According to court documents, Zakia Khan and Ahsan Ijaz owned two Brooklyn-based social adult day care organizations, Happy Family Social Adult Day Care Center Inc. and Family Social Adult Day Care Center Inc., and a financial intermediary called Responsible Care Staffing Inc.

These organizations were involved in the New York Medicaid Consumer Directed Personal Assistance Services Program (CDPAP), which allows family members of Medicaid recipients to receive payment for helping the recipients with daily activities.

Starting around October 2017, marketers Elaine Antao, Omneah Hamdi and Manal Wasef reportedly directed Medicaid recipients to Happy Family, Family Social or Responsible Care in exchange for kickbacks and bribes. In return, the marketers allegedly paid kickbacks and bribes to Medicaid recipients for social adult day care and CDPAP services that the organizations billed to Medicaid – services they either did not provide or services that were influenced by those kickbacks and bribes.

Ansir Abassi, Ansir Zaib and Amran Hashmi purportedly managed Happy Family and Family Social along with the marketers. To carry out the kickback scheme, Khan, Antao, Ijaz, Abassi and Hamdi allegedly used business entities to launder the fraud proceeds and generate cash to pay kickbacks and bribes. Seema Memon, an employee of Happy Family who was previously charged by complaint on July 1, was also indicted.

“As alleged in the indictment, these defendants orchestrated a years-long scheme to defraud Medicaid of tens of millions of dollars for social adult day care and home care services that they did not provide,” Principal Deputy Assistant Attorney General Nicole M. Argentieri, head of the Justice Department’s Criminal Division, said in a statement. “The defendants allegedly paid cash bribes and kickbacks to recruiters and Medicaid recipients as part of a scheme to enrich themselves at the expense of vital programs for senior citizens. The charges make clear that the Criminal Division will not tolerate schemes that brazenly steal from federal health care programs.”

Khan has been charged with several offenses, including conspiracy to commit health care fraud, three counts of health care fraud, conspiracy to defraud the United States and to pay and receive health care kickbacks, paying health care kickbacks, conspiracy to commit money laundering, and money laundering. If found guilty, she could face a maximum penalty of 20 years in prison for each count of conspiracy to commit money laundering and money laundering, ten years in prison for each count of conspiracy to commit health care fraud, health care fraud, and paying health care kickbacks, and five years in prison for conspiracy to defraud the United States and to pay and receive health care kickbacks.

Abassi, Antao, Hamdi and Ijaz face charges of conspiracy to commit health care fraud, conspiracy to defraud the United States and to pay and receive health care kickbacks, conspiracy to commit money laundering and money laundering. If found guilty, they could be sentenced to a maximum of 20 years for each count of conspiracy to commit money laundering and money laundering, ten years for conspiracy to commit health care fraud, and five years for conspiracy to defraud the United States and to pay and receive health care kickbacks.

Hashmi is facing charges of conspiracy to commit health care fraud, three counts of health care fraud, conspiracy to defraud the United States, and paying and receiving health care kickbacks. If found guilty, he could be sentenced to a maximum of ten years for each count of conspiracy to commit health care fraud, health care fraud, and paying health care kickbacks, as well as five years for conspiracy to defraud the United States and to pay and receive health care kickbacks.

Memon is charged with conspiracy to commit health care fraud, conspiracy to defraud the United States, and paying and receiving health care kickbacks. If convicted, she faces a maximum penalty of ten years for each count of conspiracy to commit health care fraud and paying health care kickbacks and five years for conspiracy to defraud the United States and pay and receive health care kickbacks.

Wasef faces charges of conspiracy to commit health care fraud, conspiracy to defraud the United States, and conspiracy to pay and receive health care kickbacks. If found guilty, she could face a maximum penalty of ten years for conspiracy to commit health care fraud and five years for conspiracy to defraud the United States and to pay and receive health care kickbacks.

Since March 2007, the Health Care Fraud Strike program, consisting of nine strike forces operating in 27 federal districts, has prosecuted over 5,400 defendants who have overbilled federal health care programs and private insurers by over $27 billion.

