Tag: Providers

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: More NY nursing homes are closing beds unless they get their 20% bump this year.

 
 

Clipped from: https://www.mcknights.com/news/without-20-percent-medicaid-boost-states-providers-say-bed-reductions-will-continue/

 
 

 
 

New York state nursing home advocates want a 20% Medicaid boost to pay rates, a demand struggling for traction while the governor’s budget framework puts money into home-based care instead. 

The demand was delivered officially to Gov. Kathy Hochul (D) Friday in a letter signed by the heads of five organizations representing nursing home providers and healthcare workers. Her budget proposal is scheduled to be released Wednesday. Without changes, more beds will be taken out of service and some facilities could close, providers warned.

“New York has underfunded nursing home care for the last 15 years,” said Stephen B. Hanse, president and CEO of New York State Health Facilities Association/New York State Center for Assisted Living, adding that New York was the only state to cut Medicaid to nursing homes during the pandemic.

Hanse’s organization represents 400 skilled nursing providers whose more than 60,000 employees care for more than 65,000 nursing home residents and assisted living clients. 

The statewide average Medicaid reimbursement is $211 per resident per day, Hanse said. Divide that by the 24-hour care that is required and it equates to the state paying providers $8.79 per hour to care for each resident, he noted in an email to McKnights Long-Term Care News.

“This is unacceptable … and is a driving factor why New York has a long-term care staffing crisis as nursing homes cannot compete in the labor market for desperately needed workers,” he explained. 

In addition to Hanse’s group, the letter was signed by: LeadingAge New York; Greater New York Health Care Facilities Association; 1199 SEIU, United Healthcare Workers East; and Southern New York Association Inc., which represents more than 60 nursing homes encompassing 16,000 beds in southern New York, Westchester, and Long Island.

New York requires nursing homes to provide a minimum of 3.5 hours of care per resident per day. Facilities are also required to spend at least 70% of revenue on resident care with 40% of that amount patient facing. 

In 2021, New York gave a Medicaid boost of 1%, but operating costs have surged 42%, according to the Alliance for Senior Care. A letter to the editor in the Rochester Beacon from the seven members of that group said that more than 6,700 beds in the state are “off-line” and coalition members in western New York are limiting admissions due to staffing challenges. The head of Gurwin Healthcare System told Spectrum News that its two nursing homes, which operate a total of 580 beds on Long Island, are similarly limiting admissions and “temporarily closing beds.”

Hochul’s budget priorities released earlier this month did not include any mention of a Medicaid increase for long-term care, instead making investments into teams that would care for low-income adults in their homes, reported WSHU. A Hochul spokesman said the governor is “committed to ensuring that all New Yorkers can age with dignity and independence in the community of their choosing.” 

Hanse and other nursing home advocates will be ready to scour the budget to see what kind of legislative fight they will have on their hands.

“Home-based care is not an alternative to skilled nursing care, given the fact that residents of nursing homes are unable to be cared for in the community given their acuity levels and co-morbidities,” Hanse said.

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: NY NH providers say they have a 42% inflation factor that they are stuck dealing with, and if the state doesn’t give them a 20% raise like right now several of them will shut down.

 
 

Clipped from: https://www.northcountrypublicradio.org/news/story/47197/20230118/a-ticking-time-bomb-ny-nursing-homes-push-for-medicaid-rate-increase

Jan 18, 2023 —

A coalition of nursing homes says, if the state doesn’t increase its Medicaid reimbursement rates, the eldercare facilities may have to reduce the number of beds — or even shut down all together.

 
 

 
 

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Cara Chapman’A ticking time bomb’: NY nursing homes push for Medicaid rate increase

 
 

United Helpers Rehabilitation and Senior Care in Canton is one of a couple dozen skilled nursing facilities formally advocating for Gov. Kathy Hochul to increase the Medicaid reimbursement rates for long-term care by 20% in this year’s budget. Photo provided

According to the state’s health insurance assistance program, most nursing home residents use Medicaid to pay for their care. New York State sets the reimbursement rates the facilities get paid for those residents.

United Helpers COO Stacey Cannizzo said the state hasn’t adjusted those rates for inflation since 2007. 

“There is approximately a 42% inflationary factor that we have not been able to manage because our rates have been stagnant for so long,” she said.

United Helpers — which operates the United Helpers Rehabilitation and Senior Care facility in Canton — and a couple dozen other skilled nursing facilities say they collectively lost more than $81 million last year. Cannizzo said the Medicaid rates led to those losses; United Helpers actually closed its Ogdensburg facility in 2021 due to financial difficulties. 

The nursing homes, all of whom are nonprofits located throughout Upstate, formed a coalition in November. They want the governor to include a 20% increase to the Medicaid rates in this year’s budget, as well as a process put in place to ensure the state routinely looks at and adjusts reimbursement levels. 

Republican Assemblyman Matt Simpson — whose district covers all of Warren County and parts of Essex, Washington, Saratoga and Fulton counties — said raising the Medicaid rates for long-term care is one of his top priorities this session. He said both the rates and nursing home staffing have been at crisis levels for several years.

“It’s a ticking time bomb right now,” Simpson said, “and if we lose these facilities because we’re not correctly supporting them, it’s going to be devastating for those that need those services.”

Cannizzo said the stagnant Medicaid rates hinder efforts to attract and keep staff. Since nursing homes have to meet minimum staffing levels, lack of staff means facilities across the state are leaving beds empty. She said that can mean individuals are unable to access the care they need and hospitals don’t have a place to send patients who need post-acute care. 

Republican Assemblyman Scott Gray represents the St. Lawrence “River District” that comprises parts of St. Lawrence and Jefferson County. He said there’s “no question” the rates are overdue for an adjustment, but that the biggest objective is to keep people in their homes and make sure they can afford to age in place. Gray said that’ll help reduce the cost of Medicaid for long-term care.

“Essentially, if we can address and help and assist with aging in place and keep the Medicaid costs down, then we can pay for these adjustments that are necessary — providing we don’t wait 15 years to do it again.”

