Medicaid: A Small Share of Enrollees Consistently Accounted for a Large Share of Expenditures
Published: 2015-05-08T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Studies on healthcare spending generally find that a small percentage of individuals account for a large proportion of expenditures, and Medicaid—a federal-state health financing program for low-income and medically needy individuals—is no exception. Medicaid expenditures for fiscal year 2013 totaled about $460 billion, covering about 72 million enrollees, some of whom were also eligible for Medicare. More information about Medicaid enrollees who are not also eligible for Medicare (i.e., Medicaid-only enrollees) and who account for a high proportion of expenditures could enhance efforts to manage expenditures and facilitate improvements to care.
GAO was asked to provide information about the characteristics of high-expenditure Medicaid-only enrollees and their expenditures. GAO (1) examined the distribution of expenditures among Medicaid-only enrollees, (2) determined whether the proportions of high-expenditure Medicaid-only enrollees in selected categories changed or remained consistent from year to year, and (3) determined whether the distribution of high-expenditure Medicaid-only enrollees' expenditures among selected categories of service varied across states.
GAO analyzed data from the Medicaid Statistical Information System Annual Person Summary File for fiscal years 2009, 2010, and 2011, the most recent years for which data from almost all states were available.
section_title: What GAO Found
paragraphs: A small percentage of Medicaid-only enrollees—that is, those who were not also eligible for Medicare—consistently accounted for a large percentage of total Medicaid expenditures for Medicaid-only enrollees. In each fiscal year from 2009 through 2011, the most expensive 5 percent of Medicaid-only enrollees accounted for almost half of the expenditures for all Medicaid-only enrollees. In contrast, the least expensive 50 percent of Medicaid-only enrollees accounted for less than 8 percent of the expenditures for these enrollees.
Of the Medicaid-only enrollees who were among the 5 percent with the highest expenditures within each state, the nationwide proportions of these enrollees in different eligibility groups (such as the disabled or children) and with certain conditions (such as asthma) or services (such as childbirth or delivery) were also consistent from fiscal years 2009 through 2011.
The distribution of high-expenditure Medicaid-only enrollees' expenditures among categories of service in fiscal year 2011 varied widely across states. Expenditures for managed care and premium assistance varied most widely (from 0 to 75 percent).
The Department of Health and Human Services provided technical comments on a draft of this report, which were incorporated as appropriate.

section_title: Letter
paragraphs: Studies on healthcare spending generally find that a small percentage of  individuals account for a large portion of expenditures, and Medicaid—a  federal-state health financing program for low-income and medically  needy individuals—is no exception. Financing coverage for children,  adults, individuals aged 65 and older, and those with disabilities, Medicaid  had approximately 72 million enrollees and expenditures totaling about  $460 billion in fiscal year 2013. At the federal level, the Centers for  Medicare & Medicaid Services (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 2014, we reported that a small share of enrollees in each state  collectively accounted for a disproportionately large share of total  Medicaid expenditures, whether looking at those enrolled in Medicaid only  or those dually eligible (that is, individuals enrolled in both Medicaid and  Medicare). Medicaid enrollment and expenditures are expected to  increase in states that choose to expand eligibility in response to the  Patient Protection and Affordable Care Act (PPACA), and may increase in  other states as well. The Congressional Budget Office projected that, as  a result of PPACA, about 8 million additional people could be enrolled in  Medicaid and the Children’s Health Insurance Program (CHIP) by 2016  compared with 2012. As Medicaid enrollment increases, more extensive  information about high expenditure enrollees who are not dually eligible  for Medicare—that is, Medicaid-only enrollees—could enhance efforts to  manage expenditures and facilitate improvements to care.
You asked us to provide additional information about the characteristics  of high-expenditure Medicaid-only enrollees and their expenditures. We  (1) examined the distribution of expenditures among Medicaid-only  enrollees, (2) determined whether the proportions of high-expenditure  Medicaid-only enrollees in selected categories changed or remained  consistent from year to year, and (3) determined whether the distribution  of high-expenditure Medicaid-only enrollees’ expenditures among  selected categories of service varied across states.
