These steps offer general guidance on working with your state for LTSS reimbursement. Although they are based on the experiences of successful tribal LTSS programs, they are only meant to provide a general guide. Your situation may be very different—especially if your state contracts with a managed care organization, which manages the delivery and financing of healthcare in a way that controls and improves the cost and quality of services.
Steps to Establishing Financing
Step 1: Add LTSS funding to your IHS funding agreement, and arrange for LTSS care to be provided by your tribal health department
- For your state to get 100% FMAP for LTSS care, there are two federal administrative requirements that must be met:
- LTSS must be explicitly stated in your tribe’s funding agreement with IHS
- LTSS must be provided through (or contracted by) the tribal health department. Agencies or programs that provide LTSS care cannot be part of a separate department.
- Under the permanent re authorization of the Indian Health Care Improvement Act in 2010, tribes can now include LTSS in their self-governance agreements with IHS as a service the tribe plans to provide.
- Understanding these federal administrative requirements is important, because if your tribe’s services quality for 100% FMAP reimbursement, it can help you negotiate an enhanced (increased) reimbursement rate from your state.
Step 2: Identify LTSS covered by your state under the State Medicaid Plan and Medicaid waivers
Prior to meeting with state representatives, research which services are covered in your region. Use these resources for more information:
Step 3: Meet with State Department of Health representatives
Keep the following items in mind when meeting with state representatives:
- Keep careful records of discussions and decisions. Staff changes within the state or tribe can mean new people will join the discussion. Detailed records will help ensure everyone stays informed and up to date.
- You may want to identify a tribal member who is knowledgeable about healthcare, Medicaid, Medicare, and government-to-government relations and who can help the tribal and state governments communicate effectively.
- Meet with state financial experts and policy analysts first. Once they understand the benefits of certain reimbursement rates, they can assist you in other negotiations.
- Terms and phrases can mean different things to different audiences. Make sure you and the state share the same vocabulary.
- Explain the benefits of 100% FMAP, like an increase in federal revenue and potential cost savings, to the state, as well as the tribe.
- CMS staff may not be needed in these meetings unless the state needs further clarification on federal reimbursement.
Step 4: Explore state reimbursement options
Different states use different reimbursement rates. The rate your state offers depends on several things. Your state’s Medicaid program and the type of facility or program for which your LTSS program qualifies will affect the reimbursement rates available to you. Consider what you already know about your state and look into other factors, such as whether certain waivers are available, that may affect how you work with your state to negotiate reimbursement rates.
The goal of this step is to think about where your program’s interests overlap with your state’s interests, and to identify at least one opportunity to negotiate a reimbursement rate that works well for both your program and state.