 
 

Stacey Cannizzo is the COO of United Helpers, which operates United Helpers Rehabilitation and Senior Care in Canton. Photo provided

Cannizzo said she thinks raising the Medicaid rates is an issue that affects every New Yorker. She said it could be the individual themselves, or a family member, friend or someone in their community who needs long-term care.

“These are people that have worked and paid taxes their entire lives, and we are committed to making sure that their needs are met — but we need the help and we need the support of the governor to make sure that we can afford to provide that care.”

Cannizzo said she’s “cautiously optimistic” that the rates will go up with this budget. Regardless, the coalition plans to take a long-game approach to keep the issue on people’s minds.

Gov. Kathy Hochul’s State of the State book, which outlines her priorities for the year, does not specifically mention Medicaid reimbursement rates for long-term care. But, similar to what Assemblyman Gray said, the plan proposes investing in teams to provide care for low-income adults in their homes and allow them to age in place. 

Hochul spokesperson Justin Mason said in a statement that the governor is “committed to ensuring that all New Yorkers can age with dignity and independence in the community of their choosing.” On whether she’s considering an increase to the Medicaid rates for long-term care, he said more information would be shared when she releases her executive budget later this month.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: TX dentists look upon the current state budget surplus with optimism for raising their own rates.

 
 

Clipped from: https://www.tdmr.org/72-percent-of-private-practice-dentists-plan-to-raise-fees-this-year/

The American Dental Association’s Health Policy Institute last month published the results of an ongoing survey it has been conducting since January 2022, quizzing some 3,000 participating private practice dentists each month to measure the impact of COVID-19 and other issues affecting the profession.

The report includes breakdowns by “ownership status, DSO affiliation, practice size, geographic location, sex, age group, and race/ethnicity.”  A PDF of the report is below.

Raising fees

The one remarkable statistic is that 72% of 1041 dentists across the country, representing a cross-section of private practice dentistry,  responded that they are planning to raise their patient fees in 2023.

Unfortunately, there are no survey results on why these dentists are raising their fees. But one can only conclude that the recent inflationary spiral which has hit dentistry hard plus the difficulties in staff recruitment are the reasons.

Bounty in the state budget

A few months ago, the Texas Comptroller of Public Accounts Glenn Hager estimated there would be a budget windfall for Texas of some $27 billion, thanks to high oil prices.  It was announced this week that the budget surplus is actually $32.7 billion.

Adverse effect on providers

As we have repeated in several stories, the situation is desperate for Medicaid dentists who have to cope with the same costs as private practice dentists but get fees substantially less.  The Medicaid dental fee schedule has only gone down since 2007.

The situation is becoming untenable for many who also have to put up with the erroneous behavior of DMOs, scrutiny of the OIG and the potential pitfalls and penalties of the Texas Medicaid Fraud Prevention Act and whistleblowers such as Joshua Lafountain.

We hope the legislature will look at raising Medicaid dental fees before the situation worsens.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A an OB that decided to pivot and focus on primary care (when ACA incentivized it) to meet the needs in their area can keep the payments for delivering said care.

 
 

Clipped from: https://www.ama-assn.org/practice-management/medicare-medicaid/ob-gyn-can-keep-205000-medicaid-pay-state-tried-recoup

A Hawaii ob-gyn who also provided primary care services to patients in an underserved area is entitled to retain the $205,000 in enhanced Medicaid payments the government was trying to recoup from him, the state supreme court has ruled.

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Hilo physician Frederick Nitta, MD, spent more than 60% of his time providing primary care to patients in the medically underserved area in which he practices medicine. But state officials claimed that he couldn’t collect higher Medicaid payments created under a 2010 law designed to encourage physicians to provide this care.

The Hawaii Department of Human Services (DHS) also had demanded that he pay back the $205,000 he had already been paid for the care he provided Medicaid patents and billed for at the higher rate.

After years of litigation, Hawaii’s highest court ruled in the physician’s favor.

“Congress clearly intended the enhanced payments as incentives for the provision of primary care services, regardless of a physician’s other practice areas,” the Hawaii Supreme Court said in its  November ruling (PDF).

The court quoted extensively from the amicus brief (PDF) that the Litigation Center of the American Medical Association and State Medical Societies and the Hawaii Medical Association (HMA) filed when Nitta v. Department of Human Services, State of Hawaii was at the appellate court level.

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“Amici highlighted the critical and worsening physician shortage in Hawai’i, noting that primary care has the greatest shortage, especially for Medicaid patients in East Hawai’i,” the Hawaii Supreme Court said, noting that DHS’ “continued recoupment efforts against physicians providing primary care services to Medicaid beneficiaries only worsens the shortage.”

The court referenced the AMA Litigation Center and HMA brief (PDF) cited articles and other reports that showed “‘on neighbor islands, in particular, patients often wait four to five months for a doctor’s appointment. On Hawai’i Island, it is sometimes two to three times more difficult to find a PCP [primary care physician]. Consequently, many residents seek care at the nearest hospital emergency room, costing them ‘upward of $600–$800 for an emergency room visit, as opposed to the average co-ay of $15–$50 for a visit to a primary care physician.'”

Who qualifies as “primary care?”

The Hawaii DHS had argued to the state supreme court that medical directory listings were the deciding factor of a physician’s practice characteristics. In refuting that argument, justices again referred to the AMA Litigation Center and HMA brief, noting that it “urged that the payments to Dr. Nitta were consistent with the ACA’s purpose to ‘benefit physicians that provide primary care services to the Medicaid population.'”

The AMA-HMA brief also pointed to Centers for Medicare & Medicaid Services (CMS) published questions and answers regarding how states can review a physician’s eligibility for the enhanced payment program.

“There, the CMS provided a nonexhaustive list of ways a state could verify a physician’s practice characteristics (i.e., how the physician represented himself in the community, medical directory listings, billings to other insurers, advertisements, etc.),” the court’s opinion said.

The AMA-HMA brief also “contended other evidence demonstrated Dr. Nitta’s PCP status,” the court noted. That includes “recognition by other doctors and medical providers in the East Hawaii community as a PCP,” and “acceptance and payment by medical insurers and a PCP” and “hundreds of written and oral testimony by people in support of a finding that he is a PCP.”

