Disability and Health Journal 6 (2013) 87e94

Research Paper

National and state trends in enrollment and spending for dual eligiblesunder age 65 in Medicaid managed care

Jenna Libersky, M.P.H.*, Allison Hedley Dodd, Ph.D., M.A., and Shinu Verghese, M.S.Mathematica Policy Research, USA

www.disabilityandhealthjnl.com

Abstract

Background: To reduce costs and improve care, states are increasingly enrolling individuals with disabilities in Medicaid managedcare. Many states allow or require adults who are dually eligible for Medicaid and Medicare to enroll in these plans.

Objective: This study (1) quantifies changes in enrollment by managed care arrangement for duals under age 65, between 2005 and2008 and (2) compares enrollment and spending between dual eligibles and Medicaid-only beneficiaries.

Methods: We used Medicaid Analytic eXtract data to compare the Medicaid enrollment and spending for all-year, full-benefit dualeligibles ages 21e64 with that of Medicaid-only Supplemental Security Income (SSI) and disabled beneficiaries. The study populationwas classified into 9 types of managed care to quantify enrollment and calculate expenditures by year.

Results: Nationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid healthplans (PHPs) (31.0%e46.6%), particularly behavioral health PHPs, driving the increase. In 2008, Medicaid-only disabled adults were threetimes as likely as dual adults to enroll in comprehensive managed care (CMC) (35.1% versus 11.7%). Average Medicaid expenditures perenrollee differed markedly by managed care arrangement and state.

Conclusions: From 2005 to 2008, therewas little expansion of CMC among adult duals, while the use of PHPs to cover carved out servicesincreased greatly. New federal initiatives aim to reduce barriers to enrolling duals into comprehensive, integratedmanaged care.With expandedenrollment, itwill be important tomonitor enrollment and evaluatewhether integration improves care. � 2013Elsevier Inc.All rights reserved.

Keywords: Medicaid; Dual eligibles; Managed care; Disability

In an effort to relieve budget pressures and improve it will be important to understand the distinct enrollment

access to and quality of care, states are increasinglyenrolling individuals with disabilities in Medicaid managedcare, including those who are dually eligible for Medicaidand Medicare. As of October 2010, 25 states reportedenrolling duals in managed care arrangements (excludingPrograms of All-Inclusive Care for the Elderly, or PACE)1

with the highest Medicaid managed care penetration ratesfor duals in Delaware (89%), Arizona (65%), Oregon(47%), and Minnesota (34%).2 However, most currentnational estimates of managed care enrollment and spendingdo not differentiate between duals under and over age 65,despite their very different care needs.3 As states introducenew or expand existing managed care programs for duals,

Funding andDisclosure: This workwas funded by the Centers forMedicare

& Medicaid services under CMS Contract No. HHSM-500-2005-00025I.

Its findings were presented to the Disability Research Interest Group in con-

junction with Academy Health conference on June 23, 2012.

The authors have no conflicts of interest to report.

* Corresponding author. 1100 1st Street Northeast, Suite 1200, Wash-

ington, DC 20024, USA. Tel.: þ1 202 250 3589.

E-mail address: jlibersky@mathematica-mpr.com (J. Libersky).

1936-6574/$ - see front matter � 2013 Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.dhjo.2012.11.004

and cost trends for duals under age 65 across the range ofmanaged care arrangements in which they participate.

This study quantifies changes in enrollment by managedcare arrangement for duals under age 65 between 2005 and2008. It also compares differences in Medicaid managedcare enrollment and spending between dual eligibles andMedicaid-only beneficiaries who receive SupplementalSecurity Income (SSI) for disability, which allows for infer-ences about Medicare service use and costs not included inthis study.

Methods

We used 2005 and 2008 Medicaid Analytic eXtract(MAX) dataa to gain insight into Medicaid enrollmentand spending among full-benefit dual and non-dualdisabled adults between the ages of 21 and 64. At the time

a MAX is a set of annual, person-level data files that contain Medicaid

eligibility, service utilization, and payments derived from state reporting of

Medicaid eligibility and claims data into the Medicaid Statistical Informa-

tion System (MSIS).