To address these objectives, we used the Medicaid Statistical Information  System (MSIS) Annual Person Summary File, which provides enrollee- specific data on expenditures and payment arrangements, as well as  such enrollee characteristics as basis of eligibility for Medicaid, status of  eligibility for Medicare, and demographics. We obtained from CMS the  data for three fiscal years—2009, 2010, and 2011, the most recent years  for which data from almost all states were available as of December  2014. For fiscal year 2011, data on expenditures and enrollee  characteristics were not available from Maine, and data on expenditures  were not available from Florida. We assessed the reliability of these data  by performing appropriate electronic data checks and reviewing relevant  documentation, and we made several changes to ensure that the data  were sufficiently reliable for our purposes; these changes are detailed in  appendix I. We determined that the data from Idaho for 2010 were not  sufficiently reliable for our purposes and therefore excluded them. We  determined that the remaining data were sufficiently reliable for our  purposes. Because our objectives focused on Medicaid-only enrollees,  we excluded those who were dually eligible for both Medicaid and  Medicare—about 13 percent of each year’s records. We previously  reported that dually eligible enrollees accounted for about 35 percent of  total Medicaid expenditures in fiscal year 2009. We retained about   85 percent of the original records in the summary file, and these records  represent just under 65 percent of total Medicaid expenditures.
To determine the distribution of expenditures among Medicaid-only  enrollees, we ordered Medicaid-only enrollees by their total Medicaid  expenditures, from highest to lowest, and determined the cumulative  percentage of expenditures attributable to enrollees as the percentage of  ordered enrollees increased. We analyzed data from fiscal years 2009,  2010, and 2011 separately to determine whether the relationship was  consistent across years.
To determine whether the proportions of high-expenditure Medicaid-only  enrollees in selected categories changed or remained consistent from  year to year, we defined high-expenditure Medicaid-only enrollees as the  5 percent with the highest expenditures within each state (as we had in  our earlier work on high-expenditure Medicaid enrollees) and conducted  two separate analyses based on two ways of categorizing enrollees. For  one analysis, we categorized enrollees into five mutually exclusive  eligibility groups—child, adult, aged, disabled, and unknown. For a  second analysis, we examined the percentages of enrollees with any of  the five chronic conditions and the two services that are recorded in the  MSIS summary file. The five chronic conditions recorded in this file are  asthma, diabetes, human immunodeficiency virus/acquired  immunodeficiency syndrome (HIV/AIDS), mental health conditions, and  substance abuse. The two services recorded in this file are delivery or   Enrollees could have any of  childbirth, and long-term care residence.these seven conditions or services, any combination of them, or none of  them. We analyzed data from fiscal years 2009, 2010, and 2011 to  determine whether the relationship was consistent across years.
To determine whether the distribution of high-expenditure Medicaid-only  enrollees’ expenditures among selected categories of service varied  across states, we again defined high-expenditure Medicaid-only enrollees  as the 5 percent with the highest expenditures within each state. We  examined fiscal year 2011 expenditures in eight categories of service— namely, three types of institutional care (hospital, long-term, and  psychiatric facility); three types of non-institutional services (acute care;  long term support; and other support services, such as targeted case  management or rehabilitative services); prescription drugs; and managed  care and premium assistance.expenditure enrollees’ expenditures among these types of service within  each state, and compared the distributions across states. For a more  complete description of our methodology, see appendix I.
We identified the distribution of high- We conducted this performance audit from August 2014 through 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
paragraphs: As a comprehensive health benefit program for vulnerable populations,  each state Medicaid program, by law, must cover certain categories of  individuals and provide a broad array of benefits. Within these  requirements, however, the Medicaid program allows for significant  flexibility for states to design and implement their programs, resulting in  more than 50 distinct state-based programs. These variations in design  have implications for program eligibility and services offered, as well as  how expenditures are reported and services are delivered.
