Medicaid Funding for Respite

1. Medicaid Funding for Respite David Buchanan MD Head, Section of Social Medicine Stroger Hospital of Cook County / Rush University National Respite Providers Network – Houston 2005

2. 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

3. Medicaid Funding for Respite • The Medicaid Program • Strategies for Funding • Illinois’ Effort • Updates from other states

4. 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

5. 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

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

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

8. What does it pay for? • Nursing home care • Medical, psychiatric, & substance abuse treatment • Medications • Case management • A range of other services (state specific)

9. 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

10. Medicaid Funding for Respite • The Medicaid Program • Strategies for Funding • Illinois’ Effort • Updates from other states

11. Strategies for Medicaid Funding • Bill Medicaid for Services they already cover • State Funded Programs • Apply for a 1115 Waiver (Federal Match)

12. 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

13. 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

14. 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

15. Medicaid Funding for Respite • The Medicaid Program • Strategies for Funding • Illinois’ Effort • Updates from other states

16. 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

17. Medicaid Funding for Respite • The Medicaid Program • Strategies for Funding • Illinois’ Effort • Updates from other states

18. Updates from other States

19. 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

20. Questions and Discussion

21. 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

22. 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)

23. 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