Medicaid spDATA System : characteristics of Medicaid state programs

518 Pages·1992·23.5 MB·English

by  United States. Medicaid Bureau

spDATA
System
Characteristics of Medicaid State Programs
Volume
I
National Comparisons
s^^
us DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Health Care Financing Administration
Medicaid Bureau
HCFAPub. No. 02178
May 1992
U.S. Department of Health and Human Services
Louis W. Sullivan, M.D.,Secretary
Health Care Financing Administration
William Toby, Jr., Acting Administrator
Medicaid Bureau
Christine H. Nye, Director
This report was prepared by ttie
Medicaid Operations Branch
HCFA:MB:OMM:DPP
Room 273 East High Rise Building
6325 Security Boulevard
MD
Baltimore, 21207
State Profile Data System
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.mm
MEDICAID
_
spDATA System
Characteristics of Medicaid State Programs
Volume
I
National Comparisons
'
C2-Q7-13
7^00 Soa-.,;. i:,d. II
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
Medicaid Bureau
HCFAPub. No. 02178
May 1992

DEPARTMENT OF HEALTH & HUMAN SERVICES
Health Care Financing Administratior
6325 Security Boulevard
Baltimore, MD 21207
FOREWORD
This publication introduces the Medicaid State Profile Data (spDATA) System.
The spDATA System is an automated system which provides selected information
on Medicaid State programs. The system was developed in response to
recommendations in the July 1991 Health and Human Services (HHS)/Office of
Management and Budget (OMB) report entitled Better Management for Better
Medicaid Estimates. The report recommended that the Medicaid Bureau (MB)
maintain, and make available to the public, State-by-State inventories of baseline
Medicaid program features and proposed program changes.
The spDATA System provides the recommended information. It is also a current,
on-line system which is updated as State plan amendments (SPAs) are received in
the Health Care Financing Administration's (HCFA) Regional Offices. This
publication is the first annual edition of national data generated from spDATA
displaying program characteristics from Medicaid State plans. The text describes
the spDATA System, the data collected by the system, and certain data displayed
in the National Data Tables showing Medicaid program characteristics by State.
The spDATA System information is important to the Medicaid budget estimating
process. It also provides the public with information on State Medicaid programs.
In addition, providing information and up-to-date feedback to States on State plans
will assist States in meeting Medicaid requirements. Finally, the data generated by
SpDATA are vital to HCFA and others in making policy and management
decisions, responding to inquiries, and to improving our effectiveness in ensuring
that Medicaid recipients have access to mandated services and benefits.
This System is the result of the combined efforts of staff of the Medicaid Bureau,
HCFA Regional Offices, Bureau of Data Management and Strategy, National
Governors' Association, OMB, and States. I want to personally commend and
thank everyone involved for their dedicated efforts to accomplish the
recommendations of the HHS/OMB Task Force.
I hope this publication will be useful to you. I invite your comments, suggestions,
and recommendations for improving the information collected and generated by
spDATA
the System.
(^'/^j~7^--^ /
Christine Nye
Director
Medicaid Bureau
PREFACE
The Medicaid program is a major funding source of health care for America's poor
A
and disabled. rapid increase in Medicaid expenditures in recent years has focused
attention on the need for a database with current, comprehensive information on all
State Medicaid programs. Medicaid State Profile Data (spDATA) System: Characteristics
ofMedicaid State Programs provides details on State Medicaid programs. This report
includes data generated from the Health Care Financing Administration's (HCFA's)
new data system, spDATA, and data collected through the research efforts of the
National Governors' Association (NGA). This report, comprised of two volumes,
primarily contains information from Medicaid State plans. If more comprehensive
Medicaid information is needed, additional resources may be required.
Volume I introduces the spDATA System, presents national tables of selected State
plan characteristics, and summarizes Medicaid program policy changes tracked by
NGA. Volume II presents more detailed information on each State.
Volume
I
The spDATA System primarily contains selected characteristics from Medicaid State
plans, pending State plan amendments (SPAs), and supplementary information
submitted in the "related information" report that accompanies SPAs. Some
information included in the spDATA System (e.g., disproportionate share hospital
funding source and donations and taxes programs) is obtained from monthly State
reports for the 50 States and the District of Columbia. Regional offices (ROs) enter
data into the system from the sources hsted above. SpDATA provides immediate,
on-line access to certain State plan characteristics that are important to understanding
the Medicaid program. Readers should be aware that the spDATA System is not an
automated database of the entire State plan, nor does it automate the State plan
process.
