macstats: medicaid and chip data book - macpac · macstats: medicaid and chip data book xi...

MACStats: Medicaid and CHIP Data Book

December 2016

Medicaid and CHIP Payment and Access Commission

December 2016

MACStats: Medicaid and CHIP Data Book

Medicaid and CHIP Payment and Access Commission

MACStats: Medicaid and CHIP Data Book v

Commission Members and Terms

Commission Members and TermsSara Rosenbaum, JD, Chair Washington, DC

Marsha Gold, ScD, Vice Chair Washington, DC

Term Expires April 2017Sharon Carte, MHS West Virginia Children’s Health Insurance Program South Charleston, WV

Andrea Cohen, JD NYC Health + Hospitals New York, NY

Herman Gray, MD, MBA United Way for Southeastern Michigan Detroit, MI

Norma Martínez Rogers, PhD, RN, FAAN The University of Texas Health Science Center at San Antonio San Antonio, TX

Sara Rosenbaum, JD The George Washington University Washington, DC

Term Expires April 2018Gustavo Cruz, DMD, MPH Health Equity Initiative New York, NY

Leanna George Beneficiary Representative Benson, NC

Marsha Gold, ScD Independent Consultant Washington, DC

Charles Milligan, JD, MPH UnitedHealthcare Community Plan of New Mexico Albuquerque, NM

Sheldon Retchin, MD, MSPH The Ohio State University Wexner Medical Center Columbus, OH

Peter Szilagyi, MD, MPH University of California, Los Angeles Los Angeles, CA

Term Expires April 2019Brian Burwell Truven Health Analytics Cambridge, MA

Toby Douglas, MPP, MPH Centene Corporation Davis, CA

Christopher Gorton, MD, MHSA Tufts Health Plan Watertown, MA

Stacey Lampkin, FSA, MAAA, MPA Mercer Government Human Services Consulting Tallahassee, FL

Penny Thompson, MPA Penny Thompson Consulting, LLC Ellicott City, MD

Alan Weil, JD, MPP Health Affairs Bethesda, MD

December 2016vi

Commission StaffAnne L. Schwartz, PhD, Executive Director

Office of the Executive DirectorAnnie Andrianasolo, MBA, Executive Assistant

Kathryn Ceja, Director of Communications

Angelica Hill, MA, Communications/Graphic Design Specialist

Policy DirectorsAmy Bernstein, ScD, MHSA Policy Director and Contracting Officer

Moira Forbes, MBA, Policy Director

Jane Horvath, MHSA, Policy Director

Principal AnalystsKirstin Blom, MIPA

Martha Heberlein, MA

Joanne Jee, MPH, Principal Analyst and Congressional Liaison

Jessica Morris, MPA

Chris Park, MS

Kristal Vardaman, MSPH

Senior AnalystsBenjamin Finder, MPH

Robert Nelb, MPH

Katie Weider, MPH

AnalystsKacey Buderi, MPA Kayla Holgash, MPH

Research AssistantMadeline Britvec

Operations and FinanceRicardo Villeta, MBA, Deputy Director of Operations, Finance, and Management

James Boissonnault, MA, Chief Information Officer

Allissa Jones, Administrative Assistant

Kevin Ochieng, IT Specialist

Ken Pezzella, Chief Financial Officer

Brian Robinson, Financial Analyst

Eileen Wilkie, Administrative Officer

Commission Staff

MACStats: Medicaid and CHIP Data Book vii

Table of Contents

Table of ContentsCommission Members and Terms ...................................................................................................................... v

Commission Staff ............................................................................................................................................... vi

Introduction ......................................................................................................................................................... xi

SECTION 1: Overview—Key Statistics ........................................................................................................ 1

Key Points ........................................................................................................................................... 2

EXHIBIT 1: Medicaid and CHIP Enrollment as a Share of the U.S. Population, 2015 (millions) ..... 3

EXHIBIT 2: Characteristics of Non-Institutionalized Individuals by Age and Source of Health Coverage, 2015 .................................................................................................... 4

EXHIBIT 3: National Health Expenditures by Type and Payer, 2014 ............................................... 9

EXHIBIT 4: Major Health Programs and Other Components of the Federal Budget as a Share of Federal Outlays, FYs 1965–2015 .................................................................. 12

EXHIBIT 5: Medicaid as a Share of States’ Total Budgets and State-Funded Budgets, SFY 2014 ............................................................................................................................ 14

EXHIBIT 6: Federal Medical Assistance Percentages (FMAPs) and Enhanced FMAPs (E-FMAPs) by State, FYs 2013–2017 ........................................................................... 17

SECTION 2: Trends ............................................................................................................................. 21

Key Points ......................................................................................................................................... 22

EXHIBIT 7: Medicaid Beneficiaries (Persons Served) by Eligibility Group, FYs 1975–2013 (thousands) ........................................................................................ 23

EXHIBIT 8: Medicaid Enrollment and Spending, FYs 1966–2015 ................................................. 25

EXHIBIT 9: Annual Growth in Medicaid Enrollment and Spending, FYs 1975–2015 ................... 26

EXHIBIT 10: Medicaid Enrollment and Total Spending Levels and Annual Growth, FYs 1966–2015 ............................................................................................................. 27

EXHIBIT 11: Full-Benefit Medicaid and CHIP Enrollment, Selected Months, 2013–2016 ............. 29

EXHIBIT 12: Historical and Projected National Health Expenditures by Payer for Selected Years, FYs 1970–2025 .................................................................................. 32

EXHIBIT 13: Medicaid as a Share of State Budgets Including and Excluding Federal Funds, SFYs 1987–2014 ........................................................................................................... 34

SECTION 3: Program Enrollment and Spending ....................................................................................... 37

Key Points ......................................................................................................................................... 38

Medicaid Overall

EXHIBIT 14: Medicaid Enrollment by State, Eligibility Group, and Dually Eligible Status, FY 2013 (thousands) .................................................................................................... 39

EXHIBIT 15: Medicaid Full-Year Equivalent Enrollment by State and Eligibility Group, FY 2013 (thousands) .................................................................................................... 42

December 2016viii

Table of Contents

EXHIBIT 16: Medicaid Spending by State, Category, and Source of Funds, FY 2015 (millions) .... 45

Medicaid Benefits

EXHIBIT 17: Total Medicaid Benefit Spending by State and Category, FY 2015 (millions) ..... 48

EXHIBIT 18: Distribution of Medicaid Benefit Spending by Eligibility Group and Service Category, FY 2013 ...................................................................................... 51

EXHIBIT 19: Medicaid Benefit Spending Per Full-Year Equivalent (FYE) Enrollee by Eligibility Group and Service Category, FY 2013 ................................................... 52

EXHIBIT 20: Distribution of Medicaid Enrollment and Benefit Spending by Users and Non-Users of Long-Term Services and Supports, FY 2013 .................................. 53

EXHIBIT 21: Medicaid Spending by State, Eligibility Group, and Dually Eligible Status, FY 2013 (millions) ................................................................................................... 54

EXHIBIT 22: Medicaid Benefit Spending Per Full-Year Equivalent (FYE) Enrollee by State and Eligibility Group, FY 2013 ................................................................................ 56

EXHIBIT 23: Medicaid Supplemental Payments to Hospital Providers by State, FY 2015 (millions) ................................................................................................... 59

EXHIBIT 24: Medicaid Supplemental Payments to Non-Hospital Providers by State, FY 2015 (millions) ................................................................................................... 61

EXHIBIT 25: Medicaid Gross Spending for Drugs by Delivery System and Brand or Generic Status, FY 2015 (millions) ...................................................................................... 64

EXHIBIT 26: Medicaid Drug Prescriptions by Delivery System and Brand or Generic Status, FY 2015 (thousands) .............................................................................................. 67

EXHIBIT 27: Medicaid Gross Spending and Rebates for Drugs by Delivery System, FY 2015 (millions) ................................................................................................... 69

Medicaid Managed Care

EXHIBIT 28: Percentage of Medicaid Enrollees in Managed Care by State, July 1, 2014 ....... 72

EXHIBIT 29: Percentage of Medicaid Enrollees in Managed Care by State and Eligibility Group, FY 2013 ......................................................................................................... 75

Medicaid Program Administration

EXHIBIT 30: Total Medicaid Administrative Spending by State and Category, FY 2015 (millions) .................................................................................................... 78

CHIP

EXHIBIT 31: Child Enrollment in CHIP and Medicaid by State, FY 2015 .................................. 81

EXHIBIT 32: CHIP Spending by State, FY 2015 (millions) ......................................................... 83

EXHIBIT 33: Federal CHIP Allotments, FY 2016 (millions) ........................................................ 86

MACStats: Medicaid and CHIP Data Book ix

Table of Contents

SECTION 4: Medicaid and CHIP Eligibility ....................................................................................... 89

Key Points .................................................................................................................................. 90

EXHIBIT 34: Medicaid and CHIP Income Eligibility Levels as a Percentage of the FPL for Children and Pregnant Women by State, July 2016 ............................................. 91

EXHIBIT 35: Medicaid Income Eligibility Levels as a Percentage of the FPL for Non-Aged, Non-Disabled, Non-Pregnant Adults by State, July 2016 ...................................... 94

EXHIBIT 36: Medicaid Income Eligibility Levels as a Percentage of the FPL for Individuals Age 65 and Older and Persons with Disabilities by State, 2016 .......................... 97

EXHIBIT 37: Income as a Percentage of the FPL for Various Family Sizes, 2016 ................ 100

SECTION 5: Beneficiary Health, Service Use, and Access to Care .................................................. 103

Key Points ................................................................................................................................ 104

EXHIBIT 38: Coverage, Demographic, and Health Characteristics of Non-Institutionalized Individuals Age 0–18 by Primary Source of Health Coverage, 2015 ................. 105

EXHIBIT 39: Use of Care among Non-Institutionalized Individuals Age 0–18 by Primary Source of Health Coverage, 2015, Data from National Health Interview Survey ........... 108

EXHIBIT 40: Use of Care among Non-Institutionalized Individuals Age 0–18 by Primary Source of Health Coverage, 2014, Data from Medical Expenditures Panel Survey ....... 110

EXHIBIT 41: Measures of Access to Care among Non-Institutionalized Individuals Age 0–18 by Primary Source of Health Coverage, 2015 ............................................ 112

EXHIBIT 42: Coverage, Demographic, and Health Characteristics of Non-Institutionalized Individuals Age 19–64 by Primary Source of Health Coverage, 2015 ............... 114

EXHIBIT 43: Use of Care among Non-Institutionalized Individuals Age 19–64 by Primary Source of Health Coverage, 2015, Data from National Health Interview Survey ........... 118

EXHIBIT 44: Use of Care among Non-Institutionalized Individuals Age 19–64 by Primary Source of Health Coverage, 2014, Data from Medical Expenditures Panel Survey ....... 121

EXHIBIT 45: Measures of Access to Care among Non-Institutionalized Individuals Age 19–64 by Primary Source of Health Coverage, 2015 .......................................... 123

SECTION 6: Technical Guide to MACStats ..................................................................................... 125

Interpreting Medicaid and CHIP Enrollment and Spending Numbers ...................................... 127

Understanding Data on Health and Other Characteristics of Medicaid and CHIP Populations ... 128

Methodology for Adjusting Benefit Spending Data .................................................................... 130

EXHIBIT 46: Medicaid Benefit Spending in MSIS and CMS-64 Data by State, FY 2013 (millions) ................................................................................................. 132

EXHIBIT 47: Service Categories Used to Adjust FY 2013 Medicaid Benefit Spending in the MSIS to Match CMS-64 Totals .................................................................. 134

Understanding Managed Care Enrollment and Spending Data ................................................. 136

Endnotes ................................................................................................................................ 137

MACStats: Medicaid and CHIP Data Book xi

Introduction

IntroductionThis 2016 edition of the MACStats: Medicaid and CHIP Data Book presents the most current data available on Medicaid and the State Children’s Health Insurance Program (CHIP), two programs that provide a safety net for low-income populations who otherwise would not have access to health care coverage and that cover services other payers often do not cover.

The MACStats data book compiles the broad range of Medicaid and CHIP statistics that MACPAC regularly updates on macpac.gov into a single, end-of-year publication. Our purpose is to bring together in one place federal and state data on Medicaid and CHIP that come from multiple data sources and are often difficult to find.

The data book provides context for understanding these programs and how they fit in the larger health care system. For example: Medicaid and CHIP combined still account for a smaller share of total health care spending than Medicare, despite covering more people (Section 1). After experiencing high rates of growth in 2014 and 2015, Medicaid and CHIP enrollment grew less than 1 percent in 2016 (Exhibit 11). Managed care enrollment and spending continue to climb (Exhibits 17 and 28). And children whose primary coverage source is Medicaid or CHIP are reported to have well-child checkups at rates similar to those with private coverage (Exhibit 39).

The December 2016 data book is divided into six sections:

• an overview with key statistics on Medicaid and CHIP;

• trends in Medicaid spending, enrollment, and share of state budgets;

• Medicaid and CHIP enrollment and spending, with information provided by state, service category, and eligibility group;

• Medicaid and CHIP eligibility;

• measures of beneficiary health, use of services, and access to care; and

• a technical guide.

The technical guide describes the data sources used in MACStats and the methods that MACPAC uses to analyze these data. It also provides guidance in interpreting the exhibits and how specific data—such as those on enrollment and spending—may differ from each other or from those published elsewhere.

We would like to thank the many individuals at the Centers for Medicare & Medicaid Services and our contractors—the State Health Access Data Assistance Center (SHADAC) and Acumen, LLC—who provided their insights and assistance. We would also like to thank Paula Gordon and GKV Communications for providing valuable support in copyediting, formatting, and producing this data book.

http://macpac.gov

SECTION 1

Overview— Key Statistics

December 20162

Section 1: Overview—Key Statistics


Key Points• In 2015, more than one-quarter of the U.S. population was enrolled in Medicaid or the State

Children's Health Insurance Program (CHIP) at some point during the year. The estimated number of people ever enrolled in Medicaid was 81.0 million in fiscal year (FY) 2015; for CHIP, the figure was 8.9 million (Exhibit 1).

• Nearly half (45.9 percent) of all individuals enrolled in Medicaid in 2015 had family incomes below 100 percent of the federal poverty level (FPL). Nearly two-thirds (63.8 percent) of all individuals enrolled in Medicaid had incomes less than 138 percent FPL (Exhibit 2).

• People enrolled in Medicaid or CHIP were more likely to be Hispanic or black than those enrolled in other types of coverage. Additionally, Medicaid and CHIP enrollees were more likely to be in fair or poor health than either privately insured or uninsured individuals (Exhibit 2).

• Medicaid and CHIP together accounted for 16.8 percent of national health expenditures in calendar year 2014, Medicare accounted for 20.4 percent, and private insurance accounted for 32.7 percent (Exhibit 3).

• The share of the federal budget devoted to Medicaid and Medicare has grown steadily since the programs were enacted in 1965, but Medicaid continues to account for a smaller share (9.5 percent in FY 2015) than Medicare (14.6 percent) (Exhibit 4).

• Medicaid spending as a share of state budgets varies depending on whether federal funds are included. Looking only at the state-funded portion of state budgets (that is, the portion states must finance on their own through taxes and other means), Medicaid’s share was 15.3 percent in state fiscal year (SFY) 2014. After including federal funds in state budgets, Medicaid’s share was 25.6 percent in SFY 2014 (Exhibit 5).

MACStats: Medicaid and CHIP Data Book 3


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.538

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24.6

*14

.7*

36.7

43.1

Whi

te, n

on-H

ispa

nic

62.7

*77

.4*

70.9

*40

.242

.8

53.7

*67

.4*

35.7

42.9

*

Blac

k, n

on-H

ispa

nic

12.6

*10

.0*

9.9*

21.8

13.3

*14

.6*

9.9*

21.9

8.3*

Oth

er n

on-w

hite

, non

-His

pani

c7.

0*4.

8*7.

4 6.

55.

7 7.

1*8.

0*5.

75.

7

EXH

IBIT

2.

Char

acte

ristic

s of

Non

-Inst

itutio

naliz

ed In

divi

dual

s by

Age

and

Sou

rce

of H

ealth

Cov

erag

e, 2

015



MAC

Stat

sSe

ctio

n 1

EXH

IBIT

2.

(con

tinue

d)

Char

acte

ristic

Sele

cted

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w, a

ge 1

9-64

1Se

lect

ed c

over

age

sour

ces

at

time

of in

terv

iew

, age

65

and

olde

r1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

co

vera

ge s

ourc

es)5

100.

0%3.

9%69

.6%

12.4

%12

.8%

10

0.0%

94.2

%48

.9%

7.9%

Cove

rage

Leng

th o

f tim

e w

ith a

ny c

over

age

durin

g ye

ar

Full

year

82.2

*95

.7*

94.6

*87

.2–

98.7

99

.2

99.4

99

.2

Part

yea

r8.

8*4.

3*5.

4*12

.825

.2*

0.9

0.8

0.6

†

No

cove

rage

dur

ing

year

9.1

–

–

–74

.80.

4 –

–

–

Mul

tiple

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w

Yes,

any

Med

icar

e an

d M

edic

aid/

CHIP

co

mbi

natio

n61.

2*30

.3*

–

9.5

–

6.6*

7.0*

–

83.9

Yes,

any

priv

ate

and

Med

icai

d/CH

IP

com

bina

tion

0.4*

–

0.5*

3.0

–

†–

†

†

Yes,

any

oth

er c

ombi

natio

n0.

7*17

.3*

1.0*

†–

45

.1*

48.0

*92

.4*

4.5

No

97.8

*52

.4*

98.5

*87

.310

0.0*

48.2

*45

.0*

7.5*

11.4

Dem

ogra

phic

s

Age

0–18

––

––

––

––

–

19–

6410

0.0

100.

010

0.0

100.

010

0.0

––

––

65 o

r old

er–

––

––

100.

010

0.0

100.

010

0.0

Gen

der

Mal

e49

.0*

50.0

*49

.4*

38.0

55.7

*44

.5*

44.3

*43

.5*

34.7

Fem

ale

51.0

*50

.0*

50.6

*62

.044

.3*

55.5

*55

.7*

56.5

*65

.3

Race

His

pani

c17

.2*

9.5*

12.3

*25

.637

.7*

8.0*

7.6*

3.7*

27.9

Whi

te, n

on-H

ispa

nic

62.7

*69

.1*

69.4

*45

.242

.7

78.1

*78

.9*

86.0

*44

.4

Blac

k, n

on-H

ispa

nic

12.7

*17

.5*

10.5

*22

.314

.0*

8.8*

8.7*

6.5*

17.2

Oth

er n

on-w

hite

, non

-His

pani

c7.

4*3.

9*7.

8 7.

05.

5 5.

1*4.

8*3.

9*10

.5

December 20166


MAC

Stat

sSe

ctio

n 1

Char

acte

ristic

Sele

cted

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w, a

ll ag

es1

Sele

cted

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w, a

ge 0

-181

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Educ

atio

n7

Less

than

hig

h sc

hool

12.1

%*

17.3

%*

6.1%

*28

.2%

27.7

%

–

–

––

H

igh

scho

ol d

iplo

ma/

GED

24.5

29

.9

21.0

*31

.733

.1

–

–

––

So

me

colle

ge31

.3*

26.9

*32

.0

31.3

28.1

*–

–

–

–

Colle

ge o

r gra

duat

e de

gree

32.1

*25

.9*

40.8

*8.

711

.1*

–

–

––

M

arita

l sta

tus7

Mar

ried

54.0

*52

.2*

60.6

*31

.939

.5*

–

–

––

Wid

owed

6.2*

22.6

*4.

6*6.

12.

0*–

–

–

–Di

vorc

ed o

r sep

arat

ed11

.7*

15.1

*9.

6*17

.313

.6*

–

–

––

Livi

ng w

ith p

artn

er7.

4*2.

9*6.

4*11

.113

.3*

–

–

––

Nev

er m

arrie

d20

.7*

7.2*

18.7

*33

.631

.5

–

–

––

Fam

ily in

com

eH

as in

com

e le

ss th

an 1

38 p

erce

nt F

PL22

.5*

20.8

*8.

3*63

.839

.7*

31.1

%*

8.5%

*63

.5%

38.9

%*

Has

inco

me

in ra

nges

sho

wn

belo

wLe

ss th

an 1

00 p

erce

nt F

PL14

.5*

11.1

*4.

3*45

.926

.4*

21.1

*4.

2*45

.822

.9*

100–

199

perc

ent F

PL19

.4*

23.1

*12

.0*

35.1

31.5

*23

.0*

12.6

*36

.135

.2

200–

399

perc

ent F

PL28

.7*

32.2

*31

.5*

15.1

31.0

*27

.6*

35.5

*14

.933

.0*

400

perc

ent F

PL o

r hig

her

37.2

*33

.4*

52.1

*3.

710

.9*

28.1

47

.6*

3.0

8.5*

Oth

er d

emog

raph

ic c

hara

cter

istic

sCi

tizen

of U

nite

d St

ates

93.1

*97

.6*

95.2

*93

.673

.5*

97.5

*98

.2

97.8

86.9

*Pa

rent

of a

dep

ende

nt c

hild

729

.6*

2.2*

31.1

*37

.936

.3

–

–

––

Cu

rren

tly w

orki

ng7

61.8

*13

.7*

73.6

*35

.264

.6*

–

–

––

Ve

tera

n78.

9*20

.5*

7.3*

3.8

2.8

–

–

––

Re

ceiv

es S

SI o

r SSD

I4.

2 13

.6

1.3*

13.4

0.8*

1.2*

0.5*

2.6

† H

ealth

Curr

ent h

ealth

sta

tus

Exce

llent

or v

ery

good

65.8

*40

.6*

72.1

*57

.661

.2*

84.2

*89

.9*

76.1

80.9

*G

ood

23.9

*33

.0*

21.6

*25

.628

.1*

14.0

*9.

2*20

.717

.7

Fair

or p

oor

10.3

*26

.4*

6.3*

16.8

10.8

*1.

9*0.

9*3.

3†

EXH

IBIT

2.

(con

tinue

d)



MAC

Stat

sSe

ctio

n 1

EXH

IBIT

2.

(con

tinue

d)

Char

acte

ristic

Sele

cted

cov

erag

e so

urce

s at

tim

e of

inte

rvie

w, a

ge 1

9-64

1Se

lect

ed c

over

age

sour

ces

at

time

of in

terv

iew

, age

65

and

olde

r1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Educ

atio

n7

Less

than

hig

h sc

hool

11.0

%*

22.8

%

5.2%

*25

.7%

27.7

%

16.6

%*

16.4

%*

11.3

%*

44.6

%H

igh

scho

ol d

iplo

ma/

GED

23.4

*35

.3

19.7

*32

.833

.2

28.9

29

.0

28.9

24

.9So

me

colle

ge32

.5*

30.0

33

.0

33.4

28.1

*26

.4*

26.4

*26

.5*

18.1

Colle

ge o

r gra

duat

e de

gree

33.0

*11

.9*

42.1

*8.

211

.0*

28.2

*28

.2*

33.4

*12

.4M

arita

l sta

tus7

Mar

ried

53.8

*36

.6

60.7

*32

.339

.5*

54.9

*54

.9*

60.4

*29

.0W

idow

ed1.

6*5.

2*1.

3*2.

31.

7 25

.1*

25.6

*23

.6*

30.7

Divo

rced

or s

epar

ated

11.3

*26

.3*

9.5*

15.6

13.5

*13

.4*

13.2

*10

.6*

28.0

Livi

ng w

ith p

artn

er8.

6*7.

6*7.

1*12

.413

.5

2.1

2.1

2.2

†N

ever

mar

ried

24.6

*24

.3*

21.4

*37

.431

.8*

4.5*

4.3*

3.3*

9.5

Fam

ily in

com

eH

as in

com

e le

ss th

an 1

38 p

erce

nt F

PL20

.5*

46.4

*8.

3*63

.939

.9*

16.5

*16

.3*

7.6*

65.9

Has

inco

me

in ra

nges

sho

wn

belo

wLe

ss th

an 1

00 p

erce

nt F

PL13

.3*

29.0

*4.

6*46

.026

.9*

8.5*

8.1*

3.2*

45.5

100–

199

perc

ent F

PL17

.6

34.1

11

.3*

34.4

31.1

*20

.5*

21.0

*14

.7*

32.3

200–

399

perc

ent F

PL28

.1*

25.2

*29

.7*

15.5

30.8

*33

.2*

33.5

*34

.5*

14.6

400

perc

ent F

PL o

r hig

her

40.9

*11

.7*

54.4

*3.

911

.1*

37.6

*37

.2*

47.5

*7.

2O

ther

dem

ogra

phic

cha

ract

eris

tics

Citiz

en o

f Uni

ted

Stat

es90

.3*

96.7

*93

.6*

89.2

71.7

*96

.9*

97.8

*98

.6*

88.1

Pare

nt o

f a d

epen

dent

chi

ld7

36.6

*12

.6*

36.3

*43

.836

.7*

0.5

0.4

† †

Curr

ently

wor

king

773

.0*

10.0

*82

.9*

40.1

64.9

*15

.7*

14.4

*19

.2*

3.6

Vete

ran7

5.7*

9.0*

4.6*

3.3

2.8

22.4

*22

.4*

22.5

*7.

1Re

ceiv

es S

SI o

r SSD

I5.

6*74

.7*

1.7*

24.1

0.8*

3.6*

3.4*

0.7*

30.7

Hea

lthCu

rren

t hea

lth s

tatu

sEx

celle

nt o

r ver

y go

od63

.3*

11.9

*70

.0*

40.5

58.5

*45

.3*

45.2

*51

.1*

21.3

Goo

d25

.7

30.4

23

.6*

31.1

29.6

33

.4

33.6

33

.1

29.5

Fair

or p

oor

11.0

*57

.8*

6.4*

28.5

11.9

*21

.3*

21.2

*15

.9*

49.2

December 20168


MAC

Stat

sSe

ctio

n 1

EXH

IBIT

2.

(con

tinue

d)

Not

es: F

PL is

fede

ral p

over

ty le

vel.

SSDI

is S

ocia

l Sec

urity

Dis

abili

ty In

sura

nce.

SSI

is S

uppl

emen

tal S

ecur

ity In

com

e. P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

exhi

bit

excl

ude

indi

vidu

als

with

mis

sing

and

unk

now

n va

lues

. Sta

ndar

d er

rors

are

ava

ilabl

e on

line

in th

e do

wnl

oada

ble

Exce

l ver

sion

of t

his

exhi

bit a

t htt

ps:/

/ww

w.m

acpa

c.go

v/pu

blic

atio

n/ch

arac

teris

tics-

of-n

on-in

stitu

tiona

lized

-indi

vidu

als-

by-s

ourc

e-of

-hea

lth-in

sura

nce/

. The

indi

vidu

al c

ompo

nent

s lis

ted

unde

r the

sub

cate

gorie

s ar

e no

t alw

ays

mut

ually

exc

lusi

ve a

nd m

ay n

ot a

dd to

100

per

cent

. Due

to d

iffer

ence

s in

met

hodo

logy

(suc

h as

the

wor

ding

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed

to e

licit

resp

onse

s), e

stim

ates

obt

aine

d fr

om d

iffer

ent s

urve

y da

ta s

ourc

es w

ill v

ary.

For

exa

mpl

e, th

e N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

) is

know

n to

pro

duce

hig

her

estim

ates

of s

ervi

ce u

se th

an th

e M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

(MEP

S). F

or p

urpo

ses

of c

ompa

ring

grou

ps o

f ind

ivid

uals

(as

in th

is e

xhib

it), t

he N

HIS

pro

vide

s th

e m

ost

rece

nt in

form

atio

n av

aila

ble.

For

oth

er p

urpo

ses,

suc

h as

mea

surin

g le

vels

of u

se re

lativ

e to

a p

artic

ular

ben

chm

ark

or g

oal,

it m

ay b

e ap

prop

riate

to c

onsu

lt es

timat

es fr

om

MEP

S or

ano

ther

sou

rce.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

indi

vidu

als,

rega

rdle

ss o

f cov

erag

e so

urce

. In

this

exh

ibit,

the

sum

of v

alue

s ac

ross

hea

lth in

sura

nce

cove

rage

type

s m

ay n

ot a

dd

to 1

00 p

erce

nt fo

r eac

h ag

e gr

oup

beca

use

indi

vidu

als

may

hav

e m

ultip

le s

ourc

es o

f cov

erag

e an

d be

caus

e no

t all

type

s of

cov

erag

e ar

e di

spla

yed.

Oth

er M

ACSt

ats

exhi

bits

ap

ply

a hi

erar

chy

to a

ssig

n in

divi

dual

s w

ith m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce, a

nd m

ay th

eref

ore

have

diff

eren

t res

ults

than

thos

e sh

own

here

. Cov

erag

e so

urce

is

def

ined

as

of th

e tim

e of

the

surv

ey in

terv

iew

. Sin

ce a

n in

divi

dual

may

hav

e m

ultip

le c

over

age

sour

ces

or c

hang

es o

ver t

ime,

resp

onse

s to

sur

vey

ques

tions

may

refle

ct

char

acte

ristic

s or

exp

erie

nces

ass

ocia

ted

with

a c

over

age

sour

ce o

ther

than

the

one

assi

gned

in th

is e

xhib

it.2

Priv

ate

heal

th in

sura

nce

cove

rage

exc

lude

s pl

ans

that

pai

d fo

r onl

y on

e ty

pe o

f ser

vice

, suc

h as

acc

iden

ts o

r den

tal c

are.

3 M

edic

aid/

CHIP

als

o in

clud

es p

erso

ns c

over

ed b

y ot

her s

tate

-spo

nsor

ed h

ealth

pla

ns.

4 In

divi

dual

s w

ere

defin

ed a

s un

insu

red

if th

ey d

id n

ot h

ave

any

priv

ate

heal

th in

sura

nce,

Med

icai

d, C

HIP

, Med

icar

e, s

tate

-spo

nsor

ed o

r oth

er g

over

nmen

t-spo

nsor

ed h

ealth

pl

an, o

r mili

tary

pla

n. In

divi

dual

s w

ere

also

def

ined

as

unin

sure

d if

they

had

onl

y In

dian

Hea

lth S

ervi

ce c

over

age

or h

ad o

nly

a pr

ivat

e pl

an th

at p

aid

for o

ne ty

pe o

f ser

vice

, su

ch a

s ac

cide

nts

or d

enta

l car

e.5

Com

pone

nts

may

not

sum

to 1

00 p

erce

nt b

ecau

se in

divi

dual

s m

ay h

ave

mul

tiple

sou

rces

of c

over

age

and

beca

use

not a

ll ty

pes

of c

over

age

are

disp

laye

d.6

NH

IS a

nd o

ther

sur

vey

data

und

eres

timat

e th

e nu

mbe

r of i

ndiv

idua

ls d

ually

enr

olle

d in

Med

icar

e an

d M

edic

aid,

in p

art b

ecau

se m

ost s

urve

ys d

o no

t cou

nt th

ose

who

se o

nly

Med

icai

d be

nefit

is p

aym

ent o

f Med

icar

e pr

emiu

ms

and

cost

sha

ring

as h

avin

g M

edic

aid

cove

rage

.7

Info

rmat

ion

is li

mite

d to

thos

e ag

e 19

or o

lder

.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

NH

IS d

ata.

https://www.macpac.gov/publication/characteristics-of-non-institutionalized-individuals-by-source-of-health-insurance/

https://www.macpac.gov/publication/characteristics-of-non-institutionalized-individuals-by-source-of-health-insurance/



MAC

Stat

sSe

ctio

n 1

EXH

IBIT

3.

Nat

iona

l Hea

lth E

xpen

ditu

res

by T

ype

and

Paye

r, 20

14

Type

of e

xpen

ditu

re

Paye

r am

ount

(mill

ions

)

Tota

lM

edic

aid

CHIP

Med

icar

ePr

ivat

e in

sura

nce

Oth

er

heal

th

insu

ranc

e1

Oth

er

third

par

ty

paye

rs2

Out

of

pock

et

Tota

l$3

,031

,292

$495

,766

$13,

183

$618

,706

$990

,988

$98,

245

$484

,585

$329

,819

Hos

pita

l car

e97

1,83

616

8,01

23,

362

250,

323

362,

097

56,9

9999

,669

31,3

73

Phys

icia

n an

d cl

inic

al s

ervi

ces

603,

655

63,9

933,

169

138,

366

254,

656

22,0

6567

,371

54,0

35

Dent

al s

ervi

ces

113,

549

10,0

681,

458

410

54,0

701,

333

485

45,7

26

Oth

er p

rofe

ssio

nal s

ervi

ces3

84,3

986,

266

250

19,6

1729

,713

–7,

259

21,2

92

Hom

e he

alth

car

e83

,198

29,6

4536

34,7

288,

278

429

2,71

47,

369

Oth

er n

on-d

urab

le m

edic

al p

rodu

cts4

56,9

36–

–2,

251

––

–54

,685

Pres

crip

tion

drug

s29

7,69

827

,333

1,41

386

,388

127,

288

8,51

42,

040

44,7

22

Dura

ble

med

ical

equ

ipm

ent5

46,3

556,

120

124

7,73

98,

174

–60

723

,592

Nur

sing

car

e fa

cilit

ies

and

cont

inui

ng c

are

retir

emen

t com

mun

ities

615

5,58

649

,594

1035

,704

13,0

834,

731

11,3

0641

,159

Oth

er h

ealth

, res

iden

tial,

and

pers

onal

car

e se

rvic

es7

150,

396

83,8

781,

017

5,18

411

,441

948

42,0

615,

867

Adm

inis

trat

ion8

234,

830

50,8

582,

346

37,9

9612

2,18

73,

226

18,2

17–

Publ

ic h

ealth

act

ivity

78,9

93–

––

––

78,9

92–

Inve

stm

ent

153,

862

––

––

–15

3,86

2–

December 201610


MAC

Stat

sSe

ctio

n 1

Type

of e

xpen

ditu

re

Shar

e of

tota

l

Tota

lM

edic

aid

CHIP

Med

icar

ePr

ivat

e in

sura

nce

Oth

er

heal

th

insu

ranc

e1

Oth

er

third

par

ty

paye

rs2

Out

of

pock

et

Tota

l10

0.0%

16.4

%0.

4%20

.4%

32.7

%3.

2%16

.0%

10.9

%

Hos

pita

l car

e10

0.0

17.3

0.3

25.8

37.3

5.9

10.3

3.2

Phys

icia

n an

d cl

inic

al s

ervi

ces

100.

010

.60.

522

.942

.23.

711

.29.

0

Dent

al s

ervi

ces

100.

08.

91.

30.

447

.61.

20.

440

.3

Oth

er p

rofe

ssio

nal s

ervi

ces3

100.

07.

40.

323

.235

.2–

8.6

25.2

Hom

e he

alth

car

e10

0.0

35.6

0.0

41.7

9.9

0.5

3.3

8.9

Oth

er n

on-d

urab

le m

edic

al p

rodu

cts4

100.

0–

–4.

0–

––

96.0

Pres

crip

tion

drug

s10

0.0

9.2

0.5

29.0

42.8

2.9

0.7

15.0

Dura

ble

med

ical

equ

ipm

ent5

100.

013

.20.

316

.717

.6–

1.3

50.9

Nur

sing

car

e fa

cilit

ies

and

cont

inui

ng c

are

retir

emen

t com

mun

ities

610

0.0

31.9

0.0

22.9

8.4

3.0

7.3

26.5

Oth

er h

ealth

, res

iden

tial, a

nd p

erso

nal c

are

serv

ices

710

0.0

55.8

0.7

3.4

7.6

0.6

28.0

3.9

Adm

inis

trat

ion8

100.

021

.71.

016

.252

.01.

47.

8–

Publ

ic h

ealth

act

ivity

100.

0–

––

––

100.

0–

Inve

stm

ent

100.

0–

––

––

100.

0–

Not

es: E

very

five

yea

rs th

e na

tiona

l hea

lth e

xpen

ditu

re a

ccou

nts

unde

rgo

a co

mpr

ehen

sive

revi

sion

that

incl

udes

the

inco

rpor

atio

n of

new

ly a

vaila

ble

sour

ce d

ata,

m

etho

dolo

gica

l and

def

initi

onal

cha

nges

, and

ben

chm

ark

estim

ates

from

the

U.S

. Cen

sus

Bure

au’s

qui

nque

nnia

l eco

nom

ic c

ensu

s. A

s a

resu

lt of

this

revi

sion

in 2

014,

th

e fig

ures

sho

wn

here

may

refle

ct m

etho

dolo

gica

l and

def

initi

onal

shi

fts

with

in p

ayer

and

ser

vice

cat

egor

ies

from

prio

r pub

licat

ions

of M

ACSt

ats.

For

exa

mpl

e, th

e 20

14

met

hodo

logy

impl

emen

ts a

new

met

hod

for a

lloca

ting

Med

icai

d m

anag

ed c

are

prem

ium

s to

the

good

s an

d se

rvic

es c

ateg

orie

s fo

r sta

tes

that

hav

e a

larg

e pe

rcen

tage

of

Med

icai

d m

anag

ed c

are

spen

ding

. Thi

s ch

ange

cau

sed

a do

wnw

ard

revi

sion

for h

ospi

tals

and

hom

e he

alth

car

e an

d an

upw

ard

revi

sion

for o

ther

ser

vice

cat

egor

ies.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

EXH

IBIT

3.

(con

tinue

d)



MAC

Stat

sSe

ctio

n 1

1 U

.S. D

epar

tmen

t of D

efen

se a

nd U

.S. D

epar

tmen

t of V

eter

ans’

Aff

airs

.2

Incl

udes

all

othe

r pub

lic a

nd p

rivat

e pr

ogra

ms

and

expe

nditu

res

exce

pt fo

r out

-of-p

ocke

t am

ount

s.3

The

othe

r pro

fess

iona

l ser

vice

s ca

tego

ry in

clud

es s

ervi

ces

prov

ided

in e

stab

lishm

ents

ope

rate

d by

hea

lth p

ract

ition

ers

othe

r tha

n ph

ysic

ians

and

den

tists

, inc

ludi

ng th

ose

prov

ided

by

priv

ate-

duty

nur

ses,

chi

ropr

acto

rs, p

odia

tris

ts, o

ptom

etris

ts, a

nd p

hysi

cal,

occu

patio

nal,

and

spee

ch th

erap

ists

, am

ong

othe

rs.

4 Th

e ot

her n

on-d

urab

le m

edic

al p

rodu

cts

cate

gory

incl

udes

the

reta

il sa

les

of n

on-p

resc

riptio

n dr

ugs

and

med

ical

sun

drie

s.5

The

dura

ble

med

ical

equ

ipm

ent c

ateg

ory

incl

udes

reta

il sa

les

of it

ems

such

as

cont

act l

ense

s, e

yegl

asse

s, a

nd o

ther

oph

thal

mic

pro

duct

s, s

urgi

cal a

nd o

rtho

pedi

c pr

oduc

ts,

hear

ing

aids

, whe

elch

airs

, and

med

ical

equ

ipm

ent r

enta

ls.

6 Th

e nu

rsin

g ca

re fa

cilit

ies

and

cont

inui

ng c

are

retir

emen

t com

mun

ities

cat

egor

y in

clud

es n

ursi

ng a

nd re

habi

litat

ive

serv

ices

pro

vide

d in

free

stan

ding

nur

sing

hom

e fa

cilit

ies

that

are

gen

eral

ly p

rovi

ded

for a

n ex

tend

ed p

erio

d of

tim

e by

regi

ster

ed o

r lic

ense

d pr

actic

al n

urse

s an

d ot

her s

taff

.7

The

othe

r hea

lth, r

esid

entia

l, an

d pe

rson

al c

are

cate

gory

incl

udes

spe

ndin

g fo

r Med

icai

d ho

me

and

com

mun

ity-b

ased

wai

vers

, car

e pr

ovid

ed in

resi

dent

ial f

acili

ties

for

peop

le w

ith in

telle

ctua

l dis

abili

ties

or m

enta

l hea

lth a

nd s

ubst

ance

abu

se d

isor

ders

, am

bula

nce

serv

ices

, sch

ool h

ealth

, and

wor

k si

te h

ealth

car

e.8

The

adm

inis

trat

ive

cate

gory

incl

udes

the

adm

inis

trat

ive

cost

of h

ealth

car

e pr

ogra

ms

(e.g

., M

edic

are

and

Med

icai

d) a

nd th

e ne

t cos

t of p

rivat

e he

alth

insu

ranc

e (a

dmin

istr

ativ

e co

sts,

as

wel

l as

addi

tions

to re

serv

es, r

ate

cred

its a

nd d

ivid

ends

, pre

miu

m ta

xes,

and

pla

n pr

ofits

or l

osse

s).

Sour

ces:

Off

ice

of th

e Ac

tuar

y (O

ACT)

, Cen

ters

for M

edic

are

& M

edic

aid

Serv

ices

, 201

5, N

atio

nal h

ealth

exp

endi

ture

s by

type

of s

ervi

ce a

nd s

ourc

e of

fund

s: C

alen

dar y

ears

19

60–2

014,

Bal

timor

e, M

D: O

ACT,

htt

ps:/

/ww

w.c

ms.

gov/

Res

earc

h-St

atis

tics-

Data

-and

-Sys

tem

s/St

atis

tics-

Tren

ds-a

nd-R

epor

ts/N

atio

nalH

ealth

Expe

ndDa

ta/D

ownl

oads

/N

HE2

014.

zip.

OAC

T, 2

014,

Nat

iona

l hea

lth e

xpen

ditu

re a

ccou

nts:

Met

hodo

logy

pap

er, 2

014,

htt

ps:/

/ww

w.c

ms.

gov/

Res

earc

h-St

atis

tics-

Dat

a-an

d-Sy

stem

s/St

atis

tics-

Tren

ds-

and-

Rep

orts

/Nat

iona

lHea

lthEx

pend

Dat

a/D

ownl

oads

/DSM

-14.

pdf.

OAC

T, 2

014,

Sum

mar

y of

201

4 co

mpr

ehen

sive

revi

sion

to th

e na

tiona

l hea

lth e

xpen

ditu

re a

ccou

nts,

ht

tps:

//w

ww

.cm

s.go

v/R

esea

rch-

Stat

istic

s-D

ata-

and-

Syst

ems/

Stat

istic

s-Tr

ends

-and

-Rep

orts

/Nat

iona

lHea

lthEx

pend

Dat

a/D

ownl

oads

/ben

chm

ark2

014.

pdf.

EXH

IBIT

3.

(con

tinue

d)

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/NHE2014.zip


https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/DSM-14.pdf

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/DSM-14.pdf

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/benchmark2014.pdf

December 201612


MAC

Stat

sSe

ctio

n 1

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

2015

Fiscal year

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Medicaid

Medicare

Social Security

Exchangesubsidies

CHIP

Other mandatory programs

Discretionary, defense

Discretionary, non-defense

Net interest

EXHIBIT 4. Major Health Programs and Other Components of the Federal Budget as a Share of Federal Outlays, FYs 1965–2015



MAC

Stat

sSe

ctio

n 1

Fisc

al y

ear

Man

dato

ry p

rogr

ams

Disc

retio

nary

pro

gram

s

Net

inte

rest

Med

icai

dCH

IPM

edic

are

Exch

ange

su

bsid

ies

Soci

al

Secu

rity

Oth

erDe

fens

eN

on-

defe

nse

1965

0.2%

––

–14

.4%

12.3

%43

.2%

22.6

%7.

3%19

701.

4–

3.0%

–15

.211

.641

.919

.67.

319

752.

1–

3.7

–19

.120

.626

.421

.27.

019

802.

4–

5.2

–19

.816

.922

.824

.08.

919

852.

4–

6.8

–19

.713

.526

.717

.213

.719

903.

3–

7.6

–19

.714

.724

.016

.014

.719

914.

0–

7.7

–20

.113

.224

.116

.114

.719

924.

9–

8.4

–20

.613

.021

.916

.714

.419

935.

4–

9.1

–21

.411

.720

.717

.514

.119

945.

6–

9.7

–21

.712

.119

.317

.713

.919

955.

9–

10.4

–22

.010

.518

.017

.915

.319

965.

9–

11.0

–22

.211

.317

.017

.115

.419

976.

0–

11.7

–22

.610

.317

.017

.215

.219

986.

10.

0%11

.5–

22.8

11.6

16.4

17.1

14.6

1999

6.3

0.0

11.0

–22

.712

.716

.217

.413

.520

006.

60.

110

.9–

22.7

13.0

16.5

17.9

12.5

2001

6.9

0.2

11.5

–23

.012

.416

.418

.411

.120

027.

30.

211

.3–

22.5

13.7

17.4

19.1

8.5

2003

7.4

0.2

11.4

–21

.813

.918

.719

.47.

120

047.

70.

211

.6–

21.4

13.1

19.8

19.2

7.0

2005

7.4

0.2

11.9

–21

.012

.920

.019

.27.

420

066.

80.

212

.2–

20.5

13.4

19.6

18.7

8.5

2007

7.0

0.2

13.6

–21

.311

.020

.118

.18.

720

086.

80.

212

.9–

20.5

13.0

20.5

17.5

8.5

2009

7.1

0.2

12.1

–19

.320

.818

.716

.55.

320

107.

90.

212

.9–

20.3

14.1

19.9

19.0

5.7

2011

7.6

0.2

13.3

–20

.114

.919

.418

.06.

420

127.

10.

313

.2–

21.7

15.2

19.0

17.4

6.2

2013

7.7

0.3

14.2

–23

.413

.218

.116

.76.

420

148.

60.

314

.40.

4%24

.112

.117

.016

.66.

520

159.

50.

314

.60.

723

.913

.215

.815

.96.

1

Not

es: F

Y is

fisc

al y

ear.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s am

ount

s le

ss th

an 0

.05%

that

roun

d to

zer

o.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

Off

ice

of M

anag

emen

t and

Bud

get (

OM

B), F

isca

l yea

r 201

7 H

isto

rical

Tab

les:

Bud

get o

f the

U.S

. Gov

ernm

ent,

Tabl

es 6

.1, 8

.5, a

nd 8

.7,

Was

hing

ton,

DC:

OM

B; h

ttp:

//w

ww

.gpo

.gov

/fds

ys/s

earc

h/pa

gede

tails

.act

ion?

gran

uleI

d=&p

acka

geId

=BU

DGET

-201

7-TA

B.

EXH

IBIT

4.

(con

tinue

d)

http://www.gpo.gov/fdsys/search/pagedetails.action?granuleId=&packageId=BUDGET-2017-TAB

December 201614


MAC

Stat

sSe

ctio

n 1

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MAC

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http

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https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/State%20Expenditure%20Report%20(Fiscal%202013-2015)S.pdf

https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/State%20Expenditure%20Report%20(Fiscal%202013-2015)S.pdf



MAC

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December 201618


MAC

Stat

sSe

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edic

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.00

88.2

988

.71

Sout

h Ca

rolin

a70

.43

70.5

770

.64

71.0

871

.30

79.3

079

.40

79.4

510

0.00

100.

00

Sout

h Da

kota

56.1

953

.54

51.6

451

.61

54.9

469

.33

67.4

866

.15

89.1

391

.46

Tenn

esse

e66

.13

65.2

964

.99

65.0

564

.96

76.2

975

.70

75.4

998

.54

98.4

7

Texa

s59

.30

58.6

958

.05

57.1

356

.18

71.5

171

.08

70.6

492

.99

92.3

3

Uta

h69

.61

70.3

470

.56

70.2

469

.90

78.7

379

.24

79.3

910

0.00

100.

00

Verm

ont

56.0

455

.11

54.0

153

.90

54.4

669

.23

68.5

867

.81

90.7

391

.12

Virg

inia

50.0

050

.00

50.0

050

.00

50.0

065

.00

65.0

065

.00

88.0

088

.00

Was

hing

ton

50.0

050

.00

50.0

350

.00

50.0

065

.00

65.0

065

.02

88.0

088

.00

Wes

t Virg

inia

72.0

471

.09

71.3

571

.42

71.8

080

.43

79.7

679

.95

100.

0010

0.00

Wis

cons

in59

.74

59.0

658

.27

58.2

358

.51

71.8

271

.34

70.7

993

.76

93.9

6

Wyo

min

g50

.00

50.0

050

.00

50.0

050

.00

65.0

065

.00

65.0

088

.00

88.0

0

Amer

ican

Sam

oa55

.00

55.0

055

.00

55.0

055

.00

68.5

068

.50

68.5

091

.50

91.5

0

Gua

m55

.00

55.0

055

.00

55.0

055

.00

68.5

068

.50

68.5

091

.50

91.5

0

N. M

aria

na Is

land

s55

.00

55.0

055

.00

55.0

055

.00

68.5

068

.50

68.5

091

.50

91.5

0

Puer

to R

ico

55.0

055

.00

55.0

055

.00

55.0

068

.50

68.5

068

.50

91.5

091

.50

Virg

in Is

land

s55

.00

55.0

055

.00

55.0

055

.00

68.5

068

.50

68.5

091

.50

91.5

0

EXH

IBIT

6.

(con

tinue

d)



MAC

Stat

sSe

ctio

n 1

EXH

IBIT

6.

(con

tinue

d)

Not

es: F

MAP

is fe

dera

l med

ical

ass

ista

nce

perc

enta

ge. E

-FM

AP is

enh

ance

d FM

AP. F

Y is

fisc

al y

ear.

ACA

is P

atie

nt P

rote

ctio

n an

d Af

ford

able

Car

e Ac

t (P.

L. 1

11-1

48, a

s am

ende

d). T

he fe

dera

l gov

ernm

ent’s

sha

re o

f mos

t Med

icai

d se

rvic

e co

sts

is d

eter

min

ed b

y th

e FM

AP, w

ith s

ome

exce

ptio

ns. F

or M

edic

aid

adm

inis

trat

ive

cost

s, th

e fe

dera

l sh

are

does

not

var

y by

sta

te a

nd is

gen

eral

ly 5

0 pe

rcen

t. Th

e E-

FMAP

det

erm

ines

the

fede

ral s

hare

of b

oth

serv

ice

and

adm

inis

trat

ive

cost

s fo

r CH

IP, s

ubje

ct to

the

avai

labi

lity

of fu

nds

from

a s

tate

’s fe

dera

l allo

tmen

ts fo

r CH

IP.

FMAP

s fo

r Med

icai

d ar

e ge

nera

lly c

alcu

late

d ba

sed

on a

form

ula

that

com

pare

s ea

ch s

tate

’s p

er c

apita

inco

me

rela

tive

to U

.S. p

er c

apita

inco

me

and

prov

ides

a h

ighe

r fe

dera

l mat

ch fo

r sta

tes

with

low

er p

er c

apita

inco

mes

, sub

ject

to a

sta

tuto

ry m

inim

um (5

0 pe

rcen

t) a

nd m

axim

um (8

3 pe

rcen

t). T

he g

ener

al fo

rmul

a fo

r a g

iven

sta

te is

: FM

AP =

1 -

[sta

te p

er c

apita

inco

me

squa

red

/ U.S

. per

cap

ita in

com

e sq

uare

d ×

0.45

].

Med

icai

d ex

cept

ions

to th

is fo

rmul

a in

clud

e th

e Di

stric

t of C

olum

bia

(set

in s

tatu

te a

t 70

perc

ent)

and

the

terr

itorie

s (s

et in

sta

tute

at 5

5 pe

rcen

t). O

ther

Med

icai

d ex

cept

ions

ap

ply

to c

erta

in s

ervi

ces,

pro

vide

rs, o

r situ

atio

ns (e

.g.,

serv

ices

pro

vide

d th

roug

h an

Indi

an H

ealth

Ser

vice

faci

lity

rece

ive

an F

MAP

of 1

00 p

erce

nt).

Enha

nced

FM

APs

for C

HIP

ar

e ca

lcul

ated

by

redu

cing

the

stat

e sh

are

unde

r reg

ular

FM

APs

for M

edic

aid

by 3

0 pe

rcen

t and

add

ing

23 p

erce

ntag

e po

ints

.1

For c

erta

in n

ewly

elig

ible

indi

vidu

als

unde

r the

Med

icai

d ex

pans

ion

begi

nnin

g in

201

4, th

ere

is a

n in

crea

sed

FMAP

(100

per

cent

in 2

014

thro

ugh

2016

, pha

sing

dow

n to

90

per

cent

in 2

020

and

subs

eque

nt y

ears

). An

incr

ease

d FM

AP is

als

o av

aila

ble

for c

erta

in s

tate

s th

at p

revi

ousl

y ex

pand

ed e

ligib

ility

to lo

w-in

com

e pa

rent

s an

d no

n-pr

egna

nt

adul

ts w

ithou

t chi

ldre

n pr

ior t

o en

actm

ent o

f the

ACA

.2

Und

er th

e AC

A, b

egin

ning

on

Oct

ober

1, 2

015,

and

end

ing

on S

epte

mbe

r 30,

201

9, th

e en

hanc

ed F

MAP

will

be

incr

ease

d by

23

perc

enta

ge p

oint

s, n

ot to

exc

eed

100

perc

ent,

fo

r all

stat

es.