“The crimes outlined in this indictment took advantage of a network that offers essential health care and other services to those in need,” Interim Commissioner Thomas G. Donlon of the New York City Police Department (NYPD) said in a statement. “Let it be clear: anyone who attempts to profit by defrauding the system will face consequences, as these schemes drain already limited resources and deprive beneficiaries of crucial funds. I commend our NYPD investigators and federal law enforcement partners for their continued collaboration.”

The post 8 Charged In $68M Home Care, Adult Day Fraud Scheme 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.”

The post Years After Implementation, EVV Remains Inconsistent Pain Point For Home Care Providers appeared first on Home Health Care News.

“We are excited to have the opportunity to serve CDPAP consumers and personal assistants,” Maria Perrin, chief growth and strategy officer at PPL, told Home Health Care News. “Consumer direction programs are all we do as a business. For years, we’ve not only been operating throughout several states, but we’ve made it our purpose and mission to advance access to consumer direction and make these programs stronger, sustainable and more culturally competent. This is a great opportunity for us, and we are really excited to be partnering with our [fiscal intermediary] partners.”

Through CDPAP, a Medicaid-funded home care program, people seeking care are allowed to hire a caregiver of their own choosing. This often means informal caregivers, which are paid for their services through the program.

Roughly 700 businesses currently serve as fiscal intermediaries, many of which are home care providers themselves. The state is looking to save $1 billion annually by appointing one administrator.

As part of the agreement, PPL must work with four local organizations, and a network of 30 home care agencies.

“Our approach to this was to make sure that we put together a partnership with existing CDPAP fiscal intermediaries and with the independent living centers,” Perrin said. “That would make sure there’s ample capacity from a volume standpoint and from a linguistic standpoint, making sure that people who are not english speakers continue to be served. That people who have disabilities, or cultural or religious considerations, would continue to be served. At this point, we have over 30 existing CDPAP fiscal intermediary partners that we’ve identified, in addition to the 11 independent living centers, who will continue their work.”

Perrin noted that with state approval, PPL is open to identifying and partnering with even more organizations.

PPL will also relocate its headquarters to New York. The move will create over 1,200 jobs, according to a press statement.

Additionally, The Chinese American Planning Council will aid in managing the program in Long Island, Westchester County and New York City.

Uncertainties around CDPAP

With these changes to CDPAP, Emina Poricanin, founder and managing attorney of the New York-based Poricanin Law, believes that many providers will be weighing their options.

“As far as the providers are concerned, this is just additional uncertainty about their future as a business,” she told HHCN. “A number of them are, even more expeditiously, exploring other lines of personal care services that they can offer in New York State because they have no choice but to pivot from this program.”

For some, this means transitioning patient care hours into a traditional licensed home care services setting and out of CDPAP, Poricanin noted.

In addition to fiscal intermediary restructuring, Poricanin pointed to the significant decrease in reimbursement rates as another area of concern for providers.

“[It] takes out, largely, any incentive for a provider to be in this program,” she said. “Irrespective of what happens with PPL, or any single statewide fiscal intermediary, there’s simply very little money in this program. Therefore providers, regardless of what happens with the single statewide [fiscal intermediary] restructuring, should and are looking long term into what they can do with this line of business.”

Poricanin also believes that the state may see additional lawsuits, specifically ones that challenge if the appointment was a true competitive bidding process.

“The number has not been released, but based on my own knowledge of the market, I assume there were at least 200 applications that were submitted to New York State, and yet they were able to turn those around from mid-August and send out rejection letters yesterday,” she said. “How did they get through all of those applications that quickly, if they were actually reviewing the applications and giving each applicant a fair opportunity to apply? That is probably going to be the subject of some litigation — that the process was not conducted fairly.”

The post Amid Ongoing Controversy In New York, Public Partnerships Is Awarded CDPAP Contract appeared first on Home Health Care News.

