Indiana Medicaid LTC Planning Process

Last month in the IHCA IMPACT we announced the creation of a dedicated page on the Member’s Only website that will house all information related to the Indiana Medicaid LTC planning process.  The challenge and request to create a plan and path forward on reforming nursing facility Medicaid reimbursement and policy was issued by current FSSA Secretary Dr. John Wernert in the fall of 2015.

New documents have been posted to that website since last month for the AL Workgroup and the Reimbursement Workgroup. To access the webpage, click here.

CMS Issues Memos Concerning Dementia Care Projects

On March 27, 2015, CMS issued a Survey & Certification Memorandum regarding the Final Report & 2015 Expansion for the Focused Dementia Care Survey Pilot.  The memo announces a final report that outlines the basis for the Focused Dementia Care Survey Pilot, the process utilized, conclusions gathered based upon post-pilot data analysis, as well as next steps for the future. CMS plans to expand upon the work of the focused survey pilot and has invited States to conduct such surveys in FY2015 on a voluntary basis. The expansion project will involve a more intensive, targeted effort to improve surveyor effectiveness in citing poor dementia care and the overutilization of antipsychotic medications, and broaden the opportunities for quality improvement among providers.  A conference call will be held in early summer for interested State Survey Agencies to further discuss this focused survey expansion effort.

In addition, on April 4, 2015, CMS issued another Survey & Certification Memorandum announcing a grant award to the Eden Alternative for the support and further expansion of the National Partnership to Improve Dementia Care in Nursing Homes. A grant, in the amount of $293,129.00, was awarded to The Eden Alternative for their project entitled, “Creating a Culture of Person-Directed Dementia Care.” The Eden Alternative plans to engage direct care staff from nursing homes across five states (Georgia, South Carolina, Kansas, Illinois, and Texas) in “Dementia Beyond Drugs” training.

Collection of Staffing Data for Long Term Care Facilities

On April 10, 2015, CMS issued a Survey & Certification Memorandum entitled Implementation of Section 6106 of the Affordable Care Act – Collection of Staffing Data for Long Term Care Facilities.  CMS has created a system for centers to submit staffing and census information and it is called the Payroll-Based Journal (PBJ). The PBJ is intended to meet the criteria outlined in the Affordable Care Act for electronic submission of direct care staffing information.  CMS intends to collect staffing and census data on a voluntary basis beginning October 1, 2015. All nursing centers will be required to submit staffing and census data using the PBJ beginning July 1, 2016.  The memorandum includes a link to access additional information about the system and information specifically for vendors or software developers. Additional information that is currently available for providers includes a Policy Manual for the PBJ. 

We encourage members to review the information on the PBJ website as well as the PBJ Policy Manual and send any questions or concerns directly to nhstaffing@cms.hhs.gov.  Please copy Zach Cattell (zcattell@ihca.org) or Lyn Bentley (lbentley@ahca.org) on any email you may send to CMS.

Residential Care Citation Update

The ISDH issued 4 Offense tags and 33 Deficiency tags to Residential Care Facilities in the month of March.  Ten citations were issued Tag 273 concerning maintenance of food preparation and service areas in accordance with state and local sanitation and food handling standards.  Tag 241 was cited 4 times for failure to have resident medications administered by licensed nursing personnel or QMAs.  Both of these citations are common and facilities should seek to prevent them.  Tag 217, cited with relative frequency lately, was cited 5 times in March.  Of the available survey reports, the tag continues to be cited primarily due to the lack of signature or date of signature on the service plan by the resident or resident’s legal representative.

Click here to review a summary of the March Residential Care citations.

ISDH IJ/SSQC Update

There was one event in March that resulted in and IJ citation that was also SSQC. F323 was cited for alleged failure of a facility to maintain resident transfer equipment in safe working condition and to utilize the equipment properly.  The 2567 indicated that each of the three sit to stand resident transfer slings were missing belt buckles to knee support straps. A buckle also appeared to be broken on one of the lift’s waist support belts.  The facility was notified from a prior employee concerning the condition of the lifts prior to the IJ being called and the Administrator scheduled a medical equipment professional to inspect and repair the lifts.  The medical equipment professional inspected the lifts and placed stickers on the lifts noting the inspection, which was taken by the facility as approval that the lifts were safe to use.  Email correspondence to the Administrator from the medical equipment professional, however, indicated that the missing buckles needed to be replaced. Follow-up phone interview with the medical equipment professional confirmed that the inspection resulted in recommendation to replace the buckles and the slings could not be used properly without the buckles.

Click here to review the March 2567 and a summary of 2015 IJ/SSQC citations.