Related Coverage

“Arbitrary” action has doctor on hook for $205,000 in bonus pay

And finally, the court cited the amicus brief’s argument that the DHS ” ‘formula to determine the sixty-percent-threshold requirement [was] in complete disregard for actual medical practice'” because paid billing codes don’t take into account the “‘percentage of total services provided in a managed care environment by that physician.’ “

Dr. Nitta reflected on the case in an interview with the Hawaii Tribune-Herald.

“I could have just paid them back. Instead, it’s probably costing me more to fight them in court over and over and over. But that doesn’t matter, because it’s not right what they’re doing.”

Find out more about the cases in which the AMA Litigation Center is providing assistance and learn about the Litigation Center’s case-selection criteria.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Home health workers say they are not seeing the money appropriated to up their wages; MCOs say not everybody was supposed to get a raise per the legislation; the legislator who sponsored the bill that funded the increase said it was written poorly; home health agencies cry Big Bad MCOs; and Big Union blames everybody.

 
 

Clipped from: https://www.newsday.com/business/home-health-aide-medicaid-minimum-wage-mkef5db1

Home care worker Mildred Garcia-Gallery, right, assists Christine Cipriani at Cipriani’s home in Garden City South. Credit: Newsday/J. Conrad Williams Jr.

An hourly wage increase of $2 designed to help ease the shortage of home care aides is finally in place, but industry players disagree about whether the raise can accomplish its goal without collateral damage. 

At stake is home care for Long Island’s growing older population. The region has around 40,140 home care and personal care aides, and is projected to see openings increase by over 64% by 2028,  according to the state Department of Labor. Agencies that employ home health aides have said they had trouble attracting workers for the demanding jobs at the previous $15 an hour minimum wage in a market where workers can often make more at Target or Walmart.

In the years prior to the state’s multi-year push to a $15 overall minimum, agency advocates said aides were regularly offered starting pay above minimum wage. But as the minimum wage increased,  state-assigned Medicaid reimbursements for many home care agencies did not keep pace,  leaving them  struggling to keep up.

 Home care agencies hailed the move to $17 an hour as a victory when lawmakers included it in the state budget this spring, allocating $7.7 billion to fund it over the next four years. 

But now, with the increase in effect since Oct. 1, some agencies say they’re not being reimbursed enough to cover the higher pay. They blame the insurance companies that administer the state Medicaid funds. And they say the raise could end up having the opposite effect, forcing them to reduce workers’ hours and cut staff, or even putting their businesses at risk.  

On the other side, the insurance companies charge that some agency owners, already receiving adequate reimbursements, are asking for more just to pad their profits.

A workers’ union says both things are happening. And a legislator who pushed for the higher wage blames poorly crafted language in the state budget for the mess that has threatened the goal — to address the labor shortage and make more caregivers available. 

“It is critical that the funds that legislators intended to go to worker pay do exactly that,” said Kathy Febraio, president and chief executive of the New York State Association of Health Care Providers, a trade group representing around 125 home care agencies. 

According to an Oct. 5 survey of Febraio’s membership, 75% said they were not getting reimbursement rates high enough to cover increased payroll costs. If the rates they’ve been offered weren’t raised, 29% of respondents said they would reduce staffing levels, with 72% saying they would reduce service hours.

Twelve percent of respondents said they would go out of business.

Representatives for insurance plans, though, reject the assertion that they are withholding reimbursement dollars or providing inadequate reimbursement to agencies.

 Insurance plans “have been working diligently to allocate the wage funding provided to them to home care providers which in turn should be spent on workers,” said Eric Linzer, president and chief executive of the New York Health Plan Association, a trade group representing the managed long-term care insurance plans that administer the funds.

“No health plan is paying any provider less than what they need to meet wage, benefit and administrative requirements,” Linzer said. “What’s happening here is you have some providers that already have received enough funding. It kind of begs the question of why do some of them need more, other than to pad profits.” 

“I’m very happy that [workers are] getting the increase,” said Nicole Laborde, who owns Ideal Home Care Services in Hauppauge, a provider of home health aides. “However, it’s going to affect a lot of home health care agencies, especially smaller ones.”

Laborde said the insurance providers aren’t providing high enough reimbursement rates to agencies.

“Nobody really looked at how the home care agencies are going to be compensated to be able to afford this increase,” said Laborde, who is also founder and chief executive of Ideal School of Allied Health Care in Hauppauge, which trains health care workers including home aides.

The wage increase is meant to help address a critical labor shortage that’s only expected to worsen as the need for home care aides grows in the coming years.

Aging Baby Boomers have increased the demand for home health services on Long Island as the preference for “aging in place” has grown, said economist Shital Patel with the Labor Department’s Hicksville office. Health care reform has also encouraged the use of home care as an alternative to expensive nursing homes and hospital stays, she said.

There are more than 1,300 licensed or certified home care agencies statewide, according to the New York State Association of Health Care Providers. 

Competition for entry level workers from employers like Amazon and Target offering higher hourly wages in the wake of the pandemic has only exacerbated the difficulty in recruiting aides,  who provide critical services to seniors and others living at home. Aides not only provide care, but can often become a vital source of companionship,  developing close relationships with patients and their families, said aides and care recipients. 

Because most patients use Medicaid to cover home care, wages for workers largely rely on reimbursement rates set by managed long-term care plans. While Medicaid is traditionally government health insurance for the most impoverished Americans, it is one of the few ways patients can cover the high cost of home care.

“There are only a few ways to pay for home care,” said Nicole Christensen, patient advocate and president of Care Answered, a Freeport business that helps families navigate the complex world of health care for seniors. Because private health insurance seldom covers home care, she said patients have three options when paying for those services: Paying out of pocket “which becomes very expensive very quickly;” long term care insurance, “which not many people have,” and community-based Medicaid, a form of Medicaid that specifically covers nursing home-level care in the home.

 Agencies said they would like to see the state Health Department step in and set a standard reimbursement rate  for agencies, which currently negotiate  individually with insurance firms.

On average, Febraio said members of her trade organization have been receiving $1.33 per hour in extra reimbursement, half of the $2.66 the group estimated members would need to cover wage increases plus higher payroll taxes and other related costs. 

