December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director...

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December 2015 Medicaid and CHIP Payment and Access Commission

Transcript of December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director...

Page 1: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015

Medicaid and CHIP Payment and Access Commission

Page 2: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

About MACPAC The Medicaid and CHIP Payment and Access Commission (MACPAC) is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide array of issues affecting Medicaid and the State Children’s Health Insurance Program (CHIP). The U.S. Comptroller General appoints MACPAC’s 17 commissioners, who come from diverse regions across the United States and bring broad expertise and a wide range of perspectives on Medicaid and CHIP.

MACPAC serves as an independent source of information on Medicaid and CHIP, publishing issue briefs and data reports throughout the year to support policy analysis and program accountability. The Commission’s authorizing statute, 42 USC 1396, outlines a number of areas for analysis, including:

• payment;• eligibility; • enrollment and retention;• coverage;• access to care;• quality of care; and• the programs’ interaction with Medicare and the health care system generally.

MACPAC’s authorizing statute also requires the Commission to submit reports to Congress by March 15 and June 15 of each year. In carrying out its work, the Commission holds public meetings and regularly consults with state officials, congressional and executive branch staff, beneficiaries, health care providers, researchers, and policy experts.

Page 3: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015

MACStats: Medicaid and CHIP Data Book

Medicaid and CHIP Payment and Access Commission

Page 4: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn
Page 5: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book v

Commission Members and Terms

Commission Members and TermsDiane Rowland, ScD, Chair Washington, DC

Marsha Gold, ScD, Vice Chair Washington, DC

Term Expires December 2015Donna Checkett, MPA, MSW Phoenix, AZ

Patricia Gabow, MD Denver, CO

Mark Hoyt, FSA, MAAA Phoenix, AZ

Patricia Riley, MS Brunswick, ME

Diane Rowland, ScD Washington, DC

Steven Waldren, MD, MS Leawood, KS

Term Expires December 2016

Sharon Carte, MHS South Charleston, WV

Andrea Cohen, JD New York, NY

Herman Gray, MD, MBA Detroit, MI

Norma Martínez Rogers, PhD, RN, FAAN San Antonio, TX

Sara Rosenbaum, JD Washington, DC

Term Expires December 2017Gustavo Cruz, DMD, MPH New York, NY

Marsha Gold, ScD Washington, DC

Charles Milligan, JD, MPH Albuquerque, NM

Sheldon Retchin, MD, MSPH Columbus, OH

Peter Szilagyi, MD, MPH Los Angeles, CA

Page 6: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015vi

Commission StaffAnne L. Schwartz, PhD, Executive Director

Office of the Executive DirectorAnnie Andrianasolo, MBA, Executive Assistant

Kathryn Ceja, Director of Communications

Laura Beth Pelner, Communications/Graphic Design Specialist

Policy DirectorsAmy Bernstein, ScD, MHSA Policy Director and Contracting Officer

Moira Forbes, MBA, Policy Director

April Grady, MPAff, Policy Director

Mary Ellen Stahlman, MHSA, Policy and Congressional Affairs Director

Principal AnalystsMartha Heberlein, MA

Joanne Jee, MPH

Chris Peterson, MPP

Anna Sommers, PhD, MS, MPAff

James Teisl, MPH

Kristal Vardaman, MSPH

Senior AnalystsVeronica Daher, JD

Benjamin Finder, MPH

Sarah Melecki, MPAff

Robert Nelb, MPH

Chris Park, MS

Katie Weider, MPH

AnalystsKacey Buderi, MPA Kayla Holgash, MPH

Operations and ManagementRicardo Villeta, MBA, Deputy Director of Operations, Finance, and Management

James Boissonnault, MA, Chief Information Officer

Benjamin Granata, Finance/Budget Specialist

Allissa Jones, Administrative Assistant

Ken Pezzella, Chief Financial Officer

Eileen Wilkie, Administrative Officer

Commission Staff

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MACStats: Medicaid and CHIP Data Book vii

Table of Contents

Table of ContentsCommission Members and Terms ...................................................................................................................... v

Commission Staff ............................................................................................................................................... vi

Introduction ......................................................................................................................................................... xi

SECTION 1: Overview—Key Statistics ........................................................................................................ 1

Key Points ........................................................................................................................................... 2

EXHIBIT 1: Medicaid and CHIP Enrollment as a Percentage of the U.S. Population, 2014 (millions) ................................................................................................................. 3

EXHIBIT 2: Characteristics of Non-Institutionalized Individuals by Age and Source of Health Coverage, 2014 .................................................................................................... 4

EXHIBIT 3: National Health Expenditures by Type and Payer, 2013 ............................................... 9

EXHIBIT 4: Major Health Programs and Other Components of the Federal Budget as a Share of Federal Outlays, FYs 1965–2014 .................................................................. 12

EXHIBIT 5: Medicaid as a Share of State Budgets Including and Excluding Federal Funds by State, SFY 2013 ............................................................................................................ 14

EXHIBIT 6: Federal Medical Assistance Percentages (FMAPs) and Enhanced FMAPs (E-FMAPs) by State, FYs 2012–2016 ........................................................................... 17

SECTION 2: Trends ............................................................................................................................. 21

Key Points ......................................................................................................................................... 22

EXHIBIT 7: Medicaid Beneficiaries (Persons Served) by Eligibility Group, FYs 1975–2012 (thousands) ........................................................................................ 23

EXHIBIT 8: Medicaid Enrollment and Spending, FYs 1966–2014 ................................................. 25

EXHIBIT 9: Annual Growth in Medicaid Enrollment and Spending, FYs 1975–2014 ................... 26

EXHIBIT 10: Medicaid Enrollment and Total Spending Levels and Annual Growth, FYs 1966–2014 ............................................................................................................. 27

EXHIBIT 11: Full-Benefit Medicaid and CHIP Enrollment, Selected Months, 2013–2015 ............. 29

EXHIBIT 12: Historical and Projected National Health Expenditures by Payer for Selected Years, 1970–2024 .......................................................................................... 32

EXHIBIT 13: Medicaid as a Share of State Budgets Including and Excluding Federal Funds, SFYs 1987–2013 ........................................................................................................... 34

SECTION 3: Program Enrollment and Spending ....................................................................................... 37

Key Points ......................................................................................................................................... 38

Medicaid Overall

EXHIBIT 14: Medicaid Enrollment by State, Eligibility Group, and Dually Eligible Status, FY 2012 (thousands) .................................................................................................... 39

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December 2015viii

Table of Contents

EXHIBIT 15: Medicaid Full-Year Equivalent Enrollment by State and Eligibility Group, FY 2012 (thousands) .................................................................................................... 42

EXHIBIT 16: Medicaid Spending by State, Category, and Source of Funds, FY 2014 (millions) .... 45

Medicaid Benefits

EXHIBIT 17: Total Medicaid Benefit Spending by State and Category, FY 2014 (millions) ..... 48

EXHIBIT 18: Distribution of Medicaid Benefit Spending by Eligibility Group and Service Category, FY 2012 ...................................................................................... 51

EXHIBIT 19: Medicaid Benefit Spending Per Full-Year Equivalent (FYE) Enrollee by Eligibility Group and Service Category, FY 2012 ................................................... 52

EXHIBIT 20: Distribution of Medicaid Enrollment and Benefit Spending by Users and Non-Users of Long-Term Services and Supports, FY 2012 .................................. 53

EXHIBIT 21: Medicaid Spending by State, Eligibility Group, and Dually Eligible Status, FY 2012 (millions) ................................................................................................... 54

EXHIBIT 22: Medicaid Benefit Spending Per Full-Year Equivalent (FYE) Enrollee by State and Eligibility Group, FY 2012 ................................................................................ 56

EXHIBIT 23: Medicaid Supplemental Payments to Hospital Providers by State, FY 2014 (millions) ................................................................................................... 59

EXHIBIT 24: Medicaid Supplemental Payments to Non-Hospital Providers by State, FY 2014 (millions) ................................................................................................... 61

EXHIBIT 25: Medicaid Gross Spending for Drugs by Delivery System and Brand or Generic Status, FY 2014 (millions) ...................................................................................... 64

EXHIBIT 26: Medicaid Drug Prescriptions by Delivery System and Brand or Generic Status, FY 2014 (thousands) .............................................................................................. 67

EXHIBIT 27: Medicaid Gross Spending and Rebates for Drugs by Delivery System, FY 2014 (millions) ................................................................................................... 69

Medicaid Managed Care

EXHIBIT 28: Percentage of Medicaid Enrollees in Managed Care by State, July 1, 2013 ....... 72

EXHIBIT 29: Percentage of Medicaid Enrollees in Managed Care by State and Eligibility Group, FY 2012 ......................................................................................................... 75

Medicaid Program Administration

EXHIBIT 30: Total Medicaid Administrative Spending by State and Category, FY 2014 (millions) .................................................................................................... 78

CHIP

EXHIBIT 31: Child Enrollment in CHIP and Medicaid by State, FY 2014 .................................. 81

EXHIBIT 32: CHIP Spending by State, FY 2014 (millions) ......................................................... 83

EXHIBIT 33: Federal CHIP Allotments, FY 2015 (millions) ........................................................ 86

Page 9: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book ix

Table of Contents

SECTION 4: Medicaid and CHIP Eligibility ....................................................................................... 89

Key Points .................................................................................................................................. 90

EXHIBIT 34: Medicaid and CHIP Income Eligibility Levels as a Percentage of the FPL for Children and Pregnant Women by State, September 2015 .................................. 91

EXHIBIT 35: Medicaid Income Eligibility Levels as a Percentage of the FPL for Non-Aged, Non-Disabled, Non-Pregnant Adults by State, September 2015 .......................... 94

EXHIBIT 36: Medicaid Income Eligibility Levels as a Percentage of the FPL for Individuals Age 65 and Older and Persons with Disabilities by State, 2015 .......................... 97

EXHIBIT 37: Income as a Percentage of the FPL for Various Family Sizes, 2015 ................ 100

SECTION 5: Beneficiary Health, Service Use, and Access to Care .................................................. 103

Key Points ................................................................................................................................ 104

EXHIBIT 38: Coverage, Demographic, and Health Characteristics of Non-Institutionalized Individuals Age 0–18 by Primary Source of Health Coverage, 2014 ................. 105

EXHIBIT 39: Use of Care among Non-Institutionalized Individuals Age 0–18 by Primary Source of Health Coverage, 2014, Data from National Health Interview Survey ........... 108

EXHIBIT 40: Use of Care among Non-Institutionalized Individuals Age 0–18 by Primary Source of Health Coverage, 2013, Data from Medical Expenditures Panel Survey ....... 110

EXHIBIT 41: Measures of Access to Care among Non-Institutionalized Individuals Age 0–18 by Primary Source of Health Coverage, 2014 ............................................ 112

EXHIBIT 42: Coverage, Demographic, and Health Characteristics of Non-Institutionalized Individuals Age 19–64 by Primary Source of Health Coverage, 2014 ............... 114

EXHIBIT 43: Use of Care among Non-Institutionalized Individuals Age 19–64 by Primary Source of Health Coverage, 2014, Data from National Health Interview Survey ........... 118

EXHIBIT 44: Use of Care among Non-Institutionalized Individuals Age 19–64 by Primary Source of Health Coverage, 2013, Data from Medical Expenditures Panel Survey ....... 121

EXHIBIT 45: Measures of Access to Care among Non-Institutionalized Individuals Age 19–64 by Primary Source of Health Coverage, 2014 .......................................... 123

SECTION 6: Technical Guide to MACStats ..................................................................................... 125

Interpreting Medicaid and CHIP Enrollment and Spending Numbers ...................................... 127

Understanding Data on Health and Other Characteristics of Medicaid and CHIP Populations ... 128

Methodology for Adjusting Benefit Spending Data .................................................................... 130

EXHIBIT 46: Medicaid Benefit Spending in MSIS and CMS-64 Data by State, FY 2012 (millions) ... 132

EXHIBIT 47: Service Categories Used to Adjust FY 2012 Medicaid Benefit Spending in the MSIS to Match CMS-64 Totals ...................................................................... 134

Understanding Managed Care Enrollment and Spending Data ................................................. 136

Endnotes ................................................................................................................................ 137

Page 10: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn
Page 11: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book xi

Introduction

IntroductionThe Medicaid and CHIP Payment and Access Commission is pleased to introduce the inaugural edition of the MACStats: Medicaid and CHIP Data Book.

In past years MACPAC has published Medicaid and State Children’s Health Insurance Program (CHIP) data in our semi-annual reports to Congress. This section, known as MACStats, has provided a comprehensive resource for a broad range of data on Medicaid and CHIP, which often can be difficult to find. Now MACPAC is making Medicaid and CHIP information even more accessible. Instead of publishing MACStats in two parts, we will publish tables and figures on the MACPAC website as soon as new data become available. At the end of each year, MACPAC will compile the most current Medicaid and CHIP program statistics in a stand-alone data book.

The December 2015 data book presents the most current data available on Medicaid and CHIP. Divided into six sections, it includes an overview with key statistics on Medicaid and CHIP; trends in Medicaid; Medicaid and CHIP enrollment and spending with information on benefits, managed care, and program administration; Medicaid and CHIP eligibility; and measures of beneficiary health, use of services, and access to care.

The data describe two programs that provide a safety net for low-income populations who otherwise would not have access to coverage and that cover services other payers often do not cover. The data book also provides a picture of these programs in context. For example, Medicaid and CHIP combined accounted for a smaller share of total health care spending than Medicare in fiscal year 2014, despite covering more people.

The final section of the data book contains a technical guide that describes the data sources used in MACStats, the methods that MACPAC uses to analyze these data, and guidance in interpreting how specific data—such as those on enrollment and spending—may differ from each other or from those published elsewhere.

We would like to thank the many individuals at the Centers for Medicare & Medicaid Services and our contractors—Social & Scientific Systems, and Acumen, LLC—who provided their insights and assistance. We would also like to thank Paula Gordon and GKV Communications, who provided valuable support in copyediting, formatting, and producing this data book.

Page 12: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn
Page 13: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

SECTION 1

Overview— Key Statistics

Page 14: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 20152

Section 1: Overview—Key Statistics

Section 1: Overview—Key Statistics

Key Points• In 2014, more than one-quarter of the U.S. population was enrolled in Medicaid or CHIP for

at least part of the year. The estimated number of people ever enrolled in Medicaid was 78.6 million in fiscal year (FY) 2014 (including 1 million individuals in the territories); for CHIP, the figure was 8.3 million (Exhibit 1).

• Nearly half of all individuals enrolled in Medicaid in 2014 had family incomes below the federal poverty level. People enrolled in Medicaid or CHIP were more likely to be Hispanic or black than those enrolled in other types of coverage, and they were more likely to be in fair or poor health than either privately insured or uninsured individuals (Exhibit 2).

• Medicaid and CHIP together accounted for 15.9 percent of national health expenditures in calendar year 2013; Medicare accounted for 20.1 percent; and private insurance accounted for 32.9 percent (Exhibit 3).

• The share of the federal budget devoted to Medicaid and Medicare has grown steadily since the programs were enacted in 1965, but Medicaid continues to account for a smaller share (8.6 percent in FY 2014) than Medicare (14.4 percent) (Exhibit 4).

• Medicaid spending as a share of state budgets varies depending on whether federal funds are included. Looking only at the state-funded portion of state budgets (that is, the portion states must finance on their own through taxes and other means), Medicaid’s share was 15.1 percent in state fiscal year (SFY) 2013. After including federal funds in state budgets, a typical practice in other data sources, Medicaid’s share was 24.5 percent in SFY 2013 (Exhibit 5).

Page 15: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 3

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Page 16: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 20154

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r7.

5*1.

3*4.

9*9.

822

.6*

6.1

3.2*

5.7

40.1

*

No

cove

rage

dur

ing

year

8.4*

––

–77

.4*

3.2*

––

59.9

*

Mul

tiple

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w

Yes,

any

Med

icar

e an

d M

edic

aid/

CHIP

co

mbi

natio

n61.

7*10

.8*

0.2*

9.4

–†

–†

Yes,

any

priv

ate

and

Med

icai

d/CH

IP

com

bina

tion

†–

0.8*

2.6

–1.

2*2.

3*3.

2–

Yes,

any

oth

er c

ombi

natio

n8.

149

.8*

11.5

*0.

3–

†0.

3†

No

89.7

*39

.4*

87.6

87.7

100.

098

.5*

97.4

*96

.510

0.0

Dem

ogra

phic

s

Age

0–18

24.8

*0.

5*21

.9*

53.8

12.4

*10

0.0

100.

010

0.0

100.

0

19–

6460

.8*

13.1

*66

.6*

39.9

86.5

*–

––

65 o

r old

er14

.3*

86.3

*11

.6*

6.3

1.0*

––

––

Gen

der

Mal

e48

.9*

44.4

49.1

*44

.554

.6*

51.1

51.1

50.5

53.6

Fem

ale

51.1

*55

.650

.9*

55.5

45.4

*48

.948

.949

.546

.4

Race

His

pani

c17

.4*

7.7*

11.3

*29

.936

.5*

24.3

*14

.3*

35.5

43.6

*

Whi

te, n

on-H

ispa

nic

63.4

*78

.2*

72.3

*41

.544

.3*

54.2

*68

.4*

36.6

39.5

Blac

k, n

on-H

ispa

nic

12.8

*10

.0*

9.6*

22.7

13.2

*15

.1*

9.9*

23.0

9.7*

Oth

er n

on-w

hite

, non

-His

pani

c6.

44.

1*6.

9*6.

06.

16.

4*7.

4*4.

87.

2

EXH

IBIT

2.

Char

acte

ristic

s of

Non

-Inst

itutio

naliz

ed In

divi

dual

s by

Age

and

Sou

rce

of H

ealth

Cov

erag

e, 2

014

Page 17: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 5

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

EXH

IBIT

2.

(con

tinue

d)

Char

acte

ristic

Sele

cted

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w, a

ge 1

9-64

1Se

lect

ed c

over

age

sour

ces

at

time

of in

terv

iew

, age

65

and

olde

r1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

co

vera

ge s

ourc

es)5

100.

0%3.

4%66

.7%

11.7

%16

.2%

100.

0%93

.3%

49.0

%7.

8%

Cove

rage

Leng

th o

f tim

e w

ith a

ny c

over

age

durin

g ye

ar

Full

year

78.0

*96

.7*

93.8

*83

.3–

98.3

99.1

99.3

*98

.3

Part

yea

r9.

6*3.

3*6.

2*16

.720

.2*

1.1

0.9

0.7*

1.7

No

cove

rage

dur

ing

year

12.5

*–

––

79.8

*0.

6*–

––

Mul

tiple

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w

Yes,

any

Med

icar

e an

d M

edic

aid/

CHIP

co

mbi

natio

n61.

1*31

.6*

0.1*

9.1

–7.

0*7.

5*0.

9*89

.4

Yes,

any

priv

ate

and

Med

icai

d/CH

IP

com

bina

tion

0.3*

–0.

4*2.

2–

––

††

Yes,

any

oth

er c

ombi

natio

n1.

1*20

.6*

1.4*

0.5

–51

.2*

54.6

*91

.0*

No

97.5

*47

.8*

98.2

*88

.210

0.0

41.7

*37

.9*

8.0*

10.2

Dem

ogra

phic

s

Age

0–18

––

––

––

––

19–

6410

0.0

100.

010

0.0

100.

010

0.0

––

––

65 o

r old

er–

––

––

100.

010

0.0

100.

010

0.0

Gen

der

Mal

e49

.0*

48.1

*49

.3*

37.7

54.9

*44

.4*

43.8

*44

.4*

36.4

Fem

ale

51.0

*51

.9*

50.7

*62

.345

.1*

55.6

*56

.2*

55.6

*63

.6

Race

His

pani

c16

.9*

9.1*

11.6

*23

.135

.3*

7.7*

7.2*

3.6*

24.1

Whi

te, n

on-H

ispa

nic

63.5

*67

.8*

71.0

*47

.145

.278

.9*

80.1

*87

.1*

48.0

Blac

k, n

on-H

ispa

nic

12.7

*19

.8*

10.1

*22

.813

.7*

8.7*

8.5*

6.1*

18.3

Oth

er n

on-w

hite

, non

-His

pani

c6.

93.

3*7.

36.

95.

8*4.

6*4.

2*3.

2*9.

5

Page 18: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 20156

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

Char

acte

ristic

Sele

cted

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w, a

ll ag

es1

Sele

cted

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w, a

ge 0

-181

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Educ

atio

n7

Less

than

hig

h sc

hool

12.8

%*

18.6

%*

6.4%

*30

.1%

26.2

%*

––

––

Hig

h sc

hool

dip

lom

a/G

ED26

.8*

31.9

*22

.8*

34.6

35.4

––

––

Som

e co

llege

30.4

*25

.132

.0*

25.9

28.0

*–

––

–Co

llege

or g

radu

ate

degr

ee29

.9*

24.3

*38

.8*

9.4

10.4

––

––

Mar

ital s

tatu

s7

Mar

ried

55.1

*54

.6*

62.1

*32

.540

.5*

––

––

Wid

owed

5.9

23.0

*4.

5*6.

41.

7*–

––

–Di

vorc

ed o

r sep

arat

ed10

.6*

13.5

*8.

6*16

.912

.0*

––

––

Livi

ng w

ith p

artn

er7.

5*2.

4*6.

2*10

.214

.7*

––

––

Nev

er m

arrie

d20

.9*

6.5*

18.6

*34

.031

.1*

––

––

Fam

ily in

com

eLe

ss th

an 1

38 p

erce

nt F

PL23

.4*

20.3

*7.

6*66

.143

.6*

32.8

%*

7.1%

*68

.2%

42.7

%*

Has

inco

me

in ra

nges

bel

owLe

ss th

an 1

00 p

erce

nt F

PL15

.3*

11.3

*4.

1*47

.728

.3*

22.5

*3.

7*49

.126

.1*

100–

199

perc

ent F

PL20

.0*

24.7

*12

.3*

33.8

34.7

23.0

*12

.9*

35.1

37.3

200–

399

perc

ent F

PL29

.4*

33.2

*33

.3*

14.3

27.4

*28

.1*

38.1

*13

.329

.5*

400

perc

ent F

PL o

r hig

her

35.3

*30

.8*

50.4

*4.

19.

7*26

.4*

45.3

*2.

57.

0*O

ther

dem

ogra

phic

cha

ract

eris

tics

Citiz

en o

f Uni

ted

Stat

es92

.998

.2*

95.6

*93

.374

.4*

97.3

98.6

*97

.584

.4*

Pare

nt o

f a d

epen

dent

chi

ld7

29.7

*2.

2*31

.6*

36.9

35.3

––

––

Curr

ently

wor

king

761

.8*

14.1

*73

.2*

35.5

65.4

*–

––

–Ve

tera

n79.

0*20

.9*

7.8*

3.1

3.0

––

––

Rece

ives

SSI

or S

SDI

4.0*

12.8

1.1*

13.2

0.7*

1.6*

0.5*

3.6

0.5*

Hea

lthCu

rren

t hea

lth s

tatu

sEx

celle

nt o

r ver

y go

od66

.5*

41.2

*73

.2*

59.5

59.2

84.2

*89

.8*

76.7

78.9

Goo

d23

.7*

32.2

*21

.0*

25.2

30.3

*14

.1*

9.3*

20.5

19.4

Fair

or p

oor

9.8*

26.7

*5.

8*15

.310

.4*

1.7*

0.9*

2.9

1.7*

EXH

IBIT

2.

(con

tinue

d)

Page 19: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 7

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

EXH

IBIT

2.

(con

tinue

d)

Char

acte

ristic

Sele

cted

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w, a

ge 1

9-64

1Se

lect

ed c

over

age

sour

ces

at

time

of in

terv

iew

, age

65

and

olde

r1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Educ

atio

n7

Less

than

hig

h sc

hool

11.6

%*

24.2

%*

5.4%

*27

.7%

25.9

%18

.0%

*17

.8%

*12

.2%

*45

.4%

Hig

h sc

hool

dip

lom

a/G

ED25

.9*

36.4

21.4

*35

.935

.530

.9*

31.3

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.7*

26.0

Som

e co

llege

31.8

*29

.233

.2*

27.6

28.2

24.3

*24

.5*

25.3

*14

.8Co

llege

or g

radu

ate

degr

ee30

.7*

10.2

40.1

*8.

710

.3*

26.8

*26

.5*

31.8

*13

.8M

arita

l sta

tus7

Mar

ried

54.6

*39

.1*

62.1

*32

.940

.4*

57.3

*57

.0*

62.0

*30

.2W

idow

ed1.

4*6.

2*1.

1*2.

31.

5*25

.0*

25.5

*23

.9*

32.3

Divo

rced

or s

epar

ated

10.4

*26

.9*

8.5*

15.9

11.9

*11

.6*

11.4

*9.

2*23

.4Li

ving

with

par

tner

8.8*

6.1*

7.0*

11.5

14.8

*1.

81.

91.

62.

3N

ever

mar

ried

24.8

*21

.8*

21.3

*37

.431

.3*

4.3*

4.1*

3.2*

11.8

Fam

ily in

com

eLe

ss th

an 1

38 p

erce

nt F

PL21

.3*

46.4

*7.

7*63

.843

.7*

16.3

*16

.1*

7.8*

61.9

Has

inco

me

in ra

nges

bel

owLe

ss th

an 1

00 p

erce

nt F

PL13

.9*

30.1

*4.

4*46

.928

.5*

8.5*

8.2*

2.8*

41.6

100–

199

perc

ent F

PL18

.1*

35.1

*11

.1*

31.8

34.3

*22

.7*

23.0

*17

.6*

35.7

200–

399

perc

ent F

PL28

.7*

23.0

*31

.3*

15.8

27.2

*34

.4*

34.9

*36

.0*

14.1

400

perc

ent F

PL o

r hig

her

39.2

*11

.7*

53.2

*5.

510

.0*

34.4

*33

.9*

43.6

*8.

6O

ther

dem

ogra

phic

cha

ract

eris

tics

Citiz

en o

f Uni

ted

Stat

es90

.2*

98.4

*94

.1*

88.5

73.4

*97

.1*

98.1

*99

.0*

88.3

Pare

nt o

f a d

epen

dent

chi

ld7

36.6

*12

.6*

37.0

*42

.635

.7*

0.7

0.6

0.5

1.0

Curr

ently

wor

king

772

.6*

10.4

*82

.2*

40.4

65.9

*16

.4*

14.7

*21

.3*

5.0

Vete

ran7

5.8*

9.4*

5.2*

2.3

3.0*

22.7

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22.9

*7.

8Re

ceiv

es S

SI o

r SSD

I5.

0*71

.5*

1.4*

23.2

0.8*

3.8*

3.7*

0.8*

31.7

Hea

lthCu

rren

t hea

lth s

tatu

sEx

celle

nt o

r ver

y go

od64

.3*

14.5

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.5*

42.4

56.7

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.9*

45.0

*51

.6*

22.4

Goo

d25

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25.8

*22

.9*

30.5

31.9

33.3

33.2

32.3

31.7

Fair

or p

oor

10.3

*59

.7*

5.6*

27.2

11.5

*21

.7*

21.7

*16

.1*

45.9

Page 20: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 20158

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

EXH

IBIT

2.

(con

tinue

d)

Not

es: F

PL is

fede

ral p

over

ty le

vel.

SSDI

is S

ocia

l Sec

urity

Dis

abili

ty In

sura

nce.

SSI

is S

uppl

emen

tal S

ecur

ity In

com

e. P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

exhi

bit

excl

ude

indi

vidu

als

with

mis

sing

and

unk

now

n va

lues

. Sta

ndar

d er

rors

are

ava

ilabl

e on

line

in d

ownl

oada

ble

Exce

l file

s at

https://w

ww.m

acpac.go

v/pu

blication/

characteristic

s-of-non

-institu

tionalized-individu

als-by-sou

rce-of-health

-insurance/

. Due

to d

iffer

ence

s in

met

hodo

logy

(suc

h as

the

wor

ding

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

diff

eren

t sur

vey

data

sou

rces

will

var

y. F

or e

xam

ple,

the

Nat

iona

l Hea

lth In

terv

iew

Sur

vey

(NH

IS) i

s kn

own

to p

rodu

ce h

ighe

r est

imat

es o

f ser

vice

use

than

the

Med

ical

Exp

endi

ture

s Pa

nel S

urve

y (M

EPS)

. For

pur

pose

s of

com

parin

g gr

oups

of i

ndiv

idua

ls (a

s in

this

ex

hibi

t), t

he N

HIS

pro

vide

s th

e m

ost r

ecen

t inf

orm

atio

n av

aila

ble.

For

oth

er p

urpo

ses,

suc

h as

mea

surin

g le

vels

of u

se re

lativ

e to

a p

artic

ular

ben

chm

ark

or g

oal,

it m

ay b

e ap

prop

riate

to c

onsu

lt es

timat

es fr

om M

EPS

or a

noth

er s

ourc

e.

*Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

–Da

sh in

dica

tes

zero

; 0.0

% in

dica

tes

an a

mou

nt le

ss th

an 0

.05%

that

roun

ds to

zer

o.1

Tota

l inc

lude

s al

l non

-inst

itutio

naliz

ed in

divi

dual

s, re

gard

less

of c

over

age

sour

ce. I

n th

is e

xhib

it, th

e su

m o

f val

ues

acro

ss h

ealth

insu

ranc

e co

vera

ge ty

pes

may

not

add

to

100

per

cent

for e

ach

age

grou

p be

caus

e in

divi

dual

s m

ay h

ave

mul

tiple

sou

rces

of c

over

age

and

beca

use

not a

ll ty

pes

of c

over

age

are

disp

laye

d. O

ther

MAC

Stat

s ex

hibi

ts

appl

y a

hier

arch

y to

ass

ign

indi

vidu

als

with

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

, and

may

ther

efor

e ha

ve d

iffer

ent r

esul

ts th

an th

ose

show

n he

re. C

over

age

sour

ce

is d

efin

ed a

s of

the

time

of th

e su

rvey

inte

rvie

w. S

ince

an

indi

vidu

al m

ay h

ave

mul

tiple

cov

erag

e so

urce

s or

cha

nges

ove

r tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

ch

arac

teris

tics

or e

xper

ienc

es a

ssoc

iate

d w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

.4

Indi

vidu

als

wer

e de

fined

as

unin

sure

d if

they

did

not

hav

e an

y pr

ivat

e he

alth

insu

ranc

e, M

edic

aid,

CH

IP, M

edic

are,

sta

te-s

pons

ored

or o

ther

gov

ernm

ent-s

pons

ored

hea

lth

plan

, or m

ilita

ry p

lan.

Indi

vidu

als

wer

e al

so d

efin

ed a

s un

insu

red

if th

ey h

ad o

nly

Indi

an H

ealth

Ser

vice

cov

erag

e or

had

onl

y a

priv

ate

plan

that

pai

d fo

r one

type

of s

ervi

ce,

such

as

acci

dent

s or

den

tal c

are.

5 Co

mpo

nent

s m

ay n

ot s

um to

100

per

cent

bec

ause

indi

vidu

als

may

hav

e m

ultip

le s

ourc

es o

f cov

erag

e an

d be

caus

e no

t all

type

s of

cov

erag

e ar

e di

spla

yed.

6 N

HIS

and

oth

er s

urve

y da

ta u

nder

estim

ate

the

num

ber o

f ind

ivid

uals

dua

lly e

nrol

led

in M

edic

are

and

Med

icai

d, in

par

t bec

ause

mos

t sur

veys

do

not c

ount

thos

e w

hose

onl

y M

edic

aid

bene

fit is

pay

men

t of M

edic

are

prem

ium

s an

d co

st s

harin

g as

hav

ing

Med

icai

d co

vera

ge.

7 In

form

atio

n is

lim

ited

to th

ose

age

19 o

r old

er.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

NH

IS d

ata.

Page 21: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 9

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

EXH

IBIT

3.

Nat

iona

l Hea

lth E

xpen

ditu

res

by T

ype

and

Paye

r, 20

13

Type

of e

xpen

ditu

re

Paye

r am

ount

(mill

ions

)

Tota

lM

edic

aid

CHIP

Med

icar

ePr

ivat

e in

sura

nce

Oth

er

heal

th

insu

ranc

e1

Oth

er

third

par

ty

paye

rs2

Out

of

pock

et

Tota

l$2

,919

,137

$449

,389

$13,

493

$585

,701

$961

,741

$92,

570

$476

,818

$339

,422

Hos

pita

l car

e93

6,86

716

3,53

43,

478

242,

670

348,

021

50,9

5595

,559

32,6

50

Phys

icia

n an

d cl

inic

al s

ervi

ces

586,

675

50,1

233,

534

130,

302

267,

601

20,5

9459

,170

55,3

50

Dent

al s

ervi

ces

110,

970

7,50

61,

497

475

52,6

241,

204

542

47,1

23

Oth

er p

rofe

ssio

nal s

ervi

ces3

80,2

475,

011

254

18,0

4529

,306

–7,

039

20,5

92

Hom

e he

alth

car

e79

,772

29,1

0333

34,3

816,

336

1,07

92,

412

6,42

8

Oth

er n

on-d

urab

le m

edic

al p

rodu

cts4

55,8

92–

–2,

667

––

253

,223

Pres

crip

tion

drug

s27

1,09

621

,173

1,41

574

,647

117,

937

7,50

02,

513

45,9

11

Dura

ble

med

ical

equ

ipm

ent5

42,9

874,

904

132

7,69

24,

977

–62

524

,656

Nur

sing

car

e fa

cilit

ies

and

cont

inui

ng c

are

retir

emen

t com

mun

ities

615

5,82

946

,867

1134

,555

12,5

804,

475

11,5

1945

,822

Oth

er h

ealth

, res

iden

tial,

and

pers

onal

car

e se

rvic

es7

148,

230

82,5

6095

45,

108

6,61

13,

514

41,8

157,

668

Adm

inis

trat

ion8

210,

588

38,6

072,

185

35,1

5711

5,74

93,

248

15,6

41–

Publ

ic h

ealth

act

ivity

75,3

88–

––

––

75,3

88–

Inve

stm

ent

164,

594

––

––

–16

4,59

4–

Page 22: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201510

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

Type

of e

xpen

ditu

re

Shar

e of

tota

l

Tota

lM

edic

aid

CHIP

Med

icar

ePr

ivat

e in

sura

nce

Oth

er

heal

th

insu

ranc

e1

Oth

er

third

par

ty

paye

rs2

Out

of

pock

et

Tota

l10

0.0%

15.4

%0.

5%20

.1%

32.9

%3.

2%16

.3%

11.6

%

Hos

pita

l car

e10

0.0

17.5

0.4

25.9

37.1

5.4

10.2

3.5

Phys

icia

n an

d cl

inic

al s

ervi

ces

100.

08.

50.

622

.245

.63.

510

.19.

4

Dent

al s

ervi

ces

100.

06.

81.

30.

447

.41.

10.

542

.5

Oth

er p

rofe

ssio

nal s

ervi

ces3

100.

06.

20.

322

.536

.5–

8.8

25.7

Hom

e he

alth

car

e10

0.0

36.5

0.0

43.1

7.9

1.4

3.0

8.1

Oth

er n

on-d

urab

le m

edic

al p

rodu

cts4

100.

0–

–4.

8–

–0.

095

.2

Pres

crip

tion

drug

s10

0.0

7.8

0.5

27.5

43.5

2.8

0.9

16.9

Dura

ble

med

ical

equ

ipm

ent5

100.

011

.40.

317

.911

.6–

1.5

57.4

Nur

sing

car

e fa

cilit

ies

and

cont

inui

ng c

are

retir

emen

t com

mun

ities

610

0.0

30.1

0.0

22.2

8.1

2.9

7.4

29.4

Oth

er h

ealth

, res

iden

tial,

and

pers

onal

car

e se

rvic

es7

100.

055

.70.

63.

44.

52.

428

.25.

2

Adm

inis

trat

ion8

100.

018

.31.

016

.755

.01.

57.

4–

Publ

ic h

ealth

act

ivity

100.

0–

––

––

100.

0–

Inve

stm

ent

100.

0–

––

––

100.

0–

Not

es: F

igur

es fo

r nur

sing

car

e fa

cilit

ies

and

cont

inui

ng re

tirem

ent c

omm

uniti

es a

nd o

ther

hea

lth, r

esid

entia

l, an

d pe

rson

al c

are

refle

ct n

ew d

ata

and

met

hods

as

of 2

011.

In

prio

r rel

ease

s, M

edic

aid

acco

unte

d fo

r abo

ut 4

0 pe

rcen

t of n

ursi

ng h

ome

expe

nditu

res

and

abou

t thr

ee-q

uart

ers

of o

ther

per

sona

l hea

lth c

are

expe

nditu

res.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

EXH

IBIT

3.

(con

tinue

d)

Page 23: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 11

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

1 U

.S. D

epar

tmen

t of D

efen

se a

nd U

.S. D

epar

tmen

t of V

eter

ans

Affa

irs.

2 In

clud

es a

ll ot

her p

ublic

and

priv

ate

prog

ram

s an

d ex

pend

iture

s ex

cept

for o

ut-o

f-poc

ket a

mou

nts.

3 Th

e ot

her p

rofe

ssio

nal s

ervi

ces

cate

gory

incl

udes

ser

vice

s pr

ovid

ed in

est

ablis

hmen

ts o

pera

ted

by h

ealth

pra

ctiti

oner

s ot

her t

han

phys

icia

ns a

nd d

entis

ts, i

nclu

ding

thos

e pr

ovid

ed b

y pr

ivat

e-du

ty n

urse

s, c

hiro

prac

tors

, pod

iatr

ists

, opt

omet

rists

, and

phy

sica

l, oc

cupa

tiona

l, an

d sp

eech

ther

apis

ts, a

mon

g ot

hers

.4

The

othe

r non

-dur

able

med

ical

pro

duct

s ca

tego

ry in

clud

es th

e re

tail

sale

s of

non

-pre

scrip

tion

drug

s an

d m

edic

al s

undr

ies.

5 Th

e du

rabl

e m

edic

al e

quip

men

t cat

egor

y in

clud

es re

tail

sale

s of

item

s su

ch a

s co

ntac

t len

ses,

eye

glas

ses,

and

oth

er o

phth

alm

ic p

rodu

cts,

sur

gica

l and

ort

hope

dic

prod

ucts

, he

arin

g ai

ds, w

heel

chai

rs, a

nd m

edic

al e

quip

men

t ren

tals

.6

The

nurs

ing

care

faci

litie

s an

d co

ntin

uing

car

e re

tirem

ent c

omm

uniti

es c

ateg

ory

incl

udes

nur

sing

and

reha

bilit

ativ

e se

rvic

es p

rovi

ded

in fr

eest

andi

ng n

ursi

ng h

ome

faci

litie

s th

at a

re g

ener

ally

pro

vide

d fo

r an

exte

nded

per

iod

of ti

me

by re

gist

ered

or l

icen

sed

prac

tical

nur

ses

and

othe

r sta

ff.

7 Th

e ot

her h

ealth

, res

iden

tial,

and

pers

onal

car

e ca

tego

ry in

clud

es s

pend

ing

for M

edic

aid

hom

e an

d co

mm

unity

-bas

ed w

aive

rs, c

are

prov

ided

in re

side

ntia

l fac

ilitie

s fo

r pe

ople

with

inte

llect

ual d

isab

ilitie

s or

men

tal h

ealth

and

sub

stan

ce a

buse

dis

orde

rs, a

mbu

lanc

e se

rvic

es, s

choo

l hea

lth, a

nd w

orks

ite h

ealth

car

e.8

The

adm

inis

trat

ion

cate

gory

incl

udes

the

adm

inis

trat

ive

cost

of h

ealth

car

e pr

ogra

ms

(e.g

., M

edic

are

and

Med

icai

d) a

nd th

e ne

t cos

t of p

rivat

e he

alth

insu

ranc

e (a

dmin

istr

ativ

e co

sts,

as

wel

l as

addi

tions

to re

serv

es, r

ate

cred

its a

nd d

ivid

ends

, pre

miu

m ta

xes,

and

pla

n pr

ofits

or l

osse

s).

Sour

ces:

Off

ice

of th

e Ac

tuar

y (O

ACT)

, Cen

ters

for M

edic

are

& M

edic

aid

Serv

ices

, 201

4, N

atio

nal h

ealth

exp

endi

ture

s by

type

of s

ervi

ce a

nd s

ourc

e of

fund

s: C

alen

dar y

ears

196

0–20

13, B

altim

ore,

MD:

OAC

T, ht

tps:

//w

ww

.cm

s.go

v/Re

sear

ch-S

tatis

tics-

Data

-and

-Sys

tem

s/St

atis

tics-

Tren

ds-a

nd-R

epor

ts/N

atio

nalH

ealth

Expe

ndDa

ta/D

ownl

oads

/NH

E201

3.zi

p. O

ACT,

2014

, Nat

iona

l hea

lth e

xpen

ditu

re a

ccou

nts:

Met

hodo

logy

pap

er, 2

013,

htt

p://

ww

w.c

ms.

gov/

Rese

arch

-Sta

tistic

s-Da

ta-a

nd-S

yste

ms/

Stat

istic

s-Tr

ends

-and

-Rep

orts

/N

atio

nalH

ealth

Expe

ndDa

ta/D

ownl

oads

/dsm

-13.

pdf.

EXH

IBIT

3.

(con

tinue

d)

Page 24: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201512

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

Fiscal year

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Medicaid

Medicare

Social Security

Exchangesubsidies

CHIP

Other mandatory programs

Discretionary, defense

Discretionary, non-defense

Net interest

EXHIBIT 4. Major Health Programs and Other Components of the Federal Budget as a Share of Federal Outlays, FYs 1965–2014

Page 25: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 13

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

Fisc

al y

ear

Man

dato

ry p

rogr

ams

Disc

retio

nary

pro

gram

s

Net

inte

rest

Med

icai

dCH

IPM

edic

are

Exch

ange

su

bsid

ies

Soci

al

Secu

rity

Oth

erDe

fens

eN

on-

defe

nse

1965

0.2%

––

–14

.4%

12.3

%43

.2%

22.6

%7.

3%19

701.

4–

3.0%

–15

.211

.641

.919

.67.

319

752.

1–

3.7

–19

.120

.626

.421

.27.

019

802.

4–

5.2

–19

.816

.922

.824

.08.

919

852.

4–

6.8

–19

.713

.526

.717

.213

.719

903.

3–

7.6

–19

.714

.724

.016

.014

.719

914.

0–

7.7

–20

.113

.224

.116

.114

.719

924.

9–

8.4

–20

.613

.021

.916

.714

.419

935.

4–

9.1

–21

.411

.720

.717

.514

.119

945.

6–

9.7

–21

.712

.119

.317

.713

.919

955.

9–

10.4

–22

.010

.518

.017

.915

.319

965.

9–

11.0

–22

.211

.317

.017

.115

.419

976.

0–

11.7

–22

.610

.317

.017

.215

.219

986.

10.

0%11

.5–

22.8

11.6

16.4

17.1

14.6

1999

6.3

0.0

11.0

–22

.712

.716

.217

.413

.520

006.

60.

110

.9–

22.7

13.0

16.5

17.9

12.5

2001

6.9

0.2

11.5

–23

.012

.416

.418

.411

.120

027.

30.

211

.3–

22.5

13.7

17.4

19.1

8.5

2003

7.4

0.2

11.4

–21

.813

.918

.719

.47.

120

047.

70.

211

.6–

21.4

13.1

19.8

19.2

7.0

2005

7.4

0.2

11.9

–21

.012

.920

.019

.27.

420

066.

80.

212

.2–

20.5

13.4

19.6

18.7

8.5

2007

7.0

0.2

13.6

–21

.311

.020

.118

.18.

720

086.

80.

212

.9–

20.5

13.0

20.5

17.5

8.5

2009

7.1

0.2

12.1

–19

.320

.818

.716

.55.

320

107.

90.

212

.9–

20.3

14.1

19.9

19.0

5.7

2011

7.6

0.2

13.3

–20

.114

.919

.418

.06.

420

127.

10.

313

.2–

21.7

15.2

19.0

17.4

6.2

2013

7.7

0.3

14.2

–23

.413

.218

.116

.76.

420

148.

60.

314

.40.

4%24

.112

.117

.016

.66.

5

Not

es: F

Y is

fisc

al y

ear.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

Off

ice

of M

anag

emen

t and

Bud

get (

OM

B), F

isca

l yea

r 201

6 hi

stor

ical

tabl

es: B

udge

t of t

he U

.S. g

over

nmen

t, Ta

bles

6.1

, 8.5

, and

8.7

, W

ashi

ngto

n, D

C: O

MB,

htt

p://

ww

w.g

po.g

ov/f

dsys

/sea

rch/

page

deta

ils.a

ctio

n?gr

anul

eId=

&pac

kage

Id=B

UDG

ET-2

016-

TAB.

EXH

IBIT

4.

(con

tinue

d)

Page 26: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201514

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

Stat

e

Tota

l bud

get (

incl

udin

g al

l sta

te a

nd fe

dera

l fun

ds)

Stat

e-fu

nded

bud

get (

no fe

dera

l fun

ds)

Dolla

rs

(mill

ions

)

Tota

l spe

ndin

g as

a s

hare

of

tota

l bud

get1

Dolla

rs

(mill

ions

)

Stat

e-fu

nded

spe

ndin

g as

a s

hare

of

sta

te-f

unde

d bu

dget

1

Med

icai

d

Elem

enta

ry

and

seco

ndar

y ed

ucat

ion

Hig

her

educ

atio

nM

edic

aid

Elem

enta

ry

and

seco

ndar

y ed

ucat

ion

Hig

her

educ

atio

nTo

tal

$1,6

89,5

42

24.5

%19

.8%

10.3

%$1

,186

,805

15

.1%

23.9

%13

.0%

Alab

ama

24,5

20

22.8

20.4

19.9

15,0

38

11.7

26.9

24.6

Alas

ka11

,838

12

.213

.79.

29,

108

6.7

15.4

10.6

Ariz

ona

28,2

97

29.8

18.6

14.3

16,2

89

16.4

25.4

20.3

Arka

nsas

21,4

45

21.0

15.6

15.4

15,3

63

8.7

18.4

21.5

Calif

orni

a21

1,43

2 25

.121

.46.

614

1,00

1 17

.527

.66.

5Co

lora

do29

,035

22

.026

.08.

321

,612

16

.632

.19.

1Co

nnec

ticut

27,8

52

21.8

14.1

10.6

25,2

39

24.0

13.7

10.3

Dela

war

e9,

162

17.2

24.3

4.6

7,37

9 9.

627

.34.

8Di

stric

t of C

olum

bia2

––

––

––

––

Flor

ida

63,9

71

31.8

19.3

8.5

39,6

99

21.4

25.8

13.6

Geo

rgia

42,4

44

21.3

24.1

19.0

29,3

98

10.6

26.8

27.2

Haw

aii

11,5

84

14.4

15.5

10.9

9,67

2 8.

