|On Wednesday January 3rd , the Massachusetts Legislature returned for the second year of its two-year session. After a seven-week recess, the body is looking at a traditionally busier second half than the first. The nearly 170 bills that passed in 2017 marked the lowest total in twenty years.
Lawmakers have until July 31 to complete all substantial legislative debate. In addition, all 200 members are up for election in 2018, which is expected to be a distraction from normal legislative work as a result of a polarized political landscape. Here’s what the Alliance will be focused on in 2018:
Prior to the Holiday break, the Alliance met with its ‘Enough Pay to Stay’ partners to strategize coordinated efforts to attain wage relief for direct care workers and ASAP case managers. The coalition has pending legislation which would take steps toward this initiative, but we will pursue other legislative vehicles to fight for our workforce.
In November, Governor Baker signed into law the Home Care Worker Registry. This law will establish a worker registry that requires agencies contracting with ASAPs to submit workers’ private information to the state. The law is enacted and subject to regulations. The Alliance and its partners are in active communication regarding next steps toward protecting our members and their workers’ rights.
The FY 2018 State Budget included language that will establish a licensure process for home health agencies providing skilled services. It is unclear at this point when the process to promulgate regulations will begin, but the Alliance will be providing input to the Department of Public Health as these parameters are developed. In addition, Alliance-sponsored legislation that would license private care agencies is still making its way through the legislative process. Under procedural rules, the legislature has until February to report legislation out of committee. The Alliance will continue to advocate for passage of this legislation.
Continuous Skilled Nursing:
In late 2017, MassHealth announced two rate increases for the Continuous Skilled Nursing (CSN) program that totaled nearly 11 million. This was welcomed news, but there remains work to be done. The CSN provider/parent coalition will continue to advocate for the CSN Bill of Rights legislation that would mandate bi-annual reviews of the workforce to ensure safeguards against future crises.
The Alliance has been informed that MassHealth will conduct a long-overdue review of rates for per-visit nursing, therapies, and home health aide services. The Alliance will be working to gather data to demonstrate that the current low rates are interfering with agencies’ ability to attract and retain enough workers to meet the demand for services.
MassHealth’s initiative to enroll the majority of members into managed care programs this coming spring will dramatically change the way MassHealth members access home health services, and disrupt many existing provider referral relationships. The Alliance will continue to work to ensure that MassHealth members retain access to needed home health services, and that agencies are adequately reimbursed for those services.
House of Representative Health Care Bill:
Late last year the Senate passed a health care cost containment bill aimed at curbing costs while maintaining access. It has long been rumored that the House will be embarking on similar initiatives. Though the details are scarce, this legislation could be a vehicle for many of the Alliances priorities in 2018 and we will continue to advocate where necessary.
If you have any questions about the year ahead for advocacy or would like to get involved, reach out to Jake Krilovich, the Alliance’s Director of Legislative and Public Affairs.
James Fuccione, former Director of Legislative and Public Affairs for the Home Care Alliance, was extensively quoted in an article in the Springfield Republican today. The article, “Personal care attendants have less training, checks than other home care workers,” by Shira Schoenberg, Statehouse reporter for the Republican, compares background checks and training requirements for workers in the state Personal Care Attendant program with workers employed by home care agencies that provide services under the Executive Office of Elder Affairs home care program.
The Home Care Alliance participated in several calls with MassHealth and Health and Human Services on planned budget cuts from Governor Baker’s administration. In total, the Governor announced $98 million in cuts from the $39.25 billion state budget.
Although there are reductions in home health, there are positive rates increases to report.
After years of advocacy by the Alliance and more recent efforts from a coalition of continuous skilled nursing providers as well as a family-based network called the Mass. Pediatric Nursing Campaign, MassHealth informed the HCA that payment rates for Continuous Skilled Nursing will increase by 2.6%. According to MassHealth, this equates to a $2.2 million bump in rates, which will become effective January 1st, 2017.
For the RN and LPN day and night rates, the increase hovers around a $1 boost in what those agencies currently receive. The Alliance, along with the provider coalition and family-based campaign, will continue to advocate for further adjustments to continuous skilled nursing rates in the upcoming FY18 state budget cycle.
As for home health skilled nursing rates outside of CSN, payment will be reorganized by the length of service of the MassHealth member. As of July 1, 2017, MassHealth is planning to break up the current skilled nursing rate for home health agencies into three separate tiers. The first tier will be for patients on services from day 1 through 30, which will be increased from $86.99 to $89.21. The second rate tier will be 31-180 days and the third rate tier is any home health service beyond 180 days.
MassHealth has indicated that the rates in the second tier will remain relatively static and the third tier will be decreased, but post 30-day rates as of 7/1/17 will be budget neutral from the changes taking effect on January 1st. An announcement from EOHHS will specifically outline the new tiered rates, but according to MassHealth, anything regarding rates that is seen before the New Year is not finalized and therefore subject to change.
