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 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

Design MedicaidNon-Medicaid Medicaid Agency – Limited Delegation Allowed State Units On Aging, AAA & Aging Network - Flexible Design Federal Approval RequiredProgram Develops Approval Protocol Mix of Mandatory & Optional Services Flexible, Creative, Individualized Services Clear Audit TrailCo-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 ProcessSingle Point of Entry

Services MedicaidNon-Medicaid Sufficient to Meet Needs of Most, Standardized & Comparable May Consider Financial Limitations, Vary by Locale & Individual Tied to Medical NecessityMay be Flexible Available to All Who are EligibleMay Limit Eligible Population Federal Approval of Definition and Limitations Required Requires No Federal Approval Combining Services LimitedMay Package Services Provided to Eligible ParticipantMay Provide to Family Caregivers Supports Required (Support Brokerage & Financial Management Services Support System is Flexible FMS Must Meet Federal, State, County and Local Requirements

Providers MedicaidNon-Medicaid Free Choice of ProvidersMay Target Specific Providers Qualifications – Standardized, Verified, & Reasonable Qualifications May be Flexible Provider Agreements RequiredAgreement not Required Payment Must be Paid DirectlyFlexibility in Design Legally Responsible Relatives as Providers – Limited Application May Pay Legally Responsible Relatives Training Requirements StandardizedTraining Based on Program Design Criminal Background ChecksState Law or Program Design Dictate

Assessing Need MedicaidNon-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 CareMay Support Informal Care Activity Required Annually or if ChangeMay be Flexible

Purchasing Goods & Services MedicaidNon-Medicaid Promotes Independence or Meet Personal Care Needs Program Design Defines Limitations Addresses Need in Service PlanProgram Design May be Flexible Audit Trail RequiredDocumentation 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

Reimbursement MedicaidNon-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 FullProgram May Issue Partial Payments Limitations on Cost-SharingMay 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 Management MedicaidNon-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