Medicaid Managed Care - U.S. Senate Special Committee on Aging

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exercise in purifying bad data. Although the numbers are important for policymakers who need to
evaluate <strong>Medicaid</strong> trends, it is important to emphasize that better data are needed.' 3
Counting Enrollees in <strong>Managed</strong> <strong>Care</strong>. The goal of this section is to derive two sets of numbers for
national and state level managed-care enrollment corresponding to two different criteria for including
plans and arrangements. One is a count of <strong>Medicaid</strong> beneficiaries who participate in any kind Of
managed care for a broad range of health services. The second is a count of beneficiaries who enroll in
an HMO or other health plan that is at full risk for a comprehensive range of services. In each case,
managed-care carve-out arrangements that provide only dental or behavioral health services are
excluded.
Excluding Carve-Out Plans. HCFA's annual reports on <strong>Medicaid</strong> managed-care enrollment have
overcounted managed-care enrollment in significant ways (HCFA 1996a; 1997). An indicator of the
problem was that HCFA's 1995 data showed six states (Colorado, Hawaii, Massachusetts, Oregon,
Utah, and Washington) with more than 100 percent of their beneficiaries enrolled in managed care."
Calculated enrollment rates varied from 101 percent to 589 percent.
Dental and behavioral health managed-care plans provide substantially less than the full range of
<strong>Medicaid</strong> services. For example, certain plans in 3 states provide only dental services, and plans in II
states are restricted to behavioral health services (generally mental health and substance abuse).' 5
These plans are sometimes referred to as carve-out plans. Some beneficiaries in these states enroll in
both a regular managed-care plan and either a behavioral health plan or dental plan-and are thus
counted twice. In fact, in some states enrollment in a fee-for service PCCM arrangement may
automatically trigger enrollment in a risk-based behavioral health plan. Other beneficiaries may enroll
only in these carve-out plans. Nationally, these two types of plans represent about 17 percent of
HCFA's 1995 count of <strong>Medicaid</strong> managed-care enrollees (Table 20-2).to About 4 percent are in
dental plans, and 13 percent are in behavioral health plans.
" In 1995, researchers at Lewin-VHI prepared an analysis of <strong>Medicaid</strong> managed-care enrollment. They coltected
enrollment numbers directly from state officials and compared themn with HCFA's numbers. Their analysis shows that there
may be even more inaccuracies than revealed by the Commission's analysis (Lewin-VHI 1995).
" A footnote on HCFA's enrollment tables suggested the problem, "Totals include duplicated counts of eligibles
enrolled in multiple plans." In Hawaii, HCFA reported an additional data problem. Those enrolted under Hawaii's
Section Il15 waiver are counted in the enrollment total, but not in the denominator (total recipients) (HCFA 1996a).
" In addition to the dental and behavioral health plans, there are plans in some states that provide only primary care
services or an even more limited set of services, such as delivery and postpartum care only or newborn services only. They
typically exclude hospital services, although they may require primary care physicians to review hospital admissions. These
plans, however, appear not to duplicate coverage with other plans. They are not excluded from the Commission's counts, in
part because they are not well-distinguished from some PCCM plans.
" Plans are identified, with enrollment counts, by HCFA (1996a). More detailed descriptions are in a report on plans
operating under Section 1915(b) waivers (HCFA 1996e).
1997 Annual Report to Congrers/Chapter 20 428