U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services
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This report was prepared under contract #HHS-100-97-0013 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Mathematica Policy Research, Inc. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, John Drabek, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. His e-mail address is: jdrabek@osaspe.dhhs.gov.
In 1999, for the first time, nationwide person-level electronic Medicaid data became available from the Centers for Medicare & Medicaid Services (CMS). Previously, routine Medicaid data on enrollment, utilization and expenditures were based on a combination of aggregate manual and electronic reports submitted by the states as part of form 2082. Although useful, the 2082 data were limited in scope, and had recurring issues of data quality. To address the need for more accurate, consistent and complete Medicaid data, the Balanced Budget Act of 1997 mandated that all states submit detailed, automated enrollment and claims data effective January 1, 1999 to the Medicaid Statistical Information System (MSIS) maintained by CMS. This new reporting requirement greatly expanded the information available for Medicaid analysis and research. In 1999, CMS also implemented stringent editing and data validation procedures to improve the quality of Medicaid data submitted to the MSIS system. Appendix A provides an overview of MSIS reporting requirements and information submitted by states.
In this report, the new MSIS enrollment data are utilized to provide detailed information on Medicaid eligibility patterns and managed care participation in calendar year 1999. A series of 14 tables were constructed for each of the 50 states and the District of Columbia, and then summarized at the national level. Key findings from the national tables for 1999 include:
Monthly Enrollment. Monthly Medicaid enrollment grew from 32.2 million in January to 34 million in December 1999, for a 6 percent growth rate in monthly enrollment during the year. State 1115 demonstration programs and Medicaid expansions attributable to State Children Health Insurance Programs (SCHIP) accounted for most of the growth. Growth in monthly enrollment was widespread, with 37 states and the District of Columbia reporting increases.
Turnover. Study results confirmed that Medicaid is a dynamic program, with persons entering and leaving throughout the year. About 42.7 million persons were ever enrolled in Medicaid at any point during 1999, compared to the December 1999 enrollment level of 34 million. Thus, 8.7 million individuals were enrolled in Medicaid at some point during 1999, but were no longer enrolled at year end. The persons who lost enrollment represent about 20 percent of those ever enrolled during the year, providing a lower bound measure of program turnover. Adults or parents had the highest turnover rate, followed by children, disabled, and aged persons. Turnover is a particularly important consideration in a managed care environment since Medicaid managed care plans are most efficient when investments in preventive care have sufficient time to reap benefits.
Enrollment Duration. Although complete episodes of enrollment could not be measured with just one year of data, study results provided some information on Medicaid enrollment duration. Overall, about 55 percent of those enrolled in Medicaid during 1999 were enrolled all 12 months of the year, with considerable variation by eligibility group. About 72 percent of aged persons and 79 percent of disabled persons on Medicaid during 1999 were enrolled for the entire year, compared to 52 percent of children and 36 percent of adults.
Managed Care Enrollment. Less than 50 percent of Medicaid eligibles were enrolled in a managed care plan that managed their acute medical services at the end of 1999. About 35 percent were enrolled in what MSIS refers to as comprehensive managed care organizations (labeled HMOs for health maintenance organizations in the tables), and another 11 percent were enrolled in primary care case management (PCCM) plans. An additional 9 percent were enrolled in other types of prepaid health plans, such as behavioral health plans (BHPs) or dental plans, bringing the total enrollment in any kind of managed care plan to 55 percent.
Managed Care Patterns by Eligibility Group. Managed care enrollment patterns varied by eligibility group. Persons eligible for Medicaid as a result of the cash assistance rules -- either related to the Supplemental Security Income (SSI) program or the Section 1931 provisions covering Aid to Families with Dependent Children (AFDC) -- were more likely to be enrolled in HMOs or PCCMs than persons qualifying for Medicaid through other eligibility groups. Overall, 69 percent of AFDC children (Section 1931) and 65 percent of AFDC adults (Section 1931) were either in an HMO or a PCCM, whereas only 33 percent of SSI disabled persons and 16 percent of SSI aged persons received care in that form. HMOs were the preferred method of care of AFDC children, with 57 percent in HMOs and another 13 percent in PCCMs. PCCMs played a relatively larger role for SSI disabled persons, with 21 percent in HMOs and another 11 percent in PCCMs.
Managed Care Patterns by State. States differed dramatically in the number of eligibles enrolled in Medicaid managed care and the types of managed care they used. Tennessee, for example, enrolled its entire Medicaid population in HMOs, while Alaska, Louisiana and Wyoming did not use any type of managed care for Medicaid enrollees in 1999. Of the two largest states, California had 42 percent of Medicaid eligibles enrolled in HMOs and less than 1 percent in PCCMs, while New York had 23 percent of its Medicaid population enrolled in HMOs and about 1 percent in PCCMs. Some states had almost no one enrolled in HMOs, but made significant use of the PCCM approach. For example, North Carolina had 58 percent of its Medicaid population in PCCMs, while Georgia had 61 percent.
