Tag: Medicare

“Did You See That” – May 2024

Federal Outlook

Tariffs? We are Talking About Tariffs?

This topic has absolutely nothing to do with health care in any way, but it could have an surprising impact on the presidential election race.

President Biden announced recently that United States Trade Representative (USTR) plans to increase tariffs significantly on $18 billion on imports of clean-energy goods from China. The increases will apply to imported steel and aluminum, legacy semiconductors, electric vehicles, battery components, critical minerals, solar cells, cranes, and medical products. The new tariff rates – which range from 100% on electric vehicles, to 50% for solar components, to 25% for all other sectors – will be implemented over the next two years.

As a refresher, because 2018 feels as close as to when the pyramids were built, in 2018 President Trump implemented sweeping tariffs, up to 25%, on over $300 billion in goods from China. These products stretched from washing machines, to apple chargers, to steel and aluminum. Trump’s goal was to pressure US manufacturers to move their supply chains out of China back to the US.

The Biden administration came to their decision after “reviewing” Trumps tariffs on China. I put “reviewing” in quotes because from my experience, the word “review” means nothing. The call for increases also came after signs that China is looking to increase production and exportation of their clean-energy goods, which has been a focal point of the Biden administration. Over the last 4 years, the Biden administration has handed out hundreds of millions in grants to increase production of EV vehicle and charging stations in the US. The early results are as good as my blood pressure after stepping on a Lego barefoot, pitiful. Demand for EVs has steadily dropped over the years, Multiple EV startups have gone under due to lack of sales, multiple automakers have rolled backed their EV development, and Tesla, the leading charging station producer, announced plans to drastically roll back their production of charging stations.

In response to Bidens tariff announcement, Trump, who calls himself the “tariff man”, said at a rally in New Jersey that if he was reelected, he would increase tariffs “200% tax on every car that comes in from those plants.” Trump would not only increase tariffs on Chinese automakers, but all cars coming imported into the US.

This sets up trade wars being a potential hot topic on the campaign trail for both Biden and Trump, who both believe in increasing tariffs on foreign goods. Now the one thing that both these men fail to realize is that the tariffs, for the most part, have not had the affect they hoped. US producers have not moved their supply chains out of China and back to the US. At best they have moved production to other countries like India; Or they passed on their increased costs of production to consumers, which hurts the consumer the most.

Alternative ideas that they should look at is creating additional tax breaks for companies that open plants in U.S., especially those that are moving production back to the US. Give out grants to teach workers to work in these types of plants, that can be making multiple products in one facility. Look to offset China’s currency manipulation by buying the Yen, making the Yen buying power stronger and the US dollar weaker, and in turn making US good cheaper and Chinese goods more expensive. Lastly, the U.S. should go back to embracing truly free trade. Free trade helps our economy grow, increases access to higher-quality, lower-priced goods, improves efficiency and innovation, and increases competition.

Federal Recap

Medicaid 80/20 Rule

Well after over a year of speculation, the Biden Administration announced their plans to make major change to the home and community services under Medicaid. CMS released their final Medicaid access rule in late April, which includes substantial changes to many Medicaid services. Some of the changes are positive, including creating a new HCBS quality reporting system and increasing payment rate transparency. But on the other side, the rule including language would require home-based care providers to use 80% of the Medicaid reimbursements they receive toward direct care worker compensation. It’s like finding out that you must work overtime the whole week for no extra pay, but at least your boss throws you a pizza party.

CMS originally released their proposed rule in April of 2023, in response to massive home care workforce shortage across the country, that have led to long wait times, with nearly 700,000 Americans languishing on waiting lists every year since 2016 according to one estimate. The rule would apply to direct care workers that provide homemaker, home health aide; personal care services, that fall under select Medicaid 1915 waiver services (MA Frail Elder Waiver & the MA Community Living Waiver) and the 1115 waiver services (MassHealth). CMS defines a direct care worker as a worker that:

  • Provide nursing services
  • Assist with ADLs and IADLs
  • Provide behavioral supports, employment supports, or other services to promote community integration.

Specifically includes:

  • Nurses (RNs, LPNs, NPs, Clinical Nurse Specialists) • Licensed or certified nursing assistants
  • Direct support professionals
  • Personal care attendants
  • Home health aides
  • “Other individuals” paid to directly provide Medicaid services that address ADLs/IADLs, behavioral supports, employment supports, or other services to promote community integration, including nurses and other staff providing clinical supervision.

CMS defines compensation as:

  • Salary;
  • Wages;
  • Other remuneration as defined by the Fair Labor Standards Act;
  • Benefits: health and dental benefits, life and disability insurance, paid leave, retirement, tuition reimbursement.
  • The employer share of payroll taxes for direct care workers, specifically including FICA taxes, unemployment insurance, and worker compensation.

The final rule allows providers up to 6 years to demonstrate compliance with the new rules, an increase from 3 from the proposal, and states have the option to offer “hardship exemptions” and give small providers a lower threshold than the 80% mandate. CMS hopes that the new rule will help to lure workers to the field and bring stability to the workforce.

HCA, along with providers across the nation, could not disagree more with the proposed 80/20 rule. HCA, along with others, submitted comments to CMS highlighting the dangerous effect that the proposed rule could have on already strapped agencies across the country. “This is a misguided policy that will result in agency closures, force providers to exit the Medicaid program, and will ultimately make access issues worse around the country. As NAHC and our partners across the home care industry have demonstrated, such a provision is not only unworkable due to the varied nature of Medicaid programs across the country, but CMS also lacks statutory authority to impose this mandate.” Said The National Association for Home Care and Hospice (NAHC). Jennifer Sheets, co-chair of the NAHC Medicaid Advisory Council (MAC) reiterated the same sentiment about the rule, “We know that CMS has good intentions and a desire to improve the lives of workers, but this policy is ill-advised and will have serious negative impacts on providers and their clients around the country.”

