EXPLANATION TO THE MEDI-CAL SERVICES AND EXPENDITURES MONTH-OF-PAYMENT REPORT The Services and Expenditures Month-of-Payment report is produced each month by the Department of Health Services' Information and Technology Support Division (ITSD). The report was designed by staff of the Medical Care Statistics Section (MCSS). MCSS staff review and monitor the report and inform ITSD staff when changes are needed to the computer program. The report is an "equivalent" report in the Department's Medicaid Management Information System (MMIS), and, as such, meets certain Federal General Systems Design requirements for the MMIS. From CY95 forward, there are two versions of this report, one for fee-for-service, the other for managed care plans. The latter should be considered incomplete not only because not all encounters are necessarily received from the plans, but also because many claims may not be priced since the reimbursements by the plans are sometimes in the form of capitated payments. Please Note: This report provides total Medi-Cal FFS expenditures for all aid codes except, beginning in CY98, aid code 8H, Family PACT. This program received Medi-Cal matching funds starting in December 1999 (and thus was an official Medi-Cal program at that point), and has grown from $250 million for CY2000 to $340 million for CY2001. For FY00-01, this amounted to only 3% of all FFS medical expenditures; however, for some types of expenditures, the 8H share of total FFS medical expenditures is much higher, e.g., Certified Family Nurse Practitioner (71%), Certified Pediatric Nurse Practitioner (63%), Clinical Labs (50%), Nurse Midwife (9%). Besides expenditures for aid code 8H, this report also excludes managed care expenditures. Report Format This report show essentially all provider types participating in the Medi-Cal program. For many of the major ones, there are distributions by type of service provided. Major changes to this report occur periodically. See Data Limitation and cautions. The report is produced showing statewide totals and data for each county. The county is the county of beneficiary, not the county of the provider. This is a very important distinction. Various data show that numerous Medi-Cal beneficiaries receive services in counties other than the county of residence. This may be because the beneficiary travels to another county specifically to receive care, the beneficiary needs emergency care when out of the county of residence, the beneficiary has moved but the eligibility transfer has not been completed and so on. In fact, a substantial number of out-of-state providers treat at least an occaisonal Medi-Cal beneficiary. All these services are aggregated to the county of beneficiary eligibility. On the hardcopy report, there are several groupings of aid categories within each county and an additional one for statewide (which carries the additional group of "Invalid Aid Codes/Counties"). Some of these aid category groupings are subtotals of other groups. Eliminating these subtotals results in unique groupings which, when added together, will provide the totals for the county for this time period. The MOP report was copied from a print-ready, mainframe version. The version available here has had carriage control characters substituted with equivalent, unique characters. To print this report in a manner that resembles the formal version, import into a word processing program, like Word, then substitute all characters "#" with a "new page" symbol. Likewise, a "@" symbol can be substituted for with a new line. In addition, using such software as Monarch (available for about $400 from Personics, 234 Ballardvale St., Wilimington, MA 01887; 508/658-0040), one can convert these MOP files to spreadsheet files. The MOP reports are maintained by the Medical Care Statistics Section, 714 P Street, Room 1750, Sacramento, CA. Any questions can be directed to MCSS at (916) 552-8550, (INTERNET ID=mcssweb@dhs.ca.gov) Sources of Data The Services and Expenditures/FFS version of the report report compiles claims data from computer tapes supplied to DHS from five sources: 1. Electronic Data Systems (EDS) 2. Delta Dental Services (DDS) 3. State Hosptials (SH) Each of these agencies supplies computer tapes monthly. The eligible counts shown on these reports are derived from the Department's Eligibility History File. Report Periods The Services and Expenditures report is produced each month approximately one month after the month of payment. That is, January's report is available in late February or early March. The eligible counts shown on this report exclude beneficiaries in full PHPs (i.e., managed care arrangements covering all medical services, including hospitalization). The eligibility counts are based on a four-month lag: the January 1997 report shows September 1996 eligibles. The reason for this is twofold: 1. The statistics are for when the service was paid for rather than when it occurred. Over 98 percent of services will be paid by the fourth month following the month of service. 2. Because of activity in the eligibility system, the eligible counts for any month continue to build up for about four months before leveling off. Due to the differences in the lag periods between eligiblity vs. paid claims data, for the smaller and more "active" eligibility groups, eligibility counts may slightly exceed user counts. Semi-annual and annual reports, both calendar year and fiscal year, are produced from the monthly reports. These reports are produced by simply adding up the eligibles, users, units, and expenditures counts. Only the latter two are directly additive, so the discussion below about these factors should be carefully noted. Data Elements Definitions Eligibles - Number of persons who could receive services, if needed. Figures derived from EHF with a four-month lag, as discussed above. Eligibles represent a monthly count, so when the annual report is produced the person eligible all twelve months is counted twelve times. Generally, annual eligible counts should be divided by twelve and expressed as a monthly average. Users - This is a count of the number of persons receiving a service. There is a total (all providers) unduplicated count of users. Each category of use is also reported. For example, any person with a physician office visit and a physician hospital visit is counted in six cateogries. In addition to office visit and hospital visit the person will be counted in "Inpatient Visits," "Outpatient Visits," "Physicians' Services" and "Total, All Providers." Users, like eligibles, should be expressed as monthly averages. The same user may appear month after month. Units of Service or Days of Care - This is a hodge-podge of elements, including counts of office visits, surgical procedures, anesthesia time units, prescriptions, inpatient days, etc. The title of the service usually gives a good indication of the unit of service that was paid. A 'CR' following an expenditures amount indicates a 'credit,' or provider recoupment, that was made. Expenditures - These represent the amount of money Medi-Cal paid providers during the period of the report. A 'CR' following a expenditures amount indicates a 'credit,' or provider recoupment, that was made. Monthly Averages - Four monthly averages are computed from the above data elements: 1. Average cost per unit or day. 2. Units of days per eligible. 3. Cost per user. 4. Cost per eligible. Data Limitations and Cautions Providers itemize services billed to Medi-Cal to produce this report. The computer breaks up the bill and reports in the appropriate categories. For example, a physician's bill for an office visit, an X-ray and an injection will be distributed over these three categories. When one sees that an office visit average payment runs $23.25, one has to remember that this is for the visit only and does not include the X-ray and injection. This report has been produced for many years. It is not necessarily comparable from year to year. The report is revised as needed. The various revisions have deleted some provider types entirely, deleted some categories of service, added new categories of service, and added new provider types. Certain technical changes regarding zero pay claims and crossover claims were also made. Zero pay claims (processed claims where the paid amount is zero) are not reported in the MOP. system; These are usually Medicare/Medi-Cal crossover claims. Service Definitions Services for each line of the report are created from the Short Claims file using the condition table shown below (Attachment 2). Variables from the claim used to map these services include vendor code (e.g., physician), procedure codes (e.g., Schedule of Maximum Allowance (SMA), Common Procedures Terminology (CPT-4), HCPCS), place of service, modifier codes, and type of service. Comparison to FFS Claims Files In comparing data from the MOP reports to fee-for-service claims files, it is important to note that the MOP includes dental and state hospital claims. In addition, all CMAC hospital payments are included (these are normally zeroed out of claims files released to the public), and claims with invalid aid codes and counties are excluded from the county-level reports, but included in a separate section in the MOP report. It is important to note also that COHS claims and eligible counts were included in the MOP reports through the CY94 report, but separated into their own set of reports (with the Two-Plan and GMC encounter data) from CY95 forward. A final consideration is that claims for aid code 8H (Family PACT) have been excluded from all MOP reports except for CY97.