Chapter
Auto Assignment in Medicaid Managed Care
Federal Spending for Medicaid Managed Care Was Over $100 Billion in 2014, and Selected States’ Payments to Managed Care Organizations Varied Widely
Federal Spending for Medicaid Managed Care Represented 38 Percent of Total Federal Medicaid Spending in 2014
Total and Average per Beneficiary Payments Varied Considerably across Selected States, with Differences in Covered Populations and Services Contributing to the Variation
Over Half of Selected States Set Medical Loss Ratio Minimums Similar to Federal Standards for Other Coverage Types, with Some Variation in Calculation Methods
Selected States’ Auto Assignment Methods Primarily Focused on Beneficiary Factors, and Then Considered Plan Performance and Program Goals
Appendix I: Selected States’ Comprehensive Risk-Based Managed Care Programs
Appendix II: Federal Expenditures on Managed Care as Percent of Total Medicaid Expenditures, Fiscal Years 2004 and 2014
Appendix III: Selected States’ Methods for Overseeing Quality in Medicaid Managed Care
Quality Performance Measures
Sanctions for Not Meeting Required Targets on Quality Measures
Incentives for Performance on Quality Measures
Accreditation Requirements
Other Quality Oversight Activities
End Notes for Appendix III
Medicaid Program Integrity: Improved Guidance Needed to Better Support Efforts to Screen Managed Care Providers*
Selected States and Medicaid Managed Care Plans Face Significant Challenges Screening Providers
Efforts to Screen Providers Are Based on Information that Is Fragmented across Multiple and Disparate Federal Databases
Screening Efforts Are Hampered by Difficulties Accessing and Using Databases
Accessing Particular Databases
Confirming Identified Matches
Selected States and Medicaid Managed Care Plans Use Inconsistent Practices to Make Data on Ineligible Providers Publicly Available
Recommendations for Executive Action
Agency and Third-Party Comments and Our Evaluation
Appendix I: Descriptions of Federal Databases Selected States and Medicaid Managed Care Plans Use to Screen Providers
Medicaid: Service Utilization Patterns for Beneficiaries in Managed Care*
Delivery Models for Medicaid Services
Efforts to Analyze Utilization Using Medicaid Encounter Data
Factors Affecting Medicaid Managed Care Service Utilization
Beneficiaries’ Service Utilization Varied by State, Population, Service Categories, and Length of Enrollment for Selected States
Adult Service Utilization Ranged from 13 to 55 Services per Beneficiary per Year in Selected States
Child Service Utilization Ranged from 6 to 16 Services per Beneficiary per Year in Selected States, and was Significantly Higher for Partial-Year Beneficiaries
Appendix I: Detailed Scope and Methodology
Step 2: Beneficiary and Service Identification
Step 3: Utilization Calculation
Study Limitations and State Technical Comments
Appendix II: Service Utilization Patterns
for Beneficiaries in Comprehensive Managed Care, 2010
Appendix III: Percentage of Partial-Year Beneficiaries in Selected States in 2010
Medicaid Managed Care: Expenditures, Screening of Providers, and Utilization Patterns
( Health Care in Transition )
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