicaid program and other portions of state budgets. Specifically, 36 states said the
JGTRRA FMAP increase helped to fund increased Medicaid expenditures, and 31 states said the
increase allowed states to minimize or postpone Medicaid cuts or freezes.45
ARRA FMAP Increase
ARRA provided an FMAP rate increase to states, which was later extended by P.L. 111-226.46
The ARRA FMAP rate increase lasted for nine quarters, starting October 2008 and continuing
41 §401(a) of the Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA; P.L. 108-27).
42 In addition to the $10 billion for the FMAP rate increases, JGTRRA provided $10 billion in general assistance
divided among the states to be used for essential government services.
43 Federal Medicaid funding to the states and the District of Columbia is open-ended, but the Medicaid programs in the
territories are subject to annual federal capped funding. For more information about Medicaid funding for the
territories, see CRS In Focus IF11012, Medicaid Funding for the Territories.
44 GAO-11-395, Medicaid: Improving Responsiveness.
45 Kaiser Commission on Medicaid and the Uninsured, State Fiscal Conditions and Medicaid, November 2004, at
https://www.kff.org/medicaid/fact-sheet/state-fiscal-conditions-and-medicaid-update/.
46 §5001 of the American Recovery and Reinvestment Act of 2009 (ARRA; P.L. 111-5) and amended by §201 of P.L.
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Medicaid Recession-Related FMAP Increases
through December 2010, and totaled an estimated $89 billion.47 This temporary FMAP rate
increase was extended by six months as part of P.L. 111-226—the extension totaled an estimated
$16.1 billion.48 With the extension, the ARRA FMAP rate increase ran for a total of 11 quarters,
from the first quarter of FY2009 through the third quarter of FY2011 (i.e., October 2008 through
June 2011), subject to certain requirements. Table B-1 shows the ARRA FMAP increase for the
50 states and the District of Columbia.
For a “recession adjustment period” that began with the first quarter of FY2009 and ran through
the third quarter of FY2011 (i.e., October 2008 through June 2011), ARRA held all states
harmless from any decline in their regular FMAP rates throughout the period.49 All states (i.e., the
50 states and the District of Columbia) received an across-the-board increase of 6.2 percentage
points to their regular FMAP rates until the last two quarters of the period, at which point the
across-the-board percentage point increase phased down to 3.2 and then 1.2 percentage points.50
Throughout the period, states with unemployment rates that had increased by certain amounts in a
quarter received an additional unemployment-related increase. There were three tiers of this
unemployment-related increase. See “ARRA Unemployment-Related FMAP Increase” for details
about the unemployment related increase, including how it was calculated.
ARRA Unemployment-Related FMAP Increase
The unemployment-related FMAP rate increase, which equaled a percentage reduction in the state share, was
determined for each state on a quarterly basis. A state was evaluated based on its average unemployment rate in
the most recent three-month period for which data were available (except for the first two and last two quarters
of the temporary FMAP rate increase, for which the applicable three-month period differs) compared with its
lowest average unemployment rate in any three-month period beginning on or after January 1, 2006.
The criteria were as follows: unemployment rate increase of at least 1.5 but less than 2.5 percentage points = 5.5%
reduction in state share; increase of at least 2.5 but less than 3.5 percentage points = 8.5% reduction; increase of
at least 3.5 percentage points = 11.5% reduction.
The percentage reduction was applied to the state share after the hold-harmless increase and after one-half of the
across-the-board increase. For example, after applying the across-the-board increase of 6.2 percentage points that
applied for most of the recession adjustment period, a state with a regular FMAP rate of 50% would have an FMAP
rate of 56.20%. If the state share after the hold-harmless and one-half of the across-the-board increase to the
federal share (i.e., 46.9%) were further reduced by 5.5% (the lowest unemployment rate increase tier), the state
would have receive an additional FMAP rate increase of 2.58 percentage points (46.9 state share * 0.055 reduction
in state share = 2.58). The state’s total FMAP rate increase would have been 8.78 points (6.2 + 2.58 = 8.78), and
the state’s FMAP rate would have been 58.78%. Table B-2 shows how the FMAPs under ARRA were calculated
for the second quarter of FY2010, including the 6.2 percentage point across-the-board increase and the
unemployment-related increases.
A state’s percentage reduction could increase over time as its unemployment rate increased, but the percentage
reduction was not allowed to decrease until the second quarter of FY2011.
The ARRA FMAP increase was not available to the territories, but each territory was allowed to
make a one-time choice between (1) an FMAP rate increase of 6.2 percentage points along with a
111-226.
47 GAO-11-395, Medicaid: Improving Responsiveness.
48 GAO-11-395, Medicaid: Improving Responsiveness.
49 The hold-harmless provision was determined by using as the FMAP rate for the current year, the greater of any prior
fiscal year FMAP rates between FY2008-FY2010, or the rate calculated for the current fiscal year. HHS, “Adjusted
Federal Medical Assistance Percentage (FMAP) Rates for the Second and Third Quarters of Fiscal Year 2011 (FY11),”
76 Federal Register 32204, June 3, 2011.
50 The phased down, across-the-board increase for the last six months was part of the six-month extension included in
P.L. 111-226.
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Medicaid Recession-Related FMAP Increases
15% increase in its annual capped funding or (2) the regular FMAP rate along with a 30%
increase in its capped funding. All territories chose the latter.51
The full amount of the temporary ARRA FMAP rate increase applied to most Medicaid
expenditures, but not to the following Medicaid expenditures: (1) DSH payments,52 (2) Medicaid
payments that were matched using the E-FMAP (e.g., breast and cervical cancer treatment), and
(3) most expenditures for individuals who were eligible for Medicaid because of a state expansion
of eligibility implemented after July 1, 2008.53
To receive ARRA FMAP rate increases, states were required to do the following: (1) ensure their
Medicaid “eligibility standards, methodologies, and procedures” were no more restrictive than
those that were in effect on July 1, 2008; (2) comply with requirements for prompt payment of
health care providers under Medicaid; (3) not deposit or credit the additional federal funds paid as
a result of the increase to any reserve or rainy day fund; (4) ensure that local governments did not
pay a larger percentage of the state’s nonfederal Medicaid expenditures (or a greater percentage
of the nonfederal share of Medicaid DSH payments) than otherwise would have been required on
September 30, 2008;54 and (5) submit a report to the Secretary of the Department of Health and
Human Services regarding how the additional federal funds paid as a result of the temporary
FMAP increase were expended.55 P.L. 111-226 added a requirement for the last six months (i.e.,
January 1, 2011, through June 30, 2011) that states certify that they would request and use the
funds.
