Less than a month before election day, the Democratic and Republican candidates for president are dueling over home-based care plans.

Vice President Kamala Harris announced on “The View” this week a proposal that would allow home care to be administered through traditional Medicare.

On the same day, former President Donald Trump and his campaign released a rebuttal, pointing toward home care-related policy implemented from 2017-2020, plus additional plans for a potential second term.

Harris’ proposal is a more lofty one. It would also – if implemented – create a massive tailwind for home care providers across the country. But, as LeadingAge President and CEO Katie Smith Sloan pointed out after the proposal, “we cannot overstate that without staff, there is no care.”

Trump, meanwhile, pointed to expanded supplemental benefits in Medicare Advantage (MA) as a way for seniors to access more home care-related services. His campaign team also focused on economic points that it believes will make aging in place easier for Americans under his leadership.

In this exclusive, members-only HHCN+ Update, I make the mistake of venturing into the presidential candidates’ plans for home-based care. Specifically, I examine how viable the plans are, and what they could mean for providers, if implemented.

Home-based care takes center stage

Home-based care providers were likely pulling their hair out over the predictable confusion that arose from Harris’ proposal Tuesday.

Home health care is already a robust benefit provided under the Medicare program, and generally includes services delivered to seniors after an acute health event.

Home care is not currently available under traditional Medicare, however, and generally includes non-medical services to help with activities of daily living.

The only place where home care is paid for under Medicare is through MA supplemental benefits, and MA pays for just a sliver of all home care provided currently.

So, yes, Harris’ proposal would be groundbreaking, if implemented. It would completely change the scope of the Medicare program.

As for the companies it would directly impact, pick a notable name in home care.

Currently, home care providers have a large addressable market: seniors with the ability to pay out of pocket for home care services; Medicaid beneficiaries in need of home- and community-based services (HCBS); veterans in need of home care, paid for through Veterans Affairs (VA); and a small portion of MA beneficiaries and long-term care insurance clients.

If home care were paid for by Medicare in the future, that would take the concept of “unlimited demand” to a new level. There are over 30,000 home care agencies in the country, almost all of which would have a new market opportunity if Medicare became another means to pay for home care.

The one potential downfall for providers would be former private-pay home care clients being able to use Medicare to pay for services. Private-pay home care doesn’t come without challenges, but it remains one of the most profitable forms of home-based care business.

Home health providers – which already provide care to Medicare beneficiaries, almost exclusively – would also see a business boon. Many of them already provide home care, and the ability to care for clients through one revenue source in both service lines would be massively beneficial.

After all, home-based care is responsible for one of the only successful Center for Medicare and Medicaid Innovation (CMMI) demonstrations of late. The Home Health Value-Based Purchasing (HHVBP) Model – now implemented nationwide – has already saved Medicare billions, and is likely to save many more billions moving forward.

“We think access to personal care services could at least double from six million customers today. By our estimate, the extra spending would expand the [total addressable market] by ~30% to $110 billion per year,” Macquarie Capital wrote in an analyst note this week. “Since Medicare covers home-based medical services, we expect a wider adoption of the integrated care model following added personal care services coverage. This could also expedite the transition to value-based care. Providers could benefit from aligned incentives, streamlined operations and cost synergies.”

Then comes the question of viability, however.

Harris is not the first person to propose such an idea. Home care stakeholders have suggested it for years, but so have other policymakers.

“When the Affordable Care Act was passed, a component similar to this was included and that ultimately was stripped out,” Tyler Giesting, a director of health care and life sciences at West Monroe, told me this week. “I think we’ve seen it fail in the past for reasons that come down to: can it be economically viable? The challenge would be getting something like this passed, in the way that it has been described so far.”

The Harris campaign has suggested that it would pay for the proposal, in part, by cutting Medicare payments for drugs. It estimated that the proposal would cost around $40 billion per year.

But other estimates suggest that it would cost closer to $400 billion.

Harris sees the proposal as a way to aid the “sandwich generation” – adults that have aging parents to take care of, as well as children. Those responsibilities make it tough to maintain employment.

For Harris, the key would be to convince the right stakeholders of the overall value of home care. It wouldn’t be enough to just prove that more Americans could continue contributing to the economy if they had additional help at home for their older relatives.

Harris’ team would need to instead pitch this as a long-term cost savings project. If more seniors had access to home care, less seniors would be driving up U.S. health care costs in hospitals, emergency rooms and more costly brick-and-mortar facilities.

That is already a battle home care providers face. They are regularly trying to convince payers that more home care equals less overall cost. But a concrete plan, and concrete evidence of those potential savings, would have to be laid out.

