Pennsylvania Behavioral System Market Profile · – MH/DS services are funded by grants through...

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Pennsylvania Behavioral System Market Profile

May 2018 MRC2.CORP.X.02547


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A. Executive Summary1. Health Care Coverage Map2. Medicaid System Overview3. Medicaid Care Coordination Initiatives4. Behavioral Health Safety-Net System Overview5. Behavioral Health Safety-Net System

B. Health Financing System Overview1. Population Demographics2. Population Centers3. Population Distribution By Payer4. Largest Health Plans By Enrollment5. Largest Health Plans By Estimated SMI Enrollment6. Health Insurance Marketplace

C. Medicaid Administration, Governance & Operations1. Medicaid Governance: Organizational Chart2. Medicaid Governance: Key Leadership3. Medicaid Expansion Status4. Medicaid Program Benefits

D. Medicaid Financing & Service Delivery System1. Medicaid Financing & Service Delivery System2. Medicaid Financing & Service Delivery System By Eligibility Group3. Medicaid FFS Program: Overview4. Medicaid FFS Program: Behavioral Health Benefits5. Medicaid FFS Program: SMI Population6. Medicaid Managed Care Program: Overview7. Medicaid Managed Care Program: Managed Care Plan Map8. Medicaid Managed Care Program: Managed Care Re-Procurement Map

D. Medicaid Financing & Service Delivery System (Continued)9. Medicaid Managed Care Program: Behavioral Health Overview10. Medicaid Managed Care Program: Behavioral Health Benefits11. Medicaid Managed Care Program: BH-MCO Map12. Medicaid Managed Care Program: BH-MCO Service Areas13. Medicaid Managed Care Program: SMI Population14. Medicaid Program: Care Coordination Initiatives 15. Medicaid Program Care Management & Demonstration Waivers16. Medicaid Program Section 1915 (c) HCBS Waivers17. Medicaid Program Section 1915 (c) HCBS Waivers (Continued)

E. State Behavioral Health Administration & Finance System1. Public Behavioral Health System Governance: Organizational Chart2. Public Behavioral Health System Governance: Key Leadership3. Public Behavioral Health System Governance: DDAP Organization Chart &

Key Leadership4. Mental Health & Addiction Hospital Bed Distribution 5. State Psychiatric Institutions6. State Psychiatric Institution Catchment Areas

F. State Behavioral Health Stakeholder Organizations1. Accountable Care Organizations (ACOs)2. Accountable Care Organizations (Continued)

G. Appendices1. Acronym Legend2. Glossary Of Terms3. Sources

Behavioral Health Market Profile Overview


A. Executive Summary

Table Of Contents


A.1. Pennsylvania Physical Health Care Coverage Map

Total Pennsylvania Population-12,784,227Estimated SMI Population-642,957

For acronym definitions, see Glossary


A.2. Medicaid System Overview

Medicaid Financial Delivery System Enrollment

Total Medicaid population distribution • As of January 2018: 17% in fee-for-service (FFS), 83% in managed care

SMI population inclusion in managed care • Pennsylvania does not specifically preclude individuals with SMI from enrolling in

managed care, therefore the majority of the SMI population is enrolled in managed care• Estimated 36% of population in FFS, 64% in managed care

Dual eligible population inclusion in managed care • Regional implementation of mandatory managed care enrollment for dual eligibles is in

progress between January 2018 and January 2020• Estimated 77% of population in FFS, 23% in managed care

Medicaid Financing & Risk Arrangements: Behavioral Health

Service Type FFS Population Managed Care Population

Traditional behavioral health Covered FFS by the state Excluded from the physical health plan’s (PH-MCOs) capitation rate and provided by the at-risk behavioral health plan (BH-MCO)

Specialty behavioral health Covered FFS by the state Excluded from the PH-MCO’s capitation rate and provided by the at-risk BH-MCO

Pharmaceuticals Covered FFS by the state Included in the PH-MCO’s capitation rate

Long-term services and supports (LTSS) Covered FFS by the state

The Community HealthChoices managed care program covers nursing facility and home- and community-based services (HCBS) for Medicaid only enrollees who require LTSS and dual eligibles



A.3. Medicaid Care Coordination Initiatives

Medicaid Care Coordination Entities For Chronic Care Populations (Including SMI)

Care Coordination Entity Active Program Description

Managed Care Plan Both the physical and behavioral health plans are responsible for care coordination

Primary Care Case Management (PCCM) None

Accountable Care Organization (ACO) Program No state program; ACO arrangements count towards health plan value-based reimbursement goals

Affordable Care Act (ACA) Model Health Home None

Patient-Centered Medical Home (PCMH) No state program; PCMH arrangements count towards health plan value-based reimbursement goals



A.4. Behavioral Health Safety-Net Delivery System Overview

• The Department Of Health provides funding to state health centers and county and municipal health departments to deliver physical health services to the safety-net population

Physical Health Services

• The Department Of Human Services, Office Of Mental Health & Substance Abuse Services oversees the delivery of safety-net mental health services administered by the county Mental Health & Developmental Services offices

Mental Health Services

• The Department Of Drug & Alcohol Programs and the Department Of Human Services provide funding to the single county authorities for addiction treatment safety-net services

Addiction Treatment Services

State Agency Responsible For Uninsured Citizens & Delivery System Model



• Mental Health & Developmental Services (MH/DS) offices operated at the county or joint county level administer community mental health services

– The MH/DS offices contract with local provider organizations for treatment services, assess individuals for treatment requirements, and make treatment referrals

– MH/DS services are funded by grants through the state Department Of Human Services (DHS), county funds, Medicaid and other insurance payments for individuals, and individual contributions based on ability to pay

• Single County Authority (SCA) offices operated at the county or joint county level administer safety-net addiction treatment services

– The Department Of Drug & Alcohol Programs (DDAP) provides SCAs with state and federal funding to deliver or purchase drug and alcohol services, including treatment services for Pennsylvanians who do not have insurance or resources to pay for treatment, as well as for treatment services not reimbursed under insurance programs

– SCA services are also funded by grants through the state Department Of Human Services, county funds, Medicaid and other insurance payments for individuals, and individual contributions based on ability to pay

– SCAs prepare prevention, intervention, and treatment plans tailored to meet the needs of their respective communities; DDAP approves these plans and formulates a statewide plan based on those findings

– The SCAs contract with local provider agencies for treatment services, assess individuals for treatment requirements, and make treatment referrals

A.5. Behavioral Health Safety-Net Delivery System



B. Pennsylvania Health Financing System Overview

Table Of Contents


138% of poverty level

Population Distribution By Income To Poverty Threshold Ratio

200% and above

139% to 199%

101% to 138%

100% and below

B.1. Population Demographics

6thmost populous

state in the nation4% of the U.S. population

Median Income

Pennsylvania$56,907

U.S.$57,617

PA U.S.

Pennsylvania & U.S. Racial CompositionPopulation Distribution By Age

Under 18(2,674,845)

21%

Ages 18 to 64(7,877,621)

62%

Age 65+(2,221,761)

17%

Total Pennsylvania Population- 12,784,227Estimated SMI Population- 642,957

5% 6%11% 13%

9% 11%

75% 70%

61%

77%

12%

11%

18%

7%

9%

5%

U.S.

PA

White Black Hispanic Other For acronym definitions, see Glossary


Metropolitan Statistical Areas (MSAs)

MSA Pennsylvania Residents

Percent Of Population

Total MSA Population 11,313,889 88%

Philadelphia-Camden-Wilmington

4,095,710 32%

Pittsburgh 2,342,299 18%

Allentown-Bethlehem-Easton 729,035 6%

Harrisburg-Carlisle 568,033 4%

Scranton--Wilkes-Barre—Hazleton 555,225 4%

Lancaster 538,500 4%

York-Hanover 443,744 3%

Reading 414,812 3%

Erie 276,207 2%

East Stroudsburg 166,098 1%

Other MSAs 1,184,226 9%

MSA

Urban11%

Rural89%

Distribution Of Land Area

Urban79%

Rural21%

Distribution Of Population

Erie

Youngstown-Warren-Boardman

Pittsburgh Johnstown

Altoona

State College

WilliamsportScranton-Wilkes-Barre-Hazleton

Bloomsburg-Berwick

Harrisburg-Carlisle

Chambersburg-Waynesboro Gettysburg

York-Hanover

Lancaster

LebanonReading

Philadelphia-Camden-Wilmington

Allentown-Bethlehem-Easton

New York-Newark-Jersey City

EastStroudsburg


B.2. Population Centers


B.3. Population Distribution By Payer: National vs. State

58%

61%

17%

15%

2%

3%

1%

1%

12%

14%

9%

6%

2%

1%

U.S.

