Business Intelligence Unit Medicaid Data Analytics
Winter 2016
Quarterly Statewide Medicaid Managed Care Report
Rick Scott, Governor Justin M. Senior, Secretary
Agency for Health Care Administration
Analyzing the Disease Burden of Florida
Medicaid Enrollees Using Clinical Risk Groups
i
Table of Contents List of Figures ................................................................................................................................................ ii
List of Tables ................................................................................................................................................. v
Executive Summary ...................................................................................................................................... vi
Data Sources ............................................................................................................................................. 2
Disease Classifications .............................................................................................................................. 5
Health of the Medicaid Population ............................................................................................................... 6
Top Illnesses of the Medicaid Population ................................................................................................... 13
Overall ..................................................................................................................................................... 13
SSI and Family ......................................................................................................................................... 14
By Age ..................................................................................................................................................... 15
By Sex ...................................................................................................................................................... 18
By MMA Plan ........................................................................................................................................... 19
Top Illnesses by Health Status .................................................................................................................... 26
Health Status 9-Catastrophic Conditions ................................................................................................ 27
Health Status 8-Dominant, Metastatic or Complicated Malignancies ................................................... 31
Health Status 7-Dominant Chronic Disease in Three or More Organ Systems ...................................... 35
Health Status 6-Significant Chronic Disease in Multiple Organ Systems ................................................ 40
Health Status 5-Single Dominant or Moderate Chronic Disease ............................................................ 44
Health Status 4-Minor Chronic Disease in Multiple Organ Systems ....................................................... 50
Health Status 3-Single Minor Chronic Disease ........................................................................................ 54
Health Status 2-Recent History of Significant Acute Illness .................................................................... 58
Conclusions ................................................................................................................................................. 62
ii
List of Figures
Figure 1: Percentage of Medicaid Recipients Categorized as Healthy Compared to Any of the Other Eight
Health Statuses, August 2014-July 2015 .............................................................................................. 6
Figure 2: Percentage of Medicaid Population Classified in a Non-Healthy Status by Health Status, August
2014-July 2015 ...................................................................................................................................... 6
Figure 3: Percentage of Medicaid Population in the Family-Related Eligibility Group as Compared to the
SSI-Related Eligibility Group, August 2014-July 2015 ........................................................................... 7
Figure 4: Percentage of SSI-Related Eligibility Group and Family-Related Eligibility Group in the Healthy
Category as Compared to One of the Other Eight Health Statuses, August 2014-July 2015 ............... 7
Figure 5: Distribution of Medicaid Population by Age and Eligibility Group, August 2014-July 2015 .................. 7
Figure 6: Percentage of Age Groups Classified as Healthy, August 2014-July 2015 ............................................. 8
Figure 7: Percentage of Age and Eligibility Groups Classified as Healthy, August 2014-July 2015 ...................... 8
Figure 8: Percentage of Females and Males Classified as Healthy, August 2014-July 2015 ................................. 9
Figure 9: Percentage of Medicaid Population by Gender, August 2014 -July 2015 ............................................. 9
Figure 10: Percentage of Medicaid Population in Standard Plan, Specialty Plan, and FFS, August 2014-July
2015 .................................................................................................................................................... 9
Figure 11: Percentage of Specialty Plan Enrollees Classified as Healthy, August 2014-July 2015 ..................... 10
Figure 12: Number of Enrollees in a Specialty Plan, August 2014-July 2015 ..................................................... 10
Figure 13: Percentage of Standard Plan Enrollees Classified as Healthy, August 2014-July 2015 ..................... 11
Figure 14: Number of Enrollees in a Standard Plan, August 2014-July 2015 ..................................................... 11
Figure 15: Percentage of Regions’ Recipients with a Healthy Status, August 2014-July 2015 .......................... 12
Figure 16: Top 10 Non-Healthy CRGs for the Medicaid Population, August 2014-July 2015 ............................ 13
Figure 17: Top 10 Illnesses of the Medicaid Population by Eligibility Group, August 2014-July 2015 .............. 14
Figure 18: Top 10 Illnesses of the Medicaid Population from Birth to 20, August 2014-July 2015 ................... 15
Figure 19: Top 10 Illnesses of the Medicaid Population Twenty-one Years of Age or Over, August 2014-
July 2015 ........................................................................................................................................... 16
Figure 20: Top 10 Illnesses of the Medicaid Population by Sex, August 2014-July 2015 .................................. 18
Figure 21: Top 10 Illnesses of the Fee-for-Service and MMA Populations, August 2014-July 2015.................. 19
Figure 22: Top 10 Illnesses of Standard Plan Enrollees, August 2014-July 2015 ............................................... 20
Figure 23: Top 10 Illnesses of HIV/AIDS Specialty Plan Enrollees, August 2014-July 2015 ............................... 22
Figure 24: Top 10 Illnesses of Children’s Specialty Plan Enrollees, August 2014-July 2015 .............................. 23
Figure 25: Top 10 Illnesses of Severe Mental Illness Specialty Plan Enrollees, August 2014-July 2015 ............ 24
Figure 26: Top 5 Illnesses by Region, August 2014-July 2015 ............................................................................ 25
Figure 27: Percentage of Medicaid Population Classified in a Non-Healthy Status by Health Status,
August 2014-July 2015 ...................................................................................................................... 26
Figure 28: Number of Recipients with Health Status 9 by CRG and Level of Severity, August 2014-July
2015 .................................................................................................................................................. 27
Figure 29: Top Catastrophic Conditions Compared to All Other Conditions, August 2014-July 2015 ............... 27
Figure 30: Percentage of Eligibility Groups with a Catastrophic Condition, August 2014-July 2015 ................. 28
Figure 31: Percentage of Age Groups with a Catastrophic Condition, August 2014-July 2015 ......................... 28
iii Figure 32: Percentage of Females and Males with a Catastrophic Condition, August 2014-July 2015 ............. 28
Figure 33: Percentage of Specialty Plan Enrollee Months with a Catastrophic Condition, August 2014-
July 2015 ........................................................................................................................................... 29
Figure 34: Percentage of Standard Plan Enrollee Months with a Catastrophic Condition, August 2014-
July 2015 ........................................................................................................................................... 29
Figure 35: Percentage of Regions’ Recipients with a Catastrophic Condition, August 2014-July 2015 ............ 30
Figure 36: Number of Recipients with Health Status 8 by CRG and Level of Severity, August 2014-July
2015 .................................................................................................................................................. 31
Figure 37: Top Malignancy Compared to All Other Illnesses, August 2014-July 2015....................................... 31
Figure 38: Percentage of Eligibility Groups with a Malignancy, August 2014-July 2015 ................................... 32
Figure 39: Percentage of Age Groups with a Malignancy, August 2014-July 2015 ........................................... 32
Figure 40: Percentage of Females and Males with a Malignancy, August 2014-July 2015 ............................... 32
Figure 41: Percentage of Specialty Plan Enrollee Months with a Malignancy, August 2014-July 2015 ............ 33
Figure 42: Percentage of Standard Plan Enrollee Months with a Malignancy, August 2014-July 2015 ............ 33
Figure 43: Percentage of Regions’ Population with Malignancies, August 2014-July 2015 .............................. 34
Figure 44: Number of Recipients with Health Status 7 by CRG and Level of Severity, August 2014-July
2015 .................................................................................................................................................. 35
Figure 45: Top Dominant Chronic Disease in Three or More Organ Systems Compared to All Other
Illnesses, August 2014-July 2015 ...................................................................................................... 35
Figure 46: Top 10 Individual Diseases, August 2014-July 2015 ......................................................................... 36
Figure 47: Percentage of Eligibility Groups with a Dominant Chronic Disease in 3 or More Organ
Systems, August 2014-July 2015 ....................................................................................................... 37
Figure 48: Percentage of Age Groups with a Dominant Chronic Disease in 3 or More Organ Systems,
August 2014-July 2015 ...................................................................................................................... 37
Figure 49: Percentage of Females and Males with a Dominant Chronic Disease in 3 or More Organ
Systems, August 2014-July 2015 ....................................................................................................... 37
Figure 50: Percentage of Specialty Plan Enrollee Months with a Dominant Chronic Disease in 3 or More
Organ Systems, August 2014-July 2015 ............................................................................................ 38
Figure 51: Percentage of Standard Plan Enrollee Months with a Dominant Chronic Disease in 3 or More
Organ Systems, August 2014-July 2015 ............................................................................................ 38
Figure 52: Percentage of Regions’ Population with a Dominant Chronic Disease in 3 or More Organ
Systems Status, August 2014-July 2015 ............................................................................................ 39
Figure 53: Number of Recipients with Significant Chronic Disease in Multiple Organ Systems by CRG and
Level of Severity, August 2014-July 2015.......................................................................................... 40
Figure 54: Top Significant Chronic Diseases in Multiple Organ Systems Compared to All Other Illnesses,
August 2014-July 2015 ...................................................................................................................... 40
Figure 55: Top 10 Individual Chronic Diseases, August 2014-July 2015 ............................................................ 41
Figure 56: Percentage of Eligibility Groups with Significant Chronic Disease in Multiple Organ Systems,
August 2014-July 2015 ...................................................................................................................... 42
Figure 57: Percentage of Age Groups with Significant Chronic Disease in Multiple Organ Systems, August
2014-July 2015 .................................................................................................................................. 42
iv
Figure 58: Percentage of Females and Males with Significant Chronic Disease in Multiple Organ Systems,
August 2014-July 2015 ...................................................................................................................... 42
Figure 59: Percentage of Specialty Plan Enrollee Months with Significant Chronic Disease in Multiple
Organ Systems, August 2014-July 2015 ............................................................................................ 43
Figure 60: Percentage of Standard Plan Enrollee Months with a Significant Chronic Disease in Multiple
Organ Systems, August 2014-July 2015 ............................................................................................ 43
Figure 61: Percentage of Regions’ Population with a Significant Chronic Disease in Multiple Organ
Systems, August 2014-July 2015 ....................................................................................................... 44
Figure 62: Number of Recipients with Health Status 5 by CRG and Level of Severity, August 2014-July
2015 .................................................................................................................................................. 45
Figure 63: Top Dominant Chronic Disease Compared to All Other Illnesses, August 2014-July 2015 .............. 45
Figure 64: Percentage of Eligibility Groups with Single Dominant or Moderate Chronic Disease, August
2014-July 2015 .................................................................................................................................. 46
Figure 65: Percentage of Age Groups with a Single Dominant or Moderate Chronic Disease, August
2014-July 2015 .................................................................................................................................. 46
Figure 66: Percentage of Females and Males with a Single Dominant or Moderate Chronic Disease,
August 2014-July 2015 ...................................................................................................................... 46
Figure 67: Percentage of Specialty Plan Enrollee Months with a Single Dominant or Moderate Chronic
Disease, August 2014-July 2015 ........................................................................................................ 47
Figure 68: Percentage of Standard Plan Enrollee Months with a Single Dominant or Moderate Chronic
Disease, August 2014-July 2015 ........................................................................................................ 47
Figure 69: Percentage of Regions’ Population with a Single Dominant or Moderate Chronic Disease,
August 2014-July 2015 ...................................................................................................................... 48
Figure 70: Top 10 Chronic Diseases Across Health Statuses 5, 6, and 7, August 2014-July 2015...................... 49
Figure 71: Number of Recipients with Health Status 4 by CRG and Level of Severity, August 2014-July
2015 .................................................................................................................................................. 50
Figure 72: Percentage of Eligibility Groups with Minor Chronic Disease in Multiple Organ Systems,
August 2014-July 2015 ...................................................................................................................... 51
Figure 73: Percentage of Age Groups with Minor Chronic Disease in Multiple Organ Systems, August
2014-July 2015 .................................................................................................................................. 51
Figure 74: Percentage of Females and Males with a Minor Chronic Disease in Multiple Organ Systems,
August 2014-July 2015 ...................................................................................................................... 51
Figure 75: Percentage of Specialty Plan Enrollee Months with Minor Chronic Disease in Multiple Organ
Systems, August 2014-July 2015 ....................................................................................................... 52
Figure 76: Percentage of Standard Plan Enrollee Months with a Minor Chronic Disease in Multiple Organ
Systems, August 2014-July 2015 ....................................................................................................... 52
Figure 77: Percentage of Regions’ Population with a Minor Chronic Disease in Multiple Organ Systems,
August 2014-July 2015 ...................................................................................................................... 53
Figure 78: Number of Recipients with Health Status 3 by CRG and Level of Severity, August 2014-July
2015 .................................................................................................................................................. 54
Figure 79: Top Single Minor Chronic Disease Compared to All Other Illnesses, August 2014-July 2015 .......... 54
v Figure 80: Percentage of Eligibility Groups with a Single Minor Chronic Disease, August 2014-July 2015 ....... 55
Figure 81: Percentage of Age Groups with a Single Minor Chronic Disease, August 2014-July 2015 ............... 55
Figure 82: Percentage of Females and Males with a Single Minor Chronic Disease, August 2014-July
2015 .................................................................................................................................................. 55
Figure 83: Percentage of Specialty Plan Enrollee Months with a Single Minor Chronic Disease, August
2014-July 2015 .................................................................................................................................. 56
Figure 84: Percentage of Standard Plan Enrollee Months with a Single Minor Chronic Disease, August
2014-July 2015 .................................................................................................................................. 56
Figure 85: Percentage of Regions’ Population with a Single Minor Chronic Disease Status, August 2014-
July 2015 ........................................................................................................................................... 57
Figure 86: Number of Recipients with Health Status 2 by CRG and Level of Severity, August 2014-July
2015 .................................................................................................................................................. 58
Figure 87: Percentage of Eligibility Groups with a Significant Acute Illness, August 2014-July 2015 ................ 59
Figure 88: Percentage of Age Groups with a Significant Acute Illness, August 2014-July 2015 ........................ 59
Figure 89: Percentage of Females and Males with a Significant Acute Illness, August 2014-July 2015 ............ 59
Figure 90: Percentage of Specialty Plan Enrollee Months with a Significant Acute Illness, August 2014-
July 2015 ........................................................................................................................................... 60
Figure 91: Percentage of Standard Plan Enrollee Months with a Significant Acute Illness, August 2014-
July 2015 ........................................................................................................................................... 60
Figure 92: Percentage of Regions’ Population with a Significant Acute Illness Status, August 1, 2014 - July
31, 2015 ............................................................................................................................................ 61
List of Tables
Table 1: Data Sources ........................................................................................................................................... 2
Table 2: Major Diagnostic Category Description .................................................................................................. 3
Table 3: Health Status Categories ......................................................................................................................... 4
vi
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
Percentage of Medicaid Recipients Categorized as Healthy Compared to Any of the Other Eight Health
Statuses, August 2014-July 2015
Executive Summary
Medicaid plays an important role in managing the health care of seniors, individuals with disabilities,
and low-income individuals in Florida. According to the 2016 Kaiser Family Foundation State Health
Facts, 18 percent of all Florida citizens were covered by Medicaid in 2015. The Agency for Health Care
Administration administers the Statewide Medicaid Managed Care (SMMC) program which requires
most Medicaid recipients in Florida to receive services through managed care. The SMMC Managed
Medical Assistance (MMA) plans began rolling out in May 2014, and were fully implemented in August
2014. Most recipients eligible for Medicaid are required to enroll in an SMMC MMA plan to receive
medical care. Managed care plans provide preventive health care and are required to enact procedures
to promote disease management and report on quality metrics related to health outcomes.
