MEDICAID PAYMENT

Comparisons of 

Selected Services 

under Fee-forService, Managed 

Care, and Private 

Insurance

Report to Congressional Committees

July 2014

GAO-14-533

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-533, a report to 

congressional committees

July 2014

MEDICAID PAYMENT

Comparisons of Selected Services under Fee-for- Service, Managed Care, and Private Insurance

Why GAO Did This Study

Medicaid provided health coverage for 

over 70 million individuals in fiscal year 

2013 through a combination of FFS 

and managed care at a cost of about 

$460 billion. Yet, limited information is 

available on how provider payments 

per service under Medicaid FFS and 

managed care compare with private 

insurance and with one another. This 

report builds on a prior GAO study on

Medicaid payments by comparing 

payments for E/M services under 

Medicaid FFS, managed care, and 

private insurance prior to 2013, when 

temporary Medicaid payment 

increases for these services took 

effect, as mandated by HCERA.

In this report, GAO examines: (1) how 

payments for E/M services under 

Medicaid FFS and Medicaid managed 

care compared with private health 

insurance prior to the HCERAmandated increases; and (2) how 

payments for E/M services under 

Medicaid managed care compared 

with Medicaid FFS prior to the HCERAmandated increases.

To compare these payments, GAO 

analyzed claims data from Medicaid 

FFS, managed care organizations, and 

private insurers. GAO compared 

payments to physicians for 26 E/M 

services in selected states, chosen on 

the basis of data availability. GAO 

compared Medicaid FFS payments 

with private insurance in 40 states; 

Medicaid managed care with private 

insurance in 23 states; and Medicaid 

managed care with Medicaid FFS in 

20 states. Results were based 

primarily on 2010 data—the most 

recent Medicaid FFS data available for 

most states—but 2009 data were used 

when 2010 data were unavailable. 

What GAO Found

Payments to physicians under Medicaid fee-for-service (FFS) and managed care

for the 26 evaluation and management (E/M) services, such as office visits and 

emergency care, that GAO reviewed were generally lower than private insurance 

prior to the temporary increases mandated by the Health Care and Education 

Reconciliation Act of 2010 (HCERA). Specifically, in the 40 states where GAO 

compared Medicaid FFS payments to private insurance, FFS payments were 27 

to 65 percent lower than private insurance in 31 states; and in the 23 states 

where GAO compared managed care payments to private insurance, managed 

care payments were 31 to 65 percent lower than private insurance in 18 states. 

Among the three types of E/M services analyzed (office visits, hospital care, and 

emergency care), Medicaid payments generally were lower than private 

insurance for all three types, but the magnitude of the difference was often 

largest for emergency care and smallest for office visits.

Within the Medicaid program, managed care payments for E/M services were 

generally equal to or higher than FFS prior to the HCERA-mandated increases. 

Specifically, in the 20 states where GAO compared managed care payments to 

FFS, managed care payments were 0 to 12 percent higher than FFS in 15 states. 

Managed care payments for emergency care and hospital care were 

approximately equal to FFS payments in most states, while office visits showed 

more variation.

Medicaid Managed Care Payments for Evaluation and Management Services Relative to 

Medicaid Fee-for-Service in Selected States

Note: To safeguard confidential information, results were excluded from the figure for 2 of the 20 

selected states where the number of Medicaid managed care organizations was limited.

View GAO-14-533. For more information, 

contact Carolyn L. Yocom at (202) 512-7114 

or yocomc@gao.gov.
Page i GAO-14-533 Medicaid Payment

Letter 1 

Background 6

Medicaid Payments for Evaluation and Management Services 

Were Generally Lower than Private Insurance Prior to 

Mandated Increases 7

Medicaid Managed Care Payments for Evaluation and 

Management Services Were Generally Equal to or Higher than 

Medicaid Fee-for-Service Prior to Mandated Increases 11

Concluding Observations 14

Agency Comments 14

Appendix I List of 26 Selected Evaluation and Management Services 17

Appendix II Payment Comparisons for Evaluation and Management Services 18

Appendix III Variation in Relative Payments within Three Types of Evaluation 

and Management Services 23

Appendix IV GAO Contact and Staff Acknowledgments 26

Tables

Table 1: List of 26 Selected Evaluation and Management 

Services, by Type of Service 17

Table 2: Medicaid Fee-for-Service Payments for Evaluation and 

Management Services Relative to Private Insurance in 

Selected States, by Type of Service 19

Table 3: Medicaid Managed Care Payments for Evaluation and 

Management Services Relative to Private Insurance in 

Selected States, by Type of Service 21

Table 4: Medicaid Managed Care Payments for Evaluation and 

Management Services Relative to Medicaid Fee-forService in Selected States, by Type of Service 22

Contents
Page ii GAO-14-533 Medicaid Payment

Table 5: Variation in Medicaid Fee-for-Service Payments for 

Evaluation and Management Services Relative to Private

Insurance in Selected States, by Type of Service 24

Table 6: Variation in Medicaid Managed Care Payments for 

Evaluation and Management Services Relative to Private 

Insurance in Selected States, by Type of Service 24

Table 7: Variation in Medicaid Managed Care Payments for 

Evaluation and Management Services Relative to 

Medicaid Fee-for-Service in Selected States, by Type of 

Service 25

Figures

Figure 1: Medicaid Fee-for-Service Payments for Evaluation and 

Management Services Relative to Private Insurance in 

Selected States, by Type of Service 9

Figure 2: Medicaid Managed Care Payments for Evaluation and 

Management Services Relative to Private Insurance in 

Selected States, by Type of Service 10

Figure 3: Medicaid Managed Care Payments for Evaluation and 

Management Services Relative to Medicaid Fee-forService in Selected States, by Type of Service 13
Page iii GAO-14-533 Medicaid Payment

Abbreviations

CMS Centers for Medicare & Medicaid Services

CPT Current Procedural Terminology®

ED emergency department

E/M evaluation and management

FFS fee-for-service 

HCERA Health Care and Education Reconciliation Act of 2010

MAX Medicaid Analytic eXtract

MC managed care

MCO managed care organization

MedPAC Medicare Payment Advisory Commission

This is a work of the U.S. government and is not subject to copyright protection in the 

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without further permission from GAO. However, because this work may contain 

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Page 1 GAO-14-533 Medicaid Payment

441 G St. N.W.

Washington, DC 20548

July 15, 2014

Congressional Committees

Medicaid, a joint federal-state program for certain low-income individuals, 

provided health care coverage for over 70 million individuals in fiscal year 

2013 through a combination of fee-for-service (FFS) and managed care 

at a total cost of about $460 billion.1 Despite the size of the Medicaid 

program, limited information is available on how payments per service 

under Medicaid FFS and managed care compare with private insurance 

and with one another.2 A previous GAO study used claims data to 

calculate Medicaid FFS payments for certain services and compared 

them with states’ FFS fee schedules.3

 

1

Under FFS, Medicaid pays providers for each service provided to a Medicaid beneficiary. 