3 Lo

uisi

ana

rece

ived

a d

isas

ter-r

ecov

ery

stat

e FM

AP a

djus

tmen

t for

the

four

th q

uart

er o

f FY

2011

, and

FYs

201

2–20

14.

Sour

ce: U

.S. D

epar

tmen

t of H

ealth

and

Hum

an S

ervi

ces,

Fed

eral

Reg

iste

r not

ices

for v

ario

us y

ears

.

SECTION 2

Trends

December 201622

Section 2: Trends

Section 2: Trends

Key Points• Medicaid spending and enrollment are affected by federal and state policy choices as

well as economic factors (Exhibits 8–10). For example, spending and enrollment both grew around the recessions of 2001 and 2007–2009, and slowed as economic conditions subsequently improved. More recently, Medicaid spending in fiscal year (FY) 2014 and beyond grew in part due to expanded eligibility under the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended).

• Medicaid enrollment trends vary by eligibility group. Children (excluding those eligible on the basis of disability) experienced the largest enrollment increase in absolute numbers between FYs 1975 and 2013, from 9.6 million to 30.8 million. Individuals qualifying for Medicaid on the basis of disability—the smallest eligibility group in FY 1975 in terms of absolute numbers—had the largest percentage increase in enrollment, quadrupling over this nearly 40-year period (Exhibit 7).

• Medicaid’s share of both state-funded budgets (excluding federal funds) and total state budgets (including federal funds) has grown substantially since state fiscal year (SFY) 1987. In SFYs 2009 and 2010, the program’s share of state-funded budgets remained stable or dropped, while its share of total state budgets continued to increase due to a temporary increase in federal matching rates, which effectively allowed states to maintain their programs with a smaller state contribution (Exhibit 13). In SFY 2014, Medicaid’s share of total state budgets increased, but its share of state-funded budgets remained unchanged due to 100 percent federal funding available for non-disabled adults, newly eligible for Medicaid under the ACA adult group.

• After experiencing high rates of growth in 2014 and 2015, Medicaid and CHIP enrollment grew less than 1 percent in 2016. Enrollment in July 2014 was 17.2 percent higher than average monthly enrollment during July to September 2013, a baseline period that precedes the start of open enrollment for exchange plans and state expansions of Medicaid for adults under the ACA. Between July 2014 and July 2015, enrollment grew by an additional 8.2 percent. However, enrollment growth from 2015 to 2016 grew by 0.2 percent as enrollment began to level off after the initial increase in expansion states. Because not all states have chosen to expand Medicaid, state-specific growth rates varied substantially (Exhibit 11).

• Medicaid and the State Children's Health Insurance Program (CHIP) are projected to maintain a steady share of national health expenditures at about 17.7 percent through 2025, and Medicare’s share is projected to increase from 20.2 percent to 22.8 percent (Exhibit 12).


Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Fisc

al y

ear

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Unk

now

n19

7522

,007

9,59

84,

529

2,46

43,

615

1,80

119

7622

,815

9,92

44,

773

2,66

93,

612

1,83

719

7722

,832

9,65

14,

785

2,80

23,

636

1,95

819

7821

,965

9,37

64,

643

2,71

83,

376

1,85

219

7921

,520

9,10

64,

570

2,75

33,

364

1,72

719

8021

,605

9,33

34,

877

2,91

13,

440

1,04

419

8121

,980

9,58

15,

187

3,07

93,

367

766

1982

21,6

039,

563

5,35

62,

891

3,24

055

319

8321

,554

9,53

55,

592

2,92

13,

372

134

1984

21,6

079,

684

5,60

02,

913

3,23

817

219

8521

,814

9,75

75,

518

3,01

23,

061

466

1986

22,5

1510

,029

5,64

73,

182

3,14

051

719

8723

,109

10,1

685,

599

3,38

13,

224

737

1988

22,9

0710

,037

5,50

33,

487

3,15

972

119

8923

,511

10,3

185,

717

3,59

03,

132

754

1990

25,2

5511

,220

6,01

03,

718

3,20

21,

105

1991

27,9

6712

,855

6,70

34,

033

3,34

11,

035

1992

31,1

5015

,200

7,04

04,

487

3,74

967

419

9333

,432

16,2

857,

505

5,01

63,

863

763

1994

35,0

5317

,194

7,58

65,

458

4,03

578

019

9536

,282

17,1

647,

604

5,85

84,

119

1,53

719

9636

,118

16,7

397,

127

6,22

14,

285

1,74

619

9734

,872

15,7

916,

803

6,12

93,

955

2,19

519

9840

,096

18,9

697,

895

6,63

73,

964

2,63

119

9939

,748

18,2

337,

446

6,69

03,

698

3,68

220

0041

,212

18,5

288,

538

6,68

83,

640

3,81

720

0145

,164

20,1

819,

707

7,11

43,

812

4,34

920

0246

,839

21,4

8710

,847

7,18

23,

789

3,53

4

EXH

IBIT

7.

Med

icai

d Be

nefic

iarie

s (P

erso

ns S

erve

d) b

y El

igib

ility

Gro

up, F

Ys 1

975–

2013

(tho

usan

ds)

December 201624

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Fisc

al y

ear

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Unk

now

n20

0350

,716

23,7

4211

,530

7,66

44,

041

3,73

920

0454

,250

25,4

1512

,325

8,12

34,

349

4,03

720

0556

,276

25,9

7912

,431

8,20

54,

395

5,26

620

0656

,264

26,3

5812

,495

8,33

44,

374

4,70

320

0755

,210

26,0

6112

,264

8,42

34,

044

4,41

820

0856

,962

26,4

7912

,739

8,68

54,

147

4,91

220

0960

,880

28,3

4414

,245

9,03

14,

195

5,06

620

1063

,730

30,0

2415

,368

9,34

14,

289

4,70

920

1165

,831

30,1

7516

,069

9,60

94,

331

5,64

620

1265

,584

30,4

6716

,483

9,83

64,

376

4,42

320

1367

,497

30,8

1016

,898

10,1

214,

499

5,16

9

Not

es: F

Y is

fisc

al y

ear.

Bene

ficia

ries

(enr

olle

es fo

r who

m p

aym

ents

are

mad

e) a

re s

how

n he

re b

ecau

se th

ey p

rovi

de th

e on

ly h

isto

rical

tim

e se

ries

data

dire

ctly

ava

ilabl

e pr

ior

to F

Y 19

90. M

ost c

urre

nt a

naly

ses

of in

divi

dual

s in

Med

icai

d re

flect

enr

olle

es. F

or a

dditi

onal

dis

cuss

ion,

see

htt

ps://

ww

w.m

acpa

c.go

v/m

acst

ats/

data

-sou

rces

-and

-met

hods

/.

The

incr

ease

in F

Y 19

98 re

flect

s a

chan

ge in

how

Med

icai

d be

nefic

iarie

s ar

e co

unte

d: b

egin

ning

in F

Y 19

98, a

Med

icai

d-el

igib

le p

erso

n w

ho re

ceiv

ed o

nly

cove

rage

for m

anag

ed

care

ben

efits

was

incl

uded

in th

is s

erie

s as

a b

enef

icia

ry. E

xclu

des

Med

icai

d-ex

pans

ion

CHIP

and

the

terr

itorie

s. C

hild

ren

and

adul

ts w

ho q

ualif

y fo

r Med

icai

d on

the

basi

s of

a

disa

bilit

y ar

e in

clud

ed in

the

disa

bled

cat

egor

y. In

add

ition

, alth

ough

dis

abili

ty is

not

a b

asis

of e

ligib

ility

for a

ged

indi

vidu

als,

sta

tes

may

repo

rt s

ome

enro

llees

age

65

and

olde

r in

the

disa

bled

cat

egor

y. U

nlik

e th

e m

ajor

ity o

f MAC

Stat

s, th

is e

xhib

it do

es n

ot re

code

indi

vidu

als

age

65 a

nd o

lder

who

are

repo

rted

as

disa

bled

, due

to la

ck o

f det

ail i

n th

e hi

stor

ical

dat

a. G

ener

ally

, ind

ivid

uals

who

se e

ligib

ility

gro

up is

unk

now

n ar

e pe

rson

s w

ho w

ere

enro

lled

in th

e pr

ior y

ear b

ut h

ad a

Med

icai

d cl

aim

pai

d in

the

curr

ent y

ear.

For M

ACPA

C’s

anal

ysis

, Med

icai

d en

rolle

es w

ere

assi

gned

a u

niqu

e na

tiona

l ide

ntifi

catio

n nu

mbe

r usi

ng a

n al

gorit

hm th

at in

corp

orat

es s

tate

-spe

cific

ID n

umbe

rs a

nd

bene

ficia

ry c

hara

cter

istic

s su

ch a

s da

te o

f birt

h an

d ge

nder

. The

nat

iona

l enr

ollm

ent c

ount

s sh

own

here

are

und

uplic

ated

usi

ng th

is n

atio

nal I

D.

Sour

ce: F

or F

Ys 1

999–

2013

: MAC

PAC,

201

6, a

naly

sis

of M

edic

aid

Stat

istic

al In

form

atio

n Sy

stem

(MSI

S) d

ata

for F

Ys 1

975–

1998

: Cen

ters

for M

edic

are

& M

edic

aid

Serv

ices

, Med

icar

e &

Med

icai

d st

atis

tical

sup

plem

ent,

2010

edi

tion,

Tab

le 1

3.4,

htt

ps:/

/ww

w.c

ms.

gov/

Rese

arch

-Sta

tistic

s-Da

ta-a

nd-S

yste

ms/

Stat

istic

s-Tr

ends

-and

-Rep

orts

/M

edic

areM

edic

aidS

tatS

upp/

Dow

nloa

ds/2

010_

Sect

ion1

3.pd

f#Ta

ble%

2013

.4.

EXH

IBIT

7.

(con

tinue

d)


https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/Downloads/2010_Section13.pdf#Table%2013.4

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/Downloads/2010_Section13.pdf#Table%2013.4


Section 2: Trends

MAC

Stat

sSe

ctio

n 2

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

$500

$550

$600

$650

$700

Fiscal year

Spen

ding

(bill

ions

)

FYE

enro

llmen

t (m

illio

ns)

Spending

FYE enrollment

1967

1969

1971

1973

1975

1976

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013

2015

Notes: FY is fiscal year. FYE is full-year equivalent, which also may be referred to as average monthly enrollment. All numbers exclude CHIP-financed coverage. Data prior to FY 1977 have been adjusted to the current federal fiscal year basis (October 1 to September 30). The amounts shown in this exhibit may differ from those published elsewhere due to slight differences in the timing of data and the treatment of certain adjustments. The amounts may also differ from prior versions of MACStats due to changes in methodology by the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary (OACT). See https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2015.pdf for more information. Spending consists of federal and state Medicaid expenditures for benefits and administration, excluding the Vaccines for Children program. Enrollment counts are full-year equivalents and, for fiscal years prior to FY 1990, have been estimated from counts of persons served. See https://www.macpac.gov/macstats/data-sources-and-methods/ for a discussion of how enrollees are counted. Enrollment data for FYs 2012–2015 are projected; those for FYs 1999–2015 include estimates for Puerto Rico and the Virgin Islands.

Source: OACT, CMS, 2016, data compilation provided to MACPAC staff August 15.

EXHIBIT 8. Medicaid Enrollment and Spending, FYs 1966–2015

https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2015.pdf




December 201626

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

-5%

0%

5%

10%

15%

20%

25%

30%

Spending

FYE enrollment

Fiscal year

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013

2015

Notes: FY is fiscal year. FYE is full-year equivalent, which also may be referred to as average monthly enrollment. All numbers exclude CHIP-financed coverage. Data prior to FY 1977 have been adjusted to the current federal fiscal year basis (October 1 to September 30). The amounts shown in this exhibit may differ from those published elsewhere due to slight differences in the timing of data and the treatment of certain adjustments. The amounts may also differ from prior versions of MACStats due to changes in methodology by the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary (OACT). See https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2015.pdf for more information. Spending consists of federal and state Medicaid expenditures for benefits and administration, excluding the Vaccines for Children program. Enrollment counts are full-year equivalents and, for fiscal years prior to FY 1990, have been estimated from counts of persons served. See https://www.macpac.gov/macstats/data-sources-and-methods/ for a discussion of how enrollees are counted. Enrollment data for FYs 2012–2015 are projected; those for FYs 1999–2015 include estimates for Puerto Rico and the Virgin Islands.

Source: OACT, CMS, 2016, data compilation provided to MACPAC staff August 15.

EXHIBIT 9. Annual Growth in Medicaid Enrollment and Spending, FYs 1975–2015






Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Fisc

al y

ear

Spen

ding

(b

illio

ns)

FYE

enro

llmen

t (m

illio

ns)

Spen

ding

per

FY

E en

rolle

e

Annu

al g

row

th

Spen

ding

Full-

year

equ

ival

ent

enro

llmen

tSp

endi

ng p

er

FYE

enro

llee

1966

$14.

0$2

22–

––

1967

27.

432

116

5.4%

83.3

%44

.8%

1968

410

.634

352

.442

.96.

719

694

11.5

381

21.1

8.9

11.3

1970

514

.036

515

.921

.3-4

.419

717

16.3

401

28.5

16.9

9.9

1972

816

.548

422

.41.

320

.919

739

17.6

534

17.0

6.2

10.2

1974

1119

.056

715

.18.

36.

319

7513

20.2

651

21.8

6.1

14.8

1976

1520

.772

013

.62.

710

.619

7717

20.7

830

15.3

0.1

15.3

1978

1920

.095

911

.2-3

.815

.619

7922

19.6

1,11

514

.0-2

.016

.319

8025

19.6

1,28

515

.70.

415

.219

8130

20.0

1,49

318

.21.

716

.219

8232

19.6

1,62

06.

7-1

.78.

519

8335

19.6

1,77

99.

6-0

.29.

919

8437

19.8

1,89

07.

41.

26.

219

8541

19.8

2,08

110

.20.

010

.219

8644

20.5

2,17

27.

73.

24.

419

8750

21.0

2,38

212

.52.

69.

619

8854

20.8

2,60

98.

6-0

.99.

519

8961

21.4

2,85

012

.12.

69.

319

9072

22.9

3,14

718

.67.

410

.419

9194

26.3

3,58

730

.614

.614

.019

9212

028

.94,

161

27.4

9.8

16.0

EXH

IBIT

10.

Med

icai

d En

rollm

ent a

nd T

otal

Spe

ndin

g Le

vels

and

Ann

ual G

row

th, F

Ys 1

966–

2015

December 201628

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

EXH

IBIT

10.

(co

ntin

ued)

Fisc

al y

ear

Spen

ding

(b

illio

ns)

FYE

enro

llmen

t (m

illio

ns)

Spen

ding

per

FY

E en

rolle

e

Annu

al g

row

th

Spen

ding

Full-

year

equ

ival

ent

enro

llmen

tSp

endi

ng p

er

FYE

enro

llee

1993

$131

31.2

$4,1

828.

7%8.

1%0.

5%19

9414

432

.44,

434

10.1

3.9

6.0

1995

159

33.4

4,77

910

.92.

97.

819

9616

033

.24,

804

0.1

-0.4

0.5

1997

166

33.0

5,02

53.

9-0

.64.

619

9817

732

.55,

462

6.8

-1.7

8.7

1999

190

32.1

5,92

47.

1-1

.28.

520

0020

634

.55,

972

8.6

7.7

0.8

2001

229

36.9

6,21

311

.06.

74.

020

0225

840

.56,

380

12.8

9.8

2.7

2003

276

43.5

6,35

26.

97.

4-0

.420

0429

645

.26,

560

7.3

3.9

3.3

2005

316

46.3

6,81

96.

62.

63.

920

0631

546

.76,

751

-0.3

0.7

-1.0

2007

332

46.4

7,15

75.

4-0

.56.

020

0835

247

.77,

383

5.9

2.7

3.2

2009

379

50.9

7,44

37.

66.

70.

820

1040

254

.57,

361

6.1

7.2

-1.1

2011

427

55.8

7,66

06.

42.

34.

120

1243

157

.37,

525

0.9

2.7

-1.8

2013

456

58.6

7,77

35.

72.

33.

320

1449

464

.07,

724

8.5

9.2

-0.6

2015

554

68.9

8,04

212

.17.

74.

1

Not

es: F

Y is

fisc

al y

ear.

FYE

is fu

ll-ye

ar e

quiv

alen

t, w

hich

may

als

o be

refe

rred

to a

s av

erag

e m

onth

ly e

nrol

lmen

t. Al

l num

bers

exc

lude

CH

IP-fi

nanc

ed c

over

age.

Dat

a pr

ior t

o FY

197

7 ha

ve b

een

adju

sted

to th

e cu

rren

t fed

eral

fisc

al y

ear b

asis

(Oct

ober

1 to

Sep

tem

ber 3

0). T

he a

mou

nts

show

n in

this

exh

ibit

may

diff

er fr

om th

ose

publ

ishe

d el

sew

here

du

e to

slig

ht d

iffer

ence

s in

the

timin

g of

dat

a an

d th

e tr

eatm

ent o

f cer

tain

adj

ustm

ents

. The

am

ount

s m

ay a

lso

diff

er fr

om p

rior v

ersi

ons

of M

ACSt

ats

due

to c

hang

es in

m

etho

dolo

gy b

y th

e Ce

nter

s fo

r Med

icar

e &

Med

icai

d Se

rvic

es (C

MS)

Off

ice

of th

e Ac

tuar

y (O

ACT)

. See

htt

ps:/

/ww

w.c

ms.

gov/

Rese

arch

-Sta

tistic

s-Da

ta-a

nd-S

yste

ms/

Rese

arch

/Act

uaria

lStu

dies

/Dow

nloa

ds/M

edic

aidR

epor

t201

5.pd

f for

mor

e in

form

atio

n. S

pend

ing

cons

ists

of f

eder

al a

nd s

tate

Med

icai

d ex

pend

iture

s fo

r ben

efits

and

ad

min

istr

atio

n, e

xclu

ding

the

Vacc

ines

for C

hild

ren

prog

ram

. Enr

ollm

ent c

ount

s ar

e fu

ll-ye

ar e

quiv

alen

ts a

nd, f

or fi

scal

yea

rs p

rior t

o FY

199

0, h

ave

been

est

imat

ed fr

om c

ount

s of

per

sons

ser

ved.

See

htt

ps:/

/ww

w.m

acpa

c.go

v/m

acst

ats/

data

-sou

rces

-and

-met

hods

/ for

a d

iscu

ssio

n of

how

enr

olle

es a

re c

ount

ed. E

nrol

lmen

t dat

a fo

r FYs

201

2–20

15 a

re

proj

ecte

d; th

ose

for F

Ys 1

999–

2015

incl

ude

estim

ates

for P

uert

o Ri

co a

nd th

e Vi

rgin

Isla

nds.

Sour

ce: O

ACT,

CMS,

201

6, d

ata

com

pila

tion

prov

ided

to M

ACPA

C st

aff A

ugus

t 15.





Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Stat

e

Num

ber o

f ind

ivid

uals

enr

olle

dAn

nual

and

cum

ulat

ive

grow

th

July

–Se

ptem

ber

2013

ave

rage

July

201

4 J

uly

2015

Jul

y 20

16

July

–Se

ptem

ber

2013

ave

rage

to

Jul

y 20

14Ju

ly 2

014

to

Jul

y 20

15Ju

ly 2

015

to

Jul

y 20

16

July

–Se

ptem

ber

2013

ave

rage

to

Jul

y 20

16To

tal

56,

392,

477 1

6

7,14

7,44

6 7

2,67

2,69

4 72

,810

,267

17.2

%2

8.2%

0.2%

27.3

%2

Alab

ama

799

,176

3

868

,174

8

91,9

12

885

,046

8.

62.

7-0

.810

.7Al

aska

122

,334

1

25,2

54

127

,401

1

58,4

53

2.4

1.7

24.4

29.5

Ariz

ona

1,2

01,7

70

1,4

63,7

23

1,5

95,6

17

1,6

99,6

35

21.8

9.0

6.5

41.4

Arka

nsas

556

,851

7

84,3

35

823

,741

8

89,0

82

40.9

5.0

7.9

59.7

Calif

orni

a4 7

,755

,381

1

0,90

0,00

0 5, 6

1

2,64

8,63

7 1

1,90

2,44

5 40

.516

.0-5

.953

.5Co

lora

do 7

83,4

20

1,1

06,1

34

1,2

74,8

49

1,3

53,7

57

41.2

15.3

6.2

72.8

Conn

ectic

ut–

749

,159

7

54,0

54

753

,413

–

0.7

-0.1

–De

law

are

223

,324

2

33,7

06

241

,749

2

36,2

48

4.6

3.4

-2.3

5.8

Dist

rict o

f Col

umbi

a7 2

35,7

86

250

,446

2

55,6

60

258

,918

6.

22.

11.

39.

8Fl

orid

a 3

,104

,996

3

,343

,988

8

3,5

58,0

92 8

3

,620

,085

8

7.7

6.4

1.7

16.6

Geo

rgia

1,5

35,0

90

1,7

39,1

41

1,7

81,5

37

1,7

44,0

95

13.3

2.4

-2.1

13.6

Haw

aii

288

,357

3

18,8

38

332

,027

3

40,8

29

10.6

4.1

2.7

18.2

Idah

o 2

38,1

50

283

,129

2

78,2

68

289

,858

18

.9-1

.74.

221

.7Ill

inoi

s 2

,626

,943

6

3,0

21,1

95

3,1

62,5

22

3,0

88,0

44

15.0

4.7

-2.4

17.6

Indi

ana9

1,1

20,6

74

1,2

11,1

25

1,3

89,5

19

1,4

73,4

14

8.1

14.7

6.0

31.5

Iow

a 4

93,5

15

565

,593

5

99,3

05

613

,386

14

.66.

02.

324

.3Ka

nsas

378

,160

4

01,9

80

398

,007

4

22,5

49

6.3

-1.0

6.2

11.7

Kent

ucky

606

,805

1

,048

,285

1

,119

,198

1

,223

,869

72

.86.

89.

410

1.7

Loui

sian

a 1

,019

,787

1

,037

,136

1

,075

,652

1

,308

,428

1.

73.

721

.628

.3M

aine

–

296

,206

2

80,2

41

270

,827

–

-5

.4-3

.4 –

M

aryl

and

856

,297

1

,151

,270

1

,179

,937

1

,226

,309

34

.42.

53.

943

.2M

assa

chus

etts

1,2

96,3

59

1,4

76,1

84 1

0 1

,649

,423

10

1,6

60,5

18

13.9

11.7

0.7

28.1

Mic

higa

n 1

,912

,009

2

,218

,845

2

,352

,127

2

,273

,394

16

.06.

0-3

.318

.9M

inne

sota

873

,040

11

1,0

68,3

05

1,0

28,1

61

1,0

26,0

23

22.4

-3.8

-0.2

17.5

Mis

siss

ippi

637

,229

6

93,4

25

709

,510

6

87,2

19

8.8

2.3

-3.1

7.8

Mis

sour

i 8

46,0

84

812

,785

9

32,0

26

961

,073

-3

.914

.73.

113

.6M

onta

na 1

48,9

74

163

,551

1

76,7

14

239

,250

9.

88.

035

.460

.6

EXH

IBIT

11.

Ful

l-Ben

efit

Med

icai

d an

d CH

IP E

nrol

lmen

t, Se

lect

ed M

onth

s, 2

013–

2016

December 201630

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Stat

e

Num

ber o

f ind

ivid

uals

enr

olle

dAn

nual

and

cum

ulat

ive

grow

th

July

–Se

ptem

ber

2013

ave

rage

July

201

4 J

uly

2015

Jul

y 20

16

July

–Se

ptem

ber

2013

ave

rage

to

Jul

y 20

14Ju

ly 2

014

to

Jul

y 20

15Ju

ly 2

015

to

Jul

y 20

16

July

–Se

ptem

ber

2013

ave

rage

to

Jul

y 20

16N

ebra

ska

244

,600

2

38,6

09

237

,243

2

34,8

36

-2.4

%-0

.6%

-1.0

%-4

.0%

Nev

ada

332

,560

5

27,9

29 9

5

66,0

17

609

,435

58

.77.

27.

783

.3N

ew H

amps

hire

127

,082

1

37,9

34

184

,266

1

85,7

35

8.5

33.6

0.8

46.2

New

Jer

sey

1,2

83,8

51

1,5

62,4

83

1,7

89,2

64

1,7

49,4

00

21.7

14.5

-2.2

36.3

New

Mex

ico

457

,678

7

05,1

28

717

,189

7

61,0

33

54.1

1.7

6.1

66.3

New

Yor

k 5

,678

,417

6

,143

,909

6

6,5

12,1

37 6

6

,372

,384

6

8.2

6.0

-2.1

12.2

Nor

th C

arol

ina

1,5

95,9

52

1,7

37,1

17

1,9

82,4

96

1,9

84,5

99

8.8

14.1

0.1

24.4

Nor

th D

akot

a 6

9,98

0 12

79,

076

88,

719

89,

460

13.0

12.2

0.8

27.8

Ohi

o 2

,341

,481

2

,708

,484

2

,988

,934

2

,941

,236

15

.710

.4-1

.625

.6O

klah

oma

790

,051

8

03,5

77

821

,867

7

87,3

31

1.7

2.3

-4.2

-0.3

Ore

gon

626

,356

13

997

,762

1

,055

,685

1

,019

,340

59

.35.

8-3

.462

.7Pe

nnsy

lvan

ia 2

,386

,046

2

,417

,392

2

,665

,455

2

,834

,129

1.

310

.36.

318

.8Rh

ode

Isla

nd 1

90,8

33

259

,183

14

277

,232

2

83,8

38

35.8

7.0

2.4

48.7

Sout

h Ca

rolin

a 8

89,7

44

868

,487

9

99,4

38

987

,147

-2

.415

.1-1

.211

.0So

uth

Dako

ta 1

15,5

01

116

,174

1

18,7

15

119

,252

0.

62.

20.

53.

3Te

nnes

see

1,2

44,5

16

1,3

52,2

43

1,5

12,6

58

1,6

28,1

96

8.7

11.9

7.6

30.8

Texa

s 4

,441

,605

4

,575

,968

9

4,6

78,3

94

4,7

08,0

51

3.0

2.2

0.6

6.0

Uta

h9 2

94,0

29

301

,311

3

10,2

73

306

,857

2.

53.

0-1

.14.

4Ve

rmon

t 1

61,0

81

208

,699

1

85,9

91

178

,142

29

.6-1

0.9

-4.2

10.6

Virg

inia

935

,434

9

37,4

93

980

,591

9

66,9

32

0.2

4.6

-1.4

3.4

Was

hing

ton

1,1

17,5

76

1,5

42,7

89

1,7

28,8

34

1,7

75,8

82

38.0

12.1

2.7

58.9

Wes

t Virg

inia

354

,544

5

19,6

72

542

,077

5

72,1

07

46.6

4.3

5.5

61.4

Wis

cons

in 9

85,5

31 1

5 1

,006

,257

15

1,0

48,8

17

1,0

45,1

60

2.1

4.2

-0.3

6.1

Wyo

min

g 6

7,51

8 6

7,85

8 6

4,51

6 6

3,61

8 0.

5-4

.9-1

.4-5

.8

Not

es: E

nrol

lmen

t exc

lude

s in

divi

dual

s w

ith li

mite

d be

nefit

s, s

uch

as th

ose

who

onl

y re

ceiv

e M

edic

aid

cove

rage

of M

edic

are

prem

ium

s an

d co

st s

harin

g, fa

mily

pla

nnin

g se

rvic

es, o

r em

erge

ncy

cove

rage

due

to n

on-c

itize

n st

atus

(sta

te-s

peci

fic e

xcep

tions

are

not

ed b

elow

). Th

e Ju

ly–

Sept

embe

r 201

3 pe

riod

show

n he

re s

erve

s as

a p

re-A

ffor

dabl

e Ca

re A

ct b

asel

ine,

repr

esen

ting

the

num

ber o

f peo

ple

cove

red

by M

edic

aid

and

CHIP

prio

r to

the

star

t of o

pen

enro

llmen

t for

exc

hang

e pl

ans

in O

ctob

er 2

013

and

the

stat

e ex

pans

ions

of M

edic

aid

for a

dults

that

beg

an in

Jan

uary

201

4 an

d be

yond

. Som

e da

ta a

re p

relim

inar

y or

est

imat

ed, a

nd a

ll da

ta a

re s

ubje

ct to

cha

nge

as s

tate

s m

ay re

vise

th

eir s

ubm

issi

ons

at a

ny ti

me.

See

sou

rce

docu

men

ts b

elow

for f

ull d

etai

ls.

EXH

IBIT

11.

(co

ntin

ued)


Section 2: Trends

MAC

Stat

sSe

ctio

n 2

– D

ash

indi

cate

s th

at s

tate

did

not

repo

rt d

ata.

1 Ex

clud

es tw

o st

ates

not

repo

rtin

g da

ta.

2 Pe

rcen

tage

cal

cula

ted

base

d on

sta

tes

repo

rtin

g da

ta fo

r bot

h pe

riods

.

3 Da

ta a

re fo

r Sep

tem

ber 2

013

only

.4

Incl

udes

indi

vidu

als

tran

sfer

red

from

the

Low

-Inco

me

Hea

lth P

rogr

am S

ectio

n 11

15 d

emon

stra

tion.

5 In

clud

es a

pplic

ants

like

ly e

ligib

le fo

r Med

icai

d or

CH

IP, b

ut w

hose

app

licat

ions

wer

e st

ill p

endi

ng v

erifi

catio

n.6

Incl

udes

retr

oact

ive

enro

llmen

t.7

Incl

udes

lim

ited-

bene

fit in

divi

dual

s w

ho a

re d

ually

elig

ible

for M

edic

are

and

Med

icai

d, a

nd in

divi

dual

s en

rolle

d in

the

loca

lly fu

nded

DC

Hea

lth A

llian

ce.

8 Ex

clud

es S

uppl

emen

tal S

ecur

ity In

com

e be

nefic

iarie

s en

rolle

d in

Med

icai

d.9

Incl

udes

lim

ited-

bene

fit in

divi

dual

s w

ho a

re d

ually

elig

ible

for M

edic

are

and

Med

icai

d.10

Ex

clud

es in

divi

dual

s re

ceiv

ing

tem

pora

ry tr

ansi

tiona

l cov

erag

e.11

M

ay in

clud

e du

plic

ates

.12

Da

ta a

re fo

r Jul

y 20

13 o

nly.

13 In

clud

es e

mer

genc

y M

edic

aid

popu

latio

n.14

In

clud

es o

nly

enro

llmen

ts b

ased

on

dete

rmin

atio

ns th

roug

h ne

w M

odifi

ed A

djus

ted

Gro

ss In

com

e (M

AGI)

syst

em.

15 Ex

clud

es re

troa

ctiv

e en

rollm

ent.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

Cen

ters

for M

edic

are

& M

edic

aid

Serv

ices

(CM

S), 2

016,

Med

icai

d &

CHIP

Jun

e an

d Ju

ly 2

016

appl

icat

ion,

elig

ibili

ty, a

nd e

nrol

lmen

t dat

a, h

ttps

://

ww

w.m

edic

aid.

gov/

med

icai

d/pr

ogra

m-in

form

atio

n/do

wnl

oads

/jun

e-an

d-ju

ly-2

016-

enro

llmen

t-dat

a.zi

p; C

MS,

201

5, M

edic

aid

& CH

IP A

ugus

t and

Sep

tem

ber 2

015

appl

icat

ion,

el

igib

ility

, and

enr

ollm

ent d

ata,

htt

ps:/

/ww

w.m

edic

aid.

gov/

med

icai

d/pr

ogra

m-in

form

atio

n/do

wnl

oads

/aug

ust-a

nd-s

epte

mbe

r-201

5-en

rollm

ent-d

ata.

zip;

and

CM

S, 2

014,

Med

icai

d &

CHIP

Aug

ust a

nd S

epte

mbe

r 201

4 ap

plic

atio

n, e

ligib

ility

, and

enr

ollm

ent d

ata,

htt

ps:/

/ww

w.m

edic

aid.

gov/

med

icai

d/pr

ogra

m-in

form

atio

n/do

wnl

oads

/aug

ust-a

nd-s

epte

mbe

r-20

14-e

nrol

lmen

t-dat

a.zi

p.

EXH

IBIT

11.

(co

ntin

ued)

https://www.medicaid.gov/medicaid/program-information/downloads/june-and-july-2016-enrollment-data.zip

https://www.medicaid.gov/medicaid/program-information/downloads/june-and-july-2016-enrollment-data.zip

https://www.medicaid.gov/medicaid/program-information/downloads/august-and-september-2015-enrollment-data.zip



December 201632

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Cale

ndar

ye

ar

Paye

r am

ount

(bill

ions

) and

sha

re o

f tot

al

Tota

l (b

illio

ns)

Med

icai

d

and

CHIP

Med

icar

ePr

ivat

e in

sura

nce

Oth

er h

ealth

in

sura

nce1

Oth

er th

ird

part

y pa

yers

2O

ut o

f poc

ket

His

toric

al

1970

$75

$57.

1%$8

10.3

%$1

520

.8%

$34.

4%$1

823

.9%

$25

33.5

%

1975

133

1310

.116

12.3

3122

.96

4.5

3022

.337

28.0

1980

255

2610

.237

14.6

6927

.110

3.8

5521

.558

22.8

1985

443

419.

272

16.2

131

29.6

153.

488

19.9

9621

.6

1990

721

7410

.211

015

.323

432

.421

3.0

144

20.0

138

19.1

1995

1,02

214

514

.218

418

.032

531

.827

2.6

195

19.1

145

14.2

2000

1,37

020

314

.822

516

.445

833

.533

2.4

251

18.3

199

14.5

2005

2,02

531

715

.634

016

.870

234

.756

2.8

346

17.1

264

13.0

2010

2,59

640

915

.752

120

.186

333

.384

3.2

420

16.2

299

11.5

2011

2,69

741

815

.554

620

.390

333

.588

3.3

432

16.0

310

11.5

2012

2,79

943

515

.556

920

.393

433

.490

3.2

453

16.2

319

11.4

2013

2,88

046

016

.058

620

.494

933

.092

3.2

467

16.2

325

11.3

2014

3,03

150

916

.861

920

.499

132

.798

3.2

485

16.0

330

10.9

Proj

ecte

d

2015

$3,1

97$5

6317

.6%

$647

20.2

%$1

,042

32.6

%$1

013.

2%$5

0515

.8%

$338

10.6

%

2016

3,35

159

317

.768

120

.31,

093

32.6

106

3.2

527

15.7

350

10.4

2017

3,52

262

217

.772

120

.51,

149

32.6

112

3.2

552

15.7

365

10.4

2018

3,73

165

917

.777

020

.61,

217

32.6

119

3.2

583

15.6

383

10.3

2019

3,95

970

017

.782

820

.91,

286

32.5

126

3.2

616

15.6

403

10.2

2020

4,19

874

217

.789

321

.31,

350

32.2

134

3.2

651

15.5

427

10.2

2021

4,45

778

717

.796

221

.61,

425

32.0

143

3.2

689

15.5

451

10.1

EXH

IBIT

12.

His

toric

al a

nd P

roje

cted

Nat

iona

l Hea

lth E

xpen

ditu

res

by P

ayer

for S

elec

ted

Year

s, F

Ys 1

970–

2025


Section 2: Trends

MAC

Stat

sSe

ctio

n 2

Cale

ndar

ye

ar

Paye

r am

ount

(bill

ions

) and

sha

re o

f tot

al

Tota

l (b

illio

ns)

Med

icai

d

and

CHIP

Med

icar

ePr

ivat

e in

sura

nce

Oth

er h

ealth

in

sura

nce1

Oth

er th

ird

part

y pa

yers

2O

ut o

f poc

ket

2022

$4,7

33$8

3517

.6%

$1,0

3621

.9%

$1,5

0531

.8%

$151

3.2%

$729

15.4

%$4

7610

.1%

2023

5,02

288

517

.61,

117

22.2

1,58

731

.616

03.

277

115

.350

210

.0

2024

5,32

294

017

.71,

200

22.5

1,67

131

.416

93.

281

415

.352

89.

9

2025

5,63

199

917

.71,

282

22.8

1,75

631

.217

83.

285

915

.355

69.

9

Not

es: C

ompo

nent

s m

ay n

ot s

um to

tota

l due

to ro

undi

ng. T

he la

test

pro

ject

ions

beg

in a

fter

the

late

st h

isto

rical

yea

r (20

14) a

nd g

o th

roug

h 20

25.

1 U

.S. D

epar

tmen

t of D

efen

se a

nd U

.S. D

epar

tmen

t of V

eter

ans’

Aff

airs

.2

Incl

udes

all

othe

r pub

lic a

nd p

rivat

e pr

ogra

ms

and

expe

nditu

res

exce

pt fo

r out

-of-p

ocke

t am

ount

s.

Sour

ces:

For

his

toric

al d

ata:

MAC

PAC,

201

6, a

naly

sis

of O

ffic

e of

the

Actu

ary

(OAC

T), C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es, 2

015,

Nat

iona

l hea

lth e

xpen

ditu

res

by ty

pe o

f se

rvic

e an

d so

urce

of f

unds

: Cal

enda

r yea

rs 1

960–

2014

, htt

ps://

ww

w.c

ms.

gov/

Rese

arch

-Sta

tistic

s-Da

ta-a

nd-S

yste

ms/

Stat

istic

s-Tr

ends

-and

-Rep

orts

/Nat

iona

lHea

lthEx

pend

Data

/Do

wnl

oads

/NH

E201

4.zi

p. F

or p

roje

cted

dat

a: M

ACPA

C, 2

016,

ana

lysi

s of

OAC

T, 20

16, N

atio

nal h

ealth

exp

endi

ture

(NH

E) a

mou

nts

by ty

pe o

f exp

endi

ture

and

sou

rce

of fu

nds:

Ca

lend

ar y

ears

196

0–20

25 in

pro

ject

ions

form

at, a

s of

Jul

y 20

16, h

ttps

://w

ww

.cm

s.go

v/R

esea

rch-

Stat

istic

s-D

ata-

and-

Syst

ems/

Stat

istic

s-Tr

ends

-and

-Rep

orts

/N

atio

nalH

ealth

Expe

ndDa

ta/D

ownl

oads

/nhe

60-2

5.zi

p; a

nd a

naly

sis

of O

ACT,

2016

, Tab

le 1

7: H

ealth

insu

ranc

e en

rollm

ent a

nd e

nrol

lmen

t gro

wth

rate

s, c

alen

dar y

ears

200

9–20

25,

http

s://

ww

w.c

ms.

gov/

Rese

arch

-Sta

tistic

s-Da

ta-a

nd-S

yste

ms/

Stat

istic

s-Tr

ends

-and

-Rep

orts

/Nat

iona

lHea

lthEx

pend

Data

/Dow

nloa

ds/P

roj2

015T

able

s.zi

p.

EXH

IBIT

12.

(co

ntin

ued)



https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/nhe60-25.zip

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/nhe60-25.zip

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2015Tables.zip

December 201634

Section 2: Trends

MAC

Stat

sSe

ctio

n 2

EXHIBIT 13. Medicaid as a Share of State Budgets Including and Excluding Federal Funds, SFYs 1987–2014

0%

5%

10%

15%

20%

25%

Including state general funds only (no federal funds)

Including all federal and state funds

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

State fiscal year

Including all state funds (no federal funds)

10.8%

12.5%

17.8%

19.7% 19.9% 19.6% 19.1%

20.7%

22.1%21.4%

20.5%

22.2%

23.6%

25.6%

8.7%9.5%

12.1%

14.2%14.7% 14.8% 15.0%

15.8%

16.9%17.4%

16.0%14.8%

19.2% 19.3%

6.1%

6.9%

10.0%

11.3%11.7% 11.6% 11.0%

12.2%12.9% 13.3% 12.5%

11.6%

14.5%15.3%


Section 2: Trends

MAC

Stat

sSe

ctio

n 2

EXHIBIT 13. (continued)

State fiscal yearIncluding all federal

and state funds

Including state general funds only (no federal funds)

Including all state funds (no federal funds)

1987 10.2% 8.1% 5.7%1988 10.8 8.7 6.11989 11.3 9.0 6.31990 12.5 9.5 6.91991 14.2 10.5 7.91992 17.8 12.1 10.01993 18.8 13.3 10.91994 19.7 14.2 11.31995 19.8 14.4 11.61996 19.9 14.7 11.71997 20.0 14.6 11.51998 19.6 14.8 11.61999 19.5 14.4 11.42000 19.1 15.0 11.02001 19.7 15.2 11.72002 20.7 15.8 12.22003 22.0 17.2 13.12004 22.1 16.9 12.92005 22.3 17.1 13.52006 21.4 17.4 13.32007 20.9 16.6 12.82008 20.5 16.0 12.52009 21.9 16.3 12.32010 22.2 14.8 11.62011 23.8 16.5 13.32012 23.6 19.2 14.52013 24.3 19.3 15.22014 25.6 19.3 15.3

Notes: SFY is state fiscal year. Amounts shown here reflect the most recent information available in cases where data for a given year were published and then updated in a subsequent report.

The all federal and state funds category reflects amounts from any source. The state general funds category reflects amounts from revenues raised through income, sales, and other broad-based state taxes. The all state funds category reflects amounts from any non-federal source; these include state general funds, other state funds (amounts from revenue sources that are restricted by law for particular government functions or activities, which for Medicaid includes provider taxes and local funds), and bonds (expenditures from the sale of bonds, generally for capital projects).

Source: MACPAC, 2016, analysis of state expenditure reports from the National Association of State Budget Officers, http://www.nasbo.org/mainsite/reports-data/state-expenditure-report/state-expenditure-archives.

http://www.nasbo.org/mainsite/reports-data/state-expenditure-report/state-expenditure-archives

http://www.nasbo.org/mainsite/reports-data/state-expenditure-report/state-expenditure-archives

SECTION 3

Program Enrollment and Spending

December 201638

Section 3: Program Enrollment and Spending

Section 3: Program Enrollment and Spending

Key Points• Total Medicaid spending was $556 billion in fiscal year (FY) 2015, an 11.6 percent increase

from the prior year (Exhibit 16). Total State Children's Health Insurance Program (CHIP) spending increased by about 4.7 percent, to $13.7 billion (Exhibit 32).

• The share of Medicaid benefit spending on capitation payments for managed care reached 43.1 percent of all Medicaid benefit spending in FY 2015, up from 37.5 percent in the prior year (Exhibit 17).

• In FY 2013, individuals eligible on the basis of disability and those age 65 and older accounted for about one-quarter of Medicaid enrollees, but about two-thirds of program spending (Exhibits 14 and 21). Many of these individuals were users of long-term services and supports (LTSS). This group accounted for only 5.9 percent of Medicaid enrollees, but over 41.8 percent of all Medicaid spending (Exhibit 20).

• The majority of FY 2013 Medicaid spending for enrollees eligible on the basis of disability and enrollees age 65 and older was for LTSS, while more than half of spending for children and adults eligible on a basis other than disability was for capitation payments to managed care plans (Exhibit 18).

• Medicaid benefit spending per enrollee varies substantially across states (Exhibit 22). This variation reflects many factors, including the underlying costs of delivering health care services in specific geographic areas, the breadth of covered benefits, and the health status and other characteristics of enrollees that affect their use of health care services.

• Drug rebates reduced gross drug spending by about 45.3 percent in FY 2015 (Exhibit 27). Net drug spending (i.e., after rebates) increased by 27.3 percent from FY 2014. Over half (54.8 percent) of Medicaid gross spending for outpatient prescription drugs occurred under managed care in FY 2015 (Exhibit 25).

• Disproportionate share hospital (DSH), upper payment limit, and other types of supplemental payments accounted for almost half of fee-for-service payments to hospitals in FY 2015 (Exhibit 23).


Section 3: Program Enrollment and Spending—Medicaid Overall

MAC

Stat

sSe

ctio

n 3

Stat

eTo

tal

Basi

s of

elig

ibili

ty1

Dual

ly e

ligib

le s

tatu

s2

All d

ually

elig

ible

en

rolle

esDu

ally

elig

ible

with

fu

ll be

nefit

sDu

ally

elig

ible

with

lim

ited

bene

fits

Child

Adul

tDi

sabl

edAg

edTo

tal

Age

65+

Tota

lAg

e 65

+To

tal

Age

65+

Tota

l70

,134

32,2

6120

,468

10,5

126,

893

10,8

426,

357

7,87

04,

643

2,97

31,

714

Alab

ama3

1,21

259

724

424

212

923

612

810

454

132

74Al

aska

136

7435

1710

169

158

10

Ariz

ona

1,68

180

557

917

612

119

311

314

882

4631

Arka

nsas

696

355

109

160

7313

571

7141

6529

Calif

orni

a11

,742

4,02

75,

483

1,09

41,

138

1,42

91,

004

1,38

697

143

32Co

lora

do89

650

019

413

765

104

5974

4430

16Co

nnec

ticut

858

331

325

8112

217

411

784

4990

68De

law

are

260

102

114

2816

2916

137

169

Dist

rict o

f Col

umbi

a24

684

102

3921

2918

2817

00

Flor

ida

4,31

32,

145

943

662

563

817

529

402

279

416

250

Geo

rgia

32,

013

1,12

935

034

019

432

618

915

892

168

97H

awai

i30

012

110

843

2840

2735

235

3Id

aho

275

168

4047

2036

1620

815

8Ill

inoi

s3,

039

1,58

588

332

624

539

422

334

919

645

27In

dian

a1,

250

667

260

221

102

190

8912

361

6628

Iow

a63

428

621

290

4693

4573

3320

12Ka

nsas

442

262

6181

3975

3648

2527

12Ke

ntuc

ky92

745

013

923

899

192

9610

455

8842

Loui

sian

a1,

284

623

293

245

122

217

120

116

6310

058

Mai

ne3

371

132

104

7263

106

6261

2945

34M

aryl

and

1,13

951

538

914

985

142

8090

5052

29M

assa

chus

etts

1,52

743

651

239

318

629

915

827

413

426

24M

ichi

gan

2,29

11,

149

594

392

156

315

145

267

122

4824

Min

neso

ta1,

154

469

442

142

101

156

8114

072

1710

Mis

siss

ippi

786

400

118

175

9317

093

8649

8443

EXH

IBIT

14.

Med

icai

d En

rollm

ent b

y St

ate,

Elig

ibili

ty G

roup

, and

Dua

lly E

ligib

le S

tatu

s, F

Y 20

13 (t

hous

ands

)

December 201640


MAC

Stat

sSe

ctio

n 3

EXH

IBIT

14.

(co

ntin

ued)

Stat

eTo

tal

Basi

s of

elig

ibili

ty1

Dual

ly e

ligib

le s

tatu

s2

All d

ually

elig

ible

en

rolle

esDu

ally

elig

ible

with

fu

ll be

nefit

sDu

ally

elig

ible

with

lim

ited

bene

fits

Child

Adul

tDi

sabl

edAg

edTo

tal

Age

65+

Tota

lAg

e 65

+To

tal

Age

65+

Mis

sour

i1,

122

571

238

218

9418

989

164

7625

13M

onta

na14

281

2325

1427

1417

910

5N

ebra

ska

262

147

4743

2546

2340

205

3N

evad

a42

224

883

5535

5734

2516

3117

New

Ham

pshi

re16

692

2333

1737

1623

1014

6N

ew J

erse

y1,

190

635

195

198

162

239

150

210

131

2919

New

Mex

ico

660

354

186

7446

7846

4225

3520

New

Yor

k6,

002

2,12

02,

485

710

687

892

602

756

503

137

99N

orth

Car

olin

a2,

000

1,05

838

936

019

335

218

826

714

184

47N

orth

Dak

ota

8747

1813

1017

913

73

2O

hio

2,64

51,

133

890

417

203

383

188

249

129

134

58O

klah

oma

951

499

253

130

6812

766

103

5324

13O

rego

n76

036

721

011

469

121

6772

4149

25Pe

nnsy

lvan

ia2,

567

1,09

748

772

226

146

924

938

520

085

50Rh

ode

Isla

nd17

071

3838

2337

2031

166

3So

uth

Caro

lina

1,09

156

226

717

489

169

8914

374

2715

Sout

h Da

kota

134

7723

2113

2313

148

95

Tenn

esse

e1,

557

796

325

283

152

293

150

156

7913

771

Texa

s45,

240

3,27

472

774

249

776

448

544

929

431

519

1U

tah

389

225

9649

1939

1834

156

3Ve

rmon

t20

669

8826

2338

2229

169

6Vi

rgin

ia1,

136

591

234

192

118

204

111

133

7671

35W

ashi

ngto

n1,

421

794

286

232

109

195

106

137

7958

27W

est V

irgin

ia43

720

862

124

4489

4451

2638

18W

isco

nsin

1,25

449

244

017

914

317

887

154

7124

16W

yom

ing

8958

1312

612

67

45

3



MAC

Stat

sSe

ctio

n 3

Not

es: F

Y is

fisc

al y

ear.

Enro

llmen

t num

bers

gen

eral

ly in

clud

e in

divi

dual

s ev

er e

nrol

led

in M

edic

aid-

finan

ced

cove

rage

dur

ing

the

year

, eve

n if

for a

sin

gle

mon

th; h

owev

er, i

n th

e ev

ent i

ndiv

idua

ls w

ere

also

enr

olle

d in

CH

IP-fi

nanc

ed M

edic

aid

cove

rage

(i.e

., M

edic

aid-

expa

nsio

n CH

IP) d

urin

g th

e ye

ar, t

hey

are

excl

uded

if th

eir m

ost r

ecen

t enr

ollm

ent

mon

th w

as in

Med

icai

d-ex

pans

ion

CHIP

. Num

bers

exc

lude

indi

vidu

als

enro

lled

only

in M

edic

aid-

expa

nsio

n CH

IP d

urin

g th

e ye

ar a

nd e

nrol

lees

in th

e te

rrito

ries.

For M

ACPA

C’s

anal

ysis

, Med

icai

d en

rolle

es w

ere

assi

gned

a u

niqu

e na

tiona

l ide

ntifi

catio

n (ID

) num

ber u

sing

an

algo

rithm

that

inco

rpor

ates

sta

te-s

peci

fic ID

num

bers

and

be

nefic

iary

cha

ract

eris

tics

such

as

date

of b

irth

and

gend

er. T

he s

tate

and

nat

iona

l enr

ollm

ent c

ount

s sh

own

here

are

und

uplic

ated

usi

ng th

is n

atio

nal I

D. C

ateg

orie

s m

ay

not s

um to

tota

l for

eac

h st

ate

due

to ro

undi

ng. I

n ad

ditio

n, th

e su

m o

f the

sta

te to

tals

exc

eeds

the

natio

nal t

otal

bec

ause

indi

vidu

als

may

be

enro

lled

in m

ore

than

one

sta

te

durin

g th

e ye

ar.

0 in

dica

tes

an a

mou

nt le

ss th

an 5

00 th

at ro

unds

to z

ero.

1

Child

ren

and

adul

ts u

nder

age

65

who

qua

lify

for M

edic

aid

on th

e ba

sis

of d

isab

ility

are

incl

uded

in th

e di

sabl

ed c

ateg

ory.

Abo

ut 7

46,0

00 e

nrol

lees

age

65

and

olde

r are

id

entif

ied

in th

e da

ta a

s di

sabl

ed; g

iven

that

dis

abili

ty is

not

an

elig

ibili

ty p

athw

ay fo

r ind

ivid

uals

age

65

and

olde

r, M

ACPA

C re

code

s th

ese

enro

llees

as

aged

.2

Dual

ly e

ligib

le e

nrol

lees

are

cov

ered

by

both

Med

icai

d an

d M

edic

are;

thos

e w

ith li

mite

d be

nefit

s re

ceiv

e on

ly M

edic

aid

assi

stan

ce w

ith M

edic

are

prem

ium

s an

d co

st s

harin

g.3

Stat

e ha

d a

chan

ge in

tota

l enr

ollm

ent o

f 10

perc

ent o

r mor

e ov

er th

e pr

ior y

ear.