FMAP rate increases reduced the amount of state funding required to maintain a given level of
Medicaid services. For states that contemplated cuts in order to slow the growth of or reduce
Medicaid spending (e.g., by eliminating coverage of certain benefits, freezing or reducing
provider reimbursement rates, or increasing cost-sharing or premiums for beneficiaries),
increased federal funding enabled them to avoid those cuts.56
For others, the state savings that resulted from an FMAP rate increase were used for various
purposes that were not limited to Medicaid. For example, 36 states reported that they used funds
51 HHS, “Adjusted Federal Medical Assistance Percentage (FMAP) Rates for the Second and Third Quarters of Fiscal
Year 2011 (FY11),” 76 Federal Register 32204, June 3, 2011.
52 §5002 of ARRA temporarily increased states’ disproportionate share hospital (DSH) allotments for FY2009 and
FY2010 to 102.5% of what the DSH allotment would have been without ARRA for each year. For more about
Medicaid DSH allotments, see CRS Report R42865, Medicaid Disproportionate Share Hospital Payments.
53 The Children’s Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3) included an exception to the July
1, 2008, rule for certain childless adults that states were required to transfer from CHIP to a Medicaid waiver by
December 31, 2009. Under P.L. 111-226, states were able to receive ARRA FMAP rates after January 1, 2010, for
nonpregnant childless adults in Medicaid who would have been eligible for CHIP based on standards in effect on
December 31, 2009.
54 The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) clarified that voluntary local
contributions would not lead a state to run afoul of this requirement. See HHS, CMS, State Medicaid Director letter
#10-010 (ARRA #7), June 21, 2010.
55 For the requirements related to rainy day funds and local governments’ share of nonfederal expenditures, the law was
written such that states would be denied the across-the-board and unemployment-related FMAP rate increases (and
territories would be denied cap increases) if they were out of compliance; however, they would not be denied the hold-
harmless FMAP rate increase. In contrast, for the requirements related to maintenance of eligibility and prompt
payment, states would be denied all of the temporary FMAP rate increase (including hold harmless) if they were out of
compliance.
56 GAO-11-395, Medicaid: Improving Responsiveness.
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Medicaid Recession-Related FMAP Increases
from the ARRA FMAP rate increase to close or reduce their Medicaid budget shortfall, and 44
states used the funds to close or reduce state general fund shortfalls.57
In addition to avoiding cuts to Medicaid, the Congressional Budget Office (CBO) indicated in
2009 that providing additional federal aid to states that were facing fiscal pressures would
probably stimulate the economy.58 However, CBO noted that the effects would vary. Federal aid
to states with relatively healthy budgets would have provided little stimulus if the aid were used
to build up rainy day funds (a prohibited use of the ARRA FMAP rate increase), rather than to
increase spending or reduce taxes.59 One study found the ARRA FMAP increase “had an
economically large and statistically robust positive effect on employment.”60
GAO determined that the ARRA FMAP increase was better timed than the JGTRRA FMAP
increase because the ARRA FMAP increase began during the recession, when all states were
experiencing Medicaid enrollment increases and state tax revenue decreases.61 GAO also found
that the ARRA FMAP increase was better targeted than the JGTRRA FMAP increase because the
ARRA increase included unemployment-related adjustments for certain states.62
FFCRA FMAP Increase
FFCRA provides an increase to the FMAP rate for all states, the District of Columbia, and the
territories of 6.2 percentage points, beginning on the first day of the calendar quarter in which the
COVID-19 public health emergency period began63 (i.e., January 1, 2020) and ending on the last
day of the calendar quarter in which the last day of the COVID-19 public health emergency
period ends.64 Table C-1 shows the FY2020 FMAP rates for the states, the District of Columbia,
and the territories and those FMAP rates plus 6.2 percentage points.
To receive this increased FMAP rate, states, the District of Columbia, and the territories are
required to (1) ensure that their Medicaid “eligibility standards, methodologies, and procedures”
are no more restrictive than those that were in effect on January 1, 2020;65 (2) not impose
premiums exceeding the amounts in place as of January 1, 2020;66 (3) provide continuous
57 Kaiser Commission on Medicaid and the Uninsured, State Fiscal Conditions and Medicaid, September 2009.
58 U.S. Congressional Budget Office (CBO), Letter to the Honorable Charles E. Grassley, March 2, 2009.
59 Statement of Peter R. Orszag, Director, CBO, in U.S. Congress, Senate Committee on Finance, Options for
Responding to Short-Term Economic Weakness, 110th Cong., 2nd sess., January 22, 2008.
60 Chodorow-Reich, et al., “Does State Fiscal Relief Increase Employment? Evidence from ARRA,” August 2012.
61 GAO-11-395, Medicaid: Improving Responsiveness.
62 GAO-11-395, Medicaid: Improving Responsiveness.
63 The public health emergency period is defined as paragraph (1)(B) of §1135(g) of the SSA, which is a public health
emergency declared by the HHS Secretary pursuant to §319 of the Public Health Service Act. This is referring to the
public health emergency declared with respect to the COVID-19 outbreak by the HHS Secretary on January 31, 2020.
The determination was made retroactive to January 27, 2020.
64 §6008 of the Families First Coronavirus Response Act (FFCRA; P.L. 116-127); CMS, Families First Coronavirus
Response Act – Increased FMAP FAQs, March 24, 2020 (updated April 13 2020), at https://www.medicaid.gov/state-
resource-center/downloads/covid-19-section-6008-faqs.pdf.
65 A similar provision was in place prior to FFCRA for Medicaid and CHIP children. Under SSA §1902(gg)(2) and
SSA §2105(d)(3), states are required to maintain the Medicaid and CHIP eligibility standards, methodologies, and
procedures for children in place on the date of enactment of the ACA (P.L. 111-148) through FY2027. The penalty for
states’ noncompliance with either the Medicaid or the CHIP maintenance of effort requirements for children would be
the loss of all federal Medicaid funds.
66 §3720 of the Coronavirus Aid, Relief, and Economic Security Act (P.L. 116-136) delays the application of the
premium requirement until 30 days after March 18, 2020 (i.e., the date of enactment for FFCRA).
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coverage of Medicaid enrollees during the COVID-19 public health emergency period;67 and (4)
provide coverage (without the imposition of cost sharing) for testing services and treatments for
COVID–19 (including vaccines, specialized equipment, and therapies).