Swiftly after CMS released the 80/20 Medicaid access rule, Congress moved to introduce legislation that would block implementation. Rep. Cammack (R-FL-3). The bill would prevent the Department of Health and Human Services from finalizing the “80/20” rule and to prevent the Department from promulgating, implementing, enforcing, or giving effect to any substantially similar rule requiring a minimum percentage of Medicaid spending on home and community-based services (HCBS) providers be spent on compensation for direct workers. Click the link HERE like to write to your Representative urging them to support HR.8114.

State Outlook

A Billion Here, A Billion There

Budget season is officially upon us. The House recently passed their proposed$58 billion budget for FY25, that invests in K-12 education, childcare and public transit. The House proposal does not call for tax increases, seeks to push overall state spending up by about 3.3 percent, or $2 billion, and aims to drive up the state rainy day fund balance to nearly $9 billion.

Two weeks later Senate leadership released their proposed $57.9 billion budget bill for FY25. The Senate budget is similar to the House’s proposal in many ways, but also stretches to propose a pair of novel ideas: free community college and regional transit authority trips. The Senate proposal would cover another year of free school meals, pay for another year of the multi-year K-12 funding law known as the Student Opportunity Act, and direct more money to strained emergency family shelters without seeking additional systemic reforms.’ All three budget proposals — Healey’s, the House’s and the Senate Ways and Means Committee’s — seek $325 million for the emergency family shelter system. That amount would level-fund the line item compared to fiscal 2024, though Beacon Hill already agreed via a bill Healey signed in April to allow the use of $175 million from savings on shelter costs in fiscal 2025.

The Senate proposal calls for $100 million less in spending than the final $58 billion House-approved budget. That annual rate of growth would rank close to the bottom over the past decade, and it represents a marked shift from the spending spree Democrats enacted in the past two years — 9.1 percent spending increase in fiscal 2023, 6.9 percent in fiscal 2024 — with the support of Republican Gov. Charlie Baker and then Healey. The fiscal conservation comes after months of lacking revenue collection for the state.

HCA is working with our legislative champions to insert the rate clarifying bill language in the outside section of the Senate budget proposal through the amendment process. Please use THIS LINK to write to your State Senator, to urge them to co-sponsor Amendment #535, Clarifying Rate Setting Processes for Home Health and Home Care Services.

An amendment was submitted that would require quarterly reporting on wages provided through the chapter 257-line item, 1599-6903. HCA is working with our legislative champions and the Senate Ways and Means committee to block the amendment from being passed.

State Recap

HCA Licensure Bill Moved to Health Care Financing

HCA Licensure bill that would create licensure system for non-medical home care services was voted our favorably by the Committee on Rules and was sent to House Health Care Financing. HCA has continued to advocate to committee staff for the importance of passing this bill this session. HCA will provide further updates as the bill progresses through the legislative process.

State House Unveil Expansive Hospital and Industry Reform Bill

In the wake of the ongoing Steward Hospital fiasco, on Tuesday, House leadership unveiled their highly anticipated hospital oversight and industry reform bill. The Legislature’s Health Care Financing Committee on Tuesday moved to advance a redrafted, 97-page proposal that combines lessons learned from the Steward Health Care crisis, major changes to how state regulators work to contain health care spending, and new tools to deal with facility expansions and closures. Officials in House Speaker Ron Mariano’s office pitched the wide-ranging bill as the biggest effort to contain health care costs since the 2012 law that established the Health Policy Commission, the Center for Health Information and Analysis and an annual benchmark representing a goal for spending growth.

A key component of the bill aims to strengthen data-reporting requirements and consequences. Hospitals would need to disclose audited financial statements about out-of-state operations for their parent organizations, certain private equity investors, real estate investment trusts, and management services organizations. They would also face much higher fines for falling short of those requirements, boosted from $1,000 per violation to $25,000 per violation with no maximum cap. The bill additionally empowers DPH to block certain licensure or expansion approval against a system that has failed to submit appropriate financial data to the state. The redrafted legislation would also overhaul health care cost containment and management at the state level, including by changing the existing one-year benchmark to a three-year cycle. Mariano’s office said a longer time period would better account for dips and spikes in spending by individual entities.

Senate President Karen Spilka did not commit to taking up the bill in the Senate. The Senate will likely look to expand upon the proposed bill or propose their own bill that would include more prescription drug legislation and/or strengthen the Health Policy Commissions authority.

Did You See That?!? – November 2023

Federal Recap

And the Winner Is!?!?!?!

After what has felt like an eternity, the House has finally elected a new Speaker of the House……. Rep. Mike Johnson (R-LA-4). Now I imagine that a lot of you said…. Who?!?!?! When he was elected. Well, you are not alone. After multiple weeks and several unsuccessful speaker bids from some more well-known republicans, such as controversial house member, Jim Jordan and Majority Whip Steve Scalise, the GOP seemed to be running out of people to choose from, in comes Rep. Johnson. Johnson, who is a relatively new member, only in his 4th term, is not a very well-known member amongst people outside the beltway.