88 J. Libersky et al. / Disability and Health Journal 6 (2013) 87e94

of our analysis, 2008 was the most recent year with MAXdata available for each state. We chose 2005 as a compar-ison year to (1) capture recent changes in managed careenrollment and (2) use data that were created in a structuresimilar to the 2008 files. We analyzed the experience of 2groups of disabled adults: ‘‘duals’’ and ‘‘Medicaid-only.’’The 2 study populations are similar in that they must meetessentially the same medical and functional requirementsthat determine disability, and in order to receive Medicaidbenefits, they must have the limited income and resourcesneeded to qualify for SSI. They differ in that duals alsoqualify for Medicare because they have sufficient workhistory and have had the disability at least 2 yearsb beforereceiving Medicare benefits. For 2008, duals were definedas having Medicare Eligibility Database (EDB)-confirmedfull-benefit dual status during each of the months enrolledin Medicaid. In the 2005 data, duals were defined asdisabled adults eligible for full dual benefits in each ofthe quarters they were enrolled in Medicaid andconfirmed by the EDB as a full dual in one or more quar-ters.c Full-benefit disabled adults who were never eligiblefor dual benefits during the year were classified asMedicaid-only enrollees in both years.

There are 3 models of managed care programs inMedicaid, and individuals can be enrolled in more than 1type simultaneously. First, comprehensive managed care(CMC) programs, such as Health Maintenance Organiza-tions (HMO) and Health Insuring Organizations (HIO),provide a broad range of health care services to enrollees,although some specialized services can be carved out ofthe plan. Second, prepaid health plans (PHPs) usuallyprovide a limited or specialized set of services, such asbehavioral health, dental care, long-term care, or otherservices, like prenatal care and transportation. In a thirdtype, Primary Care Case Management (PCCM), enrolleesreceive regular care from a primary care provider who isdesignated to manage that person’s care and must obtaina referral for specialty services. In the first two arrange-ments, states make monthly capitated payments for eachenrollee, regardless of the level of service use. However,for enrollees in PCCMs, services are paid on a fee-for-service (FFS) basis and a monthly case management feeis paid on capitation.

We used a hierarchical approach to classify the studypopulation into 4 managed care service types: (1) CMC;(2) PHP only (no CMC); (3) PCCM only and (4) FFS only(no managed care). Because behavioral health PHPs werethe most prevalent among the disabled population, wegrouped those enrollees together, regardless of other PHPparticipation. Given recent interest in expanding this type

b Shorter waiting periods apply for individuals with end-stage renal

disease, terminal illness, or amyotrophic lateral sclerosis (ALS).c In 2005, dual status was reported quarterly, not monthly, in both

MAX and MSIS.

of managed care arrangement, individuals with long-termcare PHP enrollment but no behavioral health PHP enroll-ment were grouped together, regardless of their enrollmentin other non-behavioral health PHPs. This resulted in 9mutually-exclusive arrangements: (1) CMC only (no PHPenrollment); (2) behavioral health PHP with CMC (withor without other PHPs); (3) long-term care PHP withCMC (with or without other PHPs); (4) other PHP withCMC; (5) behavioral health PHP without CMC (with orwithout other PHPs); (6) long-term care PHP withoutCMC (with or without other PHPs); (7) other PHP withoutCMC; (8) PCCM only; and (9) FFS only.

We used these categories to quantify enrollment andcalculate total and average Medicaid expenditures by year.Analyses were conducted using SAS 9.1. Because themajor focus of the study was to examine managed carearrangements for adult duals, we compare 2008 adult dualsto: (1) 2005 adult duals, to capture changes in managedcare arrangements and (2) 2008 Medicaid-only disabledadults, to capture differences between dual and non-dualdisabled adults. Although we adjusted spending formember months of enrollment, we chose to present theannual averages only because the trends were similarbetween the two estimates.

