National Health Statistics Reports 

Number 80 June 8, 2015

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

n

Characteristics of Children in Medicaid Managed Care

and Medicaid Fee-for-service, 2003–2005

Patricia C. Lloyd, Ph.D., Sc.M.; Alan E. Simon, M.D.; and Jennifer D. Parker, Ph.D.,

Office of Analysis and Epidemiology

Abstract

Objectives—Medicaid claims have been used to characterize utilization

patterns of child Medicaid beneficiaries. However, because states are increasingly

adopting Medicaid managed care plans, analyses of children enrolled in Medicaid

based only on claims for fee-for-service (FFS) programs may not apply to the

general Medicaid population.

Methods—The 2003–2005 National Health Interview Survey and 2003–2005

Medicaid Analytic eXtract linked files were used to examine associations

between sociodemographic, health, and geographic characteristics of children

aged 0–17 years and enrollment in Medicaid FFS compared with a

comprehensive managed care (CMC) program. Additional analyses of agespecific health outcomes were performed on a subset of children aged 6–17

years. Chi-square tests were used to assess associations, and 95% confidence

intervals are provided for point prevalence estimates.

Results—Higher percentages of children in CMC compared with FFS were

non-Hispanic white, lived in families with income less than 100% of the federal

poverty level, had excellent or very good health, lived in the Northeast and West,

and lived in large central metro areas. No significant differences were observed

by sex, age, and asthma diagnoses between children enrolled in CMC and FFS.

Among children aged 6–17 years, higher percentages of children enrolled in FFS

compared with children in CMC were diagnosed with learning disabilities or

developmental delays and attention deficit hyperactivity disorder.

Researchers using data from children enrolled only in Medicaid FFS

programs to describe children enrolled in Medicaid should understand differences

between children enrolled in CMC and FFS. Generalization of study results from

FFS claims may depend on the outcomes examined.

Keyword: health insurance coverage

Introduction

Understanding patterns of health

care utilization for Medicaid enrollees

may be helpful for both policymakers

and researchers. Claims data have often

been used to characterize the utilization

patterns of child Medicaid beneficiaries

to examine such diverse outcomes

as maltreatment of children and

asthma (1–3). However, Medicaid claims

are generally not available for children

enrolled in Medicaid managed care

plans and, over the last 10 years, states

have increasingly adopted these

plans (4,5). From the years 1999 through

2011, the percentage of Medicaid

beneficiaries aged 0–17 years enrolled

in managed care plans increased from

56.0% to 86.5% (4,6). As a result of this

shift, descriptions of utilization patterns

for Medicaid children based only on

enrollees in Medicaid fee-for-service

(FFS) programs may not be as

applicable to the general Medicaid

population if children in FFS programs

differ from those in managed care plans.

On the other hand, similarities between

groups provide some support for

inferences to the general Medicaid

population from analyses using the FFS

subset.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Health Statistics 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2 National Health Statistics Reports n Number 80 n June 8, 2015

Utilization of health care services 

has been previously compared between 

those enrolled in FFS and managed 

care (7–10). Using a cross-sectional 

survey of randomly selected Medicaid 

beneficiaries in New York City that was 

administered in 1994, Ganz et al. 

reported that parents of Medicaid 

managed care enrollees were 3.5 times 

more likely than parents of children 

enrolled in Medicaid FFS to contact a 

usual provider instead of going to the 

emergency room (7). Using individuallevel data from the 1991–1995 National 

Health Interview Survey (NHIS) linked 

by county to managed care data from 

the 1998 Urban Institute survey on 

Medicaid managed care programs, 

Garrett et al. similarly reported 

reductions in emergency room visits and 

an increased utilization of specialists 

among children in mandatory primary 

care case management or health 

maintenance organizations (HMOs), a 

specific type of Medicaid managed care 

program, relative to those in FFS (8). 

Using 1996–1997 and 1998–1999 

Community Tracking Study Household 

Surveys matched to state–year Centers 

for Medicare & Medicaid Services 

(CMS) Medicaid managed care 

enrollment data, Baker et al. reported 

that states with higher percentages of 

HMOs had reduced emergency room 

visits, lower hospitalization rates, and 

more outpatient visits than states with 

lower HMO enrollment rates (9). 

Finally, Long et al. analyzed 1998 

survey data of Medicaid recipients in 

rural Minnesota and reported few 

significant differences in access to, use 

of, and satisfaction with health care 

services for children enrolled in the two 

programs (10). Changes in eligibility 

requirements since the late 1990s may 

have impacted these results. 

Furthermore, comparisons of the 

underlying health and sociodemographic 

characteristics between children enrolled 

in Medicaid FFS and Medicaid managed 

care at the national level have not been 

conducted. This gap is largely due to the 

lack of individual-level 

sociodemographic and health data for 

children in Medicaid for whom FFS and 

managed care program status can be 

ascertained. As a result, it is unclear 

whether differences observed in 

utilization patterns between children in 

FFS and managed care might be due to 

differences in underlying health and 

sociodemographic characteristics of the 

children. 

Children enrolled in Medicaid 

managed care programs may be enrolled 

in one or more of three types of 

Medicaid managed care plan 

arrangements: a comprehensive 

risk-based plan, a primary care case 

management plan, or a limited-benefit 

plan (11). In a comprehensive risk-based 

plan, the state pays a fixed amount to a 

health plan to cover all expenses for the 

child. In a primary care case 

management plan, a primary care 

physician receives a monthly payment 

per child to coordinate care, and all 

other services are reimbursed on an FFS 

basis. A limited-benefit plan is limited 

to specific types of benefits or services, 

such as mental health services and 

dental services (11). Children may be 

enrolled in one arrangement and not 

another for unique reasons, so this 

analysis focuses on enrollment in the 

most commonly enrolled managed care 

program, Medicaid comprehensive 

managed care (CMC). 

