Florida became the first state to secure an emergency Medicaid waiver from the U.S. Centers for Medicare & Medicaid Services (CMS) to help providers maintain operations during the COVID-19 national emergency.
If Medicaid-reimbursed personal care services providers are to stay afloat during the ongoing pandemic, several more states will have to follow suit. Generally, states can land emergency assistance through 1135 waivers and other mechanisms.
“On the Medicaid side, I have heard in the last couple of days that CMS, ADvancing States and the National Association of Medicaid Directors (NAMD) have been really working with states around 1135 waivers, Appendix Ks for 1915(c) waivers and other flexibilities,” Darby Anderson, chief strategy officer at Addus HomeCare Corporation (Nasdaq: ADUS), told Home Health Care News. “Since the president declared the emergency, I think states have been really working on getting needed flexibilities to respond to the crisis.”
In addition to his role at Addus, Anderson also serves as vice chairman of the Partnership for Medicaid Home-Based Care’s board of directors. ADvancing States was formerly known as the National Association of States United for Aging and Disabilities (NASUAD).
Broadly, Florida’s 1135 waiver includes flexibilities that enable the state to waive prior authorization requirements, streamline provider enrollment processes and allow care to be provided in alternative settings. For nursing homes, the waiver also suspends some screening requirements and extends certain appeals-related deadlines, among other provisions.
“CMS is committed to removing all unnecessary administrative and bureaucratic barriers that may hinder an effective response to this public health emergency, and I have directed my team to expeditiously process these requests,” Administrator Seema Verma said in a statement.
When it comes to Medicaid-supported home-based care, there are a number of regulatory relief efforts that states could seek.
For example, many states have requirements to perform in-person clinical or non-clinical supervisory visits for the provision of home care services, Anderson said. Similarly, many states have requirements around ongoing training, where training sessions must be conducted in a face-to-face fashion.
Both of those stipulations are inconsistent with the call for social distancing.
“Supervisory visits should be done telephonically during the course of the emergency,” Anderson said. “Any face-to-face training sessions should be canceled and the requirement waived during the course of the emergency.”
Additional relief on the Medicaid side could include flexibilities around onboarding new staff and caregiver background checks, considering some fingerprinting locations have stopped offering those services.
“We’ve put together a pretty long list,” Anderson said, “which we have shared on a call with CMS this afternoon to encourage them to issue [guidance] to states that says, ‘If you’re going to be filing an Appendix K or other form of a waiver for these types of things, go ahead and implement them. Time is of the essence.”
In most cases, CMS can issue waivers on a retroactive basis.
Flexibility for onboarding, training and supervisory visits are just a piece of the puzzle for Medicaid-reimbursed home-based care providers.
Earlier this week, the U.S. House of Representatives passed sweeping coronavirus relief legislation that, if passed, would require most employers with 500 or fewer workers to provide two weeks of paid sick leave. The legislation would also provide up to 12 weeks of paid family and medical leave at two-thirds a person’s normal pay.
The Senate is expected to vote — and pass — the legislation this week. Employers mandated to offer paid sick or emergency leave would likely be reimbursed later on through a tax credit.
But there are multiple challenges with such legislation, according to Anderson.
On one hand, not many small home-based care agencies could withstand a sudden, unexpected hit to their cash flows. A tax credit could help, but that could be too little too late.
“How many of those small organizations can bridge the cash flow implications of paying a large number of people should the virus expand?” Anderson said. “Paying people sick time, then waiting for their tax credit to recoup that money on Medicaid reimbursement rates. I don’t think there are many, quite honestly. And that could drive a lot of people out of business.”
On the opposite end, not requiring employers of 500 people or more to offer paid sick, family or emergency could force caregivers to work through illness, possibly spreading COVID-19 further.
“What we don’t want to do is have an exposure of some kind and say to a home care worker, ‘OK. You can’t go to work. You need to self-quarantine for 14 days.’” Darby said. “And they say, ‘Well, I can’t afford to be off work for 14 days.’ We really need some solutions on these issues.”
Additionally, many schools are closing across the country. That poses another emerging challenge for providers, as many caregivers have children in school. Patients refusing care could also create job instability for workers, prompting additional economic hardship.
Meanwhile, some patients who normally receive personal care are refusing service, worried that caregivers could potentially expose them to coronavirus. That could lead to costly hospitalizations and additional strain on health care providers down the road, even for low-acuity patients, if conditions worsen without care.
“The workforce issues are the most complicated part of this,” Anderson said. “Things can snowball, and we’re just trying to keep our staff safe and financially stable while trying to anticipate where this is all going.
On a more positive note, Anderson noted that in-home care providers are stepping up and ready to be “a significant solution” amid the COVID-19 crisis.
“We serve the most at-risk population, and keeping them safe and cared for at home is a key to getting through this crisis,” he said. “I am really proud of our Addus team as well as the thousands of home- and community-based care organizations, caregivers and associations out there giving it their all.”