PA

Commercial Medicaid Full Duals Partial Duals Medicare Uninsured TRICARE



Plan Name Plan Type Enrollment*

Medicare Fee-For-Service (FFS) Medicare 1,407,027

Highmark, Inc Commercial Administrative Services Only (ASO) 1,300,569

Aetna Commercial ASO 1,178,174

QCC Insurance Company Commercial ASO 905,131

Highmark, Inc Commercial 652,307

Medicaid FFS Medicaid 477,745

Keystone First Medicaid Managed Care-HealthChoices 434,204

UPMC For You, Inc Medicaid Managed Care-HealthChoices 422,280

UPMC Health Options, Inc Commercial 374,548

Keystone Health Plan, Inc Commercial 356,289

B.4. Largest Pennsylvania Health Plans By Enrollment

*Medicare enrollment as of September 2017; Medicaid as of January 2018; Commercial as of 4th quarter 2016



Plan Name Plan Type Enrollment* Estimated SMI Enrollment

Medicare FFS Medicare 1,407,027 201,205

Medicaid FFS Medicaid 477,745 91,203

Highmark, Inc Commercial ASO 1,300,569 29,913

Aetna Commercial ASO 1,178,174 27,098

Keystone First Medicaid Managed Care-HealthChoices 434,204 26,177

UPMC For You, Inc Medicaid Managed Care-HealthChoices 422,280 25,458

QCC Insurance Company Commercial ASO 905,131 20,818

UPMC For Life Medicare 134,879 19,288

Gateway Health Medicaid Managed Care-HealthChoices 303,635 18,306

Highmark Medicare 114,170 16,326

B.5. Largest Pennsylvania Health Plans By Estimated SMI Enrollment

*Medicare enrollment as of December 2017; Medicaid as of November 2017; Commercial as of 4th quarter 2016



Health Insurance Marketplace

Type of Marketplace Federal

Individual Enrollment Contact

https://www.healthcare.gov/

1-800-318-2596

Small Business Enrollment Contact

https://www.healthcare.gov/small-businesses/

1-800-706-7893

2018 Individual Market Health Plans1. Capital Advantage Assurance Company2. First Priority Health3. Geisinger Health Plan4. Highmark Choice Company5. Highmark Health Insurance Company6. Highmark, Inc7. Independence Blue Cross8. Keystone Health Plan East, Inc9. UPMC Health Options, Inc

2018 Small Group Market Plans1. UPMC Health Coverage, Inc2. UPMC Health Options, Inc

B.6. Health Insurance Marketplace



C. Medicaid Administration, Governance & Operations

Table Of Contents


C.1. Medicaid Governance: Organization Chart

In June 2017, Pennsylvania Governor Tom Wolf released a plan to consolidate the Department Of Human Services with the Department Of Health, the Department Of Aging, and the Department Of Drug & Alcohol Programs into a unified organization called the Department Of Health & Human Services but the proposal failed to receive legislative support; in February 2018, he scaled back his plan to include shared administrative and budgetary functions among the four departments and a full merger of only two departments, Human Services and Health



C.2. Medicaid Governance: Key Leadership

Name Position Department

Teresa Miller Secretary Department Of Human Services

Leesa Allen Executive Deputy Secretary, State Medicaid Director Department Of Human Services

Gina Buckley Administrative Officer Office Of Medical Assistance Programs

Laurie Rock Director, Bureau Of Managed Care Operations Office Of Medical Assistance Programs

Jamie Buchenauer Director, Bureau Of Fee-For-Service (FFS) Programs Office Of Medical Assistance Programs

Allen Fisher Director, Bureau Of Fiscal Management Office Of Medical Assistance Programs

Daniel De Lellis Director, Bureau Of Policy, Analysis, & Planning Office Of Medical Assistance Programs



Medicaid Expansion

Participating In Expansion Yes

Date Of Expansion January 2015

Medicaid Eligibility Income Limit For Able-Bodied Adults

133% of FPL Note: The PPACA requires that 5% of income be disregarded when determining eligibility

Legislation Used To Expand Medicaid None: The state originally expanded Medicaid using section 1115 waiver authority; state plan amendment authority for the expansion became effective in April 2015

Number Of Individuals Enrolled In The Expansion Group (December 2016) 776,319

Number Of Enrollees Newly Eligible Due To Expansion 733,629

Benefits Plan For Expansion Population Benefits for the Medicaid expansion population are identical to state plan benefits

C.3. Medicaid Expansion Status



Federally Mandated Services1. Inpatient hospital services other than services in an institution

for mental disease (IMD)2. Outpatient hospital services 3. Rural Health Clinic services4. Federally Qualified Health Center (FQHC) services5. Laboratory and x-ray services6. Nursing facilities for individuals 21 and over7. Early and Periodic Screening and Diagnosis and Treatment

(EPSDT)8. Family planning services and supplies9. Free standing birth centers10. Pregnancy-related and postpartum services11. Nurse midwife services12. Tobacco cessation programs for pregnant women13. Physician services14. Medical and surgical services of a dentist15. Home health services16. Nurse practitioner services17. Non-emergency transportation to medical care

Pennsylvania’s Optional Services1. Podiatry2. Optometry3. Chiropractics4. Services of other practitioners5. Clinic services6. Dental services7. Prescribed drugs8. Dentures9. Prosthetic devices10. Eyeglasses11. Preventive services12. Rehabilitative services13. Services for individuals age 65 and over in IMDs14. Intermediate care facility services for individuals with

intellectual or developmental disabilities (ICF/IDD)15. Public institution services for individuals with I/DD16. Inpatient psychiatric services for individuals under age 2217. Hospice care18. Case management19. Nursing facility services for patients under 21

C.4. Medicaid Program Benefits



D. Medicaid Financing & Service Delivery System

Table Of Contents


D.1. Medicaid Financing & Service Delivery System

Medicaid System Characteristics

Characteristics Medicaid Fee-For-Service (FFS) Medicaid Managed Care-HealthChoices

Medicaid Managed Care-Community HealthChoices

Enrollment(January 2018) 477,745 2,323,090 85,389

SMI Enrollment• Pennsylvania does not specifically preclude individuals with SMI from enrolling in managed care based on a diagnosis of

SMI; as a result, the majority of the SMI population is enrolled in managed care• Estimated 64% of SMI population is enrolled in managed care

Management Department Of Human Services• Physical Health: Nine managed care

plans (PH-MCOs)• Behavioral Health: Five BH-MCOs

• Physical health: Three managed care plans (CHC-MCOs)

• Behavioral health: BH-MCOs

Payment Model Fee-for-service • Physical health: Capitated rate• Behavioral health: Capitated rate

• Physical health: Capitated rate• Behavioral health: Capitated rate

Geographic ServiceArea Statewide

• Managed care is available statewide• Physical health: PH-MCOs operate on

a regional basis• Behavioral health: BH-MCOs operate

on a county-by-county basis

• Southwest region only in 2018• Will be statewide by January 2020• Physical health: CHC-MCOs will be

statewide• Behavioral health: BH-MCOs operate

on a county-by-county basis

Total Medicaid: 2,886,224 | Total Medicaid With SMI: 256,873 For acronym definitions, see Glossary


D.2. Medicaid Service Delivery System Enrollment By Eligibility Group

Population Mandatory FFS Enrollment Option To Enroll In FFS Or Managed Care

Mandatory Managed Care Enrollment

Parents and caretakers X

Children X

Blind and disabled individuals X

Aged individuals X

Dual eligibles

• Regional phase-out of FFS enrollment for full-benefit dual eligibles between 2018 and 2020

• Partial benefit dual eligibles

Regional implementation of managed care for full-benefit dual eligiblesbetween 2018 and 2020

Medicaid expansion X

Individuals residing in nursing homes X

Individuals residing in ICF/IDD X

Individuals in foster care X

Other populations

• Individuals with I/DD receiving Office Of Developmental Program services

• Residents of state-operated nursing facilities or psychiatric hospitals

• OBRA waiver participants not nursing facility eligible

• Emergency services only

Breast and cervical cancer program



• Pennsylvania calls its Medicaid program Medical Assistance

• FFS enrollment as of January 2018 was 477,745

D.3. Medicaid FFS Program: Overview



D.4. Medicaid FFS Program: Behavioral Health Benefits

All behavioral health services and pharmacy are provided FFS by the state

FFS Addiction Treatment Benefits1. Inpatient detoxification2. Outpatient services3. Methadone maintenance clinic services4. Rehabilitation services for individuals under age

