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What are the service utilization patterns for people enrolled in Medicaid managed care?

GAO-15-481, May 29, 2015

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. MCOs, in turn, pay providers for the services they deliver. Since 1999, states have submitted data on managed care service utilization, also known as encounter data, to the Centers for Medicare & Medicaid Services, the federal agency that oversees Medicaid. Historically, these encounter data have been relatively incomplete and unreliable; thus, little is known about the utilization of services by 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. In our report and below, we describe what encounter data indicate about the service utilization of Medicaid beneficiaries enrolled in managed care plans.

The data presented below show service utilization patterns for adults and children enrolled in Medicaid comprehensive managed care in 19 states in calendar year 2010. In addition to services utilized by beneficiaries enrolled in comprehensive managed care plans, we also show information below on the extent to which the beneficiaries in our analysis received professional services paid on a fee-for-service basis while they were in comprehensive managed care. Data presented are also available for download.