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.”

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“Individuals go into the role of being a caregiver, normally because they have a passion for helping other people,” HHAeXchange President Stephen Vaccaro told Home Health Care News. “They recognize the value that it’s bringing and how fulfilling that could be, and that becomes an area they want to move into. It’s a difficult job, so you must be passionate about it.”

Founded in 2008, New York-based HHAeXchange is a home care management software company focused on the Medicaid home- and community-based services (HCBS) population.

About 60% of the 4,000 caregivers surveyed said that positively impacting their patients’ health and wellbeing is the biggest motivator for their work. Additionally, 57% of caregivers reported taking extra time to record patient observations after each visit, motivated by the knowledge that it could improve their clients’ care.

Moreover, 91% said the relationships they form with the people they care for increase their job satisfaction.

“That was a 17% increase from our survey last year,” Vaccaro said. “I think it speaks to that human bond that individuals form with each other and how important and special that is. That’s what matters to caregivers at the end of the day.”

Another important finding from the survey was caregivers’ interest in receiving professional training as an additional resource to improve their job satisfaction and longevity. Specifically, caregivers said they would be interested in receiving training on reducing stress, understanding how to treat patients with specific illnesses and using additional medical equipment.

“When taking care of an individual, it’s not always easy to focus on yourself,” Vaccaro said. “Training and strategies for interacting with the client’s families or dealing with different illnesses or medical equipment go a long way in helping caregivers do their jobs better. Because ultimately, that’s what’s most important to them. This goes a long way in retaining and bringing more workers into the field. Pay and benefits can’t always be the answer; it has to be a fulfilling job.”

Unsurprisingly, survey data also showed that 34% of respondents found pay to be the most challenging aspect of being a caregiver.

“Are caregivers going to be paid relative to the value they bring? Sadly, no,” Vaccaro said. “The value that they bring is so immense. Many of these individuals would not be able to live their lives at home without these caregivers. You can’t put a dollar amount on that. However, we need to work together as stakeholders in the industry to elevate the role of the caregiver. The industry is evolving, and the stakeholders are beginning to understand the value and importance of caregivers. That needs to continue.”

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Now, over a dozen members of Congress are trying to give states additional funding to help expand those HCBS programs further.

“A vast majority of seniors and people with disabilities would prefer to receive care at home or in their communities,” U.S. Sen. Bob Casey (D-Penn.) said in a statement. “Unfortunately, because of our nation’s caregiving crisis, home and community-based care has become increasingly difficult to access. By stabilizing and investing in the caregiving workforce, we can better provide seniors and people with disabilities with a real and significant choice to receive care in the setting of their choosing.”

Casey, the chairman of the U.S. Senate Special Committee on Aging, introduced the Home and Community-Based Services Relief Act this week with 17 of his colleagues. The legislation would provide dedicated Medicaid funds to states for two years in hopes of stabilizing their HCBS service delivery networks.

The legislation also aims to help states recruit and retain HCBS direct care workers.

Currently, all 50 states and Washington, D.C., provide HCBS to eligible adults 65 and older — and certain other populations — through a combination of state plan benefits and waivers. However, the specifics of those waivers and benefits — what those services are, who is eligible, how they are eligible, how many people are served, etc. — vary greatly from state to state.

What also varies by state is what specific HCBS services are covered under a state’s Medicaid waiver. Federal Medicaid statutes require states to cover institutional long-term services and supports (LTSS) and home health care, but the rest of HCBS are optional.

A vast majority of seniors on Medicaid want to receive LTSS in their home. Due to staffing shortages and a lack of funding, it’s becoming more difficult for HCBS providers to offer their services to more seniors.

If the new bill passes, states would receive a 10-point increase in the federal match (FMAP) for Medicaid for two fiscal years to bolster HCBS.

Those federal funds could be used to increase direct care worker pay, provide paid family or sick leave, and pay for transportation expenses for members receiving HCBS care.

Katie Smith Sloan, the president and CEO of LeadingAge, urged every lawmaker to sign the “important legislation.”

​“Older adults and families are facing a crisis in access to care in HCBS and across aging services – a situation that, given our aging population, will only grow more dire if no action is taken,” Sloan said in a statement sent to Home Health Care News. “Home health providers are already forced to reject referrals due to workforce shortages, an extremely competitive labor market, financial pressures and drastic cuts to Medicare payment rates in 2023. The kind of support Sen. Casey’s bill offers for providers of home health and other services is massively needed to keep the country’s ability to support older adults intact.”

The current administration has been vocal about its support for HCBS.

When National Association for Home Care & Hospice (NAHC) President Bill Dombi left a home health care-focused hearing in D.C. earlier this month, he did so buoyed by that support.

“Candidate Biden on the campaign trail was really pushing for home care, and he’s mentioned home care in his two consecutive State of the Union addresses, the first time ever from a president to bring about home care,” Dombi told HHCN earlier this month. “That focus on home care was home- and community-based services, be it Medicaid or otherwise, and a focus also on the workforce. A focus on the direct care workers and their compensation levels and the waitlists for beneficiaries in Medicaid waiver programs for home care services.”

HCBS woes

The new legislation comes a day after the Kaiser Family Foundation released a comprehensive survey that showed all states are dealing with workforce shortages in HCBS, and 49 states are dealing with shortages in more than one area of the workforce.

According to the survey, all 50 states and D.C. reported shortages of HCBS workers. the majority of which were among direct support professionals, personal care attendants, nursing staff and home health aides.

To combat those shortages, states have overwhelmingly increased provider payment rates while also developing or expanding worker education and training programs.

“Such shortages may reflect ongoing effects from the pandemic, but also low levels of compensation coupled with increasing requirements of providers,” KFF wrote in its survey summary. “In the summer of 2021, HCBS providers in focus groups reported that their jobs had high physical demands and mental demands that were often ‘overwhelming.’ The groups described their wages as low, particularly given the demands of their jobs; and how staffing shortages made their jobs harder because they may not know if they would be able to leave work at the end of their shift.”

These shortages are now leading to crippling closures across the country.

Within the last year, 43 states experienced permanent closures of HCBS providers. Those closures were most common among adult day health programs (32 states), group homes (29 states) and assisted living facilities (27 states).

Between 10 and 20 states reported closures of supported employment providers (19 states), providers working in enrollees’ homes (18 states), community mental health providers (14 states) and home health agencies (11 states).

Possible solutions

A majority of the states (48) told KFF that they have increased payment rates for HCBS workers in order to address these woes.

However, state budgets are already tight to begin with. Expanding worker education and training programs, incentive payments for recruiting and offering paid sick leave for workers are some other options states have used to address these issues.

“States also reported several other types of initiatives to strengthen the workforce including creating platforms or support systems to connect job seekers with employers and positions, launching a social media campaign, and providing outreach to prospective employees,” KFF wrote.

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