LeadingAge Advocacy Goals

• Ensure that vaccines and booster doses are distributed quickly and efficiently to immunize all staff who serve in aging provider organizations and individuals over age 65, starting with residents of congregate settings.
• Implement education programs to promote vaccine and booster uptake among older adults who live in LeadingAge communities and/or use LeadingAge services.
• Establish a regular system to distribute personal protective equipment (PPE) to aging services providers and ensure that all providers have a ready supply of PPE.
• Ensure that additional relief funds for all aging services providers are enacted, current reporting requirements are streamlined, and all available funds reach aging services providers swiftly.
• Increase the Federal Medical Assistance Percentage (FMAP) for home and community-based services providers, ensure funding for additional HUD 202 homes, and support investments to address the workforce crisis in aging services.
• Make permanent some of the important flexibilities permitted by the Coronavirus Preparedness and Supplemental Appropriations Act of 2020, the CARES Act, and 1135 waivers.
• Allow hospices more flexibility in the provision of respite care during any emergency.

THE ISSUE

COVID-19 fundamentally changed life in the United States – and the world. With vaccines, testing, and treatments in place and widely available, 2023 is looking to be the year when the nation emerges out of the pandemic and into the “next normal.” But the pandemic’s impact will continue to be felt and must be addressed.

Providers who serve older adults relied heavily on reserves during the pandemic and need ongoing relief – funding, staff, and supplies. Federal funding for vaccines, tests, and therapeutics must continue and must prioritize aging services.

Once the Public Health Emergency ends, aging services providers will require additional support to maintain their ability to serve older people, evolve based on lessons learned from COVID, and be ready for the next crisis.

People over age 65 are at the highest risk of severe COVID and loss of life; 80% of those who die of COVID in the United States are age 65 or older. The media focused attention on nursing homes throughout the pandemic, but all congregate living organizations experienced and continue to confront previously unimaginable challenges. And providers of home care and home and community-based services continue to struggle to serve people, regardless of where they live.

Providers face desperate staffing shortages, staff fatigue and burnout, resident and staff mental health needs, and pressures from hospitals to admit people that they cannot serve due to staffing challenges. While older residents are increasingly likely to be up to date in their vaccines, staff do not. Unanticipated expenditures have driven many to close or to the brink of closing. The rapid aging of the population of the US – by 2050 one in four Americans will be over age 65 – makes the need to come back from COVID with a strong, high-quality aging services system more pressing. Finally,

ADVOCACY ACTION 2023

118^th Congress

Click here to see the full list of COVID legislation LeadingAge is following in Congress.

• COVID-19 relief. We support legislation that will provide funds and other relief for aging services.
• Fighting COVID-19. We support the continuation of federal funding that ensures: ongoing funding so that all eligible people can be vaccinated and receive all boosters at no personal cost; free, readily available testing supplies for individual older individuals and staff, as well as for LTC providers; continued access to therapeutics, particularly for people over age 50.

Executive Branch

• Support to Ensure that Staff and Consumers of Aging Services Can Keep their Vaccinations Up to Date. We support the efficient distribution of vaccines/all necessary boosters to all individuals over age 65 and the staff who serve them. We encourage HHS to continue to implement consumer education programs to encourage keeping up to date on vaccines.
• Personal Protective Equipment. We advocate to HHS and the Administration to prioritize aging services providers in the distribution of personal protective equipment to help limit transmission of COVID-19 and protect the staff providing care to vulnerable older adults.
• Provider Reporting. We will continue to work with HRSA to advocate continued streamlining of reporting processes that ensure providers are not burdened with duplicative, time-consuming, or unnecessary data reporting.
• Regulatory waivers. We advocate that CMS continue 1135 regulatory waivers to allow providers the flexibility to focus their resources on preparing for and responding to current and new outbreaks in their communities and that additional flexibility be considered.
• Distribution of therapeutics. We advocate that the Administration prioritize the most vulnerable older people for access to therapeutics.
• Resilience in senior housing. We will carry on with our work with federal agencies to support the needs of affordable senior housing communities with necessary financial and administrative relief.