Part One, spDATA National Tables, provides national tabulations on State Medicaid
program characteristics in the areas of administration, eligibility, coverage, and
non-institutional and institutional reimbursement. Data in the Tables reflect
information from approved State plans and pending SPAs effective March 11, 1992
and entered into the system by March 12, 1992. Each Table presents information in a
State-by-State format. The National Tables display information on:
- Administration Medicaid coordination with other health insurance programs,
:
premiums, deductibles, coinsurance, and recipient cost-sharing;
- Eligibility Requirements of State Medicaid Programs Mandatory and optional
:
eligibility groups included under States' plans and the general information on the
financial criteria used by States in determining Medicaid eligibility;
- Services Covered by Medicaid Coverage and limitations of selected services
:
available to categories of Medicaid recipients (e.g., inpatient hospital; physician
services; prescribed drugs; transportation; transplants; and services provided under
the Early and Periodic, Screening, Diagnosis, and Treatment (EPSDT) program);
11
- Reimbursement for Non-institutional Services Information on methods used to
:
pay for prescribed drugs and physicians' services; and
- Reimbursement for Institutional Services Data on payment methods for hospitals,
:
nursing facilities, and intermediate care facilities for the mentally retarded.
The spDATA system was designed, developed, and implemented by staff from the
Medicaid Bureau, Bureau of Data Management and Strategy (BDMS), and the HCFA
ROs.
Medicaid State profiles were extracted from State plans and pending SPAs. The
profiles were entered into the spDATA System by RO staff who are responsible for
approving SPAs and updating and maintaining the official State plans for the States in
RO
their region. staff reviewed the data on the validation tables to verify their
accuracy and consistency with the State plans. After the ROs confirmed that the data
reflected the contents of their States' plans, each State's Tables were sent to the
appropriate State for review. States were given 30 days to verify the accuracy of the
Tables. ROs contacted every State to ensure that the Tables had been received, to
discuss issues and concerns, and to notify States that the data would be published and
made available to members of the public and private sectors.
Most States responded by suggesting changes or identifying issues related to the data
HCFA
which contributed to the accuracy of this information. appreciates the efforts
and contributions of these States. Some States (MA, CT, ME, RI, DC, MO, KS, and
CA) were not able to respond in the 30-day time frame allowed to review the
validation Tables.
Because spDATA is a new system, some inconsistencies among the data in the Tables
may exist. SpDATA is an evolving system. Our goal is to accurately reflect selected
data elements from Medicaid State plans in a format that satisfies information needs.
The Medicaid Bureau welcomes comments and suggestions from system and data users
to help meet this goal.
Part Two of Volume I summarizes Medicaid program and policy changes made by the
States during calendar year 1991. Information presented in Part Two includes:
- Summary of Selected State Program Trends Narrative on the changes made by
:
States in 1991 for service utilization controls, reimbursement, eligibility, and service
coverage;
- State Medicaid Program Changes: A list of all the changes made by States in 1991
categorized by eligibility, reimbursement, and services; and
- Selected Medicaid Program Characteristics Narrative and tabular information on
:
the current status of State Medicaid policy options including home and community-
based services waivers, coordinated care programs, and coverage of pregnant
women and children.
The information contained in Part Two comes from the State Medicaid Information
Center (SMIC) for the Center for Policy Research of the National Governors'
Association. SMIC is a clearinghouse for information on State Medicaid programs.
States submit Medicaid policy and program information to SMIC on a continuous
basis. This information, typically recipient announcements, State regulations, and State
Medicaid provider manuals, is then edited and added to the SMIC database. The
111
information is reviewed by the State Medicaid agencies for accuracy and completeness.
In addition, SMIC gathers information on a number of State Medicaid program
characteristics that have been given high priority by Federal and State officials. These
include Medicaid program waivers, financial eligibility criteria, and implementation of
policies related to pregnant women and children. SMIC publishes tables summarizing
State activity in each of the above characteristics on an annual basis.
HCFA is combining the first spDATA System report with NGA's Catalogue ofState
Medicaid Program Changes to provide readers easy access to a maximum amount of
information on States' Medicaid programs. NGA's report adds data on home and
community-based services waivers, Medicaid coordinated care, and State program
changes from previous years that are not part of the spDATA System. The two
reports provide different, but complementary, approaches to analyzing the Medicaid
program. Although combining reports with different databases may create some
analytical problems, the benefits of having comprehensive information in one
publication will compensate for these problems. Both reports include data collected
from Medicaid State plans. The reports differ in these ways:
Time Frames: spDATA Tables in this report are current as of March 11, 1992;
NGA
narrative and Tables are current as of January 1992.
Data Sources: The majority of data in the spDATA System are from Medicaid State
plans and pending SPAs. Sources outside the State plan include the
"related information" report and monthly State reports. NGA's report
includes data from State plans, SPAs, surveys, provider
NGA
announcements, and State regulations. also collects information
on freedom of choice and home and community-based services
waivers.
