In The News

Lack of Retroactive Coverage for HCBS Pushes Seniors into Institutional Care: MACPAC

McKnight’s Home Care / By Adam Healy
Determining a beneficiary’s eligibility for Medicaid home- and community-based services can be a lengthy ordeal. And while states have options to streamline the process, most lack options for retroactive coverage, which can allow for the quickest access to HCBS, experts at the Medicaid and CHIP Payment and Access Commission discussed during a meeting Thursday.
“Timely access to HCBS is essential to ensure individuals receive care in the setting of their choice,” Asmaa Albaroudi, a senior analyst at MACPAC, said during the meeting. “States have several options to streamline Medicaid enrollment for people who need HCBS.”
Eligibility offerings
The most common way states streamline Medicaid eligibility processes is through presumptive eligibility. This system allows beneficiaries to begin receiving HCBS immediately as their eligibility is determined over a two-month period. Nine states use presumptive eligibility. 
Four states use expedited eligibility when making Medicaid HCBS determinations. While there is no uniform definition for expedited eligibility, it typically involves fast-tracking beneficiaries’ applications for HCBS so that they may begin receiving services sooner.
Only one state, Connecticut, offers retroactive coverage for Medicaid HCBS. This method allows people who are eligible for services, but not yet enrolled, to get coverage for care received up to three months prior to the start of their enrollment. This type of coverage is commonplace for nursing home care, but not for Medicaid HCBS, in other states, according to Patti Killingsworth, senior vice president of long term services and supports strategy at CareBridge and MACPAC commissioner.
Institutional bias 
As a result, nursing home care is often more financially viable for older adults as they can be reimbursed for care received before they enrolled in Medicaid. On the other hand, if one chose to receive Medicaid home care, they are fully responsible for the bill until they become enrolled.
“That is the reason why so many people end up in nursing homes that don’t need to,” Killingsworth said. “And I think it is a fundamental institutional bias — one of many in the federal regulations — that results in people being institutionalized when they don’t want to be and need to be.”
And while other tools including presumptive eligibility can still help beneficiaries receive HCBS, without retroactive coverage, many are still forced to rely on institutional care.
“I appreciate the fact that presumptive eligibility is available to states,” Killingsworth said. “I do not appreciate the fact that retroactive coverage of nursing facility benefits is available to people, while home- and community-based services are not.”


Adjusting After Our Person Has Died

By Barbara Karnes

We think of grief as mourning, of our emotional reaction to a loss. The tears, the “I miss her so much,” the sadness she is no longer with you. Grief is sadness. For some, it may be a relief that someone or something is no longer a part of our life.  We don’t just grieve for those we care about. We grieve for people we are challenged by also.

Another component when experiencing the death of someone close to us is learning how to live without that person. The component that extends beyond the emotional and into the physical, day to day life experiences. The adjusting to a new way of living, of figuring out how to be productive with this person no longer in our life.

For husband and wife, partners, or any other people living together like a parents and child or friends, our entire daily routine changes. Adjustments have to be made. Habits changed. How do I cook for just one? What do I do with all this time that I used to fill with caregiving? The "you mean I really get to watch the show I want?"

If the person we lost lived somewhere other than with us, the forced change is still there, it's just not as intense. There will still be the “we always phoned each other on Wednesday,” and the “He didn’t get to know about ______.” Thoughts and habits are displaced. We react to those changes, those habits that are missing. Our person is gone.

It is a challenging part of life, both emotionally and physically, to figure out how to live productively when this person is no longer with us.

How do we learn to adjust to living without our special person? Grief is so individualized that there really aren’t specific outlines, no step one, step two, step three, to adjust to a new way of living. We will each find our own way, or not. Our personality and how we have dealt with other life challenges will determine how we adjust to the new path life has put us on.


Long-Term Services & Supports Provider Webinar Announcement

Join HCPF on April 25, 2024 from 10 to 11 a.m. for a presentation to providers on the work being done to stabilize the LTSS system amidst several concurrent changes - PHE Unwind, the new Care and Case Management IT system, and Case Management Redesign - and the impacts on provider payments. 

To ensure that the most relevant topics are being covered, please use this form to submit your questions or topic suggestions. We will collect submissions until Thursday, April 18, 2024. 

Please note: Questions about specific member issues will not be addressed at this webinar. If you are experiencing an issue specific to a member, please use the escalation form and it will be addressed as quickly as possible. 

Please register in advance for this webinar.


President Biden Appears to Tout Looming ‘80-20’ Home Care Rule in Campaign Speech