In this report, sociodemographic, 

health, and geographic characteristics of 

children enrolled in Medicaid FFS are 

described and compared with CMC 

during 2003–2005 using data from 

NHIS linked to Medicaid Analytic 

eXtract (MAX) files. The linked data 

provide a unique opportunity for this 

analysis because NHIS contains 

sociodemographic and health 

characteristics that are not collected in 

the Medicaid claims files, and MAX 

data contain more precise enrollment 

information than collected in NHIS. 

Moreover, the NHIS contains health 

information for children in Medicaid 

managed care plans that would not be 

available to users of MAX files alone. 

This report aims to aid researchers 

using the MAX data and data linked to 

the MAX data, such as NHIS and the 

National Health and Nutrition 

Examination Survey. Identifying 

potential differences between children 

enrolled in FFS and CMC programs will 

help researchers interpret results from 

studies based solely on children in FFS 

programs. Likewise, similarities in 

sociodemographic and health characteristics between children enrolled in 

FFS and CMC programs may support 

inferences from studies based on FFS 

claims to the general Medicaid 

population. 

Methods

Data sources

NHIS

The Centers for Disease Control 

and Prevention’s (CDC) National Center 

for Health Statistics (NCHS) has 

administered NHIS, a nationally 

representative, cross-sectional population 

health survey, continuously since 1957. 

Although the survey design has changed 

over time, the current design is a 

multistage sample with primary 

sampling units of counties or adjacent 

counties, secondary sampling units of 

clusters of houses, tertiary sampling 

units of households, and finally, persons 

within households. The NHIS sample 

design has been described previously 

(12–14). As part of the current design, 

one sample child aged 0–17 years is 

selected from each household to create 

the sample child files, which were used 

for this analysis. Information about 

children is provided by a knowledgeable 

adult family member (aged 18 years or 

over) living in the household. For this 

report, the 2003–2005 NHIS was used. 

The sample child response rates for the 

2003, 2004, and 2005 NHIS were 

81.1%, 79.4%, and 77.5%, respectively 

(12–14). 

MAX

Medicaid eligibility and claims files 

are submitted individually by each state 

to the Medicaid Statistical Information 

System (MSIS). Extracts of these files, 

the MAX files, are created for research 

purposes by CMS and consist of a 

person summary file, inpatient file, 

institutional long-term care file, 

prescription drugs file, and other 

services file (15). MAX data contain 

Medicaid enrollee eligibility information 

and Medicaid claims paid in each 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National Health Statistics Reports n Number 80 n June 8, 2015 Page 3

quarter of the fiscal year, and 

individual-level information and 

claims-level records for detailed 

analysis. 

Linkage of NHIS and MAX

The 1994–2005 NHIS data and 

1999–2009 MAX data were linked by 

the NCHS record linkage program 

following an established algorithm (16). 

As multiple years of MAX data are 

available for each NHIS survey 

participant, depending on the survey 

year and program participation, the 

linked data can be used for longitudinal 

studies of MAX data before or after 

NHIS interview, as well as for crosssectional studies using MAX 

information at the time of interview. 

Although multiple years of MAX data 

are available for each survey respondent, 

data from the 2003–2005 NHIS linked 

to corresponding MAX information for 

the month of the NHIS survey interview 

were used for this report. This was done 

because Medicaid eligibility, Medicaid 

enrollment, and health characteristics 

can change over time. At the time of 

this report, these were the most recent 

years of the NHIS sample that were 

linked to the MAX data. 

NHIS children were linkage eligible 

if the respondent knowledgeable about 

the child did not explicitly refuse to 

provide the child’s Social Security 

number (SSN) (17). For all years, when 

the SSN of a survey respondent was 

missing (not explicitly refused) or 

incorrect, the Social Security 

Administration used an enhanced 

electronic verification of SSNs using 

name and date of birth to determine the 

correct SSN. The NCHS Research 

Ethics Review Board approved the 

linkage of NHIS files with the MAX 

files. No additional approval was 

required by NCHS for this analysis. 

The linked NCHS-CMS Medicaid 

MAX files are restricted-use files that 

can be accessed through the NCHS 

Research Data Center. Feasibility study 

data files are publicly available to assist 

researchers who are considering using 

the linked NCHS-CMS Medicaid files 

(available from: 

http://www.cdc.gov/nchs/data_access/ 

data_linkage/cms_medicaid.htm). 

Variables

Variables in the MAX files that 

indicate monthly enrollment status, type 

of managed care program, and 

Children’s Health Insurance Program 

(CHIP) enrollment status during the 

month of the interview were used to 

classify children into Medicaid FFS, 

CMC, or non-comprehensive managed 

care. Children in any type of CMC 

program at the time of their NHIS 

interview were classified as CMC 

regardless of concurrent participation in 

any additional types of managed care 

plans (e.g., primary care case 

management or limited-benefit plans). 

Children with only noncomprehensive 

plans (e.g., dental only, behavioral only, 

 

or primary care case management only) 

were excluded from this analysis 

(n = 1,507). Children enrolled in CHIP 

during the month of the interview were 

not included in this analysis because 

claims data are not consistently made 

available for CHIP enrollees across the 

states (n = 120). Children enrolled in 

CHIP programs that were part of the 

state Medicaid program, known as 

MCHIP, were included, because claims 

for these children are reliably included 

in the MAX data set. Children in 

MCHIP may be either FFS or CMC 

depending on state policy. In this 

analysis, children enrolled in MCHIP 

are not distinguished from those 

enrolled in Medicaid, and reference to 

Medicaid is henceforth inclusive of 

children enrolled in MCHIP. 