“It’s one thing to have this idealistic proposal perspective, and it’s another to actually put it into action with a detailed plan,” Giesting said. “Then, there’s also getting it passed and put into law.”

A detailed plan is key. Even if we accept the idea that more access to home care could ease burden on Americans, while also keeping overall health care costs down, the implementation of the proposal through Medicare would need to be tirelessly thought out.

For instance, New York’s Consumer Directed Personal Assistance Program (CDPAP) – which allows family members to be paid to care for loved ones in need of home care – has been a fiscal disaster for the state.

Self-directed care has potential. It allows unpaid caregivers to be compensated, and for home care recipients to direct their own care. But it’s also hard to oversee.

For what it’s worth, if the proposal did move forward, I think the best way to go about it would be to prioritize care from existing, quality home care agencies. Agencies that train and vet their caregivers, ones that have been providing care professionally for a long time.

Trump proposals

The Trump campaign’s home care proposals are more understated. And, like Harris’ plans, more details would be needed to project true impact – for potential home care beneficiaries and providers.

“President Trump will prioritize home care benefits by shifting resources back to at-home senior care, overturning disincentives that lead to care worker shortages and supporting unpaid family caregivers through tax credits and reduced red tape,” the Trump campaign wrote in a release, in preparation for Harris’ announcement this week.

The campaign also evoked MA supplemental benefits. MA supplemental benefits – through the primarily health related pathway and the Special Supplemental Benefits for the Chronically Ill (SSBCI) pathway – were created during Trump’s presidential term.

The benefit that allows for home care services is dubbed In-Home Support Services (IHSS). MA plans have pulled back on offering IHSS in 2024, however.

“The Trump administration provided new Medicare Advantage supplemental benefits that included modifications to help keep seniors safe in their homes, respite care for caregivers, transportation coverage, additional in-home support services and assistance and non-opioid pain management alternatives,” the release continued.

The campaign also pointed out other indirect factors that have led to home care inaccessibility of late, such as inflation, which it believes it can continue to bring down.

Spotlight and policy

Home-based care being in the nationwide spotlight is a good thing for providers and older Americans.

But it’s also worth taking stock of where that spotlight has gotten us before. The Biden-Administration has been laser-focused on home care, but mostly HCBS through Medicaid.

Meanwhile, home health providers have been left behind. Advocates are in the throes of a three-year long fight against continued rate cuts from the Centers for Medicare & Medicaid Services (CMS), as other home-based care proposals are taking shape from both campaigns.

Home health providers are seeing their traditional Medicare payments cut, while also receiving payments from MA plans that often don’t cover the cost of care. All the while, MA penetration continues.

In April of 2023, I wrote about why federal support for home-based care is missing the mark.

While proposals from both campaigns this week contain some good elements, that fact remains true.

As home-based care takes center stage once again, Medicare-certified home health providers are forced to stand behind the curtains, at a time when their margins are evaporating.

“I would also want to remind the Biden, Harris administration that the existing Medicare home health program is under assault currently, and has been since 2020, with billions of dollars in cuts that have diminished access to care, so I think that investment and a stabilization of the existing Medicare home health benefit is something that is also needed,” Partnership for Quality Home Healthcare CEO Joanne Cunningham told HHCN this week. “With this news, I would just offer that recommendation and reminder.”

The post With The Election Nearing, Candidates Battle Over Home-Based Care appeared first on Home Health Care News.

Electronic Visit Verification (EVV) was established as law in 2016 under the 21st Century Cures Act to address fraud and abuse in home-based care delivery. The law provides federal guidelines, but individual states can determine which service codes are included. However, years after nationwide implementation, EVV still remains a burden for home care providers.

Simply put, EVV confirms the details of in-home visits. It holds caregivers accountable for their schedules, ensuring that their work is completed on time and in its entirety. Typically, caregivers work within a mobile app to conduct the EVV process. The app sends the necessary information from their devices to their agency’s home care software.

Six data points are captured at the point of care to verify the facts of a home care visit in real time.

Collecting this basic information in home care settings helps providers and states ensure that authorized care is provided and that caregivers deliver the proper care at the right time. When this verified visit data is collected and analyzed, states can use it to help identify and reduce Medicaid fraud, which drains resources from the system and hinders care delivery to those in need.

There was initial confusion because the act required states to implement EVV for at-home visits conducted by Medicaid personal care providers and home health agencies. However, each group had different go-live dates. Medicaid-funded personal care services were required to comply with EVV statutes by Jan. 1, 2020, and home health agencies by Jan. 1, 2023. However, delays and exemptions made compliance anything but simple.

Further, the federal government has passed legislation regarding EVV, but its implementation varies at the state level. States are categorized as “open” or “closed” models. Home health agencies have the freedom to choose their EVV provider in open states, while in closed states, they must work with a vendor selected by the state.

