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Medicaid in Pennsylvania Peg J. Dierkers Deputy Secretary for Medical Assistance Programs Department of Public Welfare.

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Presentation on theme: "Medicaid in Pennsylvania Peg J. Dierkers Deputy Secretary for Medical Assistance Programs Department of Public Welfare."— Presentation transcript:

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2 Medicaid in Pennsylvania Peg J. Dierkers Deputy Secretary for Medical Assistance Programs Department of Public Welfare

3 Definitions Medicare is: Medicare is: –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: Medicaid is: –A joint federal and state program –For people with low incomes –For people with limited resources

4 Pennsylvania Medicaid Authorization Social Security Act Social Security Act Public Welfare Code Public Welfare Code

5 Medicaid Is Mandates and options Mandates and options Options and more mandates Options and more mandates

6 Medicaid State Plan Condition of federal financial participation Condition of federal financial participation Explains state program Explains state program Must be amended when significant changes are planned Must be amended when significant changes are planned

7 Who Receives Medicaid Services in Pennsylvania 52.9% Children (Age 21 and under) 52.9% Children (Age 21 and under) 12.2% Elderly (Age 65 and older) 12.2% Elderly (Age 65 and older) 0.1% Blind 0.1% Blind 20.3% Disabled 20.3% Disabled 18.4% Families with Children 18.4% Families with Children Close to 1.4 million individuals receive Medicaid in Pennsylvania Close to 1.4 million individuals receive Medicaid in Pennsylvania Source: MA Eligibility Statistics, Office of Income Maintenance, 3/2000

8 The Cost of Medicaid in Pennsylvania Expected to cost $8.5 billion in Fiscal Year Expected to cost $8.5 billion in Fiscal Year Represents 47.95% of the Department of Public Welfare budget * Represents 47.95% of the Department of Public Welfare budget * Represents 15.41% of the General Fund budget * Represents 15.41% of the General Fund budget * Health care continues to be one of the fastest areas of growth in our economy Health care continues to be one of the fastest areas of growth in our economy Source: Budget Briefing Book, Fiscal Year

9 Pennsylvania Medicaid is one of the Largest Insurers Nationally Provides services to almost 1.4 million individuals Provides services to almost 1.4 million individuals On average, it costs $4,000 per person, per year On average, it costs $4,000 per person, per year One of the most comprehensive of all state Medicaid programs One of the most comprehensive of all state Medicaid programs

10 Pennsylvania Medicaid Administration Department of Public Welfare – State Medicaid Agency Department of Public Welfare – State Medicaid Agency –Office of Medical Assistance Programs »Bureau of Fee-for-Service Programs »Bureau of Managed Care Operations »Bureau of Long Term Care Programs »Bureau of Data and Claims Management »Bureau of Program Integrity »Bureau of Policy, Budget and Planning

11 Pennsylvania Department of Public Welfare Seven Deputates Seven Deputates –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

12 Other Administrative Supports Office of the Comptroller Office of the Comptroller Office of Budget Office of Budget Office of Policy Office of Policy Office of Legal Counsel Office of Legal Counsel Office of Communication Office of Communication Office of State and Federal Relations Office of State and Federal Relations

13 Financing Medicaid in Pennsylvania Expected to cost $8.5 billion in Fiscal Year Expected to cost $8.5 billion in Fiscal Year On October 1, 2000, Federal Medical Assistance Percentage (FMAP) will be percent On October 1, 2000, Federal Medical Assistance Percentage (FMAP) will be percent By law, FMAP cannot be lower than 50 percent or more than 83 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 FMAP can only be earned on federal categories of eligibility

14 Applying for Medicaid County Assistance offices determine eligibility County Assistance offices determine eligibility If eligible, ACCESS cards are issued If eligible, ACCESS cards are issued Eligibility periodically reviewed Eligibility periodically reviewed

15 Who Receives Medicaid in Pennsylvania More than 50 percent are children More than 50 percent are children 25 percent are Temporary Assistance for Needy Families 25 percent are Temporary Assistance for Needy Families 20 percent are Social Security Income 20 percent are Social Security Income

16 Services Children receive all medically necessary services Children receive all medically necessary services Categorically needy adults receive all benefits Categorically needy adults receive all benefits Medically needy adults receive all benefits but pharmacy, dental and durable medical equipment and supplies Medically needy adults receive all benefits but pharmacy, dental and durable medical equipment and supplies

17 Medicaid Waivers 1915(b) Freedom of Choice 1915(b) Freedom of Choice 1915(c) Home and Community-Based Services 1915(c) Home and Community-Based Services 1115 Allows states to provide services to persons who do not financially qualify 1115 Allows states to provide services to persons who do not financially qualify

18 Medicaid Services in Pennsylvania Two Parallel Delivery Systems: Two Parallel Delivery Systems: –Fee-for-Service –Managed Care »Voluntary »Mandatory

19 Fee-for-Service $160 million weekly $160 million weekly 56,008 providers 56,008 providers

20 Managed Care

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22 Payments for Medicaid Services ACCESS Card ACCESS Card Invoices Invoices Capitated Payments Capitated Payments

23 Medical Assistance Goals of the Ridge Administration Increase access to care Increase access to care Improve quality of care Improve quality of care Stabilize spending Stabilize spending

24 Human Services Goals of the Ridge Administration Home and Community Service Alternatives to Institutionalization Home and Community Service Alternatives to Institutionalization Supporting Welfare to Work Supporting Welfare to Work Expand HealthChoices Expand HealthChoices

