Medicaid: Service Utilization Patterns for Beneficiaries in Managed Care
Published: 2015-05-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Medicaid, a federal-state health financing program for low-income and medically needy individuals, covered 65 million beneficiaries at an estimated cost of $508 billion in fiscal year 2014. More than half of Medicaid beneficiaries are enrolled in managed care plans, a health care delivery model where states contract with managed care organizations to provide covered services for a set cost. Historically, states have submitted relatively unreliable managed care service utilization data, also known as encounter data, to the Centers for Medicare & Medicaid Services, the federal agency that oversees Medicaid. However, recent evidence suggests that encounter data may be improving. Information on beneficiaries' service utilization could serve as a baseline for future analyses of utilization trends over time. GAO was asked to examine the level of services provided to these beneficiaries. In this report, GAO describes what encounter data indicate about the service utilization of Medicaid beneficiaries in managed care plans.
To do this work, GAO analyzed state-reported data included in CMS's 2010 Medicaid Analytic eXtract data and determined that 19 states had data that were reliable for its purposes, but excluded the remaining 31 states and the District of Columbia. For these 19 states, GAO calculated service utilization rates for adult and child beneficiaries enrolled in comprehensive managed care plans by state, service category, and length of enrollment. GAO received technical comments on a draft of this report from HHS and incorporated them as appropriate.
section_title: What GAO Found
paragraphs: Based on GAO's analysis of 2010 encounter data reported by 19 states, the number of professional services utilized by adult beneficiaries ranged from about 13 to 55. For children, the number of professional services utilized per beneficiary was lower, ranging from about 6 to 16 among the 19 states. Professional services included four categories of services: (1) evaluation and management (E/M) services, such as office visits and emergency room and critical care services; (2) procedural services, such as surgery and ophthalmology; (3) ancillary services, such as pathology and lab services; and (4) other professional services, such as oxygen therapy.
States varied considerably in how service utilization was distributed within service categories. For example, of total services,
adult per beneficiary utilization of ancillary services ranged from 37 percent in Rhode Island to 65 percent in Washington and Illinois; and
child per beneficiary utilization of E/M services ranged from 29 percent in Minnesota to 45 percent in Georgia and Rhode Island.
Service utilization for both adult and child beneficiaries also varied by the length of enrollment. When compared with beneficiaries enrolled for a full year, total service utilization for adults was 2 to 78 percent higher for partial-year beneficiaries—those enrolled in a comprehensive managed care plan for less than the full year—in slightly more than half of selected states. For children in all but one selected state, service utilization was 4 to 44 percent higher for partial-year beneficiaries compared with full-year beneficiaries.

section_title: Letter
paragraphs: Medicaid, a federal-state health financing program for low-income and  medically needy individuals, served approximately 65 million beneficiaries  at a total cost of about $508 billion in fiscal year 2014. More than half of  those beneficiaries are enrolled in managed care plans. As Medicaid  spending and enrollment grew in recent years, states increasingly turned  to the managed care delivery model as a way to provide services to  Medicaid beneficiaries. Under this delivery model, states typically contract  with managed care organizations (MCO) to provide a specific set of  Medicaid-covered services to beneficiaries. The state pays the MCOs a  set amount per beneficiary per month to provide the specific services  covered under each managed care plan.
Medicaid serves low-income and medically needy individuals. Under PPACA, states were  allowed to expand eligibility for Medicaid under their state plan to most nonelderly,  nonpregnant adults who are not eligible for Medicare and whose income is at or below  133 percent of the federal poverty level. PPACA also provides for a 5 percent disregard  when calculating income for determining Medicaid eligibility for this population, which  effectively increases this income level to 138 percent of the federal poverty level. Pub. L.  No. 111-148, § 2001(a)(1), 124 Stat. 119, 271 (2010). For purposes of this report,  references to PPACA include the amendments made by the Health Care and Education  Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010).
Medicaid beneficiaries enrolled in managed care plans. However, recent  evidence suggests that the quality of Medicaid encounter data may be  improving and stronger requirements surrounding encounter data  submissions suggest that such improvements could continue. Analyses  of beneficiaries’ service utilization could enhance program knowledge and  serve as a baseline for future analyses of trends in utilization over time  and of the factors that may contribute to differences across states. You  asked us to examine the level of services provided to beneficiaries in  Medicaid managed care. In this report, we describe what encounter data  indicate about the service utilization of Medicaid beneficiaries enrolled in  managed care plans.