21

FFS Mental Health Benefits1. Inpatient services2. Outpatient services3. Partial hospitalization4. Mobile mental health treatment5. Peer support services6. Psychiatric clinic services7. Family-based mental health rehabilitative

services for children and youth8. Mental health crisis intervention services9. Mental health targeted case management10. Service coordination



• Pennsylvania does not specifically preclude individuals with SMI from enrolling in managed care based on a diagnosis of SMI; however, individuals with SMI may be enrolled in FFS based on other criteria

• It is estimated that as of January 2018, 36% of the SMI population was enrolled in FFS

• Ongoing implementation of the Community HealthChoices program will decrease the share of the Medicaid SMI population enrolled in FFS

D.5. Medicaid FFS Program: SMI Population



• Managed care enrollment as of January 2018 was 2,408,479• Pennsylvania operates two Medicaid managed care programs HealthChoices and CommunityHealth Choices

(CHC)– HealthChoices delivers physical health services to children, families, and the Medicaid expansion population; enrollment as of

January 2018 was 2,323,090– CHC is a new program that is being phased-in regionally to provide physical health services and long-term services and

supports (LTSS) to the aged, blind, and disabled population age 21 and over; enrollment as of January 2018 was 85,389• HealthChoices delivers services through nine health plans called PH-MCOs; PH-MCOs are available

regionally and individuals may pick any plan in their region• New HealthChoices contracts were intended to take effect in 2017, but are stalled due to bid challenges• The existing managed care contract includes a requirement for the PH-MCOs to engage in value-based

reimbursement (VBR)– The VBR goal has increased from 7.5% of the medical portion of capitation revenue in calendar year 2017, to 15% in 2018, to

30%, in year 2019 – Eligible VBR strategies are pay-for-performance (P4P), patient-centered medical homes (PCMH), shared savings

arrangements, bundled payments, full-risk arrangements, and accountable care organizations (ACOs)– In 2018, at least half of the VBR goal must be met through strategies other than P4P; in 2019, at least half of the VBR goal must

be through strategies other than P4P and PCMHs

D.6. Medicaid Managed Care Program: Overview



D.7. Medicaid Managed Care Program: HealthChoices PH-MCO Service Areas

Lehigh/Capital

Northeast

Northwest

Southeast

Southwest

HealthChoicesPH-MCO Service Areas



D.8. Medicaid Managed Care Program: Re-Procurement Protest Status

Zone Incumbent Health Plans Continuing Coverage

Re-Procurement Awards Under Stay Of Appeal

Lehigh/Capital Counties

1. Aetna Better Health Of PA 2. Amerihealth Caritas PA3. Gateway Health Plan4. UPMC For You5. UnitedHealthcare

1. Gateway Health2. Geisinger Health Plan3. Health Partners4. PA Health & Wellness

NortheastCounties

1. Aetna Better Health Of PA 2. Amerihealth North East3. Geisinger Health Plan

1. Gateway Health2. Geisinger Health Plan3. UPMC For You

Northwest Counties

1. Aetna Better Health Of PA 2. Amerihealth Caritas PA3. Gateway Health Plan4. UPMC For You

1. Gateway Health2. UPMC For You3. Vista-Amerihealth Caritas

Southeast Counties

1. Aetna Better Health Of PA 2. Health Partners3. Keystone First4. UnitedHealthcare

1. Gateway Health2. Health Partners3. PA Health & Wellness4. UPMC For You5. Vista-Keystone First

SouthwestCounties

1. Aetna Better Health Of PA 2. Gateway Health Plan3. UPMC4. UnitedHealthcare

1. Gateway Health2. PA Health & Wellness3. UPMC For You4. Vista-Amerihealth Caritas

1. In January 2017, the state announced that it had selected six managed care plans for negotiations in competitive re-procurement of the HealthChoicesPH-MCO contracts

2. UnitedHealthcare filed a bid protest; when its protest was denied by the Department Of Human Services (DHS), the company appealed to the judicial system

3. The Pennsylvania courts reversed the denial in April 2018; this may result in a restart of the re-procurement process

4. Until DHS determines how to proceed based on the judgment, the incumbent PH-MCOs will continue to provide services



• Behavioral health services are not included in the HealthChoices PH-MCOs’ capitation rate; however, the PH-MCOs are responsible for behavioral health pharmacy

• Pennsylvania contracts with at-risk BH-MCOs to provide all behavioral health services• A county, a group of counties, or their contracted entity are given right of first opportunity to act as the BH-

MCO– Of Pennsylvania’s 67 counties, 44 elected to exercise the right of first opportunity, and the county or its subcontractor acts as

the BH-MCO– The state contracts with BH-MCOs for individuals residing in the 23 counties that elected not to be party to a BH-MCO

arrangement• BH-MCOs are available by county and individuals are served by the BH-MCO in their county

– The BH-MCO operating areas do not align with the PH-MCO regions • The state imposed VBR requirements on the BH-MCOs in 2018; the BH-MCOs must achieve a minimum

target of 5% of their expenditures under VBR arrangements in calendar year 2018, 10% in 2019, and 20% in 2020

• In 2019 and 2020, at least half of the minimum target VBR arrangements must be in the moderate risk or large risk categories as described below:

– Small risk: Performance-based contracting– Moderate risk: Bundled and episodic payments, shared savings, and shared risk– Large risk: Capitation and capitation plus performance-based contracting

• Pennsylvania is preparing a section 1115 waiver application for submission to the Centers For Medicare & Medicaid Services (CMS) for expanded addiction treatment services

D.9. Medicaid Managed Care Program: Behavioral Health Overview



D.10. Medicaid Managed Care Program: HealthChoicesBehavioral Health Benefits

1. Ambulance, emergency room, and pharmacy benefits are delivered by the PH-MCOs; all other behavioral health benefits are delivered by the BH-MCOs

2. BH-MCOs may provide services in-lieu of state plan services if medically appropriate, cost-effective, and agreed to by the participant

Mental Health Benefits Delivered By The BH-MCOs

1. Inpatient psychiatric services2. Psychiatric partial hospitalization3. Emergency room evaluations for

commitments4. Psychiatric outpatient services5. Laboratory studies6. Clozapine support services7. Crisis intervention8. Mental health targeted case

management9. Family-based services, rehabilitation

services, and residential treatment for individuals under 21 years old

Authorized BH-MCO “In-Lieu Of” Benefits

1. Partial hospitalization for addiction2. Non-hospital residential detoxification and

halfway house services3. Site, clubhouse, or mobile psychiatric

rehabilitation4. Addiction targeted case management5. Supported living services6. Assistance in obtaining housing, employment,

and income support7. Continuous community-based treatment teams8. Adult residential treatment9. Addiction prevention and intervention services10. Social rehabilitation11. Addiction transitional housing12. Addiction drop-in centers

Addiction Treatment Benefits Delivered By The BH-MCOs

1. Outpatient services2. Methadone maintenance clinic3. Methadone, when used to treat opioid

dependency and dispensed by a BH-MCO provider

4. Inpatient detoxification5. Rehabilitation services for individuals

under age 21



D.11. Medicaid Managed Care Program: HealthChoices BH-MCOs By County

Community Care Behavioral Health Organization

PerformCare

Value Behavioral Health of Pennsylvania

Community Behavioral Health

Magellan Behavioral Health

HealthChoices BH-MCOs



D.12. Medicaid Managed Care Program: HealthChoicesBehavioral Health Regions

PH-MCO Zone BH-MCOs Counties Served

Lehigh/Capital

Community Care Behavioral HealthcareOrganization (CCBHO) Adams, Berks, York

Magellan Behavioral Health Lehigh, Northampton

PerformCare Cumberland, Dauphin, Lancaster, Lebanon, Perry

North/Central

CCBHO Blair, Carbon, Clinton, Erie, Lycoming, Monroe, Pike

Magellan Behavioral Health Cambria

PerformCare Bedford, Franklin, Fulton, Somerset

Value Behavioral Health of Pennsylvania Crawford, Mercer, Venango

North/Central (state contractor) CCBHO

Bradford, Cameron, Centre, Clarion, Clearfield, Columbia, Elk, Forest, Huntingdon, Jefferson, Juniata, McKean, Mifflin, Montour, Northumberland, Potter, Schuylkill, Snyder, Sullivan, Tioga, Union, Warren, Wayne