Thes

e da

ta m

ay re

flect

dat

a an

omal

ies

in th

e su

bmis

sion

of M

edic

aid

Stat

istic

al In

form

atio

n Sy

stem

(MSI

S) d

ata

for t

he c

urre

nt o

r prio

r yea

rs a

nd m

ay b

e up

date

d in

futu

re M

SIS

subm

issi

ons

by s

tate

s. M

SIS

data

ano

mal

ies

have

bee

n co

mpi

led

and

repo

rted

by

Mat

hem

atic

a Po

licy

Rese

arch

; the

dat

a an

omal

ies

repo

rt m

ay b

e fo

und

at: h

ttp:

//w

ww

.cm

s.go

v/Re

sear

ch-S

tatis

tics-

Data

-and

-Sys

tem

s/Co

mpu

ter-D

ata-

and-

Syst

ems/

Med

icai

dDat

aSou

rces

Gen

Info

/dow

nloa

ds/a

nom

alie

s1.p

df.

4 W

hen

com

pare

d to

the

Dece

mbe

r 201

5 ed

ition

of t

his

tabl

e, T

exas

had

a c

hang

e in

tota

l enr

ollm

ent o

f 10

perc

ent o

r mor

e ov

er th

e pr

ior y

ear.

How

ever

, Tex

as h

as s

ince

up

date

d its

201

2 en

rollm

ent t

otal

and

no

long

er h

as a

cha

nge

of 1

0 pe

rcen

t or m

ore.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

MSI

S da

ta a

s of

Dec

embe

r 201

5.

EXH

IBIT

14.

(co

ntin

ued)

http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/downloads/anomalies1.pdf


December 201642


MAC

Stat

sSe

ctio

n 3

Stat

e

Tota

lCh

ildAd

ult

Disa

bled

Aged

All

enro

llees

Full-

bene

fit

enro

llees

1Al

l en

rolle

esFu

ll-be

nefit

en

rolle

es1

All

enro

llees

Full-

bene

fit

enro

llees

1Al

l en

rolle

esFu

ll-be

nefit

en

rolle

es1

All

enro

llees

Full-

bene

fit

enro

llees

1

Tota

l56

,777

49,6

5526

,640

26,3

3814

,809

10,5

679,

379

8,29

55,

949

4,45

4Al

abam

a96

872

848

048

016

539

212

162

110

46Al

aska

111

110

6161

2525

1616

99

Ariz

ona

1,35

91,

235

648

636

442

373

161

147

108

78Ar

kans

as60

147

831

030

482

2314

411

365

38Ca

lifor

nia

9,30

76,

761

3,34

03,

160

3,90

71,

599

1,02

31,

013

1,03

699

0Co

lora

do2

718

690

406

406

145

142

111

9956

43Co

nnec

ticut

731

649

291

291

257

255

7556

108

47De

law

are

213

184

8584

8874

2618

147

Dist

rict o

f Col

umbi

a321

521

574

7485

8537

3719

19Fl

orid

a3,

386

2,90

91,

727

1,71

958

147

858

644

049

227

2G

eorg

ia2

1,59

31,

387

894

894

221

164

307

244

171

85H

awai

i25

224

810

710

782

8239

3725

22Id

aho

44

44

44

44

44

Illin

ois

2,67

72,

555

1,41

21,

412

746

666

302

285

217

192

Indi

ana

1,03

095

456

456

418

416

819

716

185

61Io

wa

516

458

236

234

157

119

8377

3928

Kans

as35

232

820

920

938

3872

5933

23Ke

ntuc

ky77

069

237

537

590

9021

717

688

51Lo

uisi

ana

44

44

44

44

44

Mai

ne2

322

280

115

114

8584

6555

5626

Mar

ylan

d96

389

144

844

730

527

813

711

774

48M

assa

chus

etts

31,

293

1,19

736

735

540

234

835

835

616

613

8M

ichi

gan

1,87

71,

753

971

963

418

345

355

334

132

111

Min

neso

ta90

186

338

338

031

429

313

112

574

65M

issi

ssip

pi65

454

932

832

884

5515

912

283

45

EXH

IBIT

15.

Med

icai

d Fu

ll-Ye

ar E

quiv

alen

t Enr

ollm

ent b

y St

ate

and

Elig

ibili

ty G

roup

, FY

2013

(tho

usan

ds)



MAC

Stat

sSe

ctio

n 3

Stat

e

Tota

lCh

ildAd

ult

Disa

bled

Aged

All

enro

llees

Full-

bene

fit

enro

llees

1Al

l en

rolle

esFu

ll-be

nefit

en

rolle

es1

All

enro

llees

Full-

bene

fit

enro

llees

1Al

l en

rolle

esFu

ll-be

nefit

en

rolle

es1

All

enro

llees

Full-

bene

fit

enro

llees

1

Mis

sour

i91

781

248

048

017

691

183

173

7768

Mon

tana

114

103

6565

1513

2218

117

Neb

rask

a21

320

812

412

430

3038

3621

18N

evad

a31

829

219

119

152

5147

3529

15N

ew H

amps

hire

136

124

7979

1414

2822

149

New

Jer

sey

986

959

541

541

122

120

181

172

143

125

New

Mex

ico

566

476

307

307

150

9167

5441

23N

ew Y

ork

5,11

54,

821

1,81

51,

783

2,01

01,

886

672

637

617

516

Nor

th C

arol

ina

1,64

61,

502

902

901

250

182

325

291

169

128

Nor

th D

akot

a65

6236

3610

1011

108

6O

hio

2,21

11,

913

978

973

689

515

373

305

170

120

Okl

ahom

a74

566

140

540

516

410

111

710

760

48O

rego

n62

555

729

528

916

714

710

483

6038

Penn

sylv

ania

2,15

91,

964

914

913

375

257

646

613

225

182

Rhod

e Is

land

44

44

44

44

44

Sout

h Ca

rolin

a92

680

548

948

820

110

415

714

779

66So

uth

Dako

ta10

710

063

6314

1419

1511

7Te

nnes

see

1,32

01,

200

682

682

249

249

255

198

133

71Te

xas

4,08

13,

674

2,59

02,

590

389

252

669

564

433

268

Uta

h28

628

017

017

058

5742

4016

14Ve

rmon

t17

016

258

5867

6724

2220

15Vi

rgin

ia93

582

249

649

616

311

417

314

110

271

Was

hing

ton

1,16

81,

038

678

677

195

116

202

174

9471

Wes

t Virg

inia

354

322

166

166

4040

110

9338

23W

isco

nsin

1,04

993

141

339

834

626

616

515

712

511

1W

yom

ing

6862

4444

87

119

53

EXH

IBIT

15.

(co

ntin

ued)

December 201644


MAC

Stat

sSe

ctio

n 3

EXH

IBIT

15.

(co

ntin

ued)

Not

es: F

Y is

fisc

al y

ear.

Full-

year

equ

ival

ent (

FYE)

may

als

o be

refe

rred

to a

s av

erag

e m

onth

ly e

nrol

lmen

t. En

rollm

ent n

umbe

rs g

ener

ally

incl

ude

indi

vidu

als

ever

enr

olle

d in

M

edic

aid-

finan

ced

cove

rage

dur

ing

the

year

, eve

n if

for a

sin

gle

mon

th; h

owev

er, i

n th

e ev

ent i

ndiv

idua

ls w

ere

also

enr

olle

d in

CH

IP-fi

nanc

ed M

edic

aid

cove

rage

(i.e

., M

edic

aid-

expa

nsio

n CH

IP) d

urin

g th

e ye

ar, t

hey

are

excl

uded

if th

eir m

ost r

ecen

t enr

ollm

ent m

onth

was

in M

edic

aid-

expa

nsio

n CH

IP. N

umbe

rs e

xclu

de in

divi

dual

s en

rolle

d on

ly in

M

edic

aid-

expa

nsio

n CH

IP d

urin

g th

e ye

ar a

nd e

nrol

lees

in th

e te

rrito

ries.

Chi

ldre

n an

d ad

ults

und

er a

ge 6

5 w

ho q

ualif

y fo

r Med

icai

d on

the

basi

s of

dis

abili

ty a

re in

clud

ed in

the

disa

bled

cat

egor

y. A

bout

746

,000

enr

olle

es a

ge 6

5 an

d ol

der a

re id

entif

ied

in th

e da

ta a

s di

sabl

ed; g

iven

that

dis

abili

ty is

not

an

elig

ibili

ty p

athw

ay fo

r ind

ivid

uals

age

65

and

olde

r, M

ACPA

C re

code

s th

ese

enro

llees

as

aged

.

For M

ACPA

C’s

anal

ysis

, Med

icai

d en

rolle

es w

ere

assi

gned

a u

niqu

e na

tiona

l ide

ntifi

catio

n nu

mbe

r usi

ng a

n al

gorit

hm th

at in

corp

orat

es s

tate

-spe

cific

ID n

umbe

rs a

nd

bene

ficia

ry c

hara

cter

istic

s su

ch a

s da

te o

f birt

h an

d ge

nder

. The

sta

te a

nd n

atio

nal e

nrol

lmen

t cou

nts

show

n he

re a

re u

ndup

licat

ed u

sing

this

nat

iona

l ID.

Cat

egor

ies

may

no

t sum

to to

tal f

or e

ach

stat

e du

e to

roun

ding

. In

addi

tion,

the

sum

of t

he s

tate

tota

ls e

xcee

ds th

e na

tiona

l tot

al b

ecau

se in

divi

dual

s m

ay b

e en

rolle

d in

mor

e th

an o

ne s

tate

du

ring

the

year

.1

In th

is e

xhib

it, fu

ll-be

nefit

enr

olle

es c

olum

ns e

xclu

des

enro

llees

repo

rted

by

stat

es in

the

Med

icai

d St

atis

tical

Info

rmat

ion

Syst

em (M

SIS)

as

rece

ivin

g co

vera

ge o

f onl

y fa

mily

pla

nnin

g se

rvic

es, a

ssis

tanc

e w

ith M

edic

are

prem

ium

s an

d co

st s

harin

g, o

r em

erge

ncy

serv

ices

.2

Stat

e ha

d a

chan

ge in

tota

l FYE

enr

olle

es o

f 10

perc

ent o

r mor

e ov

er th

e pr

ior y

ear.

Thes

e da

ta m

ay re

flect

dat

a an

omal

ies

in th

e su

bmis

sion

of M

SIS

data

for t

he c

urre

nt

or p

rior y

ears

and

may

be

upda

ted

in fu

ture

MSI

S su

bmis

sion

s by

sta

tes.

MSI

S da

ta a

nom

alie

s ha

ve b

een

com

pile

d an

d re

port

ed b

y M

athe

mat

ica

Polic

y Re

sear

ch; t

he d

ata

anom

alie

s re

port

may

be

foun

d at

: htt

p://

ww

w.c

ms.

gov/

Rese

arch

-Sta

tistic

s-Da

ta-a

nd-S

yste

ms/

Com

pute

r-Dat

a-an

d-Sy

stem

s/M

edic

aidD

ataS

ourc

esG

enIn

fo/d

ownl

oads

/an

omal

ies1

.pdf

.3

Whe

n co

mpa

red

to th

e De

cem

ber 2

015

editi

on o

f thi

s ta

ble,

Dis

tric

t of C

olum

bia

and

Mas

sach

uset

ts h

ad a

cha

nge

in to

tal F

YE e

nrol

lees

of 1

0 pe

rcen

t or m

ore

over

the

prio

r ye

ar. H

owev

er, b

oth

stat

es h

ave

sinc

e up

date

d th

eir 2

012

enro

llmen

t tot

al a

nd n

o lo

nger

has

a c

hang

e of

10

perc

ent o

r mor

e.4

Stat

es w

ere

excl

uded

due

to d

ata

relia

bilit

y co

ncer

ns re

gard

ing

com

plet

enes

s of

mon

thly

cla

ims

and

enro

llmen

t dat

a.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

MSI

S da

ta a

s of

Dec

embe

r 201

5.





MAC

Stat

sSe

ctio

n 3

Stat

e1

Bene

fits

Stat

e pr

ogra

m a

dmin

istr

atio

nTo

tal M

edic

aid

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Alab

ama

$5,2

65$3

,663

$1,6

02$2

31$1

52$7

9$5

,496

$3,8

15$1

,681

Alas

ka1,

405

826

580

130

7951

1,53

590

463

1Ar

izon

a10

,618

7,89

72,

721

277

199

7810

,895

8,09

62,

799

Arka

nsas

5,47

04,

302

1,16

838

326

411

95,

853

4,56

61,

287

Calif

orni

a84

,983

53,2

0931

,774

5,63

13,

509

2,12

290

,614

56,7

1833

,896

Colo

rado

7,30

14,

410

2,89

138

524

414

17,

686

4,65

43,

032

Conn

ectic

ut7,

183

4,21

12,

972

414

278

135

7,59

74,

490

3,10

7De

law

are

1,86

01,

115

745

163

120

432,

024

1,23

578

8Di

stric

t of C

olum

bia

2,37

01,

759

611

151

9457

2,52

11,

853

668

Flor

ida

21,3

2012

,877

8,44

370

343

127

222

,023

13,3

088,

715

Geo

rgia

9,66

56,

526

3,13

958

039

818

310

,245

6,92

43,

321

Haw

aii

1,95

81,

259

699

119

9227

2,07

71,

351

726

Idah

o1,

715

1,23

448

110

572

331,

820

1,30

651

4Ill

inoi

s16

,938

10,1

826,

756

1,02

460

242

217

,962

10,7

847,

178

Indi

ana

9,25

06,

366

2,88

447

228

518

69,

722

6,65

13,

070

Iow

a4,

476

2,85

91,

617

196

140

564,

672

2,99

91,

673

Kans

as3,

011

1,71

41,

297

183

120

623,

194

1,83

41,

360

Kent

ucky

9,42

37,

506

1,91

824

317

370

9,66

67,

679

1,98

7Lo

uisi

ana

7,86

34,

923

2,94

028

919

297

8,15

25,

116

3,03

7M

aine

2,47

71,

549

928

143

9944

2,62

01,

648

973

Mar

ylan

d9,

410

5,63

23,

779

471

306

166

9,88

25,

937

3,94

4M

assa

chus

etts

15,3

788,

632

6,74

678

648

530

016

,164

9,11

77,

047

Mic

higa

n15

,867

11,5

384,

329

694

479

215

16,5

6112

,017

4,54

4M

inne

sota

10,7

056,

275

4,42

959

035

723

311

,295

6,63

34,

662

Mis

siss

ippi

5,13

63,

807

1,33

017

711

760

5,31

43,

924

1,39

0M

isso

uri

9,51

86,

099

3,41

935

021

913

29,

869

6,31

83,

551

Mon

tana

1,13

276

736

675

5321

1,20

782

038

7N

ebra

ska

1,84

699

085

612

787

401,

974

1,07

789

6N

evad

a3,

106

2,34

176

516

011

347

3,26

62,

454

812

New

Ham

pshi

re1,

716

1,01

170

512

491

331,

841

1,10

273

8N

ew J

erse

y14

,049

8,63

15,

418

780

455

326

14,8

309,

086

5,74

4N

ew M

exic

o4,

920

3,89

81,

023

163

107

565,

083

4,00

51,

078

EXH

IBIT

16.

Med

icai

d Sp

endi

ng b

y St

ate,

Cat

egor

y, an

d So

urce

of F

unds

, FY

2015

(mill

ions

)

December 201646


MAC

Stat

sSe

ctio

n 3

Stat

e1

Bene

fits

Stat

e pr

ogra

m a

dmin

istr

atio

nTo

tal M

edic

aid

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

New

Yor

k$5

7,89

7$3

1,75

7$2

6,14

0$1

,784

$1,0

40$7

45$5

9,68

1$3

2,79

7$2

6,88

4N

orth

Car

olin

a13

,213

8,74

34,

470

665

486

180

13,8

789,

228

4,65

0N

orth

Dak

ota

534

319

215

169

654

932

922

1O

hio

21,4

2314

,787

6,63

686

054

631

522

,284

15,3

336,

951

Okl

ahom

a4,

703

2,98

71,

716

245

158

874,

948

3,14

61,

802

Ore

gon

8,02

76,

251

1,77

654

132

721

58,

569

6,57

81,

991

Penn

sylv

ania

23,2

2412

,978

10,2

4687

655

731

924

,100

13,5

3510

,565

Rhod

e Is

land

2,58

51,

530

1,05

414

499

452,

729

1,62

91,

100

Sout

h Ca

rolin

a5,

768

4,08

31,

685

260

172

886,

028

4,25

51,

773

Sout

h Da

kota

806

452

354

5537

1886

148

937

2Te

nnes

see

9,09

45,

917

3,17

741

225

116

29,

507

6,16

83,

339

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s34

,691

20,4

3014

,261

1,45

697

248

436

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21,4

0314

,745

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h2,

148

1,52

362

515

210

844

2,30

01,

631

669

Verm

ont

1,63

398

764

633

303

1,66

61,

017

649

Virg

inia

8,03

34,

070

3,96

347

833

014

88,

511

4,40

04,

111

Was

hing

ton

10,4

946,

818

3,67

658

135

822

311

,075

7,17

63,

899

Wes

t Virg

inia

3,64

72,

801

845

189

128

613,

836

2,92

990

7W

isco

nsin

7,89

44,

644

3,24

931

920

711

28,

212

4,85

13,

361

Wyo

min

g55

928

527

462

4418

621

329

292

Subt

otal

(sta

tes)

$523

,709

$329

,371

$194

,338

$25,

451

$16,

271

$9,1

80$5

49,1

60$3

45,6

42$2

03,5

18Am

eric

an S

amoa

3017

134

30

3421

13G

uam

7347

263

21

7649

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. Mar

iana

Isla

nds

2715

111

00

2716

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erto

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o2,

280

1,46

781

382

5428

2,36

21,

522

841

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in Is

land

s39

2316

85

347

2819

Subt

otal

(sta

tes

and

terr

itorie

s)$5

26,1

59$3

30,9

42$1

95,2

17$2

5,54

7$1

6,33

6$9

,212

$551

,706

$347

,277

$204

,429

Stat

e M

edic

aid

Frau

d Co

ntro

l Uni

ts

(MFC

Us)

––

–14

510

936

145

109

36M

edic

aid

surv

ey a

nd c

ertif

icat

ion

of n

ursi

ng a

nd in

term

edia

te c

are

faci

litie

s–

––

326

245

8232

624

582

Vacc

ines

for C

hild

ren

(VFC

) pro

gram

––

––

––

3,84

53,

845

–To

tal

$526

,159

$330

,942

$195

,217

$26,

019

$16,

689

$9,3

30$5

56,0

232

$351

,476

2$2

04,5

47

EXH

IBIT

16.

(co

ntin

ued)



MAC

Stat

sSe

ctio

n 3

Not

es: F

Y is

fisc

al y

ear.

Tota

l fed

eral

spe

ndin

g sh

own

here

($35

1,47

6 m

illio

n) w

ill d

iffer

from

tota

l fed

eral

out

lays

sho

wn

in F

Y 20

17 b

udge

t doc

umen

ts d

ue to

slig

ht d

iffer

ence

s in

the

timin

g of

dat

a fo

r the

sta

tes

and

the

trea

tmen

t of c

erta

in a

djus

tmen

ts. F

eder

al s

pend

ing

in th

e te

rrito

ries

is c

appe

d; h

owev

er, t

errit

orie

s re

port

thei

r tot

al s

pend

ing

rega

rdle

ss o

f whe

ther

they

hav

e re

ache

d th

eir c

aps.

As

a re

sult,

fede

ral s

pend

ing

show

n he

re m

ay e

xcee

d th

e am

ount

s ac

tual

ly p

aid

to th

e te

rrito

ries.

Sta

te s

hare

s fo

r MFC

Us

and

surv

ey a

nd c

ertif

icat

ion

are

MAC

PAC

estim

ates

bas

ed o

n 75

per

cent

fede

ral m

atch

. Sta

te-le

vel e

stim

ates

for t

hese

item

s ar

e av

aila

ble

but a

re n

ot s

how

n he

re. T

he

VFC

prog

ram

is a

utho

rized

in th

e M

edic

aid

stat

ute

but i

s op

erat

ed a

s a

sepa

rate

pro

gram

; 100

per

cent

fede

ral f

undi

ng fi

nanc

es th

e pu

rcha

se o

f vac

cine

s fo

r chi

ldre

n w

ho

are

enro

lled

in M

edic

aid,

uni

nsur

ed, o

r priv

atel

y in

sure

d w

ithou

t vac

cine

cov

erag

e. S

pend

ing

on a

dmin

istr

atio

n is

onl

y fo

r sta

te p

rogr

ams;

fede

ral o

vers

ight

spe

ndin

g is

not

in

clud

ed.

– D

ash

indi

cate

s ze

ro; $

0 in

dica

tes

an a

mou

nt le

ss th

an $

0.5

mill

ion

that

roun

ds to

zer

o.1

Not

all

stat

es h

ad c

ertif

ied

thei

r CM

S-64

Fin

anci

al M

anag

emen

t Rep

ort (

FMR)

sub

mis

sion

s as

of M

ay 2

4, 2

016.

Cal

iforn

ia’s

firs

t, se

cond

, thi

rd, a

nd fo

urth

qua

rter

su

bmis

sion

s ar

e no

t cer

tifie

d; C

olor

ado

and

Nor

th D

akot

a’s

seco

nd, t

hird

, and

four

th q

uart

er s

ubm

issi

ons

are

not c

ertif

ied;

New

Jer

sey’

s th

ird a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t cer

tifie

d. F

igur

es p

rese

nted

in th

is e

xhib

it m

ay c

hang

e if

stat

es re

vise

thei

r exp

endi

ture

dat

a af

ter t

his

date

.2

Amou

nts

exce

ed th

e su

m o

f ben

efits

and

sta

te p

rogr

am a

dmin

istr

atio

n co

lum

ns d

ue to

the

incl

usio

n of

the

VFC

prog

ram

.

Sour

ces:

For

sta

te a

nd te

rrito

ry s

pend

ing:

MAC

PAC,

201

6, a

naly

sis

of C

MS-

64 F

MR

net e

xpen

ditu

re d

ata

as o

f May

24,

201

6. F

or a

ll ot

her s

pend

ing

(MCF

Us,

sur

vey

and

cert

ifica

tion,

VFC

): Ce

nter

s fo

r Med

icar

e &

Med

icai

d Se

rvic

es, 2

016,

Fis

cal y

ear 2

017

just

ifica

tion

of e

stim

ates

for a

ppro

pria

tions

com

mitt

ees,

Bal

timor

e, M

D, h

ttps

://w

ww

.cm

s.go

v/Ab

out-C

MS/

Agen

cy-In

form

atio

n/Pe

rfor

man

ceBu

dget

/Dow

nloa

ds/F

Y201

7-CJ

-Fin

al.p

df.

EXH

IBIT

16.

(co

ntin

ued)

https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/Downloads/FY2017-CJ-Final.pdf

https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/Downloads/FY2017-CJ-Final.pdf

December 201648

Section 3: Program Enrollment and Spending—Medicaid Benefits

MAC

Stat

sSe

ctio

n 3

EXH

IBIT

17.

Tot

al M

edic

aid

Bene

fit S

pend

ing

by S

tate

and

Cat

egor

y, FY

201

5 (m

illio

ns)

Stat

e1

Tota

l sp

endi

ng

on b

enef

its

Fee

for s

ervi

ceM

anag

ed

care

and

pr

emiu

m

assi

stan

ce

Med

icar

e pr

emiu

ms

and

coin

sura

nce

Colle

ctio

nsH

ospi

tal

Phys

icia

nDe

ntal

Oth

er

prac

titio

nerCl

inic

and

he

alth

ce

nter

Oth

er a

cute

Drug

sIn

stitu

tiona

l LT

SS

Hom

e an

d co

mm

unity

-ba

sed

LTSS

Alab

ama

$5,2

65$1

,992

$427

$80

$50

$94

$621

$283

$1,0

21$4

67-$

2$2

61-$

29

Alas

ka1,

405

317

121

6925

201

117

2919

832

30

21-1

6

Ariz

ona

10,6

181,

143

455

614

831

58

752

8,64

924

6-2

3

Arka

nsas

5,47

01,

021

334

7923

3992

715

595

752

61,

170

305

-67

Calif

orni

a84

,983

19,4

471,

038

1,03

225

3,46

15,

886

1,38

84,

072

7,71

439

,105

2,36

2-5

48

Colo

rado

7,30

12,

419

673

256

–16

429

331

774

11,

214

1,16

012

1-5

7

Conn

ectic

ut7,

183

1,86

540

718

417

929

854

461

71,

739

1,61

30

406

-670

Dela

war

e21,

860

6615

360

4269

-64

3611

71,

508

36-2

Dist

rict o

f Col

umbi

a2,

370

332

4018

317

654

9635

440

387

438

-17

Flor

ida

21,3

203,

617

545

1919

166

556

104

970

1,11

713

,022

1,34

3-1

56

Geo

rgia

9,66

52,

228

373

3330

1967

836

91,

371

1,03

63,

269

345

-85

Haw

aii

1,95

811

41

312

195

19

107

1,67

152

-54

Idah

o1,

715

394

119

-021

2620

370

317

322

206

53-1

6

Illin

ois

16,9

385,

155

600

124

114

248

1,01

328

72,

345

1,64

05,

101

411

-101

Indi

ana

9,25

01,

221

197

160

1240

055

919

62,

312

1,15

32,

901

219

-79

Iow

a4,

476

949

230

5429

9843

217

693

079

472

015

0-8

7

Kans

as2

3,01

114

813

02

478

-181

32,

630

83-3

0

Kent

ucky

9,42

338

833

24

119

368

391,

159

785

6,39

221

0-7

6

Loui

sian

a7,

863

1,89

118

21

–63

246

199

1,47

582

02,

904

277

-195

Mai

ne2,

477

563

9427

4524

041

296

450

448

320

2-1

03

Mar

ylan

d9,

410

1,10

711

713

029

100

1,01

424

31,

353

1,18

34,

005

271

-143

Mas

sach

uset

ts15

,378

2,02

541

225

027

101

1,45

534

41,

661

2,97

25,

879

440

-186

Mic

higa

n15

,867

1,75

246

256

1226

448

438

71,

816

777

9,52

641

2-8

2

Min

neso

ta10

,705

650

197

4220

373

712

161,

031

2,63

35,

201

179

-231

Mis

siss

ippi

5,13

61,

684

172

521

8136

010

41,

099

345

1,07

421

2-2

0

Mis

sour

i9,

518

3,09

527

1412

493

922

705

1,39

51,

433

1,17

134

1-9

0

Mon

tana

1,13

231

960

3322

1720

051

198

214

-137

-17

Neb

rask

a1,

846

142

2136

23

6484

416

382

635

103

-42

Nev

ada

3,10

657

315

342

2146

303

124

288

205

1,24

512

5-2

2

New

Ham

pshi

re2

1,71

613

818

243

515

1-6

399

300

669

32-1

6



MAC

Stat

sSe

ctio

n 3

Stat

e1

Tota

l sp

endi

ng

on b

enef

its

Fee

for s

ervi

ceM

anag

ed

care

and

pr

emiu

m

assi

stan

ce

Med

icar

e pr

emiu

ms

and

coin

sura

nce

Colle

ctio

nsH

ospi

tal

Phys

icia

nDe

ntal

Oth

er

prac

titio

nerCl

inic

and

he

alth

ce

nter

Oth

er a

cute

Drug

sIn

stitu

tiona

l LT

SS

Hom

e an

d co

mm

unity

-ba

sed

LTSS

New

Jer

sey

$14,

049

$1,8

18$5

6$6

$3$2

39$7

63$2

9$2

,634

$1,0

35$7

,313

$341

-$18

6

New

Mex

ico

4,92

036

833

1143

752

929

337

3,95

589

-13

New

Yor

k57

,897

9,85

457

467

209

1,34

14,

848

1,05

97,

783

6,70

926

,053

1,31

0-1

,909

Nor

th C

arol

ina

13,2

134,

663

995

315

6618

01,

095

738

1,34

683

32,

843

407

-271

Nor

th D

akot

a53

479

296

66

2514

169

108

916

-3

Ohi

o21

,423

2,30

028

644

1655

1,65

710

92,

555

3,32

510

,862

388

-175

Okl

ahom

a4,

703

1,75

147

310

341

360

362

367

769

546

8913

6-2

94

Ore

gon

8,02

748

135

225

118

357

8541

51,

619

4,73

419

5-4

0

Penn

sylv

ania

23,2

241,

431

8628

210

836

924

4,79

73,

915

12,0

3759

8-1

71

Rhod

e Is

land

2,58

535

610

111

3654

82

181

11,

404

49-1

4

Sout

h Ca

rolin

a5,

768

1,07

913

111

419

205

380

4979

651

62,

494

181

-196

Sout

h Da

kota

806

206

6219

388

5632

172

146

228

-7

Tenn

esse

e9,

094

841

3716

00

4322

642

427

267

56,

109

358

-50

Texa

s34

,691

6,91

950

954

645

354,

992

230

2,99

32,

146

16,2

281,

055

-1,1

16

Uta

h2,

148

288

8218

411

144

6327

425

81,

016

39-4

8

Verm

ont2

1,63

345

20

01

1,54

6-9

312

08

07

-2

Virg

inia

8,03

385

316

214

730

461,

001

771,

241

1,38

32,

933

231

-71

Was

hing

ton

10,4

9495

414

718

224

653

469

170

930

1,81

44,

936

342

-127

Wes

t Virg

inia

3,64

773

223

929

2683

281

188

780

592

600

124

-29

Wis

cons

in7,

894

775

6544

2332

259

649

688

796

63,

563

237

-81

Wyo

min

g55

912

742

1420

3330

2313

612

62

14-7

Subt

otal

$523

,709

$92,

676

$11,

181

$4,2

14$2

,148

$11,

178

$38,

838

$10,

507

$59,

548

$58,

107

$227

,956

$15,

426

-$8,

070

Amer

ican

Sam

oa30

19-4

-0–

-216

1-0

––

––

Gua

m73

128

30

127

211

0–

1–

N. M

aria

na Is

land

s27

18–

0–

16

1–

0-0

0–

Puer

to R

ico

2,28

0–

––

––

16–

––

2,26

4–

–

Virg

in Is

land

s39

194

21

12

63

0–

1–

Tota

l$5

26,1

59$9

2,74

5$1

1,18

9$4

,218

$2,1

50$1

1,18

0$3

8,90

5$1

0,53

5$5

9,55

2$5

8,10

7$2

30,2

20$1

5,42

8-$

8,07

0Pe

rcen

t of t

otal

, ex

clus

ive

of

colle

ctio

ns–

17.4

%2.

1%0.

8%0.

4%2.

1%7.

3%2.

0%11

.1%

10.9

%43

.1%

2.9%

–

EXH

IBIT

17.

(co

ntin

ued)

December 201650


MAC

Stat

sSe

ctio

n 3

Not

es: F

Y is

fisc

al y

ear.

LTSS

is lo

ng-te

rm s

ervi

ces

and

supp

orts

. Inc

lude

s fe

dera

l and

sta

te fu

nds.

Ser

vice

cat

egor

y de

finiti

ons

and

spen

ding

am

ount

s sh

own

here

may

di

ffer

from

oth

er C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es d

ata

sour

ces,

suc

h as

the

Med

icai

d St

atis

tical

Info

rmat

ion

Syst

em (M

SIS)

. The

spe

cific

ser

vice

s in

clud

ed in

ea

ch c

ateg

ory

have

cha

nged

ove

r tim

e an

d th

eref

ore

may

not

be

dire

ctly

com

para

ble

to e

arlie

r edi

tions

of M

ACSt

ats.

Col

lect

ions

incl

ude

third

-par

ty li

abili

ty, e

stat

e, a

nd

othe

r rec

over

ies.

– D

ash

indi

cate

s ze

ro; $

0 or

-$0

indi

cate

s an

am

ount

bet

wee

n $0

.5 a

nd -$

0.5

mill

ion

that

roun

ds to

zer

o.

Addi

tiona

l det

ail o

n ca

tego

ries:

• H

ospi

tal i

nclu

des

inpa

tient

, out

patie

nt, c

ritic

al a

cces

s ho

spita

l, an

d em

erge

ncy

hosp

ital s

ervi

ces,

as

wel

l as

rela

ted

disp

ropo

rtio

nate

sha

re h

ospi

tal (

DSH

) pay

men

ts.

• Ph

ysic

ian

incl

udes

phy

sici

an a

nd s

urgi

cal s

ervi

ces,

bot

h re

gula

r pay

men

ts a

nd th

ose

asso

ciat

ed w

ith th

e pr

imar

y ca

re p

hysi

cian

pay

men

t inc

reas

e.

• Cl

inic

and

hea

lth c

ente

r inc

lude

s no

n-ho

spita

l out

patie

nt c

linic

, rur

al h

ealth

clin

ic, f

eder

ally

qua

lifie

d he

alth

cen

ter,

and

free

stan

ding

birt

h ce

nter

.

• O

ther

acu

te in

clud

es la

b or

X-ra

y; s

teril

izat

ions

; abo

rtio

ns; E

arly

and

Per

iodi

c Sc

reen

ing,

Dia

gnos

tic, a

nd T

reat

men

t scr

eeni

ngs;

em

erge

ncy

serv

ices

for u

naut

horiz

ed

alie

ns; n

on-e

mer

genc

y tr

ansp

orta

tion;

phy

sica

l, oc

cupa

tiona

l, sp

eech

, and

hea

ring

ther

apy;

pro

sthe

tics,

den

ture

s, a

nd e

yegl

asse

s; p

reve

ntiv

e se

rvic

es w

ith U

.S. P

reve

ntiv

e Se

rvic

es T

ask

Forc

e (U

SPST

F) G

rade

A o

r B a

nd A

dvis

ory

Com

mitt

ee o

n Im

mun

izat

ion

Prac

tices

(ACI

P) v

acci

nes;

oth

er d

iagn

ostic

scr

eeni

ng a

nd p

reve

ntiv

e se

rvic

es;

scho

ol-b

ased

ser

vice

s; h

ealth

hom

e w

ith c

hron

ic c

ondi

tions

; tob

acco

ces

satio

n fo

r pre

gnan

t wom

en; p

rivat

e du

ty n

ursi

ng; c

ase

man

agem

ent (

excl

udin

g pr

imar

y ca

re

case

man

agem

ent)

; reh

abili

tativ

e se

rvic

es; h

ospi

ce; a

nd o

ther

car

e no

t oth

erw

ise

cate

goriz

ed.

• Dr

ugs

are

net o

f reb

ates

.

• In

stitu

tiona

l LTS

S in

clud

es n

ursi

ng fa

cilit

y, in

term

edia

te c

are

faci

lity

for i

ndiv

idua

ls w

ith in

telle

ctua

l dis

abili

ties,

and

men

tal h

ealth

faci

lity.

• H

ome

and

com

mun

ity-b

ased

LTS

S in

clud

es h

ome

heal

th, w

aive

r and

sta

te p

lan

serv

ices

, and

per

sona

l car

e.

• M

anag

ed c

are

and

prem

ium

ass

ista

nce

incl

udes

com

preh

ensi

ve a

nd li

mite

d-be

nefit

man

aged

car

e pl

ans,

prim

ary

care

cas

e m

anag

emen

t, em

ploy

er-s

pons

ored

pre

miu

m

assi

stan

ce p

rogr

ams,

and

Pro

gram

s of

All-

incl

usiv

e Ca

re fo

r the

Eld

erly

. Com

preh

ensi

ve p

lans

acc

ount

for o

ver 9

0 pe

rcen

t of s

pend

ing

in th

e m

anag

ed c

are

cate

gory

. M

anag

ed c

are

also

incl

udes

reba

tes

for d

rugs

pro

vide

d by

man

aged

car

e pl

ans,

and

man

aged

car

e pa

ymen

ts a

ssoc

iate

d w

ith th

e pr

imar

y ca

re p

hysi

cian

pay

men

t in

crea

se, C

omm

unity

Firs

t Cho

ice

optio

n, a

nd p

reve

ntiv

e se

rvic

es w

ith U

SPST

F G

rade

A o

r B, a

nd A

CIP

vacc

ines

.

1 N

ot a

ll st

ates

had

cer

tifie

d th

eir C

MS-

64 F

inan

cial

Man

agem

ent R

epor

t (FM

R) s

ubm

issi

ons

as o

f May

24,

201

6. C

alifo

rnia

’s fi

rst,

seco

nd, t

hird

, and

four

th q

uart

er

subm

issi

ons

are

not c

ertif

ied;

Col

orad

o an

d N

orth

Dak

ota’

s se

cond

, thi

rd, a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t cer

tifie

d; N

ew J

erse

y’s

third

and

four

th q

uart

er s

ubm

issi

ons

are

not c

ertif

ied.

Fig

ures

pre

sent

ed in

this

exh

ibit

may

cha

nge

if st

ates

revi

se th

eir e

xpen

ditu

re d

ata

afte

r thi

s da

te.

2 St

ate

repo

rts

nega

tive

fee-

for-s

ervi

ce (F

FS) d

rug

spen

ding

aft

er th

e ap

plic

atio

n of

dru

g re

bate

s. T

he n

egat

ive

net a

mou

nt m

ay re

flect

a s

hift

of s

ome

FFS

drug

spe

ndin

g in

to

Med

icai

d m

anag

ed c

are

or th

e st

ate

not s

epar

atel

y re

port

ing

the

FFS

and

man

aged

car

e dr

ug re

bate

s. V

erm

ont s

how

s ne

gativ

e dr

ug s

pend

ing

beca

use

it re

port

s m

ost o

f its

be

nefit

spe

ndin

g un

der o

ther

car

e se

rvic

es in

its

CMS-

64 s

ubm

issi

on.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

CM

S-64

FM

R ne

t exp

endi

ture

dat

a as

of M

ay 2

4, 2

016.

EXH

IBIT

17.

(co

ntin

ued)



MAC

Stat

sSe

ctio

n 3

All enrollees$401.2 billion

Child$76.4 billion

Adult$62.2 billion

Disabled$170.2 billion

Aged$92.6 billion

Medicare premiums

LTSS institutional

LTSS non-institutional

Managed care

Drugs

Non-hospital acute

Inpatient and outpatient hospital

17.3%

2.0%

16.1%

18.7%

2.6%

12.7%

5.8%

0.3%

45.1%

18.9%

2.3%

1.2%1.5%*

28.3%

2.3%

0.5%0.2%0.3%

14.2%

3.3%

13.6%

3.1%

7.0%

8.6%

23.0%

15.5%

14.2%

3.3%

13.6%

3.1%

7.0%

8.6%

23.0%

15.5%

13.8% 22.8%

16.6%

33.3%

13.8%

26.5%

22.8%

16.6%

16.6%

53.0% 52.9%

Notes: FY is fiscal year. LTSS is long-term services and supports. Includes federal and state funds. Excludes spending for administration, the territories, and Medicaid-expansion CHIP enrollees. Children and adults under age 65 who qualify for Medicaid on the basis of disability are included in the disabled category. About 746,000 enrollees age 65 and older are identified in the data as disabled; given that disability is not an eligibility pathway for individuals age 65 and older, MACPAC recodes these enrollees as aged. Amounts are fee for service unless otherwise noted. Benefit spending from Medicaid Statistical Information System (MSIS) data has been adjusted to reflect CMS-64 totals. Due to changes in both methods and data, figures shown here are not directly comparable to earlier years. With regard to methods, spending totals now exclude disproportionate share hospital (DSH) and certain incentive and uncompensated care pool payments made under Section 1115 waiver expenditure authority, which were previously included prior to the December 2015 data book. See https://www.macpac.gov/macstats/data-sources-and-methods/ for additional information. Excludes Idaho, Louisiana, and Rhode Island due to data reliability concerns regarding completeness of monthly claims and enrollment data.

* Values less than 0.1 percent are not shown.

Sources: MACPAC, 2016, analysis of MSIS data as of December 2015 and analysis of CMS-64 Financial Management Report net expenditure data from the Centers for Medicare & Medicaid Services as of June 2016.

EXHIBIT 18. Distribution of Medicaid Benefit Spending by Eligibility Group and Service Category, FY 2013


December 201652


MAC

Stat

s

Medicare premiums

LTSS institutional

LTSS non-institutional

Managed care

Drugs

Non-hospital acute

Inpatient and outpatienthospital

All enrollees$7,067

Child$2,866

Adult$4,197

Disabled$18,145

Aged$15,557

$1,000

$140

$2,356 $2,219

$975

$1,138

$236

$1,221 $543 $1,188$3,399

$2,467

$478

$4,803

$4,138

$2,302

$558 $1,340

$7,012

$2,585

$2,584

$41

$1,087

$908

$659 $648

$67 $97

$1,520

$34 $20

$43 $10

* $14

Notes: FY is fiscal year. LTSS is long-term services and supports. Includes federal and state funds. Excludes spending for administration, the territories, and Medicaid-expansion CHIP enrollees. Children and adults under age 65 who qualify for Medicaid on the basis of disability are included in the disabled category. About 746,000 enrollees age 65 and older are identified in the data as disabled; given that disability is not an eligibility pathway for individuals age 65 and older, MACPAC recodes these enrollees as aged. Amounts are fee for service unless otherwise noted, and they reflect all enrollees, including those with limited benefits. Benefit spending from Medicaid Statistical Information System (MSIS) data has been adjusted to reflect CMS-64 totals. Due to changes in both methods and data, figures shown here are not directly comparable to earlier years. With regard to methods, spending totals now exclude disproportionate share hospital (DSH) and certain incentive and uncompensated care pool payments made under Section 1115 waiver expenditure authority, which were previously included prior to the December 2015 data book. See https://www.macpac.gov/macstats/data-sources-and-methods/ for additional information. Excludes Idaho, Louisiana, and Rhode Island due to data reliability concerns regarding completeness of monthly claims and enrollment data.

* Values less than $1 are not shown.

Sources: MACPAC, 2016, analysis of MSIS data as of December 2015 and analysis of CMS-64 Financial Management Report net expenditure data from the Centers for Medicare & Medicaid Services as of June 2016.

EXHIBIT 19. Medicaid Benefit Spending Per Full-Year Equivalent (FYE) Enrollee by Eligibility Group and Service Category, FY 2013

Sect

ion

3





MAC

Stat

sSe

ctio

n 3

All enrollees68.5 million

Benefit spending for LTSS and all other services

$401.2 billion

41.8% of spending ($167.7 billion)is for LTSS users

5.9% of enrollees(4.1 million) are

LTSS users

Not using LTSS

Using LTSS: Non-institutional only, no services under HCBS waiver1

Using LTSS: Non-institutional only,with some services under HCBS waiver1

Using LTSS: Institutional only

Using LTSS: Both institutional andnon-institutional

94.1%

58.2%

7.8%

17.9%

2.9%2.4%

13.6%

1.9%1.9%1.9%0.3%

Notes: FY is fiscal year. LTSS is long-term services and supports. HCBS is home and community-based services. Includes federal and state funds. Excludes spending on administration, the territories, and Medicaid-expansion CHIP enrollees. Benefit spending from Medicaid Statistical Information System (MSIS) data has been adjusted to reflect CMS-64 totals, and enrollment counts are unduplicated using unique national identification numbers. Due to changes in both methods and data, figures shown here are not directly comparable to earlier years. With regard to methods, spending totals now exclude disproportionate share hospital (DSH) payments and certain incentive and uncompensated care pool payments made under Section 1115 waiver expenditure authority, which were previously included prior to the December 2015 data book. See https://www.macpac.gov/macstats/data-sources-and-methods/ for additional information.

LTSS users are defined here as enrollees having at least one LTSS claim during the year under a fee-for-service arrangement. (The data do not allow a breakout of LTSS services delivered through managed care.) For example, an enrollee with a short stay in a nursing facility for rehabilitation following a hospital discharge and an enrollee with permanent residence in a nursing facility would both be counted as LTSS users. Excludes Idaho, Louisiana, and Rhode Island due to data reliability concerns regarding completeness of monthly claims and enrollment data.1 All states have HCBS waiver programs that provide a range of LTSS for targeted populations of non-institutionalized enrollees who require institutional levels of care. Based on a comparison with CMS-372 data (a state-reported source containing aggregate spending and enrollment for HCBS waivers), the number of HCBS waiver enrollees may be underreported in the MSIS.

Source: MACPAC, 2016, analysis of MSIS data as of December 2015 and CMS-64 Financial Management Report net expenditure data from the Centers for Medicare & Medicaid Services as of June 2016.

EXHIBIT 20. Distribution of Medicaid Enrollment and Benefit Spending by Users and Non-Users of Long-Term Services and Supports, FY 2013


December 201654


MAC

Stat

s

Stat

eTo

tal

Basi

s of

elig

ibilt

y1

Dual

ly e

ligib

le s

tatu

s2

All d

ually

elig

ible

en

rolle

esDu

ally

elig

ible

with

full

bene

fits

Dual

ly e

ligib

le w

ith

limite

d be

nefit

sCh

ildAd

ult

Disa

bled

Aged

Tota

lAg

e 65

+To

tal

Age

65+

Tota

lAg

e 65

+To

tal

$401

,238

19.0

%15

.5%

42.4

%23

.1%

$143

,337

60.5

%$1

37,2

9260

.8%

$6,0

4453

.7%

Alab

ama

4,56

823

.79.

941

.924

.61,

651

67.1

1,41

469

.223

754

.7Al

aska

1,33

527

.416

.336

.120

.139

957

.239

857

.21

69.3

Ariz

ona

7,58

624

.028

.533

.713

.71,

611

57.3

1,55

357

.157

62.4

Arka

nsas

4,14

125

.04.

947

.422

.71,

494

60.9

1,34

663

.414

838

.0Ca

lifor

nia

57,2

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.4

Not

es: F

Y is

fisc

al y

ear.

Incl

udes

fede

ral a

nd s

tate

fund

s. E

xclu

des

spen

ding

for a

dmin

istra

tion,

the

terri

torie

s, a

nd M

edic

aid-

expa

nsio

n CH

IP e

nrol

lees

. Ben

efit

spen

ding

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Stat

istic

al In

form

atio

n Sy

stem

(MSI

S) d

ata

has

been

adj

uste

d to

refle

ct C

MS-

64 to

tals

. Due

to c

hang

es in

bot

h m

etho

ds a

nd d

ata,

figu

res

show

n he

re a

re n

ot d

irect

ly

com

para

ble

to e

arlie

r yea

rs. W

ith re

gard

to m

etho

ds, s

pend

ing

tota

ls n

ow e

xclu

de d

ispr

opor

tiona

te s

hare

hos

pita

l (DS

H) a

nd c

erta

in in

cent

ive

and

unco

mpe

nsat

ed c

are

pool

pa

ymen

ts m

ade

unde

r Sec

tion

1115

wai

ver e

xpen

ditu

re a

utho

rity,

whi

ch w

ere

prev

ious

ly in

clud

ed p

rior t

o th

e De

cem

ber 2

015

data

boo

k. S

ee h

ttps:

//w

ww

.mac

pac.

gov/

mac

stat

s/da

ta-s

ourc

es-a

nd-m

etho

ds/ f

or a

dditi

onal

info

rmat

ion.

1 Ch

ildre

n an

d ad

ults

und

er a

ge 6

5 w

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ualif

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r Med

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the

basi

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clud

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disa

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bout

746

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5 an

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der a

re

iden

tifie

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the

data

as

disa

bled

; giv

en th

at d

isab

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n el

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for i

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MAC

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2 Du

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re c

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fits

rece

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Med

icai

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sist

ance

with

Med

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e pr

emiu

ms

and

cost

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3 St

ates

wer

e ex

clud

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ue to

dat

a re

liabi

lity

conc

erns

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of m

onth

ly c

laim

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d en

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4 Du

e to

larg

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ffer

ence

s in

the

way

spe

ndin

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repo

rted

by

Verm

ont i

n CM

S-64

and

MSI

S da

ta, M

ACPA

C’s

adju

stm

ent m

etho

dolo

gy is

app

lied

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tal M

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ding

.

Sour

ce: M

ACPA

C, 2

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ana

lysi

s of

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S da

ta a

s of

Dec

embe

r 201

5 an

d an

alys

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f CM

S-64

Fin

anci

al M

anag

emen

t Rep

ort n

et e

xpen

ditu

re d

ata

as o

f Jun

e 20

16.

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21

December 201658


MAC

Stat

sSe

ctio

n 3

Not

es: F

Y is

fisc

al y

ear.

Full

year

equ

ival

ent (

FYE)

may

als

o be

refe

rred

to a

s av

erag

e m

onth

ly e

nrol

lmen

t. In

clud

es fe

dera

l and

sta

te fu

nds.

Exc

lude

s sp

endi

ng fo

r ad

min

istr

atio

n, th

e te

rrito

ries,

and

Med

icai

d-ex

pans

ion

CHIP

enr

olle

es. C

hild

ren

and

adul

ts u

nder

age

65

who

qua

lify

for M

edic

aid

on th

e ba

sis

of a

dis

abili

ty a

re in

clud

ed in

the

disa

bled

cat

egor

y. A

bout

746

,000

enr

olle

es a

ge 6

5 an

d ol

der a

re id

entif

ied

in th

e da

ta a

s di

sabl

ed; g

iven

that

dis

abili

ty is

not

an

elig

ibili

ty p

athw

ay fo

r ind

ivid

uals

age

65

and

olde

r, M

ACPA

C re

code

s th

ese

enro

llees

as

aged

. Ben

efit

spen

ding

from

Med

icai

d St

atis

tical

Info

rmat

ion

Syst

em (M

SIS)

dat

a ha

s be

en a

djus

ted

to re

flect

CM

S-64

tota

ls. D

ue

to c

hang

es in

bot

h m

etho

ds a

nd d

ata,

figu

res

show

n he

re a

re n

ot d

irect

ly c

ompa

rabl

e to

ear

lier y

ears

. With

rega

rd to

met

hods

, spe

ndin

g to

tals

now

exc

lude

dis

prop

ortio

nate

sh

are

hosp

ital (

DSH

) and

cer

tain

ince

ntiv

e an

d un

com

pens

ated

car

e po

ol p

aym

ents

mad

e un

der S

ectio

n 11

15 w

aive

r exp

endi

ture

aut

horit

y, w

hich

wer

e pr

evio

usly

incl

uded

pr

ior t

o th

e De

cem

ber 2

015

data

boo

k. S

ee h

ttps

://w

ww

.mac

pac.

gov/

mac

stat

s/da

ta-s

ourc

es-a

nd-m

etho

ds/ f

or a

dditi

onal

info

rmat

ion.

1 In

this

tabl

e, fu

ll-be

nefit

enr

olle

es e

xclu

des

thos

e re

port

ed b

y st

ates

in M

SIS

as re

ceiv

ing

cove

rage

of o

nly

fam

ily p

lann

ing

serv

ices

, ass

ista

nce

with

Med

icar

e pr

emiu

ms

and

cost

sha

ring,

or e

mer

genc

y se

rvic

es.

2 St

ate

had

a ch

ange

in F

YE e

nrol

lees

of 1

0 pe

rcen

t or m

ore

over

the

prio

r yea

r. Th

ese

data

may

refle

ct d

ata

anom

alie

s in

the

subm

issi

on o

f MSI

S da

ta a

nd m

ay b

e up

date

d in

fu

ture

MSI

S su

bmis

sion

s. M

SIS

data

ano

mal

ies

have

bee

n co

mpi

led

and

repo

rted

by

Mat

hem

atic

a Po

licy

Rese

arch

; the

dat

a an

omal

ies

repo

rt m

ay b

e fo

und

at: h

ttp:

//w

ww

.cm

s.go

v/Re

sear

ch-S

tatis

tics-

Data

-and

-Sys

tem

s/Co

mpu

ter-D

ata-

and-

Syst

ems/

Med

icai

dDat

aSou

rces

Gen

Info

/dow

nloa

ds/a

nom

alie

s1.p

df.

3 W

hen

com

pare

d to

the

Dece

mbe

r 201

5 ed

ition

of t

his

tabl

e, D

istr

ict o

f Col

umbi

a an

d M

assa

chus

etts

had

a c

hang

e in

tota

l FYE

enr

olle

es o

f 10

perc

ent o

r mor

e ov

er th

e pr

ior

year

. How

ever

, bot

h st

ates

hav

e si

nce

upda

ted

thei

r 201

2 en

rollm

ent t

otal

and

no

long

er h

as a

cha

nge

of 1

0 pe

rcen

t or m

ore.