The agency issued an informational bulletin last month reminding states of federal renewal requirements and available flexibilities to ensure continued coverage for individuals eligible for HCBS through Medicaid. This bulletin continues CMS’ efforts to minimize coverage gaps, particularly during and after the public health emergency unwinding process, and to ensure eligible individuals retain or are re-enrolled in Medicaid.

For home care providers, a renewed government effort to clean up HCBS protocols – like in the Medicaid Access Rule – helps keep patients on census and enables better care geared toward value.

Following the end of the COVID-19 public health emergency in 2023, states restarted regular eligibility renewals for those enrolled in Medicaid and Children’s Health Insurance Program (CHIP) coverage, a process often called “Medicaid unwinding.” This included renewals for individuals who needed assistance with daily living activities.

As states restarted renewals, many individuals faced challenges renewing their coverage because of administrative barriers. States experienced unprecedented renewals, resulting in backlogs in some areas, according to CMS. Many states also experienced system and compliance issues, which the agency directed them to address.

Throughout unwinding, CMS has strongly urged states to adopt federal strategies that make it easier for eligible individuals to renew Medicaid. On Aug. 19, CMS issued guidance outlining strategies states can adopt to help eligible individuals receiving HCBS retain their coverage.

These strategies are designed to simplify eligibility and enrollment processes, maximize the use of available and accurate information, and reduce the burden on individuals and state Medicaid agencies, allowing eligible individuals receiving HCBS to maintain their coverage, independence and engagement in community life.

In accordance with the guidelines, states are required to regularly review Medicaid eligibility, in line with federal regulations, to ensure continued access to HCBS for those who are still eligible. Some of the current flexibilities that help maintain coverage and access to HCBS include collaborating with local agencies to improve “no wrong door” systems for assisting individuals in maintaining Medicaid enrollment. States can also choose to exclude some or all countable income or resources when renewing coverage for individuals receiving HCBS for a specific period of time.

No wrong door means consumers can enter any service with the expectation that if it is not appropriate for them, they will receive assistance in accessing the most relevant services.

“During the COVID-19 pandemic, the Families First Coronavirus Response Act mandated that states maintain continuous enrollment in Medicaid for people,” Home Assist Health President and CEO Sara Wilson told Home Health Care News. “However, this continuous eligibility requirement ended with the public health emergency, leading to various challenges for states transitioning out of it. These challenges included staffing shortages, training needs, outdated operating systems and communication issues. As a result, procedural errors occurred, leading to wrongful termination of participants and creating gaps in care. These gaps can pose increased financial and health risks for the individuals affected.”

Phoenix-based Home Assist Health is a nonprofit home care provider.

“HCBS enables individuals to age and recover in the comfort of their homes,” Wilson said. “Continuity in these programs is crucial in upholding this right, guaranteeing access to care, and safeguarding the health and well-being of participants.”

During the renewal process, eligibility must first be confirmed using the state’s asset verification system without requiring additional information from the individual (ex parte). Ex parte renewals are one of the most vital tools for states to keep eligible people covered and prevent terminations due to red tape, as demonstrated by CMS data last year.

“Ensuring people have access to comprehensive, high-quality health coverage is a top priority for the Biden-Harris Administration,” a CMS spokesperson told HHCN. “That is why we have urged states to take up every tool CMS made available to help eligible people renew coverage and to protect them from becoming disenrolled due to red tape as states conducted Medicaid and CHIP renewals following the end of the Medicaid continuous enrollment condition in 2023, a process often called ‘Medicaid unwinding.’

As the unwinding process demonstrated, states’ choices have real consequences for eligible people’ ability to maintain coverage during Medicaid and CHIP renewals. While states must follow federal Medicaid and CHIP requirements, they have broad flexibility within these requirements when administering their programs. States can take steps to help eligible people, including people who receive HCBS, stay covered. These steps include improving ex parte rates, taking up CMS’ strategies that make renewals easier to navigate (including strategies outlined in our recent guidance), and addressing other barriers to coverage.”