Managed Care Patterns by Age. The likelihood of being in any type of managed care generally declined with age. About 43 percent of children under age 21 were enrolled in HMOs, compared to 31 percent of working age adults (ages 21 through 64 years) and 10 percent of Medicaid enrollees age 65 or older. The working age adult group included both parents and disabled persons. Another 15 percent of children under age 21, 8 percent of working age adults and 2 percent of persons 65 or older were enrolled in PCCMs.
Managed Care Patterns for Dual Eligibles. Eligibility for Medicare influences managed care participation. States are less likely to enroll persons who are dually eligible for Medicaid and Medicare in Medicaid managed care plans because of the difficulty in managing the services covered by Medicare. Just under 88 percent of aged Medicaid enrollees and 37 percent of disabled Medicaid enrollees were dually eligible for Medicaid and Medicare in 1999, according to MSIS data. Generally, aged and disabled dual eligibles were less likely to enroll in some type of managed care than aged and disabled Medicaid enrollees not qualifying for Medicare. About 11 percent of aged dual eligibles were enrolled in HMOs or PCCMs, compared to 18 percent of aged enrollees who were not dual eligibles. Similarly, 14 percent of disabled dual eligibles were enrolled in HMOs or PCCMs, compared to 25 percent of disabled enrollees who were not dual eligibles.
Enrollment in Multiple Managed Care Plans. Just over 37 percent of the Medicaid population were only enrolled in one type of managed care, while 18 percent were enrolled in more than one type of plan. The two most frequent combinations were HMOs with dental plans, and HMOs with BHPs. The California and Tennessee Medicaid programs accounted for most of the enrollment in multiple plans.
Exhibit 1 lists the 14 tables developed for each state which were then compiled at the national level (the county information could not be presented at the national level). For all 52 sets of tables, the first five show annual counts for 1999, and Tables 6-14 present data for December 1999. Many tables have more than one version to show, for example, percent distributions or enrollment for different subpopulations by eligibility group, age or sex. Such "families" of tables are numbered 1A, 1B, and so on.
Exhibit 2 describes the population reported into each of the major Medicaid eligibility groups used throughout the tables. Exhibit 3 describes the Medicaid managed care plan types for which MSIS data are reported.
This document presents the national level tables along with a description of each and a discussion of the findings. Generally, the national level tables do not present state-by-state results. However, in a couple of instances, special national tables with state-by-state results are included. As mentioned earlier, Appendix A provides an overview of MSIS reporting requirements and Medicaid information submitted by states. Appendix B addresses data quality, based on comparisons of the MSIS results to other data sources on Medicaid managed care enrollment. Generally, aggregate totals of MSIS Medicaid managed care enrollment corresponded well with those from CMS surveys of managed care plans. Appendix C includes footnotes for each state that provide state-specific detail on unusual patterns or shortcomings in the data. The state-level tables will be available at the website for the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services.
| EXHIBIT 1. State- and National-Level Tables |
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| EXHIBIT 2. Medicaid Eligibility Groups |
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| Cash Assistance Groups. Eligibility groups 11-17 include persons qualifying for Medicaid because they either receive Supplemental Security Income (SSI) benefits, or they would have qualified under the pre-welfare reform Aid to Families with Dependent Children (AFDC) rules, hence the name "cash assistance groups." Although the 1996 welfare reform legislation replaced AFDC with the Temporary Assistance to Needy Families (TANF) program, state Medicaid programs continue to use 1996 AFDC rules to determine eligibility for Medicaid. Sometimes the AFDC groups 14-17 are referred to as the Section 1931 groups, after the section of the Social Security Act providing the rules for Medicaid AFDC-related eligibility after welfare reform. |
| Medically Needy Groups. Eligibility groups 21-25 include aged and disabled individuals, as well as children and adults qualifying for Medicaid through the medically needy provisions. Providing coverage for the medically needy is optional, and 37 states in 1999 extended Medicaid eligibility to some or all of the medically needy groups. States that cover medically needy groups use a higher income threshold than the AFDC cash assistance level to determine eligibility. In addition, applicants with income above the medically needy thresholds must be allowed to qualify for Medicaid by "spending down," a provision that allows applicants to deduct incurred medical expenses from their income to determine financial eligibility for Medicaid. |
| Poverty-related Groups. Eligibility groups 31-35 include persons who qualify for Medicaid through any of the poverty-related expansions enacted from 1988 on. States must cover certain groups under the poverty-related provisions, while coverage for others is optional. For instance, states are required to extend limited Medicaid coverage related to some or all of the Medicare cost-sharing (premiums, copayments and deductibles) to Medicare-eligible aged and disabled enrollees whose income is below 100 to 175 percent of the federal poverty level (FPL). Included in the aged and disabled poverty-related groups are Qualified Medicare Beneficiaries (QMBs), Specified Low-Income Medicaid Beneficiaries (SLMBs), and Qualified Individuals (QI-I and II). States also have the option to extend full Medicaid benefits to all aged and disabled persons with income under 100 percent of the FPL. In 1999, 12 states elected this option. Providing coverage for children and adults in poverty-related eligibility groups 34-35 is also part mandatory, part optional. States must extend full Medicaid benefits to all children under 6 years of age and to all pregnant women with family income below 133 percent of the FPL. In addition, states are required to cover all children born after September 30, 1983, with family income below 100 percent of the FPL. At their option, most states have elected to use considerably higher income thresholds for their poverty-related child and adult coverage. In particular, many states have used the enhanced federal matching available through the State Child Health Insurance Program (SCHIP) to establish higher poverty-related income thresholds in Medicaid for children. |
