Medicaid in Pennsylvania

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

2. Definitions • 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: • A joint federal and state program • For people with low incomes • For people with limited resources

3. Pennsylvania Medicaid Authorization • Social Security Act • Public Welfare Code

4. Medicaid Is • Mandates and options • Options and more mandates

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

6. Who Receives Medicaid Services in Pennsylvania • 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

7. The Cost of Medicaid in Pennsylvania • Expected to cost $8.5 billion in Fiscal Year 2000-2001 • 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

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

9. Pennsylvania Medicaid Administration • 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

10. Pennsylvania Department of Public Welfare • 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

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

12. Financing Medicaid in Pennsylvania • Expected to cost $8.5 billion in Fiscal Year 2000-2001 • 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

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

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

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

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

17. Medicaid Services in Pennsylvania • Two Parallel Delivery Systems: • Fee-for-Service • Managed Care • Voluntary • Mandatory

18. Fee-for-Service • $160 million weekly • 56,008 providers

19. Managed Care

20. Managed Care

21. Payments for Medicaid Services • ACCESS Card • Invoices • Capitated Payments

22. Medical Assistance Goals of the Ridge Administration • Increase access to care • Improve quality of care • Stabilize spending

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

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

26. Research Access Department of Public WelfareOffice of Medical Assistance Programs

27. Department of Public Welfare Resources DPW Databases

28. 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: • Demographics • MA Enrollment History • Managed Care Enrollment • Regular Health • Behavioral Health • Special Populations (Foster Care, Adoption, SSI)

29. Client Information System (CIS) Cont. • 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

30. Medical Assistance Management Information System (MAMIS) • MAMIS contains information on Medical Assistance payments. • For the Managed Care population, this system contains the monthly Capitation fee issued for each recipient. (No service data is recorded). • For Fee-For-Service clients, this system includes information on all medical services provided, including the provider, the costs, and the diagnosis.

31. Encounter Databases • The Encounter Databases contain the Service information for recipients enrolled in Managed Care. • 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.). • Behavioral Health. -information on behavioral health services provided similar to that of the MAMIS System.

32. 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.

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

34. 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.

35. 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.

36. Resources External Data Sources

37. Department Of Health • 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. 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.

38. Department Of Health Cont. • Vital Statistics. This system contains the following information: • Births: age, race of mother, prenatal care, birth weight. • Deaths: cause of death. • Marriages. • Divorces. • 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.

39. Department of Insurance • 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.

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

41. Department of Public Welfare Data Research Requests

42. 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: • 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;

43. 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.

44. 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

45. Submitting a Request, Cont. • 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 request will require resubmission of the request.

46. 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. 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. • 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.

48. Department of Public Welfare Current Research Evaluations/reports

49. 1. External Evaluations • Evaluation of Programs funded through the Pennsylvania Children’s Trust Fund: Johns Hopkins University School of Hygiene and public Health, February, 1997. • 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. • Report on Uninsured Children In Pennsylvania: Pennsylvania Partnerships for Children, with assistance from Pennsylvania Department of Public Welfare, March 2000. • Independent Assessment of -SE: Delmarva Foundation (in progress) due September,2001.

50. 2. DPW Evaluations • Independent Assessment of HealthChoices-SE: a 1915(b) Medicaid waiver evaluation, November, 1998. • Independent Assessment of the Lancaster Community Health Plan: a HCFA waiver evaluation, July 1997. A second evaluation is due in mid-July, 2000. • 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.