MEDICAID

Demographics and 

Service Usage of 

Certain HighExpenditure 

Beneficiaries

Report to the Honorable Charles E. 

Grassley, U.S. Senate

February 2014

GAO-14-176

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-176, a report to the 

Honorable Charles E. Grassley, U.S. Senate

February 2014

MEDICAID

Demographics and Service Usage of Certain High- Expenditure Beneficiaries

Why GAO Did This Study

Medicaid is an important source of 

health coverage for millions of lowincome individuals. Research on 

Medicaid has demonstrated that a 

small percentage of beneficiaries 

account for a disproportionately large 

share of Medicaid expenditures. 

Understanding states’ expenditures for 

high-expenditure populations—both 

those dually eligible for Medicare and 

Medicaid, and those who are Medicaidonly—could enhance efforts to manage 

Medicaid expenditures.

GAO was asked to examine the 

demographics and service usage of 

Medicaid beneficiaries, particularly 

those who are not eligible for 

Medicare. This report examines highexpenditure Medicaid-only 

beneficiaries, considering (1) states’ 

spending on them compared with all 

other Medicaid beneficiaries; (2) their 

key characteristics; and (3) their 

service usage compared with all other 

Medicaid-only beneficiaries.

GAO analyzed beneficiary and 

expenditure data from the Medicaid 

Statistical Information System Annual 

Person Summary File for 2009, the 

most recent year available at the time 

GAO conducted its work. GAO defined 

high-expenditure beneficiaries as those 

with total expenditures in the top 

5 percent of expenditures within each 

state. GAO combined these data at a 

national level, and analyzed the 

characteristics associated with being a 

high-expenditure beneficiary, the 

probability of being a high-expenditure 

Medicaid beneficiary, and what 

services contributed to high 

expenditures.

What GAO Found

In fiscal year 2009, states spent nearly a third (31.6 percent) of all Medicaid 

expenditures on the most expensive Medicaid-only beneficiaries, who were 

4.3 percent of total Medicaid beneficiaries. States spent another third 

(33.1 percent) on all other Medicaid-only beneficiaries, who represented 

81.2 percent of total Medicaid beneficiaries. Among dual eligible beneficiaries, 

a similar pattern existed, with a small proportion of the population accounting for 

a disproportionate share of expenditures.

Percent of Total Medicaid Expenditures on Beneficiary Spending Groups, Fiscal Year 2009

Certain characteristics significantly increased the probability of being a highexpenditure Medicaid-only beneficiary. Specifically, the results of GAO’s 

analyses indicate that the probability of being a high-expenditure Medicaid-only 

beneficiary was:

• 24.4 percent for those residing in a long-term care facility,

• 20.8 percent for those with human immunodeficiency virus/acquired 

immunodeficiency syndrome, 

• 18.3 percent for those with disabilities, and

• 13.3 percent for new mothers or infants.

Overall, hospital services and long-term services and supports in non-institutional

and institutional settings comprised nearly 65 percent of the total expenditures for 

high-expenditure Medicaid-only beneficiaries, with smaller proportions for drugs, 

payments to managed care organizations and premium assistance, and nonhospital acute care. In contrast to high-expenditure beneficiaries, payments to 

managed care organizations and premium assistance comprised 57.2 percent of 

total expenditures for all other Medicaid-only beneficiaries. 

HHS provided technical comments on a draft of this report, which were 

incorporated as appropriate.

View GAO-14-176. For more information, 

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

or YocomC@gao.gov.
Page i GAO-14-176 Medicaid Beneficiaries with High Expenditures

Letter 1 

Background 5

Nearly One-Third of States’ Medicaid Expenditures Were for HighExpenditure Medicaid-Only Beneficiaries 7

Disability, Certain Conditions, Delivery/Childbirth, and Long-Term 

Care Residency Were Strongly Associated with Being a HighExpenditure Medicaid-Only Beneficiary 11

High-Expenditure Beneficiaries Had High Hospital Expenditures 

and Significantly Different Spending Patterns Compared with All 

Other Medicaid-Only Beneficiaries 14

Agency Comments 26

Appendix I Objectives, Scope, and Methodology 28

Appendix II Characteristics of High-Expenditure Medicaid-Only Beneficiaries 33

Appendix III Key Characteristics Associated with Estimated Probability of Being 

a High-Expenditure Beneficiary 35

Appendix IV Characteristics of High-Expenditure Beneficiaries in the Top 

1 Percent of Expenditures 38

Appendix V Selected Cases of Medicaid-Only Beneficiaries with Expenditures 

in the Top 1 Percent 40

Appendix VI GAO Contact and Staff Acknowledgments 42

Related GAO Products 43

Contents
Page ii GAO-14-176 Medicaid Beneficiaries with High Expenditures

Tables

Table 1: Per Capita Spending by Beneficiary Group, Fiscal Year 

2009 9

Table 2: Percentage and Estimated Probability of Being a HighExpenditure Medicaid-Only Beneficiary by Eligibility 

Group, Fiscal Year 2009 11

Table 3: Percentage and Estimated Probability of Being a HighExpenditure Medicaid-Only Beneficiary, by Selected 

Conditions and Services, Fiscal Year 2009 12

Table 4: Per Capita Expenditures for Services and Managed Care 

and Premium Assistance for High-Expenditure MedicaidOnly Beneficiaries by Long-Term Care Residence Status, 

Fiscal Year 2009 26

Table 5: Characteristics of High-Expenditure Medicaid-Only 

Beneficiaries (Top 5 Percent of Expenditures), Fiscal Year 

2009 33

Table 6: Estimated Probability of Being a High-Expenditure 

Medicaid-Only Beneficiary (Full Model Results), by 

Selected Conditions and Services, Fiscal Year 2009 35

Table 7: Characteristics of High-Expenditure Medicaid-Only 

Beneficiaries (Top 1 Percent of Expenditures), Fiscal Year 

2009 38

Table 8: Characteristics of Selected Cases of Medicaid-Only 

Beneficiaries with Expenditures in the Top 1 Percent, 

Fiscal Year 2009 40

Figures

Figure 1: Percent of Total Medicaid Expenditures by Beneficiary 

Spending Group, Fiscal Year 2009 8

Figure 2: State Variation in Per Capita Spending on HighExpenditure Medicaid-Only Beneficiaries, Fiscal Year 

2009 10

Figure 3: Percentage of Expenditures for Services and Managed 

Care and Premium Assistance for High-Expenditure, and 

All Other Medicaid-Only Beneficiaries, Fiscal Year 2009 15

Figure 4: Percentage of Expenditures for Services and Managed 

Care and Premium Assistance for High-Expenditure, and 

All Other Medicaid-Only Disabled Beneficiaries, Fiscal 

Year 2009 17
Page iii GAO-14-176 Medicaid Beneficiaries with High Expenditures

Figure 5: Percentage of Expenditures for Services and Managed 

Care and Premium Assistance for High-Expenditure, and 

All Other Medicaid-Only Child Beneficiaries, Fiscal Year 

2009 19

Figure 6: Percentage of Expenditures for Services and Managed 

Care and Premium Assistance for High-Expenditure, and 

All Other Medicaid-Only Adult Beneficiaries, Fiscal Year 

2009 21

Figure 7: Percentage of Expenditures for Services and Managed 

Care and Premium Assistance for High-Expenditure, and 

All Other Medicaid-Only Aged Beneficiaries, Fiscal Year 

2009 23

Figure 8: Percentage of Expenditures for Services and Managed 

Care and Premium Assistance for High-Expenditure 

Medicaid-Only Beneficiaries, by Long-Term Care 

Residence Status, Fiscal Year 2009 25

Abbreviations

CHIP Children’s Health Insurance Program

CMS Centers for Medicare & Medicaid Services

FPL federal poverty level

HHS Department of Health and Human Services

HIV/AIDS human immunodeficiency virus/acquired immunodeficiency 

 syndrome

HMO health maintenance organization

LTC long-term care

LTSS long-term services and supports

MSIS Medicaid Statistical Information System

PPACA Patient Protection and Affordable Care Act

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Page 1 GAO-14-176 Medicaid Beneficiaries with High Expenditures

441 G St. N.W.

Washington, DC 20548

February 19, 2014

The Honorable Charles E. Grassley

United States Senate

Dear Senator Grassley:

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

is an important source of health coverage for millions of children, adults, 

aged individuals (individuals aged 65 and older), and those with 

disabilities. In fiscal year 2012, the Medicaid program spent

approximately $435.5 billion to provide health care services to about 

72.6 million beneficiaries. Additionally, Medicaid enrollment is likely to 

grow within states that choose to expand eligibility for Medicaid in 

response to the Patient Protection and Affordable Care Act of 2010 

(PPACA).1 The Congressional Budget Office estimated that, as a result of 

PPACA, 10 million additional people could be enrolled in Medicaid and 

the Children’s Health Insurance Program (CHIP) by 2016 compared with

2012.2 Within Medicaid, there are two groups of beneficiaries—one 

composed of individuals who are only enrolled in Medicaid, and another 

composed of individuals enrolled in both Medicaid and Medicare, 

commonly referred to as dual-eligible beneficiaries.3

 

1

The expansion will apply to Americans with incomes at or below 138 percent of the 

federal poverty level (FPL), including previously ineligible categories, such as childless 

adults. PPACA established 133 percent of the FPL as the income limit for expanded 

Medicaid eligibility; however, it also specified that an income disregard in the amount of 

5 percent of the FPL be deducted from an individual’s income when determining Medicaid 

eligibility, which effectively raised the eligibility limit for newly eligible Medicaid recipients 

to 138 percent of the FPL. Pub. L. No. 111-148, 124 Stat. 119, as amended by the Health 

Care and Education Reconciliation Act of 2010 (HCERA), Pub. L. No. 111-152, 124 Stat. 