Sociodemographic characteristics 

were examined, including: age group 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1. Selection criteria
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 4 National Health Statistics Reports n Number 80 n June 8, 2015

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 2. Percent distribution of sociodemographic characteristics of children aged 0–17 years enrolled in Medicaid at time of interview,

by type of Medicaid program: United States, 2003–2005

(0–5, 6–11, and 12–17 years), race and 

ethnicity (Hispanic, non-Hispanic white, 

non-Hispanic black, or non-Hispanic 

other race), sex, family poverty level 

[under 100% of the federal poverty level 

(FPL), 100%–200% FPL, or more than 

200% FPL]. 

Asthma diagnoses and history of 

asthma were assessed using questions in 

NHIS that determined whether the child 

had ever been diagnosed with asthma, 

had an episode of asthma (asthma 

exacerbation) within the last 12 months, 

and currently had asthma. General 

health of the child was described using 

reported health status (fair or poor, 

good, or excellent or very good). 

Access to care and service 

utilization were assessed using the 

number of times the child went to the 

emergency department (ED) in the last 

12 months, whether the child had a 

well-child visit in the last 12 months, 

and whether the child had a usual 

source of care. Having a usual source of 

care was defined as responding ‘‘Yes’’ 

or ‘‘There is more than one place’’ to 

the question: ‘‘Is there a place that 

[sample child’s name] usually goes 

when [he/she] is sick or you need 

advice about [his/her] health?’’ 

However, among children with a usual 

source of care, if the location of the 

usual source of care was the ‘‘hospital 

emergency room,’’ the child was not 

considered to have a usual source of 

care. This approach is consistent with 

other health initiatives, such as the 

U.S. Department of Health and Human 

Services’ Healthy People 2020 (18). 

Unveiled in December 2010, Healthy 

People 2020 is a 10-year agenda with 

measurable objectives for improving the 

nation’s health. 

To examine geography, the 2006 

NCHS county-level urban–rural area 

codes (large central metro, large fringe 

metro, medium metro, small metro, and 

micropolitan or noncore) (19) and U.S. 

census regions (Northeast, Midwest, 

South, and West) were used. 

Additionally, for children aged 

6 years and over, school days missed 

due to an illness or injury (0, 1–5, 6–10, 

or more than 10), mental health 

diagnoses, and an overall measure of 

emotional or behavioral health were 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National Health Statistics Reports n Number 80 n June 8, 2015 Page 5

 

Figure 3. Percent distribution of health status of children aged 0–17 years enrolled in Medicaid at time of interview, by type of Medicaid

program: United States, 2003–2005

examined. Specifically, diagnoses 

identified included ever having been 

diagnosed with a learning disability, 

intellectual disability, or developmental 

delay, or ever having been diagnosed 

with attention deficit hyperactivity 

disorder (ADHD). Overall emotional or 

behavioral difficulties were categorized 

as none, minor, or definite or severe 

based on the answer to the survey 

question: ‘‘Overall, do you think that 

[he/she] has difficulties in any of the 

following areas: emotions, 

concentration, behavior, or being able to 

get along with other people?’’ 

Analytic sample

Of the 37,196 child respondents 

(aged 0–17 years) in the 2003, 2004, 

and 2005 NHIS files, 48.7% (18,131) 

were linkage-eligible. Of these, 5,169 

linkage-eligible children aged 0–17 

years were enrolled in Medicaid during 

the same year and month of their NHIS 

interview. After excluding 1,507 

children who were enrolled in other 

Medicaid managed care programs, the 

analytic sample consisted of 3,662 

children who were enrolled in Medicaid 

FFS or CMC in the same state in which 

they lived when the NHIS interview was 

administered (Figure 1). Fifty-four 

percent (1,972) of children in the 

analytic sample were aged 6–17 years 

and were included for analyses of 

questions asked only of children in this 

age group. Although Medicaid eligibility 

criteria change at age 19, children over 

age 17 were not included in this 

analysis, because family members aged 

18 and over are considered adults in 

NHIS and are not eligible for selection 

as a sample child. Sample Adult 

questionnaire also differs from the 

Sample Child questionnaire. 

Data were missing for race and 

ethnicity for 11.8% of children included 

in the analysis, but single imputation 

was performed by NCHS and imputed 

data were used in this analysis. Family 

income was missing for 17.9% of 

children in the analysis, but multiply 

imputed data, included in the NHIS file 

for family percentage of poverty level, 

were used in all analyses. The number 

of school days missed was missing for 

2.1% of children aged 6–17 years. The 

amount of missing values for all other 

outcome variables totaled less than 1%. 

Analysis

Weighted percent distributions of 

children’s characteristics and 95% 

confidence intervals based on a logit 

transformation are presented for children 

enrolled in Medicaid FFS and CMC. 

Sample sizes are shown unweighted. 

Missing values (responses coded as 

‘‘refused’’ or ‘‘don’t know’’) were not 

counted in the denominators when 

calculating percentages or sample 

sizes. All percentages presented 

have a relative standard error, 

RSE = (SE/Est)100, less than or 

equal to 30%. 

To compare characteristics of 

children who were enrolled in Medicaid 

FFS and those enrolled in Medicaid 

CMC at the time of the interview, 

statistical significance was evaluated 

using chi-square test statistics with an 

alpha level of 0.05. 

