Why 90% Of The Medicaid Access Rule Is ‘Positive’ For Home-Based Care Providers

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When the “Ensuring Access to Medicaid Services” rule was finalized last week, the 80-20 provision stole the show, due to its unpopularity among home-based care leaders. But experts have pointed out that the rule is much more than just the 80-20 provision.

“The rule, including the preamble, was over 1,000 pages, and I joke that it’s being reduced to less than 1,000 characters,” Georgia Goodman, director of Medicaid at LeadingAge, told Home Health Care News.

Despite the response to the 80-20 provision, the rule can be seen as largely positive, according to Damon Terzaghi, director of medicaid advocacy at the National Association for Home Care & Hospice (NAHC).


“Roughly, 90% of the rule is beneficial, and a good step forward for home- and community-based services,” he told HHCN.

One aspect of the rule that can be viewed as beneficial for the home-based care industry is the Centers for Medicare & Medicaid Services’ (CMS) push for greater transparency and reporting from state agencies on things like waiting lists.

States have the ability to cap enrollment and create waiting lists for certain parts of their home- and community-based services, but there’s been a lack of information in terms of how many people are on the waiting list, and how long it takes to access services.


Terzaghi noted that time spent on these waiting lists can last anywhere from a few months to six or seven years, depending on which state an individual is in, and what program they’re applying to.

“The fact that CMS is requiring some more uniform national reporting around what happens in states that have these waiting lists is a huge benefit to individuals, providers and policymakers who are trying to improve the system,” he said. “CMS is really asking — how many people are on these waiting lists, and how long they are waiting between when they get placed on the list, and when they actually receive services. That’s a huge step forward.”

Another new reporting requirement under the rule has to do with fill rate.

Broadly, when an individual has a person-centered plan with Medicaid, they get a number of authorized hours based on their individual needs and preferences. CMS now requires reporting on how many of those authorized hours are actually delivered to the individual.

One sentiment that frequently came up in response to the 80-20 provision was that without consistent and healthy state rate increases, the provision would negatively impact providers’ ability to operate.

Under the rule, CMS is imposing new requirements for states looking to reduce rates.

Prior to the rule, there weren’t a lot of specific requirements around what states have to do in order to get a rate reduction approved. Now, CMS has put together a three-part test states need to pass to reduce rates.

“[They’re] essentially saying, if you meet these three criteria then we’ll approve your rate reduction, and you have to do ongoing monitoring to ensure that it doesn’t have a negative impact on access to care,” Terzaghi said. “However, if these three criteria are not met, then there’s a whole bunch of additional analysis that states have to go through to demonstrate that this policy is a viable one, and not just based on a goal to slash state spending willy-nilly.”

Terzaghi believes that this new requirement will hold states accountable regarding rates.

“We’ve seen many times that when state budgets are challenging the first thing they do is look to cut provider rates,” he said. “The will place some new requirements and burden on the states to actually demonstrate that they are able to do this in a manner that doesn’t have significant and serious negative impacts on the participants receiving care.”

One of the most important parts of the rule is the creation of a mandatory incident management system, and the requirement to have an updated electronic IT system that tracks trends, in order to help states identify bad actors.

“Are there areas in the state delivery system, whether they be geographic areas or programmatic areas, where there’s disproportionately high numbers of adverse incidents, things like unexpected hospitalization, injury or even death?” Terzaghi said. “There hasn’t necessarily been any standards around how states track information like this, how they examine it and use it to respond from an operational perspective.”

With the rule finalized, Goodman urges providers to stay on top of what’s happening in the states their company operates in.

“One of the other provisions included in the rule is some transformation of the advisory and stakeholder groups in the Medicaid programs,” she said. “States are required to have these advisory groups, and now there’s a bit of additional transparency about who’s on those groups, when they meet, and the content of the meetings. As states are revamping those advisory groups, I think there’s an opportunity for providers to advocate, either for inclusion or to attend those meetings and be more engaged to understand what policies are under consideration in their Medicaid program.”

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