Under managed care, states typically contract with managed care organizations (MCO) to 

provide some or all Medicaid-covered services to beneficiaries. The state pays the MCO a 

set amount per beneficiary per month to provide all covered services and, in turn, the 

MCO pays providers for the services. As of July 2011, about 57 percent of Medicaid 

beneficiaries were enrolled in Medicaid MCOs.

In this report, we build on that prior 

work and use claims data to calculate and compare payments to 

physicians for selected evaluation and management (E/M) services under 

different payers—Medicaid FFS, Medicaid managed care, and private 

insurance. The payment comparisons we present are not sufficient to 

assess the adequacy of payments made by a given payer, or whether 

one payer delivers care more or less efficiently than another. However, 

these comparisons can contribute to broader understanding of Medicaid 

payments and enhance program knowledge for the Centers for Medicare 

& Medicaid Services (CMS)—the agency that oversees the Medicaid 

program—as well as inform states and other policy makers. Furthermore, 

comparing payments prior to 2013 for E/M services can help provide a 

useful baseline for tracking the impact of the temporary Medicaid 

payment increases for these services in 2013 and 2014, which were 

2

Throughout this report, we use the term “payments” to refer to “payments per service.” 

3

In our previous study, we demonstrated that claims data have the potential to provide a 

more complete representation of payments per service than do fee schedules, as 

claims data capture both the distribution and frequency of actual payments to providers. 

See GAO, Medicaid: Use of Claims Data for Analysis of Provider Payment Rates, 

GAO-14-56R (Washington, D.C.: Jan. 6, 2014).
 

Page 2 GAO-14-533 Medicaid Payment

mandated by the Health Care and Education Reconciliation Act of 2010 

(HCERA).4

We prepared this report under the authority of the Comptroller General to 

conduct work on GAO’s initiative to assist Congress with its oversight 

responsibilities, which include oversight of the Medicaid program. This 

report describes: (1) how payments for E/M services under Medicaid FFS 

and managed care compared with private health insurance prior to the 

HCERA-mandated increases; and (2) how payments for E/M services 

under Medicaid managed care compared with Medicaid FFS prior to the 

HCERA-mandated increases.

To describe how payments for E/M services under Medicaid FFS and 

managed care compared with private insurance, and how Medicaid 

managed care payments compared with Medicaid FFS, we used claims 

data from the Medicaid Analytic eXtract (MAX) files,5 selected Medicaid 

managed care organizations (MCO), and the Truven Health Analytics 

MarketScan® Commercial Claims and Encounters Database.

6

 

4

HCERA required that Medicaid payments for E/M services, as well as certain vaccines, 

furnished by family physicians, internists, and pediatricians during calendar years 2013 

and 2014 must not be less than Medicare payments for these services. In implementing 

this requirement, the federal government must provide 100 percent of the funding for any 

increase in payments above the amount that the state’s Medicaid program would have 

paid as of July 1, 2009. Pub. L. No. 111-152, § 1202, 124 Stat. 1029, 1052 (2010). This 

requirement resulted in a Medicaid payment increase for these services in all but two 

states. See S. Zuckerman and D. Goin, How Much Will Medicaid Physician Fees for 

Primary Care Rise in 2013? Evidence from a 2012 Survey of Medicaid Physician Fees

(Washington, D.C.: Kaiser Commission on Medicaid and the Uninsured, December 2012).

We 

generally reported on data from 2010—the most recent year for which 

Medicaid FFS data were available for most states at the time of our 

analysis—however, we reported on 2009 data for the limited number of 

states in which 2010 Medicaid FFS data were unavailable. We analyzed 

5

MAX files are compiled based on data submitted from each state’s Medicaid agency, and 

include information on each Medicaid FFS service rendered during a given calendar year

and the payment for each service. We analyzed Beta-MAX files, which are preliminary 

versions of the MAX files, for states where these files were available, but the MAX files 

were not.

6

The Truven Health Analytics MarketScan Commercial Claims and Encounters Database 

contains claims for over 50 million individuals paid by over 100 private insurers across 50 

states and the District of Columbia in 2010. 
 

Page 3 GAO-14-533 Medicaid Payment

claims data for professional services that were paid on a per-service 

basis.7

We based our analysis of payments for E/M services on 26 of the 143 

E/M services identified in the 2010 Current Procedural Terminology® 

(CPT) guide. We selected these 26 services because they were used by 

Medicaid FFS, Medicaid managed care, and private insurance across a 

large number of states. Using these 26 selected services, we compared 

Medicaid FFS payments with private insurance in 40 states; Medicaid 

managed care payments with private insurance in 23 states; and 

Medicaid managed care payments with Medicaid FFS in 20 states.8

Collectively, these 26 services accounted for over 80 percent of national 

Medicaid FFS utilization and spending on E/M services in 2009.9 We 

grouped these selected services into the following 3 types of E/M services 

based on their definition in the 2010 CPT guide: (1) office visits, 

(2) hospital care, and (3) emergency care.10

 

7

Specifically, our analysis did not include institutional claims, which may capture the 

separate amount paid to a facility to cover overhead costs, or claims for services paid on a 

capitated or bundled basis. We also excluded claims for which there was more than one 

payer (such as those paid by both Medicaid and Medicare) and, to ensure the reliability of 

the data, excluded claims with a payment less than or equal to $0 and those that may not 

have been properly adjusted. Lastly, to help ensure that our analysis reflected the 

payments of standard Medicaid programs, we excluded claims for Medicaid beneficiaries 

identified in the MAX or Beta-MAX data, or by Medicaid MCOs as those enrolled in special 

programs, such as home and community based services waiver programs, and those 

beneficiaries with unknown eligibility.

