The 1999 Blueprint for Action represents our legislative agenda for the National Association for Home Care (NAHC). This book contains a discussion of the Association's priorities and other important issues and recommendations concerning home care and hospice. It was prepared through a series of meetings with home care and hospice professionals and a survey of the NAHC members, reviewed by the Government Affairs Committee and approved by the NAHC Board of Directors at its January meeting.
The Blueprint is organized within sections according to the membership's priorities. All items in the Blueprint contain a discussion of the issues and the Association's recommendations concerning home care and hospice. The Blueprint reflects NAHC's continued dedication to ensuring that high quality home care and hospice services are fully available to all individuals in need.
The Blueprint is divided into five sections. The first major section relates to the preservation of access to home care and hospice benefits under Medicare, Medicaid, Title XX Social Services Block Grants, and the Older Americans Act. The second section deals with vital issues related to maintaining the quality of home care and hospice services, consumer and caregiver protection, and fraud and abuse issues. The third section concerns ensuring availability of home care and hospice services. This section includes recommendations on long-term care, hospice benefits, and care of persons with AIDS. The fourth part of the Blueprint concerns recruitment and retention of home care and hospice personnel This section addresses the crisis in personnel shortages as they affect home care and hospice. The fifth and final section provides basic background and statistics on home care for the reader. A subject index is also included.
The central goal of NAHC's legislative agenda is the humane, cost-effective provision of high-quality home care to all who require it, whether they are needy, infirm, elderly, children, or disabled. NAHC believes that quality home care and hospice are the right of all Americans. It believes that home care and hospice are both a humane and cost-effective alternative to institutionalization. Home care and hospice reinforce and supplement the care provided by family members and friends and encourage maximum independence of thought and functioning, as well as preservation of human dignity.
This document has been produced by the National Association for Home Care, a professional association that represents the interests of nearly 6,000 home health agencies, home care aide organizations and hospices, as well as the caregivers who every year provide services to more than five million Americans. It is hoped that this document will be helpful to the Congress in its deliberations and that it will result in the enactment of legislation to improve the quality of life for millions of Americans.
Key Legislative Issues
The following issues will be the focus of the National Association for Home Care's (NAHC) legislative activities in 1999. Central to NAHC's mission is to preserve the integrity of the Medicare program, to protect the rights of both patients and providers, and to maintain a policy of zero tolerance for fraud and abuse.
- Reform the Interim Payment System (IPS)
- Protect Home Health Agencies from Financial Instability Resulting from IPS Overpayments - Congress should enact legislation which grants agencies overpayment forgiveness for payments in excess of their IPS limits, provided that the care was necessary and appropriate, and that the costs are deemed reasonable by the Medicare program.
- Reform per Beneficiary Limits by Restoring Access to Home Care Services for Patients with More Intensive Care Needs - Congress must restore access to the home health benefit for patients with more intensive care needs by including some mechanism for patient or case mix adjustments or outlier payments for sicker patients.
- Eliminate the Mandatory 15% Reduction in the Limits - Congress should eliminate the mandatory October 1, 2000, 15% reduction in the limits.
- Increase Home Health per Visit Cost Limits - Congress should restore the calculation of the limits to 112% of the mean, rather than 106% of the median, lift the application of the freeze to the cost limits, and require that the data used to calculate the limits be based on all types of home health agencies, including hospital-based programs.
- Only Prorate the IPS Per Beneficiary Limits when Patients Are Served by More than One Agency in Order to Circumvent the Limits - Congress should require that HCFA use the prorating provision only in situations where agencies are transferring or prematurely discharging patients for purposes of intentionally circumventing the limits.
- Reimburse Agencies for OASIS Costs and Schedule OASIS Implementation to Meet Data Needs - Congress should direct HCFA to require home health agencies to begin implementing OASIS based on the amount of advance time and data actually needed for the development of a home health Prospective Payment System. Congress also should provide for reimbursement of the full costs agencies will incur in implementing and continued management of OASIS. Finally, initial OASIS data submission requirements should be limited to Medicare patients.
