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.”

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That’s according to a recent report from the Medicaid and CHIP Payment and Access Commission (MACPAC). MACPAC makes recommendations to Congress, the U.S. Department of Health and Human Services (HHS) and states on issues affecting Medicaid.

“Variability in payment rate assumptions can incentivize workers to switch to higher-paying services, creating access challenges” Robert Nelb, principal analyst with MACPAC, wrote in the report.

Medicaid payment policies significantly impact the HCBS workforce. Much like other corners of the home-based care industry, there’s a growing shortage of HCBS workers due to high demand and headwinds exacerbated by the COVID-19 pandemic.

States have a wide variety of ways that they can pay for HCBS services.

In order to address workforce shortages, states will adjust Medicaid rates to supplement more funding for HCBS caregivers. Most states base their payment rates on wage data from sources like the Bureau of Labor Statistics.

Many stakeholders who were interviewed for the MACPAC report said that while short-term funding from the American Rescue Plan Act (ARPA) has helped to stabilize the workforce, these gains may be lost if funding is not sustained in the long term.

“Because of growing inflationary pressures, some stakeholders also expressed concern that simply sustaining ARPA rate increases may not be enough to address current HCBS workforce challenges,” Gabby Ballweg, a research assistant with MACPAC, said during a commission meeting in March.

However, increases in HCBS funding and payment rates do not always translate into equivalent wage increases for HCBS workers, Ballweg explained.

“Many states in our study used wage pass-through policies as a strategy to require providers to pay a direct share of the provider rate increases to workers,” Ballweg said.

The report also found that many states don’t regularly update HCBS payment rates.

“There is substantial variance in the frequency of HCBS rate updates across waiver programs ranging from annually to every five years,” Nelb wrote. “Public documentation of rate studies, processes and results is also highly variable. Some states publish formal rate study reports on their websites and others have very little external rate study reporting.”

One potential solution to this issue is self-directed care when a patient or client will select their own caregiver, often a family member or close friend.

In 2022, there were approximately 3.5 million HCBS workers. Of those, 2.8 million were home care workers – and about 40% of those workers are employed through self-direction.

MACPAC leaders believe that with more research and data, self-directed care could be an effective way to curb some of the workforce issues in HCBS.

“I really appreciate your attention to self-direction and looking more closely at family members as paid caregivers,” MACPAC Commissioner Jami Snyder said during the commission meeting.
“Many states, understanding the tremendous workforce challenges, decided to extend paid care to parents of minor children during the pandemic. That’s just one facet of the equation that we should definitely include in our study of this area.”

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