To safeguard confidential 

information when presenting our state-level results, we omitted certain 

states that did not meet the minimum requirements to protect the 

8

We did not have data for all 26 E/M services in all 50 states and the District of Columbia 

for several reasons. For example, some states did not have Medicaid FFS data for all 26 

services because these states covered most of their population under Medicaid managed 

care. Additionally, we did not have Medicaid managed care data for several states due to 

the limited number of MCOs from which we collected data.

9

These utilization and spending percentages were calculated using 2009 Medicaid FFS 

data—the most recent year with data for all states—after performing the exclusions 

described above in footnote 7.

10Our selected services consist of 13 office visit services (including office or other 

outpatient visits, and office or other outpatient consultations), 8 hospital care services 

(including initial and subsequent hospital care, and inpatient consultations), and 5 

emergency care services (including emergency department visits and critical care). See 

table 1 in appendix I for a list of the services in each type of E/M service.
 

Page 4 GAO-14-533 Medicaid Payment

confidentiality of entities that contributed private insurance data, and we 

also masked the identity of certain other states where the number of 

Medicaid managed care organizations was limited.

To help ensure that the payments we calculated for Medicaid FFS, 

Medicaid managed care, and private insurance were comparable and did 

not reflect payment differences based on factors such as provider type, 

care setting, and beneficiary age,11 we restricted our analysis to claims for 

services provided by physicians to adults in a specific setting, such as an 

office, hospital, or emergency department (ED).12 After applying these 

restrictions, we calculated the percentage difference in the median 

payment between payers for each service in each state. To summarize 

these results for a given state, we calculated the median percentage 

difference across all 26 E/M services and by type of service, weighted by 

2009 national Medicaid FFS spending on each service.13

Our analysis of the available data has five technical limitations:

To assess the 

reliability of the claims data we used in our analysis, we reviewed related 

documentation; interviewed knowledgeable officials from CMS, its 

contractor responsible for producing MAX data, each Medicaid MCO from 

which we received data, and Truven Health Analytics; and checked each 

data set for obvious errors. We determined that these data were 

sufficiently reliable for the purposes of our analysis. 

 

11We previously found that some states varied payments based several factors, including 

provider type, care setting, and beneficiary age. GAO-14-56R. 

12The specific setting to which we restricted our analysis varied by type of service: for 

office visits, we restricted to services provided in an office; for hospital care, we restricted 

to services provided in a hospital; and for emergency care, we restricted to services 

provided in an ED, except for critical care services, which we restricted to either an ED or 

a hospital. We chose to restrict to adults (instead of children), because over half of claims 

were for adults for a majority of our 26 selected services (and for all 26 services, at least a 

quarter of claims were for adults). For all 26 services, we also restricted our analysis to 

claims that did not have a modifier and that had a quantity of one. Approximately 

29 percent of 2009 Medicaid FFS claims for these 26 services met these five restrictions 

(provider type, setting, beneficiary age, modifier, and quantity).

13For additional context on our state-level results, the tables in appendix II include the total 

Medicaid enrollment in each state, and the percentage of the Medicaid population in FFS 

or managed care.
 

Page 5 GAO-14-533 Medicaid Payment

1. The results we present are neither representative of all MCOs or 

private payers in a given state, nor are our results for selected states 

representative of all states.

2. Although the 26 selected services accounted for over 80 percent of 

national Medicaid FFS utilization and spending on E/M services, our 

payment comparisons are not representative of all E/M services. In 

addition, because we restricted our analysis to claims for services 

provided in specific circumstances (such as by a physician in a certain 

setting) to promote comparability across payers, our payment 

comparisons are not representative of our selected services provided 

in all circumstances (such as when the services were provided by 

non-physicians or in other settings).

3. Medicaid and private insurers may vary payments based on factors 

not accounted for in our analysis, such as physician specialty or 

geographic region within a state.

4. The payments we calculated do not account for payments that 

physicians may receive in addition to the base payments for services 

rendered—such as bonus payments linked to quality of care or other 

types of supplemental payments.14

5. The payments under private insurance include beneficiary cost 

sharing, but the Medicaid data generally do not. Federal law generally 

restricts cost sharing for Medicaid beneficiaries to nominal amounts; 

however, states may impose additional cost sharing on certain 

Medicaid populations and for certain services, such as nonemergency use of the emergency room.

We conducted this performance audit from July 2013 to July 2014 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

 

14States can make payments to providers, such as hospitals and physician group 

practices, in addition to their base payments for providing services to Medicaid FFS 

beneficiaries. However, only a small portion of these types of supplemental payments are 

made for physician services, and such payments typically are not made on the basis of 

claims submitted for specific services provided. See GAO, Medicaid: States Reported 

Billions More in Supplemental Payments in Recent Years, GAO-12-694 (Washington, 

D.C.: July 20, 2012), and Medicaid: More Transparency of and Accountability for 

Supplemental Payments Are Needed, GAO-13-48 (Washington, D.C.: Nov. 26, 2012).
 

Page 6 GAO-14-533 Medicaid Payment

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Although few studies have directly compared Medicaid FFS payments to 

private insurance for E/M or other services, the collective results of the 

available studies suggest that Medicaid FFS payments for E/M services 

were lower than private insurance. Specifically, a recent study found that 

Medicaid FFS payments for E/M services were generally lower than 

Medicare.15 Furthermore, other recent studies found Medicare payments 

for E/M and other physician services were lower than private insurance.16

Little information is publicly available on how Medicaid managed care 

payments for E/M or other services compare with other payers; however, 

one recent study suggested that shifting beneficiaries from FFS to 

managed care may have increased Medicaid spending, on average.17

 

15This study analyzed data from fee schedules and found that Medicaid FFS payments for 

E/M and certain other services were 28 percent lower than Medicare fees, on average, in 

2008, and 34 percent lower in 2012. See S. Zuckerman and D. Goin, “Medicaid Physician 

Fees” (2012). Other studies have also analyzed data from fee schedules and found that 

Medicaid FFS payments generally were lower than Medicare. See American Academy of 

Pediatrics, Medicaid Reimbursement Survey, 2010/11, (Elk Grove, IL: American Academy 

of Pediatrics, 2011); and S. Zuckerman et al., “Trends in Medicaid Physician Fees,” Health 

Affairs, vol. 28, no. 3 (2009).

