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Colorado Department of Health Care Policy and Financing Colorado Department of Health Care Policy and Financing Medicaid Reimbursement Methodologies Home and Community Based Services Waivers February 2013
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Page 1: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Medicaid Reimbursement

Methodologies

Home and Community Based Services Waivers

February 2013

Page 2: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Improving health care access

and outcomes for the peoplewe serve while demonstrating sound

stewardship of financial resources

Our Mission:

2

Page 3: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Reimbursement Methodologies

• Long Term Services and Supports (LTSS)

Home and Community Based Services

(HCBS) Medicaid waiver services use four

reimbursement methodologies:

1. Bundled Payments

2. Fee-for-Service

3. Negotiated Market Price

4. Tiered Rates

Page 4: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Bundled Payments

• Provider receives a fixed, pre-determined

rate for a pre-determined amount of time

that includes the delivery of multiple

services

�Most commonly used for Alternative Care

Facilities, Group Homes, and Transitional

Living environments

Page 5: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Bundled Payment Example

• The Supported Living Program offered on the

HCBS waiver for person with Brain Injury is

reimbursed using a bundled payment

methodology.

�The payment includes Independent Living Skills

Training (ILST), Non-Medical Transportation,

Personal Care, Homemaker, and other services.

Page 6: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Fee-for-Service

• Provider receives a fixed, pre-determined rate for a single service for a designated unit of time

� Most waiver services are reimbursed under the fee-for-service methodology

� The rate will not vary by client, acuity, or provider

Page 7: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Fee-for-Service Methodology

• The Department developed a Fee-for-Service rate

setting process in 2011

• The Department considers:

� Salary Expectations

� Direct and Indirect Care Hours

� Full time equivalency required for delivery of services

� Other costs

� Alignment with other payers in the market

• Once rate is set, the Department compares with other

state Medicaid rates and private pay rates.

Page 8: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Fee-for-Service Example

• Personal care services offered in certain adult

waivers have a fee-for-service rate of $3.47/15

minutes• HCBS waivers for persons who are Elderly, Blind, or Disabled (EBD)

• HCBS Community Mental Health Supports (CMHS) waiver

• HCBS waiver for Persons Living with AIDS (PLWA)

• A client requires 4 hours of personal care services

per day

• For four hour of personal care service per day, a provider

bills 16 units at a rate of $3.47

Page 9: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Negotiated Market Price

• Provider receives the market price of the

service. There is an expectation that

some negotiation will take place to reach

an agreed upon market price.

� The market cost methodology is used when there

are multiple subcategories of a service such as

Assistive Technology, Home Modifications, and

Personal Emergency Response Systems (PERS).

Page 10: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Negotiated Market Price

Examples• Home Modifications can entail the remodel

of a bathroom or installing a ramp

• Each subcategory of service has its own

resource and labor costs, thus there is a

unique price for each client and each service

• If a client needed a bathroom remodel the

provider would bill 1 unit for the remodel at

the negotiated market price

Page 11: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Tiered Rates

• Provider receives payment for one service

in which the rate varies by an identified

characteristic of the client, the provider,

or some combination of both.

� Rates for Supported Living Program offered in the

HCBS waiver for Persons with Brain Injury are tiered

by client acuity for each particular provider.

� Rate is specific to the provider and based on the acuity of

that provider’s clients

Page 12: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Tiered Rates and Acuity

• The HCBS Supported Living Services waiver and the

HCBS waiver for persons with a Developmental

Disability have several rates that are tiered by using the

Supports Intensity Scale (SIS)

• The Supports Intensity Scale is an assessment tool that

evaluates practical support requirements of a person

with an intellectual disability

� Consists of an 8 page interview and profile form that tests

support needs in 87 areas

� The information provided translates into a support level for

each client

Page 13: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Tiered Rates and SIS

• The HCBS waiver for persons with a

Developmental Disability (DD) has several

services with rates tiered by support level.

• This waiver uses seven support levels.

• Services using this methodology include:� Day Habilitation Services (Specialized Habilitation and

Supported Community Connections)

� Pre-Vocational Services

� Supported Employment (Supported Employment , Job

Development, and Job Placement)

� Residential Services (Group Home, Host Home,

Personal Care Alternative)

Page 14: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Example of Tiered HCBS DD

Tiered RatesDay Habilitation Support

Level

Proc

Code

Tiered

Rate

Unit

Specialized Habilitation Level 1 T2021 $ 2.18 15 Minutes

Specialized Habilitation Level 2 T2021 $ 2.39 15 Minutes

Specialized Habilitation Level 3 T2021 $ 2.66 15 Minutes

Specialized Habilitation Level 4 T2021 $ 3.13 15 Minutes

Specialized Habilitation Level 5 T2021 $ 3.88 15 Minutes

Specialized Habilitation Level 6 T2021 $ 5.58 15 Minutes

Specialized Habilitation Level 7 T2021 $ 8.78 15 Minutes

�As the support level increases the rate increases

Page 15: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Tiered Rates and SIS

• The HCBS Supported Living Services (SLS)

waiver also has several services with rates

tiered by support level.