1029. For purposes of this report, references to PPACA include the amendments made by 

HCERA.

Research on 

Medicaid enrollment and spending has demonstrated that a small 

percentage of beneficiaries account for a disproportionately large share of 

2

CHIP is an insurance program for certain low-income, uninsured children whose family 

income is too high for Medicaid. Congressional Budget Office, Estimates for the Insurance 

Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court 

Decision (Washington, D.C.: July 2012).

3

Medicare is the federally financed health insurance program for persons aged 65 and 

over, certain individuals with disabilities, and individuals with end-stage renal disease.
 

Page 2 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Medicaid expenditures. Understanding states’ expenditures for both highexpenditure populations—those dually eligible and those who are 

Medicaid-only—could enhance efforts to manage Medicaid expenditures 

for particular types of beneficiaries.

You asked us to provide information on the demographics and service 

usage of different types of high-expenditure Medicaid beneficiaries, noting 

that less attention has been paid to the demographics and service 

utilization of high-expenditure Medicaid-only beneficiaries compared with

dual-eligible beneficiaries. In this report, we examine (1) states’ spending 

for high-expenditure beneficiaries, both Medicaid-only and dual-eligible 

beneficiaries, compared with other Medicaid beneficiaries; (2) the 

characteristics associated with high-expenditure Medicaid-only 

beneficiaries; and (3) the services that contributed to high expenditures 

for Medicaid-only beneficiaries, and how they compared with service 

usage by all other Medicaid-only beneficiaries.

To examine states’ spending for high-expenditure Medicaid-only 

beneficiaries compared with other Medicaid beneficiaries, we used data 

from the fiscal year 2009 Medicaid Statistical Information System (MSIS) 

Annual Person Summary File.4 We first calculated the total number of 

Medicaid enrollees and total Medicaid expenditures in each state 

separately for both the Medicaid-only and dual-eligible beneficiaries.5 We 

then determined the number of beneficiaries whose total expenditures fell 

within the top 5 percent of total expenditures within each state for each of 

these groups, designating them as high-expenditure beneficiaries. Finally, 

we calculated the total expenditures for high-expenditure Medicaid-only 

beneficiaries and all other Medicaid-only beneficiaries in each state, and 

combined these data at a national level.

 

4

MSIS data provides a summary of expenditures linked to specific beneficiaries on the 

basis of their medical claims for care. These data exclude other aspects of the Medicaid 

program that are not tied to specific beneficiaries. For example, the MSIS data do not 

contain supplemental payments to providers that are separate from standard Medicaid 

payments for services.

5

We excluded individuals who were only enrolled in a stand-alone, separate Children’s 

Health Insurance Program during the year.
 

Page 3 GAO-14-176 Medicaid Beneficiaries with High Expenditures

To examine the characteristics associated with high-expenditure 

Medicaid-only beneficiaries, we determined the percentage of highexpenditure Medicaid-only beneficiaries with key characteristics and used 

logistic regression to examine the effect of having key beneficiary 

characteristics on the probability of being a high-expenditure Medicaidonly beneficiary.6 The key beneficiary characteristics represented as 

independent variables in our logistic regression model included: eligibility 

group (disabled, child, adult, aged), age, gender, race/ethnicity, 

geographic location,7 participation in capitated managed care,8 period of 

enrollment in Medicaid (whether full year or partial year), as well as 

whether the beneficiaries had any of five health conditions or had 

received any of two services.9

 

6

Probabilities were calculated by converting the odds that resulted from our logistic 

regression models. The size of the effect of each enrollee characteristic is expressed as a 

probability, greater values reflecting a greater chance that the characteristic increased the 

likelihood of being a high-expenditure beneficiary. Medicaid-only beneficiaries had a 

hypothetical 5 percent probability of being in the high-expenditure group by chance alone. 

All probabilities were significant at the 0.05 level.

Finally, our logistic regression models 

included characteristics of states’ Medicaid programs, such as their 

spending on high-expenditure beneficiaries and long-term services and 

supports (LTSS) in non-institutional settings (also called home and 

community based services) and capitated managed care penetration 

7

We classified counties as metropolitan or nonmetropolitan using the 2009 Area Resource 

File provided by the Health Resources and Services Administration.

8

Capitated managed care included enrollment in a health maintenance organization 

(HMO) or capitated risk-based managed care plans. We did not consider enrollment in 

limited benefit plans as an indicator of this beneficiary characteristic.

9

The five conditions identified in the MSIS summary file (using indicators created with the 

ICD-9 diagnosis codes from the full claims file) are: (1) human immunodeficiency 

virus/acquired immunodeficiency syndrome (HIV/AIDS), (2) asthma, (3) diabetes, 

(4) mental health, and (5) substance abuse. The two service categories also identified are 

delivery/childbirth, which includes newborns and women who have given birth, and longterm care residence. The summary file does not provide information on all conditions that 

may affect the likelihood of the beneficiary being a high-expenditure Medicaid-only 

beneficiary. As a result, we could not include all relevant conditions in our models.
 

Page 4 GAO-14-176 Medicaid Beneficiaries with High Expenditures

rates.10

To examine the services that contributed to high expenditures for 

Medicaid-only beneficiaries and how they compared with service usage 

by all other Medicaid-only beneficiaries, we determined the distribution of 

expenditures for high-expenditure Medicaid-only beneficiaries. The data 

allowed us to describe patterns of usage for the following six service 

categories: (1) hospital care, (2) non-hospital acute care, (3) drugs, 

(4) managed care and premium assistance,

We report percentages that describe the high-expenditure 

beneficiary population, as well as the probabilities that demonstrate the 

association of each characteristic with the likelihood of being in the highexpenditure group.

11 (5) LTSS in non-institutional 

settings, and (6) LTSS in institutional settings.12

We assessed the reliability of the 2009 MSIS Annual Summary File data 

we received from the Centers for Medicare & Medicaid Services (CMS) 

by performing appropriate electronic data checks and by interviewing 

agency officials who were knowledgeable about the data. This allowed us 

to determine that the data were suitable for our purposes. We retained 

approximately 64.5 million of the original 71.6 million records (90 percent) 

for our analysis; the majority of exclusions were due to unknown eligibility 

status. For a more complete description of our methodology, see 

appendix I.

We compared their 

distribution to those of all other Medicaid-only beneficiaries.

 

10LTSS includes services such as home health and personal care. We created variables 

on state spending on high-expenditure Medicaid-only beneficiaries using information from 

MSIS on the percent of expenditures for the Medicaid-only group and separating states by 

quartiles. We created variables for state spending on home and community-based 

services by dividing the total Medicaid expenditures for these services by expenditures for 

all Medicaid services and separating states into quartiles. We obtained data for state 

spending on home and community-based services from MSIS and Kaiser Family 

Foundation, Medicaid Home and Community-Based Services: 2009 Data Update

(Washington, D.C.: December 2012). We created variables for state managed care 

penetration using data on the percentage of individuals covered by HMO and other riskbased capitated managed care (HMO penetration rates) by state and separating states by 

quartiles. We obtained data for this variable from GAO, Medicaid: States’ Use of Managed 

Care, GAO-12-872R (Washington, D.C.: Aug. 17, 2012).

11Managed care and premium assistance describe Medicaid health insurance payments 

made toward HMO/capitated risk-based, primary care case management, and prepaid 

managed care health plans.

12Includes facilities such as skilled nursing facilities and intermediate care facilities for 

persons with intellectual disabilities.
 

Page 5 GAO-14-176 Medicaid Beneficiaries with High Expenditures

We conducted this performance audit from September 2012 through 

February 2014 in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform our 

work to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives.

At the federal level, CMS, within the Department of Health and Human 

Services (HHS), is responsible for overseeing the design and operation of 

states’ Medicaid programs, and states administer their respective 

Medicaid programs’ day-to-day operations. In conformance with federal 

requirements, states establish beneficiaries’ eligibility for Medicaid, and 

determine the services that will be provided to beneficiaries and how they 

will be provided in their state.

Eligibility for Medicaid is based on a variety of categorical and financial 

requirements. Historically, categories of Medicaid eligibility included 

pregnant women, low-income children and their parents, individuals who 

are aged, and individuals with disabilities. In 2014, certain low-income 

adults who did not fall into one of these groups may be eligible for 

Medicaid in states that chose to expand coverage to these individuals 

under PPACA. Dual-eligible beneficiaries, who are eligible for both 

Medicaid and Medicare, generally fall into two categories: (1) low-income 

seniors (individuals aged 65 years old and over) and (2) individuals with 

disabilities under the age of 65.

While some characteristics of state programs vary, Medicaid generally 

covers a wide range of health care services. These include hospital care; 

outpatient services, such as physician services, laboratory and other 

diagnostic tests; prescription drugs; dental care; and LTSS in institutions 

and in the community.13

 

13GAO, Medicaid: Data Sets Provide Inconsistent Picture of Expenditures, 

Non-institutional LTSS include home health and 

personal care services, among other services. Medicaid is the nation’s 

GAO-13-47

(Washington, D.C.: Oct. 29, 2012).