4 St

ates

wer

e ex

clud

ed d

ue to

dat

a re

liabi

lity

conc

erns

rega

rdin

g co

mpl

eten

ess

of m

onth

ly c

laim

s an

d en

rollm

ent d

ata.

5 Du

e to

larg

e di

ffer

ence

s in

the

way

spe

ndin

g is

repo

rted

by

Verm

ont i

n CM

S-64

and

MSI

S da

ta, M

ACPA

C’s

adju

stm

ent m

etho

dolo

gy is

onl

y ap

plie

d to

tota

l Med

icai

d sp

endi

ng.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

MSI

S da

ta a

s of

Dec

embe

r 201

5 an

d CM

S-64

Fin

anci

al M

anag

emen

t Rep

ort n

et e

xpen

ditu

re d

ata

as o

f Jun

e 20

16.

EXH

IBIT

22.

(co

ntin

ued)






MAC

Stat

s

Stat

e1

Inpa

tient

and

out

patie

nt h

ospi

tals

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l Med

icai

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ymen

tsDS

H p

aym

ents

Non

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sup

plem

enta

l pa

ymen

tsSe

ctio

n 11

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aive

r au

thor

ity p

aym

ents

Supp

lem

enta

l pa

ymen

ts a

s %

of t

otal

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7,27

8.9

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663.

2$2

0,24

9.9

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931.

649

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ama

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aska

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614

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20,7

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865.

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ada

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ico

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Sect

ion

3

EXH

IBIT

23.

Med

icai

d Su

pple

men

tal P

aym

ents

to H

ospi

tal P

rovi

ders

by

Stat

e, F

Y 20

15 (m

illio

ns)

December 201660


MAC

Stat

sSe

ctio

n 3

Stat

e1

Inpa

tient

and

out

patie

nt h

ospi

tals

2

Tota

l Med

icai

d pa

ymen

tsDS

H p

aym

ents

Non

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sup

plem

enta

l pa

ymen

tsSe

ctio

n 11

15 w

aive

r au

thor

ity p

aym

ents

Supp

lem

enta

l pa

ymen

ts a

s %

of t

otal

Okl

ahom

a$1

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0.2

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rego

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1,43

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ode

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nd35

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h Ca

rolin

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078.

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esse

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xas3,

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680

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tah

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ont

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ashi

ngto

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est V

irgin

ia73

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Wis

cons

in77

5.1

31.4

57.6

–11

.5W

yom

ing

126.

50.

518

.9–

15.3

Not

es: F

Y is

fisc

al y

ear.

DSH

is d

ispr

opor

tiona

te s

hare

hos

pita

l. In

clud

es fe

dera

l and

sta

te fu

nds.

Exc

lude

s pa

ymen

ts m

ade

unde

r man

aged

car

e ar

rang

emen

ts. A

ll am

ount

s in

this

tabl

e ar

e as

repo

rted

by s

tate

s in

CM

S-64

dat

a du

ring

the

fisca

l yea

r to

obta

in fe

dera

l mat

chin

g fu

nds;

am

ount

s in

clud

e ex

pend

iture

s fo

r the

cur

rent

fisc

al y

ear a

nd a

djus

tmen

ts to

exp

endi

ture

s fo

r prio

r fis

cal y

ears

that

may

be

posi

tive

or n

egat

ive.

Am

ount

s re

porte

d by

sta

tes

for a

ny g

iven

cat

egor

y (e

.g., i

npat

ient

hos

pita

l) so

met

imes

sho

w s

ubst

antia

l ann

ual f

luct

uatio

ns. T

he

Cent

ers

for M

edic

are

& M

edic

aid

Serv

ices

onl

y be

gan

to re

quire

sep

arat

e re

porti

ng o

f non

-DSH

sup

plem

enta

l pay

men

ts in

FY

2010

and

is c

ontin

uing

to w

ork

with

sta

tes

to s

tand

ardi

ze th

is

repo

rting

. As

a re

sult,

the

info

rmat

ion

pres

ente

d m

ay n

ot re

flect

a c

onsi

sten

t cla

ssifi

catio

n of

sup

plem

enta

l pay

men

t spe

ndin

g ac

ross

sta

tes.

Rep

ortin

g is

exp

ecte

d to

impr

ove

over

tim

e.

– D

ash

indi

cate

s ze

ro; $

0.0

indi

cate

s an

am

ount

less

than

$0.

05 m

illio

n th

at ro

unds

to z

ero.

1 N

ot a

ll st

ates

had

cer

tifie

d th

eir C

MS-

64 F

inan

cial

Man

agem

ent R

epor

t (FM

R) s

ubm

issi

ons

as o

f May

24,

201

6. C

alifo

rnia

’s fi

rst,

seco

nd, t

hird

, and

four

th q

uart

er

subm

issi

ons

are

not c

ertif

ied;

Col

orad

o an

d N

orth

Dak

ota’

s se

cond

, thi

rd, a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t cer

tifie

d; N

ew J

erse

y's th

ird a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t cer

tifie

d. F

igur

es p

rese

nted

in th

is e

xhib

it m

ay c

hang

e if

stat

es re

vise

thei

r exp

endi

ture

dat

a af

ter t

his

date

.2

Incl

udes

inpa

tient

, out

patie

nt, c

ritic

al a

cces

s ho

spita

l, an

d em

erge

ncy

hosp

ital c

ateg

orie

s in

the

CMS-

64 d

ata.

The

CM

S-64

inst

ruct

ions

to s

tate

s no

te th

at D

SH p

aym

ents

ar

e th

ose

mad

e in

acc

orda

nce

with

Sec

tion

1923

of t

he S

ocia

l Sec

urity

Act

. Non

-DSH

sup

plem

enta

l pay

men

ts a

re d

escr

ibed

in th

e CM

S-64

inst

ruct

ions

to s

tate

s as

thos

e m

ade

in a

dditi

on to

the

stan

dard

fee

sche

dule

or o

ther

sta

ndar

d pa

ymen

t for

a g

iven

ser

vice

. The

y in

clud

e pa

ymen

ts m

ade

unde

r ins

titut

iona

l upp

er p

aym

ent l

imit

rule

s an

d pa

ymen

ts to

hos

pita

ls fo

r gra

duat

e m

edic

al e

duca

tion.

Sec

tion

1115

wai

ver e

xpen

ditu

re a

utho

rity

paym

ents

incl

ude

thos

e m

ade

unde

r unc

ompe

nsat

ed c

are

pool

s, d

eliv

ery

syst

em re

form

ince

ntiv

e pa

ymen

ts (D

SRIP

), an

d ot

her n

on-D

SH s

uppl

emen

tal p

aym

ents

that

hav

e be

en a

utho

rized

und

er S

ectio

n 11

15 w

aive

rs. B

ecau

se th

e m

ajor

ity o

f DSR

IP

paym

ents

go

to h

ospi

tals

, DSR

IP p

aym

ents

that

wer

e re

port

ed a

s ot

her c

are

serv

ices

on

the

CMS-

64 w

ere

incl

uded

in th

e Se

ctio

n 11

15 w

aive

r exp

endi

ture

cat

egor

y an

d th

e to

tal h

ospi

tal p

aym

ent c

ateg

ory.

3 St

ate

mad

e su

pple

men

tal p

aym

ents

thro

ugh

an u

ncom

pens

ated

car

e po

ol u

nder

Sec

tion

1115

wai

ver e

xpen

ditu

re a

utho

rity.

4

Stat

e m

ade

supp

lem

enta

l pay

men

ts th

roug

h a

DSRI

P un

der S

ectio

n 11

15 w

aive

r exp

endi

ture

aut

horit

y.5

Stat

e m

ade

othe

r sup

plem

enta

l pay

men

ts, i

nclu

ding

gra

duat

e m

edic

al e

duca

tion,

und

er S

ectio

n 11

15 w

aive

r exp

endi

ture

aut

horit

y.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

CM

S-64

FM

R ne

t exp

endi

ture

dat

a as

of M

ay 2

4, 2

016

and

CMS-

64 S

ched

ule

C w

aive

r rep

ort d

ata

as o

f Aug

ust 2

, 201

6.

EXH

IBIT

23.

(co

ntin

ued)



MAC

Stat

sSe

ctio

n 3

Stat

e1

Men

tal h

ealth

faci

litie

s2N

ursi

ng fa

cilit

ies

and

ICFs

/ID3

Phys

icia

ns a

nd o

ther

pra

ctiti

oner

s4

Tota

l M

edic

aid

paym

ents

Supp

lem

enta

l pa

ymen

ts

Supp

lem

enta

l pa

ymen

ts a

s

% o

f tot

al

Tota

l M

edic

aid

paym

ents

Supp

lem

enta

l pa

ymen

ts

Supp

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25.

(co

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December 201666


MAC

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EXH

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25.

(co

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https://www.medicaid.gov/medicaid/prescription-drugs/state-drug-utilization-data/index.html


https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/data/index.html




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68.5

0.0

32,1

8721

.678

.40.

0U

tah

2,78

318

.681

.4–

1,28

919

.680

.4–

1,49

417

.782

.3–

Verm

ont

1,53

824

.875

.20.

01,

538

24.8

75.2

0.0

––

––

Virg

inia

9,91

717

.581

.11.

41,

945

17.7

76.8

5.5

7,97

217

.582

.10.

4W

ashi

ngto

n14

,776

14.1

85.5

0.5

2,22

413

.585

.51.

012

,552

14.2

85.5

0.4

Wes

t Virg

inia

9,38

217

.682

.20.

27,

350

17.3

82.5

0.2

2,03

218

.881

.00.

1W

isco

nsin

11,8

2021

.378

.70.

111

,741

21.3

78.6

0.1

799.

890

.10.

1W

yom

ing

455

21.0

78.9

0.1

455

21.0

78.9

0.1

––

––

Not

es: F

Y is

fisc

al y

ear.

Drug

util

izat

ion

in th

is e

xhib

it re

flect

s th

e nu

mbe

r of p

resc

riptio

ns re

port

ed in

the

stat

e dr

ug u

tiliz

atio

n da

ta th

at s

tate

s su

bmit

to th

e Ce

nter

s fo

r M

edic

are

& M

edic

aid

Serv

ices

(CM

S) fo

r reb

ate

purp

oses

, and

are

diff

eren

t fro

m M

edic

aid

Stat

istic

al In

form

atio

n Sy

stem

(MSI

S) d

ata

that

ser

ve a

s ou

r usu

al s

ourc

e of

ut

iliza

tion

data

. Util

izat

ion

show

n in

the

drug

util

izat

ion

data

may

diff

er fr

om th

ese

othe

r sou

rces

due

to d

iffer

ence

s in

tim

ing

and

run-

out o

f dat

a us

ed. I

n ad

ditio

n, th

e dr

ug

utili

zatio

n da

ta m

ay in

clud

e ph

ysic

ian-

adm

inis

tere

d dr

ugs

for w

hich

reba

tes

are

avai

labl

e; th

ese

drug

s ar

e ty

pica

lly re

port

ed u

nder

the

phys

icia

n se

rvic

es c

ateg

ory

inst

ead

of

the

outp

atie

nt p

resc

riptio

n dr

ug c

ateg

ory

in o

ther

dat

a. T

he s

tate

dru

g ut

iliza

tion

data

pro

vide

bot

h fe

e-fo

r-ser

vice

and

man

aged

car

e dr

ug u

tiliz

atio

n an

d sp

endi

ng in

form

atio

n at

the

natio

nal d

rug

code

(NDC

) lev

el. T

o as

sign

bra

nd a

nd g

ener

ic s

tatu

s, w

e lin

ked

the

quar

terly

sta

te d

rug

utili

zatio

n da

ta to

the

quar

terly

Med

icai

d dr

ug p

rodu

ct d

ata

from

CM

S us

ing

the

NDC

cod

e. B

rand

and

gen

eric

sta

tus

was

ass

igne

d us

ing

the

drug

cat

egor

y in

dica

tor f

rom

the

drug

pro

duct

file

. The

sta

te d

rug

utili

zatio

n da

ta a

re a

vaila

ble

at

http

s://

ww

w.m

edic

aid.

gov/

med

icai

d/pr

escr

iptio

n-dr

ugs/

stat

e-dr

ug-u

tiliz

atio

n-da

ta/i

ndex

.htm

l and

the

drug

pro

duct

dat

a ar

e av

aila

ble

at h

ttps

://w

ww

.med

icai

d.go

v/m

edic

aid/

pres

crip

tion-

drug

s/m

edic

aid-

drug

-reba

te-p

rogr

am/d

ata/

inde

x.ht

ml.

Begi

nnin

g in

Oct

ober

201

6, C

MS,

as

oblig

ated

by

the

Priv

acy

Act o

f 197

4 (5

U.S

.C. §

552

a) a

nd th

e H

ealth

In

sura

nce

Port

abili

ty a

nd A

ccou

ntab

ility

Act

priv

acy

rule

(45

CFR

Part

s 16

0 an

d 16

4), s

uppr

esse

d al

l rec

ords

in th

e st

ate

drug

util

izat

ion

data

that

are

less

than

11

coun

ts.

The

diff

eren

t bra

nd a

nd g

ener

ic p

ropo

rtio

ns u

nder

fee

for s

ervi

ce a

nd m

anag

ed c

are

may

refle

ct d

iffer

ence

s in

the

popu

latio

ns a

nd s

peci

fic d

rugs

cov

ered

und

er e

ach

deliv

ery

syst

em (e

.g.,

beha

vior

al h

ealth

dru

gs c

arve

d ou

t of m

anag

ed c

are)

, as

wel

l as

diff

eren

ces

in h

ow th

e st

ate

and

part

icip

atin

g he

alth

pla

ns m

anag

ed th

e dr

ug b

enef

it.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 Fo

r thi

s ex

hibi

t, br

and

drug

s w

ere

defin

ed a

s si

ngle

sou

rce

drug

s an

d in

nova

tor,

mul

tiple

sou

rce

drug

s as

indi

cate

d in

that

qua

rter

’s M

edic

aid

drug

pro

duct

dat

a.2

For t

his

exhi

bit,

gene

ric d

rugs

wer

e de

fined

as

non-

inno

vato

r, m

ultip

le s

ourc

e dr

ugs

as in

dica

ted

in th

at q

uart

er’s

Med

icai

d dr

ug p

rodu

ct fi

le.

3 Fo

r thi

s ex

hibi

t, un

know

n dr

ugs

wer

e th

ose

drug

s w

hose

NDC

did

not

hav

e a

mat

ch in

that

qua

rter

’s M

edic

aid

drug

pro

duct

file

.4

The

natio

nal t

otal

doe

s no

t equ

al th

e su

m o

f the

sta

tes

due

to th

e su

ppre

ssio

n of

reco

rds

(as

desc

ribed

in th

e N

otes

abo

ve).

Reco

rds

for d

rugs

that

wer

e su

ppre

ssed

at

the

stat

e le

vel w

ere

not n

eces

saril

y su

ppre

ssed

onc

e th

e in

divi

dual

sta

te d

ata

wer

e ro

lled

up in

to th

e na

tiona

l sum

mar

y fil

e. W

hile

we

do n

ot k

now

how

man

y pr

escr

iptio

ns

has

been

sup

pres

sed

in th

e na

tiona

l sum

mar

y fil

e, c

ompa

rison

of t

he u

pdat

ed F

Y 20

14 fi

les

with

dat

a su

ppre

ssio

n to

last

yea

r's M

ACSt

ats

indi

cate

that

abo

ut 4

mill

ion

pres

crip

tions

(0.7

per

cent

) hav

e be

en s

uppr

esse

d in

the

FY 2

014

data

. So

urce

: MAC

PAC,

201

6, a

naly

sis

of M

edic

aid

drug

pro

duct

dat

a an

d st

ate

drug

reba

te u

tiliz

atio

n da

ta a

s of

Oct

ober

201

6.

EXH

IBIT

26.

(co

ntin

ued)






MAC

Stat

sSe

ctio

n 3

Stat

eG

ross

spe

ndin

gRe

bate

sTo

tal

Fee

for s

ervi

ceM

anag

ed c

are

Tota

lFe

e fo

r ser

vice

Man

aged

car

eTo

tal1

$53,

036.

3$2

3,96

1.7

$29,

074.

6-$

24,0

12.8

-$12

,135

.5-$

11,8

77.3

Alab

ama

605.

760

5.7

–-3

30.8

-330

.8–

Alas

ka67

.467

.4–

-37.

8-3

7.8

–

Ariz

ona

909.

09.

989

9.1

-395

.3-8

.5-3

86.8

Arka

nsas

358.

835

8.8

–-2

16.8

-216

.8–

Calif

orni

a6,

404.

14,

056.

82,

347.

3-2

,633

.3-2

,127

.2-5

06.1

Colo

rado

674.

867

4.8

–-3

76.6

-373

.0-3

.6

Conn

ectic

ut1,

116.

61,

116.

6–

-583

.5-5

83.5

–

Dela

war

e220

2.9

49.5

153.

4-1

29.5

-123

.1-6

.4

Dist

rict o

f Col

umbi

a13

0.6

72.1

58.5

-83.

7-4

5.4

-38.

3

Flor

ida

2,61

5.5

563.

52,

051.

9-1

,316

.0-4

45.8

-870

.2

Geo

rgia

1,05

4.7

651.

340

3.5

-486

.6-3

15.3

-171

.3

Haw

aii3

881.

80.

288

1.6

-61.

0-0

.3-6

0.7

Idah

o17

1.1

171.

1–

-104

.5-1

04.5

–

Illin

ois

1,18

8.3

671.

051

7.4

-577

.7-4

08.3

-169

.3

Indi

ana2

1,09

7.5

829.

326

8.2

-615

.7-5

87.1

-28.

6

Iow

a43

2.6

431.

61.

0-2

58.8

-258

.8-0

.0

Kans

as28

9.6

0.4

289.

2-2

24.7

-1.8

-222

.9

Kent

ucky

1,04

2.0

63.8

978.

2-4

31.1

-45.

6-3

85.5

Loui

sian

a70

3.1

226.

947

6.2

-385

.2-1

00.5

-284

.7

Mai

ne22

7.5

227.

5–

-141

.2-1

41.2

–

Mar

ylan

d99

3.1

502.

549

0.6

-504

.6-2

59.2

-245

.4

Mas

sach

uset

ts1,

113.

652

4.9

588.

7-5

41.9

-283

.0-2

58.9

Mic

higa

n1,

552.

289

4.8

657.

4-8

13.5

-519

.4-2

94.1

Min

neso

ta86

4.5

224.

564

0.0

-436

.9-2

32.1

-204

.8

Mis

siss

ippi

250

7.6

203.

930

3.6

-237

.8-1

43.3

-94.

4

Mis

sour

i41,

199.

01,

199.

0–

-542

.2-5

60.6

18.4

Mon

tana

97.8

97.8

–-6

0.9

-60.

9–

EXH

IBIT

27.

Med

icai

d G

ross

Spe

ndin

g an

d Re

bate

s fo

r Dru

gs b

y De

liver

y Sy

stem

, FY

2015

(mill

ions

)

December 201670


MAC

Stat

sSe

ctio

n 3

EXH

IBIT

27.

(co

ntin

ued)

Stat

eG

ross

spe

ndin

gRe

bate

sTo

tal

Fee

for s

ervi

ceM

anag

ed c

are

Tota

lFe

e fo

r ser

vice

Man

aged

car

eN

ebra

ska5

$168

.5$1

62.6

$5.9

-$98

.5-$

98.5

–

Nev

ada

333.

621

2.3

121.

3-1

81.0

-115

.6-$

65.4

New

Ham

pshi

re10

5.8

7.5

98.3

-97.

2-1

8.2

-79.

0

New

Jer

sey

1,35

2.6

47.6

1,30

5.0

-632

.4-3

8.7

-593

.7

New

Mex

ico

261.

65.

425

6.2

-200

.8-4

.8-1

96.0

New

Yor

k65,

306.

667

8.9

4,62

7.7

-2,2

04.4

306.

4-2

,510

.9

Nor

th C

arol

ina

1,65

6.1

1,65

6.1

–-9

06.1

-906

.1–

Nor

th D

akot

a253

.431

.222

.2-1

3.8

-10.

3-3

.5

Ohi

o2,

418.

437

5.5

2,04

2.9

-1,0

68.0

-323

.8-7

44.2

Okl

ahom

a46

5.3

465.

3–

-228

.9-2

28.9

–

Ore

gon

589.

515

2.8

436.

7-2

84.0

-84.

5-1

99.5

Penn

sylv

ania

2,12

0.7

67.2

2,05

3.5

-996

.0-5

7.1

-938

.9

Rhod

e Is

land

74.

04.

0–

-85.

4-1

3.3

-72.

1

Sout

h Ca

rolin

a47

5.8

92.5

383.

3-2

44.7

-59.

3-1

85.4

Sout

h Da

kota

81.2

81.2

–-3

3.8

-33.

8–

Tenn

esse

e593

1.3

876.

754

.6-6

08.5

-608

.5–

Texa

s3,

155.

167

9.5

2,47

5.7

-1,8

70.3

-502

.3-1

,367

.9

Uta

h18

0.0

112.

667

.4-1

11.9

-67.

3-4

4.5

Verm

ont

158.

815

8.8

–-9

6.9

-96.

9–

Virg

inia

900.

010

0.4

799.

6-3

22.3

-23.

9-2

98.4

Was

hing

ton

794.

412

8.9

665.

5-3

90.6

-83.

6-3

07.0

Wes

t Virg

inia

528.

843

3.4

95.5

-305

.1-2

52.4

-52.

8

Wis

cons

in97

8.3

977.

01.

3-4

79.4

-475

.0-4

.4

Wyo

min

g34

.234

.2–

-25.

1-2

5.1

–



MAC

Stat

sSe

ctio

n 3

EXH

IBIT

27.

(co

ntin

ued)

Not

es: F

Y is

fisc

al y

ear.

Amou

nts

incl

ude

fede

ral a

nd s

tate

fund

s. G

ross

spe

ndin

g re

flect

s ex

pend

iture

s pr

ior t

o th

e ap

plic

atio

n of

man

ufac

ture

r reb

ates

. The

gro

ss d

rug

expe

nditu

res

in th

is e

xhib

it us

e in

form

atio

n fr

om th

e st

ate

drug

util

izat

ion

data

that

sta

tes

subm

it to

the

Cent

ers

for M

edic

are

& M

edic

aid

Serv

ices

(CM

S) fo

r reb

ate

purp

oses

, and

are

diff

eren

t fro

m th

e CM

S-64

Fin

anci

al M

anag

emen

t Rep

ort (

FMR)

and

Med

icai

d St

atis

tical

Info

rmat

ion

Syst

em (M

SIS)

dat

a th

at s

erve

as

our u

sual

sou

rces

of

exp

endi

ture

dat

a. S

pend

ing

show

n in

the

drug

util

izat

ion

data

may

diff

er fr

om th

ese

othe

r sou

rces

due

to d

iffer

ence

s in

tim

ing

and

run-

out o

f dat

a us

ed. I

n ad

ditio

n, th

e dr

ug re

bate

dat

a m

ay in

clud

e ph

ysic

ian-

adm

inis

tere

d dr

ugs

for w

hich

reba

tes

are

avai

labl

e; th

e sp

endi

ng fo

r the

se d

rugs

are

typi

cally

repo

rted

und

er th

e ph

ysic

ian

serv

ices

ca

tego

ry in

stea

d of

the

outp

atie

nt p

resc

riptio

n dr

ug c

ateg

ory

in o

ther

dat

a. T

he s

tate

dru

g ut

iliza

tion

data

pro

vide

bot

h fe

e-fo

r-ser

vice

and

man

aged

car

e dr

ug u

tiliz

atio

n an

d sp

endi

ng in

form

atio

n at

the

natio

nal d

rug

code

leve

l, w

hich

is n

ot a

vaila

ble

in C

MS-

64 d

ata.

The

sta

te d

rug

utili

zatio

n da

ta a

re a

vaila

ble

at h

ttps

://w

ww

.med

icai

d.go

v/m

edic

aid/

pres

crip

tion-

drug

s/st

ate-

drug

-util

izat

ion-

data

/inde

x.ht

ml.

Begi

nnin

g in

Oct

ober

201

6, C

MS,

as

oblig

ated

by

the

Priv

acy

Act o

f 197

4 (5

U.S

.C. §

552

a) a

nd th

e H

ealth

Insu

ranc

e Po

rtab

ility

and

Acc

ount

abili

ty A

ct p

rivac

y ru

le (4

5 CF

R Pa

rts

160

and

164)

, has

sup

pres

sed

all r

ecor

ds in

the

stat

e dr

ug u

tiliz

atio

n da

ta th

at a

re le

ss th

an 1

1 co

unts

. The

dru

g re

bate

info

rmat

ion

com

es fr

om th

e CM

S-64

and

doe

s al

low

sta

tes

to s

epar

atel

y id

entif

y fe

e-fo

r-ser

vice

and

man

aged

car

e dr

ug re

bate

s. T

he re

bate

tota

ls s

how

n he

re in

clud

e fe

dera

l reb

ates

, sta

te s

uppl

emen

tal r

ebat

es, a

nd th

e re

bate

incr

ease

s at

trib

utab

le to

the

Affo

rdab

le C

are

Act.

Due

to th

e tim

e it

take

s to

col

lect

the

drug

util

izat

ion

info

rmat

ion

and

invo

ice

drug

man

ufac

ture

rs fo

r the

reba

te, t

he re

bate

s co

llect

ed in

any

par

ticul

ar q

uart

er a

re g

ener

ally

at

trib

utab

le to

dru

gs p

urch

ased

in p

rior q

uart

ers;

thus

, the

gro

ss s

pend

ing

and

reba

te d

olla

rs fo

r a g

iven

tim

e pe

riod

are

not n

eces

saril

y al

igne

d. C

hang

es in

cov

ered

po

pula

tions

or b

enef

it de

sign

(e.g

., m

anag

ed c

are

expa

nsio

n or

pha

rmac

y ca

rve-

in) c

an c

reat

e di

stor

tions

in th

e da

ta, b

ecau

se c

hang

es w

ill b

e re

flect

ed in

gro

ss s

pend

ing

befo

re th

ey a

re re

flect

ed in

reba

tes

colle

cted

.

– D

ash

indi

cate

s ze

ro; -

$0.0

indi

cate

s an

am

ount

bet

wee

n ze

ro a

nd -$

0.5

mill

ion

that

roun

ds to

zer

o.1

The

natio

nal t

otal

for g

ross

spe

ndin

g do

es n

ot e

qual

the

sum

of t

he s

tate

s du

e to

the

supp

ress

ion

of re

cord

s (a

s de

scrib

ed in

the

Not

es a

bove

). Re

cord

s fo

r dru

gs th

at w

ere

supp

ress

ed a

t the

sta

te le

vel w

ere

not n

eces

saril

y su

ppre

ssed

onc

e th

e in

divi

dual

sta

te d

ata

wer

e ro

lled

up in

to th

e na

tiona

l sum

mar

y fil

e. W

hile

we

do n

ot k

now

how

muc

h sp

endi

ng h

as b

een

supp

ress

ed in

the

natio

nal s

umm

ary

file,

com

paris

on o

f the

upd

ated

FY

2014

file

s w

ith d

ata

supp

ress

ion

to la

st y

ear's

MAC

Stat

s in

dica

te th

at a

bout

$37

0 m

illio

n do

llars

(0.9

per

cent

) hav

e be

en s

uppr

esse

d in

the

FY 2

014

data

. 2

Stat

e re

cent

ly c

arve

d th

e ph

arm

acy

bene

fit in

to m

anag

ed c

are,

impl

emen

ted

a ne

w m

anag

ed c

are

prog

ram

, or e

xpan

ded

thei

r man

aged

car

e pr

ogra

m. T

his

chan

ge c

reat

es a

la

rge

diff

eren

ce b

etw

een

gros

s sp

endi

ng a

nd re

bate

col

lect

ions

for f

ee fo

r ser

vice

and

man

aged

car

e, re

sulti

ng in

ano

mal

ous

reba

te p

erce

ntag

es a

t the

del

iver

y sy

stem

leve

l.3

Haw

aii's

man

aged

car

e sp

endi

ng m

ore

than

dou

bled

from

FY

2014

whi

le p

resc

riptio

n vo

lum

e an

d re

bate

s re

mai

ned

abou

t the

sam

e.4

Mis

sour

i rep

orts

a p

ositi

ve m

anag

ed c

are

reba

te a

mou

nt. T

he s

tate

mad

e pr

ior p

erio

d ad

just

men

ts to

off

set t

he m

anag

ed c

are

drug

reba

tes

repo

rted

in F

Y 20

14.

5 St

ate

gene

rally

car

ves

out p

resc

riptio

n dr

ugs

from

the

man

aged

car

e pr

ogra

m. S

tate

man

aged

car

e sp

endi

ng m

ay re

flect

phy

sici

an-a

dmin

iste

red

drug

s; h

owev

er, r

ebat

es fo

r th

ese

man

aged

car

e ex

pend

iture

s ar

e no

t rep

orte

d se

para

tely

in th

e CM

S-64

dat

a an

d ap

pear

to b

e re

port

ed w

ith th

e fe

e-fo

r-ser

vice

reba

tes.

6 N

ew Y

ork

repo

rts

a po

sitiv

e fe

e-fo

r-ser

vice

reba

te a

mou

nt. T

he s

tate

mad

e pr

ior p

erio

d ad

just

men

ts to

recl

assi

fy s

ome

fee-

for-s

ervi

ce d

rug

reba

tes

as m

anag

ed c

are.

7 Rh

ode

Isla

nd h

as n

ot re

port

ed a

ny m

anag

ed c

are

drug

util

izat

ion

sinc

e th

e se

cond

qua

rter

of F

Y 20

13.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

Med

icai

d st

ate

drug

reba

te u

tiliz

atio

n da

ta a

s of

Oct

ober

201

6 an

d CM

S-64

FM

R ne

t exp

endi

ture

dat

a as

of M

ay 2

4, 2

016.



December 201672

Section 3: Program Enrollment and Spending—Medicaid Managed Care

MAC

Stat

sSe

ctio

n 3

Stat

eTo

tal M

edic

aid

enro

llees

Perc

enta

ge o

f enr

olle

es in

man

aged

car

e

Com

preh

ensi

ve

man

aged

car

e1

Lim

ited-

bene

fit p

lans

PCCM

MLT

SSBH

O (P

IHP

and/

or P

AHP)

Dent

alTr

ansp

orta

tion

Oth

erTo

tal

70,2

46,1

9759

.7%

0.3%

15.5

%9.

3%11

.3%

1.7%

10.3

%

Alab

ama

1,05

4,94

10.

0–

––

–1.

958

.8

Alas

ka13

2,55

6–

––

––

––

Ariz

ona

1,54

8,32

585

.1–

––

––

–

Arka

nsas

595,

807

0.0

––

–86

.3–

81.7

Calif

orni

a11

,522

,853

67.8

–0.

07.

0–

0.0

–

Colo

rado

1,07

9,69

96.

1–

95.1

––

2.5

60.7

Conn

ectic

ut72

4,74

1–

––

––

––

Dela

war

e22

7,55

486

.2–

––

––

–

Dist

rict o

f Col

umbi

a25

7,45

066

.9–

––

20.4

––

Flor

ida2

3,53

1,94

575

.32.

40.

00.

0–

0.0

0.0

Geo

rgia

1,96

1,08

568

.6–

––

–0.

6–

Haw

aii

321,

027

98.5

––

––

––

Idah

o26

6,17

20.

3–

96.0

99.7

98.6

–91

.5

Illin

ois

3,24

9,83

513

.5–

––

––

53.1

Indi

ana

1,17

6,44

762

.7–

––

––

3.1

Iow

a59

3,57

29.

9–

89.6

–71

.1–

52.1

Kans

as39

9,29

989

.3–

––

––

–

Kent

ucky

1,20

9,55

289

.4–

––

––

–

Loui

sian

a1,

305,

671

32.1

–78

.779

.2–

–37

.0

Mai

ne26

2,33

4–

––

––

–61

.5

Mar

ylan

d1,

309,

260

82.8

––

––

––

Mas

sach

uset

ts1,

878,

120

42.8

–16

.3–

––

16.3

Mic

higa

n3,

871,

806

47.3

–50

.213

.3–

––

Min

neso

ta1,

112,

174

71.1

––

––

––

Mis

siss

ippi

699,

153

22.2

––

––

––

EXH

IBIT

28.

Per

cent

age

of M

edic

aid

Enro

llees

in M

anag

ed C

are

by S

tate

, Jul

y 1,

201

4



MAC

Stat

sSe

ctio

n 3

Stat

eTo

tal M

edic

aid

enro

llees

Perc

enta

ge o

f enr

olle

es in

man

aged

car

e

Com

preh

ensi

ve

man

aged

car

e1

Lim

ited-

bene

fit p

lans

PCCM

MLT

SSBH

O (P

IHP

and/

or P

AHP)

Dent

alTr

ansp

orta

tion

Oth

erM

isso

uri

825,

974

47.1

%–

––

49.5

%–

–

Mon

tana

131,

923

––

––

––

69.0

%

Neb

rask

a24

2,57

875

.7–

94.7

%–

––

–

Nev

ada

533,

734

67.5

––

–86

.9–

7.1

New

Ham

pshi

re14

2,31

585

.1–

––

––

–

New

Jer

sey

1,54

2,02

285

.3–

––

92.0

––

New

Mex

ico

727,

214

79.8

––

––

––

New

Yor

k5,

845,

589

73.4

2.1%

––

––

–

Nor

th C

arol

ina

1,71

7,65

80.

1–

95.1

––

–81

.6

Nor

th D

akot

a79

,031

14.9

––

––

0.3%

57.1

Ohi

o2,

796,

017

72.5

––

––

––

Okl

ahom

a82

6,43

40.

0–

––

89.2

–64

.3

Ore

gon3

1,05

1,64

578

.8–

0.4

22.6

%–

––

Penn

sylv

ania

2,15

2,84

677

.7–

91.6

–22

.1–

–

Rhod

e Is

land

263,

574

82.6

––

29.0

––

3.7

Sout

h Ca

rolin

a1,

089,

973

66.1

––

––

–0.

0

Sout

h Da

kota

122,

352

––

––

––

74.6

Tenn

esse

e31,

288,

631

100.

0–

–59

.6–

89.3

–

Texa

s4,

137,

121

78.1

–10

.765

.741

.6–

0.3

Uta

h28

7,75

470

.0–

98.1

46.3

81.5

––

Verm

ont4

188,

337

42.3

––

––

––

Virg

inia

961,

843

67.2

––

––

––

Was

hing

ton

1,24

5,32

210

0.0

–10

0.0

–10

0.0

––

Wes

t Virg

inia

486,

839

41.8

––

––

–0.

7

Wis

cons

in1,

199,

773

55.1

3.2

0.1

––

0.1

–

Wyo

min

g68

,320

0.1

––

––

––

EXH

IBIT

28.

(co

ntin

ued)

December 201674


MAC

Stat

sSe

ctio

n 3

EXH

IBIT

28.

(co

ntin

ued)

Not

es: P

CCM

is p

rimar

y ca

re c

ase

man

agem

ent.

MLT

SS is

man

aged

long

-term

ser

vice

s an

d su

ppor

ts. B

HO

is b

ehav

iora

l hea

lth o

rgan

izat

ion.

PIH

P is

pre

paid

inpa

tient

hea

lth

plan

. PAH

P is

pre

paid

am

bula

tory

hea

lth p

lan.

Exc

lude

s th

e te

rrito

ries.

Thi

s ex

hibi

t inc

lude

s M

edic

aid-

expa

nsio

n CH

IP e

nrol

lees

. Med

icai

d be

nefic

iarie

s m

ay b

e en

rolle

d co

ncur

rent

ly in

mor

e th

an o

ne ty

pe o

f man

aged

car

e pr

ogra

m (e

.g.,

a co

mpr

ehen

sive

pla

n an

d a

BHO

), so

the

sum

of e

nrol

lmen

t in

each

pro

gram

type

as

a pe

rcen

tage

of t

otal

M

edic

aid

enro

llmen

t may

be

grea

ter t

han

100

perc

ent.

– D

ash

indi

cate

s ze

ro. 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 In

clud

es c

ompr

ehen

sive

man

aged

car

e an

d Pr

ogra

ms

of A

ll-In

clus

ive

Care

for t

he E

lder

ly. C

ompr

ehen

sive

man

aged

car

e or

gani

zatio

ns (M

COs)

cov

er a

cute

, prim

ary,

and

spec

ialty

med

ical

car

e se

rvic

es; t

hey

may

als

o co

ver b

ehav

iora

l hea

lth, l

ong-

term

ser

vice

s an

d su

ppor

ts, a

nd o

ther

ben

efits

in s

ome

stat

es.

2 Fl

orid

a re

port

ed e

nrol

lmen

t as

of A

ugus

t 1, 2

014.

3 So

me

plan

s th

at a

ppea

r to

be li

mite

d-be

nefit

pla

ns (d

enta

l, BH

O, o

r oth

er m

anag

ed c

are)

wer

e cl

assi

fied

as c

ompr

ehen

sive

man

aged

car

e in

the

Cent

ers

for M

edic

are

& M

edic

aid

Serv

ices

(CM

S) re

port

. The

val

ues

show

n he

re u

se p

lan-

leve

l inf

orm

atio

n in

the

CMS

repo

rt to

reca

tego

rize

enro

llmen

t in

thos

e lim

ited-

bene

fit p

lans

as

BHO,

den

tal,

or

othe

r man

aged

car

e.4

The

Depa

rtm

ent o

f Ver

mon

t Hea

lth A

cces

s, a

sta

te a

genc

y, ac

ts a

s Ve

rmon

t’s s

ingl

e M

CO e

ntity

.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

dat

a fr

om C

MS,

201

6, M

edic

aid

man

aged

car

e en

rollm

ent a

nd p

rogr

am c

hara

cter

istic

s, 2

014,

htt

p://

ww

w.m

edic

aid.

gov/

med

icai

d-ch

ip-p

rogr

am-

info

rmat

ion/

by-to

pics

/dat

a-an

d-sy

stem

s/m

edic

aid-

man

aged

-car

e/do

wnl

oads

/201

4-m

edic

aid-

man

aged

-car

e-en

rollm

ent-r

epor

t.pdf

.

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/medicaid-managed-care/downloads/2014-medicaid-managed-care-enrollment-report.pdf

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/medicaid-managed-care/downloads/2014-medicaid-managed-care-enrollment-report.pdf



MAC

Stat

sSe

ctio

n 3

Stat

e

Tota

l M

edic

aid

enro

llees

(th

ousa

nds)

Perc

enta

ge o

f enr

olle

es in

man

aged

car

eCo

mpr

ehen

sive

man

aged

car

e1Li

mite

d-be

nefit

pla

nsPr

imar

y ca

re c

ase

man

agem

ent

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Tota

l70

,134

53.9

%67

.8%

50.9

%40

.2%

18.1

%49

.5%

58.8

%35

.9%

53.1

%40

.7%

12.7

%17

.4%

9.3%

11.3

%2.

5%

Alab

ama

1,21

22.

4–

0.0

5.6

12.4

––

––

–46

.069

.713

.444

.41.

4

Alas

ka13

6–

––

––

––

––

––

––

––

Ariz

ona

1,68

181

.191

.477

.966

.948

.190

.697

.684

.691

.371

.3–

––

––

Arka

nsas

696

0.0

–0.

0–

0.2

78.7

98.4

46.3

74.3

40.4

64.1

91.3

27.7

56.0

3.5

Calif

orni

a11

,742

49.6

76.5

29.4

67.2

34.7

68.2

94.1

37.1

99.6

96.5

––

––

–

Colo

rado

896

11.6

12.7

11.2

9.1

9.8

95.4

99.5

96.2

89.7

73.2

2.9

2.7

2.3

4.1

4.4

Conn

ectic

ut85

8–

––

––

––

––

––

––

––

Dela

war

e26

085

.995

.087

.867

.647

.889

.498

.990

.274

.249

.52.

11.

72.

52.

60.

5

Dist

rict o

f Co

lum

bia

246

73.9

92.1

93.3

22.1

3.0

37.3

20.1

28.3

80.5

69.9

––

––

–

Flor

ida

4,31

339

.653

.237

.226

.86.

346

.678

.313

.029

.52.

524

.233

.914

.224

.93.

4

Geo

rgia

2,01

368

.393

.987

.32.

80.

085

.296

.978

.674

.448

.2–

––

––

Haw

aii

300

98.2

99.8

99.6

96.4

88.9

2.2

2.0

0.0

8.9

1.5

––

––

–

Idah

o27

5–

––

––

94.4

99.9

97.6

84.7

64.9

85.5

93.6

84.9

74.5

44.6

Illin

ois

3,03

911

.09.

814

.511

.84.

84.

35.

94.

30.

10.

061

.976

.164

.429

.05.

0

Indi

ana

1,25

069

.192

.485

.111

.30.

2–

––

––

3.9

2.1

0.1

15.2

1.7

Iow

a63

46.

710

.55.

70.

30.

378

.999

.246

.892

.674

.159

.773

.872

.014

.43.

5

Kans

as44

246

.666

.052

.11.

70.

775

.082

.466

.474

.539

.45.

72.

91.

019

.62.

1

Kent

ucky

927

85.1

99.7

97.3

71.5

34.9

89.6

99.1

97.6

80.2

57.4

––

––

–

Loui

sian

a1,

284

0.0

––

0.0

0.3

83.6

66.1

100.

010

0.0

100.

036

.752

.623

.824

.311

.5

Mai

ne37

1–

––

––

––

––

–54

.478

.174

.129

.00.

7

Mar

ylan

d1,

139

81.7

97.5

86.7

59.6

2.1

––

––

––

––

––

Mas

sach

uset

ts1,

527

43.3

55.8

50.5

30.7

20.8

34.8

42.8

37.3

38.6

1.4

29.7

33.8

36.7

29.6

1.4

Mic

higa

n2,

291

73.1

87.5

70.7

58.9

11.5

93.8

98.9

85.0

95.2

85.7

––

––

–

Min

neso

ta1,

154

76.5

87.0

80.8

40.7

59.4

––

––

––

––

––

Mis

siss

ippi

786

25.6

10.9

69.9

42.3

1.0

87.3

99.9

82.9

78.6

54.8

––

––

–

EXH

IBIT

29.

Per

cent

age

of M

edic

aid

Enro

llees

in M

anag

ed C

are

by S

tate

and

Elig

ibili

ty G

roup

, FY

2013

December 201676


MAC

Stat

sSe

ctio

n 3

EXH

IBIT

29.

(co

ntin

ued)

Stat

e

Tota

l M

edic

aid

enro

llees

(th

ousa

nds)

Perc

enta

ge o

f enr

olle

es in

man

aged

car

eCo

mpr

ehen

sive

man

aged

car

e1Li

mite

d-be

nefit

pla

nsPr

imar

y ca

re c

ase

man

agem

ent

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Tota

lCh

ildre

nAd

ults

Disa

bled

Aged

Mis

sour

i1,

122

45.5

%67

.7%

50.0

%2.

0%0.

2%–

––

––

––

––

–

Mon

tana

142

––

––

–0.

6%–

0.0%

3.6%

0.1%

73.3

%92

.0%

75.8

%49

.8%

1.4%

Neb

rask

a26

273

.991

.983

.940

.65.

893

.398

.2%

89.6

91.2

74.7

––

––

–

Nev

ada

422

59.9

77.4

71.3

1.7

0.0

87.6

95.7

90.0

72.1

49.1

––

––

–

New

Ham

pshi

re16

6–

––

––

––

––

––

––

––

New

Jer

sey

1,19

084

.295

.062

.985

.565

.596

.898

.799

.495

.187

.8–

––

––

New

Mex

ico

660

66.8

84.4

58.6

43.2

2.6

67.3

84.3

38.0

68.6

53.3

––

––

–

New

Yor

k6,

002

76.9

90.5

90.0

50.6

15.0

2.0

0.0

0.1

2.5

15.0

0.0

0.0

0.0

0.0

–

Nor

th C

arol

ina

2,00

00.

0–

–0.

00.

491

.399

.181

.389

.172

.380

.096

.060

.272

.446

.6

Nor

th D

akot

a87

2.5

4.5

0.1

0.1

0.8

2.1

3.4

0.3

1.4

0.2

53.9

71.9

72.4

1.3

0.0

Ohi

o2,

645

73.0

94.1

74.2

46.4

5.6

––

––

––

––

––

Okl

ahom

a95

10.

0–

–0.

00.

288

.296

.775

.685

.279

.270

.290

.264

.341

.31.

2

Ore

gon

760

79.9

91.4

82.6

63.9

36.3

87.6

96.0

85.7

79.0

62.3

0.4

0.4

0.1

0.6

0.7

Penn

sylv

ania

2,56

775

.395

.574

.369

.68.

187

.797

.877

.792

.849

.68.

110

.57.

67.

50.

4

Rhod

e Is

land

170

58.8

88.0

81.0

15.8

1.0

31.6

70.0

0.0

9.5

––

––

––

Sout

h Ca

rolin

a1,

091

48.7

63.4

45.0

30.8

1.3

89.1

99.8

65.5

93.9

83.0

19.5

23.4

14.0

20.9

8.4

Sout

h Da

kota

134

––

––

––

––

––

72.3

91.8

87.5

28.6

0.9

Tenn

esse

e1,

557

91.6

100.

010

0.0

78.6

54.2

91.6

100.

010

0.0

78.6

54.0

––

––

–

Texa

s5,

240

81.5

96.2

62.3

67.0

34.8

11.8

14.3

7.8

10.0

4.2

0.0

0.0

–0.

0–

Uta

h38

923

.827

.818

.818

.315

.890

.198

.770

.692

.281

.828

.131

.521

.628

.919

.1

Verm

ont

206

0.1

––

0.1

0.5

––

––

–67

.186

.777

.137

.73.

1

Virg

inia

1,13

663

.584

.459

.140

.05.

5–

––

––

––

––

–

Was

hing

ton

1,42

169

.787

.659

.852

.22.

390

.999

.973

.188

.377

.40.

80.

90.

91.

10.

0

Wes

t Virg

inia

437

54.1

89.1

80.2

1.4

0.0

––

––

–1.

21.

81.

50.

50.

0

Wis

cons

in1,

254

59.1

85.4

70.7

3.8

2.4

89.0

98.0

93.7

93.3

38.6

––

––

–

Wyo

min

g89

––

––

––

––

––

––

––

–



MAC

Stat

sSe

ctio

n 3

EXH

IBIT

29.

(co

ntin

ued)

Not

es: F

Y is

fisc

al y

ear.

Enro

llmen

t num

bers

gen

eral

ly in

clud

e in

divi

dual

s ev

er e

nrol

led

in M

edic

aid-

finan

ced

cove

rage

dur

ing

the

year

, eve

n if

for a

sin

gle

mon

th; h

owev

er, i

n th

e ev

ent i

ndiv

idua

ls w

ere

also

enr

olle

d in

CH

IP-fi

nanc

ed M

edic

aid

cove

rage

(i.e

., M

edic

aid-

expa

nsio

n CH

IP) d

urin

g th

e ye

ar, t

hey

are

excl

uded

if th

eir m

ost r

ecen

t enr

ollm

ent m

onth

w

as in

Med

icai

d-ex

pans

ion

CHIP

. Num

bers

exc

lude

indi

vidu

als

enro

lled

only

in M

edic

aid-

expa

nsio

n CH

IP d

urin

g th

e ye

ar a

nd e

nrol

lees

in th

e te

rrito

ries.

Chi

ldre

n an

d ad

ults

un

der a

ge 6

5 w

ho q

ualif

y fo

r Med

icai

d on

the

basi

s of

dis

abili

ty a

re in

clud

ed in

the

disa

bled

cat

egor

y. A

bout

746

,000

enr

olle

es a

ge 6

5 an

d ol

der a

re id

entif

ied

in th

e da

ta a

s di

sabl

ed; g

iven

that

dis

abili

ty is

not

an

elig

ibili

ty p

athw

ay fo

r ind

ivid

uals

age

65

and

olde

r, M

ACPA

C re

code

s th

ese

enro

llees

as

aged

.

Due

to c

hang

es in

bot

h m

etho

ds a

nd d

ata

over

tim

e, fi

gure

s sh

own

here

may

not

be

dire

ctly

com

para

ble

to e

arlie

r yea

rs. W

ith re

gard

to m

etho

ds, i

ndiv

idua

ls a

re c

ount

ed a

s pa

rtic

ipat

ing

in m

anag

ed c

are

if th

ey h

ad a

t lea

st o

ne m

onth

indi

catin

g pl

an e

nrol

lmen

t; pr

ior t

o th

e 20

15 d

ata

book

, ind

ivid

uals

wer

e co

unte

d as

par

ticip

atin

g if

at le

ast o

ne

man

aged

car

e pa

ymen

t was

mad

e on

thei

r beh

alf d

urin

g th

e fis

cal y

ear.

For M

ACPA

C’s

anal

ysis

, Med

icai

d en

rolle

es w

ere

assi

gned

a u

niqu

e na

tiona

l ide

ntifi

catio

n nu

mbe

r usi

ng

an a

lgor

ithm

that

inco

rpor

ates

sta

te-s

peci

fic ID

num

bers

and

ben

efic

iary

cha

ract

eris

tics

such

as

date

of b

irth

and

gend

er. T

he s

tate

and

nat

iona

l enr

ollm

ent c

ount

s sh

own

here

ar

e un

dupl

icat

ed u

sing

this

nat

iona

l ID.

The

sum

of t

he s

tate

tota

ls e

xcee

ds th

e na

tiona

l tot

al b

ecau

se in

divi

dual

s m

ay b

e en

rolle

d in

mor

e th

an o

ne s

tate

dur

ing

the

year

. See

ht

tps:

//w

ww

.mac

pac.

gov/

mac

stat

s/da

ta-s

ourc

es-a

nd-m

etho

ds/ f

or a

dditi

onal

info

rmat

ion

on m

etho

ds a

nd d

ata.

Med

icai

d en

rolle

es m

ay b

e en

rolle

d co

ncur

rent

ly in

mor

e th

an

one

type

of m

anag

ed c

are

prog

ram

(e.g

., a

com

preh

ensi

ve p

lan

and

a lim

ited-

bene

fit p

lan)

, so

the

sum

of e

nrol

lmen

t in

each

pro

gram

type

as

a pe

rcen

tage

of t

otal

Med

icai

d en

rollm

ent m

ay b

e gr

eate

r tha

n 10

0 pe

rcen

t.

Figu

res

show

n he

re, w

hich

are

bas

ed o

n M

edic

aid

Stat

istic

al In

form

atio

n Sy

stem

(MSI

S) d

ata,

may

diff

er fr

om th

ose

that

use

Med

icai

d m

anag

ed c

are

enro

llmen

t rep

ort d

ata.

Re

ason

s fo

r diff

eren

ces

incl

ude

diff

erin

g tim

e pe

riods

, sta

te re

port

ing

anom

alie

s, a

nd th

e tr

eatm

ent o

f Med

icai

d-ex

pans

ion

CHIP

enr

olle

es (e

xclu

ded

here

but

incl

uded

in

enro

llmen

t rep

ort d

ata)

. Alth

ough

the

enro

llmen

t rep

ort i

s a

com

mon

ly c

ited

sour

ce, i

t doe

s no

t pro

vide

info

rmat

ion

on th

e ch

arac

teris

tics

of e

nrol

lees

in m

anag

ed c

are

(e.g

., el

igib

ility

gro

up).

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 In

clud

es c

ompr

ehen

sive

man

aged

car

e an

d Pr

ogra

ms

of A

ll-In

clus

ive

Care

for t

he E

lder

ly.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

MSI

S da

ta a

s of

Dec

embe

r 201

5.