The MAX data files for each state contain information on Medicaid eligibility, service  utilization, and payment for each Medicaid beneficiary during a given calendar year.  These files are derived from each state’s Medicaid Statistical Information System (MSIS)  data files and have been processed by CMS’s contractor into a research friendly format.  We obtained MAX data from CMS in November 2013. determined their data were unreliable or otherwise were not usable for  our purposes.
Within the four broad categories of professional services, E/M services include preventive  services, office and inpatient visits, consultations, and emergency room or critical care  visits; procedural services include allergy, cardiovascular, ophthalmology, surgery- administered drugs (including chemotherapy), and immunizations/injections; ancillary  services include pathology and lab services, physical medicine, radiology, and anesthesia  services; and other professional services include oxygen therapy, hospital-mandated on- call service, and other services that are not otherwise classified in the categories above.  We, in large part, utilized the Health Care Cost Institute’s methodology for grouping  professional services based on a range of HCPCS codes. These codes are used by  providers to bill for professional services. factors was beyond the scope of this study. (See appendix I for a detailed  description of our methodology and study limitations.)
We conducted this performance audit from November 2013 to May 2015  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.
subsections: section_title: Background
subsections: section_title: Delivery Models for Medicaid Services
paragraphs: Managed care and fee-for-service (FFS) are two possible models that  states use to deliver benefits under their Medicaid programs. Most states  provide a combination of these two delivery models, which offer different  financial incentives.
Nationally, more than half of Medicaid beneficiaries are enrolled in a  managed care plan. States contract with MCOs to provide a specific set  of Medicaid-covered services to beneficiaries, and MCOs are expected to  report encounter data to state Medicaid programs that allow the Medicaid  administrators to track the services received by enrolled beneficiaries.  The state pays the MCO a predetermined amount per beneficiary per  month—known as capitation—and, in turn, the MCO pays providers for  their services. According to CMS, by contracting with various types of  Medicaid MCOs to deliver services, states can reduce program costs and  better manage utilization of health care services. However, since MCOs  receive a fixed amount per beneficiary regardless of the number of  services used, we have noted in our prior work that there may be financial  incentives for MCOs to limit access to services, potentially compromising  quality of care and leading to underutilization of services.
Historically, most Medicaid programs relied on a FFS delivery model.  Under the FFS model, states pay providers directly for each service  provided to a Medicaid beneficiary and the data included on a Medicaid  FFS claim includes a specific amount for services delivered to a  beneficiary. Certain states continue to use the FFS model to provide  Medicaid services, such as behavioral health and dental care. We have  noted in our prior work that, unlike managed care, the FFS model may  give providers an incentive to use more services than necessary.
section_title: Efforts to Analyze Utilization Using Medicaid Encounter Data
paragraphs: Despite the fact that states have been required to submit encounter data  to CMS since 1999, little is known about the utilization of services by  Medicaid beneficiaries in MCOs. Historically, encounter data have been  relatively incomplete and unreliable; thus, little is known about these data.  At the behest of CMS, Mathematica Policy Research published a number  of studies focused primarily on the usability and completeness of 2007- 2010 Medicaid encounter data, as reported in MAX. These studies first  reported that encounter data were suitable for research purposes in  2012.
CMS has provided guidance to states on methods to improve the  completeness and accuracy of encounter data. In 2012, CMS released  a protocol for validating Medicaid encounter data that states receive from  MCOs. The protocol specifies a procedure for assessing the  completeness and accuracy of encounter data that Medicaid MCOs are  required to submit. Additionally, PPACA strengthened the requirement  that Medicaid MCOs provide encounter data to states by withholding  federal matching payments from states that do not report encounter data  to CMS in a timely manner.
section_title: Factors Affecting Medicaid Managed Care Service Utilization
paragraphs: The service utilization patterns of beneficiaries enrolled in Medicaid  managed care plans can vary substantially and be related to a variety of  factors, including the characteristics of beneficiaries and the scope of  state Medicaid benefits offered.