Another condition to receive the FFCRA FMAP increase is that states, the District of Columbia,
and the territories cannot require local governments to fund a larger percentage of the state’s
nonfederal Medicaid expenditures for the Medicaid state plan or Medicaid DSH payments than
what was required on March 11, 2020.
The FFCRA FMAP increase does not apply to most FMAP exceptions, including the FMAP
exceptions for the ACA Medicaid expansion, family planning, and home health services.
However, the FFCRA FMAP increase does apply to a few FMAP exceptions. For Community
First Choice services, the FFCRA FMAP increase is added to the six percentage point FMAP
increase under Section 1915(k) of the Social Security Act, if the expenditures otherwise qualify.68
Also, FMAP exceptions calculated based on the regular FMAP use the regular FMAP plus the
FFCRA FMAP increase for the calculation. These FMAP exceptions are for individuals eligible
on the basis of breast and cervical cancer, Certified Community Behavioral Health Clinics, and
Money Follows the Person.69
In addition to the territories receiving the FFCRA FMAP increase, FFCRA increases the federal
Medicaid funding available for each territory in FY2020 and FY2021.70 The aggregate additional
funding for the territories increases from $3.0 billion to $3.1 billion in FY2020 and from $3.1
billion to $3.2 billion in FY2021.71
In the past, GAO developed a prototype formula for temporary FMAP increases. One of the key
components of the GAO prototype was making the temporary FMAP increase automatic so the
FMAP increase could begin closer to the onset of a national recession.72 Although the FFCRA
does not provide an automatic increase, the FFCRA FMAP increase is starting prior to an
expected economic downturn.73
67 Specifically, the continuous coverage requirement means that to receive the increased FMAP rate, states need to
maintain Medicaid eligibility for individuals enrolled in Medicaid on the date of enactment (i.e., March 18, 2020) or for
individuals who enroll during the public health emergency period through the end of the month in which the public
health emergency period ends (unless the individual requests a voluntary termination of eligibility or the individual
ceases to be a resident of the state).
68 CMS, Families First Coronavirus Response Act (FFCRA), P.L. 116-127 Coronavirus Aid, Relief, and Economic
Security (CARES) Act, P.L. 116-136 Frequently Asked Questions (FAQs), April 13, 2020, at
https://www.medicaid.gov/state-resource-center/downloads/covid-19-section-6008-CARES-faqs.pdf (hereinafter cited
as CMS, FFCRA, CARES Act FAQs, April, 13, 2020).
69 CMS, FFCRA, CARES Act FAQs, April, 13, 2020.
70 The regular FMAP rates for the territories are statutorily set at 55%. However, for the remainder of FY2020 and
FY2021, the FMAP rates for the territories are increased to 83% for American Samoa, Commonwealth of the Northern
Mariana Islands, Guam, and U.S. Virgin Islands and to 76% for Puerto Rico. The FFCRA FMAP increase is added to
the FMAPs for FY2020 and FY2021 (i.e., 83% and 76%, respectively). CMS, FFCRA, CARES Act FAQs, April, 13,
2020.
71 For more information about Medicaid funding for the territories, see CRS In Focus IF11012, Medicaid Funding for
the Territories.
72 GAO-11-395, Medicaid: Improving Responsiveness.
73 Phillip Swagel, Updating CBO’s Economic Forecast to Account for the Pandemic, CBO, April 2, 2020, at
https://www.cbo.gov/publication/56314.
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Conclusion
The FMAP rate has been used as a means to provide fiscal relief to states in response to the 2001
recession, the Great Recession, and current economic conditions due to the COVID-19 public
health emergency. These recession-related FMAP increases have been provided at times when
states have experienced growth in unemployment rates that results in increases in the rate of
growth for Medicaid enrollment, which in turn increases the rate of growth for Medicaid
expenditures at the same time that state revenues decline.
These recession-related FMAP increases are similar but have some significant differences. All
three of these recession-related FMAP increases have across-the-board FMAP increases;
requirements to maintain Medicaid eligibility standards that are no more restrictive than they
were prior to the FMAP increases; and requirements to ensure that states do not increase the
percentage that local governments contribute to Medicaid expenditures.
However, the JGTRRA and ARRA FMAP increases included hold-harmless provisions that kept
the states’ regular FMAP rates from declining, and these increases excluded certain Medicaid
expenditures from the FMAP increases. The ARRA FMAP increase had an unemployment-related
increase that the JGTRRA and FFCRA increases did not have. Also, the JGTRRA FMAP increase
did not have additional requirements for states, but ARRA and FFCRA have differing sets of
additional requirements for states to adhere to in order to qualify for the FMAP increases.
In addition, many states indicated that the JGTRRA and ARRA FMAP increases provided fiscal
relief that allowed the states to prevent further reductions to the Medicaid programs and other
portions of their state budgets.
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Appendix A. Jobs and Growth Tax Relief
Reconciliation Act of 2003 FMAP Increase
The Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA; P.L. 108-27) included a
provision that increased federal medical assistance percentage (FMAP) rates for the 50 states, the
District of Columbia, and the territories during the last two quarters of FY2003 and the first three
quarters of FY2004. The FMAP rates were held harmless and increased by an across-the-board
2.95 percentage points for each state (i.e., the 50 states, the District of Columbia, and the
territories). The JGTRRA FMAP increases were subject to certain requirements for states. For
more detail about the JGTRRA FMAP increase, see “JGTRRA FMAP Increase.” Table A-1
shows states’ regular FMAP rates and JGTRRA FMAP rates for FY2003 and FY2004.