“I believe the Department of Health thought the money would flow through the plans to providers and ultimately to the workers,” Febraio said. “The information that we’re giving to them is making it clear that that’s not happening.”

Linzer, representing the insurance firms, said that when the state set aside funding for reimbursement , they did not intend for every agency to receive a bump of $2 if their existing contracts had higher rates to begin with.

“The state has been very clear that this is not supposed to be a directed payment where everyone gets a $2 increase,” he said. “In instances where you have contracts that exceed the new wage requirements, there will be less of an increase.” 

The median annual wage for home health and personal care aides is $31,893 on Long Island, according to state labor data, with experienced aides earning an average of $18.46 an hour.

Sen. Rachel May (D-Syracuse), sponsor of the original fair pay for home care workers legislation that failed to pass but instead was adopted in part in the governor’s budget, said the intent of increasing home care workers’ wages was to retain workers and grow the industry. Now, she said she’s concerned that if agencies aren’t given high enough rates, the wage increases run the risk of making a bad situation worse.

“The fact that the bill didn’t pass and got folded into the budget means a bunch of language we put in the bill to avoid this exact situation didn’t end up in law,” May said. “It’s the opposite of what we’re trying to accomplish here.”

The governor’s office said that due to financial measurements introduced through the Affordable Care Act, insurers handling Medicaid reimbursement cannot keep the money  passed through them.  Additionally, the state is encouraging home health agencies to report insufficient payments for wage increases to the Health Department.

The department will also “keep reiterating” its guidance on the matter with insurers to ensure compliance, the governor’s office said. 

May said she is now working to ensure that taxpayer dollars go to adequately funding agencies so they can pay their employees more. A major structural hurdle is that the reimbursement rates negotiated between insurance companies and agencies are not disclosed to the state, making it more difficult to determine whether insurance plans are paying high enough rates, she said.

“The biggest struggle we have is transparency,” May said. “We don’t know what the terms are of a lot of the contracts.”

Mildred Garcia-Gallery, 53, a consultant, home health aide and activist, said she worked with the New York Caring Majority — a coalition of aides, agencies and elected officials —aides to campaign for higher wages in the industry and reimbursement rates to support them.

After hearing about the state’s plans to adopt a higher wage early this year, she was ecstatic. Now, she said she worries whether higher costs for agencies will mean fewer hours for workers.

“It felt like a slap in the face,” said Garcia-Gallery, who’s worked in home care for 30 years and consults with agencies through her firm Ageless Companions LLC.

She said if agencies are forced to cut hours for workers, then aides won’t be able to earn the overtime pay they need to make ends meet, resulting in picking up work with additional agencies to get by. 

“I could find another job but what about these patients? If we exit, what happens?” she said. “It’s a job that I love. But loving it and surviving off of it are two separate things.”

Officials representing unionized aides said they have heard of plans paying rates too low to cover the increased costs, but also said some agencies are more concerned about profit than the wages of their workforce.

“We don’t always agree with the employers and we sometimes think they keep too much of the funding themselves,” said Helen Schaub, political director for 1199SEIU, the union representing 53,000 home care workers in the state, including 5,000 on Long Island. “You have to look agency by agency.”

Schaub said while the wage increase is good for workers, the ultimate problem is that for-profit insurance firms are involved in the Medicaid reimbursement process at all, instead of rates being negotiated directly with the state.

“What has been happening is that the state puts in money at the top and there’s this finger pointing between the employer and plans about who is keeping the money,” she said. 

 The $17 minimum applies to   home health workers on Long Island, in Westchester and in New York City. In other parts of the state, where the minimum for most workers is $13.20, the minimum for aides has gone up to $15.20. Home care workers across the state are scheduled to receive another $1 increase next October.

Winsome Gayle Allen, 58, said the sometimes-challenging work of caring for patients at home has been a personal calling for 40 years.

“The type of work where I feel comfortable is giving my time to elderly people,” said Gayle Allen, of Hollis, Queens, an aide with Fresh Meadows-based Reliance Senior Living Services.

Gayle Allen, who’s been serving patients in New York since moving to the states from Jamaica with her parents at 19, said she’s developed long-lasting relationships with patients and their families.

While she loves what she does, she admits the work can be difficult at times and requires a lot of empathy and patience. Given the demanding hours and low wages, she said workers are in dire need of pay increases above what’s currently being offered.  

“I’m not going to beat around the bush…I think we should get a starting pay of $20 an hour,” she said.

Christine Cipriani, 91, of South Garden City said she doesn’t know what she’d do if she didn’t have the support of her regular home care aide Mildred Garcia-Gallery.

“It’s vital for me,” Cipriani said. “My kids are very nice kids, but they have their own stuff to worry about.”

Cipriani said Garcia-Gallery first came into her life three years ago when the aide was looking after her husband until he died a year ago. “She’s like part of my family,” she said.

For Garcia-Gallery, helping Cipriani and other patients fills her with a sense of purpose and comes with emotional rewards.

“I like being needed and having that responsibility,” she said. “We like to do this job because we like to care for people, we love people and we love making people’s lives better or at least trying to.”

Still, she said, while the work “makes me feel important, it doesn’t mean my pay reflects that.”

For Thomas McCarthy, 24, a wheelchair user living in Farmingdale, having access to reliable home care gives him the opportunity to be more independent, he said.

“With just me and my aide helping me out, I’m not so dependent,” said McCarthy, who has Duchenne muscular dystrophy, a condition that progressively weakens muscles over time.

His aide, Marc Bazile, 52 — who lives in McCarthy’s family home every other week to provide round-the-clock care — said the work he does helping others makes him feel good and helps him appreciate the independence he has in his own life.

“I love family. I love to help people,” said Bazile, an aide with Ideal Home Care Services, who commutes from Lancaster, Pennsylvania every other week to assist McCarthy.

Still, Bazile said, pay remains an issue. As an experienced aide already making more than minimum wage, he said he hasn’t seen any impact from the recent $2-an-hour pay increase. 

