In The News

ACL Releases 2023 Profile of Older Americans

The Profile of Older Americans is a summary of the available statistics related to the older population in the United States. Principal sources of data are the U.S. Census Bureau, the National Center for Health Statistics, and the Bureau of Labor Statistics.

The Profile illustrates the shifting demographics of Americans 65 and older. It includes key topic areas such as future population growth, marital status, living arrangements, income, employment, and health.

Highlights from the Profile

  • In 2022, 31.9 million women and 25.9 million men were 65 or older.
  • People 65 and older represented 17.3% of the population in the year 2022. That percentage is expected to grow to 22% by 2040.
  • Of older adults 65 and older living in the community, 59% lived with their spouse/partner in 2023. About 28% lived alone.
  • States with the highest percentage of populations 65 and older in 2022 were Maine, Florida, Vermont, and West Virginia.
  • The 2022 median income of older people was $29,740 ($37,430 for men and $24,630 for women).
  • In 2023, 11.2 million Americans age 65 and older were in the labor force (working or actively seeking work).

The Profile incorporates the latest data available. Not all data are updated annually.

Access the Full Profile

 

CMS to Extend Review Choice Demonstration by Five Years, to Remove One of Three Choices

McKnight’s Home Care | By Liza Berger

The Centers for Medicare & Medicaid Services will be extending the Review Choice Demonstration (RCD) for Home Health Services for an additional five years, effective June 1, CMS said on the Home Health, Hospice & DME Open Door Forum call on Wednesday. The demonstration will continue in the states of Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma, an official said.

“This demonstration establishes the review choice process for home health services to assist in developing improved procedures to identify and prevent fraud, protect beneficiaries from harm, and safeguard taxpayer dollars to empower patients while minimizing unnecessary provider burden,” CMS said in a FAQ sheet about the model, which began on June 1, 2019. “The demonstration helps ensure that the right payments are made at the right time for home health service through either pre-claim or post-payment review, protects Medicare funding from improper payments, reduces the number of Medicare appeals, and improves provider compliance with Medicare program requirements.”

There have been three initial choices for agencies under the demonstration, which was slated to end on May 31. As part of the extension, CMS is removing Choice 3: Minimal Review with 25% Payment Reduction from the selections. Two remain: pre-claim review and post-payment review. Palmetto GBA, which administers Part A and Part B Medicare fee-for-service claims, will be reaching out to small numbers of affected providers to select from the two remaining choices, the CMS official said on the call. Selection will start on June 17 and remain open until July 1.

“Providers who do not make an initial review choice selection will default to participate in Choice 2: Postpayment Review,” CMS said on its website about the demonstration’s extension. “Providers with less than 10 reviews at the conclusion of the current cycle, will have their results included in the next cycle’s results.”

All other home health providers in the demonstration will continue in their current review cycles and follow their regular cycle timelines. Providers who believe their current review choice presents a “hardship” and would like to change their choice should notify Palmetto by June 14, CMS stated on the website.

 

Denver Rate Billing Issue

Department of Health Care Policy & Financing

Dear Home and Community-Based Services Provider,

Modifier HX is required on some Home and Community-Based Services (HCBS) claims for services provided within the City and County of Denver, effective May 1, 2024. The HX modifier allows providers to bill for prior-authorized HCBS services with Denver County rates without needing to add the HX modifier to the HCBS Prior Authorization Request (PAR). The HX modifier is being added for HCBS services with Denver County rates in a phased approach.

The Adult Day Program Transportation codes for Mileage Bands 2 and 3 on the Complementary and Integrative Health (CIH) waiver changed on May 1, 2024, for services provided outside the City and County of Denver. These changes allowed for the addition of the HX modifier for services provided in Denver without needing to add the HX modifier to HCBS PARs.

Claims billed without the required HX modifier will need to be adjusted.

Refer to the HCBS Billing Manuals on the Billing Manuals web page for information on the updated HCBS codes.

Thank you,

Department of Health Care Policy & Financing

 

Use of Preferred Provider Agreements

By Elizabeth E. Hogue, Esq.

a highly competitive marketplace, home care providers of all types, including home health agencies, hospices, private duty/home care companies and home medical equipment (HME) suppliers are looking for a “leg up,” especially for patients with certain types of payors. Providers may be able to cement important referral sources using Preferred Provider Agreements. For example, a provider may wish to approach an assisted living facility (ALF) to see if it is interested in a preferred provider relationship. If so, then management of the ALF may want to sign a Preferred Provider Agreement in order to further a relationship with this provider.

