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


This cross-state study of Medicaid/CHIP risk-based managed care uses a case study approach to investigate changes in programs over the period 2001–10. The study is focused on risk-based Medicaid and CHIP programs in 20 states: Arizona, California, Connecticut, Delaware, Florida, Maryland, Massachusetts, Michigan, Minnesota, New Jersey, New Mexico, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia, Washington, and Wisconsin.

Table 1: Medicaid Enrollment in Risk-Based Managed Care Organizations (MCOs), October 2010
State Total Medicaid MCO Enrollment (in thousands) Percent of State Total Medicaid Enrollment Percent of Total U.S. Medicaid MCO Enrollment

Source: Gifford et al., 2011.

Note: Medicaid includes enrollment in CHIP Medicaid expansion programs (M-CHIP).

California 4,079 55.0 15.3
Delaware 142 74.0 0.5
Florida 1,287 45.3 4.8
Maryland 685 73.9 2.6
Massachusetts 513 39.2 1.9
Michigan 1,251 68.1 4.7
Minnesota 477 66.3 1.8
New Jersey 974 95.0 3.6
New Mexico 335 68.0 1.3
New York 3,002 62.5 11.2
Ohio 1,730 85.9 6.5
Pennsylvania 1,222 58.5 4.6
Rhode Island 134 75.3 0.5
Tennessee 1,219 100.0 4.6
Texas 1,698 48.9 6.4
Virginia 527 62.1 2.0
Washington 627 54.2 2.3
Wisconsin 624 54.2 2.3
Subtotal 22,127 61.9 82.7
All Other States 4,613 25.4 17.3
Total U.S. 26,740 49.6 100.0

The study states are shown in Table 1. We primarily selected states for participation on the basis of having either a large number of people covered by risk-based Medicaid managed care programs, a large proportion of the state’s Medicaid population in risk-based managed care, or both. This allows for the inclusion of some more populous states that cover a relatively smaller proportion of the state’s Medicaid population under risk-based managed care (such as Florida and Texas, which each cover about half), as well as some less populous states that enroll a relatively large proportion of their Medicaid population in risk-based Medicaid managed care (such as Delaware, New Mexico, and Rhode Island). We also sought regional variation and have included at least four states from each of the four major census regions.

As shown in the table, the 20 study states account for just over 80 percent of the nationwide Medicaid enrollment in risk-based managed care in 2010. Across the 20 states, just over 60 percent of Medicaid enrollees are in comprehensive risk-based managed care, much higher than the non-study states, for which only 25.4 percent of their Medicaid population is enrolled in risk-based managed care.

At the time we selected states, there was not yet a source of data on the number of CHIP enrollees in risk-based managed care. When those data were published (MACPAC, 2011), it became evident that the study states report a similar proportion of CHIP enrollees in risk-based managed care as for Medicaid.

Data in this report come from five sources:

  • Published Data: We obtained published data from several existing sources such as the CMS web site, state web sites, the Kaiser State Health Facts web site, the Kaiser Commission/HMA report (Gifford, et al., 2011), and the MACPAC report (2011).
  • In-Person and Telephone Interviews: During January–November 2011, we conducted interviews with state Medicaid officials in person in 11 states and by telephone in nine states. For states where CHIP risk-based managed care programs are administered by a separate organization or unit of government, we interviewed those officials separately. We also conducted telephone interviews with representatives from two health plans per state and two providers or provider associations per state. Table 2 shows the number of plan and provider interviews by type of plan or provider. Thus, there were at least five interviews per state, or over 100 interviews in all. The full list of interviewees is contained in Appendix A.Interviews were conducted using a semistructured protocol, which is available on request.
Table 2: Characteristics of Plans and Providers Interviewed
Plans Non-profit 20
For profit 20
Total 40
Providers Medical Associations 13
Family Physicians Association 1
Pediatric Association 1
Individual Physicians 3
Individual Dentist 1
Hospital Associations 13
Hospital Systems 2
Community Health Center Associations 6
Total 40
  • Access and Quality Performance Measures: We requested and obtained Healthcare Effectiveness Data and Information Set (HEDIS)2 and Consumer Assessment of Healthcare Providers and Systems (CAHPS)3 data for at least one year, and usually multiple years, on a common cross-state set of performance measures for Medicaid and CHIP managed care programs. Some states provided plan-specific measures, which we used to create a statewide average weighted by plan enrollment.
  • Model Contracts between the State and Its Health Plans: We analyzed contracts to identify state requirements regarding appointment wait times, provider/ enrollee ratios, and geographic proximity requirements.
  • Medicaid Statistical Information System (MSIS): We used person-level data from the MSIS summary file to estimate enrollment in comprehensive risk-based Medicaid managed care programs by type of enrollee and year.

Key informant interviews were transcribed and the transcripts were coded with NVIVO qualitative analysis software, using a coding structure referring to the most important interview questions and topics covered, allowing for a cross-state analysis of common themes across topics. The transcripts were also used to provide selected quotes throughout the report in the voice of respondents. However, to protect respondent confidentiality, we do not directly attribute quotes or opinions to specific individuals. Factual information, either from reports or interviews, was verified with state contacts.

We obtained broad information on Medicaid and CHIP risk-based managed care programs, including limited-benefit plans (e.g., plans covering only behavioral health services or dental services) and integrated care plans that include long-term care for those dually enrolled in Medicaid and Medicare. However, due to resource and time limitations, we focus the investigation most closely on comprehensive benefit plans for acute care and programs for the nonelderly, non–dual eligible population.

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