| Other Groups. Eligibility groups 41-48 include individuals who qualify for Medicaid through a mixture of mandatory and optional coverage not reported under the other eligibility groups. Groups 41 and 42 include many institutionalized aged and disabled persons, as well as those qualifying for Medicaid through hospice and home- and community-based care waivers. These groups also include special subgroups of aged and disabled individuals who lost SSI benefits due to increases in Old-Age, Survivors and Disability Insurance (OASDI) benefits or other changes. Groups 44 and 45 include children and adults qualifying for up to 12 months of transitional medical assistance because family earnings caused them to lose AFDC eligibility. States that offer presumptive Medicaid eligibility and/or a guarantee of continuous Medicaid eligibility usually report this coverage in groups 44 and 45, although in a few states, these individuals are reported in groups 34 and 35. States are required to extend emergency Medicaid benefits to immigrants, including undocumented individuals, who would otherwise qualify for Medicaid except for their immigrant status. These immigrants are part of groups 41 through 45. Finally, group 48 includes children in foster care and adopted children. |
| 1115 Groups. Eligibility groups 51-55 include persons qualifying for Medicaid under an 1115 waiver demonstration, an optional coverage provision for states. In some states, individuals in the 1115 groups only qualify for limited Medicaid benefits. For example, some states provide only limited family planning benefits to 1115 adults, while others provide only pharmaceutical benefits to 1115 aged and disabled enrollees. However, a few states provide full Medicaid benefits to persons qualifying through 1115 provisions. |
| EXHIBIT 3. Types of Managed Care |
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Enrollment in eight types of managed care is reported in the MSIS
data. In MSIS, managed care is defined as any program in which Medicaid makes a
capitated payment, and some risk is assumed by the provider.
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Table 1A shows the distribution of Medicaid enrollment for each month of 1999 by the 23 eligibility groups used in CMS reporting. This is the first time national Medicaid enrollment data have been reported on a monthly basis. Before 1999, CMS was only able to report the number of people ever enrolled in Medicaid at some point during the year. However, the 1999 MSIS allows CMS to compile monthly enrollment information for Medicaid, both at the national and state levels, in addition to the annual data.
Monthly information greatly expands the analytic power of CMS Medicaid data. Enrollment patterns can now be tracked at a precise level. Exactly when changes in enrollment occur can now be pinpointed, as well as the groups that are affected. Monthly data also make it easier to compare CMS Medicaid data to existing state level data, since most state-generated Medicaid reports and statistics use monthly or average monthly data. Finally, the monthly enrollment data can be used in combination with the annual "ever enrolled" data to calculate a lower bound estimate of turnover in each state's Medicaid enrollment (this analysis follows in Table 2). Although not undertaken for this study, analysts can also use monthly MSIS data to track individual enrollment patterns over time.
In addition to the national level data in Table 1A, Table 1B shows monthly Medicaid enrollment during the first and last month of 1999 for each state, with separate columns for aged, disabled, child and adult enrollees. Table 1B shows which individual states experienced growth in monthly Medicaid enrollment during the year. However, these data should not be used without consulting the state specific footnotes, since the month-to-month enrollment data in some states have problems.
Table 1A shows that, during 1999, Medicaid enrollment nationwide grew from 32.2 million in January to 34 million in December. This represents an increase of 1.8 million in monthly enrollment during the year, or 6 percent growth. However, over half of the growth during the year is attributable to an expansion of coverage to about one million women in California (eligibility group 55) at year end. Persons in this expansion group qualified only for limited Medicaid benefits related to family planning under an 1115 waiver extension.
Including the California expansion, adult enrollment increased over 19 percent during 1999. Parental enrollment in 1999 would have been up about 1.5 percent without the expansion in California. Child enrollment increased by 550,000 during the year, for a growth rate of about 3.4 percent. Disabled enrollment grew about 2.4 percent during the year. Growth in aged enrollment was negligible, at 0.3 percent.
During the year, monthly enrollment averaged about 32.7 million (data in the last column). On average, half of Medicaid enrollees, or 16.4 million, were children. About 6.6 million were disabled individuals, 6 million were parents or other caretaker relatives and pregnant women (all reported under the adult grouping), and 3.6 million were aged. On average during the year, about 44 percent of individuals qualified for Medicaid because they either received SSI benefits or qualified under the AFDC rules in effect in before the 1996 federal welfare reform legislation.
According to Table 1B, 37 states and the District of Columbia reported increases in monthly Medicaid enrollment from January to December during 1999. The following nine states had growth in monthly enrollment during 1999 exceeding 10 percent: Alaska (32.7 percent), California (21.5 percent), Maryland (21.4 percent), Oklahoma (19.6 percent), Vermont (17.9 percent), Missouri (17.3 percent), Rhode Island (15.1 percent), Indiana (13.3 percent), and Wisconsin (12.2 percent). Modest declines were reported in monthly enrollment levels by year end for 13 states, including Georgia, Hawaii, Iowa, Michigan, Nevada, New Jersey, New York, Ohio, Oregon, Texas, Utah, Virginia and West Virginia.