Johnson, who looks like a live rendition of the men’s bathroom sign figure, previously served as Vice Chair of the House Republican Conference. But Johnson is most well-known for his hardline stance on abortion, being a hardcore supporter of former President Donald Trump, and for not certifying the 2020 election. Many political pundits have noted that previous candidates, such as Jordan and Scalise, had something that Johnson did not. Political enemies within the GOP. Due to their very public personas and appetite for making media catching comments, Jordan and Scalise both have made a few hard-core enemies with the GOP, that have publicly said that they would never vote for them no matter what. Johnson seems to not have that problem; his biggest appeal was that he has limited beef with fellow GOP members. Mix that with support from Trump, voting fatigue, and I would hope some embarrassment, led to Johnson being named the 56th Speaker of the House, which also makes him one of the most important GOP members in Congress.

CMS Releases Final Rule for Home Health Payments

A couple weeks ago, CMS released its CY 2024 home health final payment rule. The final rule institutes an estimated aggregate increase to 2024 home health payments of 0.8 % ($140M) compared to 2023 payments. This is a reversal from the proposed rule issued in June that would have cut home health payments in the aggregate by 2.2%. The 0.8% increase reflects a payment update of 3% and fixed dollar loss ratio (FDL) increase of 0.4%. These increases are offset by a -2.89% permanent behavioral assumption adjustment (which was originally proposed as a -5.1% cut).

All told, in the short term, this final rule offers significant relief to the industry for 2024. However, CMS and MedPAC continue to maintain their assertion that home health agencies were overpaid from 2020-2022 which leaves potential for future claw backs in the coming years.

The reversal of the proposed cuts would not have been possible without all of you. The Alliance is greatly appreciative of all the members that join our advocacy efforts over the last year, which include sending hundreds of advocacy emails to members of Congress and submitting comment letters to CMS proposed rule. We are especially grateful to the members that traveled with Alliance staff to Washington, D.C. twice in the last six months to participate in over 20 meetings with members of Congress and their staff. As proved by the final rule, your persistence and collective voice was heard. Obviously, there is more work to be done to prevent future cuts or claw backs – but for today, we breathe a sigh of relief.

House Subcommittee on Health Holds Hearing on Medicaid 80/20 Proposed Rule

Last Wednesday, the House Energy and Commerce Subcommittee on Health held a hearing on Medicaid 80/20 proposed rule and nursing home staffing requirements. As a refresher, in June, Centers for Medicare and Medicaid Services (CMS) proposed requiring at least 80% of Medicaid payments to home health agencies for personal care, homemaker and home health aide services go toward direct care workers, rather than company overhead or profits. The Subcommittee on Health held a hearing to examine the potential impact of the proposed rule.

Chairman Rep. Brett Guthrie (R-KY-2) lead the charge during the hearing, arguing that the proposed rule would cause an undue burden on agencies and in the end would impact patient access to vital care. “Biden’s unfunded mandates would restrict access to care for vulnerable population” said Chairman Guthrie. He went on to say that “finalizing the Access Rule would also force 93 percent of all home care agencies to reduce or limit their ability to accept new referrals.” Other committee members along with multiple witnesses that were brought in to testify before the committee, backed up Chairman Guthrie’s comments. Only a few committee members argued for the proposed rule, arguing that the rule would help to increase pay for workers thus encouraging more workers to come to the field. If you would like to see a recording of the hearing, please use this LINK.

Look Ahead

Time to Balance the Budget

Late on Tuesday night, in a surprising turn of events, the House of Representatives passed Speaker of the House, Mike Johnson proposed two-step continuing resolution (CR). The plan does not include budget cuts or aid for Israel. Under the two-step strategy — which Johnson and others have dubbed a “laddered CR”, would keep the government funded at current funding levels until Jan. 19, while the remaining spending bills would go on a CR until Feb. 2.

The passing of this bill marks a pretty big victory for the newly elected Speaker. But, while the bill garnered broad support from both sides of the isle, passing 336-95, with more Democrats voted for the measure than Republicans, some far-right members of the GOP voiced their frustration with the proposal. They are unhappy that Johnson worked with Dems and that the CR did not include the steep spending cuts and border-security measures they sought. These members are the same members that in September ousted former Speaker Kevin McCarthy after he made a similar deal with Democrats to fund the government through mid-November.

They’re not looking to oust Johnson over it. But some conservatives are privately entertaining other ways to retaliate. One tactic under discussion is the same one they used against McCarthy: holding the House floor hostage by tanking procedural votes. “There is a sentiment that if we can’t fight anything, then let’s just hold up everything,” said Rep. Ralph Norman (R-S.C.), one of several frustrated Freedom Caucus members who has huddled with the speaker multiple times this week.

The spending package now heads to the Senate, where Democratic and Republican leaders have voiced support. To prevent a shutdown, the Senate and Republican-controlled House must enact legislation that President Joe Biden can sign into law before current funding for federal agencies expires at midnight on Friday.

State Recap

Healey Administration Unveils Comprehensive Housing Plan

On Wednesday, Governor Healey unveiled a five-year, $4.12 billion housing bond bill.  The Affordable Homes Act is filled with funding and policy reforms aimed at spurring much-needed production of new units, upgrading the aging and neglected public housing stock, and converting state land into housing-ready plots. Governor Healey previously campaigned on addressing the state’s growing housing crisis.

In a summary of the bill that was provided to reporters, the bill includes substantial investment to support the production, preservation and rehabilitation of more than 65,000 homes statewide, as well as 28 policy riders. One of the biggest changes it proposes is letting local officials charge transfer fees of 0.5% – 2% on property sale, that would be paid by the seller, which would be used fund affordable housing development. The threshold would be either $1 million or the median single-family home sales price for the county, whichever is greater. Healey’s office estimated the fee, if adopted, would affect “fewer than 14 percent of all residential sales.” In addition, the bill would create a new Homeowner Production Tax Credit, which aims to incentivize construction of homes targeted at potential middle- and low-income owners. It would also make permanent the Community Investment Tax Credit while boosting its cap on donations from $12 million to $15 million. Healey’s office estimated that all together the housing package could lead to creation of more than 40,000 new housing units, chipping away at a shortage that has previously been estimated at roughly 200,000.