Table A-1. FY2003 and FY2004 Regular FMAP Rates and JGTRRA FMAP Rates
FY2003 FY2004
First Two Last Two First Three
Quarters— Quarters— Quarters— Last Quarter—
Regular FMAP JGTRRA FMAP JGTRRA FMAP Regular FMAP
State Rate Rate Rate Rate
Alabama 70.60 73.55 73.70 70.75
Alaskaa 58.27 61.22 61.34 58.39
American Samoab 50.00 52.95 52.95 50.00
Arizona 67.25 70.20 70.21 67.26
Arkansas 74.28 77.23 77.62 74.67
California 50.00 54.35 52.95 50.00
Colorado 50.00 52.95 52.95 50.00
Connecticut 50.00 52.95 52.95 50.00
Delaware 50.00 52.95 52.95 50.00
District of Columbiac 70.00 72.95 72.95 70.00
Florida 58.83 61.78 61.88 58.93
Georgia 59.60 62.55 62.55 59.58
Guamb 50.00 52.95 52.95 50.00
Hawaii 58.77 61.72 61.85 58.90
Idaho 70.96 73.97 73.91 70.46
Illinois 50.00 52.95 52.95 50.00
Indiana 61.97 64.99 65.27 62.32
Iowa 63.50 66.45 66.88 63.93
Kansas 60.15 63.15 63.77 60.82
Kentucky 69.89 72.89 73.04 70.09
Louisiana 71.28 74.23 74.58 71.63
Maine 66.22 69.53 69.17 66.01
Maryland 50.00 52.95 52.95 50.00
Massachusetts 50.00 52.95 52.95 50.00
Michigan 55.42 59.31 58.84 55.89
Minnesota 50.00 52.95 52.95 50.00
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FY2003 FY2004
First Two Last Two First Three
Quarters— Quarters— Quarters— Last Quarter—
Regular FMAP JGTRRA FMAP JGTRRA FMAP Regular FMAP
State Rate Rate Rate Rate
Mississippi 76.62 79.57 80.03 77.08
Missouri 61.23 64.18 64.42 61.47
Montana 72.96 75.91 75.91 72.85
Nebraska 59.52 62.50 62.84 59.89
Nevada 52.39 55.34 57.88 54.93
New Hampshire 50.00 52.95 52.95 50.00
New Jersey 50.00 52.95 52.95 50.00
New Mexico 74.56 77.51 77.80 74.85
New York 50.00 52.95 52.95 50.00
North Carolina 62.56 65.51 65.80 62.85
North Dakota 68.36 72.82 71.31 68.31
Commonwealth of
the Northern Mariana
Islandsb 50.00 52.95 52.95 50.00
Ohio 58.83 61.78 62.18 59.23
Oklahoma 70.56 73.51 73.51 70.24
Oregon 60.16 63.11 63.76 60.81
Pennsylvania 54.69 57.64 57.71 54.76
Puerto Ricob 50.00 52.95 52.95 50.00
Rhode Island 55.40 58.35 58.98 56.03
South Carolina 69.81 72.76 72.81 69.86
South Dakota 65.29 68.88 68.62 65.67
Tennessee 64.59 67.54 67.54 64.40
Texas 59.99 63.12 63.17 60.22
Utah 71.24 74.19 74.67 71.72
Vermont 62.41 66.01 65.36 61.34
U.S. Virgin Islandsb 50.00 52.95 52.95 50.00
Virginia 50.53 54.40 53.48 50.00
Washington 50.00 53.32 52.95 50.00
West Virginia 75.04 78.22 78.14 75.19
Wisconsin 58.43 61.52 61.38 58.41
Wyoming 61.32 64.92 64.27 59.77
Sources: Department of Health and Human Services (HHS), “Federal Financial Participation in State Assistance
Expenditures; Federal Matching Shares for Medicaid, the State Children’s Health Insurance Program, and Aid to
Needy, Aged, Blind, or Disabled Persons for October 1, 2002 Through September 30, 2003,” 66 Federal Register
59790, November 30, 2001; HHS, “Federal Financial Participation in State Assistance Expenditures; Federal
Matching Shares for Medicaid, the State Children’s Health Insurance Program, and Aid to Needy Aged, Blind, or
Disabled Persons for October 1, 2003 Through September 30, 2004,” 67 Federal Register 69223, November 15,
2002; HHS, “Federal Financial Participation in State Assistance Expenditures; Temporary Increase of Federal
Matching Shares for Medicaid for the Last 2 Calendar Quarters of Fiscal Year 2003 and the First 3 Quarters of
Fiscal Year 2004,” 68 Federal Register 35889, June 17, 2003.
Congressional Research Service 17
Medicaid Recession-Related FMAP Increases
Notes: FMAP = federal medical assistance percentage; JGTRRA = Jobs and Growth Tax Relief Reconciliation
Act of 2003 (JGTRRA; P.L. 108-27).
a. An alternative formula was used to determine Alaska’s regular FMAP rate for FY2001-FY2005, which
reduced the state’s per capita income by 5% (thereby increasing its FMAP rate).
b. The regular FMAP rate for the territories (American Samoa, Guam, Commonwealth of the Northern
Mariana Islands, Puerto Rico, and U.S. Virgin Islands) was set at 50%. In addition to the JGTRRA FMAP
increase, JGTRRA increased the federal Medicaid funding available for each of the territories by 5.9%.
c. The District of Columbia’s regular FMAP rate has been set at 70% since FY1998 (without this exception, it
would be at the statutory minimum of 50%).
Congressional Research Service 18
Medicaid Recession-Related FMAP Increases
Appendix B. American Recovery and Reinvestment
Act of 2009 FMAP Increase
The American Recovery and Reinvestment Act of 2009 (ARRA; P.L. 111-5) provided a
temporary FMAP rate increase to the 50 states and the District of Columbia that was later
extended by P.L. 111-226. With the extension, the ARRA FMAP increase lasted from the first
quarter of FY2009 through the third quarter of FY2011 (i.e., October 2008 through June 2011).74
ARRA held all states harmless from any decline in their regular FMAP rates throughout the
period. Under the ARRA FMAP increases, all states (i.e., the 50 states and the District of
Columbia) received an across-the-board increase of 6.2 percentage points to their regular FMAP
through the first quarter of FY2011, at which point the across-the-board percentage point increase
phased down to 3.2 and then 1.2 percentage points for the second and third quarters of FY2011,
respectively.
Throughout the period, states with unemployment rates that had increased by certain amounts for
a quarter received an additional unemployment-related increase. There were three tiers of the
unemployment-related increase. See “ARRA Unemployment-Related Increase” for details about
the unemployment-related increase, including how it was calculated.
The ARRA FMAP increases were subject to certain requirements for states. For more information
about the ARRA FMAP increases and these requirements, see “ARRA FMAP Increase.”
Table B-1 shows the FMAP rate increases under ARRA and extended by P.L. 111-226 for each
quarter, from the first quarter of FY2009 through the third quarter of FY2011. Table B-2 provides
an example of how the FMAPs under ARRA with the hold-harmless and the unemployment-
related increases were calculated for the second quarter of FY2010.
74 The American Recovery and Reinvestment Act of 2009 (ARRA; P.L. 111-5) FMAP increase was not available to the
territories, but each territory was allowed to make a one-time choice between an FMAP rate increase of 6.2 percentage
points along with a 15% increase in its annual capped funding, or its regular FMAP rate along with a 30% increase in
its capped funding. All territories chose the latter.