Beneficiary participation in managed care: States vary in the  populations enrolled in managed care plans. States that enroll their  most medically needy beneficiaries into managed care plans are likely  to have higher service utilization. Conversely, states that enroll  broader, generally healthier populations—such as children—into  managed care plans are likely to have a larger pool of beneficiaries  and potentially lower service utilization.
The amount, duration, and scope of services covered by MCOs:  Consistent with federal requirements, a state may determine the  amount, duration, and the scope of benefits covered in their Medicaid  programs. Thus, variations in service utilization patterns could  reflect states’ benefit choices that are independent of their service  delivery choices.
Variation in Medicaid managed care payments: Medicaid MCO  payments to providers for specific services vary substantially across  states and this variation could affect the service utilization of  beneficiaries. Specifically, we previously reported that in 23 states  where we compared MCO and private insurance payments for E/M  services, managed care payments were 31 to 65 percent lower in 18  states.
Access to Providers: Access to providers who serve beneficiaries  enrolled in Medicaid managed care plans can vary substantially within  a state, such as between urban and rural areas, and also across  states. Geographic variation in provider access, which can be driven  by the breadth of an MCO’s network and the availability of providers in  a given geographic area, can affect the type and amount of services  used by beneficiaries.
section_title: Beneficiaries’ Service Utilization Varied by State, Population, Service Categories, and Length of Enrollment for Selected States
paragraphs: Based on our analysis of encounter data, the number of professional  services utilized by adult and child beneficiaries per year in the 19  selected states ranged widely, with adult beneficiaries typically receiving  more services. States also varied in how adult and child service utilization  for professional services were distributed across service categories, and  by whether beneficiaries were enrolled in comprehensive managed care  plans for all of 2010 or part of the year.
A detailed, interactive display of the data used to support our findings is  available at http://www.gao.gov/products/GAO-15-481.
subsections: section_title: Adult Service Utilization Ranged from 13 to 55 Services per Beneficiary per Year in Selected States
paragraphs: For the 19 selected states, the number of services per beneficiary per  year for adults ranged from about 13 to 55 services per beneficiary per  year. (See fig. 1.) Services used by adult beneficiaries included E/M  services, such as office visits and emergency room and critical care  services; procedural services, such as surgery and ophthalmology;  ancillary services, such as pathology and lab services and  anesthesiology; and other professional services, such as oxygen therapy  and hospital-mandated on-call service. Service utilization levels for adult  beneficiaries are affected by many factors, including the extent to which  they receive services on a FFS basis. Among the states in our analysis,  the percentage of professional services that adult beneficiaries received  on a FFS basis ranged from 0 to about 11 percent, with a median of   1 percent.
Service utilization among adults was concentrated primarily in the  ancillary and E/M categories. Specifically, ancillary services were the  largest category in all but one state and accounted for 53 percent, on  average, of all services utilized by adult beneficiaries across selected  states. E/M services made up the second largest category (27 percent),  followed by procedural services (15 percent) and, lastly, other  professional services (4 percent). However, states varied considerably in  how service utilization was distributed within service categories, as was  shown in figure 1.
Ancillary: Of total services, adult per beneficiary utilization of ancillary  services ranged from 37 percent in Rhode Island to 65 percent in  Washington and Illinois—a difference of about 28 percentage points.  Pathology/lab services accounted for 63 percent, on average, of all  ancillary service utilization across selected states.
E/M: Of total services, adult per beneficiary utilization of E/M services  ranged from 19 percent in Connecticut to 38 percent in Rhode  Island—a difference of 19 percentage points. Office visits accounted  for 68 percent on average, of E/M service utilization, while emergency  room and critical care services accounted for 16 percent, on average.
Procedural: Of total services, adult per beneficiary utilization of  procedural services ranged from 8 percent in Illinois to 23 percent in  Indiana—a difference of about 15 percentage points. Surgical  services accounted for the largest portion—36 percent, on average— of all procedural service utilization across selected states.
Other professional services: Of total services, adult per beneficiary  utilization of other professional services ranged from 1 percent in  Illinois, Kentucky, Nebraska, and Washington to 15 percent in  Arizona—a difference of about 15 percentage points.