Results

Demographics

While adult duals, as defined by this study, are only 4%of all Medicaid beneficiaries nationwide, their population issizeabled2,468,266 in 2008, up from 2,439,026 enrolleesin 2005 (Table 1). Most adult duals are between the agesof 45 and 64 (63.1% in 2008) and are White (61.0%) orAfrican American (21.4%). The Medicaid-only disabledadult group is similar, though slightly younger (58.1% areaged 45e64). Females and minorities make up a largershare of the Medicaid-only disabled adult population thanthat of adult duals. Though there is some variation, similartrends are seen across states (not shown).

Enrollment

Nationwide, the proportion of adult duals in some typeof managed care arrangement (i.e., not in FFS only)increased from 37.3% in 2005 to 51.4% in 2008(Table 2), resulting in more than 360,000 more duals inmanaged care compared to 2005. While there was littlechange in enrollment in CMC only or PCCM only, theuse of PHPs to provide services increased greatly between2005 and 2008. In 2008, nearly half of adult duals(46.6%) were enrolled in a PHP, either with or withoutCMC, compared to 31.0% PHP enrollment in 2005. Theincrease in the use of behavioral health PHPs is particu-larly notable with nearly one quarter (22.4%) of 2008adult duals enrolled in a behavioral health PHP (with orwithout CMC) by 2008.

Table 1

Demographics of adult duals in 2005 and 2008, and Medicaid-only disabled adults in 2008

Nationwide

2005 2008 2008

Percentage of adult

duals (N 5 2,439,026)

Percentage of adult

duals (N 5 2,468,266)

Percentage of Medicaid-only

disabled adults (N 5 2,924,290)

Age (%)

21e44 39.2 36.9 41.9

45e64 60.8 63.1 58.1

Sex (%)

Male 49.4 48.6 43.9

Female 50.6 51.4 56.1

Race or ethnicity (%)

White 62.0 61.0 49.1

Black or African American 21.0 21.4 27.6

American Indian or Alaskan Native 0.8 0.9 1.2

Asian 0.8 0.9 1.5

Hispanic or Latino 6.1 6.4 8.1

Native Hawaiian or Other Pacific Islander 0.5 0.6 1.4

More than 1 race 1.3 1.8 2.5

Missing race 7.5 6.9 8.7

89J. Libersky et al. / Disability and Health Journal 6 (2013) 87e94

In 2008, managed care programs were used more oftento provide services to the Medicaid-only disabled adultsthan to adult duals (Table 2). Less than 20% ofMedicaid-only disabled adults were enrolled in FFS only(17.0%) compared to nearly 49% of dual adults. BothCMC programs (35.1% versus 11.7%) and PCCM Only(10.5% versus 1.6%) were more common amongMedicaid-only disabled adults than among adult duals.Enrollment among the Medicaid-only disabled adults inbehavioral health PHPs (both with and without CMC)was similar to that of adult duals, although theMedicaid-only disabled adults were more likely to beenrolled in a CMC as well.

Between 2005 and 2008, the number of states thatoffered managed care increased in 4 of the 8 managed care

Table 2

Total expenditures and enrollment by type of managed care service arrangement f

Nationwide

Total expenditures ($)

CMC only or with PHP

CMC only (%)

Behavioral health PHP with CMC (with or without other PHP) (%)

Long-term care PHP with CMC (with or without other PHP) (%)

Other PHP with CMC (%)

PHP with no CMC

Behavioral health PHP without CMC (with or without other PHP) (%)

Long-term care PHP without CMC (with or without other PHP) (%)

Other PHP without CMC (%)

PCCM only (%)

FFS only (%)

Notes: comprehensive managed care (CMC) 5 HMO/HIO or PACE; PCCM 5

behavioral or long-term care plans; other PHP includes managed dental, manage

only contain enrollment and prescription drug claims for Maine, so the state has

arrangement types (Fig. 1). The number of states with morethan 10% of adult duals enrolled in a managed carearrangement increased over this period in 3 arrangements:behavioral health, long-term care, and other PHP, allwithout simultaneous enrollment in a CMC.

