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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Heath care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

National Council on Medicaid Home Care Analyzes Why States are Dropping and Delaying Dual Eligible Demonstrations

June 17, 2013 04:06 PM

According to a report released on May 29, fourteen (14) out of the twenty-six (26) states enrolled in the in the Financial Alignment Initiative for Dual Eligibles (the Demonstration) are either dropping out of - or delaying – the Demonstration.  The Demonstration is a partnership between the Centers for Medicare & Medicaid Services (CMS) and states to integrate care for and reduce costs of their dual eligible populations. 

Three of the six states that have already signed MOUs with CMS - California, Massachusetts, and Washington - have already delayed implementation of the Demonstration. 

Below a closer look at the seven states that withdrew their Demonstration proposals, including Arizona, New York, Hawaii, Tennessee, Oregon, New Mexico, and Minnesota.  The Council discusses the various reasons behind the states’ decisions, and their plans for moving forward. 


On April 10, 2013, Thomas Betlach, director of the Arizona Health Care Cost Containment System (AHCCCS), wrote a letter to Ms. Melanie Bella, the director of the Medicare-Medicaid Coordination Office (MMCO) at CMS, in which Arizona officially withdrew its proposal to pursue the Demonstration. 

Reasons: Arizona sited six (6) factors contributing to its decision, including:

1) Arizona’s preoccupation with two major and complex managed care plan procurements with October 1 start dates

2) More managed care plan procurements are scheduled during the Demonstration period

3) “Significant political and operational challenges” regarding implementation of the Affordable Care Act

4) All current health plans are Medicare Advantage dual eligible special needs plans (D-SNPs)

5) “43,000 members are currently aligned with contracted health plans”

6) The lack of integration for substance abuse and general mental health benefits for some members 

Mr. Betlach also mentioned some additional “risks” which effected the decision, specifically:

1) Disagreements regarding supplemental benefits and capitation rates

2) The early start date of the Demonstration, and

3) The uncertain future following the Demonstration 

Next Steps: In lieu of the Demonstration, Mr. Betlach stated that Arizona will leverage its managed care model to pursue greater Medicare-Medicaid alignment.  Arizona will also be building on its existing D-SNP model, and will partner with other states and the National Association of Medicaid Directors to that end. 

To see the full letter, click here.

New York

On March 21, 2013, Gregory Allen, director of the Division of Program Development and Management of the Office of Health Insurance Programs of the New York State Department of Health, wrote a letter to Ms. Bella in which New York officially withdrew its proposal to pursue the Demonstration via a Medicaid Fee for Service (MFFS) model.  New York is still pursuing a capitated managed care form of the Demonstration.

Reasons: In the letter, Mr. Allen mentioned two reasons for dropping the MFFS Demonstration.  First, the letter indicated that New York could not manage both Demonstrations (MFFS and capitated managed care) at the same time.  Second, New York wished to pursue greater flexibility for timing of the managed care Demonstration.

Next Steps: New York will still pursue a capitated managed care Demonstration.

To see the full letter, click h​ere.


Reasons: In February 2013, Hawaii decided to withdraw its Demonstration proposal after it determined that it could not start the Demonstration until 2015, which violated the terms of the Demonstration.

To see the full story, click here.

Next Steps: Hawaii will continue to engage CMS in discussions.


On December 21, 2012, Darin J. Gordon, director of TennCare, wrote a letter to Ms. Bella in which Tennessee officially withdrew its proposal to pursue the Demonstration.

Reasons: Mr. Gordon cited reimbursement methodology as contributing to the state’s “greatest concerns” surrounding the Demonstration.  Specifically, he took issue with reimbursement being less than existing Medicare Advantage plans, while the Demonstration also demanded “higher expectations around quality and coordination of care.” 

The letter also commented that the Demonstration plans would be required to compete with D-SNP and other Medicare Advantage plans, while being reimbursed less and having more requirements surrounding quality measures.  He also said the emphasis on savings would cause plan to lose their focus on continuity of care to beneficiaries and continuity of payment to providers.

Mr. Gordon also stated that requiring Medicare medical necessity standards both services covered traditionally in both Medicare and Medicaid could result in over-utilization of Medicaid benefits such as home health therapies, and level 2 nursing.  The letter also criticized the quality withhold as not sufficiently being tied to specific quality measures. 

Furthermore, the letter claimed the rate setting process would funnel savings out of the state.  Instead of savings used to support rebalancing efforts to HCBS in the state, the letter asserted that the federal government would get “a significant portion of those savings.”