Specifically, in administering their own programs, states make decisions  regarding populations or health services to cover beyond what are  mandated by law. States must cover certain groups of individuals, such  as pregnant women with incomes at or below 133 percent of the federal  poverty level (FPL), but may elect to cover them above this required  minimum income level. For example, as of March 2011, some states  covered pregnant women with incomes at or above 250 percent of the  FPL. Similarly, while states’ Medicaid programs generally must cover  certain mandatory services—including inpatient and outpatient hospital  services, physician services, laboratory and X-ray services, and nursing  facility services for those age 21 and older—states may also elect to  cover additional optional benefits and services. These optional benefits  and services include prescription drugs, dental care, hospice care, home-  and community-based services, and rehabilitative services. In addition,  even among states that offer a particular benefit, the breadth of coverage  (i.e., amount, duration, and scope) of that benefit can vary greatly. For  example, most states cover some dental services, but some limit this  benefit to trauma care and/or emergency treatment for pain relief and  infection, while others also cover annual dental exams.
States also have flexibility, within general federal requirements, to  determine how the services they cover will be delivered to Medicaid  enrollees—whether on a fee-for-service basis or through managed care  arrangements. For example, under some managed care arrangements,  the state pays managed care organizations a fixed amount, known as a  capitation payment, to provide a package of services. States vary in terms  of the types of managed care arrangements used and the eligibility  groups enrolled. For example, while 12 states enrolled 50 percent or  more of their disabled enrollees in comprehensive risk-based managed  care in fiscal year 2011, 20 states enrolled fewer than 5 percent of  disabled enrollees in such arrangements. States may also operate  premium assistance programs to subsidize the purchase of private health  insurance—such as employer-sponsored insurance—for Medicaid  enrollees. In 2009, 35 states reported using Medicaid funds to provide  premium assistance. These differences in covered services and delivery  systems can affect the distribution of states’ spending across categories  of services. For example, states that rely heavily on managed care  arrangements to provide hospital care and acute care services to their  enrollees are likely to have a greater proportion of their expenditures  devoted to managed care, and a lower proportion to the covered services,  than states that do not have such managed care arrangements.
section_title: Among Medicaid- Only Enrollees, a Small Percentage Consistently Accounted for a Large Percentage of Expenditures
paragraphs: A small percentage of Medicaid-only enrollees consistently accounted for  a large percentage of total Medicaid expenditures for Medicaid-only  enrollees. As shown in figure 1, there was little variation across the years  we examined. In each fiscal year from 2009 through 2011,  the most expensive 1 percent of Medicaid-only enrollees in the nation  accounted for about one-quarter of the expenditures for Medicaid-only  enrollees;  the most expensive 5 percent accounted for almost half of the  expenditures;  the most expensive 25 percent accounted for more than three- quarters of the expenditures;  in contrast, the least expensive 50 percent accounted for less than   8 percent of the expenditures; and about 12 percent of enrollees had no expenditures.
These findings regarding Medicaid-only enrollees are similar to those that  others have reported for all Medicaid enrollees, as well as for Medicare  and personal healthcare spending in the United States.
A Kaiser Family Foundation report found that in fiscal year 2001, the  most expensive 1.1 percent of all Medicaid enrollees—including those  dually eligible for Medicare—accounted for more than one-quarter of  Medicaid expenditures, and the most expensive 3.6 percent  accounted for nearly half.
The Congressional Budget Office reported that in 2001, the most  expensive 5 percent of Medicare enrollees in fee-for-service plans  accounted for 43 percent of Medicare expenditures, and the most  expensive 25 percent accounted for 85 percent.
The National Institute for Health Care Management reported that in  2009, the most expensive 1 percent of the overall civilian U.S.  population living in the community accounted for more than   20 percent of personal health care spending, with the most expensive  5 percent accounting for nearly half.