Fig. 1 shows that the increase in the number of enroll-ees in behavioral health PHPs was due to greater enroll-ment of duals within each state in such plans, as well asan increase in the number of states offering theseprograms. For example, not only did the number of stateswith more than 1% of enrollees in a behavioral healthPHP without CMC increase from 14 in 2005 to 15 in2008, the number of states with more than 50% of adultduals enrolled in such plans also increased. Also of noteis the increased enrollment in long-term care PHPs

or adult duals in 2005 and 2008, and Medicaid-only disabled adults in 2008

2005 2008 2008

Adult duals

(N 5 2,439,026)

Adult duals

(N 5 2,468,266)

Medicaid-only disabled

adults (N 5 2,924,290)

38,410,417,165 34,280,359,182 47,277,918,647

10.6 11.7 35.1

3.3 3.2 17.5

4.7 5.4 12.9

O0.0 O0.0 O0.0

2.6 3.1 4.7

23.7 38.1 37.6

9.2 17.0 12.3

0.4 0.8 0.3

14.1 20.3 24.9

3.0 1.6 10.5

62.7 48.6 17.0

Primary Care Case Management; PHP 5 prepaid health plan, including

d prenatal, and other managed care plans as identified in MSIS. MAX files

been excluded from calculations of total and average expenditures.

Fig. 1. Number of states with O1% of all-year full duals age 21e64 enrolled in each managed care arrangement type in 2005 and 2008.

90 J. Libersky et al. / Disability and Health Journal 6 (2013) 87e94

without CMC, with 3 states enrolling 10e49% of duals in2008 compared to 1 state offering the arrangement to10e49% of duals in 2005.

At the same time, the prevalence of some managed carearrangements decreased from 2005 to 2008, with 6 fewerstates having more than 1% of adult duals enrolled inPCCM only and 3 fewer having more than 1% of adultduals enrolled in CMC only in 2008.

Expenditures

Medicaid expenditures for adult duals were significant,totaling about $34 billion nationwide in 2008 (Table 2),and accounting for 12% of total Medicaid spending forall full-benefit enrollees (not shown). Total Medicaidexpenditures are comprised of capitation and FFS paymentsfor all types of services, including inpatient care, long-termcare, behavioral health, prescription drugs, acute care, andother services. The average annual amount paid per dualvaried by managed care arrangement, with long-term carePHPs with CMC and without CMC having the highestaverage costs ($29,660 and $24,215, respectively;Table 3). Most of the costs in both arrangements were paidthrough capitation (85.4% for long-term care with CMC,and 86.7% for long-term care without CMC), though a verysmall number of adult duals (!0.03% in 4 states) wereenrolled in these arrangements (data not shown).

Behavioral health PHPs with CMC and CMC only hadthe lowest average costs paid among the adult duals($6664 and $7529, respectively). Here, capitation paymentsaccounted for 43.7 and 48.0% of total average costs,respectively. Across CMC arrangements (only or withPHP), an average of 56.2% of total expenditures were paidthrough capitation (not shown).

Average Medicaid expenditures for adult duals weregenerally lower than those of the Medicaid-only disabledadults, although a few managed care categories had mark-edly higher average expenditures for Medicaid-onlydisabled adults (CMC only, behavioral health PHP withCMC, and long-term care PHP without CMC) withaverage expenditures for duals less than half of thosefor the Medicaid-only disabled adults. The percentageof average total expenditures paid through capitationwas similar between the 2 populations for most managedcare arrangements, with the exception of behavioralhealth PHP and long-term care PHPs with CMC. Forbehavioral health PHP with CMC, the portion of totalaverage expenditures from capitation payments was lowerfor adult duals (43.7%) than for Medicaid-only disabledadults (71.6%), while for long-term care PHP withCMC, the portion from capitation payments was higher(85.4% versus 49.3%).

