As Medicaid spending and enrollment grew in recent years, states increasingly turned to the managed care delivery model as a way to provide services to Medicaid beneficiaries. Under this delivery model, states typically contract with managed care organizations (MCO) to provide a specific set of Medicaid-covered services to beneficiaries. The state pays the MCOs a set amount per beneficiary per month to provide the specific services covered under each managed care plan. MCOs, in turn, pay providers for the services they deliver. Since 1999, states have submitted data on managed care service utilization, also known as encounter data, to the Centers for Medicare & Medicaid Services, the federal agency that oversees Medicaid. Historically, these encounter data have been relatively incomplete and unreliable; thus, little is known about the utilization of services by Medicaid beneficiaries enrolled in managed care plans. However, recent evidence suggests that the quality of Medicaid encounter data may be improving, and stronger requirements surrounding encounter data submissions suggest that such improvements could continue. In our report and below, we describe what encounter data indicate about the service utilization of Medicaid beneficiaries enrolled in managed care plans.
The data presented below show service utilization patterns for adults and children enrolled in Medicaid comprehensive managed care in 19 states in calendar year 2010. In addition to services utilized by beneficiaries enrolled in comprehensive managed care plans, we also show information below on the extent to which the beneficiaries in our analysis received professional services paid on a fee-for-service basis while they were in comprehensive managed care. Data presented are also available for download.
This tab depicts the average number of services used by beneficiaries during the year, calculated across all enrolled beneficiaries. Some enrolled beneficiaries may not have used services during the year.
Directions
Use the filters to explore how different factors affect the way comprehensive managed care services are used.
| Type of beneficiary |
| States (19) |
| Length of enrollment |
| Professional service category |
This tab depicts the average number of services used, calculated only for beneficiaries using services.
Directions
Use the filters to explore how different factors affect the way comprehensive managed care services are used.
| Type of beneficiary |
| Length of enrollment |
| States (19) |
This tab depicts the percent of beneficiaries using at least one service in a year.
Directions
Use the filters to explore how different factors affect the way comprehensive managed care services are used.
| Type of beneficiary |
| Length of enrollment |
| States (19) |
This tab depicts the average number of services paid on a fee-for-service (FFS) basis that were used by beneficiaries enrolled in a comprehensive managed care plan during the year. Managed care services are also included for comparison.
Directions
Use the filters to explore how different factors affect the way comprehensive managed care services are used.
| Type of beneficiary |
| States (19) |
GAO Analysis of 2010 Medicaid Analytic eXtract data from the Centers for Medicare & Medicaid Services. | GAO-15-481
Notes: Our analysis does not offer conclusions regarding whether the level of service utilization identified is appropriate. In addition, there are a number of state-specific factors—such as differences in beneficiary health status and provider supply—that could contribute to variation in service utilization across the states, and attributing this variation to specific factors was beyond the scope of this study. Data shown are for adults and children with full Medicaid benefits who were enrolled in comprehensive managed care in at least one month during calendar year 2010. We focused our analysis on professional services and excluded dental and behavioral health services. We excluded beneficiaries from our analysis if they had other sources of health coverage in addition to Medicaid, such as coverage from a standalone Children’s Health Insurance Program, Medicare, or private insurance. Partial-year beneficiaries are defined as those enrolled in Medicaid comprehensive managed care in calendar year 2010 for a period of less than 12 months. We weighted our results by the number of months each beneficiary was enrolled in comprehensive managed care in calendar year 2010 to account for beneficiaries who may have been enrolled for only part of the year. Utilization measures are defined as follows:
Download the full data set:
Services per beneficiary per year: CSV
Services per user per year: CSV
User rate: CSV
Fee-for-service: CSV
About this report: This figure is a part of Medicaid: Service Utilization Patterns for Beneficiaries in Managed Care, GAO-15-481