Major provider organizations are raising concerns about equitable post-acute care regulation, given two proposed rules that would increase transparency into states’ payment for some home- and community-based direct care workers.
Two rules proposed by the Centers for Medicare & Medicaid Services in late April sought to improve access to care and improve finance, access and quality in state managed Medicaid programs. Included were provisions to increase the transparency of Fee-for-Service payment rates for some provider types.
States would be beholden to new, standardized reporting of any proposed rate reductions or restructurings on a public website.
Every other year, they would have to publish average hourly rates paid to direct care workers providing personal care, home health care and homemaker services. Such information would differentiate between rates paid to individual direct care providers and direct care providers employed by an agency.
One of the rules, if finalized, also would establish an advisory group for workers and other stakeholders to consult on provider rates. And it would require states to demonstrate that any state-level HCBS rate changes “will not put access to care at risk.”
In comments on the draft rule submitted June 30, the American Health Care Association / National Center for Assisted Living called for a more balanced approach. The organization has repeatedly raised concerns about state Medicaid underfunding of nursing homes as providers face the threat of a potentially costly new staffing minimum. As of yet, CMS has not yet required states to report average payments to nursing homes.
“We understand the aim of the proposed rule is to increase access to covered [long-term care supports and services] and transparency, however excluding skilled nursing facility services from the discussion in the proposed rule limits the discussion of a balanced approach to LTSS access, rate adequacy and transparency,” wrote Martin Allen, AHCA’s new senior vice president of reimbursement policy. “There is a link between adequacy of payment and access to care which must be part of CMS policy for all provider types.”
AHCA asked that CMS require states to ensure that Medicaid provider payments in Fee-for-Service systems are “adequate for all post-acute providers to ensure beneficiaries have sufficient access to covered primary care and HCBS.”
‘Untenable’ managed care provision
LeadingAge, in part, focused on the managed care rate aspect of the rules. The association for nonprofit providers praised a component requiring more transparency of MCO provider level rates, saying it would help providers negotiating power by allowing them to see rates paid to peers. But other, more proscriptive changes raised concerns.
“Rate adequacy in managed care is loosely defined and in further jeopardy under these proposals,” wrote Georgia Goodman, the LeadingAge director of Medicaid policy, in a July 3 letter.
“Imposing significant changes in how states finance provider rates and require [managed care organizations] MCOs to pay adequate rates will imperil access to specific services,” Goodman warned.
The current view from state officials that providers have a choice as to whether they accept managed care contract terms or negotiate for better ones is a faulty concept, she added.
“This is untenable for providers in cases where a single MCO dominates a market and a large share of the provider’s revenue is generated from Medicaid service provision,” Goodman wrote. “Mission-driven providers across the country have determined they will do all they can to continue serving their Medicaid participants, even as rates fall or remain static in the face of rising costs and inflation. This is particularly problematic in nursing facility services where a single payer in a geographic area is not subject to market pressures, but rather enjoys an anti-competitive market promoting unequal leverage in contract negotiations.”
LeadingAge cautioned CMS to “take care in requiring significant shifts in payment policy without ensuring adequate provider level protections and significant technical assistance to states to assure ongoing access to services.”
Both provider organizations also objected to a requirement that 80% of HCBS funding be used for direct care, citing a lack of data to support the breakdown and some cost exclusions.
See additional coverage of the proposed rules in other McKnight’s publications:
McKnight’s Senior Living:
CMS’ spending requirement in HCBS rule ‘not the right approach,’ senior living advocates say
Proposed federal quality measures could exacerbate providers’ financial woes, groups warn
McKnight’s Home Care:
Home care groups detail criticism of Medicaid HCBS worker wage proposal