NHIS sample weights were adjusted 

to account for linkage eligibility using 
 	 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

	 

 

 

 

 

 

	 

 

 

 

 

 

 

 

	 

 

 

 

 

 

	 

 

 

 

 

 

 

	 

 

 

 

	 

 

 

 

	 

 

 

 

 

 

	 

 

 

 

 	 

 

 

	 

 

	 

	 

	 

	 

 

 

	 

Page 6	 National Health Statistics Reports n Number 80 n June 8, 2015

 

Figure 4. Percentage of selected asthma diagnoses of children aged 0–17 years enrolled in Medicaid at time of interview, by type of

Medicaid program: United States, 2003–2005

model-based calibration (WTADJUST 

procedures) in SUDAAN (20). The 

adjustment effectively reweights the data 

to preserve the correct population totals 

within U.S census region, race and 

ethnicity, age, and sex crossstratifications. SUDAAN release 10.0 

(RTI International, Research Triangle 

Park, N.C.) was used to account for the 

complex design of the sample. 

Results

Sociodemographic

characteristics

+ More children were enrolled in CMC 

Medicaid (64.4%) compared with 

FFS Medicaid (35.6%) (Table 1, 

Figure 2). 

+ Race and ethnicity were significantly 

associated with program type 

(p < 0.01). Of children enrolled in 

FFS, 46.8% were non-Hispanic white 

compared with 29.5% in CMC 

(Table 1, Figure 2). 

+ Boys and girls were distributed similarly 

within FFS and CMC (Table 1, 

Figure 2). 

+	 No differences were seen in age 

group distributions between children 

enrolled in FFS and CMC. 

Approximately 42% of the children in 

the FFS and CMC groups were aged 

0–5 years (Table 1, Figure 2). 

+ Differences were seen in the 

distribution of family income as a 

percentage of FPL between children 

enrolled in FFS and CMC (p < 0.01). 

Of children in FFS and CMC 

programs, 46.2% and 53.4% had 

family incomes under 100% FPL, 

respectively (Table 1, Figure 2). 

Health status

+	 Although the percentage of children 

with excellent or very good health 

status was higher in CMC programs, 

the majority of children in both 

programs had excellent or very good 

health status (Table 2, Figure 3). 

+ A statistically significant difference 

was found in the distribution of 

health status across the two program 

types (p < 0.05). Among children in 

an FFS program, 6.1% had fair or 

poor health status compared with 

3.6% in CMC (Table 2, Figure 3). 

Asthma diagnoses

+	 Enrollment in FFS or CMC programs 

was not significantly associated with 

ever having been diagnosed with 

asthma (16.2% and 16.5%, 

respectively) (Table 3, Figure 4). 

+	 Having an episode of asthma within 

the last 12 months was not 

significantly associated with FFS or 

CMC programs (7.7% and 7.6%, 

respectively) (Table 3, Figure 4). 

+	 Current asthma was not significantly 

associated with enrollment in either 

FFS or CMC programs (11.4% and 

12.2%, respectively) (Table 3, Figure 4). 

Access to health care and

service utilization

+	 No difference was found between 

children enrolled in FFS and CMC in 

having a usual source of care (95.0% 

and 95.9%, respectively) (Table 4, 

Figure 5). 
 	 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

	 

 

 

 

 

 

 

 

 

 

 

	 

 

 

 

 

 

	 

 

 

 

 

	 

 

 

 

 

 

	 

 

 

 

 

 

 

	 

 

 

 

 

 

 

 

 

 

 

 

 	 

 

 

	 

 

 

 

 

	 

	 

	 

National Health Statistics Reports n Number 80 n June 8, 2015	 Page 7

 

Figure 5. Percentage with access to health care and utilizing services among children aged 0–17 years enrolled in Medicaid at time of

interview, by type of Medicaid program: United States, 2003–2005

+ The percentage of children who had a 

well-child visit in the last 12 months 

was similar for children in FFS 

(77.0%) and CMC (77.9%) (Table 4, 

Figure 5). 

+	 Nearly one-third of children in the 

two programs had visited the ED at 

least once in the last year. 

Approximately 13.5% of children in 

FFS and 12.4% of children in CMC 

had visited the ED at least twice in 

the last year. Visits to the ED were 

not significantly different between the 

FFS and CMC groups (Table 4, 

Figure 5). 

Geographic residence

+ U.S. census region was significantly 

associated with enrollment in FFS 

and CMC programs (p < 0.01). 

Among children enrolled in CMC 

programs, 20.6% lived in the South 

compared with 51.4% of children in 

FFS programs (Table 5, Figure 6). 

+ Urban–rural classification was 

significantly associated with 

enrollment in FFS and CMC 

programs (p < 0.01). Forty-five 

percent of children in CMC programs 

lived in large central metro areas, 

while only 20.4% of children in FFS 

programs lived in large central metro 

areas (Table 5, Figure 6). 

Selected diagnoses and

school days missed for

children aged 6–17 years

+	 Race and ethnicity, sex, age, and 

poverty level were similarly 

distributed in the subsample of 

children aged 6–17 years (Table 6) as 

observed in the full sample of 

children aged 0–17 years (Table 1). 

+ Learning disabilities or developmental 

delays were more common in 

children aged 6–17 years enrolled in 

FFS than in those in CMC programs 

(21.9% and 14.0%, p < 0.01) 

(Table 7, Figure 7). 