LeadingAge Advocacy Goals

• Ensure that older adults are able to receive health care and long-term services and supports in their homes and communities if they prefer to do so.
• Advance policy that promotes the availability of HCBS across funding streams, including Medicaid, Medicare, Older Americans Act, and Veterans Affairs.
• Secure funding to stabilize the adult day services field and make sure providers are able to sustain through and beyond the COVID-19 pandemic.
• Support increased availability of PACE organization services to older adults through regulatory and statutory flexibility and investment at the federal and state levels.
• Ensure that any LTSS models from the Center for Medicare and Medicaid Innovation is inclusive of all settings in the home and community (e.g., home health and personal care, adult day other day-based services, PACE services) and provide the supports (e.g., transportation) needed to facilitate these.
• Promote federal rulemaking that ensures access and quality HCBS for beneficiaries while minimizing provider burden.
• Preserve the ability and discretion of states to regulate assisted living.
• Address racial disparities in access to and quality of HCBS.
• Oppose block grant and per capita cap policies.

THE ISSUE

Home and community-based services (HCBS) providers are at an inflection point. Over the last decade, significant improvement has been made in the availability of and public investment in these critical LTSS providers, however, the COVID-19 pandemic has put these resources at risk both at present and over the long term. In addition, federal barriers exist that limit the growth and availability of HCBS, including the optional status of HCBS (waiver, state plan, PACE) as Medicaid benefit categories, limits to emergency relief provisions (e.g., retainer payments), and the lack of an HCBS-centered model from the CMS Innovation Center.

Adult day services providers in particular are at risk.  Many centers closed either by mandate or voluntarily during 2020 and 2021, and many saw most of their revenue streams evaporate overnight. Those that have since reopened have done so at reduced capacity and with fewer participants attending. This has led to centers closing across the country, jeopardizing the availability of these services over the long run. Federal funding, as well as flexibilities from payers like Medicaid and the VA, continue to be sorely needed.

PACE organizations innovated amidst the pandemic, particularly with respect to the use of telehealth and developing new ways to use their PACE centers. Most PACE organizations have also ramped up their in-home services capacity, versus the traditional center-based model many have historically used. PACE needs more investment and regulatory change in order to allow it to serve more beneficiaries.

Several other types of home and community-based services, including life plan community “at home” models, Medicaid personal and home care, also face challenges with staffing exacerbated by the pandemic.

Advocacy Action 2023

118^th Congress

Click here to see the full list of HCBS  legislation LeadingAge is following in Congress.

• Supporting the community-based care workforce. We support legislative efforts to ensure that home care workers earn at least a living wage and have opportunities for professional development. We support efforts to increase the pool of qualified applicants domestically and internationally.
• Medicaid FMAP: We support a continuation of the 10% increase in the Federal Medical Assistance Percentage (FMAP) for Medicaid HCBS to ensure states have the funds needed to sustain these services.
• Benefit categories. We ask Congress to revise Medicaid and put HCBS (including waiver and state plan services and PACE) on equal footing with nursing homes and make HCBS a mandatory Medicaid benefit.
• Protecting access. We support making permanent key provisions that ensure access to HCBS, including the federal spousal impoverishment protections for Medicaid HCBS and the Money Follows the Person program.
• Adult Day Coverage under Medicare. We believe Congress should amend the Medicare program to make adult day services available to beneficiaries (e.g., FFS and managed care)..
• Appropriations. We support increasing funding for key provisions that support HCBS, including Older Americans Act services.
• Duals integration: support and pursue efforts to both clinically and financially integrate care and services for those dually eligible for Medicare and Medicaid.