Many of the plan’s key provisions will be controversial in the eyes of municipal governments that prize local control of zoning, as well as in some corners of the real estate community. It will need to navigate a gantlet of committees and leaders on Beacon Hill, many of whom have been skeptical of big-ticket housing reform in the past. Healey plans to complement the legislation with a trio of executive orders creating a housing advisory council, standing up a commission to examine streamlining housing production, and calling for a study to identify surplus public land that can be used for housing.

Look Ahead

Holiday Slumber

Yesterday marked the last day of formal session for 2023, which means that state legislators will go into their holiday slumber till 2024. After a pretty chaotic couple of months, with the state legislature acting like college students trying to cram for finals, legislators will now be in informal session until at least January 3rd, 2024. Legislation is rarely passed during informal session, because under state rules, it only takes a single no vote for a bill to fail. During this time the legislature will continue their discussions on a supplemental budget package and a long term care bill focused around nursing homes and prescription costs.

HCA will use this time to educate members about our legislative priorities. HCA will be holding a State House Advocacy Day on January 30, 2024, where will be inviting legislators to meet with member agencies to learn about home care and the vital work that you all provide. If you would like to participate, please email Harrison Collins, at hcollins@thinkhomecare.org.

The Rundown – July 2023

State Recap

HCA Provides Testimony at Elder Affairs Hearing

On June 19th, HCA provided verbal testimony (Add Testimony HERE) at a Massachusetts state Elder Affairs Committee Hearing. HCA provided testimony on H.640/S.397, An Act to Improve Infection Control in Massachusetts Home Care, which would direct EOHHS to establish a mandatory infection control training program for personal home care attendants and all home care employees.

During the hearing we made it clear that we do not support the bill and raised our concerns with bill as drafted. We explained that this bill would prove to be duplicative with existing infection control requirements established at the federal level and in ASAP contracts. In addition, we strongly encouraged that the bill be re-written so that the text clearly clarifies that home care agencies should be allowed to conduct the training, if infectious control training is required.

If you would like to submit your own written comments on the bill, testimony may be submitted to the Committee via email to committee joseph.russo@mahouse.gov and victoria.halal@masenate.gov.

Budget, What Budget? No Movement on State Budget

I think state legislators are taking The Kink’s song “Sunny Afternoon” a little too seriously. Once again state legislators failed to pass an annual state budget for FY24 by the June 30th deadline, resulting in the state legislator passing a supplemental budget to fund the government through July. This has become a common practice for the legislature, as they have not passed an annual budget on time since 2011. For reference of how long ago that was the last Harry Potter movie came out that year, Instagram had just come out, and Osama Bin Laden was killed. to summarize, THAT’S A LONG TIME AGO. Hell, I was still in school in 2011, I won’t say what level of school, but I’ll just say that I was 4 inches shorter in 2011 than I am now.

The legislature has taken a more relaxed approach in recent years with the budget usually being passed in mid-late July. Last year, the annual budget was not formally signed into law by then Governor Charlie Baker till July 28th. Legislators are still ironing out key discrepancy between the House proposal and the Senate proposals. At the rate they are at, I don’t expect a budget to be agreed and passed till late July at the earliest.  

Look Ahead

Joint Health Finance Committee to Hold Hearing on Rate Setting Legislation

The Joint Health Finance Committee plans to hold a hearing on Tuesday, July 25th, on numerous bills that pertain to home care services. One of the bills that is being considered is H.1195/S.755 – An Act Clarifying Rate Setting Processes for Home Health and Home Care Services. As a refresher, this bill would clarify the rate setting processes that are already in place for both home health and home care services. It would NOT set the rates or dictate the amount for future rates set by Mass Health and EOHHS. It does make the rate setting process more transparent and ensures rates set by the state follow the rate setting laws and reflect the actual operating costs incurred by home health and home care providers. In addition, it articulates the cost factors that should be included in the methodology and rate setting process including new regulatory costs and governmental mandates. Recent examples include changes in the state’s minimum wage, the Paid Family and Medical Leave Act, health insurance, employee benefits and training, and increased technology costs.

This bill has been a major focus of our advocacy efforts for the last couple years, and we would like everyone to provide testimony if possible. In all seriousness, it will only take 3 minutes of your time. I will draft a template for members to use to write their testimony to either send to the committee or to provide verbally on the day of. The more people the provide testimony, verbally or written, the stronger our voice. I will be there in person to speak to the committee on behalf of the association and if anyone would like to join me, please email me at hccollins@thinkhomecare.org.

House Proposes Nearly $700 Mil in Supplemental Spending (State House News)

House Democrats are preparing to bring forward a $693 million spending bill that would steer financial support to vulnerable hospitals, allow state energy regulators to update contracts related to a key hydroelectric transmission project in Quebec, and extend horse race simulcasting for another half-decade.

The House Ways and Means Committee on Wednesday morning opened a poll on a redrafted supplemental budget (H 3869), one day before the chamber is set to meet in its first formal session since April 26.

Of note, House Speaker Ron Mariano’s office said the bill calls for spending $180 million to support hospitals still facing pandemic-related impacts, including those that serve a high percentage of Medicaid patients.