Individuals with chronic disease or catastrophic illnesses present specific challenges to managing the
health of a population in a managed care system. Because individuals with chronic illnesses generally
use more health resources than healthy individuals, their care is more costly than that of healthy
individuals. For that reason, payments in a managed care system are adjusted for the illness of
enrollees. Understanding the burden of illness of the Medicaid population and its distribution
geographically and across plans is crucial to effective health management in a managed care system.
This report examines the health and illness of Medicaid recipients in Florida using data from August
2014 to July 2015. Clinical Risk Groups (CRGs) are used to classify recipients into one of 1,080 mutually
exclusive clinical risk groups indicating the presence, extent, and severity of specific illnesses. CRGs are
aggregated into nine broad health statuses that range from catastrophic to healthy. The distribution of
illness across health plans, regions, and age, and sex, and eligibility groups is analyzed. The top ten
illnesses in the eight non-healthy statuses are also analyzed. Results are descriptive. Results do not
indicate that a particular plan, program, or region caused their recipients’ health status. Methodological
techniques used in this report do not test causal relationships between aspects of the Medicaid program
and its recipients’ health.
There were 4,026,798 recipients enrolled in Medicaid for
at least 3 months at some point between August 1, 2014
and July 31, 2015.
Recipients whose medical billing data is not received by
the Florida Medicaid Managed Information System
(FLMMIS) are excluded from analyses.
Nearly 70 percent (69%) of recipients were classified as
healthy based on their medical data for the study period.
1,251,794 recipients (31%) were classified in one of eight
health statuses not considered healthy.
Healthy 2,775,004
69%
Any Other Health Status
1,251,794 31%
vii
- 20 40 60 80 100
Asthma
Significant Acute
Significant Acute Procedure
Hypertension
Persistent Signficant Acute
ADHD
2 or More Minor Chronic
Hyperlipidemia
Diabetes
Schizoprenia
Thousands
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
25%
50%
75%
Healthy SignificantAcute
Disease
Single MinorChronicDisease
MinorChronic
Disease inMultiple
OrganSystems
SingleDominant or
ModerateChronicDisease
SignificantChronic
Disease inMultiple
OrganSystems
DominantChronic
Disease inThree or
More OrganSystems
Dominant,Metastatic
andComplicatedMalignancies
CatastrophicConditions
68.9%
6.3% 5.2% 0.8%
10.2% 6.5%
0.8% 0.3% 0.9%
The three most common health statuses after healthy are Single Dominant or Moderate Chronic
Disease (10.2% of recipients), Significant Chronic Disease in Multiple Organ Systems (6.5% of
recipients), and Significant Acute Illness (6.3% of recipients).
Slightly less than one percent of Medicaid recipients had a Catastrophic Condition.
The most common illnesses
among Medicaid recipients
include asthma, significant
acute illnesses, hypertension,
and attention
deficit/hyperactivity disorder
(ADHD).
Healthy 2,775,004
69%
Top 10 Illnesses 562,092
14%
Other Illnesses 689,634
17%
Top 10 Illnesses of Medicaid Population, August 2014-July 2015
Percentage of Medicaid Recipients Categorized as Healthy, Having a Top Ten Illness, or Having an Illness Not in
the Top Ten, August 2014-July 2015
Higher levels of severity indicate a greater extent and progression of the chronic disease.
Percentage of Medicaid Population by Health Status, August 2014-July 2015
viii
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
Some recipients are categorized as healthy because they received no services through Medicaid.
Over a third (41%) of FFS recipients are non-users of Medicaid services. The largest portion of
these non-users (69%) are eligible as Qualified Medicare Beneficiaries or SSI recipients for whom
Medicaid receives Medicare claim information but no prescribed drug information likely due to
their Medicare Part D drug coverage. It is possible that if Medicaid received the drug
information, these recipients could be assigned a status other than healthy.
The percentage of each Standard Plan’s enrollees who are classified as healthy varies from 60
percent for Simply to 76.8 percent for Community Care.
The percentage of each Specialty Plan’s enrollees who are classified as healthy varies from a low
of 26 percent for Clear Health to a high of 65 percent for Sunshine Specialty.
Some enrollees in Specialty Plans were classified as healthy because there is insufficient
information in the data related to their illness. Some enrollees’ drug prescriptions were covered
by Medicare Part D. Some enrollees lack hospital or outpatient services that meet the clinical
criteria needed for classification, or lack recent treatment during the study period. During the
analysis period, siblings of enrollees in Children’s Medical Services (CMS) were allowed to enroll
in the plan if the sibling did not meet eligibility criteria for the plan. Magellan enrollees may be
classified as healthy during periods when their illness is in remission.
0%
25%
50%
75%
100%
61
.8%
59
.6%
57
.0%
57
.0%
56
.8%
56
.3%
55
.6%
55
.5%
55
.4%
55
.4%
54
.8%
54
.1%
54
.1%
50
.0%
48
.6%
32
.5%
31
.6%
15.0% 13.0% 14.1% 14.2% 10.2% 13.8% 13.3% 16.0% 14.0% 12.4% 10.9% 11.2% 12.2% 19.8% 11.4%
41
.4%
4.6%
23
.2%
27
.4%
28
.9%
28
.8%
33
.0%
29
.9%
31
.1%
28
.5%
30
.5%
32
.3%
34
.4%
34
.6%
33
.7%
30
.2%
40
.0%
26
.2%
63
.8%
Stan
dar
d P
lan
s
Percentage of Enrollee Months Classified as Healthy Versus Any Other Health Status August 2014 - July 2015
0%
25%
50%
75%
100%
SunshineSpecialty
AggregateStandard
Fee ForService
AggregateSpecialty
CMS Positive Magellan ClearHealth
60
.7%
55
.4%
32
.5%
31
.6%
28
.3%
26
.8%
23
.1%
22
.4%
3.9% 12.4%
41
.4%
4.6% 3.5% 10.0% 7.0% 3.5%
35
.5%
32
.3%
26
.2%
63
.8%
68
.2%
63
.2%
70
.0%
74
.1%
Spe
cial
ty P
lan
s
Healthy Determined by Services-All Standard Plans Healthy Determined by Services-Fee For Service Healthy Determined by Services-All Specialty Plans Healthy No Services (Standard Chart) Healthy Determined by Services-Standard Plans Healthy No Services (Specialty Chart) Healthy Determined by Services-Specialty Plans Status Other than Healthy
Note: See page one for a description of specialty plan populations.
1
Introduction Florida Medicaid pays for medical services for low-income individuals, seniors, and individuals with
disabilities who have limited or no health insurance. In response to legislation mandating that most
Medicaid recipients receive services through a managed care program, the Agency for Health Care
Administration has been providing medical services through the Statewide Medicaid Managed Care
Program since August 2014. Under managed care, health care plans receive capitation payments for
enrollees and contract with health care providers for the provision of medical services to enrollees in
exchange for payment.
Medicaid’s managed care plans are classified as Standard Plans or Specialty Plans. Standard Plans serve
the majority of Medicaid recipients and provide an array of covered medical services. They are Staywell,
Sunshine, Amerigroup, Humana, Prestige, United, Molina, Integral, Better Health, Simply, Coventry,
Community Care, Preferred and First Coast.
Specialty plans serve recipients with a chronic medical condition, specific diagnosis, or specific age group
and are tailored to meet the specific needs of the specialty population. Specialty Plans include Sunshine
Specialty who serves recipients under the age of 21 with an open case for child welfare services;
Magellan who serves recipients diagnosed with a serious mental illness; CMS who serves recipients
under the age of 21 with a serious and chronic condition; and Clear Health Alliance and Positive Health
Care, who serve recipients diagnosed with HIV or AIDS.
In a managed care system, health plans face the challenge of covering the payment for services to
enrollees with the amount received in capitation payments. To ensure that plans can cover the cost of
services for individuals with serious health problems, capitation payments must be adjusted for the
health of each enrollee.
Providing healthcare to individuals who are ill, especially those with serious chronic illness, is more
costly than providing healthcare to healthy individuals. Understanding the disease burden of the
Medicaid population and the distribution of healthy and sick enrollees across health plans and regions is
essential to an efficient and well-functioning managed care system. Health plans with a larger
percentage of individuals with more complex illnesses will have larger medical service expenses per
enrollee than plans with a smaller percentage of enrollees with complex illnesses. Therefore, capitation
rates are adjusted for the burden of illness of each plan’s enrollees to reflect this differential in cost.
This report examines the health status of the Florida Medicaid population. Clinical Risk Groups (CRGs)
are used to categorize enrollees into one of 1,080 clinical risk groups that are aggregated into nine
health statuses that range from catastrophic to healthy. The distribution of health statuses and most
frequent illnesses by health plan, region, sex, age group, and eligibility group is examined. For each of
the eight non-healthy statuses, the top ten illnesses are shown. Results are descriptive. Results do not
indicate that a particular plan, program, or region caused their recipients’ health status. Methodological
techniques used in this report do not test causal relationships between aspects of the Medicaid program
and its recipients’ health.
2
Data Sources The results in this report are based on analyses of data from sources detailed in the table below and
cited with relevant tables and figures.
Table 1: Data Sources
Data Period Source
Enrollment Information
August 1, 2014-July 31, 2015 as of September 21, 2016
Florida Medicaid Managed Information System (FLMMIS) Eligibility Information
MMA Encounter and Claims Information
August 1, 2014-July 31, 2015 as of April 21, 2016
Florida Medicaid Managed Information System (FLMMIS) Claims and Encounter Information
Recipients whose medical billing data is not received by the Florida Medicaid Managed Information
System (FLMMIS) are excluded from analyses. This includes recipients who are dually eligible for
Medicaid and Medicare for whom Medicaid does not receive medical billing information, women who
were enrolled only for Family Planning services, recipients who did not have full Medicaid coverage and
recipients enrolled in Medicaid for less than 3 months in the period from August 1, 2014 through July 31,
2015.
Demographic and medical information present in claims and encounter data for the analysis year is used
to classify each enrollee into a clinical risk group (CRG). Clinical risk groups are a classification system for
describing the health of individuals. Each enrollee is categorized into one of 1,080 CRG codes. CRGs are
assigned using 3M’s CRG grouping software (3M™ Clinical Risk Grouping Software (Version 1.12)
[Software]). The CRG grouping software uses diagnosis codes, procedure codes, and national drug
codes, singularly or in combination, to build a disease profile for each person. It also uses other
information such as the place of service, recency of the service, persistence of the illness, and
demographic characteristics of the individual. The presence or absence of this information can change
the assignment of a health status significantly. For example, some enrollees in illness-based Specialty
Plans are classified as “healthy.” While these individuals would not normally be categorized as healthy,
the claims/encounter data submitted during the study period did not contain information relating to the
illness.
