LTSS Roadmap - Paying for LTSS

Pros

• Medicaid is the primary funder for LTSS.
• As an entitlement program, funding parameters are based on eligibility and services, not budget limit.
• States are able to get 100% federal reimbursement (100% FMAP) for Medicaid services provided through tribal health facilities. Tribal providers can offer care to patients who would otherwise be in the mainstream LTSS system, where care would be reimbursed at a lower FMAP rate (57% FMAP is the national average).
• If IHS funds are included in your LTSS program, there is potential for 100% FMAP, which  increases the incentive for the State to provide an enhanced rate.
• 100% FMAP means there is no State match required, which is an advantage in negotiating rates with the State.
• Includes services provided through home- and community-based care models such as PACE and MFP (currently a demonstration program).

Cons

• Non-Indians served at the facility may be reimbursed at the State’s usual FMAP, not at 100% FMAP.
• State Medicaid plan may not reimburse some of the services you provide or intend to provide.

Pros

• Provides up to 100 days of long-term care in a skilled nursing facility, hospice, or as home health care.
• Reliable revenue source for transitional care.

Cons

• Medicare only supports care for individuals over 65 or persons with disabilities, end-stage renal disease, and ALS, so not all patients will qualify.
• Does not cover custodial care (unskilled) like daily living supports or transportation.
• Only offers skilled nursing or home health care coverage on a limited basis, not for long-term needs.
• Medicare certification is often the hardest to get.

Pros

• Long-term care insurance and long-term disability insurance are specially designed to support individuals with long-term health needs.
• Recent changes to the products and services covered by long-term care insurance may reflect models of care that are home- and community-based, instead of focusing only on facility-based care.
• Some, but not all, employers offer long-term disability insurance to employees and their dependents.
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Cons

• American Indian and Alaska Native populations report lower percentages for coverage by private insurance, and this may not prove to be a reliable funding source.
• Private insurance plans vary widely in the services that they cover and exclude.
• Long-term care insurance can be quite costly, decreasing the likelihood that tribal members might choose to purchase it.
• Long-term care insurance is most affordable when purchased at a younger age, and much more expensive if purchased at an older age, so current consumers of LTSS are much less likely to be privately insured.

Pros

• Under the Indian Health Care Improvement Act reauthorization, LTSS are now explicitly identified as an allowable expense.
• Tribal facilities can leverage existing IHS funds to cover positions and services not reimbursable by other revenue sources.
  • Positions, such as Community Health Representatives, visiting nurses, can assist with non-reimbursable LTSS care.
  • LTSS services not covered by a State’s waiver program, Medicaid, or Medicare can be supported with IHS funds.
• Overhead and indirect costs are included in the contract/compact, unlike other revenue sources that only finance direct care.

Cons

• Although authorized, there are no funds appropriated for LTSS, so LTSS resources would come from existing contract/compact funding.

Pros

• Time-limited funding can be used as seed money or start-up funds.
• Ideal for creating a new project or starting a program.

Cons

• Time limitations.
• Grant conditions limit funds to specific activities
  • "limited fungibility," meaning you usually can't make any substitutions of funds from one purpose to another
• Funding priorities of foundation or other funder may change from one year to the next