- Ensure Development and Implementation of an Equitable PPS with an Adequate Case Mix Adjustor
Congress should ensure HCFA's development and implementation of an equitable PPS with an adequate case mix adjustor that is representative of the current home care delivery system, without an arbitrary 15% reduction, by October 1, 2000. HCFA should be required to develop, with the input of providers and case-mix study contractors, an aggressive timetable and plan for implementation of a sound PPS.
- Congress Should Closely Oversee HCFA Administration of the Home Health Benefit - Congress should actively oversee HCFA's administration of the home health benefit, paying particular attention to: HCFA compliance with public notice and comment requirements; coordination and consistent application of policies among HCFA central, regional offices, and fiscal intermediaries (FI); and HCFA's adherence to Congressional intent and direction when implementing changes to the home health program. Congress should also closely study the impact of HCFA's actions, and those of its regional offices and FIs, on providers' abilities to function and on beneficiary access to needed care within the Medicare program. Congress should conduct in-depth oversight hearings to examine these areas of concern.
- Restore the Full Market Basket Update to Home Care Payments
- Enact a Comprehensive Home- and Community-based Long-term Care Program
The federal government must take the lead in providing adequate coverage of long-term care needs for the physically disabled, chronically and terminally ill, and cognitively impaired. The foundation of this initiative should be home- and community-based care and hospice.
- Protect the Current Home Care Benefit
- Oppose Coinsurance for Medicare and Medicaid Home Health Services - Congress should oppose any copay proposal for home health services so that individuals who need medical care are not discouraged from using in-home services that could reduce the need for more costly institutional care.
- Oppose Proposals to Bundle Home Health and Hospice Payments in with Payments from Other Providers - Congress should reject proposals to bundle home care payments into hospital DRGs or other provider payments on the grounds that it would cause major disruption to the health care industry, be anti-competitive, increase the federal regulatory burden, and erect a new and unnecessary barrier to beneficiaries' access to quality care.
- Ensure Reasonable Application and Implementation of Home Health Surety Bond Requirements - Congress should repeal or significantly alter the surety bond requirements, applying them only to agencies with poor records of repayment to Medicare and/or Medicaid or to new agencies wishing to participate in the program(s). Congress must also ensure that requirements are reasonable so that legitimate, reputable home care agencies can meet them.
- Enact a New Homebound Definition That Does Not Restrict Access to the Medicare Home Care Benefit - Congress should enact a homebound definition that ensures access and eligibility to the home care benefit based upon the beneficiary's functional limitations and clinical condition, rather than an arbitrary number of absences from the home. The definition should guarantee that reasonable absences from the home for medical and nonmedical purposes would not disqualify an individual from home care eligibility. The definition should not put additional administrative burdens on home care providers beyond documentation of the beneficiary's functional and clinical status.
- Ensure Protection for Home Care Agencies from Year 2000 (Y2K) HCFA Problems
Congress should provide HCFA with authorization to issue emergency no-interest payments to health care providers where Medicare claims processing, payment, and payment rate updates are delayed as a result of incomplete or erroneous Y2K computer changes. Congress should also adjust reimbursement limits and payments for home health agencies and hospices to allow the respective organizations to complete Y2K compliance efforts.