For aged enrollees, Vermont showed the greatest percent growth in monthly enrollment, with almost a 16 percent increase by year end. This resulted in part from Vermont's special 1115 program extending pharmacy benefits to dual eligibles (who were not otherwise eligible for Medicaid benefits except for Medicare cost-sharing expenses).
For disabled enrollees, Utah showed the greatest percent growth in monthly Medicaid enrollment, with an increase of almost 10 percent by year end. Although Maryland and South Carolina appear to report large increases in disabled enrollment, footnotes to Table 1B indicate that the year end levels of disabled enrollment in these states are misleading since they largely reflect reporting anomalies.
For child enrollees, Alaska and Oklahoma showed the greatest percent growth in monthly enrollment, with 50 and 34 percent more children, respectively, enrolled in December than were enrolled in January. This resulted in part from enrollment growth in the State Children Health Insurance Program (SCHIP) that extended Medicaid coverage to additional children in each state.
For adult enrollees, several states had extraordinary growth in monthly enrollment during 1999: California (an increase of 96 percent from January to December 1999), Missouri (87 percent), Wisconsin (57 percent), Rhode Island (31 percent), and Vermont (30 percent). In all of these states except Rhode Island, the growth stemmed from 1115 demonstrations. As noted above, the California 1115 demonstration provided adults with only family planning services, not full Medicaid benefits. The Rhode Island growth in adult enrollment resulted from its expanded 1931 rules related to AFDC coverage.
Table 2A shows the number of persons ever enrolled in Medicaid during 1999 (column 13), and the duration of enrollment during 1999 (columns 1-12) by eligibility group. Individuals were included in the eligibility group under which they were enrolled for the longest time during the year. That is, if an individual was enrolled under the medically needy child group for three months and under the poverty-related child group for six months, the full nine months of enrollment for that individual was counted in the poverty-related child group. Table 2B converts the data in Table 2A to a percent distribution.
For many years, CMS has reported the number of persons ever enrolled during the year by Medicaid eligibility group (column 13), so this type of information is not new. However, using this information in conjunction with the monthly enrollment data in Table 1 is new and allows CMS to calculate a lower bound estimate of turnover in Medicaid enrollment across states and across eligibility groups.1 Enrollment at the end of the year in December (from Table 1) can be compared to the number of people ever enrolled during the year (column 13 of Table 2) to measure the rate at which people have departed the program and to determine the extent to which this rate varied by eligibility group and/or by state. In recent years, turnover has become a major concern, particularly for children. Research has shown that many uninsured children who appeared to be Medicaid eligible, were previously enrolled in Medicaid, but no longer are participating. With MSIS data, analysts now have some information for determining the extent to which turnover is occurring among eligibility groups across states.
Information on enrollment duration during the year is also new, but these data have to be interpreted with caution. The distribution of enrollment durations could be skewed if there was substantial growth in an eligibility group during the year. For example, a very low proportion of the 1115 adult group (group 55) was enrolled all 12 months of 1999 because the size of the group almost doubled at year end. It is also better to measure enrollment duration over a longer time period, since individuals can have enrollment spells that last many years. Nevertheless, these data provide useful information when used appropriately.
About 42.7 million persons were ever enrolled in Medicaid at any point during 1999, compared to the December, 1999 enrollment level of 34 million. Thus, 8.7 million individuals were enrolled in Medicaid at some point in 1999, who were no longer enrolled at year end.
In 1999, 21.4 million children were enrolled at some point during the year, with 16.7 million enrolled at year end. This means 4.7 million children were enrolled in Medicaid during 1999, but had lost enrollment by year end. The children who lost enrollment represent about 22 percent of those ever enrolled during the year, providing a measure of program turnover. This level of turnover is not necessarily inappropriate. Some children who leave Medicaid "age out" of eligibility. Others leave Medicaid because family income exceeds the Medicaid financial standards. In addition, some children leaving Medicaid become eligible for separately administered State Children Health Insurance Programs (SCHIP), or they become privately insured. However, given that many uninsured children are reported to be Medicaid eligible but not enrolled, a state with a relatively high rate of turnover for children may want to investigate whether some children may be disenrolled from Medicaid inappropriately.
Using this same measure of turnover, 15 percent of the aged lost enrollment during the year. Previous research suggests that, once enrolled, the majority of the elderly remain on Medicaid until death. Persons who were disabled had the lowest turnover rate, with only 9 percent of those ever enrolled in 1999 no longer enrolled at year end.
The highest turnover rate occurred with adults, the eligibility group encompassing parents, caretaker relatives and pregnant women. About 28 percent of adults enrolled during the year were not enrolled at year end.
About 55 percent of those ever enrolled during the year, or 23.5 million individuals, were enrolled in Medicaid in all 12 months of 1999.
Aged and disabled individuals receiving SSI benefits (groups 11 and 12) were enrolled longer during the year than any other eligibility group, with about 85 percent of eligibles remaining enrolled in Medicaid the entire year.
