The Balancing Incentive Program: What is it and what can it do for you?

Balancing Incentive Program

Our nation is getting older as a population. State Medicaid programs are feeling the squeeze to maintain the financial viability of their long-term care systems. A method to reduce long-term service and support (LTSS) costs is to transition from primarily an institution-based model to more home and community-based settings to provide individualized care. The challenge is that due to reimbursement incentives and difficulty in navigating community LTSS eligibility and enrollment, the Medicaid population has been motivated historically to rely on institutional care. CMS has recently responded with a program that seeks to shift this paradigm.

The Balancing Incentive Program provides grants to state agencies to help increase access to non-institutional LTSS[1]. Created by the Affordable Care Act (ACA), the program increases the Federal Matching Assistance Percentage (FMAP) to States that make structural reforms to increase residential and nursing home diversions and access to non-institutional LTSS. Matching payments are tied to the percentage of a state’s LTSS spending, with higher FMAP increases going to states that need to make more reforms.

The goal of the Balancing Incentive Program is to lower costs while improving outcomes through the following: improved systems performance and efficiency, the creation of tools to help consumers with care planning and assessment, and improvements in quality measurement and oversight. It will also provide new opportunities to serve more people in home and community-based settings, complying with the Olmstead decision and the integration mandate of the Americans with Disabilities Act (ADA).

How to participate

Qualifying states must have previous expenditures of less than 50% of their total Medicaid medical assistance on non-institutionally based LTSS. The amount of federal assistance is based upon a state’s current spending levels. States must also submit an application that meets specific requirements for programmatic and structural reforms. A work plan should be included with the application that provides a detailed plan for achieving the objectives outlined by the Balancing Incentive program. These include a no wrong door/single entry point system (NWD/SEP), conflict-free case management services, and core standardized assessment instruments. CMS is offering the use of consultants to help states develop their own work plan, and the plan must be finalized within 6 months of the application.

A participating state must agree to use the enhanced FMAP proceeds only to provide new or expanded home and community-based LTSS. The state also must not restrict LTSS eligibility more than the standards already in place as of December 31, 2010, even if they are increasing access for other segments of the population.

How this program can benefit patients

The no wrong door/single entry point system is designed to create a statewide system that enables consumers to access all long-term services and supports through a standardized process. An individual should be able to access information they need including availability of services, how to apply, referrals, support available in the community, and financial information. There should also be assistance to help the individual walk through the eligibility process.

The goal of conflict-free case management services is to direct the services and supports for the consumer and conduct ongoing monitoring to assure that services and supports are delivered to meet their needs and achieve intended outcomes. When developing a service plan, the needs of caregivers must also be considered.

The purpose of the development of core standardized assessment instruments for determining eligibility for non-institutionally based LTSS is to unify the determination of a beneficiary’s needs for training, support services, medical care, transportation, and other services. It will also strengthen the development of an individual’s service plan to address these needs.

With 20 states having their applications approved by CMS, and a total of 17 states having a structural change work plan in place, we’re still in the relatively early stages of this program. Time will tell if it can succeed in truly creating a nationwide shift to community- and home-based care.


[1] The following overview was prepared from a review of Medicaid information available on the Balancing Incentive program: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Balancing/Balancing-Incentive-Program.html

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