Mr. Gordon also expressed concern that CMS did not adequately address a couple of key issues in the Demonstration agreement (MOU).   Rate development, for example, occurred after the signing of the MOU.  Mr. Gordon found it unreasonable to have the plans negotiate provider agreements while not knowing how much the state and CMS would pay them.  Mr. Gordon felt that the MOU didn’t address many other major issues, but are instead pushed back to subsequent three-way contract discussions with CMS, the state, and the plans.

More broadly, Mr. Gordon objected to the Demonstration’s “lack of clarity,” short timeline to implementation, and other “competing priorities” such as the state’s Medicaid managed care organization (MCO) competitive procurement process.

Next Steps: Tennessee plans to strengthen Medicare Improvements for Patients and Providers Act (MIPPA) agreements with D-SNPs, and is considering requiring all Medicaid MCOs to become D-SNPs in counties where they operate.  Tennessee will also plan to make a decision regarding its Medicaid MCO competitive procurement process.

To see the full letter, click here.


On October 30, 2012, Susan Otter, project director of CMS Design Contract for Integrating Medicare/Medicaid for Individuals Dually Eligible, wrote a memo to “Coordinated Care Organizations [CCOs] and Stakeholders” in which she stated that the Demonstration “is not likely to be financially viable for Oregon’s CCOs and their affiliated Medicare Advantage Plans.”  Oregon had formally submitted its Demonstration proposal to CMS in May 2012.

Reasons: The letter stated that the Demonstration’s blended rate structure did not make it financially viable for Oregon.  Ms. Otter noted that Oregon’s particular circumstances of very low Medicare fee-for-service spending, coupled with a sizable Medicare advantage market currently serving Oregon’s dual eligibles, made the Demonstration incompatible with Oregon’s needs.

Next Steps: Oregon now will determine, in discussing with stakeholders, if a “modified demonstration” with CMS is warranted.  It is currently in discussions with CMS on the matter.

To see the full memo to stakeholders, click here.

New Mexico

On August 17, 2012, Julie Weinberg, director of the New Mexico’s Human Services Department, wrote a letter to Ms. Bella in which New Mexico officially withdrew its proposal to pursue the Demonstration.  This came a very short time after it had submitted its Demonstration proposal to CMS on May 31, 2012. 

Reasons: The primary reason why New Mexico dropped out is that in its proposal, it wanted (and failed to obtain) a carve-out for long-term services and supports (LTSS).  Specifically, the state wanted dual eligible beneficiaries under the New Mexico Developmental Disabilities (DD) waiver to obtain their regular medical benefits from the Demonstration, but their LTSS through Medicaid fee-for-service. 

According to Ms. Weinberg’s letter, a carve-out would only be approved after the state gave CMS a “rigorous strategy” showing “financial accountability among participating providers to avoid cost-shifting and ensure seamlessness for beneficiaries.”

Next Steps: New Mexico instead chose to focus on re-designing its existing Medicaid program, with a special focus on its new Centennial Care 1115 waiver, set to launch on January 1, 2014. 

To see the full letter, click here.


In June 2012, Minnesota withdrew its proposal to pursue the Demonstration.  Minnesota had submitted its final proposal on April 26, 2012. 

Reasons: Minnesota took issue with the Medicare financing in the Demonstration, arguing that reimbursement would be lower than its current reimbursements from Medicare programs. 

Next Steps: Minnesota remains in discussions with CMS for potential future Demonstration participation.

For a link to more information on Minnesota’s dual eligible integration efforts, click here.


More than half of all states enrolled in the Financial Alignment Initiative have been dropping, delaying, or revising their Demonstrations.  Reasons for dropping out of the Demonstration vary widely, but common areas of concern include: competing priorities, overly ambitions timelines, reimbursements, and the rate setting process. 

That said, home health providers can still look to the Demonstration as an opportunity to increased clinical coordination among the dual eligible population.  In addition, the Demonstration will give home health providers rebalancing opportunities, as a stronger emphasis is placed on community based systems over institutional settings. 

The Council does not see the withdrawals and delays as an indication that dual eligible managed care will not happen in Medicaid programs. Instead, this can be viewed as part of the natural path taken with such a significant reform. Further, it is possible the states are taking this approach to encourage CMS to loosen up its requirements for these demonstration programs knowing that CMS wants to see more of them.

Home health providers are encouraged to keep abreast of Demonstration developments on CMS’ website, and to contact the Council with any questions or concerns.




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