Northeast CCBHO Lackawanna, Luzerne, Susquehanna, Wyoming

Southeast

Community Behavioral Health Philadelphia

CCBHO Chester

Magellan Behavioral Health Bucks, Delaware, Montgomery

SouthwestCCBHO Allegheny

Value Behavioral Health of Pennsylvania Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, Westmoreland



• Pennsylvania does not specifically preclude individuals with SMI from enrolling in managed care based on a diagnosis of SMI; however, individuals with SMI may be enrolled in FFS based on other criteria

• It is estimated that as of January 2018, 64% of the SMI population was enrolled in managed care

• Ongoing implementation of the Community HealthChoices program will increase the share of the Medicaid SMI population enrolled in managed care

D.13. Medicaid Managed Care Program: SMI Population



Accountable Care Organization (ACO)

Program

Affordable Care Act Health Home

Patient-Centered Medical Home

Other Care Coordination

Initiatives

D.14. Medicaid Program: Care Coordination Initiatives

Other care coordination programs include: 1. Certified community

behavioral health clinics

2. Integrated Care Program

3. Opioid Use Disorder Centers Of Excellence

4. Healthy Beginnings Plus Health Homes

The PCMH model is among the strategies that are available to the PH-MCOs to meet their VBP targets; however, there is no statewide PCMH program

NoneThe ACO model is among the strategies that are available to the PH-MCOs to meet their VBP targets; however, there is no statewide Medicaid ACO program



D.15. Medicaid Program: Demonstration & Care Management Waivers

Waiver Title Waiver Description WaiverType

Enrollment Cap

EffectiveDate

ExpirationDate

PA 67

• Authorizes mandatory delivery of physical health benefits through managed care organizations, called PH-MCOs by the state

• Authorizes mandatory delivery of behavioral health benefits through behavioral health prepaid inpatient health plans (PIHPs), called BH-MCOs by the state

• Authorizes a specialty pharmacy program for individuals in FFS

1915 (b) None 01/01/2017 12/31/2021

Community HealthChoices(CHC)

• Authorizes mandatory delivery of physical health benefits and LTSS for dual eligibles and individuals age 21 and over in need of LTSS through a new managed care program phasing in regionally between January 2018 and January 2020; the plans are called CHC-MCOs by the state

• Operates concurrently with the PA CHC (formerly CommCare) 1915 (c) waiver

• Authorization of mandatory delivery of behavioral health benefits for the CHC population is through the PA 67 1915 (b) waiver

1915 (b) None 01/01/2018 12/31/2022

Pennsylvania Medicaid Coverage For Former Foster Care Youth From A Different State

Authorizes Medicaid state plan coverage for former foster care youth under age 26 who moved from another state 1115 None 10/01/2017 09/30/2022

Pennsylvania’s Medicaid waiver services are in a state of transition due to the phase-in of the CHC managed long-term services and supports (MLTSS) program that began in January 1, 2018



D.16. Medicaid Program: Section 1915 (c) HCBS Waivers

Waiver Title Target Population Prior To CHC Implementation

Target Population After CHC Implementation

2018Enrollment Cap

Operating UnitConcurrent Management Authority

PA HCBW for Individuals Aged 60 & Over (0279.R04.00)

Individuals age 65 and above and individuals age 60 to 64 with physical disabilities requiring a nursing facility level of care

None; phasing out regionally 42,260Office of Long-Term Living (OLTL)

None

PA Attendant Care (0277.R04.00)

Individuals with physical disabilities age 18 to 59 requiring a nursing facility level of care None; phasing out regionally 18,157 OLTL None

PA Independence (0319.R04.00)

• Individuals with physical disabilities age 18 to 59 requiring a nursing facility level of care

• Individuals with brain injury age 21 and over during regional transition

None; phasing out regionally 15,934 OLTL None

PA Community HealthChoices (CHC) (formerly known as CommCare) (0386.R03.00)

Individuals with traumatic brain injury, age 21 and over requiring a nursing facility level of care

Individuals age 21 and over requiring a nursing facility level of care• With a traumatic brain injury• With physical disabilities• Previously enrolled in PA OBRA• Aged population

13,305 OLTL 1915 (b)

PA OBRA (0235.R05.00)

• Individuals with developmental disabilities ages 18 to 59

• During transition, individuals may be reevaluated for nursing facility level of care determination for transition to the PA CHC waiver

• Individuals with developmental disabilities ages 18 to 59 requiring an ICF level of care

• Individuals ages 18 to 20 from the PA Independence and Attendant Care waivers phasing in regionally

1,485 OLTL None



D.17. Medicaid Program: Section 1915 (c) HCBS Waivers (Continued)

Waiver Title Target Population Prior To CHC Implementation

Target Population After CHC Implementation

2018Enrollment Cap

Operating UnitConcurrent Management Authority

PA Consolidated Waiver (0147.R05.00)

Individuals with autism or intellectual disabilities (all ages) or developmental disabilities (birth to age eight) requiring an ICF level of care.

No change 18,209Office Of Developmental Programs (ODP)

None

PA Person/Family Directed Support (0344.R03.00)

Individuals with autism or intellectual disabilities (all ages) or developmental disabilities (birth to age eight) requiring an ICF level of care

No change 14,720 ODP None

PA Medicaid Waiver For Infants, Toddlers, & Families (0324.R03.00)

Individuals with I/DD from birth to age two requiring an ICF level of care No change 4,300

Office Of Child Development & Early Learning

None

Community Living Waiver (PA.1486.R00.00)

Individuals with autism or intellectual disabilities (all ages) or developmental disabilities (birth to age eight) requiring an ICF level of care

No change 1,050 ODP None

PA Adult Autism (0593.R02.00)

Individuals with autism age 21 and over requiring an ICF level of care No change 702 ODP None



E. State Behavioral Health Administration & Finance System

Table Of Contents


E.1. Office Of Mental Health & Substance Abuse Services: Organization Chart

In June 2017, Pennsylvania Governor Tom Wolf released a plan to consolidate the Department Of Human Services with the Department Of Health, the Department Of Aging, and the Department Of Drug & Alcohol Programs into a unified organization called the Department Of Health & Human Services but the proposal failed to receive legislative support; in February 2018, he scaled back his plan to include shared administrative and budgetary functions among the four departments, and a full merger of only two departments: Human Services and Health For acronym definitions, see Glossary


E.2. Office Of Mental Health & Substance Abuse Services: Key Leadership


Teresa Miller Secretary Department Of Human Services

Leesa Allen Executive Deputy Secretary, State Medicaid Director Department Of Human Services

Lynn Kovich Deputy Secretary Office Of Mental Health & Substance Abuse Services

Vacant Medical Director Office Of Mental Health & Substance Abuse Services

Terry Mardis Acting Director Bureau Of Financial Management & Administration

Shannon Fagan Director Bureau Of Children’s Behavioral Health Services

Sherry Peters Director Bureau Of Policy, Planning, & Program Development

Phil Mader Director Bureau Of Community & Hospital Operations



E.3. Department Of Drug & Alcohol Programs: Organization Chart & Key Leadership


Jennifer Smith Acting Secretary Department Of Drug &Alcohol Programs

Jodi Skiles Director Bureau Of Treatment, Prevention & Intervention

Wenona Wake Director Bureau Of Quality AssuranceFor Prevention & Treatment

Terry Matulevich Director Bureau Of Administration &Program Support



E.4. Mental Health & Addiction Hospital Bed Distribution

Mental Health & Addiction Treatment Bed Capacity

Total number of hospitals with mental health and addiction beds

94

Number mental health and addiction beds 5,319

Number mental health and beds per 100,000 population

41.61

0.00 0.01 to 10.00 10.01 to 30.00 30.01 to 50.00 More than 50.00

Mental Health & Addiction Hospital Beds Per 100,000 Population



E.5. State Psychiatric Institutions

State Psychiatric Institutions

Institution Location Beds July 2018 Projected Census

Clarks Summit State Hospital Clarks Summit 200 185

Danville State Hospital Danville 160 160

Norristown State Hospital Norristown 287 287

South Mountain Restoration Center South Mountain 159 150

Torrance State Hospital Torrance 361 345

Warren State Hospital North Warren 152 150

Wernersville State Hospital Wernersville 266 260

Total 1,585 1,537For acronym definitions, see Glossary


E.6. State Psychiatric Institutions Map

State Psychiatric Institution Catchment Areas

Danville Torrance

WarrenClarks Summit Norristown

Wernersville

No catchment area; however, individuals may be served by Torrance State Hospital



F. State Behavioral Health Stakeholder Organizations

Table Of Contents


F.1. Accountable Care Organizations

Medicare Shared Savings Program1. Aledade Delaware ACO2. Aledade Freedom ACO3. Aledade Southeast Pennsylvania ACO4. Allegiance Health Group5. Atlantic Accountable Care Organization 6. Bon Secours Good Helpcare, LLC7. Bridges Health Partners8. Capital Health Accountable Care