Executive Branch

• HCBS Settings Rule Compliance: We will continue to work with states and CMS on HCBS settings rule compliance and advocate for changes to make compliance less burdensome for adult day, PACE, and assisted living providers and those they serve.
• Telehealth. We continue to advocate for revisions to CMS guidance documents to broaden access to telehealth services for PACE participants and Medicare Advantage enrollees. In addition, we ask CMS to encourage states to make telehealth available as a meaningful option for Medicaid HCBS providers unable to deliver in-person services.
• Protect Medicaid financing. We oppose any Medicaid waiver or rulemaking that reduces federal funding to the program, as these could ultimately jeopardize HCBS access. To that end, CMS should not approve and/or rescind waivers that allow per capita caps/block grant financing, work requirements and unnecessary coverage/enrollment barriers.
• Innovation Center models. We will closely monitor CMMI action to ensure that home and community-based services of all types are included as part of the proposed LTSS Innovation Fund and in other models.
• VA Coverage of HCBS. We will closely monitor developments with the VA Community Care Network program and other VA initiatives that provide HCBS and advocate for our members and the veterans they support.
• Transportation and Medicaid: We support the maintenance of current rulemaking that assigns non-emergency medical transportation (NEMT) as a mandatory Medicaid benefit. We also will continue to advocate for more integration between adult day and transportation to ensure seamless access to care.
• Supplemental Services under Medicare Advantage. We will encourage CMS to continue broadening HCBS availability in Medicare Advantage and work with plans on implementation.
• Prepare for unwinding of the PHE: work with members on the impacts of the impact of the unwinding of the Medicaid provisions tied to the public health emergency and work with CMS as needed to advocate for member needs.
• MACPAC: We will monitor and engage with MACPAC as needed regarding their recommendations around HCBS.
• Family caregiving: LeadingAge recognizes the critical role family caregivers play in the care of older adults in the community. We will continue to monitor and engage on the U.S. Department of Health and Human Services, Administration of Community Living’s (ACL) National Strategy to Support Family Caregivers

 ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center and help your members of Congress understand how policies they make impact Home and Community Based Services.
• Host a Coffee Chat with Congress in your community to help your members of Congress understand how policies impact HCBS providers and residents.
• Mobilize with the Advocacy Champions toolkit and let your representatives and senators know you support more opportunities to create and sustain home and community-based services.

ADDITIONAL RESOURCES

• • LeadingAge Response to Medicaid Request for Information

LeadingAge Advocacy Goals

• Promote initiatives to examine and address the workforce crisis. Advocate that any staffing mandates are reasonable, empirical, and fully funded.
• Seek meaningful, transformational change in the structure, care delivery, and financing of residential long-term services and supports by supporting the work of the Moving Forward Nursing Home Quality Coalition that seeks to advance the recommendations of the 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) report The National Imperative to Improve Nursing Home Quality: Honoring our Commitment to Residents, Families, and Staff.
• Advocate for evidence-based reimbursement rates that are sufficient to cover the full range of costs to provide high-quality care and services including supply needs, training, and fair wages for staff.
• Promote modernization of the survey process to include constructive approaches that focus on resident outcomes and support quality improvement.
• Ensure regulations promote person-centered quality and support positive clinical outcomes and evidence-based best practices without adding burden that does not support positive outcomes.
• Advance a quality measurement system underlying the regulatory process that truly reflects quality care and quality of life for residents.
• Promote a positive vision of the future of nursing homes as an integral part of the continuum of care where both residents and staff are supported to reach their fullest potential.

THE ISSUE

Nursing homes are an essential element of the long-term services and support system, serving individuals with serious functional impairments who are unable to live independently in the community. Although fewer than 4% of those over 65 will ever live in a nursing home, these settings provide treatment and care in a safe, home-like environment that supports a quality of life when aging in the community is no longer an option.

Medicaid is the primary payer for nursing home care, covering six out of ten stays, but Medicaid rates do not cover the cost of care. The pandemic has further exacerbated the impact of reimbursement shortfalls stemming from inadequate Medicaid rates and a lack of comprehensive investment in long-term services and supports. As COVID-19 continues to affect lasting change on the healthcare system, the gap between the cost of quality care and reimbursement for that care widens. Rising costs related to workforce challenges and aging buildings and outdated physical plant designs also demand attention.

Recalibration of the Patient-Driven Payment Model (PDPM) and stagnancy among already inadequate Medicaid rates strap nursing homes while occupancy rates struggle to recover from the public health emergency. Provider Relief Funds and other emergency-era programs do not nearly make up for the revenue lost or the additional expenditures that nursing homes have had to make to protect residents and staff.

ADVOCACY ACTION 2023

118^th Congress

Click here to see the full list of nursing home legislation LeadingAge is following in Congress.