According to Matt Kroll, practice president of Assistive Care & Assistive Care State Programs at Bayada Home Health Care, despite challenges, Bayada has found that EVV helps prevent false claims.

“It allows us to monitor caregivers in real-time, verify service delivery, and allow for faster issue resolution,” he told Home Health Care News. “For example, if a check-in is late or a caregiver indicates that the client is showing signs of a larger issue, we can see that in real time and detect and prevent adverse events before they lead to a larger medical issue or hospitalization.”

Headquartered in Moorestown, New Jersey, Bayada provides in-home clinical care and support services in 21 states and five countries.

“We believe that we will be able to leverage some care documentation data points to help improve the quality of care we provide our clients and, over time, industry-wide data points may improve the industry as a whole,” Kroll said.

Kroll explained that Bayada supports efforts to prevent fraud, waste and abuse, with the caveat that overregulation can actually hurt the industry in some instances.

“We do feel that overburdensome requirements and unfunded mandates can deter agencies from providing Medicaid-based services, which is detrimental to those populations who already struggle to access the care they need to stay safely at home,” he said.

EVV still a pain point for providers

Because EVV varies by state, its challenges differ by market.

“EVV is still a pain point for providers for various reasons – and they vary by state,” Tim Nyberg, senior vice president of strategy at Sandata, told HHCN. “These can include variance in education from states to providers, the provider’s experience in onboarding and implementing EVV systems, how caregivers are educated on EVV, and whether they understand its purpose and benefits.”

Sandata, based in Port Washington, New York, provides agency management software, systems, and services to optimize billing and claims processing and streamline administrative processes.

“Additionally, some caregivers cite privacy issues in using their personal cell phones to clock in and out of shifts and having their location tracked,” Nyberg said. “Some clients and family members share those same concerns.”

Although all states have worked to implement effective EVV programs, some have needed help with clear and open communication regarding their policies, transparent enforcement timelines and timely responses to questions and concerns from the provider community.

“EVV continues to present challenges for providers primarily due to its complex integration into existing workflows,” John Atkinson, chief technology officer at AxisCare, told HHCN. “The additional effort required is not just about submitting claims, but also ensuring that EVV data is accurately collected and transmitted to the aggregator. This process requires meticulous attention to detail, often adding layers of administrative tasks to an already burdened system. Providers must balance maintaining the quality of care and adapting to new technological requirements, often leading to frustrations. While EVV aims to streamline and enhance transparency, the transition and implementation phase continues to be arduous.”

Founded in 2013, AxisCare is a full-service home care software company based in Waco, Texas.

“Bayada has made every effort to ensure that the transition to EVV compliance is as easy as possible for our caregivers and as least disruptive to client care as possible,” Kroll said. “However, pain points persist. Most notably, cost, lack of standardization across states, technology issues for caregivers and lack of cell service in rural areas.”

Providers who fail to comply with Medicaid rules risk not being paid for their work. Non-compliance with Medicaid rules and policies may also result in the provider’s inability to do business under the Medicaid program.

Apart from the stricter compliance issues, there are also significant downstream impacts. When caregivers fail to clock in at a client’s home, the home care agency cannot verify the services provided, especially in the case of a fall or hospitalization during or after a shift.

There is a continued lack of clarity regarding the consequences of non-compliance, according to Kroll.

States and payers each have a compliance threshold that needs to be met, and most – but not all – states have published this information. Non-compliance could result in payment penalties, loss of referrals, audits, and additional penalties and corrective action plans.

The future of EVV

States that have a burdensome EVV system run the risk of losing providers that may be otherwise interested in conducting business there.

“Looking ahead, the future of EVV will be marked by increasingly stringent standards and tighter tolerances,” Atkinson said. “We anticipate a future where the manual entry of EVV data will become largely unacceptable as states demand greater accuracy and efficiency.”

He emphasized the importance of proactively creating a culture of compliance and ensuring that staff are well-prepared to meet changing standards. This includes adopting technology and simplifying processes to enable smooth data transfer to aggregators.

“By staying ahead of these developments, providers can enhance operational efficiency and continue to meet regulatory requirements effectively,” Atkinson said. “Above all, EVV will enhance the accurate delivery of care to seniors, ensuring they receive the attention and services they need when needed.”

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On Wednesday, Rep. James Comer (R-Ky), and co-sponsor Morgan McGarvey (D-Ky), introduced H.R.9812 into the House of Representatives. The bill is looking to tackle the dearth of nurses, nurse aides and more, by incentivising states to develop health care workforce partnerships.

The bill provides grant funds to offset up to 50% of a state appropriation for health care workforce public-private partnerships and scholarships.