215

.612

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aho

6,69

1 28

.024

.28.

14,

043

15.7

34.1

13.4

Illin

ois

65,2

87

23.8

13.3

3.7

49,8

15

15.9

13.2

4.3

Indi

ana

28,1

71

31.2

30.8

6.1

17,8

14

15.9

42.8

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Iow

a19

,531

19

.816

.426

.013

,804

12

.620

.033

.2Ka

nsas

13,9

69

18.5

26.8

18.2

10,0

79

11.5

32.4

19.1

Kent

ucky

25,6

73

21.9

19.6

26.7

17,6

72

9.6

23.6

33.4

Loui

sian

a27

,317

25

.119

.310

.317

,076

12

.524

.715

.5M

aine

7,67

9 32

.716

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65,

116

19.4

21.4

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Mar

ylan

d36

,255

21

.019

.214

.527

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13

.822

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assa

chus

etts

57,5

41

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229

,974

14

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inne

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Mis

siss

ippi

18,5

12

26.1

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57

11.2

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26.2

EXH

IBIT

5.

Med

icai

d as

a S

hare

of S

tate

Bud

gets

Incl

udin

g an

d Ex

clud

ing

Fede

ral F

unds

by

Stat

e, S

FY 2

013

Page 27: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 15

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

EXH

IBIT

5.

(con

tinue

d)

Stat

e

Tota

l bud

get (

incl

udin

g al

l sta

te a

nd fe

dera

l fun

ds)

Stat

e-fu

nded

bud

get (

no fe

dera

l fun

ds)

Dolla

rs

(mill

ions

)

Tota

l spe

ndin

g as

a s

hare

of

tota

l bud

get1

Dolla

rs

(mill

ions

)

Stat

e-fu

nded

spe

ndin

g as

a s

hare

of

sta

te-f

unde

d bu

dget

1

Med

icai

d

Elem

enta

ry

and

seco

ndar

y ed

ucat

ion

Hig

her

educ

atio

nM

edic

aid

Elem

enta

ry

and

seco

ndar

y ed

ucat

ion

Hig

her

educ

atio

nM

isso

uri

$22,

943

35.8

%22

.8%

4.8%

$15,

734

25.2

%27

.2%

7.0%

Mon

tana

6,04

0 17

.915

.510

.13,

925

8.8

19.7

14.2

Neb

rask

a10

,162

17

.914

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148

11.5

16.2

28.3

Nev

ada

8,89

7 22

.722

.38.

55,

979

14.3

26.7

12.7

New

Ham

pshi

re5,

017

25.6

23.4

2.2

3,41

3 19

.928

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3N

ew J

erse

y50

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20

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938

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12

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ew M

exic

o14

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25

.019

.519

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897

12.6

27.6

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New

Yor

k13

3,09

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694

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16

.323

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orth

Car

olin

a43

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30

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14

.830

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orth

Dak

ota

5,71

2 13

.715

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.04,

176

8.6

17.2

23.2

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o58

,268

29

.217

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345

,621

28

.317

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5O

klah

oma

21,4

30

23.0

16.2

22.7

14,5

07

13.7

19.4

30.0

Ore

gon

25,8

03

21.4

14.3

1.1

18,3

52

11.1

17.0

1.2

Penn

sylv

ania

85,3

78

26.9

14.9

2.1

61,4

33

17.2

16.8

2.9

Rhod

e Is

land

7,86

6 24

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346

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h Ca

rolin

a22

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414

.36.

4

Page 28: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201516

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

EXH

IBIT

5.

(con

tinue

d)

Not

es: S

FY is

sta

te fi

scal

yea

r. To

tal b

udge

t inc

lude

s fe

dera

l and

all

othe

r fun

ds. S

tate

-fund

ed b

udge

t inc

lude

s st

ate

gene

ral f

unds

, oth

er s

tate

fund

s, a

nd b

onds

. Med

icai

d,

elem

enta

ry a

nd s

econ

dary

edu

catio

n, a

nd h

ighe

r edu

catio

n re

pres

ent t

he la

rges

t tot

al b

udge

t sha

res

amon

g fu

nctio

ns b

roke

n ou

t sep

arat

ely

by th

e N

atio

nal A

ssoc

iatio

n of

St

ate

Budg

et O

ffic

ers

(NAS

BO).

Func

tions

not

sho

wn

here

are

tran

spor

tatio

n, c

orre

ctio

ns, p

ublic

ass

ista

nce,

and

all

othe

r. M

edic

aid

spen

ding

am

ount

s ex

clud

e ad

min

istr

ativ

e co

sts

but i

nclu

de M

edic

are

Part

D p

hase

d-do

wn

stat

e co

ntrib

utio

n (a

lso

refe

rred

to a

s cl

awba

ck) p

aym

ents

. 1

Tota

l and

sta

te-fu

nded

bud

get s

hare

s sh

ould

be

view

ed w

ith c

autio

n be

caus

e th

ey re

flect

var

ying

sta

te p

ract

ices

. For

exa

mpl

e, C

onne

ctic

ut re

port

s al

l of i

ts M

edic

aid

spen

ding

as

stat

e-fu

nded

spe

ndin

g du

e to

the

dire

ct d

epos

it of

fede

ral f

unds

into

the

stat

e tr

easu

ry. I

n ad

ditio

n, s

ome

func

tions

—pa

rtic

ular

ly e

lem

enta

ry a

nd s

econ

dary

ed

ucat

ion—

may

be

part

ially

fund

ed o

utsi

de o

f the

sta

te b

udge

t by

loca

l gov

ernm

ents

.

2 N

ASBO

doe

s no

t col

lect

info

rmat

ion

for t

he D

istr

ict o

f Col

umbi

a.

Sour

ce: N

atio

nal A

ssoc

iatio

n of

Sta

te B

udge

t Off

icer

s (N

ASBO

), 20

14, S

tate

exp

endi

ture

repo

rt: E

xam

inin

g fis

cal 2

012–

2014

sta

te s

pend

ing,

Was

hing

ton,

DC:

NAS

BO, h

ttps

://

ww

w.n

asbo

.org

/site

s/de

faul

t/fil

es/S

tate

%20

Expe

nditu

re%

20Re

port

%20

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Fisc

al%

2020

12-2

014%

29S.

pdf.

Page 29: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 17

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

Stat

eFM

APs

for M

edic

aid

E-FM

APs

for C

HIP

FY

201

2FY

201

3FY

201

41FY

201

51FY

201

61FY

201

2FY

201

3FY

201

4FY

201

5FY

201

62

Alab

ama

68.6

2%68

.53%

68.1

2%68

.99%

69.8

7%78

.03%

77.9

7%77

.68%

78.2

9%10

0.00

%

Alas

ka50

.00

50.0

050

.00

50.0

050

.00

65.0

065

.00

65.0

065

.00

88.0

0

Ariz

ona

67.3

065

.68

67.2

368

.46

68.9

277

.11

75.9

877

.06

77.9

210

0.00

Arka

nsas

70.7

170

.17

70.1

070

.88

70.0

079

.50

79.1

279

.07

79.6

210

0.00

Calif

orni

a50

.00

50.0

050

.00

50.0

050

.00

65.0

065

.00

65.0

065

.00

88.0

0

Colo

rado

50.0

050

.00

50.0

051

.01

50.7

265

.00

65.0

065

.00

65.7

188

.50

Conn

ectic

ut50

.00

50.0

050

.00

50.0

050

.00

65.0

065

.00

65.0

065

.00

88.0

0

Dela

war

e54

.17

55.6

755

.31

53.6

354

.83

67.9

268

.97

68.7

267

.54

91.3

8

Dist

rict o

f Col

umbi

a70

.00

70.0

070

.00

70.0

070

.00

79.0

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.00

79.0

079

.00

100.

00

Flor

ida

56.0

458

.08

58.7

959

.72

60.6

769

.23

70.6

671

.15

71.8

095

.47

Geo

rgia

66.1

665

.56

65.9

366

.94

67.5

576

.31

75.8

976

.15

76.8

610

0.00

Haw

aii

50.4

851

.86

51.8

552

.23

53.9

865

.34

66.3

066

.30

66.5

690

.79

Idah

o70

.23

71.0

071

.64

71.7

571

.24

79.1

679

.70

80.1

580

.23

100.

00

Illin

ois

50.0

050

.00

50.0

050

.76

50.8

965

.00

65.0

065

.00

65.5

388

.62

Indi

ana

66.9

667

.16

66.9

266

.52

66.6

076

.87

77.0

176

.84

76.5

699

.62

Iow

a60

.71

59.5

957

.93

55.5

454

.91

72.5

071

.71

70.5

568

.88

91.4

4

Kans

as56

.91

56.5

156

.91

56.6

355

.96

69.8

469

.56

69.8

469

.64

92.1

7

Kent

ucky

71.1

870

.55

69.8

369

.94

70.3

279

.83

79.3

978

.88

78.9

610

0.00

Loui

sian

a369

.78

65.5

162

.11

62.0

562

.21

72.7

672

.87

72.6

973

.44

96.5

5

Mai

ne63

.27

62.5

761

.55

61.8

862

.67

74.2

973

.80

73.0

973

.32

96.8

7

Mar

ylan

d50

.00

50.0

050

.00

50.0

050

.00

65.0

065

.00

65.0

065

.00

88.0

0

Mas

sach

uset

ts50

.00

50.0

050

.00

50.0

050

.00

65.0

065

.00

65.0

065

.00

88.0

0

Mic

higa

n66

.14

66.3

966

.32

65.5

465

.60

76.3

076

.47

76.4

275

.88

98.9

2

Min

neso

ta50

.00

50.0

050

.00

50.0

050

.00

65.0

065

.00

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065

.00

88.0

0

Mis

siss

ippi

74.1

873

.43

73.0

573

.58

74.1

781

.93

81.4

081

.14

81.5

110

0.00

Mis

sour

i63

.45

61.3

762

.03

63.4

563

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74.4

272

.96

73.4

274

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97.3

0

Mon

tana

66.1

166

.00

66.3

365

.90

65.2

476

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76.2

076

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76.1

398

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Neb

rask

a56

.64

55.7

654

.74

53.2

751

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69.6

569

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68.3

267

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88.8

1

EXH

IBIT

6.

Fede

ral M

edic

al A

ssis

tanc

e Pe

rcen

tage

s (F

MAP

s) a

nd E

nhan

ced

FMAP

s (E

-FM

APs)

by

Stat

e, F

Ys 2

012–

2016

Page 30: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201518

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

Stat

eFM

APs

for M

edic

aid

E-FM

APs

for C

HIP

FY

201

2FY

201

3FY

201

41FY

201

51FY

201

61FY

201

2FY

201

3FY

201

4FY

201

5FY

201

62

Nev

ada

56.2

0%59

.74%

63.1

0%64

.36%

64.9

3%69

.34%

71.8

2%74

.17%

75.0

5%98

.45%

New

Ham

pshi

re50

.00

50.0

050

.00

50.0

050

.00

65.0

065

.00

65.0

065

.00

88.0

0

New

Jer

sey

50.0

050

.00

50.0

050

.00

50.0

065

.00

65.0

065

.00

65.0

088

.00

New

Mex

ico

69.3

669

.07

69.2

069

.65

70.3

778

.55

78.3

578

.44

78.7

610

0.00

New

Yor

k50

.00

50.0

050

.00

50.0

050

.00

65.0

065

.00

65.0

065

.00

88.0

0

Nor

th C

arol

ina

65.2

865

.51

65.7

865

.88

66.2

475

.70

75.8

676

.05

76.1

299

.37

Nor

th D

akot

a55

.40

52.2

750

.00

50.0

050

.00

68.7

866

.59

65.0

065

.00

88.0

0

Ohi

o64

.15

63.5

863

.02

62.6

462

.47

74.9

174

.51

74.1

173

.85

96.7

3

Okl

ahom

a63

.88

64.0

064

.02

62.3

060

.99

74.7

274

.80

74.8

173

.61

95.6

9

Ore

gon

62.9

162

.44

63.1

464

.06

64.3

874

.04

73.7

174

.20

74.8

498

.07

Penn

sylv

ania

55.0

754

.28

53.5

251

.82

52.0

168

.55

68.0

067

.46

66.2

789

.41

Rhod

e Is

land

52.1

251

.26

50.1

150

.00

50.4

266

.48

65.8

865

.08

65.0

088

.29

Sout

h Ca

rolin

a70

.24

70.4

370

.57

70.6

471

.08

79.1

779

.30

79.4

079

.45

100.

00

Sout

h Da

kota

59.1

356

.19

53.5

451

.64

51.6

171

.39

69.3

367

.48

66.1

589

.13

Tenn

esse

e66

.36

66.1

365

.29

64.9

965

.05

76.4

576

.29

75.7

075

.49

98.5

4

Texa

s58

.22

59.3

058

.69

58.0

557

.13

70.7

571

.51

71.0

870

.64

92.9

9

Uta

h70

.99

69.6

170

.34

70.5

670

.24

79.6

978

.73

79.2

479

.39

100.

00

Verm

ont

57.5

856

.04

55.1

154

.01

53.9

070

.31

69.2

368

.58

67.8

190

.73

Virg

inia

50.0

050

.00

50.0

050

.00

50.0

065

.00

65.0

065

.00

65.0

088

.00

Was

hing

ton

50.0

050

.00

50.0

050

.03

50.0

065

.00

65.0

065

.00

65.0

288

.00

Wes

t Virg

inia

72.6

272

.04

71.0

971

.35

71.4

280

.83

80.4

379

.76

79.9

510

0.00

Wis

cons

in60

.53

59.7

459

.06

58.2

758

.23

72.3

771

.82

71.3

470

.79

93.7

6

Wyo

min

g50

.00

50.0

050

.00

50.0

050

.00

65.0

065

.00

65.0

065

.00

88.0

0

Amer

ican

Sam

oa55

.00

55.0

055

.00

55.0

055

.00

68.5

068

.50

68.5

068

.50

91.5

0

Gua

m55

.00

55.0

055

.00

55.0

055

.00

68.5

068

.50

68.5

068

.50

91.5

0

N. M

aria

na Is

land

s55

.00

55.0

055

.00

55.0

055

.00

68.5

068

.50

68.5

068

.50

91.5

0

Puer

to R

ico

55.0

055

.00

55.0

055

.00

55.0

068

.50

68.5

068

.50

68.5

091

.50

Virg

in Is

land

s55

.00

55.0

055

.00

55.0

055

.00

68.5

068

.50

68.5

068

.50

91.5

0

EXH

IBIT

6.

(con

tinue

d)

Page 31: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 19

Section 1: Overview—Key Statistics

MAC

Stat

sSe

ctio

n 1

EXH

IBIT

6.

(con

tinue

d)

Not

es: F

MAP

is fe

dera

l med

ical

ass

ista

nce

perc

enta

ge. E

-FM

AP is

enh

ance

d FM

AP. A

CA is

Pat

ient

Pro

tect

ion

and

Affo

rdab

le C

are

Act (

P.L.

111

-148

, as

amen

ded)

. The

fede

ral

gove

rnm

ent’s

sha

re o

f mos

t Med

icai

d se

rvic

e co

sts

is d

eter

min

ed b

y th

e FM

AP, w

ith s

ome

exce

ptio

ns. F

or M

edic

aid

adm

inis

trat

ive

cost

s, th

e fe

dera

l sha

re d

oes

not v

ary

by

stat

e an

d is

gen

eral

ly 5

0 pe

rcen

t. Th

e E-

FMAP

det

erm

ines

the

fede

ral s

hare

of b

oth

serv

ice

and

adm

inis

trat

ive

cost

s fo

r CH

IP, s

ubje

ct to

the

avai

labi

lity

of fu

nds

from

a s

tate

’s

fede

ral a

llotm

ents

for C

HIP

.

FMAP

s fo

r Med

icai

d ar

e ge

nera

lly c

alcu

late

d ba

sed

on a

form

ula

that

com

pare

s ea

ch s

tate

’s p

er c

apita

inco

me

rela

tive

to U

.S. p

er c

apita

inco

me

and

prov

ides

a h

ighe

r fe

dera

l mat

ch fo

r sta

tes

with

low

er p

er c

apita

inco

mes

, sub

ject

to a

sta

tuto

ry m

inim

um (5

0 pe

rcen

t) a

nd m

axim

um (8

3 pe

rcen

t). T

he g

ener

al fo

rmul

a fo

r a g

iven

sta

te is

: FM

AP =

1 —

[(st

ate

per c

apita

inco

me)

2 / (U

.S. p

er c

apita

inco

me)

2 × 0

.45]

.

Med

icai

d ex

cept

ions

to th

is fo

rmul

a in

clud

e th

e Di

stric

t of C

olum

bia

(set

in s

tatu

te a

t 70

perc

ent)

and

the

terr

itorie

s (s

et in

sta

tute

at 5

5 pe

rcen

t). O

ther

Med

icai

d ex

cept

ions

ap

ply

to c

erta

in s

ervi

ces,

pro

vide

rs, o

r situ

atio

ns (e

.g.,

serv

ices

pro

vide

d th

roug

h an

Indi

an H

ealth

Ser

vice

faci

lity

rece

ive

an F

MAP

of 1

00 p

erce

nt).

Enha

nced

FM

APs

for C

HIP

ar

e ca

lcul

ated

by

redu

cing

the

stat

e sh

are

unde

r reg

ular

FM

APs

for M

edic

aid

by 3

0 pe

rcen

t and

add

ing

23 p

erce

ntag

e po

ints

(see

not

e 2)

.1

For c

erta

in n

ewly

elig

ible

indi

vidu

als

unde

r the

Med

icai

d ex

pans

ion

begi

nnin

g in

201

4, th

ere

is a

n in

crea

sed

FMAP

(100

per

cent

in 2

014

thro

ugh

2016

, pha

sing

dow

n to

90

perc

ent i

n 20

20 a

nd s

ubse

quen

t yea

rs).

An in

crea

sed

FMAP

is a

lso

avai

labl

e fo

r cer

tain

sta

tes

that

pre

viou

sly

expa

nded

elig

ibili

ty to

low

-inco

me

pare

nts

and

non-

preg

nant

ad

ults

with

out c

hild

ren

prio

r to

enac

tmen

t of t

he A

CA.

2 Un

der t

he A

CA, b

egin

ning

on

Octo

ber 1

, 201

5, a

nd e

ndin

g on

Sep

tem

ber 3

0, 2

019,

the

enha

nced

FM

AP is

incr

ease

d by

23

perc

enta

ge p

oint

s, n

ot to

exc

eed

100

perc

ent,

for a

ll st

ates

.3

Loui

sian

a re

ceiv

ed a

dis

aste

r-rec

over

y st

ate

FMAP

adj

ustm

ent f

or th

e fo

urth

qua

rter

of F

Y 20

11 a

nd F

Ys 2

012–

2014

.

Sour

ces:

U.S

. Dep

artm

ent o

f Hea

lth a

nd H

uman

Ser

vice

s, F

eder

al R

egis

ter n

otic

es fo

r var

ious

yea

rs.

Page 32: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn
Page 33: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

SECTION 2

Trends

Page 34: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201522

Section 2: Trends

Section 2: Trends

Key Points• Trends in Medicaid spending and enrollment over time, shown in Exhibits 8–10, are

affected by federal and state policy choices as well as economic factors. Recent examples include growth around the recessions of 2001 and 2007–2009, which slowed as economic conditions subsequently improved; the fiscal year (FY) 2006 decrease in Medicaid spending driven by the implementation of Medicare Part D, which shifted dually eligible beneficiaries’ outpatient prescription drug costs from Medicaid to Medicare; and the FY 2014 increase in Medicaid spending driven in part by expanded eligibility under the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended).

• Medicaid enrollment trends vary by eligibility group. Children (excluding those eligible on the basis of disability) experienced the largest enrollment increase in absolute numbers between FY 1975 and FY 2012, from 9.6 million to 30.5 million. Individuals qualifying for Medicaid on the basis of disability—the smallest eligibility group in terms of absolute numbers—had the largest percentage increase in enrollment, almost quadrupling over this period (Exhibit 7).

• Medicaid’s share of both state-funded budgets (excluding federal funds) and total state budgets (including federal funds) has grown substantially since state fiscal year (SFY) 1987. In SFYs 2009 and 2010, the program’s share of state-funded budgets remained stable or dropped, while its share of total state budgets continued to increase. This divergence was due to a temporary increase in federal matching rates, which effectively allowed states to maintain their programs with a smaller state contribution (Exhibit 13).

• Between 2013 and 2015, the number of individuals enrolled in full-benefit Medicaid and CHIP grew by more than 14 million, largely due to changes made by the ACA. Enrollment in July 2014 was 14.4 percent higher than average monthly enrollment during July to September 2013, a baseline period that precedes the start of open enrollment for exchange plans and state expansions of Medicaid for adults under the ACA. Between July 2014 and July 2015, enrollment grew by an additional 7.3 percent. Because not all states have chosen to expand Medicaid, state-specific growth rates vary substantially (Exhibit 11).

• Medicaid and CHIP are projected to maintain a steady share of national health expenditures at about 17 percent through 2024, and Medicare’s share is projected to increase from about 20 percent to 22.5 percent (Exhibit 12).

Page 35: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 23

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Fisc

al y

ear

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Unk

now

n19

7522

,007

9,59

84,

529

2,46

43,

615

1,80

119

7622

,815

9,92

44,

773

2,66

93,

612

1,83

719

7722

,832

9,65

14,

785

2,80

23,

636

1,95

819

7821

,965

9,37

64,

643

2,71

83,

376

1,85

219

7921

,520

9,10

64,

570

2,75

33,

364

1,72

719

8021

,605

9,33

34,

877

2,91

13,

440

1,04

419

8121

,980

9,58

15,

187

3,07

93,

367

766

1982

21,6

039,

563

5,35

62,

891

3,24

055

319

8321

,554

9,53

55,

592

2,92

13,

372

134

1984

21,6

079,

684

5,60

02,

913

3,23

817

219

8521

,814

9,75

75,

518

3,01

23,

061

466

1986

22,5

1510

,029

5,64

73,

182

3,14

051

719

8723

,109

10,1

685,

599

3,38

13,

224

737

1988

22,9

0710

,037

5,50

33,

487

3,15

972

119

8923

,511

10,3

185,

717

3,59

03,

132

754

1990

25,2

5511

,220

6,01

03,

718

3,20

21,

105

1991

27,9

6712

,855

6,70

34,

033

3,34

11,

035

1992

31,1

5015

,200

7,04

04,

487

3,74

967

419

9333

,432

16,2

857,

505

5,01

63,

863

763

1994

35,0

5317

,194

7,58

65,

458

4,03

578

019

9536

,282

17,1

647,

604

5,85

84,

119

1,53

719

9636

,118

16,7

397,

127

6,22

14,

285

1,74

619

9734

,872

15,7

916,

803

6,12

93,

955

2,19

519

9840

,096

18,9

697,

895

6,63

73,

964

2,63

119

9939

,748

18,2

337,

446

6,69

03,

698

3,68

220

0041

,212

18,5

288,

538

6,68

83,

640

3,81

720

0145

,164

20,1

819,

707

7,11

43,

812

4,34

920

0246

,839

21,4

8710

,847

7,18

23,

789

3,53

4

EXH

IBIT

7.

Med

icai

d Be

nefic

iarie

s (P

erso

ns S

erve

d) b

y El

igib

ility

Gro

up, F

Ys 1

975–

2012

(tho

usan

ds)

Page 36: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201524

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Fisc

al y

ear

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Unk

now

n20

0350

,716

23,7

4211

,530

7,66

44,

041

3,73

920

0454

,250

25,4

1512

,325

8,12

34,

349

4,03

720

0556

,276

25,9

7912

,431

8,20

54,

395

5,26

620

0656

,264

26,3

5812

,495

8,33

44,

374

4,70

320

0755

,210

26,0

6112

,264

8,42

34,

044

4,41

820

0856

,962

26,4

7912

,739

8,68

54,

147

4,91

220

0960

,880

28,3

4414

,245

9,03

14,

195

5,06

620

1063

,730

30,0

2415

,368

9,34

14,

289

4,70

920

1165

,831

30,1

7516

,069

9,60

94,

331

5,64

620

1265

,584

30,4

6716

,483

9,83

64,

376

4,42

3

Not

es: F

Y is

fisc

al y

ear.

Bene

ficia

ries

(enr

olle

es fo

r who

m p

aym

ents

are

mad

e) a

re s

how

n he

re b

ecau

se th

ey p

rovi

de th

e on

ly h

isto

rical

tim

e se

ries

data

dire

ctly

ava

ilabl

e pr

ior

to F

Y 19

90. M

ost c

urre

nt a

naly

ses

of in

divi

dual

s in

Med

icai

d re

flect

enr

olle

es. F

or a

dditi

onal

dis

cuss

ion,

see

htt

ps://

ww

w.m

acpa

c.go

v/m

acst

ats/

data

-sou

rces

-and

-met

hods

/.

The

incr

ease

in F

Y 19

98 re

flect

s a

chan

ge in

how

Med

icai

d be

nefic

iarie

s ar

e co

unte

d: b

egin

ning

in F

Y 19

98, a

Med

icai

d-el

igib

le p

erso

n w

ho re

ceiv

ed o

nly

cove

rage

for m

anag

ed

care

ben

efits

was

incl

uded

in th

is s

erie

s as

a b

enef

icia

ry. E

xclu

des

Med

icai

d-ex

pans

ion

CHIP

and

the

terr

itorie

s. C

hild

ren

and

adul

ts w

ho q

ualif

y fo

r Med

icai

d on

the

basi

s of

a

disa

bilit

y ar

e in

clud

ed in

the

disa

bled

cat

egor

y. In

add

ition

, alth

ough

dis

abili

ty is

not

a b

asis

of e

ligib

ility

for a

ged

indi

vidu

als,

sta

tes

may

repo

rt s

ome

enro

llees

age

65

and

olde

r in

the

disa

bled

cat

egor

y. U

nlik

e th

e m

ajor

ity o

f MAC

Stat

s, th

is e

xhib

it do

es n

ot re

code

indi

vidu

als

age

65 a

nd o

lder

who

are

repo

rted

as

disa

bled

, due

to la

ck o

f det

ail i

n th

e hi

stor

ical

dat

a. G

ener

ally,

indi

vidu

als

who

se e

ligib

ility

gro

up is

unk

now

n ar

e pe

rson

s w

ho w

ere

enro

lled

in th

e pr

ior y

ear b

ut h

ad a

Med

icai

d cl

aim

pai

d in

the

curr

ent y

ear.

Due

to th

e un

avai

labi

lity

of s

ever

al s

tate

s’ M

edic

aid

Stat

istic

al In

form

atio

n Sy

stem

(MSI

S) A

nnua

l Per

son

Sum

mar

y (A

PS) d

ata

for f

isca

l yea

r FY

2012

, MAC

PAC

calc

ulat

ed

enro

llmen

t fro

m th

e fu

ll M

SIS

data

file

s th

at a

re u

sed

to c

reat

e th

e AP

S fil

es. F

or M

ACPA

C’s

anal

ysis

, Med

icai

d en

rolle

es w

ere

assi

gned

a u

niqu

e na

tiona

l ide

ntifi

catio

n (ID

) nu

mbe

r usi

ng a

n al

gorit

hm th

at in

corp

orat

es s

tate

-spe

cific

ID n

umbe

rs a

nd b

enef

icia

ry c

hara

cter

istic

s su

ch a

s da

te o

f birt

h an

d ge

nder

. The

sta

te a

nd n

atio

nal e

nrol

lmen

t co

unts

sho

wn

here

are

und

uplic

ated

usi

ng th

is n

atio

nal I

D.

Sour

ces:

For

FYs

199

9–20

12: M

ACPA

C, 2

015,

ana

lysi

s of

MSI

S da

ta fo

r FYs

197

5–19

98: C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es, M

edic

are

& M

edic

aid

stat

istic

al s

uppl

emen

t, 20

10 e

ditio

n, T

able

13.

4, h

ttps

://w

ww

.cm

s.go

v/Re

sear

ch-S

tatis

tics-

Data

-and

-Sys

tem

s/St

atis

tics-

Tren

ds-a

nd-R

epor

ts/M

edic

areM

edic

aidS

tatS

upp/

Dow

nloa

ds/2

010_

Sect

ion1

3.pd

f#Ta

ble%

2013

.4.

EXH

IBIT

7.

(con

tinue

d)

Page 37: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 25

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

$500

$550

$600

$650

$700

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

Fiscal year

Spen

ding

(bill

ions

)

FYE

enro

llmen

t (m

illio

ns)

Spending

FYE enrollment

Notes: FY is fiscal year. FYE is full-year equivalent, which also may be referred to as average monthly payment. All numbers exclude CHIP-financed coverage. Data prior to FY 1977 have been adjusted to the current federal fiscal year basis (October 1 to September 30). The amounts shown in this exhibit may differ from those published elsewhere due to slight differences in the timing of data and the treatment of certain adjustments. Spending consists of federal and state Medicaid expenditures for benefits and administration, excluding the Vaccines for Children program. Enrollment counts are full-year equivalents and, for fiscal years prior to FY 1990, have been estimated from counts of persons served (see https://www.macpac.gov/macstats/data-sources-and-methods/ for a discussion of how enrollees are counted). Enrollment data for FYs 2012–2014 are projected; those for FYs 1999–2014 include estimates for Puerto Rico and the Virgin Islands.

Source: Office of the Actuary (OACT), Centers for Medicare & Medicaid Services, 2015, data compilation provided to MACPAC staff, April 17.

EXHIBIT 8. Medicaid Enrollment and Spending, FYs 1966–2014

Page 38: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201526

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

-5%

0%

5%

10%

15%

20%

25%

30%

Spending

FYE enrollment

Fiscal year

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013

Notes: FY is fiscal year. FYE is full-year equivalent, which also may be referred to as average monthly enrollment. All numbers exclude CHIP-financed coverage. Data prior to FY 1977 have been adjusted to the current federal fiscal year basis (October 1 to September 30). The amounts shown in this exhibit may differ from those published elsewhere due to slight differences in the timing of data and the treatment of certain adjustments. Spending consists of federal and state Medicaid expenditures for benefits and administration, excluding the Vaccines for Children program. Enrollment counts are full-year equivalents and, for fiscal years prior to FY 1990, have been estimated from counts of persons served (see https://www.macpac.gov/macstats/data-sources-and-methods/ for a discussion of how enrollees are counted). Enrollment data for FYs 2012–2014 are projected; those for FYs 1999–2014 include estimates for Puerto Rico and the Virgin Islands.

Source: Office of the Actuary (OACT), Centers for Medicare & Medicaid Services, 2015, data compilation provided to MACPAC staff, April 17.

EXHIBIT 9. Annual Growth in Medicaid Enrollment and Spending, FYs 1975–2014

Page 39: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 27

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Fisc

al y

ear

Spen

ding

(b

illio

ns)

FYE

enro

llmen

t (m

illio

ns)

Spen

ding

per

FY

E en

rolle

e

Annu

al g

row

th

Spen

ding

Full-

year

equ

ival

ent

enro

llmen

tSp

endi

ng p

er

FYE

enro

llee

1966

$14.

0$1

98–

––

1967

27.

432

119

7.4%

83.3

%62

.2%

1968

410

.634

352

.442

.96.

719

694

11.5

382

21.2

8.9

11.3

1970

514

.036

515

.921

.3-4

.419

717

16.3

401

28.5

16.9

9.9

1972

816

.548

422

.41.

320

.919

739

17.6

534

17.0

6.2

10.2

1974

1119

.056

715

.18.

36.

319

7513

20.2

651

21.8

6.1

14.8

1976

1520

.772

013

.62.

710

.619

7717

20.7

830

15.3

0.1

15.3

1978

1920

.095

911

.2-3

.815

.619

7922

19.6

1,11

514

.0-2

.016

.319

8025

19.6

1,28

515

.70.

415

.219

8130

20.0

1,49

318

.21.

716

.219

8232

19.6

1,62

06.

7-1

.78.

519

8335

19.6

1,77

99.

6-0

.29.

819

8437

19.8

1,88

37.

11.

25.

819

8541

19.8

2,08

010

.50.

010

.519

8645

20.5

2,17

67.

93.

24.

619

8749

21.0

2,33

910

.42.

67.

519

8854

20.8

2,59

810

.1-0

.911

.019

8961

21.4

2,87

113

.42.

610

.519

9073

22.9

3,17

718

.97.

410

.719

9192

26.3

3,49

526

.014

.610

.019

9211

828

.94,

092

28.6

9.8

17.1

EXH

IBIT

10.

Med

icai

d En

rollm

ent a

nd T

otal

Spe

ndin

g Le

vels

and

Ann

ual G

row

th, F

Ys 1

966–

2014

Page 40: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201528

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

EXH

IBIT

10.

(co

ntin

ued)

Fisc

al y

ear

Spen

ding

(b

illio

ns)

FYE

enro

llmen

t (m

illio

ns)

Spen

ding

per

FY

E en

rolle

e

Annu

al g

row

th

Spen

ding

Full-

year

equ

ival

ent

enro

llmen

tSp

endi

ng p

er

FYE

enro

llee

1993

$131

31.2

$4,1

9010

.7%

8.1%

2.4%

1994

142

32.4

4,37

18.

33.

94.

319

9515

733

.44,

710

10.9

2.9

7.7

1996

160

33.2

4,81

51.

8-0

.42.

219

9716

733

.05,

054

4.3

-0.6

5.0

1998

175

32.5

5,39

34.

9-1

.76.

719

9918

832

.15,

878

7.7

-1.2

9.0

2000

203

34.5

5,88

87.

97.

70.

220

0122

536

.96,

099

10.6

6.7

3.6

2002

254

40.5

6,28

613

.29.

83.

120

0327

343

.56,

272

7.2

7.4

-0.2

2004

291

45.2

6,44

96.

83.

92.

820

0531

046

.36,

690

6.4

2.6

3.7

2006

307

46.7

6,58

7-0

.80.

7-1

.520

0732

346

.46,

968

5.2

-0.5

5.8

2008

343

47.7

7,18

85.

92.

73.

120

0936

950

.97,

256

7.7

6.7

1.0

2010

388

54.6

7,11

15.

27.

3-2

.020

1141

256

.57,

290

6.1

3.5

2.5

2012

416

58.0

7,17

71.

12.

7-1

.520

1343

258

.97,

342

3.9

1.6

2.3

2014

473

64.8

7,29

49.

310

.0-0

.7

Not

es: F

Y is

fisc

al y

ear.

FYE

is fu

ll-ye

ar e

quiv

alen

t, w

hich

may

als

o be

refe

rred

to a

s av

erag

e m

onth

ly e

nrol

lmen

t. Al

l num

bers

exc

lude

CH

IP-fi

nanc

ed c

over

age.

Dat

a pr

ior t

o FY

197

7 ha

ve b

een

adju

sted

to th

e cu

rren

t fed

eral

fisc

al y

ear b

asis

(Oct

ober

1 th

roug

h Se

ptem

ber 3

0). T

he a

mou

nts

show

n in

this

exh

ibit

may

diff

er fr

om th

ose

publ

ishe

d el

sew

here

due

to s

light

diff

eren

ces

in th

e tim

ing

of d

ata

and

the

trea

tmen

t of c

erta

in a

djus

tmen

ts. S

pend

ing

cons

ists

of f

eder

al a

nd s

tate

Med

icai

d ex

pend

iture

s fo

r ben

efits

an

d ad

min

istr

atio

n, e

xclu

ding

the

Vacc

ines

for C

hild

ren

prog

ram

. Enr

ollm

ent c

ount

s ar

e fu

ll-ye

ar e

quiv

alen

ts a

nd, f

or fi

scal

yea

rs p

rior t

o FY

199

0, h

ave

been

est

imat

ed fr

om

coun

ts o

f per

sons

ser

ved

(see

htt

ps:/

/ww

w.m

acpa

c.go

v/m

acst

ats/

data

-sou

rces

-and

-met

hods

/ for

a d

iscu

ssio

n of

how

enr

olle

es a

re c

ount

ed).

Enro

llmen

t dat

a fo

r FYs

20

12–

2014

are

pro

ject

ed; t

hose

for F

Ys 1

999–

2014

incl

ude

estim

ates

for P

uert

o Ri

co a

nd th

e Vi

rgin

Isla

nds.

Sour

ce: O

ffic

e of

the

Actu

ary

(OAC

T), C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es, 2

015,

dat

a co

mpi

latio

n pr

ovid

ed to

MAC

PAC

staf

f, Ap

ril 1

7.

Page 41: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 29

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Stat

e

Num

ber o

f ind

ivid

uals

enr

olle

dAn

nual

and

cum

ulat

ive

grow

th

July

–Se

ptem

ber

2013

ave

rage

July

201

4 J

uly

2015

July

–Se

ptem

ber

2013

ave

rage

to

Jul

y 20

14Ju

ly 2

014

to

Jul

y 20

15

July

–Se

ptem

ber

2013

ave

rage

to

Jul

y 20

15To

tal

57,

794,

096 1

67,

147,

446

72,

046,

111

14.4

%2

7.3%

22.9

%2

Alab

ama

799

,176

3 8

68,1

74

878

,270

8.

61.

29.

9Al

aska

122

,334

1

25,2

54

122

,406

2.

4-2

.30.

1Ar

izon

a 1

,201

,770

1

,463

,723

1

,595

,617

21

.89.

032

.8Ar

kans

as 5

56,8

51

784

,335

8

23,7

41

40.9

5.0

47.9

Calif

orni

a 9

,157

,000

1

0,90

0,00

0 4 1

2,64

8,63

7 19

.016

.038

.1Co

lora

do 7

83,4

20

1,1

06,1

34

1,2

65,5

37

41.2

14.4

61.5

Conn

ectic

ut –

7

49,1

59

753

,927

0.

6 –

De

law

are

223

,324

2

33,7

06

241

,749

4.

63.

48.

3Di

stric

t of C

olum

bia5

235

,786

2

50,4

46

255

,660

6.

22.

18.

4Fl

orid

a 3

,104

,996

3

,343

,988

6 3

,558

,092

67.

76.

414

.6G

eorg

ia 1

,535

,090

1

,739

,141

1

,731

,306

13

.3-0

.512

.8H

awai

i 2

88,3

57

318

,838

3

32,0

27

10.6

4.1

15.1

Idah

o 2

38,1

50

283

,129

2

77,2

13

18.9

-2.1

16.4

Illin

ois

2,6

26,9

43 7

3,0

21,1

95

3,1

20,5

81

15.0

3.3

18.8

Indi

ana8

1,1

20,6

74

1,2

11,1

25

1,3

27,9

09

8.1

9.6

18.5

Iow

a 4

93,5

15

565

,593

5

99,3

05

14.6

6.0

21.4

Kans

as 3

78,1

60

401

,980

3

97,1

44

6.3

-1.2

5.0

Kent

ucky

606

,805

1

,048

,285

1

,119

,198

72

.86.

884

.4Lo

uisi

ana

1,0

19,7

87

1,0

37,1

36

1,0

75,6

52

1.7

3.7

5.5

Mai

ne –

2

96,2

06

280

,241

-5

.4 –

M

aryl

and

856

,297

1

,151

,270

1

,167

,003

34

.41.

436

.3M

assa

chus

etts

1,2

96,3

59

1,4

76,1

84 9

1,6

39,2

59

13.9

11.0

26.5

Mic

higa

n 1

,912

,009

2

,218

,845

2

,284

,761

16

.03.

019

.5M

inne

sota

873

,040

10 1

,068

,305

1

,006

,444

22

.4-5

.815

.3M

issi

ssip

pi 6

37,2

29

693

,425

7

02,3

27

8.8

1.3

10.2

Mis

sour

i 8

46,0

84

812

,785

9

32,0

26

-3.9

14.7

10.2

Mon

tana

148

,974

1

63,5

51

176

,714

9.

88.

018

.6

EXH

IBIT

11.

Ful

l-Ben

efit

Med

icai

d an

d CH

IP E

nrol

lmen

t, Se

lect

ed M

onth

s, 2

013–

2015

Page 42: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201530

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Stat

e

Num

ber o

f ind

ivid

uals

enr

olle

dAn

nual

and

cum

ulat

ive

grow

th

July

–Se

ptem

ber

2013

ave

rage

July

201

4 J

uly

2015

July

–Se

ptem

ber

2013

ave

rage

to

Jul

y 20

14Ju

ly 2

014

to

Jul

y 20

15

July

–Se

ptem

ber

2013

ave

rage

to

Jul

y 20

15N

ebra

ska

244

,600

2

38,6

09

232

,088

-2

.4%

-2.7

%-5

.1%

Nev

ada

332

,560

5 5

27,9

29 5

566

,017

58

.77.

270

.2N

ew H

amps

hire

127

,082

1

37,9

34

181

,182

8.

531

.442

.6N

ew J

erse

y 1

,283

,851

1

,562

,483

1

,749

,110

21

.711

.936

.2N

ew M

exic

o 4

57,6

78

705

,128

7

17,1

89

54.1

1.7

56.7

New

Yor

k 5

,678

,417

6

,143

,909

6

,452

,876

8.

25.

013

.6N

orth

Car

olin

a 1

,595

,952

1

,737

,117

1

,911

,334

8.

810

.019

.8N

orth

Dak

ota

69,

980 11

79,

076

88,

719

13.0

12.2

26.8

Ohi

o 2

,341

,481

2

,708

,484

2

,988

,934

15

.710

.427

.7O

klah

oma

790

,051

8

03,5

77

821

,867

1.

72.

34.

0O

rego

n 6

26,3

56

997

,762

1

,028

,349

59

.33.

164

.2Pe

nnsy

lvan

ia 2

,386

,046

2

,417

,392

2

,635

,481

1.

39.

010

.5Rh

ode

Isla

nd 1

90,8

33

259

,183

12 2

76,0

28

35.8

6.5

44.6

Sout

h Ca

rolin

a 8

89,7

44

868

,487

9

99,4

38

-2.4

15.1

12.3

Sout

h Da

kota

115

,501

1

16,1

74

118

,715

0.

62.

22.

8Te

nnes

see

1,2

44,5

16

1,3

52,2

43

1,5

04,9

52

8.7

11.3

20.9

Texa

s8 4

,441

,605

4

,575

,968

4

,634

,046

3.

01.

34.

3U

tah8

294

,029

3

01,3

11

302

,560

2.

50.

42.

9Ve

rmon

t 1

61,0

81

208

,699

1

85,2

42

29.6

-11.

215

.0Vi

rgin

ia 9

35,4

34

937

,493

9

62,1

83

0.2

2.6

2.9

Was

hing

ton

1,1

17,5

76

1,5

42,7

89

1,7

21,6

45

38.0

11.6

54.1

Wes

t Virg

inia

354

,544

5

19,6

72

542

,077

46

.64.

352

.9W

isco

nsin

985

,531

13 1

,006

,257

13 1

,048

,817

2.

14.

26.

4W

yom

ing

67,

518

67,

858

64,

516

0.5

-4.9

-4.5

Not

es: E

nrol

lmen

t exc

lude

s in

divi

dual

s w

ith li

mite

d be

nefit

s, s

uch

as th

ose

who

onl

y re

ceiv

e M

edic

aid

cove

rage

of M

edic

are

prem

ium

s an

d co

st s

harin

g, fa

mily

pla

nnin

g se

rvic

es, o

r em

erge

ncy

cove

rage

due

to n

on-c

itize

n st

atus

(sta

te-s

peci

fic e

xcep

tions

are

not

ed b

elow

). Th

e Ju

ly–

Sept

embe

r 201

3 pe

riod

show

n he

re s

erve

s as

a p

re-A

ffor

dabl

e Ca

re A

ct b

asel

ine,

repr

esen

ting

the

num

ber o

f peo

ple

cove

red

by M

edic

aid

and

CHIP

prio

r to

the

star

t of o

pen

enro

llmen

t for

exc

hang

e pl

ans

in O

ctob

er 2

013

and

the

stat

e ex

pans

ions

of M

edic

aid

for a

dults

that

beg

an in

Jan

uary

201

4 an

d be

yond

. Som

e da

ta a

re p

relim

inar

y or

est

imat

ed, a

nd a

ll da

ta a

re s

ubje

ct to

cha

nge

as s

tate

s m

ay re

vise

th

eir s

ubm

issi

ons

at a

ny ti

me.

See

sou

rce

docu

men

ts b

elow

for f

ull d

etai

ls.

EXH

IBIT

11.

(co

ntin

ued)

Page 43: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 31

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

– D

ash

indi

cate

s th

at s

tate

did

not

repo

rt d

ata.

1 Ex

clud

es tw

o st

ates

not

repo

rtin

g da

ta.

2 Pe

rcen

tage

cal

cula

ted

base

d on

sta

tes

repo

rtin

g da

ta fo

r bot

h pe

riods

.3

Data

are

for S

epte

mbe

r 201

3 on

ly.

4 In

clud

es a

pplic

ants

like

ly e

ligib

le fo

r Med

icai

d or

CH

IP, b

ut w

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Page 44: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201532

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Cale

ndar

ye

ar

Paye

r am

ount

(bill

ions

) and

sha

re o

f tot

al

Tota

l (b

illio

ns)

Med

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IPM

edic

are

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insu

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hea

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1970

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$25

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%

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134

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3022

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4.5

3022

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28.0

1980

256

2610

.237

14.6

6927

.010

3.8

5521

.658

22.8

1985

445

419.

272

16.2

131

29.5

153.

489

20.1

9621

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1990

724

7410

.211

015

.223

432

.321

3.0

146

20.2

139

19.1

1995

1,02

714

514

.118

417

.932

731

.827

2.6

198

19.3

146

14.2

2000

1,37

820

314

.822

516

.346

033

.433

2.4

255

18.5

201

14.6

2005

2,03

531

715

.634

016

.770

334

.657

2.8

351

17.2

267

13.1

2010

2,60

440

915

.752

020

.086

233

.184

3.2

422

16.2

306

11.8

2011

2,70

541

915

.554

520

.189

933

.289

3.3

436

16.1

317

11.7

2012

2,81

743

615

.556

720

.193

633

.290

3.2

459

16.3

329

11.7

2013

2,91

946

315

.958

620

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232

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477

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339

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Proj

ecte

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2014

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80$5

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2015

3,24

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150

215

.535

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358

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140

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105

3.1

527

15.5

361

10.6

2017

3,58

761

617

.272

820

.31,

198

33.4

112

3.1

557

15.5

376

10.5

2018

3,78

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520

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258

33.2

118

3.1

590

15.6

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EXH

IBIT

12.

His

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nd P

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Page 45: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 33

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Cale

ndar

ye

ar

Paye

r am

ount

(bill

ions

) and

sha

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edic

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986

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PAC,

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enda

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EXH

IBIT

12.

