Funding LTSS in your Community

Medicaid is a crucial source of funding for Long-Term Services and Support (LTSS), aiding those with limited income to access essential medical care, including services not covered by Medicare like personal care. Tribal facilities must be equipped for electronic billing.

Benefits:

• Funding is based on eligibility and services provided.
• Tribal facilities can receive full federal funding for Medicaid services, enhancing their negotiating power and supporting individuals beyond traditional LTSS.
• Includes funding for community and home-based services such as the Program of All-Inclusive Care for the Elderly (PACE) and Money Follows the Person (MFP).

Challenges:

• Non-Indigenous patients at tribal facilities might not receive full federal reimbursement.
• Not all services provided may be reimbursed by state Medicaid, requiring alternative funding sources.

Medicaid Waivers:

• Offer state-defined services supporting community living.
• Eligibility criteria vary, sometimes more lenient than standard Medicaid.
• Some waivers protect assets, benefiting the spouse not requiring services.

Medicare is a U.S. health insurance program mainly for individuals over 65 or those with certain disabilities and diseases. It’s important for healthcare providers, including tribal facilities, to manage electronic billing efficiently.

Advantages:

• Offers up to 100 days of care in skilled nursing facilities, hospice, or some home health services.
• Acts as a stable funding source for transitional care, aiding the shift of patients between their community and care facilities.

Limitations:

• Limited to those over 65 or with specific conditions, excluding some individuals.
• Does not cover every day unskilled care needs like help with daily activities or transportation.
• Provides limited coverage for skilled nursing or home health care, not intended for ongoing care needs.
• Obtaining Medicare certification can be challenging.

The Indian Health Service (IHS) now allows tribes to include Long-Term Services and Support (LTSS) in their self-governance agreements, thanks to the reauthorization of the Indian Health Care Improvement Act (2010).

Advantages:

• LTSS can be funded through IHS, making it an approved use of funds.
• Tribes can allocate IHS funds for roles and services not covered by other sources, such as community health representatives or visiting nurses for LTSS care.
• IHS funds can cover LTSS services that are not eligible for state waiver programs, Medicaid, or Medicare.
• Unlike other funding, IHS agreements can include costs for overhead and indirect support, not just direct care.

Limitations:

• While LTSS is authorized under IHS, there’s no additional funding specifically for it. Tribes need to use their existing IHS budget to support LTSS.

In 2010, the Indian Health Care Improvement Act (IHCIA) was permanently reauthorized as part of healthcare reform. This reauthorization now allows the Indian Health Service (IHS) to cover Long-Term Services and Support (LTSS). This means tribes can include LTSS in their self-governance agreements with IHS.

This change makes it easier for tribes to include LTSS in their agreements with IHS. Before, tribes had to negotiate with IHS separately to include LTSS services in their agreements.

For a state to receive full federal funding (100%  Federal Medical Assistance Percentage (FMAP)) for LTSS provided by tribal health programs, LTSS must be explicitly added to a tribe’s IHS funding agreement. This full funding can help tribes negotiate better reimbursement rates from the state.

Unfortunately, no extra funds were provided to IHS to expand LTSS in Indian Country. Adding LTSS to allowable IHS services became a requirement without additional funding.

Long-term care insurance is a newer type of insurance designed specifically for Long-Term Services and Support (LTSS). Its coverage and costs may change over time, especially with healthcare reform.

Private health insurance, often provided by employers or available through the Health Insurance Marketplace, typically covers medically necessary long-term care for up to 100 days. You can explore the Marketplace for more details on plans covering certain long-term care services.

Advantages:

• Long-term care insurance is tailored to support those with ongoing care needs.
• Recent federal policies favor home- and community-based care over facility-based options.
• Private health insurance may cover some long-term care, though with limitations.

Disadvantages:

• American Indian and Alaska Native populations have lower rates of private insurance, making it less reliable as a funding source.
• Covered services can vary significantly between insurance plans.
• Long-term care insurance can be expensive, potentially dissuading tribal members from purchasing it.
• Costs increase with age, making it less accessible for current LTSS patients.

Private Pay

Many people pay for their own long-term care. About half of all U.S. nursing home patients pay the costs of long-term care out of their own savings.

Pros

• Paying privately for HCBS can help people stay longer in their homes.
• If a person’s savings run out, he or she may then be able to qualify for Medicaid.
• There are many options for paying privately, such as reverse mortgages, which allow homeowners to receive money against the value of their homes without selling them.

Cons

• Those who have money saved may spend most or all of it on long-term care before they are eligible for Medicaid or other assistance.
• Many people who need care may not have enough money to pay privately at all.

For a tribe to financially support Long-Term Services and Support (LTSS) programs, it needs to be a priority for tribal leadership. However, changes in leadership could alter these priorities, leading to fluctuations in funding levels unless specifically outlined in a funding agreement.

Advantages:

• Tribal support provides flexibility in how LTSS funds are utilized.
• Empowers tribal communities to have greater control over their long-term care programs.

Disadvantages:

• Convincing tribal leadership to prioritize LTSS programs may require significant time and effort in community education and funding advocacy.
• Often, tribes must navigate processes to amend tribal codes and budgets to allocate funding for LTSS programs.

Grants

Pros

• Grants are good for creating a new project or starting a program.

Cons

• Grant funds only provide money for a limited amount of time. Grants may also require that the use of funds be limited to a specific set of activities.
• Priorities of an individual grant organization may change over time, meaning you often cannot go back to the same grantor for more funding once a grant ends.