在CMS拟议访问规则下的家庭和社区服务支付充足性考虑

WHITE PAPER Home and community-based services paymentadequacy considerations under the CMSProposed Access Rule ByGwyn Volk,Dennis Finnegan, Katherine Wentworth,Jeremy Cunningham, andAlyssa Tolbert06 June 2023 On May 3, 2023, the Centers for Medicare and Medicaid Services (CMS) released anotice of proposed rulemaking titled “Medicaid Program; Ensuring Access to MedicaidServices” (Proposed Access Rule).1 This rule is part of a series of CMS proposalsseeking to improve access to Medicaid services across three keydimensions: knowledge of and ease of enrollment for services; ability to maintain coverage; and access to services andsupports. The Proposed Access Rule’s provisions are specific to the third dimension and—as described in the Summaryof Proposed Strategies sidebar—include a range of strategies to improve access to home and community-basedservices (HCBS).2 This paper focuses on the Proposed Access Rule’s HCBS payment adequacy provisions, with the goal of supportingstates’ strategic planning and submissions of comments to CMS by July 3, 2023.We highlight high-levelconsiderations related to the proposed requirement that direct care worker (DCW) compensation represent at least80% of the Medicaid payment for homemaker, home health aide, and personal care services, noting that CMS isconsidering applying a similar requirement to other HCBS services.3 SU M M A RY Proposed strategies to support access to HCBS HCBS Payment AdequacySections II.B.5 and II.B.7.d •Annually demonstrate that direct care worker compensation represents at least 80% of the Medicaid payment for homemaker, home healthaide, and personal care services Medicaid Advisory Committee (MAC) and Beneficiary Advisory Group (BAG)Sections II.A. and II.C.2 •Replace the current Medical Care Advisory Committee (MCAC) with a MAC and establish a BAG•Establish an advisory group to advise on provider rates for personal care, home health aide, and homemaker services (MAC could be used forthis purpose) HCBS Person-Centered Service PlansSections II.B.1. and II.B.7.a.(3)•Annual demonstration that reassessment of functional need was conducted at least annually for 90% of individuals continuously enrolled in1915(c) waivers •Implement electronic system to collect and track HCBS critical incidents•Demonstrate through annual report that at least 90% of critical incidents were investigated Access Reporting RequirementsSections II.B.6. and II.B.7.c •Annually report on how the state maintains any waiting lists for 1915(c) waivers•Report annually to CMS the average time from service approval to delivery for specific HCBS HCBS Quality Measure SetSections II.B.7.b and II.B.8 •Biannual reporting to CMS on measures with state-specific CMS-approved goals•Multiyear phase-in to stratify reporting measures Website TransparencySection II.B.9•Operate public website that meets availability and accessibility requirements and provides results of new reporting requirements •Publish fee-for-service (FFS) rates and provide a payment rate disclosure for certain HCBS that would permit CMS to develop and publish HCBSpayment benchmark data HCBS Grievance System – FFSSection II.B.2•Implement a beneficiary grievance system for FFS HCBS Background The Proposed Access Rule includes a broad set of new state Medicaid requirements intended to improve access to high-quality HCBS, consistent with the preferences of many beneficiaries to receive care in the community rather thaninstitutions. CMS states that “these proposed improvements seek to increase transparency and accountability,standardize data and monitoring, and create opportunities for States to promote active beneficiary engagement in theirMedicaid programs, with the goal of improving access to care.“CMS’s commentary places these requirements in thecontext of states’ ongoing HCBS direct care workforce challenges, which are attributed to high turnover and staffshortages that have been exacerbated by the COVID-19 pandemic and have the potential to negatively impact qualityand access to HCBS.As such, the Proposed Access Rule requires that state Medicaid agencies demonstrate thatpayment rates for homemaker, home health aide, and personal care services are able to support a sufficient direct careworkforce to meet beneficiaries’ needs and to provide access to quality services. Specifically, states would need todemonstrate, via annual retrospective reporting, that DCW compensation represents at least 80% of the Medicaidpayment for homemaker, home health aide, and personal care services.45 This provision includes base and supplemental payments and would apply to services provided under fee-for-service(FFS), managed care, self-directed care, 1115 waivers, and via 1915(c), (j), (k), and (i) services. (Note that 1905[a] stateplan services are excluded from this requirement.) Payments would presumably include value-based payments (e.g.,pay-for-performance), negotiated rates, and other non-claims-based payments made to HCBS provide