The difference in costs between adult duals and theMedicaid-only disabled was likely due to services that

Table 3

Average Medicaid expenditures by managed care service arrangement type for adult duals age 21e64 and Medicaid-only disabled adults in 2008

Number of states

with O0% enrollment

in service type

Average annual Medicaid expenditures

Adult duals Medicaid-only disabled adults

Total ($) Capitation (%) FFS (%) Total ($) Capitation (%) FFS (%)

CMC only 31 7529 48.0 52.0 15,107 52.1 47.9

Behavioral health PHP with CMC (with or

without other PHPs)

14 6664 43.7 56.3 13,619 71.6 28.4

Long-term care PHP with CMC (with or

without other PHPs)

4 29,660 85.4 14.6 47,597 49.3 50.7

Other PHP with CMC 12 12,032 47.7 52.3 11,893 46.3 53.7

Behavioral health PHP without CMC (with or

without other PHPs)

18 8051 18.4 81.6 14,053 10.0 90.0

Long-term care PHP without CMC (with or

without other PHPs)

5 24,215 86.7 13.3 51,227 75.8 24.2

Other PHP without CMC 20 9870 1.1 98.9 13,894 2.5 97.5

PCCM only 22 8097 0.8 99.2 12,506 0.5 99.5

FFS only 47 19,373 0.1 99.9 27,441 0.2 99.8

Notes: comprehensive managed care (CMC) 5 HMO/HIO or PACE; PCCM 5 Primary Care Case Management; PHP 5 prepaid health plan, including

behavioral or long-term care plans; other PHP includes managed dental, managed prenatal, and other managed care plans as identified in MSIS. MAX files

only contain enrollment and prescription drug claims for Maine, so the state has been excluded from calculations of total and average expenditures.

Source: MAX 2008.

91J. Libersky et al. / Disability and Health Journal 6 (2013) 87e94

Medicare covered for the dual enrollees, namely inpatient,outpatient, post-acute (e.g., skilled nursing facilities), andprescription drug claims. Although capitation payments toPHP and CMC plans would likely reflect this difference inbenefits covered by Medicaid and Medicare, we did nothave verifying information. Therefore, we compared theaverage 2008 FFS expenditures for PCCM only and FFSonly, which are comprised almost entirely of FFSpayments, by claim type, to identify which servicesaccounted for differences in total expenditures (Table 4).For PCCM only and FFS only, the average expenditures

Table 4

Average fee-for-service (FFS) Medicaid expenditures in 2008 for adult

duals and Medicaid-only disabled adults for PCCM only or FFS only

enrollees

Nationwide

Average Medicaid expenditures ($)

PCCM only FFS only

Adult

duals

Medicaid-only

disabled adults

Adult

duals

Medicaid-only

disabled adults

Total FFS e all

types of service

8033 12,449 19,355 27,374

Inpatient hospital 2182 13,423 2198 21,286

Institutional

long-term care

22,117 13,654 68,919 82,476

Prescribed drugs 661 4049 224 5593

All other services 7672 6868 13,010 14,385

Note: Institutional long-term care includes mental hospital services for the

aged, inpatient psychiatric facility services for individuals under the age of

21, intermediate care facility services for the mentally retarded, and all

other nursing facility services. All other services includes those not

counted in other categories, like durable medical equipment, home- and

community-based services, personal care, transportation, and home health

care. MAX files only contain enrollment and prescription drug claims for

Maine, so the state has been excluded from calculations of total and

average expenditures.

Source: MAX 2008.

for both inpatient hospital and prescription drug costsamong adult duals are only a fraction of those forMedicaid-only disabled adults (for example, $2198 versus$21,286 for FFS only 2008 inpatient hospital averageexpenditures). For institutional long-term care, theaverage FFS cost for adult duals is higher than those forthe Medicaid-only group in PCCM only ($22,117compared to $13,654), but lower in the FFS only group($68,919 compared to $82,476). Average FFS costs forall other types of services were roughly similar for adultduals and Medicaid-only disabled adults in both thePCCM only and FFS only arrangements.

While the national averages give us insight into differ-ences in costs between adult duals and Medicaid-onlydisabled adults, there is a great deal of variation in averageMedicaid expenditures across states within each type ofmanaged care arrangement. Table 5 illustrates the stateswith the highest and lowest costs for each type of managedcare arrangement among states that had more than 1% ofadult duals enrolled in a given managed care arrangement.The greatest range in the 2008 average expenditure was forPHPs without CMC. Behavioral health PHP without CMChad the largest range, from $38,191 in Georgia to $3375 inHawaii. In contrast, PHPs with CMC had more narrowranges in cost, with the lowest range for behavioral healthPHP with CMC (from $10,258 in Colorado to $3672 inTexas). There was also a great deal of variation in CMC on-ly arrangements due largely to differences in the types ofservices covered. For example, Minnesota’s CMC onlyprogram, Disability Health Options, had the highestaverage Medicaid expenditures ($24,282) because itcovered Medicaid-funded acute and long-term careservices, including extensive home- and community-basedwaiver services and nursing facility care for up to 180 daysthrough a Medicare Advantage Special Needs Plan. In