The bill is modeled after an approach that’s being taken in Kentucky. For Kentucky, the passage of the bill has been a positive development.

“The statute itself lists 14 health care occupations that are in critical need in Kentucky, and it supplies funding, so that we can match industry donations for both training scholarships and incentive funds,” Leslie Sizemore, associate vice president of workforce and economic development at the Kentucky Council On Postsecondary Education, told Home Health Care News. “The majority of the interest has been in the training scholarships, and we have just recently gone through our very first submission period and award notices. We were able to really impact the potential for developing the workforce in this area.”

Success in Kentucky points to the potential of a federal health care workforce program that is bolstered by collaboration.

Plus, Kentucky isn’t an anomaly. Louisiana recently passed similar legislation, and Florida has a system with a similar mechanism.

Sizemore believes that the public-private partnership aspect, in particular, has been a game changer.

“People have always looked to higher education as really supplying the talent needs that the workforce has to have to continue to work, but we’ve really never capitalized on the industry as being a partner in that,” she said. “For the very first time, we’re pulling together industry partners, government officials and our higher education officials in the same room to say, ‘What do we need to do to make sure that Kentucky has enough resources?”

What’s more, in a March response letter to the U.S. Senate’s request for information regarding solutions to the national health care workforce crisis, the Partnership for Quality Home Healthcare (PQHH) pointed to Kentucky and Florida as blueprints. PQHH also spoke about nationalizing these models.

At the time, PQHH CEO Joanne Cunningham expressed optimism around what she viewed as a true effort to find actionable solutions to the health care workforce crisis.

“It feels different to me,” she previously told HHCN. “It feels like there is some renewed interest and effort to, on a bipartisan basis, work together on creative solutions that leverage all the interest and all the good ideas out there, to see something happen. I’m hopeful and I think this momentum is exciting.”

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On Wednesday, the policymakers introduced the Ensuring Access to Medicaid Buy-In Programs Act.

If enacted, the legislation would eliminate a restriction that blocks people living with disabilities from buying into Medicaid once they reach age 65.

Broadly, the Medicaid buy-in program offers long-term care services — that aren’t usually covered by employee insurance plans — for people with disabilities. The program allows states to cover workers with disabilities.

“People with disabilities who have health care coverage through Medicaid to provide for essential supports such as home and community-based services lose that benefit when they turn 65 years of age because of a restriction that doesn’t allow them to buy-in to Medicaid Services,” a fact sheet read. “For people with disabilities who are working, being able to buy-in to Medicaid means they can get the supports they need, such as personal care attendants to help them prepare for the day and to be independent.”

Currently, regulations take the option to buy into Medicaid off the table once someone turns 65 years old. This causes many people with disabilities to retire so they can keep their coverage.

“People with disabilities deserve to be given the resources and support they need to live and work independently no matter their age,” Casey said in a press release statement. “The Medicaid buy-in program is a critical way for many people with disabilities to receive that support, and should not be restricted to those under 65. This new bipartisan bill will prevent people with disabilities from being forced into retirement just to maintain access to the support they need to live independently.”

Most recently, Casey introduced a bill aimed at improving access to the Program of All-Inclusive Care for the Elderly (PACE). In general, Casey has been at the forefront of pushing legislation meant to increase access to care for seniors and people living with disabilities.

Similar to Casey, Sen. Blackburn also emphasized the importance of removing barriers to Medicaid coverage.

“Americans with disabilities should be able to continue working without losing coverage or care through Medicaid when they turn 65,” she said in the statement. “The Ensuring Access to Medicaid Buy-In Program Act would ensure adults with disabilities over the age of 65 can continue to work without sacrificing their Medicaid coverage and benefits.”

The Ensuring Access to Medicaid Buy-In Programs Act has a House companion bill — H.R. 8107 — which was introduced back in April.

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The company, along with Alpharetta, Georgia-based Public Partnerships LLC, is one of the organizations to publicly surface as one of the contestants involved in the process.

PALCO has provided coordinated financial management services since 1999 for older adults, people with disabilities, veterans, foster children and others. The organization collaborates with government agencies, nonprofit and managed-care organizations, and the private sector.

It was the first FMS in the country to pilot the self-direction model more than 20 years ago, according to CEO Alicia Paladino. PALCO assists clients in hiring and paying for their choice of support workers and services within a state-approved personalized spending budget.

“PALCO has been expanding its services into larger states in recent years,” Paladino told Home Health Care News. “In some cases, we’ve been helping to rebuild programs that were no longer working properly. We look forward to helping New York revamp its existing Medicaid program by switching to a single provider.”