— with Coralie Saint-Louis

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]:

The Medicaid agency is appealing a court ruling that would stop admissions to facilities for I/DD members in 2028, but has also offered a counter-proposal.

 
 

Clipped from: https://www.stltoday.com/lifestyles/health-med-fit/nc-health-agency-appealing-ruling-on-services-for-disabled/article_429ab8ee-ca1c-56cb-a53b-6013d1ecb0d3.html

 
 

FILE – North Carolina Health and Human Services Secretary Kody Kinsley speaks during a news conference, Jan. 4, 2022, in Raleigh, N.C. North Carolina government is appealing a trial judge’s order that demands many more community services by certain dates for people with intellectual and development disabilities who live at institutions, Kinsley said Wednesday, Nov. 30, 2022.

Julia Wall – member image share, The News & Observer

By GARY D. ROBERTSON – Associated Press

RALEIGH, N.C. (AP) — North Carolina’s government is appealing a trial judge’s order that demands many more community services by certain dates for people with intellectual and development disabilities who otherwise live at institutions, the top state health official said Wednesday.

Department of Health and Human Services Secretary Kody Kinsley said the formal challenge is needed because he has “grave concerns” about some of the directives issued Nov. 2 by Superior Court Judge Allen Baddour. The group that was the driving force behind a 2017 lawsuit that led to his order said it was discouraged by Kinsley’s challenge.

Kinsley pointed in particular to Baddour’s directive that new admissions at state-run development centers, privately intermediate care facilities and certain adult care homes must stop as of January 2028 for people with intellectual and developmental disabilities.

The secretary said that could ultimately lead to closures of small group homes, leaving potentially 1,000 or more clients seeking new accommodations while creating instability for people who are happy in their current situations.

“We cannot have a ruling go into place that’s going to bind our hands, that’s going to push people into homelessness, essentially,” Kinsley told reporters. “We’ve got to find a different path.”

Kinsley also on Wednesday unveiled a policy and funding counterproposal of sorts that he said would promote independence for people with such disabilities and choices for services in a deliberate fashion.

Some formal General Assembly legislation would be needed to ultimately reach the $150 million in annual federal and state spending starting next July that the proposal envisions. These requests and others should be in Democratic Gov. Roy Cooper’s upcoming budget proposal, the secretary said.

Kinsley said the GOP-controlled legislature appears willing to help improve community services and called 2022 a “year of considerable advancement.”

“This plan recognizes the real, sizable investments and I believe puts us on a path for a vision of a very different North Carolina, that instead of pushing people out of safety, gives people choice,” Kinsley told reporters.

Baddour already had ruled in 2020 that too many people with such disabilities were forced to live away from home in violation of state law. In ordering remedies four weeks ago to address that ruling, Baddour told DHHS that at least 3,000 people must be diverted or shifted to community-based programs by early 2031. No one would be forced to move.

He also told DHHS to eliminate by mid-2032 a waiting list of roughly 16,000 people who are qualified to participate in a Medicaid-funded program that helps them live at home or outside of an institution. Baddour’s order also directs DHHS to a shortage of well-paid direct-care workers. Kinsley’s summary released Wednesday doesn’t identify specific long-term dates to complete initiatives.

The head of the nonprofit Disability Rights North Carolina — a plaintiff in the lawsuit — said the appeal likely will fail and delay “justice for North Carolinians with I/DD (intellectual and developmental disabilities) even longer.”

“It is so deeply disappointing to hear over and over that I/DD services are a priority, but then have progress undermined in this way,” Disability Rights CEO Virginia Knowlton Marcus said in a news release.

The price tag to carry out the judge’s directives isn’t clear, although Disability Rights has suggested it could take hundreds of millions of dollars annually. Federal dollars would cover much of the Medicaid-related services, however.

Disability Rights has said the order would lead private facilities to transition to more community-based services instead, and that the injection of federal funds would generate more jobs and services.

The DHHS proposal in part would spend $36 million next year to help raise wages for direct-support professionals and $24 million to reduce the waiting list for the Medicaid-funded Innovations Waiver option by another 1,000 people.

Kinsley mentioned Keith McDonald, whose 18-year-old daughter lives at TLC, an intermediate care facility in Raleigh for young people with disabilities. McDonald said later Wednesday that he’s worried that denying new admissions even years from now will discourage investments at private facilities and harm their current clients.

“It’ll have a disastrous impact,” McDonald said.

The lawsuit’s lead plaintiff is a western North Carolina woman who had been forced to move into a state-run development center in Morganton when community-based services dried up. She is no longer living at the center.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: KFF reports out how states are responding to the ongoing crisis that is the home and community based services workforce.

Clipped from: https://www.kff.org/medicaid/issue-brief/ongoing-impacts-of-the-pandemic-on-medicaid-home-community-based-services-hcbs-programs-findings-from-a-50-state-survey/

Executive Summary

Widespread workforce shortages are the biggest challenges facing state Medicaid home and community-based (HCBS) programs and those shortages were greatly amplified by the COVID-19 pandemic, which reduced the number of potential workers and increased the demand for services. The American Rescue Plan Act (ARPA) and COVID-19 public health emergency (PHE) authorities gave states new—but temporary—flexibility and funding to address pandemic-related challenges, which all states used. Those initiatives enabled states to respond to the pandemic and invest in HCBS programs, helping millions of seniors and people with disabilities who rely on Medicaid HCBS to meet daily self-care and independent living needs in community-based settings.

This issue brief presents the latest findings on key state policy choices about Medicaid HCBS in 2022 based on the 20^th KFF survey of state officials administering Medicaid HCBS programs in all 50 states and DC. The data were collected from April through September 2022. The survey was sent to each state official responsible for overseeing the administration of HCBS benefits (e.g., home health, personal care, and services for specific populations such as people with physical disabilities), but some states submitted responses for the state overall. All states responded to the 2022 survey, but response rates for certain questions varied. Key findings include:

All responding states indicated they were experiencing shortages of direct care workers in 2022 (see Figure). States most frequently cited workforce shortages as the pandemic’s primary impact across all HCBS settings. As the pandemic persisted, HCBS workforce shortages contributed to provider closures. Most states (44) reported a permanent closure of at least one Medicaid HCBS provider during the pandemic, up from 30 states in 2021. This trend suggests that even as the broader economy returns to normal, HCBS providers continue to struggle.