The poverty-related adult group, which includes pregnant women (group 35) was enrolled for the least amount of time over the year, with only about 16 percent of eligibles remaining enrolled the entire year. This is not unexpected, since women in this group are generally only enrolled in Medicaid from a few months into pregnancy through 60 days postpartum.
In general, disabled and aged persons were enrolled for longer than were persons in the child and adult groups in 1999. The four summary rows at the bottom of the table show that persons in the disabled groups were enrolled the longest of any group during 1999: 79 percent of disabled persons were enrolled all 12 months, compared to 72 percent of persons in the aged group. In contrast, about 52 percent of children and 36 percent of adults were enrolled the entire year. However, the duration of child enrollment was effectively reduced by newborns, while the duration of adult enrollment was reduced by pregnant women and the year end addition of the large 1115 group in California that was enrolled for only one month in 1999.
Tables 3A shows the number of Medicaid beneficiaries enrolled in any of the eight types of managed care plans during each month of 1999. The last column presents a monthly average for 1999. The state-specific footnotes describe the type of plan included in the "other" category. Persons could be counted in Table 3A more than once during a month if they were enrolled in more than one managed care plan. As a result, the table presents a "duplicated" count of enrollees. (An unduplicated count follows in Table 4.) Table 3B converts the data in Table 3A to a percent distribution by month; the percentages reflect the duplicated count in Table 3A.
Much of this information has not been available in the past. The number of persons enrolled in different types of Medicaid managed care each month was not reported in 2082 data. The only nationwide data on enrollment in Medicaid managed care from CMS has been the number of persons in different types of Medicaid managed care in June of each year (nationwide and at the state level). Since managed care enrollment levels can fluctuate during the year, this more comprehensive information in Table 3A is a useful addition. The MSIS data also provide enrollment for several types of managed care not explicitly reported in the other CMS data, including BHPs, dental plans, prenatal/delivery plans, LTC plans, and PACE plans.
On average during 1999, 11.6 million Medicaid eligibles, or just over one-third of the Medicaid beneficiaries, were enrolled in HMOs. Close to 5 million individuals were enrolled in dental managed care plans under Medicaid; 3.6 million were enrolled in PCCMs; and 3.3 million were enrolled in BHPs. Enrollment in three types of plan -- prenatal/delivery, long-term care and PACE -- was considerably smaller, with a combined total of 44,000 a month nationwide. Finally, almost 900,000 Medicaid beneficiaries were enrolled on average in "other" managed care plans during 1999.
During 1999, the number of Medicaid enrollees in each of the eight types of managed care increased each month. HMO enrollment increased by just over 2 percent from January to December. BHP enrollment grew by 10 percent, PCCM enrollment grew 8 percent, and dental plan enrollment increased by less than 1 percent. Enrollment in the prenatal/delivery plans and "other" plans increased at even greater rates, but these plans continued to be relatively small nationwide relative to the other types of plans.
Although not explicitly reported in Table 3A, all but 3 states (Alaska, Louisiana, and Wyoming) reported some enrollment in at least one type of Medicaid managed care during the year. The number of states reporting enrollment in each type of managed care was as follows: HMO -- 45 states; dental -- 3 states; BHP -- 13 states; prenatal/delivery -- 1 state; LTC -- 1 state; PACE -- 6 states; PCCMs -- 28 states; and "other" -- 9 states.
Table 4A presents an unduplicated count of Medicaid managed care enrollment nationwide, showing, for each month, the number of Medicaid enrollees in only one type of managed care plan as well as the number in more than one type of plan. Table 4B converts the data in Table 4A to a percent distribution by month. The last column of the tables presents average monthly data.
Table 4C provides state-by-state information, showing monthly Medicaid enrollment by plan type combination for each state during December 1999. This table indicates the extent to which individual states were using various types of managed care, including combinations with more than one plan.
This information on Medicaid managed care is completely new and confirms that a sizeable proportion of Medicaid eligibles participated in more than one type of managed care plan during 1999.
In every month of 1999, about 55 percent of Medicaid beneficiaries were enrolled in some type of managed care. Just over 37 percent were enrolled in only one type of managed care plan, while 18 percent were enrolled in more than one type of plan. The two most frequent combinations were HMO/dental and HMO/BHP. Enrollment patterns changed little from month to month over the year.
On average and in every month, 20 percent of beneficiaries were enrolled only in an HMO, 8 percent only in a PCCM, 6 percent only in a dental plan, 8 percent in an HMO and dental combination, and 6 percent in an HMO and BHP plan combination. An additional 1.7 percent were enrolled in a PCCM/BHP combination, while 1.4 percent were enrolled solely in a BHP. Enrollment in other single or combination plan types was less than 4 percent.
As depicted in Table 4C, the December MSIS data show that two states accounted for most of the enrollment in more than one managed care plan. California's Medicaid program accounted for almost all the enrollees in the HMO/dental plan combination. Of the 2.6 million enrollees in the HMO/dental combination in December 1999, 2.5 million were from California. Similarly, Tennessee's Medicaid program accounted for about two-thirds of the enrollment in the HMO/BHP combination (1.3 of the 2.1 million enrollees in the HMO/BHP combination).