As previously reported, any company that becomes the exclusive administrator for New York’s CDPAP could secure a contract worth billions of dollars in revenue over the next five years.

To qualify, a competing company must have been in business before 2012 and be a statewide vendor, serving the entire population in at least one state besides New York. Proposals were required to be submitted in writing and include a bid, company background, information on how the company plans to work with the state and any questions.

The bidding process is on an aggressive timeline. Legislation was put into effect in April 2024, and a request for proposal (RFP) was issued in June. Candidates were required to submit their bids by August 21, and the contract will be awarded by October 1. Once awarded, the winning bidder will have up to 90 days to take on administrative responsibilities.

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“We believe we will not end up with this proposed rule as a final rule,” he said during the opening presentation at NAHC’s Financial Management Conference in Las Vegas on Sunday. “We will end up with something less draconian. The cuts will be reduced because, No. 1, that’s what they’ve done for the last several years, and, No. 2, it’s an election year.”

Even with a prediction of a “less draconian” final payment rule, NAHC is still gearing up to fight against home health cuts and the Centers for Medicare & Medicaid Services’ (CMS) payment-setting methodologies.

“Our focus more than anything else is remedy coming by way of Congress,” Dombi said. “If we run the clock back 365 days, we had a Congress that was telling us, very overtly, ‘We will not help you.’ They were telling us that because they believed [providers] were making too much profit in the Medicare program. They were not understanding how the business runs. They weren’t understanding how any margin [providers] got was subsidizing other government programs like Medicaid and Medicare Advantage. They now understand it.”

Dombi credits a meeting the organization had with Sen. Ron Wyden (D-Ore.), which took place in Portland, Oregon and included five home health agency representatives from the state.

“Senator Wyden asked the question: ‘MedPAC says your margins average 22%, are those numbers wrong or has something changed?’” Dombi said. “One agency representative immediately spoke up and said, ‘the numbers are wrong and things have changed for the worse.’ He started explaining what happened within his home health agency. Now Senator Wyden is working with us to help us bring about some positive legislative changes.”

Dombi noted that there is already pending legislation.

Still, working with Congress isn’t the only way NAHC plans to address the issue. The organization is still moving forward on its plan to sue the Department of Health and Human Services.

“The action plan continues with this litigation,” Dombi said. “This litigation does not give us quick remedies. My estimate is if we succeed in the first round, we will be facing an appeal by the government. If we lose, they’ll be facing an appeal. Then there’s still the step above that — the U.S. Supreme Court. This kind of litigation may take many years to get through.”

However, Dombi believes that last month’s Supreme Court decision, which struck down the Chevron doctrine, may help NAHC’s lawsuit.

The proposed payment rule wasn’t the only issue highlighted during Dombi’s rundown of legislative and regulatory updates, however.

80-20 silver lining

The “Ensuring Access to Medicaid Services” rule also came under fire, specifically its 80-20 provision, which is controversial among providers.

Dombi pointed out that caregivers should receive higher compensation for their work, but NAHC doesn’t believe that the 80-20 provision is the right method to achieve this.

“We’re in agreement that the direct care workforce is underpaid and underappreciated,” he said. “We don’t agree that the solution is to say, ‘You have to pay 80% of your payment rate as compensation to that workforce,’ when the states are paying you at such an abysmal level for the service. There’s nothing in this rule that increases payment rates for the providers of services.”

There is, however, a silver lining to the provision. It doesn’t require compliance for the first six years.

“In Washington circles, giving that much of a glide path for something to take effect is almost a death sentence, so we expect that there’ll be a number of changes or it will be abandoned along the way,” Dombi said.

Despite the 80-20 provision, Dombi explained that the rule had other aspects that would be beneficial to providers, including more accountability for the states regarding payment rates.

Personal care sees more regulation

Dombi warned private-duty personal care providers not to fall into the trap of viewing the industry as being free of regulation.

“They may not be getting paid by federal or state governments, but they’re subject to a lot of rules and regulations, particularly under the Department of Labor,” he said.

Specifically, personal care is an industry that the department has its eye on when it comes to compliance with the Fair Labor Standards Act.

Aside from the DOL’s personal care focus, The Federal Trade Commission (FTC) also finalized a rule that effectively banned non-competes. Though this impacts all industries, Dombi noted that home care companies often rely on non-competes.

More recently, a federal court in Texas temporarily blocked the FTC’s non-compete ban. Dombi advised providers to follow these updates closely.

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The news comes just two days after the home health proposed payment rule was released, which included significant cuts for the third straight year.

Broadly, moving away from the Chevron precedent – usually known as the Chevron doctrine – will mean less regulatory power for government agencies. Government agencies often take their own interpretations of certain laws and statutes, and then act upon those interpretations. Moving forward, it’s likely that these agencies will need more explicit direction from Congress to regulate on firm standing.

