Transcript Florida Association of County Social Service Executives

Low Income Pool
Genevieve Carroll,
Agency for Health Care Administration,
Medicaid Program Analysis
January 18, 2006
www.fdhc.state.fl.us – Medicaid Reform
[email protected]
Medicaid Reform Waiver:
Low Income Pool (LIP)
Low Income Pool Definition
“A Low Income Pool (LIP) will be established to
ensure continued government support for the
provision of health care services to Medicaid,
underinsured and uninsured populations. The
low-income pool consists of a capped annual
allotment of $1 billion total computable for each
year of the 5-year demonstration period.”
Medicaid Reform Waiver:
Low Income Pool (LIP)
Medicaid Reform is authorized as an 1115 Waiver for a
demonstration period of 5 year. The LIP can operate
ONLY under the authority of the implemented waiver.
Implementation is still subject to legislative approval.
Federal funds are provided via the waiver under the
technical terminology Costs Not Otherwise Matchable
(CNOM).
Upon implementation of the LIP the state will submit a
State Plan Amendment to CMS to terminate the current
inpatient hospital UPL program.
UPL Program
 The hospital inpatient upper payment limit (UPL)
program (Title 42 Section 447.271 CFR) was
first approved by CMS in Florida during State
Fiscal Year (SFY) 2000-2001.
 The initial distributions through the UPL program
were $144M with approximately 5 local
government entities contributing the state share.
 Currently the distributions are approximately
$1B with approximately 24 local government
entities contributing the state share.
UPL Programs
The hospital UPL payments include:
Trauma Hospitals
Family Practice Teaching Hospitals
GME Teaching Hospitals
Rural Hospitals
Primary Care Hospitals
Specialty Children’s Hospitals
Reimbursement at Medicaid Cost to qualifying
hospitals
UPL/LIP Comparison
UPL
 Balance available
dependent upon the
annual UPL calculation
LIP
 $1B available each year
 $300M (of $1B) available
pursuant to certain
general requirements
 $700M (of $1B) available
each year, and any
unspent funds can be
rolled forward for
payments in the following
year
UPL/LIP Comparison
UPL
 Available for
payments to hospitals
ONLY
LIP
 Available for
payments to ANY
Medicaid provider
 Primary payments
projected to continue
to hospitals given the
amount of current
expenditures on
uncompensated care
UPL/LIP Comparison
UPL
 Payment based upon
services provided to
Medicaid recipients
ONLY
LIP
 Payment based upon
services provided to
Medicaid recipients,
the underinsured, or
the uninsured
UPL/LIP Comparison
UPL
 100% of payments based
upon a calculation
derived from Medicaid
services to Medicaid
recipients
LIP
 Payment based upon
services provided to
Medicaid recipients, the
underinsured, or the
uninsured
 $100M (of the $1B) may
be paid based upon a
methodology other than
Medicaid, underinsured,
or uninsured individuals
UPL/LIP Comparison
UPL
 Funding
arrangements
pursuant to the Social
Security Act
 Title 42 Section
433.51 CRF
LIP
 Funding
arrangements
pursuant to the Social
Security Act and CMS
approval
UPL/LIP Comparison
UPL
 Each hospital limited
in total Medicaid
payments, generally
defined as the cost of
Medicaid services
and uncompensated
care (includes regular
Medicaid and DSH
payments)
LIP
 Each provider limited
to the combined costs
of providing Medicaid
services and
uncompensated care
(includes regular
Medicaid and DSH
payments)
Funding
Availability of the $1B dependent upon
qualified state share
IGTs may continue as the primary funding
source
IGTs subject to federal requirements
Terms and Conditions
Major references within the waiver:
Annual Report Requirement: 23
Low Income Pool: 91-99
Budget Neutrality: 114
Rollover quantification: 120
Annual Report Requirement (#23)
“Beginning with the annual report for
demonstration year four, the State must
include a section that provides qualitative
and quantitative data that describes the
impact the Low Income Pool had on the
rate of uninsurance in Florida starting with
the implementation of the demonstration.”
Discussion: uninsurance!?!
Low Income Pool (#91-99)
“…continued government support for the
provision of health care services…”
“…Medicaid, underinsured, and
uninsured…”
“…capped annual allotment of $1 billion…”
“…for each year of the 5-year
demonstration…”
Low Income Pool
“…available upon implementation of
Florida Medicaid Reform…”
“…no later than July 1, 2006…”
Low Income Pool
“…for CMS approval a Reimbursement
and Funding Methodology document for
the LIP expenditures and LIP parameters
defining State authorized expenditures…”
Low Income Pool
 “…may be used for health care expenditures (medical
care costs or premiums) that would be within the
definition of medical assistance in Section 1905(a) of the
Act.”
 “…incurred by the State, by hospitals, clinics, or by other
provider types for uncompensated medical care costs of
medical services…”
 “…for the uninsured, Medicaid shortfall…may include
premium payments, payments for provider access
systems…and insurance products for such services
provided to otherwise uninsured individuals, as agreed
upon by the State and CMS.”
Low Income Pool
 “Up to 10 percent of the capped annual
allotment…may be used for hospital
expenditures other than payments to providers
for the provision of health care services to an
uninsured or underinsured individual.”
 “…such as capacity building and infrastructure,
hospital trauma services, hospital neonatal
services, rural hospital services, pediatric
hospital services, teaching or specialty hospital
services, or safety net providers.”
Low Income Pool
 “Hospital cost expenditures from the LIP will be
paid at cost…”
 “To ensure services are paid at cost, CMS and
the State will agree upon cost-reporting
strategies and define them…”
 “At least 120 days prior to the demonstration
implementation the State must submit for CMS
approval the source of non-Federal share…The
State shall not have access to these funds until
the source of non-Federal share has been
approved by CMS…”
Milestones (#100-105)
Pre-Implementation
Reimbursement and Funding Methodology
SPA terminating inpatient UPL
Reinstatement of inpatient UPL not prohibited
No other hospital UPL programs during
demonstration
Limit Title XIX hospital payments to cost
Approval of funding sources
Budget Neutrality (#114, 120)
$1B annual cap
$5B demonstration period cap
Unexpended funds from the restricted
amount may not be carried forward
Unrestricted funds may be rolled forward
Summary for 5 year period in #120.
Updates/Discussion
Reimbursement and Funding Methodology
Limit Title XIX hospital payments to cost
Approval of funding sources
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