(co

ntin

ued)

Page 46: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201534

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

0%

5%

10%

15%

20%

25%

Including state general funds only (no federal funds)

10.2%11.3%

14.2%

18.8%

19.8% 20.0%19.5% 19.7%

22.0% 22.3%

20.9%21.9%

23.8%24.5%

8.1%9.0%

10.5%

13.3%

14.4% 14.6% 14.4%15.2%

17.2% 17.1% 16.6%16.3% 16.5%

18.9%

5.7%6.3%

7.9%

10.9%11.6% 11.5% 11.4% 11.7%

13.1%13.5%

12.8%12.3%

13.3%

15.1%

Including all federal and state funds

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013

Fiscal year

Including all state funds (no federal funds)

EXHIBIT 13. Medicaid as a Share of State Budgets Including and Excluding Federal Funds, SFYs 1987–2013

Page 47: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 35

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

EXHIBIT 13. (continued)

State fiscal yearIncluding all federal

and state funds

Including state general funds only (no federal funds)

Including all state funds (no federal funds)

1987 10.2% 8.1% 5.7%1988 10.8 8.7 6.11989 11.3 9.0 6.31990 12.5 9.5 6.91991 14.2 10.5 7.91992 17.8 12.1 10.01993 18.8 13.3 10.91994 19.7 14.2 11.31995 19.8 14.4 11.61996 19.9 14.7 11.71997 20.0 14.6 11.51998 19.6 14.8 11.61999 19.5 14.4 11.42000 19.1 15.0 11.02001 19.7 15.2 11.72002 20.7 15.8 12.22003 22.0 17.2 13.12004 22.1 16.9 12.92005 22.3 17.1 13.52006 21.4 17.4 13.32007 20.9 16.6 12.82008 20.5 16.0 12.52009 21.9 16.3 12.32010 22.2 14.8 11.62011 23.8 16.5 13.32012 23.6 19.2 14.52013 24.5 18.9 15.1

Notes: SFY is state fiscal year. Amounts shown here reflect the most recent information available in cases where data for a given year were published and then updated in a subsequent report.

The all federal and state funds category reflects amounts from any source. The state general funds category reflects amounts from revenues raised through income, sales, and other broad-based state taxes. The all state funds category reflects amounts from any non-federal source; these include state general funds, other state funds (amounts from revenue sources that are restricted by law for particular government functions or activities, which for Medicaid includes provider taxes and local funds), and bonds (expenditures from the sale of bonds, generally for capital projects).

Source: MACPAC, 2015, analysis of state expenditure reports from the National Association of State Budget Officers, http://www.nasbo.org/publications-data/state-expenditure-report/archives.

Page 48: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn
Page 49: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

SECTION 3

Program Enrollment and Spending

Page 50: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201538

Section 3: Program Enrollment and Spending

Section 3: Program Enrollment and Spending

Key Points• Total Medicaid spending was $498.3 billion in fiscal year (FY) 2014, an 8 percent increase

from the prior year (Exhibit 16). Total CHIP spending decreased by about 1 percent, to $13.0 billion (Exhibit 32).

• The share of Medicaid benefit spending on capitation payments for managed care reached about 38 percent of all Medicaid benefit spending in FY 2014, an increase of 6 percentage points over the prior year (Exhibit 17).

• Individuals eligible on the basis of disability and those age 65 and older account for about a quarter of Medicaid enrollees, but about two-thirds of program spending (Exhibits 14 and 21). Many of these individuals are users of long-term services and supports (LTSS). This group accounts for only about 6 percent of Medicaid enrollees, but nearly half of all Medicaid spending (Exhibit 20).

• A large share of Medicaid spending for enrollees eligible on the basis of disability and enrollees age 65 and older is for LTSS, while more than half of spending for children and adults eligible on a basis other than disability is for capitation payments to managed care plans (Exhibit 18).

• Medicaid benefit spending per enrollee varies substantially across states (Exhibit 22). This variation may reflect several factors, including the underlying costs of delivering health care services in specific geographic areas, the breadth of benefit packages offered by states, and the health status and other characteristics of enrollees.

• Almost half (47 percent) of Medicaid gross spending for drugs occurred under managed care in FY 2014 (Exhibit 25). Drug rebates reduced gross drug spending by about 47 percent in FY 2014 (Exhibit 27).

• Disproportionate share hospital (DSH), upper payment limit (UPL), and other types of supplemental payments accounted for more than 40 percent of fee-for-service payments to hospitals in FY 2014 (Exhibit 23).

Page 51: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 39

Section 3: Program Enrollment and Spending—Medicaid Overall

MAC

Stat

sSe

ctio

n 3

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tal

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ty1

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Page 52: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201540

Section 3: Program Enrollment and Spending—Medicaid Overall

MAC

Stat

sSe

ctio

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nnsy

lvan

ia2,

562

1,10

750

069

925

645

724

537

419

582

49Rh

ode

Isla

nd18

580

4040

2439

2233

186

4So

uth

Caro

lina

1,04

452

625

717

288

167

8814

274

2514

Sout

h Da

kota

134

7724

2013

2213

148

84

Tenn

esse

e1,

545

794

323

278

150

288

148

157

8013

168

Texa

s34,

641

2,97

955

765

445

168

644

341

227

327

417

0U

tah

388

225

9847

1938

1733

155

3Ve

rmon

t20

569

8726

2338

2229

168

6Vi

rgin

ia1,

093

580

208

190

115

199

109

130

7569

34W

ashi

ngto

n1,

408

795

286

222

105

189

102

135

7854

24W

est V

irgin

ia43

920

864

124

4489

4452

2638

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isco

nsin

1,26

449

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217

414

521

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519

011

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yom

ing

8958

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612

67

45

2

Page 53: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 41

Section 3: Program Enrollment and Spending—Medicaid Overall

MAC

Stat

sSe

ctio

n 3

Not

es: F

Y is

fisc

al y

ear.

Enro

llmen

t num

bers

gen

eral

ly in

clud

e in

divi

dual

s ev

er e

nrol

led

in M

edic

aid-

finan

ced

cove

rage

dur

ing

the

year

, eve

n if

for a

sin

gle

mon

th; h

owev

er, i

n th

e ev

ent i

ndiv

idua

ls w

ere

also

enr

olle

d in

CH

IP-fi

nanc

ed M

edic

aid

cove

rage

(i.e

., M

edic

aid-

expa

nsio

n CH

IP) d

urin

g th

e ye

ar, t

hey

are

excl

uded

if th

eir m

ost r

ecen

t enr

ollm

ent

mon

th w

as in

Med

icai

d-ex

pans

ion

CHIP

. Num

bers

exc

lude

indi

vidu

als

enro

lled

only

in M

edic

aid-

expa

nsio

n CH

IP d

urin

g th

e ye

ar a

nd e

nrol

lees

in th

e te

rrito

ries.

Due

to th

e un

avai

labi

lity

of s

ever

al s

tate

s’ M

edic

aid

Stat

istic

al In

form

atio

n Sy

stem

(MSI

S) A

nnua

l Per

son

Sum

mar

y (A

PS) d

ata

for F

Y 20

12, t

he s

ourc

e us

ed in

prio

r edi

tions

of

this

tabl

e, M

ACPA

C ca

lcul

ated

enr

ollm

ent f

rom

the

full

MSI

S da

ta fi

les

that

are

use

d to

cre

ate

the

APS

files

. For

MAC

PAC’

s an

alys

is, M

edic

aid

enro

llees

wer

e as

sign

ed a

uni

que

natio

nal i

dent

ifica

tion

(ID) n

umbe

r usi

ng a

n al

gorit

hm th

at in

corp

orat

es s

tate

-spe

cific

ID n

umbe

rs a

nd b

enef

icia

ry c

hara

cter

istic

s su

ch a

s da

te o

f birt

h an

d ge

nder

. The

sta

te

and

natio

nal e

nrol

lmen

t cou

nts

show

n he

re a

re u

ndup

licat

ed u

sing

this

nat

iona

l ID.

Cat

egor

ies

may

not

sum

to to

tal f

or e

ach

stat

e du

e to

roun

ding

. In

addi

tion,

the

sum

of t

he

stat

e to

tals

exc

eeds

the

natio

nal t

otal

bec

ause

indi

vidu

als

may

be

enro

lled

in m

ore

than

one

sta

te d

urin

g th

e ye

ar.

1 Ch

ildre

n an

d ad

ults

und

er a

ge 6

5 w

ho q

ualif

y fo

r Med

icai

d on

the

basi

s of

dis

abili

ty a

re in

clud

ed in

the

disa

bled

cat

egor

y. A

bout

737

,000

enr

olle

es a

ge 6

5 an

d ol

der a

re

iden

tifie

d in

the

data

as

disa

bled

; giv

en th

at d

isab

ility

is n

ot a

n el

igib

ility

pat

hway

for i

ndiv

idua

ls a

ge 6

5 an

d ol

der,

MAC

PAC

reco

des

thes

e en

rolle

es a

s ag

ed.

2 Du

ally

elig

ible

enr

olle

es a

re c

over

ed b

y bo

th M

edic

aid

and

Med

icar

e; th

ose

with

lim

ited

bene

fits

rece

ive

only

Med

icai

d as

sist

ance

with

Med

icar

e pr

emiu

ms

and

cost

sha

ring.

3 St

ate

had

a ch

ange

in to

tal e

nrol

lmen

t of 1

0 pe

rcen

t or m

ore

over

the

prio

r yea

r. Th

ese

data

may

refle

ct d

ata

anom

alie

s in

the

subm

issi

on o

f MSI

S da

ta a

nd m

ay b

e up

date

d in

futu

re M

SIS

subm

issi

ons

by s

tate

s. M

SIS

data

ano

mal

ies

have

bee

n co

mpi

led

and

repo

rted

by

Mat

hem

atic

a Po

licy

Rese

arch

; the

dat

a an

omal

ies

repo

rt m

ay b

e fo

und

at:

http

://w

ww

.cm

s.go

v/Re

sear

ch-S

tatis

tics-

Data

-and

-Sys

tem

s/Co

mpu

ter-D

ata-

and-

Syst

ems/

Med

icai

dDat

aSou

rces

Gen

Info

/dow

nloa

ds/a

nom

alie

s1.p

df.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

MSI

S da

ta a

s of

Sep

tem

ber 2

014.

EXH

IBIT

14.

(co

ntin

ued)

Page 54: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201542

Section 3: Program Enrollment and Spending—Medicaid Overall

MAC

Stat

sSe

ctio

n 3

Stat

e

Tota

lCh

ildAd

ult

Disa

bled

Aged

All

enro

llees

Full

bene

fit

enro

llees

1Al

l en

rolle

esFu

ll be

nefit

en

rolle

es1

All

enro

llees

Full

bene

fit

enro

llees

1Al

l en

rolle

esFu

ll be

nefit

en

rolle

es1

All

enro

llees

Full

bene

fit

enro

llees

1

Tota

l56

,995

50,0

1927

,027

26,7

0414

,707

10,5

919,

347

8,29

35,

913

4,43

0Al

abam

a94

371

847

347

315

338

207

160

109

46Al

aska

110

110

6161

2424

1616

98

Ariz

ona2

1,38

51,

277

642

630

486

429

156

144

101

75Ar

kans

as59

447

230

730

083

2314

011

063

38Ca

lifor

nia

9,47

56,

900

3,56

33,

358

3,89

31,

579

1,00

899

81,

012

965

Colo

rado

651

625

368

368

129

127

100

8954

42Co

nnec

ticut

695

623

283

283

238

237

7256

102

47De

law

are

209

180

8483

8673

2518

146

Dist

rict o

f Col

umbi

a315

715

755

5561

6127

2714

13Fl

orid

a3,

248

2,80

11,

672

1,66

454

544

656

242

746

926

4G

eorg

ia2

1,24

31,

087

682

682

139

109

272

220

150

77H

awai

i24

924

510

610

690

9030

2824

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aho

223

211

139

139

2626

4135

1711

Illin

ois

2,67

22,

532

1,44

71,

447

711

610

302

287

212

188

Indi

ana

1,00

794

756

556

517

717

718

114

684

59Io

wa

499

446

232

230

147

113

8175

3828

Kans

as34

932

720

720

738

3772

5933

23Ke

ntuc

ky77

069

237

137

192

9221

717

789

52Lo

uisi

ana

1,11

494

256

556

521

713

422

218

511

058

Mai

ne2

371

326

112

112

9796

100

9060

28M

aryl

and

915

848

430

429

277

253

136

118

7247

Mas

sach

uset

ts1,

080

1,01

125

124

242

238

427

927

712

810

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ichi

gan

1,88

51,

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984

976

421

347

350

330

130

108

Min

neso

ta88

985

037

437

231

329

212

912

373

64M

issi

ssip

pi65

555

333

233

183

5515

812

283

45

EXH

IBIT

15.

Med

icai

d Fu

ll-Ye

ar E

quiv

alen

t Enr

ollm

ent b

y St

ate

and

Elig

ibili

ty G

roup

, FY

2012

(tho

usan

ds)

Page 55: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 43

Section 3: Program Enrollment and Spending—Medicaid Overall

MAC

Stat

sSe

ctio

n 3

Stat

e

Tota

lCh

ildAd

ult

Disa

bled

Aged

All

enro

llees

Full

bene

fit

enro

llees

1Al

l en

rolle

esFu

ll be

nefit

en

rolle

es1

All

enro

llees

Full

bene

fit

enro

llees

1Al

l en

rolle

esFu

ll be

nefit

en

rolle

es1

All

enro

llees

Full

bene

fit

enro

llees

1

Mis

sour

i93

183

448

548

518

093

187

182

8074

Mon

tana

108

100

6262

1313

2218

117

Neb

rask

a20

820

412

212

230

3037

3519

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evad

a30

628

018

518

548

4744

3328

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ew H

amps

hire

137

126

8080

1515

2821

149

New

Jer

sey

971

943

533

533

118

117

178

170

142

124

New

Mex

ico

557

478

307

307

143

9467

5440

23N

ew Y

ork

4,95

14,

668

1,76

51,

731

1,92

11,

802

666

634

600

501

Nor

th C

arol

ina

1,62

01,

470

873

873

263

187

314

281

169

128

Nor

th D

akot

a65

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1111

108

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hio

2,10

61,

928

1,00

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004

602

535

329

269

168

120

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ahom

a72

364

639

339

315

599

115

105

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Ore

gon

618

552

293

286

168

149

9980

5737

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sylv

ania

2,14

51,

953

919

918

379

261

627

596

220

178

Rhod

e Is

land

162

155

6969

3331

3736

2219

Sout

h Ca

rolin

a85

374

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514

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uth

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ta10

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063

6315

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1511

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nnes

see

1,32

21,

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687

687

252

252

251

197

132

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xas

4,07

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661

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62,

606

394

245

646

544

426

266

Uta

h28

127

616

516

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rmon

t16

816

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6524

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rgin

ia89

880

648

548

514

211

017

013

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171

Was

hing

ton

1,15

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029

676

675

197

116

194

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t Virg

inia

355

323

166

166

4040

111

9438

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isco

nsin

1,06

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736

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616

115

312

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yom

ing

6863

4544

87

109

53

EXH

IBIT

15.

(co

ntin

ued)

Page 56: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201544

Section 3: Program Enrollment and Spending—Medicaid Overall

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

15.

(co

ntin

ued)

Not

es: F

Y is

fisc

al y

ear.

Full-

year

equ

ival

ent (

FYE)

may

als

o be

refe

rred

to a

s av

erag

e m

onth

ly e

nrol

lmen

t. En

rollm

ent n

umbe

rs g

ener

ally

incl

ude

indi

vidu

als

ever

enr

olle

d in

M

edic

aid-

finan

ced

cove

rage

dur

ing

the

year

, eve

n if

for a

sin

gle

mon

th; h

owev

er, i

n th

e ev

ent i

ndiv

idua

ls w

ere

also

enr

olle

d in

CH

IP-fi

nanc

ed M

edic

aid

cove

rage

(i.e

., M

edic

aid-

expa

nsio

n CH

IP) d

urin

g th

e ye

ar, t

hey

are

excl

uded

if th

eir m

ost r

ecen

t enr

ollm

ent m

onth

was

in M

edic

aid-

expa

nsio

n CH

IP. N

umbe

rs e

xclu

de in

divi

dual

s en

rolle

d on

ly in

M

edic

aid-

expa

nsio

n CH

IP d

urin

g th

e ye

ar a

nd e

nrol

lees

in th

e te

rrito

ries.

Chi

ldre

n an

d ad

ults

und

er a

ge 6

5 w

ho q

ualif

y fo

r Med

icai

d on

the

basi

s of

dis

abili

ty a

re in

clud

ed in

the

disa

bled

cat

egor

y. A

bout

737

,000

enr

olle

es a

ge 6

5 an

d ol

der a

re id

entif

ied

in th

e da

ta a

s di

sabl

ed; g

iven

that

dis

abili

ty is

not

an

elig

ibili

ty p

athw

ay fo

r ind

ivid

uals

age

65

and

olde

r, M

ACPA

C re

code

s th

ese

enro

llees

as

aged

.

Due

to th

e un

avai

labi

lity

of s

ever

al s

tate

s’ M

edic

aid

Stat

istic

al In

form

atio

n Sy

stem

(MSI

S) A

nnua

l Per

son

Sum

mar

y (A

PS) d

ata

for f

isca

l yea

r FY

2012

, MAC

PAC

calc

ulat

ed

enro

llmen

t fro

m th

e fu

ll M

SIS

data

file

s th

at a

re u

sed

to c

reat

e th

e AP

S fil

es. C

ateg

orie

s m

ay n

ot s

um to

tota

l for

eac

h st

ate

due

to ro

undi

ng. I

n ad

ditio

n, th

e su

m o

f the

sta

te

tota

ls e

xcee

ds th

e na

tiona

l tot

al b

ecau

se in

divi

dual

s m

ay b

e en

rolle

d in

mor

e th

an o

ne s

tate

dur

ing

the

year

.1

In th

is e

xhib

it, fu

ll be

nefit

enr

olle

es c

olum

ns e

xclu

des

enro

llees

repo

rted

by

stat

es in

the

MSI

S as

rece

ivin

g co

vera

ge o

f onl

y fa

mily

pla

nnin

g se

rvic

es, a

ssis

tanc

e w

ith

Med

icar

e pr

emiu

ms

and

cost

sha

ring,

or e

mer

genc

y se

rvic

es.

2 St

ate

had

a ch

ange

in F

YE e

nrol

lees

of 1

0 pe

rcen

t or m

ore

over

the

prio

r yea

r. Th

ese

data

may

refle

ct a

nom

alie

s in

the

MSI

S da

ta a

nd m

ay b

e up

date

d in

futu

re M

SIS

subm

issi

ons

by s

tate

s. M

SIS

data

ano

mal

ies

have

bee

n co

mpi

led

and

repo

rted

by

Mat

hem

atic

a Po

licy

Rese

arch

; the

dat

a an

omal

ies

repo

rt m

ay b

e fo

und

at: h

ttp:

//w

ww

.cm

s.go

v/Re

sear

ch-S

tatis

tics-

Data

-and

-Sys

tem

s/Co

mpu

ter-D

ata-

and-

Syst

ems/

Med

icai

dDat

aSou

rces

Gen

Info

/dow

nloa

ds/a

nom

alie

s1.p

df.

3 Th

e Di

stric

t of C

olum

bia

had

a sl

ight

incr

ease

in to

tal e

nrol

lees

but

a la

rge

decr

ease

in to

tal e

nrol

led

mon

ths,

thus

cre

atin

g a

decr

ease

in F

YE e

nrol

lees

and

num

ber o

f m

onth

s pe

r enr

olle

e of

10

perc

ent o

r mor

e ov

er th

e pr

ior y

ear.

Thes

e da

ta m

ay re

flect

ano

mal

ies

in th

e M

SIS

data

and

may

be

upda

ted

in fu

ture

MSI

S su

bmis

sion

s. M

SIS

data

an

omal

ies

have

bee

n co

mpi

led

and

repo

rted

by

Mat

hem

atic

a Po

licy

Rese

arch

; the

dat

a an

omal

ies

repo

rt m

ay b

e fo

und

at: h

ttp:

//w

ww

.cm

s.go

v/Re

sear

ch-S

tatis

tics-

Data

-and

-Sy

stem

s/Co

mpu

ter-D

ata-

and-

Syst

ems/

Med

icai

dDat

aSou

rces

Gen

Info

/dow

nloa

ds/a

nom

alie

s1.p

df.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

MSI

S da

ta a

s of

Dec

embe

r 201

4.

Page 57: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 45

Section 3: Program Enrollment and Spending—Medicaid Overall

MAC

Stat

sSe

ctio

n 3

Stat

e1

Bene

fits

Stat

e pr

ogra

m a

dmin

istr

atio

nTo

tal M

edic

aid

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Alab

ama

$5,2

13$3

,599

$1,6

14$2

12$1

36$7

6$5

,425

$3,7

35$1

,690

Alas

ka1,

412

832

580

134

8550

1,54

791

763

0Ar

izon

a9,

185

6,56

52,

620

268

195

739,

453

6,76

02,

693

Arka

nsas

4,84

03,

615

1,22

531

421

110

45,

154

3,82

61,

328

Calif

orni

a63

,384

35,7

5627

,628

4,86

42,

724

2,14

068

,248

38,4

8029

,769

Colo

rado

5,91

93,

335

2,58

434

622

412

26,

265

3,55

92,

706

Conn

ectic

ut6,

821

3,87

92,

942

347

215

132

7,16

84,

094

3,07

4De

law

are

1,69

21,

004

688

113

8033

1,80

51,

084

721

Dist

rict o

f Col

umbi

a2,

368

1,72

164

715

710

057

2,52

41,

821

704

Flor

ida

20,3

0312

,151

8,15

274

747

127

621

,050

12,6

238,

428

Geo

rgia

9,39

76,

347

3,05

046

131

215

09,

858

6,65

93,

199

Haw

aii

1,95

01,

125

824

100

7624

2,05

01,

201

848

Idah

o1,

586

1,13

744

810

777

301,

692

1,21

447

8Ill

inoi

s16

,616

8,94

07,

676

1,10

666

943

817

,723

9,60

98,

114

Indi

ana

9,09

46,

145

2,94

950

632

418

29,

600

6,46

93,

131

Iow

a3,

922

2,46

01,

462

189

137

514,

110

2,59

71,

513

Kans

as2,

728

1,56

21,

165

205

136

692,

933

1,69

91,

234

Kent

ucky

7,79

35,

935

1,85

822

315

766

8,01

66,

092

1,92

4Lo

uisi

ana

7,05

64,

408

2,64

728

217

710

57,

338

4,58

62,

752

Mai

ne2,

365

1,47

189

516

311

747

2,52

91,

587

941

Mar

ylan

d9,

210

5,25

53,

955

415

268

147

9,62

65,

523

4,10

2M

assa

chus

etts

14,2

517,

321

6,92

970

242

228

014

,952

7,74

37,

209

Mic

higa

n13

,503

9,27

04,

233

645

439

206

14,1

489,

709

4,43

9M

inne

sota

9,91

85,

481

4,43

759

537

022

510

,513

5,85

14,

663

Mis

siss

ippi

4,86

53,

585

1,28

015

110

249

5,01

63,

687

1,33

0M

isso

uri

8,82

95,

545

3,28

441

027

113

99,

239

5,81

63,

423

Mon

tana

1,07

272

934

372

5221

1,14

578

136

3N

ebra

ska

1,77

297

979

313

691

451,

907

1,07

083

8N

evad

a2,

281

1,58

969

215

110

942

2,43

21,

698

734

New

Ham

pshi

re1,

323

678

645

9866

321,

421

744

677

New

Jer

sey

12,4

707,

099

5,37

172

440

831

613

,194

7,50

75,

687

New

Mex

ico

4,16

93,

140

1,02

918

012

159

4,34

93,

261

1,08

8

EXH

IBIT

16.

Med

icai

d Sp

endi

ng b

y St

ate,

Cat

egor

y, an

d So

urce

of F

unds

, FY

2014

(mill

ions

)

Page 58: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201546

Section 3: Program Enrollment and Spending—Medicaid Overall

MAC

Stat

sSe

ctio

n 3

Stat

e1

Bene

fits

Stat

e pr

ogra

m a

dmin

istr

atio

nTo

tal M

edic

aid

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

New

Yor

k$5

1,80

6$2

7,62

2$2

4,18

4$1

,792

$1,0

74$7

19$5

3,59

9$2

8,69

6$2

4,90

3N

orth

Car

olin

a11

,993

7,94

54,

047

663

440

222

12,6

558,

386

4,26

9N

orth

Dak

ota

402

206

195

4932

1745

123

921

2O

hio

19,4

3913

,068

6,37

178

450

228

220

,223

13,5

706,

653

Okl

ahom

a4,

666

3,03

81,

629

259

178

814,

925

3,21

51,

710

Ore

gon

6,78

44,

952

1,83

250

728

122

67,

291

5,23

32,

058

Penn

sylv

ania

23,4

6212

,705

10,7

5795

360

235

124

,415

13,3

0611

,109

Rhod

e Is

land

2,43

71,

410

1,02

712

988

422,

566

1,49

81,

069

Sout

h Ca

rolin

a5,

321

3,77

11,

550

276

185

905,

597

3,95

61,

640

Sout

h Da

kota

778

455

323

6342

2184

149

734

4Te

nnes

see

9,20

56,

064

3,14

144

928

216

79,

654

6,34

63,

308

Texa

s31

,385

18,7

9012

,595

1,44

688

456

232

,831

19,6

7413

,157

Uta

h2,

064

1,45

960

617

012

446

2,23

51,

583

652

Verm

ont

1,52

690

162

544

395

1,57

094

063

0Vi

rgin

ia7,

547

3,84

33,

704

433

299

134

7,98

04,

142

3,83

8W

ashi

ngto

n10

,250

6,43

43,

816

596

361

235

10,8

466,

794

4,05

1W

est V

irgin

ia3,

331

2,45

487

715

710

552

3,48

82,

559

929

Wis

cons

in7,

396

4,44

82,

949

387

241

146

7,78

34,

689

3,09

4W

yom

ing

539

276

263

5537

1859

531

328

1Su

btot

al (s

tate

s)$4

67,6

39$2

82,5

00$1

85,1

39$2

4,33

7$1

5,13

6$9

,201

$491

,976

$297

,636

$194

,340

Amer

ican

Sam

oa25

1411

10

026

1511

Gua

m74

4232

53

178

4533

Nor

ther

n M

aria

na Is

land

s34

1914

10

034

2014

Puer

to R

ico

1,84

21,

139

703

8762

261,

929

1,20

172

8Vi

rgin

Isla

nds

7140

319

81

8047

32Su

btot

al (s

tate

s an

d te

rrito

ries)

$469

,683

$283

,754

$185

,929

$24,

440

$15,

209

$9,2

30$4

94,1

23$2

98,9

64$1

95,1

59St

ate

Med

icai

d Fr

aud

Cont

rol U

nits

(M

FCU

s)–

––

285

214

7128

521

471

Med

icai

d su

rvey

and

cer

tific

atio

n of

nur

sing

and

inte

rmed

iate

car

e fa

cilit

ies

––

–29

322

073

293

220

73

Vacc

ines

for C

hild

ren

(VFC

) pro

gram

––

––

––

3,55

73,

557

–To

tal

$469

,683

$283

,754

$185

,929

$25,

018

$15,

643

$9,3

75$4

98,2

582

$302

,954

2$1

95,3

04

EXH

IBIT

16.

(co

ntin

ued)

Page 59: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 47

Section 3: Program Enrollment and Spending—Medicaid Overall

MAC

Stat

sSe

ctio

n 3

Not

es: F

Y is

fisc

al y

ear.

Tota

l fed

eral

spe

ndin

g sh

own

here

($30

2,95

4 m

illio

n) w

ill d

iffer

from

tota

l fed

eral

out

lays

sho

wn

in F

Y 20

16 b

udge

t doc

umen

ts d

ue to

slig

ht d

iffer

ence

s in

the

timin

g of

dat

a fo

r the

sta

tes

and

the

trea

tmen

t of c

erta

in a

djus

tmen

ts. F

eder

al s

pend

ing

in th

e te

rrito

ries

is c

appe

d; h

owev

er, t

errit

orie

s re

port

thei

r tot

al s

pend

ing

rega

rdle

ss o

f whe

ther

they

hav

e re

ache

d th

eir c

aps.

As

a re

sult,

fede

ral s

pend

ing

show

n he

re m

ay e

xcee

d th

e am

ount

s ac

tual

ly p

aid

to th

e te

rrito

ries.

Sta

te s

hare

s fo

r MFC

Us

and

surv

ey a

nd c

ertif

icat

ion

are

MAC

PAC

estim

ates

bas

ed o

n 75

per

cent

fede

ral m

atch

. Sta

te-le

vel e

stim

ates

for t

hese

item

s ar

e av

aila

ble

but a

re n

ot s

how

n he

re. T

he

VFC

prog

ram

is a

utho

rized

in th

e M

edic

aid

stat

ute

but i

s op

erat

ed a

s a

sepa

rate

pro

gram

; 100

per

cent

fede

ral f

undi

ng fi

nanc

es th

e pu

rcha

se o

f vac

cine

s fo

r chi

ldre

n w

ho

are

enro

lled

in M

edic

aid,

uni

nsur

ed, o

r priv

atel

y in

sure

d w

ithou

t vac

cine

cov

erag

e. S

pend

ing

on a

dmin

istr

atio

n is

onl

y fo

r sta

te p

rogr

ams;

fede

ral o

vers

ight

spe

ndin

g is

not

in

clud

ed.

– D

ash

indi

cate

s ze

ro; $

0 in

dica

tes

an a

mou

nt le

ss th

an $

0.5

mill

ion

that

roun

ds to

zer

o.

1 N

ot a

ll st

ates

hav

e ce

rtifi

ed th

eir C

MS-

64 F

MR

subm

issi

ons

as o

f Feb

ruar

y 25

, 201

5. C

alifo

rnia

’s a

nd C

olor

ado’

s se

cond

, thi

rd, a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t ce

rtifi

ed; N

orth

Dak

ota’

s th

ird a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t cer

tifie

d; S

outh

Car

olin

a’s

seco

nd q

uart

er s

ubm

issi

on is

not

cer

tifie

d; R

hode

Isla

nd’s

four

th q

uart

er

subm

issi

on is

not

cer

tifie

d. F

igur

es p

rese

nted

in th

is e

xhib

it m

ay c

hang

e if

stat

es re

vise

thei

r exp

endi

ture

dat

a af

ter t

his

date

.2

Amou

nts

exce

ed th

e su

m o

f ben

efits

and

sta

te p

rogr

am a

dmin

istr

atio

n co

lum

ns d

ue to

the

incl

usio

n of

the

VFC

prog

ram

.

Sour

ces:

For

sta

te a

nd te

rrito

ry s

pend

ing:

MAC

PAC,

201

5, a

naly

sis

of C

MS-

64 F

MR

net e

xpen

ditu

re d

ata

as o

f Feb

ruar

y 25

, 201

5. F

or a

ll ot

her s

pend

ing

(MCF

Us,

sur

vey

and

cert

ifica

tion,

VFC

): Ce

nter

s fo

r Med

icar

e &

Med

icai

d Se

rvic

es, 2

015,

Fis

cal y

ear 2

016

just

ifica

tion

of e

stim

ates

for A

ppro

pria

tions

Com

mitt

ees,

Bal

timor

e, M

D, h

ttp:

//w

ww

.cm

s.go

v/Ab

out-C

MS/

Agen

cy-In

form

atio

n/Pe

rfor

man

ceBu

dget

/Dow

nloa

ds/F

Y201

6-CJ

-Fin

al.p

df.

EXH

IBIT

16.

(co

ntin

ued)

Page 60: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201548

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

17.

Tot

al M

edic

aid

Bene

fit S

pend

ing

by S

tate

and

Cat

egor

y, FY

201

4 (m

illio

ns)

Stat

e1

Tota

l sp

endi

ng

on b

enef

its

Fee

for s

ervi

ceM

anag

ed

care

and

pr

emiu

m

assi

stan

ce

Med

icar

e pr

emiu

ms

and

coin

sura

nce

Colle

ctio

nsH

ospi

tal

Phys

icia

nDe

ntal

Oth

er

prac

titio

nerCl

inic

and

he

alth

ce

nter

Oth

er a

cute

Drug

sIn

stitu

tiona

l LT

SS

Hom

e an

d co

mm

unity

-ba

sed

LTSS

Alab

ama

$5,2

13$1

,909

$503

$84

$49

$89

$499

$293

$1,0

03$4

59$9

6$2

58-$

30

Alas

ka1,

412

308

119

7421

208

112

3915

936

30

24-1

5

Ariz

ona

9,18

51,

175

375

514

826

45

725

7,30

022

5-5

4

Arka

nsas

4,84

01,

009

339

7422

4990

318

599

848

952

929

9-5

6

Calif

orni

a63

,384

13,2

741,

446

593

252,

485

5,83

51,

408

5,68

29,

010

21,8

382,

257

-469

Colo

rado

5,91

91,

910

493

146

–15

425

028

071

01,

064

843

109

-41

Conn

ectic

ut6,

821

1,97

239

617

111

626

447

146

71,

613

1,38

00

380

-411

Dela

war

e1,

692

5413

341

5864

106

3710

81,

218

35-3

4

Dist

rict o

f Col

umbi

a2,

368

379

4624

314

911

779

372

408

769

37-1

3

Flor

ida

20,3

034,

942

1,33

018

442

184

1,44

641

71,

836

1,22

47,

459

1,36

1-1

23

Geo

rgia

9,39

72,

139

431

3932

1571

427

71,

380

932

3,19

433

4-8

9

Haw

aii

1,95

011

43

360

374

310

106

1,62

853

-45

Idah

o1,

586

434

111

-018

2218

462

272

299

165

41-2

3

Illin

ois

16,6

166,

722

892

183

109

288

1,18

941

42,

508

1,73

32,

286

401

-110

Indi

ana

9,09

41,

906

320

184

1139

435

746

32,

358

1,05

91,

907

172

-36

Iow

a3,

922

802

196

5423

7936

812

694

174

555

914

4-1

16

Kans

as2

2,72

814

621

03

546

-182

139

2,24

085

-37

Kent

ucky

7,79

345

857

34

113

386

361,

148

735

4,76

919

8-1

15

Loui

sian

a7,

056

2,21

232

882

–89

314

234

1,33

483

51,

659

271

-303

Mai

ne2,

365

510

102

2743

233

384

7542

843

93

213

-92

Mar

ylan

d9,

210

1,21

012

812

525

5793

629

11,

338

1,10

33,

892

267

-162

Mas

sach

uset

ts14

,251

2,25

738

722

723

332

1,00

233

91,

901

2,36

85,

339

427

-352

Mic

higa

n13

,503

1,48

644

071

923

051

328

82,

034

799

7,31

539

7-7

9

Min

esso

ta9,

918

642

237

3619

263

647

118

1,00

32,

387

4,55

417

7-1

38

Mis

siss

ippi

4,86

51,

661

198

423

9537

514

71,

096

315

763

207

-19

Mis

sour

i8,

829

2,88

142

1412

445

819

648

1,38

91,

298

1,05

532

0-9

5

Mon

tana

1,07

230

256

2819

2019

041

193

175

2536

-13

Neb

rask

a1,

772

186

3334

35

6759

421

340

566

103

-45

Nev

ada

2,28

151

412

633

1632

202

9827

518

769

712

0-1

9

New

Ham

pshi

re2

1,32

316

338

217

514

5-9

404

301

243

27-2

1

Page 61: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 49

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

Stat

e1

Tota

l sp

endi

ng

on b

enef

its

Fee

for s

ervi

ceM

anag

ed

care

and

pr

emiu

m

assi

stan

ce

Med

icar

e pr

emiu

ms

and

coin

sura

nce

Colle

ctio

nsH

ospi

tal

Phys

icia

nDe

ntal

Oth

er

prac

titio

nerCl

inic

and

he

alth

ce

nter

Oth

er a

cute

Drug

sIn

stitu

tiona

l LT

SS

Hom

e an

d co

mm

unity

-ba

sed

LTSS

New

Jer

sey

$12,

470

$1,7

76$7

1$8

$3$1

96$8

38$1

9$2

,967

$1,0

57$5

,307

$333

-$10

4

New

Mex

ico2

4,16

936

035

1138

2841

-14

3432

13,

236

91-1

3

New

Yor

k251

,806

7,70

738

876

216

1,26

35,

101

-1,4

899,

661

6,11

723

,861

1,30

2-2

,398

Nor

th C

arol

ina

11,9

933,

471

730

318

320

247

1,04

661

01,

377

860

2,69

742

1-1

05

Nor

th D

akot

a40

263

266

56

2610

163

928

6-7

Ohi

o19

,439

2,45

938

753

2611

81,

539

772,

859

2,60

39,

078

385

-143

Okl

ahom

a4,

666

1,67

349

111

643

389

359

297

770

526

157

146

-300

Ore

gon

6,78

451

431

223

7854

065

411

1,23

53,

762

169

-47

Penn

sylv

ania

23,4

621,

822

105

282

103

346

144,

896

3,53

012

,203

574

-161

Rhod

e Is

land

2,43

736

516

101

2956

73

239

21,

177

43-1

4

Sout

h Ca

rolin

a5,

321

1,08

915

994

2224

132

56

812

488

2,14

017

8-2

32

Sout

h Da

kota

778

193

6415

291

5732

165

136

228

-7

Tenn

esse

e9,

205

856

5314

21

4023

548

525

968

46,

163

346

-58

Texa

s31

,385

5,47

11,

690

8523

738

4,54

234

63,

692

2,44

512

,634

1,02

3-8

17

Uta

h2,

064

303

7619

311

9363

275

238

975

37-3

0

Verm

ont2

1,52

644

20

01

1,42

8-7

412

08

-06

-9

Virg

inia

7,54

799

220

212

833

501,

006

441,

246

1,32

62,

356

228

-64

Was

hing

ton

10,2

501,

080

193

155

2953

638

059

910

1,71

05,

022

331

-154

Wes

t Virg

inia

3,33

162

219

940

1847

261

156

747

586

552

121

-18

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cons

in7,

396

779

130

4423

312

676

321

956

899

3,03

332

2-9

9

Wyo

min

g53

911

746

1413

3628

1813

312

82

14-8

Subt

otal

$467

,639

$85,

432

$13,

960

$3,9

55$1

,912

$10,

209

$38,

235

$8,0

34$6

5,68

7$5

5,79

5$1

77,2

77$1

5,08

4-$

7,94

1Am

eric

an S

amoa

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––

––

10

––

––

Gua

m74

159

20

127

171

0–

1–

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aria

na Is

land

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1–

33

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to R

ico

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in Is

land

s71

444

11

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l$4

69,6

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7$1

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3$3

,960

$1,9

13$1

0,21

6$3

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4$8

,059

$65,

692

$55,

796

$179

,089

$15,

094

-$7,

940

Perc

ent o

f tot

al,

excl

usiv

e of

co

llect

ions

–17

.9%

2.9%

0.8%

0.4%

2.1%

8.0%

1.7%

13.8

%11

.7%

37.5

%3.

2%–

EXH

IBIT

17.

(co

ntin

ued)

Page 62: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201550

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

Not

es: L

TSS

is lo

ng-te

rm s

ervi

ces

and

supp

orts

. Inc

lude

s fe

dera

l and

sta

te fu

nds.

Ser

vice

cat

egor

y de

finiti

ons

and

spen

ding

am

ount

s sh

own

here

may

diff

er fr

om o

ther

CM

S da

ta s

ourc

es, s

uch

as th

e M

edic

aid

Stat

istic

al In

form

atio

n Sy

stem

(MSI

S). T

he s

peci

fic s

ervi

ces

incl

uded

in e

ach

cate

gory

hav

e ch

ange

d ov

er ti

me

and

ther

efor

e m

ay n

ot b

e di

rect

ly c

ompa

rabl

e to

ear

lier e

ditio

ns o

f MAC

Stat

s. C

olle

ctio

ns in

clud

e th

ird-p

arty

liab

ility

, est

ate,

and

oth

er re

cove

ries.

– D

ash

indi

cate

s ze

ro; $

0 or

-$0

indi

cate

s an

am

ount

bet

wee

n $0

.5 a

nd -$

0.5

mill

ion

that

roun

ds to

zer

o.

Addi

tiona

l det

ail o

n ca

tego

ries:

• Hos

pita

l inc

lude

s in

patie

nt, o

utpa

tient

, crit

ical

acc

ess

hosp

ital,

and

emer

genc

y ho

spita

l ser

vice

s, a

s w

ell a

s re

late

d di

spro

port

iona

te s

hare

hos

pita

l (DS

H) p

aym

ents

. • P

hysi

cian

incl

udes

phy

sici

an a

nd s

urgi

cal s

ervi

ces,

bot

h re

gula

r pay

men

ts a

nd th

ose

asso

ciat

ed w

ith th

e pr

imar

y ca

re p

hysi

cian

pay

men

t inc

reas

e.• C

linic

and

hea

lth c

ente

r inc

lude

s no

n-ho

spita

l out

patie

nt c

linic

, rur

al h

ealth

clin

ic, f

eder

ally

qua

lifie

d he

alth

cen

ter,

and

free

stan

ding

birt

h ce

nter

.• O

ther

acu

te in

clud

es la

b or

X-ra

y; s

teril

izat

ions

; abo

rtio

ns; E

arly

and

Per

iodi

c Sc

reen

ing,

Dia

gnos

tic, a

nd T

reat

men

t (EP

SDT)

scr

eeni

ngs;

em

erge

ncy

serv

ices

for u

naut

horiz

ed

alie

ns; n

on-e

mer

genc

y tr

ansp

orta

tion;

phy

sica

l, oc

cupa

tiona

l, sp

eech

, and

hea

ring

ther

apy;

pro

sthe

tics,

den

ture

s, a

nd e

yegl

asse

s; p

reve

ntiv

e se

rvic

es w

ith U

.S. P

reve

ntiv

e Se

rvic

es T

ask

Forc

e (U

SPST

F) G

rade

A o

r B a

nd A

dvis

ory

Com

mitt

ee o

n Im

mun

izat

ion

Prac

tices

(ACI

P) v

acci

nes;

oth

er d

iagn

ostic

scr

eeni

ng a

nd p

reve

ntiv

e se

rvic

es;

scho

ol-b

ased

ser

vice

s; h

ealth

hom

e w

ith c

hron

ic c

ondi

tions

; tob

acco

ces

satio

n fo

r pre

gnan

t wom

en; p

rivat

e du

ty n

ursi

ng; c

ase

man

agem

ent (

excl

udin

g pr

imar

y ca

re c

ase

man

agem

ent)

; reh

abili

tativ

e se

rvic

es; h

ospi

ce; a

nd o

ther

car

e no

t oth

erw

ise

cate

goriz

ed.

• Dru

gs a

re n

et o

f reb

ates

.• I

nstit

utio

nal L

TSS

incl

udes

nur

sing

faci

lity,

inte

rmed

iate

car

e fa

cilit

y fo

r ind

ivid

uals

with

inte

llect

ual d

isab

ilitie

s, a

nd m

enta

l hea

lth fa

cilit

y.• H

ome

and

com

mun

ity-b

ased

LTS

S in

clud

es h

ome

heal

th, w

aive

r and

sta

te p

lan

serv

ices

, and

per

sona

l car

e.• M

anag

ed c

are

and

prem

ium

ass

ista

nce

incl

udes

com

preh

ensi

ve a

nd li

mite

d-be

nefit

man

aged

car

e pl

ans,

prim

ary

care

cas

e m

anag

emen

t (PC

CM),

empl

oyer

-spo

nsor

ed

prem

ium

ass

ista

nce

prog

ram

s, a

nd P

rogr

ams

of A

ll-in

clus

ive

Care

for t

he E

lder

ly (P

ACE)

. Com

preh

ensi

ve p

lans

acc

ount

for a

bout

90

perc

ent o

f spe

ndin

g in

the

man

aged

ca

re c

ateg

ory.

Man

aged

car

e al

so in

clud

es re

bate

s fo

r dru

gs p

rovi

ded

by m

anag

ed c

are

plan

s, a

nd m

anag

ed c

are

paym

ents

ass

ocia

ted

with

the

prim

ary

care

phy

sici

an

paym

ent i

ncre

ase,

Com

mun

ity F

irst C

hoic

e op

tion,

and

pre

vent

ive

serv

ices

with

USP

STF

Gra

de A

or B

, and

ACI

P va

ccin

es.

1 N

ot a

ll st

ates

had

cer

tifie

d th

eir C

MS-

64 F

MR

subm

issi

ons

as o

f Feb

ruar

y 25

, 201

5. C

alifo

rnia

’s a

nd C

olor

ado’

s se

cond

, thi

rd, a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t ce

rtifi

ed; N

orth

Dak

ota’

s th

ird a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t cer

tifie

d; S

outh

Car

olin

a’s

seco

nd q

uart

er s

ubm

issi

on is

not

cer

tifie

d; R

hode

Isla

nd’s

four

th q

uart

er

subm

issi

on is

not

cer

tifie

d. F

igur

es p

rese

nted

in th

is e

xhib

it m

ay c

hang

e if

stat

es re

vise

thei

r exp

endi

ture

dat

a af

ter t

his

date

.2

Stat

e re

port

s ne

gativ

e fe

e-fo

r-ser

vice

(FFS

) dru

g sp

endi

ng a

fter

the

appl

icat

ion

of d

rug

reba

tes.

The

neg

ativ

e ne

t am

ount

may

refle

ct a

shi

ft o

f som

e FF

S dr

ug s

pend

ing

into

M

edic

aid

man

aged

car

e or

the

stat

e no

t sep

arat

ely

repo

rtin

g th

e FF

S an

d m

anag

ed c

are

drug

reba

tes.

Ver

mon

t sho

ws

nega

tive

drug

spe

ndin

g be

caus

e it

repo

rts

mos

t of i

ts

bene

fit s

pend

ing

unde

r oth

er c

are

serv

ices

in it

s CM

S-64

sub

mis

sion

.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

CM

S-64

FM

R ne

t exp

endi

ture

dat

a as

of F

ebru

ary

25, 2

015.

EXH

IBIT

17.

