Improving Care for Medicaid Beneficiaries with Complex Care Needs and High Costs

Patient Need Addressed: Behavioral health, Substance Use
Population Focus: Complex care, Medicaid beneficiaries
Type of Literature: Grey
link: https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/program-areas/beneficiaries-with-complex-needs/index.html
Abstract

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Insights Results

Overview of article

  • Beneficiaries with Complex Care Needs and High Costs (BCNs) are Medicaid beneficiaries who, because of their health and/or social conditions, are likely to experience high levels of costly but preventable service utilization. This subset of Medicaid beneficiaries (“super-utilizers”) is an extremely heterogeneous group with varying medical, behavioral, and psycho-social needs. The distribution of spending is uneven within Medicaid, with just 5% of Medicaid beneficiaries accounting for 54% of total Medicaid expenditures
  • This site outlines several tools and programs that state Medicaid agencies can use to identify and better understand BCNs. For example, one technical resource outlines preliminary steps that state Medicaid agencies can use to identify Medicaid adult beneficiaries with Serious Mental Illness (SMI) and to gain a better understanding of this population to inform future decision-making. This resource also provides examples of potential data outputs that can be replicated using a state’s Medicaid claims and encounters data. State Medicaid agencies can use this resource in collaboration with state mental health and substance abuse authorities to foster mutual understanding of Medicaid beneficiaries with SMI, key population attributes, their use of Medicaid services, and Medicaid service costs
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