Summary: The report recommends several ways that the State can maximize the amount of federal matching funds available. In some cases, the State may cut the amount of general funds needed to provide existing services to Alaskans by increasing the share that the federal government provides. In other cases the State could expand services by providing additional federal matching funds. However, this would require the State to expend additional general funds. The report also highlights other ways that the department can increase revenues, such as improving fee structures, implementing new fees, and looking for new ways to collaborate with tribal entities and other groups.

Key Recommendations for Maximizing Revenue

1. The department should implement a Medicaid 1915(i) option.
(Recommendation 2.2)
(Recommendation 6.2)

Section 1915(i) of the Social Security Act established an optional Medicaid benefit, giving states a new method with which to cover home- and community-based services. Fifteen states now have approved 1915(i) programs and five others have pending amendments. The services authorized under 1915(i) specifically include “day treatment or other partial hospitalization services, psychosocial rehabilitation services, and clinic services (whether or not furnished in a facility) for individuals with chronic mental illness.” This implementation will allow an estimated $4,494,300 in federal funds to be captured, allowing a reduction in State general funds expended.

2. Alaska should implement the Community First Choice 1915(k) option.
(Recommendation 2.3)
(Recommendation 6.1)

Section 1915(k) of the Social Security Act established the Community First Choice program, a new Medicaid state plan option to provide home- and community-based attendant services and supports a six percentage point increase in the federal medical assistance percentage. As a “state plan” benefit, the option is available to states without the need for special waiver authority. The purpose of the program is to encourage the use of home- and community- based services. The department should submit a Medicaid state plan amendment to the federal Center for Medicaid Services to operate a Community First Choice program. A DHSS-commissioned 2012 study of the feasibility of the program indicated substantive savings could be accomplished, but the department chose not to implement it because of a lack of staff. In the case of the Community First Choice program, it is more cost effective to hire a staff person to supervise the implementation of the program than put off implementation of a cost effective program because staff are not available. The additional six percent federal match would allow the department to offer more quality/quantity of service with current spending levels. This is estimated to generate savings up to $2,500,000 annually.

3. Alaska should submit a Medicaid State Plan amendment to obtain approval for implementing a Long Term Care Insurance Partnership Program.
(Recommendation 2.4)

The Insurance Partnership Program is a public/private partnership between states and private insurance companies, designed to reduce Medicaid expenditures by delaying or eliminating the need for some people to rely on Medicaid to pay for long-term services and supports. Over 40 states have initiated these insurances programs and found such programs cost effective.

4. The department should implement a person-centered rate setting system that ties acuity to payment level, allowing higher acuity patients to receive a higher reimbursement.
(Recommendation 2.9)

Currently, the assisted living reimbursement rate is tied to the number of beds in the facility and not related to the characteristics of persons receiving care. The creation of a person-centered rate setting system that ties resident acuity to reimbursement rates would provide the Alaska Pioneer Homes higher reimbursement for Level III residents.

5. The department should explore expanding the Traumatic and Acquired Brain Injury Grant through a Medicaid waiver.
(Recommendation 3.7)
(Recommendation 6.11)

The State currently provides state funding for traumatic brain injuries and related injuries through three general funded grant programs: the Traumatic and Acquired Brain Injury Grant totaling $70,624, Traumatic and Acquired Brain Injury Case Management services totaling $300,000, and Traumatic and Acquired Brain Injury Mini Grants totaling $200,000. The department could pay for the services through a waiver and receive federal match funds for the service provision. This could be used to expand services under the waiver with an estimated potential savings of $285,000 annually.

6. Alaska should implement a provider assessment fee to further capture federal dollars.
(Recommendation 6.9)

Provider assessment fees or taxes are mandated payments set by a state on health care providers. A state voluntarily decides whether to implement a fee and what the fee applies to. States are allowed to use the collected and federally-matched money to increase reimbursement to Medicaid providers or to support the Medicaid program in other ways. This practice allows states to increase revenue for their Medicaid program, which in turn allows the state to expand coverage to its residents, to prevent provider rate cuts, or to fill budget gaps in the Medicaid program. Currently, all states but Alaska impose at least one type of provider assessment.

7. The department should upgrade the Pioneer Home in Palmer to provide both domiciliary and veteran’s skilled nursing home care.
(Recommendation 6.5)

The Palmer Pioneer Home received Veteran Affairs certification as a veteran’s nursing home in 2006, and is regarded as a domiciliary care unit which lies in the continuum of care as an Assisted Living Facility. The Veteran Affairs per diem rate does not cover the monthly Pioneer Home rate of $2,100, or roughly $70 per day. Currently, the Palmer Pioneer and Veterans Home receives a domiciliary rate of $44.19 per veteran resident per day. If the Pioneer Home expands services to offer nursing facility level of care, this Palmer Pioneer and Veterans Home would receive $102.38 per day for providing veterans this level of care. The department also has the option of only licensing limited portions of the home as a skilled nursing facility.

8. The State of Alaska should amend its policy to make waiver eligibility for Alzheimer’s disease and related dementia less of an exclusionary process.
(Recommendation 2.6)

The assessment tools used for Medicaid waiver eligibility make it difficult to allow an individual with Alzheimer’s disease and related dementia access to Medicaid funds. The State has the power to amend this policy, which will allow better care for individuals suffering from Alzheimer’s disease and related dementia. Furthermore, federal match on expenditures can be utilized to allow more individuals access to waiver services.

