AHCA/NCAL Strongly Voice Concerns about Medicaid HCBS Waiver Policies

AHCA/NCAL submitted comments to CMS on August 4th in response to an Advanced Notice of Proposed Rulemaking (ANPR) regarding the agency's intent to publish proposed amendments to the regulations implementing Medicaid home and community based (HCB) services waivers under Section 1915(c) of the Social Security Act. 

The National Center for Assisted Living has been working with CMS on this issue for more than a year and have had some success in getting CMS to look at the issue differently.  But any comments to CMS would be appreciated. 

In response to the ANPR, AHCA/NCAL’s main concerns are as follows:

-- Attempts to define what qualifies as a community-based setting may limit beneficiary choice by excluding some types of assisted living providers or homes for people with developmental disabilities (DD) from the Medicaid HCB program;
-- Combining target populations may lead to a loss of access to Medicaid services for beneficiary groups that are less politically powerful than others; and
-- Combining target populations such as persons with mental illness with persons with DD or frail seniors in waivers may increase the risk of inappropriate placement of vulnerable populations, as well as create safety issues.

AHCA/NCAL recommended that CMS should:

-- Continue gathering stakeholder input, including several stakeholder meetings, before defining what qualifies as a community-based setting so as to ensure that there are no negative, inadvertent consequences for Medicaid beneficiaries.
-- Ensure that beneficiaries have choice of the entire spectrum of long term care settings and ensure that attempts to define community-based settings do not limit that choice.
-- Acknowledge that assisted living communities must meet care and regulatory standards under state law that help ensure resident safety and that these standards typically do not apply to beneficiaries receiving services in their own homes.
-- Not use the number of residents in a setting as a factor in determining whether a setting is considered institutional or community-like.
-- Acknowledge that assisted living communities offer residents a wide variety of opportunities for community integration while maximizing independence, privacy, choice, and freedom of action, and respecting the rights and needs of other residents.
-- Continue working with the Center for Excellence in Assisted Living (CEAL) and take into consideration a white paper on what person-centered care means in the assisted living context soon to be published by CEAL.
-- Acknowledge that Medicaid’s failure to pay for room and board in assisted living settings creates a payment gap that makes it difficult to provide private apartments in many states.
-- Not attempt to mandate exact congruency between standards applying to 1915(i) and 1915(c) programs since the levels of care under the two programs are set at different points.
-- Develop safeguards ensuring that politically weaker target groups do not lose access to services and that target groups are not inappropriately mixed in residential settings and thereby exposed to harm, if states are allowed to mix target populations under Medicaid waivers.

Click here to read the AHCA/NCAL comments to CMS about this issue.  You have until August 21st to make comments.  Send your comments to the following:

Ms. Cindy Mann
Director Center for medicaid and State Operations
Center for Medicare and Medicaid Services
200 Independent Avenue, S. W.
Room 310,H2
HHH Building
Washington, DC 20201

KHCA/KCAL is continuing to monitor this situation and we have several meetings set up with the Congressional Delegation during their recess to discuss this unacceptable rule.  Please contact Cindy for more information., cluxem@khca.org  If you have an opportunity to see your Congressional folks during the recess let them know about this rule.

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  Tell Congress to Stop Medicare Cuts to SNFs in Health Care Reform

As members of Congress return to their districts for the August recess, it is critical that you contact them immedidately to oppose the massive cuts to nursing facility Medicare rates that are being prepared to proposed to pay for the cost of the health care reform legislation being considered in Washington. 

Our national affliate, the American Health Care Association (AHCA), has sent out an urgent alert kicking off their SAVE OUR SENIORS grassroots campaign to edudcate Congress about the impact of the $32 billion in cuts to skilled nursing homes included in the America's Health Choices Act of 2009.  The Act contains billions of dollars of cuts to SNF Medicare rates over the next 10 years that would threaten quality and jeopardize thousands of jobs.

Kansas Health Care Association urges you to take the following steps through KHCA website:

Send a letter to your Senators and US Representatives today by visiting the KHCA website.
Call you Senators and US Representatives today!  Click here for the phone script to assist you.