The reaction to the Supreme Court decision has mostly been centered around issues like the environment and reproductive rights.

But the decision could also be the breakthrough that home health providers needed to stop – and potentially undo – payment cuts. This week, CMS proposed a 1.7%, or $280 million, decrease to aggregate home health payments for 2025. The final rule is expected in late October or early November.

The National Association for Home Care & Hospice (NAHC) already filed a lawsuit against the U.S. Department of Health & Human Services (HHS) and CMS over rate cuts in 2023.

“In our own analysis, we believe that providers of home health have been underpaid as it relates to budget neutrality,” NAHC President William A. Dombi said when the lawsuit was filed. “At minimum, we would expect to see the rate cuts from 2023, that were permanent readjustments to the base rate, and the one proposed for 2024, along with the temporary adjustments … to go away. The end product of that is that we would have a stable system to deliver home health services to Medicare beneficiaries.”

NAHC has now re-filed that lawsuit, after it was initially dismissed by a federal court.

Even before Chevron was officially overturned, there was evidence to suggest that the Supreme Court was moving away from its line of thinking. The first was in West Virginia v. Environmental Protection Agency (EPA), where the court undercut the EPA’s power in restricting carbon dioxide emissions.

In a health care context, it showed up in American Hospital Association v. Becerra, which was similar to the current NAHC lawsuit.

Like West Virginia v. EPA, the AHA v. Becerra case went the opposite direction of the Chevron precedent.

Prior to 2020, CMS proposed a series of policy changes for hospitals, one of which would have reduced payment, specifically through the 340B drug pricing program. For context, 340B hospitals are generally those that serve lower-income or rural populations.

The 340B cuts represented at least $1.6 billion in lost revenue annually for hospitals.

Like NAHC will with home health cuts, the AHA argued those cuts would hurt patient care, and that CMS did not have the power to levy those cuts in the first place.

In 2022, the Supreme Court ruled unanimously against HHS and CMS in that case. It was later ruled, too, that CMS pay hospitals back for the underpayments, with interest.

“The Supreme Court basically said the law requires certain actions to be taken by CMS in setting the hospital rates as it relates to the 340B, and they had two ways to go. And CMS chose not to go those two ways,” Dombi told HHCN in 2022. “What we’ve got going on in the home health payment rule is a comparable legal argument that starts with the position that the law does not allow CMS to do what it did do on the budget neutrality methodology. And second, that the law requires a specific set of actions, none of which the CMS methodology complies with.”

Home health advocates have lobbied against CMS cuts through public comments during the time between the proposed and final rules. They’ve provided data and storytelling to do so. They’ve also successfully lobbied lawmakers to introduce the Preserving Access to Home Health Act in both the Senate and the House, but that legislation hasn’t moved forward in past years.

A lawsuit was not the desired outcome for NAHC, but one of its last options. Now, that lawsuit may have more wind behind its sails.

“It improves the chances of success for our lawsuit going forward,” Dombi told HHCN Friday, regarding the Chevron decision. “It also means Congress is going to have to offer more detail in its legislative language, leaving less to the administrative agency to bring in interpretations. That, in many ways, is a good thing too.”

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As it has been to most other parts of health care, prior authorization has long been problematic for home health providers and patients. That’s been increasingly true as more insurers have started to adopt systems and processes that use predictive analytics and algorithms to guide their decision-making, too.

In the Senate, the legislation – the Improving Seniors’ Timely Access to Care Act – was introduced by Sens. Kyrsten Sinema (I-Ariz.), Roger Marshall (R-Kan.), Sherrod Brown (D-Ohio) and John Thune (R-S.D.). Companion legislation was likewise put forth in the House, led by U.S. Reps. Mike Kelly (R-Penn.), Suzan DelBene (D-Wash.), Larry Bucshon (R-Ind.) and Ami Bera (D-Calif.).

“Right now, too many older Americans enrolled in Medicare Advantage are forced to deal with unnecessary delays when seeking out [care],” Sen. Brown said in a statement. “We need to update the Medicare Advantage program so it works better, faster, and is more transparent for patients and providers.”

If passed, the Improving Seniors’ Timely Access to Care Act would increase transparency around MA prior-authorization requirements and their use. It would additionally establish an e-PA process for MA plans, including a standardization for transactions and clinical attachments.

By digitizing parts of prior authorization, the hope is that some decisions could be reached faster – even in real time.

The Alzheimer’s Association, AARP, the American Hospital Association, the American Academy of Hospice and Palliative Care, and LeadingAge are among the many health and senior care groups to support the legislation.

