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|
|EXHIBIT 2. Medicaid Eligibility Groups|
|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|
|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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