December 201678

Section 3: Program Enrollment and Spending—Medicaid Program Administration

MAC

Stat

sSe

ctio

n 3

Stat

e1

Tota

l sp

endi

ng o

n ad

min

istr

atio

n

Spen

ding

by

cate

gory

Colle

ctio

nsM

MIS

2El

igib

ility

sy

stem

2

EHR

ince

ntiv

e pr

ogra

m3

Oth

er fu

nctio

ns,

fede

ral m

atch

, ab

ove

50%

4

Oth

er fu

nctio

ns,

fede

ral m

atch

of

50%

5

Alab

ama

$231

$32

$39

$28

$10

$123

-$0

Alas

ka13

08

259

584

–Ar

izon

a27

727

138

448

60-0

Arka

nsas

383

8556

1948

175

–Ca

lifor

nia

5,63

164

11,

626

166

240

2,95

8–

Colo

rado

385

7146

289

231

–Co

nnec

ticut

414

4015

614

3416

9–

Dela

war

e16

334

565

662

–Di

stric

t of C

olum

bia

151

2022

73

98–

Flor

ida

703

7310

254

3444

0–

Geo

rgia

580

130

164

498

230

-0H

awai

i11

914

5519

328

–Id

aho

105

2721

105

41–

Illin

ois

1,02

458

4479

6677

7–

Indi

ana

472

7628

2518

325

–Io

wa

196

5776

245

33–

Kans

as18

328

4815

388

-0Ke

ntuc

ky24

349

4538

1595

–Lo

uisi

ana

289

4458

3910

138

–M

aine

143

4414

1810

57–

Mar

ylan

d47

135

8935

6225

0–

Mas

sach

uset

ts78

611

013

329

3148

3–

Mic

higa

n69

428

952

6347

242

–M

inne

sota

590

6297

507

374

–M

issi

ssip

pi17

745

1228

983

-0M

isso

uri

350

5265

2910

195

-0M

onta

na75

634

63

27-0

Neb

rask

a12

722

4014

943

–N

evad

a16

026

789

1038

–

EXH

IBIT

30.

Tot

al M

edic

aid

Adm

inis

trat

ive

Spen

ding

by

Stat

e an

d Ca

tego

ry, F

Y 20

15 (m

illio

ns)



MAC

Stat

sSe

ctio

n 3

EXH

IBIT

30.

(co

ntin

ued)

Stat

e1

Tota

l sp

endi

ng o

n ad

min

istr

atio

n

Spen

ding

by

cate

gory

Colle

ctio

nsM

MIS

2El

igib

ility

sy

stem

2

EHR

ince

ntiv

e pr

ogra

m3

Oth

er fu

nctio

ns,

fede

ral m

atch

, ab

ove

50%

4

Oth

er fu

nctio

ns,

fede

ral m

atch

of

50%

5

New

Ham

pshi

re$1

24$3

7$4

9$3

$4$3

1–

New

Jer

sey

780

5510

428

3356

1–

New

Mex

ico

163

2644

1111

75-$

3N

ew Y

ork

1,78

419

621

140

691,

357

–N

orth

Car

olin

a66

570

339

5225

180

–N

orth

Dak

ota

163

11

010

–O

hio

860

8917

169

1451

8–

Okl

ahom

a24

540

1029

3413

2–

Ore

gon

541

3698

247

376

-0Pe

nnsy

lvan

ia87

610

723

148

2346

8–

Rhod

e Is

land

144

2934

94

69–

Sout

h Ca

rolin

a26

071

4820

1310

9–

Sout

h Da

kota

559

210

231

–Te

nnes

see

412

6864

3915

228

-1Te

xas

1,45

628

259

975

4346

6-8

Uta

h15

229

3920

1252

–Ve

rmon

t33

815

80

1–

Virg

inia

478

3124

430

3114

1–

Was

hing

ton

581

8268

467

377

–W

est V

irgin

ia18

968

613

2279

–W

isco

nsin

319

7844

309

167

-10

Wyo

min

g62

1617

82

20–

Subt

otal

(sta

tes)

$25,

451

$3,6

36$5

,667

$1,6

65$1

,110

$13,

396

-$23

Amer

ican

Sam

oa4

––

3–

1–

Gua

m3

––

00

2–

N. M

aria

na Is

land

s1

––

0–

0–

Puer

to R

ico

822

–25

–55

–Vi

rgin

Isla

nds

81

02

–5

–Su

btot

al (s

tate

s an

d te

rrito

ries)

$25,

547

$3,6

39$5

,668

$1,6

96$1

,110

$13,

458

-$23

December 201680


MAC

Stat

sSe

ctio

n 3

EXH

IBIT

30.

(co

ntin

ued)

Stat

e1

Tota

l sp

endi

ng o

n ad

min

istr

atio

n

Spen

ding

by

cate

gory

Colle

ctio

nsM

MIS

2El

igib

ility

sy

stem

2

EHR

ince

ntiv

e pr

ogra

m3

Oth

er fu

nctio

ns,

fede

ral m

atch

, ab

ove

50%

4

Oth

er fu

nctio

ns,

fede

ral m

atch

of

50%

5

Med

icai

d Fr

aud

Cont

rol U

nits

(MFC

U)6

$145

––

–$1

45–

–M

edic

aid

surv

ey a

nd c

ertif

icat

ion

of

nurs

ing

and

inte

rmed

iate

car

e fa

cilit

ies6

326

––

–32

6–

–To

tal

$26,

019

$3,6

39$5

,668

$1,6

96$1

,581

$13,

458

-$23

Perc

ent o

f tot

al, e

xclu

sive

of c

olle

ctio

ns–

14.0

%21

.8%

6.5%

6.1%

51.7

%–

Not

es: F

Y is

fisc

al y

ear.

MM

IS is

Med

icai

d m

anag

emen

t inf

orm

atio

n sy

stem

. EH

R is

ele

ctro

nic

heal

th re

cord

. Inc

lude

s fe

dera

l and

sta

te fu

nds.

Exc

lude

s ad

min

istr

ativ

e ac

tiviti

es p

erfo

rmed

by

Med

icai

d m

anag

ed c

are

plan

s (w

hich

are

incl

uded

in th

e ca

pita

tion

paym

ents

that

sta

tes

mak

e to

thes

e pl

ans)

and

act

iviti

es th

at a

re e

xclu

sive

ly

fede

ral,

such

as

prog

ram

ove

rsig

ht b

y Ce

nter

s fo

r Med

icar

e &

Med

icai

d Se

rvic

es (C

MS)

sta

ff. C

olle

ctio

ns m

ay in

clud

e, fo

r exa

mpl

e, d

onat

ions

mad

e by

hos

pita

ls to

co

mpe

nsat

e fo

r the

cos

t of o

n-si

te s

tatio

ning

of s

tate

or l

ocal

Med

icai

d ag

ency

per

sonn

el to

det

erm

ine

elig

ibili

ty o

r pro

vide

out

reac

h. F

or m

ore

info

rmat

ion

on s

peci

fic

item

s no

ted

in th

is e

xhib

it, s

ee C

MS,

201

4, M

BES

CBES

cat

egor

y of

ser

vice

line

def

initi

ons

for t

he 6

4.10

bas

e fo

rm, h

ttps

://w

ww

.med

icai

d.go

v/m

edic

aid/

finan

cing

-and

-re

imbu

rsem

ent/

dow

nloa

ds/c

ms-

6410

-adm

in-c

ateg

ory-

of-s

ervi

ces-

defin

ition

-2-1

4.pd

f.

– D

ash

indi

cate

s ze

ro; $

0 or

-$0

indi

cate

an

amou

nt b

etw

een

$0.5

and

-$0.

5 m

illio

n th

at ro

unds

to z

ero.

1 N

ot a

ll st

ates

had

cer

tifie

d th

eir C

MS-

64 F

inan

cial

Man

agem

ent R

epor

t (FM

R) s

ubm

issi

ons

as o

f May

24,

201

6. C

alifo

rnia

’s fi

rst,

seco

nd, t

hird

, and

four

th q

uart

er

subm

issi

ons

are

not c

ertif

ied;

Col

orad

o an

d N

orth

Dak

ota’

s se

cond

, thi

rd, a

nd fo

urth

qua

rter

sub

mis

sion

s ar

e no

t cer

tifie

d; N

ew J

erse

y’s

third

and

four

th q

uart

er s

ubm

issi

ons

are

not c

ertif

ied.

Fig

ures

pre

sent

ed in

this

exh

ibit

may

cha

nge

if st

ates

revi

se th

eir e

xpen

ditu

re d

ata

afte

r thi

s da

te.

2 In

clud

es d

esig

n an

d de

velo

pmen

t of s

yste

ms

(90

perc

ent f

eder

al m

atch

), op

erat

ion

of a

ppro

ved

syst

ems

(75

perc

ent)

, and

oth

er c

osts

(50

perc

ent)

.3

Incl

udes

EH

R in

cent

ive

paym

ents

to p

rovi

ders

(100

per

cent

fede

ral m

atch

) and

adm

inis

trat

ion

of p

aym

ents

(90

perc

ent)

.4

Incl

udes

ski

lled

med

ical

pro

fess

iona

ls, p

read

mis

sion

scr

eeni

ng a

nd re

side

nt re

view

, med

ical

and

util

izat

ion

revi

ew, e

xter

nal i

ndep

ende

nt re

view

, sur

vey

and

cert

ifica

tion,

an

d M

FCU

ope

ratio

ns (a

ll at

75

perc

ent f

eder

al m

atch

); tr

ansl

atio

n an

d in

terp

reta

tion

serv

ices

for c

hild

ren

and

plan

ning

act

iviti

es fo

r the

Hea

lth H

ome

bene

fit (b

oth

at m

atch

eq

ual t

o a

stat

e’s

fede

ral m

edic

al a

ssis

tanc

e pe

rcen

tage

); el

igib

ility

cha

nges

ass

ocia

ted

with

the

Tem

pora

ry A

ssis

tanc

e fo

r Nee

dy F

amili

es p

rogr

am (7

5 or

90

perc

ent)

; ad

min

istr

atio

n of

fam

ily p

lann

ing

serv

ices

(90

perc

ent)

; and

imm

igra

tion

stat

us v

erifi

catio

n sy

stem

s (1

00 p

erce

nt).

Excl

udes

MM

IS a

nd e

ligib

ility

sys

tem

s, w

hich

are

incl

uded

in

thei

r ow

n ca

tego

ries.

5 Ex

clud

es M

MIS

and

elig

ibili

ty s

yste

ms,

whi

ch a

re in

clud

ed in

thei

r ow

n ca

tego

ries.

6 St

ate-

leve

l est

imat

es fo

r MFC

Us

and

surv

ey a

nd c

ertif

icat

ion

are

avai

labl

e bu

t are

not

incl

uded

in th

e CM

S-64

dat

a th

at M

ACPA

C ty

pica

lly u

ses

to a

naly

ze M

edic

aid

spen

ding

.

Sour

ces:

For

sta

te a

nd te

rrito

ry s

pend

ing:

MAC

PAC,

201

6, a

naly

sis

of C

MS-

64 F

MR

net e

xpen

ditu

re d

ata

as o

f May

24,

201

6; fo

r MCF

Us

and

surv

ey a

nd c

ertif

icat

ion:

CM

S,

2016

, Fis

cal y

ear 2

017

just

ifica

tion

of e

stim

ates

for a

ppro

pria

tions

com

mitt

ees,

Bal

timor

e, M

D: C

MS,

htt

p://

ww

w.c

ms.

gov/

Abou

t-CM

S/Ag

ency

-Info

rmat

ion/

Perf

orm

ance

Budg

et/

Dow

nloa

ds/F

Y201

7-CJ

-Fin

al.p

df.

https://www.medicaid.gov/medicaid/financing-and-reimbursement/downloads/cms-6410-admin-category-of-services-definition-2-14.pdf

https://www.medicaid.gov/medicaid/financing-and-reimbursement/downloads/cms-6410-admin-category-of-services-definition-2-14.pdf

http://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/Downloads/FY2017-CJ-Final.pdf

http://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/Downloads/FY2017-CJ-Final.pdf


Section 3: Program Enrollment and Spending—CHIP

MAC

Stat

sSe

ctio

n 3

Stat

eCH

IP a

nd M

edic

aid

CHIP

-fun

ded

cove

rage

Med

icai

d-fu

nded

co

vera

geTo

tal

Med

icai

d ex

pans

ion

Sepa

rate

CH

IPTo

tal1

Tota

lTo

tal

45,2

31,3

154,

702,

185

3,68

9,81

78,

397,

651

36,8

33,6

64Al

abam

a79

1,28

545

,697

87,3

4613

3,04

365

8,24

2Al

aska

97,7

1910

,182

–10

,182

87,5

37Ar

izon

a98

1,35

737

,412

1,39

938

,811

942,

546

Arka

nsas

476,

893

108,

706

3,36

511

2,07

136

4,82

2Ca

lifor

nia2

6,80

0,80

21,

787,

470

124,

658

1,91

2,12

84,

888,

674

Colo

rado

588,

343

23,6

8762

,446

86,1

3350

2,21

0Co

nnec

ticut

390,

560

–24

,884

24,8

8436

5,67

6De

law

are

116,

637

238

16,1

4116

,379

100,

258

Dist

rict o

f Col

umbi

a99

,886

10,6

76–

10,6

7689

,210

Flor

ida

2,69

2,43

813

4,70

829

3,38

642

8,09

42,

264,

344

Geo

rgia

1,57

2,48

353

,906

176,

909

230,

815

1,34

1,66

8H

awai

i17

0,31

427

,239

–27

,239

143,

075

Idah

o23

6,70

38,

937

25,5

7634

,513

202,

190

Illin

ois

1,87

1,26

511

3,10

521

7,46

633

0,57

11,

540,

694

Indi

ana

790,

232

69,4

6231

,098

100,

560

689,

672

Iow

a41

7,07

621

,777

60,8

8082

,657

334,

419

Kans

as32

7,22

354

77,0

8577

,139

250,

084

Kent

ucky

612,

492

50,9

2636

,050

86,9

7652

5,51

6Lo

uisi

ana

820,

777

122,

878

12,7

3613

5,61

468

5,16

3M

aine

189,

181

13,4

408,

870

22,3

1016

6,87

1M

aryl

and

674,

417

142,

327

–14

2,32

753

2,09

0M

assa

chus

etts

373

7,38

779

,299

89,6

4216

8,94

156

8,44

6M

ichi

gan4

1,25

9,68

129

,226

90,4

7311

9,69

91,

139,

982

Min

neso

ta60

3,56

547

43,

361

3,83

559

9,73

0M

issi

ssip

pi53

4,98

830

,819

56,2

8687

,105

447,

883

Mis

sour

i65

7,36

338

,600

39,7

4478

,344

579,

019

Mon

tana

139,

807

16,0

0829

,253

45,2

6194

,546

Neb

rask

a22

7,39

955

,515

6,70

362

,218

165,

181

Nev

ada

414,

418

17,7

6344

,145

61,9

0835

2,51

0N

ew H

amps

hire

111,

139

16,6

51–

16,6

5194

,488

New

Jer

sey

970,

667

100,

826

114,

365

215,

191

755,

476

New

Mex

ico

416,

059

17,1

5540

17,1

9539

8,86

4N

ew Y

ork

2,92

4,44

023

5,94

539

4,78

763

0,73

22,

293,

708

Nor

th C

arol

ina

1,38

0,62

913

4,41

310

0,24

123

4,65

41,

145,

975

Nor

th D

akot

a66

,480

–4,

955

4,95

561

,525

EXH

IBIT

31.

Chi

ld E

nrol

lmen

t in

CHIP

and

Med

icai

d by

Sta

te, F

Y 20

15

December 201682


MAC

Stat

sSe

ctio

n 3

EXH

IBIT

31.

(co

ntin

ued)

Stat

eCH

IP a

nd M

edic

aid

CHIP

-fun

ded

cove

rage

Med

icai

d-fu

nded

co

vera

geTo

tal

Med

icai

d ex

pans

ion

Sepa

rate

CH

IPTo

tal1

Tota

lO

hio

1,54

4,42

918

1,10

0–

181,

100

1,36

3,32

9O

klah

oma

710,

552

174,

167

16,6

9119

0,85

851

9,69

4O

rego

n560

8,88

2–

121,

869

121,

869

487,

013

Penn

sylv

ania

1,53

5,59

164

,638

229,

704

294,

342

1,24

1,24

9Rh

ode

Isla

nd13

1,03

629

,948

1,37

631

,324

99,7

12So

uth

Caro

lina

718,

195

98,3

36–

98,3

3661

9,85

9So

uth

Dako

ta96

,980

12,4

413,

775

16,2

1680

,764

Tenn

esse

e92

5,67

117

,971

88,2

4410

6,21

581

9,45

6Te

xas

4,58

5,37

833

6,76

971

2,85

41,

049,

623

3,53

5,75

5U

tah

310,

061

27,7

6227

,523

55,2

8525

4,77

6Ve

rmon

t79

,484

4,76

6–

4,76

674

,718

Virg

inia

865,

234

86,5

5110

2,81

518

9,36

667

5,86

8W

ashi

ngto

n83

3,52

3–

46,0

3746

,037

787,

486

Wes

t Virg

inia

634

5,72

815

,242

33,0

3648

,278

297,

450

Wis

cons

in71

5,15

596

,973

71,6

0316

8,57

654

6,57

9W

yom

ing7

63,3

118

85,

649

57,6

62

Not

es: F

Y is

fisc

al y

ear.

Tota

l col

umn

refle

cts

child

ren

ever

enr

olle

d in

CH

IP o

r Med

icai

d du

ring

the

year

, eve

n if

for a

sin

gle

mon

th. M

ost s

tate

s co

unte

d ch

ildre

n w

ho w

ere

enro

lled

in m

ultip

le c

ateg

orie

s du

ring

the

year

(for

exa

mpl

e, in

Med

icai

d-fu

nded

cov

erag

e fo

r the

firs

t hal

f of t

he y

ear b

ut in

CH

IP-fu

nded

cov

erag

e fo

r the

sec

ond

half)

in th

e m

ost r

ecen

t cat

egor

y (s

tate

-spe

cific

exc

eptio

ns to

this

rule

are

not

ed b

elow

). M

edic

aid-

fund

ed c

hild

enr

ollm

ent s

how

n he

re in

clud

es a

ll ch

ildre

n, re

gard

less

of d

isab

ility

sta

tus;

in

oth

er M

ACSt

ats

exhi

bits

that

bre

ak e

nrol

lmen

t out

by

elig

ibili

ty g

roup

, chi

ldre

n qu

alify

ing

on th

e ba

sis

of d

isab

ility

may

be

coun

ted

in th

e di

sabl

ed c

ateg

ory

rath

er th

an th

e ch

ild c

ateg

ory.

Dat

a w

ere

repo

rted

by

indi

vidu

al s

tate

s as

of M

ay 2

, 201

6, a

nd m

ay b

e re

vise

d at

a la

ter d

ate.

– D

ash

indi

cate

s ze

ro.

1 To

tal e

xcee

ds th

e su

m o

f Med

icai

d ex

pans

ion

and

sepa

rate

CH

IP c

olum

ns d

ue to

onl

y to

tal C

HIP

enr

ollm

ent b

eing

repo

rted

for W

yom

ing.

2 Du

e to

repo

rtin

g sy

stem

upd

ates

, CH

IP e

nrol

lmen

t tot

als

are

estim

ates

as

a re

sult

of th

e ex

clus

ion

of c

erta

in u

nbor

n CH

IP e

nrol

lees

in re

port

ing.

3 Ce

rtai

n en

rolle

es w

ho s

houl

d ha

ve b

een

assi

gned

to C

HIP

wer

e as

sign

ed to

Med

icai

d be

ginn

ing

in th

e se

cond

qua

rter

of 2

014,

mak

ing

FY 2

015

tota

ls a

rtifi

cial

ly lo

w.

4 CH

IP-fu

nded

Med

icai

d en

rolle

es a

re in

clud

ed in

Med

icai

d en

rollm

ent c

ount

s, ra

ther

than

in C

HIP

for F

Y 20

15. T

here

fore

, the

CH

IP e

nrol

lmen

t tot

als

are

artif

icia

lly lo

w a

nd th

e M

edic

aid

enro

llmen

t tot

als

are

artif

icia

lly h

igh.

5 Ce

rtai

n en

rolle

es w

ho s

houl

d ha

ve b

een

assi

gned

to C

HIP

wer

e as

sign

ed to

Med

icai

d-fu

nded

cov

erag

e fo

r FY

2014

and

FY

2015

.6

Enro

llmen

t tot

als

are

artif

icia

lly h

igh

beca

use

child

ren

who

tran

sitio

ned

betw

een

CHIP

and

Med

icai

d ar

e re

porte

d in

bot

h pr

ogra

ms,

rath

er th

an th

e pr

ogra

m th

ey w

ere

last

enr

olle

d.7

The

Cent

ers

for M

edic

are

& M

edic

aid

Serv

ices

(CM

S) F

Y 20

15 c

hild

ren’

s en

rollm

ent r

epor

t con

side

rs th

ese

valu

es to

be

estim

ates

.8

Due

to in

cons

iste

ncie

s be

twee

n th

e St

atis

tical

Enr

ollm

ent D

ata

Syst

em (S

EDS)

dat

a an

d th

e CM

S FY

201

5 ch

ildre

n’s

enro

llmen

t rep

ort,

we

do n

ot re

port

enr

ollm

ent f

or

Med

icai

d ex

pans

ion

and

sepa

rate

CH

IP. W

e on

ly re

port

tota

l CH

IP e

nrol

lmen

t as

prov

ided

in th

e CM

S FY

201

5 ch

ildre

n’s

enro

llmen

t rep

ort.

Sour

ce: C

MS,

201

6, F

Y 20

15 n

umbe

r of c

hild

ren

ever

enr

olle

d in

Med

icai

d an

d CH

IP, h

ttp:

//w

ww

.med

icai

d.go

v/ch

ip/d

ownl

oads

/fy-

2015

-chi

ldre

ns-e

nrol

lmen

t-rep

ort.p

df a

nd

MAC

PAC,

201

6, a

naly

sis

of C

HIP

SED

S da

ta.

http://www.medicaid.gov/chip/downloads/fy-2015-childrens-enrollment-report.pdf



MAC

Stat

sSe

ctio

n 3

EXH

IBIT

32.

CH

IP S

pend

ing

by S

tate

, FY

2015

(mill

ions

)

Stat

e

Tota

l CH

IP

Bene

fits

Stat

e pr

ogra

m

adm

inis

trat

ion

Sect

ion

2105

(g)

spen

ding

2M

edic

aid-

expa

nsio

n CH

IPSe

para

te C

HIP

pro

gram

s an

d co

vera

ge o

f pre

gnan

t wom

en1

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Fede

ral

Alab

ama

$267

.4$2

09.0

$58.

4$1

18.7

$92.

6$2

6.1

$141

.3$1

10.6

$30.

7$7

.4$5

.8$1

.6–

Alas

ka22

.114

.37.

721

.413

.97.

5–

––

0.6

0.4

0.2

–

Ariz

ona

118.

392

.126

.211

1.2

86.6

24.6

6.6

5.1

1.5

0.6

0.4

0.1

–

Arka

nsas

170.

013

5.4

34.6

167.

613

3.3

34.3

0.8

0.7

0.1

1.6

1.4

0.2

–

Calif

orni

a2,

216.

31,

440.

677

5.7

1,99

5.4

1,29

7.0

698.

413

2.2

86.0

46.3

88.6

57.6

31.0

–

Colo

rado

239.

415

7.3

82.0

112.

674

.038

.712

0.9

79.5

41.4

5.9

3.9

2.0

–

Conn

ectic

ut36

.634

.42.

2–

––

33.0

21.4

11.5

3.7

2.4

1.3

$10.

6

Dela

war

e42

.228

.613

.616

.611

.45.

324

.816

.78.

10.

80.

60.

3–

Dist

rict o

f Col

umbi

a23

.718

.75.

023

.318

.44.

9–

––

0.7

0.5

0.1

–

Flor

ida

581.

641

7.9

163.

714

8.2

106.

841

.437

5.4

269.

510

5.9

58.0

41.7

16.4

–

Geo

rgia

403.

030

9.6

93.4

96.9

74.3

22.6

274.

221

0.7

63.4

31.9

24.6

7.4

–

Haw

aii

49.2

32.7

16.5

46.3

30.8

15.5

––

–2.

92.

01.

0–

Idah

o61

.749

.512

.210

.08.

02.

049

.039

.39.

72.

72.

20.

5–

Illin

ois

437.

828

6.8

151.

011

4.0

74.4

39.6

288.

218

9.1

99.1

35.6

23.4

12.2

–

Indi

ana

157.

612

0.7

37.0

104.

379

.924

.547

.336

.211

.16.

04.

61.

4–

Iow

a15

3.3

105.

747

.634

.623

.810

.810

6.9

73.7

33.2

11.8

8.2

3.7

–

Kans

as11

6.0

80.8

35.2

––

–10

5.9

73.8

32.1

10.1

7.0

3.1

–

Kent

ucky

222.

017

4.8

47.2

130.

510

2.5

27.9

80.5

63.5

16.9

11.0

8.7

2.3

–

Loui

sian

a23

7.4

174.

363

.117

9.4

131.

747

.745

.533

.512

.112

.59.

23.

3–

Mai

ne31

.823

.48.

518

.713

.75.

012

.29.

03.

21.

00.

70.

3–

Mar

ylan

d31

3.2

203.

610

9.6

289.

018

7.9

101.

2–

––

24.2

15.7

8.5

–

Mas

sach

uset

ts58

1.3

377.

920

3.5

271.

617

6.6

95.1

251.

516

3.5

88.0

58.1

37.8

20.3

–

Mic

higa

n32

7.5

248.

978

.621

8.6

166.

352

.410

4.5

79.3

25.2

4.3

3.3

1.0

–

Min

neso

ta32

.546

.8-1

4.3

1.1

0.7

0.4

30.5

19.9

10.6

0.9

0.6

0.3

25.6

Mis

siss

ippi

235.

019

1.5

43.4

58.1

47.3

10.7

173.

714

1.6

32.1

3.2

2.6

0.6

–

Mis

sour

i17

1.8

127.

744

.110

6.3

79.1

27.2

48.4

35.9

12.4

17.1

12.7

4.4

–

Mon

tana

91.7

69.8

21.9

24.7

18.8

5.9

62.0

47.2

14.8

5.1

3.9

1.2

–

Neb

rask

a82

.555

.527

.067

.145

.222

.013

.59.

14.

41.

91.

30.

6–

Nev

ada

61.2

45.9

15.3

15.2

11.4

3.8

43.4

32.6

10.8

2.6

1.9

0.6

–

December 201684


MAC

Stat

sSe

ctio

n 3

Stat

e

Tota

l CH

IP

Bene

fits

Stat

e pr

ogra

m

adm

inis

trat

ion

Sect

ion

2105

(g)

spen

ding

2M

edic

aid-

expa

nsio

n CH

IPSe

para

te C

HIP

pro

gram

s an

d co

vera

ge o

f pre

gnan

t wom

en1

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Tota

lFe

dera

lSt

ate

Fede

ral

New

Ham

pshi

re$2

9.0

$24.

8$4

.2$2

8.9

$18.

8$1

0.1

$0.0

$0.0

$0.0

$0.0

$0.0

$0.0

$6.0

New

Jer

sey

441.

928

7.6

154.

321

6.7

140.

875

.820

2.5

131.

970

.522

.714

.87.

9–

New

Mex

ico

116.

191

.524

.711

3.6

89.4

24.1

1.5

1.2

0.3

1.1

0.8

0.2

–

New

Yor

k1,

165.

475

7.7

407.

861

7.6

401.

421

6.2

532.

534

6.3

186.

315

.310

.05.

4–

Nor

th C

arol

ina

430.

332

7.6

102.

825

3.6

193.

160

.616

8.4

128.

240

.28.

36.

32.

0–

Nor

th D

akot

a22

.314

.57.

812

.48.

04.

38.

95.

83.

11.

00.

70.

4–

Ohi

o34

9.2

257.

991

.334

6.7

256.

190

.6–

––

2.5

1.9

0.7

–

Okl

ahom

a17

9.6

131.

847

.815

5.2

113.

841

.418

.913

.95.

05.

64.

11.

5–

Ore

gon

206.

315

4.4

51.9

5.3

4.0

1.3

186.

813

9.8

47.0

14.1

10.6

3.6

–

Penn

sylv

ania

388.

825

7.7

131.

163

.642

.221

.530

8.0

204.

110

3.8

17.2

11.4

5.8

–

Rhod

e Is

land

72.8

47.3

25.5

68.1

44.2

23.9

2.7

1.8

1.0

2.0

1.3

0.7

–

Sout

h Ca

rolin

a15

4.4

122.

431

.914

9.2

118.

530

.7–

––

5.2

3.9

1.3

–

Sout

h Da

kota

24.7

16.3

8.4

18.2

12.0

6.2

6.0

4.0

2.0

0.4

0.3

0.1

–

Tenn

esse

e20

5.5

155.

150

.452

.439

.612

.813

5.6

102.

333

.217

.513

.24.

3–

Texa

s1,

354.

195

6.4

397.

742

1.8

297.

812

3.9

866.

361

1.9

254.

466

.146

.719

.4–

Uta

h14

7.5

117.

030

.411

4.2

90.6

23.6

27.3

21.7

5.6

6.0

4.7

1.2

–

Verm

ont

9.5

13.6

-4.1

10.0

6.9

3.1

––

–0.

90.

70.

37.

0

Virg

inia

287.

718

7.0

100.

711

9.9

78.0

42.0

146.

495

.251

.321

.313

.97.

5–

Was

hing

ton

117.

912

5.3

-7.4

28.3

18.4

9.9

84.9

55.3

29.6

4.6

3.0

1.6

48.6

Wes

t Virg

inia

62.1

49.7

12.5

18.3

14.6

3.7

39.7

31.8

8.0

4.1

3.3

0.8

–

Wis

cons

in20

0.4

150.

549

.810

0.5

71.0

29.5

92.1

65.2

26.9

7.8

5.5

2.3

8.8

Wyo

min

g12

.07.

84.

21.

71.

10.

69.

56.

23.

30.

80.

50.

3–

Subt

otal

$13,

461.

4$9

,528

.0$3

,933

.4$7

,417

.6$5

,166

.6$2

,251

.0$5

,410

.1$3

,813

.8$1

,596

.3$6

35.5

$442

.3$1

93.2

$106

.6

Amer

ican

Sam

oa2.

11.

70.

42.

11.

70.

4–

––

––

––

Gua

m8.

15.

92.

28.

15.

92.

2–

––

––

––

N. M

aria

na Is

land

s1.

00.

90.

11.

00.

90.

1–

––

––

––

Puer

to R

ico

184.

112

8.9

55.1

184.

112

8.9

55.1

––

––

––

–

Virg

in Is

land

s5.

43.

81.

65.

43.

81.

6–

––

––

––

Tota

l$1

3,66

2.2

$9,6

69.3

$3,9

93.0

$7,6

18.4

$5,3

07.9

$2,3

10.5

$5,4

10.1

$3,8

13.8

$1,5

96.3

$635

.5$4

42.3

$193

.2$1

06.6

EXH

IBIT

32.

(co

ntin

ued)



MAC

Stat

sSe

ctio

n 3

Not

es: F

Y is

fisc

al y

ear.

Com

pone

nts

may

not

add

to to

tal d

ue to

roun

ding

. Fed

eral

CH

IP s

pend

ing

on a

dmin

istr

atio

n is

gen

eral

ly li

mite

d to

10

perc

ent o

f a s

tate

’s to

tal f

eder

al

CHIP

spe

ndin

g fo

r the

yea

r. St

ates

with

a M

edic

aid-

expa

nsio

n CH

IP p

rogr

am m

ay e

lect

to re

ceiv

e re

imbu

rsem

ent f

or a

dmin

istr

ativ

e sp

endi

ng fr

om M

edic

aid

rath

er th

an C

HIP

fu

nds;

Med

icai

d fu

nds

are

not s

how

n in

this

exh

ibit.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 Fo

ur s

tate

s (C

olor

ado,

New

Jer

sey,

Rhod

e Is

land

, and

Virg

inia

) use

CH

IP fu

nds

to p

rovi

de c

over

age

for p

regn

ant w

omen

.2

Sect

ion

2105

(g) o

f the

Soc

ial S

ecur

ity A

ct p

erm

its 1

1 qu

alify

ing

stat

es to

use

CH

IP fu

nds

to p

ay th

e di

ffer

ence

bet

wee

n th

e re

gula

r Med

icai

d m

atch

ing

rate

and

the

enha

nced

CH

IP m

atch

ing

rate

for M

edic

aid-

enro

lled,

Med

icai

d-fin

ance

d ch

ildre

n w

hose

fam

ily in

com

e ex

ceed

s 13

3 pe

rcen

t of t

he fe

dera

l pov

erty

leve

l. Al

thou

gh th

ese

are

CHIP

fund

s, th

ey e

ffec

tivel

y re

duce

sta

te s

pend

ing

on c

hild

ren

in M

edic

aid

and

do n

ot re

quire

a s

tate

mat

ch w

ithin

the

CHIP

pro

gram

. In

case

s w

here

the

sum

of 2

105(

g)

fede

ral C

HIP

spe

ndin

g (f

or M

edic

aid

enro

llees

) and

regu

lar f

eder

al C

HIP

spe

ndin

g (f

or C

HIP

enr

olle

es) e

xcee

ds to

tal s

pend

ing

for C

HIP

enr

olle

es, s

tate

s ar

e sh

own

in th

is ta

ble

as h

avin

g ne

gativ

e st

ate

CHIP

spe

ndin

g (M

inne

sota

, Ver

mon

t, an

d W

ashi

ngto

n).

Sour

ce: M

ACPA

C, 2

015,

ana

lysi

s of

Med

icai

d an

d CH

IP B

udge

t Exp

endi

ture

Sys

tem

dat

a fr

om C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es a

s of

Dec

embe

r 30,

201

5.

EXH

IBIT

32.

(co

ntin

ued)

December 201686


MAC

Stat

sSe

ctio

n 3

Stat

eFY

201

4 fe

dera

l CH

IP a

llotm

ents

1FY

201

5 fe

dera

l CH

IP a

llotm

ents

FY 2

016

fede

ral C

HIP

allo

tmen

ts2

Alab

ama

$173

.1

$172

.9

$267

.6

Alas

ka21

.8

23.9

20

.4

Ariz

ona

145.

4 80

.7

123.

7 Ar

kans

as10

9.7

94.0

17

4.5

Calif

orni

a1,

377.

3 1,

744.

1 1,

995.

2 Co

lora

do14

0.5

157.

5 22

8.3

Conn

ectic

ut43

.9

48.1

61

.9

Dela

war

e16

.7

20.3

38

.5

Dist

rict o

f Col

umbi

a16

.3

20.7

25

.6

Flor

ida

382.

3 56

6.0

595.

0 G

eorg

ia30

0.9

410.

6 41

8.2

Haw

aii

27.5

46

.3

46.3

Id

aho

38.2

66

.2

66.4

Ill

inoi

s29

2.8

361.

4 40

6.2

Indi

ana

153.

9 16

2.9

165.

7 Io

wa

98.3

12

6.0

147.

6 Ka

nsas

58.9

85

.1

112.

2 Ke

ntuc

ky15

7.2

171.

9 23

2.0

Loui

sian

a18

2.9

180.

1 23

8.9

Mai

ne33

.5

27.4

32

.3

Mar

ylan

d17

0.5

234.

3 29

0.8

Mas

sach

uset

ts35

1.6

413.

8 53

5.8

Mic

higa

n358

.2

118.

6 32

3.9

Min

neso

ta34

.1

41.1

98

.6

Mis

siss

ippi

188.

0 22

6.2

246.

7 M

isso

uri

130.

7 16

3.2

172.

9 M

onta

na68

.2

91.7

95

.8

Neb

rask

a64

.4

69.7

78

.2

Nev

ada

33.5

43

.1

63.3

N

ew H

amps

hire

19.3

20

.0

39.2

N

ew J

erse

y68

0.3

344.

8 40

6.8

New

Mex

ico

132.

0 73

.6

122.

5 N

ew Y

ork

677.

3 97

2.8

1,07

4.6

Nor

th C

arol

ina

323.

7 39

5.0

448.

2 N

orth

Dak

ota

18.8

21

.0

21.2

O

hio

357.

1 34

2.8

352.

6

EXH

IBIT

33.

Fed

eral

CH

IP A

llotm

ents

, FY

2016

(mill

ions

)



MAC

Stat

sSe

ctio

n 3

Stat

eFY

201

4 fe

dera

l CH

IP a

llotm

ents

1FY

201

5 fe

dera

l CH

IP a

llotm

ents

FY 2

016

fede

ral C

HIP

allo

tmen

ts2

Okl

ahom

a$1

21.9

$1

73.1

$1

89.2

O

rego

n15

2.9

193.

5 21

1.3

Penn

sylv

ania

324.

9 37

1.1

364.

3 Rh

ode

Isla

nd42

.0

46.0

65

.4

Sout

h Ca

rolin

a10

4.7

142.

9 16

2.0

Sout

h Da

kota

20.8

18

.9

23.6

Te

nnes

see

212.

9 19

8.1

213.

3 Te

xas

955.

8 1,

068.

7 1,

345.

1 U

tah

66.8

59

.1

148.

9 Ve

rmon

t13

.9

15.6

29

.3

Virg

inia

198.

3 24

7.6

265.

2 W

ashi

ngto

n10

3.3

129.

0 21

5.3

Wes

t Virg

inia

51.3

55

.2

65.4

W

isco

nsin

109.

5 22

1.2

225.

8 W

yom

ing

11.5

11

.4

10.9

Su

btot

al

$9,5

69.5

$1

1,08

9.2

$13,

302.

8 Am

eric

an S

amoa

1.4

1.7

2.1

Gua

m4.

8 5.

9 8.

0 N

. Mar

iana

Isla

nds

1.0

1.2

1.0

Puer

to R

ico

141.

0 18

3.2

179.

8 Vi

rgin

Isla

nds

0.0

5.0

5.3

Tota

l $9

,717

.7

$11,

286.

1 $1

3,49

9.2

Not

es: F

Y is

fisc

al y

ear.

1 Th

ese

amou

nts

refle

ct in

crea

ses

prov

ided

to A

rizon

a, M

onta

na, N

ebra

ska,

and

New

Yor

k fo

r app

rove

d pr

ogra

m e

xpan

sion

s de

scrib

ed in

Sec

tion

2104

(m)(

7) o

f the

Soc

ial

Secu

rity

Act (

the

Act)

.2

Per s

tatu

te, F

Y 20

15 a

nd F

Y 20

16 fe

dera

l CH

IP a

llotm

ents

wer

e bo

th b

ased

on

each

sta

te's

prio

r-yea

r fed

eral

CH

IP s

pend

ing.

In a

dditi

on b

ecau

se a

23

perc

enta

ge p

oint

in

crea

se in

the

CHIP

mat

chin

g ra

te w

ent i

nto

effe

ct in

FY

2016

, the

FY

2016

allo

tmen

ts w

ere

calc

ulat

ed b

y in

crea

sing

fede

ral C

HIP

spe

ndin

g by

eac

h st

ate

in F

Y 20

15 a

s if

the

23 p

erce

ntag

e po

int i

ncre

ase

in th

e CH

IP m

atch

ing

rate

had

bee

n in

eff

ect i

n FY

201

5. T

he F

Y 20

16 a

llotm

ent i

ncre

ase

fact

or w

as th

en a

pplie

d, w

hich

was

app

roxi

mat

ely

5 pe

rcen

t for

mos

t sta

tes.

3

In F

Y 20

15, M

ichi

gan

was

poi

sed

to e

xhau

st it

s fe

dera

l CH

IP a

llotm

ents

. As

a re

sult,

the

stat

e re

ques

ted

and

qual

ified

for f

eder

al C

HIP

con

tinge

ncy

fund

s to

talin

g $5

2.6

mill

ion

(§21

04(n

) of t

he A

ct).

Beca

use

the

cont

inge

ncy

fund

pay

men

t was

insu

ffic

ient

to e

limin

ate

the

stat

e's s

hort

fall,

Mic

higa

n al

so q

ualif

ied

for $

61.5

mill

ion

in

redi

strib

utio

n fu

nds

(§21

04(f

) of t

he A

ct).

The

com

bina

tion

of c

ontin

genc

y an

d re

dist

ribut

ion

fund

s el

imin

ated

the

stat

e's s

hort

fall.

The

onl

y ot

her s

tate

to e

ver q

ualif

y fo

r co

ntin

genc

y fu

nds

was

Iow

a, in

FY

2011

, whi

ch d

id n

ot th

en re

quire

redi

strib

utio

n fu

nds.

Sour

ce: C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es, 2

016,

com

mun

icat

ion

with

MAC

PAC

staf

f, Fe

brua

ry 2

4, 2

016.

EXH

IBIT

33.

(co

ntin

ued)

SECTION 4

Medicaid and CHIP Eligibility

December 201690

Section 4: Medicaid and CHIP Eligibility


Key Points• More than half of states are now covering non-disabled low-income adults, a new Medicaid

eligibility group created under the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) (Exhibit 35). Most of these new adults are eligible at incomes up to 138 percent of the federal poverty level (FPL). This amounts to $16,394 for a single individual in 2016 (Exhibit 37).

• Beginning in 2014, Medicaid and State Children's Health Insurance Program (CHIP) eligibility levels for most child and adult populations reflect the application of uniform modified adjusted gross income (MAGI) rules across states. A maintenance of effort provision prevents states from lowering their existing eligibility levels for children through the end of fiscal year (FY) 2019 (Exhibits 34 and 35).

• Eligibility criteria for individuals eligible for Medicaid on the basis of disability and for individuals age 65 and older, who are not subject to MAGI rules, were largely unchanged between 2015 and 2016 (Exhibit 36).

• In 2016, in the lower 48 states and the District of Columbia, 100 percent FPL is $11,880 for an individual plus $4,140–$4,160 for each additional family member, depending on the size of the family (Exhibit 37).



MAC

Stat

s

Stat

e

Med

icai

d co

vera

ge

CHIP

pro

gram

type

2 (a

s of

Jul

y 1,

201

6)

Sepa

rate

CH

IP

cove

rage

Med

icai

d/CH

IP

cove

rage

Infa

nts

unde

r age

1Ag

e 1–

5Ag

e 6–

18Bi

rth

thro

ugh

age

183

Unb

orn

child

ren3

Preg

nant

wom

en

and

deem

ed

new

born

s4M

edic

aid

fund

ed1

CHIP

fu

nded

1M

edic

aid

fund

ed1

CHIP

fu

nded

1M

edic

aid

fund

ed1

CHIP

fu

nded

1

Alab

ama

141%

–14

1%–

141%

107–

141%

Com

bina

tion

312%

–14

1%Al

aska

17

715

9–20

3%17

715

9–20

3%17

712

4–20

3M

edic

aid

expa

nsio

n–

–20

0Ar

izon

a14

7–

141

–13

310

4–13

3Co

mbi

natio

n20

05–

156

Arka

nsas

142

–14

2–

142

107–

142

Com

bina

tion

211

209%

209

Calif

orni

a20

820

8–26

114

214

2–26

113

310

8–26

1Co

mbi

natio

n31

7631

720

8Co

lora

do

142

–14

2–

142

108–

142

Com

bina

tion

260

–19

5/26

0Co

nnec

ticut

19

6–

196

–19

6–

Sepa

rate

318

–25

8De

law

are

212

194–

212

142

–13

311

0–13

3Co

mbi

natio

n21

27–

212

Dist

rict o

f Col

umbi

a31

920

6–31

931

914

6–31

931

911

2–31

9M

edic

aid

expa

nsio

n–

–31

9Fl

orid

a20

619

2–20

614

0–

133

112–

133

Com

bina

tion

2107

–19

1G

eorg

ia

205

–14

9–

133

113–

133

Com

bina

tion

247

–22

0H

awai

i 19

119

1–30

813

913

9–30

813

310

5–30

8M

edic

aid

expa

nsio

n–

–19

1Id

aho

142

–14

2–

133

107–

133

Com

bina

tion

185

–13

3Ill

inoi

s 14

2–

142

–14

210

8–14

2Co

mbi

natio

n31

320

820

8In

dian

a 20

815

7–20

815

814

1–15

815

810

6–15

8Co

mbi

natio

n25

0–

208

Iow

a37

524

0–37

516

7–

167

122–

167

Com

bina

tion

3027

–37

5Ka

nsas

16

6–

149

–13

311

3–13

3Co

mbi

natio

n23

8–

166

Kent

ucky

19

5–

142

142–

159

133

109–

159

Com

bina

tion

213

–19

5Lo

uisi

ana

142

142–

212

142

142–

212

142

108–

212

Com

bina

tion

250

209

133

Mai

ne

191

–15

714

0–15

715

713

2–15

7Co

mbi

natio

n20

8–

209

Mar

ylan

d 19

419

4–31

713

813

8–31

713

310

9–31

7M

edic

aid

expa

nsio

n–

–25

9M

assa

chus

etts

200

185–

200

150

133–

150

150

114–

150

Com

bina

tion

300

200

200

Mic

higa

n 19

519

5–21

216

014

3–21

216

010

9–21

2M

edic

aid

expa

nsio

n–

195

195

Min

neso

ta27

527

5–28

3827

5–

275

–Co

mbi

natio

n–

278

278

Mis

siss

ippi

19

4–

143

–13

310

7–13

3Co

mbi

natio

n20

9–

194

Mis

sour

i19

6–

148

148–

150

148

110–

150

Com

bina

tion

300

300

196/

300

Mon

tana

143

–14

3–

133

109–

143

Com

bina

tion

261

–15

7N

ebra

ska

162

162–

213

145

145–

213

133

109–

213

Com

bina

tion

–19

719

4N

evad

a16

0–

160

–13

312

2–13

3Co

mbi

natio

n20

0–

160

New

Ham

pshi

re

196

196–

318

196

196–

318

196

196–

318

Med

icai

d ex

pans

ion

––

196

New

Jer

sey

194

–14

2–

142

107–

142

Com

bina

tion

350

–19

4/20

0N

ew M

exic

o 24

020

0–30

024

020

0–30

019

013

8–24

0M

edic

aid

expa

nsio

n–

–25

0

EXH

IBIT

34.

Med

icai

d an

d CH

IP In

com

e El

igib

ility

Lev

els

as a

Per

cent

age

of th

e FP

L fo

r Chi

ldre

n an

d Pr

egna

nt W

omen

by

Stat

e,

July

201

6

Sect

ion

4

December 201692


MAC

Stat

sSe

ctio

n 4

EXH

IBIT

34.

(co

ntin

ued)

Stat

e

Med

icai

d co

vera

ge

CHIP

pro

gram

type

2 (a

s of

Jul

y 1,

201

6)

Sepa

rate

CH

IP

cove

rage

Med

icai

d/CH

IP

cove

rage

Infa

nts

unde

r age

1Ag

e 1–

5Ag

e 6–

18Bi

rth

thro

ugh

age

183

Unb

orn

child

ren3

Preg

nant

wom

en

and

deem

ed

new

born

s4M

edic

aid

fund

ed1

CHIP

fu

nded

1M

edic

aid

fund

ed1

CHIP

fu

nded

1M

edic

aid

fund

ed1

CHIP

fu

nded

1

New

Yor

k 21

8%19

6–21

8%14

9%–

149%

110–

149%

Com

bina

tion

400%

–21

8%N

orth

Car

olin

a 21

019

4–21

021

014

1–21

0%13

310

7–13

3Co

mbi

natio

n21

19–

196

Nor

th D

akot

a14

7–

147

–13

311

1–13

3Co

mbi

natio

n17

0–

147

Ohi

o15

614

1–20

615

614

1–20

615

610

7–20

6M

edic

aid

expa

nsio

n–

–20

0O

klah

oma

205

169–

205

205

151–

205

205

115–

205

Com

bina

tion

–20

5%13

3O

rego

n 18

513

3–18

513

3–

133

100–

133

Com

bina

tion

300

185

185

Penn

sylv

ania

21

5–

157

–13

311

9–13

3Co

mbi

natio

n31

4–

215

Rhod

e Is

land

190

190–

261

142

142–

261

133

109–

261

Com

bina

tion

–25

319

0/25

3So

uth

Caro

lina

194

194–

208

143

143–

208

133

107–

208

Med

icai

d ex

pans

ion

––

194

Sout

h Da

kota

18

217

7–18

218

217

7–18

218

212

4–18

2Co

mbi

natio

n20

4–

133

Tenn

esse

e1019

5–

142

–13

310

9–13

3Co

mbi

natio

n25

025

019

5Te

xas

198

–14

4–

133

109–

133

Com

bina

tion

201

202

198

Uta

h13

9–

139

–13

310

5–13

3Co

mbi

natio

n20

0–

139

Verm

ont

312

237–

312

312

237–

312

312

237–

312

Med

icai

d ex

pans

ion

––

208

Virg

inia

143

–14

3–

143

109–

143

Com

bina

tion

200

–14

3/20

0W

ashi

ngto

n 21

0–

210

–21

0–

Sepa

rate

312

193

193

Wes

t Virg

inia

15

8–

141

–13

310

8–13

3Co

mbi

natio

n30

0–

158

Wis

cons

in

301

–18

6–

133

101–

151

Com

bina

tion

3017

301

301

Wyo

min

g 15

4–

154

–13

311

9–13

3Co

mbi

natio

n20

0–

154

Not

es: F

PL is

fede

ral p

over

ty le

vel.

In 2

016,

100

per

cent

FPL

is $

11,8

80 fo

r an

indi

vidu

al p

lus

$4,1

40–

$4,1

60 fo

r eac

h ad

ditio

nal f

amily

mem

ber i

n th

e lo

wer

48

stat

es a

nd

the

Dist

rict o

f Col

umbi

a. W

hen

dete

rmin

ing

Med

icai

d an

d CH

IP e

ligib

ility

prio

r to

2014

, sta

tes

had

the

flexi

bilit

y to

dis

rega

rd in

com

e so

urce

s an

d am

ount

s of

thei

r cho

osin

g.

Begi

nnin

g in

201

4, u

nifo

rm m

odifi

ed a

djus

ted

gros

s in

com

e (M

AGI)

rule

s m

ust b

e us

ed to

det

erm

ine

Med

icai

d an

d CH

IP e

ligib

ility

for m

ost n

on-d

isab

led

child

ren

and

adul

ts

unde

r age

65,

incl

udin

g th

e gr

oups

sho

wn

in th

is ta

ble.

As

a re

sult,

sta

tes

are

now

requ

ired

to u

se M

AGI-c

onve

rted

elig

ibili

ty le

vels

that

acc

ount

for t

he c

hang

e in

inco

me-

coun

ting

rule

s. T

he e

ligib

ility

leve

ls s

how

n in

this

tabl

e re

flect

thes

e M

AGI-c

onve

rted

leve

ls o

r ano

ther

MAG

I-bas

ed in

com

e lim

it in

eff

ect i

n ea

ch s

tate

for t

hese

gro

ups

as

of J

uly

2016

. Und

er fe

dera

l reg

ulat

ions

, the

eff

ectiv

e in

com

e lim

its m

ay b

e hi

gher

by

5 pe

rcen

tage

poi

nts

of th

e FP

L th

an th

ose

show

n on

this

tabl

e to

acc

ount

for a

gen

eral

in

com

e di

sreg

ard

that

app

lies

to a

n in

divi

dual

’s d

eter

min

atio

n of

elig

ibili

ty fo

r Med

icai

d an

d CH

IP o

vera

ll, ra

ther

than

for p

artic

ular

elig

ibili

ty g

roup

s w

ithin

Med

icai

d or

CH

IP.

Med

icai

d co

vera

ge o

f chi

ldre

n un

der a

ge 1

9 w

ith in

com

es b

elow

sta

tes’

elig

ibili

ty le

vels

in e

ffec

t as

of M

arch

31,

199

7, c

ontin

ues

to b

e fin

ance

d by

Med

icai

d (T

itle

XIX)

fund

ing.

An

y ex

pans

ion

of e

ligib

ility

to u

nins

ured

chi

ldre

n ab

ove

thos

e le

vels

—th

roug

h ex

pans

ions

of M

edic

aid

or th

roug

h se

para

te C

HIP

pro

gram

s—is

gen

eral

ly fi

nanc

ed b

y CH

IP

(Titl

e XX

I) fu

ndin

g. C

HIP

fund

ing

is n

ot p

erm

itted

for c

hild

ren

with

oth

er c

over

age.

Thu

s, w

here

Med

icai

d co

vera

ge in

this

tabl

e sh

ows

over

lapp

ing

elig

ibili

ty le

vels

for M

edic

aid

fund

ing

and

CHIP

fund

ing,

chi

ldre

n w

ith n

o ot

her c

over

age

are

fund

ed b

y CH

IP, w

hile

chi

ldre

n w

ith o

ther

cov

erag

e ar

e fu

nded

by

Med

icai

d. P

regn

ant w

omen

can

rece

ive

Med

icai

d- o

r CH

IP-fu

nded

ser

vice

s th

roug

h re

gula

r sta

te p

lan

elig

ibili

ty p

athw

ays

or th

roug

h Se

ctio

n 11

15 w

aive

rs; i

n ad

ditio

n, th

e un

born

chi

ldre

n of

pre

gnan

t wom

en m

ay

rece

ive

CHIP

-fund

ed c

over

age

unde

r a s

tate

pla

n op

tion.

