Montana: Reimbursement Options

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Montana Reimbursement Options

• Rate Architectures
• and Medicaid

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VISION, MISSION AND DIRECTION
FACILITY/ CENTER-BASED
COMMUNITY- BASED
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Define the Structure of the System

• Flexibility
• Service Protocol

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Flexible Waiver Services

Attendant Care
Personal

Respite
Changes
Supports

Transportation
to

Housekeeping

Home Health Aide

Personal Assistance
Habilitation

Group Homes
Changes

Day Programs
to

Early Intervention

Nursing
Therapies
Changes

OT/PT
to

Speech Therapy
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What is the Role of the System

• Prevent Harm
• emphasis on rules
• emphasis on monitoring
• rigid structures to minimize deviation

• Promote Consumer Growth
• emphasis on outcomes
• emphasis on flexibility
• rules as guidelines rather than absolutes

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Rate Architectures

• Negotiated Rates
• Published Rates
• Capitation and Sub-captitation
• Cost Reimbursement

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Mandatory Requirement

• Negotiated
  Published
• MMIS
• Capitation Cost
  Reimbursement

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Medicaid Management Information System

• The TRINITY
• An eligible consumer
• An eligible service
• An eligible provider of service
• Bottom line All costs must be linked to the
  above

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Negotiated Rate

• A method of reimbursement where a set fee is
  agreed upon between the payer and the contractor.
  Generally, once set and agreed upon no
  additional adjustments are permitted without a
  new solicitation

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Negotiated Rate Key Elements

• Develop service scope as part of RFP
• Provider response to RFP includes an itemized
  service budget (ISB)
• Negotiation centers on ISB
• The Rate is the Rate is the Rate
• Set and non- adjustable
• Accountability to the service delivery, not to
  the components of the ISB

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Negotiated Rate

• Solicitation is through a Request for Proposal
  (RFP), or Request for Quote (RFQ)
• Theoretically may be the most accurate for
  addressing true consumer needs
• State Budgets are fixed
• Negotiation Skills vary
• Costs versus Expenditures

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Negotiated Rate (cont.)

• Satisfies the Client/Unit of time requirement
• Does NOT accommodate the Appendix G cost
  neutrality demonstration
• Administratively burdensome to solicit and to
  manage

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Negotiated Rate (cont..)

• Common Outcomes
• Varied rates for similar services
• Historical levels of reimbursement carried
  forward
• Difficulty demonstrating fair and equitable
  resource allocation
• Winners and losers

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Published Rate

• A method of reimbursement where all possible
  rates are set and listed, either in rule or as
  part of a contract solicitation. There are no
  negotiations concerning the value of a service,
  all negotiations revolve around service
  utilization

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Published Rates Key Components

• Offer and accept
• Services are defined
• Units of services are defined
• Reporting structures are established
• Cost controls through service utilization
• Accountability through service delivery

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Published Rates

• Least Administratively Burdensome
• RFP process NOT used
• Certification and provider agreements
• Most Complex to Establish
• Agreements on definition of units
• Agreements on components of the rate
• Reconciling history
• Agency and independents

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Published Rates (cont..)

• Introduces market-forces as the foundation
• Portability versus Capacity
• Policy and Infrastructure supports
• Provider availability and access
• Meets the Fair and Equitable standard
• Meets the MMIS data requirement
• Does NOT accommodate Appendix G

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Capitation

• A method of reimbursement involving the
  establishment of an all inclusive fee for each
  individual enrolled rather than paying a fee for
  each service provided.

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Capitation

• Most Complex to establish
• PM/PM
• Presents Multiple Challenges
• Very data dependent and driven
• Mandates the establishment and management of
  risk pools
• Should involve actuary opinion and involvement

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Capitation (con.t)

• Calculations involve service bundles
• Reimbursement reflects service bundles
• Need vigilance on changes with services
• Need vigilance on changes in acuity
• Prospective payments
• Requires vigilance
• Bias towards large corporation
• Risk pool

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Capitation (cont..)

• Complies with MMIS requirements
• Accommodates Appendix G requirements
• RFP and RFQ may be used in combination with
  Provider Certification/Agreements

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Cost Reimbursement

• A method of reimbursement that provides for
  payment of allowable costs, often to fixed cap
  that is prescribe in the contract. Cost
  reimbursement contracts often are based on
  estimate of total cost the estimate is in the
  form of an itemized service budget that has been
  reviewed and approved

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Cost Reimbusement

• Various forms
• Cost-sharing
• Cost Plus
• Cost Plus Incentives
• Ideal for uncertainty
• Highly dependent on a contractors ability to
  project cost

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Cost Reimbursement

• Most administrative burdensome to establish
• The most burdensome to operate
• Present challenges
• Predictability
• Capacity-based
• Principles of Reimbursement
• Audit and reconciliation

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Cost Reimbursement (con.t)

• Does not satisfy MMIS (requires sorting and
  classification of costs)
• Does not accommodate Appendix G
• Addresses concerns of fair and equitable
• Can provide good foundation for the provider
  network
• Can be used to incentives efficiency

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Hybrids

• Published Rate and Cost Reimbursement can be
  combined
• Negotiated Rate and Capitation can be combined

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Sample Rate Model
Individual Needs Assessment
Standard Rate
Market Analysis
Cost Per Unit of Service
Individual Budget Flexible Services
X
X

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What is the Best???????

• Depends on your PolicyVisionDirectionView of
  the System

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Need to Understand

• Your desired policy outcomes
• Your current infrastructure
• Your current skill sets
• Gap Analysis
• Outcomes, both intended and unintended
• MMIS requirements
• Budget