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Medi-Cal Waivers Kathryn Smith, RN, MN USC University Center for Excellence in Developmental Disabilities, Childrens Hospital Los Angeles.

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Presentation on theme: "Medi-Cal Waivers Kathryn Smith, RN, MN USC University Center for Excellence in Developmental Disabilities, Childrens Hospital Los Angeles."— Presentation transcript:

1 Medi-Cal Waivers Kathryn Smith, RN, MN USC University Center for Excellence in Developmental Disabilities, Childrens Hospital Los Angeles

2 Review of Medi-Cal Any questions from previous presentation?

3 Medi-Cal Overview Federal/state/county program Federal- provides regulatory oversight, reviews and monitors waivers CA Dept. of Health Services- administers Medi- Cal, sets eligibility, benefits, provider payment, and cost sharing levels County health and social services departments- conduct eligibility determination, oversees enrollment and recertification

4 Medi-Cal Overview State budget distribution- Medi-Cal is 17% of the State’s budget distribution, second largest share of the State’s general fund 43% of the Medi-Cal budget comes from the State, 51% from the federal government Federal matches (the FMAP or Federal Medical Assistance Percentages) range from 50% to over 70%)

5 Medi-Cal Overview 16% of CA population covered by Medi- Cal, compared to 14% nationally, and 19% in NY CA spends on average $5,257 per beneficiary per year, compared to $7,188 nationally, and $10,510 in NY Medi-Cal pays for nearly one half of care delivered in nursing facilities

6 What is a Waiver? Simply put, a waiver is a document that asks permission from the federal government to waive a Medicaid rule To make a change to its Medicaid program, CA must either amend its State Medicaid Plan (its contact with the federal government), or receive an exemption or Medicaid waiver from some portion of Title XIX of the Social Security Act (the Medicaid legislation)

7 Change to State Plan or Waiver? The route taken depends on the change desired If changes are in alignment with existing Medicaid law, then a State Plan amendment can be filed. If changes are not consistent with existing law, a waiver is required in order to receive federal matching funds

8 Waiver Types Program waivers- 1915(b) or 1915(c) waivers relate to managed care and home and community based care Research and demonstration waivers waivers, to allow experimentation or testing of a pilot program

9 1915(b) and (c) Waivers To allow states flexibility in two areas, managed care enrollment (b) and eligibility for home and community-based alternatives to institutional care (c) Used to control Medicaid spending without increasing costs to the federal government

10 1915 (b) Waiver Often called freedom of choice waiver as it exempts states from mandate that recipients have a choice of providers Provisions typically apply to statewideness (this allows different models in different parts of the state), comparability of services (this allows the state to add services to the benefits package for certain individuals), choice of provider (although recipients must be offered a choice of at least 2 health plans), and upper payment limit (managed care cannot cost more than fee for service)

11 1915(c) Waiver Known as the home and community based services waiver Allows states to treat certain Medicaid populations in home or other community-based settings rather than institutional or long term care facilities Created in 1981 For individuals who would be Medicaid eligible if they were in a long-term care facility Eligible populations include the elderly, disabled, mentally ill, developmentally disabled or mentally retarded

12 1915(c) Waiver Allows states to cover services beyond the scope of traditional Medicaid benefits to cover additional medical and non-medical services May cover home health care, case management, personal care, homemaker, adult day health, respite, in home support, transportation, environmental modifications, some psychosocial and treatment services for chronically mentally ill

13 1915(c) Waiver Exempts from the Income and Resource Standards which requires states to apply same income standards throughout the state The state’s waiver must specify a limit or cap on the number of recipients eligible Typically for a specific population: individuals with developmental disabilities, physical disabilities or seniors

14 1115 Waivers Research and Demonstration Waivers Provide exemptions from a wider set of Medicaid regulations than 1915 waivers Allows states to experiment, pilot or demonstrate projects Mostly used by states to implement Medicaid managed care or extend family planning services

15 1115 Waivers Can be used to waive a broader set of Medicaid provisions as long as they are budget neutral Can be used for such things as altering the benefits package, extending coverage to new populations, eligibility expansions, managed care, develop cost sharing requirements, creating lock in periods

16 1115 Waivers Certain things not allowed, limiting services for pregnant women and children, imposing certain cost sharing, and changing the federal match rate

17 Current 1115 Waivers Family PACT- federal reimbursement for family planning services for indigent males and females In-Home Supportive Services Plus- provides aged, blind and disabled individuals with personal assistance

18 1915 (b) Waivers Intermediate Care Facility for the Developmentally Delayed- new licensing category Specialty Mental Health Consolidation Program- county mental health plans

19 1915 (c) Waivers Home and Community Based Services Waiver for the Developmentally Disabled- home and community based services In-Home Operations- require services by a licensed nurse

20 Applying for Waivers First must apply for Medi-Cal IHSS Plus- determined by county social services staff HCBS-DD- must be a regional center consumer, assisted by regional centers

21 Additional Information Medi-Cal Facts and Figures s2006.pdf Medicaid Waivers: California’s Use of a Federal Option What are Medi-Cal Waivers CAL/Pages/MediCalWaivers.aspx Kathryn Smith, RN, MN


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