+	 A higher percentage of children aged 

6–17 years enrolled in FFS plans 

were diagnosed with ADHD 

compared with children aged 6–17 

years in CMC programs (16.1% and 

9.4%, p < 0.01) (Table 7, Figure 7). 

+	 Of children aged 6–17 years, 12.2% 

in FFS plans and 8.1% in CMC 

programs had definite or severe 

difficulties related to emotions, 

concentration, behavior, or being 

able to get along with other people 

(p = 0.05) (Table 7, Figure 7). 

+ More than three-quarters of children 

aged 6–17 years enrolled in FFS 

plans missed at least 1 day of school 

in the last 12 months; however, the 

distribution of the number of days 

missed from school was not 

statistically significant when 

comparing children aged 6–17 years 

enrolled in FFS plans with those in 

CMC programs (76.6% and 69.7%, 

respectively, missed at least 1 day of 

school, p > 0.05) (Table 7, Figure 8). 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 8 National Health Statistics Reports n Number 80 n June 8, 2015

 

Figure 6. Percent distribution of geographic residence of children aged 0–17 years enrolled in Medicaid at time of interview, by type of

Medicaid program: United States, 2003–2005

Discussion

Approximately 64% of children 

were enrolled in a CMC program, which 

is consistent with reports during the 

time period of interest (21). This 

analysis revealed several key features 

about the sociodemographic, health, and 

geographic characteristics of children 

enrolled in Medicaid FFS plans and 

children enrolled in Medicaid CMC 

plans. 

No statistically significant 

differences were seen in the sex and age 

distributions of children between 

programs. Statistically significant 

differences in the distribution of race 

and ethnicity and poverty status between 

the two plan types were observed. While 

non-Hispanic white children made up 

the largest percentage of children in FFS 

programs, Hispanic children made up 

the largest percentage of children in 

CMC programs. A higher percentage of 

children living in families with income 

under 100% FPL were enrolled in FFS 

than in CMC, and the percentage of 

children in families with income above 

200% FPL was higher among children 

enrolled in CMC than in FFS. 

The percentage of children ever 

diagnosed with asthma, having current 

asthma, or having had an asthma 

episode in the last 12 months did not 

differ between children enrolled in 

Medicaid FFS and those in Medicaid 

CMC plans. Outcomes related to access 

and utilization of health services did not 

differ between children enrolled in 

Medicaid FFS and children enrolled in 

Medicaid CMC plans. 

Among children aged 6–17 years, 

the percentage with overall emotional or 

behavioral difficulties in FFS did not 

differ from the percentage in CMC. 

Similarly, no differences in the 

distribution of school days missed due 

to illness or injury were observed 

between children aged 6–17 years 

enrolled in FFS and in CMC. However, 

statistically significant differences were 

found in the percentages of children 

aged 6–17 years with learning 

disabilities and ADHD between those 

enrolled in FFS and in CMC. 

Results of this analysis are not 

consistent with other studies that have 

reported statistically significant 

differences in access to and utilization 

of health services between all children 

in FFS and managed care programs 

(7–10). Some such studies were 

ecological in nature (8,9), others used 

data from a sample of Medicaid 

managed care recipients in a specific 

state (7,10), and all were conducted 

using data from the 1990s (7–10).

However, our analysis was conducted at 

the person level and used a nationally 

representative sample of children who 

participated in NHIS from 2003 through 

2005. Variations in Medicaid enrollment 

requirements and populations across the 

states during this time frame may 

explain these differences. 

Significant differences were seen in 

the geographic distribution of children 

enrolled in the two types of plans by 

U.S. census region and rural–urban 
 	 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 	 

 

 

National Health Statistics Reports n Number 80 n June 8, 2015	 Page 9

 

Figure 7. Percent distribution of selected conditions for children aged 6–17 years enrolled in Medicaid at time of interview, by type of

Medicaid program: United States, 2003–2005

classification. This finding is consistent 

with MSIS annual reports on managed 

care enrollment. In 2004, the rates of 

managed care enrollment were as low as 

44% in the East North Central Census 

Division and as high as 80% in the 

Mountain Census Division of the 

country (21). 

Several limitations of the analysis 

warrant discussion. First, the crosssectional nature of the analysis does not 

allow inferring causal associations 

between enrollment plan type and 

sociodemographic and health conditions 

or characteristics of Medicaid children. 

Second, the data represent the 

population of children enrolled in 

Medicaid during 2003–2005; with 

increases in managed care in recent 

years (4,5), these results may not reflect 

current data. Third, not all children in 

the 2003–2005 NHIS were linkageeligible, which may introduce bias. 

Although the data were reweighted to 

account for linkage eligibility, which 

may reduce bias, other factors may 

differ between children who are 

linkage-eligible and children who 

are not linkage-eligible that could affect 

the comparisons in this report. Fourth, 

some children experience gaps in 

Medicaid coverage, known as 

‘‘churning,’’ by which a child may be 

enrolled in Medicaid one month and not 

enrolled the next month. While this is 

an important consideration when 

analyzing Medicaid claims, this analysis 

examines differences in FFS and CMC 

populations at the time of interview, 

cross-sectionally; hence, bias should not 

be introduced by churning. 

Despite these limitations, this report 

provides an understanding of similarities 

and differences in the distributions of 

sociodemographic and health 

characteristics between children enrolled 

in Medicaid FFS and those enrolled in 

CMC. Generalization of study results 

based on analysis of FFS claims may 

depend on the outcomes examined. 

Claims data from children enrolled in 

FFS have often been used for health 

studies of the Medicaid population. 