CMS Approves Hoosier Care Connect – A New Indiana Medicaid Managed Care Program for the Aged, Blind and Disabled

On March 31, 2015 Indiana Health Coverage Programs sent out notice that CMS has approved implementation of Hoosier Care Connect (click here to see the notice).   A more detailed description of the program can be found here and at the Hoosier Care Connect website.  Hoosier Care Connect is a “coordinated care program for Hoosiers age 65 and over, or with blindness or a disability who live in the community and are not eligible for Medicare.”  The program excludes individuals enrolled in Medicare, and those residing in an institution or are receiving services through the Home and Community Based Services wavier.  Three Managed Care Entities, Anthem, MHS, and MD Wise are enrolling eligible persons and are responsible for coordinating the care with medical providers.   

Nursing facilities will be involved in the Hoosier Care Connect program as there are care coordination issues to address for Medicaid beneficiaries that transition between this new managed care program and traditional Medicaid for services within nursing facilities.  Indiana Medicaid has also published a lengthy FAQ document that can be accessed here or at the Hoosier Care Connect website.

US Supreme Court Rules - Providers Cannot Challenge Medicaid Reimbursement Rates

In a 5-4 decision, the US Supreme Court released an opinion today, holding private healthcare providers cannot sue the state over low reimbursement rates (Armstrong v Exceptional Child Center Inc.).  By way of background, in 2009, private healthcare providers delivering residential care to disabled patients in Idaho, sued the state alleging that it was illegally keeping Medicaid reimbursement rates at 2006 levels despite data showing that the cost of providing services had significantly increased. A Federal  District Court judge sided with the providers, holding that the Idaho Medicaid rates weren’t in line with the federal law’s requirements that states “assure that payments are consistent with efficiency, economy and quality of care and are sufficient to enlist enough providers” to ensure adequate access to care.  The District Court decision was upheld by the US Court of Appeals for the Ninth Circuit.  As a result of that ruling, Idaho was forced to pay an additional $12 million in 2013 reimbursements.  Idaho appealed the ruling to the US Supreme Court. 

On appeal to the US Supreme Court, healthcare providers argued that the courts are an important venue for challenging low reimbursement rates, which often are the only way to enforce federal payment requirements.  Furthermore, providers argued when reimbursement rates are too low, there is lower provider participation in the Medicaid program, which can lead to less access to care for Medicaid beneficiaries. The Idaho Medicaid officials countered those arguments asserting that Congress had not authorized lawsuits under the Medicaid Act, codified under Title XIX of the Social Security Act, and that allowing such a course of action would result in endless litigation.  The majority of the US Supreme Court Justices agreed with the state of Idaho, and concluded that a private cause of action is not permitted under the U.S. Constitution’s Supremacy Clause.  Further, Title XIX does not allow private parties to enforce the provision in the Medicaid Act that requires state plans to “assure that payments are consistent with efficiency, economy, and quality of care” while “safeguard[ing] against unnecessary utilization of . . .care and services.” Rather, only CMS may scrutinize rate adequacy following its process for reviewing state plan amendments (SPA) pertaining to reimbursement.  CMS guidance on SPA review is located here in a State Medicaid Directors’ Letter. 

AHCA/NCAL Advocacy To-Date
AHCA/NCAL submitted an amicus brief in support of the Idaho providers in Armstrong v Exceptional Child Center Inc., and the Association is greatly disappointed in the US Supreme Court decision released today.  As you know, AHCA has ample data demonstrating nursing facility Medicaid rates do not cover  allowable costs.  To view the 2015 Medicaid Shortfall Report, click here.  As a result of this decision, providers with insufficient Medicaid rates may continue to address rate complaints to the Single State Medicaid Agency (SSMA) as under current state practice but now have little hope of judicial relief. 

Advocacy Next Steps
In the last year, recognizing existing challenges with court action related to rate adequacy, the Association opened a dialogue with CMS and the National Association of Medicaid Directors (NAMD) on a revised Medicaid SPA process which would allow providers and other stakeholders to engage in a standardized and CMS-regulated rate development and SPA submission process.   AHCA has developed and vetted through the Legal Committee, Finance Committee and State Executives a preliminary SPA approach which has been shared both with CMS and the National Association of Medicaid Directors (NAMD).  Next week, AHCA/NCAL staff are meeting with the Acting Deputy Administrator for the Center for Medicaid and CHIP Services (CMCS), Tim Hill, to review our proposed framework and highlight Medicaid rate issues including the annual Shortfall Report and news articles indicating physician and hospital withdrawal from the Medicaid program due to inadequate reimbursement.  The goal is to accelerate and influence CMS promulgation of key parts of is long languishing proposed “Equal Access Rule” which includes helpful provisions on rate development and related SPA submission.  Click here to view the proposed rule.  In the upcoming months, AHCA’s Legal Committee will review the US Supreme Court opinion carefully and will work with the Finance Committee, Reimbursement Cabinet and State Executives to develop other strategic action steps.   If you have questions, suggestions or concerns, please contact Dianne De La Mare at ddmare@AHCA.org.