NGA Submits Medicaid Reform Proposals to Administration
March 11, 2014 03:40 PM
On February 24, the National Governors Association (NGA) delivered its proposals for Medicaid reform to President Obama and Secretary of Health and Human Services Kathleen Sebelius. These recommendations echo the NGA Health Care Sustainability Task Force Report (the Report), which the NGA approved February 22. The Council discusses the major provisions in the Report relating to Medicaid home care below.
About the Task Force
The Health Care Sustainability Task Force (the Task Force) is a bipartisan group of twelve (12) governors, including: Gov. Mike Beebe (D-AR); Gov. Robert Bentley (R-AL); Gov. Jerry Brown (D-CA); Gov. Andrew Cuomo (D-NY); Gov. Dennis Daugaard (R-SD); Gov. Bill Haslam (R-TN) (co-chair); Gov. Gary Herbert (R-UT); Gov. John Kizhaber (D-OR) (co-chair); Gov. Martin O’Malley (D-MD) (ex-officio); Gov. Susana Martinez (R-NM); Gov. Brian Sandoval (R-NV) (ex-officio); and Gov. Peter Shumlin (D-VT).
The staff advisory committee of the Task Force met from May through November 2013. The Task Force developed four key areas for recommendations to Congress and the Centers for Medicare and Medicaid Services to reform health care in the states:
1) federal support of state health care innovation;
2) Medicare-Medicaid Enrollees (Dual Eligibles);
3) long-term services and supports (LTSS); and
4) payment and delivery reform.
Federal Support of State Health Care Innovations
The Task Force made the following recommendations, among others, regarding federal support of state health care innovations:
Standardize and streamline the state plan amendment and waiver proposal process in Medicaid innovation;
Streamline the ability for states to replicate previously approved state amendments and waivers adopted by other states;
Create a “path to permanency” for Medicaid waivers, especially those relating to managed care; and
Create clearer objectives in quality and performance for state health care transformation proposals.
The National Council on Medicaid Home Care – a NAHC affiliate - supports streamlining the waiver and state plan amendment process, as it will improve access to home and community-based services (HCBS).
As stated in a previous Council brief in January, the new HCBS final rule published by CMS is a good step in this direction. Additionally, supporting permanent waivers in managed care will reflect the growing reality that managed long-term services and supports (MLTSS) is here to stay.
Medicare-Medicaid Enrollees (Dual Eligibles)
The Task Force made the following recommendations, among others, regarding dual eligibles:
Have a formal process to pursue dual eligible demonstrations, like the D-SNP demonstrations, that are alternatives to the Financial Alignment Initiative (FAI);
Create a federal/state workgroup to determine policies that would allow states to serve more populations in their dual eligible programs and to allow states more flexibility to finance these programs, for example through a shared savings component;
Develop through the National Committee for Quality Assurance standardized “a standard set of performance measures around quality and access”;
Devise more effective policy for “pre-duals,” i.e. “high-cost Medicare beneficiaries with chronic conditions and functional impairments who are in the process of spending down personal assets to Medicaid eligibility” and “partial duals” who are enrolled in the Medicare Savings Program through Medicaid; and
Establish various cost-shifting proposals which would limit cost-shifting from Medicare to Medicaid.
The Council agrees with these recommendations. Given the numerous delays and complaints surrounding the FAI, encouraging alternatives to the FAI - like Minnesota's, for example - is critical to ensure improved coordination of care and expenditures for the dual population. An alternative option would be extremely beneficial for states like Arizona and Tennessee, who dropped the FAI as they perceived it in direct competition with their D-SNP programs.
The Report is also rightfully concerned about quality and access, as stakeholders claim the FAI compromises quality of care through the incentives of its shared savings program, as well as continuity of care. Having a standard set of performance measures would best enable states to measure the effectiveness of dual eligible initiatives.
Long-Term Services and Supports (LTSS)
The Task Force made the following recommendations, among others, regarding LTSS:
Provide incentives for family caregiving and/or private reimbursement of LTSS;
Create a demonstration project for providing LTSS to disabled individuals who choose to work; and
Allow states to expand Medicaid coverage to provide personal care attendants and other support services for disabled individuals and those with incomes up to 300 percent of the federal poverty line regardless of level of care.
While promising, the Council is wary of the Report’s recommendation for incentives for family caregiving. In October’s AARP Solutions Forum, Modernizing Medicaid: Putting Home and Community-Based Services on Equal Footing with Nursing Homes, both Josefina Carbonell, Senior Vice President for Long-Term Care and Nutrition, Independent Living Systems LLC, and Charles Milligan, Jr. Deputy Secretary, Health Care Financing, Maryland Dept. of Health & Mental Hygiene, stressed the importance of incentivizing family caregiving.
As recent legislation in Georgia highlights, family caregivers are unpaid, overworked, and undertrained, and are thus not adequately equipped to provide the care that is demanded of them. While New Hampshire is moving forward with a modest family support program, the Council is concerned that even such modest proposals of incentivizing family caregiving will “mission creep” into unreasonable demands on family caregivers, such as those in Georgia.
Regarding LTSS, the Task Force also called for several pro-HCBS measures:
Include HCBS programs, such as the Balancing Incentive Program and the Money Follows the Person demonstration, into a streamlined, permanent optional state plan benefit;
Consolidate waivers with a uniform quality measure set, and streamline reporting requirements;
Provide FFP to states that provide HCBS that reduces inpatient care and corresponding costs to the non-Medicaid population; and
Provide limited FFP for room and board in community-based residential alternative settings
As the Council recently reported, the new HCBS rule clarified that room and board costs are unallowable under the HCBS 1915(i) state plan benefit, with limited exceptions such as temporary food and shelter in a facility providing respite care services. The Council supports the increased reimbursement of room and board costs wherever possible, so long as CMS does not reimburse these at the expense of other home care payments.
Some of the LTSS recommendations specifically support re-balancing:
Further incentivize HCBS within the Balancing Incentive Program by giving states enhanced federal financial participation (FFP) if they increase utilization of HCBS as a percentage of total LTSS beneficiaries; and
Make HCBS, not institutional care, the default LTSS, and make it so individuals must be informed of HCBS and affirmatively choose institutional care before being placed in an institution.
The Council supports greater incentives for HCBS. Incentivizing HCBS will further improve availability of these services, as stakeholders will be more motivated to participate in rebalancing. One thing that the NGA did not mention in its Report which would further HCBS, and rebalancing specifically, would be to support legislation and/or funding that would eliminate HCBS waitlists in states.
Payment and Delivery Reform
The Task Force made the following recommendation, among others, regarding payment and delivery reform:
Give states enhanced FFP if their integrated models (i.e. health homes, Medicaid accountable care organizations)) demonstrate federal savings.
To see the full report, click here.
The Council encourages providers to continue advocating for favorable Medicaid reforms through their state associations, as well as through state and federal governments. Home care providers are encouraged to keep abreast of developments with regard to waivers, dual eligibles, HCBS, and payment and delivery reform in their states and nationally, and to contact the Council with any questions or concerns.