“By removing unnecessary barriers that create delays in treatment, this meaningful bill will improve access to care for seniors and allow caregivers to spend more valuable time at the bedside with patients and less time on burdensome paperwork,” American Hospital Association Executive Vice President Stacey Hughes said in a statement

A flawed process

Broadly, prior authorization is designed to help health plans determine the medical necessity of services and minimize unnecessary services. In turn, that allows them to better contain costs and protect patients from receiving unnecessary care.

Between 2009 and 2019, the use of prior authorizations by MA plans increased substantially, previous research has found.

The process normally kicks off when a provider submits to an MA plan a request for prior authorization of services, which could include home health care services, home medical equipment (HME) and several other categories of services.

From there, the MA must decide as quickly as possible whether those services are appropriate. Plans have 14 days after receiving a standard request and 72 hours after receiving an expedited request.

Studies, government-watchdog investigations and U.S. Centers for Medicare & Medicaid Services (CMS) audits have suggested plans frequently get their prior-authorization decisions wrong.

The Medicare Payment Advisory Commission (MedPAC) highlighted the issue in its most recent report to Congress, in fact.

“Although only a small share of prior authorization requests are denied, CMS audits suggest that many denied requests should actually have been approved,” MedPAC wrote in the report. “The Office of Inspector General (OIG) found that CMS cited about half of audited MA contracts in 2015 for inappropriately denying prior authorization requests, for sending insufficient denial letters, and for missing required information such as why the request was denied or how to appeal.”

In 2021, the vast majority of MA prior-authorization reconsiderations were fully approved.

In a sample of 229,000 MA prior-authorization reconsiderations that year, 80% were returned fully favorable. Just 18% were upheld as adverse decisions, with 1% partially favorable.

“Prior authorization has been identified as a major source of administrative burden for providers and can become a health risk for patients if policies affect the treatments clinicians offer (e.g., step therapy requirements), inefficiencies in the process cause needed care to be delayed or abandoned, or poor decisions cause necessary care to be denied,” the MedPAC report continued.

For a health care provider or business, this back-and-forth can have a profoundly negative impact.

“For the past year to two years, we went from a manageable amount of prior authorizations or denials to an absurd amount of denials right off the bat … ,” one physician said in a 2023 focus group, with MedPAC noting this comment in its report. “We’ve had to hire staff just to deal with [authorizations] and denials.”

Home health and prior authorizations

Over the past two years, multiple MA plans have begun to shed prior-authorizations requirements for home health care, in particular.

In August 2023, for example, The Cigna Group (NYSE: CI) announced that it was removing nearly 25% of medical services from its prior authorization requirements.

In November of last year, Blue Cross Blue Shield of Massachusetts announced it was eliminating prior authorization for home health care.

“We know from our clinical partners that local hospitals are experiencing a capacity crunch – we’re doing what we can to help,” BCBS of Massachusetts Chief Medical Officer Dr. Sandhya Rao told Home Health Care News at the time. “By removing prior authorization requirements for home care services, we’ll help hospitals to expedite discharges at a time when many are struggling with overcrowding.

Additionally, this past April, Point32Health announced that it is removing prior-authorization requirements for the first 30 days of home health care.

“We continuously evaluate all our programs to ensure our members are receiving the highest quality of care and work closely with our provider partners to decrease their administrative burden wherever possible,” Dr. Hemant Hora, senior medical director at Point32Health, previously told HHCN.

The post ‘An Absurd Amount of Denials’: New Legislation Seeks to Streamline Access to Home Health Services, Improve Senior Care appeared first on Home Health Care News.

“Since Hospital at Home was implemented just a few years ago, we have seen this program deliver positive patient outcomes and reduce costs nationwide,” Carper said in a press statement.

Currently, the hospital-at-home waiver program is set to end on Dec. 31.

In 2020, CMS rolled out the Acute Hospital Care At Home program. The CMS waiver program was a response to the COVID-19 pandemic, and allowed providers to receive reimbursement for delivering hospital-level care in the home at a time when hospitals were struggling with capacity.

By creating a reimbursement mechanism, the waiver effectively addressed one of the biggest challenges to implementing hospital-at-home programs at-scale across the country.

As of May, 330 hospitals, across 136 systems, in 37 states have been approved to take part in the waiver program.

“The Acute Hospital Care at Home program has revolutionized health care for so many Americans by improving care while cutting down on the health risks associated with hospital stays,” Scott said in a press statement. “I’m proud of our efforts to extend this program, ease pressure on our health care system, and allow thousands of vulnerable Americans to continue receiving high quality care from the safety of their homes.”

This isn’t the first time that extending the waiver program has been on the table.

