Transcript Medicaid Waiver 101 June 11, 2009 Peter Harbage, Peter

Intergovernmental Transfers
May 28, 2015
Presentation
Medi-Cal Rate Range
Intergovernmental Transfer (IGT)
Rate Range IGT has significantly
benefited many local governments
Scheduled to being June 16 for nonCOHS rural counties
Stan Rosenstein
1
Background
 Two Medi-Cal payment systems
 Fee for service (FFS)
 Managed care
 Each has own rules, opportunities and
controls
 Focus has been on FFS, with managed
care expansion changing
Stan Rosenstein
2
General Rules
 Federal government reimburses state for 50% of
legitimate Medi-Cal expenditure
 Federal government pays based on limits
 Non-federal share can be paid by state or local
government-not by private entities
 Non-federal share can be either:
 Certified Public Expense (CPE)-limited to cost
 Intergovernmental transfer (IGT)-payment for rate that
can be more than cost
 FFS can be either, managed care must be IGT
Stan Rosenstein
3
Fee for Service
 Payment for a service based on a rate
 Payment cannot exceed charges
 Pay lessor of rate or charges
 Rates must be economic and efficient
 Hospitals and nursing facilities have upper payment
limits (UPL)
 All other providers rates cannot exceed what top 3
commercial insurance plans pay
 Counties can increase reimbursement by CPE to cost
or IGT up to UPL or commercial rates
Stan Rosenstein
4
Managed care
 Limit on what state can pay plans-rate must be
actuarially certified using federal standards
 Actuaries establish a range of plan rates-low to high
 State pays low
 Local government can put up IGT to increase to high
rate generating increased payments to local providers
 Operational and federally approved since 2006
 $500 million in federal revenue per year
 State determines amount of funds available for plan
and area-”headroom”. Finite amount
 State takes 20% fee on most managed care IGTs
Stan Rosenstein
5
Managed Care IGT program
 No formal state or federal rules on what plans can pay
providers
 Plan payments must be for services to plan members
for plan covered services For prior rate year and services
 To ensure that plan payments are not-excessive state
has adopted ever changing informal policies
 State limits plan payment to provides based on either
uncompensated cost or charges for plan covered
services and enrollees
Stan Rosenstein
6
How it works
 State sets “headroom”
 Local government IGTs ½ of headroom amount
 Local government IGTs 20% of IGT amount for state
fee
 State takes first IGT and doubles it with federal money
to pay plan-keeps 20%
 Plan takes any fee it requires and pays the rest to local
government provider
 Local government providers get net benefit
 Federal government oversight of total plan payment
Stan Rosenstein
7
Agreements
 Requires agreements between
 Local Government and State for IGT
 Local Government and State for any 20% fee, waived in
limited conditions
 Agreement between plan and local government provider


Boiler plate
Plan may require administrative fee and place conditions on
payment
 No recycling of total plan payment


Payment up to plan cost no limits
Any payment above plan cost must be used for health care
Stan Rosenstein
8
Plan Covered Services
 Only services for which plan can compensate
 Cannot compensate for any carved out services such as
Short-Doyle, LEA, or CCS
 Can include any Medi-Cal services plan provides as
part of its contract with DHCS or in addition to its
contract-generally in Evidence Of Coverage
 For mental health, any service that is billed to ShortDoyle cannot be included
 Mental health services that are plan covered can be
included-mild or moderate conditions, screening
programs and perhaps ED diversion programs
Stan Rosenstein
9
Plan Members
 Payment for only services to plan members
 Person must be enrolled in the plan
 Service must be provided during a month person was
enrolled
 Services prior to plan enrollment or to people not
enrolled in managed care cannot be compensated in
this program
Stan Rosenstein
10
Opportunity
 IGT program provides an opportunity for additional
compensation for any services covered by a plan where
the plan has paid less than cost
 Potential to get payment that fully compensates for any
managed care cost shortfall
 However, must have uncompensated managed care
member and service cost to benefit
 Finite amount of money in IGT program and there
may or may not be enough money to fully compensate
all requestors
 Plan decides allocation
Stan Rosenstein
11
Process
 State asks plan to query counties and district hospitals
for interest
 Query may not be complete so important to stay on
top of this if interested
 Local government provides plan funding requests and
supporting data
 Plan puts together request
 DHCS reviews, modifies, and approves request
 Extensive contract work
 Local government transfers money and plan pays local
government Stan Rosenstein
12
Questions?
Stan Rosenstein
[email protected]
(916) 792-3740
Stan Rosenstein
13