Utility: Part One introduces spDATA, HCFA's new computerized data
collection system. The Tables are samples of the types of Medicaid
State plan comparisons that system users can generate for themselves
with up-to-date data. Part Two (prepared by NGA) highlights
Medicaid program changes made by States in 1991 and describes
annual trends.
Preparation of Part Two of this document, NGA's 1991 Catalogue ofState Medicaid
Program Changes, was supported by a contract from the Intergovernmental Affairs
Office, HCFA. Data in the NGA portion of the report have not been validated by
HCFA, nor has HCFA attempted to reconcile NGA's data in Part Two with the data
in the spDATA System or the spDATA Tables in Part One. Any interpretations,
views, or opinions expressed in Part Two are those of NGA authors and do not
represent those of the Department of Health and Human Services.
IV
TABLE OF CONTENTS
FOREWARD
i
PREFACE
ii
PART ONE
BACKGROUND
1
Scope of spDATA 1
Outlook 2
The Administrative Structure of the
Medicaid Program and the Medicaid State Plan 2
The spDATA System Organization 4
SUMMARY OF THE MEDICAID PROGRAM
5
DATA PRESENTED IN THE NATIONAL TABLES 12
NATIONAL TABLES
1. Administration of the State Medicaid Programs 13
Table 1-1. Medicaid Coordination With Other Insurance
Programs: Premiums, Deductibles, and Coinsurance 17
Table 1-2. Recipient Cost-sharing Policies 24
2. Eligibility Profiles of State Medicaid Programs 31
Table 2-1 Implementation of Mandatory Eligibility Groups 44
Table 2-2 Implementation of Optional Eligibility Groups 58
Table 2-3. Optional Coverage of the Medically Needy 72
AFDC
Table 2-4. Payment Standards (Dollars) 78
Table 2-5. Financial Criteria Used in Eligibility
Determinations for the Medically Needy 80
Table 2-6. Financial Criteria Used in Eligibility
Determinations for the Aged, Blind, and
Disabled in 209(b) States 85
Table 2-7. More Liberal Income and Resource Methods as
Defined in Section 1902(r)(2) 87
3. Services Covered by Medicaid 93
Table 3-1. Medicaid Services for the Categorically and
Medically Needy Populations 100
Table 3-2. Inpatient Hospital Services: Coverage and
Limitations 114
Table 3-3. Outpatient Hospital Services: Coverage and
Limitations 121
Table 3-4. Physician Services: Coverage and Limitations 128
Table 3-5. Targeted Case Management (TCM) Services:
Coverage and Limitations 142
Table 3-6. Prescribed Drugs: Coverage and Limitations 156
Table 3-7. Transportation Services: Coverage and
Limitations 164
Table 3-8. Coverage of Transplant Services 178
Table 3-9. Profile of the EPSDT Program 181
Table 3-10. Rural Health Clinics: Coverage and Limitations 188
Table 3-11. Federally Qualified Health Services: Coverage
and Limitations 195
Table 3-12. Clinic Services - Maternal and Child Health
Clinics: Coverage and Limitations 202
Table 3-13. Clinic Services - Mental Health Clinics:
Coverage and Limitations 209
Table 3-14. Clinic Services - Alcohol and Substance Abuse
Clinics: Coverage and Limitations 216
Table 3-15. Clinic Services - Birthing Centers: Coverage
and Limitations 223
Table 3-16. Clinic Services - Ambulatory Surgical Centers:
Coverage and Limitations 230
Table 3-17. Clinic Services - End Stage Renal Disease
Facilities: Coverage and Limitations 237
Table 3-18. Clinic Services - MR/Day Treatment Facilities:
Coverage and Limitations 244
Payment for Non-institutional Services 251
Table 4-1. Payment for Prescribed Drugs by Payment Methodology
and Dispensing Fee 256
Table 4-2. Payment Methodology for Physicians Services 258
Table 4-3. States with Disproportionate Share Payments and/or
&
Donations Taxes Programs for Non-institutional Services 262
.
Table 4-4. States with Disproportionate Share Payments by
Non-institutional Service or Donation and Taxes
Programs by Service Type 263
Payment for Institutional Services 265
Table 5-1. States with Disproportionate Share Hospitals (DSH)
Provisions and Source of Funding 270
Table 5-2. States with Donations and/or Taxes Programs for
Institutional Services 284
Table 5-3. Payment for Acute Care Hospital Services 286
Table 5-4. Payment for Psychiatric Hospital Services 293
Table 5-5. Payment for Other Types of Hospital Services 300
Table 5-6. Payment for Nursing Home FaciHty Services 307
Table 5-7. Payment for Intermediate Care Facility Services for
the Mentally Retarded (ICF/MR) 314
VI