L1. PROTECT HOME HEALTH AGENCIES FROM FINANCIAL INSTABILITY RESULTING FROM IPS OVERPAYMENTS
L2. RESTORE ACCESS TO HOME CARE SERVICES FOR PATIENTS WITH MORE INTENSIVE CARE NEEDS
L3. ELIMINATE THE MANDATORY OCTOBER 1, 2000 15% REDUCTION IN HOME HEALTH REIMBURSEMENT
L4. INCREASE HOME HEALTH PER VISIT COST LIMITS
L5. RESTRICT THE PRORATION OF THE PER BENEFICIARY LIMITS TO WHEN PATIENTS ARE SERVED BY MORE THAN ONE AGENCY TO CIRCUMVENT LIMITS
L6. FULLY REIMBURSE HOME HEALTH AGENCIES FOR COSTS OF IMPLEMENTING OASIS; SCHEDULE OASIS IMPLEMENTATION BASED ON PPS DATA NEEDS
L7. ENSURE DEVELOPMENT AND IMPLEMENTATION OF AN EQUITABLE PPS WITH AN ADEQUATE CASE MIX ADJUSTOR
L8. CLOSELY OVERSEE HCFA ADMINISTRATION OF HOME HEALTH BENEFIT
L9. RESTORE THE FULL MARKET BASKET UPDATE TO HOME HEALTH PAYMENTS
L10. ENACT A COMPREHENSIVE, HIGH-QUALITY HOME- AND COMMUNITY-BASED LONG-TERM CARE PROGRAM
L11. OPPOSE COPAYMENTS FOR MEDICARE HOME HEALTH SERVICES
L12. OPPOSE PROPOSALS TO ìBUNDLEî HOME HEALTH AND HOSPICE BENEFIT PAYMENTS WITH PAYMENTS TO OTHER PROVIDERS
L13. ENSURE REASONABLE APPLICATION AND IMPLEMENTATION OF HOME HEALTH SURETY BOND REQUIREMENTS
L14. ENACT A HOMEBOUND DEFINITION THAT ENSURES ACCESS AND ELIGIBILITY FOR NEEDED HOME HEALTH SERVICES
L15. ENSURE YEAR 2000 PROTECTIONS FOR HHAs
L16. SUSPEND THE PER BENEFICIARY LIMIT UNDER THE INTERIM PAYMENT SYSTEM
L17. INSTITUTE MINIMUM PAYMENT FLOOR FOR MEDICARE HOME HEALTH SERVICES
L18. MAINTAIN PERIODIC INTERIM PAYMENT FOR HOME HEALTH AGENCIES AND HOSPICES
L19. INCREASE PER BENEFICIARY LIMITS FOR NEW SOLE-COMMUNITY PROVIDERS AND NEW PROVIDERS IN UNDERSERVED AREAS
L20. MODIFY THE REPORTING OF VISIT TIME REQUIREMENT UNDER IPS
L21. REINSTATE VENIPUNCTURE AS A SKILLED SERVICE FOR HOME HEALTH COVERAGE
L22. MAINTAIN COVERAGE FOR INDIVIDUALS WITH ONGOING HOME CARE NEEDS
L23. MAINTAIN AGGREGATION OF HOME HEALTH COST LIMITS
L24. REINSTATE THE PRESUMPTIVE STATUS FOR HOME HEALTH WAIVER OF LIABILITY
L25. PROHIBIT USE OF SAMPLING AUDITS
L26. SUPPORT MEDICARE COVERAGE OF DRUG THERAPIES IN THE HOME
L27. PERMIT DIRECT PROVIDER APPEAL RIGHTS
L28. REINFORCE BENEFICIARY DUE PROCESS RIGHTS
L29. ESTABLISH PROCEDURES FOR PROVIDER APPEALS OF SURVEY AND CERTIFICATION DEFICIENCIES
L30. AMEND THE EMPLOYEE RETIREMENT INCOME SECURITY ACT TO REQUIRE DIRECT PROVIDER APPEAL RIGHTS
L31. REQUIRE INCLUSION OF HOME CARE COVERAGE FOR EARLY MATERNITY DISCHARGE
L32. OPPOSE USER FEES FOR SURVEY AND CERTIFICATION ACTIVITIES