(co

ntin

ued)

Page 63: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 51

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

All enrollees$389.5 billion

Child$72.4 billion

Adult$59.5 billion

Disabled$166.8 billion

Aged$90.7 billion

Medicare premiums

LTSS institutional

LTSS non-institutional

Managed care

Drugs

Non-hospital acute

Inpatient and outpatient hospital

17.5%

17.3%

19.5%

14.0%

5.8%

0.4%

47.0%

19.0%

1.3%1.7%*

27.7%

2.6%3.4%

3.1% 3.0%

0.5%0.3%0.3%

15.0%

3.5%

14.4%

3.3%

7.8%

8.6%

24.9%15.7%

15.0%

3.5%

14.4%

3.3%

7.8%

8.6%

24.9%15.7%

14.2% 23.2%

16.9%

30.0%

14.2%

22.2%

23.2%

13.6%

16.9%

50.0% 52.4%

Notes: FY is fiscal year. LTSS is long-term services and supports. Includes federal and state funds. Excludes spending for administration, the territories, and Medicaid-expansion CHIP enrollees. Children and adults under age 65 who qualify for Medicaid on the basis of disability are included in the disabled category. About 737,000 enrollees age 65 and older are identified in the data as disabled; given that disability is not an eligibility pathway for individuals age 65 and older, MACPAC recodes these enrollees as aged. Amounts are fee for service unless otherwise noted. Benefit spending from Medicaid Statistical Information System (MSIS) data has been adjusted to reflect CMS-64 totals. Due to changes in both methods and data, figures shown here are not directly comparable to earlier years. With regard to methods, spending totals now exclude disproportionate share hospital (DSH) payments and certain incentive and uncompensated care pool payments made under Section 1115 waiver expenditure authority, which were previously included. In addition, due to the unavailability of several states’ MSIS Annual Person Summary (APS) data for FY 2012, the source used in prior editions of this exhibit, MACPAC calculated spending and enrollment from the full MSIS data files that are used to create the APS files. See https://www.macpac.gov/macstats/data-sources-and-methods/ for additional information.

* Values less than 0.1 percent are not shown.

Sources: MACPAC, 2015, analysis of MSIS data as of December 2014 and analysis of CMS-64 FMR net expenditure data from CMS as of June 2015.

EXHIBIT 18. Distribution of Medicaid Benefit Spending by Eligibility Group and Service Category, FY 2012

Page 64: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201552

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

s

Medicare premiums

LTSS institutional

LTSS non-institutional

Managed care

Drugs

Non-hospital acute

Inpatient and outpatienthospital

All enrollees$6,833

Child$2,679

Adult$4,044

Disabled$17,848

Aged$15,346

$1,027

$177

$2,047 $2,119

$969

$1,183

$237

$1,194 $508 $1,121$3,486

$2,575

$609

$3,959

$4,135

$2,502

$582 $1,326

$7,210

$2,590

$2,079

$60

$1,196

$885

$667 $635

$83 $123

$1,339

$36 $21

$46 $11

* $14

Notes: FY is fiscal year. LTSS is long-term services and supports. Includes federal and state funds. Excludes spending for administration, the territories, and Medicaid-expansion CHIP enrollees. Children and adults under age 65 who qualify for Medicaid on the basis of disability are included in the disabled category. About 737,000 enrollees age 65 and older are identified in the data as disabled; given that disability is not an eligibility pathway for individuals age 65 and older, MACPAC recodes these enrollees as aged. Amounts are fee for service unless otherwise noted, and they reflect all enrollees, including those with limited benefits. Benefit spending from Medicaid Statistical Information System (MSIS) data has been adjusted to reflect CMS-64 totals. Due to changes in both methods and data, figures shown here are not directly comparable to earlier years. With regard to methods, spending totals now exclude disproportionate share hospital (DSH) and certain incentive and uncompensated care pool payments made under Section 1115 waiver expenditure authority, which were previously included. In addition, due to the unavailability of several states’ MSIS Annual Person Summary (APS) data for FY 2012, the source used in prior editions of this exhibit, MACPAC calculated spending and enrollment from the full MSIS data files that are used to create the APS files. See https://www.macpac.gov/macstats/data-sources-and-methods/ for additional information.

* Values less than $1 are not shown.

Sources: MACPAC, 2015, analysis of MSIS data as of December 2014 and analysis of CMS-64 FMR net expenditure data from CMS as of June 2015.

EXHIBIT 19. Medicaid Benefit Spending Per Full-Year Equivalent (FYE) Enrollee by Eligibility Group and Service Category, FY 2012

Sect

ion

3

Page 65: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 53

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

All enrollees69.2 million

Benefit spending for LTSS and all other services

$389.5 billion

43.4% of spending ($169.2 billion)is for LTSS users

6.2% of enrollees(4.3 million) are

LTSS users

Not using LTSS

Using LTSS: Non-institutional only, no services under HCBS waiver1

Using LTSS: Non-institutional only,with some services under HCBS waiver1

Using LTSS: Institutional only

Using LTSS: Both institutional andnon-institutional

93.8%

56.6%

8.3%

18.8%

2.9%2.9%

13.4%

2.1%1.9%1.9%

Notes: FY is fiscal year. LTSS is long-term services and supports. HCBS is home and community-based services. Includes federal and state funds. Excludes administrative spending and spending and enrollees in the territories and in Medicaid-expansion CHIP. Benefit spending from Medicaid Statistical Information System (MSIS) data has been adjusted to reflect CMS-64 totals, and enrollment counts are unduplicated using unique national identification numbers. Due to changes in both methods and data, figures shown here are not directly comparable to earlier years. With regard to methods, spending totals now exclude disproportionate share hospital (DSH) payments and certain incentive and uncompensated care pool payments made under Section 1115 waiver expenditure authority, which were previously included. In addition, due to the unavailability of several states’ MSIS Annual Person Summary (APS) data for FY 2012, the source used in prior editions of this exhibit, MACPAC calculated spending and enrollment from the full MSIS data files that are used to create the APS files. See https://www.macpac.gov/macstats/data-sources-and-methods/ for additional information.

LTSS users are defined here as enrollees using at least one LTSS service during the year under a fee-for-service arrangement. (The data do not allow a breakout of LTSS services delivered through managed care.) For example, an enrollee with a short stay in a nursing facility for rehabilitation following a hospital discharge and an enrollee with permanent residence in a nursing facility would both be counted as LTSS users. More refined definitions that take these and other factors into account would produce different results and will be considered in future Commission work.1 All states have HCBS waiver programs that provide a range of LTSS for targeted populations of non-institutionalized enrollees who require institutional levels of care. Based on a comparison with CMS-372 data (a state-reported source containing aggregate spending and enrollment for HCBS waivers), the number of HCBS waiver enrollees may be underreported in the MSIS.

Source: MACPAC, 2015, analysis of MSIS data as of December 2014 and CMS-64 FMR net expenditure data from CMS as of June 2015.

EXHIBIT 20. Distribution of Medicaid Enrollment and Benefit Spending by Users and Non-Users of Long-Term Services and Supports, FY 2012

Page 66: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201554

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

s

Stat

eTo

tal

Basi

s of

elig

ibilt

y1

Dual

ly e

ligib

le s

tatu

s2

All d

ually

elig

ible

en

rolle

esDu

ally

elig

ible

with

full

bene

fits

Dual

ly e

ligib

le w

ith

limite

d be

nefit

sCh

ildAd

ult

Disa

bled

Aged

Tota

lAg

e 65

+To

tal

Age

65+

Tota

lAg

e 65

+To

tal

$389

,456

18.6

%15

.3%

42.8

%23

.3%

$144

,690

59.1

%$1

38,1

7459

.4%

$6,5

1553

.1%

Alab

ama

4,56

923

.810

.441

.024

.81,

643

67.6

1,41

969

.622

454

.7Al

aska

1,33

126

.916

.038

.219

.039

254

.739

154

.71

70.6

Ariz

ona

7,51

622

.732

.131

.613

.61,

590

57.4

1,53

057

.160

63.6

Arka

nsas

4,09

324

.75.

346

.823

.31,

486

62.0

1,34

464

.514

238

.1Ca

lifor

nia

45,5

0417

.016

.439

.826

.816

,181

68.2

15,6

8468

.249

768

.4Co

lora

do4,

534

21.2

14.8

42.3

21.7

1,51

061

.41,

472

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ion

3

Page 67: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 55

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

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ctio

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EXH

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(co

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Page 68: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201556

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

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3

Page 69: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 57

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

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sSe

ctio

n 3

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6,31

96,

834

17,0

8220

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17,2

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Penn

sylv

ania

8,96

79,

672

3,45

93,

457

3,61

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546

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20,5

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e Is

land

10,6

8910

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4,25

64,

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7,67

77,

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20,6

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18,3

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h Ca

rolin

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5,63

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131

2,13

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706

5,09

211

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h Da

kota

6,96

97,

292

2,83

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5,89

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18

Page 70: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201558

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

Not

es: F

Y is

fisc

al y

ear.

Full

year

equ

ival

ent (

FYE)

may

als

o be

refe

rred

to a

s av

erag

e m

onth

ly e

nrol

lmen

t. In

clud

es fe

dera

l and

sta

te fu

nds.

Exc

lude

s sp

endi

ng fo

r ad

min

istr

atio

n, th

e te

rrito

ries,

and

Med

icai

d-ex

pans

ion

CHIP

enr

olle

es. C

hild

ren

and

adul

ts u

nder

age

65

who

qua

lify

for M

edic

aid

on th

e ba

sis

of d

isab

ility

are

incl

uded

in

the

disa

bled

cat

egor

y. A

bout

737

,000

enr

olle

es a

ge 6

5 an

d ol

der a

re id

entif

ied

in th

e da

ta a

s di

sabl

ed; g

iven

that

dis

abili

ty is

not

an

elig

ibili

ty p

athw

ay fo

r ind

ivid

uals

age

65

and

olde

r, M

ACPA

C re

code

s th

ese

enro

llees

as

aged

. Ben

efit

spen

ding

from

Med

icai

d St

atis

tical

Info

rmat

ion

Syst

em (M

SIS)

dat

a ha

s be

en a

djus

ted

to re

flect

CM

S-64

tota

ls.

Due

to c

hang

es in

bot

h m

etho

ds a

nd d

ata,

figu

res

show

n he

re a

re n

ot d

irect

ly c

ompa

rabl

e to

ear

lier y

ears

. With

rega

rd to

met

hods

, spe

ndin

g to

tals

exc

lude

dis

prop

ortio

nate

sh

are

hosp

ital (

DSH

) pay

men

ts a

nd c

erta

in in

cent

ive

and

unco

mpe

nsat

ed c

are

pool

pay

men

ts m

ade

unde

r Sec

tion

1115

wai

ver e

xpen

ditu

re a

utho

rity,

whi

ch w

ere

prev

ious

ly

incl

uded

. In

addi

tion,

due

to th

e un

avai

labi

lity

of s

ever

al s

tate

s’ M

SIS

Annu

al P

erso

n Su

mm

ary

(APS

) dat

a fo

r FY

2012

, the

sou

rces

use

d in

prio

r edi

tions

of t

his

exhi

bit,

MAC

PAC

calc

ulat

ed s

pend

ing

and

enro

llmen

t fro

m th

e fu

ll M

SIS

data

file

s th

at a

re u

sed

to c

reat

e th

e AP

S fil

es. S

ee h

ttps

://w

ww

.mac

pac.

gov/

mac

stat

s/da

ta-s

ourc

es-a

nd-

met

hods

/ for

add

ition

al in

form

atio

n.1

In th

is ta

ble,

the

full

bene

fit c

olum

ns e

xclu

de e

nrol

lees

repo

rted

by

stat

es in

the

MSI

S as

rece

ivin

g co

vera

ge o

f onl

y fa

mily

pla

nnin

g se

rvic

es, a

ssis

tanc

e w

ith M

edic

are

prem

ium

s an

d co

st s

harin

g, o

r em

erge

ncy

serv

ices

.2

Stat

e ha

d a

chan

ge in

FYE

enr

olle

es o

f 10

perc

ent o

r mor

e ov

er th

e pr

ior y

ear.

Thes

e da

ta m

ay re

flect

ano

mal

ies

in th

e M

SIS

data

and

may

be

upda

ted

in fu

ture

MSI

S su

bmis

sion

s by

sta

tes.

MSI

S da

ta a

nom

alie

s ha

ve b

een

com

pile

d an

d re

port

ed b

y M

athe

mat

ica

Polic

y Re

sear

ch; t

he d

ata

anom

alie

s re

port

may

be

foun

d at

: htt

p://

ww

w.c

ms.

gov/

Rese

arch

-Sta

tistic

s-Da

ta-a

nd-S

yste

ms/

Com

pute

r-Dat

a-an

d-Sy

stem

s/M

edic

aidD

ataS

ourc

esG

enIn

fo/d

ownl

oads

/ano

mal

ies1

.pdf

.3

The

Dist

rict o

f Col

umbi

a ha

d a

slig

ht in

crea

se in

tota

l enr

olle

es b

ut a

larg

e de

crea

se in

tota

l enr

olle

d m

onth

s, th

us c

reat

ing

a de

crea

se in

FYE

enr

olle

es a

nd n

umbe

r of

mon

ths

per e

nrol

lee

of 1

0 pe

rcen

t or m

ore

over

the

prio

r yea

r. Th

ese

data

may

refle

ct a

nom

alie

s in

the

MSI

S da

ta a

nd m

ay b

e up

date

d in

futu

re M

SIS

subm

issi

ons.

MSI

S da

ta

anom

alie

s ha

ve b

een

com

pile

d an

d re

port

ed b

y M

athe

mat

ica

Polic

y Re

sear

ch; t

he d

ata

anom

alie

s re

port

may

be

foun

d at

: htt

p://

ww

w.c

ms.

gov/

Rese

arch

-Sta

tistic

s-Da

ta-a

nd-

Syst

ems/

Com

pute

r-Dat

a-an

d-Sy

stem

s/M

edic

aidD

ataS

ourc

esG

enIn

fo/d

ownl

oads

/ano

mal

ies1

.pdf

.4

Due

to la

rge

diff

eren

ces

in th

e w

ay s

pend

ing

is re

port

ed b

y Ve

rmon

t in

CMS-

64 a

nd M

SIS

data

, MAC

PAC’

s ad

just

men

t met

hodo

logy

is a

pplie

d on

ly to

tota

l Med

icai

d sp

endi

ng.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

MSI

S da

ta a

s of

Dec

embe

r 201

4 an

d CM

S-64

FM

R ne

t exp

endi

ture

dat

a as

of J

une

2015

.

EXH

IBIT

22.

(co

ntin

ued)

Page 71: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 59

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

s

Stat

e1

Inpa

tient

and

out

patie

nt h

ospi

tals

2

Tota

l Med

icai

d pa

ymen

tsDS

H p

aym

ents

Non

-DSH

sup

plem

enta

l pa

ymen

tsSe

ctio

n 11

15 w

aive

r au

thor

ity p

aym

ents

Supp

lem

enta

l pa

ymen

ts a

s %

of t

otal

Tota

l$8

9,26

0.4

$15,

204.

2$1

3,66

9.7

$10,

545.

644

.2%

Alab

ama

1,90

9.4

481.

261

9.1

–57

.6Al

aska

308.

08.

8–

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8Ar

izon

a31,

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4.9

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nsas

1,00

9.0

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295.

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orni

a3, 4

14,7

77.9

2,48

1.9

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rado

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197.

373

7.8

–49

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stric

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378.

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ida3

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EXH

IBIT

23.

Med

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men

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ents

to H

ospi

tal P

rovi

ders

by

Stat

e, F

Y 20

14 (m

illio

ns)

Page 72: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201560

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

Stat

e1

Inpa

tient

and

out

patie

nt h

ospi

tals

2

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l Med

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ents

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ymen

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s %

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Not

es: F

Y is

fisc

al y

ear.

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is d

ispr

opor

tiona

te s

hare

hos

pita

l. In

clud

es fe

dera

l and

sta

te fu

nds.

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lude

s pa

ymen

ts m

ade

unde

r man

aged

car

e ar

rang

emen

ts. A

ll am

ount

s in

this

tabl

e ar

e as

repo

rted

by

stat

es in

CM

S-64

dat

a du

ring

the

fisca

l yea

r to

obta

in fe

dera

l mat

chin

g fu

nds;

am

ount

s in

clud

e ex

pend

iture

s fo

r the

cur

rent

fisc

al y

ear a

nd

adju

stm

ents

to e

xpen

ditu

res

for p

rior f

isca

l yea

rs th

at m

ay b

e po

sitiv

e or

neg

ativ

e. A

mou

nts

repo

rted

by

stat

es fo

r any

giv

en c

ateg

ory

(e.g

., in

patie

nt h

ospi

tal)

som

etim

es

show

sub

stan

tial a

nnua

l flu

ctua

tions

. CM

S on

ly b

egan

to re

quire

sep

arat

e re

port

ing

of n

on-D

SH s

uppl

emen

tal p

aym

ents

in F

Y 20

10 a

nd is

con

tinui

ng to

wor

k w

ith s

tate

s to

st

anda

rdiz

e th

is re

port

ing.

As

a re

sult,

the

info

rmat

ion

pres

ente

d m

ay n

ot re

flect

a c

onsi

sten

t cla

ssifi

catio

n of

sup

plem

enta

l pay

men

t spe

ndin

g ac

ross

sta

tes.

Rep

ortin

g is

ex

pect

ed to

impr

ove

over

tim

e.

– D

ash

indi

cate

s ze

ro; $

0.0

indi

cate

s an

am

ount

less

than

$0.

05 m

illio

n th

at ro

unds

to z

ero.

1 N

ot a

ll st

ates

had

cer

tifie

d th

eir C

MS-

64 F

inan

cial

Man

agem

ent R

epor

t (FM

R) s

ubm

issi

ons

as o

f Feb

ruar

y 25

, 201

5. C

alifo

rnia

’s a

nd C

olor

ado’

s se

cond

, thi

rd, a

nd fo

urth

qu

arte

r sub

mis

sion

s ar

e no

t cer

tifie

d; N

orth

Dak

ota’

s th

ird a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t cer

tifie

d; S

outh

Car

olin

a’s

seco

nd q

uart

er s

ubm

issi

on is

not

cer

tifie

d; R

hode

Is

land

’s a

nd W

ashi

ngto

n’s

four

th q

uart

er s

ubm

issi

ons

are

not c

ertif

ied.

Fig

ures

pre

sent

ed in

this

tabl

e m

ay c

hang

e if

stat

es re

vise

thei

r exp

endi

ture

dat

a af

ter t

his

date

.2

Incl

udes

inpa

tient

, out

patie

nt, c

ritic

al a

cces

s ho

spita

l, and

em

erge

ncy

hosp

ital c

ateg

orie

s in

the

CMS-

64 d

ata.

The

CM

S-64

inst

ruct

ions

to s

tate

s no

te th

at D

SH p

aym

ents

are

thos

e m

ade

in a

ccor

danc

e w

ith S

ectio

n 19

23 o

f the

Soc

ial S

ecur

ity A

ct. N

on-D

SH s

uppl

emen

tal p

aym

ents

are

des

crib

ed in

the

CMS-

64 in

stru

ctio

ns to

sta

tes

as th

ose

mad

e in

add

ition

to

the

stan

dard

fee

sche

dule

or o

ther

sta

ndar

d pa

ymen

t for

a g

iven

ser

vice

. The

y in

clud

e pa

ymen

ts m

ade

unde

r ins

titut

iona

l upp

er p

aym

ent l

imit

rule

s an

d pa

ymen

ts to

hos

pita

ls

for g

radu

ate

med

ical

edu

catio

n. S

ectio

n 11

15 w

aive

r exp

endi

ture

aut

horit

y pa

ymen

ts in

clud

e th

ose

mad

e un

der u

ncom

pens

ated

car

e po

ols,

del

iver

y sy

stem

refo

rm in

cent

ive

paym

ents

(DSR

IP),

and

othe

r non

-DSH

sup

plem

enta

l pay

men

ts th

at h

ave

been

aut

horiz

ed u

nder

Sec

tion

1115

wai

vers

. Bec

ause

the

maj

ority

of D

SRIP

pay

men

ts g

o to

hos

pita

ls,

DSRI

P pa

ymen

ts th

at w

ere

repo

rted

as

othe

r car

e se

rvic

es o

n th

e CM

S-64

wer

e in

clud

ed in

the

Sect

ion

1115

wai

ver e

xpen

ditu

re c

ateg

ory

and

the

tota

l hos

pita

l pay

men

t cat

egor

y.3

Stat

e m

ade

supp

lem

enta

l pay

men

ts th

roug

h an

unc

ompe

nsat

ed c

are

pool

und

er S

ectio

n 11

15 w

aive

r exp

endi

ture

aut

horit

y.4

Stat

e m

ade

supp

lem

enta

l pay

men

ts th

roug

h a

DSRI

P un

der S

ectio

n 11

15 w

aive

r exp

endi

ture

aut

horit

y.5

Stat

e m

ade

othe

r sup

plem

enta

l pay

men

ts, i

nclu

ding

gra

duat

e m

edic

al e

duca

tion,

und

er S

ectio

n 11

15 w

aive

r exp

endi

ture

aut

horit

y.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

CM

S-64

FM

R ne

t exp

endi

ture

dat

a as

of F

ebru

ary

25, 2

015

and

CMS-

64 S

ched

ule

C w

aive

r rep

ort d

ata

as o

f Aug

ust 1

8, 2

015.

EXH

IBIT

23.

(co

ntin

ued)

Page 73: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 61

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

Stat

e1

Men

tal h

ealth

faci

litie

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EXH

IBIT

24.

Med

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men

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Stat

e, F

Y 20

14 (m

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Page 74: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201562

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

Stat

e1

Men

tal h

ealth

faci

litie

s2N

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ates

in C

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cal y

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mou

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nditu

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nt fi

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ents

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rior f

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l yea

rs th

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ay b

e po

sitiv

e or

neg

ativ

e. A

mou

nts

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rted

by

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es fo

r any

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en c

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ory

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., nu

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cilit

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imes

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ual f

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uatio

ns.

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cate

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ro; $

0.0

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am

ount

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than

$0.

05 m

illio

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at ro

unds

to z

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1 N

ot a

ll st

ates

had

cer

tifie

d th

eir C

MS-

64 F

inan

cial

Man

agem

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epor

t (FM

R) s

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issi

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as o

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ruar

y 25

, 201

5. C

alifo

rnia

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nd C

olor

ado’

s se

cond

, thi

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nd fo

urth

qu

arte

r sub

mis

sion

s ar

e no

t cer

tifie

d; N

orth

Dak

ota’

s th

ird a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t cer

tifie

d; S

outh

Car

olin

a’s

seco

nd q

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er s

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on is

not

cer

tifie

d; R

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Is

land

’s a

nd W

ashi

ngto

n’s

four

th q

uart

er s

ubm

issi

ons

are

not c

ertif

ied.

Fig

ures

pre

sent

ed in

this

tabl

e m

ay c

hang

e if

stat

es re

vise

thei

r exp

endi

ture

dat

a af

ter t

his

date

.

EXH

IBIT

24.

(co

ntin

ued)

Page 75: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 63

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

2 In

clud

es in

patie

nt p

sych

iatr

ic s

ervi

ces

for i

ndiv

idua

ls u

nder

age

21

and

inpa

tient

hos

pita

l or n

ursi

ng fa

cilit

y se

rvic

es fo

r ind

ivid

uals

age

65

and

olde

r in

an in

stitu

tion

for

men

tal d

isea

ses.

Sup

plem

enta

l pay

men

ts in

clud

e DS

H p

aym

ents

mad

e in

acc

orda

nce

with

Sec

tion

1923

of t

he S

ocia

l Sec

urity

Act

as

wel

l as

unco

mpe

nsat

ed c

are

pool

and

ot

her n

on-D

SH s

uppl

emen

tal p

aym

ents

mad

e un

der S

ectio

n 11

15 w

aive

r exp

endi

ture

aut

horit

y. S

tate

s ar

e no

t ins

truc

ted

to b

reak

out

non

-DSH

sup

plem

enta

l pay

men

ts fo

r m

enta

l hea

lth fa

cilit

ies.

3 In

clud

es n

ursi

ng fa

cilit

ies

and

inte

rmed

iate

car

e fa

cilit

ies

for p

erso

ns w

ith in

telle

ctua

l dis

abili

ties

(ICF/

ID).

Supp

lem

enta

l pay

men

ts in

clud

e th

ose

paym

ents

that

are

m

ade

in a

dditi

on to

the

stan

dard

fee

sche

dule

or o

ther

sta

ndar

d pa

ymen

ts fo

r a g

iven

ser

vice

, inc

ludi

ng p

aym

ents

mad

e un

der i

nstit

utio

nal u

pper

pay

men

t lim

it ru

les

and

unco

mpe

nsat

ed c

are

pool

s m

ade

unde

r Sec

tion

1115

wai

ver e

xpen

ditu

re a

utho

rity.

4

Incl

udes

the

phys

icia

n an

d ot

her p

ract

ition

er c

ateg

orie

s in

CM

S-64

dat

a; e

xclu

des

addi

tiona

l cat

egor

ies

(e.g

., de

ntal

, nur

se-m

idw

ife, n

urse

pra

ctiti

oner

) for

whi

ch s

tate

s ar

e no

t ins

truc

ted

to b

reak

out

sup

plem

enta

l pay

men

ts. S

uppl

emen

tal p

aym

ents

incl

ude

thos

e pa

ymen

ts th

at a

re m

ade

in a

dditi

on to

the

stan

dard

fee

sche

dule

pay

men

t as

wel

l as

unc

ompe

nsat

ed c

are

pool

pay

men

ts m

ade

unde

r Sec

tion

1115

wai

ver e

xpen

ditu

re a

utho

rity.

Unl

ike

for i

nstit

utio

nal p

rovi

ders

, the

re is

not

a re

gula

tory

upp

er p

aym

ent l

imit

for p

hysi

cian

s an

d ot

her p

ract

ition

ers.

5 St

ate

mad

e no

n-DS

H p

aym

ents

to m

enta

l hea

lth fa

cilit

ies

thro

ugh

an u

ncom

pens

ated

car

e po

ol o

r mad

e ot

her n

on-D

SH s

uppl

emen

tal p

aym

ents

und

er S

ectio

n 11

15 w

aive

r ex

pend

iture

aut

horit

y.6

Stat

e m

ade

paym

ents

to n

ursi

ng fa

cilit

ies

thro

ugh

an u

ncom

pens

ated

car

e po

ol u

nder

Sec

tion

1115

wai

ver e

xpen

ditu

re a

utho

rity.

7 St

ate

mad

e pa

ymen

ts to

phy

sici

ans

and

othe

r pra

ctiti

oner

s th

roug

h an

unc

ompe

nsat

ed c

are

pool

und

er S

ectio

n 11

15 w

aive

r exp

endi

ture

aut

horit

y.8

Mas

sach

uset

ts a

nd M

ichi

gan

repo

rted

sup

plem

enta

l pay

men

ts th

at w

ere

grea

ter t

han

the

tota

l pay

men

ts, c

reat

ing

a pe

rcen

tage

abo

ve 1

00 p

erce

nt.

9 O

hio

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rted

neg

ativ

e no

n-DS

H p

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to m

enta

l hea

lth fa

cilit

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e gr

eate

r tha

n th

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H p

aym

ents

, cre

atin

g a

nega

tive

tota

l pay

men

t and

a n

egat

ive

perc

enta

ge.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

CM

S-64

FM

R ne

t exp

endi

ture

dat

a as

of F

ebru

ary

25, 2

015

and

CMS-

64 S

ched

ule

C w

aive

r rep

ort d

ata

as o

f Aug

ust 1

8, 2

015.

EXH

IBIT

24.

(co

ntin

ued)

Page 76: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201564

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

Stat

eTo

tal

Fee

for s

ervi

ceM

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EXH

IBIT

25.

Med

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Spe

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r Dru

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liver

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FY

2014

(mill

ions

)

Page 77: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 65

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

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sSe

ctio

n 3

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EXH

IBIT

25.

(co

ntin

ued)

Page 78: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201566

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

usin

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htt

p://

ww

w.m

edic

aid.

gov/

med

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ip-p

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form

atio

n/by

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data

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urce

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e dr

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htt

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ww

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aid.

gov/

med

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ram

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ion/

by-to

pics

/ben

efits

/pre

scrip

tion-

drug

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edic

aid-

drug

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te-p

rogr

am-d

ata.

htm

l. Th

e di

ffer

ent b

rand

and

gen

eric

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port

ions

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e fo

r ser

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m

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EXH

IBIT

25.

(co

ntin

ued)

Page 79: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 67

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

Stat

eTo

tal

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EXH

IBIT

26.

Med

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Page 80: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201568

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

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ear.

Drug

util

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in th

is e

xhib

it re

flect

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port

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stat

e dr

ug u

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tate

s su

bmit

to C

MS

for r

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Med

icai

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atis

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Info

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Syst

em (M

SIS)

dat

a th

at s

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as

our u

sual

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of u

tiliz

atio

n da

ta. U

tiliz

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own

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utili

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ta m

ay d

iffer

from

oth

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diff

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in ti

min

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ata

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. In

addi

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the

drug

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izat

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data

may

incl

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phys

icia

n-ad

min

iste

red

drug

s fo

r whi

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bate

s ar

e av

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e dr

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typi

cally

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e ph

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cat

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stea

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outp

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n dr

ug c

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ta. T

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g ut

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bot

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d sp

endi

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atio

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natio

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(NDC

) lev

el. T

o as

sign

br

and

and

gene

ric s

tatu

s, w

e lin

ked

the

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terly

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te d

rug

utili

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ta to

the

quar

terly

Med

icai

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ug p

rodu

ct d

ata

from

CM

S us

ing

the

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cod

e. B

rand

and

gen

eric

st

atus

was

ass

igne

d us

ing

the

drug

cat

egor

y in

dica

tor f

rom

the

drug

pro

duct

file

. The

sta

te d

rug

utili

zatio

n da

ta a

re a

vaila

ble

at h

ttp:

//w

ww

.med

icai

d.go

v/m

edic

aid-

chip

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ogra

m-in

form

atio

n/by

-topi

cs/b

enef

its/p

resc

riptio

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ugs/

med

icai

d-dr

ug-p

rogr

ams-

data

-and

-reso

urce

s.ht

ml a

nd th

e dr

ug p

rodu

ct d

ata

are

avai

labl

e at

htt

p://

ww

w.m

edic

aid.

gov/

med

icai

d-ch

ip-p

rogr

am-in

form

atio

n/by

-topi

cs/b

enef

its/p

resc

riptio

n-dr

ugs/

med

icai

d-dr

ug-re

bate

-pro

gram

-dat

a.ht

ml.

The

diff

eren

t bra

nd a

nd g

ener

ic p

ropo

rtio

ns u

nder

fe

e fo

r ser

vice

and

man

aged

car

e m

ay re

flect

diff

eren

ces

in th

e po

pula

tions

and

spe

cific

dru

gs c

over

ed u

nder

eac

h de

liver

y sy

stem

(e.g

., be

havi

oral

hea

lth d

rugs

car

ved

out o

f m

anag

ed c

are)

as

wel

l as

diff

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in h

ow th

e st

ate

and

part

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alth

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– D

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ro; 0

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am

ount

less

than

0.0

5% th

at ro

unds

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1 Fo

r thi

s ex

hibi

t, br

and

drug

s w

ere

defin

ed a

s si

ngle

sou

rce

drug

s an

d in

nova

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mul

tiple

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drug

s as

indi

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that

qua

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’s M

edic

aid

drug

pro

duct

dat

a.2

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his

exhi

bit,

gene

ric d

rugs

wer

e de

fined

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non-

inno

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at q

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ose

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hav

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mat

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.

Sour

ce: M

ACPA

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015,

ana

lysi

s of

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icai

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ata

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stat

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util

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data

as

of O

ctob

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015.

EXH

IBIT

26.

(co

ntin

ued)

Page 81: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 69

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

Stat

eG

ross

spe

ndin

gRe

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EXH

IBIT

27.

Med

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Spe

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r Dru

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liver

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2014

(mill

ions

)

Page 82: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201570

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

27.

(co

ntin

ued)

Stat

eG

ross

spe

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nts

incl

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s ex

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s pr

ior t

o th

e ap

plic

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n of

man

ufac

ture

r reb

ates

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gro

ss d

rug

expe

nditu

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in th

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form

atio

n fr

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ate

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adm

inis

tere

d

Page 83: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 71

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

27.

(co

ntin

ued)

drug

s fo

r whi

ch re

bate

s ar

e av

aila

ble;

the

spen

ding

for t

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dru

gs a

re ty

pica

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rmat

ion/

by-to

pics

/ben

efits

/pr

escr

iptio

n-dr

ugs/

med

icai

d-dr

ug-p

rogr

ams-

data

-and

-reso

urce

s.ht

ml.

The

drug

reba

te in

form

atio

n co

mes

from

the

CMS-

64 a

nd d

oes

allo

w s

tate

s to

sep

arat

ely

iden

tify

fee-

for-s

ervi

ce a

nd m

anag

ed c

are

drug

reba

tes.

The

reba

te to

tals

sho

wn

here

incl

ude

fede

ral r

ebat

es, s

tate

sup

plem

enta

l reb

ates

, and

the

reba

te in

crea

ses

attr

ibut

able

to th

e Af

ford

able

Car

e Ac

t.

Due

to th

e tim

e it

take

s to

col

lect

the

drug

util

izat

ion

info

rmat

ion

and

invo

ice

drug

man

ufac

ture

rs fo

r the

reba

te, t

he re

bate

s co

llect

ed in

any

par

ticul

ar q

uart

er a

re g

ener

ally

at

trib

utab

le to

dru

gs p

urch

ased

in p

rior q

uart

ers;

thus

, the

gro

ss s

pend

ing

and

reba

te d

olla

rs fo

r a g

iven

tim

e pe

riod

are

not n

eces

saril

y al

igne

d. C

hang

es in

cov

ered

po

pula

tions

or b

enef

it de

sign

(e.g

., m

anag

ed c

are

expa

nsio

n or

pha

rmac

y ca

rve-

in) c

an c

reat

e di

stor

tions

in th

e da

ta, b

ecau

se c

hang

es w

ill b

e re

flect

ed in

gro

ss s

pend

ing

befo

re th

ey a

re re

flect

ed in

reba

tes

colle

cted

.

– D

ash

indi

cate

s ze

ro; -

$0.0

indi

cate

s an

am

ount

bet

wee

n ze

ro a

nd -$

0.5

mill

ion

that

roun

ds to

zer

o.1

Haw

aii s

how

s w

ide

quar

terly

var

iatio

ns in

thei

r man

aged

car

e dr

ug s

pend

ing;

this

is d

ue in

par

t due

to th

e st

ate’

s pr

actic

e of

repo

rtin

g a

larg

e am

ount

of s

pend

ing

unde

r an

unid

entif

iabl

e N

DC c

ode

and

drug

nam

e.2

Stat

e re

cent

ly im

plem

ente

d or

exp

ande

d m

anag

ed c

are.

Thi

s ch

ange

cre

ates

a la

rge

diff

eren

ce b

etw

een

gros

s sp

endi

ng a

nd re

bate

col

lect

ions

for f

ee-fo

r-ser

vice

and

m

anag

ed c

are,

resu

lting

in a

nom

alou

s re

bate

per

cent

ages

at t

he d

eliv

ery

syst

em le

vel.

3 St

ate

repo

rts

little

or n

o m

anag

ed c

are

reba

tes

in C

MS-

64 d

ata.

The

reba

tes

for t

hese

man

aged

car

e ex

pend

iture

s ap

pear

s to

be

repo

rted

with

the

fee-

for-s

ervi

ce re

bate

s.4

Stat

e ge

nera

lly c

arve

s ou

t pre

scrip

tion

drug

s fr

om th

e m

anag

ed c

are

prog

ram

. Sta

te m

anag

ed c

are

spen

ding

may

refle

ct p

hysi

cian

-adm

inis

tere

d dr

ugs;

how

ever

, reb

ates

for

thes

e m

anag

ed c

are

expe

nditu

res

are

not r

epor

ted

sepa

rate

ly in

the

CMS-

64 d

ata

and

appe

ar to

be

repo

rted

with

the

fee-

for-s

ervi

ce re

bate

s.5

Rhod

e Is

land

has

not

repo

rted

any

man

aged

car

e dr

ug u

tiliz

atio

n si

nce

the

seco

nd q

uart

er o

f FY

2013

.6

Virg

inia

dat

a w

ere

corr

ecte

d fo

r an

appa

rent

err

or in

fee-

for-s

ervi

ce s

pend

ing

in th

e se

cond

qua

rter

of F

Y 20

14.

Sour

ces:

MAC

PAC,

201

5, a

naly

sis

of M

edic

aid

stat

e dr

ug re

bate

util

izat

ion

data

as

of O

ctob

er 2

015

and

CMS-

64 F

MR

net e

xpen

ditu

re d

ata

as o

f Feb

ruar

y 25

, 201

5.

Page 84: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201572

Section 3: Program Enrollment and Spending—Medicaid Managed Care

MAC

Stat

sSe

ctio

n 3

Stat

e

Tota

l Med

icai

d en

rolle

es

(tho

usan

ds)

Perc

enta

ge o

f enr

olle

es in

man

aged

car

e

Com

preh

ensi

ve

man

aged

car

e1

Lim

ited-

bene

fit p

lans

PCCM

MLT

SSBH

O (P

IHP

and/

or P

AHP)

Dent

alTr

ansp

orta

tion

Oth

erTo

tal

60,5

1255

.3%

0.3%

15.9

%10

.8%

11.7

%1.

9%13

.2%

Alab

ama

960

0.0

––

––

2.4

57.1

Alas

ka14

5–

––

––

––

Ariz

ona

1,27

184

.4–

––

––

Arka

nsas

614

0.0

––

–75

.3–

71.6

Calif

orni

a8,

469

67.2

––

7.8

–0.

0–

Colo

rado

740

10.6

–94

.9–

–2.

948

.0

Conn

ectic

ut62

2–

––

––

––

Dela

war

e21

684

.4–

––

––

Dist

rict o

f Col

umbi

a25

362

.4–

––

20.3

––

Flor

ida

3,38

444

.80.

617

.338

.9–

0.2

17.4

Geo

rgia

1,81

463

.3–

––

––

Haw

aii

307

93.9

––

––

––

Idah

o225

5–

–0.

094

.594

.60.

385

.6

Illin

ois

2,93

19.

6–

––

––

63.8

Indi

ana

1,12

664

.9–

––

––

3.1

Iow

a43

47.

0–

96.9

–93

.2–

47.6

Kans

as39

982

.5–

––

––

Kent

ucky

847

84.6

––

––

––

Loui

sian

a1,

257

34.1

–82

.5–

––

41.1

Mai

ne26

2–

––

––

–68

.0

Mar

ylan

d1,

089

79.4

––

––

––

Mas

sach

uset

ts1,

410

31.6

–4.

8–

––

25.6

Mic

higa

n1,

816

71.1

–88

.223

.7–

––

Min

neso

ta90

270

.2–

––

––

Mis

siss

ippi

689

22.5

––

––

––

EXH

IBIT

28.

Per

cent

age

of M

edic

aid

Enro

llees

in M

anag

ed C

are

by S

tate

, Jul

y 1,

201

3

Page 85: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 73

Section 3: Program Enrollment and Spending—Medicaid Managed Care

MAC

Stat

sSe

ctio

n 3

Stat

e

Tota

l Med

icai

d en

rolle

es

(tho

usan

ds)

Perc

enta

ge o

f enr

olle

es in

man

aged

car

e

Com

preh

ensi

ve

man

aged

car

e1

Lim

ited-

bene

fit p

lans

PCCM

MLT

SSBH

O (P

IHP

and/

or P

AHP)

Dent

alTr

ansp

orta

tion

Oth

erM

isso

uri

868

47.9

%–

––

49.4

%–

Mon

tana

119

––

––

––

65.5

%

Neb

rask

a324

475

.7–

86.9

%–

––

Nev

ada

329

54.9

––

–54

.9–

New

Ham

pshi

re2

146

0.0

––

––

––

New

Jer

sey

1,20

187

.9–

––

84.5

––

New

Mex

ico

555

74.5

–67

.6–

––

New

Yor

k5,

353

73.6

1.9%

––

––

Nor

th C

arol

ina

1,58

90.

0–

76.2

––

–96

.2

Nor

th D

akot

a77

0.1

–0.

4–

––

54.8

Ohi

o2,

390

69.8

––

––

––

Okl

ahom

a73

60.

0–

––

93.7

–10

0.0

Ore

gon4

695

78.8

–3.

586

.7%

––

0.1

Penn

sylv

ania

3,44

747

.2–

53.8

–14

.3–

Rhod

e Is

land

197

71.3

––

32.5

––

0.8

Sout

h Ca

rolin

a1,

002

45.9

––

–10

0.0

–17

.9

Sout

h Da

kota

122

––

––

––

74.8

Tenn

esse

e41,

216

100.

0–

–60

.7–

88.7

%–

Texa

s3,

879

77.3

–12

.363

.848

.60.

3–

Uta

h326

670

.1–

98.0

–81

.4–

Verm

ont

182

56.5

––

––

––

Virg

inia

938

67.8

––

––

––

Was

hing

ton

1,17

367

.3–

65.3

–2.

2–

0.7

Wes

t Virg

inia

330

51.6

––

––

–1.

2

Wis

cons

in1,

179

59.5

3.2

0.1

––

––

Wyo

min

g66

0.0

––

––

––

EXH

IBIT

28.

(co

ntin

ued)

Page 86: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201574

Section 3: Program Enrollment and Spending—Medicaid Managed Care

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

28.

(co

ntin

ued)

Not

es: P

CCM

is p

rimar

y ca

re c

ase

man

agem

ent.

MLT

SS is

man

aged

long

-term

ser

vice

s an

d su

ppor

ts. B

HO

is b

ehav

iora

l hea

lth o

rgan

izat

ion.

PIH

P is

pre

paid

inpa

tient

hea

lth

plan

. PAH

P is

pre

paid

am

bula

tory

hea

lth p

lan.

Exc

lude

s th

e te

rrito

ries.

Thi

s ex

hibi

t inc

lude

s M

edic

aid-

expa

nsio

n CH

IP e

nrol

lees

. Med

icai

d be

nefic

iarie

s m

ay b

e en

rolle

d co

ncur

rent

ly in

mor

e th

an o

ne ty

pe o

f man

aged

car

e pr

ogra

m (e

.g.,

a co

mpr

ehen

sive

pla

n an

d a

BHO

), so

the

sum

of e

nrol

lmen

t in

each

pro

gram

type

as

a pe

rcen

tage

of t

otal

M

edic

aid

enro

llmen

t may

be

grea

ter t

han

100

perc

ent.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 In

clud

es c

ompr

ehen

sive

man

aged

car

e an

d Pr

ogra

ms

of A

ll-In

clus

ive

Care

for t

he E

lder

ly (P

ACE)

.2

Stat

e op

erat

ed a

Med

icai

d m

anag

ed c

are

prog

ram

in 2

013

but t

he p

rogr

am e

ither

end

ed b

efor

e Ju

ly 1

, 201

3 or

beg

an a

fter

that

dat

e. Id

aho

had

a BH

O p

rogr

am a

nd N

ew

Ham

pshi

re h

ad a

com

preh

ensi

ve m

anag

ed c

are

prog

ram

in 2

013,

but

bot

h ha

d ze

ro e

nrol

lmen

t on

July

1, 2

013.

3 Th

e to

tal f

or B

HO

pla

ns p

ublis

hed

by C

MS

was

gre

ater

than

the

tota

l num

ber o

f Med

icai

d en

rolle

es d

ue to

the

stat

e ha

ving

two

beha

vior

al h

ealth

pro

gram

s th

at a

llow

ed fo

r co

ncur

rent

enr

ollm

ent.

The

valu

e sh

own

here

use

s th

e en

rollm

ent t

otal

from

the

larg

est o

f the

two

type

s of

BH

O p

rogr

ams.

4 Th

e to

tal f

or c

ompr

ehen

sive

man

aged

car

e pl

ans

publ

ishe

d by

CM

S w

as g

reat

er th

an th

e to

tal n

umbe

r of M

edic

aid

enro

llees

due

to a

n ap

pare

nt c

lass

ifica

tion

erro

r; so

me

plan

s th

at a

ppea

r to

be li

mite

d-be

nefit

pla

ns (d

enta

l, BH

O, o

r oth

er m

anag

ed c

are)

wer

e cl

assi

fied

as c

ompr

ehen

sive

man

aged

car

e. T

he v

alue

s sh

own

here

use

pla

n-le

vel

info

rmat

ion

in th

e CM

S re

port

to s

epar

ate

enro

llmen

t in

the

limite

d pl

ans

from

the

com

preh

ensi

ve m

anag

ed c

are

tota

l and

cat

egor

ize

enro

llmen

t in

thos

e lim

ited-

bene

fit p

lans

as

BH

O, d

enta

l, or

oth

er m

anag

ed c

are.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

CM

S, 2

015,

Med

icai

d m

anag

ed c

are

enro

llmen

t and

pro

gram

cha

ract

eris

tics,

201

3, h

ttp:

//w

ww

.med

icai

d.go

v/m

edic

aid-

chip

-pro

gram

-in

form

atio

n/by

-topi

cs/d

ata-

and-

syst

ems/

med

icai

d-m

anag

ed-c

are/

dow

nloa

ds/2

013-

med

icai

d-m

anag

ed-c

are-

enro

llmen

t-rep

ort.p

df.

Page 87: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 75

Section 3: Program Enrollment and Spending—Medicaid Managed Care

MAC

Stat

sSe

ctio

n 3

Stat

e

Tota

l M

edic

aid

enro

llees

(th

ousa

nds)

Perc

enta

ge o

f enr

olle

es in

man

aged

car

eCo

mpr

ehen

sive

man

aged

car

e1Li

mite

d-be

nefit

pla

nsPC

CM

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Tota

l68

,680

52.5

%66

.2%

50.1

%37

.3%

17.0

%48

.0%

56.3

%35

.6%

52.0

%39

.0%

15.9

%22

.0%

10.8

%14

.9%

3.5%

Alab

ama

1,10

43.

0–

0.0

6.9

14.6

––

––

–61

.993

.222

.251

.51.

5

Alas

ka13

9–

––

––

––

––

––

––

––

Ariz

ona

1,71

379

.188

.177

.365

.647

.288

.494

.384

.189

.670

.3–

––

––

Arka

nsas

695

0.0

–0.

00.

00.

278

.798

.146

.975

.141

.263

.890

.728

.056

.13.

8

Calif

orni

a12

,005

47.8

72.1

28.8

62.4

30.6

68.8

93.8

36.9

99.8

96.6

––

––

Colo

rado

826

12.1

12.9

11.5

10.4

10.3

95.1

99.2

95.5

89.1

75.2

3.9

3.4

3.1

6.3

5.1

Conn

ectic

ut82

348

.881

.944

.40.

70.

0–

––

––

––

––

Dela

war

e25

584

.893

.987

.066

.243

.989

.498

.890

.274

.749

.33.

03.

03.

33.

20.

6

Dist

rict o

f Co

lum

bia

225

71.4

89.6

89.7

22.3

2.9

36.7

20.6

26.2

79.0

71.9

––

––

Flor

ida

4,14

540

.053

.537

.027

.97.

127

.041

.011

.323

.72.