While children in the two programs 

share some similarities, researchers are 

cautioned 

that some analyses may not be 

generalizable to all Medicaid children. 

References

1.Wendt JK, Symanski E, Du XL. 

Estimation of asthma incidence 

among low-income children in Texas: 

A novel approach using Medicaid 

claims data. Am J Epidemiol 

176(8):744–50. 2012. 

2.Florence C, Brown DS, Fang X, 

Thompson HF. Health care costs 

associated with child maltreatment: 

Impact on Medicaid. Pediatrics 

132(2):312–8. 2013. 

3.Raghavan R, Brown DS, Allaire BT, 

Garfield LD, Ross RE, Snowden LR. 

Racial/ethnic differences in Medicaid 

expenditures on psychotropic 

medications among maltreated 

children. Child Abuse Negl 

38(6):1002–10. 2014. 

4.Tang SS, Yudowsky BK. Medicaid 

(Title XIX and Title XXI) State 

Reports–FY 1999. 1999. 

5.Tang S. Medicaid (Title XIX and 

Title XXI) State Reports–FY 2009. 

2009. 

6.MACPAC. June 2014 MACStats: 

Table 14. Percentage of Medicaid 
 	 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 	 

 

 

Page 10	 National Health Statistics Reports n Number 80 n June 8, 2015

 

Figure 8. Percent distribution of school days missed by children aged 6–17 years enrolled in Medicaid at time of interview, by type of

Medicaid program: United States, 2003–2005

enrollees in managed care by state 

and eligibility group, FY 2011. 2014. 

7.Ganz ML, Sisk JE. Evaluation of 

Medicaid managed care for children: 

Access and satisfaction. Am J Public 

Health 90(12):1947–8. 2000. 

8.Garrett B, Davidoff AJ, Yemane A. 

Effects of Medicaid managed care 

programs on health services access 

and use. Health Serv Res 38(2): 

575–94. 2003. 

9.Baker LC, Afendulis C. Medicaid 

managed care and health care 

for children. Health Serv Res 

40(5 Pt 1):1466–88. 2005. 

10. Long SK, Coughlin TA. Impacts of 

Medicaid managed care on children. 

Health Serv Res 36(1 Pt 1):7–23. 

2001. 

11. MACPAC. Report to the Congress: 

The evolution of managed care in 

Medicaid. Washington, DC: 2011. 

12. NCHS. Data file documentation, 

National Health Interview Survey, 

2003 (machine readable data file and 

documentation). Hyattsville, MD: 

2004. 

13. NCHS. Data file documentation, 

National Health Interview Survey, 

2004 (machine readable data file and 

documentation). Hyattsville, MD: 

2005. 

14. NCHS. Data file documentation, 

National Health Interview Survey, 

2005 (machine readable data file and 

documentation). Hyattsville, MD: 

2006. 

15. Medicaid. Medicaid Analytic eXtract 

(MAX) general information. 

Available from: http://www.medicaid. 

gov/Medicaid-CHIP-ProgramInformation/By-Topics/Data-andSystems/MAX/MAX-GeneralInformation.html. 

16. Simon AE, Driscoll AK, Golden C, 

et al. Documentation and analytic 

guidelines for NCHS surveys linked 

to Medicaid Analytic eXtract (MAX) 

files. Hyattsville, MD: National 

Center for Health Statistics. 2014. 

17. Miller DM, Gindi RM, Parker JD. 

Trends in record linkage refusal 

rates: Characteristics of National 

Health Interview Survey participants 

who refuse record linkage. In: 

Proceedings of the American 

Statistical Association, Survey 

Research Methods Section. Miami, 

FL: American Statistical Association. 

2011. 

18. HHS, Office of Disease Prevention 

and Health Promotion. Healthy 

People 2020. Washington, DC. 

19. Ingram DD, Franco SJ. NCHS 

urban–rural classification scheme for 

counties. National Center for Health 

Statistics. Vital Health Stat 2(154). 

2012. 

20. Judson DH, Parker JD, Larsen MD. 

Adjusting sample weights for 

linkage-eligibility using SUDAAN. 

Hyattsville, MD: National Center for 

Health Statistics. 2013. 

21. Tang S. Medicaid (Title XIX and 

Title XXI) State Reports–FY 2004. 

2004. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

National Health Statistics Reports n Number 80 n June 8, 2015 Page 11

Table 1. Unweighted sample sizes and weighted percent distributions of sociodemographic characteristics for NHIS-MAX linked children

aged 0–17 years at time of NHIS interview (2003–2005), by type of Medicaid program

Comprehensive

Fee-for-service managed care

Comprehensive

Fee-for-service Percent (95% managed care Percent (95%

Characteristic (n = 1,373) confidence interval) (n = 2,289) confidence interval)

Race and ethnicity1

Hispanic .......................... 447 22.5 (19.6, 25.7) 1,053 38.5 (35.4, 41.8)

Non-Hispanic white ................... 555 46.8 (42.8, 50.9) 592 29.5 (26.5, 32.6)

Non-Hispanic black ................... 344 28.0 (24.6, 31.7) 578 27.3 (24.2, 30.7)

All other races and ethnicities ............. 27 2.7 (1.6, 4.5) 66 4.7 (3.4, 6.4)

Sex

Male ............................ 671 47.8 (45.0, 50.5) 1,163 50.0 (47.5, 52.5)

Female........................... 702 52.2 (49.5, 55.0) 1,126 50.0 (47.5, 52.5)

Age (years)

0–5 ............................. 638 41.8 (38.8, 44.8) 1,052 41.7 (39.1, 44.3)

6–11 ............................ 374 31.1 (28.1, 34.3) 691 32.0 (29.4, 34.6)

12–17 ........................... 361 27.1 (24.2, 30.2) 546 26.3 (24.1, 28.8)

Federal poverty level1

Less than 100% ..................... 616 46.2 (42.9, 49.6) 1,135 52.4 (49.4, 55.4)

100%–199% ....................... 463 32.8 (29.5, 36.3) 753 32.8 (30.1, 35.6)

200% or more ...................... 294 20.9 (18.0, 24.2) 401 14.8 (13.0, 16.7)

1Chi-square p value < 0.01.
 