Congressional Research Service 19
Table B-1. FMAP Rate Increase Under ARRA and Extended by P.L. 111-226
FY2009 1st Quarter to FY2011 3rd Quarter
FY2009 FY2009 FY2009 FY2009 FY2010 FY2010 FY2010 FY2010 FY2011 FY2011 FY2011
State
1st quarter 2nd quarter 3rd quarter 4th quarter 1st quarter 2nd quarter 3rd quarter 4th quarter 1st quarter 2nd quarter 3rd quarter
Alabama 76.64 76.64 77.51 77.51 77.53 77.53 77.53 77.53 78.00 75.17 73.29
Alaska 58.68 58.68 61.12 61.12 61.12 62.46 62.46 62.46 62.46 59.58 57.67
Arizona 75.01 75.01 75.93 75.93 75.93 75.93 75.93 75.93 75.93 73.10 71.22
Arkansas 79.14 79.14 80.46 80.46 80.46 81.18 81.18 81.18 81.18 78.30 76.39
California 61.59 61.59 61.59 61.59 61.59 61.59 61.59 61.59 61.59 58.77 56.88
Colorado 58.78 58.78 61.59 61.59 61.59 61.59 61.59 61.59 61.59 58.77 56.88
Connecticut 60.19 60.19 60.19 61.59 61.59 61.59 61.59 61.59 61.59 58.77 56.88
Delaware 60.19 60.19 61.59 61.59 61.78 61.78 61.78 61.78 64.38 61.55 59.67
District of Columbiaa 77.68 77.68 79.29 79.29 79.29 79.29 79.29 79.29 79.29 76.47 74.58
Florida 67.64 67.64 67.64 67.64 67.64 67.64 67.64 67.64 67.64 64.81 62.93
Georgia 73.44 73.44 74.42 74.42 74.96 74.96 74.96 74.96 75.16 72.33 70.45
Hawaii 66.13 66.13 67.35 67.35 67.35 67.35 67.35 67.35 67.35 64.52 62.63
Idaho 78.37 78.37 79.18 79.18 79.18 79.18 79.18 79.18 79.18 76.35 74.47
Illinois 60.48 60.48 61.88 61.88 61.88 61.88 61.88 61.88 61.88 59.05 57.16
Indiana 73.23 73.23 74.21 74.21 75.69 75.69 75.69 75.69 76.21 73.39 71.50
Iowa 68.82 68.82 68.82 70.71 72.55 72.55 72.55 72.55 72.55 69.68 67.76
Kansas 66.28 66.28 68.31 69.41 69.68 69.68 69.68 69.68 69.68 66.81 64.90
Kentucky 77.80 77.80 79.41 79.41 80.14 80.14 80.14 80.14 80.61 77.78 75.90
Louisiana 80.01 80.01 80.01 80.75 81.48 81.48 81.48 81.48 81.48 78.65 76.77
Maine 72.40 72.40 74.35 74.35 74.86 74.86 74.86 74.86 74.86 72.03 70.15
Maryland 58.78 58.78 60.19 61.59 61.59 61.59 61.59 61.59 61.59 58.77 56.88
CRS-20
FY2009 FY2009 FY2009 FY2009 FY2010 FY2010 FY2010 FY2010 FY2011 FY2011 FY2011
State
1st quarter 2nd quarter 3rd quarter 4th quarter 1st quarter 2nd quarter 3rd quarter 4th quarter 1st quarter 2nd quarter 3rd quarter
Massachusetts 58.78 58.78 60.19 61.59 61.59 61.59 61.59 61.59 61.59 58.77 56.88
Michigan 69.58 69.58 70.68 70.68 73.27 73.27 73.27 73.27 75.57 72.74 70.86
Minnesota 60.19 60.19 61.59 61.59 61.59 61.59 61.59 61.59 61.59 58.77 56.88
Mississippi 83.62 83.62 84.24 84.24 84.86 84.86 84.86 84.86 84.86 82.03 80.15
Missouri 71.24 71.24 73.27 73.27 74.43 74.43 74.43 74.43 74.43 71.61 69.72
Montana 76.29 76.29 77.14 77.14 77.99 77.99 77.99 77.99 77.99 75.17 73.28
Nebraska 65.74 65.74 67.79 67.79 68.76 68.76 68.76 68.76 68.76 65.84 63.90
Nevada 63.93 63.93 63.93 63.93 63.93 63.93 63.93 63.93 63.93 61.10 59.22
New Hampshire 56.20 56.20 58.78 60.19 61.59 61.59 61.59 61.59 61.59 58.77 56.88
New Jersey 58.78 58.78 61.59 61.59 61.59 61.59 61.59 61.59 61.59 58.77 56.88
New Mexico 77.24 77.24 78.66 79.44 80.49 80.49 80.49 80.49 80.49 77.66 75.78
New York 58.78 58.78 60.19 61.59 61.59 61.59 61.59 61.59 61.59 58.77 56.88
North Carolina 73.55 73.55 74.51 74.51 74.98 74.98 74.98 74.98 74.98 72.16 70.27
North Dakota 69.95 69.95 69.95 69.95 69.95 69.95 69.95 69.95 69.95 66.95 64.95
Ohio 70.25 70.25 72.34 72.34 73.47 73.47 73.47 73.47 73.71 70.88 69.00
Oklahoma 74.94 74.94 74.94 75.83 75.83 76.73 76.73 76.73 76.73 73.90 72.01
Oregon 71.58 71.58 72.61 72.61 72.87 72.87 72.87 72.87 72.97 70.14 68.25
Pennsylvania 63.05 63.05 64.32 65.59 65.85 65.85 65.85 65.85 66.58 63.76 61.87
Rhode Island 63.89 63.89 63.89 63.89 63.92 63.92 63.92 63.92 64.22 61.39 59.51
South Carolina 78.55 78.55 79.36 79.36 79.58 79.58 79.58 79.58 79.58 76.75 74.86
South Dakota 68.75 68.75 70.64 70.64 70.80 70.80 70.80 70.80 70.80 68.95 67.04
Tennessee 73.25 73.25 74.23 74.23 75.37 75.37 75.37 75.37 75.62 72.79 70.91
Texas 68.76 68.76 68.76 69.85 70.94 70.94 70.94 70.94 70.94 68.11 66.23
CRS-21
FY2009 FY2009 FY2009 FY2009 FY2010 FY2010 FY2010 FY2010 FY2011 FY2011 FY2011
State
1st quarter 2nd quarter 3rd quarter 4th quarter 1st quarter 2nd quarter 3rd quarter 4th quarter 1st quarter 2nd quarter 3rd quarter
Utah 77.83 77.83 79.98 79.98 80.78 80.78 80.78 80.78 80.78 77.95 76.07
Vermont 67.71 67.71 69.96 69.96 69.96 69.96 69.96 69.96 69.96 67.13 65.24
Virginia 58.78 58.78 61.59 61.59 61.59 61.59 61.59 61.59 61.59 58.77 56.88
Washington 60.22 60.22 62.94 62.94 62.94 62.94 62.94 62.94 62.94 60.11 58.23
West Virginia 80.45 80.45 81.70 83.05 83.05 83.05 83.05 83.05 83.05 80.23 78.34