The other notable decrease will take effect on January 1st when MassHealth plans to approximate the budget impact of those proposed second and third rate tiers into the current post 60-rate. The cut in the post 60-day rate from 1/1/17 to 7/1/17 will be a 6.75% reduction. This means the current post 60-day rate of $69.59 will be roughly $64.89 for the first six months of 2017. (This rate remains higher than the medication administration rate originally considered by MassHealth.)
Laid out in another way, this will be how rates are currently planned to change:
January 1 – July 1:
Home health services post 60-day rate will be roughly $64.89 (6.75% reduction)
Service days 1-30: $89.21
Service days 31-180: Rates will remain roughly the same, but are not yet finalized
Service days 180: Rates will be slightly reduced from the current post 60-day rate, but are not yet finalized.
MassHealth is also streamlining enrollment in the Independent Nursing program to cut their application process from 8 weeks down to one week.
The net state cut for home health is approximately $3.8 million out of $758 million in MassHealth spending on home health care services.
Most of the other cuts announced by the administration are restoring vetoes previously proposed by the Governor in the FY2017 budget, but that were overridden by the legislature. At that time, the Governor vetoed $255 million and the legislature overrode $231 million. Included in these cut overrides are certain hospital supplementary payments (particularly to pediatric and Western MA hospitals) as well as $1.1 million in cuts to public health hospitals.
Other impacted accounts include supplemental payments to nursing homes, which will be reduced by $2.8 million, as well as a $2.8 million cut to adult foster care (AFC).
The Pediatric Palliative Care account (4590-1503) is being reduced by $400,000.
The legislature has already announced their view that Governor Baker went too far with some of the announced cuts and they will be working on restoring some of the funding reductions.
HCA of MA has an upcoming meeting with MassHealth to review the Governor’s proposal. Also on the agenda are issues with ICD-10 changes that are impacting agency billing and payment.
Return to www.thinkhomecare.org.
CMS announced yesterday afternoon that they are delaying the expansion of the Pre-Claim Review Demonstration for Home Health Services which began in Illinois on August 3, 2016.
According a notice on CMS’s website, based on early information from the problems encountered in Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states; therefore, they will not move forward with initiating the demonstration in Florida in October. This education effort will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.
According to the notice, CMS views these efforts as crucial to the long-term success of the demonstration for beneficiaries, providers, and the Medicare program. CMS will therefore take additional time prior to expanding to other states. The start dates for Florida, Texas, Michigan, and Massachusetts have not been announced; however, CMS will provide at least 30 days’ notice on this website prior to beginning in any state. CMS continues to expect a staggered start, beginning with Florida.
The Alliance has been working closely with the state associations in the other demonstration states and national home health groups to advocate for major changes to the project. Building off of this short-term victory, HCA will continue those efforts and is also briefing our Congressional delegation on the issue. HCA will, of course, keep members informed of any changes in the demonstration.
Return to www.thinkhomecare.org.
The Massachusetts Board of Registration in Nursing (BORN) has released proposed regulations that sets guidelines for, among other activities, delegation by nurses to “unlicensed personnel.” These guidelines are NOT a change in the nursing scope of practice around medication delegation, which requires a law approved by the legislature and signed by the Governor.
The BORN is merely aiming to establish a nurse delegation framework inclusive of much more specificity in areas such as training, supervision and documentation should nurse delegation practices become allowable in Massachusetts.
The proposed regulations also protect nurses by setting criteria for delegation that includes the following:
- Ensuring that the delegating nurse would not bear any responsibility for any deviation by the unlicensed personnel from the nursing directive, instruction, or plan of care.
- Formalizes the nurse’s role in knowing what is within the ability of the unlicensed personnel to carry out and what can be delegated that would not require judgment or assessment by the unlicensed personnel.
- The final decision to delegate is made by the nurse and not the employing healthcare provider.
- The employing healthcare provider must have the competencies of the unlicensed personnel documented for each nursing activity along with periodic validation of those abilities.
- The nurse can determine at any time that an activity can no longer be delegated based on the health status of the patient, the unlicensed personnel’s performance of the activity, or any other reason the nurse believes would jeopardize the health and safety of the patient.
The proposed regulation follows years of discussion and a BORN subcommittee report on the state’s readiness for potential changes to nursing practice.
One of the possible changes is a longstanding policy priority of the Home Care Alliance, which is to allow home health care nurses to delegate certain medication administration tasks to a trained and certified home health aide. The HCA has dubbed the proposed policy as the “Nurse Delegation Bill.”
This bill will not pass in the current legislative session that ends with the New Year in 2017, but the HCA plans to continue pursuing a change that would allow – not mandate – that home health and home care agencies can implement proper training and procedures to maximize the efficiency of their direct care staff.
It should be noted that this bill includes protections, such as the fact that delegation is limited to medications which are NOT controlled substances and are administered in the following methods:
- prefilled auto-injectables designed for self-administration
- Products which are administered by inhalation.