Mariano’s office said the bill would also give the Department of Public Utilities the flexibility to approve amended transmission contracts related to the New England Clean Energy Connect (NECEC) project, which would carry hydroelectric power generated in Quebec through Maine to end points including Massachusetts.

Representatives on the House Ways and Means Committee were given until 11 a.m. Wednesday to indicate their support or opposition for the spending bill. The bill is a supplemental budget for fiscal year 2023, which ended June 30. House and Senate negotiators have not come to terms on a compromise annual budget for fiscal year 2024, which began July 1.

Federal Recap

CMS Proposes Massive Cuts to Home Health Payment Rates

On the last Friday of June, CMS published its FY 2024 home health proposed payment rule. First before I get into the proposed rule, I have to vent really quickly about how annoying it is that both federal agencies tend to release major regulations/proposed rules on Fridays, especially before holiday breaks. CMS released their proposal (though it was accidentally leaked early) in the afternoon on the FRIDAY BEFORE JULY 4th WEEKEND. Not only did this ruin my plan to leave work a little early to get a jumpstart of the long weekend, but it ruined the entire weekend because I had to read and analyze the entire proposal. Listen I understand that they do this because they want to bury proposals like this so that it doesn’t get major new coverage, but for us professionals, whose entire job are affected by these releases, it is such a slap in the face. I don’t pay my taxes that help to pay CMS staffs salaries for them to turn around and basically pull a beer out of my hand and throw a big regulatory rule at my face. It’s rude, inconsiderate, and ill argue it hurts the economy by keeping my hard-working (relative) people stuck inside reading, rather than out spending money at bars, restaurants and stores. It should be legally required that federal agencies have to release regulations/proposed rules on Mondays or at least 5 business days before a holiday break.

Alright, back to the proposal. CMS is proposing a 2.2% decrease aggregate home health payments, or an estimated $375 million less compared to 2023 levels. The proposed update would bump payments 2.7%, or $460 million, but that is completely undermined because home health agencies are being forced to absorb a 5.1% decrease, or a decrease of $870 million. As a refresher, last year CMS originally proposed a 7.85% permanent rate adjustment based on the conclusion that HHAs were overpaid in 2020 and 2021 due to provider behavior changes in coding and services provided. In the end, CMS only applied a 3.925% permanent rate reduction after objection from agencies and home care associations. At the time, CMS explained that the lower adjustment would be applied because “we recognize the potential hardship of implementing the full -7.85 percent permanent adjustment in a single year.” The 5.1% proposed rate reduction represents the remainder of the original 7.85% rate reduction that CMS calculated as warranted under its methodology for 2020 and 2021 along with an additional 1.636% for 2022, totaling 9.36% overall from the beginning of PDGM.  An early analysis indicates that the additional 2022 element to the proposed permanent adjustment is due to further visit decreases in a 30-day episode, particularly with therapy services. For an in-depth summary of the proposal rule, CLICK HERE.

CMS will accept comments on the proposed rule through Aug. 29. HCA will be submitting comments, and we strongly encourage members to submit comments as well. We will provide further updates as they develop on the proposed rule.

NAHC Files Lawsuit Against CMS and HHS

After the CMS proposed rule was released, The National Association for Home Care and Hospice (NAHC) filed a lawsuit against the Centers for Medicare and Medicaid Services (CMS) and the United States Department of Health and Human Services (HHS) challenging the validity of a change in Medicare home health payment that reduced rates by 3.925% in 2023 with significant additional cuts expected over the next several years. The lawsuit, which was filed in the District of Columbia, comes just a couple days after CMS released their proposed rule for 2024 which includes an addition additional 5.653% permanent rate cut in 2024.

In the lawsuit, NAHC argues that the methodology used to calculate the rates is flawed, and that the rate adjustment will worsen home care staffing shortages and patients’ access to care. In a statement released today by NAHC Until recently, nearly 3.5 million Medicare beneficiaries received home health services annually. Since the new payment model began in 2020, over 500,000 fewer Medicare patients have accessed home health services. According to a statement released by NAHC, they are seeking declaratory and injunctive relief including a reversal of the rate adjustments in the 2023 rule and requirement that Medicare implement the budget neutrality mandate consistent with the law. It should be noted that it could take months for the case to be heard with no timetable set. HCA will be closely following the court case and will provide updates as they unfold.

Look Ahead

With August recess right around the corner, July is usually a slower month where Capitol Hill wraps up last minute things before takin a month break. But not this year, Congress decided they wanted to set off some last second fireworks before everyone left. The big piece of legislation that everyone is talking about is the NDAA, the National Defense Authorization Act. The NDAA is a massive $886 billion must-pass bill that details the annual budget and expenditures of the U.S. Department of Defense. The NDAA is one of few pieces of legislation that usually passes with bipartisan support, and with minimal debate, but this year is very much different.

House Republicans have chosen the NDAA as the next battle ground in the culture war. Far Right Republicans have been adding countless poison pill amendments that risk driving away any chance of Democratic support. The most controversial amendment being Rep. Ronny Jackson (R-TX) proposal that would remove a Pentagon policy that allows service members to take up to three weeks of leave to travel out of state for an abortion and other “non-covered reproductive health care services.” The policy also states the Department of Defense will reimburse members for any expenses related to that travel. This rule was established in the wake of the Supreme Court decision that stripped abortion rights and left them up to individual states. Republicans argue that the new rule circumvents laws barring taxpayer money for the procedure in most cases, but language to undo this new policy could be a red line for Democrats. The abortion rule has been a major sticking point for Republicans in both the House and the Senate. In the Senate Sen. Tommy Tuberville (R-AL), who looks like the human version of Squidward, has been holding up high level defense appointments until the rule is taken out, leaving many key positions unfilled.

