There might be some recourse for home-based care providers that aren’t able to meet the requirements of the “Ensuring Access to Medicaid Services” rule’s 80-20 provision.
“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.”
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