We also found that in each state, a similarly small percentage of high- expenditure Medicaid–only enrollees was responsible for a  disproportionately large share of expenditures for Medicaid-only  enrollees, although the magnitude of this effect varied widely across  states. For example, the percentage of expenditures for the most  expensive 5 percent of Medicaid-only enrollees ranged from 28.8 percent  in Tennessee to 63.2 percent in California. For additional state-by-state  information about the distribution of expenditures among Medicaid-only  enrollees in fiscal year 2011, see appendix II.
section_title: The Proportions of High-Expenditure Medicaid-Only Enrollees in Selected Eligibility and Other Categories Were Consistent from 2009 through 2011
paragraphs: The proportions of high-expenditure Medicaid-only enrollees in different  eligibility groups were consistent from fiscal year 2009 through 2011, as  shown in figure 2.enrollees were disabled (less than 10 percent), disabled enrollees were  disproportionately represented in the high-expenditure group, consistently  constituting about 64 percent of those with the highest expenditures.  Conversely, although children were the largest group of Medicaid-only  enrollees (about 50 percent), they consistently constituted about   16 percent of the high-expenditure group.
section_title: For High-Expenditure Medicaid-Only Enrollees, the Distribution of Expenditures among Service Categories Varied Widely across States
paragraphs: The distribution of high-expenditure Medicaid-only enrollees’ expenditures  among selected categories of service in fiscal year 2011 varied widely  across states. As noted above, managed care arrangements can affect  the distribution of expenditures for covered services. For some states,  such as Tennessee and Hawaii, a high percentage of expenditures were  for managed care or premium assistance, and correspondingly low  percentages were for expenditures such as hospital care or acute care  services. For other states, such as Idaho and Oklahoma, a low  percentage of expenditures were for managed care or premium  assistance, and correspondingly higher percentages were for hospital  care or acute care services. States’ reliance on managed care plans to  provide certain services limits what can be learned from the MSIS  summary data regarding the services received by enrollees, because the  data show the per-enrollee payments made by state Medicaid programs  to plans, not the payments the plans made to providers for the services  for which the plans are responsible. In a state such as Tennessee, for  example, in which all Medicaid enrollees are in managed care plans that  are responsible for providing hospital care and a broad array of acute  care services, the state’s low percentages of expenditures in those  service categories reflect the delivery system structure of the state  Medicaid program, not enrollees’ utilization of services.
The greatest variation among states in their expenditures for specific  service categories was for managed care and premium assistance. As  shown in figure 3, four states reported that 0 percent of their expenditures  were for managed care or premium assistance. For states that did report  expenditures in this category, the percentage ranged from less than   1 percent to 75 percent. Nationwide, about 15 percent of expenditures for  high-expenditure Medicaid-only enrollees were in this category. The  variation among states in the percentages of expenditures in this service  category reflects the wide variation among states in their reliance on  managed care arrangements to provide services to enrollees, and  particularly disabled enrollees, who constituted almost two-thirds of high- expenditure Medicaid-only enrollees. In the five states with the highest  percentage of expenditures for managed care and premium assistance,  the percentage of disabled enrollees in comprehensive risk-based  managed care plans ranged from 44 percent in New Mexico to more than  90 percent in Hawaii and Tennessee, compared with 0 percent in the five  states with the lowest percentages of expenditures in this service  category.
States also varied widely—from 0 to about 45 percent—in the  percentages of high-expenditure Medicaid-only enrollees’ expenditures  for hospital care (inpatient and outpatient). About 27 percent of  nationwide expenditures for high-expenditure Medicaid-only enrollees  were in this category. (See fig. 4.)
