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Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southeast Zone Rate Region 1 - Utilization per 1,000
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 212,632 2,933,667 825,603 993,968 1,691,554 704,406 3,576 9,441 Categories of Service
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 1 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southeast Zone Rate Region 1 - Unit Cost
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 212,632 2,933,667 825,603 993,968 1,691,554 704,406 3,576 9,441 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 2 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southeast Zone Rate Region 1 - PMPM / PMPD
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 212,632 2,933,667 825,603 993,968 1,691,554 704,406 3,576 9,441 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 3 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southeast Zone Rate Region 2 - Utilization per 1,000
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 69,538 883,596 205,880 418,213 489,422 227,224 1,071 2,366 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
10,221 568
2,437 1,220 4,330
45 495
1 816
--
475 130 996 382
1,700 167
3 14,607
1,083 38
217 0
3,049 10 30
-
4,835 268
1,926 522 683
1,237 276
-406 35
176 620
52 480 166 820
6,310 169
3,111 611
68 128
0 55
6 1 -
14,976 631
9,173 2,581
-337 452
0 285 295 796
1,217 149 732 344
1,653 1,782
278 4,001 1,820
428 274
42 248
17 16
-
23,864 2,263 6,432 1,796
226 794
2,894 22
5,766 39
191 3,550
221 1,327
157 1,040 2,747
160 5,203 1,210
350 464 220 512
18 287
-
11,424 409
6,363 1,541
27 389 276
0 128 179 848 929 172 542 232
1,341 1,802
223 2,905 1,091
297 201
24 222
11 25
-
25,543 1,529 9,670 3,377
-587 985
17 600
30 78
3,057 216
1,469 318
1,168 1,618
295 6,070 1,758
559 488
84 654 104 220
-
3,234 824
11,255 6,183
2 86
192 -
105 126
21 171 109 319 621 401 341 15
4,768 7,567
736 1,747
181 3,777
---
2,374 532
9,226 4,159
6 90
142 -
191 21 17
122 140 202 604 318 358 34
4,925 5,489
820 1,201
119 2,606
---
Total Notes:
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 4 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southeast Zone Rate Region 2 - Unit Cost
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 69,538 883,596 205,880 418,213 489,422 227,224 1,071 2,366 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 5 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southeast Zone Rate Region 2 - PMPM / PMPD
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 69,538 883,596 205,880 418,213 489,422 227,224 1,071 2,366 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 6 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southwest Zone Rate Region 1 - Utilization per 1,000
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 129,013 1,653,123 510,663 801,599 971,795 450,064 2,298 5,497 Categories of Service
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 7 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southwest Zone Rate Region 1 - Unit Cost
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 129,013 1,653,123 510,663 801,599 971,795 450,064 2,298 5,497 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 8 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southwest Zone Rate Region 1 - PMPM / PMPD
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 129,013 1,653,123 510,663 801,599 971,795 450,064 2,298 5,497 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 9 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southwest Zone Rate Region 2 - Utilization per 1,000
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 27,419 363,614 103,282 176,776 213,870 99,097 490 1,201 Categories of Service
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 10 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southwest Zone Rate Region 2 - Unit Cost
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 27,419 363,614 103,282 176,776 213,870 99,097 490 1,201 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 11 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Southwest Zone Rate Region 2 - PMPM / PMPD
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 27,419 363,614 103,282 176,776 213,870 99,097 490 1,201 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 12 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Lehigh/Capital Zone Rate Region 1 - Utilization per 1,000
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 150,766 1,851,433 477,593 671,268 887,781 381,318 2,767 6,377 Categories of Service
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 13 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Lehigh/Capital Zone Rate Region 1 - Unit Cost
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 150,766 1,851,433 477,593 671,268 887,781 381,318 2,767 6,377 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 14 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Lehigh/Capital Zone Rate Region 1 - PMPM / PMPD
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 150,766 1,851,433 477,593 671,268 887,781 381,318 2,767 6,377 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 15 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Lehigh/Capital Zone Rate Region 2 - Utilization per 1,000
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 49,358 583,455 157,960 187,881 268,698 119,318 898 2,061 Categories of Service