In 2022, the “Hospital Inpatient Services Modernization Act” was introduced. The legislation was, again, sponsored by Sens. Tom Carper (D-Del.) and Tim Scott (R-S.C.). Reps. Brad Wenstrup (R-Ohio) and Earl Blumenauer (D-Ore.) also sponsored this bill, which extended the waiver two more years.

What’s more, Sens. Marco Rubio (R-Fla.) and Tom Carper (D – Del.) also introduced the At Home Observation and Medical Evaluation (HOME) Services Act last month. The bill would expand the scope of hospital-at-home providers by allowing them to care for “observation status patients.”

“Addressing our health care challenges requires innovative solutions,” Rubio said in a press statement. “The HOME Services Act builds on the success of the hospital-at-home program to lower costs and burdens and improve patient outcomes and satisfaction.”

Aside from legislative action from policymakers, providers and other industry stakeholders have been vocal in their efforts to extend the waiver.

In March, a large group of hospital-at-home stakeholders penned a letter addressed to Senate majority leader and Senate minority leader – Sens. Chuck Schumer (D–N.Y.) and Mitch McConnell (R–Ky.).

The letter called for at least a 5-year extension of the waiver program before its expiration at the end of 2024.

“The waiver must be extended to enable hospitals and health systems nationwide to continue building out the logistics, supply chain, and workforce for hospital-at-home (HaH) and to encourage multiple payers outside the Medicare program, including Medicaid programs, to enter the HaH market,” the cohort wrote in the letter. “An extension will also allow home-based services to be developed equitably across populations everywhere and ensure hospital inpatient unit care is available for the patients who need it while enabling patients who can and want to be treated in their home to have the opportunity to do so, creating needed capacity for hospitals without increasing health system costs.”

The letter includes signatures from companies like ChristianaCare, CommonSpirit Health, Right at Home and Best Buy Health. Advocacy group Moving Health Home was also among those that signed the letter.

The post US Senators Move To Extend CMS’ Acute Hospital Care at Home Waiver With Bill Introduction appeared first on Home Health Care News.

At the start of the week, the “Ensuring Access to Medicaid Services” rule was finalized. The 80-20 provision is, arguably, the most controversial component of the Medicaid rule. In summary, the provision calls for 80% of Medicaid payments for home- and community-based services (HCBS) to be earmarked for direct care workers’ compensation.

On Thursday, Congresswoman Kat Cammack (R-Fla.) introduced a bill to block the U.S. Department of Health and Human Services (HHS) from finalizing the 80-20 provision.

Additionally, the legislation would also block HHS from implementing any similar rules that place a minimum requirement for how much of Medicaid spending on HCBS goes towards direct workers’ wages.

Cammack’s reason for introducing this legislation is her belief that the 80-20 provision will severely limit access to care at a time when providers are already struggling to serve patients.

“The Biden administration’s proposed ’80/20′ rule would require states to spend billions in new unfunded mandates or force HCBS providers to reduce access to care for those who need it most,” Cammack said in a press statement. “Because of top-down demands from the Biden administration, home care agencies can’t keep up with staffing levels and overall care levels while complying with this rule. It’s putting millions of Americans at a sharp disadvantage and only exacerbating the challenging issues we already face.”

Cammack isn’t the only person that has expressed similar concern about providers’ ability to deliver services under the 80-20 rule.

Leaders at organizations like Home Assist Health, the National Association for Home Care & Hospice (NAHC) and Addus HomeCare Corp. (Nasdaq: ADUS) have spoken out against the rule for similar reasons.

“It compromises our network integrity for care at home,” Sara Wilson, president and CEO of Home Assist Health, previously told Home Health Care News. “It makes me nervous, because it could affect our ability to care for the people who we are here to serve.”

NAHC President William A. Dombi took aim at what he believed to be a contradictory rule.

“At its core, the rule is a fundamental contradiction,” Dombi previously told HHCN. “It’s saying, we have all of these things we need to do to improve the quality of care, to improve the lives and the health and safety of individuals. All of those things require administrative expenses to achieve. Yet at the same time, the rule is saying, ‘We’re cutting the available funding for you to implement those same activities we’re requiring.’”

Despite Addus’ pushback against the 80-20 provision, the company believes that it is well-positioned to push for rate increases to combat the rule’s impact. 

“The conclusion is that you have to be big,” Addus CEO Dirk Allison said at the Raymond James conference last month. “That’s not just big nationally, you have to be big in a state. If you look in the states where we are very large, we have a great deal of access to the state government, and can work with them on the reasons why we need increases in rates, which is what it will take for certain state programs to remain competitive, if this goes through. We’re working on that.”

The post Congresswoman Kat Cammack Introduces Legislation To Block 80-20 Rule appeared first on Home Health Care News.