Dee

med

new

born

s ar

e in

fant

s up

to a

ge 1

who

are

dee

med

elig

ible

for M

edic

aid

or C

HIP

—w

ith n

o se

para

te a

pplic

atio

n or

elig

ibili

ty d

eter

min

atio

n re

quire

d—if

thei

r mot

her w

as e

nrol

led

at th

e tim

e of

thei

r birt

h.



MAC

Stat

sSe

ctio

n 4

EXH

IBIT

34.

(co

ntin

ued)

– D

ash

indi

cate

s th

at s

tate

doe

s no

t use

this

elig

ibili

ty p

athw

ay.

1 U

nder

Med

icai

d fu

nded

, the

re is

no

low

er b

ound

for i

ncom

e el

igib

ility

. The

elig

ibili

ty le

vels

list

ed u

nder

Med

icai

d fu

nded

are

the

high

est i

ncom

e le

vels

und

er w

hich

eac

h ag

e gr

oup

of c

hild

ren

is c

over

ed u

nder

the

Med

icai

d st

ate

plan

, whe

re e

ither

all

or ju

st in

sure

d ch

ildre

n ar

e cl

aim

ed w

ith M

edic

aid

fund

ing.

The

elig

ibili

ty le

vels

list

ed u

nder

CH

IP fu

nded

are

the

inco

me

leve

ls to

whi

ch M

edic

aid

has

expa

nded

with

CH

IP fu

ndin

g si

nce

its c

reat

ion

in 1

997.

For

sta

tes

that

hav

e di

ffer

ent C

HIP

-fund

ed e

ligib

ility

leve

ls

for c

hild

ren

age

6 th

roug

h 13

and

age

14

thro

ugh

18, t

his

tabl

e sh

ows

only

the

leve

ls fo

r chi

ldre

n ag

e 6

thro

ugh

13. I

n ad

ditio

n, S

ectio

n 21

05(g

) of t

he S

ocia

l Sec

urity

Act

pe

rmits

11

qual

ifyin

g st

ates

to u

se C

HIP

fund

s to

pay

the

diff

eren

ce b

etw

een

the

regu

lar M

edic

aid

mat

chin

g ra

te a

nd th

e en

hanc

ed C

HIP

mat

chin

g ra

te fo

r Med

icai

d-en

rolle

d,

Med

icai

d-fin

ance

d un

insu

red

child

ren

who

se fa

mily

inco

me

exce

eds

133

perc

ent F

PL (n

ot s

epar

atel

y no

ted

on th

is ta

ble)

.2

Und

er C

HIP

, sta

tes

have

the

optio

n to

use

an

expa

nsio

n of

Med

icai

d, a

sep

arat

e CH

IP p

rogr

am, o

r a c

ombi

natio

n of

bot

h ap

proa

ches

. Ten

sta

tes

(incl

udin

g th

e Di

stric

t of

Colu

mbi

a) a

re M

edic

aid

expa

nsio

ns a

nd 2

sta

tes

are

sepa

rate

CH

IP o

nly

(Con

nect

icut

and

Was

hing

ton)

. Thi

rty-

nine

sta

tes

are

com

bina

tion

prog

ram

s—an

d am

ong

thos

e, 1

1 co

nsid

er th

emse

lves

to h

ave

sepa

rate

pro

gram

s bu

t are

tech

nica

lly c

ombi

natio

ns d

ue to

the

tran

sitio

n of

chi

ldre

n be

low

133

per

cent

FPL

from

sep

arat

e CH

IP to

Med

icai

d (A

laba

ma,

Ariz

ona,

Geo

rgia

, Kan

sas,

Mis

siss

ippi

, Ore

gon,

Pen

nsyl

vani

a, T

exas

, Uta

h, W

est V

irgin

ia, W

yom

ing)

.3

Sepa

rate

CH

IP e

ligib

ility

for c

hild

ren

birt

h th

roug

h ag

e 18

gen

eral

ly b

egin

s w

here

Med

icai

d co

vera

ge e

nds

(as

show

n in

the

prev

ious

col

umns

). Fo

r unb

orn

child

ren,

ther

e is

no

low

er b

ound

for i

ncom

e el

igib

ility

if th

e m

othe

r is

not e

ligib

le fo

r Med

icai

d.4

Preg

nant

wom

en c

an b

e co

vere

d w

ith M

edic

aid

or C

HIP

fund

ing.

Und

er C

HIP

, cov

erag

e ca

n be

thro

ugh

a st

ate

plan

opt

ion

for t

arge

ted

low

-inco

me

preg

nant

wom

en o

r th

roug

h co

ntin

uatio

n of

an

exis

ting

Sect

ion

1115

wai

ver.

Whe

n tw

o va

lues

are

sho

wn

in th

is c

olum

n, th

e fir

st is

for M

edic

aid

and

the

seco

nd is

for C

HIP

.5

Ariz

ona

clos

ed it

s se

para

te C

HIP

pro

gram

(Kid

sCar

e) to

new

enr

ollm

ent i

n Ja

nuar

y 20

10. T

he s

tate

rein

stat

ed th

e pr

ogra

m o

n Se

ptem

ber 1

, 201

6.6

Calif

orni

a ha

s a

sepa

rate

CH

IP p

rogr

am in

thre

e co

untie

s on

ly th

at c

over

s ch

ildre

n up

to 3

17 p

erce

nt F

PL.

7 Th

e se

para

te C

HIP

pro

gram

s in

Del

awar

e, F

lorid

a, Io

wa,

and

Wis

cons

in c

over

chi

ldre

n ag

e 1–

18.

8 In

Min

neso

ta, o

nly

infa

nts

(def

ined

by

the

stat

e as

bei

ng u

nder

age

2) a

re e

ligib

le fo

r the

Med

icai

d-ex

pans

ion

CHIP

pro

gram

up

to 2

83 p

erce

nt F

PL.

9 N

orth

Car

olin

a’s

sepa

rate

CH

IP p

rogr

am c

over

s ch

ildre

n ag

e 6–

18.

10 W

hile

Ten

ness

ee c

over

s ch

ildre

n w

ith C

HIP

-fund

ed M

edic

aid,

enr

ollm

ent i

s cu

rren

tly c

appe

d, e

xcep

t for

chi

ldre

n w

ho ro

ll ov

er fr

om tr

aditi

onal

Med

icai

d.

Sour

ces:

MAC

PAC,

201

6, a

naly

sis

of C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es (C

MS)

, 201

6, S

tate

Med

icai

d an

d CH

IP in

com

e el

igib

ility

sta

ndar

ds (F

or s

elec

ted

MAG

I Gro

ups,

bas

ed

on s

tate

dec

isio

ns a

s of

Jun

e 1,

201

6), h

ttps

://w

ww

.med

icai

d.go

v/m

edic

aid-

chip

-pro

gram

-info

rmat

ion/

prog

ram

-info

rmat

ion/

med

icai

d-an

d-ch

ip-e

ligib

ility

-leve

ls/m

edic

aid-

chip

-el

igib

ility

-leve

ls.h

tml;

MAC

PAC,

201

6, a

naly

sis

of s

tate

web

site

s; M

ACPA

C, 2

015,

ana

lysi

s of

CM

S, 2

015,

MAG

I con

vers

ion

plan

s an

d SI

PP-b

ased

MAG

I con

vers

ion

resu

lts, h

ttp:

//w

ww

.med

icai

d.go

v/m

edic

aid-

chip

-pro

gram

-info

rmat

ion/

by-s

tate

/by-

stat

e.ht

ml;

MAC

PAC,

201

5, a

naly

sis

of C

MS,

201

5, M

edic

aid

stat

e pl

an a

men

dmen

ts, h

ttp://

ww

w.m

edic

aid.

gov/

stat

e-re

sour

ce-c

ente

r/m

edic

aid-

stat

e-pl

an-a

men

dmen

ts/m

edic

aid-

stat

e-pl

an-a

men

dmen

ts.h

tml;

MAC

PAC,

201

5, a

naly

sis

of C

MS,

201

5, C

HIP

sta

te p

lan

amen

dmen

ts, h

ttp:

//w

ww

.med

icai

d.go

v/ch

ip/s

tate

-pro

gram

-info

rmat

ion/

chip

-sta

te-p

rogr

am-in

form

atio

n.ht

ml;

MAC

PAC,

201

5, a

naly

sis

of C

MS,

201

5, C

hild

ren’

s H

ealth

Insu

ranc

e Pr

ogra

m: P

lan

activ

ity

as o

f May

1, 2

015,

htt

p://

ww

w.m

edic

aid.

gov/

chip

/dow

nloa

ds/c

hip-

map

.pdf

; and

MAC

PAC,

201

5, a

naly

sis

of C

MS,

201

5, e

mai

l to

MAC

PAC

staf

f, O

ctob

er 2

9.

https://www.medicaid.gov/medicaid-chip-program-information/program-information/medicaid-and-chip-eligibility-levels/medicaid-chip-eligibility-levels.html


http://www.medicaid.gov/medicaid-chip-program-information/by-state/by-state.html

http://www.medicaid.gov/medicaid-chip-program-information/by-state/by-state.html

http://www.medicaid.gov/state-resource-center/medicaid-state-plan-amendments/medicaid-state-plan-amendments.html

http://www.medicaid.gov/state-resource-center/medicaid-state-plan-amendments/medicaid-state-plan-amendments.html

http://www.medicaid.gov/chip/state-program-information/chip-state-program-information.html

http://www.medicaid.gov/chip/state-program-information/chip-state-program-information.html

http://www.medicaid.gov/chip/downloads/chip-map.pdf

December 201694


MAC

Stat

sSe

ctio

n 4

EXH

IBIT

35.

Med

icai

d In

com

e El

igib

ility

Lev

els

as a

Per

cent

age

of th

e FP

L fo

r Non

-Age

d, N

on-D

isab

led,

Non

-Pre

gnan

t Adu

lts

by S

tate

, Jul

y 20

16

Stat

ePa

rent

s an

d ca

reta

ker r

elat

ives

of

dep

ende

nt c

hild

ren1

Addi

tiona

l ind

ivid

uals

age

19–

642

Alab

ama

13%

–Al

aska

142

133

(142

onl

y fo

r tho

se a

ge 1

9–20

)%Ar

izon

a10

613

3Ar

kans

as17

133

Calif

orni

a10

913

3Co

lora

do68

133

Conn

ectic

ut15

013

3De

law

are

8713

3Di

stric

t of C

olum

bia

216

210

(216

onl

y fo

r tho

se a

ge 1

9–20

)Fl

orid

a29

29 o

nly

for t

hose

age

19–

20G

eorg

ia34

–H

awai

i10

513

3Id

aho

243

–4

Illin

ois

133

133

Indi

ana

1913

3Io

wa

5413

3Ka

nsas

33–

Kent

ucky

2313

3Lo

uisi

ana

1913

3M

aine

100

156

only

for t

hose

age

19–

20M

aryl

and

123

133

Mas

sach

uset

ts13

313

3 (1

50 o

nly

for t

hose

age

19–

20)

Mic

higa

n54

133

Min

neso

ta13

3513

35

Mis

siss

ippi

23–

Mis

sour

i18

3–

4

Mon

tana

2413

3N

ebra

ska

58–

Nev

ada

3213

3



MAC

Stat

sSe

ctio

n 4

Stat

ePa

rent

s an

d ca

reta

ker r

elat

ives

of

dep

ende

nt c

hild

ren1

Addi

tiona

l ind

ivid

uals

age

19–

642

New

Ham

pshi

re68

%13

3%N

ew J

erse

y32

133

New

Mex

ico

4613

3N

ew Y

ork

1335

1335

Nor

th C

arol

ina

4444

onl

y fo

r tho

se a

ge 1

9–20

Nor

th D

akot

a52

133

Ohi

o90

133

Okl

ahom

a41

3–

4

Ore

gon

4013

3Pe

nnsy

lvan

ia33

133

Rhod

e Is

land

116

133

Sout

h Ca

rolin

a62

–So

uth

Dako

ta57

–Te

nnes

see

103

–Te

xas

15–

Uta

h44

3–

4

Verm

ont

5313

3Vi

rgin

ia49

–W

ashi

ngto

n40

133

Wes

t Virg

inia

1913

3W

isco

nsin

9595

Wyo

min

g55

–

Not

es: F

PL is

fede

ral p

over

ty le

vel.

In 2

016,

100

per

cent

FPL

is $

11,8

80 fo

r an

indi

vidu

al p

lus

$4,1

40–

$4,1

60 fo

r eac

h ad

ditio

nal f

amily

mem

ber i

n th

e lo

wer

48

stat

es a

nd

the

Dist

rict o

f Col

umbi

a. W

hen

dete

rmin

ing

Med

icai

d an

d CH

IP e

ligib

ility

prio

r to

2014

, sta

tes

had

the

flexi

bilit

y to

dis

rega

rd in

com

e so

urce

s an

d am

ount

s of

thei

r cho

osin

g.

Begi

nnin

g in

201

4, u

nifo

rm m

odifi

ed a

djus

ted

gros

s in

com

e (M

AGI)

rule

s m

ust b

e us

ed to

det

erm

ine

Med

icai

d an

d CH

IP e

ligib

ility

for m

ost n

on-d

isab

led

child

ren

and

adul

ts

unde

r age

65,

incl

udin

g th

e gr

oups

sho

wn

in th

is ta

ble.

As

a re

sult,

sta

tes

are

now

requ

ired

to u

se M

AGI-c

onve

rted

elig

ibili

ty le

vels

that

acc

ount

for t

he c

hang

e in

inco

me-

coun

ting

rule

s. T

he e

ligib

ility

leve

ls s

how

n in

this

tabl

e re

flect

thes

e M

AGI-c

onve

rted

leve

ls o

r ano

ther

MAG

I-bas

ed in

com

e lim

it in

eff

ect i

n ea

ch s

tate

for t

hese

gro

ups

as

of J

uly

2016

. Und

er fe

dera

l reg

ulat

ions

, the

eff

ectiv

e in

com

e lim

its m

ay b

e hi

gher

by

5 pe

rcen

tage

poi

nts

of th

e FP

L th

an th

ose

show

n on

this

tabl

e to

acc

ount

for a

gen

eral

in

com

e di

sreg

ard

that

app

lies

to a

n in

divi

dual

’s d

eter

min

atio

n of

elig

ibili

ty fo

r Med

icai

d an

d CH

IP o

vera

ll, ra

ther

than

for p

artic

ular

elig

ibili

ty g

roup

s w

ithin

Med

icai

d or

CH

IP.

EXH

IBIT

35.

(co

ntin

ued)

December 201696


MAC

Stat

s

Stat

es a

re re

quire

d to

pro

vide

Med

icai

d co

vera

ge fo

r par

ents

and

oth

er c

aret

aker

rela

tives

(and

thei

r dep

ende

nt c

hild

ren)

, at a

min

imum

, at t

heir

1988

Aid

to F

amili

es w

ith

Depe

nden

t Chi

ldre

n el

igib

ility

leve

ls. U

nder

regu

lar M

edic

aid

stat

e pl

an ru

les,

sta

tes

may

opt

to c

over

add

ition

al p

aren

ts a

nd c

aret

aker

rela

tives

; chi

ldre

n ag

e 19

or 2

0; a

nd

othe

r ind

ivid

uals

age

d 19

–64

who

are

not

pre

gnan

t, no

t elig

ible

for M

edic

are,

and

hav

e in

com

es a

t or b

elow

133

per

cent

of t

he fe

dera

l pov

erty

leve

l. St

ates

may

als

o pr

ovid

e co

vera

ge u

nder

Sec

tion

1115

wai

vers

, whi

ch a

llow

them

to o

pera

te th

eir M

edic

aid

prog

ram

s w

ithou

t reg

ard

to c

erta

in s

tatu

tory

requ

irem

ents

. As

note

d in

this

tabl

e, th

e co

vere

d be

nefit

s un

der t

hese

wai

vers

may

be

mor

e lim

ited

than

thos

e pr

ovid

ed u

nder

regu

lar s

tate

pla

n ru

les

and

may

not

be

avai

labl

e to

all

indi

vidu

als

at th

e in

com

e le

vels

sh

own.

– D

ash

indi

cate

s th

at s

tate

doe

s no

t use

this

elig

ibili

ty p

athw

ay.

1 In

sta

tes

that

use

dol

lar a

mou

nts

rath

er th

an p

erce

ntag

es o

f the

FPL

to d

eter

min

e el

igib

ility

for p

aren

ts, t

hose

am

ount

s w

ere

conv

erte

d to

a p

erce

nt o

f the

FPL

for 2

016,

and

th

e hi

ghes

t per

cent

age

was

sel

ecte

d to

refle

ct e

ligib

ility

leve

l for

the

grou

p.2

Refle

cts

stat

e pl

an c

over

age

unde

r Sec

tion

1902

(a)(

10)(

A)(i)

(VIII

) of t

he S

ocia

l Sec

urity

Act

for i

ndiv

idua

ls w

ho a

re a

ge 1

9–64

, not

pre

gnan

t, no

t elig

ible

for M

edic

are,

and

ha

ve in

com

e at

or b

elow

133

per

cent

FPL

; sta

te p

lan

cove

rage

for c

hild

ren

age

19 o

r 20

whe

re in

dica

ted;

and

Sec

tion

1115

wai

ver c

over

age

that

is n

ot s

ubje

ct to

the

limita

tions

in

dica

ted

in n

ote

4.3

Refle

cts

pare

nt c

over

age

unde

r the

Med

icai

d st

ate

plan

. The

sta

te h

as s

ome

addi

tiona

l cov

erag

e ab

ove

stat

e pl

an e

ligib

ility

sta

ndar

ds th

roug

h a

Sect

ion

1115

dem

onst

ratio

n or

a p

endi

ng d

emon

stra

tion

prop

osal

. The

dem

onst

ratio

n in

clud

es li

mita

tions

on

elig

ibili

ty o

r ben

efits

, is

not o

ffer

ed to

all

resi

dent

s of

the

stat

e, o

r inc

lude

s an

enr

ollm

ent c

ap.

4 Th

e st

ate

has

a Se

ctio

n 11

15 d

emon

stra

tion

or a

pen

ding

dem

onst

ratio

n pr

opos

al th

at p

rovi

des

Med

icai

d co

vera

ge to

som

e lo

w-in

com

e ad

ults

. The

dem

onst

ratio

n in

clud

es

limita

tions

on

elig

ibili

ty o

r ben

efits

, is

not o

ffer

ed to

all

resi

dent

s of

the

stat

e, o

r inc

lude

s an

enr

ollm

ent c

ap.

5 In

Min

neso

ta a

nd N

ew Y

ork,

indi

vidu

als

with

inco

mes

bet

wee

n 13

3 an

d 20

0 pe

rcen

t FPL

are

cov

ered

und

er th

e Ba

sic

Hea

lth P

rogr

am.

Sour

ces:

MAC

PAC,

201

6, a

naly

sis

of C

ente

rs fo

r Med

icar

e &

Med

icai

d Se

rvic

es, 2

016,

Sta

te M

edic

aid

and

CHIP

inco

me

elig

ibili

ty s

tand

ards

(For

sel

ecte

d M

AGI G

roup

s, b

ased

on

sta

te d

ecis

ions

as

of J

une

1, 2

016)

, htt

ps:/

/ww

w.m

edic

aid.

gov/

med

icai

d-ch

ip-p

rogr

am-in

form

atio

n/pr

ogra

m-in

form

atio

n/m

edic

aid-

and-

chip

-elig

ibili

ty-le

vels

/med

icai

d-ch

ip-

elig

ibili

ty-le

vels

.htm

l; an

d M

ACPA

C, 2

016,

ana

lysi

s of

sta

te w

ebsi

tes.

EXH

IBIT

35.

(co

ntin

ued)

Sect

ion

4





MAC

Stat

s

Stat

eSt

ate

elig

ibili

ty

type

1SS

I rec

ipie

nts2

209(

b) e

ligib

ility

1Po

vert

y le

vel3

Med

ical

ly n

eedy

4Sp

ecia

l inc

ome

leve

l5

Alab

ama

1634

74%

––

–22

2%Al

aska

SSI c

riter

ia59

6–

––

178

Ariz

ona

1634

74–

100%

–22

2Ar

kans

as16

3474

–80

(age

d on

ly)

11%

222

Calif

orni

a16

3474

–10

061

–Co

lora

do16

3474

––

–22

2Co

nnec

ticut

209(

b)–

64%

7–

6422

2De

law

are

1634

74–

––

185

Dist

rict o

f Col

umbi

a16

3474

–10

064

222

Flor

ida

1634

74–

8818

222

Geo

rgia

1634

74–

–32

222

Haw

aii

209(

b)–

6410

041

–Id

aho

SSI c

riter

ia74

–77

–22

2Ill

inoi

s20

9(b)

–10

010

010

0–

Indi

ana

1634

74–

100

–22

2Io

wa

1634

74–

–49

222

Kans

asSS

I crit

eria

74–

–48

222

Kent

ucky

1634

74–

–22

222

Loui

sian

a16

3474

––

1022

2M

aine

1634

74–

100

3222

2M

aryl

and

1634

74–

–35

222

Mas

sach

uset

ts8

1634

74–

100

(age

d) /

133

(dis

able

d)53

222

Mic

higa

n16

3474

–10

041

222

Min

neso

ta20

9(b)

–80

100

8022

2M

issi

ssip

pi16

3474

––

–22

2M

isso

uri

209(

b)–

8585

8513

0M

onta

na16

3474

––

53–

Neb

rask

aSS

I crit

eria

74–

100

40–

Nev

ada

SSI c

riter

ia74

––

–22

2

EXH

IBIT

36.

Med

icai

d In

com

e El

igib

ility

Lev

els

as a

Per

cent

age

of th

e FP

L fo

r Ind

ivid

uals

Age

65

and

Old

er a

nd P

erso

ns w

ith

Disa

bilit

ies

by S

tate

, 201

6

Sect

ion

4

December 201698


MAC

Stat

sSe

ctio

n 4

EXH

IBIT

36.

(co

ntin

ued)

Stat

eSt

ate

elig

ibili

ty

type

1SS

I rec

ipie

nts2

209(

b) e

ligib

ility

1Po

vert

y le

vel3

Med

ical

ly n

eedy

4Sp

ecia

l inc

ome

leve

l5

New

Ham

pshi

re20

9(b)

–75

%–

60%

222%

New

Jer

sey

1634

74%

–10

0%37

222

New

Mex

ico

1634

74–

––

222

New

Yor

k16

3474

–83

83–

Nor

th C

arol

ina

1634

74–

100

24–

Nor

th D

akot

a20

9(b)

–83

–83

–O

hio9

1634

74–

––

222

Okl

ahom

a9SS

I crit

eria

74–

100

–22

2O

rego

nSS

I crit

eria

74–

––

222

Penn

sylv

ania

1634

74–

100

4322

2Rh

ode

Isla

nd16

3474

–10

088

222

Sout

h Ca

rolin

a16

3474

–10

0–

222

Sout

h Da

kota

1634

74–

––

222

Tenn

esse

e16

3474

––

–22

2Te

xas

1634

74–

––

222

Uta

hSS

I crit

eria

74–

100

100

222

Verm

ont

1634

74–

–10

922

2Vi

rgin

ia20

9(b)

–74

8047

222

Was

hing

ton

1634

74–

–74

222

Wes

t Virg

inia

1634

74–

–20

222

Wis

cons

in16

3474

–83

6022

2W

yom

ing

1634

74–

––

222

Not

es: F

PL is

fede

ral p

over

ty le

vel.

SSI i

s Su

pple

men

tal S

ecur

ity In

com

e. 2

09(b

) ref

ers

to S

ectio

n 20

9(b)

of t

he S

ocia

l Sec

urity

Am

endm

ents

of 1

972;

163

4 re

fers

to S

ectio

n 16

34 o

f the

Soc

ial S

ecur

ity A

ct. I

n 20

16, 1

00 p

erce

nt F

PL is

$11

,880

for a

n in

divi

dual

and

$4,

140–

$4,1

60 fo

r eac

h ad

ditio

nal f

amily

mem

ber i

n th

e lo

wer

48

stat

es a

nd th

e Di

stric

t of C

olum

bia.

Elig

ibili

ty le

vels

sho

wn

here

app

ly to

cou

ntab

le in

com

e; a

s a

resu

lt, s

tate

s th

at u

se o

ptio

nal i

ncom

e di

sreg

ards

to re

duce

cou

ntab

le in

com

e ef

fect

ivel

y al

low

a la

rger

num

ber o

f peo

ple

to q

ualif

y at

a g

iven

elig

ibili

ty le

vel (

e.g.

, 100

per

cent

FPL

) rel

ativ

e to

sta

tes

that

do

not.

The

elig

ibili

ty le

vels

list

ed in

this

tabl

e ar

e fo

r in

divi

dual

s; th

e el

igib

ility

leve

ls fo

r cou

ples

diff

er fo

r cer

tain

cat

egor

ies.

In a

dditi

on, i

ncom

e el

igib

ility

leve

ls fo

r ind

ivid

uals

who

qua

lify

base

d on

blin

dnes

s m

ay b

e hi

gher

than

fo

r ind

ivid

uals

who

qua

lify

base

d on

oth

er d

isab

ilitie

s or

bei

ng a

ge 6

5 or

old

er.

In m

ost s

tate

s, e

nrol

lmen

t in

the

SSI p

rogr

am fo

r ind

ivid

uals

age

65

and

olde

r and

per

sons

with

dis

abili

ties

auto

mat

ical

ly q

ualif

ies

them

for M

edic

aid.

How

ever

, 209

(b) s

tate

s m

ay u

se m

ore

rest

rictiv

e cr

iteria

(rel

ated

to in

com

e an

d as

sets

, dis

abili

ty, o

r bot

h) th

an S

SI w

hen

dete

rmin

ing

Med

icai

d el

igib

ility

. All

stat

es h

ave

the

optio

n of

cov

erin

g ad

ditio

nal p

eopl

e w

ith lo

w in

com

es o

r hig

h m

edic

al e

xpen

ses

thro

ugh

othe

r elig

ibili

ty p

athw

ays,

suc

h as

pov

erty

leve

l, m

edic

ally

nee

dy, a

nd s

peci

al in

com

e le

vel.



MAC

Stat

sSe

ctio

n 4

1 SS

I crit

eria

are

use

d to

det

erm

ine

Med

icai

d el

igib

ility

in b

oth

1634

and

SSI

-crit

eria

sta

tes.

In 1

634

stat

es, t

he fe

dera

l elig

ibili

ty d

eter

min

atio

n pr

oces

s fo

r SSI

aut

omat

ical

ly

qual

ifies

an

indi

vidu

al fo

r Med

icai

d; in

SSI

-crit

eria

sta

tes,

indi

vidu

als

mus

t sub

mit

info

rmat

ion

to th

e st

ate

for a

sep

arat

e el

igib

ility

det

erm

inat

ion.

209

(b) s

tate

s m

ay u

se

elig

ibili

ty c

riter

ia (r

elat

ed to

inco

me

and

asse

ts, d

isab

ility

, or b

oth)

mor

e re

stric

tive

than

the

SSI p

rogr

am b

ut m

ay n

ot u

se m

ore

rest

rictiv

e cr

iteria

than

thos

e in

eff

ect i

n th

e st

ate

on J

anua

ry 1

, 197

2. If

a 2

09(b

) sta

te d

oes

not h

ave

a se

para

te m

edic

ally

nee

dy s

tand

ard,

it m

ust a

llow

indi

vidu

als

with

hig

her i

ncom

es to

spe

nd d

own

to th

e 20

9(b)

in

com

e le

vel s

how

n he

re b

y de

duct

ing

incu

rred

med

ical

exp

ense

s fr

om th

e am

ount

of i

ncom

e th

at is

cou

nted

for M

edic

aid

elig

ibili

ty p

urpo

ses.

2 Th

e SS

I fed

eral

ben

efit

rate

as

a pe

rcen

t of t

he F

PL d

ecre

ased

from

last

yea

r due

the

FPL

incr

easi

ng a

bout

1 p

erce

nt fr

om 2

015

to 2

016

whi

le th

e SS

I fed

eral

ben

efit

rate

did

no

t cha

nge.

3 U

nder

the

pove

rty

leve

l opt

ion,

sta

tes

may

cho

ose

to p

rovi

de M

edic

aid

cove

rage

to p

erso

ns w

ho a

re a

ged

or d

isab

led

and

who

se in

com

e is

abo

ve th

e SS

I or 2

09(b

) lev

el, b

ut

is a

t or b

elow

the

FPL.

4 U

nder

the

med

ical

ly n

eedy

opt

ion,

indi

vidu

als

with

hig

her i

ncom

es c

an s

pend

dow

n to

the

med

ical

ly n

eedy

inco

me

leve

l sho

wn

here

by

dedu

ctin

g in

curr

ed m

edic

al e

xpen

ses

from

the

amou

nt o

f inc

ome

that

is c

ount

ed fo

r Med

icai

d el

igib

ility

pur

pose

s. F

ive

stat

es (C

onne

ctic

ut, L

ouis

iana

, Mic

higa

n, V

erm

ont,

and

Virg

inia

) hav

e a

med

ical

ly n

eedy

in

com

e st

anda

rd th

at v

arie

s by

loca

tion;

the

high

est i

ncom

e st

anda

rd is

list

ed fo

r eac

h of

thes

e st

ates

.5

Und

er th

e sp

ecia

l inc

ome

leve

l opt

ion,

sta

tes

have

the

optio

n to

pro

vide

Med

icai

d be

nefit

s to

peo

ple

who

requ

ire a

t lea

st 3

0 da

ys o

f nur

sing

hom

e or

oth

er in

stitu

tiona

l car

e an

d ha

ve in

com

es u

p to

300

per

cent

of t

he S

SI b

enef

it ra

te (w

hich

was

abo

ut 2

22 p

erce

nt F

PL in

201

6). T

he in

com

e st

anda

rd li

sted

in th

is c

olum

n m

ay b

e fo

r ins

titut

iona

l se

rvic

es, h

ome

and

com

mun

ity-b

ased

wai

ver s

ervi

ces,

or b

oth.

6 Th

e do

llar a

mou

nt th

at e

qual

s th

e up

per i

ncom

e el

igib

ility

leve

l for

SSI

doe

s no

t var

y by

sta

te; h

owev

er, t

he d

olla

r am

ount

that

equ

als

the

FPL

is h

ighe

r in

Alas

ka, r

esul

ting

in

a lo

wer

per

cent

age.

7 Th

e in

com

e st

anda

rds

in C

onne

ctic

ut v

ary

by g

eogr

aphy

; the

hig

hest

inco

me

stan

dard

for r

egio

n A

is li

sted

. The

inco

me

stan

dard

in re

gion

s B

and

C is

53

perc

ent o

f FPL

.8

Mas

sach

uset

ts p

rovi

des

med

ical

ly n

eedy

cov

erag

e fo

r ind

ivid

uals

age

65

and

olde

r and

thos

e w

ho a

re e

ligib

le o

n th

e ba

sis

of d

isab

ility

, but

the

rule

s fo

r cou

ntin

g in

com

e an

d sp

end-

dow

n ex

pens

es v

ary

for t

hese

gro

ups.

9 O

klah

oma

was

a 2

09(b

) sta

te u

ntil

Oct

ober

1, 2

015,

at w

hich

poi

nt it

bec

ame

an S

SI-c

riter

ia s

tate

. Ohi

o w

as a

209

(b) s

tate

unt

il Au

gust

1, 2

016,

at w

hich

poi

nt it

bec

ame

a 16

34 s

tate

; the

sta

te a

lso

elim

inat

ed it

s m

edic

ally

nee

dy p

rogr

am d

urin

g th

e co

nver

sion

to 1

634

crite

ria.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

elig

ibili

ty in

form

atio

n fr

om s

tate

web

site

s an

d M

edic

aid

stat

e pl

ans

as o

f Oct

ober

201

6.

EXH

IBIT

36.

(co

ntin

ued)

December 2016100


MAC

Stat

s

Stat

eFP

L

Annu

al a

mou

ntM

onth

ly a

mou

nt

Fam

ily s

ize

Fam

ily s

ize

12

34

Each

ad

ditio

nal

pers

on1

12

34

Each

ad

ditio

nal

pers

on1

Low

er 4

8 st

ates

an

d th

e Di

stric

t of

Col

umbi

a

100%

$11,

880

$16,

020

$20,

160

$24,

300

$4,1

40–

$4,1

60$9

90$1

,335

$1,6

80$2

,025

$345

–$3

47

133

15,8

0021

,307

26,8

1332

,319

5,50

6–5,

533

1,31

71,

776

2,23

42,

693

459-

461

138

16,3

9422

,108

27,8

2133

,534

5,71

3–5,

741

1,36

61,

842

2,31

82,

795

476-

478

150

17,8

2024

,030

30,2

4036

,450

6,21

0–6,

240

1,48

52,

003

2,52

03,

038

518-

520

185

21,9

7829

,637

37,2

9644

,955

7,65

9–7,

696

1,83

22,

470

3,10

83,

746

638-

641

200

23,7

6032

,040

40,3

2048

,600

8,28

0–8,

320

1,98

02,

670

3,36

04,

050

690-

693

250

29,7

0040

,050

50,4

0060

,750

10,3

50–

10,4

002,

475

3,33

84,

200

5,06

386

3-86

7

300

35,6

4048

,060

60,4

8072

,900

12,4

20–

12,4

802,

970

4,00

55,

040

6,07

51,

035-

1,04

0

400

47,5

2064

,080

80,6

4097

,200

16,5

60–

16,6

403,

960

5,34

06,

720

8,10

01,

380-

1,38

7

Alas

ka10

0%$1

4,84

0$2

0,02

0$2

5,20

0$3

0,38

0$5

,180

–$5

,200

$1,2

37$1

,668

$2,1

00$2

,532

$432

-$43

3

133

19,7

3726

,627

33,5

1640

,405

6,88

9–6,

916

1,64

52,

219

2,79

33,

367

574-

576

138

20,4

7927

,628

34,7

7641

,924

7,14

8–7,

176

1,70

72,

302

2,89

83,

494

596-

598

150

22,2

6030

,030

37,8

0045

,570

7,77

0–7,

800

1,85

52,

503

3,15

03,

798

648-

650

185

27,4

5437

,037

46,6

2056

,203

9,58

3–9,

620

2,28

83,

086

3,88

54,

684

799-

802

200

29,6

8040

,040

50,4

0060

,760

10,3

60–

10,4

002,

473

3,33

74,

200

5,06

386

3-86

7

250

37,1

0050

,050

63,0

0075

,950

12,9

50–

13,0

003,

092

4,17

15,

250

6,32

91,

079-

1,08

3

300

44,5

2060

,060

75,6

0091

,140

15,5

40–

15,6

003,

710

5,00

56,

300

7,59

51,

295-

1,30

0

400

59,3

6080

,080

100,

800

121,

520

20,7

20–

20,8

004,

947

6,67

38,

400

10,1

271,

727-

1,73

3

EXH

IBIT

37.

Inc

ome

as a

Per

cent

age

of th

e FP

L fo

r Var

ious

Fam

ily S

izes

, 201

6

Sect

ion

4



MAC

Stat

s

Stat

eFP

L

Annu

al a

mou

ntM

onth

ly a

mou

nt

Fam

ily s

ize

Fam

ily s

ize

12

34

Each

ad

ditio

nal

pers

on1

12

34

Each

ad

ditio

nal

pers

on1

Haw

aii

100%

$13,

670

$18,

430

$23,

190

$27,

950

$4,7

60–

$4,7

80$1

,139

$1,5

36$1

,933

$2,3

29$3

97-$

398

133

18,1

8124

,512

30,8

4337

,174

6,33

1–6,

357

1,51

52,

043

2,57

03,

098

528-

530

138

18,8

6525

,433

32,0

0238

,571

6,56

9–6,

596

1,57

22,

119

2,66

73,

214

547-

550

150

20,5

0527

,645

34,7

8541

,925

7,14

0–7,

170

1,70

92,

304

2,89

93,

494

595-

598

185

25,2

9034

,096

42,9

0251

,708

8,80

6–8,

843

2,10

72,

841

3,57

54,

309

734-

737

200

27,3

4036

,860

46,3

8055

,900

9,52

0–9,

560

2,27

83,

072

3,86

54,

658

793-

797

250

34,1

7546

,075

57,9

7569

,875

11,9

00–

11,9

502,

848

3,84

04,

831

5,82

399

2-99

6

300

41,0

1055

,290

69,5

7083

,850

14,2

80–

14,3

403,

418

4,60

85,

798

6,98

81,

190-

1,19

5

400

54,6

8073

,720

92,7

6011

1,80

019

,040

–19

,120

4,55

76,

143

7,73

09,

317

1,58

7-1,

593

Not

es: F

PL is

fede

ral p

over

ty le

vel.

The

FPLs

sho

wn

here

are

bas

ed o

n th

e U

.S. D

epar

tmen

t of H

ealth

and

Hum

an S

ervi

ces

2016

fede

ral p

over

ty g

uide

lines

. The

se d

iffer

slig

htly

fr

om th

e U

.S. C

ensu

s Bu

reau

’s fe

dera

l pov

erty

thre

shol

ds, w

hich

are

use

d m

ainl

y fo

r sta

tistic

al p

urpo

ses.

The

sep

arat

e po

vert

y gu

idel

ines

for A

lask

a an

d H

awai

i ref

lect

Off

ice

of E

cono

mic

Opp

ortu

nity

adm

inis

trat

ive

prac

tice

begi

nnin

g in

the

1966

–19

70 p

erio

d.

1 In

rare

circ

umst

ance

s, th

e ro

undi

ng a

nd s

tand

ardi

zing

adj

ustm

ents

in th

e up

date

form

ula

resu

lt in

sm

all d

ecre

ases

in th

e po

vert

y gu

idel

ines

for s

ome

hous

ehol

d si

zes

even

w

hen

the

infla

tion

fact

or is

not

neg

ativ

e. In

ord

er to

pre

vent

a re

duct

ion

in th

e gu

idel

ines

in th

ese

rare

circ

umst

ance

s, a

min

or a

djus

tmen

t was

impl

emen

ted

to th

e fo

rmul

a be

ginn

ing

in 2

016.

In c

ases

whe

re th

e ye

ar-to

-yea

r cha

nge

in in

flatio

n is

not

neg

ativ

e an

d th

e ro

undi

ng a

nd s

tand

ardi

zing

adj

ustm

ents

in th

e fo

rmul

a re

sult

in re

duct

ions

to th

e gu

idel

ines

from

the

prev

ious

yea

r for

som

e ho

useh

old

size

s, th

e gu

idel

ines

for t

he a

ffec

ted

hous

ehol

d si

zes

are

fixed

at t

he p

rior y

ear’s

gui

delin

es. F

or th

e lo

wer

48

stat

es a

nd

DC, t

he in

crea

se p

er p

erso

n is

$4,

140

for a

fam

ily s

ize

of fi

ve o

r six

, $4,

150

for a

fam

ily s

ize

of s

even

, and

$4,

160

for a

fam

ily s

ize

of e

ight

or m

ore.

For

Ala

ska,

the

incr

ease

per

pe

rson

is $

5,18

0 fo

r a fa

mily

siz

e of

five

, six

, or s

even

and

$5,

200

for a

fam

ily s

ize

of e

ight

or m

ore.

For

Haw

aii,

the

incr

ease

per

per

son

is $

4,76

0 fo

r a fa

mily

siz

e of

five

, six

, or

seve

n an

d $4

,780

for a

fam

ily s

ize

of e

ight

or m

ore.

Sour

ce: U

.S. D

epar

tmen

t of H

ealth

and

Hum

an S

ervi

ces

(HH

S), 2

016,

Ann

ual u

pdat

e of

the

HH

S po

vert

y gu

idel

ines

, Fed

eral

Reg

iste

r 81,

no.

15

(Jan

uary

25)

: 403

6–40

37.

EXH

IBIT

37.

(co

ntin

ued)

Sect

ion

4

SECTION 5

Beneficiary Health, Service Use, and Access to Care

December 2016104

Section 5: Beneficiary Health, Service Use, and Access to Care


Key Points• Children whose primary coverage source is Medicaid or the State Children's Health

Insurance Program (CHIP) are less likely to be in excellent or very good health than those who have private coverage or are uninsured (Exhibit 38). However, estimates of their use of services relative to other groups vary depending on the type of care and data source. For example, data from both the National Health Interview Survey (NHIS) and the Medical Expenditures Panel Survey (MEPS) indicate that children with Medicaid or CHIP are less likely than those with private coverage and more likely than those who are uninsured to have seen a dentist in the last 12 months. However, the percentage of children with Medicaid or CHIP reported as having seen a dentist differs substantially between the NHIS (80.9 percent in 2015) and MEPS (38.0 percent in 2014), with similar differences observed for children who have private coverage or are uninsured (Exhibits 39 and 40).

• Like children, adults age 19–64 whose primary coverage source is Medicaid or CHIP are less likely to be in excellent or very good health than those who have private coverage or are uninsured, and comparisons of their service use relative to other groups vary by data source. Adults age 19–64 whose primary coverage source is Medicare, who must meet federal disability criteria to receive coverage, report the poorest health and highest service use in this age group (Exhibits 42–44).

• Children whose primary coverage source is Medicaid or CHIP are reported as seeing a general doctor or having a well-child checkup at rates similar to those with private coverage (Exhibit 39). However, they are more likely to have trouble finding a doctor or delayed care than those with private coverage (Exhibit 41).

• Adults age 19–64 whose primary coverage is Medicaid report having a usual source of care at a similar rate as those with private coverage but are more likely to report having difficulties with access to care. Adults age 19–64 whose primary coverage source is Medicare report the highest rates of delayed care and unmet need due to cost when adults who are uninsured are excluded (Exhibit 45).

• Measures of use of care for specific types of services, reported in Exhibits 38–45, should be interpreted with caution due to the limitations of survey data and the characteristics of the populations examined. For example, these results are unadjusted for differences in age, health, income, race and ethnicity, and family and household characteristics that are known to explain some of the differences in access and use observed between individuals with different coverage sources. In addition, Exhibits 38–45 reflect an individual’s primary payer of care—individuals who have multiple coverage sources were assigned to a single source based on a hierarchy. For selected characteristics of individuals without the application of this hierarchy, see Exhibit 2.



MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%54

.9%

36.5

%4.

7%Co

vera

geLe

ngth

of t

ime

with

any

cov

erag

e du

ring

the

year

Full

year

92.7

*97

.5*

95.5

–Pa

rt y

ear

4.9

2.5*

4.5

41.4

*N

o co

vera

ge d

urin

g ye

ar2.

5*–

–58

.6*

Dem

ogra

phic

sAg

e0–

530

.8*

28.9

*34

.320

.7*

6–11

31.8

*30

.7*

34.0

27.3

*12

–18

37.4

*40

.3*

31.7

51.9

*G

ende

rM

ale

51.1

50.4

51.6

49.7

Fem

ale

48.9

49.6

48.4

50.3

Race

His

pani

c24

.6*

14.7

*37

.243

.1W

hite

, non

-His

pani

c53

.7*

67.4

*34

.942

.9*

Blac

k, n

on-H

ispa

nic

14.6

*9.

9*22

.18.

3*O

ther

non

-whi

te, n

on-H

ispa

nic

7.1

8.0*

5.8

5.7

Pare

nts

pres

ent i

n fa

mily

Mot

her,

no fa

ther

23.2

*13

.3*

37.8

22.2

*Fa

ther

, no

mot

her

3.6

3.4

3.8

4.8

Both

pre

sent

69.9

*82

.1*

52.3

69.0

*N

o pa

rent

s3.

2*1.

2*6.

14.

1Fa

mily

inco

me

Has

inco

me

less

than

138

per

cent

FPL

31.1

*8.

5*63

.938

.9*

Has

inco

me

in ra

nges

sho

wn

belo

wLe

ss th

an 1

00 p

erce

nt F

PL21

.1*

4.2*

46.6

22.9

*10

0–19

9 pe

rcen

t FPL

23.0

*12

.6*

35.7

35.2

200–

399

perc

ent F

PL27

.6*

35.5

*14

.733

.0*

400

perc

ent F

PL o

r hig

her

28.1

*47

.6*

2.9

8.5*

EXH

IBIT

38.

Cov

erag

e, D

emog

raph

ic, a

nd H

ealth

Cha

ract

eris

tics

of N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

0–18

by

Prim

ary

Sour

ce

of H

ealth

Cov

erag

e, 2

015

December 2016106


MAC

Stat

sSe

ctio

n 5

EXH

IBIT

38.

(co

ntin

ued)

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Oth

er d

emog

raph

ic c

hara

cter

istic

sCi

tizen

of U

nite

d St

ates

97.5

%98

.2%

97.7

%86

.9%

*Re

ceiv

es S

SI6

1.0*

0.4*

2.1

†Fa

mily

rece

ives

WIC

6.9*

1.4*

15.5

4.0*

Hea

lthCu

rren

t hea

lth s

tatu

sEx

celle

nt o

r ver

y go

od84

.3*

89.9

*76

.180

.9*

Goo

d14

.0*

9.2*

20.7

17.7

Fair

or p

oor

1.8*

0.9*

3.2

†Bo

dy M

ass

Inde

x (B

MI)7

Hea

lthy

wei

ght (

BMI l

ess

than

25)

75.9

*79

.2*

71.4

66.8

Ove

rwei

ght (

BMI 2

5–29

)16

.214

.4*

17.8

24.0

Obe

se (B

MI 3

0 or

hig

her)

7.9*

6.4*

10.8

9.3

Spec

ial n

eeds

, im

pairm

ents

, and

hea

lth c

ondi

tions

Has

spe

cial

hea

lth c

are

need

s821

.3*

19.0

*24

.815

.4*

Rece

ives

spe

cial

edu

catio

n or

ear

ly in

terv

entio

n se

rvic

es9

8.2

7.4*

9.5

3.6*

Has

impa

irmen

t req

uirin

g sp

ecia

l equ

ipm

ent

1.0

0.9

1.1

†H

as im

pairm

ent l

imiti

ng a

bilit

y to

cra

wl, w

alk,

run,

or p

lay9

1.3

1.1

1.6

†H

as im

pairm

ent l

imiti

ng a

bilit

y to

cra

wl,

wal

k, ru

n, o

r pl

ay th

at is

exp

ecte

d to

last

12+

mon

ths9

1.0

0.9

1.3

†Ev

er b

een

told

he

or s

he h

as s

elec

ted

cond

ition

sAD

HD/

ADD10

9.3*

8.4*

10.9

4.4*

Asth

ma

13.3

*12

.1*

15.2

13.4

Autis

m10

2.3

2.1

2.6

†Ce

rebr

al p

alsy

90.

3†

†–

Cong

enita

l hea

rt d

isea

se9

0.2

††

–Di

abet

es0.

3†

††

Dow

n sy

ndro

me9

0.1

††

†In

telle

ctua

l dis

abili

ty9

1.2

0.7*

1.7

†O

ther

dev

elop

men

tal d

elay

93.

43.

33.

6†



MAC

Stat

sSe

ctio

n 5

EXH

IBIT

38.

(co

ntin

ued)

Not

es: F

PL is

fede

ral p

over

ty le

vel.

SSI i

s Su

pple

men

tal S

ecur

ity In

com

e. W

IC is

Sup

plem

enta

l Nut

ritio

n Pr

ogra

m fo

r Wom

en, I

nfan

ts, a

nd C

hild

ren.

ADH

D is

att

entio

n de

ficit

hype

ract

ivity

dis

orde

r. AD

D is

att

entio

n de

ficit

diso

rder

. Per

cent

age

calc

ulat

ions

for e

ach

item

in th

e ex

hibi

t exc

lude

indi

vidu

als

with

mis

sing

and

unk

now

n va

lues

. The

indi

vidu

al

com

pone

nts

liste

d un

der t

he s

ubca

tego

ries

are

not a

lway

s m

utua

lly e

xclu

sive

and

may

not

add

to 1

00 p

erce

nt. S

tand

ard

erro

rs a

re a

vaila

ble

onlin

e in

the

dow

nloa

dabl

e Ex

cel

vers

ion

of th

is e

xhib

it at

htt

ps://

ww

w.m

acpa

c.go

v/pu

blic

atio

n/co

vera

ge-d

emog

raph

ic-a

nd-h

ealth

-cha

ract

eris

tics-

of-n

on-in

stitu

tiona

lized

-indi

vidu

als-

age-

0-18

-by-

prim

ary-

sour

ce-

of-h

ealth

-cov

erag

e/. D

ue to

diff

eren

ces

in m

etho

dolo

gy (s

uch

as th

e w

ordi

ng o

f que

stio

ns, l

engt

h of

reca

ll pe

riods

, and

pro

mpt

s or

pro

bes

used

to e

licit

resp

onse

s), e

stim

ates

ob

tain

ed fr

om d

iffer

ent s

urve

y da

ta s

ourc

es w

ill v

ary.

For

exa

mpl

e, th

e N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

) is

know

n to

pro

duce

hig

her e

stim

ates

of s

ervi

ce u

se th

an th

e M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

(MEP

S). F

or p

urpo

ses

of c

ompa

ring

grou

ps o

f ind

ivid

uals

(as

in th

is e

xhib

it), t

he N

HIS

pro

vide

s th

e m

ost r

ecen

t inf

orm

atio

n av

aila

ble.

For

oth

er

purp

oses

, suc

h as

mea

surin

g le

vels

of u

se re

lativ

e to

a p

artic

ular

ben

chm

ark

or g

oal,

it m

ay b

e ap

prop

riate

to c

onsu

lt es

timat

es fr

om M

EPS

or a

noth

er s

ourc

e.

* Diff

eren

ce fr

om M

edic

aid/

CHIP

is s

tatis

tical

ly s

igni

fican

t at t

he 0

.05

leve

l.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

erro

r gre

ater

than

30

perc

ent.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

chi

ldre

n un

der a

ge 1

9, re

gard

less

of c

over

age

sour

ce. I

n th

is e

xhib

it, th

e fo

llow

ing

hier

arch

y w

as u

sed

to a

ssig

n in

divi

dual

s w

ith

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

: Med

icar

e, p

rivat

e, M

edic

aid/

CHIP

, oth

er, u

nins

ured

. Not

sep

arat

ely

show

n ar

e th

e es

timat

es fo

r tho

se c

over

ed b

y M

edic

are

(gen

eral

ly c

hild

ren

with

end

-sta

ge re

nal d

isea

se),

any

type

of m

ilita

ry h

ealth

pla

n, o

r oth

er g

over

nmen

t-spo

nsor

ed p

rogr

ams.

Cov

erag

e so

urce

is d

efin

ed a

s of

the

time

of th

e su

rvey

inte

rvie

w. S

ince

an

indi

vidu

al m

ay h

ave

mul

tiple

cov

erag

e so

urce

s or

cha

nges

ove

r tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

cha

ract

eris

tics

or e

xper

ienc

es

asso

ciat

ed w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2

Priv

ate

heal

th in

sura

nce

cove

rage

exc

lude

s pl

ans

that

pai

d fo

r onl

y on

e ty

pe o

f ser

vice

, suc

h as

acc

iden

ts o

r den

tal c

are.

3 M

edic

aid/

CHIP

als

o in

clud

es p

erso

ns c

over

ed b

y ot

her s

tate

-spo

nsor

ed h

ealth

pla

ns.

4 In

divi

dual

s w

ere

defin

ed a

s un

insu

red

if th

ey d

id n

ot h

ave

any

priv

ate

heal

th in

sura

nce,

Med

icai

d, C

HIP

, Med

icar

e, s

tate

- or o

ther

gov

ernm

ent-s

pons

ored

hea

lth p

lan,

or

mili

tary

pla

n. In

divi

dual

s w

ere

also

def

ined

as

unin

sure

d if

they

had

onl

y In

dian

Hea

lth S

ervi

ce c

over

age

or h

ad o

nly

a pr

ivat

e pl

an th

at p

aid

for o

ne ty

pe o

f ser

vice

, suc

h as

ac

cide

nts

or d

enta

l car

e.5

Due

to th

e fa

ct th

at a

hie

rarc

hy w

as u

sed

in th

is e

xhib

it to

ass

ign

indi

vidu

als

with

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

(see

not

e 1)

, the

Med

icai

d/CH

IP

perc

enta

ges

show

n in

this

row

exc

lude

indi

vidu

als

who

als

o ha

ve M

edic

are

(whi

ch is

rare

for c

hild

ren)

or p

rivat

e co

vera

ge. C

ompo

nent

s do

not

sum

to 1

00 p

erce

nt b

ecau

se

not a

ll co

vera

ge s

ourc

es a

re s

how

n.