Similarly, states varied widely—from nearly 0 to about 45 percent—in the  percentages of high-expenditure Medicaid-only enrollees’ expenditures  that were for non-institutional support services other than acute or long- term support services. These other support services include hospice  benefits, private duty nursing, rehabilitative services, and targeted case  management. About 17 percent of nationwide expenditures were for  enrollees in this category. (See fig. 5.)
States also varied in the percentages of high-expenditure Medicaid-only  enrollees’ expenditures in other categories, if not as widely. States varied  least—from 0 to 11 percent—in the percentage of expenditures for high- expenditure Medicaid-only enrollees that were for psychiatric facility  care, which accounted for about 2 percent of nationwide expenditures   for high-expenditure Medicaid-only enrollees. The percentage of a state’s  expenditures for high-expenditure Medicaid-only enrollees varied in other  categories from
0 to 33 percent for acute care services,11 percent of nationwide expenditures;
0 to 25 percent for prescription drugs, which accounted for 14 percent
0 to about 23 percent for long-term non-institutional support  services,expenditures; and   which accounted for about 6 percent of nationwide
0 to 22 percent for long-term institutional care, 9 percent of nationwide expenditures.
Long-term institutional care includes nursing facilities and intermediate care facilities for  individuals with intellectual disabilities.
See GAO, Medicaid: Assessment of Variation among States in Per-Enrollee Spending,  GAO-14-456 (Washington, D.C.: June 16, 2014), and GAO, Medicaid: Alternative  Measures Could Be Used to Allocate Funding More Equitably, GAO-13-434 (Washington,  D.C.: May 10, 2013). percentage of expenditures reported in the MSIS summary file that was  attributable to prescription drugs was lower on average in states that  included some or all drugs in the package of services provided by  managed care plans than in states that paid for all drugs on a fee-for- service basis, and the three states in which the share of expenditures that  went to drugs was lowest—Arizona, Hawaii, and New Mexico—included  all drugs in their managed care packages.
States vary widely in the distribution of their expenditures among service  categories; for state-by-state information about the percentage of high- expenditure Medicaid-only enrollees’ expenditures for selected categories  of services in fiscal year 2011, see appendix V.
section_title: Agency Comments
paragraphs: 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 other  interested parties. The report also will be available at no charge on the  GAO website at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or YocomC@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made major contributions to  this report are listed in appendix VI.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: This appendix describes the methodology for addressing our three  objectives regarding high-expenditure Medicaid enrollees who are not  also enrolled in Medicare, that is, Medicaid-only enrollees. These  objectives were to: (1) examine the distribution of expenditures among  Medicaid-only enrollees, (2) determine whether the proportions of high- expenditure Medicaid-only enrollees in selected categories changed or  remained consistent from year to year, and (3) determine whether the  distribution of high-expenditure Medicaid-only enrollees’ expenditures  among selected categories of service varied across states.
We analyzed data from the Medicaid Statistical Information System  (MSIS) Annual Person Summary File. This summary file consolidates  individual enrollees’ claims for a single fiscal year, including data on their  enrollment and expenditures. The file includes enrollee-specific  information regarding enrollment categories, expenditures, dual eligibility  status, age, gender, payment arrangements—including fee-for-service  payments and capitated payments made to managed care  organizations—and indicators for five chronic conditions and two service  categories. The five chronic condition indicators are for asthma, diabetes,  human immunodeficiency virus/acquired immunodeficiency syndrome  (HIV/AIDS), mental health conditions, and substance abuse. The two  service category indicators are for delivery or childbirth (which may  include costs attributed to a mother during delivery or the child soon after  birth) and long-term care residence. The summary file does not provide  information on other conditions that may affect enrollees’ expenditures.
We used data from fiscal years 2009, 2010, and 2011—the most recent  years for which data from almost all states were available. As of  December 2014, the summary file did not include expenditure or  enrollment data from Maine for fiscal year 2011. We made several  changes to limit our analyses to Medicaid-only enrollees and ensure that  the data were sufficiently reliable for our purposes. For example, because  our objectives focused on Medicaid-only enrollees, we excluded those  who were dually eligible for both Medicaid and Medicare. Specifically, we  made the following adjustments to the data:  If an individual’s enrollment category was listed as child, adult, or  aged, and the recorded age or other information was inconsistent  with that category, we re-defined the enrollment category as unknown.