Findings from this study also suggest that, in states where Medicaid 

payments were below private insurance to a greater extent than in other 

states, shifting Medicaid FFS beneficiaries into managed care did not 

16One study found that Medicare payments for physician services overall in 2009 were 

about 18 percent lower than the payments of private insurance, on average, and Medicare 

payments for E/M services were about 12 percent lower, on average. See N. Nguyen et 

al., “Comparing Physician Payment Rates between Medicare and Private Payers in 2009” 

(presentation at Academy Health, Washington, D.C.: June 2013). Similarly, the Medicare 

Payment Advisory Commission (MedPAC) reported that Medicare payments for services 

provided by physicians and other health professionals have been around 20 percent lower 

than the amounts paid by private insurers from 1999 through 2012. See MedPAC, Report 

to the Congress: Medicare Payment Policy (Washington, D.C.: March 2014).

17See M. Duggan and T. Hayford, “Has the Shift to Managed Care Reduced Medicaid 

Expenditures? Evidence from State and Local-Level Mandates,”Journal of Policy Analysis 

and Management, vol. 32, no. 3 (2013). This study analyzed data for 1991 to 2009 on 

state-level Medicaid spending, and data for 1991 through 2003 on state- and local-level 

mandates for Medicaid managed care to investigate the relationship between Medicaid 

spending and the shift of Medicaid beneficiaries from FFS to managed care.

Background
 

Page 7 GAO-14-533 Medicaid Payment

reduce spending. On the other hand, this study found that shifting 

Medicaid FFS beneficiaries into managed care did save money—on 

average—in states where Medicaid payments relative to private 

insurance were more generous than other states. One key limitation of 

these findings related to data used to measure the generosity of Medicaid 

payments. Specifically, because of the lack of information on how 

Medicaid payments compared with private insurance, the study relied on 

comparisons of payments in 1989 for a single service: the delivery of a 

newborn.18

Payments to physicians for E/M services under Medicaid FFS and 

managed care were generally 27 to 65 percent lower than private 

insurance prior to the HCERA-mandated increases.

• Under Medicaid FFS, payments for E/M services were 27 to 

65 percent lower than private insurance in 31 of 40 states. Among the 

remaining 9 states, 3 states had Medicaid FFS payments between 

72 and 74 percent lower than private insurance, and 6 states had 

Medicaid FFS payments that ranged from 23 percent lower to 

12 percent higher than private insurance.

• Under Medicaid managed care, payments for E/M services were 31 to 

65 percent lower than private insurance in 18 of 23 states. Among the 

remaining 5 states, 1 state had Medicaid managed care payments 

72 percent lower than private insurance, and 4 states had Medicaid 

managed care payments between 8 and 20 percent lower than private 

insurance.

Payments under both Medicaid FFS and managed care were lower than 

private insurance for each of the three types of E/M services in almost all 

states, but the magnitude of the difference varied based on the type of 

E/M service. For example, the percentage difference between Medicaid 

FFS and private insurance was largest for emergency care and smallest 

for office visits in 23 of 40 states. This was also the case for Medicaid 

 

18M. Duggan and T. Hayford, “Shift to Managed Care,” cited a previous study indicating 

that newborns accounted for the majority of all hospital discharges in Medicaid, and noted 

that this was likely to be the case for the Medicaid managed care population as well. See 

M. Duggan, “Hospital ownership and public medical spending,” Quarterly Journal of 

Economics, vol. 115 (2000).

Medicaid Payments 

for Evaluation and 

Management 

Services Were 

Generally Lower than 

Private Insurance 

Prior to Mandated 

Increases
 

Page 8 GAO-14-533 Medicaid Payment

managed care payments in 16 of 23 states. Figures 1 and 2, below, 

present payment comparisons for most of our selected states.19

 

19To safeguard confidential information, we omitted results from figures 1 and 2 for certain 

states that did not meet the minimum requirements to protect the confidentiality of entities 

that contributed private insurance data, and we masked the names of certain other states 

where the number of Medicaid managed care organizations was limited. 
Page 9 GAO-14-533 Medicaid Payment

Minnesota

Rhode Island

Wisconsin

New Jersey

Michigan

Oregon

Florida

California

Washington

Nebraska

Texas

Indiana

Ohio

Iowa

Georgia

Massachusetts

Kansas

Alaska

Idaho

Vermont

New York

Colorado

North Carolina

Louisiana

Kentucky

New Mexico

Wyoming

Alabama

Oklahoma

Nevada

Mississippi

Arizona

-95 -90 -85 -80 -75 -70 -65 -60 -55 -50 -45 -40 -35 -30 -25 -20 - 15 -10 -5 0 5 10 15 20

Source: GAO analysis of 2009 and 2010 claims data from the Centers for Medicare & Medicaid Services and Truven Health Analytics. | GAO-14-533

Percentage difference between Medicaid FFS and private insurance payments

Note: The icons in the figure show the median percentage difference between Medicaid fee-for-service (FFS) and private insurance 

payments to physicians across 26 evaluation and management services, weighted by 2009 national Medicaid FFS spending on each 

service. To safeguard confidential information, results were omitted for 8 of the 40 selected states that did not meet the minimum 

requirements to protect the confidentiality of entities that contributed private insurance data. Results were based on 2010 data for the 

states in the figure except for Idaho, Kansas, Massachusetts, Nevada, New Jersey, and Wisconsin, which were based on 2009 data.

Figure 1: Medicaid Fee-for-Service Payments for Evaluation and Management Services Relative to Private Insurance in 

Selected States, by Type of Service

Interactivity instructions: Roll over each legend icon or group of icons to see data points for only those types of services displayed.