CMS issued guidance to help states adopt strategies to improve ex parte rates. With these efforts, Medicaid and CHIP ex parte rates doubled nationwide from about 25% in April 2023 to 50% of renewals due in May 2024.

The agency also recently finalized a rule that builds on critical lessons learned during Medicaid unwinding by streamlining and simplifying how people enroll in and renew Medicaid and CHIP from now on. These improvements will reportedly help millions of eligible people with HCBS enroll in and maintain Medicaid coverage moving forward.

For example, for those eligible for Medicaid based on disability, the rule prohibits states from requiring in-person interviews, requires states to provide a reasonable period for applicants to return information and documentation, and requires states to accept renewals in multiple ways, such as online, by phone, mail or in person.

Regarding compliance with renewal requirements, the guidance issued on Sept. 20 details steps that all states must take to ensure their compliance with federal renewal requirements for Medicaid and CHIP and avoid further action by CMS.

States must assess their compliance with federal requirements, submit the results to CMS, and submit a plan to resolve any issues. Building on insights from the unwinding period, this action will help ensure state compliance with key federal renewal requirements, safeguarding individuals’ ability to renew their health coverage and strengthening the integrity of the Medicaid program, according to CMS.

“HCBS is crucial for long-term care services, allowing participants to choose home-based care while promoting individual choice and control,” Wilson said. “Home care providers should work with their state Medicaid authorities to support this transition process for members.”

The post CMS Releases HCBS Continuity Of Coverage Requirements appeared first on Home Health Care News.

In a recent MACPAC meeting, Tamara Huson, a senior analyst and contracting officer at the organization, presented early findings on the use of presumptive eligibility and expedited eligibility, as a way to clear up those wait times.

“We’ve been working to understand states’ eligibility and enrollment processes, particularly ways in which states streamline the process to enable more timely receipt of services,” Huson said during the meeting, which took place last week.

Broadly, presumptive eligibility lets people who aren’t eligible for Medicaid to receive services under the program while they’re completing the application process. This period lasts up to 60 days.

“Providers, such as a home health care agency, furnishing HCBS during the period in which a beneficiary is deemed presumptively eligible are reimbursed by Medicaid,” Huson said.

On the flip side, expedited eligibility is when someone’s Medicaid application is processed faster to make a Medicaid eligibility determination. However, the applicant doesn’t receive services until determination is made.

Huson noted that this was the key distinction between presumptive and expedited eligibility.

In order to examine states’ use of presumptive eligibility and expedited eligibility, MACPAC interviewed six states, four national organizations, as well as some Centers for Medicare & Medicaid (CMS) officials.

Of the six states, five are using presumptive eligibility and one is using expedited eligibility, according to Huson.

“We also heard a number of common characteristics from state programs,” she said. “First is that states are generally using presumptive and expedited eligibility for older adults and individuals with disabilities, with a focus on helping individuals transition from hospitals back to the community. Four states that we spoke with currently include hospitalized individuals, and one state was exploring how to expand their population to hospitalized individuals.”

Additionally, three of the national experts MACPAC interviewed emphasized the importance of “disrupting” the hospital to nursing facility pipeline.

“They were hopeful that state efforts to use these flexibilities would be effective in ensuring that individuals are able to receive care in the setting of their choice,” Huson said.

Some of those interviewed did, however, bring up their financial concerns.

“A few interviewees expressed concern about a state’s financial risk for services provided to individuals found presumptively eligible for HCBS and then later found ineligible, despite CMS policy to the contrary,” Huson said.

Ultimately, those interviewed believe that timely access to care services is crucial.

“Interviewees agreed that timely access to services is critical, particularly when an individual may be in an emergency situation, citing particular concerns around individuals discharging from hospitals as to prevent institutionalization,” Huson said. “Experts also reiterated that these policy tools support consumer preferences to remain in the community.”