Background

Medicaid Eligibility and 

Financing
 

Page 6 GAO-14-176 Medicaid Beneficiaries with High Expenditures

primary payer for LTSS, and provided approximately 41 percent of LTSS 

funding in the United States in 2010.14

As we have previously reported, nearly all states enroll some Medicaid 

beneficiaries in a form of managed care.15 States vary widely in terms of 

the scope of services they provide and the populations they enroll in 

managed care. Some states contract with managed care organizations to 

provide the full range of covered Medicaid services to certain enrollees, 

for which they pay a set, or capitated, amount per member per month. 

Alternatively, states may rely on arrangements, such as limited benefit 

plans—which provide a limited set of services, including dental care or 

behavioral health services—or primary care case management programs 

in which enrollees are assigned a primary care provider who is 

responsible for providing primary care services and for coordinating other 

needed health care. States often provide long-term care services outside 

of managed care arrangements.16

Researchers have examined patterns of service utilization and 

expenditures within the Medicaid population, with a number of articles 

focused on dual-eligible beneficiaries. For example, one study examining 

Medicaid enrollment and expenditures found that dual-eligible 

beneficiaries comprised 14 percent of all Medicaid enrollees, but 

36 percent of Medicaid expenditures in 2010.17

 

14Kaiser Family Foundation, Medicaid’s Role in Meeting the Long Term Care Needs of 

America’s Seniors (Washington, D.C.: January 2013).

Studies focused on dualeligible beneficiaries have further found that a small proportion of these 

beneficiaries were responsible for a significant portion of Medicaid 

expenditures spent on dual-eligible beneficiaries. For example, one study 

found that in 2007 full benefit dual-eligible beneficiaries who were in the 

15GAO, Medicaid: States’ Use of Managed Care, GAO-12-872R (Washington, D.C.: 

Aug. 17, 2012).

16Kaiser Family Foundation, A Profile of Medicaid Managed Care Programs in 2010: 

Findings from a 50-State Survey (Washington, D.C.: September 2011).

17Kaiser Family Foundation, Medicaid’s Role for Dual Eligible Beneficiaries (Washington, 

D.C., August 2013).

Service Utilization and 

Expenditures among 

Medicaid Beneficiaries
 

Page 7 GAO-14-176 Medicaid Beneficiaries with High Expenditures

top 10 percent of Medicaid spending were responsible for 51 percent of 

Medicaid spending on dual-eligible beneficiaries.18

The research also indicates that there is a subset of Medicaid-only 

beneficiaries who are very costly, such as those with institutional care 

needs or chronic conditions. One study showed that high-expenditure 

Medicaid beneficiaries in 2001 included subgroups from each eligibility 

category, with the elderly and disabled making up the greatest shares of 

this high-expenditure group. The largest portions of spending were for 

hospital care for children and adults, intermediate care for individuals with 

disabilities, and nursing home care for the elderly.19 Another study 

showed that annual per capita expenditures ranged from $8,000 to nearly 

$16,000 for Medicaid beneficiaries with chronic conditions, including 

asthma, coronary heart disease, congestive heart failure, diabetes, or 

hypertension. This study also noted that annual per capita expenditures 

may double and sometimes triple when single chronic conditions are 

coupled with mental illness and a drug or alcohol disorder.20

High-expenditure Medicaid-only beneficiaries accounted for almost a third 

of states’ total Medicaid expenditures. When aggregated at the national 

level, states spent 31.6 percent of Medicaid expenditures on these 

beneficiaries, who represented 4.3 percent of all beneficiaries. States 

spent another 33.1 percent of Medicaid expenditures on all other 

Medicaid-only beneficiaries, who represented 81.2 percent of total 

Medicaid beneficiaries. The last 35.2 percent of state Medicaid 

expenditures went for dual-eligible Medicaid beneficiaries. States spent 

13.3 percent of total Medicaid expenditures on high-cost dual-eligible 

 

18Full benefit dual-eligible beneficiaries may receive the entire range of Medicaid benefits 

as opposed to partial dual-eligible beneficiaries. Partial dual-eligible beneficiaries may 

receive assistance for covering Medicare premiums, cost-sharing, or both. Medicaid and 

CHIP Payment and Access Commission, Report to the Congress on Medicaid and CHIP

(Washington, D.C.: March 2013). 

19Intermediate care included intermediate care facility services for persons with intellectual 

disabilities, services in institutions for mental disease for the elderly, and inpatient 

psychiatric care under age 21. Kaiser Family Foundation, Medicaid’s High Cost Enrollees

(Washington, D.C.: March 2006).

20Center for Health Care Strategy, Inc., Clarifying Multimorbidity Patterns to Improve 

Targeting and Delivery of Clinical Services for Medicaid Populations (Hamilton, N.J.: 

December 2010).

Nearly One-Third of 

States’ Medicaid 

Expenditures Were 

for High-Expenditure 

Medicaid-Only 

Beneficiaries
 

Page 8 GAO-14-176 Medicaid Beneficiaries with High Expenditures

beneficiaries (less than 1 percent of the total Medicaid population) and 

21.9 percent of total Medicaid expenditures on other dual-eligible 

beneficiaries (13.8 percent of total Medicaid beneficiaries). (See fig. 1).

Figure 1: Percent of Total Medicaid Expenditures by Beneficiary Spending Group, 

Fiscal Year 2009

Note: Dual-eligible beneficiaries are eligible for Medicare and Medicaid. Medicaid-only beneficiaries 

are eligible for Medicaid but not Medicare. Both dual-eligible and Medicaid-only beneficiaries may 

also have other sources of health care coverage. High-expenditure beneficiaries represent those 

whose total expenditures fell within the top 5 percent of total expenditures within each state for their 

group—Medicaid-only or dual-eligible beneficiaries. All other beneficiaries represent those whose 

spending for their group was less than the spending for the top 5 percent. Percentages may not add 

to 100 due to rounding.

At the beneficiary level, per-capita spending on high-expenditure 

Medicaid-only beneficiaries greatly exceeded that of all other Medicaidonly beneficiaries, but was less than what was spent on high-expenditure 

dual-eligible beneficiaries. (See table 1.) Overall, per capita spending by 

states on high-expenditure Medicaid-only beneficiaries was approximately 

18 times higher than per capita spending on all other Medicaid-only 

beneficiaries. This was similar to the pattern of spending for dual-eligible 

beneficiaries, with per capita spending significantly higher for highexpenditure dual-eligible beneficiaries compared with all other dualeligible beneficiaries.
 

Page 9 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Table 1: Per Capita Spending by Beneficiary Group, Fiscal Year 2009

Beneficiary 

group

Per capita spending,

high-expenditure beneficiaries

Per capita spending,

all other beneficiaries

Medicaid-only $35,983 $1,989

Dual-eligible $89,440 $7,762

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Note: Medicaid-only beneficiaries are eligible for Medicaid but not Medicare. Dual-eligible 

beneficiaries are eligible for Medicare and Medicaid. Medicaid-only and dual–eligible beneficiaries 

may also have other sources of health care coverage. High-expenditure beneficiaries represent those 

whose total expenditures fell within the top 5 percent of total expenditures within each state.

At the state level, there was wide variation in spending per capita on highexpenditure Medicaid-only beneficiaries. (See fig. 2.) Per-capita 

expenditures by state per beneficiary ranged from $20,896 to $83,365.21

 

21Figures include beneficiaries with restricted benefits, such as those who only receive 

family planning benefits.
 

Page 10 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Figure 2: State Variation in Per Capita Spending on High-Expenditure Medicaid-Only Beneficiaries, Fiscal Year 2009

Note: Medicaid-only beneficiaries are eligible for Medicaid but not Medicare. Medicaid-only 

beneficiaries may also have other sources of health care coverage. High-expenditure beneficiaries 

represent those whose total expenditures fell within the top 5 percent of total expenditures within 

each state.

Figures include beneficiaries with restricted benefits, such as those who only receive family planning 

benefits.
 

Page 11 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Key characteristics—such as having a disability, having certain 

conditions, delivery/childbirth, and residing in a LTC facility—were 

strongly associated with being a high-expenditure Medicaid-only 

beneficiary. These key characteristics had consistently strong 

associations with being a high-expenditure Medicaid-only beneficiary 

even when the data were examined separately for each eligibility group.22

We found that about two-thirds of the high-expenditure group was 

comprised of beneficiaries who were eligible for Medicaid due to 

disability.23

Table 2: Percentage and Estimated Probability of Being a High-Expenditure 

Medicaid-Only Beneficiary by Eligibility Group, Fiscal Year 2009

Further, the probability of being a high-expenditure Medicaidonly beneficiary was 18.3 percent for disabled Medicaid-only 

beneficiaries, which was higher than for any other eligibility group. (See 

table 2.) In contrast, non-disabled children and adult beneficiaries each 

had less than a 3 percent probability of being in the high-expenditure 

group, but made up 16.1 and 15 percent, respectively, of the highexpenditure Medicaid-only beneficiaries.

Eligibility 

Category

Percentage of 

high-expenditure population

Probability of being a highexpenditure beneficiary (percent)

Child 16.1 2.0

Adult 15.0 2.6

Aged 2.5 10.5

Disabled 66.3 18.3

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Note: High-expenditure beneficiaries represent those whose total expenditures fell within the top 

5 percent of total expenditures within each state. All other beneficiaries represent those whose 

spending was less than the spending for the top 5 percent. Medicaid-only beneficiaries are eligible for 

Medicaid but not Medicare.