We reset all negative expenditures (which can indicate adjustments to  expenditures recorded in prior years) to 0.
Generally, states may report adjustments to their Medicaid expenditures for up to two  years. To the extent that negative expenditures reflect adjustments to prior year  expenditures, retaining them would result in an underestimate of expenditures for any  specific year. records because we could not determine which expenditures for these  enrollees were Medicaid expenditures.
After making these changes, we retained about 85 percent of the original  records in the summary file for each fiscal year, counting the records from  all states and the District of Columbia (but not counting records from  Maine in 2011, which were unavailable). These records represent just  under 65 percent of total Medicaid expenditures in these years. (We  previously reported that dual-eligible enrollees—whom we excluded from  our analyses—accounted for about 35 percent of total Medicaid  expenditures in fiscal year 2009.) As of December 2014, the summary  file did not include fiscal year 2011 expenditure data from Florida, and so  we excluded Florida from all further analyses of 2011 data. We assessed  the reliability of these data by performing appropriate electronic data  checks and reviewing relevant documentation, and determined that the  data from Idaho for 2010 were not sufficiently reliable for our purposes.  We determined that the remaining data were sufficiently reliable for our  purposes. Our analyses were thus based on data from all states and the  District of Columbia, but excluded Idaho in fiscal year 2010, and excluded  Florida and Maine in fiscal year 2011.
To determine the distribution of expenditures among Medicaid-only  enrollees, we calculated the cumulative frequency distribution of  expenditures for enrollees. That is, we placed all Medicaid-only enrollees  nationwide in rank order by their total Medicaid expenditures, from  highest to lowest, and determined the cumulative percentage of  nationwide expenditures for Medicaid-only enrollees attributable to  enrollees as the percentage of ordered enrollees increased. We analyzed  data from 3 years—fiscal years 2009, 2010, and 2011—separately to  determine whether the relationship was similar or different across years.  To facilitate interpretation of these frequency distributions, we also  computed a mathematical coefficient that provides information about the  relationship between the percentage of Medicaid-only enrollees and the  percentage of total Medicaid expenditures for these enrollees—the Gini  coefficient. This coefficient indicates the degree of inequality, that is, the  extent to which the frequency distribution differs from one in which  expenditures are equal for all enrollees. Figure 6 illustrates the difference  between frequency distributions with differing Gini coefficients.
To determine whether the proportions of high-expenditure Medicaid-only  enrollees in selected categories changed or remained consistent from  year to year, we conducted two separate analyses. For both, we defined  high-expenditure Medicaid-only enrollees as the 5 percent with the  highest expenditures within each state, as we had in our earlier work on  high-expenditure Medicaid enrollees. For one analysis, we examined the  percentage of high-expenditure Medicaid-only enrollees in five mutually  exclusive eligibility groups (child, adult, aged, disabled, or unknown). For  another analysis, we examined the percentage of high-expenditure  Medicaid-only enrollees identified as having any one of the five chronic  conditions recorded in the summary file (asthma, diabetes, HIV/AIDS,  mental health conditions, or substance abuse) or either of the two  services (delivery or childbirth, and long-term care residence) recorded in  the summary file. Enrollees could have any of these seven conditions or  services, any combination of them, or none of them. We compared the  proportions of high-expenditure enrollees in each of these sets of  categories in fiscal years 2009, 2010, and 2011.