Organization, LLC9. Care Is Primary ACO, LLC10. Carroll ACO, LLC11. Chautauqua Region Associated Medical

Partners12. Christiana Care Quality Partners ACO13. Community Care Collaborative Of

Pennsylvania & New Jersey, LLC14. Crystal Run Healthcare ACO, LLC15. Delaware Care Collaboration 16. Delaware Valley ACO17. Einstein Care Partners, LLC18. Genesis Healthcare ACO, LLC 19. Greater Baltimore Health Alliance, LLC

1. Healthy Communities ACO, LLC2. Heritage Valley Healthcare Network

ACO, LLC3. Keystone Accountable Care

Organization, LLC4. Keystone Clinical Partners, LLC5. Lancaster General Health Community

Care Collaborative, LLC6. Lehigh Valley Health Network

Accountable Care Organization, LLC7. Mercy Accountable Care, LLC8. Meritus Health ACO9. Penn State Health Care Partners 10. Physicians Accountable Care Solutions,

LLC11. Princeton HealthCare Partners, LLC 12. Saint Vincent Healthcare Partners13. Trinity Health Integrated Care14. United Medical Accountable Care

Organization15. Western Maryland Physician Network,

LLC16. York Health Plan



F.2. Accountable Care Organizations (Continued)

Commercial

ACO Commercial InsurerAbington Health Independence Blue Cross

Atlantic Accountable Care Organization Aetna, UnitedHealthcare

Children's Hospital Of Philadelphia (CHOP) Aetna

Delaware Valley ACO Blue Cross, Humana

Lancaster General Health Community Care Collaborative, LLC Highmark

Penn Medicine Independence Blue Cross

PinnacleHealth System Aetna, Capital BlueCross

Tandigm Health Independence Blue Cross

Valley Preferred Aetna, Cigna

WellSpan Health Aetna

Other Medicare ACO Models

ACO ModelACO Health Partners Advance Payment Model

LHS Health Network, LLC Next Generation Model

Ohio River Basin ACO Investment Model

Western Maryland Accountable Care Organization Advance Payment Model



G. Appendices

Table Of Contents


Acronym Legend

Table Of Contents

Acronym Definition Acronym Definition Acronym Definition Acronym Definition

ACA Affordable Care Act DHS Department Of Human Services LHS Lourdes Health System PCMH Patient-Centered Medical Home

ACO Accountable Care Organizations EPSDT Early & Periodic Screening,

Diagnosis & Treatment LTSS Long-Term Services & Supports PH-MCO Physical HealthChoicesManaged Care Organizations

ASO Administrative Services Organization FFS Fee-For-Service MH/DS Mental Health & Developmental

Services PIHP Prepaid Inpatient Health Plan

BH-MCO Behavioral HealthChoicesManaged Care Organizations FPL Federal Poverty Level MLTSS Managed Long-Term Services &

Supports PPACA Patient Protection & Affordable Care Act

CCBHO Community Care Behavioral Healthcare Organization FQHC Federally Qualified Health

Center MSA Metropolitan Statistical Area SCA Single County Authority

CHC Community HealthChoices HCBS Home- & Community-Based Services OBRA Omnibus Budget Reconciliation Act

Of 1987 SMI Serious Mental Illness

CHC-MCO Community HealthChoicesManaged Care Organizations HCBW Home- & Community-Based

Waiver ODP Office Of Developmental Programs SNP-DE Dual Eligible Special Needs Plan

CHIP Children's Health Insurance Program I/DD Intellectual/Developmental

Disability OLTL Office Of Long-Term Living UHC UnitedHealthcare

CHOP Children's Hospital Of Philadelphia ICF Intermediate Care Facility P4P Pay-For-Performance UPMC University Of Pittsburgh

Medical Center

CMS Centers For Medicare & Medicaid Services ICF/IDD

Intermediate Care Facility / Intellectual Or Developmental Disabilities

PA Pennsylvania VBP Value-Based Payment

DDAP Department Of Drug & Alcohol Programs IMD Institutions For Mental Disease PCCM Primary Care Case Management VBR Value-Based Reimbursement


Glossary Of Terms

Word Abbreviation Definition

Accountable Care Organizations ACO

ACOs are groups of providers—such as physicians and hospital systems—that form an agreement to coordinate care for a set group of consumers. If the ACO delivers high quality care—measured through performance metrics—and lowers the cost of providing care against a baseline, then the organization receives a portion of the savings generated. ACOs can exist alongside all payment structures (fee-for-service and managed care delivery systems) and payers (Medicare, Medicaid, commercial).

Administrative Services Organization ASO An arrangement in which an organization hires a third party to deliver administrative services to the organization,

such as claims processing and billing. The organization bears the risk for all claims.

Behavioral HealthChoicesManaged Care Organizations

BH-MCOsThe five behavioral health organizations that finance and deliver behavioral health services to enrollees in Pennsylvania’s Medicaid managed care programs. Physical health services are financed and delivered through either the PH-MCOs or the CHC-MCOs.

Capitation A set amount of money paid per enrollee per month to a health care entity to cover the cost of health care services. Generally the entity assumes full-risk for the cost of each enrollee's care.

Community HealthChoicesManaged Care Organizations

CHC-MCOs

The three health care plans that finance and deliver physical health services and MLTSS to dual eligible and individuals in need of LTSS in Pennsylvania’s Medicaid Community HealthChoices managed care program. Behavioral health services are delivered through the Behavioral HealthChoices Managed Care Organizations (BH-MCOs).

Table Of Contents


Glossary Of Terms


Dual EligibleAn individual who is eligible for Medicare (Part A and B) and Medicaid. Medicare serves as the individual's primary insurance, and Medicaid acts as a supplement. Dual eligibles are sometimes referred to as Medicare-Medicaid enrollees (MMEs).

Federal Poverty Level FPLThe U.S. Department of Health and Human Services sets a standard level of income that is used to determine eligibility for services and benefits, including Medicaid. In 2018, the FPL is $12,140 for an individual and $25,100 for a family of four.

Fee-For-Service FFS A system in which provider organizations are reimbursed for each covered service such as an office visit, test, or procedure according to rates set by the payer.

Health Home

A “whole person” care coordination model that specifically targets populations with chronic conditions including those with SMI. Health homes provide six essential functions: 1.) Comprehensive care management; 2.) Care coordination and health promotion; 3.) Comprehensive transitional care from inpatient to other settings, including appropriate follow-up; 4.) Individual and family support; 5.) Referral to community and social support services; 6.) Use of health information technology to link services.

Home- & Community-Based Services HCBS

Long-term services and supports provided in the home or community in order to avoid institutionalization. Traditionally provided through 1915(c) waivers, HCBS services are usually limited to specific populations and a specific number of people. HCBS services include skilled nursing care, personnel care services, assistance with activities of daily living, and custodial care.

Table Of Contents


Glossary Of Terms


Institutions For Mental Disease IMD

A hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including substance abuse. Federal financial participation is available for Medicaid IMD services for individuals under the age of 21 and age 65 and over. In recent years, CMS has relaxed the rules prohibiting payments in IMDs for individuals age 21-64. Medicaid health plans may provide up to 15 days of IMD services per month in lieu of state plan services if medically appropriate, cost effective, and consented to by the individual. Additionally, states may be granted a 1115 waiver authority to allow individuals to receive residential addiction treatment in IMDs.

Long-Term Services & Supports LTSS

Services provided in the home, community, or institutional setting to those who experience difficulty living independently and completing activities of daily living as a result of cognitive disabilities, physical impairments,disabling chronic conditions and/or age.

