Administration encompasses the executive and general administrative oversight of the agency. Functions in this area include: executive leadership, financial management, employee services, facilities, legal support, and administrative support.

Direct Operations represents those activities where there is direct contact with clients, enrollees, and/or providers in the delivery of benefits or the development of policy that impacts benefits. Functions in this area include: eligibility determination, coordination of benefits, call center operations, claims processing, pre-authorization review, hearings and appeals, program integrity, provider and hospital rate development, healthcare benefits and utilization management, and quality and care management..

Information technology provides support for daily operations, ProviderOne System maintenance and enhancement efforts, the Health Information Technology (HIT) project, and other IT based projects.

This represents payments made to a Third Party Administrators to provide benefits to members (Uniform Medical and Dental) and costs associated with the Voluntary Employee Benefit Account (VEBA) and the Flexible Spending Account (FSA) programs.

This represents costs and workload driven by the implementation of the Affordable Care Act (ACA).

The federally funded waiver program provides family planning services. Services include annual exams, birth control, emergency contraception, and limited testing for sexually transmitted infections.

Healthcare coverage is provided for children who are not eligible for Medicaid because their families do not meet medical income eligibility criteria or are unable to qualify for other reasons.

Limited healthcare coverage is provided via state funding for clients who are not covered by Medicaid. Programs include Kidney Disease and Alien Emergency Medical.

Federally mandated healthcare services are provided for Medicaid clients who are not in the state’s Apple Health managed care program. Clients include families and children eligible to receive Temporary Assistance to Needy Families (TANF); families and individuals terminated from TANF because they have increased earnings or hours of employment or Social Security Disability Insurance income; individuals who are ineligible for TANF because of requirements that do not apply to Medicaid; eligible pregnant women and their newborns; individuals receiving Social Security Income or those eligible to receive mandatory state supplements; and children in foster care or adoption support. Mandatory services for eligible clients include inpatient and outpatient hospital care, rural health clinic services, nursing home services for clients 21 years or older (other than those in mental hospitals or institutions for the developmentally disabled), Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) health care program for children, and physician care.

Congress established the Disproportionate Share Hospital (DSH) program to ensure continued operation of those hospitals most heavily impacted by charity and Medicaid caseloads. The Health Care Authority operates DSH, the Certified Public Expenditure (CPE) program and several intergovernmental transfer (IGT) and refinancing programs to maximize federal revenue. In the 2005-2007 Biennium, the state, with direction from CMS, transitioned from utilizing IGTs for DSH and other programs to CPEs. This shift also included public hospital district nursing homes. Funds for participating trauma providers are also leveraged using funding provided by the Department of Health.

HCA enters into agreements with other entities to provide the means for them to receive federal Medicaid funding to support their administrative costs. HCA partnerships include: school districts, Indian Nations, local health jurisdictions, and the Health Benefit Exchange.

This represents the costs to design and obtain health care and other benefits for eligible school employees statewide.

Community Mental Health Services - financial support and program direction for community mental health programs delivered by Behavioral Health Organizations and Integrated Managed Care providers for Medicaid eligible and non-Medicaid eligible clients and services. Programs include mental health services for outpatient, inpatient, acute care, emergency, day treatment, consultation and education, employment services, and Medicaid Transportation. Community support services include screening of voluntary referrals to state hospitals, hospital discharge planning, crisis response, case management for chronic clients in the community, and residential programs that supervise, support, treat, and rehabilitate adults and children.

Program Support provides administrative and technical support for all programs within Mental Health including policy development, fiscal planning, information services, federal demonstration grants as well as legislative and regional coordination.

Prevention Services are contracted by the Division of Behavioral Health and Recovery (DBHR) through Counties, the Office of the Superintendent of Public Instruction, or with community based providers. Prevention Services are designed to prevent or reduce the misuse and abuse of alcohol, marijuana, tobacco, and other drugs. Services include prevention education, best-practices, training, public education and awareness, technical support, and other substance use resources for providers and clients.

Financial support and program direction for community substance use disorder programs delivered by Behavioral Health Organizations and Integrated Managed Care providers for Medicaid eligible and non-Medicaid eligible clients and services. Programs include Community Engagement and Referral, Triage Services, Outpatient Treatment, Housing, Residential, Recovery Support and Secure Detox.

Program Support provides the administrative support for substance use disorder services. Activities include statewide program/policy development, strategic/fiscal planning, information system management, personnel, budget oversight, discretionary grants as well as legislative and regional coordination

Residential treatment includes intensive inpatient, long term, recovery house, and treatment services for American Indian/Alaskan Native clients and residential services delivered by BHO and IMC providers.

Support services include Parent Child Assistance for pregnant and parenting women, Fetal Alcohol Spectrum Disorders Diagnosis and Prevention, Parent Trust parenting education and family support services, Tribal and Non-Native Encounters and Treatment and Native American Government to Government contracts