Medicaid finances the delivery of health care services for a diverse low- income and medically needy population. The Social Security Act, which Congress amended in 1965 to establish the Medicaid program, provides the statutory framework for the program, setting broad parameters for states that choose to participate and implement their own Medicaid programs. CMS is responsible for overseeing state Medicaid programs to ensure compliance with federal requirements. Historically, Medicaid eligibility has been limited to certain categories of low-income individuals—such as children, parents, pregnant women, persons with disabilities, and individuals age 65 and older. In addition to these historical eligibility standards, PPACA permitted states to expand their Medicaid programs by covering non-elderly, non-pregnant adults with incomes at or below 133 percent of the federal poverty level (FPL). As of May 2015, 29 states, including the District of Columbia, had expanded their Medicaid programs to cover this new adult group, and one other state’s proposed expansion was pending federal approval. Federal law requires state Medicaid programs to cover a wide array of mandatory services, and permits states to cover additional services at their option. Consequently, Medicaid generally covers a wide range of health care services that can be categorized into broad types of coverage, including hospital care; non-hospital acute care, such as physician, dental, laboratory, and preventive services; prescription drugs; and LTSS in institutions and in the community. (See figure 2 for an overview of Medicaid expenditures by category.) In recent years, we and others have examined patterns of service utilization and expenditures within the Medicaid population and found that enrollment and expenditures vary among the different categories of enrollees. For example, for fiscal year 2011, children constituted the largest category of enrollees (47.4 percent), but accounted for a small share of Medicaid expenditures (19 percent). In that same year, enrollees with disabilities (14.7 percent of Medicaid enrollees) accounted for the largest share of Medicaid expenditures (42.7 percent). (See fig. 3.) In addition, we found that, generally, a small subset of Medicaid enrollees— such as those with institutional care needs or chronic conditions—account for a large portion of Medicaid expenditures. States have traditionally provided Medicaid benefits using a fee-for- service system, where health care providers are paid for each service delivered. However, according to CMS, in the past 15 years, states have increasingly implemented managed care systems for delivering Medicaid services. In a managed care delivery system, enrollees obtain some portion of their Medicaid services from a managed care organization (MCO) under contract with the state, and capitation payments to MCOs are typically made on a predetermined, per person per month basis. Nationally, about 37 percent of Medicaid spending in fiscal year 2014 was attributable to Medicaid managed care. Many states are expanding their use of managed care to additional geographic areas and Medicaid populations. States oversee Medicaid MCOs through contracts and reporting requirements. CMS provides oversight and technical assistance for the Medicaid program, but states are primarily responsible for administering their respective Medicaid programs’ day-to-day operations—including determining eligibility, enrolling individuals and providers, and adjudicating claims—within broad federal requirements. Each state has a Medicaid state plan that describes how the state will administer its Medicaid program consistent with federal requirements. States submit these state plans for approval to CMS, but have significant flexibility to structure their programs to best suit their needs. In addition, within certain parameters, states may innovate outside of many of Medicaid’s otherwise applicable requirements through Medicaid demonstrations, with HHS approval. For example, states may test ways to obtain savings or efficiencies in how services are delivered in order to cover otherwise ineligible services or populations. State FMAP = 1.00 – 0.45 (State PCI / U.S. PCI) Federal law specifies that the regular FMAP will be no lower than 50 percent and no higher than 83 percent. For fiscal year 2015, regular FMAP rates ranged from 50.00 percent to 73.58 percent. Under PPACA, state Medicaid expenditures for certain Medicaid enrollees, newly eligible under the statute, are subject to a higher federal match. States that choose to expand their Medicaid programs receive an FMAP of 100 percent beginning in 2014 for expenditures for the PPACA- expansion enrollees—those who were not previously eligible for Medicaid and are eligible now under PPACA’s expansion of eligibility criteria. The FMAP is to gradually diminish to 90 percent by 2020. States also receive an FMAP above the state’s regular match (but below the PPACA- expansion FMAP) for their Medicaid expenditures for the state-expansion enrollees—those who would not have been eligible for Medicaid prior to PPACA except that they were covered under a state’s pre-PPACA “expansion” of eligibility through, for example, a Medicaid demonstration. This FMAP is to gradually increase and eventually equal the FMAP for the PPACA-expansion enrollees beginning in 2019. The formula used to calculate the state-expansion FMAP rates is based on a state’s regular FMAP rate so the enhanced FMAP rate will vary from state to