NOTES: NHIS is National Health Interview Survey. MAX is Medicaid Analytic eXtract.
 
 

 

 

 

 

 

 

 
 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 12 National Health Statistics Reports n Number 80 n June 8, 2015

Table 2. Unweighted sample sizes and weighted percent distribution of health status for NHIS-MAX linked children aged 0–17 years at

time of NHIS interview (2003–2005), by type of Medicaid program

Comprehensive

Fee-for-service managed care

Comprehensive

Fee-for-service Percent (95% managed care Percent (95%

Characteristic (n = 1,373) confidence interval) (n = 2,289) confidence interval)

Health status1

Excellent or very good ................. 956 69.2 (66.5, 71.9) 1,661 72.7 (69.9, 75.4)

Good ............................ 331 24.7 (21.7, 27.9) 536 23.6 (21.2, 26.2)

Fair or poor ........................ 80 6.1 (4.7, 7.9) 86 3.6 (2.7, 4.8)

1Chi-square p value < 0.01.
 

NOTES: NHIS is National Health Interview Survey. MAX is Medicaid Analytic eXtract.
 

Table 3. Unweighted sample sizes and weighted percentages of selected asthma diagnoses for NHIS-MAX linked children aged 0–17

years at time of NHIS interview (2003–2005), by type of Medicaid program

Comprehensive

Fee-for-service managed care

Comprehensive

Fee-for-service Percent (95% managed care Percent (95%

Characteristic (n = 1,373) confidence interval) (n = 2,289) confidence interval)

Ever diagnosed with asthma

Yes .............................

No..............................

217

1,154

16.2 (13.9, 18.9)

83.6 (80.9, 86.0)

380

1,906

16.5 (14.6, 18.6)

83.4 (81.4, 85.3)

Episode of asthma within last 12 months

Yes .............................

No..............................

104

1,262

7.7 (6.0, 9.8)

92.3 (90.2, 94.0)

171

2,109

7.6 (6.4, 9.1)

92.4 (90.9, 93.6)

Current asthma

Yes .............................

No..............................

154

1,210

11.4 (9.3, 13.9)

88.6 (86.1, 90.7)

272

2,002

12.2 (10.4, 14.1)

87.8 (85.9, 89.6)

NOTES: NHIS is National Health Interview Survey. MAX is Medicaid Analytic eXtract.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National Health Statistics Reports n Number 80 n June 8, 2015 Page 13

Table 4. Unweighted sample sizes and weighted percentages of access to health care and service utilization outcomes for NHIS-MAX

linked children aged 0–17 years at time of NHIS interview (2003–2005), by type of Medicaid program

Comprehensive

Fee-for-service managed care

Comprehensive

Fee-for-service Percent (95% managed care Percent (95%

Characteristic (n = 1,373) confidence interval) (n = 2,289) confidence interval)

Has usual place of care

Yes ............................. 1,290 95.0 (93.4, 96.3) 2,191 95.9 (94.7, 96.9)

No.............................. 78 5.0 (3.7, 6.6) 90 4.1 (3.1, 5.3)

Well-child visit in last year

Yes ............................. 1,045 77.0 (73.9, 79.9) 1,785 77.9 (75.5, 80.1)

No.............................. 319 22.4 (19.5, 25.6) 484 21.1 (19.0, 23.4)

Number of visits to the ED in

the last 12 months1

0............................... 916 69.4 (66.5, 72.2) 1,539 68.6 (65.9, 71.1)

1............................... 248 17.0 (14.7, 19.6) 441 19.0 (16.9, 21.3)

2............................... 150 10.1 (8.3, 12.4) 217 9.1 (7.7, 10.7)

3 or more ......................... 48 3.5 (2.6, 4.7) 76 3.3 (2.3, 4.7)

1 or more ......................... 446 30.4 (27.7, 33.3) 735 31.3 (28.7, 33.9)

2 or more ......................... 198 13.5 (11.4, 15.9) 294 12.4 (10.7, 14.2)

1ED is emergency department.

NOTES: NHIS is National Health Interview Survey. MAX is Medicaid Analytic eXtract.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

Page 14 National Health Statistics Reports n Number 80 n June 8, 2015

Table 5. Unweighted sample sizes and weighted percentages of geographic areas for NHIS-MAX linked children aged 0–17 years at time

of NHIS interview (2003–2005), by type of Medicaid program

Comprehensive

Fee-for-service managed care

Comprehensive

Fee-for-service Percent (95% managed care Percent (95%

Characteristic (n = 1,373) confidence interval) (n = 2,289) confidence interval)

Region1

Northeast ......................... 153 11.8 ( 9.7, 14.2) 519 22.9 (20.2, 25.8)

Midwest .......................... 383 32.0 (28.1, 36.2) 490 23.4 (20.4, 26.6)

South............................ 778 51.4 (47.4, 55.4) 506 20.6 (17.8, 23.7)

West ............................ 59 4.8 ( 3.1, 7.3) 774 33.1 (29.4, 37.1)

Urban or rural (2006 codes)1

Large central metro ................... 293 20.4 (17.8, 23.3) 1,085 45.3 (41.7, 49.0)

Large fringe metro .................... 157 12.3 ( 9.9, 15.0) 383 18.5 (15.9, 21.3)

Medium metro ...................... 364 24.9 (20.6, 29.8) 475 20.8 (18.0, 23.9)

Small metro ........................ 161 11.6 ( 7.9, 16.6) 186 8.6 ( 5.7, 12.7)

Micropolitan or noncore (nonmetro) ......... 398 30.9 (26.2, 35.9) 160 6.8 ( 4.7, 9.7)

1Chi-square p value < 0.01.
 