Medicaid

Medicaid is a joint federal-state program that provides health coverage to economically disadvantaged populations, such as low-income adults, children, and aged, blind, and disabled (ABD) individuals. States establish their own eligibility standards, benefit packages, provider payment policies, and administrative structures under broad federal guidelines. Financing is a shared responsibility of the federal government and the states

Medicaid Waiver Granted by CMS, waivers allow states to make temporary changes to their Medicaid State Plan in order to test out new ways to deliver health coverage. Importantly, the waivers must be budget neutral.

Medical HomeA medical home is not a physical place, but a model for care coordination. Medical homes provide primary care services, care coordination, enhanced access to care, and care that is culturally and linguistically appropriate. Medical homes exist across multiple payers.

Table Of Contents


Glossary Of Terms


MedicareFederal health insurance for individuals over the age of 65, individuals with certain disabilities, and individuals with end stage renal disease. Medicare covers most acute care services (which may include psychiatric care), but does not cover LTSS or non-physician behavioral health services.

Medicare Advantage Special Needs Plan SNP

A special type of Medicare Advantage plan that is designed to provide targeted coordinated care to individuals who are a) institutionalized; b) dual eligible; and/or c) meet the severe chronic disabled conditions set forth by CMS. Plans emphasize improved care primarily through continuity of care and care coordination.

MetropolitanStatistical Area MSA An urbanized area of 50,000 or more population plus adjacent territory that has a high degree of social and

economic integration as measured by commuting ties.

Patient-Centered Medical Home PCMH See Medical Home.

Patient Protection & Affordable Care Act

PPACA or ACA

U.S. health care reform signed into law in 2010. The legislation regulates certain aspects of private and public health insurance programs and authorizes an individual mandate to secure essential health coverage, premium tax credits for the purchase of private health insurance, and increased insurance coverage of preexisting conditions. In 2012 the Supreme Court ruled that state participation is optional for provisions of the law expanding Medicaid coverage to adults ages 18 to 64 with incomes under 138% of the FPL. In 2017, Congress repealed the tax penalties associated with the individual mandate essentially ending the mandate.

Pay-for-Performance P4P A health care payment model that offers financial rewards to organizations that meet or exceed pre-determined quality benchmarks. Typically, services continue to be reimbursed FFS.

Table Of Contents


Glossary Of Terms

Word Abbreviation DefinitionPhysical HealthChoicesManaged Care Organizations

PH-MCOsThe nine health care plans that finance and delivery physical health services for enrollees in Pennsylvania’s Medicaid HealthChoices managed care program. Behavioral health services are delivered through the Behavioral HealthChoices Managed Care Organizations (BH-MCOs).

Primary Care Case Management PCCM

A health care delivery system model with limited utilization and cost control. Under the PCCM model, Medicaid enrollees choose a primary care physician who acts as a gatekeeper for more intensive services. The primary care physician generally receives a per person per month (PMPM) fee for care coordination, and is reimbursed fee-for-service for all medical services provided. Some states consider PCCM a managed care delivery model, while other states consider it an FFS delivery model.

Serious Mental Illness SMI

A mental, behavioral, or emotional disorder that lasts for a sufficient duration of time and causes impairment of major life activities. Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD), and borderline personality disorder.

Value-BasedReimbursement VBR

Reimbursement model in which payers financially reward or penalize health care provider organizations for performance on quality and cost of care. VBR payment mechanisms include P4P; capitation; shared savings models; shared risk models; and payments based on clinically-defined episodes, called episodes of care or bundled payments.

Table Of Contents


A. Executive SummaryA.1. Health Care Coverage Map• Information compiled from sources provided throughout the profile.

A.2. Medicaid System Overview• Information compiled from sources provided throughout the profile.

A.3. Medicaid Care Coordination Initiatives• Information compiled from sources provided throughout the profile.

A.4. State Behavioral Health Safety-Net Delivery System Overview• Pennsylvania Association of County Drug and Alcohol Administrators. Welcome to PACDAA. Retrieved March 6, 2018 from http://www.pacdaa.org/Pages/PACDAAHome.aspx• Governor of Pennsylvania. (2018, February 6). Executive Budget. Retrieved March 6, 2018 from

http://www.budget.pa.gov/PublicationsAndReports/CommonwealthBudget/Documents/2018-19%20Proposed%20Budget/2018-19%20Governor%27s%20Executive%20Budget%20-%20Web.pdf

• Pennsylvania Department of Drug and Alcohol Programs. 2015-2016 State Plan Retrieved March 6, 2018 from http://www.ddap.pa.gov/Reports/State%20Plan%20and%20Annual%20Reports/2015-2016%20DDAP%20State%20Plan%20and%202013-2014%20Report.pdf

• Pennsylvania Department of Human Services. Mental Health Services. Retrieved March 6, 2018 from http://www.dhs.pa.gov/citizens/mentalhealthservices/• Pennsylvania Department of Human Services. County Mental Health System. Retrieved March 6, 2018 from http://dhs.pa.gov/provider/mentalhealth/countymentalhealthsystem/

A.5. State Behavioral Health Safety-Net Delivery System• Pennsylvania Association of County Drug and Alcohol Administrators. Welcome to PACDAA. Retrieved March 6, 2018 from http://www.pacdaa.org/Pages/PACDAAHome.aspx• Governor of Pennsylvania. (2018, February 6). Executive Budget. Retrieved March 6, 2018 from


• Pennsylvania Department of Drug and Alcohol Programs. 2015-2016 State Plan Retrieved March 6, 2018 from http://www.ddap.pa.gov/Reports/State%20Plan%20and%20Annual%20Reports/2015-2016%20DDAP%20State%20Plan%20and%202013-2014%20Report.pdf

• Pennsylvania Department of Human Services. Mental Health Services. Retrieved March 6, 2018 from http://www.dhs.pa.gov/citizens/mentalhealthservices/• Pennsylvania Department of Human Services. County Mental Health System. Retrieved March 6, 2018 from http://dhs.pa.gov/provider/mentalhealth/countymentalhealthsystem/

Sources

Table Of Contents

http://www.pacdaa.org/Pages/PACDAAHome.aspx

http://www.budget.pa.gov/PublicationsAndReports/CommonwealthBudget/Documents/2018-19%20Proposed%20Budget/2018-19%20Governor's%20Executive%20Budget%20-%20Web.pdf

http://www.ddap.pa.gov/Reports/State%20Plan%20and%20Annual%20Reports/2015-2016%20DDAP%20State%20Plan%20and%202013-2014%20Report.pdf

http://www.dhs.pa.gov/citizens/mentalhealthservices/

http://dhs.pa.gov/provider/mentalhealth/countymentalhealthsystem/

http://www.pacdaa.org/Pages/PACDAAHome.aspx


http://www.ddap.pa.gov/Reports/State%20Plan%20and%20Annual%20Reports/2015-2016%20DDAP%20State%20Plan%20and%202013-2014%20Report.pdf

http://www.dhs.pa.gov/citizens/mentalhealthservices/

http://dhs.pa.gov/provider/mentalhealth/countymentalhealthsystem/


B. Pennsylvania Health Financing System OverviewB.1. Population Demographics• United States Census Bureau. 2016 American Community Survey 1-Year Estimates K200104 Population By Age. Retrieved November 29, 2017 from

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml• United States Census Bureau. 2016 American Community Survey 1-Year Estimates K200104 Population By Age. Retrieved November 29, 2017 from

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml• United States Census Bureau. 2016 American Community Survey 1-Year Estimates B03002 Hispanic or Latino Origin By Race. Retrieved November 29, 2017 from

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml• United States Census Bureau. 2016 American Community Survey 1-Year Estimates S1903 Median Income In the Past 12 Months. Retrieved November 29, 2017 from

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml• United States Census Bureau. 2017 Current Population Survey Annual Social and Economic Supplement POV-46 Poverty Status By State. Retrieved November 29, 2017 from

https://www.census.gov/data/tables/time-series/demo/income-poverty/cps-pov/pov-46.html

B.2. Population Centers• United States Census Bureau. Percent Urban and Rural in 2010 By State. Retrieved December 4, 2017 from https://www.census.gov/geo/reference/ua/urban-rural-2010.html• United States Census Bureau. 2016 Annual Estimates of Residential Population-Metropolitan and Micropolitan Statistical Area GCT-PEPANNRES. Retrieved December 21, 2017 from

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml• United State Department of Commerce. (2013, February 28). Counties in Metropolitan Statistical Areas. Retrieved December 21, 2017 from

https://www.bea.gov/regional/docs/msalist.cfm?mlist=45

B.3. Population Distribution By Payer: National vs. State• OPEN MINDS. (2018). Serious Mental Illness Prevalence Estimates.