725

.135

.214

.325

.93.

5

Geo

rgia

1,64

063

.189

.285

.02.

80.

082

.693

.577

.073

.147

.9–

––

––

Haw

aii

296

98.0

99.7

99.0

95.6

89.4

1.2

2.1

0.0

3.3

0.2

––

––

Idah

o27

9–

––

––

94.8

100.

097

.485

.666

.786

.294

.283

.677

.145

.3

Illin

ois

3,00

5–

––

––

10.6

12.2

9.4

9.8

4.4

65.3

77.9

72.6

29.4

4.9

Indi

ana

1,22

870

.692

.289

.111

.70.

2–

––

––

3.9

2.2

0.1

15.3

1.8

Iow

a62

21.

62.

61.

10.

10.

279

.499

.147

.992

.774

.956

.371

.070

.04.

51.

0

Kans

as43

059

.282

.078

.91.

70.

692

.510

0.0

96.9

86.5

49.8

7.4

3.9

2.0

24.8

2.3

Kent

ucky

926

84.8

99.1

95.0

72.7

34.6

90.8

99.9

99.7

81.7

58.7

22.5

35.4

25.7

5.7

0.5

Loui

sian

a1,

311

0.0

––

0.0

0.2

75.9

59.1

90.8

96.1

94.2

64.3

91.0

38.5

46.8

10.5

Mai

ne44

6–

––

––

––

––

–98

.297

.197

.999

.298

.8

Mar

ylan

d1,

098

81.3

97.3

86.1

60.1

2.1

––

––

––

––

––

Mas

sach

uset

ts1,

549

45.1

53.4

57.3

27.0

16.0

28.3

38.3

24.7

36.7

0.2

24.1

30.2

24.4

27.8

0.2

Mic

higa

n2,

297

71.4

86.5

69.1

54.3

8.4

93.4

98.7

83.9

95.2

85.7

––

––

Min

neso

ta1,

145

76.1

86.4

80.5

40.4

59.2

––

––

––

––

––

Mis

siss

ippi

781

8.2

0.4

0.2

35.5

0.7

87.5

99.8

82.7

79.4

55.2

––

––

EXH

IBIT

29.

Per

cent

age

of M

edic

aid

Enro

llees

in M

anag

ed C

are

by S

tate

and

Elig

ibili

ty G

roup

, FY

2012

Page 88: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201576

Section 3: Program Enrollment and Spending—Medicaid Managed Care

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

29.

(co

ntin

ued)

Stat

e

Tota

l M

edic

aid

enro

llees

(th

ousa

nds)

Perc

enta

ge o

f enr

olle

es in

man

aged

car

eCo

mpr

ehen

sive

man

aged

car

e1Li

mite

d-be

nefit

pla

nsPC

CM

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Mis

sour

i1,

135

45.2

%67

.8%

49.0

%2.

0%0.

2%–

––

––

––

––

Mon

tana

136

––

––

–0.

7%–

0.0%

3.6%

0.1%

74.6

%92

.7%

83.0

%51

.0%

1.6%

Neb

rask

a26

465

.882

.769

.037

.65.

185

.796

.0%

84.7

74.8

43.2

––

––

Nev

ada

405

60.3

77.9

71.1

1.8

0.0

87.6

95.6

89.5

71.9

50.0

––

––

New

Ham

pshi

re16

80.

00.

0–

––

––

––

––

––

––

New

Jer

sey

1,18

483

.895

.563

.184

.563

.996

.699

.795

.995

.287

.1–

––

––

New

Mex

ico

652

68.1

84.1

63.3

42.9

2.6

68.1

84.1

40.0

67.6

53.9

––

––

New

Yor

k5,

865

75.0

87.8

88.4

49.0

14.5

1.0

0.0

0.0

1.3

7.5

0.3

0.3

0.2

0.6

0.0

Nor

th C

arol

ina

1,97

60.

0–

–0.

00.

281

.196

.578

.867

.327

.980

.396

.261

.274

.745

.8

Nor

th D

akot

a87

2.4

4.3

0.1

0.1

0.8

0.4

0.3

0.2

1.5

0.2

54.5

72.6

72.1

1.8

0.0

Ohi

o2,

474

74.3

93.5

80.9

38.7

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––

––

––

––

––

Okl

ahom

a93

10.

0–

–0.

00.

281

.596

.450

.585

.178

.868

.388

.061

.442

.11.

2

Ore

gon

751

77.6

87.8

80.0

63.5

36.6

88.5

96.6

86.4

80.2

63.5

0.5

0.5

0.2

0.8

0.9

Penn

sylv

ania

2,56

262

.278

.561

.257

.47.

487

.797

.677

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.049

.816

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.916

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1

Rhod

e Is

land

185

59.8

88.2

81.4

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27.2

59.3

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90.

0–

––

––

Sout

h Ca

rolin

a1,

044

50.7

65.5

49.7

31.8

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90.2

99.8

70.0

94.2

84.0

19.2

23.3

13.8

20.1

8.1

Sout

h Da

kota

134

––

––

––

––

––

73.0

92.0

88.4

29.3

0.7

Tenn

esse

e1,

545

92.0

100.

010

0.0

79.8

55.1

92.0

100.

010

0.0

79.8

54.9

––

––

Texa

s4,

641

79.7

94.1

55.9

67.5

34.9

11.7

14.2

7.0

9.9

4.2

18.5

23.5

12.6

13.7

0.3

Uta

h38

822

.926

.918

.217

.215

.190

.098

.870

.392

.482

.227

.631

.021

.228

.818

.6

Verm

ont

205

0.1

––

0.1

0.6

––

––

–68

.086

.978

.639

.33.

3

Virg

inia

1,09

366

.587

.164

.942

.45.

2–

––

––

5.3

5.9

5.2

6.3

0.4

Was

hing

ton

1,40

866

.687

.460

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.51.

391

.399

.973

.988

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.50.

70.

80.

90.

50.

0

Wes

t Virg

inia

439

53.2

88.3

76.8

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––

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42.

21.

70.

50.

0

Wis

cons

in1,

264

59.5

83.3

72.8

4.5

2.5

84.6

92.8

88.4

93.2

35.0

––

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Wyo

min

g89

––

––

––

––

––

––

––

Page 89: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 77

Section 3: Program Enrollment and Spending—Medicaid Managed Care

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

29.

(co

ntin

ued)

Not

es: F

Y is

fisc

al y

ear.

PCCM

is p

rimar

y ca

re c

ase

man

agem

ent.

Enro

llmen

t num

bers

gen

eral

ly in

clud

e in

divi

dual

s ev

er e

nrol

led

in M

edic

aid-

finan

ced

cove

rage

dur

ing

the

year

, ev

en if

for a

sin

gle

mon

th; h

owev

er, i

n th

e ev

ent i

ndiv

idua

ls w

ere

also

enr

olle

d in

CH

IP-fi

nanc

ed M

edic

aid

cove

rage

(i.e

., M

edic

aid-

expa

nsio

n CH

IP) d

urin

g th

e ye

ar, t

hey

are

excl

uded

if th

eir m

ost r

ecen

t enr

ollm

ent m

onth

was

in M

edic

aid-

expa

nsio

n CH

IP. N

umbe

rs e

xclu

de in

divi

dual

s en

rolle

d on

ly in

Med

icai

d-ex

pans

ion

CHIP

dur

ing

the

year

and

en

rolle

es in

the

terr

itorie

s. C

hild

ren

and

adul

ts u

nder

age

65

who

qua

lify

for M

edic

aid

on th

e ba

sis

of d

isab

ility

are

incl

uded

in th

e di

sabl

ed c

ateg

ory.

Abo

ut 7

37,0

00 e

nrol

lees

age

65

and

old

er a

re id

entif

ied

in th

e da

ta a

s di

sabl

ed; g

iven

that

dis

abili

ty is

not

an

elig

ibili

ty p

athw

ay fo

r ind

ivid

uals

age

65

and

olde

r, M

ACPA

C re

code

s th

ese

enro

llees

as

aged

.

Due

to c

hang

es in

bot

h m

etho

ds a

nd d

ata,

figu

res

show

n he

re a

re n

ot d

irect

ly c

ompa

rabl

e to

ear

lier y

ears

. With

rega

rd to

met

hods

, ind

ivid

uals

are

cou

nted

as

part

icip

atin

g in

m

anag

ed c

are

if th

ey h

ad a

t lea

st o

ne m

onth

indi

catin

g pl

an e

nrol

lmen

t; pr

evio

usly

, ind

ivid

uals

wer

e co

unte

d as

par

ticip

atin

g if

at le

ast o

ne m

anag

ed c

are

paym

ent w

as m

ade

on th

eir b

ehal

f dur

ing

the

fisca

l yea

r. In

add

ition

, due

to th

e un

avai

labi

lity

of a

sta

tes’

MSI

S An

nual

Per

son

Sum

mar

y (A

PS) d

ata

for F

Y 20

12, t

he s

ourc

e us

ed in

prio

r edi

tions

of

this

exh

ibit,

MAC

PAC

calc

ulat

ed s

pend

ing

and

enro

llmen

t fro

m th

e fu

ll M

SIS

data

file

s th

at a

re u

sed

to c

reat

e th

e AP

S fil

es. F

or M

ACPA

C’s

anal

ysis

, Med

icai

d en

rolle

es

wer

e as

sign

ed a

uni

que

natio

nal i

dent

ifica

tion

(ID) n

umbe

r usi

ng a

n al

gorit

hm th

at in

corp

orat

es s

tate

-spe

cific

ID n

umbe

rs a

nd b

enef

icia

ry c

hara

cter

istic

s su

ch a

s da

te o

f bi

rth

and

gend

er. T

he s

tate

and

nat

iona

l enr

ollm

ent c

ount

s sh

own

here

are

und

uplic

ated

usi

ng th

is n

atio

nal I

D. T

he s

um o

f the

sta

te to

tals

exc

eeds

the

natio

nal t

otal

bec

ause

in

divi

dual

s m

ay b

e en

rolle

d in

mor

e th

an o

ne s

tate

dur

ing

the

year

. See

htt

ps:/

/ww

w.m

acpa

c.go

v/m

acst

ats/

data

-sou

rces

-and

-met

hods

/ for

add

ition

al in

form

atio

n. M

edic

aid

enro

llees

may

be

enro

lled

conc

urre

ntly

in m

ore

than

one

type

of m

anag

ed c

are

prog

ram

(e.g

., a

com

preh

ensi

ve p

lan

and

a lim

ited-

bene

fit p

lan)

, so

the

sum

of e

nrol

lmen

t in

each

pro

gram

type

as

a pe

rcen

tage

of t

otal

Med

icai

d en

rollm

ent m

ay b

e gr

eate

r tha

n 10

0 pe

rcen

t.

Figu

res

show

n he

re, w

hich

are

bas

ed o

n M

SIS

data

, may

diff

er fr

om th

ose

that

use

Med

icai

d m

anag

ed c

are

enro

llmen

t rep

ort d

ata.

Rea

sons

for d

iffer

ence

s in

clud

e di

ffer

ing

time

perio

ds, s

tate

repo

rtin

g an

omal

ies,

and

the

trea

tmen

t of M

edic

aid-

expa

nsio

n CH

IP e

nrol

lees

(exc

lude

d he

re b

ut in

clud

ed in

enr

ollm

ent r

epor

t dat

a). A

lthou

gh th

e en

rollm

ent r

epor

t is

a co

mm

only

cite

d so

urce

, it d

oes

not p

rovi

de in

form

atio

n on

the

char

acte

ristic

s of

enr

olle

es in

man

aged

car

e (e

.g.,

elig

ibili

ty g

roup

).

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 In

clud

es c

ompr

ehen

sive

man

aged

car

e pl

ans

and

Prog

ram

s of

All-

Incl

usiv

e Ca

re fo

r the

Eld

erly

(PAC

E).

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

MSI

S da

ta a

s of

Dec

embe

r 201

4.

Page 90: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201578

Section 3: Program Enrollment and Spending—Medicaid Program Administration

MAC

Stat

sSe

ctio

n 3

Stat

e1

Tota

l sp

endi

ng o

n ad

min

istr

atio

n

Spen

ding

by

cate

gory

Colle

ctio

nsM

MIS

2El

igib

ility

sy

stem

2

EHR

ince

ntiv

e pr

ogra

m3

Oth

er fu

nctio

ns,

fede

ral m

atch

, ab

ove

50%

4

Oth

er fu

nctio

ns,

fede

ral m

atch

of

50%

5

Alab

ama

$212

$35

$19

$26

$10

$122

-$0

Alas

ka13

416

1016

687

–Ar

izon

a26

830

125

458

60-0

Arka

nsas

314

4847

1748

154

–Ca

lifor

nia

4,86

439

987

250

262

3,86

6–

Colo

rado

346

4544

446

207

–Co

nnec

ticut

347

4055

237

222

–De

law

are

113

2723

76

52–

Dist

rict o

f Col

umbi

a15

725

239

595

–Fl

orid

a74

770

4990

4848

9–

Geo

rgia

461

101

7676

320

6-0

Haw

aii

100

1434

192

30–

Idah

o10

723

2417

637

–Ill

inoi

s1,

106

4436

144

7281

0–

Indi

ana

506

8831

5318

316

–Io

wa

189

5972

275

26–

Kans

as20

525

4024

411

2-0

Kent

ucky

223

4313

4623

98–

Loui

sian

a28

235

1340

1118

3–

Mai

ne16

356

1823

858

–M

aryl

and

415

2857

4660

226

–M

assa

chus

etts

702

9114

6634

497

–M

ichi

gan

645

199

4666

1531

9–

Min

neso

ta59

567

9169

836

1–

Mis

siss

ippi

151

316

339

71–

Mis

sour

i41

048

4757

3222

6-0

Mon

tana

727

2610

327

-0N

ebra

ska

136

2632

166

56–

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ada

151

3450

1611

40–

EXH

IBIT

30.

Tot

al M

edic

aid

Adm

inis

trat

ive

Spen

ding

by

Stat

e an

d Ca

tego

ry, F

Y 20

14 (m

illio

ns)

Page 91: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 79

Section 3: Program Enrollment and Spending—Medicaid Program Administration

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

30.

(co

ntin

ued)

Stat

e1

Tota

l sp

endi

ng o

n ad

min

istr

atio

n

Spen

ding

by

cate

gory

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ctio

nsM

MIS

2El

igib

ility

sy

stem

2

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ince

ntiv

e pr

ogra

m3

Oth

er fu

nctio

ns,

fede

ral m

atch

, ab

ove

50%

4

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er fu

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ns,

fede

ral m

atch

of

50%

5

New

Ham

pshi

re$9

8$1

6$4

2$6

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1–

New

Jer

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724

5519

3229

589

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986

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1,79

219

732

174

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Car

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a66

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55

127

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784

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276

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5125

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ashi

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157

386

1721

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$24,

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Page 92: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201580

Section 3: Program Enrollment and Spending—Medicaid Program Administration

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

30.

(co

ntin

ued)

Stat

e1

Tota

l sp

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Med

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and

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term

edia

te c

are

faci

litie

s629

3–

––

293

––

Tota

l$2

5,01

8$3

,075

$2,2

60$2

,423

$1,6

90$1

5,58

0-$

9Pe

rcen

t of t

otal

, exc

lusi

ve o

f col

lect

ions

–12

.3%

9.0%

9.7%

6.8%

62.3

%–

Not

es: F

Y is

fisc

al y

ear.

MM

IS is

Med

icai

d m

anag

emen

t inf

orm

atio

n sy

stem

. EH

R is

ele

ctro

nic

heal

th re

cord

. Inc

lude

s fe

dera

l and

sta

te fu

nds.

Exc

lude

s ad

min

istr

ativ

e ac

tiviti

es p

erfo

rmed

by

Med

icai

d m

anag

ed c

are

plan

s (w

hich

are

incl

uded

in th

e ca

pita

tion

paym

ents

that

sta

tes

mak

e to

thes

e pl

ans)

and

act

iviti

es th

at a

re e

xclu

sive

ly

fede

ral,

such

as

prog

ram

ove

rsig

ht b

y CM

S st

aff.

Colle

ctio

ns m

ay in

clud

e, fo

r exa

mpl

e, d

onat

ions

mad

e by

hos

pita

ls to

com

pens

ate

for t

he c

ost o

f on-

site

sta

tioni

ng o

f sta

te o

r lo

cal M

edic

aid

agen

cy p

erso

nnel

to d

eter

min

e el

igib

ility

or p

rovi

de o

utre

ach.

For

mor

e in

form

atio

n on

spe

cific

item

s no

ted

in th

is e

xhib

it, s

ee C

MS,

201

0, M

BES

CBES

cat

egor

y of

ser

vice

line

def

initi

ons

for t

he 6

4.10

bas

e fo

rm, h

ttps

://w

ww

.cm

s.go

v/Re

sear

ch-S

tatis

tics-

Data

-and

-Sys

tem

s/Co

mpu

ter-D

ata-

and-

Syst

ems/

Med

icai

dBud

getE

xpen

dSys

tem

/Do

wnl

oads

/CM

S641

0Bas

e.pd

f.

– D

ash

indi

cate

s ze

ro; $

0 or

-$0

indi

cate

s an

am

ount

bet

wee

n $0

.5 a

nd -$

0.5

mill

ion

that

roun

ds to

zer

o.1

Not

all

stat

es h

ad c

ertif

ied

thei

r CM

S-64

Fin

anci

al M

anag

emen

t Rep

ort (

FMR)

sub

mis

sion

s as

of F

ebru

ary

25, 2

015.

Cal

iforn

ia’s

and

Col

orad

o’s

seco

nd, t

hird

, and

four

th

quar

ter s

ubm

issi

ons

are

not c

ertif

ied;

Nor

th D

akot

a’s

third

and

four

th q

uart

er s

ubm

issi

ons

are

not c

ertif

ied;

Sou

th C

arol

ina’

s se

cond

qua

rter

sub

mis

sion

is n

ot c

ertif

ied;

Rho

de

Isla

nd’s

four

th q

uart

er s

ubm

issi

on is

not

cer

tifie

d. F

igur

es p

rese

nted

in th

is ta

ble

may

cha

nge

if st

ates

revi

se th

eir e

xpen

ditu

re d

ata

afte

r thi

s da

te.

2 In

clud

es d

esig

n an

d de

velo

pmen

t of s

yste

ms

(90

perc

ent f

eder

al m

atch

), op

erat

ion

of a

ppro

ved

syst

ems

(75

perc

ent)

, and

oth

er c

osts

(50

perc

ent)

.3

Incl

udes

EH

R in

cent

ive

paym

ents

to p

rovi

ders

(100

per

cent

fede

ral m

atch

) and

adm

inis

trat

ion

of p

aym

ents

(90

perc

ent)

.4

Incl

udes

ski

lled

med

ical

pro

fess

iona

ls, p

read

mis

sion

scr

eeni

ng a

nd re

side

nt re

view

, med

ical

and

util

izat

ion

revi

ew, e

xter

nal i

ndep

ende

nt re

view

, sur

vey

and

cert

ifica

tion,

and

M

FCU

ope

ratio

ns (a

ll at

75

perc

ent f

eder

al m

atch

); tr

ansl

atio

n an

d in

terp

reta

tion

serv

ices

for c

hild

ren

and

plan

ning

act

iviti

es fo

r the

Hea

lth H

ome

bene

fit (b

oth

at m

atch

equ

al to

a

stat

e’s fe

dera

l med

ical

ass

ista

nce

perc

enta

ge);

elig

ibili

ty c

hang

es a

ssoc

iate

d w

ith th

e Te

mpo

rary

Ass

ista

nce

for N

eedy

Fam

ilies

pro

gram

(75

or 9

0 pe

rcen

t); a

dmin

istra

tion

of fa

mily

pl

anni

ng s

ervi

ces

(90

perc

ent)

; and

imm

igra

tion

stat

us v

erifi

catio

n sy

stem

s (1

00 p

erce

nt).

Excl

udes

MM

IS a

nd e

ligib

ility

sys

tem

spe

ndin

g, w

hich

hav

e th

eir o

wn

cate

gorie

s.5

Excl

udes

MM

IS a

nd e

ligib

ility

sys

tem

spe

ndin

g, w

hich

hav

e th

eir o

wn

cate

gorie

s.6

Stat

e-le

vel e

stim

ates

for M

FCU

s an

d su

rvey

and

cer

tific

atio

n ar

e av

aila

ble

but a

re n

ot in

clud

ed in

the

CMS-

64 d

ata

that

MAC

PAC

typi

cally

use

s to

ana

lyze

Med

icai

d sp

endi

ng.

Sour

ces:

For

sta

te a

nd te

rrito

ry s

pend

ing:

MAC

PAC,

201

5, a

naly

sis

of C

MS-

64 F

MR

net e

xpen

ditu

re d

ata

as o

f Feb

ruar

y 25

, 201

5; fo

r MCF

Us

and

surv

ey a

nd c

ertif

icat

ion:

CM

S,

2015

, Fis

cal y

ear 2

016

just

ifica

tion

of e

stim

ates

for A

ppro

pria

tions

Com

mitt

ees,

Bal

timor

e, M

D: C

MS,

htt

p://

ww

w.c

ms.

gov/

Abou

t-CM

S/Ag

ency

-Info

rmat

ion/

Perf

orm

ance

Budg

et/

Dow

nloa

ds/F

Y201

6-CJ

-Fin

al.p

df.

Page 93: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 81

Section 3: Program Enrollment and Spending—CHIP

MAC

Stat

sSe

ctio

n 3

Stat

eTo

tal

CHIP

-fun

ded

cove

rage

Med

icai

d-fu

nded

cov

erag

eTo

tal

43,6

89,8

248,

129,

426

36,1

33,2

60Al

abam

a74

3,24

110

5,49

163

7,75

0Al

aska

96,2

329,

661

86,5

71Ar

izon

a11,

006,

893

54,3

6195

2,53

2Ar

kans

as50

6,29

010

0,11

240

6,17

8Ca

lifor

nia2

5,90

4,34

71,

874,

939

4,60

2,27

0Co

lora

do59

3,44

012

5,47

146

7,96

9Co

nnec

ticut

352,

626

19,9

2733

2,69

9De

law

are

119,

594

18,6

5010

0,94

4Di

stric

t of C

olum

bia

98,2

347,

085

91,1

49Fl

orid

a2,

710,

000

423,

351

2,28

6,64

9G

eorg

ia3

1,47

2,52

423

1,27

01,

241,

254

Haw

aii

174,

062

30,5

0514

3,55

7Id

aho

220,

383

30,6

1518

9,76

8Ill

inoi

s1,

912,

477

295,

844

1,61

6,63

3In

dian

a86

8,55

615

3,52

371

5,03

3Io

wa

404,

006

83,4

1132

0,59

5Ka

nsas

306,

335

73,5

7423

2,76

1Ke

ntuc

ky3

596,

706

61,4

7353

5,23

3Lo

uisi

ana

799,

554

136,

263

663,

291

Mai

ne20

6,63

127

,461

179,

170

Mar

ylan

d65

1,76

813

7,19

251

4,57

6M

assa

chus

etts

467

3,19

012

6,38

454

6,80

6M

ichi

gan

1,27

8,29

710

4,12

71,

174,

170

Min

neso

ta54

2,38

23,

590

538,

792

Mis

siss

ippi

533,

140

80,5

7545

2,56

5M

isso

uri

632,

734

86,8

2854

5,90

6M

onta

na13

9,60

349

,671

89,9

32N

ebra

ska

214,

638

56,4

7615

8,16

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evad

a34

3,60

845

,870

297,

738

New

Ham

pshi

re11

0,67

616

,523

94,1

53N

ew J

erse

y92

0,51

521

1,37

170

9,14

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ew M

exic

o40

0,96

116

,037

384,

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797,

987

604,

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2,19

3,42

1

EXH

IBIT

31.

Chi

ld E

nrol

lmen

t in

CHIP

and

Med

icai

d by

Sta

te, F

Y 20

14

Page 94: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201582

Section 3: Program Enrollment and Spending—CHIP

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

31.

(co

ntin

ued)

Stat

eTo

tal

CHIP

-fun

ded

cove

rage

Med

icai

d-fu

nded

cov

erag

eN

orth

Car

olin

a1,

404,

270

236,

893

1,16

7,37

7N

orth

Dak

ota

59,1

085,

032

54,0

76O

hio5

1,38

6,82

413

6,16

91,

250,

655

Okl

ahom

a69

8,69

016

4,83

153

3,85

9O

rego

n354

0,19

410

9,08

543

1,10

9Pe

nnsy

lvan

ia3

1,57

2,27

525

8,45

51,

313,

820

Rhod

e Is

land

120,

825

22,1

3698

,689

Sout

h Ca

rolin

a68

8,15

579

,740

608,

415

Sout

h Da

kota

682

,271

15,8

7066

,401

Tenn

esse

e88

8,30

611

2,82

677

5,48

0Te

xas

4,72

1,45

71,

041,

482

3,67

9,97

5U

tah

380,

762

76,5

3330

4,22

9Ve

rmon

t79

,490

5,95

373

,537

Virg

inia

842,

607

186,

513

656,

094

Was

hing

ton

762,

451

42,6

3771

9,81

4W

est V

irgin

ia1

330,

901

40,8

6429

0,03

7W

isco

nsin

734,

922

183,

115

551,

807

Wyo

min

g64

,686

9,09

555

,591

Not

es: F

Y is

fisc

al y

ear.

Tota

l col

umn

refle

cts

child

ren

ever

enr

olle

d in

CH

IP o

r Med

icai

d du

ring

the

year

, eve

n if

for a

sin

gle

mon

th. M

ost s

tate

s co

unte

d ch

ildre

n w

ho w

ere

enro

lled

in m

ultip

le c

ateg

orie

s du

ring

the

year

(for

exa

mpl

e, in

Med

icai

d-fu

nded

cov

erag

e fo

r the

firs

t hal

f of t

he y

ear b

ut in

CH

IP-fu

nded

cov

erag

e fo

r the

sec

ond

half)

in th

e m

ost r

ecen

t cat

egor

y (s

tate

-spe

cific

exc

eptio

ns to

this

rule

are

not

ed b

elow

). M

edic

aid-

fund

ed c

hild

enr

ollm

ent s

how

n he

re in

clud

es a

ll ch

ildre

n, re

gard

less

of d

isab

ility

sta

tus;

in

oth

er M

ACSt

ats

exhi

bits

that

bre

ak e

nrol

lmen

t out

by

elig

ibili

ty g

roup

, chi

ldre

n qu

alify

ing

on th

e ba

sis

of d

isab

ility

may

be

coun

ted

in th

e di

sabl

ed c

ateg

ory

rath

er th

an th

e ch

ild c

ateg

ory.

Dat

a w

ere

repo

rted

by

indi

vidu

al s

tate

s as

of M

ay 1

3, 2

015,

and

may

be

revi

sed

at a

late

r dat

e.1

Child

ren

who

tran

sitio

ned

betw

een

CHIP

and

Med

icai

d w

ere

repo

rted

in b

oth

prog

ram

s ra

ther

than

the

prog

ram

in w

hich

they

wer

e la

st e

nrol

led.

The

refo

re, e

nrol

lmen

t tot

als

are

artif

icia

lly h

igh.

2 Th

e to

tal r

efle

cts

undu

plic

ated

enr

ollm

ent a

nd is

acc

urat

e; h

owev

er, t

he d

ata

repo

rted

for e

ach

prog

ram

con

tain

dup

licat

es a

nd a

re a

rtifi

cial

ly h

igh.

3 Du

e to

elig

ibili

ty a

nd e

nrol

lmen

t sys

tem

cha

lleng

es, s

ome

CHIP

-fund

ed M

edic

aid

enro

llees

wer

e in

clud

ed in

Med

icai

d en

rollm

ent c

ount

s, ra

ther

than

CH

IP.

4 Du

e to

elig

ibili

ty a

nd e

nrol

lmen

t sys

tem

cha

lleng

es, c

erta

in m

embe

rs w

ho s

houl

d ha

ve b

een

assi

gned

to C

HIP

wer

e as

sign

ed to

Med

icai

d-fu

nded

cov

erag

e be

ginn

ing

in th

e se

cond

qua

rter

of 2

014.

5 Du

e to

elig

ibili

ty a

nd e

nrol

lmen

t sys

tem

cha

lleng

es, c

erta

in m

embe

rs w

ho s

houl

d ha

ve b

een

assi

gned

to C

HIP

wer

e as

sign

ed to

Med

icai

d-fu

nded

cov

erag

e fo

r FY

2014

.6

Due

to th

e ex

clus

ion

of c

erta

in M

edic

aid

enro

llees

in re

port

ing,

dat

a ar

e ar

tific

ially

low

.

Sour

ce: C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es (C

MS)

, 201

5, F

Y 20

14 u

ndup

licat

ed n

umbe

r of c

hild

ren

ever

enr

olle

d in

Med

icai

d an

d CH

IP, h

ttp:

//w

ww

.med

icai

d.go

v/ch

ip/

dow

nloa

ds/f

y-20

14-c

hild

rens

-enr

ollm

ent-r

epor

t.pdf

.

Page 95: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 83

Section 3: Program Enrollment and Spending—CHIP

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

32.

CH

IP S

pend

ing

by S

tate

, FY

2014

(mill

ions

)

Stat

e

Tota

l CH

IP

Bene

fits

Stat

e pr

ogra

m a

dmin

istr

atio

n

Sect

ion

2105

(g)

spen

ding

2M

edic

aid-

expa

nsio

n CH

IPSe

para

te C

HIP

pro

gram

s an

d co

vera

ge o

f pre

gnan

t wom

en1

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Fede

ral

Alab

ama

$181

.6$1

41.1

$40.

5$2

2.6

$17.

5$5

.0$1

52.1

$118

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3.9

$6.9

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Alas

ka30

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.528

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1.1

0.7

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Ariz

ona

85.4

65.8

19.6

50.8

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11.7

32.8

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Arka

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97.0

76.7

20.3

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57.6

15.3

20.6

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Calif

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189.

21,

423.

176

6.1

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640.

527

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179.

696

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rado

196.

912

8.0

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20.8

130.

785

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94.

52.

4–

Conn

ectic

ut30

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27.5

17.9

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3

Dela

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f Col

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0.8

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546

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472.

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rgia

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533

4.7

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8–

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408.

831

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30.7

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aii

57.0

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41.

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a14

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as99

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ucky

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ylan

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sach

uset

ts51

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337.

618

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815

8.5

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714

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higa

n12

6.6

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neso

ta16

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siss

ippi

227.

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142

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50.

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sour

i18

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133.

148

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3.8

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13.3

17.6

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tana

97.4

74.5

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rask

a82

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82.

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50.

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ada

47.3

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6.3

4.6

1.6

38.9

28.9

10.1

2.1

1.6

0.5

Page 96: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201584

Section 3: Program Enrollment and Spending—CHIP

MAC

Stat

sSe

ctio

n 3

Stat

e

Tota

l CH

IP

Bene

fits

Stat

e pr

ogra

m a

dmin

istr

atio

n

Sect

ion

2105

(g)

spen

ding

2M

edic

aid-

expa

nsio

n CH

IPSe

para

te C

HIP

pro

gram

s an

d co

vera

ge o

f pre

gnan

t wom

en1

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

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lFe

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lSt

ate

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lFe

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ate

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ral

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Ham

pshi

re$1

5.7

$16.

3-$

0.6

$15.

6$1

0.1

$5.4

$0.0

$0.0

$0.0

$0.1

$0.1

$0.1

$6.1

New

Jer

sey

433.

728

1.3

152.

420

8.1

135.

372

.819

5.3

126.

468

.830

.319

.610

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New

Mex

ico

76.6

60.1

16.5

75.2

59.0

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61.

30.

3–

New

Yor

k1,

221.

079

3.7

427.

261

9.9

402.

921

7.0

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th C

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ina

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t Virg

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9.7

EXH

IBIT

32.

(co

ntin

ued)

Page 97: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 85

Section 3: Program Enrollment and Spending—CHIP

MAC

Stat

sSe

ctio

n 3

Not

es: F

Y is

fisc

al y

ear.

Com

pone

nts

may

not

add

to to

tal d

ue to

roun

ding

. Fed

eral

CH

IP s

pend

ing

on a

dmin

istr

atio

n is

gen

eral

ly li

mite

d to

10

perc

ent o

f a s

tate

’s to

tal f

eder

al

CHIP

spe

ndin

g fo

r the

yea

r. St

ates

with

a M

edic

aid-

expa

nsio

n CH

IP p

rogr

am m

ay e

lect

to re

ceiv

e re

imbu

rsem

ent f

or a

dmin

istr

ativ

e sp

endi

ng fr

om M

edic

aid

rath

er th

an C

HIP

fu

nds;

Med

icai

d fu

nds

are

not s

how

n in

this

exh

ibit.

1

Thre

e st

ates

(Col

orad

o, N

ew J

erse

y, an

d Rh

ode

Isla

nd) u

se C

HIP

fund

s to

pro

vide

cov

erag

e fo

r pre

gnan

t wom

en.

2 Se

ctio

n 21

05(g

) of t

he S

ocia

l Sec

urity

Act

per

mits

11

qual

ifyin

g st

ates

to u

se C

HIP

fund

s to

pay

the

diff

eren

ce b

etw

een

the

regu

lar M

edic

aid

mat

chin

g ra

te a

nd th

e en

hanc

ed C

HIP

mat

chin

g ra

te fo

r Med

icai

d-en

rolle

d, M

edic

aid-

finan

ced

child

ren

who

se fa

mily

inco

me

exce

eds

133

perc

ent o

f the

fede

ral p

over

ty le

vel.

Alth

ough

thes

e ar

e CH

IP fu

nds,

they

eff

ectiv

ely

redu

ce s

tate

spe

ndin

g on

chi

ldre

n in

Med

icai

d an

d do

not

requ

ire a

sta

te m

atch

with

in th

e CH

IP p

rogr

am. I

n ca

ses

whe

re th

e su

m o

f 210

5(g)

fe

dera

l CH

IP s

pend

ing

(for

Med

icai

d en

rolle

es) a

nd re

gula

r fed

eral

CH

IP s

pend

ing

(for

CH

IP e

nrol

lees

) exc

eeds

tota

l spe

ndin

g fo

r CH

IP e

nrol

lees

, sta

tes

are

show

n in

this

ex

hibi

t as

havi

ng n

egat

ive

stat

e CH

IP s

pend

ing

(Con

nect

icut

, Min

neso

ta, N

ew H

amps

hire

, and

Ver

mon

t).

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

Med

icai

d an

d CH

IP B

udge

t Exp

endi

ture

Sys

tem

(MBE

S/CB

ES) d

ata

from

the

Cent

ers

for M

edic

are

& M

edic

aid

Serv

ices

as

of M

arch

6, 2

015.

EXH

IBIT

32.

(co

ntin

ued)

Page 98: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201586

Section 3: Program Enrollment and Spending—CHIP

MAC

Stat

sSe

ctio

n 3

Stat

e

FY 2

014

fe

dera

l CH

IP

spen

ding

FY 2

015

allo

tmen

t in

crea

se fa

ctor

Full

year

FY

2015

am

ount

bas

ed o

n re

base

d am

ount

1

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t hal

f FY

201

5 al

lotm

ent2

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nd h

alf

FY 2

015

allo

tmen

t3

FY 2

015

fe

dera

l CH

IP

allo

tmen

ts

AB

C =

A ×

BD

= C

× 86

.5%

E =

2.85

0 bi

llion

×

(D /

colu

mn

D to

tal)

F =

D +

EAl

abam

a$1

41.1

1.

0595

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.5

$129

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$43.

7 $1

72.9

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aska

19.5

1.

0609

20.7

17

.9

6.0

23.9

Ar

izon

a65

.8

1.05

9669

.7

60.3

20

.4

80.7

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kans

as76

.7

1.05

9581

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70.2

23

.7

94.0

Ca

lifor

nia

1,42

3.1

1.05

951,

507.

7 1,

303.

7 44

0.4

1,74

4.1

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rado

128.

0 1.

0639

136.

2 11

7.7

39.8

15

7.5

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ectic

ut39

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1.05

9541

.6

35.9

12

.1

48.1

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law

are

16.5

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0595

17.5

15

.1

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stric

t of C

olum

bia

16.4

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1 14

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6 H

awai

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1.06

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46.3

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3 1.

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6 12

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6 45

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1 M

aine

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aryl

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sach

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8 M

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5 88

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esso

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issi

ssip

pi18

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9519

5.5

169.

1 57

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226.

2 M

isso

uri

133.

1 1.

0595

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1 12

2.0

41.2

16

3.2

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tana

74.5

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0650

79.3

68

.6

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91

.7

Neb

rask

a56

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1.06

4660

.2

52.1

17

.6

69.7

N

evad

a35

.1

1.06

1437

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32.2

10

.9

43.1

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ew H

amps

hire

16.3

1.

0595

17.3

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ew J

erse

y28

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8 N

ew M

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7 1.

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9 72

7.1

245.

7 97

2.8

EXH

IBIT

33.

Fed

eral

CH

IP A

llotm

ents

, FY

2015

(mill

ions

)

Page 99: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 87

Section 3: Program Enrollment and Spending—CHIP

MAC

Stat

sSe

ctio

n 3

Stat

e

FY 2

014

fe

dera

l CH

IP

spen

ding

FY 2

015

allo

tmen

t in

crea

se fa

ctor

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year

FY

2015

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ount

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ed o

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base

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ount

1

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f FY

201

5 al

lotm

ent2

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nd h

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015

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015

fe

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l CH

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AB

C =

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= C

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tal)

F =

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5 1.

0595

158.

4 13

7.0

46.3

18

3.2

Virg

in Is

land

s4.

0 1.

0595

4.3

3.7

1.3

5.0

Tota

l $9

,193

.7

$9,7

56.3

$8

,436

.1

$2,8

50.0

$1

1,28

6.1

Not

es: F

Y is

fisc

al y

ear.

For o

dd-n

umbe

red

year

s (e

.g.,

FY 2

015)

, fed

eral

CH

IP a

llotm

ents

are

bas

ed o

n ea

ch s

tate

’s p

rior-y

ear s

pend

ing.

1

Colu

mn

C co

ntai

ns th

e fu

ll ye

ar a

mou

nt b

ased

on

reba

sed

amou

nt d

escr

ibed

in S

ectio

n 21

04(m

)(3)

(C) o

f the

Soc

ial S

ecur

ity A

ct.

2 Th

e fir

st h

alf a

llotm

ent i

s ca

lcul

ated

by

mul

tiply

ing

the

full

year

am

ount

in C

olum

n C

by th

e fir

st h

alf r

atio

des

crib

ed in

Sec

tion

2104

(m)(

3)(D

) of t

he S

ocia

l Sec

urity

Act

, w

hich

is e

qual

to 8

6.46

7879

%.

3 Th

e se

cond

hal

f allo

tmen

t is

calc

ulat

ed b

y m

ultip

lyin

g th

e $2

.850

bill

ion

prov

ided

in s

ectio

n 21

04(a

)(18

)(B)

of t

he S

ocia

l Sec

urity

Act

by

the

ratio

equ

al to

eac

h st

ate’

s pr

opor

tion

of th

e to

tal a

mou

nt a

war

ded

for t

he fi

rst h

alf F

Y 20

15 C

HIP

allo

tmen

ts in

Col

umn

D.

Sour

ce: C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es (C

MS)

, 201

5, e

mai

l to

MAC

PAC

staf

f, Fe

brua

ry 9

.

EXH

IBIT

33.

(co

ntin

ued)

Page 100: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn
Page 101: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

SECTION 4

Medicaid and CHIP Eligibility

Page 102: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201590

Section 4: Medicaid and CHIP Eligibility

Section 4: Medicaid and CHIP Eligibility

Key Points• More than half of states are now covering low-income adults, for whom a new Medicaid

eligibility group was added in 2014. Most of these new adults are eligible at incomes up to 138 percent of the federal poverty level (FPL), which amounts to $16,243 for a single individual (Exhibits 35 and 37).

• Beginning in 2014, Medicaid and CHIP eligibility levels for most child and adult populations reflect the application of uniform modified adjusted gross income (MAGI) rules across states. A maintenance of effort provision also prevents states from lowering their existing eligibility levels for children through the end of FY 2019 (Exhibits 34 and 35).

• Eligibility criteria for individuals eligible for Medicaid on the basis of disability and for individuals age 65 and older, who are not subject to MAGI rules, were largely unchanged between 2014 and 2015 (Exhibit 36).

• In the lower 48 states and the District of Columbia, 100 percent of the 2015 FPL is $11,770 for an individual, plus $4,160 for each additional family member (Exhibit 37).

Page 103: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 91

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

s

Stat

e

Med

icai

d co

vera

ge

CHIP

pro

gram

type

2 (a

s of

May

1, 2

015)

Sepa

rate

CH

IP

cove

rage

Med

icai

d/CH

IP

cove

rage

Infa

nts

unde

r age

1Ag

e 1–

5Ag

e 6–

18Bi

rth

thro

ugh

age

18U

nbor

n ch

ildre

n3

Preg

nant

wom

en

and

deem

ed

new

born

s4M

edic

aid

fund

ed1

CHIP

fu

nded

1M

edic

aid

fund

ed1

CHIP

fu

nded

1M

edic

aid

fund

ed1

CHIP

fu

nded

1

Alab

ama

141%

–14

1%–

141%

107–

141%

Com

bina

tion

312%

–14

1%Al

aska

17

715

9–20

3%17

715

9–20

3%17

712

4–20

3M

edic

aid

expa

nsio

n–

–20

0Ar

izon

a514

7–

141

–13

310

4–13

3Co

mbi

natio

n20

0–

156

Arka

nsas

142

–14

2–

142

107–

142

Com

bina

tion

211

209%

209

Calif

orni

a20

820

8–26

114

214

2–26

113

310

8–26

1Co

mbi

natio

n31

7631

720

8Co

lora

do

142

–14

2–

142

108–

142

Com

bina

tion

260

–19

5/26

0Co

nnec

ticut

19

6–

196

–19

6–

Sepa

rate

318

–25

8De

law

are

212

194–

212

142

–13

311

0–13

3Co

mbi

natio

n21

2–

212

Dist

rict o

f Col

umbi

a31

920

6–31

931

914

6–31

931

911

2–31

9M

edic

aid

expa

nsio

n–

–31

9Fl

orid

a20

619

2–20

614

0–

133

112–

133

Com

bina

tion

2107

–19

1G

eorg

ia

205

–14

9–

133

113–

133

Com

bina

tion

247

–22

0H

awai

i 19

119

1–30

813

913

9–30

813

310

5–30

8M

edic

aid

expa

nsio

n–

–19

1Id

aho

142

–14

2–

133

107–

133

Com

bina

tion

185

–13

3Ill

inoi

s 14

2–

142

–14

210

8–14

2Co

mbi

natio

n31

320

820

8In

dian

a 20

815

7–20

815

814

1–15

815

810

6–15

8Co

mbi

natio

n25

0–

208

Iow

a37

524

0–37

516

7–

167

122–

167

Com

bina

tion

302

–37

5Ka

nsas

16

6–

149

–13

311

3–13

3Co

mbi

natio

n23

9–

166

Kent

ucky

19

5–

142

142–

159

133

109–

159

Com

bina

tion

213

–19

5Lo

uisi

ana

142

142–

212

142

142–

212

142

108–

212

Com

bina

tion

250

209

133

Mai

ne

191

–15

714

0–15

715

713

2–15

7Co

mbi

natio

n20

8–

209

Mar

ylan

d 19

419

4–31

713

813

8–31

713

310

9–31

7M

edic

aid

expa

nsio

n–

–25

9M

assa

chus

etts

200

185–

200

150

133–

150

150

114–

150

Com

bina

tion

300

200

200

Mic

higa

n 19

5–

160

143–

160

160

109–

160

Com

bina

tion

212

195

195

Min

neso

ta8

275

275-

283

275

–27

5–

Com

bina

tion

–27

827

8M

issi

ssip

pi

194

–14

3–

133

107–

133

Com

bina

tion

209

–19

4M

isso

uri

196

–14

814

8–15

014

811

0–15

0Co

mbi

natio

n30

0–

196

Mon

tana

143

–14

3–

133

109–

143

Com

bina

tion

261

–15

7N

ebra

ska

162

162–

213

145

145–

213

133

109–

213

Com

bina

tion

–19

719

4N

evad

a16

0–

160

–13

312

2–13

3Co

mbi

natio

n20

0–

160

New

Ham

pshi

re

196

196–

318

196

196–

318

196

196–

318

Med

icai

d ex

pans

ion

––

196

New

Jer

sey

194

–14

2–

142

107–

142

Com

bina

tion

350

–19

4/20

0N

ew M

exic

o 24

020

0–30

024

020

0–30

019

013

8–24

0M

edic

aid

expa

nsio

n–

–25

0

EXH

IBIT

34.

Med

icai

d an

d CH

IP In

com

e El

igib

ility

Lev

els

as a

Per

cent

age

of th

e FP

L fo

r Chi

ldre

n an

d Pr

egna

nt W

omen

by

Stat

e,

Sept

embe

r 201

5

Sect

ion

4

Page 104: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201592

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

sSe

ctio

n 4

EXH

IBIT

34.

(co

ntin

ued)

Stat

e

Med

icai

d co

vera

ge

CHIP

pro

gram

type

2 (a

s of

May

1, 2

015)

Sepa

rate

CH

IP

cove

rage

Med

icai

d/CH

IP

cove

rage

Infa

nts

unde

r age

1Ag

e 1–

5Ag

e 6–

18Bi

rth

thro

ugh

age

18U

nbor

n ch

ildre

n3

Preg

nant

wom

en

and

deem

ed

new

born

s4M

edic

aid

fund

ed1

CHIP

fu

nded

1M

edic

aid

fund

ed1

CHIP

fu

nded

1M

edic

aid

fund

ed1

CHIP

fu

nded

1

New

Yor

k 21

8%19

6–21

8%14

9%–

149%

110–

149%

Com

bina

tion

400%

–21

8%N

orth

Car

olin

a 21

019

4–21

021

014

1–21

0%13

310

7–13

3Co

mbi

natio

n21

19–

196

Nor

th D

akot

a14

7–

147

–13

311

1–13

3Co

mbi

natio

n17

0–

147

Ohi

o15

614

1–20

615

614

1–20

615

610

7–20

6M

edic

aid

expa

nsio

n–

–20

0O

klah

oma

205

169–

205

205

151–

205

205

115–

205

Com

bina

tion

–20

5%13

3O

rego

n 18

513

3–18

513

3–

133

100–

133

Com

bina

tion

300

185

185

Penn

sylv

ania

21

5–

157

–13

311

9–13

3Co

mbi

natio

n31

4–

215

Rhod

e Is

land

190

190–

261

142

142–

261

133

109–

261

Com

bina

tion

–25

319

0/25

3So

uth

Caro

lina

194

194–

208

143

143–

208

133

107–

208

Med

icai

d ex

pans

ion

––

194

Sout

h Da

kota

18

217

7–18

218

217

7–18

218

212

4–18

2Co

mbi

natio

n20

4–

133

Tenn

esse

e1019

5–

142

–13

310

9–13

3Co

mbi

natio

n25

025

019

5Te

xas

198

–14

4–

133

109–

133

Com

bina

tion

201

202

198

Uta

h13

9–

139

–13

310

5–13

3Co

mbi

natio

n20

0–

139

Verm

ont

312

237–

312

312

237–

312

312

237–

312

Med

icai

d ex

pans

ion

––

208

Virg

inia

143

–14

3–

143

109–

143

Com

bina

tion

200

–14

3/20

0W

ashi

ngto

n 21

0–

210

–21

0–

Sepa

rate

312

193

193

Wes

t Virg

inia

15

8–

141

–13

310

8–13

3Co

mbi

natio

n30

0–

158

Wis

cons

in

301

–18

6–

133

101–

151

Com

bina

tion

301

301

301

Wyo

min

g 15

4–

154

–13

311

9–13

3Co

mbi

natio

n20

0–

154

Not

es: F

PL is

fede

ral p

over

ty le

vel.

