State |
CMS-approved MLTSS plan1 |
Medicaid rate-setting methods2 |
|||||
Flat |
Tiered |
Case mix |
Cost based |
Fee for service |
Negotiated |
||
Total | 24 | 18 | 16 | 6 | 7 | 10 | 14 |
Alabama | – | N/A | N/A | N/A | N/A | N/A | N/A |
Alaska | – | ✓ | – | – | ✓ | – | – |
Arizona | ✓ | – | – | – | – | – | ✓ |
Arkansas | – | – | ✓ | – | – | ✓ | – |
California | ✓3 | – | ✓ | – | – | – | – |
Colorado | – | ✓ | – | – | – | ✓ | – |
Connecticut | – | – | ✓ | ✓ | – | – | ✓ |
Delaware | ✓ | – | – | – | – | – | ✓ |
District of Columbia | – | ✓ | – | – | – | – | – |
Florida | ✓ | ✓ | – | – | – | – | ✓ |
Georgia | – | – | – | – | ✓ | ✓ | – |
Hawaii | ✓ | – | – | – | – | – | ✓ |
Idaho | ✓ | – | ✓ | ✓ | – | – | – |
Illinois | ✓4 | ✓ | – | – | – | – | ✓ |
Indiana | – | ✓ | – | – | ✓ | – | – |
Iowa | ✓5 | – | – | – | ✓ | – | – |
Kansas | ✓ | – | – | – | – | – | ✓ |
Kentucky | – | N/A | N/A | N/A | N/A | N/A | N/A |
Louisiana | – | N/A | N/A | N/A | N/A | N/A | N/A |
Maine | – | – | – | ✓ | – | – | – |
Maryland | – | – | ✓ | – | – | – | – |
Massachusetts | ✓6 | ✓ | ✓ | – | – | ✓ | – |
Michigan | ✓7 | – | – | ✓ | – | ✓ | – |
Minnesota | ✓8 | – | – | ✓ | – | – | – |
Mississippi | – | ✓ | – | – | – | – | – |
Missouri | – | – | ✓ | – | – | – | – |
Montana | – | – | – | – | ✓ | – | – |
Nebraska | – | ✓ | – | – | – | ✓ | – |
Nevada | – | ✓ | ✓ | – | – | – | – |
New Hampshire | ✓9 | ✓ | ✓ | – | – | – | – |
New Jersey | ✓ | – | – | – | – | – | ✓ |
New Mexico | ✓ | – | – | – | – | – | ✓ |
New York | ✓10 | – | ✓ | – | – | – | – |
North Carolina | – | ✓ | – | – | – | ✓ | – |
North Dakota | – | – | – | ✓ | – | ✓ | – |
Ohio | ✓11 | – | ✓ | – | – | – | ✓ |
Oklahoma | – | – | ✓ | – | – | – | – |
Oregon | – | – | ✓ | – | – | – | ✓ |
Pennsylvania | – | N/A | N/A | N/A | N/A | N/A | N/A |
Rhode Island | ✓12 | ✓ | – | – | – | – | – |
South Carolina | ✓13 | ✓ | – | – | – | ✓ | – |
South Dakota | – | – | – | – | ✓ | – | – |
Tennessee | ✓ | – | – | – | ✓ | – | – |
Texas | ✓14 | ✓ | – | – | – | – | ✓ |
Utah | – | ✓ | – | – | – | ✓ | – |
Vermont | ✓ | ✓ | ✓ | – | – | – | – |
Virginia | ✓15 | ✓ | – | – | – | – | – |
Washington16 | – | – | ✓ | – | – | – | ✓ |
West Virginia | – | N/A | N/A | N/A | N/A | N/A | N/A |
Wisconsin | ✓ | – | – | – | – | – | ✓ |
Wyoming | – | – | ✓ | – | – | – | – |
Notes: HCBS is home-and community-based services. LTSS is long-term services and supports. MLTSS is managed long-term services and supports. Dash (–) indicates state does not have MLTSS or uses other rate-setting method. N/A is not applicable, as the state does not provide Medicaid coverage for services delivered in residential care settings.
1 Data on states that use MLTSS are current as of April 2016. Count includes states with Financial Alignment Initiative (FAI) demonstration managed care plans.
2 Medicaid rate-setting methodology definitions:
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Flat rates: The facility receives the same payment regardless of its individual facility costs and regardless of the type and amount of services actually provided. These rates may vary by factors such as urban/rural location or single/multiple occupancy unit.
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Tiered: Reimbursement system is based on state-defined levels of care for the facility level or at the individual level. At the individual level, individuals are slotted into tiers based on their assessment or needs and there is a payment level associated with each category. At the facility level, the entire facility is slotted into a tier, which could be by licensure category that varies by the level of service they provide or the disability level of the residents that they serve.
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Case mix: Reimbursement rates vary by the case mix of the facilities or individuals. Case mix only applies when there are no tiers or categories and the payment rate is determined along a continuum based on the individual’s assessment. Providers are paid based on the number of hours and level of assistance needed by the resident. The case-mix adjusted rate for a facility is calculated by averaging the assessment levels for all residents and multiplying that index by the standard rate set by the state.
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Cost based: The reimbursement rate of each facility varies with the costs of each facility.
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Fee for service: Payment is made for each separate service provided. Payment amounts are determined by the number of units of specific types of services used by a Medicaid beneficiary, which are identified from the resident’s service plan.
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Negotiated: Reimbursement rates are not fixed, but are the result of deliberations between stakeholders (e.g., individual residents, providers, the state, or a managed care organization).