Table 5

Top 3 and bottom 3 average Medicaid expenditures for states with O1% enrollment of adult duals in 2008 by managed care service arrangement type

Service arrangement

United

States

No. of states

with O1%

enrolled Top 3 Bottom 3

CMC only State e e Minnesota Maryland New Jersey Indiana Rhode Island Florida

Avg ($) 7529 13 24,282 14,457 13,754 3688 3260 2863

Behavioral health PHP with CMC

(with or without other PHPs)

State e e Colorado Oregon Tennessee Pennsylvania Arizona Texas

Avg ($) 6664 7 10,258 9526 8183 6498 3727 3672

Long-term care PHP with CMC

(with or without other PHPs)

State e e e e e e e e

Avg ($) 29,659 0 e e e e e e

Other PHP with CMC State e e California Delaware Kentucky e e eAvg ($) 12,041 3 13,067 3723 3094 e e e

Behavioral health PHP without CMC

(with or without other PHPs)

State e e Georgia Arizona Colorado Nebraska Pennsylvania Hawaii

Avg ($) 8051 15 38,191 37,713 17,196 4558 4497 3375

Long-term care PHP without CMC

(with or without other PHPs)

State e e Arizona Wisconsin New Mexico e e eAvg ($) 24,215 3 37,458 22,402 5,614 e e e

Other PHP without CMC State e e DC Delaware Utah Alabama Florida Wisconsin

Avg ($) 9870 16 31,329 26,176 25,983 4432 3167 2847

PCCM only State e e Idaho Indiana Vermont Louisiana Illinois Texas

Avg ($) 8097 8 13,198 10,731 7622 6280 5353 2726

FFS only State e e DC Iowa Pennsylvania Alabama Wisconsin Nevada

Avg ($) 19,373 41 113,616 113,027 67,811 7860 6770 3300

Note: MAX files only contain enrollment and prescription drug claims for Maine, so the state has been excluded from calculations of total and average

expenditures.

Source: MAX 2008.

92 J. Libersky et al. / Disability and Health Journal 6 (2013) 87e94

contrast, the next highest spending state in that category(Maryland) covered many Medicaid-covered services butdid not cover specialty mental health, personal care, andlong-term care after 30 days in its CMC only program(HealthChoice).

Discussion

The proportion of Medicaid-only disabled adultsenrolled in comprehensive managed care programs in2008 (35.1%) was more than three times greater than thatamong dual enrollees (11.7%). This trend was driven, atleast in part, by research indicating that risk-basedmanaged care can improve care and control costs foradults with disabilities. If programs are structured,financed, and implemented well,4 managed care canreduce preventable hospitalizations,5 increase access toservices,6 and improve quality of care and patientsatisfaction.7,8

Enrollment in Medicaid managed care for adult dualsgrew from 2005 to 2008, but most of the growth occurredin PHPs without CMC. This is unlikely to lead to bettercare, more coordinated care, or cost control because PHPplans divide covered benefits into separate Medicaidmanaged care contracts or carve out many services paidon a FFS basis. Because the services covered by eachPHP differ, there was also significant variation in annualcosts per enrollee across states.

Since 2008, states have begun to contract with managedcare plans for an expanded array of services for duals en-rollees. Only 3 states operated long-term care PHPs in2008, but by October 2010, 11 states had started managed

long-term care programs, with aggregate enrollmentexceeding 400,000. Moreover, several states that had previ-ously carved out pharmacy benefits, behavioral health, orother Medicaid services had begun to carve the benefitsback into their managed care contracts.1

To ensure better coordination of care and lower total costsfor duals, however, managed care plans must coordinatebenefits across Medicare and Medicaid. By receiving capi-tated payments for the full set of Medicare and Medicaidservices, managed care plans have no need to shift costsfrom one payer to another as often occurs in FFS care9 andhave more incentive to reduce duplicate or unnecessaryservices and deliver care in the least costly setting.

