To better understand how states develop their nursing facility payment policies, MACPAC contracted with RTI International to interview state officials and stakeholders in seven states (Alabama, Colorado, Kansas, New York, Rhode Island, Utah, and Wisconsin). This presentation reviewed themes that emerged about the barriers to increasing the use of value-based payments, the factors that affect states’ use of supplemental payments, and how managed care affects Medicaid payments to nursing facilities. In addition, the presentation reviewed early findings about how states are changing their payment policies in response to the COVID-19 pandemic and recent changes in Medicare nursing facility payment policy.