Wisconsin 65.58 65.58 68.77 69.89 70.63 70.63 70.63 70.63 70.63 67.80 65.92
Wyoming 56.20 56.20 56.20 58.78 61.59 61.59 61.59 61.59 61.59 58.77 56.88
Sources: Department of Health and Human Services (HHS), “Notice of Availability of Federal Matching Shares for Medicaid and Foster Care and Adoption Assistance,”
74 Federal Register 18235, April 21, 2009; HHS, “Implementation of Section 5001 of the American Recovery and Reinvestment Act of 2009 for Adjustments to the Third
and Fourth Quarters of Fiscal Year 2009 Federal Medical Assistance Percentage Rates for Federal Matching Shares for Medicaid and Title IV-E Foster Care, Adoption
Assistance and Guardianship Assistance Programs,” 74 Federal Register 64697, December 8, 2009; HHS, “Implementation of Section 5001 of the American Recovery and
Reinvestment Act of 2009 (P.L. 111-5) for Adjustments to the First Quarter of Fiscal Year 2010 Federal Medical Assistance Percentage Rates for Federal Matching Shares
for Medicaid and Title IV-E Foster Care, Adoption Assistance and Guardianship Assistance Programs,” 75 Federal Register 5325, February 2, 2010; HHS, “Implementation
of Section 5001 of the American Recovery and Reinvestment Act of 2009 (P.L. 111-5) for Adjustments to the Second Quarter of Fiscal Year 2010 Federal Medical
Assistance Percentage Rates for Federal Matching Shares for Medicaid and Title IV-E Foster Care, Adoption Assistance and Guardianship Assistance Programs,” 75
Federal Register 22807, April 30, 2010; HHS, “Implementation of Section 5001 of the American Recovery and Reinvestment Act of 2009 (P.L. 111-5) for Adjustments to
the Third Quarter of Fiscal Year 2010 Federal Medical Assistance Percentage Rates for Federal Matching Shares for Medicaid and Title IV-E Foster Care, Adoption
Assistance and Guardianship Assistance Programs,” 75 Federal Register 52530, August 26, 2010; HHS, “Implementation of Section 5001 of the American Recovery and
Reinvestment Act of 2009 (P.L. 111-5) for Adjustments to the Fourth Quarter of Fiscal Year 2010 Federal Medical Assistance Percentage Rates for Federal Matching
Shares for Medicaid and Title IV-E Foster Care, Adoption Assistance and Guardianship Assistance Programs,” 75 Federal Register 66763, October 29, 2010; HHS,
“Implementation of Section 5001 of the American Recovery and Reinvestment Act of 2009 (P.L. 111-5) for Adjustments to the Fourth Quarter of Fiscal Year 2010
Federal Medical Assistance Percentage Rates for Federal Matching Shares for Medicaid and Title IV-E Foster Care, Adoption Assistance and Guardianship Assistance
Programs,” 75 FR 66763, October 29, 2010; HHS, “Adjusted Federal Medical Assistance Percentage (FMAP) Rate for the First Quarter of Fiscal Year 2011,” 76 Federal
Register 5811, February 2, 2011; HHS, “Adjusted Federal Medical Assistance Percentage (FMAP) Rates for the Second and Third Quarters of Fiscal Year 2011 (FY11),” 76
FR 32204, June 3, 2011.
Notes: FMAP = federal medical assistance percentage; ARRA = American Recovery and Reinvestment Act of 2009 (P.L. 111-5).
a. The District of Columbia’s regular FMAP rate has been set at 70% since FY1998 (without this exception, it would be at the statutory minimum of 50%).
CRS-22
Table B-2. Calculation of Increased FMAPs Under ARRA for the Second Quarter of FY2010
Calculation of ARRA FMAP 2nd quarter FY2010
Hold Three- Lowest
harmless: month three-
highest of Hold average month ARRA
FY2008- harmless unemploy- average FMAP
FY2010 plus 6.2 ment unemploy- Unemploy- Unemploy- Unemploy- 2nd
ARRA regular percentage ending ment since ment ment ment quarter
FMAP FMAPs points Dec. 2009 Jan. 2006 difference tier adjustment FY2010
Regular 1st
FMAP quarter G=(100-A-
A B=A+6.2 C D E=C-D F H=B+G
State FY2010 FY2010 3.1)*F%
Alabama 68.01 77.53 68.01 74.21 10.9 3.3 7.6 11.5 3.32 77.53
Alaska 51.43 61.12 52.48 58.68 8.5 6.0 2.5 8.5 3.78 62.46
Arizona 65.75 75.93 66.20 72.40 9.2 3.6 5.6 11.5 3.53 75.93
Arkansas 72.78 80.46 72.94 79.14 7.6 4.8 2.8 8.5 2.04 81.18
California 50.00 61.59 50.00 56.20 12.3 4.8 7.5 11.5 5.39 61.59
Colorado 50.00 61.59 50.00 56.20 7.4 3.6 3.8 11.5 5.39 61.59
Connecticut 50.00 61.59 50.00 56.20 8.7 4.3 4.4 11.5 5.39 61.59
Delaware 50.21 61.78 50.21 56.41 8.6 3.3 5.3 11.5 5.37 61.78
District of 70.00 79.29 70.00 76.20 11.6 5.4 6.2 11.5 3.09 79.29
Columbiaa
Florida 54.98 67.64 56.83 63.03 11.6 3.3 8.3 11.5 4.61 67.64
Georgia 65.10 74.96 65.10 71.30 10.2 4.3 5.9 11.5 3.66 74.96
Hawaii 54.24 67.35 56.50 62.70 6.9 2.2 4.7 11.5 4.65 67.35
Idaho 69.40 79.18 69.87 76.07 9.0 2.8 6.2 11.5 3.11 79.18