For slightly more than half of the selected states, total service utilization  among adults was higher for partial-year beneficiaries—those in  comprehensive managed care plans for less than the full-year of 2010.  Specifically, in 11 of the 19 states, the number of services utilized per  year ranged from 2 to 78 percent higher for partial-year beneficiaries than  for full-year beneficiaries. In the remaining 8 states, service utilization for  partial-year beneficiaries was 3 to 15 percent lower than for full-year  beneficiaries. Of the states that had comparatively higher service  utilization for partial-year beneficiaries, there were generally no major  differences in service utilization among partial-year beneficiaries based  on the length of their enrollment. Specifically, partial-year beneficiaries  who were enrolled for 1 to 3 months, 4 to 6 months, or 7 to 11 months  generally had similarly high utilization rates.
Further, we found that partial-year adult beneficiaries utilized more  procedural and ancillary services than full-year beneficiaries in about two- thirds of the selected states. Among those states, partial-year adult  beneficiaries used 19 and 26 percent more of these services,  respectively, than full-year adult beneficiaries. (See fig. 2.)
section_title: Child Service Utilization Ranged from 6 to 16 Services per Beneficiary per Year in Selected States, and was Significantly Higher for Partial-Year Beneficiaries
paragraphs: The utilization of professional services by children was generally lower  than adults in selected states. In the 19 selected states, the number of  services per beneficiary per year for children ranged from about 6 to 16.  (See fig. 3.) Services used by child beneficiaries included E/M services,  such as office visits and emergency room and critical care services;  procedural services, such as surgery and ophthalmology; ancillary  services, such as pathology and lab services and anesthesiology; and  other professional services, such as oxygen therapy and hospital- mandated on-call service. Service utilization for child beneficiaries is  affected by many factors, including the extent to which beneficiaries  receive services on a FFS basis. Among selected states, the percentage  of professional services that child beneficiaries received on a FFS basis  ranged from 0 to about 29 percent, with a median of 9 percent.
In contrast to adults, for which service utilization consisted mostly of  ancillary services, utilization for children was distributed more evenly  across service categories. For example, on average, E/M services were  utilized most commonly by children (37 percent of services), followed by  procedural services (33 percent), ancillary services (24 percent), and  other professional services (5 percent). However, considerable state  variation existed within service categories, as was shown in figure 3.
E/M: Of total services, child per beneficiary utilization of E/M services  ranged from 29 percent in Minnesota to 45 percent in Georgia and  Rhode Island—a difference of 16 percentage points. On average,  office visits (58 percent) and preventive visits (22 percent) comprised  most E/M service utilization across selected states.
Procedural: Of total services, child per beneficiary utilization of  procedural services ranged from 25 percent in Arizona to 41 percent  in Oregon and Texas—a difference of 16 percentage points. On  average, immunizations and injections (60 percent) made up the  majority of procedural service utilization across selected states.
Ancillary: Of total services, child per beneficiary utilization of ancillary  services ranged from 17 percent in Oregon to 36 percent in Illinois—a  difference of 19 percentage points. On average, pathology and lab  services (63 percent) made up the majority of ancillary service  utilization across selected states.
Other professional services: Of total services, child per beneficiary  utilization of other professional services ranged from 1 percent in  Georgia, Illinois, and New York to 21 percent in Arizona—a difference  of 20 percentage points.
Total service utilization among children was higher for partial-year  beneficiaries—those enrolled in comprehensive managed care for less  than the full year of 2010—than full-year beneficiaries for almost every  selected state. For example, for all but one state, the number of  services utilized per year was 4 to 44 percent higher for partial-year child  beneficiaries than for full-year child beneficiaries. In the remaining state,  the number of services utilized per year for partial-year child beneficiaries  was 5 percent less than for full-year child beneficiaries.
Further, partial-year child beneficiaries utilized more E/M and procedural  services than full-year child beneficiaries across all selected states;  specifically, partial-year child beneficiaries utilized 19 percent more E/M  services and 22 percent more procedural services than full-year child  beneficiaries. (See fig. 4.)
