Medicaid Waiver Budgeting

INTRODUCTION

This is going to be a very important issue and we should understand it in order to advocate effectively to FREE OUR PEOPLE. If you have difficulty understanding this after reading it and you want to understand it, ask someone. I know a lot of really smart people who didn't know this stuff. You would not be alone.

Don't be embarrassed about asking. I personally hated asking questions and getting help in school. For a variety of little reasons and one really big one, I had to. I'm not in school anymore, but I DID ask for help with this. Honestly, if you don't understand it, I simply did not explain it well enough….

After reading this, even if you can't personally explain all of this perfectly by yourself, don't worry. Most Albany bureaucrats wouldn't know half of this stuff.

EXPLANATION OF MEDICAID WAIVER BUDGETING

Medicaid waivers are required by federal law to be cost neutral. The cost of waiver services cannot cost more that institutionalization. But states have choices in how they do that in their waivers.

Individually capped waivers limit the services an individual enrolled in the program receives to a set cost which is below the comparable cost of institutionalization. For example, in New York State, the Long Term Home Health Care program is individually capped. The services for each individual person in the program may not exceed 75 percent of the average monthly rate for nursing facilities in the social services district. This cap may be extended to 100 percent in certain limited cases. In no case may a person in this program receive services which exceed this cap.

Aggregately capped waivers limit all of the services that all of the people enrolled in the program receive to a cost which is below the comparable cost of institutionalizing the entire group. This means that services to some individuals may actually cost more than it costs to keep them in the institution. Other individuals, who use less service, help balance those costs. In New York State, the Traumatic Brain Injury waiver program is aggregately capped. Some individuals in the program receive services which cost more than the cost of placement in a nursing facility. Others receive less. But most importantly, they balance each other so that the total cost is less.

There are also waivers which are hybrids. These waivers place individual caps on services, but report the information to the federal government on an aggregate basis. As far as we would be concerned (on the recipient end) this would function like an individually capped waiver. We don't care about this option, but need to know it exists.

WHY WE WANT A WAIVER WITH AN AGGREGATE CAP

We are pushing the state to develop an aggregately capped waiver because we want to free as many people as possible. People who need more assistance shouldn't have less of a right to live in freedom.

As far as I am concerned this is the most important argument, but the state would rather we explain this in financial terms or Medicaid savings.

WHY NEW YORK STATE SHOULD DEVELOP AN AGGREGATELY BUDGETED WAIVER

We know the state is having financial problems. You may be told that people think an aggregately capped waiver will cost more for taxpayers. They are mistaken. This is why.

1. ALL waivers are cost neutral. They don't cost any more that institutionalization. It's federal law. The state isn't really risking anything more by doing this. In practice waivers actually cost LESS than institutionalization.

2. People are only approved for the services they need. In a nursing home, although there may be adjustments to a payment, the facility is paid a standardized rate. The full range of services is always included in that rate. Community-based waiver services allow greater flexibility. People are only approved for the services they need. If you don't need it, you don't get approved for it. We have just saved money for the state.

3. Another way we save money is that Medicaid only pays for the waiver services an individual actually receives. If an attendant or other support staff doesn't show up, the person and the agency don't get paid. Compare that to a nursing home or other institutional setting. In those places, if there is a staffing shortage and people don't show up (or get paid) the facility still gets paid its rate.

4. We further save money with an aggregate waiver because people often need more support when they first get out. They may not feel "safe" on their own at first. As people live in the community for a while, they become more comfortable. They develop skills and support systems which mean they may rely less on paid support. Consider this an investment in that individual. At first their services may cost more, but once those costs are reduced, they keep saving money for the state year after year. Over the years a person may be living in the community, the savings can really add up! If the state develops an individually capped waiver, it will never benefit from these savings. That would be "Penney wise and pound foolish."

5. Finally, the state is required under the Olmstead decision, to provide services in the Most Integrated Setting. If the state develops an individually capped waiver program, it will continue to have "an Olmstead problem" and may face the possibility of legal action by people who are still stuck in facilities and want to get out. This is not a direct financial argument. Nor is it a threat. It's just another example of how the state can reduce or avoid unnecessary costs by developing an aggregately capped waiver. In this case the savings just don't come out of the Medicaid budget.

Enough about waivers. Class is over.
Now that you know this stuff, you can take action and FREE OUR PEOPLE!.