25 Challenges Cost of Pharmaceuticals Cost of Pharmaceuticals Growing Elderly Population Growing Elderly Population Supporting Welfare to Work Supporting Welfare to Work Technology Technology Continued Growth of Long Term Care Program Continued Growth of Long Term Care Program

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27 Research Access Department of Public Welfare Office of Medical Assistance Programs

28 Department of Public Welfare Resources DPW Databases DPW Databases

29 Client Information System (CIS) 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: 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.Demographics 2.MA Enrollment History 3.Managed Care Enrollment a.Regular Health b.Behavioral Health 4.Special Populations (Foster Care, Adoption, SSI)

30 Client Information System (CIS) Cont. 5.Special Facilities (Personal Care Homes, Long Term Care, MH, MR, etc..) 6.Waiver (MA, MR, OSP, Aging) **Aggregating data to School District or Zip Code levels for local summarization and GIS

31 Medical Assistance Management Information System (MAMIS) MAMIS contains information on Medical Assistance payments. 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.

32 Encounter Databases The Encounter Databases contain the Service information for recipients enrolled in Managed Care. 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.

33 CCRS/POMS (Consolidated Community Reporting System) (Performance Outcomes Measures System) These systems contain Client-specific information reported by the counties for clients receiving mental health and substance abuse services. These systems contain Client-specific information reported by the counties for clients receiving mental health and substance abuse services.

34 Early Intervention This system contains client-specific information on children who receive Early Intervention service from DPW (ages 0-2). This system contains client-specific information on children who receive Early Intervention service from DPW (ages 0-2).

35 Licensed Facilities This system contains information on licensed personal care homes, day care, mental health, mental retardation and child welfare facilities including capacity and addresses. This system contains information on licensed personal care homes, day care, mental health, mental retardation and child welfare facilities including capacity and addresses.

36 Community Service Program for Persons With Physical Disabilities (CSPPD) and Attendant Care These systems contain client-specific information for persons with physical disabilities and persons who require Attendant Care. These systems contain client-specific information for persons with physical disabilities and persons who require Attendant Care.

37 Resources External Data Sources

38 Department Of Health Drug and Alcohol. 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. Reportable Diseases. 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.

39 Department Of Health Cont. Vital Statistics. 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. Hospitals, Nursing Home and Drug and Alcohol Facilities (D&A). 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.

40 Department of Insurance Children’s Health Insurance Program (CHIP). 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.

41 Health Care Cost Containment Council (HC4) This system contains information on all inpatient hospitalizations. This is an extensive database which includes: This system contains information on all inpatient hospitalizations. This is an extensive database which includes: 1.Length of Stay 2.Charges 3.Diagnosis 4.Provider information 5.Other related information

42 Department of Public Welfare Data Research Requests

43 Data Research Request Criteria The Office of Medical Assistance Programs considers the following general approval criteria when deciding to participate in any data request or project: 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;

44 Data Research Request Criteria, Cont.. –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.

45 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

46 Submitting a Request, Cont. All requests must be submitted at least 45 days in advance of the need for a decision; 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; 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 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; 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 request will require resubmission of the request.

47 Submitting a Request, Cont.. The result of the evaluation of the request against the participation criteria will determine OMAP’s continued or expanded participation in the project. 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. The requestor must sign a confidentiality agreement prior to the release of any data. 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. 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.

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49 Department of Public Welfare Current Research Evaluations/reports

50 1. External Evaluations Evaluation of Programs funded through the Pennsylvania Children’s Trust Fund : Johns Hopkins University School of Hygiene and public Health, February, Evaluation of Programs funded through the Pennsylvania Children’s Trust Fund : Johns Hopkins University School of Hygiene and public Health, February, Family to Family Foster Care Reform : R esearch 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. Family to Family Foster Care Reform : R esearch 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. Report on Uninsured Children In Pennsylvania : Pennsylvania Partnerships for Children, with assistance from Pennsylvania Department of Public Welfare, March Report on Uninsured Children In Pennsylvania : Pennsylvania Partnerships for Children, with assistance from Pennsylvania Department of Public Welfare, March Independent Assessment of - SE : Delmarva Foundation (in progress) due September,2001. Independent Assessment of - SE : Delmarva Foundation (in progress) due September,2001.

51 2. DPW Evaluations Independent Assessment of HealthChoices-SE: a 1915(b) Medicaid waiver evaluation, November, Independent Assessment of HealthChoices-SE: a 1915(b) Medicaid waiver evaluation, November, Independent Assessment of the Lancaster Community Health Plan: a HCFA waiver evaluation, July A second evaluation is due in mid-July, Independent Assessment of the Lancaster Community Health Plan: a HCFA waiver evaluation, July A second evaluation is due in mid-July, Independent Assessment of the Family Care Network: a HCFA waiver evaluation, December, Independent Assessment of the Family Care Network: a HCFA waiver evaluation, December, Analysis of “Scott Data” : performance indicators for children enrolled in Pennsylvania’s Medical Assistance Program. Analysis of “Scott Data” : performance indicators for children enrolled in Pennsylvania’s Medical Assistance Program.

52 3. Additional Reports Available Annual Child Abuse Report. Annual Child Abuse Report. Health Choices: The First Year: Office of Medical Assistance Programs;Office of Mental Health and Substance Abuse Services. Health Choices: The First Year: Office of Medical Assistance Programs;Office of Mental Health and Substance Abuse Services. Health Choices Southwest: An Introduction: Office of Medical Assistance Programs; Office of Mental Health and Substance Abuse Services. Health Choices Southwest: An Introduction: Office of Medical Assistance Programs; Office of Mental Health and Substance Abuse Services.


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