Among selected states with higher utilization for partial-year child  beneficiaries, most experienced the highest utilization for child  beneficiaries who were enrolled for 1 to 3 months as compared with 4 to   6 months or 7 to 11 months. When compared with full-year child  beneficiaries, partial-year child beneficiaries enrolled for 1 to 3 months  utilized, on average, significantly more E/M and procedural services   (61 percent and 34 percent, respectively). Furthermore, the increased  utilization among child beneficiaries enrolled for 1 to 3 months was  particularly pronounced for certain E/M, procedural, and ancillary  services. We found the following examples:  Inpatient visits: Across all selected states, utilization of inpatient  visits ranged from 1.4 to over 15 times greater for child beneficiaries  enrolled for 1 to 3 months than for full-year child beneficiaries.
Preventive services: For all but one selected state, utilization of  preventive visits ranged from 1.5 to almost 4 times greater for child  beneficiaries enrolled for 1 to 3 months than for full-year child  beneficiaries.
Emergency room and critical care: For all but one selected state,  utilization of emergency room and critical care services ranged from  1.2 to almost 3 times greater among child beneficiaries enrolled for   1 to 3 months than for full-year child beneficiaries.
Surgery: For all but one selected state, utilization of surgery ranged  from 1 to 2.5 times greater for child beneficiaries enrolled for 1 to   3 months than for full-year child beneficiaries.
Radiology: Across all selected states, utilization of radiology ranged  from 1.2 to 2.5 times greater for child beneficiaries enrolled for 1 to   3 months than for full-year child beneficiaries.
section_title: Agency Comments
paragraphs: We provided the Secretary of Health and Human Services with a draft of  this report. The Department of Health and Human Services provided  technical comments, which we incorporated as appropriate.
As arranged with your offices, unless you publicly announce the contents  of this report earlier, we plan no further distribution until 30 days after its  issuance date. At that time, we will send copies of this report to the  Secretary of Health and Human Services. In addition, the report will be  available at no charge on the GAO Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff members who made major contributions to  this report are listed in appendix IV.
section_title: Appendix I: Detailed Scope and Methodology
paragraphs: We examined service utilization patterns for Medicaid beneficiaries  enrolled in comprehensive managed care plans using Medicaid Analytic  eXtract (MAX) encounter data for calendar year 2010, the most recent  year for which encounter data were available for the majority of states at  the time we began our analyses. Our analysis consisted of the following  three steps: (1) state selection, which included assessing data reliability  for our selected states; (2) beneficiary and service identification; and   (3) utilization calculation. Lastly, we present limitations of this study and  technical comments that we received from 13 of the 19 selected states.
Step 1: State Selection  To assess the reliability and usability of the MAX data for our purposes,  we reviewed related documentation and studies that assessed the  reliability of or analyzed MAX data, and we interviewed officials from the  Centers for Medicare & Medicaid Services (CMS) and its contractor  responsible for processing the MAX data (Mathematica Policy Research,   We determined that 19 states reported data that were reliable for  Inc.).our purposes: Arizona, Connecticut, Delaware, Florida, Georgia, Illinois,  Indiana, Kentucky, Michigan, Minnesota, Nebraska, New Mexico, New  York, Oregon, Rhode Island, Tennessee, Texas, Virginia, and  Washington.
We excluded the remaining 31 states and the District of Columbia  because we determined their data were unreliable or not usable for our  purposes for one or more of the following reasons: (1) no adults or  children were enrolled in comprehensive managed care plans, according  to MAX (13 states); (2) MAX data were unavailable at the time we began  our analysis (11 states); (3) the data were unreliable, such as if fewer  than 30 percent of beneficiaries used at least one service—one of the  thresholds established by Mathematica when evaluating the  completeness and usability of MAX data (6 states); and (4) services were  not reported using a standard coding convention, namely the Health Care  Common Procedural Coding System (HCPCS) (2 states). (See table 1.)
Step 2: Beneficiary and Service Identification  Based on eligibility information in the MAX Person Summary file, we  restricted our study to adults and children who (1) were eligible to receive  full Medicaid benefits and were enrolled for any given month during  calendar year 2010, and (2) did not have other sources of health  coverage during the calendar year in addition to Medicaid, such as  coverage from Medicare or private insurance.95 percent of the adults and children in comprehensive managed care  among the 19 states in our analysis in 2010.
We used the MAX Other Services file to identify professional services  used by beneficiaries while they were enrolled in a comprehensive  managed care plan. We, in large part, used the Health Care Cost  Institute’s methodology for grouping professional services based on a  range of HCPCS codes. These codes are used by providers to bill for  professional services. We grouped the professional services in our analysis into four broad categories. (See table 2.)