The post In What Could Be A Tailwind For HCBS Providers, MACPAC Pushes For Easier Medicaid Enrollment appeared first on Home Health Care News.

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.

The post Lawmakers Set Sights On Eliminating Age Restrictions For Medicaid Buy-In Program appeared first on Home Health Care News.

New York’s CDPAP has been in the headlines for months. Gov. Kathy Hochul deemed the home care program a “racket” and lawsuits protesting changes to the plan have mounted.

The Alpharetta, Georgia-based PPL is now aiming to secure the contract to be the sole administrator of New York’s program, which cost Medicaid $9 billion last year. The state plans to reduce the number of administrators from 700 to just one in order to save $1 billion a year. If finalized, the move is expected to phase out existing administrators in the next eight months.

Backed by the Park City, Utah-based DW Healthcare Partners and the Chicago-based Linden Capital Partners, PPL currently operates 49 self-directed programs with over 500,000 participants, according to its website.

Any company that becomes the exclusive administrator for New York’s CDPAP could secure a contract worth billions in revenue over the next five years.

PPL is strategically positioning itself at the forefront of the race by reaching out to existing fiscal intermediaries in New York and offering them potential subcontracts that could save their businesses once the state awards the contract on October 1.

The company is currently seeking a market implementation director to “oversee the New York market and consumer implementation function.” The director will be “responsible for supporting the stand up of a single financial management services program and enable the successful transition of consumers and caregivers into a singular operating platform.”

PPL is considered one of the few companies eligible for the contract because of its experience in operating as a statewide fiscal intermediary in other states. Companies interested in competing for the contract had to submit their bids by August 21.

Home Health Care News reached out to PPL, but the company’s leaders declined to comment during the ongoing selection process.

The post Georgia-Based Company Hopes To Win New York CDPAP Administration Contract appeared first on Home Health Care News.

“We heard, consistently, that there were concerns about the applicability of the 80% threshold to small providers,” Melissa Harris, the deputy director of the Medicaid and benefits health programs group at the Centers for Medicare & Medicaid Services (CMS), said Tuesday during a CMS open door forum. “There might be other circumstances in which it would be a particular hardship for providers to meet the 80% threshold.”

Indeed, home-based care providers and industry advocates have been vocal critics of the 80-20 provision. While many industry insiders are in support of higher caregiver wages, they pointed out that provider’s rate concerns remain unanswered.

“We’re in agreement that the direct care workforce is underpaid and underappreciated,” National Association for Home Care & Hospice President William A. Dombi said last week at the organization’s annual conference. “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.”

As part of the finalized version of the rule, there are a few exceptions that attempt to address provider concerns.

For small providers, states can choose to develop a threshold with a percentage separate from the required 80%.

“States need to do some things when they take advantage of that small provider threshold,” Harris said. “They need to tell us what that threshold is. They need to tell us how many of their providers are going to be meeting that threshold, and then they need to give us a plan for how to bring those providers, over time, into compliance with the 80% threshold.”

Another option under the rule, states can choose to have a hardship exemption. This exempts providers from meeting a specific payment adequacy threshold at all.

Similar to the small provider threshold, states will need to determine a criteria for defining hardship. States will need to identify how many providers fit into this category.

Plus, states will need to have a plan to eventually bring those providers into compliance at a certain point.

However, CMS is able to remove the compliance plan requirement for states if the combined total of organizations that fall under the hardship exemption and the small private provider exemption is less than 10% of the state’s providers.

“We’re very hopeful that this provides some opportunities for relief, and in specific circumstances,” Harris said. “But we also stand behind the achievability of the 80%, based on our conversations with a broad range of stakeholders. Should states, in their conversations with providers, decide to avail themselves of either of these opportunities, they’re certainly available, as long as states adhere to the requirements that surround both.”

During the open forum, Harris also emphasized the importance of providers communicating with state Medicaid agencies.