• Telehealth Extension and Expansion. We support the extension of telehealth flexibilities granted under the COVID-19 public health emergency and advocate for expansion of telehealth flexibilities for the future of aging services. We support Advancing Telehealth Beyond COVID-19 Act and Telehealth Extension and Evaluation Act, each of which would extend key Medicare telehealth flexibilities that were granted during the COVID-19 Public Health Emergency (PHE). We additionally support CONNECT for Health Act and the Telehealth Modernization Act that remove geographic and originating site restrictions on telehealth.
• Observation Stays. We support the reintroduction of the Improving Access to Medicare Coverage Act that would mandate that all time spent in a hospital, regardless of admission status, would count toward the 3-day qualifying stay required for SNF services under the Medicare benefit. The waiver of the 3-day stay requirement during COVID reinforces the lack of rationale for this restriction on Part A eligibility.
• CNA Training Lock-Out. We support the reintroduction of the Ensuring Seniors’ Access to Quality Care Act that would allow reinstatement of a nurse aide training program once a nursing home has been determined by CMS to be in substantial compliance. The ability of nursing homes to provide in-house training is especially critical given the workforce shortages exacerbated by the COVID-19 pandemic.
• TNA Flexibilities. We support reintroduction of the Building America’s Health Care Workforce Act, which would extend CMS’s TNA waiver flexibilities for 24 months beyond the COVID-19 Public Health Emergency, enable TNAs to continue working in their current roles, and put their on-the-job experience and training toward the 75-hour federal CNA training requirement. The legislation was introduced in response to CMS’s announced roll back of certain 1135 waiver modifications implemented at the beginning of the COVID-19 pandemic.
• Nursing Home Infrastructure. We support reintroduction of the Infrastructure Modernization Project Related to the Overall Enhancement (IMPROVE) Nursing Homes Act to create a grant program that would convert traditional nursing homes into small-house nursing homes with person-centered cultures. The bill would ensure that at least 50% of grant funding goes to nursing homes where 85% or more of residents pay for care via Medicaid.

• Special Focus Facilities. We support the Nursing Home Reform Modernization Act to revamp the Special Focus Facility Program, authorize CMS to create national standards for low-rated and high-rated nursing homes, create a consultation program separate from enforcement that is mandatory for low rated facilities, and make other changes to the 5 Star program. LeadingAge provided substantial technical assistance to Senate staff as this legislation was being developed.
• IMAGINE Proposal: We propose the creation of an aging-forward immigration system that would engage foreign-born workers to address the workforce crisis faced by many nursing homes and aging services providers.

Executive Branch

• Staffing Standards. We support a staffing study that critically examines the needs and realities of nursing home care in a post-COVID world where a nation-wide workforce shortage and increased scrutiny force nursing homes to innovate on ways to effectively deliver care. We will provide feedback on proposed staffing standards to ensure that mandated staffing levels are reasonable and attainable, and that resources exist to support nursing homes that are unable to meet staffing standards to assist them in continuing to provide quality care to residents.
• Workforce Support. We call on CMS and the Administration to provide resources to support nursing homes in developing a robust, well-trained workforce. We provide feedback on identified needs, such as emergency preparedness resources and resources to support the wellness and mental health of staff. We work with CMS on regulatory solutions, such as telehealth, delegation of physician tasks, and federal nurse aide training requirements.
• Medicare/Medicaid Reimbursement. We comment on annual Medicare rate adjustments, including recalibration of the Patient-Driven Payment Model. We are conducting research on the adequacy of Medicaid reimbursement rates that can be used in state-level advocacy and we engage with the Medicare Payment Advisory Commission (MedPAC) and Medicaid and CHIP Payment and Access Commission (MACPAC).
• Integrated MA benefits. We support ongoing flexibility for Medicare Advantage plans to add or amend benefits and policies that improve access to services or deliver a more integrated approach to care, (e.g., adding new supplemental benefit – home delivered meals during the pandemic) and doesn’t add administrative burden to providers.
• Alternative Payment Models. We engage in activities geared toward the development of alternative payment models, such as the Unified Post-Acute Care Prospective Payment System Technical Expert Panel.
• Survey and Certification. We call on CMS to improve consistency and accuracy in the survey and enforcement process. We promote alternatives focused on a collaborative approach to quality improvement and utilization of enforcement remedies that reflect a just culture. We support enhanced data monitoring to more effectively focus surveyor resources on lower performing nursing homes and advocate for CMS to strengthen internal processes to link nursing homes with needed technical support to improve quality rather than simply penalizing nursing homes for noncompliance and walking away.
• Requirements of Participation (RoPs). We will provide feedback to CMS to ensure that regulations and interpretive guidance are clear and evidence-based. We advocate for regulatory and sub-regulatory changes that allow members to focus staff resources on the activity of providing quality care as opposed to draining staff resources through paper compliance and mounting reporting requirements.
• COVID-19 Resources. We call on the Administration to ensure that all aging services providers have adequate access to COVID-19 testing materials, vaccines, and therapeutics and that nursing homes specifically have the resources needed to ensure the safety of residents and staff and compliance with CMS requirements. We support members in maintaining Provider Relief Funds through assistance with reporting compliance and advocating to the agency for appropriate exceptions or corrections.