In 2

015,

100

per

cent

FPL

is $

11,7

70 fo

r an

indi

vidu

al p

lus

$4,1

60 fo

r eac

h ad

ditio

nal f

amily

mem

ber i

n th

e lo

wer

48

stat

es a

nd th

e Di

stric

t of

Col

umbi

a. W

hen

dete

rmin

ing

Med

icai

d an

d CH

IP e

ligib

ility

prio

r to

2014

, sta

tes

had

the

flexi

bilit

y to

dis

rega

rd in

com

e so

urce

s an

d am

ount

s of

thei

r cho

osin

g. B

egin

ning

in

201

4, u

nifo

rm m

odifi

ed a

djus

ted

gros

s in

com

e (M

AGI)

rule

s m

ust b

e us

ed to

det

erm

ine

Med

icai

d an

d CH

IP e

ligib

ility

for m

ost n

on-d

isab

led

child

ren

and

adul

ts u

nder

age

65

, inc

ludi

ng th

e gr

oups

sho

wn

in th

is ta

ble.

As

a re

sult,

sta

tes

are

now

requ

ired

to u

se M

AGI-c

onve

rted

elig

ibili

ty le

vels

that

acc

ount

for t

he c

hang

e in

inco

me-

coun

ting

rule

s.

The

elig

ibili

ty le

vels

sho

wn

in th

is ta

ble

refle

ct th

ese

MAG

I-con

vert

ed le

vels

or a

noth

er M

AGI-b

ased

inco

me

limit

in e

ffec

t in

each

sta

te fo

r the

se g

roup

s as

of S

epte

mbe

r 201

5.

Und

er fe

dera

l reg

ulat

ions

, the

eff

ectiv

e in

com

e lim

its m

ay b

e hi

gher

by

5 pe

rcen

t of t

he F

PL th

an th

ose

show

n on

this

tabl

e to

acc

ount

for a

gen

eral

inco

me

disr

egar

d th

at

appl

ies

to a

n in

divi

dual

’s d

eter

min

atio

n of

elig

ibili

ty fo

r Med

icai

d an

d CH

IP o

vera

ll, ra

ther

than

for p

artic

ular

elig

ibili

ty g

roup

s w

ithin

Med

icai

d or

CH

IP.

Med

icai

d co

vera

ge o

f chi

ldre

n un

der a

ge 1

9 w

ith in

com

es b

elow

sta

tes’

elig

ibili

ty le

vels

in e

ffec

t as

of M

arch

31,

199

7, c

ontin

ues

to b

e fin

ance

d by

Med

icai

d (T

itle

XIX)

fund

ing.

An

y ex

pans

ion

of e

ligib

ility

to u

nins

ured

chi

ldre

n ab

ove

thos

e le

vels

—th

roug

h ex

pans

ions

of M

edic

aid

or th

roug

h se

para

te C

HIP

pro

gram

s—is

gen

eral

ly fi

nanc

ed b

y CH

IP

(Titl

e XX

I) fu

ndin

g. C

HIP

fund

ing

is n

ot p

erm

itted

for c

hild

ren

with

oth

er c

over

age.

Thu

s, w

here

Med

icai

d co

vera

ge in

this

tabl

e sh

ows

over

lapp

ing

elig

ibili

ty le

vels

for M

edic

aid

fund

ing

and

CHIP

fund

ing,

chi

ldre

n w

ith n

o ot

her c

over

age

are

fund

ed b

y CH

IP, w

hile

chi

ldre

n w

ith o

ther

cov

erag

e ar

e fu

nded

by

Med

icai

d. P

regn

ant w

omen

can

rece

ive

Med

icai

d- o

r CH

IP-fu

nded

ser

vice

s th

roug

h re

gula

r sta

te p

lan

elig

ibili

ty p

athw

ays

or th

roug

h Se

ctio

n 11

15 w

aive

rs; i

n ad

ditio

n, th

e un

born

chi

ldre

n of

pre

gnan

t wom

en m

ay

rece

ive

CHIP

-fund

ed c

over

age

unde

r a s

tate

pla

n op

tion.

Dee

med

new

born

s ar

e in

fant

s up

to a

ge 1

who

are

dee

med

elig

ible

for M

edic

aid

or C

HIP

—w

ith n

o se

para

te a

pplic

atio

n or

elig

ibili

ty d

eter

min

atio

n re

quire

d—if

thei

r mot

her w

as e

nrol

led

at th

e tim

e of

thei

r birt

h.

Page 105: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 93

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

sSe

ctio

n 4

EXH

IBIT

34.

(co

ntin

ued)

1 U

nder

Med

icai

d fu

nded

, the

re is

no

low

er b

ound

for i

ncom

e el

igib

ility

. The

elig

ibili

ty le

vels

list

ed u

nder

Med

icai

d fu

nded

are

the

high

est i

ncom

e le

vels

und

er w

hich

eac

h ag

e gr

oup

of c

hild

ren

is c

over

ed u

nder

the

Med

icai

d st

ate

plan

, whe

re e

ither

all

or ju

st in

sure

d ch

ildre

n ar

e cl

aim

ed w

ith M

edic

aid

fund

ing.

The

elig

ibili

ty le

vels

list

ed u

nder

CH

IP fu

nded

are

the

inco

me

leve

ls to

whi

ch M

edic

aid

has

expa

nded

with

CH

IP fu

ndin

g si

nce

its c

reat

ion

in 1

997.

For

sta

tes

that

hav

e di

ffer

ent C

HIP

-fund

ed e

ligib

ility

leve

ls

for c

hild

ren

age

6 th

roug

h 13

and

age

14

thro

ugh

18, t

his

tabl

e sh

ows

only

the

leve

ls fo

r chi

ldre

n ag

e 6

thro

ugh

13. I

n ad

ditio

n, S

ectio

n 21

05(g

) of t

he S

ocia

l Sec

urity

Act

pe

rmits

11

qual

ifyin

g st

ates

to u

se C

HIP

fund

s to

pay

the

diff

eren

ce b

etw

een

the

regu

lar M

edic

aid

mat

chin

g ra

te a

nd th

e en

hanc

ed C

HIP

mat

chin

g ra

te fo

r Med

icai

d-en

rolle

d,

Med

icai

d-fin

ance

d un

insu

red

child

ren

who

se fa

mily

inco

me

exce

eds

133

perc

ent F

PL (n

ot s

epar

atel

y no

ted

on th

is ta

ble)

.2

Und

er C

HIP

, sta

tes

have

the

optio

n to

use

an

expa

nsio

n of

Med

icai

d, a

sep

arat

e CH

IP p

rogr

am, o

r a c

ombi

natio

n of

bot

h ap

proa

ches

. Nin

e st

ates

(inc

ludi

ng th

e Di

stric

t of

Col

umbi

a) a

re M

edic

aid

expa

nsio

ns a

nd 2

sta

tes

are

sepa

rate

CH

IP o

nly

(Con

nect

icut

and

Was

hing

ton)

. Fo

rty

stat

es a

re c

ombi

natio

n pr

ogra

ms—

and

amon

g th

ose,

11

cons

ider

them

selv

es to

hav

e se

para

te p

rogr

ams

but a

re te

chni

cally

com

bina

tions

due

to th

e tr

ansi

tion

of c

hild

ren

belo

w 1

33 p

erce

nt F

PL fr

om s

epar

ate

CHIP

to M

edic

aid

(Ala

bam

a, A

rizon

a, G

eorg

ia, K

ansa

s, M

issi

ssip

pi, O

rego

n, P

enns

ylva

nia,

Tex

as, U

tah,

Wes

t Virg

inia

, Wyo

min

g).

3 Se

para

te C

HIP

elig

ibili

ty fo

r chi

ldre

n bi

rth

thro

ugh

age

18 g

ener

ally

beg

ins

whe

re M

edic

aid

cove

rage

end

s (a

s sh

own

in th

e pr

evio

us c

olum

ns).

For u

nbor

n ch

ildre

n, th

ere

is

no lo

wer

bou

nd fo

r inc

ome

elig

ibili

ty if

the

mot

her i

s no

t elig

ible

for M

edic

aid.

4 Pr

egna

nt w

omen

can

be

cove

red

with

Med

icai

d or

CH

IP fu

ndin

g. U

nder

CH

IP, c

over

age

can

be th

roug

h a

stat

e pl

an o

ptio

n fo

r tar

gete

d lo

w-in

com

e pr

egna

nt w

omen

or

thro

ugh

cont

inua

tion

of a

n ex

istin

g Se

ctio

n 11

15 w

aive

r. W

hen

two

valu

es a

re s

how

n in

this

col

umn,

the

first

is fo

r Med

icai

d an

d th

e se

cond

is fo

r CH

IP.

5 Al

thou

gh A

rizon

a’s

sepa

rate

CH

IP p

rogr

am u

p to

200

per

cent

FPL

(Kid

sCar

e) h

as b

een

clos

ed to

new

enr

ollm

ent s

ince

Jan

uary

201

0, th

ousa

nds

of c

hild

ren

wer

e ad

ded

to

the

stat

e’s

CHIP

-fund

ed c

over

age

thro

ugh

the

stat

e’s

Kids

Care

II w

aive

r, w

hich

was

in e

ffec

t fro

m M

ay 2

012

until

Jan

uary

201

4.6

Calif

orni

a ha

s a

sepa

rate

CH

IP p

rogr

am in

thre

e co

untie

s on

ly th

at c

over

s ch

ildre

n up

to 3

17 p

erce

nt F

PL.

7 Fl

orid

a’s

sepa

rate

CH

IP p

rogr

am c

over

s ch

ildre

n ag

e 1–

18.

8 In

Min

neso

ta, o

nly

infa

nts

(def

ined

by

the

stat

e as

bei

ng u

nder

age

2) a

re e

ligib

le fo

r the

Med

icai

d-ex

pans

ion

CHIP

pro

gram

.9

Nor

th C

arol

ina’

s se

para

te C

HIP

pro

gram

cov

ers

child

ren

age

6–18

.10

W

hile

Ten

ness

ee c

over

s ch

ildre

n w

ith C

HIP

-fund

ed M

edic

aid,

enr

ollm

ent i

s cu

rren

tly c

appe

d, e

xcep

t for

chi

ldre

n w

ho ro

ll ov

er fr

om tr

aditi

onal

Med

icai

d.

Sour

ces:

MAC

PAC,

201

5, a

naly

sis

of C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es (C

MS)

, 201

4, S

tate

Med

icai

d an

d CH

IP in

com

e el

igib

ility

sta

ndar

ds (F

or M

AGI G

roup

s, ba

sed

on s

tate

de

cisi

ons

as o

f Oct

ober

1, 2

014)

, htt

p://

ww

w.m

edic

aid.

gov/

med

icai

d-ch

ip-p

rogr

am-in

form

atio

n/pr

ogra

m-in

form

atio

n/do

wnl

oads

/med

icai

d-an

d-ch

ip-e

ligib

ility

-leve

ls-ta

ble.

pdf;

MAC

PAC,

201

5, a

naly

sis

of C

MS,

201

5, M

AGI c

onve

rsio

n pl

ans

and

SIPP

-bas

ed M

AGI c

onve

rsio

n re

sults

, htt

p://

ww

w.m

edic

aid.

gov/

med

icai

d-ch

ip-p

rogr

am-in

form

atio

n/by

-sta

te/b

y-st

ate.

htm

l; M

ACPA

C, 2

015,

ana

lysi

s of

CM

S, 2

015,

Med

icai

d st

ate

plan

am

endm

ents

, htt

p://

ww

w.m

edic

aid.

gov/

stat

e-re

sour

ce-c

ente

r/m

edic

aid-

stat

e-pl

an-

amen

dmen

ts/m

edic

aid-

stat

e-pl

an-a

men

dmen

ts.h

tml;

MAC

PAC,

201

5, a

naly

sis

of C

MS,

201

5, C

HIP

sta

te p

lan

amen

dmen

ts, h

ttp:

//w

ww

.med

icai

d.go

v/ch

ip/s

tate

-pro

gram

-in

form

atio

n/ch

ip-s

tate

-pro

gram

-info

rmat

ion.

htm

l; M

ACPA

C, 2

015,

ana

lysi

s of

CM

S, 2

015,

Chi

ldre

n’s

Hea

lth In

sura

nce

Prog

ram

: Pla

n ac

tivity

as

of M

ay 1

, 201

5, h

ttp:

//w

ww

.m

edic

aid.

gov/

chip

/dow

nloa

ds/c

hip-

map

.pdf

; MAC

PAC,

201

5, a

naly

sis

of s

tate

web

site

s; a

nd M

ACPA

C, 2

015,

ana

lysi

s of

CM

S, 2

015,

em

ail t

o M

ACPA

C st

aff,

Oct

ober

29.

Page 106: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201594

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

sSe

ctio

n 4

EXH

IBIT

35.

Med

icai

d In

com

e El

igib

ility

Lev

els

as a

Per

cent

age

of th

e FP

L fo

r Non

-Age

d, N

on-D

isab

led,

Non

-Pre

gnan

t Adu

lts b

y St

ate,

Sep

tem

ber 2

015

Stat

ePa

rent

s an

d ca

reta

ker r

elat

ives

of

dep

ende

nt c

hild

ren1

Addi

tiona

l ind

ivid

uals

age

19–

642

Alab

ama

13%

–Al

aska

143

133%

(143

onl

y fo

r tho

se a

ge 1

9–20

)Ar

izon

a10

613

3Ar

kans

as17

133

Calif

orni

a10

913

3Co

lora

do68

133

Conn

ectic

ut15

013

3De

law

are

8713

3Di

stric

t of C

olum

bia

216

210

(216

onl

y fo

r tho

se a

ge 1

9–20

)Fl

orid

a29

29 o

nly

for t

hose

age

19–

20G

eorg

ia34

–H

awai

i10

513

3Id

aho

243

–4

Illin

ois

133

133

Indi

ana

1913

3Io

wa

5413

3Ka

nsas

33–

Kent

ucky

2313

3Lo

uisi

ana

193

–4

Mai

ne10

015

6 on

ly fo

r tho

se a

ge 1

9–20

4

Mar

ylan

d12

313

3M

assa

chus

etts

133

133

(150

onl

y fo

r tho

se a

ge 1

9–20

)M

ichi

gan

5413

3M

inne

sota

1335

1335

Mis

siss

ippi

23–

Mis

sour

i18

3–

4

Mon

tana

46–

4

Neb

rask

a58

–N

evad

a33

133

Page 107: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 95

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

sSe

ctio

n 4

Stat

ePa

rent

s an

d ca

reta

ker r

elat

ives

of

dep

ende

nt c

hild

ren1

Addi

tiona

l ind

ivid

uals

age

19–

642

New

Ham

pshi

re68

%13

3%N

ew J

erse

y32

133

New

Mex

ico

4613

3N

ew Y

ork

133

133

Nor

th C

arol

ina

4444

onl

y fo

r tho

se a

ge 1

9–20

Nor

th D

akot

a53

133

Ohi

o90

133

Okl

ahom

a42

3–

4

Ore

gon

4113

3Pe

nnsy

lvan

ia33

133

Rhod

e Is

land

116

133

Sout

h Ca

rolin

a62

–So

uth

Dako

ta57

–Te

nnes

see

104

–Te

xas

15–

Uta

h45

3–

4

Verm

ont

5313

3Vi

rgin

ia49

–W

ashi

ngto

n40

133

Wes

t Virg

inia

1913

3W

isco

nsin

9595

Wyo

min

g56

Not

es: F

PL is

fede

ral p

over

ty le

vel.

In 2

015,

100

per

cent

FPL

is $

11,7

70 fo

r an

indi

vidu

al p

lus

$4,1

60 fo

r eac

h ad

ditio

nal f

amily

mem

ber i

n th

e lo

wer

48

stat

es a

nd th

e Di

stric

t of

Col

umbi

a. W

hen

dete

rmin

ing

Med

icai

d an

d CH

IP e

ligib

ility

prio

r to

2014

, sta

tes

had

the

flexi

bilit

y to

dis

rega

rd in

com

e so

urce

s an

d am

ount

s of

thei

r cho

osin

g. B

egin

ning

in

201

4, u

nifo

rm m

odifi

ed a

djus

ted

gros

s in

com

e (M

AGI)

rule

s m

ust b

e us

ed to

det

erm

ine

Med

icai

d an

d CH

IP e

ligib

ility

for m

ost n

on-d

isab

led

child

ren

and

adul

ts u

nder

age

65

, inc

ludi

ng th

e gr

oups

sho

wn

in th

is ta

ble.

As

a re

sult,

sta

tes

are

now

requ

ired

to u

se M

AGI-c

onve

rted

elig

ibili

ty le

vels

that

acc

ount

for t

he c

hang

e in

inco

me-

coun

ting

rule

s.

The

elig

ibili

ty le

vels

sho

wn

in th

is ta

ble

refle

ct th

ese

MAG

I-con

vert

ed le

vels

or a

noth

er M

AGI-b

ased

inco

me

limit

in e

ffec

t in

each

sta

te fo

r the

se g

roup

s as

of S

epte

mbe

r 20

15. U

nder

fede

ral r

egul

atio

ns, t

he e

ffec

tive

inco

me

limits

may

be

high

er b

y 5

perc

enta

ge p

oint

s of

the

FPL

than

thos

e sh

own

on th

is ta

ble

to a

ccou

nt fo

r a g

ener

al in

com

e di

sreg

ard

that

app

lies

to a

n in

divi

dual

’s d

eter

min

atio

n of

elig

ibili

ty fo

r Med

icai

d an

d CH

IP o

vera

ll, ra

ther

than

for p

artic

ular

elig

ibili

ty g

roup

s w

ithin

Med

icai

d or

CH

IP.

EXH

IBIT

35.

(co

ntin

ued)

Page 108: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201596

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

s

Stat

es a

re re

quire

d to

pro

vide

Med

icai

d co

vera

ge fo

r par

ents

and

oth

er c

aret

aker

rela

tives

(and

thei

r dep

ende

nt c

hild

ren)

, at a

min

imum

, at t

heir

1988

Aid

to F

amili

es w

ith

Depe

nden

t Chi

ldre

n (A

FDC)

elig

ibili

ty le

vels

. Und

er re

gula

r Med

icai

d st

ate

plan

rule

s, s

tate

s m

ay o

pt to

cov

er a

dditi

onal

par

ents

and

car

etak

er re

lativ

es; c

hild

ren

age

19 o

r 20;

an

d ot

her i

ndiv

idua

ls a

ged

19–

64 w

ho a

re n

ot p

regn

ant,

not e

ligib

le fo

r Med

icar

e, a

nd h

ave

inco

mes

at o

r bel

ow 1

33 p

erce

nt o

f the

fede

ral p

over

ty le

vel.

Stat

es m

ay a

lso

prov

ide

cove

rage

und

er S

ectio

n 11

15 w

aive

rs, w

hich

allo

w th

em to

ope

rate

thei

r Med

icai

d pr

ogra

ms

with

out r

egar

d to

cer

tain

sta

tuto

ry re

quire

men

ts. A

s no

ted

in th

is ta

ble,

the

cove

red

bene

fits

unde

r the

se w

aive

rs m

ay b

e m

ore

limite

d th

an th

ose

prov

ided

und

er re

gula

r sta

te p

lan

rule

s an

d m

ay n

ot b

e av

aila

ble

to a

ll in

divi

dual

s at

the

inco

me

leve

ls s

how

n.1

In s

tate

s th

at u

se d

olla

r am

ount

s ra

ther

than

per

cent

ages

of t

he F

PL to

det

erm

ine

elig

ibili

ty fo

r par

ents

, tho

se a

mou

nts

wer

e co

nver

ted

to a

per

cent

of t

he F

PL fo

r 201

5, a

nd

the

high

est p

erce

ntag

e w

as s

elec

ted

to re

flect

elig

ibili

ty le

vel f

or th

e gr

oup.

2 Re

flect

s st

ate

plan

cov

erag

e un

der S

ectio

n 19

02(a

)(10

)(A)

(i)(V

III) o

f the

Soc

ial S

ecur

ity A

ct fo

r ind

ivid

uals

who

are

age

19–

64, n

ot p

regn

ant,

not e

ligib

le fo

r Med

icar

e, a

nd

have

inco

me

at o

r bel

ow 1

33 p

erce

nt F

PL; s

tate

pla

n co

vera

ge fo

r chi

ldre

n ag

e 19

or 2

0 w

here

indi

cate

d; a

nd S

ectio

n 11

15 w

aive

r cov

erag

e th

at is

not

sub

ject

to th

e lim

itatio

ns

indi

cate

d in

not

e 4.

3 Re

flect

s pa

rent

cov

erag

e un

der t

he M

edic

aid

stat

e pl

an. T

he s

tate

has

som

e ad

ditio

nal c

over

age

abov

e st

ate

plan

elig

ibili

ty s

tand

ards

thro

ugh

a Se

ctio

n 11

15 d

emon

stra

tion

or a

pen

ding

dem

onst

ratio

n pr

opos

al. T

he d

emon

stra

tion

incl

udes

lim

itatio

ns o

n el

igib

ility

or b

enef

its, i

s no

t off

ered

to a

ll re

side

nts

of th

e st

ate,

or i

nclu

des

an e

nrol

lmen

t cap

.4

The

stat

e ha

s a

Sect

ion

1115

dem

onst

ratio

n or

a p

endi

ng d

emon

stra

tion

prop

osal

that

pro

vide

s M

edic

aid

cove

rage

to s

ome

low

-inco

me

adul

ts. T

he d

emon

stra

tion

incl

udes

lim

itatio

ns o

n el

igib

ility

or b

enef

its, i

s no

t off

ered

to a

ll re

side

nts

of th

e st

ate,

or i

nclu

des

an e

nrol

lmen

t cap

.5

Min

neso

ta im

plem

ente

d a

Basi

c H

ealth

Pro

gram

(BH

P) in

Jan

uary

201

5. In

divi

dual

s w

ith in

com

es b

etw

een

133

and

200

perc

ent F

PL w

ho w

ere

prev

ious

ly c

over

ed u

nder

a

Med

icai

d Se

ctio

n 11

15 w

aive

r are

now

cov

ered

und

er th

e BH

P.

Sour

ces:

MAC

PAC,

201

5, a

naly

sis

of C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es (C

MS)

, 201

4, S

tate

Med

icai

d an

d CH

IP in

com

e el

igib

ility

sta

ndar

ds (F

or M

AGI G

roup

s, b

ased

on

stat

e de

cisi

ons

as o

f Oct

ober

1, 2

014)

, htt

p://

ww

w.m

edic

aid.

gov/

med

icai

d-ch

ip-p

rogr

am-in

form

atio

n/pr

ogra

m-in

form

atio

n/do

wnl

oads

/med

icai

d-an

d-ch

ip-e

ligib

ility

-leve

ls-ta

ble.

pdf;

MAC

PAC,

201

5, a

naly

sis

of C

MS,

201

5, M

edic

aid

stat

e pl

an a

men

dmen

ts, h

ttp:

//w

ww

.med

icai

d.go

v/st

ate-

reso

urce

-cen

ter/

med

icai

d-st

ate-

plan

-am

endm

ents

/med

icai

d-st

ate-

plan

-am

endm

ents

.htm

l; M

ACPA

C, 2

015,

ana

lysi

s of

sta

te w

ebsi

tes;

and

MAC

PAC,

201

5, a

naly

sis

of C

MS,

201

5, e

mai

l to

MAC

PAC

staf

f, O

ctob

er 2

9, 2

015.

EXH

IBIT

35.

(co

ntin

ued)

Sect

ion

4

Page 109: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 97

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

s

Stat

eSt

ate

elig

ibili

ty

type

1SS

I rec

ipie

nts

209(

b) e

ligib

ility

Pove

rty

leve

l2M

edic

ally

nee

dy3

Spec

ial i

ncom

e le

vel4

Alab

ama

1634

75%

––

–22

4%Al

aska

SSI c

riter

ia60

5–

––

179

Ariz

ona

1634

75–

100%

–22

4Ar

kans

as16

3475

–80

(age

d on

ly)

11%

224

Calif

orni

a16

3475

–10

061

–Co

lora

do16

3475

––

–22

4Co

nnec

ticut

209(

b)–

62%

–62

224

Dela

war

e16

3475

––

–18

7Di

stric

t of C

olum

bia

1634

75–

100

6422

4Fl

orid

a16

3475

–88

1822

4G

eorg

ia16

3475

––

3222

4H

awai

i20

9(b)

–65

100

42–

Idah

oSS

I crit

eria

75–

––

224

Illin

ois

209(

b)–

100

100

100

–In

dian

a616

3475

–10

0–

224

Iow

a16

3475

––

4922

4Ka

nsas

SSI c

riter

ia75

––

4822

4Ke

ntuc

ky16

3475

––

2222

4Lo

uisi

ana

1634

75–

7510

224

Mai

ne16

3475

–10

032

224

Mar

ylan

d16

3475

––

3622

4

Mas

sach

uset

ts7

1634

75–

100

(age

d)/

133

(dis

able

d)53

224

Mic

higa

n16

3475

–10

042

224

Min

neso

ta20

9(b)

–75

100

7522

4M

issi

ssip

pi16

3475

––

–22

4M

isso

uri

209(

b)–

8585

8513

1M

onta

na16

3475

––

64–

Neb

rask

aSS

I crit

eria

75–

100

40–

Nev

ada

SSI c

riter

ia75

––

–22

4

EXH

IBIT

36.

Med

icai

d In

com

e El

igib

ility

Lev

els

as a

Per

cent

age

of th

e FP

L fo

r Ind

ivid

uals

Age

65

and

Old

er a

nd P

erso

ns w

ith

Disa

bilit

ies

by S

tate

, 201

5

Sect

ion

4

Page 110: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 201598

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

sSe

ctio

n 4

EXH

IBIT

36.

(co

ntin

ued)

Stat

eSt

ate

elig

ibili

ty

type

1SS

I rec

ipie

nts

209(

b) e

ligib

ility

Pove

rty

leve

l2M

edic

ally

nee

dy3

Spec

ial i

ncom

e le

vel4

New

Ham

pshi

re20

9(b)

–76

%–

60%

224%

New

Jer

sey

1634

75%

–10

0%37

224

New

Mex

ico

1634

75–

––

224

New

Yor

k16

3475

–84

84–

Nor

th C

arol

ina

1634

75–

100

25–

Nor

th D

akot

a20

9(b)

–83

–83

–O

hio

209(

b)–

64–

6422

4O

klah

oma6

SSI c

riter

ia75

–10

0–

224

Ore

gon

SSI c

riter

ia75

––

–22

4Pe

nnsy

lvan

ia16

3475

–10

043

224

Rhod

e Is

land

1634

75–

100

8722

4So

uth

Caro

lina

1634

75–

100

–22

4So

uth

Dako

ta16

3475

––

–22

4Te

nnes

see

1634

75–

––

224

Texa

s16

3475

––

–22

4U

tah

SSI c

riter

ia75

–10

010

022

4Ve

rmon

t16

3475

––

110

224

Virg

inia

209(

b)–

7580

4722

4W

ashi

ngto

n16

3475

––

7522

4W

est V

irgin

ia16

3475

––

2022

4W

isco

nsin

1634

75–

–60

224

Wyo

min

g16

3475

––

–22

4

Not

es: F

PL is

fede

ral p

over

ty le

vel.

SSI i

s Su

pple

men

tal S

ecur

ity In

com

e. In

201

5, 1

00 p

erce

nt F

PL is

$11

,770

for a

n in

divi

dual

and

$4,

160

for e

ach

addi

tiona

l fam

ily m

embe

r in

the

low

er 4

8 st

ates

and

the

Dist

rict o

f Col

umbi

a. E

ligib

ility

leve

ls s

how

n he

re a

pply

to c

ount

able

inco

me;

as

a re

sult,

sta

tes

that

use

opt

iona

l inc

ome

disr

egar

ds to

redu

ce

coun

tabl

e in

com

e ef

fect

ivel

y al

low

a la

rger

num

ber o

f peo

ple

to q

ualif

y at

a g

iven

elig

ibili

ty le

vel (

e.g.

, 100

per

cent

FPL

) rel

ativ

e to

sta

tes

that

do

not.

The

elig

ibili

ty le

vels

list

ed

in th

is e

xhib

it ar

e fo

r ind

ivid

uals

; the

elig

ibili

ty le

vels

for c

oupl

es d

iffer

for c

erta

in c

ateg

orie

s. In

add

ition

, inc

ome

elig

ibili

ty le

vels

for i

ndiv

idua

ls w

ho q

ualif

y ba

sed

on b

lindn

ess

may

be

high

er th

an fo

r ind

ivid

uals

who

qua

lify

base

d on

oth

er d

isab

ilitie

s or

bei

ng a

ge 6

5 or

old

er.

In m

ost s

tate

s, e

nrol

lmen

t in

the

SSI p

rogr

am fo

r ind

ivid

uals

age

65

and

olde

r and

per

sons

with

dis

abili

ties

auto

mat

ical

ly q

ualif

ies

them

for M

edic

aid.

How

ever

, 209

(b) s

tate

s m

ay u

se m

ore

rest

rictiv

e cr

iteria

(rel

ated

to in

com

e an

d as

sets

, dis

abili

ty, o

r bot

h) th

an S

SI w

hen

dete

rmin

ing

Med

icai

d el

igib

ility

. All

stat

es h

ave

the

optio

n of

cov

erin

g ad

ditio

nal p

eopl

e w

ith lo

w in

com

es o

r hig

h m

edic

al e

xpen

ses

thro

ugh

othe

r elig

ibili

ty p

athw

ays,

suc

h as

pov

erty

leve

l, m

edic

ally

nee

dy, a

nd s

peci

al in

com

e le

vel.

Page 111: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 99

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

sSe

ctio

n 4

– D

ash

indi

cate

s th

at s

tate

doe

s no

t use

this

elig

ibili

ty p

athw

ay.

1 SS

I crit

eria

are

use

d to

det

erm

ine

Med

icai

d el

igib

ility

in b

oth

Sect

ion

1634

and

SSI

-crit

eria

sta

tes.

In S

ectio

n 16

34 s

tate

s, th

e fe

dera

l elig

ibili

ty d

eter

min

atio

n pr

oces

s fo

r SSI

au

tom

atic

ally

qua

lifie

s an

indi

vidu

al fo

r Med

icai

d; in

SSI

-crit

eria

sta

tes,

indi

vidu

als

mus

t sub

mit

info

rmat

ion

to th

e st

ate

for a

sep

arat

e el

igib

ility

det

erm

inat

ion.

Sec

tion

209(

b)

stat

es m

ay u

se e

ligib

ility

crit

eria

(rel

ated

to in

com

e an

d as

sets

, dis

abili

ty, o

r bot

h) m

ore

rest

rictiv

e th

an th

e SS

I pro

gram

but

may

not

use

mor

e re

stric

tive

crite

ria th

an th

ose

in e

ffec

t in

the

stat

e on

Jan

uary

1, 1

972.

If a

Sec

tion

209(

b) s

tate

doe

s no

t hav

e a

sepa

rate

med

ical

ly n

eedy

sta

ndar

d, it

mus

t allo

w in

divi

dual

s w

ith h

ighe

r inc

omes

to s

pend

do

wn

to th

e 20

9(b)

inco

me

leve

l sho

wn

here

by

dedu

ctin

g in

curr

ed m

edic

al e

xpen

ses

from

the

amou

nt o

f inc

ome

that

is c

ount

ed fo

r Med

icai

d el

igib

ility

pur

pose

s.2

Und

er th

e po

vert

y le

vel o

ptio

n, s

tate

s m

ay c

hoos

e to

pro

vide

Med

icai

d co

vera

ge to

per

sons

who

are

age

d or

dis

able

d an

d w

hose

inco

me

is a

bove

the

SSI o

r 209

(b) l

evel

, but

is

at o

r bel

ow th

e FP

L.3

Und

er th

e m

edic

ally

nee

dy o

ptio

n, in

divi

dual

s w

ith h

ighe

r inc

omes

can

spe

nd d

own

to th

e m

edic

ally

nee

dy in

com

e le

vel s

how

n he

re b

y de

duct

ing

incu

rred

med

ical

exp

ense

s fr

om th

e am

ount

of i

ncom

e th

at is

cou

nted

for M

edic

aid

elig

ibili

ty p

urpo

ses.

Fiv

e st

ates

(Con

nect

icut

, Lou

isia

na, M

ichi

gan,

Ver

mon

t, an

d Vi

rgin

ia) h

ave

a m

edic

ally

nee

dy

inco

me

stan

dard

that

var

ies

by lo

catio

n; th

e hi

ghes

t inc

ome

stan

dard

is li

sted

for e

ach

of th

ese

stat

es.

4 U

nder

the

spec

ial i

ncom

e le

vel o

ptio

n, s

tate

s ha

ve th

e op

tion

to p

rovi

de M

edic

aid

bene

fits

to p

eopl

e w

ho re

quire

at l

east

30

days

of n

ursi

ng h

ome

or o

ther

inst

itutio

nal c

are

and

have

inco

mes

up

to 3

00 p

erce

nt o

f the

SSI

ben

efit

rate

(whi

ch w

as a

bout

224

per

cent

FPL

in 2

015)

. The

inco

me

stan

dard

list

ed in

this

col

umn

may

be

for i

nstit

utio

nal

serv

ices

, hom

e an

d co

mm

unity

-bas

ed w

aive

r ser

vice

s, o

r bot

h.5

The

dolla

r am

ount

that

equ

als

the

uppe

r inc

ome

elig

ibili

ty le

vel f

or S

SI d

oes

not v

ary

by s

tate

; how

ever

, the

dol

lar a

mou

nt th

at e

qual

s th

e FP

L is

hig

her i

n Al

aska

, res

ultin

g in

a

low

er p

erce

ntag

e.6

Indi

ana

was

a 2

09(b

) sta

te u

ntil

June

1, 2

014,

at w

hich

poi

nt it

bec

ame

a 16

34 s

tate

; the

sta

te’s

pov

erty

leve

l gro

up a

lso

took

eff

ect o

n Ju

ne 1

, 201

4. O

klah

oma

was

a 2

09(b

) st

ate

until

Oct

ober

1, 2

015,

at w

hich

poi

nt it

bec

ame

an S

SI-c

riter

ia s

tate

.7

Mas

sach

uset

ts p

rovi

des

med

ical

ly n

eedy

cov

erag

e fo

r ind

ivid

uals

age

65

and

olde

r and

thos

e w

ho a

re e

ligib

le o

n th

e ba

sis

of d

isab

ility

, but

the

rule

s fo

r cou

ntin

g in

com

e an

d sp

end-

dow

n ex

pens

es v

ary

for t

hese

gro

ups.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

elig

ibili

ty in

form

atio

n fr

om s

tate

web

site

s an

d M

edic

aid

stat

e pl

ans

as o

f Jul

y 20

15.

EXH

IBIT

36.

(co

ntin

ued)

Page 112: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015100

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

s

Stat

eFP

L

Annu

al a

mou

ntM

onth

ly a

mou

nt

Fam

ily s

ize

Fam

ily s

ize

12

34

Each

ad

ditio

nal

pers

on1

23

4

Each

ad

ditio

nal

pers

on

Low

er 4

8 st

ates

an

d DC

100%

$11,

770

$15,

930

$20,

090

$24,

250

$4,1

60$9

81$1

,328

$1,6

74$2

,021

$347

133

15,6

5421

,187

26,7

2032

,253

5,53

31,

305

1,76

62,

227

2,68

846

1

138

16,2

4321

,983

27,7

2433

,465

5,74

11,

354

1,83

22,

310

2,78

947

8

150

17,6

5523

,895

30,1

3536

,375

6,24

01,

471

1,99

12,

511

3,03

152

0

185

21,7

7529

,471

37,1

6744

,863

7,69

61,

815

2,45

63,

097

3,73

964

1

200

23,5

4031

,860

40,1

8048

,500

8,32

01,

962

2,65

53,

348

4,04

269

3

250

29,4

2539

,825

50,2

2560

,625

10,4

002,

452

3,31

94,

185

5,05

286

7

300

35,3

1047

,790

60,2

7072

,750

12,4

802,

943

3,98

35,

023

6,06

31,

040

400

47,0

8063

,720

80,3

6097

,000

16,6

403,

923

5,31

06,

697

8,08

31,

387

Alas

ka10

0%$1

4,72

0$1

9,92

0$2

5,12

0$3

0,32

0$5

,200

$1,2

27$1

,660

$2,0

93$2

,527

$433

133

19,5

7826

,494

33,4

1040

,326

6,91

61,

631

2,20

82,

784

3,36

057

6

138

20,3

1427

,490

34,6

6641

,842

7,17

61,

693

2,29

12,

889

3,48

759

8

150

22,0

8029

,880

37,6

8045

,480

7,80

01,

840

2,49

03,

140

3,79

065

0

185

27,2

3236

,852

46,4

7256

,092

9,62

02,

269

3,07

13,

873

4,67

480

2

200

29,4

4039

,840

50,2

4060

,640

10,4

002,

453

3,32

04,

187

5,05

386

7

250

36,8

0049

,800

62,8

0075

,800

13,0

003,

067

4,15

05,

233

6,31

71,

083

300

44,1

6059

,760

75,3

6090

,960

15,6

003,

680

4,98

06,

280

7,58

01,

300

400

58,8

8079

,680

100,

480

121,

280

20,8

004,

907

6,64

08,

373

10,1

071,

733

EXH

IBIT

37.

Inc

ome

as a

Per

cent

age

of th

e FP

L fo

r Var

ious

Fam

ily S

izes

, 201

5

Sect

ion

4

Page 113: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 101

Section 4: Medicaid and CHIP Eligibility

MAC

Stat

s

Stat

eFP

L

Annu

al a

mou

ntM

onth

ly a

mou

nt

Fam

ily s

ize

Fam

ily s

ize

12

34

Each

ad

ditio

nal

pers

on1

23

4

Each

ad

ditio

nal

pers

on

Haw

aii

100%

$13,

550

$18,

330

$23,

110

$27,

890

$4,7

80$1

,129

$1,5

28$1

,926

$2,3

24$3

98

133

18,0

2224

,379

30,7

3637

,094

6,35

71,

502

2,03

22,

561

3,09

153

0

138

18,6

9925

,295

31,8

9238

,488

6,59

61,

558

2,10

82,

658

3,20

755

0

150

20,3

2527

,495

34,6

6541

,835

7,17

01,

694

2,29

12,

889

3,48

659

8

185

25,0

6833

,911

42,7

5451

,597

8,84

32,

089

2,82

63,

563

4,30

073

7

200

27,1

0036

,660

46,2

2055

,780

9,56

02,

258

3,05

53,

852

4,64

879

7

250

33,8

7545

,825

57,7

7569

,725

11,9

502,

823

3,81

94,

815

5,81

099

6

300

40,6

5054

,990

69,3

3083

,670

14,3

403,

388

4,58

35,

778

6,97

31,

195

400

54,2

0073

,320

92,4

4011

1,56

019

,120

4,51

76,

110

7,70

39,

297

1,59

3

Not

es: F

PL is

fede

ral p

over

ty le

vel.

The

FPLs

sho

wn

here

are

bas

ed o

n th

e U

.S. D

epar

tmen

t of H

ealth

and

Hum

an S

ervi

ces

2015

fede

ral p

over

ty g

uide

lines

. The

se d

iffer

slig

htly

fr

om th

e U

.S. C

ensu

s Bu

reau

’s fe

dera

l pov

erty

thre

shol

ds, w

hich

are

use

d m

ainl

y fo

r sta

tistic

al p

urpo

ses.

The

sep

arat

e po

vert

y gu

idel

ines

for A

lask

a an

d H

awai

i ref

lect

Off

ice

of E

cono

mic

Opp

ortu

nity

adm

inis

trat

ive

prac

tice

begi

nnin

g in

the

1966

–19

70 p

erio

d.

Sour

ce: U

.S. D

epar

tmen

t of H

ealth

and

Hum

an S

ervi

ces

(HH

S), 2

015,

Ann

ual u

pdat

e of

the

HH

S po

vert

y gu

idel

ines

, Fed

eral

Reg

iste

r 80,

no.

14

(Jan

uary

22)

: 323

7.

EXH

IBIT

37.

(co

ntin

ued)

Sect

ion

4

Page 114: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn
Page 115: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

SECTION 5

Beneficiary Health, Service Use, and Access to Care

Page 116: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015104

Section 5: Beneficiary Health, Service Use, and Access to Care

Section 5: Beneficiary Health, Service Use, and Access to Care

Key Points• Children whose primary coverage source is Medicaid or CHIP report being in poorer health

than those who have private coverage or are uninsured (Exhibit 38). However, their use of services relative to other groups varies depending on the type of care and data source. For example, both National Health Interview Survey (NHIS) and Medical Expenditures Panel Survey (MEPS) data indicate that children with Medicaid or CHIP are less likely than those with private coverage and more likely than those who are uninsured to have seen a dentist in the last 12 months. However, the percentage of children with Medicaid or CHIP reported as having seen a dentist differs substantially between the NHIS (77.0 percent in 2014) and MEPS (41.5 percent in 2013), with similar differences observed for children who have private coverage or are uninsured (Exhibits 39 and 40).

• As with children, adults age 19–64 whose primary coverage source is Medicaid or CHIP generally report being in poorer health, and comparisons of their service use relative to other groups varies by data source. Those whose primary coverage source is Medicare, who must meet federal disability criteria to receive coverage, report the poorest health and highest service use among adults age 19–64 (Exhibits 42–44).

• Children whose primary coverage source is Medicaid or CHIP report having seen a general doctor or had a well-child checkup at rates similar to those with private coverage. However, they are more likely to have had trouble finding a doctor or delayed care than those with private coverage; reports of unmet need due to cost vary depending on the type of care in question (Exhibit 41). Relative to those with private coverage, adults age 19–64 with Medicaid report having a usual source of care at a similar rate, but are more likely to report having difficulties with access to care. Among adults age 19–64, those whose primary coverage source is Medicare report the highest rates of delayed care and unmet need due to cost (Exhibit 45).

• The measures reported in Exhibits 38–45 should be interpreted with caution due to the limitations of survey data, and the characteristics of the populations examined. For example, the results shown are unadjusted for differences in age, health, income, race, ethnicity, and family and household characteristics that are known to explain some of the differences in access and use observed between individuals with different coverage sources. In addition, Exhibits 38–45 reflect an individual’s primary payer of care because those with multiple coverage sources are assigned to a single source based on a hierarchy. For selected characteristics of individuals without the application of this hierarchy, see Exhibit 2. For information on individuals who are dually eligible for Medicare and Medicaid, see the latest joint data book published by MACPAC and the Medicare Payment Advisory Commission (MedPAC).

Page 117: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 105

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%53

.5%

37.6

%5.

6%Co

vera

geLe

ngth

of t

ime

with

any

cov

erag

e du

ring

the

year

Full

year

90.8

*96

.9*

93.9

Part

yea

r6.

1 3.

1*6.

139

.6*

No

cove

rage

dur

ing

year

3.2

–60

.4

Dem

ogra

phic

sAg

e0–

530

.9*

28.4

*35

.622

.1*

6–11

31.3

31

.0

31.8

29.5

12

–18

37.8

*40

.6*

32.6

48.4

*G

ende

rM

ale

51.1

51

.1

50.6

54.2

Fe

mal

e48

.9

48.9

49

.445

.8

Race

His

pani

c24

.3*

14.3

*36

.342

.8*

Whi

te, n

on-H

ispa

nic

54.1

*68

.3*

35.6

39.4

Bl

ack,

non

-His

pani

c15

.3*

10.1

*23

.310

.7*

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er n

on-w

hite

, non

-His

pani

c6.

3*

7.3

*4.

87.

1

Pare

nts

pres

ent i

n fa

mily

Mot

her,

no fa

ther

24.0

*13

.7*

39.0

23.4

*Fa

ther

, no

mot

her

3.9

3.

6

4.3

5.3

Bo

th p

rese

nt68

.4*

81.0

*50

.865

.8*

No

pare

nts

3.6

*1.

7*

6.0

5.6

Fa

mily

inco

me

Has

inco

me

less

than

138

per

cent

FPL

32.9

*7.

2*

69.1

41.9

*H

as in

com

e in

rang

es s

how

n be

low

Less

than

100

per

cent

FPL

22.7

*3.

9*50

.125

.1*

100–

299

perc

ent F

PL23

.0*

12.7

*34

.838

.930

0–39

9 pe

rcen

t FPL

27.9

*38

.1*

12.8

28.0

*40

0 pe

rcen

t FPL

or h

ighe

r26

.3*

45.3

*2.

37.

9*

EXH

IBIT

38.

Cov

erag

e, D

emog

raph

ic, a

nd H

ealth

Cha

ract

eris

tics

of N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

0–18

by

Prim

ary

Sour

ce

of H

ealth

Cov

erag

e, 2

014

Page 118: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015106

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

EXH

IBIT

38.

(co

ntin

ued)

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Oth

er d

emog

raph

ic c

hara

cter

istic

sCi

tizen

of U

nite

d St

ates

97.4

%98

.7%

*97

.5%

84.6

%*

Rece

ives

SSI

61.

5*0.

6*3.

00.

3*Fa

mily

rece

ives

WIC

7.6*

1.8*

16.3

5.1*

Hea

lthCu

rren

t hea

lth s

tatu

sEx

celle

nt o

r ver

y go

od84

.5*

89.9

*77

.280

.2

Goo

d13

.8*

9.1*

20.0

17.7

Fa

ir or

poo

r1.

7*1.

0*2.

82.