Probabilities were derived from logistic regression results. A probability greater than 5 percent 

indicates that a characteristic’s influence on the beneficiary being in the high-expenditure group was 

 

22Delivery/childbirth may include costs attributed to a mother during delivery or the child 

soon after birth.

23Some individuals with a disability may be enrolled in Medicaid under other eligibility 

groups. For example, in some states, children with disabilities may be assigned to an 

eligibility group based on their age and not their disability status. Our analysis of 

beneficiaries who resided in a long-term care facility found that 15.3 percent were in the 

eligibility group for children, while 74.3 percent were in the disabled eligibility group, and 

the rest were in the aged or adult eligibility groups.

Disability, Certain 

Conditions, 

Delivery/Childbirth, 

and Long-Term Care 

Residency Were 

Strongly Associated 

with Being a HighExpenditure 

Medicaid-Only 

Beneficiary
 

Page 12 GAO-14-176 Medicaid Beneficiaries with High Expenditures

more than what would have occurred by chance alone. All probabilities were significant at the 

0.05 level.

Residing in a long-term care (LTC) facility or having certain conditions, 

such as human immunodeficiency virus/acquired immunodeficiency 

syndrome (HIV/AIDS), was also strongly associated with being a highexpenditure Medicaid-only beneficiary. (See table 3.) We found that while 

beneficiaries residing in a LTC facility comprised 8.8 percent of the 

Medicaid-only high-expenditure group, they had a 24.2 percent probability 

of being high-expenditure beneficiaries. Regarding the impact of certain 

conditions, beneficiaries with HIV/AIDS comprised just 3.4 percent of the 

high-expenditure group, but had a 20.8 percent probability of being highexpenditure beneficiaries. Additionally, delivery/childbirth—giving birth for 

the mother or being born for the infant—increased the probability of being 

a high-cost beneficiary. New mothers and infants were 9.8 percent of the 

high-expenditure population, but had a 13.3 percent probability of being 

high-expenditure beneficiaries. (See app. II for characteristics of highexpenditure beneficiaries.)

Table 3: Percentage and Estimated Probability of Being a High-Expenditure 

Medicaid-Only Beneficiary, by Selected Conditions and Services, Fiscal Year 2009

Characteristic

Percentage of 

high-expenditure

population

Probability of being a 

high-expenditure 

beneficiary (percent)

Conditions

HIV/AIDS 3.4 a 20.8

Mental health condition 51.8 9.1

Diabetes 18.6 8.8

Substance abuse 19.1 7.9

Asthma 14.5 6.8

Services

Long-term care residence 8.8 24.2

Delivery/childbirth 9.8 b 13.3

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Note: High-expenditure beneficiaries represent those whose total expenditures fell within the top 

5 percent of total expenditures within each state. All other beneficiaries represent those whose 

spending was less than the spending for the top 5 percent. Medicaid-only beneficiaries are eligible for 

Medicaid but not Medicare.

Probabilities were derived from logistic regression results. A probability greater than 5 percent 

indicates that a characteristic’s influence on the beneficiary being in the high-expenditure group was 

more than what would have occurred by chance alone. All probabilities were significant at the 

0.05 level.

a

HIV/AIDS stands for human immunodeficiency virus/acquired immunodeficiency syndrome.
 

Page 13 GAO-14-176 Medicaid Beneficiaries with High Expenditures

b

We also found that while demographic factors like age and race, 

capitated managed care participation, and characteristics of the state 

where the beneficiary was enrolled helped to describe the Medicaid-only 

population,

Delivery/childbirth may include costs attributed to a mother during delivery or the child soon after 

birth.

24

In addition, we used logistic regression to examine the factors that 

influence the probability of being a high-expenditure beneficiary 

separately for each of the four eligibility groups (children, adults, aged, 

and disabled). We found that having one of the identified conditions or 

using one of the included services was consistently associated with a 

greater probability of being a high-expenditure Medicaid-only beneficiary 

compared with those without such characteristics. However, the size of 

their influence differed. For example, children had an 11.4 percent 

probability of being high-expenditure Medicaid-only beneficiaries if they 

had HIV/AIDS, but individuals with disabilities had a 71.6 percent 

probability if they had that condition. (See app. III for complete table of 

probabilities.)

these factors were generally less strongly associated with 

being a high-expenditure beneficiary. (See app. III for a complete table of 

probabilities.)

 

24Characteristics of the state included state spending on high-expenditure Medicaid-only 

beneficiaries, state spending on home and community based services, and state managed 

care penetration rates.
 

Page 14 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Overall, hospital services and LTSS represented the bulk of spending for 

high expenditure Medicaid-only beneficiaries—almost 65 percent. In 

contrast, payments to managed care organizations and premium 

assistance constituted the largest proportion of expenditures for all other 

Medicaid-only beneficiaries. In addition, when we examined Medicaidonly high-expenditure and other beneficiaries separately by eligibility 

group, the differences in service use were generally consistent, but the 

proportion of expenditures for the different services varied. Separately 

examining high-expenditure Medicaid-only beneficiaries in LTC 

institutions and beneficiaries with spending in the top 1 percent of 

expenditures showed that these beneficiaries had the highest spending 

for hospital services and LTSS.

For high-expenditure Medicaid-only beneficiaries as a whole, hospital 

services comprised 30.6 percent, LTSS in non-institutional settings 

comprised 24.3 percent, and LTSS in institutions comprised 9.7 percent 

of their expenditures. Other expenditures were for drugs, managed care 

and premium assistance, and non-hospital acute care. In contrast to highexpenditure Medicaid-only beneficiaries, the largest share of total 

expenditures for all other Medicaid-only beneficiaries was for managed 

care and premium assistance (57.2 percent), followed by non-hospital 

acute care (16.6 percent), hospital services (11.9 percent), drugs 

(9.7 percent) and LTSS in non-institutional settings (4.5 percent). (See 

fig. 3.)

High-Expenditure 

Beneficiaries Had 

High Hospital 

Expenditures and 

Significantly Different 

Spending Patterns 

Compared with All 

Other Medicaid-Only 

Beneficiaries

Spending Patterns for All 

High-Expenditure 

Medicaid-Only 

Beneficiaries Compared 

with All Other MedicaidOnly Beneficiaries
 

Page 15 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Figure 3: Percentage of Expenditures for Services and Managed Care and Premium Assistance for High-Expenditure, and All 

Other Medicaid-Only Beneficiaries, Fiscal Year 2009

Notes: High-expenditure beneficiaries are those whose total expenditures fell within the top 5 percent 

of total expenditures within each state. All other beneficiaries represent those whose spending was 

less than the spending for the top 5 percent. Medicaid-only beneficiaries are eligible for Medicaid but 

not Medicare.

LTSS stands for long-term care services and supports. The spending category managed care and 

premium assistance includes Medicaid health insurance payments made to risk-based health 

maintenance organizations, primary care case management services, and prepaid health plans.

Percentages may not add to 100 due to rounding.

The general pattern of greater hospital and LTSS service use by high 

expenditure Medicaid-only beneficiaries compared with greater spending 

on managed care and premium support by all other Medicaid-only 

beneficiaries was consistent across eligibility groups. However, there 

were some differences in expenditures by eligibility category among highexpenditure Medicaid-only beneficiaries and all other Medicaid-only 

beneficiaries.

Spending Patterns for 

Eligibility Groups
 

Page 16 GAO-14-176 Medicaid Beneficiaries with High Expenditures

• Disabled: For high expenditure Medicaid-only beneficiaries in the 

disabled category, LTSS non-institutional (27.5 percent), hospital 

(24.8 percent), and LTSS institutional services (11.9 percent) 

represent almost two-thirds of their expenditures. (See fig. 4.) In 

contrast, all other Medicaid-only beneficiaries in the disabled category 

had over half of their expenditures for managed care and premium 

assistance (52.1 percent), and had almost no LTSS institutional 

expenditures (0.1 percent). Overall, 79.5 percent of expenditures for 

Medicaid-only beneficiaries in the disabled group were for the highexpenditure beneficiaries.

Beneficiary Profile

Beneficiary A was a 61-year-old disabled 

African American male in 2009, with $73,539 

in total Medicaid expenditures in that year. He 

was not enrolled in managed care at any point 

in the year. He was indicated to have 

diabetes, a mental health condition, and 

resided in a long-term care facility. His 

expenditures were highly concentrated in 

LTSS non-institutional care (81.9 percent). 

About 10 percent of his expenditures were for 

prescription drugs.
 

Page 17 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Figure 4: Percentage of Expenditures for Services and Managed Care and Premium Assistance for High-Expenditure, and All 

Other Medicaid-Only Disabled Beneficiaries, Fiscal Year 2009

Notes: High-expenditure beneficiaries are those whose total expenditures fell within the top 5 percent 

of total expenditures within each state. All other beneficiaries represent those whose spending was 
 

Page 18 GAO-14-176 Medicaid Beneficiaries with High Expenditures

less than the spending for the top 5 percent. Medicaid-only beneficiaries are eligible for Medicaid but 

not Medicare.

LTSS stands for long-term care services and supports. The spending category managed care and 

premium assistance includes Medicaid health insurance payments made to risk-based health 

maintenance organizations, primary care case management services, and prepaid health plans.

Percentages may not add to 100 due to rounding.

Children: Medicaid-only children had almost no LTSS institutional 

expenditures (less than 1 percent), whether in the high-expenditure group 

or not.25

 

25This suggests that states are generally classifying beneficiaries aged 21 and under who 

need institutional care as disabled. Our data shows that 27.8 percent of beneficiaries 

receiving LTSS institutional care were aged 21 and under.