In 1999, about 23.5 million persons were enrolled in Medicaid all 12 months of the year. For these individuals, Table 5 shows the number who were enrolled in HMOs and PCCMs for the entire year and those who were enrolled in HMOs or PCCMs for 6 to 11 months. The count in this table is duplicated, since an individual could have been enrolled in an HMO for 6 months and then in a PCCM for 6 months, in which case he or she would have been counted twice.
This information was not previously available from CMS and sheds light on the extent to which persons on Medicaid participated in HMOs and PCCMs year round. Continuity in enrollment is a critical component for Medicaid managed care to work as expected.
Of the 23.5 million persons continuously enrolled in Medicaid for all of 1999, about 30 percent were continuously enrolled in HMOs, and about 8 percent were continuously enrolled in PCCMs.
While Tables 1-5 provided annual information for 1999, Tables 6-14 provide information from MSIS for a one month time period. By limiting the time period to one month, more detailed information from the MSIS data base can be used. Table 6A shows the number of Medicaid enrollees in each type of managed care plan by age group in December 1999. The count is duplicated since individuals could have been enrolled in more than one type of managed care plan, in which case, they would have been counted more than once. It is important to note that the working-age adult group (21 to 64 years) includes both disabled enrollees and adult enrollees who are parents, caretaker relatives or pregnant women. Table 6B converts the data in Table 6A to a percent distribution by age cohort; percentages reflect the duplicated counts in Table 6A.
National data on Medicaid managed care participation by age cohort have not been available before. Thus, in the past, it was not possible to determine the extent to which age groups, such as infants or the very old, were participating in various types of managed care plans.
In December 1999, the likelihood of being enrolled in any type of Medicaid managed care generally declined with age except for infants. About two-thirds of Medicaid children ages 1 to 15 were enrolled in some type of managed care. About 60 percent of infants were enrolled in some type of managed care, slightly below the rate for children in the 1-to-15-year-old group. The rate dropped to 56 percent for enrollees age 15 to 20. Just under half of working-age adults (age 21-64) were enrolled in some type of managed care plan. For persons age 65 or older, the likelihood of enrollment in a managed care plan was lower still and declined with age. Of those in the 65-to-74-year-old group, 33 percent were enrolled in some type of managed care, compared to 27 percent in the 75-to-84-year-old group and 21 percent of those over age 85.
For infants, children and working-age adults, the highest managed care participation rates were for HMOs, followed by PCCMs, dental plans, and BHPs. Medicaid enrollees age 65 or older were most likely to be enrolled in dental managed care plans, followed by HMOs and then BHPs. Only one to two percent of aged Medicaid enrollees were reported to be enrolled in PCCM plans.
Children were almost twice as likely as working-age adults to be enrolled in PCCM plans. However, most of the disabled individuals are included in the working-age adult population, so this may explain the difference.
Table 7A shows the number of Medicaid beneficiaries, by age group, enrolled in one plan type or plan type combinations in December 1999. The count is unduplicated. Table 7B converts the data in Table 7A to a percent distribution by age cohort.
Of the 18.6 million children under age 21 on Medicaid in December 1999, about 27 percent were only enrolled in HMOs. Another 11 percent were only enrolled in PCCM plans. About 10 percent were enrolled in an HMO and a dental managed care plan, and about 6 percent were enrolled in an HMO and a BHP. Finally, about 4 percent were only enrolled in dental managed care plans.
Working-age adults (age 21 to 64) on Medicaid numbered 11.1 million in December 1999. A slight majority of this group (52 percent) were not enrolled in any type of managed care plan. About 15 percent were only enrolled in an HMO. About 8 percent were enrolled in an HMO and a BHP, and about 7 percent were enrolled in an HMO and a dental managed care plan. Another 5 percent were only enrolled in a PCCM plan. Finally, just under 7 percent were only enrolled in dental managed care plans.
Among the elderly on Medicaid in December 1999, the vast majority (72 percent) were not enrolled in any form of managed care. About 13 percent were enrolled in dental managed care plans. Another 10 percent were enrolled in HMOs, sometimes in combination with dental plans and/or BHPs.
Table 8A shows the number of Medicaid enrollees, by eligibility group, in each of the eight types of managed care plans in December 1999 The count is duplicated because an individual could have been enrolled in more than one type of plan, in which case he or she would have been counted more than once. Table 8B converts the data in Table 8A to a percent distribution; the percentages reflect the duplicated counts in Table 8A.
Data have not been available in the past showing the differences in managed care enrollment across Medicaid eligibility groups. A priori, it seemed likely that all the medically needy groups, the poverty-related aged and disabled groups, and the other aged and other disabled groups would have relatively lower rates of managed care enrollment. The medically needy often have intermittent Medicaid eligibility due to the spend-down requirements, making it more difficult for them to have the continuity in enrollment important to managed care. The poverty-related aged and disabled would not be likely to enroll in managed care plans in many states, since their Medicaid benefits are limited to Medicare cost-sharing expenses. The other aged and other disabled groups include many of the institutionalized, making them less likely to enroll in managed care.
Although managed care enrollment numbers are reported for the 1115 eligibility groups in Table 8A, they are analyzed separately, since the 1115 demonstration programs across states vary considerably in their size and focus.