Other poison pill provisions revolve around Ukraine, NATO, sea-launched cruise missiles, and Buy American provisions. House Democratic leadership has signaled that if Republicans choose to move forward with any or some of these amendments (especially the abortion proposal) they would pull their support for the bill. that would leave Republicans with little wiggle room to pass the bill.

In the end the NDAA will be the central focus till they leave for August recess, with the Senate needing to pass the NDAA once it finally moves through the House. So there is still an opportunity for these people to say stupid stuff, like that being a white nationalists doesn’t make you racists, that will get everyone on Twitter and Thread (what ever that is) into a frenzy.

The Rundown – June 2023

State Recap

EOHHS Holds Hearing on Chapter 257 Rates for Certain Elder Care Services

On May 19th, HCA testified at the EOHHS Chapter 257 rate review hearing. As a reminder, EOHHS has proposed increasing rates for Enhanced Community Options Program (ECOP) Direct Services from $749.47 to $976.08 per client per month and rates for Home Care Program Direct Services from $326.35 to $424.34 per client per month, which amounts to a 30% increase to the base rate for both ECOP and Home Care Program Services.

During our testimony, HCA highlighted our concerns with the lack of transparency when it comes to the rate review process and that EOHHS should use real-time inflation data rather than projected, expected inflation data when determining cost adjustment factors (CAF). HCA wants to thank all members that submitted written testimony for the hearing, your input is very important. EOHHS still plans to meet the July 1st, 2023, deadline to promulgate the new proposed rates.

Senate Starts Debate over Senate FY24 Budget Amendment

In the end of May, the Senate started debates over amendments to their proposed FY24 budget. After 2 days of debate, the Senate has added $65.4 million in line-item spending to its $55.8 billion plan. One amendment of note that is set to pass is Sen. Patricia Jehlen amendment # 400, which would amend the Chapter 257 Rate Reserve line item 1599-6903 as follows: “By inserting after the words “any human service provider receiving revenue under said Chapter 257” the following: “, and any home care agency subcontracting with such human service providers to provide home care services,”. This amendment would specifically single out that home care providers would need to comply with the 75% pass-through requirement that is stipulated in the line item. We would like to note that this pass-through requirement is much broader than a pass-through amendment that was floated during the House budget debate, that HCA along with the Home Care Aide Council successfully blocked. HCA along with the Home Care Aide Council drafted a letter to Senate Ways and Means staff and Senator Jehlen that stipulated our concerns with the amendment.

We emphasized that the amendment is redundant since home care is already mentioned in the line item and that it has the potential to create regulatory confusion. We also noted the by including the amendment language it would single out one provider group under Chapter 257 and would raise an issue of equity. We argued that the pass-through requirement should apply to chapter 257 requirements broadly and equitably to all providers. In the end the amendment was added to the Senate budget proposal that should be passed in the coming days. Once passed by the Senate the legislature will create a conference committee to debate the differences between the house and senate bills before sending a final bill for the governors signature. HCA will continue to advocate for the amendment to not be included in the final budget proposal.

Look Ahead

State Budget

In the beginning of June, the Senate should pass their state budget proposal for FY24. Once passed, the lengthy budget process will move to the next stop, conference committee debate. In June, after the senate passes their proposal a conference committee will be formed with legislators from both the House and Senate. The committee’s purpose is to iron out the differences between both budget proposals and create one final budget proposal for the legislator to pass.

While it seems like we are getting close to the finish line, that’s far from true. It could take a couple of weeks for the conference committee to debate the differences. Even then, once it’s created and passed by the legislature, it will still need to be reviewed and approved by Governor Healey, who is allowed to send back the proposal with suggested changes. Which is a common occurrence, last year former Governor Charlie Baker sent back the legislature proposal with amended language for an outside section.

Technically, the state has until June 30, 2023, when last year’s budget runs out, to pass a new budget and continue funding the government. The state never meets this deadline and passes a supplemental budget to extend FY23 funding until they are able to pass a new budget. Last year it took till July 28th, for Massachusetts to pass their FY23 budget, making Massachusetts one of the last states to pass a budget.

I will provide another budget update next month when inevitably the FY24 budget has not been passed.

Federal Recap

Debt Ceiling Debate Rages On

The main focus of everyone on Capitol Hill has been the on-going debate surrounding increasing the debt ceiling. For a brief backstory, the debt ceiling is the maximum amount of money that the United States can borrow cumulatively by issuing bonds. The debt ceiling was created under the Second Liberty Bond Act of 1917 and is also known as the debt limit or statutory debt limit. If U.S. government national debt levels bump up against the ceiling, then the Treasury Department must resort to other extraordinary measures to pay government obligations and expenditures until the ceiling is raised again or risk a drop in the U.S. credit rating or defaulting on loans (which both would be disastrous). The debt ceiling has been raised or suspended over 78 times since 1917 with the most recent raise being in 2021. Treasury Secretary Janet Yellen has been sounding the alarms for the last couple of months that the U.S. is at risk of hitting the debt ceiling as soon as June 5, NEXT MONDAY, setting a deadline for Congress to vote to either raise or suspend the debt limit.

Since the end of April, there has surprisingly been progress in the negotiations. President Biden and Speaker of the House Kevin McCarthy struck a true compromise over Memorial Day weekend on a package to avert a disaster. The package would suspend the debt ceiling through Jan. 1, 2025, effectively moving any future debate till after the 2024 presidential election but would also reign in future government spending. Under the deal, non-defense spending, such as Medicare and Medicaid, would remain relatively flat in fiscal 2024 and increase by only 1% in fiscal 2025, 2% below a planned 3% increase in defense spending. After fiscal 2025, there would be no budget caps. One of the most contentious points of the deal is an increase to work requirements for adults that receive food stamps through SNAP. Lastly the deal stipulates that the student loan payment moratorium would be lifted this August.