The disease profile is used by the software to group clinical information into 37 major diagnostic
categories based on the organ system involved or the disease etiology. The CRG software uses a set of
detailed clinical criteria to assign a primary chronic disease with corresponding severity level to each
major diagnostic category if any illness is present. Table 2 lists the major diagnostic categories in
hierarchal order beginning with the most severe.
3 Table 2: Major Diagnostic Category Description
Rank Major Diagnostic Category (MDC) Description
1 Catastrophic Respiratory Conditions
2 Catastrophic Neurological Conditions
3 Heart Transplant Status
4 Liver or Pancreas Transplant Status
5 Bone Marrow Transplant Status
6 HIV Infection
7 Secondary Malignancy
8 Malignancies
9 Diseases and Disorders of the Nervous System
10 Diseases and Disorders of the Cardiovascular System
11 Diseases and Disorders of the Respiratory System
12 Diabetes Mellitus
13 Diseases and Disorders of the Digestive System
14 Diseases and Disorders of the Hepatobiliary System and Pancreas
15 Diseases and Disorders of the Kidney and Urinary Tract
16 Disease and Disorders of the Blood and Blood Forming Organs
17 Infectious and Parasitic Diseases
18 Diseases and Disorders of the Eye
19 Diseases and Disorders of the Ear, Nose, Mouth and Throat
20 Peripheral Vascular Disease and Other Non-Cardiac Vascular Diseases
21 Diseases and Disorders of the Musculoskeletal System
22 Connective Tissue Diseases
23 Other Endocrine, Metabolic and Thyroid Disorders
24 Diseases and Disorders of the Male Reproductive System
25 Diseases and Disorders of the Female Reproductive System
26 Newborns and Other Neonates
27 Diseases and Disorders of the Skin, Subcutaneous Tissue, and Breast
28 Mental Diseases and Disorders
29 Substance Abuse
30 Burns
31 Factors Influencing Health Status and Other Contacts with Health Services
32 Pregnancy, Childbirth and the Puerperium
33 Other Trauma
34 Injuries, Poisoning and Toxic Effects of Drugs
35 Neoplasms of Uncertain Behavior
36 Chromosomal Anomalies, Mental Retardation and Other Developmental / Cognitive Diagnoses
37 Craniofacial Anomalies
4
Once the primary chronic illnesses are assigned to each of the major diagnostic categories, the CRG software applies additional detailed clinical criteria to categorize each person into one of 1,080 detailed CRG categories. The CRG categories indicate the presence or absence of specific acute and chronic illnesses, the severity level of illnesses, and the presence of multiple illnesses. Detailed CRG categories can be used to examine the prevalence of specific illnesses in a population and identify the most frequent illnesses experienced by groups within the population. Detailed CRG categories are also aggregated into the following nine health statuses which range from catastrophic to healthy and are used to more broadly summarize the health of a population. Table 3: Health Status Categories
Health Status
Title Description
9 Catastrophic Conditions
Includes long term dependency on a medical technology such as dialysis, respirator, or total parenteral nutrition (TPN), and life-defining chronic diseases or conditions that dominate the medical care required such as persistent vegetative state, cystic fibrosis, AIDS, or a history of heart transplant.
8 Dominant, Metastatic or Complicated Malignancies
Identified by a malignancy that dominates the medical care required such as brain malignancy, or a non-dominant malignancy such as prostate malignancy that is metastatic or complicated (requiring a bone marrow transplant).
7 Dominant Chronic Disease in Three or More Organ Systems
Identified by the presence of three or more dominant chronic diseases, or two dominant and a selected moderate chronic disease. An example is the presence of congestive heart failure, diabetes, and chronic obstructive pulmonary disease.
6 Significant Chronic Disease in Multiple Organ Systems
Identified by the presence of two or more chronic diseases of which at least one is a dominant or moderate chronic disease such as diabetes and hypertension or asthma and hypertension.
5 Single Dominant or Moderate Chronic Disease
Identified by the presence of a single dominant or moderate chronic disease such as asthma, epilepsy, or cerebral palsy.
4 Minor Chronic Disease in Multiple Organ Systems
Identified by the presence of two or more minor chronic diseases such as migraines and depression, or migraines and hyperlipidemia.
3 Single Minor Chronic Disease
Identified by the presence of a single minor chronic disease such as migraines, depression, or hyperlipidemia.
2 Recent History of Significant Acute Disease
Identified by the presence within the most recent six month period of one or more significant acute diseases or procedures. No chronic diseases are present. Examples are: pneumonia, blood transfusion, or bacterial infections.
1 Healthy Identified by the absence of any chronic disease or significant acute disease or procedures. Minor acute disease may be present such as upper respiratory infection, appendicitis, or ear infection.
5
Disease Classifications
The following classifications are used throughout this report to describe a specific type of medical
condition. They are based on the terminology and definitions used to define a CRG.
A Dominant Chronic (DC) disease is a serious lifelong chronic disease which usually leads to the
progressive deterioration of health.
A Moderate Chronic (MC) disease is a serious chronic disease which does not typically lead to the deterioration of health but does contribute to the individual’s overall health and future need for medical care. A Minor Chronic (MinC) disease is a chronic disease that can be managed successfully and has limited effect on the need for future care. A Significant Acute Illness (SA) can be a precursor to, or place the individual at risk for, the development of chronic illness. A Minor Acute (A) illness is limited in duration and does not increase the risk of developing a chronic disease.
6
Healthy 2,775,004
69%
Any Other Health Status
1,251,794 31%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0% 2% 4% 6% 8% 10% 12%
Significant Acute Disease
Single Minor Chronic Disease
Minor Chronic Disease in Multiple OrganSystems
Single Dominant or Moderate Chronic Disease
Significant Chronic Disease in Multiple OrganSystems
Dominant Chronic Disease in Three or MoreOrgan Systems
Dominant, Metastatic and ComplicatedMalignancies
Catastrophic Conditions
6.3%
5.2%
0.8%
10.2%
6.5%
0.8%
0.3%
0.9%
Health of the Medicaid Population
Overall, 69 percent of the Medicaid
population is classified as healthy. A
healthy status is assigned to all individuals
in the population with Medicaid services
that do not meet the clinical criteria
indicating the presence of a significant
acute illness or chronic disease during the
study period as well as those individuals
who have not received any service.
Thirty-one percent of Medicaid’s total population is categorized as other than healthy. The largest
portion of this group (10%) is in the Single Dominant or Moderate Chronic Disease health status.
Figure 1: Percentage of Medicaid Recipients Categorized as Healthy Compared to Any of the Other Eight Health Statuses,
August 2014-July 2015
Figure 2: Percentage of Medicaid Population Classified in a Non-Healthy Status by Health Status, August 2014-July 2015
7
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
SSI-Related Eligibility
Group 1,026,575
25% Family-Related
Eligibility Group
3,000,223 75%
The demographic composition of the
Medicaid population plays a role in the
health of the population. The Medicaid
population is divided into two main eligibility
groups. The SSI-Related eligibility group
consists of individuals who meet the age or
disability standards for Supplemental
Security Income (SSI). The Family-Related
eligibility group consists of children and
families who meet Medicaid eligibility
standards. The largest number of Medicaid
recipients (75%) is in the children and
families group.
The Family-Related eligibility group
is typically younger and healthier as
their eligibility is based either on
age for the under 21 population or
the existence of dependent children
for the over 21 population.
By definition, the aged
and disabled population
is older or has a
disability. They
comprise 25 percent of
the Medicaid
population. Overall,
Medicaid’s population is
largely comprised of
children less than 21
years of age.
Figure 5: Distribution of Medicaid Population by Age and Eligibility Group, August 2014-July 2015
Figure 3: Percentage of Medicaid Population in the Family-Related Eligibility Group as Compared to the SSI-Related Eligibility Group,
August 2014-July 2015
Figure 4: Percentage of SSI-Related Eligibility Group and Family-Related Eligibility Group in the Healthy Category as Compared to One of the Other Eight Health
Statuses, August 2014-July 2015
0%
25%
50%
75%
SSI-Related Eligibility Group Family-Related Eligibility Group
Healthy 50.4%
Healthy 75.3% Other
49.6% Other 24.7%
0%
20%
40%
60%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
0.1% 3.4% 1.7% 1.7% 3.1% 4.6%
9.1%
1.9% 6.3%
51.0%
8.4% 5.9%
2.4% 0.4% 0.0% 0.0%
SSI-Related Eligibility Group Family-Related Eligibility Group
8
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
20%
40%
60%
80%
100%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
73
.2%
78
.0%
65
.2%
55
.6%
43
.3%
35
.4%
64
.9%
50
.0%
26
.8%
22
.0%
34
.8%
44
.4%
56
.7%
64
.6%
35
.1%
50
.0%
Healthy Any Other Health Status
0%
25%
50%
75%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
20
.5%
45
.3%
51
.0%
45
.9%
39
.0%
35
.0%
64
.9%
50
.0%
73
.7%
80
.1%
68
.0%
58
.4%
48
.8%
39
.5%
39
.0%
34
.4%
SSI-Related Eligibility Group Family-Related Eligibility Group
Typically, the burden of illness increases as the population ages. In Medicaid, the percentage of non-
healthy individuals follows this pattern beginning with the 21-31 age group until it reaches the 65-84 age
group when the burden of illness declines. The decline may be attributed to an increase in number of
individuals in the 65 and older group who, because of age and income, are now eligible to receive both
Medicaid and Medicare. Once that occurs, Medicaid no longer receives pharmacy claims and encounter
data for Medicare Part D recipients, a key component in determining health status. Thus, the CRG
assignments for the 65 and older age groups likely underestimate the true burden of illness for these
age groups. In addition, new entrants to Medicaid who are eligible solely due to age and income rather
than disability status change the composition of the 65 and older group making it relatively healthier.
The increase in the percentage of healthy recipients among 65 to 84 year olds is observed only for
recipients in the SSI-Related eligibility group, suggesting the loss of pharmacy data and the change in
the population’s composition are the likely explanations for the increase in the percentage of healthy
recipients among those 65 and older.
Figure 6: Percentage of Age Groups Classified as Healthy, August 2014-July 2015
Figure 7: Percentage of Age and Eligibility Groups Classified as Healthy, August 2014-July 2015
9
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
25%
50%
75%
Healthy Any Other Health Status
Female 67.9%
Female 32.1%
Male 70.2%
Male 29.8%
Female 56%
Male 44%
The majority of Medicaid recipients were in
enrolled in the managed care program
during the study period. Only 16 percent of
the Medicaid population was in the fee-for-
service program. Medicaid enrollees were
unevenly distributed across MMA health
plans. Eighty percent of the Medicaid
population was enrolled in a Standard Plan
and 3.6 percent was enrolled in a Specialty
Plan.
Figure 9: Percentage of Medicaid Population by Gender,
August 2014 -July 2015
Figure 8: Percentage of Females and Males Classified as Healthy, August 2014-July 2015
The health status of the Medicaid
population varies only slightly by
gender. About 56 percent of the
Medicaid population is female.
Figure 10: Percentage of Medicaid Population in Standard Plan, Specialty Plan, and FFS,
August 2014-July 2015
Standard Plans 80.2%
FFS 16.2%
Specialty Plans 3.6%
10
Figure 12: Number of Enrollees in a Specialty Plan, August 2014-July 2015
Figure 11: Percentage of Specialty Plan Enrollees Classified as Healthy, August 2014-July 2015
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
Healthy and ill enrollees
are unevenly
distributed across
health plans. With the
exception of Sunshine
Specialty, Specialty
Plans are designed to
serve enrollees with a
serious illness and have
a larger percentage of
enrollees with serious
illnesses.
The two HIV/AIDS Specialty plans
have the smallest number of
enrollees among Specialty plans.
Together, they account for less
than nine percent of all Specialty
plan enrollees.
Some enrollees in Positive and Clear Health were classified as healthy because they did not have any HIV
or AIDS related hospital or outpatient medical services, and in some instances, their drug prescriptions
were covered by Medicare Part D and thus were not present in Medicaid encounter data. Information
necessary for a health status determination was thus lacking in the data. The 32 percent of CMS
enrollees who are healthy likely results from the policy in place at the time allowing siblings who did not
meet the CMS criteria to also enroll in CMS plan. Given that mental illness can fluctuate in its severity
and expression, some Magellan enrollees may be classified as healthy during periods when their mental
illness is in remission or is being controlled.
Note: Because enrollees may be in different programs or plans over the course of the study period,
totals by plan or program associate a person’s CRG with the number of member months the person
was enrolled in a plan or the FFS program.