Almost all states (48) responded to the workforce crisis by increasing HCBS provider payment rates. While some of these increases may have been supported through temporary ARPA funding or emergency PHE authorities, more than half of states plan to continue rate increases even after temporary funding and authorities expire. States also increased self-directed and family caregiving opportunities for HCBS beneficiaries throughout the pandemic. All states offer at least one HCBS program with the option for enrollees to self-direct their services. Forty-eight states allow legally responsible relatives (LRRs) to be paid caregivers, up from 36 states in 2020.

When asked about how they used the ARPA funding, over two-thirds of states (35) reported initiatives with high start-up costs that were generally time-limited to avoid higher ongoing costs after enhanced federal funding ended. Ten (of those 35) states reported pursuing both time-limited and ongoing HCBS initiatives using ARPA funds. Some of the most common initiatives included offering providers bonuses or incentive payments to stay on, developing or expanding worker training or certification programs, funding studies to assess provider rates or workforce development, expanding workforce registries, and upgrading IT systems.

States adopted policies to streamline enrollment processes and expand access to Medicaid HCBS during the PHE, and states reported that some policies (e.g. telehealth) will continue after the PHE ends. All states (49 of 49 reporting) allowed virtual evaluations for eligibility determinations and almost all (47 of 49 reporting) provided telehealth service delivery. Many states also provided more services to HCBS users by increasing utilization limits or offering new waiver services. Telehealth service delivery will continue in most states but increases in utilization limits are more likely to expire at the end of the PHE. Fewer states opted to use the PHE authorities to expand waiver slots or eligibility.

The COVID-19 pandemic illuminated fundamental, long-term challenges for states in providing Medicaid HCBS, but also provided opportunities for change, particularly with new authorities and funding.  While states have adopted a number of policies to bolster the HCBS workforce, it remains to be seen whether initiatives undertaken during the pandemic will yield more systemic changes longer-term. Policymakers of both parties have called for additional changes to HCBS including eliminating waiting lists for services (nearly 656,000 people were on a waiting list in 2021), increasing opportunities for family members to be paid caregivers, increasing wages for all HCBS providers, and enabling more people to live in their homes as they age. Although there is consensus on those broad policy goals, there is little consensus on how to pay for significant federal investments needed to achieve these goals, suggesting it may be some time before major reforms are enacted.

Introduction

The COVID-19 pandemic exacerbated existing challenges for state Medicaid home and community-based (HCBS) programs and the people they serve, most notably a heightened shortage of direct care workers coupled with increased demand for services. Together, the American Rescue Plan Act (ARPA) and the COVID-19 public health emergency (PHE) authorities gave states new but temporary federal funding and policy flexibility to address pandemic-related challenges. All states used these initiatives to make investments in their HCBS programs, helping millions of seniors and people with disabilities who rely on Medicaid HCBS to meet daily self-care and independent living needs in community-based settings. As states continue pandemic recovery efforts, consumer demand for HCBS remains high and longstanding challenges facing Medicaid HCBS including the aging population and provider workforce shortages will likely continue for the foreseeable future.

Medicaid paid for about two-thirds of all HCBS in 2020, and waivers are the primary authority that states use to offer HCBS benefit packages with all of the 50 states and D.C. providing at least some HCBS through either a 1915(c) or an 1115 waiver. Medicaid HCBS encompass a wide range of medical and nonmedical services that assist Medicaid beneficiaries with physical, mental, and other chronic conditions or disabilities. States are required to cover Medicaid long-term services and supports (LTSS) provided in nursing homes, while all HCBS other than home health care services are optional. HCBS may be provided through state plans but are more commonly provided through waivers. Unlike Medicaid state plan authorities, which require states to cover everyone who meets certain eligibility criteria, waivers allow states to provide services to specific populations, limit the number of people served, and expand financial eligibility. The Centers for Medicare & Medicaid Services (CMS) estimates that nearly 8 million Medicaid enrollees had at least one claim for a service that could potentially be HCBS during 2019.

This issue brief presents the latest findings from a survey of states on key state policy choices about Medicaid HCBS in 2022 and the HCBS waiver landscape as of 2021. We also asked states about policies they adopted in response to the COVID-19 pandemic through the ARPA and PHE authorities, and whether they planned to continue policies adopted through PHE authorities. The Appendix Tables contain detailed state-level data.

What is the Current Landscape of Medicaid HCBS?

When asked about the waivers they had in 2021, states reported offering 255 waivers under 1915(c) authority, which is the largest source of HCBS spending. (The four states that do not provide HCBS through 1915(c) authority all offer HCBS services through an 1115 waiver.) Section 1915(c) waivers are generally targeted to a single population, such as people with physical disabilities or people with intellectual and development disabilities (I/DD). The number of Section 1915(c) waivers averages five per state. Almost all states serve people with I/DD, seniors, and nonelderly adults with physical disabilities through 1915(c) waivers (Figure 2, Appendix Table 1). Fewer states use HCBS waivers to serve people with traumatic brain and/or spinal cord injuries (TBI/SCI), children who are medically fragile or technology dependent, people with mental health disparities, and people with HIV/AIDS. States may use other authorities such as 1115 waivers to provide HCBS, but when HCBS are provided through 1115 waivers, they may be provided to multiple—or broader—target populations and may be part of larger Medicaid reforms. Thirteen states reported offering HCBS waivers authorized under Section 1115 in 2021.

Four states reported offering new waivers in 2021, the most recent year in which states were asked to report all of their HCBS waivers. Alabama and the District of Columbia reported new 1915(c) waivers serving populations with I/DD, while Missouri had a new 1915(c) waiver serving seniors and adults with physical disabilities. Idaho reported offering a new Section 1115 waiver serving individuals with mental illness. Additionally, Oregon submitted a new 1115 waiver request to provide in-home supports to individuals with higher income and assets and for those who do not meet nursing facility level of care criteria. Tennessee has pending waiver amendments to integrate the 1915 (c) waivers into its 1115 waiver.