Overall, 25 percent of aged individuals and 43 percent of disabled individuals on Medicaid were enrolled in some type of managed care in December 1999. Those in the SSI-related eligibility groups were most likely to be managed care participants, with 38 percent of SSI aged and 50 percent of SSI disabled persons enrolled in some type of managed care plan. For SSI aged persons, about 22 percent were enrolled in dental plans, 13 percent were in HMOs, 7 percent were in BHPs and less than 3 percent were in PCCMs. Among SSI disabled persons, 21 percent were enrolled in HMOs, 15 percent were in dental plans, 12 percent were in BHPs and 11 percent were in PCCMs. Only 31 percent of the aged and 22 percent of the disabled medically needy groups reported any managed care plan enrollment. As expected, the rates were lower for the poverty-related and other aged and disabled groups.
Similarly, children and adults in the AFDC cash assistance-related (Section 1931) groups were more likely to be enrolled in some type of managed care plan than children and adults in any of the other eligibility groups. The overall managed care participation rate for children on Medicaid was 67 percent, but it was 76 percent for AFDC children. The overall rate for parents or adults was 52 percent, but 72 percent for AFDC adults. For the remaining child eligibility groups, 69 percent of children in the other eligibility group were enrolled in some type of managed care plan, compared to 66 percent of children in the medically needy group and 60 percent of children in the poverty-related group. Only 42 percent of foster care children were enrolled in some type of managed care plan, the lowest managed care participation rate for children.
Compared to AFDC adults, the managed care enrollment rates for medically needy adults and other adults were lower with 52 percent and 60 percent, respectively, enrolled in some type of managed care plan. Only 33 percent of poverty-related adults were enrolled in some type of managed care. This lower rate probably results in part because this group consists entirely of pregnant or post-partum women.
About 89 percent of children and 82 percent of disabled individuals who were eligible for Medicaid through state 1115 demonstration programs were enrolled in some type of managed care plan. In contrast, only 31 percent of 1115 adults were enrolled in some type of managed care. However, a majority of the 1115 adults only qualified for limited family planning benefits. None of the 1115 aged were in managed care. (Only Vermont reported any 1115 aged enrollees, and their benefits were limited to pharmaceutical coverage and Medicare cost-sharing.)
Table 9A shows the number of Medicaid beneficiaries, by eligibility group, enrolled in only one plan type or the various plan type combinations in December 1999. The counts in this table are unduplicated. Table 9B converts the data in Table 9A to a percent distribution by eligibility group.
As with Table 8, the findings for 1115 eligibles are analyzed separately.
Overall, 23 percent of adults, 21 percent of children, 13 percent of disabled persons, and 6 percent of aged persons were enrolled in more than one type of managed care plan in December 1999.
Most of the children and adults in more than one type of managed care plan were in the AFDC and medically needy eligibility groups, and they were in the HMO/dental plan combination. As discussed earlier, California accounted for the vast majority of children and adults enrolled in HMO and dental plan combinations.
Aged and disabled persons in the SSI groups were more likely to be in more than one type of managed cared than aged and disabled persons in the other eligibility groups. About 9 percent of aged SSI enrollees and 14 percent of disabled SSI enrollees were in more than one type of managed care plan.
Over 77 percent of persons in the 1115 disabled group were enrolled in an HMO and a BHP, as were about 50 percent of the 1115 children and 13 percent of the 1115 adults. TennCare 1115 enrollees were the dominant population in all these groups, except 1115 adults.
Table 10A shows managed care enrollment patterns for two groups of special interest to policymakers: disabled persons and children in foster care. For both groups, results are presented by age. For disabled persons, results are also stratified by eligibility group. Tables 10B and 10C present the same information for females and males, respectively. These special compilations of data on disabled and foster care enrollees were requested by OASPE staff. The counts in these three tables are duplicated, since an individual could have been enrolled in more than one type of managed care plan in December 1999, in which case he or she would have been counted more than once. Tables 10D-F convert the data in Tables 10A-C to a percent distribution; percentages reflect the duplicated counts in Tables 10A-C.
Three age groups are used for disabled persons: under age 21, age 21-64, and age 65 and older. Unlike other Medicaid eligibility groups, disabled persons can be any age. Children can qualify as disabled if they have medically determinable physical or mental impairment which result in marked and severe functional limitations that are expected to last for a continuous period of not less than 12 months, or to result in death.2 Low-income working age adults are considered disabled if they are unable to engage in substantial gainful activity by reason of any medically determinable mental or physical impairment which can be expected to result in death or can be expected to last for a continuous period of not less than 12 months. Finally, some (but not all) states report persons age 65 and over as disabled. Generally, disabled persons who are age 65 or over in Medicaid data are persons who initially qualified for Medicaid as disabled who continue to be reported in the disabled eligibility group when they turn age 65. Six age groups are used for foster care children: less than 1 year, 1 to 4 years, 5 to 9 years, 10 to 14 years, 15 to 18 years and over age 18.
As reported earlier, in December 1999, just over half (57 percent) of the disabled enrolled in Medicaid were not enrolled in any type of managed care plan (Table 10D). The pattern is similar for foster care children -- about 58 percent were not enrolled in any type of managed care plan.
