Medicaid in Pennsylvania Peg J. Dierkers Deputy Secretary for Medical Assistance Programs Department of Public Welfare Definitions пЃ® Medicare is: вЂ“ вЂ“ вЂ“ вЂ“ пЃ® A federal health insurance program For people 65 years of age or older For certain younger people with disabilities For people with End-Stage Renal Disease Medicaid is: вЂ“ A joint federal and state program вЂ“ For people with low incomes вЂ“ For people with limited resources Pennsylvania Medicaid Authorization пЃ® Social Security Act пЃ® Public Welfare Code Medicaid Is пЃ® Mandates and options пЃ® Options and more mandates Medicaid State Plan пЃ® Condition of federal financial participation пЃ® Explains state program пЃ® Must be amended when significant changes are planned Who Receives Medicaid Services in Pennsylvania пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® 52.9% Children (Age 21 and under) 12.2% Elderly (Age 65 and older) 0.1% Blind 20.3% Disabled 18.4% Families with Children Close to 1.4 million individuals receive Medicaid in Pennsylvania Source: MA Eligibility Statistics, Office of Income Maintenance, 3/2000 The Cost of Medicaid in Pennsylvania пЃ® пЃ® пЃ® пЃ® Expected to cost $8.5 billion in Fiscal Year 20002001 Represents 47.95% of the Department of Public Welfare budget * Represents 15.41% of the General Fund budget * Health care continues to be one of the fastest areas of growth in our economy Source: Budget Briefing Book, Fiscal Year 1997-98 Pennsylvania Medicaid is one of the Largest Insurers Nationally пЃ® Provides services to almost 1.4 million individuals пЃ® On average, it costs $4,000 per person, per year пЃ® One of the most comprehensive of all state Medicaid programs Pennsylvania Medicaid Administration пЃ® Department of Public Welfare вЂ“ State Medicaid Agency вЂ“ Office of Medical Assistance Programs В» Bureau of Fee-for-Service Programs В» Bureau of Managed Care Operations В» Bureau of Long Term Care Programs В» Bureau of Data and Claims Management В» Bureau of Program Integrity В» Bureau of Policy, Budget and Planning Pennsylvania Department of Public Welfare пЃ® Seven Deputates вЂ“ вЂ“ вЂ“ вЂ“ вЂ“ вЂ“ вЂ“ Office of Income Maintenance Office of Mental Health and Substance Abuse Services Office of Mental Retardation Office of Social Programs Office of Children, Youth and Families Office of Administration Office of Medical Assistance Programs Other Administrative Supports Office of the Comptroller пЃ® Office of Budget пЃ® Office of Policy пЃ® Office of Legal Counsel пЃ® Office of Communication пЃ® Office of State and Federal Relations пЃ® Financing Medicaid in Pennsylvania пЃ® пЃ® пЃ® пЃ® Expected to cost $8.5 billion in Fiscal Year 20002001 On October 1, 2000, Federal Medical Assistance Percentage (FMAP) will be 53.67 percent By law, FMAP cannot be lower than 50 percent or more than 83 percent FMAP can only be earned on federal categories of eligibility Applying for Medicaid пЃ® County Assistance offices determine eligibility пЃ® If eligible, ACCESS cards are issued пЃ® Eligibility periodically reviewed Who Receives Medicaid in Pennsylvania пЃ® More than 50 percent are children пЃ® 25 percent are Temporary Assistance for Needy Families пЃ® 20 percent are Social Security Income Services пЃ® Children receive all medically necessary services пЃ® Categorically needy adults receive all benefits пЃ® Medically needy adults receive all benefits but pharmacy, dental and durable medical equipment and supplies Medicaid Waivers пЃ® 1915(b) Freedom of Choice пЃ® 1915(c) Home and Community-Based Services пЃ® 1115 Allows states to provide services to persons who do not financially qualify Medicaid Services in Pennsylvania пЃ® Two Parallel Delivery Systems: вЂ“ Fee-for-Service вЂ“ Managed Care В» Voluntary В» Mandatory Fee-for-Service пЃ® $160 million weekly пЃ® 56,008 providers Managed Care Managed Care Payments for Medicaid Services пЃ® ACCESS Card пЃ® Invoices пЃ® Capitated Payments Medical Assistance Goals of the Ridge Administration пЃ® Increase access to care пЃ® Improve quality of care пЃ® Stabilize spending Human Services Goals of the Ridge Administration