Healthy Determined by Services-All Standard Plans Healthy Determined by Services-FFS Healthy Determined by Services-All Specialty Plans Healthy No Services Healthy Determined by Services-Specialty Plan Status Other than Healthy
0%
25%
50%
75%
100%
SunshineSpecialty
AggregateStandard
Fee ForService
AggregateSpecialty
CMS Positive Magellan ClearHealth
60
.7%
55
.4%
32
.5%
31
.6%
28
.3%
26
.8%
23
.1%
22
.4%
3.9% 12.4%
41
.4%
4.6% 3.5% 10.0% 7.0% 3.5%
35
.5%
32
.3%
26
.2%
63
.8%
68
.2%
63
.2%
70
.0%
74
.1%
-
20,000
40,000
60,000
80,000
CMS Magellan SunshineSpecialty
ClearHealth
Positive
65,599
45,136
22,428
10,050 1,957
Note: See page one for a description of specialty plan populations.
11
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
Community Care has the largest percentage of healthy enrollees of any Standard plan. The fee-for-
service program has the second largest percentage of healthy recipients. The percentage of healthy
enrollees in a Standard plan ranges from a low of 60 percent for Simply to a high of 77 percent for
Community Care. Some recipients are categorized as healthy because they received no services through
Medicaid. Over a third (41%) of FFS recipients are non-users of Medicaid services. The largest portion
of these non-users (69%) are classified as Qualified Medicare Beneficiaries or SSI recipients for whom
Medicaid receives Medicare claim information but no prescribed drug information likely due to their
Medicare Part D drug coverage. It is possible that if Medicaid received the drug information, these
recipients could be assigned a status other than healthy.
0%
25%
50%
75%
100%
61
.8%
59
.6%
57
.0%
57
.0%
56
.8%
56
.3%
55
.6%
55
.5%
55
.4%
55
.4%
54
.8%
54
.1%
54
.1%
50
.0%
48
.6%
32
.5%
31
.6%
15.0% 13.0% 14.1% 14.2% 10.2% 13.8% 13.3% 16.0% 14.0% 12.4% 10.9% 11.2% 12.2% 19.8% 11.4%
41
.4%
4.6% 2
3.2
%
27
.4%
28
.9%
28
.8%
33
.0%
29
.9%
31
.1%
28
.5%
30
.5%
32
.3%
34
.4%
34
.6%
33
.7%
30
.2%
40
.0%
26
.2%
63
.8%
Figure 14: Number of Enrollees in a Standard Plan, August 2014-July 2015
Fee For Service Standard Plan
Staywell is the largest Standard plan accounting for 23.5 percent of all Standard plan enrollees.
In contrast, Community Care accounts for 1.5 percent of all Standard plan enrollees.
Figure 13: Percentage of Standard Plan Enrollees Classified as Healthy, August 2014-July 2015
Healthy Determined by Services-All Standard Plans Healthy Determined by Services-FFS Healthy Determined by Services-All Specialty Plans Healthy No Services Healthy Determined by Services-Standard Plan Status Other than Healthy
-
250,000
500,000
750,000
75
7,9
31
65
1,9
02
46
8,6
22
37
4,7
50
35
8,4
45
34
9,4
32
30
4,9
55
12
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
70.0% - 74.9%
65.0% - 69.9%
60.0% - 64.9%Region 9
Region 8
Region 4
Region 2
Pensacola
Jacksonville
Tallahassee
St. Petersburg
Naples
Ft. Myers
Sarasota
Miami
Panama City
Daytona Beach
Tampa
Region 5
West Palm Beach
Region 10Ft. Lauderdale
Key West
Region 11
Orlando
M elbourne
Region 3
Gainesville
Ocala
Region 1
Region 6
Region 7
The map displays the percentage of Medicaid recipients in each region with a status of healthy. A larger
percentage of Medicaid recipients in Regions 9 and 10 as compared to other regions are categorized as
healthy. Regions 1, 2, and 5 have the smallest percentage of healthy recipients in the state.
Note: Because enrollees may be in different regions over the course of the study period, these totals associate
a person’s CRG with the number of member months a person resided in a region.
Figure 15: Percentage of Regions’ Recipients with a Healthy Status, August 2014-July 2015
13
- 20 40 60 80 100
Asthma
SA
SA Procedure
HBP
Presistent SA
ADHD
2+ MinC
HLD
DB
Schizop
Thousands
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
Healthy 2,775,004
69%
Top 10 Illnesses 562,092
14%
Other Illnesses 689,634
17%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
Top Illnesses of the Medicaid Population
Overall
Detailed clinical risk group
categories are ranked in
order of most to least
frequent to identify the
most common illnesses in
the Medicaid population.
Asthma is the most
prevalent illness across all
Medicaid recipients.
Three of the top ten
illnesses are acute rather
than chronic.
Asthma is a chronic
disease affecting the
lungs. It causes episodes
of wheezing,
breathlessness, chest
tightness, and coughing
which may limit a person’s
daily activities. However,
it can be controlled by
medication and
environmental changes.
Figure 16: Top 10 Non-Healthy CRGs for the Medicaid Population, August 2014-July 2015
ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DB Diabetes MinC Minor Chronic HLD Hyperlipidemia SA Significant Acute Disease HBP Hypertension Schizop Schizophrenia
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
14
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
0 10 20 30
HBP
DB & HBP
Schizop
SA Procedure
2 MC
DB
HIV
DB & MC
ADHD
SA
Thousands
SSI-Related
0 50 100
Asthma
SA
SA Procedure
Persistent SA
ADHD
HBP
HLD
2+ MinC
2+ SA
Endocrine MC
Thousands
Family-Related
Healthy 517,307
50%
Top 10 Illnesses 150,894
15%
Other Illnesses 358,374
35%
Healthy 2,257,697
75%
Top 10 Illnesses 444,973
15%
Other Illnesses 297,553
10%
SSI and Family
Among individuals in the
SSI-Related eligibility
group, hypertension is the
leading illness and only
one of the top five
illnesses is acute. Among
individuals in the Family-
Related eligibility group
asthma is the leading
illness and three of the
top five illnesses are
acute.
Hypertension is high
blood pressure, a
common and potentially
dangerous condition that
increases the risk of heart
attack and stroke. It
occurs when the pressure
of the blood in a person’s
blood vessels is higher
than it should be.
Hypertension can be
managed to lower the risk
of heart disease and
stroke.
Figure 17: Top 10 Illnesses of the Medicaid Population by Eligibility Group, August 2014-July 2015
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DB Diabetes MC Moderate Chronic Disease HLD Hyperlipidemia MinC Minor Chronic HBP Hypertension SA Significant Acute Disease Schizop Schizophrenia
15
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
0 50 100
Asthma
ADHD
SA
SA Procedure
Presistent SA
DD
Epilepsy
HLD
Schizop
Endocrine MC
Thousands
Age 1-20
Healthy 188,619
73%
Top 10 Illnesses 54,558
21%
Other Illnesses 14,477
6%
Healthy 1,708,262
78%
Top 10 Illnesses 312,605
14%
Other Illnesses 169,643
8%
0 10 20
SA
SA Procedure
Presistent SA
Asthma
2+ SA
DD
VASD
HLD
Osteo
Endocrine MC
Thousands
Age <1
Figure 18: Top 10 Illnesses of the Medicaid Population from Birth to 20, August 2014-July 2015
By Age
Acute illnesses and
asthma dominate the top
illnesses of newborns
under the age of one.
Asthma, attention deficit /
hyperactivity disorder,
and acute illnesses
dominate the illnesses of
children between the ages
of one and twenty.
An acute illness is
characterized by a rapid
onset and time limited
duration. It does not
place the individual at risk
for development of a
chronic disease.
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DD Developmental Delay DC Dominant Chronic Disease HLD Hyperlipidemia MC Moderate Chronic Disease Osteo Osteoarthritis SA Significant Acute Disease Schizop Schizophrenia VASD Ventricular and Atrial Septal Defects
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
16
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0 5 10 15
SA
HBP
Presistent SA
SA Procedure
Asthma
2+ MinC
Schizop
HLD
2+ SA
Obesity
Thousands
Age 21-31
0 10 20
HBP
2+ MinC
SA
SA Procedure
HLD
Presistent SA
2 MC
DB
Schizop
DB & HBP
Thousands
Age 32-42
0 5 10 15
HBP
DB & HBP
HIV
2+ MinC
DB
2 MC
HLD
DB & MC
MC & C
Schizop
Thousands
Age 43-53
Healthy 170,775
56% Top 10
Illnesses 59,860
19%
Other Illnesses 76,314
25% Healthy 95,890
43%
Top 10 Illnesses 51,939
24%
Other Illnesses 73,623
33%
Figure 19: Top 10 Illnesses of the Medicaid Population Twenty-one Years of Age or Over, August 2014-July 2015
Among adults 21 years and older, acute illness becomes less prevalent as individuals age, and hypertension becomes more prevalent, dominating illnesses for adults in Medicaid through their 30s, 40s, 50s, 60s, 70s, and mid-80s. Chronic illnesses such as diabetes, HIV, and Chronic Obstructive Pulmonary Disease become more common for adults in their 40s and older. Dementing illnesses and Alzheimer’s become the dominant illnesses for adults 85 and over. Alzheimer’s disease involves parts of the brain that control thought, memory, and language and over time can seriously affect a person’s ability to carry out daily activities. Although the cause is still unknown, it is believed to be influenced by a mix of genetic, environmental, and lifestyle factors.
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
Healthy 262,926
65%
Top 10 Illnesses 70,053
17%
Other Illnesses 70,289
18%
17
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0 5 10 15
HBP
DB & HBP
DB & MC
2 MC
HIV
DB
DB & HBP & DC
2+ MinC
COPD & MC
MC & C
Thousands
Age 54-64
0 5 10 15
HBP
SA Procedure
DB & HBP
DB
Dementia & MC
2 MC
DB & MC
SA
Alzheimer's
DB & DC
Thousands
Age 65-84
0 2 4
Dementia & MC
Alzheimer's
SA Procedure
HBP
CHF
Presistent SA
DB & DC
COPD & DC
2 MC
DB
Thousands Age 85+
Healthy 38,252
50%
Top 10 Illnesses 14,938
20%
Other Illnesses 23,253
30% Healthy 71,843
35%
Top 10 Illnesses 48,604
24%
Other Illnesses 82,446
41% Healthy 238,437
65%
Top 10 Illnesses 49,288
13%
Other Illnesses 79,904
22%
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
CHF Congestive Heart Failure 2+ Two or More COPD Chronic Obstructive Pulmonary Disease C Chronic DB Diabetes DC Dominant Chronic Disease HLD Hyperlipidemia MC Moderate Chronic Disease HBP Hypertension MinC Minor Chronic Schizop Schizophrenia SA Significant Acute Disease
18
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
0 20 40 60
SA
HBP
Asthma
SA Procedure
Presistent SA
2+ MinC
HLD
DB
ADHD
2 MC
Thousands
Female
0 20 40 60
Asthma
ADHD
SA
SA Procedure
Presistent SA
HBP
Schizop
HLD
DD
2+ MinC
Thousands
Male
Healthy 1,241,662
70%
Top 10 Illnesses 256,192
15%
Other Illnesses 272,066
15%
Healthy 1,533,342
68%
Top 10 Illnesses 312,548
14%
Other Illnesses 410,988
18%
By Sex
Acute illnesses, asthma,
and hypertension are the
most common illnesses
for girls and women in
Medicaid. Acute illnesses
are also among the most
common illnesses for boys
and men in Medicaid,
however asthma and
attention deficit/
hyperactivity disorder are
the leading illnesses for
boys and men.
ADHD is a chronic
condition characterized by
an inability to focus, over-
activity, and/or an
inability to control
behavior which can
interfere with normal
functions and
development. It can be
treated with medications
and therapies.
Figure 20: Top 10 Illnesses of the Medicaid Population by Sex, August 2014-July 2015
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DB Diabetes MC Moderate Chronic Disease DD Developmental Delay MinC Minor Chronic HLD Hyperlipidemia SA Significant Acute Disease HBP Hypertension
Schizop Schizophrenia
19
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
0 100 200
SA Procedure
SA
HBP
DB
Persistent SA
Asthma
Schizop
2 MC
DB & HBP
DB & MC
Thousands
FFS
Healthy 6,115,807
74%
Top 10 Illnesses 767,876
9%
Other llnesses
1,398,859 17%
0 500 1000
Asthma
SA
ADHD
Presistent SA
SA Procedure
HBP
2+ MinC
HLD
Schizop
Endocrine MC
Thousands
MMA Plans
Top 10 Illnesses
5,443,232 16%
Other Illnesses
6,113,859 18%
By MMA Plan
Asthma and attention
deficit / hyperactivity
disorder are the only non-
acute illnesses among the
top 5 illnesses for MMA
Plans. In contrast,
hypertension and
diabetes are the only non-
acute illnesses among the
top 5 illnesses for the Fee-
for-Service population.