6 Ch

arac

teris

tic is

list

ed u

nder

dem

ogra

phic

s be

caus

e lo

w in

com

e is

one

of t

he c

riter

ia fo

r SSI

elig

ibili

ty. H

owev

er, S

SI re

ceip

t is

also

an

indi

cato

r of d

isab

ility

. For

a c

hild

to

be e

ligib

le fo

r SSI

, he

or s

he m

ust h

ave

a m

edic

ally

det

erm

inab

le p

hysi

cal o

r men

tal i

mpa

irmen

t tha

t res

ults

in m

arke

d an

d se

vere

func

tiona

l lim

itatio

ns a

nd th

at is

gen

eral

ly

expe

cted

to la

st a

t lea

st 1

2 m

onth

s or

resu

lt in

dea

th.

7 Su

rvey

info

rmat

ion

is li

mite

d to

chi

ldre

n ag

e 12

or o

lder

.8

Due

in p

art t

o ch

ange

s in

the

2011

NH

IS q

uest

ionn

aire

as

wel

l as

othe

r met

hodo

logi

cal c

hang

es, t

he d

efin

ition

of c

hild

ren

with

spe

cial

hea

lth c

are

need

s di

ffer

s sl

ight

ly

from

the

defin

ition

MAC

PAC

used

in p

rior v

ersi

ons.

Und

er th

e ch

ildre

n w

ith s

peci

al h

ealth

car

e ne

eds

defin

ition

app

lied

here

, a c

hild

mus

t hav

e at

leas

t one

dia

gnos

ed o

r pa

rent

-repo

rted

con

ditio

n ex

pect

ed to

be

an o

ngoi

ng h

ealth

con

ditio

n an

d al

so m

ust m

eet a

t lea

st o

ne o

f the

crit

eria

rela

ted

to e

leva

ted

serv

ice

use

or e

leva

ted

need

, inc

ludi

ng

repo

rted

unm

et n

eed

for c

are.

For

mor

e in

form

atio

n on

the

met

hods

use

d to

iden

tify

child

ren

with

spe

cial

hea

lth c

are

need

s, s

ee h

ttps

://w

ww

.mac

pac.

gov/

mac

stat

s/da

ta-

sour

ces-

and-

met

hods

/.9

Surv

ey in

form

atio

n is

lim

ited

to c

hild

ren

age

0–17

.10

Su

rvey

info

rmat

ion

is li

mite

d to

chi

ldre

n ag

e 2–

17.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

NH

IS d

ata.

https://www.macpac.gov/publication/coverage-demographic-and-health-characteristics-of-non-institutionalized-individuals-age-0-18-by-primary-source-of-health-coverage/




December 2016108


MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%54

.9%

36.5

%4.

7%Co

ntac

t with

hea

lth c

are

prof

essi

onal

s (p

ast 1

2 m

onth

s)

N

umbe

r of t

imes

saw

a d

octo

r or o

ther

hea

lth p

rofe

ssio

nal,

excl

udin

g de

ntal

vis

its a

nd in

patie

nt h

ospi

tal s

tays

Non

e8.

9 7.

7 8.

228

.6*

At le

ast 1

91.1

92

.3

91.8

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*1

23.5

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.6

22.9

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2–

336

.9

37.5

37

.424

.1*

4 or

mor

e30

.7

31.2

31

.519

.8*

Saw

sel

ecte

d he

alth

pro

fess

iona

lG

ener

al d

octo

r83

.5

85.5

83

.957

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Gen

eral

doc

tor,

nurs

e pr

actit

ione

r, ph

ysic

ian

assi

stan

t, m

idw

ife, o

r ob-

gyn

85.1

87

.3*

85.2

59.9

*M

edic

al s

peci

alis

t14

.4*

16.9

*11

.28.

8 Ey

e do

ctor

25.8

27

.9*

24.3

15.5

*M

enta

l hea

lth p

rofe

ssio

nal6

8.9*

8.0*

10.5

3.7*

Doct

or, f

or e

mot

iona

l or b

ehav

iora

l pro

blem

75.

1*3.

8*7.

1†

Dent

ist8

81.4

83

.9*

80.9

57.7

*An

y he

alth

pro

fess

iona

l, ex

clud

ing

dent

al9

89.1

91

.5*

88.4

67.3

*An

y he

alth

pro

fess

iona

l, in

clud

ing

dent

al96

.5

98.1

*96

.081

.4*

Had

at l

east

1 o

vern

ight

hos

pita

l sta

y105.

0 5.

0 5.

0†

Rece

ived

car

e at

hom

e0.

9 0.

9 1.

0†

Rece

ipt o

f app

ropr

iate

car

e (p

ast 1

2 m

onth

s)H

ad w

ell-c

hild

che

ckup

784

.0

86.1

84

.552

.7H

ad m

ore

than

15

offic

e or

clin

ic v

isits

2.2

2.

2

2.1

†

Num

ber o

f em

erge

ncy

room

vis

itsN

one

83.0

*87

.1*

77.4

86.9

*At

leas

t 117

.0*

12.9

*22

.613

.1*

111

.7*

9.9*

13.8

9.5*

2–3

4.1*

2.5*

6.6

3.1*

4 or

mor

e1.

2*0.

5*2.

1†

Had

at l

east

1 e

mer

genc

y ro

om v

isit,

and

mos

t rec

ent v

isit

was

for a

ser

ious

hea

lth p

robl

em12

.1*

9.7*

14.9

9.0*

EXH

IBIT

39.

Use

of C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

0–18

by

Prim

ary

Sour

ce o

f Hea

lth C

over

age,

201

5, D

ata

from

N

atio

nal H

ealth

Inte

rvie

w S

urve

y



MAC

Stat

sSe

ctio

n 5

EXH

IBIT

39.

(co

ntin

ued)

Not

es: O

b-gy

n is

obs

tetr

icia

n-gy

neco

logi

st. P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

exhi

bit e

xclu

de in

divi

dual

s w

ith m

issi

ng a

nd u

nkno

wn

valu

es. T

he in

divi

dual

co

mpo

nent

s lis

ted

unde

r the

sub

cate

gorie

s ar

e no

t alw

ays

mut

ually

exc

lusi

ve a

nd m

ay n

ot a

dd to

100

per

cent

. Sta

ndar

d er

rors

are

ava

ilabl

e on

line

in th

e do

wnl

oada

ble

Exce

l ve

rsio

n of

this

exh

ibit

at h

ttps

://w

ww

.mac

pac.

gov/

publ

icat

ion/

use-

of-c

are-

amon

g-no

n-in

stitu

tiona

lized

-indi

vidu

als-

age-

0-18

-by-

prim

ary-

sour

ce-o

f-hea

lth-c

over

age-

data

-fr

om-n

atio

nal-h

ealth

-inte

rvie

w-s

urve

y/. D

ue to

diff

eren

ces

in m

etho

dolo

gy (s

uch

as th

e w

ordi

ng o

f que

stio

ns, l

engt

h of

reca

ll pe

riods

, and

pro

mpt

s or

pro

bes

used

to e

licit

resp

onse

s), e

stim

ates

obt

aine

d fr

om d

iffer

ent s

urve

y da

ta s

ourc

es w

ill v

ary.

For

exa

mpl

e, th

e N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

) is

know

n to

pro

duce

hig

her e

stim

ates

of

ser

vice

use

than

the

Med

ical

Exp

endi

ture

s Pa

nel S

urve

y (M

EPS)

. For

pur

pose

s of

com

parin

g gr

oups

of i

ndiv

idua

ls (a

s in

this

exh

ibit)

, the

NH

IS p

rovi

des

the

mos

t rec

ent

info

rmat

ion

avai

labl

e. F

or o

ther

pur

pose

s, s

uch

as m

easu

ring

leve

ls o

f use

rela

tive

to a

par

ticul

ar b

ench

mar

k or

goa

l, it

may

be

appr

opria

te to

con

sult

estim

ates

from

MEP

S or

an

othe

r sou

rce.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

chi

ldre

n un

der a

ge 1

9, re

gard

less

of c

over

age

sour

ce. I

n th

is e

xhib

it, th

e fo

llow

ing

hier

arch

y w

as u

sed

to a

ssig

n in

divi

dual

s w

ith

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

: Med

icar

e, p

rivat

e, M

edic

aid/

CHIP

, oth

er, u

nins

ured

. Not

sep

arat

ely

show

n ar

e th

e es

timat

es fo

r tho

se c

over

ed b

y M

edic

are

(gen

eral

ly c

hild

ren

with

end

-sta

ge re

nal d

isea

se),

any

type

of m

ilita

ry h

ealth

pla

n, o

r oth

er g

over

nmen

t-spo

nsor

ed p

rogr

ams.

Cov

erag

e so

urce

is d

efin

ed a

s of

the

time

of th

e su

rvey

inte

rvie

w. S

ince

an

indi

vidu

al m

ay h

ave

mul

tiple

cov

erag

e so

urce

s or

cha

nges

ove

r tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

cha

ract

eris

tics

or e

xper

ienc

es

asso

ciat

ed w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

. 4

Indi

vidu

als

wer

e de

fined

as

unin

sure

d if

they

did

not

hav

e an

y pr

ivat

e he

alth

insu

ranc

e, M

edic

aid,

CH

IP, M

edic

are,

sta

te- o

r oth

er g

over

nmen

t-spo

nsor

ed h

ealth

pla

n, o

r m

ilita

ry p

lan.

Indi

vidu

als

wer

e al

so d

efin

ed a

s un

insu

red

if th

ey h

ad o

nly

Indi

an H

ealth

Ser

vice

cov

erag

e or

had

onl

y a

priv

ate

plan

that

pai

d fo

r one

type

of s

ervi

ce, s

uch

as

acci

dent

s or

den

tal c

are.

5 Du

e to

the

fact

that

a h

iera

rchy

was

use

d in

this

exh

ibit

to a

ssig

n in

divi

dual

s w

ith m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce (s

ee n

ote

1), t

he M

edic

aid/

CHIP

pe

rcen

tage

s sh

own

in th

is ro

w e

xclu

de in

divi

dual

s w

ho a

lso

have

Med

icar

e (w

hich

is ra

re fo

r chi

ldre

n) o

r priv

ate

cove

rage

. Com

pone

nts

do n

ot s

um to

100

per

cent

bec

ause

no

t all

cove

rage

sou

rces

are

sho

wn.

6 Su

rvey

info

rmat

ion

is li

mite

d to

chi

ldre

n ag

e tw

o or

old

er.

7 Su

rvey

info

rmat

ion

is li

mite

d to

chi

ldre

n ag

e 0

to 1

7.8

Surv

ey in

form

atio

n is

lim

ited

to c

hild

ren

age

one

or o

lder

.9

Any

heal

th p

rofe

ssio

nal i

nclu

des

gene

ral d

octo

r, nu

rse

prac

titio

ner,

phys

icia

n as

sist

ant,

mid

wife

, ob-

gyn,

med

ical

spe

cial

ist,

eye

doct

or, m

enta

l hea

lth p

rofe

ssio

nal,

doct

or fo

r em

otio

nal o

r beh

avio

ral p

robl

em, t

hera

pist

, chi

ropr

acto

r, or

pod

iatr

ist.

10 In

clud

es s

tays

for n

ewbo

rns.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

NH

IS d

ata.

https://www.macpac.gov/publication/use-of-care-among-non-institutionalized-individuals-age-0-18-by-primary-source-of-health-coverage-data-from-national-health-interview-survey/


December 2016110


MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

mos

t rec

ent i

nter

view

1

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%53

.5%

37.5

%7.

3%Co

ntac

t with

hea

lth c

are

prof

essi

onal

s (p

ast 1

2 m

onth

s)

N

umbe

r of o

ffic

e-ba

sed

visi

ts (t

o a

doct

or o

r oth

er h

ealth

pro

fess

iona

l), e

xclu

ding

den

tal v

isits

and

inpa

tient

hos

pita

l sta

ysN

one

25.3

20

.6*

27.2

46.7

*At

leas

t 174

.7

79.4

*72

.853

.3*

123

.5

23.0

24.4

22.0

2–3

26.4

28

.026

.617

.9*

4 or

mor

e24

.8*

28.4

*21

.713

.4*

Had

at l

east

1 o

vern

ight

hos

pita

l sta

y2.

9 1.

9*2.

8†

Rece

ived

car

e at

hom

e1.

3 †

1.4

† Sa

w a

gen

eral

den

tist

43.6

*50

.7*

38.0

29.0

*Sa

w a

n or

thod

ontis

t9.

2*13

.5*

4.1

4.4

Rece

ipt o

f app

ropr

iate

car

e (p

ast 1

2 m

onth

s)H

ad d

enta

l cle

anin

g, p

roph

ylax

is, o

r pol

ishi

ng6

47.8

*46

.0*

53.1

48.5

Had

mor

e th

an 1

5 of

fice-

base

d or

hos

pita

l out

patie

nt v

isits

4.

1 5.

0 *3.

4†

Num

ber o

f em

erge

ncy

room

vis

itsN

one

87.2

*89

.7*

84.4

88.8

*At

leas

t 112

.8*

10.3

*15

.611

.2*

19.

8*8.

4*11

.48.

1*2–

32.

7*1.

9*3.

8†

4 or

mor

e0.

3 †

††

Not

es: P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

exhi

bit e

xclu

de in

divi

dual

s w

ith m

issi

ng a

nd u

nkno

wn

valu

es. S

tand

ard

erro

rs a

re a

vaila

ble

onlin

e in

the

dow

nloa

dabl

e Ex

cel v

ersi

on o

f thi

s ex

hibi

t at h

ttps

://w

ww

.mac

pac.

gov/

publ

icat

ion/

use-

of-c

are-

amon

g-no

n-in

stitu

tiona

lized

-indi

vidu

als-

age-

0-18

-by-

prim

ary-

sour

ce-o

f-hea

lth-c

over

age-

data

-fr

om-m

edic

al-e

xpen

ditu

res-

pane

l-sur

vey/

. Due

to d

iffer

ence

s in

met

hodo

logy

(suc

h as

the

wor

ding

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

diff

eren

t sur

vey

data

sou

rces

will

var

y. F

or e

xam

ple,

the

Nat

iona

l Hea

lth In

terv

iew

Sur

vey

(NH

IS) i

s kn

own

to p

rodu

ce h

ighe

r est

imat

es o

f se

rvic

e us

e th

an th

e M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

(MEP

S). F

or p

urpo

ses

of c

ompa

ring

grou

ps o

f ind

ivid

uals

, the

NH

IS p

rovi

des

the

mos

t rec

ent i

nfor

mat

ion

avai

labl

e.

For o

ther

pur

pose

s, s

uch

as m

easu

ring

leve

ls o

f use

rela

tive

to a

par

ticul

ar b

ench

mar

k or

goa

l, it

may

be

appr

opria

te to

con

sult

estim

ates

from

MEP

S or

ano

ther

sou

rce.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

EXH

IBIT

40.

Use

of C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

0–18

by

Prim

ary

Sour

ce o

f Hea

lth C

over

age,

201

4, D

ata

from

M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

https://www.macpac.gov/publication/use-of-care-among-non-institutionalized-individuals-age-0-18-by-primary-source-of-health-coverage-data-from-medical-expenditures-panel-survey/




MAC

Stat

sSe

ctio

n 5

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

chi

ldre

n un

der a

ge 1

9, re

gard

less

of c

over

age

sour

ce. I

n th

is e

xhib

it, th

e fo

llow

ing

hier

arch

y w

as u

sed

to a

ssig

n in

divi

dual

s w

ith

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

: Med

icar

e, p

rivat

e, M

edic

aid/

CHIP

, oth

er, u

nins

ured

. Not

sep

arat

ely

show

n ar

e th

e es

timat

es fo

r tho

se c

over

ed b

y M

edic

are

(gen

eral

ly c

hild

ren

with

end

-sta

ge re

nal d

isea

se),

any

type

of m

ilita

ry h

ealth

pla

n, o

r oth

er g

over

nmen

t-spo

nsor

ed p

rogr

ams.

Cov

erag

e so

urce

is d

efin

ed a

s of

the

time

of th

e m

ost r

ecen

t sur

vey

inte

rvie

w. S

ince

an

indi

vidu

al m

ay h

ave

mul

tiple

cov

erag

e so

urce

s or

cha

nges

ove

r tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

cha

ract

eris

tics

or

expe

rienc

es a

ssoc

iate

d w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

.4

Indi

vidu

als

wer

e de

fined

as

unin

sure

d if

they

did

not

hav

e an

y pr

ivat

e he

alth

insu

ranc

e, M

edic

aid,

CH

IP, M

edic

are,

sta

te- o

r oth

er g

over

nmen

t-spo

nsor

ed h

ealth

pla

n, o

r m

ilita

ry p

lan.

Indi

vidu

als

wer

e al

so d

efin

ed a

s un

insu

red

if th

ey h

ad o

nly

Indi

an H

ealth

Ser

vice

cov

erag

e or

had

onl

y a

priv

ate

plan

that

pai

d fo

r one

type

of s

ervi

ce, s

uch

as

acci

dent

s or

den

tal c

are.

5 Du

e to

the

fact

that

a h

iera

rchy

was

use

d in

this

exh

ibit

to a

ssig

n in

divi

dual

s w

ith m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce (s

ee n

ote

1), t

he M

edic

aid/

CHIP

pe

rcen

tage

s sh

own

in th

is ro

w e

xclu

de in

divi

dual

s w

ho a

lso

have

Med

icar

e (w

hich

is ra

re fo

r chi

ldre

n) o

r priv

ate

cove

rage

. Com

pone

nts

do n

ot s

um to

100

per

cent

bec

ause

no

t all

cove

rage

sou

rces

are

sho

wn.

6 Li

mite

d to

peo

ple

who

repo

rted

a d

enta

l eve

nt in

201

4.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

MEP

S da

ta.

EXH

IBIT

40.

(co

ntin

ued)

December 2016112


MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lPr

ivat

e2M

edic

aid/

CHIP

3U

nins

ured

4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%54

.9%

36.5

%4.

7%Co

nnec

tion

to th

e he

alth

car

e sy

stem

(pas

t 12

mon

ths)

Has

a u

sual

sou

rce

of c

are6

95.2

97

.3*

95.1

68.9

*H

ad th

e sa

me

usua

l sou

rce

of m

edic

al c

are

12 m

onth

s ag

o88

.2

90.7

*87

.865

.8*

Had

trou

ble

findi

ng a

doc

tor o

r was

told

that

cov

erag

e or

ne

w p

atie

nts

wer

e no

t acc

epte

d73.

4*2.

4*4.

35.

9 Ti

mel

ines

s of

car

e (p

ast 1

2 m

onth

s)De

laye

d m

edic

al c

are

due

to a

ny a

cces

s ba

rrie

r ind

icat

ed

belo

w10

.1*

6.6*

13.4

22.6

*De

laye

d be

caus

e of

cos

ts2.

6 1.

82.

117

.0*

Dela

yed

for p

rovi

der-r

elat

ed re

ason

s87.

2*5.

2*9.

79.

1 De

laye

d du

e to

lack

of t

rans

port

atio

n1.

8*0.

3*3.

6†

Unm

et n

eed

for s

elec

ted

type

s of

car

e du

e to

cos

tM

edic

al c

are

1.4

0.7*

1.2

10.4

*M

enta

l hea

lth c

are

or c

ouns

elin

g90.

7 0.

50.

8†

Dent

al c

are9

4.2

2.6*

4.7

18.6

*Pr

escr

iptio

n dr

ugs

1.6

1.2

1.7

7.1*

Eyeg

lass

es9

1.9*

1.0*

2.6

8.2*

Spec

ialis

t car

e1.

20.

7*1.

36.

1*Fo

llow

-up

care

1.3

0.6*

1.4

8.8*

Not

es: P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

tabl

e ex

clud

e in

divi

dual

s w

ith m

issi

ng a

nd u

nkno

wn

valu

es. T

he in

divi

dual

com

pone

nts

liste

d un

der t

he s

ubca

tego

ries

are

not m

utua

lly e

xclu

sive

and

may

not

add

to 1

00 p

erce

nt. S

tand

ard

erro

rs a

re a

vaila

ble

onlin

e in

the

dow

nloa

dabl

e Ex

cel v

ersi

on o

f thi

s ex

hibi

t at h

ttps

://w

ww

.mac

pac.

gov/

publ

icat

ion/

mea

sure

s-of

-acc

ess-

to-c

are-

for-n

on-in

stitu

tiona

lized

-chi

ldre

n-by

-sou

rce-

of-h

ealth

-cov

erag

e/. D

ue to

diff

eren

ces

in m

etho

dolo

gy (s

uch

as th

e w

ordi

ng o

f que

stio

ns,

leng

th o

f rec

all p

erio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

diff

eren

t sur

vey

data

sou

rces

will

var

y. F

or e

xam

ple,

the

Nat

iona

l Hea

lth

Inte

rvie

w S

urve

y (N

HIS

) is

know

n to

pro

duce

hig

her e

stim

ates

of s

ervi

ce u

se th

an th

e M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

(MEP

S). F

or p

urpo

ses

of c

ompa

ring

grou

ps o

f in

divi

dual

s (a

s in

this

exh

ibit)

, the

NH

IS p

rovi

des

the

mos

t rec

ent i

nfor

mat

ion

avai

labl

e. F

or o

ther

pur

pose

s, s

uch

as m

easu

ring

leve

ls o

f use

rela

tive

to a

par

ticul

ar b

ench

mar

k or

goa

l, it

may

be

appr

opria

te to

con

sult

estim

ates

from

MEP

S or

ano

ther

sou

rce.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

EXH

IBIT

41.

Mea

sure

s of

Acc

ess

to C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

0–18

by

Prim

ary

Sour

ce o

f Hea

lth C

over

age,

201

5

https://www.macpac.gov/publication/measures-of-access-to-care-for-non-institutionalized-children-by-source-of-health-coverage/

https://www.macpac.gov/publication/measures-of-access-to-care-for-non-institutionalized-children-by-source-of-health-coverage/



MAC

Stat

sSe

ctio

n 5

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

chi

ldre

n un

der a

ge 1

9, re

gard

less

of c

over

age

sour

ce. I

n th

is e

xhib

it, th

e fo

llow

ing

hier

arch

y w

as u

sed

to a

ssig

n in

divi

dual

s w

ith

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

: Med

icar

e, p

rivat

e, M

edic

aid/

CHIP

, oth

er, u

nins

ured

. Not

sep

arat

ely

show

n ar

e th

e es

timat

es fo

r tho

se c

over

ed b

y M

edic

are

(gen

eral

ly c

hild

ren

with

end

-sta

ge re

nal d

isea

se),

any

type

of m

ilita

ry h

ealth

pla

n, o

r oth

er g

over

nmen

t-spo

nsor

ed p

rogr

ams.

Cov

erag

e so

urce

is d

efin

ed a

s of

the

time

of th

e su

rvey

inte

rvie

w. S

ince

an

indi

vidu

al m

ay h

ave

mul

tiple

cov

erag

e so

urce

s or

cha

nges

ove

r tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

cha

ract

eris

tics

or e

xper

ienc

es

asso

ciat

ed w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

.4

Indi

vidu

als

wer

e de

fined

as

unin

sure

d if

they

did

not

hav

e an

y pr

ivat

e he

alth

insu

ranc

e, M

edic

aid,

CH

IP, M

edic

are,

sta

te- o

r oth

er g

over

nmen

t-spo

nsor

ed h

ealth

pla

n, o

r m

ilita

ry p

lan.

Indi

vidu

als

wer

e al

so d

efin

ed a

s un

insu

red

if th

ey h

ad o

nly

Indi

an H

ealth

Ser

vice

cov

erag

e or

had

onl

y a

priv

ate

plan

that

pai

d fo

r one

type

of s

ervi

ce, s

uch

as

acci

dent

s or

den

tal c

are.

5 Du

e to

the

fact

that

a h

iera

rchy

was

use

d in

this

exh

ibit

to a

ssig

n in

divi

dual

s w

ith m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce (s

ee n

ote

1), t

he M

edic

aid/

CHIP

pe

rcen

tage

s sh

own

in th

is ro

w e

xclu

de in

divi

dual

s w

ho a

lso

have

Med

icar

e (w

hich

is ra

re fo

r chi

ldre

n) o

r priv

ate

cove

rage

. Com

pone

nts

do n

ot s

um to

100

per

cent

bec

ause

no

t all

cove

rage

sou

rces

are

sho

wn.

6 Ex

clud

es e

mer

genc

y ro

om.

7 Pa

rent

repo

rted

one

of t

hese

bar

riers

in th

e pa

st 1

2 m

onth

s: tr

oubl

e fin

ding

a d

octo

r or p

rovi

der,

doct

or’s

off

ice/

clin

ic d

id n

ot a

ccep

t chi

ld’s

insu

ranc

e co

vera

ge, o

r off

ice/

clin

ic d

id n

ot a

ccep

t the

chi

ld a

s a

new

pat

ient

.8

Incl

udes

any

of t

he fo

llow

ing:

par

ent c

ould

not

get

an

appo

intm

ent,

had

to w

ait t

oo lo

ng to

see

doc

tor,

coul

d no

t go

whe

n op

en, c

ould

not

get

thro

ugh

on p

hone

, par

ent

spea

ks a

diff

eren

t lan

guag

e.9

Surv

ey in

form

atio

n is

lim

ited

to c

hild

ren

age

two

or o

lder

.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

NH

IS d

ata.

EXH

IBIT

41.

(co

ntin

ued)

December 2016114


MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

Prim

ary

cove

rage

sou

rce

at ti

me

of in

terv

iew

1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%3.

9%69

.0%

10.8

%12

.8%

Cove

rage

Leng

th o

f tim

e w

ith a

ny c

over

age

durin

g ye

arFu

ll ye

ar 8

2.2*

95.

7* 9

4.6*

85.

8–

Pa

rt y

ear

8.8

* 4

.3*

5.4

* 1

4.2

25.

2*N

o co

vera

ge d

urin

g ye

ar 9

.1–

–

–

74.

8De

mog

raph

ics

Age

19–

25 1

5.6*

2.0

* 1

4.7*

21.

7 1

9.2

26–

44 4

0.9*

16.

1* 4

0.0*

46.

6 5

0.8*

45–

54 2

2.4*

25.

1* 2

3.6*

18.

5 1

7.9

55–

64 2

1.1*

56.

9* 2

1.8*

13.

2 1

2.0

Gen

der

Mal

e 4

9.0*

50.

0* 4

9.4*

36.

6 5

5.7*

Fem

ale

51.

0* 5

0.0*

50.

6* 6

3.4

44.

3*Ra

ceH

ispa

nic

17.

2* 9

.5*

12.

4* 2

7.4

37.

7*W

hite

, non

-His

pani

c 6

2.8*

69.

1* 6

9.3*

43.

3 4

2.7

Blac

k, n

on-H

ispa

nic

12.

6* 1

7.5*

10.

4* 2

1.9

14.

0*O

ther

non

-whi

te, n

on-H

ispa

nic

7.3

3

.9*

7.9

7

.4 5

.5*

Mar

ital s

tatu

s6

Mar

ried

54.

0* 3

6.6

60.

7* 3

3.2

39.

5*W

idow

ed 1

.6*

5.2

* 1

.3

1.9

1.7

Di

vorc

ed o

r sep

arat

ed 1

1.3*

26.

3* 9

.4*

14.

7 1

3.5

Livi

ng w

ith p

artn

er 8

.6*

7.6

* 7

.1*

13.

1 1

3.5

Nev

er m

arrie

d 2

4.5*

24.

3* 2

1.5*

37.

1 3

1.8*

Fam

ily in

com

eLe

ss th

an 1

38 p

erce

nt F

PL 2

0.5*

46.

4* 8

.2*

64.

1 3

9.9*

Has

inco

me

in ra

nges

bel

owLe

ss th

an 1

00 p

erce

nt F

PL 1

3.3*

29.

0* 4

.5*

46.

4 2

6.9*

100–

199

perc

ent F

PL 1

7.6*

34.

1 1

1.1*

34.

3 3

1.1

200–

399

perc

ent F

PL 2

8.1*

25.

2* 2

9.6*

15.

4 3

0.8*

400

perc

ent F

PL o

r hig

her

40.

9* 1

1.7*

54.

7* 3

.7 1

1.1*

EXH

IBIT

42.

Cov

erag

e, D

emog

raph

ic, a

nd H

ealth

Cha

ract

eris

tics

of N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

19–

64 b

y Pr

imar

y So

urce

of

Hea

lth C

over

age,

201

5



MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

Prim

ary

cove

rage

sou

rce

at ti

me

of in

terv

iew

1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Educ

atio

nLe

ss th

an h

igh

scho

ol 1

1.0%

* 2

2.8%

5

.1%

* 2

5.5%

27.

7%

Hig

h sc

hool

dip

lom

a/G

ED 2

3.4*

35.

3 1

9.6*

31.

9 3

3.2

Som

e co

llege

32.

5* 3

0.0

33.

0 3

4.1

28.

1*Co

llege

or g

radu

ate

degr

ee 3

3.1*

11.

9* 4

2.4*

8.6

11.

0*O

ther

dem

ogra

phic

cha

ract

eris

tics

Citiz

en o

f Uni

ted

Stat

es 9

0.3*

96.

7* 9

3.6*

88.

3 7

1.7*

Pare

nt o

f a d

epen

dent

chi

ld 3

6.6*

12.

6* 3

6.5*

47.

6 3

6.7*

Curr

ently

wor

king

73.

1* 1

0.0*

83.

6* 4

3.7

64.

9*Ve

tera

n 5

.7*

9.0

* 4

.6*

3.3

2.8

Re

ceiv

es S

SI o

r SSD

I7 5

.6*

74.

7* 1

.0*

16.

6 0

.8*

Rece

ives

SSI

2.6

* 2

2.4*

0.4

* 1

3.0

† Re

ceiv

es S

SDI

3.8

* 6

3.8*

0.7

* 6

.3 0

.6*

Hea

lthCu

rren

t hea

lth s

tatu

sEx

celle

nt o

r ver

y go

od 6

3.4*

11.

9* 7

0.5*

43.

8 5

8.5*

Goo

d 2

5.6*

30.

4 2

3.6*

31.

7 2

9.6

Fair

or p

oor

11.

0* 5

7.8*

5.9

* 2

4.5

11.

9*Bo

dy M

ass

Inde

x (B

MI)

Hea

lthy

wei

ght (

BMI l

ess

than

25)

36.

0* 2

2.6*

37.

4* 3

3.2

36.

0 O

verw

eigh

t (BM

I 25–

29)

33.

3* 2

9.0

33.

4* 3

0.4

36.

4*O

bese

(BM

I 30

or h

ighe

r) 3

0.7*

48.

4* 2

9.3*

36.

4 2

7.7*

Smok

ing

stat

usCu

rren

t sm

oker

16.

9* 2

9.4

12.

0* 3

0.1

27.

8 Fo

rmer

sm

oker

17.

9* 2

7.1*

18.

4* 1

4.3

14.

8 N

ever

sm

oked

65.

1* 4

3.5*

69.

6* 5

5.6

57.

4 Li

mita

tions

and

hea

lth c

ondi

tions

Has

bas

ic a

ctio

n di

fficu

lty o

r com

plex

act

ivity

limita

tion

Any

basi

c ac

tion

diff

icul

ty8

24.

9* 8

6.2*

18.

8* 4

1.8

23.

0*An

y co

mpl

ex a

ctiv

ity li

mita

tion9

12.

5* 8

5.6*

6.1

* 2

9.3

9.1

*Ei

ther

one

26.

6* 9

2.4*

19.

9* 4

5.8

24.

1*H

as fu

nctio

nal l

imita

tion10

11.

5* 6

9.5*

6.6

* 2

3.6

8.6

*

EXH

IBIT

42.

(co

ntin

ued)

December 2016116


MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

Prim

ary

cove

rage

sou

rce

at ti

me

of in

terv

iew

1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Has

diff

icul

ty w

alki

ng w

ithou

t equ

ipm

ent

3.4

%*

31.

2%*

1.3

%*

8.3

% 1

.5%

*H

as h

ealth

con

ditio

n re

quiri

ng s

peci

al e

quip

men

t 4

.2*

31.

8* 2

.2*

9.0

1.7

*N

eeds

hel

p w

ith a

ny o

f the

follo

win

g AD

LsPe

rson

al c

are

1.4

* 1

3.1*

0.5

* 4

.0†

Bath

ing

0.8

* 8

.4*

0.3

* 2

.2†

Eatin

g 0

.3*

2.3

†

1.1

† Tr

ansf

errin

g 0

.6*

5.1

* 0

.2*

2.1

† To

iletin

g 0

.5*

3.6

*†

1.5

† G

ettin

g ar

ound

in h

ome

0.5

* 5

.4*

0.2

* 1

.6†

Num

ber o

f ADL

s ne

edin

g as

sist

ance

Non

e 9

8.9*

88.

7* 9

9.6*

96.

7 9

9.8*

1–2

0.6

* 6

.7*

0.2

* 1

.7†

3–4

0.4

* 4

.1*

† 1

.0†

5–6

0.1

*†

† 0

.6–

U

nabl

e to

wor

k no

w d

ue to

hea

lth p

robl

em 7

.6*

73.

0* 2

.4*

20.

0 4

.3*

Lim

ited

in a

mou

nt o

r kin

d of

wor

k du

e to

hea

lth 1

0.3*

81.

6* 4

.5*

25.

5 6

.2*

Lost

all

natu

ral t

eeth

4.4

* 2

1.3*

2.9

* 7

.9 4

.1*

Has

dep

ress

ed o

r anx

ious

feel

ings

11 3

.9*

14.

8* 2

.0*

9.3

5.7

*Cu

rren

tly p

regn

ant12

3.9

*†

3.4

* 8

.0 1

.7*

Ever

bee

n to

ld h

e or

she

has

sel

ecte

d co

nditi

ons

Hyp

erte

nsio

n 2

4.1*

58.

3* 2

2.7*

26.

8 1

7.5*

Coro

nary

hea

rt d

isea

se 2

.2*

12.

0* 1

.5*

3.6

1.2

*H

eart

att

ack

1.6

* 1

1.6*

1.0

* 2

.5 0

.9*

Stro

ke 1

.5*

10.

9* 0

.7*

3.2

1.2

*Ca

ncer

4.8

1

4.3*

4.7

5

.3 2

.3*

Diab

etes

6.9

* 2

9.5*

5.6

* 9

.0 4

.9*

Arth

ritis

16.

7* 5

6.4*

15.

0* 1

9.7

9.7

*As

thm

a 1

3.1*

24.

7* 1

2.4*

16.

7 1

0.3*

Chro

nic

bron

chiti

s (p

ast 1

2 m

onth

s) 3

.4*

15.

4* 2

.5*

5.8

2.6

*Li

ver c

ondi

tion

(pas

t 12

mon

ths)

1.6

* 7

.2*

1.0

* 2

.6 1

.4*

Wea

k or

faili

ng k

idne

ys (p

ast 1

2 m

onth

s) 1

.2*

10.

3* 0

.6*

2.1

1.0

*

EXH

IBIT

42.

(co

ntin

ued)



MAC

Stat

sSe

ctio

n 5

Not

es: F

PL is

fede

ral p

over

ty le

vel.

SSI i

s Su

pple

men

tal S

ecur

ity In

com

e. S

SDI i

s So

cial

Sec

urity

Dis

abili

ty In

sura

nce.

ADL

is a

ctiv

ity o

f dai

ly li

ving

. Per

cent

age

calc

ulat

ions

for

each

item

in th

e ex

hibi

t exc

lude

indi

vidu

als

with

mis

sing

and

unk

now

n va

lues

. The

indi

vidu

al c

ompo

nent

s lis

ted

unde

r the

sub

cate

gorie

s ar

e no

t alw

ays

mut

ually

exc

lusi

ve

and

may

not

add

to 1

00 p

erce

nt. S

tand

ard

erro

rs a

re a

vaila

ble

onlin

e in

the

dow

nloa

dabl

e Ex

cel v

ersi

on o

f thi

s ex

hibi

t at h

ttps

://w

ww

.mac

pac.

gov/

publ

icat

ion/

cove

rage

-de

mog

raph

ic-a

nd-h

ealth

-cha

ract

eris

tics-

of-n

on-in

stitu

tiona

lized

-indi

vidu

als-

age-

19-6

4-by

-prim

ary-

sour

ce-o

f-hea

lth-c

over

age/

.

Due

to d

iffer

ence

s in

met

hodo

logy

(suc

h as

the

wor

ding

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

di

ffer

ent s

urve

y da

ta s

ourc

es w

ill v

ary.

For

exa

mpl

e, th

e N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

) is

know

n to

pro

duce

hig

her e

stim

ates

of s

ervi

ce u

se th

an th

e M

edic

al

Expe

nditu

res

Pane

l Sur

vey

(MEP

S). F

or p

urpo

ses

of c

ompa

ring

grou

ps o

f ind

ivid

uals

(as

in th

is e

xhib

it), t

he N

HIS

pro

vide

s th

e m

ost r

ecen

t inf

orm

atio

n av

aila

ble.

For

oth

er

purp

oses

, suc

h as

mea

surin

g le

vels

of u

se re

lativ

e to

a p

artic

ular

ben

chm

ark

or g

oal,

it m

ay b

e ap

prop

riate

to c

onsu

lt es

timat

es fr

om M

EPS

or a

noth

er s

ourc

e.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

indi

vidu

als

age

19–

64, r

egar

dles

s of

cov

erag

e so

urce

. In

this

exh

ibit,

the

follo

win

g hi

erar

chy

was

use

d to

ass

ign

indi

vidu

als

with

m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce: M

edic

are,

priv

ate,

Med

icai

d/CH

IP, o

ther

, uni

nsur

ed. N

ot s

epar

atel

y sh

own

are

the

estim

ates

for t

hose

cov

ered

by

any

type

of

mili

tary

hea

lth p

lan

or o

ther

gov

ernm

ent-s

pons

ored

pro

gram

s. C

over

age

sour

ce is

def

ined

as

of th

e tim

e of

the

surv

ey in

terv

iew

. Sin

ce a

n in

divi

dual

may

hav

e m

ultip

le

cove

rage

sou

rces

or c

hang

es o

ver t

ime,

resp

onse

s to

sur

vey

ques

tions

may

refle

ct c

hara

cter

istic

s or

exp

erie

nces

ass

ocia

ted

with

a c

over

age

sour

ce o

ther

than

the

one

assi

gned

in th

is e

xhib

it.2

Priv

ate

heal

th in

sura

nce

cove

rage

exc

lude

s pl

ans

that

pai

d fo

r onl

y on

e ty

pe o

f ser

vice

, suc

h as

acc

iden

ts o

r den

tal c

are.

3 M

edic

aid/

CHIP

als

o in

clud

es p

erso

ns c

over

ed b

y ot

her s

tate

-spo

nsor

ed h

ealth

pla

ns.

4 In

divi

dual

s w

ere

defin

ed a

s un

insu

red

if th

ey d

id n

ot h

ave

any

priv

ate

heal

th in

sura

nce,

Med

icai

d, C

HIP

, Med

icar

e, s

tate

- or o

ther

gov

ernm

ent-s

pons

ored

hea

lth p

lan,

or

mili

tary

pla

n. In

divi

dual

s w

ere

also

def

ined

as

unin

sure

d if

they

had

onl

y In

dian

Hea

lth S

ervi

ce c

over

age

or h

ad o

nly

a pr

ivat

e pl

an th

at p

aid

for o

ne ty

pe o

f ser

vice

, suc

h as

ac

cide

nts

or d

enta

l car

e.5

Due

to th

e fa

ct th

at a

hie

rarc

hy w

as u

sed

in th

is e

xhib

it to

ass

ign

indi

vidu

als

with

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

(see

not

e 1)

, the

Med

icai

d/CH

IP p

erce

ntag

es

show

n in

this

row

exc

lude

indi

vidu

als

who

als

o ha

ve M

edic

are

or p

rivat

e co

vera

ge. C

ompo

nent

s do

not

sum

to 1

00 p

erce

nt b

ecau

se n

ot a

ll co

vera

ge s

ourc

es a

re s

how

n.6

Thes

e es

timat

es s

houl

d no

t be

com

pare

d to

the

2014

est

imat

es p

ublis

hed

in th

e De

cem

ber 2

015

data

boo

k du

e to

err

ors

in la

st’s

yea

r pub

licat

ion.

7 Ch

arac

teris

tic is

list

ed u

nder

dem

ogra

phic

s be

caus

e lo

w in

com

e is

one

of t

he c

riter

ia fo

r SSI

elig

ibili

ty, a

nd th

e in

abili

ty to

eng

age

in a

spe

cifie

d le

vel o

f wor

k ac

tivity

and

ea

rnin

gs (r

efer

red

to a

s su

bsta

ntia

l gai

nful

act

ivity

in fe

dera

l sta

tute

) is

one

of th

e cr

iteria

for S

SDI e

ligib

ility

. How

ever

, SSI

or S

SDI r

ecei

pt is

als

o an

indi

cato

r of d

isab

ility

. For

an

adul

t to

be e

ligib

le fo

r SSI

or S

SDI,

he o

r she

mus

t hav

e a

med

ical

ly d

eter

min

able

phy

sica

l or m

enta

l im

pairm

ent t

hat i

s ex

pect

ed to

last

at l

east

12

mon

ths

or re

sult

in d

eath

.8

Cap

ture

s lim

itatio

ns o

r diff

icul

ties

in m

ovem

ent (

wal

king

, sta

ndin

g, b

endi

ng o

r kne

elin

g, re

achi

ng o

verh

ead,

and

usi

ng th

e ha

nds

and

finge

rs) a

nd s

enso

ry, e

mot

iona

l (i.e

., fe

elin

gs

that

inte

rfere

with

acc

ompl

ishi

ng d

aily

act

iviti

es),

or m

enta

l (i.e

., di

fficu

lties

with

rem

embe

ring

or e

xper

ienc

ing

conf

usio

n) fu

nctio

ning

that

are

ass

ocia

ted

with

som

e he

alth

pro

blem

.9

Refle

cts

a lim

itatio

n in

the

task

s an

d or

gani

zed

activ

ities

that

, whe

n ex

ecut

ed, m

ake

up n

umer

ous

soci

al ro

les,

suc

h as

wor

king

, att

endi

ng s

choo

l, or

mai

ntai

ning

a h

ouse

hold

. Ad

ults

are

def

ined

as

havi

ng a

com

plex

act

ivity

lim

itatio

n if

they

hav

e on

e or

mor

e of

the

follo

win

g ty

pes

of li

mita

tions

: sel

f-car

e lim

itatio

n, s

ocia

l lim

itatio

n, o

r wor

k lim

itatio

n.10

Fu

nctio

nal l

imita

tion

is d

efin

ed a

s “v

ery

diff

icul

t” o

r “ca

nnot

do”

for t

he fo

llow

ing

activ

ities

: gra

sp s

mal

l obj

ects

; rea

ch a

bove

one

’s h

ead;

sit

mor

e th

an 2

hou

rs; l

ift o

r car

ry

10 p

ound

s; c

limb

a fli

ght o

f sta

irs; p

ush

a he

avy

obje

ct; w

alk

a 1/

4 m

ile; s

tand

mor

e th

an 2

hou

rs; s

toop

, ben

d, o

r kne

el. T

hese

est

imat

es s

houl

d no

t be

com

pare

d to

the

2014

es

timat

es p

ublis

hed

in th

e De

cem

ber 2

015

data

boo

k w

hich

als

o in

clud

ed re

spon

ses

of “o

nly

a lit

tle” a

nd “s

omew

hat d

iffic

ult”

.11

Th

ese

estim

ates

sho

uld

not b

e co

mpa

red

to th

e 20

14 e

stim

ates

pub

lishe

d in

the

Dece

mbe

r 201

5 da

ta b

ook

due

to a

cha

nge

in th

e ch

arac

teris

tic’s

def

initi

on.

12 In

form

atio

n is

lim

ited

to w

omen

age

19–

44.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

NH

IS d

ata.

EXH

IBIT

42.

(co

ntin

ued)



December 2016118


MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%3.

9%69

.0%

10.8

%12

.8%

Cont

act w

ith h

ealth

car

e pr

ofes

sion

als

(pas

t 12

mon

ths)

Num

ber o

f tim

es s

aw a

doc

tor o

r oth

er h

ealth

pro

fess

iona

l, ex

clud

ing

dent

al v

isits

and

inpa

tient

hos

pita

l sta

ysN

one

20.7

*6.

0*16

.6*

18.8

51.0

*At

leas

t 179

.3*

94.0

*83

.4*

81.2

49.0

*1

19.2

*4.

8*21

.1*

14.3

17.3

*2–

326

.8*

19.4

*29

.8*

23.3

16.4

*4

or m

ore

33.3

69

.8*

32.5

*43

.615

.3*

Saw

sel

ecte

d he

alth

pro

fess

iona

lG

ener

al d

octo

r65

.2*

85.1

*68

.5

69.0

35.7

*G

ener

al d

octo

r, nu

rse

prac

titio

ner,

phys

icia

n as

sist

ant,

mid

wife

, or o

b-gy

n73

.4*

89.5

*77

.2

77.7

42.5

*M

edic

al s

peci

alis

t23

.4

52.0

*24

.4

22.7

8.4*

Eye

doct

or36

.4*

39.5

*41

.7*

27.5

14.3

*M

enta

l hea

lth p

rofe

ssio

nal

8.7

22.3

*7.

3*14

.34.

6*De

ntis

t63

.7*

42.5

*72

.5*

50.7

33.8

*An

y he

alth

pro

fess

iona

l, ex

clud

ing

dent

al6

81.2

*94

.0*

85.4

*82

.951

.7*

Any

heal

th p

rofe

ssio

nal,

incl

udin

g de

ntal

89.3

*95

.4*

93.4

*89

.164

.4*

Had

at l

east

1 o

vern

ight

hos

pita

l sta

y7.

1 24

.0*

5.5*

13.5

4.8*

Rece

ived

car

e at

hom

e1.

4 10

.9*

0.8*

3.2

† Re

ceip

t of a

ppro

pria

te c

are

(pas

t 12

mon

ths)

Had

cho

lest

erol

che

cked

7

All i

ndiv

idua

ls59

.7*

80.9

*63

.8*

59.7

29.2

*M

en a

ge 3

5–64

66.6

79

.9*

70.7

*65

.032

.1*

Indi

vidu

als

with

ele

vate

d ris

k of

car

diac

dis

ease

7, 8

69.1

*84

.6*

75.7

*65

.135

.3*

Had

flu

shot

All i

ndiv

idua

ls36

.5*

52.6

*40

.4*

31.0

14.7

*In

divi

dual

s ag

e 50

–64

47.9

56

.5*

50.8

*41

.619

.6*

EXH

IBIT

43.

Use

of C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

19–

64 b

y Pr

imar

y So

urce

of H

ealth

Cov

erag

e, 2

015,

Dat

a fr

om

Nat

iona

l Hea

lth In

terv

iew

Sur

vey



MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

vera

ge s

ourc

e at

tim

e of

inte

rvie

w1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Had

any

test

for c

olor

ecta

l can

cer (

age

50–

64)

23.8

%30

.8%

*24

.4%

*20

.3%

11.3

%*

Had

Pap

sm

ear o

r tes

t for

cer

vica

l can

cer

(wom

en a

ge 2

1–60

)56

.5*

44.2

*60

.9*

56.4

33.3

*H

ad p

rofe

ssio

nal c

ouns

elin

g ab

out s

mok

ing

(cur

rent

sm

oker

s)53

.9

77.7

*56

.8

60.2

30.9

*H

ad m

ore

than

15

offic

e or

clin

ic v

isits

5.2

18.2

*4.

5*7.

81.

6*N

umbe

r of e

mer

genc

y ro

om v

isits

Non

e82

.0*

56.8

*86

.4*

66.1

81.6

*At

leas

t 118

.0*

43.2

*13

.6*

33.9

18.4

*1

11.4

21

.0*

9.9*

16.6

11.3

*2–

34.

7*15

.3*

2.7*

11.8

5.6*

4 or

mor

e1.

9 6.

9 1.

0*5.

51.

5*H

ad a

t lea

st 1

em

erge

ncy

room

vis

it, a

nd m

ost

rece

nt v

isit

was

for a

ser

ious

hea

lth p

robl

em13

.8*

36.2

*10

.3*

26.1

13.4

*

Not

es: O

b-gy

n is

obs

tetr

icia

n-gy

neco

logi

st. P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

exhi

bit e

xclu

de in

divi

dual

s w

ith m

issi

ng a

nd u

nkno

wn

valu

es. T

he in

divi

dual

co

mpo

nent

s lis

ted

unde

r the

sub

cate

gorie

s ar

e no

t alw

ays

mut

ually

exc

lusi

ve a

nd m

ay n

ot a

dd to

100

per

cent

. Sta

ndar

d er

rors

are

ava

ilabl

e on

line

in th

e do

wnl

oada

ble

Exce

l ve

rsio

n of

this

exh

ibit

at h

ttps

://w

ww

.mac

pac.

gov/

publ

icat

ion/

use-

of-c

are-

amon

g-no

n-in

stitu

tiona

lized

-indi

vidu

als-

age-

19-6

4-by

-prim

ary-

sour

ce-o

f-hea

lth-c

over

age-

data

-fr

om-n

atio

nal-h

ealth

-inte

rvie

w-s

urve

y/. D

ue to

diff

eren

ces

in m

etho

dolo

gy (s

uch

as th

e w

ordi

ng o

f que

stio

ns, l

engt

h of

reca

ll pe

riods

, and

pro

mpt

s or

pro

bes

used

to e

licit

resp

onse

s), e

stim

ates

obt

aine

d fr

om d

iffer

ent s

urve

y da

ta s

ourc

es w

ill v

ary.

For

exa

mpl

e, th

e N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

) is

know

n to

pro

duce

hig

her e

stim

ates

of

ser

vice

use

than

the

Med

ical

Exp

endi

ture

s Pa

nel S

urve

y (M

EPS)

. For

pur

pose

s of

com

parin

g gr

oups

of i

ndiv

idua

ls (a

s in

this

exh

ibit)

, the

NH

IS p

rovi

des

the

mos

t rec

ent

info

rmat

ion

avai

labl

e. F

or o

ther

pur

pose

s, s

uch

as m

easu

ring

leve

ls o

f use

rela

tive

to a

par

ticul

ar b

ench

mar

k or

goa

l, it

may

be

appr

opria

te to

con

sult

estim

ates

from

MEP

S or

an

othe

r sou

rce.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

indi

vidu

als

age

19–

64, r

egar

dles

s of

cov

erag

e so

urce

. In

this

exh

ibit,

the

follo

win

g hi

erar

chy

was

use

d to

ass

ign

indi

vidu

als

with

mul

tiple

co

vera

ge s

ourc

es to

a p

rimar

y so

urce

: Med

icar

e, p

rivat

e, M

edic

aid/

CHIP

, oth

er, u

nins

ured

. Not

sep

arat

ely

show

n ar

e th

e es

timat

es fo

r tho

se c

over

ed b

y an

y ty

pe o

f mili

tary

hea

lth

plan

or o

ther

gov

ernm

ent-s

pons

ored

pro

gram

s. C

over

age

sour

ce is

def

ined

as

of th

e tim

e of

the

surv

ey in

terv

iew

. Sin

ce a

n in

divi

dual

may

hav

e m

ultip

le c

over

age

sour

ces

or

chan

ges

over

tim

e, re

spon

ses

to s

urve

y qu

estio

ns m

ay re

flect

cha

ract

eris

tics

or e

xper

ienc

es a

ssoc

iate

d w

ith a

cov

erag

e so

urce

oth

er th

an th

e on

e as

sign

ed in

this

exh

ibit.

2 Pr

ivat

e he

alth

insu

ranc

e co

vera

ge e

xclu

des

plan

s th

at p

aid

for o

nly

one

type

of s

ervi

ce, s

uch

as a

ccid

ents

or d

enta

l car

e.3

Med

icai

d/CH

IP a

lso

incl

udes

per

sons

cov

ered

by

othe

r sta

te-s

pons

ored

hea

lth p

lans

.

EXH

IBIT

43.