L33. CLARIFY THE A TO B SHIFT TO PROTECT AGENCIES FROM THE IMPACT OF SEQUENTIAL BILLING
L34. CLARIFY THE DEFINITION OF BRANCH OFFICE
L35. EXEMPT ENTITIES THAT PERFORM WAIVED TESTS FROM CLIA CERTIFICATION
L36. OPPOSE DECREASING HOSPICE REIMBURSEMENT FOR DUALLY ELIGIBLE PATIENTS RESIDING IN NURSING FACILITIES
L37. ENSURE THE PORTABILITY OF ADVANCE DIRECTIVES
L38. REQUIRE DEMONSTRATION PROJECTS TO STUDY SPECIAL SERVICES AND FINANCING OF END-OF-LIFE CARE
L39. ENSURE THE PROVISION OF MEDICARE COVERAGE OF PAIN MEDICATIONS
L40. ENSURE ACCESS TO MEDICATIONS NECESSARY FOR PAIN CONTROL
L41. ELIMINATE MEDICARE PROVISION REQUIRING HOSPICE SOCIAL WORKER TO PRACTICE UNDER THE DIRECTION OF A PHYSICIAN
L42. COORDINATE GOVERNMENT REVIEWS OF HOME HEALTH AGENCIES TO REDUCE PAPERWORK BURDEN
L43. STRENGTHEN THE HOME HEALTH AIDE TRAINING REQUIREMENTS CONTAINED IN OBRA-87 AND APPROPRIATELY REIMBURSE AGENCIES FOR TRAINING COSTS
L44. IMPLEMENT INFORMAL COST REPORT REIMBURSEMENT APPEALS
L45. PERMIT SUITS AND AUTHORIZE PUNITIVE DAMAGES AGAINST FISCAL INTERMEDIARIES FOR BAD FAITH MEDICARE DECISIONS
L46. AUTHORIZE PUNITIVE DAMAGES LAWSUITS FOR BAD FAITH INSURANCE DECISIONS
L47. ENSURE THE RIGHT OF HOME HEALTH AGENCIES AND HOSPICES TO SELECT THEIR FISCAL INTERMEDIARIES
L48. CLARIFY STANDARDS FOR THE IMPOSITION OF INTERMEDIATE SANCTIONS ON HOME HEALTH AGENCIES UNDER THE MEDICARE ACT
L49. LIMIT RETROACTIVITY OF FISCAL INTERMEDIARY DETERMINATIONS
L50. PRESERVE INDEPENDENCE OF ADMINISTRATIVE LAW JUDGES
L51. ENACT A NATIONAL STANDARD FOR PROCESSING ALJ APPEALS
L52. IMPROVE ACCESS TO JUDICIAL REVIEW FOR MEDICARE CLAIMS
L53. ENSURE AND ENFORCE BENEFICIARY CHOICE IN ALL HEALTH CARE PROGRAMS
L54. PRESERVE THE PUBLIC NATURE OF THE MEDICARE PROGRAM
L55. ALLOW EXPEDITED JUDICIAL REVIEW OF MEDICARE REIMBURSEMENT DISPUTES
L56. PROTECT CONSUMERS FROM ERRONEOUS SERVICE AND COVERAGE DETERMINATIONS
L57. STRENGTHEN REQUIREMENTS FOR PUBLICATION OF POLICY CHANGES BY HCFA
L58. OPPOSE COST-SHARING BY MEDICAID BENEFICIARIES
L59. REQUIRE COVERAGE OF HOME CARE, HOSPICE, AND PERSONAL CARE SERVICES IN ANY MEDICAID REFORM
L60. ESTABLISH FEDERAL MINIMUM STANDARDS FOR HOME HEALTH COVERAGE UNDER MEDICAID
L61. IMPROVE REIMBURSEMENT REQUIREMENTS FOR HOME HEALTH UNDER MEDICAID
L62. PROHIBIT STATES FROM USING COSTLY INDIVIDUAL CLAIMS REVIEW IN THIRD-PARTY PAYOR RECOVERY EFFORTS
L63. EXTEND SPOUSAL IMPOVERISHMENT PROTECTIONS TO HOME CARE
