Washington State Department of Social and Health Services

MAA assures that necessary medical care is available to income Assistance and other eligible low income persons. Medical Assistance-paid services include fee-for-service payments and managed health care premiums. Medical Assistance-paid services also include primary care case management clients, regardless of whether they received fee-for-service services. Through the provision of Medicaid services, MAA uses both federal and state funds to pay for services to Categorically Needy clients, those meeting categorical and income eligibility requirements set by the federal government for income Assistance services; and to Medically Needy clients, those meeting categorical eligibility requirements but with assets and/or incomes slightly higher than the allowable limits. Categorically Needy clients include pregnant women in Washington State who are at or below 185 percent of the federal poverty level as well as Medicaid eligible children under the age of 19 with family incomes at or below 200 percent of the federal poverty level. Under the Refugee Act of 1980 the federal government pays for services provided to refugees in their first 8 months in the United States. In addition to federally-funded services, Washington State covers the cost of services to non-Medicaid eligible children under the age of 18 with family incomes below 100 percent of the federal poverty level, to non-Medicaid eligible clients receiving GA-U, and to clients receiving Medically Indigent services.

MAA Services Medical Assistance Eligibility Categories Medically Eligible Clients (title XIX Assistance) Medically Eligible Clients (non-title XIX Assistance) Services Hospital Inpatient Care: Hospital Outpatient Care: Physician Services Dental Services:  Prescription Drugs Managed Health Care Payments: Other Medical Services Other Medical Services Excluded in this presentation: Detailed medical encounter data

Categories

Medically Eligible Clients (Title XIX Assistance). Clients who are eligible to receive medical services for which the state receives federal Title XIX matching funds. Title XIX of the Social Security Act funds: "(1) medical Assistance on behalf of families with dependent children and of aged, blind, or disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services, and (2) rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care." 

Medically Eligible Clients (Not Title XIX Assistance).  Clients who are eligible to receive medical services which are not Title XIX funded.

Services

Hospital Inpatient Care:  Hospital Inpatient Care includes care and treatment to clients admitted to stay at a facility under the direction of a physician or dentist. A licensed or formally approved hospital furnishes these services. This program includes emergency room services to clients admitted through the emergency room to an inpatient stay. Hospital Inpatient Care includes room and board and other ancillary services such as drugs, laboratory, and radiology.

Hospital Outpatient Care: A licensed or approved hospital provides Hospital Outpatient Care to clients treated, but not admitted to stay, at the facility.

Physician Service: A provider of Physician Services is, or is under the personal supervision of, an individual licensed to practice medicine or osteopathy. Providers furnish Physician Services in the physician's office, the client's home, a hospital, a nursing home, or a clinic. Physician Services include primary care case management.

Dental Services: These include diagnostic, preventive, or corrective services provided by or under the supervision of an individual licensed to practice dentistry or dental surgery.

Prescription Drugs: These include simple or compound substances or mixtures prescribed by a physician or other licensed practitioner and dispensed by licensed pharmacists or other authorized practitioners, with no adjustment for drug rebate.

Managed Health Care Payments: Managed Health Care Payments are fixed monthly premiums paid on a per client basis to managed health care providers. In return for the payment, a managed health care provider makes a range of services available to the client. The one-time payment is independent of the client's use of those services and replaces the traditional fee-for-service arrangement. Health maintenance organizations, which provide services through staff physicians; or health insuring organizations, which contract with primary care physicians to provide services, administer managed health care plans.

Other Medical Services: Other Medical Services includes durable medical equipment, home health care, hospice care, maternity case management, medically necessary transportation, optometrists, opticians and eyeglasses, chiropractic care, oxygen, hearing aids, and a variety of other services that represent a small proportion of MAA expenditures..

Changes from CSDB-Fiscal Year 99 to CSDB-Fiscal Year 00

Counts for "Medically Eligible Clients" in CSDB for Fiscal Year 99 were reported in a single category comprised of both those clients eligible for Title XIX Assistance and those eligible for non-Title XIX Assistance. In CSDB for Fiscal Year 00, clients eligible for medical Assistance are reported in two categories: (1) Medically Eligible Clients (Title XIX Assistance) and (2) Medically Eligible Clients (non-Title XIX Assistance).

• Medically Eligible Clients (Title XIX). Clients who are eligible to receive medical services for which the state receives federal Title XIX matching funds.
• Medically Eligible Clients (non-Title XIX). Clients who are eligible to receive medical services that are not Title XIX funded.

Changes from CSDB-Fiscal Year 00 to CSDB-Fiscal Year 01

Counts for clients eligible to have their claims paid for admissions to community inpatient mental health facilities authorized under the Involuntary Treatment Act (ITA) were included in the MAA program total only in CSDB for Fiscal Year 99 and Fiscal Year 00. These counts are no longer included in CSDB for Fiscal Year 01.

CSDB for Fiscal Year 99 and Fiscal Year 00 reported the number of persons eligible to receive Medical Assistance and, for Fiscal Year 00, whether their eligibility was covered in part by Title XIX federal funding or was covered by funding sources other than Title XIX. In addition to these 2 eligibility categories, CSDB for Fiscal Year 01 reports detailed encounter information for the following:

1. Hospital Inpatient Care
2. Hospital Outpatient Care
3. Physician Services
4. Dental Services
5. Prescription Drugs
6. Managed Health Care Payments
7. Other Medical Services

Special Note on Data Comparability

Client counts and dollar amounts reported from CSDB may differ to some extent from those reported by MAA for the following reasons:

1. CSDB obtains it's medical information from the MMIS Billing/Warrants File while MAA reports are based on its Extended Data Base (EDB).
2. Methodological differences between CSDB and EDB in terms of how client counts are calculated.
3. Classification differences between CSDB and EDB in terms of how services are categorized.
4. Methodological differences between CSDB and EDB in terms of how dollar amounts are calculated.
5. CSDB does not include payment adjustments that are not attributable to individual clients; EDB includes certain adjustments

Source: CSDB - State Fiscal Year 2002