The home care community generally approves of the Ensuring Access to Medicaid Services (Access NPRM) rule, which the Centers for Medicare & Medicaid Services proposed in April. However, it is unequivocally opposed to one provision — that 80% of Medicaid payments for three home- and community-based services (HCBS) be spent on direct care worker wages.
In pages of comments to CMS, which were due last week, providers drilled down into why they don’t believe CMS should set a Medicaid threshold for workers’ compensation. Arguments include: The requirement lacks statutory authority; there is no data to support it; it contradicts CMS HCBS quality efforts; it would be challenging to enforce; it would create inequities within and across state lines; and it would disproportionately hurt small and rural home care providers.
“Existing low reimbursement rates, coupled with the current administrative requirements and the new pressures from the different parts of this rule will create an untenable situation for many providers,” William Dombi, president of the National Association for Home Care & Hospice, and Vicki Hoak, CEO of the Home Care Association of America, said in a 65-page letter to CMS. “This results in the proposed rule being counterproductive to its stated purpose. Instead of increasing access to Medicaid services, the sum of the rule’s components will put providers, including many rural providers and small businesses that serve ethnic and cultural minority populations, out of business, thus exacerbating access challenges.”
A fear of ‘unintended consequences’
LeadingAge, which represents nonprofit home care providers, also expressed opposition to the so-called “80/20” provision.
“While we are supportive of the intent, this threshold is not tenable for LeadingAge members, and we fear unintended consequences including erosion of service quality, inadequate clinical support for direct care staff causing unnecessary stress on front line staff, and access issues — the antithesis of the goal of the Access Rule,” Georgia Goodman, director of Medicaid policy for LeadingAge, said in a letter to CMS.
Flaws of the provision include a failure to give providers enough room in their budgets to cover necessary costs, such as training and supervision. It also would require more federal dollars, she said.
“As mission-driven providers of aging services – our members are already teetering on the edge by offering these services through the Medicaid program,” Goodman said. “This proposal would make most if not all of them reconsider whether they could continue to provide care.”
Dearth of data for HCBS proposal
The provision fundamentally lacks data to support it, the three provider groups argued. Only two states — Illinois and Minnesota — implement a similar pass-through, and both have set thresholds below 80%. Pushing up the worker pay requirement thresholds would result in a reduction to administrative expenditures. For example, just a rise from 77% to 80% would result in a 15% reduction to administrative expenditures, Dombi and Hoak said.
“In Medicaid programs that already operate on razor thin margins and often struggle to find funding to pay for all the required, let alone desired, quality and health and welfare functions, a 27% or even 15% reduction to administrative expenses would be devastating,” they wrote.
Despite the groups’ criticisms of the worker wage requirement, they offered support for other provisions in the proposed rule, such as payment rate transparency, the requirement for states to report on a national set of HCBS quality measures and the establishment of an HCBS Grievance System.
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