• Emergency Preparedness. We provide feedback to CMS on barriers to emergency planning and needed resources and advocate for increased collaboration with federal, tribal, state, and local entities to ensure nursing homes are included in disaster planning, response, and recovery activities.
• Regulatory waivers. We advocate that CMS make permanent 1135 regulatory waivers related to telehealth and the 3-day Qualifying Hospital Stay to expand beneficiaries’ access to care despite geographical barriers or workforce insufficiency.
• Quality Measures. We promote activities to establish quality measures that are evidence-based and accurately reflect quality care. We provide feedback to CMS on proposed measures and advocate for changes to measures and public reporting of measures that are misleading or give an incomplete picture of nursing home care such as staff turnover measures, the long-stay antipsychotic measure, and COVID-19 vaccination coverage measures.
• Health Equity. We work with CMS, nursing home members, and other stakeholders to integrate practices that will help identify, evaluate, address, and remediate health disparities in the populations we serve. We support efforts that utilize accessible and understandable data that can be easily operationalized by nursing homes in their internal quality improvement work.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your representative and senators hear your voice on the issues facing nursing homes.
• Host a Coffee Chat with Congress in your community to help your members of Congress understand how policies impact nursing homes and the people who live and work in them.
• Mobilize with the Advocacy Champions toolkit and let your representatives and senators know you support nursing homes and the care they provide for residents.

ADDITIONAL RESOURCES

• National Academies of Sciences, Engineering, and Medicine study on the quality of care in nursing homes
• Moving Forward Nursing Home Quality Coalition
• COVID-19 Emergency Declaration Blanket Waivers for Healthcare Providers
• LeadingAge Nursing Home RoPs Tools and Resources

LeadingAge Advocacy Goals

• Address the severe shortage of affordable senior housing by expanding, preserving, and improving housing assistance for older adults.
• Improve resident outcomes by using affordable housing as a platform to connect residents to services and supports, including by expanding the number of service coordinators and bridging the digital divide.
• Improve processes, requirements, and inspection protocols in federal housing programs to support the operation of high-quality affordable senior housing.

THE ISSUE

There is a severe shortage of affordable housing for older adults with low incomes. Between 2009 and 2019, the number of very low income older adult households spending more than half of their incomes on rent increased by an astonishing 68%. While 47% of all renters are cost-burdened, more than half of older renter households (53% or 4.7 million households) are housing cost-burdened, and almost one in three (30% or 2.6 million households) experience a severe cost burden.

There is a clear racial disproportionality of need for affordable senior housing. Black and Latina/o older renters are also disproportionately rental cost-burdened. High housing cost burdens result in older adults spending half as much as their non-cost-burdened peers on food and healthcare. Meanwhile, the number of older adults experiencing homelessness is rising faster than the nation is aging.

In addition to expanding the supply of housing, we need to preserve and improve existing affordable and accessible housing for older adults. Currently, less than half of properties in HUD’s Section 202 Supportive Housing for the Elderly have a Service Coordination program. Service Coordinators are crucial to connecting residents with services and supports needed to age in community.