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 16 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Lehigh/Capital Zone Rate Region 2 - Unit Cost
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 49,358 583,455 157,960 187,881 268,698 119,318 898 2,061 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 17 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Lehigh/Capital Zone Rate Region 2 - PMPM / PMPD
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 49,358 583,455 157,960 187,881 268,698 119,318 898 2,061 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 18 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northeast Zone Rate Region 1 - Utilization per 1,000
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 84,909 1,074,589 306,255 396,829 590,851 270,338 1,700 3,524 Categories of Service
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 19 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northeast Zone Rate Region 1 - Unit Cost
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 84,909 1,074,589 306,255 396,829 590,851 270,338 1,700 3,524 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 20 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northeast Zone Rate Region 1 - PMPM / PMPD
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 84,909 1,074,589 306,255 396,829 590,851 270,338 1,700 3,524 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 21 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northeast Zone Rate Region 2 - Utilization per 1,000
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 31,279 399,529 112,360 151,007 210,429 100,648 572 1,369 Categories of Service
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 22 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northeast Zone Rate Region 2 - Unit Cost
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 31,279 399,529 112,360 151,007 210,429 100,648 572 1,369 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 23 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northeast Zone Rate Region 2 - PMPM / PMPD
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 31,279 399,529 112,360 151,007 210,429 100,648 572 1,369 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 24 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northwest Zone Rate Region 1 - Utilization per 1,000
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 39,531 529,663 144,106 215,998 284,418 114,990 788 1,666 Categories of Service
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 25 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northwest Zone Rate Region 1 - Unit Cost
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 39,531 529,663 144,106 215,998 284,418 114,990 788 1,666 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 26 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northwest Zone Rate Region 1 - PMPM / PMPD
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 39,531 529,663 144,106 215,998 284,418 114,990 788 1,666 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 27 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northwest Zone Rate Region 2 - Utilization per 1,000
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 15,450 195,314 55,843 104,523 105,003 50,361 249 613 Categories of Service
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 28 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northwest Zone Rate Region 2 - Unit Cost
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 15,450 195,314 55,843 104,523 105,003 50,361 249 613 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.
Page 29 of 30 3/8/2021
Commonwealth of Pennsylvania CY 2022 HealthChoices Physical Health Final & Confidential
Encounter Databook
CY 2019 Experience
Northwest Zone Rate Region 2 - PMPM / PMPD
Rate Cells Under Age 1 TANF-MAGI Ages 1-20
TANF-MAGI Ages 21+
Disabled-BCC Ages 1+
Newly Eligible Ages 19 to 44
Newly Eligible Ages 45 to 64
Maternity C-Section
Maternity Vaginal
Member Months / Delivery Count 15,450 195,314 55,843 104,523 105,003 50,361 249 613 Categories of Service
Pharmaceutical Pharmaceutical Non-Drug Laboratory Radiology Complete EPSDT Screens Vision DME / Medical Supplies Hospice Home Health Care / HIV-AIDS Waiver Family Planning Services Family Planning - Pharmaceutical Therapy Ambulance / Transportation Medical Diagnostic FQHC & Rural Health Clinics Emergency Room Dental Dental / Oral Surgery Primary Care Providers Specialty Physician Other Practitioners Facility Non-Inpatient (includes SPU / ASC) Other Outpatient Inpatient Acute Care Inpatient - Rehab Nursing Home Miscellaneous Medical Expense
1. In some cases totals may not tie due to rounding.
2. These values do not include reinsurance or other risk mitigation adjustments, but do reflect benefits from TPL-COB. Values do not include subcapitation not captured in encounters and are gross of pharmacy rebates. For additional encounter data detail, please see the accompanying databook narrative. 3. Data represents PH-MCO submitted, accepted PROMISe™ encounter data with incurred dates between 1/1/2019 – 12/31/2019 and runout through 9/30/2020. No adjustments have been made for any underreporting within the encounter data in this databook. 4. Utilization and unit cost metrics shown use detailed encounter line counts for all categories of service, except for Inpatient Acute Care, Inpatient - Rehab, and Nursing Home categories of service, which use covered days as reported in PHMCO submitted PROMISe™ encounter data.