2 BM

I7

Hea

lthy

wei

ght (

BMI l

ess

than

25)

77.6

*81

.8*

72.7

65.2

O

verw

eigh

t (BM

I 25–

29)

14.1

11

.6*

16.8

22.7

O

bese

(BM

I 30

or h

ighe

r)8.

3 6.

6*10

.512

.1

Spec

ial n

eeds

, im

pairm

ents

, and

hea

lth c

ondi

tions

Has

spe

cial

hea

lth c

are

need

s814

.4*

12.2

*18

.29.

8*Re

ceiv

es s

peci

al e

duca

tion

or e

arly

inte

rven

tion

serv

ices

7.2*

5.7*

9.1

5.5*

Has

impa

irmen

t req

uirin

g sp

ecia

l equ

ipm

ent

1.3

1.3

1.5

†H

as im

pairm

ent l

imiti

ng a

bilit

y to

cra

wl, w

alk,

run,

or p

lay9

1.6

1.3*

2.0

†H

as im

pairm

ent l

imiti

ng a

bilit

y to

cra

wl,

wal

k, ru

n, o

r pl

ay th

at is

exp

ecte

d to

last

12+

mon

ths9

1.3

1.1*

1.8

Ever

bee

n to

ld h

e or

she

has

sel

ecte

d co

nditi

ons

ADH

D/AD

D108.

4*6.

8*11

.14.

2*As

thm

a13

.5*

12.4

*15

.411

.9

Autis

m9

2.2

2.1

2.3

† Ce

rebr

al p

alsy

90.

3 †

0.4

† Co

ngen

ital h

eart

dis

ease

1.0

0.9

1.0

† Di

abet

es0.

1 †

0.2

† Do

wn

synd

rom

e90.

2 †

0.1

† In

telle

ctua

l dis

abili

ty (m

enta

l ret

arda

tion)

91.

0 0.

8 1.

2†

Oth

er d

evel

opm

enta

l del

ay9

3.3

2.8*

3.8

2.3*

Page 119: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 107

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

EXH

IBIT

38.

(co

ntin

ued)

Not

es: F

PL is

fede

ral p

over

ty le

vel.

SSI i

s Su

pple

men

tal S

ecur

ity In

com

e. W

IC is

Sup

plem

enta

l Nut

ritio

n Pr

ogra

m fo

r Wom

en, I

nfan

ts, a

nd C

hild

ren.

BM

I is

body

mas

s in

dex.

ADH

D is

att

entio

n de

ficit

hype

ract

ivity

dis

orde

r. AD

D is

att

entio

n de

ficit

diso

rder

. Per

cent

age

calc

ulat

ions

for e

ach

item

in th

e ex

hibi

t exc

lude

indi

vidu

als

with

mis

sing

and

unk

now

n va

lues

. Sta

ndar

d er

rors

are

ava

ilabl

e on

line

in d

ownl

oada

ble

Exce

l file

s at

htt

ps:/

/ww

w.m

acpa

c.go

v/m

acst

ats/

heal

th-a

nd-o

ther

-cha

ract

eris

tics-

of-b

enef

icia

ries-

serv

ice-

use-

and-

acce

ss-to

-car

e/. D

ue to

diff

eren

ces

in m

etho

dolo

gy (s

uch

as th

e w

ordi

ng o

f que

stio

ns, l

engt

h of

reca

ll pe

riods

, and

pro

mpt

s or

pro

bes

used

to e

licit

resp

onse

s), e

stim

ates

ob

tain

ed fr

om d

iffer

ent s

urve

y da

ta s

ourc

es w

ill v

ary.

For

exa

mpl

e, th

e N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

) is

know

n to

pro

duce

hig

her e

stim

ates

of s

ervi

ce u

se th

an th

e M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

(MEP

S). F

or p

urpo

ses

of c

ompa

ring

grou

ps o

f ind

ivid

uals

(as

in th

is e

xhib

it), t

he N

HIS

pro

vide

s th

e m

ost r

ecen

t inf

orm

atio

n av

aila

ble.

For

ot

her p

urpo

ses,

suc

h as

mea

surin

g le

vels

of u

se re

lativ

e to

a p

artic

ular

ben

chm

ark

or g

oal,

it m

ay b

e ap

prop

riate

to c

onsu

lt es

timat

es fr

om M

EPS

or a

noth

er s

ourc

e.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

chi

ldre

n un

der a

ge 1

9, re

gard

less

of c

over

age

sour

ce. I

n th

is e

xhib

it, th

e fo

llow

ing

hier

arch

y w

as u

sed

to a

ssig

n in

divi

dual

s w

ith

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

: Med

icar

e, p

rivat

e, M

edic

aid/

CHIP

, oth

er, u

nins

ured

. Not

sep

arat

ely

show

n ar

e th

e es

timat

es fo

r tho

se c

over

ed b

y M

edic

are

(gen

eral

ly c

hild

ren

with

end

-sta

ge re

nal d

isea

se),

any

type

of m

ilita

ry h

ealth

pla

n, o

r oth

er g

over

nmen

t-spo

nsor

ed p

rogr

ams.

Cov

erag

e so

urce

is d

efin

ed a

s of

the

time

of th

e su

rvey

inte

rvie

w. S

ince

an

indi

vidu

al m

ay h

ave

mul

tiple

cov

erag

e so

urce

s or

cha

nges

ove

r tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

cha

ract

eris

tics

or e

xper

ienc

es

asso

ciat

ed w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

.4

Indi

vidu

als

wer

e de

fined

as

unin

sure

d if

they

did

not

hav

e an

y pr

ivat

e he

alth

insu

ranc

e, M

edic

aid,

CH

IP, M

edic

are,

sta

te- o

r oth

er g

over

nmen

t-spo

nsor

ed h

ealth

pla

n, o

r m

ilita

ry p

lan.

Indi

vidu

als

wer

e al

so d

efin

ed a

s un

insu

red

if th

ey h

ad o

nly

Indi

an H

ealth

Ser

vice

cov

erag

e or

had

onl

y a

priv

ate

plan

that

pai

d fo

r one

type

of s

ervi

ce, s

uch

as

acci

dent

s or

den

tal c

are.

5 Du

e to

the

fact

that

a h

iera

rchy

was

use

d in

this

exh

ibit

to a

ssig

n in

divi

dual

s w

ith m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce (s

ee n

ote

1), t

he M

edic

aid/

CHIP

pe

rcen

tage

s sh

own

in th

is ro

w e

xclu

de in

divi

dual

s w

ho a

lso

have

Med

icar

e (w

hich

is ra

re fo

r chi

ldre

n) o

r priv

ate

cove

rage

. Com

pone

nts

do n

ot s

um to

100

per

cent

bec

ause

no

t all

cove

rage

sou

rces

are

sho

wn.

6 Ch

arac

teris

tic is

list

ed u

nder

dem

ogra

phic

s be

caus

e lo

w in

com

e is

one

of t

he c

riter

ia fo

r SSI

elig

ibili

ty. H

owev

er, S

SI re

ceip

t is

also

an

indi

cato

r of d

isab

ility

. For

a c

hild

to

be e

ligib

le fo

r SSI

, he

or s

he m

ust h

ave

a m

edic

ally

det

erm

inab

le p

hysi

cal o

r men

tal i

mpa

irmen

t tha

t res

ults

in m

arke

d an

d se

vere

func

tiona

l lim

itatio

ns a

nd th

at is

gen

eral

ly

expe

cted

to la

st a

t lea

st 1

2 m

onth

s or

resu

lt in

dea

th.

7 Su

rvey

info

rmat

ion

is li

mite

d to

chi

ldre

n ag

e 2

or o

lder

.8

Due

in p

art t

o ch

ange

s in

the

2011

Nat

iona

l Hea

lth In

terv

iew

Sur

vey

(NH

IS) q

uest

ionn

aire

, the

def

initi

on o

f chi

ldre

n w

ith s

peci

al h

ealth

car

e ne

eds

diff

ers

slig

htly

from

the

defin

ition

MAC

PAC

used

in re

port

s be

fore

201

3. T

he d

efin

ition

app

lied

here

is b

ased

on

an a

ppro

ach

deve

lope

d by

the

Child

and

Ado

lesc

ent H

ealth

Mea

sure

men

t Ini

tiativ

e (C

AHM

I) to

iden

tify

“chi

ldre

n w

ith c

hron

ic c

ondi

tions

and

ele

vate

d se

rvic

e us

e or

nee

d” in

the

2007

NH

IS a

nd o

ther

prio

r res

earc

h. (S

ee C

AMH

I, 20

12, I

dent

ifyin

g ch

ildre

n w

ith

chro

nic

cond

ition

s an

d el

evat

ed s

ervi

ce u

se o

r nee

d (C

CCES

UN) i

n th

e N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

), Po

rtla

nd, O

R: O

rego

n H

ealth

and

Sci

ence

Uni

vers

ity; D

avid

off,

A.J.

, 20

04, “

Iden

tifyi

ng c

hild

ren

with

spe

cial

hea

lth c

are

need

s in

the

Nat

iona

l Hea

lth In

terv

iew

Sur

vey:

A n

ew re

sour

ce fo

r pol

icy

anal

ysis

,” H

ealth

Ser

vice

s Re

sear

ch 3

9, n

o. 1

: 53–

71.)

Und

er th

e ch

ildre

n w

ith s

peci

al h

ealth

car

e ne

eds

defin

ition

app

lied

here

, a c

hild

mus

t hav

e at

leas

t one

dia

gnos

ed o

r par

ent-r

epor

ted

cond

ition

exp

ecte

d to

be

an o

ngoi

ng

heal

th c

ondi

tion

and

also

mus

t mee

t at l

east

one

of f

ive

crite

ria re

late

d to

ele

vate

d se

rvic

e us

e or

ele

vate

d ne

ed, i

nclu

ding

repo

rted

unm

et n

eed

for c

are.

For

mor

e in

form

atio

n on

the

met

hods

use

d to

iden

tify

child

ren

with

spe

cial

hea

lth c

are

need

s, s

ee h

ttps

://w

ww

.mac

pac.

gov/

mac

stat

s/da

ta-s

ourc

es-a

nd-m

etho

ds/.

9 Su

rvey

info

rmat

ion

is li

mite

d to

chi

ldre

n ag

e 0

to 1

7.10

Su

rvey

info

rmat

ion

is li

mite

d to

chi

ldre

n ag

e 2

to 1

7.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

NH

IS d

ata.

Page 120: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015108

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%53

.5%

37.6

%5.

6%Co

ntac

t with

hea

lth c

are

prof

essi

onal

s (p

ast 1

2 m

onth

s)

N

umbe

r of t

imes

saw

a d

octo

r or o

ther

hea

lth p

rofe

ssio

nal,

excl

udin

g de

ntal

vis

its a

nd in

patie

nt h

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tal s

tays

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e9.

4 8.

0 8.

330

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ast 1

90.6

92

.0

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.6

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37

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e27

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29

.012

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Saw

sel

ecte

d he

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fess

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sed

or c

linic

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ting6

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eral

doc

tor

83.2

85

.1

84.6

58.3

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ener

al d

octo

r, nu

rse

prac

titio

ner,

phys

icia

n as

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ant,

mid

wife

, or o

b-gy

n84

.5

86.5

85

.761

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ical

spe

cial

ist

13.5

15

.0*

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doct

or24

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Men

tal h

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l7.

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9†

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or, f

or e

mot

iona

l or b

ehav

iora

l pro

blem

4.2*

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ntis

t79

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82.7

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Any

heal

th p

rofe

ssio

nal,

excl

udin

g de

ntal

788

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heal

th p

rofe

ssio

nal,

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g de

ntal

96.7

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ad a

t lea

st 1

ove

rnig

ht h

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tal s

tay8

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Rece

ived

car

e at

hom

e1.

0 0.

8*1.

3†

Rece

ipt o

f app

ropr

iate

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e (p

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onth

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ad w

ell-c

hild

che

ckup

983

.8

85.8

84

.956

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Had

mor

e th

an 1

5 of

fice

or c

linic

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9

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0†

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ber o

f em

erge

ncy

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vis

itsN

one

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t 117

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Had

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mer

genc

y ro

om v

isit,

and

mos

t rec

ent v

isit

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for a

ser

ious

hea

lth p

robl

em9.

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1*13

.06.

9*

EXH

IBIT

39.

Use

of C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

0–18

by

Prim

ary

Sour

ce o

f Hea

lth C

over

age,

201

4, D

ata

from

N

atio

nal H

ealth

Inte

rvie

w S

urve

y

Page 121: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 109

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

EXH

IBIT

39.

(co

ntin

ued)

Not

es: O

b-gy

n is

obs

tetr

icia

n-gy

neco

logi

st. P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

exhi

bit e

xclu

de in

divi

dual

s w

ith m

issi

ng a

nd u

nkno

wn

valu

es. S

tand

ard

erro

rs a

re

avai

labl

e on

line

in d

ownl

oada

ble

Exce

l file

s at

htt

ps:/

/ww

w.m

acpa

c.go

v/m

acst

ats/

heal

th-a

nd-o

ther

-cha

ract

eris

tics-

of-b

enef

icia

ries-

serv

ice-

use-

and-

acce

ss-to

-car

e/. D

ue to

di

ffer

ence

s in

met

hodo

logy

(suc

h as

the

wor

ding

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

diff

eren

t su

rvey

dat

a so

urce

s w

ill v

ary.

For

exa

mpl

e, th

e N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

) is

know

n to

pro

duce

hig

her e

stim

ates

of s

ervi

ce u

se th

an th

e M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

(MEP

S). F

or p

urpo

ses

of c

ompa

ring

grou

ps o

f ind

ivid

uals

(as

in th

is e

xhib

it), t

he N

HIS

pro

vide

s th

e m

ost r

ecen

t inf

orm

atio

n av

aila

ble.

For

oth

er p

urpo

ses,

suc

h as

mea

surin

g le

vels

of u

se re

lativ

e to

a p

artic

ular

ben

chm

ark

or g

oal,

it m

ay b

e ap

prop

riate

to c

onsu

lt es

timat

es fr

om M

EPS

or a

noth

er s

ourc

e.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

chi

ldre

n un

der a

ge 1

9, re

gard

less

of c

over

age

sour

ce. I

n th

is e

xhib

it, th

e fo

llow

ing

hier

arch

y w

as u

sed

to a

ssig

n in

divi

dual

s w

ith

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

: Med

icar

e, p

rivat

e, M

edic

aid/

CHIP

, oth

er, u

nins

ured

. Not

sep

arat

ely

show

n ar

e th

e es

timat

es fo

r tho

se c

over

ed b

y M

edic

are

(gen

eral

ly c

hild

ren

with

end

-sta

ge re

nal d

isea

se),

any

type

of m

ilita

ry h

ealth

pla

n, o

r oth

er g

over

nmen

t-spo

nsor

ed p

rogr

ams.

Cov

erag

e so

urce

is d

efin

ed a

s of

the

time

of th

e su

rvey

inte

rvie

w. S

ince

an

indi

vidu

al m

ay h

ave

mul

tiple

cov

erag

e so

urce

s or

cha

nges

ove

r tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

cha

ract

eris

tics

or e

xper

ienc

es

asso

ciat

ed w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

.4

Indi

vidu

als

wer

e de

fined

as

unin

sure

d if

they

did

not

hav

e an

y pr

ivat

e he

alth

insu

ranc

e, M

edic

aid,

CH

IP, M

edic

are,

sta

te- o

r oth

er g

over

nmen

t-spo

nsor

ed h

ealth

pla

n, o

r m

ilita

ry p

lan.

Indi

vidu

als

wer

e al

so d

efin

ed a

s un

insu

red

if th

ey h

ad o

nly

Indi

an H

ealth

Ser

vice

cov

erag

e or

had

onl

y a

priv

ate

plan

that

pai

d fo

r one

type

of s

ervi

ce, s

uch

as

acci

dent

s or

den

tal c

are.

5 Du

e to

the

fact

that

a h

iera

rchy

was

use

d in

this

exh

ibit

to a

ssig

n in

divi

dual

s w

ith m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce (s

ee n

ote

1), t

he M

edic

aid/

CHIP

pe

rcen

tage

s sh

own

in th

is ro

w e

xclu

de in

divi

dual

s w

ho a

lso

have

Med

icar

e (w

hich

is ra

re fo

r chi

ldre

n) o

r priv

ate

cove

rage

. Com

pone

nts

do n

ot s

um to

100

per

cent

bec

ause

no

t all

cove

rage

sou

rces

are

sho

wn.

6 Pa

rent

s m

ay re

port

enc

ount

ers

with

a b

road

rang

e of

hea

lth p

rofe

ssio

nals

(e.g

., sp

eech

ther

apis

t or s

ocia

l wor

ker)

but t

he q

uest

ion

is li

mite

d to

vis

its in

a d

octo

r’s o

ffice

or c

linic

.7

Perc

enta

ges

are

low

er th

an fo

r a m

easu

re s

how

n ea

rlier

in th

is e

xhib

it be

caus

e th

e m

easu

re s

how

n in

this

row

is li

mite

d to

off

ice

and

clin

ic s

ettin

gs.

8 In

clud

es s

tays

for n

ewbo

rns.

9 Su

rvey

info

rmat

ion

is li

mite

d to

chi

ldre

n ag

e 0

to 1

7.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

NH

IS d

ata.

Page 122: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015110

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

mos

t rec

ent i

nter

view

1

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%54

.5%

35.5

%8.

7%Co

ntac

t with

hea

lth c

are

prof

essi

onal

s (p

ast 1

2 m

onth

s)

N

umbe

r of t

imes

saw

a d

octo

r or o

ther

hea

lth p

rofe

ssio

nal,

excl

udin

g de

ntal

vis

its a

nd in

patie

nt h

ospi

tal s

tays

Non

e23

.418

.9*

25.5

43.5

*At

leas

t 176

.681

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74.5

56.5

*1

23.3

22.6

23.7

26.4

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25.6

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25.8

16.9

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or m

ore

27.7

*31

.6*

25.1

13.3

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ad a

t lea

st 1

ove

rnig

ht h

ospi

tal s

tay

2.4*

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3.2

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ceiv

ed c

are

at h

ome

0.9

0.7

1.4

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w a

gen

eral

den

tist

45.9

*52

.2*

41.5

24.2

*Sa

w a

n or

thod

ontis

t9.

2*13

.0*

4.5

4.4

Rece

ipt o

f app

ropr

iate

car

e (p

ast 1

2 m

onth

s)H

ad d

enta

l cle

anin

g, p

roph

ylax

is, o

r pol

ishi

ng43

.1*

50.0

*37

.920

.9*

Had

mor

e th

an 1

5 of

fice

or c

linic

vis

its6

3.9

4.6

3.1

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umbe

r of e

mer

genc

y ro

om v

isits

Non

e87

.8*

89.7

*84

.091

.3*

At le

ast 1

12.2

*10

.3*

16.0

8.7*

19.

7*8.

6*12

.16.

5*2–

32.

2*1.

4*3.

4†

4 or

mor

e0.

4†

††

Not

es: P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

exhi

bit e

xclu

de in

divi

dual

s w

ith m

issi

ng a

nd u

nkno

wn

valu

es. S

tand

ard

erro

rs a

re a

vaila

ble

onlin

e in

dow

nloa

dabl

e Ex

cel

files

at h

ttps

://w

ww

.mac

pac.

gov/

mac

stat

s/he

alth

-and

-oth

er-c

hara

cter

istic

s-of

-ben

efic

iarie

s-se

rvic

e-us

e-an

d-ac

cess

-to-c

are/

. Due

to d

iffer

ence

s in

met

hodo

logy

(suc

h as

the

wor

ding

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

diff

eren

t sur

vey

data

sou

rces

will

var

y. F

or

exam

ple,

the

Nat

iona

l Hea

lth In

terv

iew

Sur

vey

(NH

IS) i

s kn

own

to p

rodu

ce h

ighe

r est

imat

es o

f ser

vice

use

than

the

Med

ical

Exp

endi

ture

s Pa

nel S

urve

y (M

EPS)

. For

pur

pose

s of

com

parin

g gr

oups

of i

ndiv

idua

ls, t

he N

HIS

pro

vide

s th

e m

ost r

ecen

t inf

orm

atio

n av

aila

ble.

For

oth

er p

urpo

ses,

suc

h as

mea

surin

g le

vels

of u

se re

lativ

e to

a p

artic

ular

be

nchm

ark

or g

oal,

it m

ay b

e ap

prop

riate

to c

onsu

lt es

timat

es fr

om M

EPS

or a

noth

er s

ourc

e.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

EXH

IBIT

40.

Use

of C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

0–18

by

Prim

ary

Sour

ce o

f Hea

lth C

over

age,

201

3, D

ata

from

M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

Page 123: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 111

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

chi

ldre

n un

der a

ge 1

9, re

gard

less

of c

over

age

sour

ce. I

n th

is e

xhib

it, th

e fo

llow

ing

hier

arch

y w

as u

sed

to a

ssig

n in

divi

dual

s w

ith

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

: Med

icar

e, p

rivat

e, M

edic

aid/

CHIP

, oth

er, u

nins

ured

. Not

sep

arat

ely

show

n ar

e th

e es

timat

es fo

r tho

se c

over

ed b

y M

edic

are

(gen

eral

ly c

hild

ren

with

end

-sta

ge re

nal d

isea

se),

any

type

of m

ilita

ry h

ealth

pla

n, o

r oth

er g

over

nmen

t-spo

nsor

ed p

rogr

ams.

Cov

erag

e so

urce

is d

efin

ed a

s of

the

time

of th

e m

ost r

ecen

t sur

vey

inte

rvie

w. S

ince

an

indi

vidu

al m

ay h

ave

mul

tiple

cov

erag

e so

urce

s or

cha

nges

ove

r tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

cha

ract

eris

tics

or

expe

rienc

es a

ssoc

iate

d w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

.4

Indi

vidu

als

wer

e de

fined

as

unin

sure

d if

they

did

not

hav

e an

y pr

ivat

e he

alth

insu

ranc

e, M

edic

aid,

CH

IP, M

edic

are,

sta

te- o

r oth

er g

over

nmen

t-spo

nsor

ed h

ealth

pla

n, o

r m

ilita

ry p

lan.

Indi

vidu

als

wer

e al

so d

efin

ed a

s un

insu

red

if th

ey h

ad o

nly

Indi

an H

ealth

Ser

vice

cov

erag

e or

had

onl

y a

priv

ate

plan

that

pai

d fo

r one

type

of s

ervi

ce, s

uch

as

acci

dent

s or

den

tal c

are.

5 Du

e to

the

fact

that

a h

iera

rchy

was

use

d in

this

exh

ibit

to a

ssig

n in

divi

dual

s w

ith m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce (s

ee n

ote

1), t

he M

edic

aid/

CHIP

pe

rcen

tage

s sh

own

in th

is ro

w e

xclu

de in

divi

dual

s w

ho a

lso

have

Med

icar

e (w

hich

is ra

re fo

r chi

ldre

n) o

r priv

ate

cove

rage

. Com

pone

nts

do n

ot s

um to

100

per

cent

bec

ause

no

t all

cove

rage

sou

rces

are

sho

wn.

6 Re

flect

s in

form

atio

n fr

om th

e of

fice-

base

d an

d ho

spita

l out

patie

nt d

epar

tmen

t file

s in

MEP

S.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

MEP

S da

ta.

EXH

IBIT

40.

(co

ntin

ued)

Page 124: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015112

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%53

.5%

37.6

%5.

6%Ti

mel

ines

s of

car

e (p

ast 1

2 m

onth

s)H

as a

usu

al s

ourc

e of

car

e95

.9

98.0

*96

.670

.8*

Had

the

sam

e us

ual s

ourc

e of

med

ical

car

e 12

mon

ths

ago

89.2

91

.5*

89.7

66.3

*Do

es n

ot h

ave

a us

ual s

ourc

e of

car

e, a

nd a

cces

s ba

rrie

r is

the

reas

on6

1.1 *

0.3

0.6

12.3

*

Had

trou

ble

findi

ng a

doc

tor o

r was

told

that

cov

erag

e or

ne

w p

atie

nts

wer

e no

t acc

epte

d73.

0*1.

7*4.

65.

0

Tim

elin

ess

of c

are

(pas

t 12

mon

ths)

Dela

yed

med

ical

car

e du

e to

any

acc

ess

barr

ier i

ndic

ated

be

low

9.7 *

6.5*

12.1

24.3

*

Dela

yed

beca

use

of c

osts

2.8 *

1.8

2.1

17.9

*De

laye

d fo

r pro

vide

r-rel

ated

reas

ons8

6.6 *

4.9 *

8.8

8.2

Dela

yed

due

to la

ck o

f tra

nspo

rtat

ion

1.6 *

0.2 *

3.4

† U

nmet

nee

d fo

r sel

ecte

d ty

pes

of c

are

due

to c

ost

Med

ical

car

e1.

6*0.

9 1.

113

.5*

Men

tal h

ealth

car

e or

cou

nsel

ing9

0.8

0.8

0.5

1.9 *

Dent

al c

are

4.3

2.7*

4.9

16.6

*Pr

escr

iptio

n dr

ugs

1.6

0.9*

2.0

5.7 *

Eyeg

lass

es1.

8 1.

0*2.

17.

8*Sp

ecia

list c

are

1.2

0.7

1.2

6.2 *

Follo

w-u

p ca

re1.

1 0.

6*1.

26.

4*

Not

es: P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

tabl

e ex

clud

e in

divi

dual

s w

ith m

issi

ng a

nd u

nkno

wn

valu

es. S

tand

ard

erro

rs a

re a

vaila

ble

onlin

e in

dow

nloa

dabl

e Ex

cel

files

at h

ttps

://w

ww

.mac

pac.

gov/

mac

stat

s/he

alth

-and

-oth

er-c

hara

cter

istic

s-of

-ben

efic

iarie

s-se

rvic

e-us

e-an

d-ac

cess

-to-c

are/

. Due

to d

iffer

ence

s in

met

hodo

logy

(suc

h as

the

wor

ding

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

diff

eren

t sur

vey

data

sou

rces

will

var

y. F

or e

xam

ple,

th

e N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

) is

know

n to

pro

duce

hig

her e

stim

ates

of s

ervi

ce u

se th

an th

e M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

(MEP

S). F

or p

urpo

ses

of

com

parin

g gr

oups

of i

ndiv

idua

ls (a

s in

this

exh

ibit)

, the

NH

IS p

rovi

des

the

mos

t rec

ent i

nfor

mat

ion

avai

labl

e. F

or o

ther

pur

pose

s, s

uch

as m

easu

ring

leve

ls o

f use

rela

tive

to a

pa

rtic

ular

ben

chm

ark

or g

oal,

it m

ay b

e ap

prop

riate

to c

onsu

lt es

timat

es fr

om M

EPS

or a

noth

er s

ourc

e.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

EXH

IBIT

41.

Mea

sure

s of

Acc

ess

to C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

0–18

by

Prim

ary

Sour

ce o

f Hea

lth C

over

age,

201

4

Page 125: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 113

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

chi

ldre

n un

der a

ge 1

9, re

gard

less

of c

over

age

sour

ce. I

n th

is e

xhib

it, th

e fo

llow

ing

hier

arch

y w

as u

sed

to a

ssig

n in

divi

dual

s w

ith

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

: Med

icar

e, p

rivat

e, M

edic

aid/

CHIP

, oth

er, u

nins

ured

. Not

sep

arat

ely

show

n ar

e th

e es

timat

es fo

r tho

se c

over

ed b

y M

edic

are

(gen

eral

ly c

hild

ren

with

end

-sta

ge re

nal d

isea

se),

any

type

of m

ilita

ry h

ealth

pla

n, o

r oth

er g

over

nmen

t-spo

nsor

ed p

rogr

ams.

Cov

erag

e so

urce

is d

efin

ed a

s of

the

time

of th

e su

rvey

inte

rvie

w. S

ince

an

indi

vidu

al m

ay h

ave

mul

tiple

cov

erag

e so

urce

s or

cha

nges

ove

r tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

cha

ract

eris

tics

or e

xper

ienc

es

asso

ciat

ed w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

.4

Indi

vidu

als

wer

e de

fined

as

unin

sure

d if

they

did

not

hav

e an

y pr

ivat

e he

alth

insu

ranc

e, M

edic

aid,

CH

IP, M

edic

are,

sta

te- o

r oth

er g

over

nmen

t-spo

nsor

ed h

ealth

pla

n, o

r m

ilita

ry p

lan.

Indi

vidu

als

wer

e al

so d

efin

ed a

s un

insu

red

if th

ey h

ad o

nly

Indi

an H

ealth

Ser

vice

cov

erag

e or

had

onl

y a

priv

ate

plan

that

pai

d fo

r one

type

of s

ervi

ce, s

uch

as

acci

dent

s or

den

tal c

are.

5 Du

e to

the

fact

that

a h

iera

rchy

was

use

d in

this

exh

ibit

to a

ssig

n in

divi

dual

s w

ith m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce (s

ee n

ote

1), t

he M

edic

aid/

CHIP

pe

rcen

tage

s sh

own

in th

is ro

w e

xclu

de in

divi

dual

s w

ho a

lso

have

Med

icar

e (w

hich

is ra

re fo

r chi

ldre

n) o

r priv

ate

cove

rage

. Com

pone

nts

do n

ot s

um to

100

per

cent

bec

ause

no

t all

cove

rage

sou

rces

are

sho

wn.

6 Re

ason

s gi

ven

by th

ose

who

repo

rted

no

usua

l pla

ce o

f car

e th

at w

ere

clas

sifie

d as

acc

ess

barr

iers

incl

ude

the

follo

win

g: to

o ex

pens

ive/

cost

, pre

viou

s do

ctor

not

ava

ilabl

e,

pare

nt d

oes

not k

now

whe

re to

go,

and

spe

aks

a di

ffer

ent l

angu

age.

7 Pa

rent

repo

rted

one

of t

hese

bar

riers

in th

e pa

st 1

2 m

onth

s: tr

oubl

e fin

ding

a d

octo

r or p

rovi

der,

doct

or’s

off

ice/

clin

ic d

id n

ot a

ccep

t chi

ld’s

insu

ranc

e co

vera

ge, o

r off

ice/

clin

ic d

id n

ot a

ccep

t the

chi

ld a

s a

new

pat

ient

.8

Incl

udes

any

of t

he fo

llow

ing:

par

ent c

ould

not

get

an

appo

intm

ent,

had

to w

ait t

oo lo

ng to

see

doc

tor,

coul

d no

t go

whe

n op

en, c

ould

not

get

thro

ugh

on p

hone

, par

ent

spea

ks a

diff

eren

t lan

guag

e.9

Surv

ey in

form

atio

n is

lim

ited

to c

hild

ren

age

2 or

old

er.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

NH

IS d

ata.

EXH

IBIT

41.

(co

ntin

ued)

Page 126: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015114

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

s

Prim

ary

cove

rage

sou

rce

at ti

me

of in

terv

iew

1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%3.

6%*

66.2

%*

10.5

%16

.3%

*Co

vera

geLe

ngth

of t

ime

with

any

cov

erag

e du

ring

year

Full

year

77.3

*96

.0*

93.6

*79

.9–

Pa

rt y

ear

10.0

*4.

0*6.

4*20

.120

.6

No

cove

rage

dur

ing

year

12.6

79.4

De

mog

raph

ics

Age

19–

2513

.5*

†12

.2*

20.4

15.9

*26

–44

43.0

*14

.7*

42.4

*47

.251

.8*

45–

5422

.5*

26.5

*23

.8*

17.8

19.7

55

–64

20.9

*57

.3*

21.7

*14

.512

.6

Gen

der

Mal

e49

.0*

49.3

*49

.7*

36.1

54.3

*Fe

mal

e51

.0*

50.7

*50

.3*

63.9

45.7

*Ra

ceH

ispa

nic

16.9

*8.

5*

11.5

*25

.136

.0*

Whi

te, n

on-H

ispa

nic

63.6

*69

.1*

71.0

*46

.044

.1

Blac

k, n

on-H

ispa

nic

12.7

*18

.9

10.1

*22

.113

.9*

Oth

er n

on-w

hite

, non

-His

pani

c6.

9

3.5

*7.

4

6.8

5.9

M

arita

l sta

tus

Mar

ried

53.3

*37

.6*

61.3

*31

.639

.0*

Wid

owed

25.0

*20

.6*

21.4

*38

.031

.8*

Divo

rced

or s

epar

ated

11.2

*29

.4*

9.1

*15

.912

.4*

Livi

ng w

ith p

artn

er1.

6

6.5

*1.

2*

2.0

1.7

N

ever

mar

ried

8.7

*5.

8*

6.9

*12

.315

.0*

Fam

ily in

com

eLe

ss th

an 1

38 p

erce

nt F

PL21

.8*

49.2

*7.

9*

65.5

43.8

*H

as in

com

e in

rang

es b

elow

Less

than

100

per

cent

FPL

14.6

*31

.6*

4.7*

47.5

29.8

*10

0–29

9 pe

rcen

t FPL

18.1

*36

.7

11.2

*32

.832

.2

200–

399

perc

ent F

PL28

.8*

22.4

*31

.4*

15.2

28.2

*40

0 pe

rcen

t FPL

or h

ighe

r38

.5*

9.3*

52.8

*4.

49.

7*

EXH

IBIT

42.

Cov

erag

e, D

emog

raph

ic, a

nd H

ealth

Cha

ract

eris

tics

of N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

19–

64 b

y Pr

imar

y So

urce

of

Hea

lth C

over

age,

201

4

Page 127: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 115

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

s

Prim

ary

cove

rage

sou

rce

at ti

me

of in

terv

iew

1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Educ

atio

nLe

ss th

an h

igh

scho

ol11

.6%

*24

.2%

5.2%

*26

.3%

26.2

%

Hig

h sc

hool

dip

lom

a/G

ED24

.9*

33.8

20

.0*

36.1

34.8

So

me

colle

ge32

.3*

33.3

*33

.4*

28.0

28.8

Co

llege

or g

radu

ate

degr

ee31

.3*

8.7

41.5

*9.

610

.2

Oth

er d

emog

raph

ic c

hara

cter

istic

sCi

tizen

of U

nite

d St

ates

89.9

*98

.8*

93.8

*88

.172

.2*

Pare

nt o

f a d

epen

dent

chi

ld37

.3*

12.2

*37

.6*

48.6

36.5

*Cu

rren

tly w

orki

ng72

.4*

10.1

*83

.2*

43.3

63.9

*Ve

tera

n6.

2*10

.1*

5.5*

2.0

3.8*

Rece

ives

SSI

or S

SDI6

5.5*

76.5

*0.

8*17

.80.

8*Re

ceiv

es S

SI2.

6*18

.9*

0.3*

14.4

0.3*

Rece

ives

SSD

I3.

6*66

.7*

0.5*

6.6

0.6*

Hea

lthCu

rren

t hea

lth s

tatu

sEx

celle

nt o

r ver

y go

od64

.2*

14.1

*72

.2*

44.9

56.3

*G

ood

24.9

*21

.2*

22.4

*31

.331

.2

Fair

or p

oor

10.9

*64

.7*

5.4*

23.7

12.4

*BM

IH

ealth

y w

eigh

t (BM

I les

s th

an 2

5)35

.8*

25.5

*36

.9*

32.9

35.8

O

verw

eigh

t (BM

I 25–

30)

34.0

*28

.8

34.7

*29

.634

.9*

Obe

se (B

MI 3

0 or

hig

her)

30.1

*45

.7*

28.4

*37

.529

.3*

Smok

ing

stat

usCu

rren

t sm

oker

18.9

*32

.1

14.1

*29

.628

.2

Form

er s

mok

er18

.4*

28.1

*19

.5*

14.4

13.8

N

ever

sm

oked

62.7

*39

.7*

66.4

*56

.058

.0

Lim

itatio

ns a

nd h

ealth

con

ditio

nsH

as b

asic

act

ion

diffi

culty

or c

ompl

ex a

ctiv

ity lim

itatio

nAn

y ba

sic

actio

n di

ffic

ulty

724

.9*

86.4

*18

.7*

40.1

24.8

*An

y co

mpl

ex a

ctiv

ity li

mita

tion8

11.6

*84

.1*

5.2*

28.8

8.9*

Eith

er o

ne26

.6*

92.4

*19

.7*

44.4

26.2

*H

as fu

nctio

nal l

imita

tion9

27.0

*85

.3*

21.9

*39

.925

.2*

EXH

IBIT

42.

(co

ntin

ued)

Page 128: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015116

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

s

Prim

ary

cove

rage

sou

rce

at ti

me

of in

terv

iew

1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Has

diff

icul

ty w

alki

ng w

ithou

t equ

ipm

ent

3.3%

*34

.3%

*1.

2%*

7.7%

1.7%

*H

as h

ealth

con

ditio

n re

quiri

ng s

peci

al e

quip

men

t4.

0*35

.0*

1.8*

8.3

2.6*

Nee

ds h

elp

with

any

of t

he fo

llow

ing

ADLs

Pers

onal

car

e1.

3*12

.5*

0.4*

4.6

0.5*

Bath

ing

0.8*

8.0*

0.2*

3.2

†Ea

ting

0.2*

2.3*

†0.

8†

Tran

sfer

ring

0.6*

6.5*

0.2*

1.9

†To

iletin

g0.

4*4.

2*0.

1*1.

3†

Get

ting

arou

nd in

hom

e0.

5*5.

5*0.

1*1.

7†

Num

ber o

f ADL

s ne

edin

g as

sist

ance

Non

e98

.9*

89.2

*99

.7*

96.0

99.6

*1–

20.

6*5.

0*†

2.4

†3–

40.

3*2.

7*†

0.8

†5–

60.

3*3.

1*†

0.8

†U

nabl

e to

wor

k no

w d

ue to

hea

lth p

robl

em7.

1*70

.8*

2.1*

19.6

4.3*

Lim

ited

in a

mou

nt o

r kin

d of

wor

k du

e to

hea

lth10

.1*

80.0

*4.

0*26

.47.

1*Lo

st a

ll na

tura

l tee

th4.

4*18

.9*

3.0*

6.8

4.7*

Has

dep

ress

ed o

r anx

ious

feel

ings

12.6

*35

.2*

8.5*

23.2

16.9

*Cu

rren

tly p

regn

ant10

4.4*

† 3.

9*7.

82.

5*Ev

er b

een

told

he

or s

he h

as s

elec

ted

cond

ition

sH

yper

tens

ion

24.2

*62

.0*

22.3

*29

.718

.7*

Coro

nary

hea

rt d

isea

se2.

0 11

.5*

1.5*

2.7

1.6*

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rt a

ttac

k1.

9*11

.0*

1.2*

3.5

1.3*

Stro

ke1.

6*10

.5*

0.9*

3.6

0.9*

Canc

er3.

8 12

.0*

3.7

4.2

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etes

6.7*

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.05.

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thrit

is16

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56.8

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19.2

11.5

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thm

a13

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25.5

*12

.5*

17.0

10.6

*Ch

roni

c br

onch

itis

(pas

t 12

mon

ths)

3.3*

13.1

*2.

5*5.

83.

0*Li

ver c

ondi

tion

(pas

t 12

mon

ths)

1.3*

5.9*

1.0*

2.8

0.8*

Wea

k or

faili

ng k

idne

ys (p

ast 1

2 m

onth

s)1.

1*6.

9*0.

6*2.

61.

2*

EXH

IBIT

42.

(co

ntin

ued)

Page 129: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 117

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Not

es: F

PL is

fede

ral p

over

ty le

vel.

SSI i

s Su

pple

men

tal S

ecur

ity In

com

e. S

SDI i

s So

cial

Sec

urity

Dis

abili

ty In

sura

nce.

BM

I is

body

mas

s in

dex.

ADL

is a

ctiv

ity o

f dai

ly li

ving

. Pe

rcen

tage

cal

cula

tions

for e

ach

item

in th

e ex

hibi

t exc

lude

indi

vidu

als

with

mis

sing

and

unk

now

n va

lues

. Sta

ndar

d er

rors

are

ava

ilabl

e on

line

in d

ownl

oada

ble

Exce

l file

s at

ht

tps:

//w

ww

.mac

pac.

gov/

mac

stat

s/he

alth

-and

-oth

er-c

hara

cter

istic

s-of

-ben

efic

iarie

s-se

rvic

e-us

e-an

d-ac

cess

-to-c

are/

.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

indi

vidu

als

age

19–

64, r

egar

dles

s of

cov

erag

e so

urce

. In

this

exh

ibit,

the

follo

win

g hi

erar

chy

was

use

d to

ass

ign

indi

vidu

als

with

m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce: M

edic

are,

priv

ate,

Med

icai

d/CH

IP, o

ther

, uni

nsur

ed. N

ot s

epar

atel

y sh

own

are

the

estim

ates

for t

hose

cov

ered

by

Med

icar

e, a

ny

type

of m

ilita

ry h

ealth

pla

n, o

r oth

er g

over

nmen

t-spo

nsor

ed p

rogr

ams.

Cov

erag

e so

urce

is d

efin

ed a

s of

the

time

of th

e su

rvey

inte

rvie

w. S

ince

an

indi

vidu

al m

ay h

ave

mul

tiple

co

vera

ge s

ourc

es o

r cha

nges

ove

r tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

cha

ract

eris

tics

or e

xper

ienc

es a

ssoc

iate

d w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

. 4

Indi

vidu

als

wer

e de

fined

as

unin

sure

d if

they

did

not

hav

e an

y pr

ivat

e he

alth

insu

ranc

e, M

edic

aid,

CH

IP, M

edic

are,

sta

te-s

pons

ored

or o

ther

gov

ernm

ent-s

pons

ored

hea

lth

plan

, or m

ilita

ry p

lan.

Indi

vidu

als

wer

e al

so d

efin

ed a

s un

insu

red

if th

ey h

ad o

nly

Indi

an H

ealth

Ser

vice

cov

erag

e or

had

onl

y a

priv

ate

plan

that

pai

d fo

r one

type

of s

ervi

ce,

such

as

acci

dent

s or

den

tal c

are.

5 Du

e to

the

fact

that

a h

iera

rchy

was

use

d in

this

exh

ibit

to a

ssig

n in

divi

dual

s w

ith m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce (s

ee e

arlie

r not

e), t

he M

edic

aid/

CHIP

per

cent

ages

sh

own

in th

is ro

w e

xclu

de in

divi

dual

s w

ho a

lso

have

Med

icar

e or

priv

ate

cove

rage

. Com

pone

nts

do n

ot s

um to

100

per

cent

bec

ause

not

all

cove

rage

sou

rces

are

sho

wn.

6 Ch

arac

teris

tic is

list

ed u

nder

dem

ogra

phic

s be

caus

e lo

w in

com

e is

one

of t

he c

riter

ia fo

r SSI

elig

ibili

ty, a

nd th

e in

abili

ty to

eng

age

in a

spe

cifie

d le

vel o

f wor

k ac

tivity

and

ea

rnin

gs (r

efer

red

to a

s su

bsta

ntia

l gai

nful

act

ivity

in fe

dera

l sta

tute

) is

one

of th

e cr

iteria

for S

SDI e

ligib

ility

. How

ever

, SSI

or S

SDI r

ecei

pt is

als

o an

indi

cato

r of d

isab

ility

. For

an

adul

t to

be e

ligib

le fo

r SSI

or S

SDI,

he o

r she

mus

t hav

e a

med

ical

ly d

eter

min

able

phy

sica

l or m

enta

l im

pairm

ent t

hat i

s ex

pect

ed to

last

at l

east

12

mon

ths

or re

sult

in d

eath

.7

Capt

ures

lim

itatio

ns o

r diff

icul

ties

in m

ovem

ent (

wal

king

, sta

ndin

g, b

endi

ng o

r kne

elin

g, re

achi

ng o

verh

ead,

and

usi

ng th

e ha

nds

and

finge

rs) a

nd s

enso

ry, e

mot

iona

l (i.e

., fe

elin

gs th

at in

terf

ere

with

acc

ompl

ishi

ng d

aily

act

iviti

es),

or m

enta

l (i.e

., di

ffic

ultie

s w

ith re

mem

berin

g or

exp

erie

ncin

g co

nfus

ion)

func

tioni

ng th

at a

re a

ssoc

iate

d w

ith s

ome

heal

th p

robl

em.

8 Re

flect

s a

limita

tion

in th

e ta

sks

and

orga

nize

d ac

tiviti

es th

at, w

hen

exec

uted

, mak

e up

num

erou

s so

cial

role

s, s

uch

as w

orki

ng, a

tten

ding

sch

ool,

or m

aint

aini

ng a

hou

seho

ld.

Adul

ts a

re d

efin

ed a

s ha

ving

a c

ompl

ex a

ctiv

ity li

mita

tion

if th

ey h

ave

one

or m

ore

of th

e fo

llow

ing

type

s of

lim

itatio

ns: s

elf-c

are

limita

tion,

soc

ial l

imita

tion,

or w

ork

limita

tion.

9 Fu

nctio

nal l

imita

tion

is d

efin

ed a

s “v

ery

diff

icul

t” o

r “ca

nnot

do”

for t

he fo

llow

ing

activ

ities

: gra

sp s

mal

l obj

ects

; rea

ch a

bove

one

’s h

ead;

sit

mor

e th

an 2

hou

rs; l

ift o

r ca

rry

10 p

ound

s; c

limb

a fli

ght o

f sta

irs; p

ush

a he

avy

obje

ct; w

alk

a 1/

4 m

ile; s

tand

mor

e th

an 2

hou

rs; s

toop

, ben

d, o

r kne

el.

10 In

form

atio

n is

lim

ited

to w

omen

age

19–

44.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

NH

IS d

ata.

EXH

IBIT

42.

(co

ntin

ued)

Page 130: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015118

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%3.

6%66

.2%

10.5

%16

.3%

Cont

act w

ith h

ealth

car

e pr

ofes

sion

als

(pas

t 12

mon

ths)

Num

ber o

f tim

es s

aw a

doc

tor o

r oth

er h

ealth

pro

fess

iona

l, ex

clud

ing

dent

al v

isits

and

inpa

tient

hos

pita

l sta

ysN

one

21.1

*6.

0*16

.2

17.0

48.6

*At

leas

t 178

.9*

94.0

*83

.8

83.0

51.4

*1

21.0

*7.

5*22

.7*

15.9

20.4

*2–

327

.0*

14.9

*30

.6*

24.3

16.5

*4

or m

ore

30.9

*71

.6*

30.4

*42

.814

.5*

Saw

sel

ecte

d he

alth

pro

fess

iona

ls in

an

offic

e-ba

sed

or c

linic

set

ting6

Gen

eral

doc

tor

66.1

*86

.0*

70.4

72

.138

.2*

Gen

eral

doc

tor,

nurs

e pr

actit

ione

r, ph

ysic

ian

assi

stan

t, m

idw

ife, o

r ob-

gyn

73.7

*88

.9*

78.5

80

.044

.8*

Med

ical

spe

cial

ist

21.6

54

.0*

23.2

22

.37.