Sources

Table Of Contents

https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml




https://www.census.gov/data/tables/time-series/demo/income-poverty/cps-pov/pov-46.html

https://www.census.gov/geo/reference/ua/urban-rural-2010.html


https://www.bea.gov/regional/docs/msalist.cfm?mlist=45


B.4. Largest State Health Plans By Enrollment• OPEN MINDS. (2017, December). Health Plans Database.• TRICARE. (2017, February 15). Beneficiaries by Location. Retrieved January 11, 2018 from http://www.tricare.mil/About/Facts/BeneNumbers/States• Health Plans USA. (2017, September). Subscription Database. Available from http://www.markfarrah.com/products/health-plans-usa.aspx• Pennsylvania Department of Human Services. (2018, January). Monthly data report. Retrieved March 12, 2018 from

http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/c_213880.pdf• Pennsylvania Department of Human Services. (2018, February 21). Monthly Physical Health Managed Care Program Enrollment Report. Retrieved March 12, 2018 from

http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/c_270802.pdf• Pennsylvania Department of Human Services. (2018, January 18). Community HealthChoices Third Thursday Webinar. Retrieved March 7, 2018 from

http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/document/c_269515.pdf

B.5. Largest State Health Plans By Estimated SMI Enrollment• OPEN MINDS. (2017, December). Health Plans Database.• TRICARE. (2017, February 15). Beneficiaries by Location. Retrieved January 11, 2018 from http://www.tricare.mil/About/Facts/BeneNumbers/States• Health Plans USA. (2017, September). Subscription Database. Available from http://www.markfarrah.com/products/health-plans-usa.aspx• Pennsylvania Department of Human Services. (2018, January). Monthly data report. Retrieved March 12, 2018 from




B.6. Health Insurance Marketplace• United States Department of Health and Human Services. (2017, October 25). Plan Year 2018 Individual Medical Coverage Landscape. Retrieved November 1, 2017 from

https://data.healthcare.gov/dataset/QHP-PY2018-Medi-Indi-Land-10-23-2017/hd64-a3rh• United State Department of Health and Human Services. (2017, October 25). Plan Year 2018 SHOP Medical Landscape. Retrieved November 1, 2017 from

https://data.healthcare.gov/dataset/QHP-PY2018-Medi-SHOP-Land-10-23-2017/7r3j-8gie

Sources

Table Of Contents

http://www.tricare.mil/About/Facts/BeneNumbers/States

http://www.markfarrah.com/products/health-plans-usa.aspx

http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/c_213880.pdf



http://www.tricare.mil/About/Facts/BeneNumbers/States

http://www.markfarrah.com/products/health-plans-usa.aspx




https://data.healthcare.gov/dataset/QHP-PY2018-Medi-Indi-Land-10-23-2017/hd64-a3rh

https://data.healthcare.gov/dataset/QHP-PY2018-Medi-SHOP-Land-10-23-2017/7r3j-8gie


C. Medicaid Administration, Governance & OperationsC.1. Medicaid Governance: Organizational Chart• Pennsylvania Office of Administration. (2018, January 3). Department of Human Services. Organization Chart. Retrieved March 5, 2018 from

http://www.oa.pa.gov/Policies/Documents/Human%20Services.pdf• Pennsylvania Department of Human Services. DHS Organization. Retrieved March 5, 2018 from http://www.dhs.pa.gov/learnaboutdhs/dhsorganization/index.htm• Governor of Pennsylvania. (2018, February 6). 2018-2019 Governor’s Executive Budget in Brief. Retrieved March 5, 2018 from

http://www.budget.pa.gov/PublicationsAndReports/CommonwealthBudget/Documents/2018-19%20Proposed%20Budget/2018-19%20Budget%20In%20Brief%20-%20Web.pdf

C.2. Medicaid Governance: Key Leadership• Pennsylvania Department of General Services. (2017). Online Commonwealth Telephone Directory. Retrieved May 5, 2018 from http://www.dgs.pa.gov/About/Pages/Directory.aspx

C.3. Medicaid Expansion Status• Centers for Medicare and Medicaid Services. (2017, December). MACStats: Medicaid and CHIP Data Book. Retrieved January 2, 2018 from https://www.macpac.gov/macstats/• Centers for Medicare and Medicaid Services. (2017, December). Medicaid Enrollment Data Collected Through MBES. Retrieved February 2, 2018 from

https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/enrollment-mbes/index.html• US Government Publishing Office. (2011, October 1). Code of Federal Regulations Title 42. Retrieved February 2, 2018 from https://www.gpo.gov/fdsys/granule/CFR-2011-title42-

vol4/CFR-2011-title42-vol4-sec440-315• Pennsylvania Department of Human Services. (2015, November 19). Medicaid State Plan Amendment 15-0016. Retrieved March 5, 2018 from https://www.medicaid.gov/State-resource-

center/Medicaid-State-Plan-Amendments/Downloads/PA/PA-15-0016.pdf

C.4. Medicaid Program Benefits• Medicaid and CHIP Payment and Access Commission. Mandatory and Optional Benefits. Retrieved December 6, 2017 from https://www.macpac.gov/subtopic/mandatory-and-optional-

benefits/• Pennsylvania Department of Human Services. (2018, January 11). Medicaid State Plan. CD-ROM.

Sources

Table Of Contents

http://www.oa.pa.gov/Policies/Documents/Human%20Services.pdf

http://www.dhs.pa.gov/learnaboutdhs/dhsorganization/index.htm


http://www.dgs.pa.gov/About/Pages/Directory.aspx

https://www.macpac.gov/macstats/

https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/enrollment-mbes/index.html

https://www.gpo.gov/fdsys/granule/CFR-2011-title42-vol4/CFR-2011-title42-vol4-sec440-315

https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/PA/PA-15-0016.pdf

https://www.macpac.gov/subtopic/mandatory-and-optional-benefits/


D. Medicaid Financing & Service Delivery SystemD.1. Medicaid Financing & Service Delivery System• Pennsylvania Department of Human Services. (2018, January). Monthly data report. Retrieved March 12, 2018 from



http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/document/c_269515.pdf• Pennsylvania Department of Human Services. (2017, April 28). Approved Community Health Choices Waiver Proposal. Retrieved March 7, 2018 from

http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/document/c_264257.pdf• Pennsylvania Department of Human Services. (2015, October 1). PA 67 Section 1915 (b) Waiver. Retrieved March 7, 2018 from https://www.medicaid.gov/medicaid/section-1115-

demo/demonstration-and-waiver-list/?entry=24363

D.2. Medicaid Service Delivery System Enrollment By Eligibility Group• Pennsylvania Department of Human Services. (2017, April 28). Approved Community Health Choices Waiver Proposal. Retrieved March 7, 2018 from



D.3. Medicaid Fee-For-Service Program: Overview• FFS enrollment was derived by subtracting January 2018 managed care enrollment from November 2017 total enrollment.• Pennsylvania Department of Human Services. (2018, January). Monthly data report. Retrieved March 12, 2018 from




Sources

Table Of Contents





https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/?entry=24363







D.4. Medicaid FFS Program: Behavioral Health Benefits• Pennsylvania Department of Human Services. (2018, January 11). Medicaid State Plan. CD-ROM.• Pennsylvania Department of Human Services. (2017, December). Office of Medical Assistance Programs Health Care Benefit Packages Reference Chart. Retrieved March 13, 2018 from

http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/c_268952.pdf• Commonwealth of Pennsylvania. The Pennsylvania Code. Retrieved March 13, 2018 from https://www.pacode.com/

D.5. Medicaid FFS Program: SMI Population• Pennsylvania Department of Human Services. (2017, April 28). Approved Community Health Choices Waiver Proposal. Retrieved March 7, 2018 from



D.6. Medicaid Managed Care Program: Overview• Pennsylvania Department of Human Services. (2018, February 21). Monthly Physical Health Managed Care Program Enrollment Report. Retrieved March 12, 2018 from


http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/document/c_269515.pdf• Pennsylvania Department of Human Services. (2017, June 1). Community HealthChoices MCO Contract. Retrieved March 7, 2018 from

http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/document/c_215951.pdf• Pennsylvania Department of Human Services. (2017, January 1). HealthChoices Managed Care Contract. Retrieved March 13, 2018 from

http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/p_040149.pdf

D.7. Medicaid Managed Care Program: Managed Care Plan Map• Pennsylvania Department of Human Services. (2018, January). Pennsylvania Health Choices Map. Retrieved March 13, 2018 from

http://www.dhs.pa.gov/provider/healthcaremedicalassistance/managedcareinformation/statewidemanagedcaremap/index.htm