Long Term Care Maximizing Revenue Recommendations Table
Recommendation NumberRecommendation
2.2The Department should implement a Medicaid 1915(i) Waiver. This implementation will allow an estimated $4,494,300 Federal funds to be captured allowing a reduction in State General Funds expended.
2.3Alaska should implement the Community First Choice (CFC), 1915(k) waiver. The Department should revisit the CFC program through the 1915(k) Waiver and submit a Medicaid state plan amendment to CMS to operate a CFC program. Having staff to implement new initiatives is always a problem. In the case of CFC, it is more cost effective to hire a staff person to supervise the implementation of the program, than put off implementation of a cost effective program because staff are not available.
2.4Alaska should submit a Medicaid State Plan amendment to obtain approval for implementing an LTC Partnership Program.
2.6The State of Alaska should amend its policy to make waiver eligibility for Alzheimer’s disease related dementia (ADRDs) less of an exclusionary process. The assessment tools used for Medicaid waiver eligibility make it difficult to allow an individual with an ADRD access to Medicaid funds. The state has the power to amend this policy, which will allow better care for individuals suffering from ADRDs. Furthermore, federal match on expenditures can be utilized by allowing more individuals access to waiver services.
2.9The Department should implement a person-centered rate setting system that ties acuity to payment level, allowing higher acuity patients to receive a higher reimbursement.
3.5PCG recommends the Department consider revising AKPH fee structure to further reflect person centered care so residents are more responsible for the level of services they actually use. Please refer to Review Objective 02: Delivery and Administration for additional information.
3.6For the following grants, the Department should explore potential opportunities for additional matching funds: the SDS Community Developmental Disabilities Grant totaling $11,555,795 in general funds; the Nursing Facility Transition Program grant totaling $120,000 in General Funds; the Adult Day Services grant totaling $1,757,011 in general funds; the Alaska Mental Health Trust Authority Developmental Disabilities mini-grants totaling $285,975 in general funds, and the Senior In-Home Services grant totaling $2,917,265 in general funds.(The total grant figures represent the current grant value, not the potential value.)
3.7The Department should explore expanding Traumatic and Acquired Brain Injury (TABI) Grant through a Traumatic Brain Injury (TBI) Medicaid waiver. This would allow expansion of the TABI Grant which currently totals $70,624. This will present an opportunity to potentially expand this program. The Department could pay for the services through a waiver and receive federal match funds for the service provision. The increased federal funding could be used to expand services under the waiver. There is additional room to expand this program by providing case management services. The Department is currently paying $300,000 in general funds for TABI Case Management services. Additionally, the TABI Mini Grants totaling $200,000 could further be covered through a waiver service which would help increase match funds. These three services could be better covered through a new TBI Waiver. For additional information please see Review Objective 06: Cost Collaboration.
3.8The Department should consider expanding the Funded Human Services Community Matching Grant Program for FY 2014 to other municipalities that do not exceed 65,000 in population. This is a good way to meet the needs of additional citizens while receiving additional match funds.
6.1The Department should move with the CFC waiver program to receive the additional 6% federal match.
6.2The Department should move forward with implementing a 1915(i) option. Please refer to PCG’s Behavioral Health Performance Review report for more details on the Medicaid 1915(i) option.
6.3Adjustments to the calculation of cognition on the CAT should be made. Adjusting CAT scoring is something the state could do without going to the time and expense involved with a 1915(i).
6.5The Department should upgrade the AKPH in Palmer to provide both domiciliary and veterans skilled nursing home care. This will allow the Pioneer Home to receive a higher average per diem rate than the domiciliary-only rate currently received from the VA. Currently, the Palmer Pioneer and Veterans Home receives a domiciliary rate of $44.19 per veteran resident per day. If the Pioneer Home expands services to offer nursing facility level of care, this Pioneer Home would receive $102.38 per day for providing veterans this level of care.13 Additionally, the Department may consider licensing only certain portions of the home as skilled nursing facility level of care while other portions can remain as an assisted living facility. This would help avoid potential problems such as what to do with current residents who do not meet skilled nursing level of care requirements, persons on the active wait list, and the Home could still meet the needs of non-veterans.
6.6The Department should ensure as many providers as possible are enrolled as an Indian Health Service provider to receive a 100% federal match for all eligible recipients.
6.9Alaska should implement an assessment fee to further capture federal dollars. To align with peer states and national trends, Alaska should explore a provider assessment imposed on either hospitals, nursing homes, and/or assisted living facilities including the AKPH. Projections would need to be calculated to determine possible revenue outcomes for each type of potential provider assessment at different tax amounts to gain a better understanding of the financial impact on the state’s Medicaid program.
6.10Recommendations provided in the Grants and Contracts Section in order to further pursue additional federal dollars should be reviewed. See Review Objective 03: Grants and Contracts.
6.11The Department should consider implementing a TBI waiver to enroll additional individuals in a waiver program and which, based on Medicaid eligibility, will help bring in additional federal dollars. This waiver would be granted under the authority of section 1915(c) of the Social Security Act. The waiver would be designed to help Medicaid-eligible individuals who might otherwise be admitted to a hospital or nursing facility to live independently in the community and to permit the state to provide services that are not typically covered under the state’s regular Medicaid program.
10.8The state should consider a one-time amnesty program for HCBS providers.