Three-quarters of the disabled persons enrolled in Medicaid in December 1999 qualified through the SSI eligibility group. Disabled persons in the SSI group were more likely to be participating in a managed care plan than disabled persons in the medically needy, poverty-related and other eligibility groups. Within the SSI group, children were more likely than disabled persons in the other two age groups to be participating in a managed care plan. About 55 percent of children under age 21 in the SSI group were participating in some type of managed care, compared to 49 percent of SSI disabled persons aged 21 to 64, and 45 percent age 65 or older (Table 10D).
Foster care children did not show major differences in managed care participation by age (Table 10D).
Managed care enrollment patterns did not differ by gender for disabled beneficiaries and foster care children (Tables 10E and 10F).
Table 11A shows the number of individuals in the disabled and foster care groups by age cohort who were enrolled in more than one type of managed care plan. Tables 11B and 11C show the same information for females and males, respectively. Tables 11D-F convert the data in Tables 11A-C to a percent distribution. All counts are unduplicated.
About half of the disabled HMO enrollees were also enrolled in other managed care plans (Table 11D). Overall, 9 percent of the disabled were in HMOs only, 7 percent were in HMOs and BHPs, and about 2 percent were enrolled in HMOs and dental plans.
Just over half the children in foster care who were enrolled in HMOs were also enrolled in other managed care plans (Table 11D). Overall, just under 10 percent of foster care children were in HMOs only, 4 percent were in HMOs and BHPs, 3 percent were enrolled in HMOs and dental plans, and 1 percent were enrolled in all three types of plans.
Tables 12A and 12B show the number of aged and disabled persons, respectively, who were dually eligible for Medicaid and Medicare and enrolled in managed care plans in December 1999. The counts in these tables are duplicated, since an individual could have been enrolled in more than one type of plan, in which case he or she would have been counted twice. Tables 12C and 12D convert the data in Tables 12A and 12B to a percent distribution; the percentages reflect duplicated counts in Tables 12A and 12B.
Managed care programs for dual eligibles are complicated because Medicare is the first payor, and state Medicaid programs are generally responsible for Medicare copayments, deductibles and premiums. In addition, Medicaid programs have total responsibility for some services, such as prescription drugs and long-term care, which are not covered by Medicare.
Just under 88 percent of aged Medicaid enrollees were dually eligible for Medicaid and Medicare in December 1999 (Table 12A). This is believed to be an undercount, since not all states were able to fully identify their dual eligible population. For the most part, the only Medicaid beneficiaries over age 65 who would not qualify for some Medicare coverage are some groups of noncitizen immigrants.
About 37 percent of disabled Medicaid enrollees were dually eligible for Medicaid and Medicare in December 1999 (Table 12B). The majority of disabled persons on Medicaid do not qualify for Medicare, either because they have not worked enough quarters with contributions to Social Security to have qualified for Social Security benefits, or because they are in the two-year waiting period between the commencement of Social Security benefits and eligibility for Medicare. Generally, disabled children are not able to qualify for Medicare benefits, since they have not worked and contributed to Social Security.
Aged and disabled dual eligibles were less likely to be enrolled in some type of managed care plan than aged and disabled persons not identified as dual eligibles. About 24 percent of aged dual eligibles were enrolled in some type of managed care, versus 35 percent for aged persons who were not identified as dual eligibles (Table 12C). About 31 percent of disabled dual eligibles were enrolled in some type of managed care, versus 50 percent of disabled persons who were not dual eligibles (Table 12D).
Tables 13A and 13B show the number of aged and disable dual eligibles enrolled in more than one type of managed care in December, 1999. Counts in these tables are unduplicated. Tables 13C and 13D convert the data in Tables 13A and 13B to a percent distribution.
As reported earlier, aged and disabled dual eligibles were less likely than non-dual eligible aged and disabled persons to be in some type of managed care plan. However, if they were enrolled in HMOs, they were more likely to be also enrolled in another type of managed care. Almost two-thirds (65 percent) of the aged dual eligibles enrolled in HMOs were enrolled in other managed care plans as well (Table 13A). About 71 percent of the disabled dual eligibles enrolled in HMOs were also enrolled in other types of managed care (Table 13B).
For the non-dual eligible aged and disabled, just over 40 percent of those enrolled in HMOs were also enrolled in other types of managed care, respectively (Tables 13A and 13B).
Each set of state tables also includes a final table, showing the number of enrollees in each type of managed care for each county in the state. It was not possible to summarize these county-based tables at the national level.
A more complete measure of turnover would also count persons who disenrolled at any point earlier in the year, but had reenrolled before year end.
SSI disability rules for children only apply to those under age 18. This age group includes persons ages 18 to 20 who would have to satisfy adult disability rules to qualify for Medicaid.
| National tables can be viewed in PDF (http://aspe.hhs.gov/daltcp/reports/msisdata-natl.pdf) or as Microsoft Excel files (http://aspe.hhs.gov/daltcp/reports/msisdata-natl1.xls for tables 1-5 and http://aspe.hhs.gov/daltcp/reports/msisdata-natl2.xls for tables 6-13). |
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