Improving affordable housing options for older adults over the long-term also means increasing accessibility features, improving digital connectivity, and addressing the need for energy and climate resilience throughout federally-assisted rental housing.

ADVOCACY ACTION 2023

118^th Session of Congress

Click here to see the full list of affordable housing legislation LeadingAge is following in Congress.

Secure robust Fiscal Year 2024 HUD appropriations funding:

• Expand access to affordable senior housing.
  • Provide $600 million for new capital advances and operating assistance, including service coordination, for approximately 6,200 new Section 202 Supportive Housing for the Elderly homes nationwide, including in rural areas.
  • Allow capital advances for new Section 202 properties to be paired with project-based Section 8 operating subsidy.
  • Provide $50 million for about 5,000 new Older Adult Special Purpose Vouchers, at least 50% of which could be project-based.
•  Preserve and improve HUD-assisted housing.
  • Provide full funding for Section 8 Project-Based Rental Assistance (PBRA) and Project Rental Assistance Contract (PRAC) renewals, including funding that reflects increased costs for insurance, staffing, utilities, service coordination, and internet connectivity.
  • Expand ongoing budget adjustment options for Section 202/PRAC properties, including by implementing market-driven adjustments option such, as Operating Cost Adjustment Factors (OCAFs).

• Ensure RAD for PRAC success.

• • • Allow converted RAD for PRACs to access a Rent Comparability Study (RCS) every five years, in addition to annual OCAFs, and adjust initial rent-setting to improve financial viability of the converted property.
    • Provide $10 million for RAD for PRAC conversion subsidy to ensure the successful and long-term preservation of 202/PRAC homes.
• Connect HUD-assisted residents to the services and supports they need to age in the community. 
  • Provide $125 million for the renewal of existing service coordinator grants.
  • Provide $100 million for 400 new, three-year service coordinator grants and expand eligibility to 202/PRAC communities.
  • Provide a $31 million increase for new, budget-based service coordinators.
  • Further improve the FCC’s Affordable Connectivity Program to allow for whole-building eligibility and enrollment for HUD-assisted communities.
  • Expand resources to install building-wide internet in HUD-assisted communities.

Expand and improve the Low-Income Housing Tax Credit program.

• Enact the Affordable Housing Credit Improvement Act (AHCIA) to:

• Increase state Housing Credit allocations by 50%.
• Fix Right of First Refusal issues that continue to rob nonprofit housing providers of their housing credit-financed developments.
• Lower the threshold of Private Activity Bond financing required to trigger the maximum amount of 4% Housing Credits from 50% to 25%.
• Enable the Housing Credit to better serve households with extremely low incomes.

• Enact solutions to bring service coordinators to housing credit communities.

Prevent and end homelessness among older adults.

• Fully fund HUD’s homeless assistance programs.
• Improve data collection on homelessness among older adults.
• Improve partnerships between Continuums of Care and Area Agencies on Aging.

Support efforts to improve accessibility of the nation’s housing stock.

• Ensure HUD’s Older Adult Home Modification Program serves renters and homeowners.
• Expand resources to increase the accessibility of the nation’s housing stock.
• Support legislation that requires universal design and visitability.

Executive Branch

Expand and Preserve Affordable Senior Housing Options:

• Significantly expand the supply of federally subsidized housing for older adults with low incomes and older adults experiencing homelessness, including by issuing timely funding opportunities for new Section 202 capital advances and operating subsidy.
• Preserve and improve the existing supply of affordable housing, including through improvements to the Rental Assistance Demonstration (RAD) to achieve improved initial rent-setting, better energy efficiency, and long-term financial viability.

Cultivate Connected, Service-Enriched Housing:

• Support service-enhanced housing, including by improving HUD’s Service Coordinator grant administration, leveraging Service Coordinator reporting data, and implementing Supportive Services funding for Section 202/PRAC communities.
• Increase internet connectivity in affordable housing, including by adjusting HUD rules and by partnering with other federal agencies, like the Federal Communications Commission (FCC) and the National Telecommunications and Information Administration (NTIA). for infrastructure and internet service resources.