New funding from the ARPA and authorities granted to states under the PHE helped states respond to the challenges posed by the pandemic. Under the PHE authority, the federal government granted states temporary authorities that were intended to maintain enrollment and service levels during extraordinary times. The current PHE is currently in effect until January 11, 2023, and the Biden administration has said it will give states a 60-day notice before ending the PHE. Since that notice was not issued in November 2022, it is expected the PHE will be extended again. At the end of the PHE, most waivers and broad flexibilities will expire, requiring states to either end the temporary practices or transition the practices to a permanent authority with CMS approval.

Enacted in March 2021, the ARPA increased the federal medical assistance percentage (FMAP) by 10 percentage points for states’ HCBS expenditures that were paid between April 1, 2021, and March 31, 2022. Receipt of the funds required states to demonstrate that the additional federal funding would not supplant any state funds for HCBS. To implement that requirement, participating states are required to submit spending plans that describe the amount of funds they received from the higher FMAP and on how they are spending those funds on HCBS. Activities funded with the additional ARPA money must be intended to enhance, expand, or strengthen HCBS such as providing retention bonuses or student loan forgiveness for HCBS workers, expanding coverage of HCBS, or funding infrastructure investments related to the delivery of HCBS. States have until March 31, 2025 to spend the extra federal funds that were provided for HCBS expenditures that were paid between April 1, 2021 and March 31, 2022. Funds spent after March 31, 2022, are reimbursed at the states’ normal FMAPs instead of at the higher FMAP.

How is the Pandemic Affecting the Workforce?

Workforce shortages have been exacerbated by the pandemic: All states that responded to this question indicated they were experiencing shortages of direct care workers in 2022.  When asked about shortages for specific types of workers, states reported shortages of all types of HCBS providers including home health aides, personal care attendants, direct support professionals, and community-based mental health providers. States most frequently cited workforce shortages as the pandemic’s primary impact across all HCBS settings including in-home services, group homes, adult day health programs, and supported employment programs (Figure 3).

As the pandemic persisted, HCBS workforce shortages contributed to provider closures: 44 states reported a permanent closure of at least one Medicaid HCBS provider during the pandemic (Figure 4). States reported more closures in 2022 than the year prior (30), suggesting that even as the broader economy returns to normal, HCBS providers continue to struggle. Although states did not provide explanations for why so many HCBS providers closed in 2022, it could be attributed to ongoing workforce shortages potentially coupled with provider financial difficulties stemming from pandemic-related service disruptions. Other research shows that the pandemic’s effect on employment was particularly profound for LTSS workers. Recent analysis on the Peterson-KFF Health System Tracker shows that the number of workers dropped by 14% in nursing care facilities and by 9% in community elder care facilities between February 2020 and June 2022. Many states (31) reported permanent closures affecting services provided in enrollees’ homes, adult day programs (32), and group homes (25). Fewer states reported permanent closures of other types of HBCS providers such as community mental health providers and supported employment providers, who provide job search, placement, and coaching support.

“As the pandemic has persisted, staffing shortages have extended closures of adult day programs; some providers have closed and consolidated group homes to adjust to staffing shortages.” – State official

How did States Respond to the Workforce Crisis?

When asked about their overall responses to workforce shortages, most states reported that they increased HCBS provider payment rates and most plan to continue those rate increases even after pandemic authorities and funding end (Figure 5). Among the 48 states that increased rates, over half (28) plan ongoing increases to provider payment rates. For the remaining states,14 implemented time-limited increases, 5 implemented a combination of both time-limited and ongoing increases, and 1 state reported that they didn’t know whether the rate increases would be permanent.

“There are currently not enough licensed nurses to meet the demand for nursing jobs, including nursing HCBS jobs. The decreased workforce is coupled with an increased demand for HCBS services, particularly as people are increasingly seeking medical care in a homecare setting.” – State official

Half (24) of the states that increased provider payment rates required the rate increase to be passed through to worker wages. These requirements typically are being implemented through provider attestation (18 states) or another method such as a statutorily specified split between the workers and the agency or through post-payment audits and cost reporting (10 states). Few states added such a requirement to Medicaid provider agreements (4) or health plan contracts (2). The other strategies states reported using to address the workforce shortage included offering incentive payments to recruit workers (36), developing or expanding worker education programs (34 states), and establishing or raising a minimum wage requirement for workers (20 states) (Appendix Table 2).

All states participated in the ARPA HCBS program and when asked how they used the funding, most states reported making upfront investments and confronting immediate recruitment and retention challenges in the workforce (Appendix Table 3). Most states (35) chose initiatives with high start-up costs that were generally time limited so that they would not face higher ongoing costs in the future after the period of enhanced federal funding ended. For example, states used ARPA funding to provide bonuses or incentive payments (36), develop or expand worker training or certification programs (33), expand family caregiver supports (23), fund studies to assess provider rates or workforce development (21), and develop or expand workforce registries (15). It is unknown to what extent those initiatives will continue after states have exhausted the additional federal funding they received from the ARPA.

“Self-direction has increased in all programs in which it is offered.  When traditional site-based programs were closed/short-staffed due to the pandemic, this provided additional opportunities to learn about self-direction, and individuals and families were able to hire staff to continue to receive support.” – State official

States increased self-directed and family caregiving opportunities for HCBS beneficiaries throughout the pandemic as one way of addressing workforce challenges (Figure 6, Appendix Table 4). All states offer self-directed opportunities for Medicaid HCBS beneficiaries. Self-direction typically allows individuals to select and dismiss their direct care workers, determine worker schedules, set worker payments rates, and/or allocate their services budgets. Over half of states (30) reported an increase in the number of enrollees self-directing Medicaid HCBS since the onset of the pandemic, while just two states (OR, TX) reported a decline.