While this is not exactly what both sides wanted, it is a true compromise between no cuts to spending that Dems wanted and massive cuts in spending that Republicans wanted. The biggest news is that this deal would prevent a potential economic meltdown that none of us have ever experienced. Just think about how hard life was when you had shitty credit. Now imagine if the U.S. credit rating was so bad that couldn’t even get pre-approved for a Kouls card. That is exactly what this deal would avert.

Look Ahead

Debt Ceiling

While there has been progress on the debt ceiling package, we are still not at the finish line. It wouldn’t be Congress without some superficial fanfare. Since Sunday, when text of the bill was released, Republicans and Democrats opponents of the bill in the House and Senate, mainly the house, have been SCREAMING for the last couple of days, calling this bill a shame. Republicans mad that they aren’t going farther with spending cuts, while Democrats hate the new work requirements and cuts to non-defense spending. There’s a lot of truly idiotic comments that I could write about, that just proved that there are a lot of members of Congress that only want the job for fanfare and notoriety and don’t even understand basic economics. But that would only give those members exactly what they want.

In the end all their shouting is as effective as a screen door in submarine. It’s a part of the game when both sides come to an actual agreement. The House passed the debt ceiling last night and Senate leadership on both sides has promised to move swiftly to pass the package before the June 5th deadline. Opponents on both sides in the Senate will still vocalize their opposition while the Senate debates the bill, but in the end, I believe that a deal will be met before June 5th. But when it comes to Congress you really never know what can happen, so, let’s all just hope for the best.

The main thing that we all need to keep a close eye on after the package is hopefully passed is now expected cuts to Medicare. With measly planned increases to all non-defense spending, there is a potential for deeper cuts to Medicare home care rates. CMS is already expected to propose further cuts and it could get a lot worse in the coming years. HCA is working closely with NAHC to stay up to date on any potential rate cuts that would directly impact our members. We will be sure to keep everyone updated if there are any potential cuts announced.

Home Care Alliance Signs onto CMS Letter to House and Senate Leadership

The Alliance signed onto an advocacy letter written by the National Association for Home Care and Hospice (NAHC) to House and Senate leadership asking for their support in suspending the implementation of CMS’s final for the Home Health Prospective Payment System (HHPPS).

This week, the Alliance signed onto an advocacy letter written by the National Association for Home Care and Hospice (NAHC) to House and Senate leadership asking for their support in suspending the implementation of CMS’s final for the Home Health Prospective Payment System (HHPPS). As a reminder, CMS’s final rule if implemented would reduce Medicare payments for home health services by $635 million in 2023 and trigger an estimated $18 billion in payment reductions over the next decade.

The Alliance joined 49 other home care associations across the nation in signing this letter. The letter highlights the immense impact that the final rule would have on the agency across the country, noting that “the impact of those payment cuts would exacerbate the ongoing dismantling of this essential benefit that serves over 3 million of the most vulnerable Medicare beneficiaries, providing them with exceptional care quality in their own homes, preventing high-cost hospitalizations, and offering an alternative to life-changing institutional care while saving Medicare billions in spending every year.”

NAHC is currently working with key sponsors and co-sponsors of the CMS bill (S.4605/H.R.8581)that was introduced in August, to re-write the bill in response to CMS’s final ruling. The exact details of the revision of the bill have not yet been determined, but once they are the Alliance will re-engage with the Massachusetts delegation to update them on the changes and to garner their support for the new version of the bill. We will also be asking our members to once again reach out to their member of Congress to support the new version of the bill.

Introducing Home Health 101

Introducing Home Health 101, our new online orientation for home health clinicians and managers, with a focus on compliance regulation.

Have you hired staff new to home health care? Need a refresher on the basics of home health compliance? Due for a review on the latest regulation changes?

As the Alliance’s director of clinical and regulatory affairs, I’m often asked these questions from members looking to ensure that their clinical staff and managers have the tools they need to successfully navigate the regulatory challenges they’ll face in home health. In the past, I’ve done in-person presentations on this material but now—to ensure that even more people have access to it—I’m pleased to announce that Home Health 101 is available digitally for the first time.

In Home Health 101, I highlight the Conditions of Participation standards (COPs), Medicare regulations related to the survey process, and how the survey process works. 5 CEU credits are available (for a small processing fee) to those who complete the course and pass an evaluation.

Learn More
Purchase HH101

Objectives include how to:

  • Review the Home Health’s Conditions of Participation (COPs);
  • Identify three of the five criteria for Medicare certification for home health benefit;
  • Understand Requirements for Physician Orders and Face-to-Face (F2F);
  • Identify Medicare’s definitions of “confined to home”; and
  • Review patient notices.

The program is broken into five sections:

  • Part 1: Orientation to Home Health
  • Part 2: Conditions of Participation (CoPs)
  • Part 3: Patient Notices
  • Part 4: Conditions of Participation, Contin.
  • Part 5: Skilled Professional Services and HHA Services

Alliance Comments to CMS on CY2022 Home Health Rule

To ensure that home health agencies in Massachusetts can provide high-quality care to older adults, the Home Care Alliance of Massachusetts has submitted comments to the federal government regarding the proposed rule for next year’s Medicare home health rates. Our comments to the Centers for Medicare and Medicaid Services (CMS) address several sections of the proposed rule, including:

  • CMS’s flawed reasoning behind the -4.36% “behavioral adjustment” to the rates;
  • Concerns about a budget neutrality adjustment based on 2020 data skewed by COVID;
  • A market basket adjustment that does not account for ongoing costs related to COVID;
  • Protections for counties with large wage index reductions;
  • Modifications to the Value Based Purchasing model before it is implemented nationwide;
  • Greater flexibility around the five-day deadline to submit the new Notice of Admission;
  • Greater flexibility to allow therapist to conduct initial assessments; and
  • Expanded allowances for virtual aide supervisions.