The 2010 Affordable Care Act (ACA) included a numberof provisions designed to promote integration of Medicareand Medicaid benefits and services for duals throughimproved care quality, service coordination, and increasedaccess to home- and community-based long-term servicesand supports. For example, the Financial Alignment Initia-tives, also known as ‘‘dual demonstrations,’’ will allowstates to test two delivery system models that integrateMedicare and Medicaid financing and operations; up to 2million duals are expected to participate in these demon-strations. As of September 2012, 26 states have submittedproposals, a handful of which are scheduled to enroll bene-ficiaries as early as 2013. To support the demonstrations,CMS is also making Medicare Parts A, B, and D data forduals available to states for use in coordinating care.10

While the impact of the demonstrations is not yet known,they hold promise for more integrated systems of care foradult duals.

93J. Libersky et al. / Disability and Health Journal 6 (2013) 87e94

Limitations

This analysis was unable to examine total spending forduals due to the lack of linked Medicare data; consequently,we could not assess whether total Medicare and Medicaidcosts are affected by different Medicaid managed carearrangements for duals across states.d Second, we cannotexplain all of the reasons for cross-state variation inmanaged care program costs using Medicaid claims alone.Differences in total state costs may reflect different benefitsincluded in managed care plans of the same type, variationin how capitation rates are set for the same types ofservices, differences in the amount of services providedwithin a plan, or differences in the quality and complete-ness of claims data submitted for managed care enrollees.e

Understanding the reasons for differences in state costs willrequire in-depth analysis of state managed care programs toexamine the amount or type of services covered under capi-tation payments, analysis of the quality of capitation data,and analysis of encounter data on the services that are actu-ally provided.11 In addition, costs by managed care arrange-ment type may also differ due to the way state statesclassify plans in the data. For example, some behavioralhealth PHPs may look more like CMC plans in the rangeof services covered but the state classifies the plan asa PHP because it contains a behavioral health component.The variety in the types of PHPs classified as ‘‘other’’ alsomakes it difficult to compare data across states.12

Conclusion

From 2005 to 2008, the number of states with managedcare programs for adult duals increased, as did thepercentage of duals enrolled in these programs within

d Using a linked dataset that became available more recently, Bubolz,

et al. 2012, found that for dual beneficiaries under age 65, Medicare expen-

ditures appeared to substitute for Medicaid expenditures. ‘‘States with

lower rates of Medicaid spending experienced higher rates of Medicare

expenditures, and vice versa.’’ While the study did not examine all the

reasons for this finding, they cited a lack of evidence ‘‘that variations in

the proportion of patients enrolled in managed care programs across states

was systematically associated with per capita state-level Medicare or

Medicaid expenditures.’’ Thomas B,, Emerson C, and Skinner J, Shifting

From Medicaid To Medicare: State Spending On Dual Eligibles Under

Age 65 Shows Variations, Evidence Of Cost, Health Aff (Millwood).

2012; 31(5):939e947.e As required by the Balanced Budget Act of 1997, states submit quar-

terly eligibility and claims program data to CMS through the Medicaid

Statistical Information System (MSIS), which is used to construct MAX.

States are more likely to submit capitated payment data for CMC enrollees

than PHP enrollees. In 2008, 86.0% of states with CMC enrollees

submitted capitation data for more than 90 percent of their CMC enrollees,

while 11.6% of states submitted no capitation data. Among states with

PHP enrollees, 64.7% of states submitted capitation data for more than

90 percent of their PHP enrollees, while 17.6% of states submitted no capi-

tation data. Borck R, Dodd A, Zlatinov A, Verghese S, Malsberger R, Pet-

roski C. The Medicaid Analytic eXtract 2008 Chartbook. Baltimore, MD:

Centers for Medicare & Medicaid Services; 2012. 14.