 See table 2 in appendix II for additional details. 
Page 10 GAO-14-533 Medicaid Payment

Wisconsin

California

Florida

Washington

Michigan

State 1

Indiana

Rhode Island

State 2

Ohio

State 3

Texas

Georgia

New Mexico

New Jersey

New York

Maryland

State 4

Arizona

-95 -90 -85 -80 -75 -70 -65 -60 -55 -50 -45 -40 -35 -30 -25 -20 - 15 -10 -5 0 5 10 15 20

Percentage difference between Medicaid managed care and private insurance payments

Source: GAO analysis of 2009 and 2010 claims data from Medicaid managed care organizations and Truven Health Analytics. | GAO-14-533

Note: The icons in the figure show the median percentage difference between Medicaid managed care and private insurance payments 

to physicians across 26 evaluation and management services, weighted by 2009 national Medicaid FFS spending on each service. To 

safeguard confidential information, results were omitted for 4 of the 23 selected states that did not meet the minimum requirements to 

protect the confidentiality of entities that contributed private insurance data, and state names were masked for an additional 4 states 

where the number of Medicaid managed care organizations was limited. Results were based on 2010 data for the states identified by 

name in the figure except for New Jersey and Wisconsin, which were based on 2009 data. 

Figure 2: Medicaid Managed Care Payments for Evaluation and Management Services Relative to Private Insurance in 

Selected States, by Type of Service

Interactivity instructions: Roll over each legend icon or group of icons to see data points for only those types of services displayed.

 See table 3 in appendix II for additional details. 
 

Page 11 GAO-14-533 Medicaid Payment

In addition to the variation across the 3 types of E/M services, Medicaid 

payments relative to private insurance varied among individual services of 

the same type. For example, among the individual services classified as 

office visits, Medicaid FFS payments relative to private insurance varied 

by at least 25 percentage points in 13 of 40 states, and this also was the 

case for managed care payments in 4 of 23 states. (See tables 5 and 6 in 

appendix III for more detail.) Despite this variation, Medicaid FFS 

payments were below private insurance for all 26 selected services in 37 

of 40 states, and managed care payments were below private insurance 

for all 26 selected services in 20 of 23 states.

Medicaid managed care payments to physicians for E/M services were 0 

to 12 percent higher than Medicaid FFS in 15 of 20 states prior to the 

HCERA-mandated increases. Among the remaining 5 states, 3 states had 

managed care payments that exceeded FFS by 24 to 110 percent,20

Although managed care payments in most states were approximately 

equal to or higher than FFS for each of the three types of E/M services, 

payments for the two payers were more similar for emergency care and 

hospital care than for office visits. In 18 of 20 states, managed care 

payments for all three types of E/M services were approximately equal to 

FFS (that is, differed by 0 or 1 percent) or exceeded FFS.

and 

2 states had managed care payments that were 5 and 6 percent lower 

than FFS.

• For emergency care and hospital care, managed care payments were 

approximately equal to FFS in most states. Specifically:

• Managed care payments for emergency care were approximately 

equal to FFS in 16 states, and exceeded FFS by at least 

10 percent in only 1 state.

• For hospital care, managed care payments were approximately 

equal to FFS in 13 states, and exceeded FFS by at least 

10 percent in 4 states.

 

20In these three states, Medicaid FFS payments to physicians for E/M services were 51 to 

73 percent lower than private insurance. (See fig. 1.)

Medicaid Managed 

Care Payments for 

Evaluation and 

Management 

Services Were 

Generally Equal to or 

Higher than Medicaid 

Fee-for-Service Prior 

to Mandated 

Increases
 

Page 12 GAO-14-533 Medicaid Payment

• For office visits, managed care payments were approximately equal to 

FFS in only 4 states, exceeded FFS by at least 10 percent in 6 states, 

and were lower than FFS by at least 10 percent in 1 state.

Figure 3 presents payment comparisons for our selected states.21

 

21To safeguard confidential information, we masked the names of 2 of the 20 selected 

states where the number of Medicaid managed care organizations was limited.
Page 13 GAO-14-533 Medicaid Payment

New Mexico

California

State A

Connecticut

Indiana

Arizona

Wisconsin

New York

Georgia

Florida

Washington

Michigan

South Carolina

Ohio

Virginia

Pennsylvania

State B

Texas

New Jersey

Rhode Island

-10 -5 0 5 10 15 20 25 30 35 40 45 50 55 60 65 110 120 125 130 135 // // //

Source: GAO analysis of 2009 and 2010 claims data from Medicaid managed care organizations and the Centers for Medicare & Medicaid Services. | GAO-14-533

Percentage difference between Medicaid managed care and Medicaid FFS payments

Note: The icons in the figure show the median percentage difference between Medicaid managed care and Medicaid fee-for-service 

(FFS) payments to physicians across 26 evaluation and management services, weighted by 2009 national Medicaid FFS spending on each 

service. To safeguard confidential information, state names were masked for 2 of the 20 selected states where the number of Medicaid 

managed care organizations was limited. Results were based on 2010 data for the states identified by name in the figure except for New 

Jersey and Wisconsin, which were based on 2009 data.

Figure 3: Medicaid Managed Care Payments for Evaluation and Management Services Relative to Medicaid Fee-for-Service in 

Selected States, by Type of Service

Interactivity instructions: Roll over each legend icon or group of icons to see data points for only those types of services displayed.

 See table 4 in appendix II for additional details. 
 

Page 14 GAO-14-533 Medicaid Payment

Medicaid managed care payments relative to FFS varied not only across 

types of E/M services, but also among individual services of the same 

type.

• Among the individual services classified as office visits, the 

percentage difference between managed care and FFS payments 

varied by less than 10 percentage points in 7 of 20 states, and by 

more than 25 percentage points in 4 states.

• Among the individual emergency care services, the percentage 

difference between managed care and FFS payments varied by 

less than 10 percentage points in 15 states, and by more than 

25 percentage points in 3 states. (See table 7 in appendix III for more 

detail.)

Despite the variation within each type of E/M service, managed care 

payments in 18 of 20 states were approximately equal to or exceeded 

FFS for at least 22 of 26 services.

Comparisons of payments to physicians under Medicaid FFS and 

managed care with private insurance and with one another can contribute 

to a broader understanding of Medicaid payments to providers. In 

comparing payments for E/M services, we found general patterns: 

Medicaid payments were generally lower than private insurance, and 

Medicaid managed care payments were generally equal to or higher than 

Medicaid FFS. However, we also found significant variation in relative 

payments, not only across states, but also across types of E/M services 

and across similar E/M services. This variation highlights the challenges 

of using payment comparisons to help assess the adequacy of Medicaid 

payments, or the financial implications of shifting enrollment between 

Medicaid FFS and managed care. However, they also highlight the 

importance and utility of future studies, including those that explore which 

factors affect how Medicaid FFS and managed care payments compare 

with private insurance and with one another.