L64. ALLOW HOME CARE AGENCIES TO SERVE AS CASE MANAGERS IN FEDERALLY FUNDED PROGRAMS
L65. REINSTATE ACCESS TO MEDICAID IN WELFARE REFORM
L66. MONITOR SECTION 1115 MEDICAID WAIVER INVOLVEMENT IN CHRONIC CARE
L67. ENSURE HOME CARE REPRESENTATION ON MEDPAC
L68. ENSURE ACCESS TO QUALITY SERVICES IN MANAGED CARE PLANS
L69. ENACT HOME CARE SPECIFIC ANTI-FRAUD MEASURES
L70. ENCOURAGE APPROPRIATE COLLABORATIVE ROLE OF PHYSICIANS IN HOME CARE
L71. ENSURE ACCESS TO HOME CARE AND FULL FEDERAL FUNDING IN ANY PROPOSALS TO REQUIRE MEDICAL DOCTORS IN HOME HEALTH AGENCIES
L72. OPPOSE EFFORTS TO STRIP BANKRUPTCY PROTECTIONS FROM HEALTH PROVIDERS
L73. ESTABLISH SAFE HARBORS AND DE MINIMUS THRESHOLDS UNDER THE FALSE CLAIMS ACT
L74. OPPOSE IMPLEMENTATION OF FEES FOR MEDICARE OVERPAYMENTS AND AUDITS
L75. REQUIRE FEDERALLY FUNDED CRIMINAL BACKGROUND CHECKS AND ESTABLISH A NATIONAL REGISTRY SYSTEM
L76. PROHIBIT GAG RULES IN MANAGED CARE CONTRACTS
L77. REQUIRE CONTRACTORS OF CARE IN THE HOME TO ENSURE SUPERVISION AND SUPPORT OF PARAPROFESSIONALS
L78. ENHANCE CONSUMER PROTECTIONS FOR HOME CARE RECIPIENTS
L79. DEVELOP QUALITY OF CARE STANDARDS FOR CONSUMER-DIRECTED CARE
L80. PREVENT VIOLENCE AGAINST HOME CARE WORKERS
L81. COORDINATE HOME CARE AIDE AND NURSING HOME AIDE TRAINING REQUIREMENTS
L82. ESTABLISH FEDERAL MEDICAID STANDARDS FOR PERSONAL CARE SERVICES
L83. MODIFY PREEMPTION PROVISION OF THE EMPLOYEE RETIREMENT INCOME SECURITY ACT
L84. ELIMINATE ELDER ABUSE
L85. AUTHORIZE THE IRS TO ISSUE RULINGS REGARDING INDEPENDENT CONTRACTOR STATUS
L86. ENCOURAGE STATES TO ADOPT A LICENSURE LAW AND REGULATIONS FOR HOME CARE AGENCIES
L87. RESTORE PERSONAL ASSISTANCE SERVICES AS A MANDATORY MEDICAID SERVICE
L88. PROVIDE SUFFICIENT HOME CARE PAYMENTS SO THAT AGENCIES CAN PROVIDE APPROPRIATE WAGES AND BENEFITS TO PARAPROFESSIONALS
L89. PROVIDE ACCESS TO MEDICARE HMO ENROLLMENT INFORMATION
L90. ALLOW PAYMENT FOR HOME HEALTH SERVICES FOR THOSE RECEIVING ADULT DAY CARE
L91. SUPPORT TAX INCENTIVES FOR FAMILY CAREGIVERS
L92. MAKE HOME CARE MORE ACCESSIBLE TO PERSONS IN RURAL AREAS
L93. REQUIRE MEDICARE PAYMENT FOR TELEHOME CARE SERVICES
L94. MAKE ALL PROFESSIONAL HOME HEALTH SERVICES QUALIFYING SERVICES
L95. PROMOTE RESPITE CARE FOR FAMILY CAREGIVERS
L96. INCLUDE IN-HOME RESPITE CARE IN THE MEDICARE HOSPICE BENEFIT
L97. CREATE A NUTRITIONAL SERVICES HOME HEALTH BENEFIT
L98. CREATE A PHARMACEUTICAL SERVICES HOME HEALTH BENEFIT
L99. PROTECT PATIENTS' FREEDOM TO CHOOSE
L100. ENACT INSURANCE MARKET REFORMS
