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Department of Public Welfare

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Medicaid in Pennsylvania
Peg J. Dierkers
Deputy Secretary for Medical
Assistance Programs
Department of Public Welfare
Definitions
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Medicare is:
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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:
– A joint federal and state program
– For people with low incomes
– For people with limited resources
Pennsylvania Medicaid
Authorization
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Social Security Act
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Public Welfare Code
Medicaid Is
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Mandates and options
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Options and more mandates
Medicaid State Plan
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Condition of federal financial participation
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Explains state program
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Must be amended when significant changes
are planned
Who Receives Medicaid Services
in Pennsylvania
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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
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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
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Provides services to almost 1.4 million
individuals
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On average, it costs $4,000 per person, per
year
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One of the most comprehensive of all state
Medicaid programs
Pennsylvania Medicaid
Administration
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Department of Public Welfare – State
Medicaid Agency
– 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
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Seven Deputates
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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
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Financing Medicaid in
Pennsylvania
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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
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County Assistance offices determine
eligibility
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If eligible, ACCESS cards are issued
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Eligibility periodically reviewed
Who Receives Medicaid in
Pennsylvania
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More than 50 percent are children
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25 percent are Temporary Assistance for
Needy Families
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20 percent are Social Security Income
Services
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Children receive all medically necessary services
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Categorically needy adults receive all benefits
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Medically needy adults receive all benefits but
pharmacy, dental and durable medical equipment
and supplies
Medicaid Waivers
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1915(b) Freedom of Choice
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1915(c) Home and Community-Based
Services
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1115 Allows states to provide services to
persons who do not financially qualify
Medicaid Services in
Pennsylvania
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Two Parallel Delivery Systems:
– Fee-for-Service
– Managed Care
В» Voluntary
В» Mandatory
Fee-for-Service
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$160 million weekly
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56,008 providers
Managed Care
Managed Care
Payments for Medicaid Services
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ACCESS Card
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Invoices
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Capitated Payments
Medical Assistance Goals of the
Ridge Administration
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Increase access to care
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Improve quality of care
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Stabilize spending
Human Services Goals of the
Ridge Administration
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Home and Community Service Alternatives
to Institutionalization
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Supporting Welfare to Work
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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
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Research Access
Department of Public Welfare
Office of Medical Assistance Programs
Department of Public Welfare
Resources
DPW Databases
Client Information System
(CIS)
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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.
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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)
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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
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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)
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These systems contain Client-specific information
reported by the counties for clients receiving
mental health and substance abuse services.
Early Intervention
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This system contains client-specific information
on children who receive Early Intervention service
from DPW (ages 0-2).
Licensed Facilities
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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
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These systems contain client-specific information
for persons with physical disabilities and persons
who require Attendant Care.
Resources
External Data Sources
Department Of Health
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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.
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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.
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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.
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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
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Children’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)
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This system contains information on all
inpatient hospitalizations. This is an extensive
database which includes:
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Length of Stay
Charges
Diagnosis
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Provider information
Other related information
Department of Public Welfare
Data Research Requests
Data Research Request Criteria
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The Office of Medical Assistance Programs
considers the following general approval criteria
when deciding to participate in any data request or
project:
– Advance the goals of the Department of Public Welfare;
– Provide benefit to the Department commensurate with
the level of effort;
– Be consistent with existing Department resources;
– Does not duplicate current or planned Department
activities;
Data Research Request Criteria,
Cont..
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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 Department’s review
and right to comment on work products prior to release
or publication;
– 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.
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All requests must be submitted at least 45 days in advance
of the need for a decision;
The request must be made on the organization’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..
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The result of the evaluation of the request against the
participation criteria will determine OMAP’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.
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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
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Evaluation of Programs funded through the
Pennsylvania Children’s Trust Fund: Johns Hopkins
University School of Hygiene and public Health, February, 1997.
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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 cohorts”survival analysis, reentry rates,and placement patterns for Pennsylvania and
other states receiving funding through the Annie E. Casey foundation.
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Report on Uninsured Children In
Pennsylvania: Pennsylvania Partnerships for Children, with
assistance from Pennsylvania Department of Public Welfare, March 2000.
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Independent Assessment of -SE:
(in progress) due September,2001.
Delmarva Foundation
2. DPW Evaluations
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Independent Assessment of HealthChoices-SE:
a 1915(b) Medicaid waiver evaluation, November, 1998.
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Independent Assessment of the Lancaster
Community Health Plan: a HCFA waiver evaluation, July
1997. A second evaluation is due in mid-July, 2000.
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Independent Assessment of the Family Care
Network: a HCFA waiver evaluation, December, 1998.
Analysis of “Scott Data” : performance indicators for
children enrolled in Pennsylvania’s Medical Assistance Program.
3. Additional Reports Available
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Annual Child Abuse Report.
Health Choices: The First Year:
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Health Choices Southwest: An Introduction:
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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.
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