• This waiver uses six support levels.

• Services using this methodology include:� Day Habilitation (Specialized Habilitation, Supported

Community Connections)

� Prevocational Services

� Supported Employment (Supported Employment, Job

Placement, Job Development

Page 16: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Example of HCBS SLS Tiered

Rates

Supported Employment Support Level Proc

Code

Tiered

Rate

Unit

Supported Employment Group Level 1 T2019 $ 2.92 15 Minutes

Supported Employment Group Level 2 T2019 $ 3.19 15 Minutes

Supported Employment Group Level 3 T2019 $ 3.56 15 Minutes

Supported Employment Group Level 4 T2019 $ 4.11 15 Minutes

Supported Employment Group Level 5 T2019 $ 4.91 15 Minutes

Supported Employment Group Level 6 T2019 $ 6.40 15 Minutes

Page 17: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Hybrid Rate Methodologies

• Rate methodologies can be combined to create

a hybrid rate methodology

� The Supported Living Program offered on the HCBS

waiver for Persons with Brain injury is a bundled payment

that is tiered by client acuity within each facility.

� Bundled: several services offered include:

� Supported Living Program including independent living skills

training, non-medical transportation, personal care, thus the rate

is bundled.

� Tiered: aggregate client acuity determines tiered rate

Page 18: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Service Plan Authorization Limit

(SPAL)• An annual upper payment limit of total

funds available to purchase services to

meet the client’s ongoing needs

�The annual dollar limit is dependent on

support level

• The HCBS SLS waiver is the only waiver

that uses the SPAL methodology

Page 19: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

SPALs

• Each support level has a designated

annual dollar limit

Support Intensity Level HCBS SLS SPAL Amount

Level 1 $12,193.00

Level 2 $13,367.00

Level 3 $15,038.00

Level 4 $17,296.00

Level 5 $20,818.00

Level 6 $27,366.00

Page 20: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

SPALs

• All SPAL services must be provided within the

annual dollar limit.

• Each SPAL service has its own rate

methodology.

• Not all waiver services are included in the SPAL

� Some service expenditures are excluded from the

amounts counted toward the limit.

Page 21: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

SPAL Services

HCBS SLS services included in SPAL

Behavioral Consultation Job Development Respite-Group

Behavioral Counseling-Individual Job Placement-Group Respite-Individual (15 minutes)

Behavioral Counseling-Group Massage Therapy Respite-Individual

Behavioral Health Plan Assessment Mentorship Specialized Day Rehabilitation

Caregiver Services CCT Service Movement Therapy Specialized Medical Equipment and

Supplies

Enhanced Nursing CCT Service Personal Care Substance Abuse Counseling-Individual CCT Service

Hippo Therapy Personal Emergency Response System

(PERS)

Substance Abuse Counseling-Group CCT

Service

Homemaker-Basic Pre-Vocational Services Supported Community Connections

Homemaker-Enhanced Recreational Pass (to access

professional services)

Supported Employment-Group

Page 22: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Services excluded from SPAL

HCBS SLS services excluded from SPAL

Community Transition Services CCT

Service

Home Accessible Adaptations-Extended CCT

Service

Vehicle Modifications

Dental Intensive Case Management CCT Service Vision

Home Accessible Adaptations Non-Medical Transportation

�The above service expenditures are not included in the

Service Plan Authorization Limit

Page 23: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing

Medicaid Reimbursement

Handouts

• Home and Community Services Waiver

Rates Comparison

• Division of Developmental Disabilities

Waiver Rates Comparison

• Colorado Choice Transitions (CCT)

Demonstration Services Rate Schedule

• Universal HCBS and CCT Rate Schedules

Page 24: Medicaid Reimbursement Methodologies - Colorado.gov · 2014-05-13 · Fee-for-Service Methodology • The Department developed a Fee-for-Service rate setting process in 2011 • The

Colorado Department of Healthcare Policy and FinancingColorado Department of Healthcare Policy and Financing

Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resourceImproving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources s

Thank You!

Presented by:Randi Wilson

[email protected] of Health Care Policy and Financing

24


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