The Medicaid Landscape for Community Support Payment Methodologies

1
The Medicaid Landscape for Community Support
Payment Methodologies

December 11, 2008
2
Agenda
Section 1 The Problem for Community
Support Services Medicaid Rate
Methodologies Section 2 Rate Methodologies
Fee-for-Service Models Section 3 Rate
Methodologies Funding Levels Section 4
Cross Cutting Issues Section 5 Emerging
Programs Section 6 Questions /
Discussion
3
The Problem for Community Support Services
Medicaid Rate Methodologies

4
Section 1 The Problem for Community Support
Services Medicaid Rate Methodologies

• Why are community service rates a problem in
  terms of Medicaid rate setting methodologies?
• Single purchaser
• Non-medical nature of services
• Still relatively new coverage area within
  Medicaid

5
Rate Methodologies Fee-for-Service Models

6
Section 2 Rate Methodologies Fee-for-Service
Models

• Over the years, various fee-for-service models
  have been used to pay for community-based
  services
• Grant-based methodologies
• Negotiated rate methodologies
• Independent model rate methodologies

7
Section 2 Rate Methodologies Fee-for-Service
Models

• Independent Models were developed in response to
  a lack of market data and were designed to help
  develop rates that supported and developed the
  community provider network and were competitive
  for attracting and retaining direct care staff
• Wages
• Benefits
• Training
• Non-billable time
• Program support
• Administration
• Capital

8
Section 2 Rate Methodologies Fee-for-Service
Models

• Strengths of Independent Models
• Have helped make rates more competitive in the
  market
• Have helped define and structure the service
  being purchased
• Have provided a structure for rate development
  and maintenance/updates

9
Section 2 Rate Methodologies Fee-for-Service
Models

• Concerns stemming from the use of Independent
  Models
• Availability of consistent information
• Over the long-term, may have tendency to lead to
  micromanagement of provider business decisions in
  a manner that differs from other Medicaid services

10
Section 2 Rate Methodologies Fee-for-Service
Models

• Transitioning from grant-based methodologies to
  other fee-for-service models
• Key drivers
• Relationship to other Medicaid program goals
• Transition approaches

11
Section 2 Rate Methodologies Fee-for-Service
Models

• Day Program models
• Connecticuts Initiative
• Other states approaches

12
Rate Methodologies Funding Levels

13
Section 3 Rate Methodologies Funding Levels

• Funding Levels the details make the difference
• Purpose of funding levels
• General approach to creating funding levels
• Assessment
• Historical expenditures

14
Section 3 Rate Methodologies Funding Levels

• Funding Levels the details make the difference
  (cont.)
• Technical development of funding levels
• Key technical considerations
• Level of historical rates built into funding
  levels
• Variations in historical service utilization not
  linked to variations in service need
• Recognition of natural supports
• Funding amount or range

15
Section 3 Rate Methodologies Funding Levels

• Funding Levels the details make the difference
  (cont.)
• Key operational considerations
• Monitoring funding levels during the year
• Budget impact of ranges over time
• Savings assumptions
• Frequency of updates
• Emergency pools or funds
• Consistency in assessments over time

16
Cross Cutting Issues

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Section 4 Cross Cutting Issues

• Comparability of rates across programs
• Consumer-directed services and rates
• Increased medical complexity
• Need for information/data

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Emerging Programs

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Section 5 Emerging Programs

• State Waiver Programs
• 39 states have distinct Autism waivers - this
  includes 5 states whose waivers only cover
  children with Autism
• 3 states have set up distinct administrative
  units responsible for Autism services (MA, PA,
  SC)

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Section 5 Emerging Programs

• State Waiver Programs (cont.)
• States can cover different services under their
  home and community-based (HCBS) Autism waivers.
  Examples of services and interventions covered by
  state HCBS waivers include
• Consultative Clinical and Therapeutic Services
• Intensive Individual Supports
• Respite Care
• Parent/Family Support, Counseling and Training
• Environmental Accessibility Adaptations (ex
  locks,
• plexiglass, fencing)
• Supported Employment
• Residential Habilitation
• Day Habilitation
• Targeted Case Management

21
Section 5 Emerging Programs

• Legislative Directives for Insurance Coverage of
  ASD
• 22 states mandate some amount of coverage for the
  treatment of Autism
• 8 states require behavioral health services for
  the treatment of Autism (AZ, FL, IN, KY, LA, PA,
  SC, TX)
• 5 states require other coverage related to Autism
  (CO, GA, MD, NY, TN)
• 9 states include Autism in their laws mandating
  coverage for mental illness (CA, IL, IA, KS, ME,
  MT, NH, NJ,VA)
• President-Elect Barack Obama has drafted
  comprehensive autism legislation, including a
  section addressing a broad based federal Autism
  insurance mandate

22
Section 5 Emerging Programs

• Mandated Insurance Coverage
• Most states do not require private insurance
  companies to cover Autism treatments and
  services. However, when ASD services are covered
  by private insurance companies, services include
  
• Medications
• Occupational therapy
• Speech therapy
• Physical therapy
• Direct or consultative services provided by a
  psychiatrist or psychologist
• Professional, counseling and guidance services
  and treatment programs, including Applied
  Behavior Analysis and other structured behavioral
  programs

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Questions / Discussion