Support Improved Housing Operations:

• Streamline asset management, including through improved budget increase and contract renewal processes at HUD.
• Update HUD oversight mechanisms, including by implementing feasible changes to housing inspections and by updating portfolio oversight.

Climate Resilience in Senior Housing:

• Emphasize energy and water efficiencies throughout the senior housing portfolio to improve climate outcomes and better leverage HUD funding.
• Increase equity in climate resilience while improving the federal approach to disaster preparedness and response.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support the expansion and preservation of affordable housing programs for older adults.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies impact HCBS providers and residents.
• Engage with other affordable senior housing providers through the LeadingAge Housing Network (and its five working groups), as well as other regular national, regional, and state meetings. Contact Linda or Juliana for more information.

ADDITIONAL RESOURCES

• HUD’s Worst Case Housing Needs 2021 Report to Congress
• The Urban Institute’s 2020 – 2040 household formation projections: The Future of Headship and Homeownership
• Exploring Financing Options for Services in Affordable Senior Housing Communities
• Aging Research from the Joint Center for Housing Studies of Harvard University
• The Impact of Climate Change: Why Older Adults are Vulnerable

LeadingAge Advocacy Goals

• Ensure that older adults are able to receive health care and long-term services and supports in their homes and communities if they prefer to do so.
• Support increased availability of PACE organization services to older adults through regulatory and statutory flexibility and investment at the federal and state levels.
• Promote PACE across the country via new and expanded service areas and increased enrollment.
• Advance policy that promotes the availability of PACE across funding streams.
• Ensure that any LTSS models from the Center for Medicare and Medicaid Innovation are inclusive of all settings in the home and community (e.g., home health and personal care, adult day other day-based services, PACE services) and provide the supports (e.g., transportation) needed to facilitate these.
• Promote federal rulemaking and compliance with current regulations that ensures access and quality HCBS for beneficiaries while minimizing provider burden.

THE ISSUE

PACE organizations have risen to the challenge COVID-19 has presented.. The combination of nimble service delivery, stable reimbursement, and the ability of PACE to keep older adults in their homes and communities make the model attractive to participants, payer (e.g., Medicare and Medicaid), and PACE organizations both during and beyond the pandemic.

PACE organizations innovated amidst the pandemic, particularly with respect to the use of telehealth and developing new ways to use their PACE centers. Most PACE organizations have also ramped up their in-home services capacity, versus the traditional center-based model many have historically used. PACE needs more investment and regulatory change in order to allow it to serve more beneficiaries.

In addition, federal barriers exist that limit the growth and availability of PACE, including the optional status of all home and community-based services (waiver, state plan, PACE) as Medicaid benefit categories, limits to emergency relief provisions (e.g., retainer payments), and the lack of an HCBS-centered model from the CMS Innovation Center. Some states used their American Rescue Plan Act (ARPA) dollars to expand access to PACE. But a longer term, sustainable investment in the PACE program is needed to ensure it can grow to match demand while maintaining the “gold standard” of care that PACE is known for.

ADVOCACY ACTION 2023

118^th Congress

Click here to see the full list of PACE legislation LeadingAge is following in Congress.

•  Supporting the home and community-based care workforce. We support legislative efforts to ensure that home and community-based care workers earn at least a living wage and have opportunities for professional development. We support efforts to increase the pool of qualified applicants domestically and internationally.
• Medicaid FMAP: We support a continuation of the 10% increase in the Federal Medical Assistance Percentage (FMAP) for Medicaid HCBS to ensure states have the funds needed to sustain these services.
• Benefit categories. We ask Congress to revise Medicaid and put HCBS (including waiver and state plan services and PACE) on equal footing with nursing homes and make HCBS a mandatory Medicaid benefit.
• Appropriations. We support increasing funding for key provisions that support HCBS, including Older Americans Act services.
• PACE expansion: we support legislation that expands the scope of the PACE program and removes regulatory barriers that create barriers to access.
• PACE and Part D: we support legislation that adds the protections afforded to standard Part D plans by the Inflation Reduction Act to the PACE program.