(See fig. 5.) High-expenditure Medicaid-only children had 

70 percent of their expenditures for hospital (46.1 percent) and LTSS 

non-institutional services (23.9 percent). For all other Medicaid-only 

children, over 58 percent of their expenditures were for managed care 

and premium assistance, followed by non-hospital acute (18.8 percent) 

and hospital services (9.8 percent). About 22 percent of expenditures for 

Medicaid-only children were for those in the high-expenditure group.

Beneficiary Profile

Beneficiary B was a 1-year-old white male in 

the child eligibility group in 2009, with $90,609 

in total Medicaid expenditures in that year. He 

was not enrolled in managed care, but had 

costs associated with his delivery. His total 

expenditures were highly concentrated in 

hospital services (79.4 percent). About 

12 percent of his expenditures were for nonhospital acute care.
 

Page 19 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Figure 5: Percentage of Expenditures for Services and Managed Care and Premium Assistance for High-Expenditure, and All 

Other Medicaid-Only Child Beneficiaries, Fiscal Year 2009

Notes: High-expenditure beneficiaries are those whose total expenditures fell within the top 5 percent 

of total expenditures within each state. All other beneficiaries represent those whose spending was 
 

Page 20 GAO-14-176 Medicaid Beneficiaries with High Expenditures

less than the spending for the top 5 percent. Medicaid-only beneficiaries are eligible for Medicaid but 

not Medicare.

LTSS stands for long-term care services and supports. The spending category managed care and 

premium assistance includes Medicaid health insurance payments made to risk-based health 

maintenance organizations, primary care case management services, and prepaid health plans.

Percentages may not add to 100 due to rounding.

• Adults: Similar to children, Medicaid-only adult beneficiaries had 

almost no LTSS institutional expenditures (less than 1 percent of each 

of their total expenditures) whether in the high-expenditure group or 

not.26

 

26This suggests that states are generally classifying individuals of adult age who need 

institutional care as disabled. Our data shows that 18.3 percent of beneficiaries receiving 

LTSS institutional care were aged 22 to 44, and 44 percent were aged 45 to 64.

(See fig. 6.) Hospital services represented over half the 

expenditures for high-expenditure adult beneficiaries. The remaining 

expenditures were almost equally distributed between non-hospital 

acute care (15.2 percent), drugs (14.2 percent), and managed care 

and premium support (14.1 percent). LTSS non-institutional services 

were a relatively small part of their total expenditures (3.4 percent). 

The greatest share of expenditures for all other Medicaid-only adult 

beneficiaries were for managed care and premium support 

(58.4 percent) followed by hospital (16.2 percent) and non-hospital 

acute care (15.4 percent) services. About 22 percent of expenditures 

for Medicaid-only adult beneficiaries were for the high-expenditure 

group.

Beneficiary Profile

Beneficiary C was a 21-year-old disabled 

white female in 2009 with $267,202 in total 

Medicaid expenditures in that year. She was 

not enrolled in Medicaid managed care at any 

point in the year, but was indicated to have a 

mental health condition, a substance abuse 

condition, and reside in a long-term care 

facility. Her expenditures were highly 

concentrated in hospital services 

(54.4 percent) and LTSS non-institutional 

care (30.8 percent).
 

Page 21 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Figure 6: Percentage of Expenditures for Services and Managed Care and Premium Assistance for High-Expenditure, and All 

Other Medicaid-Only Adult Beneficiaries, Fiscal Year 2009

Notes: High-expenditure beneficiaries are those whose total expenditures fell within the top 5 percent 

of total expenditures within each state. All other beneficiaries represent those whose spending was 
 

Page 22 GAO-14-176 Medicaid Beneficiaries with High Expenditures

less than the spending for the top 5 percent. Medicaid-only beneficiaries are eligible for Medicaid but 

not Medicare.

LTSS stands for long-term care services and supports. The spending category managed care and 

premium assistance includes Medicaid health insurance payments made to risk-based health 

maintenance organizations, primary care case management services, and prepaid health plans.

• Aged: For the aged, both high-expenditure and all other Medicaidonly beneficiaries had LTC institutional expenditures, but the share of 

those expenditures differed—28.2 percent compared with 4.2 percent. 

Among the high-expenditure Medicaid-only aged beneficiaries, 

hospital (28.6 percent), LTSS institutional (28.2 percent), and LTSS 

non-institutional (15.4 percent) services represented over 70 percent 

of total expenditures. (See fig.7.) For all other Medicaid-only aged 

beneficiaries, managed care and premium support represented 

48.3 percent of their expenditures, followed by drugs (18.2 percent), 

hospital (13.7 percent), and non-hospital acute care (10.6 percent) 

services. Over 73 percent of expenditures for the Medicaid-only aged 

were for those in the high-expenditure group.

Beneficiary Profile 

Beneficiary D was an under 1-year-old 

disabled male of unknown race in 2009, with 

$101,225 in total Medicaid expenditures in 

that year. He was enrolled in Medicaid 

managed care for 6 to 11 months. He was 

indicated to have asthma and costs 

associated with his delivery. His expenditures 

were highly concentrated in hospital services 

(84.9 percent). About 9 percent of his 

expenditures were for non-acute hospital 

care.
 

Page 23 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Figure 7: Percentage of Expenditures for Services and Managed Care and Premium Assistance for High-Expenditure, and All 

Other Medicaid-Only Aged Beneficiaries, Fiscal Year 2009

Notes: High-expenditure beneficiaries are those whose total expenditures fell within the top 5 percent 

of total expenditures within each state. All other beneficiaries represent those whose spending was 
 

Page 24 GAO-14-176 Medicaid Beneficiaries with High Expenditures

less than the spending for the top 5 percent. Medicaid-only beneficiaries are eligible for Medicaid but 

not Medicare.

LTSS stands for long-term care services and supports. The spending category managed care and 

premium assistance includes Medicaid health insurance payments made to risk-based health 

maintenance organizations, primary care case management services, and prepaid health plans.

LTSS spending differed for high expenditure Medicaid-only beneficiaries

living in LTC facilities and those living in the community. (See fig. 8.)

• Among high-expenditure Medicaid-only beneficiaries residing in a LTC 

facility, expenditures for LTSS in institutional settings (50 percent), 

hospital services (27.2 percent), and LTSS in non-institutional settings 

(7.3 percent) accounted for almost 85 percent of their total 

expenditures.

• Among high-expenditure beneficiaries not residing in a LTC facility, 

expenditures for LTSS in non-institutional settings (28.4 percent) were 

much greater, and expenditures for hospital services were similar 

(31.4 percent)—and these two services represented almost 

60 percent of their total expenditures. In addition, the percentage of 

expenditures on drugs and non-hospital acute care was greater for 

high expenditure Medicaid-only beneficiaries who were not living in 

LTC facilities.

Spending Patterns for 

High-Expenditure 

Medicaid-Only 

Beneficiaries by LTC 

Facility Residence Status
 

Page 25 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Figure 8: Percentage of Expenditures for Services and Managed Care and Premium Assistance for High-Expenditure 

Medicaid-Only Beneficiaries, by Long-Term Care Residence Status, Fiscal Year 2009

Notes: High-expenditure beneficiaries are those whose total expenditures fell within the top 5 percent 

of total expenditures within each state. All other beneficiaries represent those whose spending was 

less than the spending for the top 5 percent. Medicaid-only beneficiaries are eligible for Medicaid but 

not Medicare.

LTC stands for long-term care. LTSS stands for long-term care services and supports. The spending 

category managed care and premium assistance includes Medicaid health insurance payments made 

to risk-based health maintenance organizations, primary care case management services, and 

prepaid health plans.

Percentages may not add to 100 due to rounding.

While hospital services were the largest expenditure category among 

high-expenditure beneficiaries not residing in a LTC facility, per-capita 

hospital expenditures for beneficiaries residing in a LTC facility were over 

two times as much ($21,589 compared with $9,978). (See table 4.)
 

Page 26 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Table 4: Per Capita Expenditures for Services and Managed Care and Premium 

Assistance for High-Expenditure Medicaid-Only Beneficiaries by Long-Term Care 

Residence Status, Fiscal Year 2009

Long-term care facility No long-term care facility

Per capita expenditures 

(dollars)

Per capita expenditures

(dollars)

Hospital 21,589 9,978

Non-Hospital Acute Care 4,420 3,543

Drugs 5,738 4,879

Managed Care & Premium Assistance 2,151 4,349

LTSS Non-Institutional 5,833 9,022

LTSS Institutional 39,671 0 

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Note: LTSS stands for long-term services and supports.

Beneficiaries with expenditures within the top 1 percent for their state—

the top one-fifth of the high-expenditure group—had a greater share of 

spending on hospital services, LTSS in non-institutional settings, and 

LTSS in institutional settings compared with all of the high-expenditure 

beneficiaries. Spending on these services comprised almost 80 percent of 

the total expenditures for beneficiaries with expenditures within the top 

1 percent for their state. (See app. IV for complete table of results, and 

app. V for the demographic characteristics and spending for some 

randomly selected beneficiaries in that group.)

HHS reviewed a draft of this report and provided technical comments, 

which we incorporated as appropriate.

We are sending copies of this report to the Secretary of HHS and to 

interested congressional committees. In addition, the report is available at 

no charge on the GAO website at http://www.gao.gov. 

