Medicaid and CHIP Risk-Based Managed Care in 20 States. Experiences Over the Past Decade and Lessons for the Future.. Endnotes


1 Comprehensive risk-based managed care does not include Primary Care Case Management (PCCM) or managed care plans covering limited benefits such as dental and behavioral health benefits.

2 For more information on HEDIS, see NCQA website at

3 For more information on CAHPS, see AHQR website at

4 Such programs require enrollees to select a Primary Care Provider, who manages their care for a fee but is not at risk.

5 Sometimes states (such as Wisconsin) automatically enroll SSI-related beneficiaries into MCOs and then allow them to voluntarily opt out. This approach is categorized as voluntary.

6 In 2001 constant dollars. Prior to 2006, the MSIS did not have a flag to indicate comprehensive risk-based managed care enrollment. However, we compared the counts of enrollees by type using both methods (the $200 inflation-adjusted premium payments and the managed care enrollment flags) for 2008 and found very similar counts nationally and for the two largest states (California and New York), both in total and by enrollment group. For example, in 2008 using premium payment indicators, there were 20.2 million people enrolled in Medicaid comprehensive risk-based managed care nationally and using enrollment flags there were 21.0 million.

7 Comprehensive programs include at a minimum ambulatory and inpatient hospital services among others.

8 EPSDT services are mandatory for Medicaid children; any health problems identified in these routine screenings (including behavioral, dental, and vision services) must be referred for treatment, which must in turn be covered by Medicaid.

9 California counties with Medicaid managed care choose one of three approaches. In the COHS model, the state contracts with selected counties to provide care for all Medicaid enrollees in the county for a fixed capitation rate.

10 Minnesota requires HMOs to be nonprofit and to participate in Medicaid managed care as a condition of licensure.

11 This requirement does not pertain to CHIP MCOs.

12 The ACA required the development of voluntary quality measures for Medicaid adults. An initial set of measures was released on January 4, 2012, and states are encouraged to adopt the measures. CHIPRA required the development of voluntary quality measures for children.

13 Arizona required CAHPS reporting prior to 2001 and will be reinstituting it in 2013.

14 Four DTaP/DT, three IPV, one MMR, three H influenza type B, three hepatitis B, and one chicken pox vaccination.

15 See Appendix D for more detail on changes in NCQA-specified HEDIS definitions during the study period.

16 In 1996, Felt-Lisk and Yang (1997) found 355 health plans participating in risk-based managed care in 15 states, but by 2010 we found only 174 such plans in the 20 states with over 80 percent of Medicaid risk-based managed care enrollment nationwide.

View full report


"rpt.pdf" (pdf, 1.42Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®