Illinois 50.17 61.88 50.32 56.52 10.9 4.4 6.5 11.5 5.36 61.88
Indiana 65.93 75.69 65.93 72.13 9.8 4.4 5.4 11.5 3.56 75.69
Iowa 63.51 72.55 63.51 69.71 6.5 3.7 2.8 8.5 2.84 72.55
CRS-23
Calculation of ARRA FMAP 2nd quarter FY2010
Hold Three- Lowest
harmless: month three-
highest of Hold average month ARRA
FY2008- harmless unemploy- average FMAP
FY2010 plus 6.2 ment unemploy- Unemploy- Unemploy- Unemploy- 2nd
ARRA regular percentage ending ment since ment ment ment quarter
FMAP FMAPs points Dec. 2009 Jan. 2006 difference tier adjustment FY2010
Regular 1st
FMAP quarter G=(100-A-
A B=A+6.2 C D E=C-D F H=B+G
State FY2010 FY2010 3.1)*F%
Kansas 60.38 69.68 60.38 66.58 6.7 4.0 2.7 8.5 3.10 69.68
Kentucky 70.96 80.14 70.96 77.16 10.7 5.4 5.3 11.5 2.98 80.14
Louisiana 67.61 81.48 72.47 78.67 7.3 3.5 3.8 11.5 2.81 81.48
Maine 64.99 74.86 64.99 71.19 8.1 4.4 3.7 11.5 3.67 74.86
Maryland 50.00 61.59 50.00 56.20 7.3 3.4 3.9 11.5 5.39 61.59
Massachusetts 50.00 61.59 50.00 56.20 9.2 4.4 4.8 11.5 5.39 61.59
Michigan 63.19 73.27 63.19 69.39 14.4 6.7 7.7 11.5 3.88 73.27
Minnesota 50.00 61.59 50.00 56.20 7.6 3.9 3.7 11.5 5.39 61.59
Mississippi 75.67 84.86 76.29 82.49 10.4 6.0 4.4 11.5 2.37 84.86
Missouri 64.51 74.43 64.51 70.71 9.6 4.7 4.9 11.5 3.72 74.43
Montana 67.42 77.99 68.53 74.73 6.6 3.2 3.4 8.5 3.26b 77.99
Nebraska 60.56 68.76 60.56 66.76 4.6 2.8 1.8 5.5 2.00 68.76
Nevada 50.16 63.93 52.64 58.84 12.9 4.2 8.7 11.5 5.09 63.93
New Hampshire 50.00 61.59 50.00 56.20 6.9 3.4 3.5 11.5 5.39 61.59
New Jersey 50.00 61.59 50.00 56.20 9.9 4.2 5.7 11.5 5.39 61.59
New Mexico 71.35 80.49 71.35 77.55 8.1 3.5 4.6 11.5 2.94 80.49
New York 50.00 61.59 50.00 56.20 8.9 4.3 4.6 11.5 5.39 61.59
CRS-24
Calculation of ARRA FMAP 2nd quarter FY2010
Hold Three- Lowest
harmless: month three-
highest of Hold average month ARRA
FY2008- harmless unemploy- average FMAP
FY2010 plus 6.2 ment unemploy- Unemploy- Unemploy- Unemploy- 2nd
ARRA regular percentage ending ment since ment ment ment quarter
FMAP FMAPs points Dec. 2009 Jan. 2006 difference tier adjustment FY2010
Regular 1st
FMAP quarter G=(100-A-
A B=A+6.2 C D E=C-D F H=B+G
State FY2010 FY2010 3.1)*F%
North Carolina 65.13 74.98 65.13 71.33 10.9 4.5 6.4 11.5 3.65 74.98
North Dakota 63.01 69.95 63.75 69.95 4.3 3.0 1.3 0.0 0.00c 69.95
Ohio 63.42 73.47 63.42 69.62 10.8 5.3 5.5 11.5 3.85 73.47
Oklahoma 64.43 75.83 67.10 73.30 6.9 3.3 3.6 11.5 3.43 76.73
Oregon 62.74 72.87 62.74 68.94 10.7 5.0 5.7 11.5 3.93 72.87
Pennsylvania 54.81 65.85 54.81 61.01 8.7 4.3 4.4 11.5 4.84 65.85
Rhode Island 52.63 63.92 52.63 58.83 12.5 4.8 7.7 11.5 5.09 63.92
South Carolina 70.32 79.58 70.32 76.52 12.3 5.5 6.8 11.5 3.06 79.58
South Dakota 62.72 70.80 62.72 68.92 4.7 2.7 2.0 5.5 1.88 70.80
Tennessee 65.57 75.37 65.57 71.77 10.7 4.5 6.2 11.5 3.60 75.37
Texas 58.73 70.94 60.56 66.76 8.2 4.4 3.8 11.5 4.18 70.94
Utah 71.68 80.78 71.68 77.88 6.6 2.5 4.1 11.5 2.90 80.78
Vermont 58.73 69.96 59.45 65.65 6.7 3.5 3.2 8.5 4.31b 69.96
Virginia 50.00 61.59 50.00 56.20 6.8 2.8 4.0 11.5 5.39 61.59
Washington 50.12 62.94 51.52 57.72 9.2 4.4 4.8 11.5 5.22 62.94
West Virginia 74.04 83.05 74.25 80.45 8.9 4.2 4.7 11.5 2.60 83.05
Wisconsin 60.21 70.63 60.21 66.41 8.6 4.4 4.2 11.5 4.22 70.63
CRS-25
Calculation of ARRA FMAP 2nd quarter FY2010
Hold Three- Lowest
harmless: month three-
highest of Hold average month ARRA
FY2008- harmless unemploy- average FMAP
FY2010 plus 6.2 ment unemploy- Unemploy- Unemploy- Unemploy- 2nd
ARRA regular percentage ending ment since ment ment ment quarter
FMAP FMAPs points Dec. 2009 Jan. 2006 difference tier adjustment FY2010
Regular 1st
FMAP quarter G=(100-A-
A B=A+6.2 C D E=C-D F H=B+G
State FY2010 FY2010 3.1)*F%
Wyoming 50.00 61.59 50.00 56.20 7.5 2.8 4.7 11.5 5.39 61.59
Sources: Department of Health and Human Services (HHS), “Implementation of Section 5001 of the American Recovery and Reinvestment Act of 2009 (P.L. 111-5) for
Adjustments to the First Quarter of Fiscal Year 2010 Federal Medical Assistance Percentage Rates for Federal Matching Shares for Medicaid and Title IV-E Foster Care,
Adoption Assistance and Guardianship Assistance Programs,” 75 Federal Register 5325, February 2, 2010; HHS, “Implementation of Section 5001 of the American
Recovery and Reinvestment Act of 2009 (P.L. 111-5) for Adjustments to the Second Quarter of Fiscal Year 2010 Federal Medical Assistance Percentage Rates for Federal
Matching Shares for Medicaid and Title IV-E Foster Care, Adoption Assistance and Guardianship Assistance Programs,” 75 Federal Register 22807, April 30, 2010.