The anti-kickback statute may apply if providers involved in referral arrangements receive any type of federal or state funds, including, but not limited to, payments for services provided from Medicaid waiver programs, managed Medicaid programs, the Tri-Care Program, the VA, or any other state or federal programs. The anti-kickback statute generally says that anyone who either offers to give or actually gives anyone anything in order to induce referrals has engaged in criminal conduct. There are, however, several exceptions to this statute that may be applicable. 

Providers should ask two crucial questions about the application of the anti-kickback statute to referral arrangements:

  1. Is there a kickback or rebate?
  2. If so, is there an exception or "safe harbor" that permits the arrangement even though it would otherwise violate the statute?

A kickback or rebate occurs when a provider receives referrals from another provider and something flows back to the referral source from the provider who received referrals. If there is a kickback or rebate, providers must automatically ask the second question listed above. If they fail to utilize applicable exceptions, they may miss out on useful marketing strategies that are likely to result in numerous referrals.

With regard to Preferred Provider Agreements, however, it is important to note that they can be structured so that no money or anything of value changes hands between providers and the other party involved. If so, there is no kickback or rebate.  

The parties to Preferred Provider Agreements must also make certain that they honor patients’ choices of providers. There are a number of sources of patients’ right to freedom of choice of providers applicable to preferred provider arrangements, including:

  • Court decisions or the common law says that all patients – regardless of payor source, type of care rendered, or types of providers involved – have the right to control the care they receive and who provides it.
  • A federal statute that guarantees all Medicare and Medicaid patients the right to freedom of choice of providers. This statute may be applicable if either party receives reimbursement from the Medicare or Medicaid Programs. 

When patients express preferences for certain providers, however, their choices must be honored despite the existence of Preferred Provider Agreements. The agreement of the parties to honor patients’ choices should be included in Preferred Provider Agreements.

The market to provide services to patients in their homes is expanding, but the competition for referrals among providers seems to be extremely fierce. Providers are well advised to utilize Preferred Provider Agreements to help them to increase and/or maintain referrals in order to help ensure profitability.

©2024 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.

 

In-Home Care Support Helps MA Plans Significantly Lower Costs, Study Suggests

Home Health Care News | By Andrew Donlan
 
A new study of Medicare Advantage (MA) beneficiaries found that in-home companion care reduced care costs by close to 10%. 
 
The study – conducted by a national actuarial firm and commissioned by the companion care company Papa – also found that in-home companion care boosted home health utilization among MA members, while reducing more costly care. 
 
Specifically, Papa was able to reduce health care costs by 9% among MA beneficiaries on behalf of health plans. 
 
“As Medicare Advantage organizations face rising health care costs, slimmer margins and mounting regulatory pressures, they need to to show value for every dollar spent,” Kelsey McNamara, head of research and impact at Papa, told Home Health Care News in an email. “And with CMS’ ramp up of supplemental benefit scrutiny and data collection, there’s heightened interest in solutions that reduce costs, improve utilization and help members seek and remain in lower-acuity care settings for longer. Today’s results affirm Papa’s ability to do just this.”
 
Founded in 2017 and backed by a slew of investors, Papa is a social support and companion care company. It sends Papa Pals into seniors’ homes to mitigate loneliness and help with activities of daily living. It has contracts with a wide variety of MA plans across the country. 
 
The study was based on 2,386 MA members from a regional health plan that were enrolled in Papa between Jan. 2021 and Aug. 2023. The members used Papa for at least one visit. 
Members also experienced a 18% reduction in inpatient hospital admissions and a 22% reduction in skilled nursing facility usage. 
 
Furthermore, for members that used Papa’s services more than two times per month, there was a 19% reduction in medical costs. For those that had three or more visits per month, there was a 30% reduction in medical costs. 
 
“These reductions are in addition to revenue plans experience from improved member experience and reduced member churn,” McNamara said. “One study of a Florida-based health plan, conducted by health economics research firm DataMed Solutions, found Papa participants had a churn rate that was 15.8% lower than members who did not participate in Papa.”
 
The results suggest that, even while health plans are cutting benefits, they should pause before cutting home-based care supports that help keep members healthy…

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