NOTES: NHIS is National Health Interview Survey. MAX is Medicaid Analytic eXtract.
 

Table 6. Unweighted sample sizes and weighted percentages of sociodemographic characteristics for NHIS-MAX linked children aged

6–17 years at time of NHIS interview (2003–2005), by type of Medicaid program

Comprehensive

Fee-for-service managed care

Comprehensive

Fee-for-service Percent (95% managed care Percent (95%

Characteristic (n = 735) confidence interval) (n = 1,237) confidence interval)

Race and ethnicity1

Hispanic .......................... 214 19.9 (16.6, 23.7) 525 36.6 (32.8, 40.5)

Non-Hispanic white ................... 299 47.3 (42.2, 52.3) 318 27.9 (24.2, 31.9)

Non-Hispanic black ................... 207 29.8 (25.3, 34.7) 355 30.5 (26.4, 34.9)

All other races and ethnicities ............. 15 3.0 ( 1.5, 6.0) 39 5.0 ( 3.3, 7.5)

Sex

Male ............................ 369 49.3 (45.3, 53.3) 621 49.4 (46.0, 52.8)

Female........................... 366 50.7 (46.7, 54.7) 616 50.6 (47.2, 54.0)

Age (years)

6–11 ............................ 374 53.4 (48.8, 58.0) 691 54.8 (51.2, 58.4)

12–17 ........................... 361 46.6 (42.0, 51.2) 546 45.2 (41.6, 48.8)

Federal poverty level1

Less than 100% ..................... 336 46.1 (41.3, 50.9) 633 54.3 (50.1, 58.4)

100%–199% ....................... 241 31.7 (27.5, 36.1) 403 32.1 (28.5, 36.0)

200% or more ...................... 158 22.2 (18.5, 26.5) 201 13.6 (11.5, 16.0)

1Chi-square p value < 0.01.
 

NOTES: NHIS is National Health Interview Survey. MAX is Medicaid Analytic eXtract.
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 
 

National Health Statistics Reports n Number 80 n June 8, 2015 Page 15

Table 7. Unweighted sample sizes and weighted percentages of selected conditions for NHIS-MAX linked children aged 6–17 years at

time of NHIS interview (2003–2005), by type of Medicaid program

Comprehensive

Fee-for-service managed care

Comprehensive

Fee-for-service Percent (95% managed care Percent (95%

Characteristic (n = 735) confidence interval) (n = 1,237) confidence interval)

Learning disability or developmental delay1

Yes ............................. 157 21.9 (18.0, 26.2) 187 14.0 (12.0, 16.3)

No.............................. 575 78.1 (73.8, 82.0) 1,048 86.0 (83.7, 88.0)

ADHD1,2

Yes ............................. 120 16.1 (12.9, 20.0) 119 9.4 (7.8, 11.2)

No.............................. 612 83.5 (79.6, 86.8) 1,117 90.6 (88.8, 92.2)

Emotional or behavioral difficulties

None ............................ 458 62.6 (58.3, 66.8) 816 67.6 (64.1, 70.9)

Minor ............................ 172 25.2 (21.3, 29.5) 302 24.3 (21.2, 27.7)

Definite or severe .................... 91 12.2 (9.4, 15.6) 101 8.1 (6.4, 10.2)

School days missed within last 12 months

0............................... 182 23.4 (19.6, 27.7) 343 30.3 (26.8, 34.0)

1–5 ............................. 363 52.3 (47.5, 57.0) 573 48.0 (44.3, 51.8)

6–10 ............................ 93 13.3 (10.4, 16.9) 176 12.3 (10.2, 14.8)

More than 10 ....................... 82 11.4 (8.7, 14.8) 119 9.7 (7.6, 12.2)

1Chi-square p value < 0.05.
 2ADHD is attention deficit hyperactivity disorder.
 

NOTES: NHIS is National Health Interview Survey. MAX is Medicaid Analytic eXtract.
 
 

 

 

 

 

 

 
 

 
 


 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 
 

 
 

 

 

 

 

 

 

 
 

 
 


 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 
 

 
 

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National Health Statistics Reports n Number 80 n June 8, 2015

Suggested citation

Lloyd PC, Simon AE, Parker JD.

Characteristics of children in Medicaid

managed care and Medicaid fee-for-service,

2003–2005. National health statistics reports;

no 80. Hyattsville, MD: National Center for

Health Statistics. 2015.

Copyright information

All material appearing in this report is in the

public domain and may be reproduced or

copied without permission; citation as to

source, however, is appreciated.

National Center for Health Statistics

Charles J. Rothwell, M.S., M.B.A., Director

Nathaniel Schenker, Ph.D., Deputy Director

Jennifer H. Madans, Ph.D., Associate Director

for Science

Office of Analysis and Epidemiology

Irma E. Arispe, Ph.D., Director

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DHHS Publication No. 2015–1250 • CS256398