Modernizing the Medicare Home Health Benefit—at Last

Please help us advocate for The Choose Home Care Act, which would provide eligible recipients with SNF-like levels of care at home for 30 days post hospital discharge.

Last week, legislation was introduced in the US Senate that would provide the most significant update to the Medicare home health benefit since its inception. A strong bipartisan group of senators filed the Choose Home Care Act, which would provide eligible recipients with SNF-like levels of care at home for 30 days post hospital discharge. Services would include not only traditional nursing and therapy, but also meals, personal care, remote patient monitoring, and non-emergent transportation, if needed.

A study commissioned by NAHC and the Partnership for Quality Home Health care estimates that the Choose Home Care program could generate Medicare annual savings of $144-247 million with $1.6-2.8 billion in savings over 10 years. NAHC President Bill Dombi called this “must pass” legislation. So, we have a bipartisan bill that could save Medicare dollars, with support from AARP and others in the aging advocacy networks. Sounds like a slam dunk. But this is DC, so there are no such things.

Contact Your Senators

While the advocacy focus is currently on the Senate bill, I hope that when the House acts, Massachusetts can lead the way and get our full delegation on board. Please help Choose Home and send a message to our two senators.

NGS Resumes Home Health Medical Record Review

NGS will resume medical record review after suspension from Public Health Emergency

National Government Services (NGS) recently contacted Alliance staff to review details for the resumption of medical record reviews. This follows the suspension of the Targeted Probe and Educate (TPE) audit because of the Public Health Emergency. We expect that this review will start this week. All the Medicare Administrative Contractors (MACs) will publish information indicating that medical reviews will resume.

NGS has shared some details with Alliance staff about this resumption, which are summarized below; however, the details are not yet posted on their website.

    • NGS will resume post-payment medical reviews. This is different than the TPE program. CMS has not provided any direction to the MACs thus far regarding the resumption of TPE.
    • The post-payment reviews are service-specific (as opposed to provider-specific) and will be a random sample. A service-specific review is one where the MAC is focused on the claim and not the provider.
    • CMS has given a resumption date of August 17, 2020. It is anticipated that providers will begin receiving Additional Documentation Requests (ADRs) once NGS posts more information on their website. NGS indicated it will post a brief description of the service-specific audits on its website and ADRs will be sent approximately 2-3 days after this posting.
    • The timeframe from which NGS will pull claims is January 2019 through February 29, 2020
    • The maximum number of claims to be pulled per provider is 20. There is no minimum. This is less than the total number under the TPE program, and a provider may or may not receive ADRs for a full 20 claims. It is anticipated that the majority of hospice and home health providers will not have this many claims pulled. Any providers having difficulty responding to the ADRs on time should contact NGS and they may be able to work with the provider if the provider makes them aware of the situation.
    • Providers should not wait to receive an ADR request in the mail, but should check the status of their claims processing and identify any with the S B6001 status. These are claims that have had an ADR generated.
    • NGS has 60 days to review the provider’s response to the post-payment ADR. Though providers have 45 days to respond to the ADR, a 30-day response is strongly recommended to ensure that the response is received and recorded by the 45th day.
    • A results letter will be sent after each claim is reviewed.
    • A provider may request education and the NGS may suggest education. Providers are not required to participate in education, although the Alliance strongly recommends it.
    • The error rate (payment error rate or claim error rate) is not as important with a service-specific post-payment review as it is with TPE, since there are no “rounds” in post-payment review as there are with TPE. The MACs are not setting error rate thresholds upon which further NGS action is predicated. As with all medical reviews, if NGS identifies a concern, i.e. a quality concern or indication of potential fraud or abuse, NGS will refer to the appropriate entity (i.e., the appropriate QIO or the division of CMS).
    • NGS will continue to make phone calls to providers for missing documentation or questions about documentation submitted.

It is still possible that providers will receive some other ADRs as part of other review programs such as CERT. CMS contractors, including Unified Program Integrity Contractors, may conduct targeted prepayment and post-payment reviews when there is evidence of potential fraud or gaming. CMS has not yet indicated if the results of the post-payment reviews that are resuming this month would be used for future TPE audits.

If you have any questions, please contact Colleen Bayard at cbayard@thinkhomecare.org.

CMS Finally Releases Updated ABN Form!

Providers will need to use the renewed ABN form starting this August.

CMS just released the long-awaited Advance Beneficiary Notice of Noncoverage (ABN). The current ABN form expired in March 2020, so CMS instructed providers to continue using the expired form, since the form’s renewal was on hold at the Office of Management and Budget during the Public Health Emergency. Yesterday, CMS posted the updated ABN Form CMS-R-131 and form instructions (see the Downloads section at the bottom of the linked page).

The renewed form (with the expiration date of June 30, 2023) will be mandatory beginning August 31, 2020.  The ABN is issued by home health and hospice providers to Medicare beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances. Guidelines for issuing the ABN can be found beginning in Section 50 in the Medicare Claims Processing Manual, 100-4, Chapter 30 (PDF).