To determine whether the distribution of high-expenditure Medicaid-only  enrollees’ expenditures among selected categories of service varied  across states, we again defined high-expenditure Medicaid-only enrollees  as the 5 percent with the highest expenditures within each state and  examined expenditures for fiscal year 2011 in eight categories of  service. These categories were three types of institutional care— hospital, long-term, and psychiatric facility; three types of non-institutional  services—acute care; long-term support; and other support services,  such as targeted case management or rehabilitative services; prescription  drugs; and managed care and premium assistance. We identified the  distribution of expenditures for high-expenditure enrollees among these  types of service within each state in fiscal year 2011 and compared the  distributions across states.
section_title: Appendix II: Distribution of Expenditures among Medicaid-Only Enrollees, Fiscal Year 2011
paragraphs: Table 4 provides information about the distribution of expenditures among  Medicaid-only enrollees nationally and in each state and the District of  Columbia in fiscal year 2011, including  the percentages of expenditures for Medicaid-only enrollees that were  attributable to the most expensive 1, 5, 10, and 25 percent of these  enrollees;  the percentage of expenditures for Medicaid-only enrollees that were  attributable to the least expensive 50 percent of these enrollees  (including those with 0 expenditures); and  the Gini coefficient, which indicates the degree of inequality; that is,  the extent to which the frequency distribution differs from one in which  expenditures are equal for all enrollees.
These state-by-state data illustrate that states differ widely in the degree  to which their distribution of expenditures varied across enrollees, but in  each state, a small percentage of high-expenditure Medicaid–only  enrollees was responsible for a disproportionately large share of the  expenditures for Medicaid-only enrollees.
section_title: Appendix III: High-Expenditure Medicaid- Only Enrollees in Different Eligibility Groups, Fiscal Year 2011
paragraphs: Table 5 provides information about the percentage of high-expenditure  Medicaid-only enrollees in five mutually exclusive eligibility groups (child,  adult, aged, disabled, or unknown) nationally and in each state and the  District of Columbia in fiscal year 2011. These data indicate that while  there was considerable variation across the states, in each state, the  greatest percentage of high-expenditure Medicaid-only enrollees were  disabled and the lowest percentage in a known eligibility group were  aged.
section_title: Appendix IV: High-Expenditure Medicaid- Only Enrollees with Certain Conditions or Services, Fiscal Year 2011
paragraphs: Table 6 provides information about the percentage of high-expenditure  Medicaid-only enrollees with certain conditions or services nationally and  in each state and the District of Columbia in fiscal year 2011. The  conditions are five chronic conditions recorded in the Medicaid Statistical  Information System Annual Person Summary File—asthma, diabetes,  human immunodeficiency virus/acquired immunodeficiency syndrome  (HIV/AIDS), mental health conditions, or substance abuse. The services  are two services—delivery or childbirth, and long-term care residence— recorded in the summary file. Enrollees could have any of these  conditions or services, any combination of them, or none of them. These  data indicate considerable variation across states, although the majority  of these enrollees in each state except Pennsylvania had at least one of  these conditions or services, and within each state, mental health  conditions were the most common of these conditions and services.
section_title: Appendix V: High-Expenditure Medicaid- Only Enrollees’ Expenditures in Different Service Categories, Fiscal Year 2011
paragraphs: Table 7 provides information about the percentage of high-expenditure  Medicaid-only enrollees’ expenditures in different categories of services  nationally and in each state and the District of Columbia in fiscal year  2011, and illustrates that states vary widely in the distribution of their  expenditures among service categories. These categories were three  types of institutional care—hospital, long-term, and psychiatric facility;  three types of non-institutional services—acute care; long-term support;  and other support services, such as targeted case management or  rehabilitative services; prescription drugs; and managed care and  premium assistance. Expenditures for categories of service other than  managed care and premium assistance do not include payments for  those services that were made by managed care plans. As a result, the  percentage of expenditures does not necessarily reflect enrollees’  utilization of services.
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, key contributors to this   report were Robert Copeland, Assistant Director; Dee Abasute;   Kristen Joan Anderson; Nancy Fasciano; Giselle Hicks; Drew Long;   and Jennifer Whitworth.