We provided a draft of this product to the Department of Health and 

Human Services for comment, and the agency stated that it had no 

comments.

Concluding 

Observations

Agency Comments
 

Page 15 GAO-14-533 Medicaid Payment

We are sending a copy of this report to the Secretary of Health and 

Human Services. In addition, the report is available at no charge on the 

GAO website at http://www.gao.gov. 

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made key contributions to this report 

are listed in appendix IV.

Carolyn L. Yocom

Director, Health Care
Page 16 GAO-14-533 Medicaid Payment

List of Committees

The Honorable Ron Wyden

Chairman

The Honorable Orrin G. Hatch

Ranking Member

Committee on Finance

United States Senate

The Honorable Thomas R. Carper

Chairman

The Honorable Tom Coburn, M.D.

Ranking Member

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Fred Upton

Chairman

The Honorable Henry Waxman

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Darrell E. Issa

Chairman

The Honorable Elijah Cummings

Ranking Member

Committee on Oversight and Government Reform

House of Representatives
Appendix I: List of 26 Selected Evaluation and 

Management Services

Page 17 GAO-14-533 Medicaid Payment

The table below lists the 26 evaluation and management (E/M) services 

included in our analysis, by type of E/M service (office visits, hospital 

care, and emergency care).

Table 1: List of 26 Selected Evaluation and Management Services, by Type of 

Service

Office visits (13 services)

Office or other outpatient visit, new patient, 20 minutes

Office or other outpatient visit, new patient, 30 minutes

Office or other outpatient visit, new patient, 45 minutes

Office or other outpatient visit, new patient, 60 minutes

Office or other outpatient visit, established patient, 5 minutes

Office or other outpatient visit, established patient, 10 minutes

Office or other outpatient visit, established patient, 15 minutes

Office or other outpatient visit, established patient, 25 minutes

Office or other outpatient visit, established patient, 40 minutes

Office consultation, 30 minutes

Office consultation, 40 minutes

Office consultation, 60 minutes

Office consultation, 80 minutes

Hospital care (8 services)

Initial hospital care, 50 minutes

Initial hospital care, 70 minutes

Subsequent hospital care, 15 minutes

Subsequent hospital care, 25 minutes

Subsequent hospital care, 35 minutes

Inpatient consultation, 55 minutes

Inpatient consultation, 80 minutes

Inpatient consultation, 110 minutes

Emergency care (5 services)

Emergency department visit, low to moderate severity

Emergency department visit, moderate severity

Emergency department visit, high severity but no immediate threat

Emergency department visit, high severity and immediate threat

Critical care, first 30-74 minutes

Source: American Medical Association. | GAO-14-533

Appendix I: List of 26 Selected Evaluation 

and Management Services
Appendix II: Payment Comparisons for 

Evaluation and Management Services

Page 18 GAO-14-533 Medicaid Payment

The three tables below compare payments for selected evaluation and 

management (E/M) services under Medicaid fee-for-service (FFS), 

Medicaid managed care, and private insurance prior to the temporary 

2013 and 2014 Medicaid payment increases for E/M services mandated 

by the Health Care and Education Reconciliation Act of 2010.1

• Medicaid FFS payments were 27 to 65 percent lower than private 

insurance in 31 of 40 selected states. Table 2 presents payment 

comparisons for most of our selected states.

In addition 

to showing the state-level percentage difference in payments for E/M 

services in general, each table shows the percentage difference in 

payments by type of E/M service (office visits, hospital care, and 

emergency care), as well as the total Medicaid enrollment in each state, 

and the percentage of the Medicaid population in FFS or managed care. 

In summary, we found the following:

2

• Medicaid managed care payments were 31 to 65 percent lower than 

private insurance in 18 of 23 selected states. Table 3 presents 

payment comparisons for most of our selected states.3

• Medicaid managed care payments were 0 to 12 percent higher than 

Medicaid FFS in 15 of 20 selected states. Table 4 presents payment 

comparisons for our selected states.4

 

1

HCERA required that Medicaid payments for E/M services, as well as certain vaccines, 

furnished by family physicians, internists, and pediatricians during calendar years 2013 

and 2014 must not be less than Medicare payments for these services. Pub. L. No. 111-

152, § 1202, 124 Stat. 1029, 1052 (2010).

2

To safeguard confidential information, we omitted results for 8 of the 40 selected states 

that did not meet the minimum requirements to protect the confidentiality of entities that 

contributed private insurance data.

3

To safeguard confidential information, we omitted results for 4 of the 23 selected states 

that did not meet the minimum requirements to protect the confidentiality of entities that 

contributed private insurance data, and we masked the names of 4 additional states 

where the number of Medicaid managed care organizations was limited.

4

To safeguard confidential information, we masked the names of 2 of the 20 selected 

states where the number of Medicaid managed care organizations was limited.

Appendix II: Payment Comparisons for 

Evaluation and Management Services 
Appendix II: Payment Comparisons for 

Evaluation and Management Services

Page 19 GAO-14-533 Medicaid Payment

Table 2: Medicaid Fee-for-Service Payments for Evaluation and Management Services Relative to Private Insurance in 

Selected States, by Type of Service

Percentage difference between Medicaid FFS and private 

insurance payments Medicaid enrolleesa

State All selected services Office visits Hospital care Emergency care Number (millions) Percentage in FFS