Home Health Care News | By Andrew Donlan
President Joe Biden made remarks on the care economy – including home care – in a speech Tuesday at Union Station in Washington, D.C.
“You know, take home care,” he said. “The cost of long-term care for aging loved ones and people with disabilities rose 40% in the last decade. Medicaid offers help, but it can’t meet the demand. You know, there are 700,000 seniors waiting in line — 700,000 waiting in line, and people with disabilities are stuck on Medicaid home care waiting lists for as long as 10 years if they survive to be qualified. It’s amazing. Think about it.”
Biden at first honed in on family caregivers, saying that “no one should choose between caring for a parent who’s raised them, a child who depends on them, or a paycheck that they need.”
Then, he pivoted to home- and community-based services (HCBS) workers, evoking the looming “80-20 rule,” which would force HCBS providers to direct 80% of reimbursement to care workers. 
That rule, which was proposed last year, has drawn heavy criticism from home care providers, who believe that the rule will hurt smaller providers and disproportionately affect providers based on which states they’re operating in. 
A final rule is expected some time this month, and it appears Biden’s administration will be moving forward with some version of the proposed rule. 
“In the coming weeks, we plan to release new rules to strengthen staffing standards in nursing homes, to get home care workers a bigger share of Medicaid payments,” Biden said.
The president also said that his administration would work to reduce waitlists for Medicaid HCBS. 
“Seniors and people with disabilities, we’re going to expand Medicaid home care services and reduce that 700,000-person backlog,” he continued. “That’ll mean more folks can live and work in their own communities with dignity and independence. More home care workers will start getting a better pay and benefits and dignity they deserve.”
Katie Smith Sloan, the president and CEO of the advocacy organization LeadingAge, highlighted some of the home care industry’s gripes with the Biden administration’s approach after Tuesday’s speech.
“For the first time in decades, our federal government is committed to meaningful action to ensure America’s older adults and families can receive quality care in nursing homes, and in their homes and communities,” Sloan said in a statement. “LeadingAge and our nonprofit, mission-driven aging services providers share the Biden Administration’s goal. Caregivers, as the president noted, are critical; without staff, as our nonprofit mission-driven members know, there is no care. Yet, unfortunately, the administration’s approach misses the mark.”
While the Biden administration may believe that better pay will lead to more workers, and thus more home access, advocates and providers disagree. 
“First, on the goal of ensuring more Medicaid dollars go to the home care workforce, via the proposed Medicaid Access Rule,” Sloan continued. “While well-intentioned, the ‘80-20’ provision … will likely reduce, rather than increase, older adults’ access to care and services.”
LeadingAge estimates that state rates for HCBS would need to increase by 45% – on average – for the 80-20 provision to be sustainable. Providers would need to cut their non-caregiver expenses by two-thirds otherwise. 
“We expect that the rule, if implemented as proposed, will lead to provider closures and exits from the sector,” Sloan said. 
LeadingAge urged the president and his administration to take a more “broad” and wide-ranging approach to senior care needs. 
“Imagine what we can do — imagine what we can do for America,” Biden said. “Look, folks, imagine a future with affordable childcare, home care, eldercare, paid leave.”


New Study Calls Home Health Star Ratings into Question

McKnight’s Home Care | By Adam Healy
A comparison of agency-reported functional measures and claims-based hospitalization measures raises doubts about the value of star ratings as a means of evaluating home health agency (HHA) quality.
The study, published Wednesday in JAMA Network Open, analyzed differences between claims-based and agency-reported outcomes for nearly 23 million patient episodes before and after the introduction of the star ratings system to compare changes over time. The researchers found that observed improvement in agency-reported functional measures had corresponding increases in hospitalization rates and less timely initiation of care. The data included claims-based hospitalization measures (both during the patient spell and 30 days after HHA discharge). Agency-reported functional measures included improvement in ambulation, bathing and bed transferring.
“The observed functional improvement was dampened by corresponding increases in more objective measures, such as hospitalizations and declines in timely initiation of care,” study authors Amanda C. Chen, Christina Xiang Fu, PhD, and David C. Grabowski, PhD, wrote. “This raises concern about how HHA-reported outcomes should be interpreted and used to assess quality.”
These discrepancies are not a surprise to home care providers. The Centers for Medicare & Medicaid Services uses Outcome and Assessment Information Set (OASIS) survey responses, an agency-reported measure, and medical claims data, to determine agencies’ star ratings. The OASIS portion is not objective, affirmed Mary Carr, vice president for home health regulatory policy at the National Association for Home Care & Hospice.
“The disparity in OASIS-based measures [versus] claims-based measures is not surprising,” she said in a statement to McKnight’s Home Care Daily Pulse. “Responses to the OASIS items for the functional measures can be very subjective and influenced by the accuracy of the assessor when completing the item.”
“And, as the author(s) noted, data does not capture more recent changes for HHAs, such as the Patient-Driven Groupings Model or nationwide expansion of the Home Health Value-Based Purchasing Model, which might contribute to changes in HHA behavior and performance,” she added. 
The study also found that the introduction of the star ratings was associated with sustained increases in the hospitalization rate and functional improvement measures for patients with Alzheimer’s disease, those who are dual-eligible, and those who are Black and Hispanic. 
A widening gap between self-reported and objective measures
CMS launched the 5-star rating system on Care Compare to provide summary information using the number of stars to denote quality. The system began with a quality of patient care star rating in July 2015 and added a patient satisfaction star rating in January 2016.
Since the introduction of quality of patient care star ratings, the differences between agencies’ self-reported measures of patient improvement and more objective measures has only widened, study co-author Amanda Chen told McKnight’s Home Care Daily Pulse.
“In the pre-period before the star ratings were introduced, we kind of see some of these trends,” she said. “But it’s really magnified after the star ratings were introduced.”
Agencies might be incentivized to inflate functional improvement scores on OASIS surveys to achieve higher scores, according to the researchers. 
“Once these star ratings were introduced, I think there was an incentive for home health agencies to prioritize perhaps, achieving high performance on some measures that allow them to have a higher star rating,” Chen said. “Particularly, we see these in terms of self-reported measures by the agencies. So again, it’s these OASIS-based measures. And so I think it’s a little bit easier to move the needle on measures that you’re reporting yourself as a home health agency versus something that is collected — what we’re calling a little bit more of these objective measures — like hospitalization rates.”
She added that these issues are not unique to home care. Other healthcare sectors that use self-reporting to inform quality measures, such as nursing homes, have also seen subjectivity influence results…
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