The legislation states that “delegation of intramuscular, subcutaneous, intradermal, intraosseous or intravenous administration of medication shall not be permitted.”
Although the Alliance has comments and suggestions for the BORN’s proposed regulations, HCA fully supports the move to ensure the state is prepared for laws that promote nurses practicing at the top of their licenses. The Alliance appreciates the BORN’s thoughtful approach that further solidifies the importance of nurses in healthcare delivery.
The BORN will hold a public hearing on October 4th and will accept written comments until October 11th.
Return to www.thinkhomecare.org.
Though no final announcements on participants have been made, several areas of Massachusetts were declared “eligible” by CMS for random selection of nearly 100 metropolitan statistical areas (MSA) across the country for a new innovation initiative that offers bundled payment for cardiac care.
CMS released the proposed rule on July 25th where the hospital in which a patient is admitted for care for a heart attack, bypass surgery, or surgical hip/femur fracture treatment would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge.
As with many similar alternative payment programs, established quality metrics would help determine whether the hospital would be required to pay Medicare for poor performance or receive reward payments for higher-quality care. CMS chose July 2017 to March 2018 as the “performance year” and then a gradual increase in the gains and downside risk for hospitals beginning at 5 percent in 2018 and capped at 20 percent in 2020-2021.
CMS is encouraging collaboration with other providers, including home health care and other post-acute providers. Equally important are a list of waivers this program will grant relative to the provision of post-acute care. Some notable highlights are listed below, with explanatory excerpts from the proposed rule, but the full list of waivers can be found in the proposed rule under “Subpart G” on page 885.
- Waiver of direct supervision requirement for certain post-discharge home visits:
- “CMS waives the requirement in § 410.26(b)(5) of this chapter that services and supplies furnished incident to a physician’s service must be furnished under the direct supervision of the physician (or other practitioner) to permit home visits as specified in this section. The services furnished under this waiver are not considered to be “hospital services,” even when furnished by the clinical staff of the hospital.”
- Waiver of certain telehealth requirements:
- “Except for the geographic site requirements for a face – to – face encounter for home health certification, CMS waives the geographic site requirements of sec tion 1834(m)(4)(C)(i)(I) through (III) of the Act for episodes being tested in an EPM, but only for services that (1) May be furnished via telehealth under existing requirements; and (2) Are included in the episode in accordance with § 512.210”
- The Alliance is researching whether this is restricted to physicians performing telehealth or whether home health agencies would be allowed to engage in remote patient monitoring.
- Waiver of the SNF 3-day rule
- Only applies to the AMI (Acute Myocardial Infarction) model.
There is a 60-day public comment period and it is unlikely that the participating MSAs will be revealed before the final rule, but the “eligible” areas in Massachusetts are included below:
- Barnstable Town, MA
- Boston-Cambridge-Newton, MA-NH
- Providence-Warwick, RI-MA
Based on CMS’ selection criteria, the Pittsfield and Springfield Metropolitan Statistical Areas are “excluded” from selection eligibility.
Return to www.thinkhomecare.org.
Both the state and federal governments are extending moratoria on new home health providers.
MassHealth will be extending the six-month moratorium on new home health providers, which will become effective on August 12 for an additional six months, according to MassHealth. The Home Care Alliance has been supportive of the measure and has collaborated with the state Medicaid office on program integrity efforts, but attempts to kick-start a state oversight policy for home care agencies have been unsuccessful.
In a letter requesting the initial stoppage on new providers from Massachusetts Health and Human Services Secretary Marylou Sudders to federal HHS Secretary Sylvia Mathews Burwell, it was noted that home health spending under MassHealth increased 41% from fiscal years 2014 to 2015. The letter continued to explain that 85% of that growth was driven by providers that were new to the MassHealth program since 2013.
Meanwhile, the Centers for Medicare and Medicaid Services (CMS) announced that they will be not only extending their temporary moratoria on enrollment of specific locations within Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey, but will also be broadening moratorium across each of those states.
Below is an excerpt from the Federal Register with CMS’ reasoning in announcing the extension and expansion:
CMS has determined that the factors initially evaluated to implement the temporary moratoria show that a high risk of fraud, waste, and abuse exists beyond the current moratoria areas, which may suggest that a high risk of fraud, waste, or abuse exists due largely to circumvention of the moratoria by some providers and suppliers.
The primary means of circumvention includes enrolling a new practice location outside of a moratorium area and servicing beneficiaries within the moratorium area. Additionally, CMS has continued to see areas of saturation that exceed the national average in the moratoria states. As a result, CMS, in consultation with the OIG, has determined that it is necessary to expand the temporary moratoria on a statewide basis, by implementing temporary moratoria on all newly enrolling HHAs in the remaining counties in Florida, Illinois, Michigan, and Texas, and on all newly enrolling Part B non-emergency ground ambulance suppliers in the remaining counties in Texas, New Jersey, and Pennsylvania, in order to combat fraud, waste, or abuse in those states.