Use talking points.  Please use AHCA's feedback form to provide AHCA with any information you received from your communications.

Please ask you Members of Congress to stop proposals that further cut nursing home care.  This is an opportunity to educate Congress on the impact cuts of this magnitude will have on patients and providers.

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  Medicare Rate Calculator- AHCA Tool

This calculator is being provided to allow members to estimate the impact to their facility (or facilities) of the provisions of the final Medicare SNF PPS rule, effective October 1, 2009, and the provisions of America’s Affordable Health Choices Act (H. R. 3200).  For comparison purposes, the Medicare rates that would have been paid if no changes had been made to the payment system are also provided.  These rates are referred to as “Current System”.  All tabs are formatted for printing.

Go to AHCA's website to use the tool.  Click here to reach the site.

** After this exercise we hope you are concerned enough to call your Congressional office.

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  Important Documents Relating to the Medicaid Integrity Program

By now I hope that all of you are familiar  with the permanent RAC program and AHCA’s efforts to bring you in depth information on this initiative and the activity in all four RAC regions.  The RACs however are merely one component, albeit a big one, of the overall CMS Medicare Integrity program.  There are so many -- too many --  Medicare and Medicaid claims reviewing entities out there and providers  need to know who is sending you a demand for records and why.  

AHCA is developing a comprehensive grid of the Medicare and Medicaid Integrity programs and fraud and abuse initiatives -- program goals, authority etc.  We will be providing that shortly. 

From Dianne DeLaMare:

As reported previously, CMS held its first special open door forum in July to discuss its Medicaid Integrity Program (MIP), which was created to review provider actions to determine whether fraud, waste or abuse occurred or may have occurred; audit provider claims; identify overpayments; and educate state or local employees involved in Medicaid administration, providers, managed care entities, beneficiaries and others with respect to payment integrity and quality of care. During that forum that was a lot of new information presented, including the statistic that 29 percent of the on-going and upcoming Medicaid audits will be directed towards long term care facilities. To obtain a copy of a transcript of that forum see attachment “bulfileMIP…”

In follow-up to the July CMS Open Door Forum, AHCA/NCAL staff reached out to CMS, and spoke to Robb Miller, Director, Field Operations, and CMS staff responsible for coordinating the Medicaid audits nationwide.  Mr. Miller shared three separate documents; which are not on CMS’ website yet, but will be eventually.  The first document, Medicaid Integrity Program (MIP), Provider Audits: Frequently Asked Questions, July 2009, covers basic questions/answers in the areas of:  background and general information; identifying providers for audits; audit process and procedures, interaction with law enforcement, Medicaid data used for audits, overpayment identification and recovery, interaction with the provider. 

The second document, Medicaid Integrity Program A to Z, discusses the MIP since its inception within the Deficit Reduction Act of 2005 (DRA).  The last document, Medicaid Program Integrity Review Schedule 2010-2012, is the timeline of when CMS expects to be in each state reviewing and auditing Medicaid payments.  These important documents highlight the actions that the federal government is and will be taking in the next several years.  Medicaid Integrity Contractors (MICs) are already in 40 states, so if you haven’t had interactions with them yet, you will in the near future. 

If you have questions or concerns contact  Dianne De La Mare.
Dianne J. De La Mare
VP, Regulatory Affairs
1201 L Street NW
Washington, DC 20005
202/898-2830
ddmare@ahca.org

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  CMS Solicits For-Profit Organizations to Establish Prepaid Fully-Capitated PACE Programs

Recently, CMS published a notice in the Federal Register to encourage organizations to submit proposals to establish a for-profit Program of All-Inclusive Care for the Elderly (PACE) demonstration project. The notice encourages for-profit organizations to submit proposals to demonstrate that they can successfully provide comprehensive, coordinated care for the frail elderly under a prepaid fully-capitated payment system over a three year period. Proposals must be submitted by Monday July 26, 2010.

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