Sources

Table Of Contents


https://www.pacode.com/







http://www.dhs.pa.gov/provider/healthcaremedicalassistance/managedcareinformation/statewidemanagedcaremap/index.htm


D.8. Medicaid Managed Care Program: Managed Care Re-Procurement Protest• Pennsylvania Department of Human Services. (2017, September 7). Physical HealthChoices Stakeholder Notice. Retrieved March 13, 2018 from

http://listserv.dpw.state.pa.us/Scripts/wa.exe?A2=ind1709a&L=dhs-stakeholders&F=&S=&P=93• Pennsylvania Department of Human Services. (2017, September 7). DHS Awards Medicaid Agreements Stakeholder Notice. Retrieved March 13, 2018 from

http://listserv.dpw.state.pa.us/Scripts/wa.exe?A2=ind1701a&L=dhs-stakeholders&F=&S=&P=1670

D.9. Medicaid Managed Care Program: Behavioral Health Overview• Pennsylvania Department of Human Services. (2017, January 1). HealthChoices Managed Care Contract. Retrieved March 13, 2018 from

http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/p_040149.pdf• Pennsylvania Department of Human Services. (2017, January 1). HealthChoices Managed Care Contract Appendices. Retrieved March 13, 2018 from

http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/p_040150.pdf• Pennsylvania Department of Human Services. Behavioral HealthChoices. Retrieved March 13, 2018 from http://www.healthchoices.pa.gov/providers/about/behavioral/• Pennsylvania Department of Human Services. Behavioral HealthChoices Standards Appendices. Retrieved March 13, 2018 from

http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/communication/p_004161.pdf• Pennsylvania Department of Human Services. Behavioral HealthChoices Standards. Retrieved March 13, 2018 from

http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/manual/p_003130.pdf

D.10. Medicaid Managed Care Program: Behavioral Health Benefits• Pennsylvania Department of Human Services. (2017, January 1). HealthChoices Managed Care Contract. Retrieved March 13, 2018 from

http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/p_040149.pdf• Pennsylvania Department of Human Services. (2017, January 1). HealthChoices Managed Care Contract Appendices. Retrieved March 13, 2018 from

http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/p_040150.pdf• Pennsylvania Department of Human Services. Behavioral HealthChoices Standards Appendices. Retrieved March 13, 2018 from

http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/communication/p_004161.pdf• Pennsylvania Department of Human Services. Behavioral HealthChoices Standards. Retrieved March 13, 2018 from


D.11. Medicaid Managed Care Program: BH-MCO Map• Pennsylvania Department of Human Services. Behavioral HealthChoices. Retrieved March 13, 2018 from http://www.healthchoices.pa.gov/providers/about/behavioral/

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http://www.healthchoices.pa.gov/providers/about/behavioral/

http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/communication/p_004161.pdf




http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/communication/p_004161.pdf




D.12. Medicaid Managed Care Program: BH-MCO Service Areas• Pennsylvania Department of Human Services. Behavioral HealthChoices. Retrieved March 13, 2018 from http://www.healthchoices.pa.gov/providers/about/behavioral/

D.13. Medicaid Managed Care Program: SMI Population• Pennsylvania Department of Human Services. (2017, April 28). Approved Community Health Choices Waiver Proposal. Retrieved March 7, 2018 from



D.14. Medicaid Program: Care Coordination Initiatives • Pennsylvania Department of Human Services. CCBHC. Retrieved March 7, 2018 from http://www.dhs.pa.gov/provider/mentalhealth/CCBHC/• Pennsylvania Department of Human Services. (2017, January 1). HealthChoices Managed Care Contract. Retrieved March 13, 2018 from


D.15. Medicaid Program Care Management & Demonstration Waivers• Centers for Medicare and Medicaid Services. Demonstrations and Waivers. Retrieved January 5, 2018 from https://www.medicaid.gov/medicaid-chip-program-information/by-

topics/waivers/waivers_faceted.html• Pennsylvania Department of Human Services. (2017, April 28). Approved Community HealthChoices Waiver Proposal. Retrieved March 7, 2018 from


D.16. Medicaid Program Section 1915 (c) HCBS Waivers• Centers for Medicare and Medicaid Services. Demonstrations and Waivers. Retrieved January 5, 2018 from https://www.medicaid.gov/medicaid-chip-program-information/by-

topics/waivers/waivers_faceted.html• Pennsylvania Department of Human Services. CHC Waiver Transitions. Flow Chart. Retrieved March 9, 2018 from


D.17. Medicaid Program Section 1915 (c) HCBS Waivers (Continued)• Pennsylvania Department of Human Services. Proposed SUD 1115 Demonstration. Retrieved March 13, 2018 from

http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/document/c_267449.pdf• Pennsylvania Department of Human Services. 1115 Waiver Application for SUD. Retrieved March 13, 2018 from

http://www.healthchoices.pa.gov/info/about/behavioral/1115WaiverApplicationforSUD/index.htm

Sources

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http://www.dhs.pa.gov/provider/mentalhealth/CCBHC/


https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/waivers_faceted.html


https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/waivers_faceted.html



http://www.healthchoices.pa.gov/info/about/behavioral/1115WaiverApplicationforSUD/index.htm


E. State Behavioral Health Administration & Finance System E.1. Public Behavioral Health System Governance: Organization Chart• Pennsylvania Office of Administration. (2018, January 3). Department of Human Services Organization Chart. Retrieved March 5, 2018 from

http://www.oa.pa.gov/Policies/Documents/Human%20Services.pdf• Governor of Pennsylvania. (2018, February 6). 2018-2019 Governor’s Executive Budget in Brief. Retrieved March 5, 2018 from


E.2. Public Behavioral Health System Governance: Key Leadership• Pennsylvania Department of General Services. (2017). Online Commonwealth Telephone Directory. Retrieved May 5, 2018 from http://www.dgs.pa.gov/About/Pages/Directory.aspx

E.3. Public Behavioral Health System Governance: DDAP Organization Chart and Key Leadership• Pennsylvania Office of Administration. (2014, October 25). Department of Drug and Alcohol Programs Organization Chart. Retrieved March 5, 2018 from

http://www.oa.pa.gov/Policies/Documents/Drug%20and%20Alcohol%20Programs.pdf• Pennsylvania Department of General Services. (2017). Online Commonwealth Telephone Directory. Retrieved May 5, 2018 from http://www.dgs.pa.gov/About/Pages/Directory.aspx

E.4. Mental Health & Addiction Hospital Bed Distribution • Private hospital beds were aggregated from data made available by the American Hospital Association. State hospital data was obtained from the state.

E.5. State Psychiatric Institutions• Governor of Pennsylvania. (2018, February 6). Executive Budget. Retrieved March 6, 2018 from


E.6 State Psychiatric Institution Catchment Areas• Pennsylvania Department of Human Services. (2014, December 31). Pennsylvania State Hospital System Length of State, Demographics, and Diagnosis Report. Retrieved March 6, 2018

from http://www.dhs.pa.gov/cs/groups/webcontent/documents/report/c_149849.pdf• Pennsylvania Department of Human Services. Pennsylvania State Hospitals. Retrieved March 6, 2018 from http://www.dhs.pa.gov/citizens/statehospitals/

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http://www.oa.pa.gov/Policies/Documents/Human%20Services.pdf



http://www.oa.pa.gov/Policies/Documents/Drug%20and%20Alcohol%20Programs.pdf



http://www.dhs.pa.gov/cs/groups/webcontent/documents/report/c_149849.pdf

http://www.dhs.pa.gov/citizens/statehospitals/


F. State Behavioral Health Stakeholder OrganizationsF.1. State Behavioral Health Stakeholder Organizations• OPEN MINDS. (2018). Stakeholder Database.

F.2. State Behavioral Health Stakeholder Organizations• OPEN MINDS. (2018). Stakeholder Database.

Sources

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Pennsylvania Behavioral System Market Profile · – MH/DS services are funded by grants through...

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Transcript of Pennsylvania Behavioral System Market Profile · – MH/DS services are funded by grants through...