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