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 Non-institutional LTSS include home health and and in the community.personal care services, among other services. Medicaid is the nation’s primary payer for LTSS, and provided approximately 41 percent of LTSS funding in the United States in 2010. As we have previously reported, nearly all states enroll some Medicaid beneficiaries in a form of managed care. 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. GAO, Medicaid: States’ Use of Managed Care, GAO-12-872R (Washington, D.C.: Aug. 17, 2012). top 10 percent of Medicaid spending were responsible for 51 percent of Medicaid spending on dual-eligible beneficiaries. 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. 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. Intermediate 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). 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). At the beneficiary level, per-capita spending on high-expenditure Medicaid-only beneficiaries greatly exceeded that of all other Medicaid- only 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 high- expenditure dual-eligible beneficiaries compared with all other dual- eligible beneficiaries. At the state level, there was wide variation in spending per capita on high- expenditure Medicaid-only beneficiaries. (See fig. 2.) Per-capita expenditures by state per beneficiary ranged from $20,896 to $83,365. 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. We found that about two-thirds of the high-expenditure group was comprised of beneficiaries who were eligible for Medicaid due to disability. only 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 high- expenditure Medicaid-only beneficiaries. 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 Medicaid- only 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 high- expenditure 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.) 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 high- expenditure Medicaid-only beneficiaries and all other Medicaid-only 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. 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 high- expenditure beneficiaries. Children: Medicaid-only children had almost no LTSS institutional expenditures (less than 1 percent), whether in the high-expenditure group or not. (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. 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. (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).