Figure 21: Top 10 Illnesses of the Fee-for-Service and MMA Populations, August 2014-July 2015
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DB Diabetes MC Moderate Chronic Disease HLD Hyperlipidemia MinC Minor Chronic HBP Hypertension SA Significant Acute Disease Schizop Schizophrenia
Note: Because enrollees may be in different programs or plans over the course of the study period,
totals by plan or program associate a person’s CRG with the number of member months the person was
enrolled in a plan or the FFS program.
Healthy
22,705,103
66%
20
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0 500 1000
Asthma
SA
Presistent SA
SA Procedure
HBP
ADHD
2+ MinC
HLD
Endocrine MC
DB & HBP
Thousands
Aggregated Standard
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
0 100 200 300
Asthma
SA
ADHD
Presistent SA
HLD
Thousands Staywell
0 50 100 150
Asthma
SA
SA Procedure
ADHD
Presistent SA
Thousands Sunshine
0 50 100 150
Asthma
SA
Presistent SA
SA Procedure
ADHD
Thousands Amerigroup
0 50 100 150
Asthma
HBP
SA
SA Procedure
Presistent SA
Thousands Humana Healthy
22,127,888 68%
Top 10 Illnesses
5,145,217 16%
Other Illnesses
5,394,281 16%
Figure 22: Top 10 Illnesses of Standard Plan Enrollees, August 2014-July 2015
Maximum axis values and population sizes vary
between the MMA Plans.
Asthma, acute illness, and hypertension are among
the top illnesses for Standard plans although the order
of prevalence varies from plan to plan.
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DB Diabetes MC Moderate Chronic Disease HLD Hyperlipidemia MinC Minor Chronic HBP Hypertension SA Significant Acute Disease
21
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0 50 100
Asthma
SA
HBP
ADHD
Presistent SA
Thousands Prestige
0 20 40 60 80
Asthma
SA
HBP
ADHD
Presistent SA
Thousands United
0 20 40 60
Asthma
SA
SA Procedure
Presistent SA
HBP
Thousands Molina
0 10 20 30 40
Asthma
HBP
SA Procedure
SA
Presistent SA
Thousands Simply
0 10 20 30
Asthma
SA
SA Procedure
Presistent SA
HBP
Thousands Better Health
0 10 20 30
Asthma
SA
Presistent SA
ADHD
HBP
Thousands Integral
0 5 10 15 20
SA Procedure
Asthma
SA
HBP
Presistent SA
Thousands Coventry
0 5 10 15
Asthma
SA
SA Procedure
ADHD
Presistent SA
Thousands Community Care
0 5 10
HBP
Asthma
SA
SA Procedure
Presistent SA
Thousands Preferred
0 5 10
Asthma
ADHD
SA
HBP
Presistent SA
Thousands First Coast
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or
program associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS
program.
22
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
Healthy 7,795 37%
Top 10 Illnesses 12,582
59%
Other Illnesss
827 4%
Healthy 28,164
26%
Top 10 Illnesses 74,091
68%
Other Illnesses
6,477 6%
0 20 40 60 80
HIV
Dial w/o DB
SA Procedure
SA
HBP
Persistent SA
Asthma
DB
Dial w DB
Endocrine MC
Thousands Clear Health
0 5 10 15
HIV
HBP
Dial w/o DB
Endocrine MC
Dial w DB
SA
Persistent SA
SA Procedure
Asthma & MC
Schizop
Thousands Positive
DB Diabetes MC Moderate Chronic Disease Dial Dialysis SA Significant Acute Disease HBP Hypertension Schizop Schizophrenia
The population size is significantly
higher in Clear Health than in Positive
Health Care.
HIV is the predominant disease among enrollees
in Clear Health and Positive, the two HIV/AIDS
Specialty Plans.
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or program
associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS program.
Figure 23: Top 10 Illnesses of HIV/AIDS Specialty Plan Enrollees, August 2014-July 2015
23
Healthy 165,103
65%
Top 10 Illnesses 64,267
25%
Other Illnesses 26,478
10%
0 5 10 15
ADHD
Asthma
DD
SA
Schizop
Persistent SA
SA Procedure
DBD
CMH Dx
DOP
Thousands
Sunshine Specialty
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0 20 40 60
ADHD
Asthma
DD
PDD
Epilepsy
DC & MC
Asthma & DC
CQDH
Persistent SA
SA
Thousands
CMS
Healthy 238,113
32%
Top 10 Illnesses 245,793
33%
Other Illnesss
265,712 35%
Attention deficit / hyperactivity disorder, asthma, and developmental delay are the predominant diseases
among enrollees in CMS, the Specialty Plan for children with chronic conditions, and Sunshine Specialty,
the Specialty Plan for Child Welfare.
CMH Dx Chronic Mental Health Diagnoses - Moderate DC Dominant Chronic Disease CQDH Congenital Quadriplegia, Diplegia or Hemiplegia MC Moderate Chronic Disease DOP Depressive and Other Psychoses SA Significant Acute Disease DD Developmental Delay PDD Pervasive Development Disorder Schizop Schizophrenia
Figure 24: Top 10 Illnesses of Children’s Specialty Plan Enrollees, August 2014-July 2015
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
24
0 10 20 30 40
Schizop
Dementia & DC
Schizop & MC
HBP
Dep
2+ MinC
DOP
ADHD
BiP
PsyD & MC
Thousands Magellan
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
Healthy 138,040
30%
Top 10 Illnesses 155,568
34%
Other Illnesses 165,798
36%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
Figure 25: Top 10 Illnesses of Severe Mental Illness Specialty Plan Enrollees, August 2014-July 2015
The most common diseases among enrollees in Magellan, the Specialty Plan for serious mental illness, are schizophrenia, dementia, hypertension, and depression. Schizophrenia is a chronic severe mental disorder which requires lifelong treatment. It is characterized by abnormal behavior and an inability to understand what is real. Symptoms include hallucinations, delusions, and extremely disordered thinking and behavior.
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or
program associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS
program.
ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More BiP Bi-Polar Disorder DC Dominant Chronic Disease Dep Depression MC Moderate Chronic Disease DOP Depressive and Other Psychoses MinC Minor Chronic HBP Hypertension PsyD Psychiatric Disease Excluding Schizophrenia Schizop Schizophrenia
25
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
Asthma, attention deficit / hyperactivity disorder, significant acute illness, and
hypertension, are among the most common illnesses in most Florida regions. The order
of prevalence varies slightly from region to region.
Note: Because enrollees may be in different regions over the course of the study period, these totals associate a
person’s CRG with the number of member months a person resided in a region.
Figure 26: Top 5 Illnesses by Region, August 2014-July 2015
26
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0% 2% 4% 6% 8% 10% 12%
Significant Acute Disease
Single Minor Chronic Disease
Minor Chronic Disease in Multiple OrganSystems
Single Dominant or Moderate Chronic Disease
Significant Chronic Disease in Multiple OrganSystems
Dominant Chronic Disease in Three or MoreOrgan Systems
Dominant, Metastatic and ComplicatedMalignancies
Catastrophic Conditions
6.3%
5.2%
0.8%
10.2%
6.5%
0.8%
0.3%
0.9%
Top Illnesses by Health Status Each of the 8 non-healthy health statuses is defined by a specific set of illnesses. Within each health
status, detailed CRG categories are ranked in order of most to least frequent to examine which illnesses
dominates each health status. This allows us to see which illnesses are most common among Medicaid
recipients with chronic illnesses.
Figure 27: Percentage of Medicaid Population Classified in a Non-Healthy Status by Health Status, August 2014-July 2015
27
Top Illness 16,235
44%
Illnesses 2-11
20,872 56%
- 5 10 15 20
HIV Disease
Dialysis without Diabetes
Dialysis with Diabetes
Congenital Quadriplegia, Diplegia orHemiplegia
Spina Bifida
Acquired Quadriplegia or PermanentVegetative State
Cystic Fibrosis
History of a Major Organ Transplant
Dependence on a Mechanical Ventilator
Progressive Muscular Dystrophy or SpinalMuscle Atrophy
Total Parenteral Nutrition
Thousands
Level 1 Level 2 Level 3 Level 4
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
Health Status 9-Catastrophic Conditions
A Catastrophic Conditions
health status is assigned
to an individual when one
of eleven chronic illnesses
is present. The chart to
the left lists each of the
illnesses and displays its
prevalence across the
population. It also
displays the number of
people within each
severity level.
HIV is the most prevalent
disease affecting 44
percent of those with a
catastrophic condition.
Fifty-six percent of people
with HIV are categorized
as severity level 1 or the
least severe.
Figure 29: Top Catastrophic Conditions Compared to All Other Conditions, August 2014-July 2015
Figure 28: Number of Recipients with Health Status 9 by CRG and Level of Severity, August 2014-July 2015
Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.
28
0%
1%
2%
3%
4%
5%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
0.3% 0.3%
0.9%
1.7%
4.0% 4.1%
1.1%
0.5%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
2%
4%
SSI-Related EligibilityGroup
Family-RelatedEligibility Group
3.1%
0.2%
0.0%
0.5%
1.0%
1.5%
Female Male
0.8%
1.1%
He
alth
Sta
tus
9 –
Cat
astr
op
hic
Co
nd
itio
ns
A larger percentage of recipients that
are eligible for Medicaid because they
are aged or disabled have a
catastrophic condition as compared to
recipients in the Family-Related
eligibility group.
A larger percentage of
recipients between the
ages of 43 and 64 have a
catastrophic condition
compared to recipients in
other age groups.
A slightly larger percentage of males
than females have a catastrophic
condition.
Figure 30: Percentage of Eligibility Groups with a Catastrophic Condition, August 2014-July 2015
Figure 31: Percentage of Age Groups with a Catastrophic Condition, August 2014-July 2015
Figure 32: Percentage of Females and Males with a Catastrophic Condition, August 2014-July 2015
29
0%
2%
4%
6%
8%
7.9%
1.2% 0.9%
0.8% 0.8% 0.7% 0.7% 0.6% 0.5% 0.5% 0.5% 0.5% 0.5% 0.5% 0.4% 0.3%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
25%
50%
75%
ClearHealth
Positive AllSpecialty
CMS Magellan FFS AllStandard
SunshineSpecialty
64.7%
56.7%
7.9% 4.9%
1.3% 1.2% 0.6% 0.2%
Only 0.9 percent of Medicaid recipients are classified in the Catastrophic Conditions health status.
Almost eight percent of all Specialty Plans’ enrollees are classified with a Catastrophic Conditions health
status. Sunshine Specialty Plan has the smallest percentage of enrollees with this health status
category. Positive and Clear Health, the two HIV Specialty Plans, have the largest percentage of
enrollees with a Catastrophic Conditions health status.
A very small percentage of Standard Plans’ enrollees have a health status of Catastrophic Conditions.
Overall, only 0.6 percent of the enrollees in a Standard plan are in this health status. A little over one
percent of recipients in the fee-for-service program are classified in the Catastrophic Conditions
category.
Figure 34: Percentage of Standard Plan Enrollee Months with a Catastrophic Condition, August 2014-July 2015
He
alth Statu
s 9 – C
atastrop
hic C
on
ditio
ns
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or
program associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS
program.
Aggregated Specialty Plans Specialty Plan Aggregated Standard Plans Fee-for-Service
Standard Plan Aggregated Specialty Plans Fee-for-Service
Figure 33: Percentage of Specialty Plan Enrollee Months with a Catastrophic Condition, August 2014-July 2015
30
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
1.00% - 1.40%
0.70% - 0.99%
Region 9
Region 8
Region 4
Region 2
Pensacola
Jacksonville
Tallahassee
St. Petersburg
Naples
Ft. Myers
Sarasota
Miami
Panama City
Daytona Beach
Tampa
Region 5
West Palm Beach
Region 10Ft. Lauderdale
Key West
Region 11
Orlando
M elbourne
Region 3
Gainesville
Ocala
Region 1
Region 6
Region 7
Regions 4, 9, 10, and 11 are the only regions where more than 1 percent of the region’s recipients are
classified with a catastrophic condition.
Figure 35: Percentage of Regions’ Recipients with a Catastrophic Condition, August 2014-July 2015
Note: Because enrollees may be in different regions over the course of the study period, these totals associate a person’s
CRG with the number of member months a person resided in a region.
He
alth
Sta
tus
9 –
Cat
astr
op
hic
Co
nd
itio
ns
31
Top Illness 2,348 17%
Illnesses 2-10
9,292 67%
Other Illnesses
2,247 16%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
0.0 0.5 1.0 1.5 2.0 2.5
Lung Malignancy
Digestive Malignancy
Other Malignancies
Breast Malignancy
Colon Malignancy
Brain and Central Nervous System Malignancies
Acute Lymphoid Leukemia
Kidney Malignancy
Pancreatic Malignancy
Ovarian Malignancy
Thousands
Level 1 Level 2 Level 3 Level 4
Health Status 8-Dominant, Metastatic or
Complicated Malignancies
A Dominant, Metastatic or
Complicated Malignancies
health status is assigned
when an individual has
one of 22 dominant or
chronic malignancies.