L101. ENSURE COVERAGE OF ACUTE AND LONG-TERM HOME CARE AND HOSPICE
L102. PROVIDE ACCESS TO MEDICAID ENROLLMENT INFORMATION
L103. CREATE A COMPREHENSIVE HOME CARE BENEFIT IN THE MILITARY HEALTH SERVICES SYSTEM
L104. MAKE THE PROGRAM FOR PERSONS WITH DISABILITIES SUPPLEMENTAL TO STANDARD CHAMPUS BENEFITS
L105. FINANCE A HUMANE SYSTEM OF CARE FOR PERSONS WITH AIDS
L106. MANDATE HOSPICE COVERAGE UNDER MEDICAID
L107. PROVIDE APPROPRIATE MEDICAID REIMBURSEMENT OF CARE INTENSIVE SERVICES
L108. IMPROVE HOME CARE SERVICES FOR VETERANS
L109. PRESERVE RIGHTS OF HOME CARE PATIENTS IN FEDERALLY QUALIFIED HMOs
L110. REAUTHORIZE AND AMEND THE OLDER AMERICANS ACT
L111. ESTABLISH MEANINGFUL STANDARDS FOR PRIVATE LONG-TERM CARE INSURANCE
L112. ALLOW LPNs TO SUPERVISE HOME CARE AIDES
L113. INCREASE AVAILABILITY OF THERAPISTS AND OTHER HOME CARE AND HOSPICE PERSONNEL
L114. PROVIDE FINANCIAL ASSISTANCE TO HOME CARE AGENCIES TO IMPLEMENT ELECTRONIC CAPABILITIES
L115. REQUIRE MEDICAL RESIDENTS AND INTERNS TO HAVE HOME CARE AND HOSPICE EXPERIENCE AS PART OF THEIR GRADUATE MEDICAL EDUCATION
L116. ALLOW FAXED CERTIFICATES OF MEDICAL NECESSITY FOR HOME MEDICAL EQUIPMENT
L117. ENSURE REASONABLE APPLICATION AND IMPLEMENTATION OF HOME MEDICAL EQUIPMENT SURETY BOND REQUIREMENTS
L118. PROTECT ADEQUATE REIMBURSEMENT FOR DURABLE MEDICAL EQUIPMENT AND PARENTERAL AND ENTERAL NUTRITION
L119. REPEAL CONSOLIDATED BILLING FOR SNF SERVICES
L120. MAINTAIN INDUSTRY INPUT IN HCFA'S MEDICARE INHERENT REASONABLENESS AUTHORITY
L121. ENSURE ADEQUATE REIMBURSEMENT FOR DURABLE MEDICAL EQUIPMENT AND PARENTERAL AND ENTERAL NUTRITION
L122. ENCOURAGE STATES TO ADOPT A LICENSURE LAW AND REGULATIONS FOR HOME MEDICAL EQUIPMENT PROVIDERS
L123. PROTECT HOME OXYGEN SERVICES MEDICARE REIMBURSEMENT
L124. REPEAL HOME MEDICAL EQUIPMENT COMPETITIVE BIDDING DEMONSTRATION PROJECTS
L125. ALLOW PAYMENT FOR HOME HEALTH SERVICES FOR CENTER-BASED CARE FOR TECHNOLOGY-DEPENDENT CHILDREN
L126. IMPROVE REIMBURSEMENT REQUIREMENTS FOR PEDIATRIC HOME CARE UNDER MEDICAID
L127. REQUIRE DEMONSTRATION PROJECTS TO STUDY SPECIAL SERVICES AND FINANCING OF END-OF-LIFE CARE FOR PEDIATRIC PATIENTS
L128. PROVIDE ACCESS TO HOME CARE SERVICES FOR PEDIATRIC PATIENTS WITH MORE INTENSIVE CARE NEEDS
L129. PRESERVE RIGHTS OF PEDIATRIC HOME CARE PATIENTS IN FEDERALLY-QUALIFIED HMOs
L130. ENACT A HOMEBOUND DEFINITION THAT ENSURES ACCESS AND ELIGIBILITY FOR NEEDED HOME CARE SERVICES FOR PEDIATRIC PATIENTS