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

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 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