Each of the malignancies
is divided into one of four
severity levels.
The following chart
depicts the ten most
prevalent malignancies
along with the severity
levels of individuals in this
health status. Most of the
individuals in this health
status are Severity Level 2
and 3. Digestive
Malignancy has the
largest number of
individuals in Severity
Level 4.
Lung malignancies are the
top illness with 17 percent
or nearly 3,000
individuals. Eighty-two
percent of the individuals
in this category have one
of the top ten chronic
illnesses.
Figure 37: Top Malignancy Compared to All Other Illnesses, August 2014-July 2015
Figure 36: Number of Recipients with Health Status 8 by CRG and Level of Severity, August 2014-July 2015
32
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
0.0% 0.1% 0.1% 0.3%
1.1%
2.3%
1.0%
0.7%
0.0%
0.5%
1.0%
1.5%
SSI-Related Eligibility Group Family-Related EligibilityGroup
1.2%
0.0%
0.0%0.1%0.2%0.3%0.4%0.5%
Female Male
0.3% 0.4%
He
alth
Sta
tus
8 -
Do
min
ant,
Me
tast
atic
or
Co
mp
licat
ed M
alig
nan
cie
s
There is little difference by gender in
the percentage of recipients in the
metastatic health status.
Figure 38: Percentage of Eligibility Groups with a Malignancy, August 2014-July 2015
Figure 39: Percentage of Age Groups with a Malignancy, August 2014-July 2015
Figure 40: Percentage of Females and Males with a Malignancy, August 2014-July 2015
The percentage of
recipients with a metastatic
health status increases
among 43 to 53 year olds
and reaches its maximum
among 54 to 64 year olds.
A larger percentage of
recipients in the SSI-
Related eligibility group
than Family-Related
eligibility group have a
dominant, metastatic,
or complicated
malignancy. From
Health Status 9 through
Health Status 4, a larger
percentage of recipients
in the SSI-Related
eligibility group have
the health status than
the Family-Related
eligibility group.
33
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0.00%
0.25%
0.50%
0.75%
0.58%
0.42% 0.40%
0.33% 0.30%
0.28% 0.28% 0.27% 0.27% 0.22% 0.21% 0.21% 0.20% 0.19% 0.19%
0.16%
Only 0.3 percent of the Medicaid population is classified in Dominant, Metastatic, or Complicated
Malignancies. On average, Specialty Plans had 0.4 percent of their enrollees in this health status. CMS
had the largest percentage of enrollees of all the Specialty Plans. Fee-for-service has the largest
percentage of recipients in this category.
Overall, 0.3 percent of Standard Plans’ enrollees are in this category. United has the largest percentage
of Standard Plan enrollees in this health status with 0.42 percent.
0.00%
0.25%
0.50%
0.75%
FFS CMS Magellan All Specialty All Standard Clear Health Positive SunshineSpecialty
0.58% 0.56%
0.43% 0.40%
0.25%
0.11% 0.08%
0.04%
Figure 41: Percentage of Specialty Plan Enrollee Months with a Malignancy, August 2014-July 2015
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or
program associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS
program.
He
alth Statu
s 8 - D
om
inan
t, Me
tastatic or C
om
plicated
Malign
ancie
s
Aggregated Specialty Plans Specialty Plan Aggregated Standard Plans Fee-for-Service
Standard Plan
Aggregated Specialty Plans
Fee-for-Service
Figure 42: Percentage of Standard Plan Enrollee Months with a Malignancy, August 2014-July 2015
34
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0.40% - 0.42%
0.30% - 0.39%
0.20% - 0.29% Region 9
Region 8
Region 4
Region 2
Pensacola
Jacksonville
Tallahassee
St. Petersburg
Naples
Ft. Myers
Sarasota
Miami
Panama City
Daytona Beach
Tampa
Region 5
West Palm Beach
Region 10Ft. Lauderdale
Key West
Region 11
Orlando
M elbourne
Region 3
Gainesville
Ocala
Region 1
Region 6
Region 7
A larger percentage of recipients in Regions 5 than any other region are in the dominant metastatic
health status. Regions 6, 7, 8, and 9 have the smallest percentage of recipients in this health status.
Note: Because enrollees may be in different regions over the course of the study period, these totals
associate a person’s CRG with the number of member months a person resided in a region.
He
alth
Sta
tus
8 -
Do
min
ant,
Me
tast
atic
or
Co
mp
licat
ed M
alig
nan
cie
s
Figure 43: Percentage of Regions’ Population with Malignancies, August 2014-July 2015
35
0 3 6 9
Diabetes - Hypertension - Other Dominant ChronicDisease
Diabetes - 2 or More Other Dominant ChronicDiseases
Diabetes - COPD - Other Dominant Chronic Disease
Congestive Heart Failure - Diabetes - COPD
Chronic Renal Failure - Diabetes - Other DominantChronic Disease
Diabetes - Advanced Coronary Artery Disease -Other Dominant Chronic Disease
COPD - 2 or More Other Dominant ChronicDiseases
Congestive Heart Failure - Diabetes - OtherDominant Chronic Disease
Congestive Heart Failure - COPD - Other DominantChronic Disease
3 or More Other Dominant Chronic Diseases
Thousands
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
Top Illness 8,204 27%
Illnesses 2-10
17,404 56%
Other Illnesses
5,152 17%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims
Information, August 2014-July 2015.
Health Status 7-Dominant Chronic Disease in Three
or More Organ Systems
Dominant Chronic Disease
in Three or More Organ
Systems is assigned when
an individual has one of
21 dominant or moderate
chronic illnesses in three
or more organ systems.
The combination of
illnesses is divided into
one of six severity levels.
The chart displays the top
ten combinations of
illnesses among this group
along with severity levels.
Diabetes and
hypertension are the most
common chronic illnesses
in this health status.
Diabetes has the most
individuals classified as
Severity Level 6, the most
severe. Less than 1
percent of the Medicaid
population is in this
category.
The top ten illnesses are
present in 83 percent of
the individuals in this
health status. Only 17
percent have a CRG below
the top 10.
Figure 44: Number of Recipients with Health Status 7 by CRG and Level of Severity, August 2014-July 2015
Figure 45: Top Dominant Chronic Disease in Three or More Organ Systems Compared to All Other Illnesses,
August 2014-July 2015
36
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
- 10 20 30
Diabetes
Hypertension
Chronic Obstructive Pulmonary Disease
Congestive Heart Failure
Chronic Renal Failure
Advanced Coronary Artery Disease
Cerebrovascular Disease
Peripheral Vascular Disease
Other Dominant Chronic Disease
Thousands
Individuals in this health status by definition have more than one disease. The most frequent individual
illnesses among the combinations are shown in the following chart. Aside from the “other dominant
disease” category, diabetes is the most prevalent disease affecting 22 percent of this group.
He
alth
Sta
tus
7 -
Do
min
ant
Ch
ron
ic D
ise
ase
in T
hre
e o
r M
ore
Org
an S
yste
ms
Figure 46: Top 10 Individual Diseases, August 2014-July 2015
37
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
1%
2%
3%
4%
5%
6%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
0.0% 0.0% 0.2% 0.7%
2.8%
5.6%
2.0%
2.9%
0%
1%
2%
3%
SSI-Related EligibilityGroup
Family-Related EligibilityGroup
2.8%
0.1%
0%
1%
Female Male
0.8% 0.7%
He
alth
Sta
tus
7 -
Do
min
ant
Ch
ron
ic D
ise
ase
in T
hre
e o
r M
ore
Org
an S
yste
ms
Figure 49: Percentage of Females and Males with a Dominant Chronic Disease in 3 or More Organ Systems,
August 2014-July 2015
A larger percentage of
recipients in the SSI-Related
eligibility group than Family-
Related eligibility group are
classified in this health
status.
The percentage of
recipients with a
dominant chronic
disease in three or
more organ systems
increases among 43 to
53 year olds and
reaches its maximum
among 54 to 64 year
olds.
There is little difference by
gender in the percentage of
recipients with a dominant
chronic disease in three or more
organ systems.
Figure 47: Percentage of Eligibility Groups with a Dominant Chronic Disease in 3 or More Organ Systems, August 2014-July 2015
Figure 48: Percentage of Age Groups with a Dominant Chronic Disease in 3 or More Organ Systems, August 2014-July 2015
38
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
Only 0.8 percent of the Medicaid population is classified in this health status. Magellan, the serious
mental illness (SMI) Specialty Plan, has the largest percentage of enrollees in this category among the
Specialty Plans. Although mental health disease does not appear as one of the top ten illnesses, it is
included in the “other dominant chronic disease category.”
Simply and Humana are the Standard Plans with the largest percentage of enrollees in this category.
0%
1%
2%
3%
4%
5%
Magellan All Specialty FFS All Standard CMS Positive Clear Health SunshineSpecialty
4.79%
1.60%
0.89% 0.75% 0.44%
0.19% 0.15% 0.02%
0.0%
0.5%
1.0%
1.5%
2.0%
1.6%
1.4%
1.1% 1.0% 1.0% 0.9% 0.9%
0.7% 0.6% 0.6% 0.6% 0.6% 0.6% 0.5% 0.5%
0.4%
Figure 50: Percentage of Specialty Plan Enrollee Months with a Dominant Chronic Disease in 3 or More Organ Systems, August 2014-July 2015
Figure 51: Percentage of Standard Plan Enrollee Months with a Dominant Chronic Disease in 3 or More Organ Systems, August 2014-July 2015
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or
program associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS
program.
He
alth
Sta
tus
7 -
Do
min
ant
Ch
ron
ic D
ise
ase
in T
hre
e o
r M
ore
Org
an S
yste
ms
Aggregated Specialty Plans Specialty Plan Aggregated Standard Plans Fee-for-Service
Standard Plan Aggregated Specialty Plans Fee-for-Service
39
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
1.00% - 1.09%
0.60% - 0.99%Region 9
Region 8
Region 4
Region 2
Pensacola
Jacksonville
Tallahassee
St. Petersburg
Naples
Ft. Myers
Sarasota
Miami
Panama City
Daytona Beach
Tampa
Region 5
West Palm Beach
Region 10Ft. Lauderdale
Key West
Region 11
Orlando
M elbourne
Region 3
Gainesville
Ocala
Region 1
Region 6
Region 7
Regions 1, 5, and 11 are the only regions where more than one percent of recipients are classified as
Dominant Chronic Disease in Three or More Organ Systems.
Note: Because enrollees may be in different regions over the course of the study period, these totals
associate a person’s CRG with the number of member months a person resided in a region.
He
alth Statu
s 7 - D
om
inan
t Ch
ron
ic Dise
ase in
Thre
e o
r Mo
re Organ
System
s
Figure 52: Percentage of Regions’ Population with a Dominant Chronic Disease in 3 or More Organ Systems Status, August 2014-July 2015
40
0 5 10 15 20 25
Diabetes and Hypertension
Two Other Moderate Chronic Diseases
Diabetes and Other Moderate Chronic Disease
One Other Moderate Chronic Disease and OtherChronic Disease Level 2
Schizophrenia and Other Moderate ChronicDisease
One Other Dominant Chronic Disease and One orMore Moderate Chronic Disease
Asthma and Other Moderate Chronic Disease
Dementing Disease and Other Moderate ChronicDisease
Dementing Disease and Other Dominant ChronicDisease
Psychiatric Disease (Except Schizophrenia) andOther Moderate Chronic Disease
Thousands
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
Top Illness 23,866
9%
Illnesses 2-10
122,952 47%
Other Illnesses 116,697
44%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
Health Status 6-Significant Chronic Disease in Multiple
Organ Systems
Significant Chronic
Disease in Multiple Organ
Systems is assigned when
an individual has one of
22 combinations of
dominant, moderate or
minor chronic illnesses
present in multiple organ
systems. 6.5 percent of
Medicaid recipients are in
this Health Status. It is
the third most prevalent
Health Status.
The top ten conditions are
present in 56 percent of
the individuals in this
Health Status. 44 percent
have one of the other
combinations of
conditions.
Figure 53: Number of Recipients with Significant Chronic Disease in Multiple Organ Systems by CRG and Level of Severity, August 2014-July 2015
Figure 54: Top Significant Chronic Diseases in Multiple Organ Systems Compared to All Other Illnesses, August 2014-July 2015
41
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
- 25 50 75
Diabetes
Asthma
Hypertension
Chronic Obstructive Pulmonary Disease
Dementing Disease
Schizophrenia
Congestive Heart Failure
Psychiatric Disease (Except Schizophrenia)
Cerebrovascular Disease
Advanced Coronary Artery Disease
Thousands
Individuals in this health status by definition have more than one disease. The most frequent individual
illnesses among the combinations are shown in the following chart. Diabetes is the most prevalent
disease among Medicaid recipients in this category. Thirty-three percent of the individuals have
diabetes in combination with another chronic disease. Diabetes was also prevalent among recipients in
the previous Health Status 7. Mental illnesses are in the top ten illnesses in this health status but were
not uniquely identified in Health Status 7.
