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

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, and whose care patterns and costs are potentially “impactable” (CMCS July 24, 2013 Informational Bulletin (PDF, 423.03 KB)). 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 five percent of Medicaid beneficiaries accounting for 54 percent of total Medicaid expenditures and one percent of Medicaid beneficiaries accounting for 25 percent of total Medicaid expenditures.

Using Data Analytics to Better Understand Medicaid Populations with Serious Mental Illness

This technical resource (PDF, 1.12 MB) 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.

This second technical resource (PDF, 1.17 MB) describes approaches to supplementing and matching Medicaid data with additional data sources that can assist state Medicaid agencies with better understanding Medicaid populations with serious mental illness. Data analyses related to housing, corrections/justice involvement and food insecurity are highlighted as examples. The Medicaid IAP created this technical resource to assist state Medicaid agencies in developing approaches for engaging external partners to share data and conduct analytics to better understand these impacts.

Using Data Analytics to Better Understand Medicaid Populations with Serious Mental Illness Technical Assistance

In 2020, IAP is offering technical assistance to Medicaid agencies in Hawaii, Iowa, Indiana, Michigan, New Jersey, and Virginia that aims to utilize data analytics to gain a better understanding of their adult population with SMI and to help inform related programmatic decisions. This technical assistance includes interactive webinars and coaching assistance. The technical assistance is provided through three inter-related components which will run sequentially. Participating Medicaid agencies can select one or all three to join.

  • Component 1: Build an SMI Population Profile
    • Conduct analyses to further understand state populations with SMI using Medicaid claims and encounters data (demographic, cost, and utilization information)
    • Develop or start developing state Medicaid SMI population profiles
  • Component 2: Leverage External Data Sources
    • Augment state SMI population profiles with external data sources (e.g. corrections, housing data)
    • Navigate challenges in data matching and other SMI data sharing barriers
    • Develop data sharing and use strategies with other state or external data partners
  • Component 3: Consider SMI Data-Informed Delivery System Reform
    • Exchange lessons learned
    • Apply SMI data in the design if a consider delivery system reform

Review the Technical Assistance Program Overview (PDF, 171.92 KB) and Information Session Slides (PDF, 1.07 MB).

BCN Program Support for State Medicaid Agencies

Under this program priority area, targeted program support is available for states that have ongoing efforts to improve care coordination for Medicaid BCNs. Medicaid IAP’s specific goals are to:

  1. Enhance state capacity to use data analytics to better serve the BCN population
  2. Develop/refine payment reforms to support BCN programs
  3. Facilitate the replication/spread of BCN programs demonstrating promising results

IAP selected five states (District of Columbia, New Jersey, Oregon, Texas, and Virginia) for the first BCN activity which began in October 2015. After ten months of structured program support through in-person meetings, virtual collaborative workshops, and one-on-one assistance, these participating states can access additional program support as needed to assist in the successful progress of their BCN initiatives. Additional information about the program support offered and these states’ specific focus areas can be found in the IAP BCN Factsheet (PDF, 44.81 KB).

2016-2017 National Dissemination Webinars

In October 2016, IAP began holding a four-part national webinar series to share insights from the first 10-month IAP BCN initiative along with lessons learned and tools that states can use as they design and implement activities related to Medicaid beneficiaries with complex needs and high costs.

Tools and Resources

Previous Webinars: June 29, 2015 Information Session for States (PDF, 2.01 MB).


Thomas-Henkel C., Hamblin A., and Hendricks T. Supporting a Culture of Health for High-Need, High-Cost Populations: Opportunities to Improve Models of Care for People with Complex Needs. The Robert Wood Johnson Foundation and the Center for Health Care Strategies. November 2015.

Cohen S and Yu W. The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2008-2009. Agency for Healthcare Research and Quality. January 2012.

Mann C. Medicaid and CHIP: On the Road to Reform. Presentation to the Alliance for Health Reform/Kaiser Family Foundation. March 2011. Based on FY 2008 MSIS claims data.