Spending Patterns for 

Beneficiaries in the Top 

1 Percent of Expenditures

Agency Comments
 

Page 27 GAO-14-176 Medicaid Beneficiaries with High Expenditures

If you or your staff 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 major contributions to 

this report are listed in appendix VI.

Sincerely yours,

Carolyn L. Yocom

Director, Health Care
Appendix I: Objectives, Scope, and 

Methodology

Page 28 GAO-14-176 Medicaid Beneficiaries with High Expenditures

This appendix describes the methodology for addressing three objectives 

that examine: (1) states’ spending for high-expenditure beneficiaries, both 

Medicaid-only and dual-eligible beneficiaries, compared with other 

Medicaid beneficiaries; (2) the characteristics associated with highexpenditure Medicaid-only beneficiaries; and (3) the services that 

contributed to high expenditures for Medicaid-only beneficiaries, and how 

they compared with service usage by all other Medicaid-only 

beneficiaries.

We analyzed data from the fiscal year 2009 Medicaid Statistical 

Information System (MSIS) Annual Person Summary File.1 The summary 

file consolidates individual beneficiaries’ claims for the fiscal year, 

including data on their enrollment and information on their expenditures. 

The summary file also includes beneficiary specific information regarding 

enrollment categories, expenditures among six categories,2 dual eligibility 

status, age, gender, payment arrangements—including fee-for-service 

payments and capitated payments made to managed care 

organizations—and indicators for five conditions and two service 

categories.3

 

1

MSIS data provide a summary of expenditures linked to specific beneficiaries on the 

basis of their medical claims for care. These data exclude other aspects of the Medicaid 

program that are not tied to specific beneficiaries. For example, the MSIS data do not 

contain supplemental payments to providers that are separate from standard Medicaid 

payments for services. 

The summary file excludes some encounter details included 

in the full claims files (for example, the summary file may not include 

2

The summary file includes information on spending for 30 types of services. We 

consolidated 28 of these types of services into the six categories we report:(1) hospital 

care, (2) non-hospital acute care, (3) drugs, (4) managed care and premium assistance, 

(5) long-term services and supports in non-institutional settings, and (6) long-term services 

and supports in institutional settings. The summary file does not provide information on all 

conditions that may affect the likelihood of the beneficiary being a high-expenditure 

Medicaid-only beneficiary. As a result, we could not include all relevant conditions in our 

models.

3

The five chronic condition indicators are for human immunodeficiency virus/acquired 

immunodeficiency syndrome (HIV/AIDS), mental health issues, diabetes, substance 

abuse, and asthma. The two service category indicators are for delivery/childbirth and 

long-term care residency. Childbirth may include costs attributed to a mother during 

delivery or the child soon after birth. We reviewed the algorithms the indicators were 

based on by looking up the ICD-9 codes indicated and, where possible, comparing them 

to codes included in CMS’s Chronic Condition Data Warehouse indicators. We determined 

that despite small differences with the Chronic Condition Data Warehouse (e.g., MSIS did 

not include secondary diabetes diagnoses) they were sufficient for our purposes.

Appendix I: Objectives, Scope, and 

Methodology
Appendix I: Objectives, Scope, and 

Methodology

Page 29 GAO-14-176 Medicaid Beneficiaries with High Expenditures

details regarding the care encounter, such as individual cost per 

encounter; however, it does include monthly enrollment data).

We made several adjustments to the summary file in order to ensure that 

the data were reliable for our purposes. Specifically we excluded:

• records with unknown eligibility status (eliminated 5,166,648 records, 

or 7.21 percent of total records);

• all records associated with duplicate MSIS IDs or Social Security 

numbers within a state (eliminated 277,363 records, or 0.39 percent of 

total records);

• records with negative total spending amounts (eliminated 975,869 

records, or 1.36 percent of total records), which may reflect 

adjustments to claims made in the prior year;

• records of individuals who were only enrolled in a stand-alone, 

separate Children’s Health Insurance Program during the year 

(eliminated 471,507 records, or 0.66 percent of total records);

• records associated with a payment adjustment rather than an 

individual (eliminated 202,456 records, or 0.28 percent of total 

records);

• records of individuals whose age appeared to conflict with their 

identified eligibility group (eliminated 65,016 records, or 0.09 percent 

of total records). For example, records of individuals in the child 

eligibility group whose age was 85 and older;

• records with unknown dual status (eliminated 698 records, or less 

than 0.01 percent of total records); and,

• records of individuals whose age was over 65, but indicated as having 

delivered a child (eliminated 126 records, or less than 0.01 percent of 

total records).

After making these adjustments, we were able to retain 64,457,343, or 

90 percent, of the summary file’s 71,617,026 original records.

In order to determine variations in states’ spending for high-expenditure 

Medicaid-only beneficiaries compared with other Medicaid beneficiaries, 

we calculated the total number of Medicaid enrollees and total Medicaid 

expenditures in each state. We then calculated these same statistics for 

our subpopulations of Medicaid-only and dual-eligible beneficiaries based 

on the “last-best” indicator of dual eligibility status available in the 

summary file. Medicaid-only beneficiaries were eligible for Medicaid but 
Appendix I: Objectives, Scope, and 

Methodology

Page 30 GAO-14-176 Medicaid Beneficiaries with High Expenditures

not Medicare. Dual-eligible beneficiaries were eligible for both Medicaid 

and Medicare. Next, we determined the number of beneficiaries whose 

total expenditures fell within the top 5 percent of total expenditures within 

each state (we calculated these figures separately for Medicaid-only and 

dual-eligible beneficiaries). We termed these 2,763,407 beneficiaries as 

high-expenditure beneficiaries. We then separately calculated the total 

expenditures for our high-expenditure beneficiaries and other 

beneficiaries in each state for Medicaid-only and dual-eligible 

beneficiaries, and summed this data at a national level.

To examine the characteristics associated with high-expenditure 

Medicaid-only beneficiaries, we determined the percentage of highexpenditure Medicaid-only beneficiaries with key characteristics and used 

logistic regression to examine the effect of having key beneficiary 

characteristics on the probability of being a high-expenditure Medicaidonly beneficiary. The key beneficiary characteristics for which we 

describe the high-expenditure beneficiary population and represented as 

independent variables in our logistic regression model included: eligibility 

group (disabled, child, adult, aged), age, gender, race/ethnicity, 

geographic location,4 participation in capitated managed care,5

 

4

We classified counties as metropolitan or nonmetropolitan using the 2009 Area Resource 

File provided by the Health Resources and Services Administration.

period of 

enrollment in Medicaid (whether full year or partial year), as well as 

whether the beneficiaries had any of five health conditions or had 

received any of two services. Finally, our logistic regression models 

included characteristics of states’ Medicaid programs, including their 

spending on high-expenditure beneficiaries and long-term services and 

supports (LTSS) in non-institutional settings (also called home and 

community based services) and capitated managed care penetration 

5

Capitated managed care included enrollment in a HMO or capitated risk-based managed 

care plans. We did not consider enrollment in limited benefit plans as an indicator of this 

beneficiary characteristic.
Appendix I: Objectives, Scope, and 

Methodology

Page 31 GAO-14-176 Medicaid Beneficiaries with High Expenditures

rates.6

In order to determine which service categories contributed to 

expenditures for high-expenditure Medicaid-only beneficiaries, we 

examined how total expenditures for high-expenditure Medicaid-only 

beneficiaries were distributed among the following six expenditure 

categories: (1) hospital care, (2) non-hospital acute care, (3) drugs, 

(4) managed care and premium assistance, (5) long-term services and 

supports (LTSS) in non-institutional settings, and (6) long-term services 

and supports in institutional settings.

We report percentages that describe the high-expenditure 

beneficiary population, as well as the probabilities that demonstrate the 

association of each characteristic with the likelihood of being in the highexpenditure group if all beneficiaries had a particular characteristic while 

holding all other characteristics constant. Probabilities were calculated by 

converting the odds that resulted from our logistic regression models. The 

size of the independent effect of each enrollee characteristic is expressed 

as a probability, with greater values reflecting a greater chance that the 

characteristic increased the likelihood of being a high-expenditure 

beneficiary. Medicaid-only beneficiaries had a hypothetical 5 percent 

probability of being in the high-expenditure group by chance alone. All 

probabilities were significant at the 0.05 level.

7

 

6

LTSS includes services such as home health and personal care. We created variables on 

state spending on high-expenditure Medicaid-only beneficiaries using information from 

MSIS on the percent of expenditures for the Medicaid-only group and separating states by 

quartiles. We created variables for state spending on home and community-based 

services by dividing the total Medicaid expenditures for these services by expenditures for 

all Medicaid services and separating states into quartiles. We obtained data for state 

spending on home and community-based services from MSIS and Kaiser Family 

Foundation, Medicaid Home and Community-Based Services: 2009 Data Update

(Washington, D.C.: December 2012). We created variables for state managed care 

penetration using data on the percentage of individuals covered by HMO and other riskbased capitated managed care (HMO penetration rates) by state and separating states by 

quartiles. We obtained data for this variable from GAO, Medicaid: States’ Use of Managed 

Care, 

We then examined the distribution 

of spending among each of the six expenditure categories for 

beneficiaries in our high-expenditure group compared to the distribution of 

spending among each of the six expenditure categories for all other 

Medicaid-only beneficiaries.

GAO-12-872R (Washington, D.C.: Aug. 17, 2012).

