Medicaid Funding for Respite

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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

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Why talk about Medicaid?

• Medicaid Its 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

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Medicaid Funding for Respite

• The Medicaid Program
• Strategies for Funding
• Illinois Effort
• Updates from other states

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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

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Medicaid Who pays for it?

• State pays the bills
• Federal Government reimburses states
• Federal Financial Participation varies 50-83
• Based on states per capita income
• Covers services in Medicaid Law or in a Waiver

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Mandatory Eligibility

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

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Optional Eligibility

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

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What does it pay for?

• Nursing home care
• Medical, psychiatric, substance abuse treatment
• Medications
• Case management
• A range of other services (state specific)

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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

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Medicaid Funding for Respite

• The Medicaid Program
• Strategies for Funding
• Illinois Effort
• Updates from other states

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Strategies for Medicaid Funding

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

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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 isnt covered

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State Funded Respite Program

• Doesnt require a waiver / permission from Feds
• Costs of waiver application may be gt the return
• More flexibility (eligibility)
• Eligibility
• Per-diem payment possible
• Example Washington State
• Challenges Novel state program / Tight budgets

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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

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Medicaid Funding for Respite

• The Medicaid Program
• Strategies for Funding
• Illinois Effort
• Updates from other states

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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

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Medicaid Funding for Respite

• The Medicaid Program
• Strategies for Funding
• Illinois Effort
• Updates from other states

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Updates from other States
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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

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Questions and Discussion
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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 states program is unique

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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)

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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