Notes: FMAP = federal medical assistance percentage; ARRA = American Recovery and Reinvestment Act of 2009 (P.L. 111-5).
a. The District of Columbia’s regular FMAP rate has been set at 70% since FY1998 (without this exception, it would be at the statutory minimum of 50%).
b. Unemployment adjustments were held harmless (through the first quarter of FY2011) from reductions. Although Montana and Vermont were in the middle
unemployment tier for the second quarter of FY2010, they were previously in the highest tier. As a result, their unemployment adjustments for the second quarter
of FY2010 were calculated as if they were still in the highest tier.
c. North Dakota did not receive an unemployment adjustment because its unemployment rate did not exceed its lowest unemployment rate by at least 1.5 percentage
points.
CRS-26
Medicaid Recession-Related FMAP Increases
Appendix C. Families First Coronavirus Response
Act FMAP Increase
The Families First Coronavirus Response Act (FFCRA; P.L. 116-127) provides an increase to the
FMAP rate for the 50 states, the District of Columbia, and the territories of 6.2 percentage points,
beginning on the first day of calendar quarter in which the public health emergency period began
(i.e., January 1, 2020) and ending on the last day of the calendar quarter in which the last day of
the public health emergency period ends. See the “FFCRA FMAP Increase” section for
information about the state requirements for receiving the FFCRA FMAP increase. Table C-1
shows states’ FY2020 FMAP rates and those FMAP rates plus the 6.2 percentage points added by
FFCRA.
Table C-1. FY2020 Regular FMAP Rates and Regular Rates Plus 6.2 Percentage
Points for the FFCRA FMAP Increase
Last Three Quarters,
First Quarter, Regular FMAP Rates
Regular FY2020 Plus 6.2 Percentage
State FMAP Rates Points
Alabama 71.97 78.17
Alaska 50.00 56.20
American Samoaa 83.00 89.20
Arizona 70.02 76.22
Arkansas 71.42 77.62
California 50.00 56.20
Colorado 50.00 56.20
Connecticut 50.00 56.20
Delaware 57.86 64.06
District of Columbiab 70.00 76.20
Florida 61.47 67.67
Georgia 67.30 73.50
Guama 83.00 89.20
Hawaii 53.47 59.67
Idaho 70.34 76.54
Illinois 50.14 56.34
Indiana 65.84 72.04
Iowa 61.20 67.40
Kansas 59.16 65.36
Kentucky 71.82 78.02
Louisiana 66.86 73.06
Maine 63.80 70.00
Maryland 50.00 56.20
Congressional Research Service 27
Medicaid Recession-Related FMAP Increases
Last Three Quarters,
First Quarter, Regular FMAP Rates
Regular FY2020 Plus 6.2 Percentage
State FMAP Rates Points
Massachusetts 50.00 56.20
Michigan 64.06 70.26
Minnesota 50.00 56.20
Mississippi 76.98 83.18
Missouri 65.65 71.85
Montana 64.78 70.98
Nebraska 54.72 60.92
Nevada 63.93 70.13
New Hampshire 50.00 56.20
New Jersey 50.00 56.20
New Mexico 72.71 78.91
New York 50.00 56.20
North Carolina 67.03 73.23
North Dakota 50.05 56.25
Commonwealth of the
83.00 89.20
Northern Mariana Islandsa
Ohio 63.02 69.22
Oklahoma 66.02 72.22
Oregon 61.23 67.43
Pennsylvania 52.25 58.45
Puerto Ricoa 76.00 88.20
Rhode Island 52.95 59.15
South Carolina 70.70 76.90
South Dakota 57.62 63.82
Tennessee 65.21 71.41
Texas 60.89 67.09
Utah 68.19 74.39
Vermont 53.86 60.06
U.S. Virgin Islandsa 83.00 89.20
Virginia 50.00 56.20
Washington 50.00 56.20
West Virginia 74.94 81.14
Wisconsin 59.36 65.56
Wyoming 50.00 56.20
Sources: The regular FY2020 FMAP rates are from Department of Health and Human Services, “Federal
Financial Participation in State Assistance Expenditures; Federal Matching Shares for Medicaid, the Children’s
Congressional Research Service 28
Medicaid Recession-Related FMAP Increases
Health Insurance Program, and Aid to Needy Aged, Blind, or Disabled Persons for October 1, 2019 Through
September 30, 2020,” 83 Federal Register 61157, November 28, 2018. Congressional Research Service added the
6.2 percentage points for the last column.
Notes: FMAP = federal medical assistance percentage; FFCRA = Families First Coronavirus Response Act (P.L.
116-127).
a. The regular FMAP rates for the territories are statutorily set at 55%. However, for the remainder of
FY2020 and FY2021, the FMAP rates for the territories are increased to 83% for American Samoa,
Commonwealth of the Northern Mariana Islands, Guam, and U.S. Virgin Islands and to 76% for Puerto Rico.
The FFCRA FMAP increase is added to the FMAPs for FY2020 and FY2021 (i.e., 83% and 76%). Centers for
Medicare & Medicaid Services, Families First Coronavirus Response Act (FFCRA), P.L. 116-127 Coronavirus Aid,
Relief, and Economic Security (CARES) Act, P.L. 116-136 Frequently Asked Questions (FAQs), April 13, 2020,
https://www.medicaid.gov/state-resource-center/downloads/covid-19-section-6008-CARES-faqs.pdf.
b. The District of Columbia’s regular FMAP rate has been set at 70% since FY1998 (without this exception, it
would be at the statutory minimum of 50%).
Author Contact Information
Alison Mitchell
Specialist in Health Care Financing
#redacted#@crs.loc.gov , 7-....
Congressional Research Service R46346 · VERSION 1 · NEW 29
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