(co

ntin

ued)



December 2016120


MAC

Stat

sSe

ctio

n 5

4 In

divi

dual

s w

ere

defin

ed a

s un

insu

red

if th

ey d

id n

ot h

ave

any

priv

ate

heal

th in

sura

nce,

Med

icai

d, C

HIP

, Med

icar

e, s

tate

- or o

ther

gov

ernm

ent-s

pons

ored

hea

lth p

lan,

or

mili

tary

pla

n. In

divi

dual

s w

ere

also

def

ined

as

unin

sure

d if

they

had

onl

y In

dian

Hea

lth S

ervi

ce c

over

age

or h

ad o

nly

a pr

ivat

e pl

an th

at p

aid

for o

ne ty

pe o

f ser

vice

, suc

h as

ac

cide

nts

or d

enta

l car

e.5

Due

to th

e fa

ct th

at a

hie

rarc

hy w

as u

sed

in th

is e

xhib

it to

ass

ign

indi

vidu

als

with

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

(see

not

e 1)

, the

Med

icai

d/CH

IP p

erce

ntag

es

show

n in

this

row

exc

lude

indi

vidu

als

who

als

o ha

ve M

edic

are

or p

rivat

e co

vera

ge. C

ompo

nent

s do

not

sum

to 1

00 p

erce

nt b

ecau

se n

ot a

ll co

vera

ge s

ourc

es a

re s

how

n.6

Any

heal

th p

rofe

ssio

nal i

nclu

des

gene

ral d

octo

r, nu

rse

prac

titio

ner,

phys

icia

n as

sist

ant,

mid

wife

, ob-

gyn,

med

ical

spe

cial

ist,

eye

doct

or, m

enta

l hea

lth p

rofe

ssio

nal,

ther

apis

t, ch

iropr

acto

r, or

pod

iatr

ist.

7 Th

ese

estim

ates

sho

uld

not b

e co

mpa

red

to th

e 20

14 e

stim

ates

pub

lishe

d in

the

Dece

mbe

r 201

5 da

ta b

ook

due

to a

cha

nge

in th

e sc

reen

ing

ques

tions

for c

hole

ster

ol,

bloo

d pr

essu

re, a

nd d

iabe

tes.

In 2

014,

the

NH

IS in

clud

ed a

dditi

onal

blo

od p

ress

ure

and

chol

este

rol s

cree

ning

que

stio

ns a

s pa

rt o

f the

sup

plem

enta

l que

stio

ns p

erta

inin

g to

th

e M

illio

n H

eart

s® In

itiat

ive

that

wer

e on

ly u

sed

in 2

014.

The

201

5 N

HIS

scr

eeni

ng q

uest

ions

reve

rted

bac

k to

the

orig

inal

scr

eeni

ng q

uest

ions

and

sho

uld

be c

ompa

rabl

e w

ith

year

s ea

rlier

than

201

4.8

Indi

vidu

als

of a

ny a

ge o

r sex

who

repo

rt h

yper

tens

ion

or d

iabe

tes,

or w

ho c

urre

ntly

sm

oke.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

NH

IS d

ata.

EXH

IBIT

43.

(co

ntin

ued)



MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

s

Prim

ary

cove

rage

sou

rce

at ti

me

of m

ost r

ecen

t int

ervi

ew1

Tota

lM

edic

are

Priv

ate2

Med

icai

d/CH

IP3

Uni

nsur

ed4

Tota

l (pe

rcen

t dis

trib

utio

n ac

ross

cov

erag

e so

urce

s)5

100.

0%3.

9%65

.8%

10.0

%18

.6%

Cont

act w

ith h

ealth

car

e pr

ofes

sion

als

(pas

t 12

mon

ths)

Num

ber o

f off

ice-

base

d vi

sits

(to

a do

ctor

or o

ther

hea

lth p

rofe

ssio

nal),

exc

ludi

ng d

enta

l vis

its a

nd in

patie

nt h

ospi

tal s

tays

Non

e30

.3

6.1 *

25.0

*29

.654

.6*

At le

ast 1

69.7

93

.9*

75.0

*70

.445

.4*

115

.6*

4.6*

16.3

*13

.716

.9*

2–3

18.3

*12

.1*

20.8

*15

.811

.7*

4 or

mor

e35

.8*

77.2

*37

.8

41.0

16.8

*H

ad a

t lea

st 1

ove

rnig

ht h

ospi

tal s

tay

5.7*

22.3

*4.

5*10

.93.

4 *Re

ceiv

ed c

are

at h

ome

1.7 *

16.5

*0.

8*3.

40.

9*Sa

w a

gen

eral

den

tist

35.6

*25

.7

43.8

*25

.314

.2*

Saw

an

orth

odon

tist

1.2

† 1.

4 1.

00.

5 *Re

ceip

t of a

ppro

pria

te c

are

(pas

t 12

mon

ths)

Had

den

tal c

lean

ing,

pro

phyl

axis

, or p

olis

hing

655

.0*

33.0

58

.2*

37.7

46.5

*H

ad m

ore

than

15

offic

e-ba

sed

or h

ospi

tal o

utpa

tient

vis

its9.

3*34

.0*

9.0*

12.2

3.4*

Num

ber o

f em

erge

ncy

room

vis

itsN

one

87.1

*65

.3*

90.2

*76

.387

.1*

At le

ast 1

12.9

*34

.7*

9.8*

23.7

12.9

*1

9.3 *

17.9

7.

7 *15

.69.

4 *2–

33.

0*13

.7*

1.9*

6.3

3.2*

4 or

mor

e0.

6*3.

2 0.

3 *1.

8†

Not

es: P

erce

ntag

e ca

lcul

atio

ns fo

r eac

h ite

m in

the

exhi

bit e

xclu

de in

divi

dual

s w

ith m

issi

ng a

nd u

nkno

wn

valu

es. S

tand

ard

erro

rs a

re a

vaila

ble

onlin

e in

the

dow

nloa

dabl

e Ex

cel v

ersi

on o

f thi

s ex

hibi

t at h

ttps

://w

ww

.mac

pac.

gov/

publ

icat

ion/

use-

of-c

are-

amon

g-no

n-in

stitu

tiona

lized

-indi

vidu

als-

age-

19-6

4-by

-prim

ary-

sour

ce-o

f-hea

lth-c

over

age-

data

-fr

om-m

edic

al-e

xpen

ditu

res-

pane

l-sur

vey/

. Due

to d

iffer

ence

s in

met

hodo

logy

(suc

h as

the

wor

ding

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

diff

eren

t sur

vey

data

sou

rces

will

var

y. F

or e

xam

ple,

the

Nat

iona

l Hea

lth In

terv

iew

Sur

vey

(NH

IS) i

s kn

own

to p

rodu

ce h

ighe

r est

imat

es o

f se

rvic

e us

e th

an th

e M

edic

al E

xpen

ditu

res

Pane

l Sur

vey

(MEP

S). F

or p

urpo

ses

of c

ompa

ring

grou

ps o

f ind

ivid

uals

, the

NH

IS p

rovi

des

the

mos

t rec

ent i

nfor

mat

ion

avai

labl

e.

For o

ther

pur

pose

s, s

uch

as m

easu

ring

leve

ls o

f use

rela

tive

to a

par

ticul

ar b

ench

mar

k or

goa

l, it

may

be

appr

opria

te to

con

sult

estim

ates

from

MEP

S or

ano

ther

sou

rce.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

EXH

IBIT

44.

Use

of C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

19–

64 b

y Pr

imar

y So

urce

of H

ealth

Cov

erag

e, 2

014,

Dat

a fro

m

Med

ical

Exp

endi

ture

s Pa

nel S

urve

y



December 2016122


MAC

Stat

sSe

ctio

n 5

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

indi

vidu

als

age

19–

64, r

egar

dles

s of

cov

erag

e so

urce

. In

this

exh

ibit,

the

follo

win

g hi

erar

chy

was

use

d to

ass

ign

indi

vidu

als

with

m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce: M

edic

are,

priv

ate,

Med

icai

d/CH

IP, o

ther

, uni

nsur

ed. N

ot s

epar

atel

y sh

own

are

the

estim

ates

for t

hose

cov

ered

by

any

type

of

mili

tary

hea

lth p

lan

or o

ther

gov

ernm

ent-s

pons

ored

pro

gram

s. C

over

age

sour

ce is

def

ined

as

of th

e tim

e of

the

mos

t rec

ent s

urve

y in

terv

iew

. Sin

ce a

n in

divi

dual

may

hav

e m

ultip

le c

over

age

sour

ces

or c

hang

es o

ver t

ime,

resp

onse

s to

sur

vey

ques

tions

may

refle

ct c

hara

cter

istic

s or

exp

erie

nces

ass

ocia

ted

with

a c

over

age

sour

ce o

ther

than

the

one

assi

gned

in th

is e

xhib

it.2

Priv

ate

heal

th in

sura

nce

cove

rage

exc

lude

s pl

ans

that

pai

d fo

r onl

y on

e ty

pe o

f ser

vice

, suc

h as

acc

iden

ts o

r den

tal c

are.

3 M

edic

aid/

CHIP

als

o in

clud

es p

erso

ns c

over

ed b

y ot

her s

tate

-spo

nsor

ed h

ealth

pla

ns.

4 In

divi

dual

s w

ere

defin

ed a

s un

insu

red

if th

ey d

id n

ot h

ave

any

priv

ate

heal

th in

sura

nce,

Med

icai

d, C

HIP

, Med

icar

e, s

tate

- or o

ther

gov

ernm

ent-s

pons

ored

hea

lth p

lan,

or

mili

tary

pla

n. In

divi

dual

s w

ere

also

def

ined

as

unin

sure

d if

they

had

onl

y In

dian

Hea

lth S

ervi

ce c

over

age

or h

ad o

nly

a pr

ivat

e pl

an th

at p

aid

for o

ne ty

pe o

f ser

vice

, suc

h as

ac

cide

nts

or d

enta

l car

e.5

Due

to th

e fa

ct th

at a

hie

rarc

hy w

as u

sed

in th

is e

xhib

it to

ass

ign

indi

vidu

als

with

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

(see

not

e 1)

, the

Med

icai

d/CH

IP

perc

enta

ges

show

n in

this

row

exc

lude

indi

vidu

als

who

als

o ha

ve M

edic

are

or p

rivat

e co

vera

ge. C

ompo

nent

s do

not

sum

to 1

00 p

erce

nt b

ecau

se n

ot a

ll co

vera

ge s

ourc

es a

re

show

n.6

Lim

ited

to p

eopl

e w

ho re

port

ed a

den

tal e

vent

in 2

014.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

MEP

S da

ta.

EXH

IBIT

44.

(co

ntin

ued)



MAC

Stat

sSe

ctio

n 5

Char

acte

ristic

sPr

imar

y co

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ourc

e at

tim

e of

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rvie

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ate2

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icai

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nsur

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as a

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ourc

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car

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*88

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*H

ad th

e sa

me

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l sou

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of m

edic

al c

are

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mon

ths

ago

75.4

83

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Had

trou

ble

findi

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tor o

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ccep

ted7

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89.

1 Ti

mel

ines

s of

car

e (p

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d m

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are

due

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ny a

cces

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rrie

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icat

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elow

18.1

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es: P

erce

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e ca

lcul

atio

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r eac

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the

tabl

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to 1

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erce

nt. S

tand

ard

erro

rs a

re a

vaila

ble

onlin

e in

the

dow

nloa

dabl

e Ex

cel v

ersi

on o

f thi

s ex

hibi

t at h

ttps

://w

ww

.mac

pac.

gov/

publ

icat

ion/

mea

sure

s-of

-acc

ess-

to-c

are-

for-n

on-in

stitu

tiona

lized

-indi

vidu

als-

age-

19-6

4-by

-sou

rce-

of-h

ealth

-cov

erag

e/. D

ue to

diff

eren

ces

in m

etho

dolo

gy (s

uch

as th

e w

ordi

ng

of q

uest

ions

, len

gth

of re

call

perio

ds, a

nd p

rom

pts

or p

robe

s us

ed to

elic

it re

spon

ses)

, est

imat

es o

btai

ned

from

diff

eren

t sur

vey

data

sou

rces

will

var

y. F

or e

xam

ple,

the

Nat

iona

l Hea

lth In

terv

iew

Sur

vey

(NH

IS) i

s kn

own

to p

rodu

ce h

ighe

r est

imat

es o

f ser

vice

use

than

the

Med

ical

Exp

endi

ture

s Pa

nel S

urve

y (M

EPS)

. For

pur

pose

s of

com

parin

g gr

oups

of i

ndiv

idua

ls (a

s in

this

exh

ibit)

, the

NH

IS p

rovi

des

the

mos

t rec

ent i

nfor

mat

ion

avai

labl

e. F

or o

ther

pur

pose

s, s

uch

as m

easu

ring

leve

ls o

f use

rela

tive

to a

par

ticul

ar

benc

hmar

k or

goa

l, it

may

be

appr

opria

te to

con

sult

estim

ates

from

MEP

S or

ano

ther

sou

rce.

* Di

ffer

ence

from

Med

icai

d/CH

IP is

sta

tistic

ally

sig

nific

ant a

t the

0.0

5 le

vel.

EXH

IBIT

45.

Mea

sure

s of

Acc

ess

to C

are

amon

g N

on-In

stitu

tiona

lized

Indi

vidu

als

Age

19–

64 b

y Pr

imar

y So

urce

of H

ealth

Co

vera

ge, 2

015

https://www.macpac.gov/publication/measures-of-access-to-care-for-non-institutionalized-individuals-age-19-64-by-source-of-health-coverage/

https://www.macpac.gov/publication/measures-of-access-to-care-for-non-institutionalized-individuals-age-19-64-by-source-of-health-coverage/

December 2016124


MAC

Stat

sSe

ctio

n 5

† Es

timat

e is

unr

elia

ble

beca

use

it ha

s a

rela

tive

stan

dard

err

or g

reat

er th

an 3

0 pe

rcen

t.

– D

ash

indi

cate

s ze

ro; 0

.0%

indi

cate

s an

am

ount

less

than

0.0

5% th

at ro

unds

to z

ero.

1 To

tal i

nclu

des

all n

on-in

stitu

tiona

lized

indi

vidu

als

age

19–

64, r

egar

dles

s of

cov

erag

e so

urce

. In

this

exh

ibit,

the

follo

win

g hi

erar

chy

was

use

d to

ass

ign

indi

vidu

als

with

m

ultip

le c

over

age

sour

ces

to a

prim

ary

sour

ce: M

edic

are,

priv

ate,

Med

icai

d/CH

IP, o

ther

, uni

nsur

ed. N

ot s

epar

atel

y sh

own

are

the

estim

ates

for t

hose

cov

ered

by

any

type

of

mili

tary

hea

lth p

lan

or o

ther

gov

ernm

ent-s

pons

ored

pro

gram

s. C

over

age

sour

ce is

def

ined

as

of th

e tim

e of

the

surv

ey in

terv

iew

. Sin

ce a

n in

divi

dual

may

hav

e m

ultip

le

cove

rage

sou

rces

or c

hang

es o

ver t

ime,

resp

onse

s to

sur

vey

ques

tions

may

refle

ct c

hara

cter

istic

s or

exp

erie

nces

ass

ocia

ted

with

a c

over

age

sour

ce o

ther

than

the

one

assi

gned

in th

is e

xhib

it.2

Priv

ate

heal

th in

sura

nce

cove

rage

exc

lude

s pl

ans

that

pai

d fo

r onl

y on

e ty

pe o

f ser

vice

, suc

h as

acc

iden

ts o

r den

tal c

are.

3 M

edic

aid/

CHIP

als

o in

clud

es p

erso

ns c

over

ed b

y ot

her s

tate

-spo

nsor

ed h

ealth

pla

ns.

4 In

divi

dual

s w

ere

defin

ed a

s un

insu

red

if th

ey d

id n

ot h

ave

any

priv

ate

heal

th in

sura

nce,

Med

icai

d, C

HIP

, Med

icar

e, s

tate

- or o

ther

gov

ernm

ent-s

pons

ored

hea

lth p

lan,

or

mili

tary

pla

n. In

divi

dual

s w

ere

also

def

ined

as

unin

sure

d if

they

had

onl

y In

dian

Hea

lth S

ervi

ce c

over

age

or h

ad o

nly

a pr

ivat

e pl

an th

at p

aid

for o

ne ty

pe o

f ser

vice

, suc

h as

ac

cide

nts

or d

enta

l car

e.5

Due

to th

e fa

ct th

at a

hie

rarc

hy w

as u

sed

in th

is e

xhib

it to

ass

ign

indi

vidu

als

with

mul

tiple

cov

erag

e so

urce

s to

a p

rimar

y so

urce

(see

not

e 1)

, the

Med

icai

d/CH

IP p

erce

ntag

es

show

n in

this

row

exc

lude

indi

vidu

als

who

als

o ha

ve M

edic

are

or p

rivat

e co

vera

ge. C

ompo

nent

s do

not

sum

to 1

00 p

erce

nt b

ecau

se n

ot a

ll co

vera

ge s

ourc

es a

re s

how

n.6

Excl

udes

em

erge

ncy

room

.7

Indi

vidu

al re

port

ed o

ne o

f the

se b

arrie

rs in

the

past

12

mon

ths:

trou

ble

findi

ng a

doc

tor o

r pro

vide

r, do

ctor

’s o

ffic

e/cl

inic

did

not

acc

ept c

hild

’s in

sura

nce

cove

rage

, or o

ffic

e/cl

inic

did

not

acc

ept t

he c

hild

as

a ne

w p

atie

nt.

8 In

clud

es a

ny o

f the

follo

win

g: in

divi

dual

cou

ld n

ot g

et a

n ap

poin

tmen

t, ha

d to

wai

t too

long

to s

ee d

octo

r, co

uld

not g

o w

hen

open

, cou

ld n

ot g

et th

roug

h on

pho

ne, i

ndiv

idua

l sp

eaks

a d

iffer

ent l

angu

age.

Sour

ce: M

ACPA

C, 2

016,

ana

lysi

s of

NH

IS d

ata.

EXH

IBIT

45.

(co

ntin

ued)

SECTION 6

Technical Guide to MACStats


Section 6: Technical Guide to MACStats

MAC

Stat

sSe

ctio

n 6

This technical guide provides supplementary information to help readers interpret the exhibits in this data book as well as understand the data sources and methods used. In addition, we explain why MACPAC’s statistics, particularly those on enrollment and spending, may differ from each other or from those published elsewhere.1

Interpreting Medicaid and CHIP Enrollment and Spending NumbersPublished numbers for enrollment in Medicaid and the State Children’s Health Insurance Program (CHIP) can vary substantially depending on the source of data, the enrollment period examined, and the individuals included in the data.

Data sourcesMedicaid and CHIP enrollment and spending numbers are available from data compiled by states and the federal government in the course of administering these programs. Program data are updated on different schedules, so the latest year of available data may differ depending on the source. MACPAC commonly uses the following types of administrative data, which are submitted by the states to the Centers for Medicare & Medicaid Services (CMS):

• Form CMS-64 data for state-level Medicaid spending;

• Medicaid Statistical Information System (MSIS) data for person-level detail;

• Medicaid managed care enrollment reports; and

• Statistical Enrollment Data System (SEDS) data for CHIP enrollment.

In addition, CMS recently began compiling two new administrative data sources, referred to here as

performance indicator enrollment data and CMS-64 enrollment data.2 Notable differences between these sources include the timing of the reports and the beneficiaries covered: the performance indicator enrollment data are published monthly by CMS and only include full-benefit Medicaid and CHIP enrollees, while CMS-64 enrollment data are published quarterly and include those with limited benefits but exclude CHIP enrollees. Both sources provide more up-to-date information than the MSIS. Although timelier reporting is expected under a new version of the MSIS, referred to as the transformed MSIS (T-MSIS), full implementation has been delayed and states are still in the process of transitioning to T-MSIS reporting.

MACStats also uses nationally representative surveys based on interviews of individuals including the National Health Interview Survey (NHIS) and the Medical Expenditures Panel Survey (MEPS). Estimates of Medicaid and CHIP enrollment from survey data tend to be lower than estimates generated from administrative data, in part because survey respondents tend to underreport Medicaid and CHIP coverage. However, survey data provide many more details on individual and family circumstances (for example, health status, ease in accessing services, and reasons for delaying care) and can therefore provide a richer picture of the individuals enrolled in Medicaid and CHIP.

Enrollment period examinedCharacterizations of the size of the Medicaid and CHIP populations may vary based on the enrollment period examined. The number of individuals enrolled at a particular point during the year will be lower than the total number enrolled at any point during an entire year. Point-in-time numbers are sometimes referred to as average, full-year equivalent, or person-year enrollment. These statistics are often used for budget analyses (such as those by the CMS Office of the Actuary) and when comparing enrollment and expenditure numbers. Per enrollee spending levels based on

December 2016128


MAC

Stat

sSe

ctio

n 6

full-year equivalents ensure that amounts are not biased by individuals’ transitions in and out of Medicaid coverage during the year.

Enrollees versus beneficiariesDepending on the source and the year in question, data may reflect different ways of characterizing individuals in Medicaid. Certain terms commonly used to refer to people with Medicaid have extremely specific definitions in administrative data sources provided by CMS:3

• Enrollees (less commonly referred to as eligibles) are individuals who are eligible for and enrolled in Medicaid or CHIP. Prior to fiscal year (FY) 1990, CMS did not track the number of Medicaid enrollees, and tracked only beneficiaries (see below). In some cases, CMS has estimated the number of enrollees prior to 1990.

• Beneficiaries, or persons served (less commonly referred to as recipients), are enrollees who receive covered services or for whom Medicaid or CHIP payments are made. Prior to FY 1998, individuals were not counted as beneficiaries if managed care payments were the only Medicaid payments made on their behalf. Beginning in FY 1998, however, Medicaid managed care enrollees with no fee-for-service (FFS) spending were also counted as beneficiaries, which increased the number of individuals reflected in enrollment statistics. Generally, the number of beneficiaries will approach the number of enrollees as more of these individuals use Medicaid-covered services or are enrolled in managed care.4 (In common usage outside of statistical publications from CMS, the term beneficiaries typically is synonymous with enrollees.)

Institutionalized and limited-benefit enrollees Administrative Medicaid data include enrollees who are in institutions such as nursing homes, as well as individuals who receive only limited benefits (for example, only coverage for emergency services). Survey data tend to exclude such individuals from counts of coverage. In percentage terms, the difference between estimates from administrative data and estimates from survey data tends to be largest among older beneficiaries, who are more likely to be living in institutions (in which case they are excluded from most surveys) and more likely to be receiving limited Medicaid benefits that pay only for their Medicare premiums and cost sharing (which may not be counted as Medicaid coverage in some surveys).

State Children’s Health Insurance Program enrolleesMedicaid-expansion CHIP enrollees are children who are entitled to the covered services of a state’s Medicaid program, but whose Medicaid coverage is generally funded with CHIP dollars. Depending on the data source, Medicaid enrollment and spending figures may include not only Medicaid enrollees funded with Medicaid dollars, but also Medicaid-expansion CHIP enrollees funded with CHIP dollars. For MACStats, we generally exclude Medicaid-expansion CHIP enrollees from Medicaid analyses, but some data sources do not allow these children to be broken out separately.

Understanding Data on Health and Other Characteristics of Medicaid and CHIP PopulationsMACStats uses data from the federal NHIS and MEPS to describe Medicaid and CHIP enrollees in terms of their self-reported demographic, socioeconomic, and health characteristics as well as their use of care. Background information



MAC

Stat

sSe

ctio

n 6

on these surveys is provided here, along with information on how children with special health care needs are identified using NHIS data.

National Health Interview Survey and Medical Expenditures Panel Survey dataThe NHIS is an annual face-to-face household survey of civilian non-institutionalized persons designed to monitor the health of the U.S. population through the collection of information on a broad range of health topics.5 A subsample of households that participated in the previous year’s NHIS undergo further interviews for the household component of the MEPS, which collects more detailed information on use of health care services and expenditures.6

Although other surveys are available, the NHIS is the main survey data source used in MACStats because it provides relatively timely estimates and because its sample size is large enough to produce reliable subgroup estimates and to detect meaningful differences between them. In addition, it is generally considered to be one of the best surveys for health insurance coverage estimates, and it captures detailed information on individuals’ health status.7

However, the NHIS is known to produce higher estimates of service use than the MEPS.8 As a result, MACStats includes estimates of service use from both sources. For purposes of comparing groups of individuals, the NHIS has the advantage of providing the most recent information available; for other purposes, such as measuring levels of service use relative to a particular benchmark or goal, consulting estimates from the MEPS or another source might be more appropriate.

The NHIS does have some limitations. As in most surveys, respondents in the NHIS do not always accurately report information about participation in programs such as Medicaid, CHIP, Medicare, Supplemental Security Income (SSI), and Social Security Disability Insurance. As a result, survey data may not match estimates of program

participation computed from the programs’ own administrative data. In addition, although the NHIS asks about participation in Medicaid and CHIP in two different questions, program participation estimates from the survey are not reported separately. One reason for this is that many states’ CHIP and Medicaid programs use the same name, so respondents may not necessarily know which program funds their children’s coverage. Even when the programs have different names, it may be difficult for respondents and interviewers to correctly categorize the coverage. As a result, separate survey questions regarding participation in Medicaid and CHIP are generally used to minimize the undercounting of Medicaid and CHIP enrollees, not to produce valid estimates separately for each program. Thus, survey data analyses typically combine Medicaid and CHIP into a single category.

Children with special health care needsThe term children with special health care needs (CSHCN), is defined by the U.S. Department of Health and Human Services’ Maternal and Child Health Bureau as a group of children who “have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”9 This definition is used by all states for policy and program planning purposes and encompasses children with disabilities and also children with chronic conditions (e.g., asthma, juvenile diabetes, sickle cell anemia) that range from mild to severe. The category of CSHCN covers a broader range of children than the category of children with conditions severe enough and family incomes low enough to qualify for SSI.10

MACPAC uses responses to several questions on the NHIS to identify such children. This definition includes children with at least one diagnosed or parent-reported condition expected to be an ongoing health condition who also meet at least one of five criteria related to elevated service use or elevated need:11

December 2016130


MAC

Stat

sSe

ctio

n 6

• The child is limited in his or her ability or unable to do things most children the same age can do.12

• The child needs or uses medications prescribed by a doctor (other than vitamins).13

• The child needs or uses specialized therapies such as physical, occupational, or speech therapy.14

• The child has above-routine need or use of medical, mental health, home care, or education services.15

• The child needs or receives treatment or counseling for an emotional, behavioral, or developmental problem.16

Estimates for the category of CSHCN in this edition of MACStats are not directly comparable to those in prior years, which used a slightly different definition.17

Methodology for Adjusting Benefit Spending DataThe FY 2013 Medicaid benefit spending amounts presented in this data book were calculated based on MSIS data that have been adjusted to match total benefit spending reported by states in CMS-64 data.18

Although the CMS-64 provides a more complete accounting of spending than the MSIS and is preferred when examining state or federal spending totals, it cannot be used for analysis of benefit spending by eligibility group and other enrollee characteristics.19 Thus, we adjust MSIS amounts for several reasons:

• CMS-64 data provide an official accounting of state spending on Medicaid for purposes of receiving federal matching dollars; in contrast, MSIS data are used primarily for statistical purposes.

• The MSIS generally understates total Medicaid benefit spending because it

excludes disproportionate share hospital (DSH) payments and additional types of supplemental payments made to hospitals and other providers, Medicare premium payments, and certain other amounts.20

• The MSIS generally overstates net spending on prescribed drugs because it excludes rebates from drug manufacturers.

• Even after accounting for differences in their scope and design, the MSIS still tends to produce lower total benefit spending than the CMS-64.21

• The extent to which the MSIS differs from the CMS-64 varies by state, meaning that a cross-state comparison of unadjusted MSIS amounts may not reflect true differences in benefit spending. See Exhibit 46 for unadjusted benefit spending amounts in the MSIS as a percentage of benefit spending in the CMS-64.

The methodology MACPAC uses for adjusting MSIS benefit spending data involves the following steps:

• We aggregate the service types into broad categories that are comparable between the two sources. This is necessary because there is not a one-to-one correspondence of service types in MSIS and CMS-64 data. Even service types that have identical names may still be reported differently in the two sources due to differences in the instructions given to states. Exhibit 47 provides additional detail on the categories used.

• We calculate state-specific adjustment factors for each of the service categories by dividing CMS-64 benefit spending by MSIS benefit spending.

• We then multiply MSIS dollar amounts in each service category by the state-specific factors to obtain adjusted MSIS spending. For example, in a state with an FFS hospital factor of 1.2, each Medicaid enrollee with



MAC

Stat

sSe

ctio

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hospital spending in the MSIS would have that spending multiplied by 1.2; doing so makes the sum of adjusted hospital spending amounts among individual Medicaid enrollees in the MSIS total the aggregate hospital spending reported by states in the CMS-64 (as noted later, MACPAC excludes some amounts from the CMS-64 hospital total).22

These adjustments to MSIS data are meant to provide more complete estimates of Medicaid benefit spending across states that can be analyzed by eligibility group and other enrollee characteristics. Other organizations, including the CMS Office of the Actuary, the Kaiser Commission on Medicaid and the Uninsured, and the Urban Institute, use similar methodologies although these may differ in some ways—for example, by using different service categories or producing estimates for future years based on actual data from earlier years.

Readers should note that due to changes in both methods and data, MSIS figures shown here are not directly comparable to earlier years. Key differences between the current and previous methodologies include the following:

• Beginning with the 2014 edition of MACStats, we excluded DSH payments from CMS-64 totals used to adjust MSIS spending. In earlier editions, DSH payments were included in CMS-64 totals. The rationale for doing so was that DSH payments are used to support hospitals that serve a large number of low-income and Medicaid patients, and could therefore be partially attributed to Medicaid enrollees in the MSIS. However, an examination of annual DSH audit data submitted by states indicates that for some hospitals, Medicaid DSH payments far exceed their uncompensated care costs for Medicaid patients and may therefore be attributed largely to uninsured patients.23 As a result, we now exclude DSH payments from CMS-64 totals when we adjust MSIS spending.

• Also starting with the 2014 edition, we obtained a more precise separation of home- and community-based services (HCBS) waiver spending in the MSIS, due to the use of more detailed MSIS data files than in editions of MACStats prior to 2014.

• Beginning with the 2015 edition, we excluded incentive and uncompensated care pool payments made under Section 1115 waiver expenditure authority from CMS-64 totals used to adjust MSIS spending.24 In earlier editions, these payments were included in CMS-64 totals. Because these payments may be made for purposes other than providing services to Medicaid patients, we now exclude them when we adjust MSIS spending.

• Also starting with the 2015 edition, we shifted a portion of drug rebate amounts in the CMS-64 from fee for service to managed care for a small number of states that, despite reporting drug utilization data for managed care, reported little or no drug rebates for managed care.

With regard to changes in data, complete MSIS Annual Person Summary (APS) files have not been available in a timely manner for use in MACStats since the 2013 edition. Therefore, beginning with the 2014 edition, we calculated spending and enrollment from the full MSIS data files that are used to create APS files. In general, our calculations closely match those used to create the APS. However, our development of enrollment counts is a notable exception. In MACPAC’s analysis of the full MSIS data files, Medicaid enrollees were assigned a unique national identification (ID) number using an algorithm that incorporates state-specific ID numbers and beneficiary characteristics such as date of birth and gender. The state and national enrollment counts were then unduplicated using this national ID, which results in MACPAC reporting slightly lower enrollment counts than would be the case had we used APS files.

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State

Benefit spending totals included in analysis

Amounts excluded from CMS-64 benefit spending totals

Unadjusted MSIS CMS-641

MSIS as a percentage of CMS-64 DSH

Incentive and uncompensated

care pool waivers

Total $375,433 $401,239 93.6% $15,457 $10,799Alabama 4,179 4,568 91.5 471 –Alaska 1,321 1,335 99.0 22 –Arizona 8,229 7,586 108.5 173 679Arkansas 3,497 4,141 84.4 61 5California 41,003 57,297 71.6 2,120 2,487Colorado 4,004 4,898 81.7 194 –Connecticut 6,241 6,453 96.7 273 –Delaware 1,662 1,552 107.1 11 –District of Columbia 2,360 2,232 105.7 56 –Florida 20,301 17,233 117.8 335 994Georgia 9,310 8,530 109.1 430 –Hawaii 1,464 1,524 96.1 25 82Idaho 2 2 2 2 2

Illinois 13,782 15,211 90.6 447 –Indiana 6,603 7,630 86.5 338 –Iowa 3,547 3,649 97.2 55 6Kansas 2,533 2,441 103.7 77 60Kentucky 5,575 5,606 99.4 216 –Louisiana 2 2 2 2 2

Maine 2,041 2,850 71.6 37 –Maryland 7,195 7,647 94.1 134 –Massachusetts 11,144 12,338 90.3 – 828Michigan 11,529 11,998 96.1 388 –Minnesota 8,561 8,873 96.5 46 –Mississippi 3,842 4,518 85.0 218 –Missouri 7,121 8,248 86.3 703 –Montana 864 989 87.3 18 –Nebraska 1,749 1,788 97.8 45 –Nevada 1,477 1,742 84.8 81 –New Hampshire 1,045 1,162 89.9 41 –New Jersey 9,075 9,266 97.9 1,298 42New Mexico 2,615 3,270 80.0 25 –

EXHIBIT 46. Medicaid Benefit Spending in MSIS and CMS-64 Data by State, FY 2013 (millions)



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State

Benefit spending totals included in analysis

Amounts excluded from CMS-64 benefit spending totals

Unadjusted MSIS CMS-641

MSIS as a percentage of CMS-64 DSH

Incentive and uncompensated

care pool waivers

New York $50,560 $50,354 100.4% $3,423 $644North Carolina 9,932 11,298 87.9 617 –North Dakota 805 783 102.8 1 –Ohio 16,001 16,154 99.0 649 –Oklahoma 3,925 4,754 82.6 42 –Oregon 3,996 4,782 83.6 77 253Pennsylvania 18,749 20,245 92.6 847 –Rhode Island 2 2 2 2 2

South Carolina 4,862 4,449 109.3 457 –South Dakota 757 765 99.0 1 –Tennessee 13,563 7,617 178.1 80 1,020Texas 22,084 24,417 90.4 227 3,695Utah 2,640 2,101 125.6 29 –Vermont 1,136 1,431 79.4 37 5Virginia 6,363 7,105 89.6 186 –Washington 6,684 7,805 85.6 367 –West Virginia 3,216 2,949 109.1 75 –Wisconsin 5,689 7,105 80.1 1 –Wyoming 603 554 108.9 0 –

Notes: MSIS is Medicaid Statistical Information System. FY is fiscal year. DSH is disproportionate share hospital. Includes federal and state funds. MSIS and CMS-64 data reflect unadjusted amounts as reported by states. Both sources exclude spending on administration, the territories, and Medicaid-expansion CHIP enrollees; in addition, CMS-64 amounts exclude $6.8 billion in offsetting collections from third-party liability, estate, and other recoveries. See https://www.macpac.gov/macstats/data-sources-and-methods/ for a discussion of differences between MSIS and CMS-64 data. Beginning with the 2014 edition of MACStats, DSH payments have been excluded from CMS-64 totals used to adjust MSIS spending; beginning with the 2015 edition, incentive and uncompensated care pool payments made under Section 1115 waiver authority have also been excluded. For informational purposes, the DSH and waiver expenditure amounts that were excluded are shown here.

– Dash indicates zero; $0 indicates an amount less than $0.5 million that rounds to zero.1 The total amount reported on the CMS-64 may differ slightly from the state and national totals of our adjusted MSIS spending reported in other exhibits due to rounding when applying certain adjustments.2 Idaho, Louisiana, and Rhode Island were excluded due to data reliability concerns regarding completeness of monthly claims and enrollment data.

Source: MACPAC, 2016, analysis of MSIS data as of December 2015 and CMS-64 Financial Management Report net expenditure data as of June 2016.



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Service category MSIS service types1 CMS-64 service types

Hospital • Inpatient hospital• Outpatient hospital

• Inpatient hospital non-DSH• Inpatient hospital non-DSH supplemental payments• Inpatient hospital GME payments• Outpatient hospital non-DSH• Outpatient hospital non-DSH supplemental payments• Emergency services for aliens2

• Emergency hospital services• Critical access hospitals

Non-hospital acute care

• Physician• Dental• Nurse-midwife• Nurse practitioner• Other practitioner• Non-hospital outpatient

clinic• Lab and X-ray• Sterilizations• Abortions• Hospice• Targeted case management• Physical, occupational,

speech, and hearing therapy• Non-emergency

transportation• Private duty nursing• Rehabilitative services• Other care, excluding HCBS

waiver

• Physician (including primary care physician payment increase)

• Physician services supplemental payments• Preventive services with USPSTF Grade A or B and

ACIP vaccines• Dental• Nurse-midwife• Nurse practitioner• Other practitioner • Other practitioner supplemental payments• Non-hospital clinic• Rural health clinic• Federally qualified health center• Lab and X-ray• Sterilizations• Abortions• Hospice• Targeted case management• Statewide case management• Physical therapy• Occupational therapy• Services for speech, hearing, and language• Non-emergency transportation• Private duty nursing• Rehabilitative services (non-school-based)• School-based services• EPSDT screenings• Diagnostic screening and preventive services• Prosthetic devices, dentures, eyeglasses• Freestanding birth center• Health home with chronic conditions• Tobacco cessation for pregnant women• Care not otherwise categorized

Drugs • Drugs (gross spending) • Drugs (gross spending)• Drug rebates

EXHIBIT 47. Service Categories Used to Adjust FY 2013 Medicaid Benefit Spending in the MSIS to Match CMS-64 Totals



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Service category MSIS service types1 CMS-64 service typesManaged care and premium assistance

• HMO (i.e., comprehensive risk-based managed care; includes PACE)

• PHP• PCCM

• MCO (i.e., comprehensive risk-based managed care)• MCO drug rebates• PACE• PAHP• PIHP• PCCM• MCO, PAHP, and PIHP payments associated with the

primary care physician payment increase, Community First Choice option, preventive services with USPSTF Grade A or B, and ACIP vaccines

• Premium assistance for private coverageLTSS non-institutional • Home health

• Personal care• HCBS waiver

• Home health• Personal care• Personal care—1915(j)• HCBS waiver• HCBS—1915(i)• HCBS—1915(j)• HCBS–1915(k)

LTSS institutional • Nursing facility• ICF/ID• Inpatient psychiatric for

individuals under age 21• Mental health facility for

individuals age 65 and older

• Nursing facility• Nursing facility supplemental payments• ICF/ID• ICF/ID supplemental payments• Mental health facility for individuals under age 21 or

age 65 and older, non-DSHMedicare3, 4 • Medicare Part A and Part B premiums

• Medicare coinsurance and deductibles for QMBs

Notes: FY is fiscal year. MSIS is Medicaid Statistical Information System. DSH is disproportionate share hospital. GME is graduate medical education. HCBS is home and community-based services. USPSTF is U.S. Preventive Services Task Force. ACIP is Advisory Committee on Immunization Practices. EPSDT is early and periodic screening, diagnostic, and treatment services. HMO is health maintenance organization. PACE is Program of All-Inclusive Care for the Elderly. PHP is prepaid health plan. PCCM is primary care case management. MCO is managed care organization. PAHP is prepaid ambulatory health plan (a type of PHP). PIHP is prepaid inpatient health plan (a type of PHP). LTSS is long-term services and supports. ICF/ID is intermediate care facility for persons with intellectual disabilities. QMB is qualified Medicare beneficiary.Service categories and types reflect fee-for-service spending unless noted otherwise. Service types with identical names in MSIS and CMS-64 data may still be reported differently in the two sources due to differences in the instructions given to states; amounts for those that appear only in the CMS-64 (e.g., drug rebates) are distributed across Medicaid enrollees with MSIS spending in the relevant service categories (e.g., drugs).1 Claims in the MSIS include both a service type (such as inpatient hospital, physician, personal care, etc.) and a program type (including HCBS waiver). When adjusting MSIS data to match CMS-64 totals, we count all claims with an HCBS waiver program type as HCBS waiver, regardless of their specific service type. Among claims with an HCBS waiver program type, the most common service types are other, home health, rehabilitation, and personal care.2 Emergency services for aliens are reported under individual service types throughout the MSIS, but primarily as inpatient and outpatient hospital. As a result, we include this CMS-64 amount in the hospital category.3 Medicare premiums are not reported in the MSIS. We distribute CMS-64 amounts proportionately across dually eligible enrollees identified in the MSIS for each state.4 Medicare coinsurance and deductibles are reported under individual service types throughout the MSIS. We distribute CMS-64 amounts for QMBs across CMS-64 spending in the hospital, non-hospital acute, and LTSS institutional categories prior to calculating state-level adjustment factors based on the distribution of Medicare cost sharing for hospital, Part B, and skilled nursing facility services among QMBs in 2011 Medicare data. See MedPAC and MACPAC, 2016, Data book: Beneficiaries dually eligible for Medicare and Medicaid, Table 4, Fee-for-service Medicare Part A and Part B cost sharing incurred by dually eligible and non-dually eligible Medicare beneficiaries (page 13), https://www.macpac.gov/wp-content/uploads/2015/01/Dually-Eligible-Beneficiares-DataBook.pdf.Sources: MACPAC, 2016, analysis of MSIS and CMS-64 Financial Management Report net expenditure data.


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Understanding Managed Care Enrollment and Spending DataThere are four main sources of data on Medicaid managed care available from Centers for Medicare & Medicaid Services (CMS).

• Medicaid Managed Care Data Collection System (MMCDCS). The MMCDCS provides state-reported aggregate enrollment statistics and other basic information for each managed care plan within a state. CMS uses the MMCDCS to create an annual Medicaid managed care enrollment report, which is the source of information on Medicaid managed care most commonly cited by CMS, as well as by outside analysts and researchers.

• MSIS. The MSIS provides person-level and claims-level information for all Medicaid enrollees. For managed care, MSIS claims include records of each capitated payment made on behalf of an enrollee to a managed care plan (generally referred to as capitated claims), as well as records of each service received by the enrollee from a provider under contract with a managed care plan (which generally do not include payment amounts and may be referred to as encounter or “dummy” claims). All states collect encounter data from their Medicaid managed care plans, but some do not report them in the MSIS. Managed care enrollees may also have FFS claims in the MSIS if they used services beyond those covered by a managed care plan’s contract with the state.

• CMS-64. The CMS-64 Financial Management Report (FMR) provides aggregate spending information for Medicaid by major benefit categories, including managed care. The spending amounts reported by states on the CMS-64 are used to calculate their federal matching dollars.

• SEDS. The SEDS provides aggregate statistics on CHIP enrollment and child Medicaid enrollment that include the number covered under FFS and managed care systems. The SEDS is the only comprehensive source of information on managed care participation among separate CHIP enrollees across states.

Although the annual Medicaid managed care enrollment report generally contains the most recent information available from CMS on Medicaid managed care for all states, it does not provide information on many characteristics of enrollees in managed care (e.g., basis of eligibility and demographics such as age, sex, race, and ethnicity). It does provide information on whether individuals are dually eligible for Medicare. As a result, MACStats also includes statistics based on MSIS and CMS-64 data, such as the percentage of individuals enrolled in managed care by eligibility group and the percentage of Medicaid benefit spending attributable to managed care.

When examining managed care statistics from various sources, the following issues should be noted:

• Figures in the annual Medicaid managed care enrollment report published by CMS include Medicaid-expansion CHIP enrollees. Although we generally exclude these children (between 2 and 5 million, depending on the time period) from Medicaid analyses in MACStats, it is not possible to do so with CMS’s annual Medicaid managed care enrollment report data.25

• The types of managed care reported by states may differ somewhat between the Medicaid managed care enrollment report and the MSIS. For example, some states report a small number of enrollees in comprehensive risk-based managed care in one data source but not the other. Anomalies in MSIS data are documented by CMS as it reviews each



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state’s quarterly submission, but all issues may not be identified in this process.

• The Medicaid managed care enrollment report provides point-in-time figures. In contrast, MSIS data allow for reporting on the number of enrollees ever enrolled in managed care during a fiscal year or other period of time.

Endnotes1 For technical guides to earlier editions of MACStats, see MACPAC’s June reports to Congress, which are accessible through the publications page of the MACPAC website. https://www.macpac.gov/publication/.2 CMS has been collecting Medicaid and CHIP performance indicator data on key processes related to eligibility and enrollment since late 2013. In part because the new Medicaid and CHIP performance indicator enrollment data do not identify newly eligible individuals for whom there is a higher federal matching rate, CMS is using a separate process to collect monthly Medicaid enrollment by eligibility category when states submit their CMS-64 quarterly expenditures. Specifically, a new CMS-64 enrollment form has been created to accompany the current expenditure forms. Although enrollment is submitted at the same time as expenditures, there is not a direct link between the amount of federal expenditures claimed by states and the number of enrollees reported. Instead, CMS uses CMS-64 enrollment data for monitoring and oversight purposes.3 See, for example, Centers for Medicare & Medicaid Services (CMS), 2010, Medicare & Medicaid statistical supplement, 2010 edition, Brief summaries and glossary, Baltimore, MD: CMS, http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/Downloads/2010SummariesGlossary.zip. 4 States make capitated payments for all individuals enrolled in managed care plans even if no health care services are used. Therefore, all managed care enrollees currently are counted as beneficiaries or persons served, regardless of whether or not they have any health service use.5 Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2016, About the National Health Interview Survey, http://www.cdc.gov/nchs/nhis/about_nhis.htm. 6 Agency for Health Care Research and Quality, U.S. Department of Health and Human Services, 2016, Medical Expenditures Panel Survey: Survey background, http://meps.ahrq.gov/mepsweb/about_meps/survey_back.jsp. 7 Kenney, G., and V. Lynch, 2010, Monitoring children’s health insurance coverage under CHIPRA using federal surveys, in Databases for estimating health insurance coverage for children: A workshop summary, Plewes, T.J., ed., Washington, DC: The National Academies Press, http://www.nap.edu/catalog/13024.html.8 Rhoades, J.A., J.W. Cohen, and S.R. Machlin, 2010, Methodological comparison of estimates of ambulatory health care use from the Medical Expenditure Panel Survey and other data sources, in JSM Proceedings, Section on Health Policy, Alexandria, VA: American Statistical Association, 2828–2837, http://ww2.amstat.org/sections/srms/Proceedings/y2010/Files/307444_58577.pdf. 9 McPherson, M., P. Arrango, H. Fox, et al, 1998, A new definition of children with special health care needs, Pediatrics 102: 137–140.

https://www.macpac.gov/publication/

https://www.macpac.gov/publication/

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/Downloads/2010SummariesGlossary.zip



http://www.cdc.gov/nchs/nhis/about_nhis.htm

http://meps.ahrq.gov/mepsweb/about_meps/survey_back.jsp

http://meps.ahrq.gov/mepsweb/about_meps/survey_back.jsp

http://www.nap.edu/catalog/13024.html

http://ww2.amstat.org/sections/srms/Proceedings/y2010/Files/307444_58577.pdf

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10 For children under age 18 to be determined disabled under Supplemental Security Income (SSI) rules, the child must have at least one medically determinable physical or mental impairment that causes marked and severe functional limitations and that can be expected to cause death or last at least 12 months (§ 1614(a)(3)(C)(i) of the Social Security Act).11 The following conditions were identified in the most recent NHIS: attention deficit disorder; intellectual disability; other developmental delay or problems that cause difficulty with activity; other mental health condition; Down syndrome; cerebral palsy; muscular dystrophy; cystic fibrosis; sickle cell anemia; autism; diabetes; arthritis; heart disease or condition; cancer; any of the following episodes/attacks in the past 12 months: seizure, asthma, respiratory allergy, eczema or skin allergy, food or digestive allergy, anemia, frequent severe headache or migraines, or frequent diarrhea or colitis; depressed or anxious feelings most or all of the time in the past 30 days, feelings interfered with life a lot in the past 30 days; depression/anxiety/emotional problem causes difficulty with activity, difficulties with emotions/concentration/behavior/getting along; very low birth weight (less than 1500 grams) and under two years old; chronic condition that limits activity; at least one condition that causes functional limitation and is chronic; or reported fair or poor health status. 12 Limitations in ability to do things other children do include the following: any activity limitation, needs help with activities of daily living, has mobility impairment that has lasted or is expected to last more than 12 months, has any functional limitation, is blind, or has a lot of trouble with hearing ability without a hearing aid.13 Need or use of medications includes the following: took a prescription medicine for three or more months or reported unmet need for prescription medications due to cost in the past 12 months. 14 Need or use of specialized therapies includes the following: saw or talked to a therapist in the past 12 months.15 Above-routine need or use or services includes the following: has impairment or health problem that requires use of special equipment, had 10 or more visits to a health professional in the past 12 months, had two or more emergency department visits in the past 12 months, had one or more hospital stays other than for birth in the past 12 months, any homecare visits in the past 12 months, received special education or early intervention services, or reported unmet need for medical care due to cost in the past 12 months. 16 Need or receives counseling includes the following: family member seen/talked to a mental health professional concerning health of the child in the past 12 months or reported unmet need for mental health counseling due to cost in the past 12 months.17 The 2016 estimates may differ from 2015 due to changes in the conditions or criteria used to identify CSHCN. For full details on the definition of CSHCN used in MACStats editions prior to December 2015, see Medicaid and CHIP Payment and Access Commission (MACPAC), 2014, Technical guide to the June 2014 MACStats, in Report to the Congress on Medicaid and CHIP, June 2014, Washington, DC: MACPAC, https://www.macpac.gov/wp-content/uploads/2015/03/June-2014-MACStats.pdf.18 Medicaid benefit spending reported here excludes amounts for Medicaid-expansion CHIP enrollees, the territories, administrative

activities, the Vaccines for Children program (which is authorized by the Medicaid statute but operates as a separate program), and offsetting collections from third-party liability, estate, and other recoveries.19 For a discussion of these data sources, see Medicaid and CHIP Payment and Access Commission (MACPAC), 2011, Improving Medicaid and CHIP data for policy analysis and program accountability, in Report to the Congress on Medicaid and CHIP, March 2011, Washington, DC: MACPAC, –.20 Some of these amounts, including certain supplemental payments to hospitals and drug rebates, are lump sums that are not paid on a claim-by-claim basis for individual Medicaid enrollees. Nonetheless, we refer to these CMS-64 amounts as benefit spending, and the adjustment methodology described here distributes them across Medicaid enrollees with MSIS spending in the relevant service categories.21 U.S. Government Accountability Office (GAO), 2012, Medicaid: Data sets provide inconsistent picture of expenditures, Washington, DC: GAO, http://www.gao.gov/assets/650/649733.pdf; National Research Council, 2010, Administrative databases, in Databases for estimating health insurance coverage for children: A workshop summary, Plewes, T.J., ed., Washington, DC: The National Academies Press, http://www.nap.edu/catalog/13024.html.22 The sum of adjusted MSIS benefit spending amounts for all service categories totals CMS-64 benefit spending, exclusive of offsetting collections from third-party liability, estate, and other recoveries. These collections are not reported by type of service in the CMS-64 and are not reported at all in the MSIS.23 See Medicaid and CHIP Payment and Access Commission (MACPAC), 2016, Improving data as the first step to a more targeted disproportionate share hospital policy, in Report to Congress on Medicaid and CHIP, March 2016, Washington, DC: MACPAC, https://www.macpac.gov/wp-content/uploads/2016/03/Improving-Data-as-the-First-Step-to-a-More-Targeted-Disproportionate-Share-Hospital-Policy.pdf; and Centers for Medicare & Medicaid Services (CMS), 2016, Medicaid disproportionate share hospital payments, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Financing-and-Reimbursement/Medicaid-Disproportionate-Share-Hospital-DSH-Payments.html.24 For more on these payments, see Medicaid and CHIP Payment and Access Commission (MACPAC), 2015, Using Medicaid supplemental payments to drive delivery system reform, in Report to Congress on Medicaid and CHIP, June 2015, Washington, DC: MACPAC, https://www.macpac.gov/wp-content/uploads/2015/06/Using-Medicaid-Supplemental-Payments-to-Drive-Delivery-System-Reform.pdf.25 We generally exclude children enrolled in Medicaid-expansion CHIP from Medicaid analyses because their funding stream (CHIP, under Title XXI of the Social Security Act) differs from that of other Medicaid enrollees (Medicaid, under Title XIX of the Social Security Act). In addition, spending (and often enrollment) for the Medicaid-expansion CHIP population is reported by CMS in CHIP statistics along with information on separate CHIP enrollees.

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http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Financing-and-Reimbursement/Medicaid-Disproportionate-Share-Hospital-DSH-Payments.html




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