Minnesota -74% -77% -65% -80% 0.7 36%

Rhode Island -73% -70% -68% -76% 0.2 33%

Wisconsin -72% -71% -78% -91% 1.1 40%

New Jersey -65% -58% -65% -83% 1.0 23%

Michigan -63% -61% -64% -68% 1.8 35%

Oregon -63% -63% -60% -64% 0.6 29%

Florida -62% -62% -50% -73% 2.9 62%

California -61% -61% -57% -67% 7.3 45%

Washington -59% -59% -59% -69% 1.1 42%

Nebraska -53% -53% -58% -64% 0.2 83%

Texas -51% -51% -40% -82% 3.8 56%

Indiana -49% -49% -41% -51% 1.0 32%

Ohio -48% -36% -57% -65% 2.1 27%

Iowa -46% -52% -46% -43% 0.4 100%

Georgia -41% -41% -36% -55% 1.5 38%

Massachusetts -40% -34% -40% -44% 1.4 67%

Kansas -39% -37% -39% -54% 0.3 50%

Alaska -37% -29% -50% -58% 0.1 100%

Idaho -37% -37% -39% -44% 0.2 100%

Vermont -37% -29% -40% -51% 0.2 43%

New York -35% -34% -53% -79% 4.7 33%

Colorado -33% -33% -33% -47% 0.6 92%

North Carolina -32% -30% -32% -47% 1.5 100%

Louisiana -31% -31% -29% -44% 1.2 100%

Kentucky -30% -27% -28% -44% 0.8 80%

New Mexico -29% -26% -31% -45% 0.5 27%

Wyoming -27% -24% -37% -57% 0.1 100%

Alabama -27% -22% -32% -50% 0.9 100%

Oklahoma -23% -23% -21% -24% 0.7 100%

Nevada -19% -19% -28% -68% 0.3 45%

Mississippi -18% -18% -18% -17% 0.7 100%

Arizona -9% -7% -8% -55% 1.3 10%

Source: Medicaid and CHIP Payment and Access Commission, and GAO analysis of 2009 and 2010 claims data from the Centers for Medicare & Medicaid Services and Truven Health Analytics. 

 | GAO-14-533
Appendix II: Payment Comparisons for 

Evaluation and Management Services

Page 20 GAO-14-533 Medicaid Payment

Note: The table contains the median percentage difference between Medicaid fee-for-service (FFS) 

and private insurance payments to physicians across 26 evaluation and management services, 

weighted by 2009 national Medicaid FFS spending on each service. To safeguard confidential 

information, results were omitted for 8 of the 40 selected states that did not meet the minimum 

requirements to protect the confidentiality of entities that contributed private insurance data. Results 

were based on 2010 data for the states in the table except for Idaho, Kansas, Massachusetts, 

Nevada, New Jersey, and Wisconsin, which were based on 2009 data. The payment comparisons in 

this table are also presented in interactive figure 1 of this report.

a

Medicaid enrollment is as of July 2010, and the percentage in FFS was calculated as the percentage 

of Medicaid enrollees who were not in a comprehensive, risk-based managed care plan.
Appendix II: Payment Comparisons for 

Evaluation and Management Services

Page 21 GAO-14-533 Medicaid Payment

Table 3: Medicaid Managed Care Payments for Evaluation and Management Services Relative to Private Insurance in Selected 

States, by Type of Service

Percentage difference between Medicaid managed care (MC) 

and private insurance payments Medicaid enrolleesa

State All selected services Office visits Hospital care Emergency care Number (millions) Percentage in MC

Wisconsin -72% -71% -76% -91% 1.1 60%

California -65% -65% -57% -67% 7.3 55%

Florida -60% -60% -50% -73% 2.9 38%

Washington -59% -57% -58% -68% 1.1 58%

Michigan -59% -59% -65% -68% 1.8 66%

State 1 -53% -53% -59% -64% — — 

Indiana -48% -48% -41% -51% 1.0 68%

Rhode Island -46% -35% -48% -75% 0.2 67%

State 2 -45% -42% -49% -65% — — 

Ohio -45% -32% -55% -65% 2.1 74%

State 3 -40% -40% -29% -54% — — 

Texas -40% -38% -40% -74% 3.8 44%

Georgia -39% -39% -36% -55% 1.5 62%

New Mexico -34% -31% -31% -49% 0.5 73%

New Jersey -33% -33% -64% -83% 1.0 77%

New York -31% -31% -53% -78% 4.7 67%

Maryland -20% -18% -23% -32% 0.9 75%

State 4 -14% -3% -19% -68% — — 

Arizona -8% -6% -8% -55% 1.3 91%

Source: Medicaid and CHIP Payment and Access Commission, and GAO analysis of 2009 and 2010 claims data from Medicaid managed care organizations and Truven Health Analytics. | GAO-14-533

Note: The table contains the median percentage difference between Medicaid managed care and 

private insurance payments to physicians across 26 evaluation and management services, weighted 

by 2009 national Medicaid fee-for-service spending on each service. To safeguard confidential 

information, results were omitted for 4 of the 23 selected states that did not meet the minimum 

requirements to protect the confidentiality of entities that contributed private insurance data, and state 

names (and Medicaid enrollment) were masked for an additional 4 states where the number of 

Medicaid managed care organizations was limited. Results were based on 2010 data for the states 

identified by name in the table except for New Jersey and Wisconsin, which were based on 2009 

data. The payment comparisons in this table are also presented in interactive figure 2 of this report.

a

Medicaid enrollment is as of July 2010, and the percentage in managed care (MC) was calculated as 

the percentage of Medicaid enrollees in a comprehensive, risk-based managed care plan.
Appendix II: Payment Comparisons for 

Evaluation and Management Services

Page 22 GAO-14-533 Medicaid Payment

Table 4: Medicaid Managed Care Payments for Evaluation and Management Services Relative to Medicaid Fee-for-Service in 

Selected States, by Type of Service

Percentage difference between Medicaid managed care (MC) 

and Medicaid FFS payments Medicaid enrolleesa

State All selected services Office visits Hospital care Emergency care Number (millions) Percentage in MC

New Mexico -6% -6% 0% -1% 0.5 73%

California -5% -10% 1% 0% 7.3 55%

State A 0% 0% 0% 0% — — 

Connecticut 0% 1% 0% 0% 0.5 70%

Indiana 1% 2% 1% 0% 1.0 68%

Arizona 1% 1% 0% 0% 1.3 91%

Wisconsin 1% 1% 6% 0% 1.1 60%

New York 1% 4% 1% 1% 4.7 67%

Georgia 2% 4% 0% 0% 1.5 62%

Florida 3% 6% 0% 0% 2.9 38%

Washington 3% 3% 1% 0% 1.1 58%

Michigan 4% 11% 0% -1% 1.8 66%

South Carolina 5% 7% 6% 1% 0.8 49%

Ohio 5% 6% 6% 0% 2.1 74%

Virginia 7% 7% 10% 5% 0.9 59%

Pennsylvania 11% 11% 12% 5% 2.0 54%

State B 12% 15% 17% 0% — — 

Texas 24% 25% 0% 58% 3.8 44%

New Jersey 59% 59% 0% 1% 1.0 77%

Rhode Island 110% 132% 61% 4% 0.2 67%

Source: Medicaid and CHIP Payment and Access Commission, and GAO analysis of 2009 and 2010 claims data from Medicaid managed care organizations and the Centers for Medicare & Medicaid 