“Even though this is a federal regulatory requirement, there’s a lot of state shaping of how they’re going to meet the 80%, including whether or not they’re going to take advantage of the small provider threshold, [or] the hardship exemption opportunity,” she said. “They’ll want to be hearing from their provider community with the very detailed concerns that you’re laying out. Our goal, obviously, is not, through this provision, to make it harder for a provider to participate in Medicaid. Our goal is to say that we have to take action in recognition of the national crisis that is jeopardizing the stability of the direct service workforce.”

The post CMS Highlights 80-20 Provision Exceptions That Could Be Lifelines For Providers appeared first on Home Health Care News.

Broadly, Medicaid is a state and federal partnership. The federal government sets rules and parameters. The state takes those parameters and implements their own programs within the framework that the Centers for Medicare & Medicaid Services (CMS) provides.

However, the federal guidance around state rates is minimal, according to Damon Terzaghi, senior director of Medicaid advocacy at the National Association for Home Care & Hospice (NAHC).

“What we always refer to, when we’re talking about Medicaid payment policy, is section 1902(a)(30)(A),” he said during a presentation at NAHC’s Financial Management Conference, which took place last week. “[It] basically says that CMS, the federal government, does not have statutory authority to tell states what they must pay for programs, for services and those sorts of things.”

Hospice is one of the few exceptions. It is one of the programs that has a federal minimum payment rate.

In general, the Medicaid program has a history of under-reimbursing for services in comparison to Medicare and private insurance.

“It has led to a lot of challenges and concerns around whether they’re truly meeting that access-to-care requirement,” Terzaghi said.

Terzaghi noted that these problems eventually led to the “Ensuring Access to Medicaid Services” rule.

“You can draw a direct line from the [Armstrong v. Exceptional Child Center] Supreme Court decision, through various iterations of CMS rulemaking, straight to this access regulation where CMS says, ‘We can’t tell you a minimum payment rate, providers can’t sue, [but] we can start to put a framework around what equal access looks like,” he said.

One of the main positives of the rule is that it’s now a regulatory standard for states to have rates high enough to attract a sufficient workforce to deliver care.

There are a handful of ways that different states approach payment. Fee for services is one of the most common ways that HCBS are reimbursed through Medicaid.

There are some states that adjust payment rates to keep pace with cost-of-living differences based on geography.

In addition to geographic adjustments, some states do acuity use adjustments.

“In the Medicaid program, frequently there’s a comprehensive functional assessment of need, for individuals before you start delivering these in-home care services, so we’ve seen more and more states start to tie reimbursement to acuity,” Terzaghi said.

There are also bundled payments, which groups services together, and then providers receive a single rate.

“The states are trying to give some flexibility to meet the individual where they’re at, as opposed to having a more regimented prior authorization process,” Terzaghi said.

Managed care

Managed care organizations (MCO) get paid a per member, per month risk adjusted rate from the state.

It’s important for providers to understand that operating in a state that has managed care doesn’t mean that every home- and community-based service is under the MCO.

“I’ll use Georgia as an example, it’s mandatory managed Medicaid, except if you are using an LTSS service, for example, or if you have private-duty nursing that falls under the GAPP program, which falls outside of the MCO,” Jim Melançon, senior vice president of government affairs at Aveanna Healthcare, said during the presentation.

Melançon noted that managed Medicaid is the predominant service delivery model that most states are following.

Ultimately, providers should pay attention to services covered in their states, how rates are established and their state’s budgeting process.

“The market is going to dictate what the rate is going to be for your workers, and that’s what you will – as a provider – have to look at,” Melançon said.

The post Sorting Through The Complex HCBS Medicaid Landscape appeared first on Home Health Care News.

In March, the U.S. Centers for Medicare & Medicaid Services (CMS) approved a request from one state to allow more personal care service delivery within acute care facilities. Though not yet widespread, the amendment could open doors for providers and patients needing personal care in alternative settings in the future. 

One change to a Medicaid program may seem negligible, but with Medicaid program directors talking to each other as much as they do – and taking feedback while applying it to their own state programs – the change is worth paying attention to. 