7

The summary file includes information on spending for 30 types of services. We 

consolidated 28 of these types of services into the six categories we report.
Appendix I: Objectives, Scope, and 

Methodology

Page 32 GAO-14-176 Medicaid Beneficiaries with High Expenditures

We conducted this performance audit from September 2012 through 

February 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 the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives.
Appendix II: Characteristics of HighExpenditure Medicaid-Only Beneficiaries

Page 33 GAO-14-176 Medicaid Beneficiaries with High Expenditures

The table below demonstrates the characteristics of high-expenditure 

Medicaid-only beneficiaries, and how expenditures were distributed within 

each characteristic of interest. For each subpopulation, we also 

calculated the per-capita expenditures in dollars. High-expenditure 

Medicaid-only beneficiaries who resided in a long-term care (LTC) facility 

during fiscal year 2009 had the highest per capita expenditures ($79,464).

Table 5: Characteristics of High-Expenditure Medicaid-Only Beneficiaries (Top 5 Percent of Expenditures), Fiscal Year 2009

Beneficiaries 

(percent)

Expenditures

(percent)

Per capita expenditures 

(dollars)

Overall 100 100 35,983

Eligibility Group

Children 16.1 14.3 32,005

Adults 15.0 9.6 23,064

Disabled 66.3 73.4 39,799

Aged 2.5 2.7 38,112

Age

Under 1 2.8 3.8 48,069

1-21 31.1 30.4 35,177

22-44 28.3 28.2 35,942

45-64 34.6 34.1 35,465

65-84 2.8 3.0 38,705

85 & Over 0.4 0.5 40,422

Gender

Female 55.1 49.5 32,368

Male 44.9 50.5 40,404

Race/Ethnicity

White 45.7 45.9 36,110

Black or African American 23.9 24.6 37,089

American Indian or Alaska Native 1.7 1.7 37,345

Asian 2.0 1.9 33,638

Hispanic or Latino (includes Hispanic or Latino with 1+ races) 16.6 14.8 32,136

Native Hawaiian or other Pacific Islander 1.1 0.8 27,468

More than one race 0.2 0.4 53,682

Appendix II: Characteristics of HighExpenditure Medicaid-Only Beneficiaries
Appendix II: Characteristics of HighExpenditure Medicaid-Only Beneficiaries

Page 34 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Beneficiaries 

(percent)

Expenditures

(percent)

Per capita expenditures 

(dollars)

Capitated Managed Care

12 months 25.3 16.0 22,780

6-11 months 8.2 6.0 26,462

1-5 months 5.2 5.2 35,900

0 months 61.4 72.8 42,703

Length of Medicaid Coverage

Partial-year coverage 11.5 12.0 37,630

Full-year coverage 88.5 88.0 35,769

Metropolitan Status

Metropolitan counties 79.5 78.8 35,674

Nonmetropolitan counties 17.6 16.9 34,615

Condition and Services

HIV/AIDS 3.4 4.4 45,825

Asthma 14.5 15.4 38,324

Diabetes 18.6 20.5 39,642

Delivery/Childbirth 9.8 8.0 29,227

Mental health 51.8 55.2 38,374

Substance abuse 19.1 19.3 36,302

Long-term care residence 8.8 19.4 79,464

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Notes: High-expenditure beneficiaries represent those whose total expenditures fell within the top 

5 percent of total expenditures within each state. Medicaid-only beneficiaries are eligible for Medicaid 

but not Medicare.

Capitated managed care includes enrollment in a health maintenance organization or capitated riskbased managed care plans. Limited benefit plans were excluded from this analysis.

HIV/AIDS stands for human immunodeficiency virus/acquired immunodeficiency syndrome.

Delivery/childbirth may include costs attributed to a mother during delivery or the child soon after 

birth.

Percentages may not add to 100 due to missing or unknown data.
Appendix III: Key Characteristics Associated 

with Estimated Probability of Being a HighExpenditure Beneficiary

Page 35 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Our logistic regression analysis found that key characteristics—such as 

having a disability, having certain conditions, delivery/childbirth, and 

residing in a LTC facility—were consistently strongly associated with 

being a high-expenditure Medicaid-only beneficiary when looking at all 

records, and when the data was examined separately for each eligibility 

group.

Table 6: Estimated Probability of Being a High-Expenditure Medicaid-Only Beneficiary (Full Model Results), by Selected

Conditions and Services, Fiscal Year 2009

Probability (Percent)

(1) All Records (2) Children (3) Adults (4) Aged (5) Disabled

Eligibility Group

Children 2.0 N/A N/A a N/A N/A

Adult 2.6 N/A N/A N/A N/A

Disabled 18.3 N/A N/A N/A N/A

Aged 10.5 N/A N/A N/A N/A

Age

Under <1 7.7 N/A N/A N/A 63.7

1-21 5.4 N/A N/A N/A 35.9

22-44 5.9 N/A N/A N/A 39.9

45-64 6.8 N/A N/A N/A 41.2

65-84 6.8 N/A N/A N/A 40.7

85 & over 7.0 N/A N/A N/A 32.7

Gender

Males 5.1 1.5 2.6 17.6 32.5

Females 4.9 1.3 2.4 16.6 32.8

Race/Ethnicity

White 4.9 1.5 2.5 16.2 31.7

Black or African American 4.5 1.6 2.7 17.7 27.0

Hispanic or Latino (includes Hispanic or Latino with 1+ races) 4.5 1.5 2.4 13.4 30.7

Asian 4.4 1.4 2.2 12.2 35.0

American Indian or Alaska Native 6.8 2.7 4.7 16.1 33.3

Native Hawaiian or other Pacific Islander 4.2 1.5 2.9 11.6 27.5

More than one race 4.2 1.4 2.2 11.5 27.1

Unknown 4.3 1.6 2.3 12.0 28.8

Appendix III: Key Characteristics Associated 

with Estimated Probability of Being a HighExpenditure Beneficiary
Appendix III: Key Characteristics Associated 

with Estimated Probability of Being a HighExpenditure Beneficiary

Page 36 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Probability (Percent)

(1) All Records (2) Children (3) Adults (4) Aged (5) Disabled

Capitated Managed Care

12 months 4.9 0.9 1.5 15.0 36.9

6-11 months 3.8 0.9 2.0 12.3 24.7

1-5 months 4.3 1.3 2.5 13.6 24.9

0 months 5.4 2.0 3.2 18.1 32.3

Length of Medicaid Coverage

Partial-year coverage 2.9 0.8 1.4 9.1 18.4

Full-year coverage 5.6 1.6 3.2 21.7 34.9

Metropolitan Status

Metropolitan counties 5.1 1.4 2.4 17.3 33.2

Non-metropolitan counties 4.6 1.2 2.5 13.5 30.5

Condition and Services

HIV/AIDS 20.8 11.4 23.9 41.2 71.6

No HIV/AIDS 4.9 1.4 2.3 16.9 32.1

Asthma 6.8 2.3 4.4 29.7 39.4

No asthma 4.8 1.3 2.3 16.4 31.8

Delivery/childbirth 13.3 8.2 8.9 17.0 46.7

No delivery/childbirth 4.6 1.1 1.8 17.0 32.5

Diabetic 8.8 5.9 7.7 26.3 47.1

Not diabetic 4.6 1.4 2.2 14.2 30.3

Long-term care 24.2 11.6 8.6 53.9 82.1

Not long-term care 4.7 1.3 2.4 14.0 31.0

Mental health conditions 9.1 7.0 5.4 32.0 42.4

No mental health conditions 3.7 0.7 1.9 14.7 26.4

Substance abuse 7.9 3.5 6.3 30.2 42.7

No substance abuse 4.7 1.3 2.0 16.7 31.2

State Characteristics

State’s HMO penetration in Q1 4.2 1.0 1.5 21.7 30.3

State’s HMO penetration in Q2 4.3 1.4 1.7 16.6 27.1

State’s HMO penetration in Q3 5.3 1.3 2.8 24.1 35.1

State’s HMO penetration in Q4 5.5 1.8 2.9 14.5 35.1

State’s Medicaid spending in Q1 4.6 1.0 1.7 16.3 31.5

State’s Medicaid spending in Q2 5.1 1.5 2.4 17.3 33.7

State’s Medicaid spending in Q3 4.5 1.3 2.7 12.9 27.4

State’s Medicaid spending in Q4 5.8 1.6 3.1 20.4 39.2

State home and community-based services spending in Q1 4.7 1.5 4.0 14.0 27.6
Appendix III: Key Characteristics Associated 

with Estimated Probability of Being a HighExpenditure Beneficiary

Page 37 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Probability (Percent)

(1) All Records (2) Children (3) Adults (4) Aged (5) Disabled

State home and community-based services spending in Q2 5.3 1.3 2.6 17.1 36.3

State home and community-based services spending in Q3 5.1 1.7 2.1 17.0 32.8

State home and community-based services spending in Q4 4.4 0.9 1.9 18.3 32.0

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Notes: 

High-expenditure beneficiaries represent those whose total expenditures fell within the top 5 percent 

of total expenditures within each state. All other beneficiaries represent those whose spending was 

less than the spending for the top 5 percent. Medicaid-only beneficiaries are eligible for Medicaid but 

not Medicare.

Probabilities are derived from logistic regression results. Medicaid-only beneficiaries had a 

hypothetical 5 percent probability of being in the high-expenditure group by chance alone. A 

probability less than 5 percent indicates that a characteristic’s influence on the beneficiary’s being in 

the high-expenditure group was less than what would have occurred by chance alone, while 

probabilities greater than 5 percent indicate the opposite. All probabilities were significant at the 

0.05 level. 