4*Ey

e do

ctor

33.0

*41

.0*

38.2

*26

.314

.4*

Men

tal h

ealth

pro

fess

iona

l8.

0*25

.2*

6.6*

13.6

4.1*

Dent

ist

61.7

*47

.2

71.7

*49

.231

.6*

Any

heal

th p

rofe

ssio

nal,

excl

udin

g de

ntal

778

.9*

94.9

*84

.1*

81.6

51.3

*An

y he

alth

pro

fess

iona

l, in

clud

ing

dent

al87

.9

97.1

*93

.1*

89.5

62.9

*H

ad a

t lea

st 1

ove

rnig

ht h

ospi

tal s

tay

7.2*

22.5

*5.

7*14

.25.

2*Re

ceiv

ed c

are

at h

ome

1.2*

11.0

*0.

7*2.

6†

Rece

ipt o

f app

ropr

iate

car

e (p

ast 1

2 m

onth

s)H

ad c

hole

ster

ol c

heck

edAl

l ind

ivid

uals

69.1

87

.3*

73.1

71

.244

.9*

Men

age

35–

6473

.6*

86.7

77

.0

81.3

44.6

*In

divi

dual

s w

ith e

leva

ted

risk

of c

ardi

ac d

isea

se8

72.6

87

.2*

77.2

75

.045

.9*

Had

flu

shot

All i

ndiv

idua

ls35

.8*

53.7

*40

.0*

30.5

15.7

*

EXH

IBIT

43.

Use

of C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

19–

64 b

y Pr

imar

y So

urce

of H

ealth

Cov

erag

e, 2

014,

Dat

a fr

om

Nat

iona

l Hea

lth In

terv

iew

Sur

vey

Page 131: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 119

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Indi

vidu

als

age

50–

6445

.4%

57.2

%*

47.8

%*

42.5

%20

.9%

*In

divi

dual

s w

ho h

ave

a ch

roni

c co

nditi

on o

r ar

e pr

egna

nt43

.3*

56.9

*47

.2*

36.6

20.1

*

Had

any

test

for c

olor

ecta

l can

cer (

age

50–

64)

20.7

25

.1

21.6

23

.27.

1*H

ad P

ap s

mea

r or t

est f

or c

ervi

cal c

ance

r (w

omen

age

21–

60)

55.9

43

.6*

61.8

*54

.133

.3*

Had

pro

fess

iona

l cou

nsel

ing

abou

t sm

okin

g (c

urre

nt s

mok

ers)

50.9

*68

.2*

54.3

60

.330

.4*

Had

mor

e th

an 1

5 of

fice

or c

linic

vis

its4.

9*23

.0*

4.1*

8.3

1.7*

Num

ber o

f em

erge

ncy

room

vis

itsN

one

82.1

*58

.0*

85.9

*65

.883

.5*

At le

ast 1

17.9

*42

.0*

14.1

*34

.216

.5*

111

.4*

19.7

10

.2*

16.6

10.7

*2–

34.

4*12

.6

2.9*

11.7

3.9*

4 or

mor

e2.

0*9.

8*1.

0*5.

91.

9*H

ad a

t lea

st 1

em

erge

ncy

room

vis

it, a

nd m

ost

rece

nt v

isit

was

for a

ser

ious

hea

lth p

robl

em12

.2*

31.6

*9.

8*23

.010

.1*

Not

es: O

b-gy

n is

obs

tetr

icia

n-gy

neco

logi

st. P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

exhi

bit e

xclu

de in

divi

dual

s w

ith m

issi

ng a

nd u

nkno

wn

valu

es. S

tand

ard

erro

rs a

re

avai

labl

e on

line

in d

ownl

oada

ble

Exce

l file

s at

htt

ps:/

/ww

w.m

acpa

c.go

v/m

acst

ats/

heal

th-a

nd-o

ther

-cha

ract

eris

tics-

of-b

enef

icia

ries-

serv

ice-

use-

and-

acce

ss-to

-car

e/. D

ue to

di

ffer

ence

s in

met

hodo

logy

(suc

h as

the

wor

ding

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

diff

eren

t su

rvey

dat

a so

urce

s w

ill v

ary.

For

exa

mpl

e, th

e N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

) is

know

n to

pro

duce

hig

her e

stim

ates

of s

ervi

ce u

se th

an th

e M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

(MEP

S). F

or p

urpo

ses

of c

ompa

ring

grou

ps o

f ind

ivid

uals

(as

in th

is e

xhib

it), t

he N

HIS

pro

vide

s th

e m

ost r

ecen

t inf

orm

atio

n av

aila

ble.

For

oth

er p

urpo

ses,

suc

h as

mea

surin

g le

vels

of u

se re

lativ

e to

a p

artic

ular

ben

chm

ark

or g

oal,

it m

ay b

e ap

prop

riate

to c

onsu

lt es

timat

es fr

om M

EPS

or a

noth

er s

ourc

e.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

indi

vidu

als

age

19–

64, r

egar

dles

s of

cov

erag

e so

urce

. In

this

exh

ibit,

the

follo

win

g hi

erar

chy

was

use

d to

ass

ign

indi

vidu

als

with

m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce: M

edic

are,

priv

ate,

Med

icai

d/CH

IP, o

ther

, uni

nsur

ed. N

ot s

epar

atel

y sh

own

are

the

estim

ates

for t

hose

cov

ered

by

any

type

of

mili

tary

hea

lth p

lan

or o

ther

gov

ernm

ent-s

pons

ored

pro

gram

s. C

over

age

sour

ce is

def

ined

as

of th

e tim

e of

the

surv

ey in

terv

iew

. Sin

ce a

n in

divi

dual

may

hav

e m

ultip

le

cove

rage

sou

rces

or c

hang

es o

ver t

ime,

resp

onse

s to

sur

vey

ques

tions

may

refle

ct c

hara

cter

istic

s or

exp

erie

nces

ass

ocia

ted

with

a c

over

age

sour

ce o

ther

than

the

one

assi

gned

in th

is e

xhib

it.

EXH

IBIT

43.

(co

ntin

ued)

Page 132: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015120

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

.4

Indi

vidu

als

wer

e de

fined

as

unin

sure

d if

they

did

not

hav

e an

y pr

ivat

e he

alth

insu

ranc

e, M

edic

aid,

CH

IP, M

edic

are,

sta

te- o

r oth

er g

over

nmen

t-spo

nsor

ed h

ealth

pla

n, o

r m

ilita

ry p

lan.

Indi

vidu

als

wer

e al

so d

efin

ed a

s un

insu

red

if th

ey h

ad o

nly

Indi

an H

ealth

Ser

vice

cov

erag

e or

had

onl

y a

priv

ate

plan

that

pai

d fo

r one

type

of s

ervi

ce, s

uch

as

acci

dent

s or

den

tal c

are.

5 Du

e to

the

fact

that

a h

iera

rchy

was

use

d in

this

exh

ibit

to a

ssig

n in

divi

dual

s w

ith m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce (s

ee n

ote

1), t

he M

edic

aid/

CHIP

per

cent

ages

sh

own

in th

is ro

w e

xclu

de in

divi

dual

s w

ho a

lso

have

Med

icar

e or

priv

ate

cove

rage

. Com

pone

nts

do n

ot s

um to

100

per

cent

bec

ause

not

all

cove

rage

sou

rces

are

sho

wn.

6 In

divi

dual

s m

ay re

port

enc

ount

ers

with

a b

road

rang

e of

hea

lth p

rofe

ssio

nals

(e.g

., sp

eech

ther

apis

t or s

ocia

l wor

ker)

but

the

ques

tion

is li

mite

d to

vis

its in

a d

octo

r’s o

ffic

e or

clin

ic.

7 Pe

rcen

tage

s ar

e lo

wer

than

for a

mea

sure

sho

wn

earli

er in

this

exh

ibit

beca

use

the

mea

sure

sho

wn

in th

is ro

w is

lim

ited

to o

ffic

e an

d cl

inic

set

tings

.8

Indi

vidu

als

of a

ny a

ge o

r sex

who

repo

rt h

yper

tens

ion

or d

iabe

tes,

or w

ho c

urre

ntly

sm

oke.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

NH

IS d

ata.

EXH

IBIT

43.

(co

ntin

ued)

Page 133: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 121

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

mos

t rec

ent i

nter

view

1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%3.

4%63

.7%

7.6 %

24.0

%

Cont

act w

ith h

ealth

car

e pr

ofes

sion

als

(pas

t 12

mon

ths)

Num

ber o

f tim

es s

aw a

doc

tor o

r oth

er h

ealth

pro

fess

iona

l, ex

clud

ing

dent

al v

isits

and

inpa

tient

hos

pita

l sta

ysN

one

27.7

*5.

1 *21

.821

.148

.9*

At le

ast 1

72.3

*94

.9*

78.2

78.9

51.1

*1

15.7

*6.

4*15

.9*

11.8

17.9

*2–

318

.310

.4*

20.4

*17

.813

.8*

4 or

mor

e38

.4*

78.1

*41

.9*

49.3

19.4

*H

ad a

t lea

st 1

ove

rnig

ht h

ospi

tal s

tay

6.7*

19.1

5.8*

16.0

4.3 *

Rece

ived

car

e at

hom

e1.

6 *12

.9*

0.8*

5.1

0.7*

Saw

a g

ener

al d

entis

t35

.8*

27.9

*45

.5*

21.4

15.9

*Sa

w a

n or

thod

ontis

t1.

2†

1.3

1.3

0.8

Rece

ipt o

f app

ropr

iate

car

e (p

ast 1

2 m

onth

s)H

ad d

enta

l cle

anin

g, p

roph

ylax

is, o

r pol

ishi

ng31

.0*

17.2

41.2

*15

.011

.2*

Had

mor

e th

an 1

5 of

fice

or c

linic

vis

its6

8.8*

30.4

*9.

1*13

.33.

5*N

umbe

r of e

mer

genc

y ro

om v

isits

Non

e86

.6*

67.0

89.5

*70

.987

.2*

At le

ast 1

13.4

*33

.010

.5*

29.1

12.8

*1

9.6 *

19.2

8.3 *

16.6

9.3 *

2–3

3.2*

10.9

2.0*

10.2

3.0*

4 or

mor

e0.

5*2.

9†

2.3

0.5*

Not

es: P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

exhi

bit e

xclu

de in

divi

dual

s w

ith m

issi

ng a

nd u

nkno

wn

valu

es. S

tand

ard

erro

rs a

re a

vaila

ble

onlin

e in

dow

nloa

dabl

e Ex

cel

files

at h

ttps

://w

ww

.mac

pac.

gov/

mac

stat

s/he

alth

-and

-oth

er-c

hara

cter

istic

s-of

-ben

efic

iarie

s-se

rvic

e-us

e-an

d-ac

cess

-to-c

are/

. Due

to d

iffer

ence

s in

met

hodo

logy

(suc

h as

the

wor

ding

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

diff

eren

t sur

vey

data

sou

rces

will

var

y. F

or

exam

ple,

the

Nat

iona

l Hea

lth In

terv

iew

Sur

vey

(NH

IS) i

s kn

own

to p

rodu

ce h

ighe

r est

imat

es o

f ser

vice

use

than

the

Med

ical

Exp

endi

ture

s Pa

nel S

urve

y (M

EPS)

. For

pur

pose

s of

com

parin

g gr

oups

of i

ndiv

idua

ls, t

he N

HIS

pro

vide

s th

e m

ost r

ecen

t inf

orm

atio

n av

aila

ble.

For

oth

er p

urpo

ses,

suc

h as

mea

surin

g le

vels

of u

se re

lativ

e to

a p

artic

ular

be

nchm

ark

or g

oal,

it m

ay b

e ap

prop

riate

to c

onsu

lt es

timat

es fr

om M

EPS

or a

noth

er s

ourc

e.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

EXH

IBIT

44.

Use

of C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

19–

64 b

y Pr

imar

y So

urce

of H

ealth

Cov

erag

e, 2

013,

Dat

a fro

m

Med

ical

Exp

endi

ture

s Pa

nel S

urve

y

Page 134: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

December 2015122

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

indi

vidu

als

age

19–

64, r

egar

dles

s of

cov

erag

e so

urce

. In

this

exh

ibit,

the

follo

win

g hi

erar

chy

was

use

d to

ass

ign

indi

vidu

als

with

m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce: M

edic

are,

priv

ate,

Med

icai

d/CH

IP, o

ther

, uni

nsur

ed. N

ot s

epar

atel

y sh

own

are

the

estim

ates

for t

hose

cov

ered

by

any

type

of

mili

tary

hea

lth p

lan

or o

ther

gov

ernm

ent-s

pons

ored

pro

gram

s. C

over

age

sour

ce is

def

ined

as

of th

e tim

e of

the

mos

t rec

ent s

urve

y in

terv

iew

. Sin

ce a

n in

divi

dual

may

hav

e m

ultip

le c

over

age

sour

ces

or c

hang

es o

ver t

ime,

resp

onse

s to

sur

vey

ques

tions

may

refle

ct c

hara

cter

istic

s or

exp

erie

nces

ass

ocia

ted

with

a c

over

age

sour

ce o

ther

than

the

one

assi

gned

in th

is e

xhib

it.2

Priv

ate

heal

th in

sura

nce

cove

rage

exc

lude

s pl

ans

that

pai

d fo

r onl

y on

e ty

pe o

f ser

vice

, suc

h as

acc

iden

ts o

r den

tal c

are.

3 M

edic

aid/

CHIP

als

o in

clud

es p

erso

ns c

over

ed b

y ot

her s

tate

-spo

nsor

ed h

ealth

pla

ns.

4 In

divi

dual

s w

ere

defin

ed a

s un

insu

red

if th

ey d

id n

ot h

ave

any

priv

ate

heal

th in

sura

nce,

Med

icai

d, C

HIP

, Med

icar

e, s

tate

- or o

ther

gov

ernm

ent-s

pons

ored

hea

lth p

lan,

or

mili

tary

pla

n. In

divi

dual

s w

ere

also

def

ined

as

unin

sure

d if

they

had

onl

y In

dian

Hea

lth S

ervi

ce c

over

age

or h

ad o

nly

a pr

ivat

e pl

an th

at p

aid

for o

ne ty

pe o

f ser

vice

, suc

h as

ac

cide

nts

or d

enta

l car

e.5

Due

to th

e fa

ct th

at a

hie

rarc

hy w

as u

sed

in th

is e

xhib

it to

ass

ign

indi

vidu

als

with

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

(see

not

e 1)

, the

Med

icai

d/CH

IP p

erce

ntag

es

show

n in

this

row

exc

lude

indi

vidu

als

who

als

o ha

ve M

edic

are

or p

rivat

e co

vera

ge. C

ompo

nent

s do

not

sum

to 1

00 p

erce

nt b

ecau

se n

ot a

ll co

vera

ge s

ourc

es a

re s

how

n.6

Refle

cts

info

rmat

ion

from

the

offic

e-ba

sed

and

hosp

ital o

utpa

tient

dep

artm

ent f

iles

in M

EPS.

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

MEP

S da

ta.

EXH

IBIT

44.

(co

ntin

ued)

Page 135: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn

MACStats: Medicaid and CHIP Data Book 123

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%3.

6%66

.2%

10.5

%16

.3%

Conn

ectio

n to

the

heal

th c

are

syst

em (p

ast 1

2 m

onth

s)H

as a

usu

al s

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December 2015124

Section 5: Beneficiary Health, Service Use, and Access to Care

MAC

Stat

sSe

ctio

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vidu

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ll co

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port

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st, p

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rent

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t kno

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here

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o, a

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peak

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diff

eren

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guag

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divi

dual

repo

rted

one

of t

hese

bar

riers

in th

e pa

st 1

2 m

onth

s: tr

oubl

e fin

ding

a d

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vidu

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ait t

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, ind

ivid

ual

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Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

NH

IS d

ata.

EXH

IBIT

45.

(co

ntin

ued)

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SECTION 6

Technical Guide to MACStats

Page 138: December 2015 - MACPAC...vi December 2015 Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA, Executive AssistantKathryn
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Stat

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n 6

This technical guide provides supplementary information to help readers interpret the exhibits in this data book as well as to understand the data sources and methods used. In addition, we explain why MACPAC’s statistics, particularly those on enrollment and spending, may differ from each other or from those published elsewhere.1

Interpreting Medicaid and CHIP Enrollment and Spending NumbersPublished numbers for enrollment in Medicaid and the State Children’s Health Insurance Program (CHIP) can vary substantially depending on the source of data, the enrollment period examined, and the individuals included in the data.

Data sourcesMedicaid and CHIP enrollment and spending numbers are available from data which states and the federal government compile in the course of administering these programs. Program data are updated on different schedules, so the latest year of available data may differ depending on the source. MACPAC commonly uses the following types of administrative data, which are submitted by the states to the Centers for Medicare & Medicaid Services (CMS):

• Form CMS-64 data for state-level Medicaid spending;

• Medicaid Statistical Information System (MSIS) data for person-level detail;

• Medicaid managed care enrollment reports; and

• Statistical Enrollment Data System (SEDS) data for CHIP enrollment.

In addition, CMS recently began compiling two new administrative data sources, referred to here as performance indicator enrollment data and CMS-64 enrollment data.2 Notable differences between these sources include that the performance indicator enrollment data are published monthly by CMS and only include full-benefit Medicaid and CHIP enrollees, while CMS-64 enrollment data are published quarterly and include those with limited benefits but exclude CHIP enrollees. Both sources provide more up-to-date information than the MSIS. Although timelier reporting is expected under a new version of the MSIS, referred to as the transformed MSIS (T-MSIS), full implementation has been delayed and states are still in the process of transitioning to T-MSIS reporting.

MACStats also uses nationally representative surveys based on interviews of individuals including the National Health Interview Survey (NHIS) and the Medical Expenditures Panel Survey (MEPS). Estimates of Medicaid and CHIP enrollment from survey data tend to be lower those generated from administrative data, in part because survey respondents tend to underreport Medicaid and CHIP coverage. However, survey data provide many more details on individual and family circumstances (for example, health status, ease in accessing services, reasons for delaying care) and can therefore provide a richer picture of the individuals enrolled in Medicaid and CHIP.

Enrollment period examinedCharacterizations of the size of the Medicaid and CHIP populations may vary based on the enrollment period examined. The number of individuals enrolled at a particular point during the year will be lower than the total number enrolled at any point during an entire year. Point-in-time numbers are sometimes referred to as average, full-year equivalent, or person-year enrollment. These statistics are often used for budget analyses (such as those by the CMS Office of the Actuary) and when comparing enrollment and expenditure

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numbers. Per enrollee spending levels based on full-year equivalents ensure that amounts are not biased by individuals’ transitions in and out of Medicaid coverage during the year.

Enrollees versus beneficiariesDepending on the source and the year in question, data may reflect different ways of characterizing individuals in Medicaid. Certain terms commonly used to refer to people with Medicaid coverage have extremely specific definitions in administrative data sources provided by CMS:3

• Enrollees (less commonly referred to as eligibles) are individuals who are eligible for and enrolled in Medicaid or CHIP. Prior to fiscal year (FY) 1990, CMS did not track the number of Medicaid enrollees, and tracked only beneficiaries (see below). In some cases, CMS has estimated the number of enrollees prior to 1990.

• Beneficiaries, or persons served (less commonly referred to as recipients), are enrollees who receive covered services or for whom Medicaid or CHIP payments are made. Prior to FY 1998, individuals were not counted as beneficiaries if managed care payments were the only Medicaid payments made on their behalf. Beginning in FY 1998, however, Medicaid managed care enrollees with no fee-for-service (FFS) spending were also counted as beneficiaries, which increased the number of individuals reflected in enrollment statistics. Generally, the number of beneficiaries will approach the number of enrollees as more of these individuals use Medicaid-covered services or are enrolled in managed care.4 (In common usage outside of statistical publications from CMS, the term beneficiaries typically is synonymous with enrollees.)

Institutionalized and limited-benefit enrollees Administrative Medicaid data include enrollees who are in institutions such as nursing homes, as well as individuals who receive only limited benefits (for example, only coverage for emergency services). Survey data tend to exclude such individuals from counts of coverage. In percentage terms, the difference between estimates from administrative data versus survey data tends to be largest among older beneficiaries, who are more likely to be living in institutions (in which case they are excluded from most surveys) and receiving limited Medicaid benefits that pay only for their Medicare premiums and cost sharing (which may not be counted as Medicaid coverage in some surveys).

State Children’s Health Insurance Program enrolleesMedicaid-expansion CHIP enrollees are children who are entitled to the covered services of a state’s Medicaid program, but whose Medicaid coverage is generally funded with CHIP dollars. Depending on the data source, Medicaid enrollment and spending figures may include not only Medicaid enrollees funded with Medicaid dollars, but also Medicaid-expansion CHIP enrollees funded with CHIP dollars. For MACStats, we generally exclude Medicaid-expansion CHIP enrollees from Medicaid analyses, but some data sources do not allow these children to be broken out separately.

Understanding Data on Health and Other Characteristics of Medicaid and CHIP PopulationsMACStats uses data from the federal National Health Interview Survey and the Medical Expenditures Panel Survey to describe Medicaid and CHIP enrollees in terms of their self-reported demographic, socioeconomic, and health

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characteristics as well as their use of care. Background information on these surveys is provided here, along with information on how children with special health care needs are identified using NHIS data.

National Health Interview Survey and Medical Expenditures Panel Survey dataThe NHIS is an annual face-to-face household survey of civilian non-institutionalized persons designed to monitor the health of the U.S. population through the collection of information on a broad range of health topics.5 A subsample of households that participated in the previous year’s NHIS undergo further interviews for the household component of the MEPS, which collects more detailed information on use of health care services and expenditures.6

Although other surveys are available, the NHIS is the main survey data source used in MACStats because it provides relatively timely estimates and because its sample size is large enough to produce reliable subgroup estimates and to detect meaningful differences between them. In addition, it is generally considered to be one of the best surveys for health insurance coverage estimates, and it captures detailed information on individuals’ health status.7

However, the NHIS is known to produce higher estimates of service use than the MEPS.8 As a result, MACStats includes estimates of service use from both sources. For purposes of comparing groups of individuals, the NHIS has the advantage of providing the most recent information available; for other purposes, such as measuring levels of service use relative to a particular benchmark or goal, consulting estimates from the MEPS or another source might be more appropriate.

The NHIS and MEPS have some limitations. As in most surveys, respondents do not always accurately report information about participation in programs such as Medicaid, CHIP, Medicare, Supplemental Security Income (SSI), and Social

Security Disability Insurance (SSDI). As a result, survey data may not match estimates of program participation computed from the programs’ own administrative data. In addition, although surveys typically ask about participation in Medicaid and CHIP in two different questions, program participation estimates are not reported separately. One reason for this is that many states’ CHIP and Medicaid programs use the same name, so respondents may not necessarily know which program funds their children’s coverage. Even when the programs have different names, it may be difficult for respondents and interviewers to correctly categorize the coverage. As a result, separate survey questions regarding participation in Medicaid and CHIP are generally used to minimize the undercounting of Medicaid and CHIP enrollees, not to produce valid estimates separately for each program. Thus, survey data analyses typically combine Medicaid and CHIP into a single category.

Children with special health care needsThe term, children with special health care needs (CSHCN), is defined by the U.S. Department of Health and Human Services’ Maternal and Child Health Bureau (MCHB) as a group of children who “have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”9 This definition is used by all states for policy and program planning purposes and encompasses children with disabilities and also children with chronic conditions (e.g., asthma, juvenile diabetes, sickle cell anemia) that range from mild to severe. The category of CSHCN covers a broader range of children than the category of children with conditions severe enough and family incomes low enough to qualify for SSI.10

MACPAC uses responses to several questions on the NHIS to identify such children. This definition includes children with at least one diagnosed or parent-reported condition expected to be an ongoing health condition, who also meet at least

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one of five criteria related to elevated service use or elevated need:

• The child is limited or prevented in his or her ability to do things most children of the same age can do.

• The child needs or uses medications prescribed by a doctor (other than vitamins).

• The child needs or uses specialized therapies such as physical, occupational, or speech therapy.

• The child has above-routine need or use of medical, mental health, home care, or education services.

• The child needs or receives treatment or counseling for an emotional, behavioral, or developmental problem.

Estimates for the category of CSHCN in this edition of MACStats are not directly comparable to those in MACPAC reports prior to 2013, which used a slightly different definition.11

Methodology for Adjusting Benefit Spending DataThe FY 2012 Medicaid benefit spending amounts presented in this data book were calculated based on MSIS data that have been adjusted to match total benefit spending reported by states in CMS-64 data.12 Although the CMS-64 provides a more complete accounting of spending than the MSIS and is preferred when examining state or federal spending totals, it cannot be used for analysis of benefit spending by eligibility group and other enrollee characteristics.13 Thus, we adjust MSIS amounts for several reasons:

• CMS-64 data provide an official accounting of state spending on Medicaid for purposes of receiving federal matching dollars; in contrast, MSIS data are used primarily for statistical purposes.

• The MSIS generally understates total Medicaid benefit spending because it excludes disproportionate share hospital payments and additional types of supplemental payments made to hospitals and other providers, Medicare premium payments, and certain other amounts.14

• The MSIS generally overstates net spending on prescribed drugs, because it excludes rebates from drug manufacturers.

• Even after accounting for differences in their scope and design, the MSIS still tends to produce lower total benefit spending than the CMS-64.15

• The extent to which the MSIS differs from the CMS-64 varies by state, meaning that a cross-state comparison of unadjusted MSIS amounts may not reflect true differences in benefit spending. See Exhibit 46 for unadjusted benefit spending amounts in the MSIS as a percentage of benefit spending in the CMS-64.

The methodology MACPAC uses for adjusting MSIS benefit spending data involves the following steps:

• We aggregate the service types into broad categories that are comparable between the two sources. This is necessary because there is not a one-to-one correspondence of service types in MSIS and CMS-64 data. Even service types that have identical names may still be reported differently in the two sources due to differences in the instructions given to states. Exhibit 47 provides additional detail on the categories used.

• We calculate state-specific adjustment factors for each of the service categories by dividing CMS-64 benefit spending by MSIS benefit spending.

• We then multiply MSIS dollar amounts in each service category by the state-specific factors to obtain adjusted MSIS spending. For example, in a state with an FFS hospital factor of 1.2, each Medicaid enrollee with

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hospital spending in the MSIS would have that spending multiplied by 1.2; doing so makes the sum of adjusted hospital spending amounts among individual Medicaid enrollees in the MSIS total the aggregate hospital spending reported by states in the CMS-64 (as noted later, MACPAC excludes some amounts from the CMS-64 hospital total).16

These adjustments to MSIS data are meant to provide more complete estimates of Medicaid benefit spending across states that can be analyzed by eligibility group and other enrollee characteristics. Other organizations, including the CMS Office of the Actuary, the Kaiser Commission on Medicaid and the Uninsured, and the Urban Institute, use similar methodologies although these may differ in some ways—for example, by using different service categories or producing estimates for future years based on actual data for earlier years.

Readers should note that due to changes in both methods and data, MSIS figures shown here are not directly comparable to earlier years. Key differences between the current and previous methodologies include the following:

• In the 2014 and 2015 editions of MACStats, we excluded disproportionate share hospital (DSH) payments from CMS-64 totals used to adjust MSIS spending. In earlier editions, DSH payments were included in CMS-64 totals. The rationale for doing so was that DSH payments are used to support hospitals that serve a large number of low-income and Medicaid patients, and could therefore be partially attributed to Medicaid enrollees in the MSIS. However, an examination of annual DSH report data submitted by states indicates that for some hospitals, Medicaid DSH payments far exceed their uncompensated care costs for Medicaid patients and may therefore be attributed largely to uninsured patients.17 As a result, we now exclude DSH payments from CMS-64 totals when we adjust MSIS spending.

• In the 2015 edition, we exclude incentive and uncompensated care pool payments made under Section 1115 waiver expenditure authority from CMS-64 totals used to adjust MSIS spending.18 In earlier editions, these payments were included in CMS-64 totals. Because these payments may be made for purposes other than Medicaid patient costs, we now exclude them when we adjust MSIS spending.

• In the 2015 edition, we shifted a portion of drug rebate amounts in the CMS-64 from fee for service to managed care for a small number of states that, despite reporting drug utilization data for managed care, reported little or no drug rebates for managed care.

• In the 2014 and 2015 editions, we obtained a more precise separation of home- and community-based services (HCBS) waiver spending in the MSIS, due to the use of more detailed MSIS data files than in editions of MACStats prior to 2014.

With regard to changes in data, complete MSIS Annual Person Summary (APS) files have not been available in a timely manner for use in the 2014 and 2015 editions of MACStats. Therefore, we calculated spending and enrollment from the full MSIS data files that are used to create APS files. In general, our calculations closely match those used to create the APS. However, our development of enrollment counts is a notable exception. In MACPAC’s analysis of the full MSIS data files, Medicaid enrollees were assigned a unique national identification (ID) number using an algorithm that incorporates state-specific ID numbers and beneficiary characteristics such as date of birth and gender. The state and national enrollment counts were then unduplicated using this national ID, which results in MACPAC reporting slightly lower enrollment counts than would be the case had we used APS files.

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State

Benefit spending totals included in analysis

Amounts excluded from CMS-64 benefit spending totals

Unadjusted MSIS CMS-64

MSIS as a percentage of CMS-64 DSH

Incentive and uncompensated

care pool waivers

Total $365,746 $389,456 93.9% $17,076 $8,624Alabama 4,107 4,569 89.9 458 –Alaska 1,294 1,331 97.3 20 –Arizona 8,223 7,516 109.4 195 194Arkansas 3,457 4,093 84.5 61 5California 35,154 45,504 77.3 2,102 2,560Colorado 3,688 4,534 81.3 189 –Connecticut 5,882 6,281 93.6 478 –Delaware 1,569 1,472 106.6 13 –District of Columbia 2,197 2,050 107.2 61 –Florida 18,865 16,602 113.6 365 939Georgia 9,098 8,110 112.2 416 –Hawaii 1,448 1,465 98.8 – 27Idaho 1,459 1,428 102.1 23 –Illinois 13,274 12,949 102.5 444 –Indiana 6,453 7,487 86.2 -1 –Iowa 3,391 3,439 98.6 52 4Kansas 2,559 2,593 98.7 74 –Kentucky 5,529 5,493 100.7 208 –Louisiana 5,587 6,625 84.3 733 –Maine 1,902 2,372 80.2 41 –Maryland 7,214 7,650 94.3 36 –Massachusetts 10,609 11,994 88.5 – 931Michigan 11,750 12,184 96.4 276 –Minnesota 8,654 8,846 97.8 48 –Mississippi 3,732 4,255 87.7 211 –Missouri 6,464 7,971 81.1 756 –Montana 807 955 84.5 17 –Nebraska 1,630 1,680 97.0 42 –Nevada 1,377 1,653 83.3 86 –New Hampshire 1,047 1,145 91.4 42 –New Jersey 8,752 9,146 95.7 1,243 –New Mexico 2,520 3,374 74.7 56 –

EXHIBIT 46. Medicaid Benefit Spending in MSIS and CMS-64 Data by State, FY 2012 (millions)

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State

Benefit spending totals included in analysis

Amounts excluded from CMS-64 benefit spending totals

Unadjusted MSIS CMS-64

MSIS as a percentage of CMS-64 DSH

Incentive and uncompensated

care pool waivers

New York $48,151 $49,668 96.9% $3,250 $387North Carolina 9,919 11,972 82.9 310 –North Dakota 766 743 103.0 1 –Ohio 15,752 15,808 99.7 544 –Oklahoma 3,732 4,606 81.0 36 –Oregon 3,756 4,518 83.1 69 –Pennsylvania 17,793 19,232 92.5 1,162 –Rhode Island 1,497 1,727 86.7 128 1South Carolina 4,644 4,391 105.8 457 –South Dakota 744 749 99.4 1 –Tennessee 12,216 7,520 162.5 102 1,176Texas 22,117 24,375 90.7 1,516 2,394Utah 2,365 1,870 126.5 33 –Vermont 1,077 1,311 82.1 37 5Virginia 6,005 6,692 89.7 215 –Washington 6,255 7,168 87.3 392 –West Virginia 3,049 2,714 112.3 75 –Wisconsin 5,641 7,096 79.5 0 –Wyoming 582 528 110.1 0 –

Notes: MSIS is Medicaid Statistical Information System. FY is fiscal year. DSH is disproportionate share hospital. Includes federal and state funds. MSIS and CMS-64 data reflect unadjusted amounts as reported by states. Both sources exclude spending on administration, the territories, and Medicaid-expansion CHIP enrollees; in addition, CMS-64 amounts exclude $8.0 billion in offsetting collections from third-party liability, estate, and other recoveries. See https://www.macpac.gov/macstats/data-sources-and-methods/ for a discussion of differences between MSIS and CMS-64 data. Beginning with the 2014 edition of MACStats, DSH payments were excluded from CMS-64 totals used to adjust MSIS spending; beginning with the 2015 edition, incentive and uncompensated care pool payments made under Section 1115 waiver authority were also excluded. For informational purposes, the DSH and waiver expenditure amounts that were excluded are shown here.

– Dash indicates zero; $0 indicates an amount less than $0.5 million that rounds to zero; negative sign indicates that state reported an amount less than zero (which may reflect, for example, a correction to an amount reported in a prior period).

Source: MACPAC, 2015, analysis of MSIS data as of December 2014 and CMS-64 Financial Management Report (FMR) net expenditure data as of June 2015.

EXHIBIT 46. (continued)

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Service category MSIS service types1 CMS-64 service typesHospital • Inpatient hospital

• Outpatient hospital• Inpatient hospital non-DSH• Inpatient hospital non-DSH supplemental

payments• Inpatient hospital GME payments• Outpatient hospital non-DSH• Outpatient hospital non-DSH supplemental

payments• Emergency services for aliens2

• Emergency hospital services• Critical access hospitals

Non-hospital acute care

• Physician• Dental• Nurse-midwife• Nurse practitioner• Other practitioner• Non-hospital outpatient clinic• Lab and X-ray• Sterilizations• Abortions• Hospice• Targeted case management• Physical, occupational, speech, and

hearing therapy• Non-emergency transportation• Private duty nursing• Rehabilitative services• Other care, excluding HCBS waiver

• Physician• Physician services supplemental payments• Dental• Nurse-midwife• Nurse practitioner• Other practitioner • Other practitioner supplemental payments• Non-hospital clinic• Rural health clinic• Federally qualified health center• Lab and X-ray• Sterilizations• Abortions• Hospice• Targeted case management• Statewide case management• Physical therapy• Occupational therapy• Services for speech, hearing, and language• Non-emergency transportation• Private duty nursing• Rehabilitative services (non-school-based)• School-based services• EPSDT screenings• Diagnostic screening and preventive services• Prosthetic devices, dentures, eyeglasses• Freestanding birth center• Health home with chronic conditions• Tobacco cessation for pregnant women• Care not otherwise categorized

Drugs • Drugs (gross spending) • Drugs (gross spending)• Drug rebates

EXHIBIT 47. Service Categories Used to Adjust FY 2012 Medicaid Benefit Spending in the MSIS to Match CMS-64 Totals

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Service category MSIS service types1 CMS-64 service typesManaged care and premium assistance

• HMO (i.e., comprehensive risk based managed care; includes PACE)

• PHP• PCCM

• MCO (i.e., comprehensive risk-based managed care)

• MCO drug rebates• PACE• PAHP• PIHP• PCCM• Premium assistance for private coverage

LTSS non-institutional • Home health• Personal care• HCBS waiver

• Home health• Personal care• Personal care—1915(j)• HCBS waiver• HCBS—1915(i)• HCBS—1915(j)

LTSS institutional • Nursing facility• ICF/ID• Inpatient psychiatric for individuals

under age 21• Mental health facility for individuals

age 65 and older

• Nursing facility• Nursing facility supplemental payments• ICF/ID• ICF/ID supplemental payments• Mental health facility for individuals under age

21 or age 65 and older, non-DSH

Medicare3, 4 • Medicare Part A and Part B premiums• Medicare coinsurance and deductibles for QMBs

Notes: FY is fiscal year. MSIS is Medicaid Statistical Information System. DSH is disproportionate share hospital. GME is graduate medical education. HCBS is home and community-based services. EPSDT is Early and Periodic Screening, Diagnostic, and Treatment. HMO is health maintenance organization. PACE is Program of All-Inclusive Care for the Elderly. PHP is prepaid health plan. PCCM is primary care case management. MCO is managed care organization. PAHP is prepaid ambulatory health plan (a type of PHP). PIHP is prepaid inpatient health plan (a type of PHP). LTSS is long-term services and supports. ICF/ID is intermediate care facility for persons with intellectual disabilities. QMB is qualified Medicare beneficiary.

Service categories and types reflect fee-for-service spending unless noted otherwise. Service types with identical names in MSIS and CMS-64 data may still be reported differently in the two sources due to differences in the instructions given to states; amounts for those that appear only in the CMS-64 (e.g., drug rebates) are distributed across Medicaid enrollees with MSIS spending in the relevant service categories (e.g., drugs).1 Claims in the MSIS include both a service type (such as inpatient hospital, physician, personal care, etc.) and a program type (including HCBS waiver). When adjusting MSIS data to match CMS-64 totals, we count all claims with an HCBS waiver program type as HCBS waiver, regardless of their specific service type. Among claims with an HCBS waiver program type, the most common service types are other, home health, rehabilitation, and personal care.2 Emergency services for aliens are reported under individual service types throughout the MSIS, but primarily inpatient and outpatient hospital. As a result, we include this CMS-64 amount in the hospital category. 3 Medicare premiums are not reported in the MSIS. We distribute CMS-64 amounts proportionately across dually eligible enrollees in the MSIS for each state.4 Medicare coinsurance and deductibles are reported under individual service types throughout the MSIS. We distribute CMS-64 amount for QMBs across CMS-64 spending in the hospital, non-hospital acute, and LTSS institutional categories prior to calculating state-level adjustment factors, based on the distribution of Medicare cost sharing for hospital, Part B, and skilled nursing facility services among QMBs in 2010 Medicare data. See MedPAC and MACPAC, 2015, Data book: Beneficiaries dually eligible for Medicare and Medicaid, Table 4, fee-for-service Medicare Part A and Part B cost sharing incurred by dually eligible and non-dually eligible Medicare beneficiaries, https://www.macpac.gov/wp-content/uploads/2015/01/Duals_DataBook_2015-01.pdf.

Source: MACPAC, 2015, analysis of MSIS and CMS-64 Financial Management Report (FMR) net expenditure data.

EXHIBIT 47. (continued)

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Understanding Managed Care Enrollment and Spending DataThere are four main sources of data on Medicaid managed care available from CMS.

• Medicaid Managed Care Data Collection System (MMCDCS). The MMCDCS provides state-reported aggregate enrollment statistics and other basic information for each managed care plan within a state. CMS uses the MMCDCS to create an annual Medicaid managed care enrollment report, which is the source of information on Medicaid managed care most commonly cited by CMS, as well as by outside analysts and researchers.

• MSIS. The MSIS provides person-level and claims-level information for all Medicaid enrollees. For managed care, MSIS claims include records of each capitated payment made on behalf of an enrollee to a managed care plan (generally referred to as capitated claims), as well as records of each service received by the enrollee from a provider under contract with a managed care plan (which generally do not include payment amounts and may be referred to as encounter or dummy claims). All states collect encounter data from their Medicaid managed care plans, but some do not report them in the MSIS. Managed care enrollees may also have FFS claims in the MSIS if they used services beyond those covered by a managed care plan’s contract with the state.

• CMS-64. The CMS-64 Financial Management Report (FMR) provides aggregate spending information for Medicaid by major benefit categories, including managed care. The spending amounts reported by states on the CMS-64 are used to calculate their federal matching dollars.

• Statistical Enrollment Data System (SEDS). The SEDS provides aggregate statistics on CHIP enrollment and child Medicaid

enrollment that include the number covered under FFS and managed care systems. The SEDS is the only comprehensive source of information on managed care participation among separate CHIP enrollees across states.

Although the annual Medicaid managed care enrollment report generally contains the most recent information available from CMS on Medicaid managed care for all states, it does not provide information on many characteristics of enrollees in managed care (e.g., basis of eligibility and demographics such as age, sex, race, and ethnicity). It does provide information on whether individuals are dually eligible for Medicare. As a result, MACStats also includes statistics based on MSIS and CMS-64 data, such as the percentage of individuals enrolled in managed care by eligibility group and the percentage of Medicaid benefit spending attributable to managed care.

When examining managed care statistics from various sources, the following issues should be noted:

• Figures in the annual Medicaid managed care enrollment report published by CMS include Medicaid-expansion CHIP enrollees. Although we generally exclude these children (about 2 million, depending on the time period) from Medicaid analyses in MACStats, it is not possible to do so with CMS’s annual Medicaid managed care enrollment report data.19

• The types of managed care reported by states may differ somewhat between the Medicaid managed care enrollment report and the MSIS. For example, some states report a small number of enrollees in comprehensive risk-based managed care in one data source but not the other. Anomalies in MSIS data are documented by CMS as it reviews each state’s quarterly submission, but all issues may not be identified in this process.

• The Medicaid managed care enrollment report provides point-in-time figures. In contrast, MSIS data allow for reporting on the number of enrollees ever in managed care during a fiscal year or other period of time.

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Endnotes1 For technical guides to earlier editions of MACStats, see MACPAC’s June reports to Congress, which are accessible through the publications page of the MACPAC website; https://www.macpac.gov/publication/.2 CMS has been collecting Medicaid and CHIP performance indicator data on key processes related to eligibility and enrollment since late 2013. In part because the new Medicaid and CHIP performance indicator enrollment data do not identify newly eligible individuals for whom there is a higher federal matching rate, CMS is using a separate process to collect monthly Medicaid enrollment by eligibility category when states submit their CMS-64 quarterly expenditures. Specifically, a new CMS-64 enrollment form has been created to accompany the current expenditure forms. While enrollment is submitted at the same time as expenditures, there is not a direct link between the amount of federal expenditures claimed by states and the number of enrollees reported. Instead, CMS uses CMS-64 enrollment data for monitoring and oversight purposes.3 See, for example, Centers for Medicare & Medicaid Services (CMS), 2010, Medicare & Medicaid statistical supplement, 2010 edition, Brief summaries and glossary, Baltimore, MD: CMS, http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/2010.html. 4 States make capitated payments for all individuals enrolled in managed care plans, even if no health care services are used. Therefore, all managed care enrollees currently are counted as beneficiaries or persons served, regardless of whether or not they have any health service use.5 Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, 2015, About the National Health Interview Survey, http://www.cdc.gov/nchs/nhis/about_nhis.htm. 6 Agency for Health Care Research and Quality (AHRQ), U.S. Department of Health and Human Services, 2015, Medical Expenditures Panel Survey: Survey background, http://meps.ahrq.gov/mepsweb/about_meps/survey_back.jsp. 7 Kenney, G., and V. Lynch, 2010, Monitoring children’s health insurance coverage under CHIPRA using federal surveys, in Databases for estimating health insurance coverage for children: A workshop summary, edited by T.J. Plewes, Washington, DC: The National Academies Press. http://www.nap.edu/catalog/13024.html.8 Rhoades, J.A., J.W. Cohen, and S.R. Machlin, 2010, Methodological comparison of estimates of ambulatory health care use from the Medical Expenditure Panel Survey and other data sources, in JSM Proceedings, Section on Health Policy, Alexandria, VA: American Statistical Association, 2828–2837, https://www.amstat.org/sections/srms/proceedings/y2010/Files/307444_58577.pdf. 9 McPherson, M., et al., 1998, A new definition of children with special health care needs, Pediatrics 102: 137–140.

10 For children under age 18 to be determined disabled under SSI rules, the child must have at least one medically determinable physical or mental impairment that causes marked and severe functional limitations and that can be expected to cause death or last at least 12 months (§1614(a)(3)(C)(i) of the Social Security Act).11 For full details on the definition of CSHCN, see Medicaid and CHIP Payment and Access Commission (MACPAC), 2014, Technical guide to the June 2014 MACStats, in Report to the Congress on Medicaid and CHIP, June 2014, Washington, DC: MACPAC, https://www.macpac.gov/wp-content/uploads/2015/03/June-2014-MACStats.pdf.12 Medicaid benefit spending reported here excludes amounts for Medicaid-expansion CHIP enrollees, the territories, administrative activities, the Vaccines for Children program (which is authorized by the Medicaid statute but operates as a separate program), and offsetting collections from third-party liability, estate, and other recoveries.13 For a discussion of these data sources, see Medicaid and CHIP Payment and Access Commission (MACPAC), 2011, Improving Medicaid and CHIP data for policy analysis and program accountability, in Report to the Congress on Medicaid and CHIP, March 2011, Washington, DC: MACPAC, https://www.macpac.gov/wp-content/uploads/2015/01/MACPAC_March2011_web.pdf.14 Some of these amounts, including certain supplemental payments to hospitals and drug rebates, are lump sums that are not paid on a claim-by-claim basis for individual Medicaid enrollees. Nonetheless, we refer to these CMS-64 amounts as benefit spending, and the adjustment methodology described here distributes them across Medicaid enrollees with MSIS spending in the relevant service categories.15 U.S. Government Accountability Office (GAO), 2012, Medicaid: Data sets provide inconsistent picture of expenditures, Washington, DC: GAO, http://www.gao.gov/assets/650/649733.pdf; National Research Council, 2010, Administrative databases, in Databases for estimating health insurance coverage for children: A workshop summary, edited by T.J. Plewes, Washington, DC: The National Academies Press. http://www.nap.edu/catalog/13024.html16 The sum of adjusted MSIS benefit spending amounts for all service categories totals CMS-64 benefit spending, exclusive of offsetting collections from third-party liability, estate, and other recoveries. These collections are not reported by type of service in the CMS-64 and are not reported at all in the MSIS.17 See Centers for Medicare & Medicaid Services (CMS), 2015, Medicaid disproportionate share hospital (DSH) payments, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Financing-and-Reimbursement/Medicaid-Disproportionate-Share-Hospital-DSH-Payments.html.18 For more on these payments, see Medicaid and CHIP Payment and Access Commission (MACPAC), 2015, Using Medicaid supplemental payments to drive delivery system reform, in Report to Congress on Medicaid and CHIP, June 2015, Washington, DC: MACPAC, https://www.macpac.gov/wp-content/uploads/2015/06/Using-Medicaid-Supplemental-Payments-to-Drive-Delivery-System-Reform.pdf.

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19 We generally exclude children enrolled in Medicaid-expansion CHIP from Medicaid analyses because their funding stream (CHIP, under Title XXI of the Social Security Act) differs from that of other Medicaid enrollees (Medicaid, under Title XIX). In addition, spending (and often enrollment) for the Medicaid-expansion CHIP population is reported by CMS in CHIP statistics, along with information on separate CHIP enrollees.

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