He
alth Statu
s 6 - Sign
ificant C
hro
nic D
isease
in M
ultip
le O
rgan Syste
ms
Figure 55: Top 10 Individual Chronic Diseases, August 2014-July 2015
42
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
10%
20%
30%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
1.2% 1.6%
5.6%
11.2%
20.8%
29.4%
13.0%
19.8%
0%
10%
20%
SSI-Related EligibilityGroup
Family-Related EligibilityGroup
18.4%
2.5%
0%
5%
10%
Female Male
7.3% 5.6%
He
alth
Sta
tus
6 -
Sig
nif
ican
t C
hro
nic
Dis
eas
e in
Mu
ltip
le O
rgan
Sys
tem
s
A slightly larger percentage of females
than males are classified with a
significant chronic disease in multiple
organ systems.
The percentage of
recipients with a
significant chronic
disease in multiple organ
systems increases with
age reaching its
maximum among 54 to
64 year olds.
A larger percentage of
recipients in the SSI-Related
eligibility group than Family-
Related eligibility group are
classified in this health status.
Figure 56: Percentage of Eligibility Groups with Significant Chronic Disease in Multiple Organ Systems, August 2014-July 2015
Figure 57: Percentage of Age Groups with Significant Chronic Disease in Multiple Organ Systems, August 2014-July 2015
Figure 58: Percentage of Females and Males with Significant Chronic Disease in Multiple Organ Systems,
August 2014-July 2015
43
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
5%
10%
15%
15.2%
10.4%
8.0% 7.7% 7.2% 6.9% 6.8% 6.6% 6.3% 6.2% 5.6% 5.3% 5.1% 5.1% 4.8%
3.5%
0%
10%
20%
30%
Magellan AllSpecialty
CMS FFS AllStandard
SunshineSpecialty
ClearHealth
Positive
26.7%
15.2% 14.6%
6.8% 6.5%
2.9% 2.1% 1.6%
Magellan, the serious mental illness (SMI) Specialty Plan, has the largest percentage of enrollees with a
significant chronic disease in multiple organ systems among the Specialty Plans with over a quarter of its
enrollees classified in this health status.
Simply and Humana are the Standard Plans with the largest percentage of enrollees with a significant
chronic disease in multiple organ systems. On average, 15 percent of Specialty Plan enrollees as
compared to 6.5 percent of Standard Plan enrollees are classified in this health status.
Figure 59: Percentage of Specialty Plan Enrollee Months with Significant Chronic Disease in Multiple Organ Systems, August 2014-July 2015
Figure 60: Percentage of Standard Plan Enrollee Months with a Significant Chronic Disease in Multiple Organ Systems, August 2014-July 2015
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or
program associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS
program.
He
alth Statu
s 6 - Sign
ificant C
hro
nic D
isease
in M
ultip
le O
rgan Syste
ms
Aggregated Specialty Plans Specialty Plan Aggregated Standard Plans Fee-for-Service
Standard Plan Aggregated Specialty Plans Fee-for-Service
44
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0.0% - 5.9%
8.0% - 8.9%
7.0% - 7.9%
6.0% - 6.9% Region 9
Region 8
Region 4
Region 2
Pensacola
Jacksonville
Tallahassee
St. Petersburg
Naples
Ft. Myers
Sarasota
Miami
Panama City
Daytona Beach
Tampa
Region 5
West Palm Beach
Region 10Ft. Lauderdale
Key West
Region 11
Orlando
M elbourne
Region 3
Gainesville
Ocala
Region 1
Region 6
Region 7
Regions 1, 2 and 5 have the largest percentage of recipients classified with a Significant Chronic Disease
in Multiple Organ Systems.
Figure 61: Percentage of Regions’ Population with a Significant Chronic Disease in Multiple Organ Systems, August 2014-July 2015
Note: Because enrollees may be in different regions over the course of the study period, these totals associate a person’s
CRG with the number of member months a person resided in a region.
He
alth
Sta
tus
6 -
Sig
nif
ican
t C
hro
nic
Dis
eas
e in
Mu
ltip
le O
rgan
Sys
tem
s
45
Top Illness 93,284
23%
Illnesses 2-10
206,346 50%
Other Illnesses 112,914
27%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
- 20 40 60 80 100
Asthma
Hypertension
Diabetes
Schizophrenia
Chronic Endocrine, Nutritional, Fluid, Electrolyteand Immune Diagnoses - Moderate
Developmental Delay NOS / NEC / Mixed
Epilepsy
Chronic Obstructive Pulmonary Disease andBronchiectasis
Depressive and Other Psychoses
Obesity
Thousands
Level 1 Level 2 Level 3 Level 4
Health Status 5-Single Dominant or Moderate
Chronic Disease
Single Dominant or
Moderate Chronic Disease
is assigned when an
individual has one of 107
dominant or moderate
chronic illnesses. 10.2
percent of Medicaid
recipients are in this
Health Status. It is the
second most prevalent
Health Status after
healthy. Asthma and
hypertension are the most
common illnesses in this
health status. There are
slightly more individuals
with asthma and
hypertension than all the
other eight illnesses
combined. The largest
number of individuals
with a severity level two
has asthma.
73 percent of the
individuals in this health
status had one of the top
ten illnesses.
Figure 63: Top Dominant Chronic Disease Compared to All Other Illnesses, August 2014-July 2015
Figure 62: Number of Recipients with Health Status 5 by CRG and Level of Severity, August 2014-July 2015
46
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
5%
10%
15%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
6.4%
8.2%
11.5%
14.9%
16.7% 15.6%
11.5%
17.4%
0%
5%
10%
15%
SSI-Related EligibilityGroup
Family-RelatedEligibility Group
15.1%
8.6%
0%
5%
10%
15%
Female Male
10.3% 10.2%
A larger percentage of recipients in
the SSI-Related eligibility group than
Family-Related eligibility group are
classified in this health status.
The percentage of
recipients with a single
dominant or moderate
chronic disease is
largest among the 85
and older age group,
although only by a
small amount
compared to 43 to 53
year olds.
There is little difference by gender in the
percentage of recipients with a single
dominant or moderate chronic disease.
Figure 64: Percentage of Eligibility Groups with Single Dominant or Moderate Chronic Disease, August 2014-July 2015
He
alth
Sta
tus
5 -
Sin
gle
Do
min
ant
or
Mo
de
rate
Ch
ron
ic D
ise
ase
Figure 66: Percentage of Females and Males with a Single Dominant or Moderate Chronic Disease, August 2014-July 2015
Figure 65: Percentage of Age Groups with a Single Dominant or Moderate Chronic Disease, August 2014-July 2015
47
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
10%
20%
30%
CMS AllSpecialty
Magellan SunshineSpecialty
AllStandard
FFS ClearHealth
Positive
29.0%
23.0% 22.8%
16.3%
10.5% 8.7%
3.3% 2.8%
0%
5%
10%
15%
20%
25% 23.0%
12.9%
11.0% 10.9% 10.8% 10.5% 10.1% 9.9% 9.9% 9.9% 9.7% 9.5% 9.5% 9.4% 8.7% 8.7%
Among Specialty Plans, CMS has the largest percentage of enrollees with a Single Dominant or moderate
chronic disease. Clear Health and Positive have the smallest percentage.
On average, 23 percent of Specialty Plan enrollees are classified in this health status as compared to 11
percent of Standard Plan enrollees. Simply and Humana are the Standard Plans with the largest
percentage of enrollees classified in this health status.
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or
program associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS
program.
He
alth Statu
s 5 - Sin
gle Do
min
ant o
r Mo
de
rate C
hro
nic D
isease
Aggregated Specialty Plans Specialty Plan Aggregated Standard Plans Fee-for-Service
Standard Plan Aggregated Specialty Plans Fee-for-Service
Figure 67: Percentage of Specialty Plan Enrollee Months with a Single Dominant or Moderate Chronic Disease, August 2014-July 2015
Figure 68: Percentage of Standard Plan Enrollee Months with a Single Dominant or Moderate Chronic Disease, August 2014-July 2015
48
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
9.0% - 9.9%
12.0% - 12.9%
11.0% - 11.9%
10.0% - 10.9% Region 9
Region 8
Region 4
Region 2
Pensacola
Jacksonville
Tallahassee
St. Petersburg
Naples
Ft. Myers
Sarasota
Miami
Panama City
Daytona Beach
Tampa
Region 5
West Palm Beach
Region 10Ft. Lauderdale
Key West
Region 11
Orlando
M elbourne
Region 3
Gainesville
Ocala
Region 1
Region 6
Region 7
Region 2 has the largest percentage of recipients with a Single Dominant or moderate chronic disease.
Regions 9 and 10 have the smallest percentage of recipients with this health status.
Note: Because enrollees may be in different regions over the course of the study period, these totals associate a person’s CRG
with the number of member months a person resided in a region.
He
alth
Sta
tus
5 -
Sin
gle
Do
min
ant
or
Mo
de
rate
Ch
ron
ic D
ise
ase
Figure 69: Percentage of Regions’ Population with a Single Dominant or Moderate Chronic Disease, August 2014-July 2015
49
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
- 50 100 150
Asthma
Diabetes
Hypertension
Chronic Obstructive Pulmonary Disease andBronchiectasis
Schizophrenia
Congestive Heart Failure
Chronic Endocrine, Nutritional, Fluid,Electrolyte and Immune Diagnoses - Moderate
Dementing Disease
Developmental Delay NOS / NEC / Mixed
Cerebrovascular Disease
Thousands
Health Status 5 Health Status 6 Health Status 7
Comparing Health
Status 5, 6, and 7
Health Status categories
5, 6, and 7 include
individuals who have one
or more dominant or
moderate illnesses. 17.5
percent of the Medicaid
population is categorized
in the three health
statuses combined. The
top ten individual illnesses
across all three health
statuses are shown in the
chart. Asthma, diabetes,
and hypertension are the
most prevalent illnesses
among Medicaid
recipients with a
dominant or moderate
chronic disease alone or in
combination.
Figure 70: Top 10 Chronic Diseases Across Health Statuses 5, 6, and 7, August 2014-July 2015
50
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,
August 2014-July 2015.
- 10 20 30 40
Multiple Minor ChronicPCDs
Thousands
Level 1 Level 2 Level 3 Level 4
Health Status 4-Minor Chronic Disease in Multiple Organ
Systems
Note: The CRG software does not identify the specific illnesses associated with the individuals in this
health status.
Minor Chronic Disease in
Multiple Organ systems is
assigned when an
individual has two or
more minor chronic
illnesses such as attention
deficit hyperactivity
disorder, hyperlipidemia,
or depression. The level
of severity corresponds to
the number of Minor
Chronic illnesses present
and their severity. Less
than one percent of
Medicaid recipients are
classified in this Health
Status.
Figure 71: Number of Recipients with Health Status 4 by CRG and Level of Severity, August 2014-July 2015
51
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
0.1%
0.4%
1.4%
2.5%
2.1%
1.4%
0.5% 0.6%
0.0%
0.5%
1.0%
SSI-Related EligibilityGroup
Family-Related EligibilityGroup
1.0%
0.7%
0.0%
0.5%
1.0%
Female Male
1.0%
0.6%
There is little difference by
gender in the percentage of
recipients with a minor chronic
disease in multiple organ
systems.
The percentage of
recipients with a
minor chronic
disease in multiple
organ systems is
largest among 32 to
53 year olds.
A larger percentage of
recipients in the SSI-
Related eligibility group
than Family-Related
eligibility group are
classified in this health
status.
Figure 72: Percentage of Eligibility Groups with Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015
Figure 73: Percentage of Age Groups with Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015
He
alth Statu
s 4 - M
ino
r Ch
ron
ic Dise
ase in
Mu
ltiple
Organ
Systems
Figure 74: Percentage of Females and Males with a Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015
52
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
1%
2%
3%
Magellan AllSpecialty
CMS AllStandard
FFS SunshineSpecialty
ClearHealth
Positive
2.5%
1.4% 1.2%
0.9%
0.4% 0.2% 0.2%
0.0%
0.00%
0.50%
1.00%
1.50% 1.4%
1.2%
1.1%
1.0% 1.0% 0.9% 0.9% 0.9%
0.8%
0.7% 0.7% 0.6% 0.6%
0.4% 0.4%
0.3%
Magellan and CMS have a larger percentage of enrollees with minor chronic disease in multiple organ
systems than other Specialty Plans at 2.5 percent and 1.2 percent respectively.
One percent or less of enrollees in each Standard Plan has a minor chronic disease in multiple organ
systems.
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or program
associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS program.