The probabilities in each column are derived from logistic regressions that used different samples and 

are therefore inappropriate for cross comparison.

Capitated managed care includes enrollment in a health maintenance organization (HMO) or 

capitated risk-based managed care plans. Limited benefit plans were excluded from this analysis.

HIV/AIDS stands for human immunodeficiency virus/acquired immunodeficiency syndrome.

Q stands for quarter of the fiscal year.

Delivery/childbirth may include costs attributed to a mother during delivery or the child soon after 

birth.

State spending on high-expenditure Medicaid-only beneficiaries uses information on the distribution 

of expenditures for the Medicaid-only group and separates states by quartiles. The variable for state 

spending on home and community-based services divides the total Medicaid expenditures for home 

and community-based services by expenditures for all Medicaid beneficiaries, and separates states 

into quartiles. The state managed care penetration variable of data on HMO penetration rates by 

state also separates states by quartiles.

a

Not included in model.
Appendix IV: Characteristics of HighExpenditure Beneficiaries in the Top 1 Percent 

of Expenditures

Page 38 GAO-14-176 Medicaid Beneficiaries with High Expenditures

The table below demonstrates the characteristics of Medicaid-only 

beneficiaries with expenditures in the top 1 percent of total expenditures 

(558,798 beneficiaries). For each subpopulation, we also calculated the 

per capita expenditures in dollars. The top 1 percent of Medicaid-only 

beneficiaries had per capita spending of $94,821, over 2.5 times that of 

beneficiaries in the top 5 percent of total expenditures whose per capita 

spending was $35,983 (top 1 percent included).

Table 7: Characteristics of High-Expenditure Medicaid-Only Beneficiaries (Top 1 Percent of Expenditures), Fiscal Year 2009

Beneficiaries

(percent)

Expenditures

(percent)

Per capita expenditures 

(dollars)

Overall 100 100 94,821

Eligibility Category

Children 11.8 12.4 99,588

Adults 5.3 4.7 83,809

Disabled 79.8 80.2 95,279

Aged 3.1 2.7 83,621

Age

Under 1 4.0 4.8 113,685

1-21 28.2 29.9 100,686

22-44 28.2 29.2 97,910

45-64 35.4 32.4 86,746

65-84 3.6 3.3 85,610

85 & Over 0.6 0.5 76,137

Gender

Female 47.3 44.8 89,842

Male 52.7 55.1 99,268

Race/Ethnicity

White 47.7 45.8 91,141

Black or African American 23.4 24.2 97,848

American Indian or Alaska Native 1.7 1.7 94,123

Asian 1.9 1.8 89,060

Hispanic or Latino (includes Hispanic or Latino with 1+ races) 14.0 14.2 95,667

Native Hawaiian or other Pacific Islander 1.0 0.9 82,900

More than one race 0.2 0.4 171,292

Appendix IV: Characteristics of HighExpenditure Beneficiaries in the Top 1 

Percent of Expenditures
Appendix IV: Characteristics of HighExpenditure Beneficiaries in the Top 1 Percent 

of Expenditures

Page 39 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Beneficiaries

(percent)

Expenditures

(percent)

Per capita expenditures 

(dollars)

Capitated Managed Care 

12 months 10.5 8.3 75,519

6-11 months 4.8 4.2 82,202

1-5 months 5.2 5.1 92,982

0 months 79.5 82.4 98,245

Length of Medicaid Coverage

Partial-year coverage 12.1 12.3 97,035

Full-year coverage 88.0 87.7 94,518

Metropolitan Status

Metropolitan counties 80.5 79.4 93,582

Non-metropolitan counties 16.6 15.5 88,696

Condition and Service Flags

HIV/AIDS 4.0 4.2 98,379

Asthma 14.7 15.5 99,783

Diabetes 22.4 21.9 92,790

Delivery 6.4 7.5 110,078

Mental health 56.7 56.5 94,468

Substance abuse 18.2 17.2 89,500

Long-term care residence 26.0 30.8 112,528

Expenditure Categories

Hospital 34.8 32,967

Non-hospital acute care 7.6 7,157

Drugs 9.8 9,326

Managed care & premium assistance 4.6 4,402

LTSS non-institutional 26.4 25,043

LTSS institutional 16.7 15,849

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Notes: The top 1 percent of beneficiaries represent those whose total expenditures fell within the top 

1 percent of total expenditures within each state. Medicaid-only beneficiaries are eligible for Medicaid 

but not Medicare. However, Medicaid-only beneficiaries may have other sources of health care 

coverage.

Capitated managed care includes enrollment in a health maintenance organization or capitated riskbased managed care plans. Limited benefit plans were excluded from this analysis.

HIV/AIDS stands for human immunodeficiency virus/acquired immunodeficiency syndrome.

Delivery/childbirth may include costs attributed to a mother during delivery or the child soon after 

birth.

Percentages may not add to 100 due to missing or unknown data.
Appendix V: Selected Cases of Medicaid-Only 

Beneficiaries with Expenditures in the Top 1 

Percent

Page 40 GAO-14-176 Medicaid Beneficiaries with High Expenditures

We examined individual cases of a random group of Medicaid-only 

beneficiaries in the top 1 percent of expenditures. Some of these 

beneficiaries illustrated the trends identified in our analysis, but we also 

found beneficiaries who demonstrated that there was diversity among the 

high-expenditure group. Below are some examples of the characteristics 

and spending patterns for individual beneficiaries. Overall, per capita 

spending in the top 1 percent ranged from $19,068 to $43,728,641, with 

an average expenditure of $94,821.

Table 8: Characteristics of Selected Cases of Medicaid-Only Beneficiaries with Expenditures in the Top 1 Percent, Fiscal Year 

2009

Beneficiary 

Eligibility 

category

Conditions and/or 

services

HMO/capitated 

risk-based 

managed care 

enrollment

Total 

expenditures in 

2009 (dollars)

Largest expenditure 

category

74-year-old black or African 

American male

Aged None None 142,809 95.3 percent hospital

55-year-old black or African 

American male

Disabled Diabetes, mental health, 

substance abuse, LTC 

residence

None 107,182 44.9 percent LTSS 

institutional

Under 1-year-old white 

female

Child Mental health None 91,314 84.5 percent hospital

85-year-old black or African 

American male

Aged Diabetes, mental health, 

LTC residence

None 71,346 84.6 percent LTSS 

institutional

57-year-old white male Disabled Diabetes, substance 

abuse

None 57,719 76.3 percent LTSS 

non-institutional

15-year-old Hispanic or 

Latino female

Disabled Mental health 12 months 55,736 65.1 percent LTSS 

non-institutional

7-year-old male, race 

unknown

Disabled None 12 months 46,153 81 percent prescription 

drugs

3-year-old white male Disabled Mental health None 42,027 100 percent managed 

care and premium 

assistance

40-year-old Hispanic or 

Latino female

Adult None 1-5 months 39,182 87 percent nonhospital acute care

52-year-old white female Adult Asthma, mental health None 20,363 54.2 percent 

prescription drugs

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Note: The top 1 percent of beneficiaries represent those whose total expenditures fell within the top 

1 percent of total expenditures within each state. Medicaid-only beneficiaries are eligible for Medicaid 

but not Medicare. However, Medicaid-only beneficiaries may have other sources of health care 

coverage.

Capitated managed care includes enrollment in a health maintenance organization (HMO) or 

capitated risk-based managed care plans.

Appendix V: Selected Cases of MedicaidOnly Beneficiaries with Expenditures in the 

Top 1 Percent
Appendix V: Selected Cases of Medicaid-Only 

Beneficiaries with Expenditures in the Top 1 

Percent

Page 41 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Limited benefit plans were excluded from this analysis.

LTSS stands for long-term services and supports.
Appendix VI: GAO Contact and Staff 

Acknowledgments

Page 42 GAO-14-176 Medicaid Beneficiaries with High Expenditures

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

In addition to the contact named above, Sheila K. Avruch, Assistant 

Director; Giselle Hicks; Drew Long; Vikki Porter; Kristal Vardaman; 

Eric Wedum; Jennifer Whitworth; and Carla Willis made key contributions 

to this report.

Appendix VI: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments
Related GAO Products

Page 43 GAO-14-176 Medicaid Beneficiaries with High Expenditures

Medicaid: States Reported Billions More in Supplemental Payments in 

Recent Years. GAO-12-694. Washington, D.C.: July 20, 2012.

High Risk Series: An Update. GAO-13-283. Washington, D.C.: 

February 14, 2013.

Medicaid: CMS Needs More Information on the Billions of Dollars Spent 

on Supplemental Payments. GAO-08-614. Washington, D.C.: May 30, 

2008.

Medicaid Demonstration Waivers: Recent HHS Approvals Continue to 

Raise Cost and Oversight Concerns. GAO-08-87. Washington, D.C.: 

January 31, 2008.

Medicaid Long-Term Care: Information Obtained by States about 

Applicants’ Assets Varies and May Be Insufficient. GAO-12-749. 

Washington, D.C.: July 26, 2012.

Medicaid: Data Sets Provide Inconsistent Picture of Expenditures. 

GAO-13-47. Washington, D.C.: October 29, 2012.

Medicaid Home and Community-Based Waivers: CMS Should Encourage 

States to Conduct Mortality Reviews for Individuals with Developmental 

Disabilities. GAO-08-529. Washington, D.C.: May 23, 2008.

Medicaid: States’ Use of Managed Care. GAO-12-872R. Washington, 

D.C.: August 17, 2012.

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