Medicaid Funding for Respite

David Buchanan MD

Head, Section of Social MedicineStroger Hospital of Cook County / Rush University

National Respite Providers Network – Houston 2005

Why talk about Medicaid?

• Medicaid – It’s where the money is!– Multi-billion dollar budget in many states – Second only to education in state budgets

• Medicaid funds healthcare for low income people

• Bears the costs of an inefficient health system– They need us to save them money

Medicaid Funding for Respite

• The Medicaid Program

• Strategies for Funding

• Illinois’ Effort

• Updates from other states

The Medicaid Program

• Centers for Medicare and Medicaid Services – “CMS”• Medical Services to Low Income and Disabled• Generally Fee for Service• Federal Medicaid Law specifies

– Basic requirements– Optional components

• States choose– service and eligibility options to cover– how much it will pay for each service

Medicaid: Who pays for it?

• State pays the bills

• Federal Government reimburses states

• Federal Financial Participation varies 50-83%– Based on state’s per capita income– Covers services in Medicaid Law or in a Waiver

Mandatory Eligibility

• “Mandatory Categorically Needy”– Based on Eligibility for AFDC in 1996– Women with Children– Pregnant Women– Low Income Children– Blind– SSI recipients

Optional Eligibility

• Optional Categorically Needy & Medically Needy– Expanded income limits– Breast and Cervical Cancer– Tuberculosis – Low Income Elderly

What does it pay for?

• Nursing home care

• Medical, psychiatric, & substance abuse treatment

• Medications

• Case management

• A range of other services (state specific)

Medicaid Waivers

• States can ask for Fed match for programs which:– Are within the spirit of the Medicaid Program– Are Cost Neutral to the Federal Government

• States Apply to CMS• CMS decides based on:

– Merits of program– Cost Neutrality– Politics

Medicaid Funding for Respite

• The Medicaid Program

• Strategies for Funding

• Illinois’ Effort

• Updates from other states

Strategies for Medicaid Funding

• Bill Medicaid for Services they already cover

• State Funded Programs

• Apply for a 1115 Waiver (Federal Match)

Bill Medicaid for Covered Services

• Outpatient Visits (all states)• Targeted Case Management (state option)• Skilled Living Facilities (state option)• Consider Partnering with a FQHC

– Higher re-imbursement rates

– Medicaid Billing system in place

• Reimbursements are low• Much of what we call respite care isn’t covered

State Funded Respite Program

• Doesn’t require a waiver / permission from Feds

• Costs of waiver application may be > the return

• More flexibility (eligibility)– Eligibility– Per-diem payment possible

• Example: Washington State

• Challenges: Novel state program / Tight budgets

Apply for a 1115 Waiver (Federal Match)

• State Medicaid officials submit application• Must indicate cost neutrality• May require pressure to be processed• Most difficult way to obtain funding• Most sustainable

Medicaid Funding for Respite

• The Medicaid Program

• Strategies for Funding

• Illinois’ Effort

• Updates from other states

Illinois’ (long term) Medicaid Plan

• Describe a bundle of services called respite

• Ask IL Medicaid to pay a per-diem rate to cover these services (based on hospice model)

• Apply for an 1115 waiver for Federal match

• If successful, we hope this will be a model for other states

• Challenge: Medicaid budget crisis

Medicaid Funding for Respite

• The Medicaid Program

• Strategies for Funding

• Illinois’ Effort

• Updates from other states

Updates from other States

Resources

• “Advocates Guide to the Medicaid Program” – National Health Law Program (NHeLP)

• “Medicaid in Supportive Housing: Lessons for Policy-Makers” - Corporation for Supportive Housing

• http://www.cms.gov/medicaid/

• Other respite providers

Questions and Discussion

Targeted Case Management Option

• Coverage for assessment, goal setting, & linkages

• Generally target high risk groups– Children– People with Developmental Disabilities– Uniquely defined “high risk groups”

• Some programs are intended to be time limited

• Each state’s program is unique

Waiver Types

• Home and Community Based Care Waivers– Programs keep people out of nursing homes / hospitals– Long term primary care– No Room and Board Charges Allowed

• Freedom of Choice Waivers (1915B)– Programs save money by managing care– Often include long term case management

• Research and Demonstration Projects (1115)

Research & Demonstration Project 1115 Waivers

• Tests promising programs

• Most waivers are for 5 years

• Programs are evaluated by CMS

• Must document cost neutrality

• Can lead to Medicaid Law changes – PACE program

• Most difficult type of waiver to obtain