He
alth
Sta
tus
4 -
Min
or
Ch
ron
ic D
ise
ase
in M
ult
iple
Org
an S
yste
ms
Aggregated Specialty Plans Specialty Plan Aggregated Standard Plans Fee-for-Service
Figure 75: Percentage of Specialty Plan Enrollee Months with Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015
Figure 76: Percentage of Standard Plan Enrollee Months with a Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015
Standard Plan Aggregated Specialty Plans Fee-for-Service
53
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
1.00% - 1.19%
0.40% - 0.99%Region 9
Region 8
Region 4
Region 2
Pensacola
Jacksonville
Tallahassee
St. Petersburg
Naples
Ft. Myers
Sarasota
Miami
Panama City
Daytona Beach
Tampa
Region 5
West Palm Beach
Region 10Ft. Lauderdale
Key West
Region 11
Orlando
M elbourne
Region 3
Gainesville
Ocala
Region 1
Region 6
Region 7
Regions 1, 2, 3, and 5 have 1 percent or more of recipients with a minor chronic disease in multiple
organ systems. Less than 1 percent of recipients in other regions are in this health status.
Note: Because enrollees may be in different regions over the course of the study period, these totals associate a
person’s CRG with the number of member months a person resided in a region.
He
alth Statu
s 4 - M
ino
r Ch
ron
ic Dise
ase in
Mu
ltiple
Organ
Systems
Figure 77: Percentage of Regions’ Population with a Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015
54
Top Illness 57,426
28%
Illnesses 2-10
113,875 54%
Other Illnesses 37,835
18%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims
Information, August 2014-July 2015.
- 20 40 60
Attention Deficit / Hyperactivity Disorder
Hyperlipidemia
Osteoarthritis
Depression
Chronic Thyroid Disease
Chronic Neuromuscular and Other NeurologicalDiagnoses - Minor
Chronic Joint and Musculoskeletal Diagnoses -Minor
Developmental Language Disorder
Chronic Pain
Psoriasis
Thousands
Level 1 Level 2
Health Status 3-Single Minor Chronic Disease
Single Minor Chronic
Disease is assigned when
an individual has one of
41 minor chronic illnesses
present. 5.2 percent of
Medicaid recipients are in
this Health Status. The
most common single
minor chronic disease is
attention deficit /
hyperactivity disorder.
Depression is the only
disease among the top
ten with a larger
percentage of individuals
in severity level two than
severity level one.
82 percent of recipients in
this health status have
one of the top ten
illnesses.
Figure 79: Top Single Minor Chronic Disease Compared to All Other Illnesses, August 2014-July 2015
Figure 78: Number of Recipients with Health Status 3 by CRG and Level of Severity, August 2014-July 2015
55
0%
2%
4%
6%
8%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
3.1%
5.5%
6.7%
7.4%
5.5%
3.3%
2.4% 2.9%
0%
2%
4%
6%
SSI-Related EligibilityGroup
Family-Related EligibilityGroup
4.3%
5.5%
0%
2%
4%
6%
Female Male
5.1% 5.4%
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
This is the first Health
Status where a larger
percentage of recipients in
the Family-Related
eligibility group than SSI-
Related eligibility group
are classified in the health
status.
He
alth Statu
s 3 - Sin
gle Min
or C
hro
nic D
isease
The percentage of
recipients with a
single minor chronic
disease is largest
among 1 to 53 year
olds.
There is little difference by
gender in the percentage of
recipients with a single minor
chronic disease.
Figure 80: Percentage of Eligibility Groups with a Single Minor Chronic Disease, August 2014-July 2015
Figure 81: Percentage of Age Groups with a Single Minor Chronic Disease, August 2014-July 2015
Figure 82: Percentage of Females and Males with a Single Minor Chronic Disease, August 2014-July 2015
56
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
5%
10%
CMS AllSpecialty
SunshineSpecialty
Magellan AllStandard
FFS ClearHealth
Positive
11.8%
9.3% 8.8%
7.8%
5.9%
2.9%
1.3% 0.8%
0%
2%
4%
6%
8%
10% 9.3%
7.1% 7.0%
5.8% 5.7% 5.7% 5.6% 5.5% 5.5% 4.9% 4.7% 4.5% 4.3% 4.2%
3.8% 2.9%
CMS has the largest percentage of enrollees with a single minor chronic disease. Twelve percent of
CMS’ enrollees are classified in this health status. On average, nine percent of Specialty as compared to
six percent of Standard Plan enrollees is classified in this health status.
Staywell and Amerigroup are the Standard Plans with the largest percentage of enrollees with a single
minor chronic disease.
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or
program associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS
program.
He
alth
Sta
tus
3 -
Sin
gle
Min
or
Ch
ron
ic D
ise
ase
Aggregated Specialty Plans Specialty Plan Aggregated Standard Plans Fee-for-Service
Standard Plan Aggregated Specialty Plans Fee-for-Service
Figure 83: Percentage of Specialty Plan Enrollee Months with a Single Minor Chronic Disease, August 2014-July 2015
Figure 84: Percentage of Standard Plan Enrollee Months with a Single Minor Chronic Disease, August 2014-July 2015
57
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
3.0% - 3.9%
7.0% - 7.9%
6.0% - 6.9%
5.0% - 5.9%
4.0% - 4.9%
Region 9
Region 8
Region 4
Region 2
Pensacola
Jacksonville
Tallahassee
St. Petersburg
Naples
Ft. Myers
Sarasota
Miami
Panama City
Daytona Beach
Tampa
Region 5
West Palm Beach
Region 10Ft. Lauderdale
Key West
Region 11
Orlando
M elbourne
Region 3
Gainesville
Ocala
Region 1
Region 6
Region 7
Regions 1, 2, and 3 have a larger percentage of recipients than other regions classified in the single
minor chronic disease health status.
Note: Because enrollees may be in different regions over the course of the study period, these totals associate a
person’s CRG with the number of member months a person resided in a region.
He
alth Statu
s 3 - Sin
gle Min
or C
hro
nic D
isease
Figure 85: Percentage of Regions’ Population with a Single Minor Chronic Disease Status, August 2014-July 2015
58
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims
Information, August 2014-July 2015.
- 25 50 75 100
Significant Acute Illness Excluding ENT
Significant Acute Procedure
Persistent Significant Acute IllnessExcluding ENT
Two or More Significant Acute Illnessesfrom Different MDCs Excluding ENT
Persistent Significant Acute ENT Illness
Significant Acute ENT Illness
Thousands
Health Status 2-Recent History of Significant Acute
Illness
Significant Acute Illness is
assigned when an
individual has a significant
acute illness present.
Only 6 categories of acute
illness are defined by the
3M grouper. 6.3 percent
of Medicaid recipients are
in this Health Status. It is
the fourth most prevalent
Health Status.
Examples of Significant
Acute Illnesses include
pneumonia, blood
transfusions, and bacterial
infections.
Figure 86: Number of Recipients with Health Status 2 by CRG and Level of Severity, August 2014-July 2015
59
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
5%
10%
15%
20%
<1 1-20 21-31 32-42 43-53 54-64 65-84 85+
15.7%
5.9%
8.4%
5.8%
3.6% 2.8% 3.5% 5.2%
0%
2%
4%
6%
8%
SSI-Related EligibilityGroup
Family-Related EligibilityGroup
3.7%
7.2%
0%
2%
4%
6%
8%
Female Male
6.5% 6.0%
He
alth Statu
s 2 – R
ece
nt H
istory o
f Significan
t Acu
te Illn
ess
There is little difference by
gender in the percentage of
recipients with an acute
illness.
The percentage of
recipients with a
significant acute
illness is largest
among children
under the age of one.
A larger percentage of
recipients in the Family-
Related eligibility group
than SSI-Related eligibility
group are classified in this
health status.
Figure 87: Percentage of Eligibility Groups with a Significant Acute Illness, August 2014-July 2015
Figure 88: Percentage of Age Groups with a Significant Acute Illness, August 2014-July 2015
Figure 89: Percentage of Females and Males with a Significant Acute Illness, August 2014-July 2015
60
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
0%
2%
4%
6%
8%
SunshineSpecialty
AllStandard
CMS AllSpecialty
FFS Magellan ClearHealth
Positive
7.1% 6.9%
5.7%
5.0% 4.6%
3.6%
2.2%
1.0%
0%
2%
4%
6%
8%
10%8.1%
8.0% 7.9% 7.3%
7.0% 6.9% 6.7% 6.6% 6.5% 6.4% 6.3% 6.2% 6.1%
5.5% 5.0%
4.6%
Figure 91: Percentage of Standard Plan Enrollee Months with a Significant Acute Illness, August 2014-July 2015
Sunshine Specialty is the specialty plan with the largest percentage of enrollees classified in the Acute
Illness health status. On average, five percent of Specialty Plan enrollees are categorized in this health
status.
On average, seven percent of standard plan enrollees are categorized in this health status. Coventry,
Amerigroup, and Simply Healthcare have the largest percentage of enrollees in this health status with
about eight percent each.
Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or
program associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS
program.
He
alth
Sta
tus
2 –
Re
cen
t H
isto
ry o
f Si
gnif
ican
t A
cute
Illn
ess
Aggregated Specialty Plans Specialty Plan Aggregated Standard Plans Fee-for-Service
Standard Plan Aggregated Specialty Plans Fee-for-Service
Figure 90: Percentage of Specialty Plan Enrollee Months with a Significant Acute Illness, August 2014-July 2015
61
Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.
6.0% - 6.9%
5.0% - 5.9%
Region 9
Region 8
Region 4
Region 2
Pensacola
Jacksonville
Tallahassee
St. Petersburg
Naples
Ft. Myers
Sarasota
Miami
Panama City
Daytona Beach
Tampa
Region 5
West Palm Beach
Region 10Ft. Lauderdale
Key West
Region 11
Orlando
M elbourne
Region 3
Gainesville
Ocala
Region 1
Region 6
Region 7
Only 3 regions, Regions 2, 4, and 10, have less than 6 percent of recipients classified with a health status
of Significant Acute Illness.
Note: Because enrollees may be in different regions over the course of the study period, these totals associate a person’s
CRG with the number of member months a person resided in a region.
He
alth Statu
s 2 – R
ece
nt H
istory o
f Significan
t Acu
te Illn
ess
Figure 92: Percentage of Regions’ Population with a Significant Acute Illness Status, August 1, 2014 - July 31, 2015
62
Conclusions Almost 70 percent of all Medicaid recipients are classified as healthy. However, a smaller percentage of
recipients in an SSI-Related eligibility group as opposed to Family-Related eligibility group, adults as
opposed to children, Specialty Plan enrollees as opposed to Standard Plan enrollees and recipients in the
fee-for-service program, and recipients in more rural as opposed to urban regions of Florida are healthy.
A larger percentage of recipients in the fee-for-service program are categorized as healthy than
Standard Plan enrollees and Specialty Plan enrollees. Community Care is the only Standard Plan with a
larger percentage of enrollees categorized as healthy as compared to recipients in the fee-for-service
program. Among Specialty Plans, Sunshine Specialty has the largest percentage of enrollees categorized
as healthy. These results are descriptive and are not indicative of causal relationship.
The most common illnesses among Medicaid recipients are asthma, acute illness, and hypertension. The
prevalence of disease is highly related to age and eligibility group. Asthma and acute illness is common
among recipients in a Family-Related eligibility group and children under the age of 21. Hypertension is
common among recipients in an SSI-Related eligibility group and adults 21 and over. Attention deficit/
hyperactivity disorder is also common among recipients in a Family-Related eligibility group and children
under the age of 21. Other common illnesses among recipients in an SSI-Related eligibility group and
adults include diabetes, schizophrenia, and hyperlipidemia. Dementing illnesses and Alzheimer’s are the
most common illnesses among recipients 85 and older. Asthma, acute illness, hypertension, attention
deficit / hyperactivity disorder, and hyperlipidemia are among the top illnesses among Standard Plans
although the order of prevalence shifts some among the plans. These are also the top illnesses in every
region with the order of prevalence shifting slightly among the regions. Because the Specialty Plans,
with the exception of Sunshine Specialty, are designed to serve populations with specific illnesses, the
top illnesses vary among Specialty Plans. The most common disease among enrollees in Clear Health
and Positive, the two HIV/AIDS Specialty Plans, is HIV. Schizophrenia is the most common disease
among enrollees in Magellan, the Specialty Plan for serious mental illness. Enrollees in CMS, the
Specialty Plan for children with chronic disease, and Sunshine specialty, the Specialty Plan for Child
Welfare, share the same 3 most common illnesses – attention deficit/hyperactivity disorder, asthma,
and developmental disability.
Thirty-one percent of the Medicaid population is categorized as other than healthy. Ten percent have a
single dominant or moderate chronic disease, 6.5 percent have a chronic disease in multiple organ
systems, 6.3 percent have a history of significant acute illness, and 5.2 percent have a single minor
chronic disease. Less than a percent have a catastrophic illness. HIV/AIDS is the dominant disease
among recipients with a catastrophic illness. Diabetes, hypertension, and asthma are the most frequent
illnesses among dominant chronic illnesses. Attention deficit/hyperactivity disorder and hyperlipidemia
are the most common illnesses among minor chronic illnesses.
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