LeadingAge prepared and submitted separate comments on two proposed Medicaid rules, that seem to be traveling in tandem: the Medicaid Access Rule and the Medicaid and CHIP managed care rule. This article offers a brief overview of LeadingAge comments and links to the comment documents.

LeadingAge generally supports the provisions of both rules but pointed out in the comments several issues of concern. One point rises to the top for members of LeadingAge who rely on Medicaid to provide some or all of their home and community-based services. In the Access Rule, CMS proposed a requirement that 80% of all Medicaid HCBS dollars be passed through to workers in the form of wages and benefits. While LeadingAge supports efforts to increase staff compensation, this mandatory pass through is unworkable and will put many HCBS providers out of business.

CMS states in the fact sheet that accompanied the release of these proposed rules, “These proposed requirements are intended to increase transparency and accountability, standardize data and monitoring, and create opportunities for states to promote active beneficiary engagement in their Medicaid programs. CMS’s proposed rules address a range of access-related challenges that affect how beneficiaries are served by Medicaid across all of its delivery systems and benefits.”

Give Providers a Voice – And Listen to Them

Our comments on the proposed Managed Care Rule urged CMS to carefully consider if their proposals would achieve their stated goals of assuring ongoing access to services and provide the level of transparency to meaningfully impact provider contracting and rate negotiations and beneficiary experience.

Our comments centered around three main points:

• Beneficiaries need ways to offer MCOs feedback, but so do providers. In the proposed rule, CMS suggests more opportunities for an additional beneficiary feedback loop but remains silent on providers’ ability to voice concerns about MCOs. We stressed that provider experience with MCOs is critical to maintaining access and robust provider networks.
• Transparency is good for rate negotiations, but rate adequacy remains poorly defined. Ongoing scrutiny to particular rate and payment types remains a concern. We reiterate that drastic changes to rate development or supplemental payment availability should be carefully considered as it could affect providers’ decisions about whether or not to continue to participate in Medicaid programs.
• CMS should protect providers proactively. CMS monitoring of network adequacy through state level remedial plans when networks are too narrow is retrospective and won’t bring back providers that may have opted out of Medicaid because of preventable or fixable issues with managed care plans. CMS should consider more prospective protections, like we noted in our first point – establishing accountable provider feedback loops with their state allowing states to proactively fix issues that are arising.

If you’re interested in reviewing our comment in full, you can do so here.

Work to Increase Wages, but Extreme Wage Pass-Throughs Won’t Work

In the Access Rule, CMS proposes broad transparency and infrastructure improvements to state Medicaid programs aimed at improving rate adequacy, participant access to necessary services and monitoring to improve home and community based setting (HCBS) service quality.

We expressed support for all of these provisions individually, though we shared concerns for states around costs and staffing capacity. We know states’ complements have struggled just like your workforce.  There is concern that allocating staff away from ongoing operations could result in system and access disruption. Each proposal would be costly and require a significant investment in staff time and acumen. Additionally, administrative compliance would add to states’ Medicaid bills on the administrative side while not addressing long-standing provider rate inadequacy or access expansion.

LeadingAge spent significant time on one very small but powerful piece of the proposed rule: a requirement that 80% of Medicaid funds must be directed to direct care worker compensation for HCBS delivered under service types of homemaker, home health, and personal care services.  While we are supportive of CMS intent – to increase wages for direct care staff – LeadingAge is cites a number of reasons CMS proposal is ill-advised. We spoke extensively with provider members and state partners about this provision in particular, to inform and mold our comments.

We highlighted a number of concerns including the lack of data and infrastructure, built in perverse incentives, inadequate consideration of the disparate effect a rule like this would have across different payor models, geographies, and provider types.

Two specific items of note: 1) Data across states is variable or unavailable as many states don’t require cost reporting for these services within Medicaid HCBS. Even where states do collect information, differences across definitions and cost centers makes comparison difficult at best, and more accurately, impossible. 2) CMS overt exclusion of clinical supervisory expenses in direct care worker compensation is irresponsible and will force providers to limit supervisory structures to mandatory minimums. We have concerns that decreases in supervisory support will erode the professionalism providers have attempted to build in direct care positions. LeadingAge cites research from the LTSS Center at UMass Boston that indicates clinical and supervisory support of direct care staff promotes staff retention, quality, and satisfaction. Additionally, we believe limitations on clinical oversight are likely to result in decreased quality of care as direct care staff are less able to seek guidance on clinically complex questions.

We expand on these and other points within the full comments.