пЃ® Home and Community Service Alternatives to Institutionalization пЃ® Supporting Welfare to Work пЃ® Expand HealthChoices Challenges Cost of Pharmaceuticals пЃ® Growing Elderly Population пЃ® Supporting Welfare to Work пЃ® Technology пЃ® Continued Growth of Long Term Care Program пЃ® Research Access Department of Public Welfare Office of Medical Assistance Programs Department of Public Welfare Resources DPW Databases Client Information System (CIS) пЃ® The Client Information system (CIS) contains information on clients and members of their households enrolled in Cash, Medical Assistance, and/or Food Stamps. This system includes: 1. 2. 3. 4. Demographics MA Enrollment History Managed Care Enrollment a. Regular Health b. Behavioral Health Special Populations (Foster Care, Adoption, SSI) Client Information System (CIS) Cont. 5. 6. Special Facilities (Personal Care Homes, Long Term Care, MH, MR, etc..) Waiver (MA, MR, OSP, Aging) **Aggregating data to School District or Zip Code levels for local summarization and GIS Medical Assistance Management Information System (MAMIS) пЃ® MAMIS contains information on Medical Assistance payments. 1. For the Managed Care population, this system contains the monthly Capitation fee issued for each recipient. (No service data is recorded). 2. For Fee-For-Service clients, this system includes information on all medical services provided, including the provider, the costs, and the diagnosis. Encounter Databases пЃ® The Encounter Databases contain the Service information for recipients enrolled in Managed Care. 1. Regular. -information on medical services provided similar to that of the MAMIS System., (This is a relatively new reporting system. Since we are still working on data accuracy and integrity issues, information from this system is not being released at this time.). 2. Behavioral Health. -information on behavioral health services provided similar to that of the MAMIS System. CCRS/POMS (Consolidated Community Reporting System) (Performance Outcomes Measures System) пЃ® These systems contain Client-specific information reported by the counties for clients receiving mental health and substance abuse services. Early Intervention пЃ® This system contains client-specific information on children who receive Early Intervention service from DPW (ages 0-2). Licensed Facilities пЃ® This system contains information on licensed personal care homes, day care, mental health, mental retardation and child welfare facilities including capacity and addresses. Community Service Program for Persons With Physical Disabilities (CSPPD) and Attendant Care пЃ® These systems contain client-specific information for persons with physical disabilities and persons who require Attendant Care. Resources External Data Sources Department Of Health пЃ® Drug and Alcohol. This system is a client-specific database maintained by extremely tight security measures which are enforced. Aggregate information may be available but client-specific information is not available. пЃ® Reportable Diseases. This system includes AIDS and other reportable diseases and related information. This system is also an extremely secure database where only aggregate information may be available. Department Of Health Cont. пЃ® Vital Statistics. This system contains the following information: 1. Births: age, race of mother, prenatal care, birth weight. 2. Deaths: cause of death. 3. Marriages. 4. Divorces. пЃ® Hospitals, Nursing Home and Drug and Alcohol Facilities (D&A). These system contains information on licensed hospitals, nursing homes, and D&A facilities including licensed beds and length of stay. Department of Insurance пЃ® ChildrenвЂ™s Health Insurance Program (CHIP). CHIP is Pennsylvania's program to provide quality health insurance for children of working families who otherwise could not afford it. This is a very new data system. Health Care Cost Containment Council (HC4) пЃ® This system contains information on all inpatient hospitalizations. This is an extensive database which includes: 1. 2. 3. Length of Stay Charges Diagnosis 4. 