Interestingly enough, it appears that conflicting state policies about cost-effectiveness and consumer choice are surfacing in the most bizarre fashion. Before I give you descriptors of these cats we are herding, however, I want to give you some assurances:  

First, we are working on your behalf to provide explanations, to challenge, to demonstrate inconsistencies, and to advocate for better ways to accomplish certain goals. Some of this advocacy may not be evident to you because change is still sweeping over you like a giant wave—but we ARE working on these issues. 

 

Secondly, try not to panic! We are developing tools, education and resources to help you manage and will make those available as quickly as possible. 

 

Finally, know that you are not alone in this minefield of new policies and payment structures - that is why we are building in “venting” or discussion opportunities during the next six-twelve months. The best way to problem solve is to learn from your peers. 

What is Going on Here—or what cats are being herded??

1. The nearly final version of the Elderly Waiver Customized Living ratesetting tool will soon be released. Some version of this tool is a requirement of our federal waiver approval - we can no longer have 87 different mechanisms for establishing rates for home and community-based services under the waiver program. Department of Human Services lead.

2. The Home Care Regulatory workgroup is reconvening after a hiaitus about the length of a pregnancy! Their intent is to draft a set of updated proposed regulations that helps to streamline the various versions of home care licensure. Department of Health lead.

3. Waiver-wide ratesetting study to look across all of the home and community based waiver programs for consistent methodologies: CADI, TBI, DD, EW. Department of Human Services lead.

4. Provider Enrollment and Enhanced Provider standards workgroup. Again, to advance consistency across all of the state waiver programs for the elderly and disabled and because the state is “taking over” some of the county functions. Department of Human Services lead.

5. Quality Commission: discussion on defining and measuring quality consistently for all waiver programs. Department of Human Services lead.

6. Home and Community Based Services “Expert Panel” is the stakeholder group that has been meeting for over a year, including representation by the Association. This panel is overseeing the work of the consultants hired by the state to develop a state profile of aging and disabilities services under a contract with the Center for Medicare and Medicaid Services (CMS). Department of Human Services/Center for Medicare and Medicaid Services lead.

7. COMPASS: the Department of Human Services developed and is testing a universal comprehensive assessment tool (Compass) specifically to overcome the “silo” effect, so that all persons accessing long term care services are assessed using the same tool.  The initial testing demonstrated a lengthier assessment time, which is one of the issues along with the fact that health plans now play an increasingly large role in assessments.

8. Health plans have started to express concerns over their financial obligation under the waiver program—it appears their recent experience of serving the “higher” needs clients at the cap didn’t match their actuarial projections, so at least one health plan is holding back on elderly waiver contracts. The policy challenge is that health plans are only liable for 180 days of nursing facility care but are liable “forever” under the elderly waiver. We are meeting with DHS on this issue.

9. Defining what constitutes an institution versus home and community-based setting is coming up in a variety of venues. Several of the waivers (CADI and TBI) include language on size and concentration—total number of individuals living in the home shall not exceed four. The issue is they don’t define “home” as a specific setting but now want to do so within DHS—a new stakeholder group is forming on this issue.   This is the main question: Does the size restriction apply to the building or individual apartments within the building??

10. CMS recently issued advance notice of proposed rulemaking (ANPR) announcing its intention to later publish rules that would 1) define what can qualify as a community-based setting under 1915(c) HCB waivers and 2) remove barriers to states combining target population groups under such waivers. Our main concerns are that attempts to define what qualifies as a community-based setting may exclude some types of assisted living providers from the Medicaid program and that combining target populations may lead to a loss of access to Medicaid for groups. Comments are due to CMS by August 21st. 

11. I wanted to get to a top ten list of things that can keep us all up at night but there are eleven instead. There continues to be pressure on “quality” issues/consumer confidence issues within housing with services settings so we have established a task force to once again review the various ways we could be proactive (regulatory/statutorily or education or awards/customer satisfaction) with recommendations coming to the Board this fall.

Whew! 

We did predict several years ago that as more government dollars went into housing with services settings that there would be an increasing number of government officials who care what we do and how we do it  -- but I don’t think we expected this level of interest! 

Your thoughts?