One of the biggest changes during the pandemic is that 48 states now allow legally responsible relatives (LRRs) to be paid caregivers (up from 36 in 2020). Legally responsible relatives may include a spouse, parent, or adult child. Covering more provider types, including LRRs, can help to increase access to services that meet daily need such as personal care and habilitation, especially when other providers are not available. About half of states (27 of 45 reporting) report an increase in the number of paid LRRs since the onset of the COVID-19 pandemic, while the remaining states saw no change (6) or reported unknown (12). Over three-quarters of states (39) reported that payment to LLRs was granted through the PHE/Medicaid emergency authority and half of those states (20) plan to make this flexibility permanent for at least one HCBS program/waiver.

A second major change is that all states now offer some types of supports for family caregivers, who may be either paid or unpaid. Most states (36) offer more than one type of support for family caregivers. Frequently reported family supports include respite care (48), caregiver training (29), and caregiver counseling/support groups (18). There were 14 states that reported other types of supports such as peer support services, family caregiver stipends, child day support, and supported family living.

Most (37) states report using HCBS provider sufficiency standards to help measure the extent to which there are sufficient providers to meet enrollee needs (Figure 7). For services that the states pay for directly, there are no consequences for failing to meet the standards, but they provide a useful tool for assessing provider availability and the sufficiency of the provider network. Alternatively, states are required to use provider sufficiency standards in their contracts with private care plans when HCBS are delivered by those plans. CMS finalized changes to those managed care regulations in 2020. The 2020 rule removes the requirement that states use time and distance standards to ensure health plans’ provider network adequacy and instead allows states to choose any quantitative standard. Alternate standards could include minimum provider to enrollee ratios, maximum travel time or distance to providers, minimum percentage of contracting providers accepting new patients, maximum wait times for an appointment, or hours of operation requirements.

About half of states (27) required at least one network adequacy standard for HCBS providers in a fee-for-service (FFS) model, while 23 states required at least one standard in a capitated (risk-based) model. The most common standards include time and distance when an enrollee must travel to a provider (22 states), maximum travel time or distance to a provider (22 states), and minimum provider to enrollee ratio (20 states). Fewer states reported hours of operation requirements, minimum percentage of providers accepting new patients and maximum wait time for an appointment.

What Other HCBS Strategies Did States Use to Respond to the Pandemic?

States have adopted numerous policies to streamline and expand access to Medicaid HCBS during the PHE, and some policies are expected to continue after the PHE ends (Figure 8, Appendix Table 5). One of the biggest changes to Medicaid HCBS policy during the pandemic was the use of virtual evaluations for determining enrollees’ eligibility for HCBS and their appropriate level of care. All states (49 of 49 reporting) adopted virtual evaluations. Of those, 10 states plan to continue this policy once the PHE ends and 9 noted the policy would only continue under certain circumstances or as needed. The remaining states were either uncertain about future plans (16) or plan to discontinue the policy (14) once the PHE ends.

Fewer states opted to use the PHE authorities to expand waiver slots or eligibility. Ten states reported increasing the number of waiver slots during the PHE, and eight states will continue after the PHE ends. Five states expanded eligibility either by expanding waiver financial eligibility limits (IL, NC, NV, OR) or functional eligibility criteria (MD).

“Limits for some HCBS were extended to better support individuals through the pandemic. Pre-pandemic limitations will be in place 6 months after the PHE ends.”
– State official

Twenty-five states added new services to at least one HCBS waiver during the PHE, with home delivered meals the most frequently reported new service (9 states). Sixteen states will continue to offer these new waiver services after the PHE ends, five states were planning to end the services when the PHE ends, and the final four states were still undecided at the time of the survey. Most states provided more services to HCBS users by increasing utilization limits, but many of those changes will end when the PHE does. Thirty-seven states increased utilization limits on existing HCBS services, with less than one third (eleven) of states opting to continue the policy after the PHE ends. States reported increasing limits for home delivered meals, respite, day supports, personal care services, dental, and home modifications.

Almost all states provided telehealth services to address challenges in delivering in-person HCBS during the pandemic. All but two (47 of 49 responding) states reported providing HCBS via telehealth in at least one waiver, and almost two-thirds (29) of states plan to allow at least some telehealth service delivery moving forward. States reported relying on telehealth for services such as: wellness checks, case management, supported employment, life skills training, behavioral and mental health counseling, companion, and adult day and habilitation services.

Some states used ARPA funds to make changes to their HCBS programs beyond confronting workforce challenges. Although most states reported workforce-related uses of the ARPA funding, over half of states reported offering new HCBS services and adopting or upgrading information technology systems (e.g., incident reporting, case management, and electronic visit verification) with the ARPA money (30 states each). Twelve states reported adopting or expanding HCBS quality measures (Appendix Table 3).

Looking Ahead

The COVID-19 pandemic illuminated fundamental, long-term challenges for states in providing Medicaid HCBS, but also provided opportunities for change, particularly with new authorities and funding. While states have adopted many new policies to bolster the HCBS workforce, it remains to be seen whether initiatives undertaken during the pandemic will yield more systemic changes longer-term.

In the recent months, CMS has also taken steps to improve the accessibility and quality of Medicaid HCBS. In July, the agency released the first-ever set of HCBS quality measures to promote consistent evaluation of quality across state HCBS programs and over time. The list of measures is extensive and encompasses a number of difference outcomes, but reporting is currently voluntary and it’s uncertain how widely the measures will be used. In August, CMS awarded planning grants to three states and two territories, joining the 36 states that participate in the Money Follows the Person program, which is a demonstration that allows states to receive additional federal funding for HCBS delivered to people who transition from institutional to community-based settings. That month, the agency also issued a proposed rule aimed at easing the application and enrollment process for Medicaid, which included several changes intended to increase Medicaid enrollment among seniors and individuals with disabilities.

States reported that a permanent FMAP increase for HCBS would enable them to prioritize more systemic improvements over the longer-term, such as increasing the number of waiver slots or adding permanent wage increases instead of temporary increases in the form of bonuses or incentive payments. Although it’s unlikely that the ARPA FMAP increase – which would require increased federal funding – will be made permanent in the near term, policymakers of both parties have called for systemic changes to HCBS including eliminating waiting lists, increasing opportunities for family members to be paid caregivers, increasing wages for all HCBS providers, and enabling more people to live in their homes as they age. It is unclear whether the consensus on those broad policy goals will translate into new federal laws or funding.