state until 2019. See figure 5 for the variation across states in the regular FMAP; Medicaid spending, enrollment, and managed care enrollment; and whether the state had expanded Medicaid coverage to newly eligible adults under PPACA as of May 2015. See appendix II for the information in tabular form. Medicaid enrollees report access to medical care that is generally comparable to that of privately insured individuals. However, some enrollees may face access challenges, such as in obtaining specialty care or dental care. CMS has taken steps to help ensure enrollees’ access to care and additional steps could bolster those efforts. CMS also has ongoing efforts to collect data from states to help assess Medicaid enrollees’ access to care, but better data are needed. Medicaid enrollees report access to care that is generally comparable to the privately insured, but some face particular access challenges. We have found that Medicaid enrollees report experiencing access to medical care that is generally comparable to that of privately insured individuals. For example, according to national survey data, few enrollees covered by Medicaid for a full year—less than 4 percent—reported difficulty obtaining necessary medical care or prescription medicine in 2008 and 2009, similar to privately insured individuals. (See fig. 6.) Regarding children, respondents with children covered by Medicaid reported positive responses to most questions about their ability to obtain care, and at levels generally comparable to those with private insurance, from 2007 through 2010. Although few Medicaid enrollees report difficulty obtaining necessary care in general, our work indicates that particular populations can face particular challenges obtaining care. For example, about 7.8 percent of working-age adults with full-year Medicaid reported difficulty obtaining care compared with 3.3 percent of similar adults with private insurance— a statistically significant difference. Some enrollees face particular challenges, such as accessing services. For example, Medicaid enrollees were more likely than individuals with private insurance to report factors such as lack of transportation and long wait times as reasons for delaying medical care. (See fig. 7.) We have also found that Medicaid-covered adults may be more likely to have certain health conditions that can be identified and managed through preventive services, such as obesity and diabetes, than individuals with private insurance. However, states’ Medicaid coverage of certain preventive services for adults has varied, which has resulted in different levels of coverage across states. Specialty care, such as mental health care and dental care, may be particularly difficult for some Medicaid enrollees to obtain. Access to Specialty Care, Including Mental Health Care National surveys of enrollees and our own surveys of state Medicaid officials and physicians have consistently indicated that Medicaid enrollees may have difficulty obtaining specialty care, such as mental health care. In our survey of state Medicaid officials in 2012, for example, officials in about half of the states reported challenges ensuring enough participating specialty providers for Medicaid enrollees, such as in obstetrics and gynecology, surgical specialties, and pediatric services. In addition, we found that about 21 percent of respondents with Medicaid- covered children reported that it was only sometimes or never easy to see a specialist, compared to about 13 percent of respondents with privately insured children, from 2008 through 2010. Our 2010 national survey of physicians found that specialty physicians were generally more willing to accept privately insured children as new patients than Medicaid-covered children; similarly, more physicians reported having difficulty referring Medicaid-covered children to specialty providers than reported having difficulty referring privately insured children. (See fig. 8.) We have also found that both Medicaid-covered adults and children may face challenges obtaining mental health care. Research has shown that Medicaid enrollees experience a higher rate of mental health conditions than those with private insurance. Officials we interviewed from six states that expanded Medicaid under PPACA generally reported that Medicaid expansion had increased the availability of mental health treatment for newly eligible adults, but cited access concerns for new Medicaid enrollees due to shortages of Medicaid-participating psychiatrists and psychiatric drug prescribers.survey, state officials reported problems ensuring sufficient psychiatry In our 2012 national providers for Medicaid enrollees. Among Medicaid-covered children, national survey data from 2007 through 2009 indicated that 14 percent of noninstitutionalized Medicaid-covered children had a potential need for mental health services, but most of these children did not receive mental health services. In addition, many Medicaid-covered children who took psychotropic medications (medications that affect mood, thought, or behavior) did not receive other mental health services during the same year. In December 2011, we reported that Medicaid-covered children in foster care in selected states were prescribed psychotropic medications at higher rates than nonfoster children in Medicaid during 2008. In 2012, HHS’s Administration for Children and Families issued guidance to state agencies seeking to improve their monitoring and oversight practices for psychotropic medications.