5. Provider information Other related information Department of Public Welfare Data Research Requests Data Research Request Criteria пЃ® The Office of Medical Assistance Programs considers the following general approval criteria when deciding to participate in any data request or project: вЂ“ Advance the goals of the Department of Public Welfare; вЂ“ Provide benefit to the Department commensurate with the level of effort; вЂ“ Be consistent with existing Department resources; вЂ“ Does not duplicate current or planned Department activities; Data Research Request Criteria, Cont.. вЂ“ вЂ“ вЂ“ вЂ“ Feasible within existing Department resources; Consistent with the rules of confidentiality; Consistent with federal and state statute and regulation; The requestor must agree to the DepartmentвЂ™s review and right to comment on work products prior to release or publication; вЂ“ Must include appropriate research methodology. Once a project meets these criteria, it is further reviewed for consistency with Policy and Clinical approval criteria. Submitting a Request A request should be submitted to: Ms. Suzanne Love Director Bureau of Policy, Budget and Planning Office of Medical Assistance Programs P.O. Box 2675 Harrisburg, PA 17105 Submitting a Request, Cont. пЃ® пЃ® пЃ® пЃ® All requests must be submitted at least 45 days in advance of the need for a decision; The request must be made on the organizationвЂ™s official letterhead; It must provide the exact specifications of the data needed or other indication of the level of participation being requested of OMAP; It must contain the name and telephone number of the contact person who can respond to any questions that may arise during the evaluation of the request; NOTE: Any changes in the scope of the original will require resubmission of the request. request Submitting a Request, Cont.. пЃ® The result of the evaluation of the request against the participation criteria will determine OMAPвЂ™s continued or expanded participation in the project. NOTE: The Department reserves the right to deny any requests, even those that have met all criteria. пЃ® пЃ® The requestor must sign a confidentiality agreement prior to the release of any data. Under some circumstances, especially when OMAP is asked to conduct special data runs or analysis, the Department will negotiate a payment with the requestor to cover administrative costs. NOTE: Participation of OMAP will be contingent upon receipt of payment. Department of Public Welfare Current Research Evaluations/reports 1. External Evaluations пЃ® Evaluation of Programs funded through the Pennsylvania ChildrenвЂ™s Trust Fund: Johns Hopkins University School of Hygiene and public Health, February, 1997. пЃ® Family to Family Foster Care Reform: Research Triangle Institute and University of North Carolina School of social work and Pennsylvania Department of Public Welfare. Analysis of entry cohortsвЂќsurvival analysis, reentry rates,and placement patterns for Pennsylvania and other states receiving funding through the Annie E. Casey foundation. пЃ® Report on Uninsured Children In Pennsylvania: Pennsylvania Partnerships for Children, with assistance from Pennsylvania Department of Public Welfare, March 2000. пЃ® Independent Assessment of -SE: (in progress) due September,2001. Delmarva Foundation 2. DPW Evaluations пЃ® Independent Assessment of HealthChoices-SE: a 1915(b) Medicaid waiver evaluation, November, 1998. пЃ® Independent Assessment of the Lancaster Community Health Plan: a HCFA waiver evaluation, July 1997. A second evaluation is due in mid-July, 2000. пЃ® пЃ® Independent Assessment of the Family Care Network: a HCFA waiver evaluation, December, 1998. Analysis of вЂњScott DataвЂќ : performance indicators for children enrolled in PennsylvaniaвЂ™s Medical Assistance Program. 3. Additional Reports Available пЃ® Annual Child Abuse Report. Health Choices: The First Year: пЃ® Health Choices Southwest: An Introduction: пЃ® Office of Medical Assistance Programs;Office of Mental Health and Substance Abuse Services. Office of Medical Assistance Programs; Office of Mental Health and Substance Abuse Services.