We excluded dental and behavioral health services from our analysis  because these services may be contracted out by managed care  organizations (MCO) and provided on a fee-for-service (FFS) basis.  Additionally, Mathematica reported concerns regarding the quality of  managed care behavioral health data.
Step 3: Utilization Calculation  For each service provided to each beneficiary described in steps 1 and 2  above, we calculated the number of services per beneficiary per year.  This is defined as the number of services that beneficiaries enrolled in  comprehensive managed care plans used in a year (includes users and  nonusers enrolled in comprehensive managed care plans within the  state).
We presented service utilization patterns for adults and children by state,  by service category, and by the length of beneficiary enrollment—in  particular, whether beneficiaries were enrolled in a comprehensive  managed care plan for a full or partial year. We then further grouped  partial-year beneficiaries into monthly increments—1-3, 4-6, and   7-11 months—to determine whether there were differences in   utilization patterns by the varying lengths of enrollment.
In addition to services used by beneficiaries enrolled in a comprehensive  managed care plan, we also calculated the extent to which the  beneficiaries in our analysis received professional services paid on a FFS  basis while they were enrolled in a comprehensive managed care plan.
See http://www.gao.gov/products/GAO-15-481 for further detail on these  measures and the FFS data.
subsections: section_title: Study Limitations and State Technical Comments
paragraphs: The results we present are based on data reported to CMS by the 19  states in our analysis. We did not independently verify whether the  individual MCOs in these states submitted complete and accurate data on  the enrollment and services for beneficiaries enrolled in comprehensive  managed care.
To better understand the factors that may affect service utilization, we  asked representatives from each state to comment on the accuracy and  completeness of the state’s 2010 managed care data submitted to  CMS. Thirteen of the 19 selected states responded to our request.  These states met our criteria for inclusion, as well as the minimum  threshold for the number of services per adult or child beneficiary used by  Mathematica to assess the completeness of each state’s data.  Nevertheless, of these 13 states, 4 states indicated that they may have  submitted incomplete enrollment or encounter data in 2010, citing a  variety of reasons. For example, 1 state indicated its Medicaid managed  care program was in the process of major changes and service data were  likely not complete. Another state indicated that, in calendar year 2010,  some of the state’s managed care data were not reported due to quality  problems. Officials from the remaining 9 states noted their results either  seemed reasonable based on their knowledge of their state’s Medicaid  managed care program or that the managed care data they submitted to  CMS for 2010 was believed to be accurate.
The results we present for the 19 states in our analysis are not  representative of all states and their managed care programs, nor do our  results draw any conclusions regarding whether the level of service  utilization identified is appropriate. There are a number of state-specific  factors—such as differences in beneficiary health status and provider  supply—that could contribute to variation in service utilization across the  states. For example, officials from 1 state noted that the state’s MCOs  were limited to certain geographical areas of the state. As such,  geographic variation in provider access, which can be driven by the  breadth of an MCO’s network and the availability of providers in a given  geographic area, can affect the type and amount of services used by  beneficiaries in Medicaid managed care.
section_title: Appendix II: Service Utilization Patterns for Beneficiaries in Comprehensive Managed Care, 2010
paragraphs: The tables below provide the number of services per beneficiary per year  for adults and children by state, service category, and length of  enrollment.
Based on our analysis of encounter data, the number of professional  services utilized per beneficiary per year reported by the 19 selected  states for adults enrolled in comprehensive managed care plans in 2010  ranged from about 13 to 55; the range for children was generally lower,  from about 6 to 16. States varied in how adult and child utilization of  professional services were distributed across service categories. In  addition, service utilization for both adults and children varied by whether  beneficiaries were enrolled in comprehensive managed care plans for all  of 2010 or part of the year. In particular, for nearly all states in our  analysis, partial-year child beneficiaries utilized significantly more  services overall than those enrolled for the full year.
section_title: Appendix III: Percentage of Partial-Year Beneficiaries in Selected States in 2010
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, William Black, Assistant Director;  Christine Brudevold, Assistant Director; Ramsey Asaly; Stella Chiang;  Greg Dybalski; Sandra George; Drew Long; Jessica Morris; and   Vikki Porter made key contributions to this report.