Essentially, this option for additional personal care to be provided to patients in acute care settings was granted during the COVID-19 pandemic, with Rhode Island later on getting approval to make the amendment permanent through a 1115 demonstration.

“CMS has determined that Rhode Island’s demonstration amendment is likely to assist in promoting the objectives of the Medicaid statute by increasing access to high-quality medical assistance coverage for certain low-income individuals,” the agency wrote in a letter to the state’s Medicaid director.

Home- and community-based services (HCBS) providers can now step in and offer care that would otherwise not be a part of a hospital’s care plan. For instance, certain individuals may have needs that hospital staff are unequipped to address, such as dementia or other behavioral challenges, Damon Terzaghi, the director of Medicaid advocacy at the National Association for Home Care & Hospice (NAHC), told Home Health Care News.

That’s one reason that, in particular, the IDD provider and advocacy community was pushing for these types of amendments during the peak of the pandemic. Eventually, the option was included in the CARES Act.

The more care patients can receive in an acute setting, the better. More specifically, the more care they can receive tailored to their specific needs, the better.

Home-based care providers can now step in and elevate the level of care and comfort for patients in Rhode Island.

“The real impetus of this policy is to make things easier for the participant,” Terzaghi said.

He offered a few examples. Take an older adult with dementia who has broken his or her hip and been placed in the hospital. The cognitive issues may lead to challenges that hospital staff are unable to address, potentially leading to a worse health outcome for the patient. At that point, behavioral health care or personal care could be provided by an outside home-based care agency.

Providers wouldn’t be delivering care the hospital is already obligated to provide, but instead augmenting care plans for these types of individuals.

“Having a caregiver that may be a little bit more trusted – or that’s familiar with their own routines, nuances or the specifics of their behaviors – would be extremely valuable in alleviating potential adverse incidents,” Terzaghi said. “Helping the individual calm down, making sure that their needs are matched, and those sorts of things. And then also, just having that person in the hospital helps get them back into the community faster and smoother.”

Popularizing the concept

Rhode Island is a trailblazer in its adoption of Medicaid-funded personal care services in acute care settings, but it’s likely other states will adopt, if there’s positive outcome data driven by the change.

“When a state makes an innovation and has a good experience with it – meaning there’s good cost effectiveness attached to it – other states adopt it,” Darby Anderson, executive vice president and chief government relations officer at Addus HomeCare Corp. (Nasdaq: ADUS), told HHCN. “In this day and age, state Medicaid directors talk, and so do the more programmatic people involved with the programs.” 

Frisco, Texas-based Addus provides home care services that primarily include personal care services that assist with activities of daily living (ADLs). It also delivers hospice and home health services, with its overall footprint stretching across 217 locations in nearly two dozen states.

If more states did adopt the flexibility, it would be a major win for patients, for one. But it would also be a tailwind for providers and payers, though to what extent remains unclear.

Anderson believes the flexibility is already one worth advocating for, but doesn’t see a direct line yet to an upturn in business for HCBS providers.

But, symbolically, further adoption would be a win for the HCBS provider community. There would also be ancillary benefits to providers’ care plans, Terzaghi said.

“What this does do is it increases predictability, it increases the ability of the providers to schedule and assume that, even if this individual does ultimately get admitted to a hospital setting for whatever reason, we’re not going to have to scramble and reallocate hours,” he said. “It’s much more predictable for everyone across the board. I think it’s definitely beneficial to providers, I think that it will increase predictability, and also potentially lead to some revenue upside.”

With the flexibility implemented, the next step is to wait and see how things turn out for Rhode Island.

If HCBS providers, patients and hospitals all benefit – through better outcomes and perhaps some cost savings – it’s the sort of change that could bring on a ripple effect across the country.

“What were the outcomes we saw? Did the benefit to the individuals, providers and the state ultimately demonstrate through the provision of these services?” Terzaghi said. “And if so, will this be something that catches on nationwide and is made permanent? I think that those are really important questions to examine further.”

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