LTSS Roadmap - Educate Your State

What is the Federal Medicaid Assistance Percentage (FMAP)?

• Medicaid is a Federal program administered by the States, and costs are shared between the Federal and State governments.
• CMS pays each state a percentage of its total Medicaid expenditures. This percentage is the Federal Medicaid Assistance Percentage (FMAP).
• FMAP varies by State based on the State’s per capita income. Wealthier States have a lower FMAP rate than less affluent States.
  • Average FMAP is 57%, but it can range from 50% to a maxiumum of 82%
• Services provided to Medicaid-eligible AI/AN patients in IHS or tribal facilities can be reimbursed at 100% FMAP, instead of your State's regular FMAP
  • Since CMS reimburses 100%, services reimbursed at 100% FMAP cost the State nothing.
  • This is a significantly higher Medicaid reimbursement for tribally provided services than for other State Medicaid services.
• FMAP percentages are adjusted every 3 years.
• State FMAP rates are published yearly in the Federal Register.
  • See published FMAP rates

Materials

• Memorandum of Agreement (MOA) (PDF) that extends IHS rate to tribally operated health programs and 100% FMAP to states for AI/AN patients receiving care at tribally operated health programs
• IHS expanded authority under permanent reauthorization of Indian Health Care Improvement Act (IHCIA) for the administration of LTSS - see more policy background on IHCIA

100% FMAP as a Win-Win Situation for Tribes and States

By educating your state about the possibility of receiving 100% federal reimbursement for Medicaid services provided in tribal facilities, you can help both your state and your tribe access more federal dollars to support health care. Both parties benefit: states can receive more federal dollars in Medicaid support, and, by passing those dollars along to tribes, tribes can provide better care for their citizens. This partnership helps support health for everyone.

• Sit down with your state and explain how the money works (educate!)
  • Explain the key elements: 100% FMAP is available for services, requirements for enhanced reimbursement
  • Explain the win-win scenario:
    • Tribe receive an enhanced rate, which then allows the tribe to increase capacity to provide service.
    • The state saves money, because through 100% FMAP, the state doesn't have to pay its normal share for Medicaid services.
• Key components
  • 100% federally funded
  • Budget neutral on State Medicaid budget

By using 100% FMAP and an enhanced rate (such as the Medicare-like rate), the amount of Federal funds coming to the State is increased. The Tribe gets reimbursed for providing care and the State does not have to match funds.

The process of education as you work with your state can take some time, but the benefits can be substantial. See Oneida Nation's story about using the benefits of 100% FMAP to negotiate with their state.

Receiving 100% FMAP for LTSS

To be eligible for 100% FMAP, LTSS must be provided through (or contracted by) the tribal health department. LTSS must also be explicitly included in a tribe's funding agreement with IHS.

• What does it mean to provide LTSS "through" the tribal health department?
  • Two options:
    • Move LTSS (eg, Aging Program/Department) under the health center on the org. chart
    • Health center contracts with the Aging Program/Department to provide LTSS
• Money must "go through" the health center
  • The health center invoices the state Medicaid office
• Issues
  • Program directors can be very territorial… meaning the LTSS program director may oppose the move
  • The health program must work to "keep the books straight" (e.g., protect any LTSS-specific funding)
  • Rule of thumb: The program that handles the billing is the program that “owns” the patient. Since the state can only claim 100% FMAP on patients of tribal health programs, the tribal health program should handle the billing of the tribal LTSS program.

Learn more about the reimbursement process and reimbursement rates next. >