states. However, this trend did not result in expandeduse of CMC among adult duals. With over one-third ofMedicaid-only disabled adults enrolled in CMC programs(CMC only or with PHP), states are clearly interested inusing managed care to contain costs and improve servicedelivery for adults with disabilities. However, untilrecently federal Medicare rules have given states littleincentive, and in some cases prohibited them, fromenrolling adult duals into comprehensive managed careplans. To encourage greater integration of care for duals,new federal initiatives aim to reduce barriers that havemade it difficult for states to enroll duals into comprehen-sive managed care. As more dual enrollees are enrolled inmanaged care plans, it will be important to monitor thetypes of managed care programs in which adult dualsare enrolled and evaluate the degree to which they canintegrate care and reduce costs.

Acknowledgments

The authors would like to thank Cara Petroski of theCenters for Medicare & Medicaid Services (CMS) for hersupport. At Mathematica, we also thank Julie Sykes forher guidance and encouragement. In addition, we thank De-bra Lipson, Jim Verdier, and Catherine Desroches forproviding helpful comments on drafts.

References

1. Gifford K, Smith V, Snipes D, Paradise J. A Profile of Medicaid

Managed Care Programs in 2010: Findings from a 50-State Survey.

Washington, DC: Kaiser Commission on Medicaid and the Uninsured;

2011 Sep.

2. Verdier J. Including Medicare-Medicaid dual eligibles in managed

care: current status and future prospects. In: Paper presented at World

Congress 6th Annual Leadership Summit on Medicare, 2010 Jul 20,

Washington, DC.

3. Kasper J, Watts M, Lyons B. Chronic Disease and Co-Morbidity

Among Dual Eligibles: Implications and Patterns of Medicaid and

Medicare Service Use and Spending. Washington, DC: Kaiser Family

Foundation; 2010 Jul.

4. Highsmith N, Somers S. Adults with Disabilities in Medi-Cal

Managed Care: Lessons from Other States. Oakland, CA: Medi-Cal

Policy Institute; 2003 Sep.

5. Bindman A, Chattopadhyay A, Osmond D, Huen W, Bacchetti P. Pre-

venting Unnecessary Hospitalizations in Medi-Cal: Comparing Fee-

for-Service with Managed Care. San Francisco, CA: California

Healthcare Foundation; 2004 Feb.

6. Coughlin TA, Long SK, Graves JA. Does managed care improve

access to care for Medicaid beneficiaries with disabilities? A national

study. Inquiry. 2008e2009 Winter;45(4):395e407.

7. Palsbo SE, Ho PS. Consumer evaluation of a disability care coordina-

tion organization. J Health Care Poor Underserved. 2007 Nov;18(4):

887e901.

8. Hill SC, Wooldridge J. Informed participation in TennCare by people

with disabilities. J Health Care Poor Underserved. 2006 Nov;17(4):

851e875.9. Grabowski C. Medicare and Medicaid: conflicting incentives for long-

term care. Milbank Q. 2007;85(4):579e610.

10. CMS Medicare-Medicaid Coordination Office. Access to Medicare

Data to Coordinate Care for Dual Eligible Beneficiaries. Baltimore,

94 J. Libersky et al. / Disability and Health Journal 6 (2013) 87e94

MD: Center for Medicaid, CHIP and Survey & Certification Informa-

tional Bulletin; 2011 May 11.

11. Dodd A, Nysenbaum J, Zlatinov A. Assessing the Usability of the

MAX 2007 Inpatient and Prescription Encounter Data for Enrollees

in Comprehensive Managed Care. CMS Medicaid Policy Brief 5.

Washington, DC: Mathematica Policy Research; 2012 Apr. Service

use for CMC and PHPs is captured in encounter data, which are claims

records that contain utilization but no Medicaid expenditure

information. While states have not submitted encounter data as consis-

tently as FFS data, an initial review of this data showed that for many

states it appears to be usable.

12. Refer to the MAX anomaly tables for a description of other PHPs in

each state. The tables are available from the CMS Medicaid Analytic

eXtract (MAX) General Information site at https://www.cms.gov/

Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/

MedicaidDataSourcesGenInfo/MAXGeneralInformation.html.