Comparing Medicaid & Non-Medicaid Environments

Suzanne Crisp

National Program Office

February 13, 2008

Exploring Opportunities Compare Medicaid Requirements to Non-Medicaid

Practices Identify Potential for Flexibility and Efficiency Create System Unique to Aging Network Develop Promising Practices Design Plans for Success and Sustainability

Non-Medicaid Funding

Older Americans Act Alzheimer’s Disease

Demonstration Grants to States

State General Revenue County & Local Revenue Private Insurance Private Pay Medicare

Other Public2.6%

Medicaid48.9%

Other Private2.7%Private

Insurance7.2%

Out-of-Pocket18.1%

Medicare20.4%

Long-Term Care Expenditures by Payer

2005 Columbia University

Comparing Medicaid & Non-Medicaid Overview

Design Services Providers Assessing Need Purchasing Goods and Services Reimbursement Quality Management

DesignMedicaid Non-Medicaid

Medicaid Agency – Limited Delegation Allowed

State Units On Aging, AAA & Aging Network - Flexible Design

Federal Approval Required Program Develops Approval Protocol

Mix of Mandatory & Optional Services

Flexible, Creative, Individualized Services

Clear Audit Trail Co-Mingling of Funding Allowed

Authority Retained at State Medicaid Level

Authority May be Distributed

Predefined Eligibility Groups

Income & Resource Limitations

Non-Medicaid at risk of Nursing Facility Placement or Spend-Down

Complex Application Process Single Point of Entry

ServicesMedicaid Non-Medicaid

Sufficient to Meet Needs of Most, Standardized & Comparable

May Consider Financial Limitations, Vary by Locale & Individual

Tied to Medical Necessity May be Flexible

Available to All Who are Eligible May Limit Eligible Population

Federal Approval of Definition and Limitations Required

Requires No Federal Approval

Combining Services Limited May Package Services

Provided to Eligible Participant May Provide to Family Caregivers

Supports Required (Support Brokerage & Financial Management Services

Support System is Flexible

FMS Must Meet Federal, State, County and Local Requirements

ProvidersMedicaid Non-Medicaid

Free Choice of Providers May Target Specific Providers

Qualifications – Standardized, Verified, & Reasonable

Qualifications May be Flexible

Provider Agreements Required Agreement not Required

Payment Must be Paid Directly Flexibility in Design

Legally Responsible Relatives as Providers – Limited Application

May Pay Legally Responsible Relatives

Training Requirements Standardized Training Based on Program Design

Criminal Background Checks State Law or Program Design Dictate

Assessing NeedMedicaid Non-Medicaid

Formalized, Standardized & Yields Consist Outcomes

Flexible and Personalized

Require Signature of Licensed Medical Professional

Based on Program Design

All Needs (Medicaid and Non-Medicaid) Assessed and Plan Developed

Includes Functional, Health, Cognitive/Emotional Status & Support System Information

Deduct the Amount of Informal Care May Support Informal Care Activity

Required Annually or if Change May be Flexible

Purchasing Goods & Services

Medicaid Non-Medicaid

Promotes Independence or Meet Personal Care Needs

Program Design Defines Limitations

Addresses Need in Service Plan Program Design May be Flexible

Audit Trail Required Documentation Standards Set by Program

May not Include Housing, Food or Utilities (Room & Board)

Program Design Defines Limitations

Provided Before Payment (Except 1915(i) or 1115)

Payments May be Paid Prior to Service Delivery

ReimbursementMedicaid Non-Medicaid

Usual, Customary & Standardized Methodology

May Use Per-Capita or Unit Rate – May Vary

High Enough to Attract Qualified Providers

Set by Program

Represents Payment in Full Program May Issue Partial Payments

Limitations on Cost-Sharing May Develop Co-Pays, Sliding Fee Schedules or Other Cost-Sharing Strategies

Cash to Participants Prohibited (except 1915(i) & 1115)

Program Design May be Flexible

Quality ManagementMedicaid Non-Medicaid

Must Develop Integrated QM Plan Based on Accountability, Assurances or Terms & Conditions

Is Program Operating as Intended? Are Goals and Objectives Met? Is System Improvement Achieved?

Programs Must Develop Performance Measures Across Program

Performance Measures Specified

Ultimate Responsibility Rests with Medicaid Agency – Across Waivers

AAA or State Unit on Aging Ensures Quality of Services

Discovery, Remediation & Improvement Requirements

Program May Design Quality Collection, Corrective Action and Improvement Activities

Focus Includes: Reporting Incidents, Developing Contingency Plans, & Managing Risks

Focus Determined by Program

Conclusion Flexibility Can Improve:

Access Efficiency Satisfaction

Additional Areas of Technical Assistance If Questions Later suzanne.crisp@thomson.com