Services. | GAO-14-533

Note: The table contains the median percentage difference between Medicaid managed care and 

Medicaid fee-for-service (FFS) payments to physicians across 26 evaluation and management 

services, weighted by 2009 national Medicaid FFS spending on each service. To safeguard 

confidential information, state names (and Medicaid enrollment) were masked for 2 of the 20 selected 

states where the number of Medicaid managed care organizations was limited. Results were based 

on 2010 data for the states identified by name in the table except for New Jersey and Wisconsin, 

which were based on 2009 data. The payment comparisons in this table are also presented in 

interactive figure 3 of this report.

a

Medicaid enrollment is as of July 2010, and the percentage in managed care (MC) was calculated as 

the percentage of Medicaid enrollees in a comprehensive, risk-based managed care plan.
Appendix III: Variation in Relative Payments 

within Three Types of Evaluation and 

Management Services

Page 23 GAO-14-533 Medicaid Payment

Tables 5 through 7 below summarize the extent to which the percentage 

differences in payments varied among individual services within each of 

our three types of evaluation and management (E/M) services (office 

visits, hospital care, and emergency care) prior to the temporary 2013 

and 2014 Medicaid payment increases for E/M services mandated by the 

Health Care and Education Reconciliation Act of 2010.1

• Table 5 shows the variation in Medicaid FFS payments relative to 

private insurance;

Each table 

summarizes the range in the percentage difference in payments across 

individual services within each of the three types of E/M services. The 

range for a given state and type of E/M service is calculated as the 

difference (in percentage points) between the smallest and largest 

percentage difference in payments. Specifically:

• Table 6 shows the variation in Medicaid managed care payments 

relative to private insurance; and

• Table 7 shows the variation in Medicaid managed care payments 

relative to Medicaid FFS.

 

1

HCERA required that Medicaid payments for E/M services, as well as certain vaccines, 

furnished by family physicians, internists, and pediatricians during calendar years 2013 

and 2014 must not be less than Medicare payments for these services. Pub. L. No. 111-

152, § 1202, 124 Stat. 1029, 1052 (2010).

Appendix III: Variation in Relative Payments 

within Three Types of Evaluation and 

Management Services
Appendix III: Variation in Relative Payments 

within Three Types of Evaluation and 

Management Services

Page 24 GAO-14-533 Medicaid Payment

Table 5: Variation in Medicaid Fee-for-Service Payments for Evaluation and 

Management Services Relative to Private Insurance in Selected States, by Type of 

Service 

Number of states

Range of percentage 

difference in payments

Office visits 

(13 services)

Hospital care

(8 services)

Emergency care

(5 services)

< 10 percentage points 5 21 5 

10 to 25 percentage points 22 15 21

> 25 percentage points 13 4 14

Total 40 40 40

Source: GAO analysis of 2009 and 2010 claims data from the Centers for Medicare & Medicaid Services and Truven Health Analytics. 

 | GAO-14-533

Note: The table shows the number of states with a specified range in the percentage difference 

between Medicaid fee-for-service (FFS) and private insurance median payments among individual 

services of a given type of evaluation and management (E/M) service. The range for a given state 

and type of E/M service was calculated as the difference (in percentage points) between the smallest 

and largest percentage difference in the median payments of Medicaid FFS and private insurance 

among services of that type.

Table 6: Variation in Medicaid Managed Care Payments for Evaluation and 

Management Services Relative to Private Insurance in Selected States, by Type of 

Service 

Number of states

Range of percentage 

difference in payments

Office visits 

(13 services)

Hospital care

(8 services)

Emergency care

(5 services)

< 10 percentage points 4 12 5 

10 to 25 percentage points 15 9 9 

> 25 percentage points 4 2 9 

Total 23 23 23

Source: GAO analysis of 2009 and 2010 claims data from Medicaid managed care organizations and Truven Health Analytics.

 | GAO-14-533

Note: The table shows the number of states with a specified range in the percentage difference 

between Medicaid managed care and private insurance median payments among individual services 

of a given type of evaluation and management (E/M) service. The range for a given state and type of 

E/M service was calculated as the difference (in percentage points) between the smallest and largest 

percentage difference in the median payments of Medicaid managed care and private insurance 

among services of that type.
Appendix III: Variation in Relative Payments 

within Three Types of Evaluation and 

Management Services

Page 25 GAO-14-533 Medicaid Payment

Table 7: Variation in Medicaid Managed Care Payments for Evaluation and 

Management Services Relative to Medicaid Fee-for-Service in Selected States, by 

Type of Service

Number of states

Range of percentage 

difference in payments

Office visits 

(13 services)

Hospital care

(8 services)

Emergency care

(5 services)

< 10 percentage points 7 13 15

10 to 25 percentage points 9 4 2 

> 25 percentage points 4 3 3 

Total 20 20 20

Source: GAO analysis of 2009 and 2010 claims data from Medicaid managed care organizations and the Centers for Medicare & 

Medicaid Services. | GAO-14-533

Note: The table shows the number of states with a specified range in the percentage difference 

between Medicaid managed care and Medicaid fee-for-service (FFS) median payments among 

individual services of a given type of evaluation and management (E/M) service. The range for a 

given state and type of E/M service was calculated as the difference (in percentage points) between 

the smallest and largest percentage difference in the median payments of managed care and FFS 

among services of that type.
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 26 GAO-14-533 Medicaid Payment

Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov

In addition to the contact named above, William Black, Assistant Director; 

Christine Brudevold, Assistant Director; Eric Anderson; Alison Binkowski; 

Greg Dybalski; Nancy Fasciano; Sandra George; Dan Lee; Drew Long; 

Vikki Porter; and Hemi Tewarson made key contributions to this report.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(291107)
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