Executive Branch

•  HCBS Settings Rule Compliance: We will continue to work with states and CMS on HCBS settings rule compliance and advocate for changes to make compliance less burdensome for both adult day providers and those they serve.
• Telehealth. We continue to advocate for revisions to CMS guidance documents to broaden access to telehealth services for PACE participants and Medicare Advantage enrollees. If the executive branch does not act, Congress should.
• Protect Medicaid financing. We oppose any Medicaid waiver or rulemaking that reduces federal funding to the program, as these could ultimately jeopardize PACE access. To that end, CMS should not approve and/or rescind waivers that allow per capita caps/block grant financing, work requirements, and unnecessary coverage/enrollment barriers. CMS should not propose rulemaking similar to the 2019 Medicaid Fiscal Accountability Regulation (MFAR).
• Family caregiving: LeadingAge recognizes the critical role family caregivers play in the care of older adults in the community. We will continue to monitor and engage on the U.S. Department of Health and Human Services Administration of Community Living’s (ACL) National Strategy to Support Family Caregivers
• Prepare for unwinding of the PHE: work with members on the impacts of the impact of the unwinding of the Medicaid provisions tied to the public health emergency and work with CMS as needed to advocate for member needs.
• MACPAC: We will monitor and engage with MACPAC as needed regarding their recommendations around HCBS.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center and help your Members of Congress understand how policies they make impact PACE organizations.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies impact PACE organizations and participants.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support more opportunities to create and sustain home and community-based services.

ADDITIONAL RESOURCES

• Bipartisan Policy Center Report on Improving PACE

LeadingAge Advocacy Goals

(NOTE: Assisted living services are not federally funded or regulated. However, they are affected by some federal policies. Further, they have received federal support to fight COVID-19 in the form of testing and plans for vaccines. It is critical to note that these communities respond to local need, are regulated by states, and are not federally funded or regulated. We work closely with LeadingAge state partners to support relevant state- specific advocacy. In this section of LeadingAge’s 2023 Policy Priorities, we simply pull together the elements of the priorities that are most relevant to assisted living providers.)

• Seek proactive protections for assisted living and memory support providers to help offset the tremendous rising costs of providing higher acuity care amidst crippling workforce and occupancy shortages, specifically related to liability and bankruptcy protections.
• Advocate for assisted living communities to have all the resources needed to fight the COVID-19 pandemic, including staff, testing, PPE, and vaccines.
• Understand and advise members on the current framework of varying state regulations and standards governing assisted living and memory care.
• Work with members and stakeholders to explore ideas to bring more affordable assisted living options to the “middle market” that is currently underserved.
• Analyze existing programs and experiment with new ways to determine the most effective avenues to reduce abuse/incidents and increase quality in assisted living.

• Establish and implement a vision and action plan to drive a national consensus process to improve care.

• Raise legislators’ awareness of the increasing need for behavioral and mental health supports and services for older adults as they age in place in congregate settings, and advocate on a federal level for funding or programs that train and prepare employees and organizations to address these needs.

THE ISSUE

With close to one million assisted living residents nationwide, assisted living and memory care providers are faced with many of the issues that all aging services providers faced this year –workforce shortages, severe occupancy vacancies, rising acuity of patient care, behavioral and mental health program gaps, inadequate Medicare/ Medicaid reimbursement, the ongoing COVID-19 pandemic, and more.

Assisted living providers have struggled with the financial sustainability of their operations because of the precipitous drops in occupancy, coupled with the costs of rising acuity levels of resident care and the increased wage expenses required to fill crippling staffing shortages. In addition, there is a looming and unwarranted burden of liability claims and the associated rising cost of insurance because of the COVID-19 pandemic.

In addition to COVID-19, quality of care and resident safety are perennial challenges that have only been compounded by the other pressures AL and memory support providers face. LeadingAge is looking to ensure a constructive, future-focused action plan to promote smart approaches to quality in assisted living and memory care without federal regulations.

ADVOCACY ACTION 2023

118th Congress

Click here to see the full list of assisted living legislation LeadingAge is following in Congress.

• Telehealth. We support solutions to improve access to telehealth services in assisted living residences.
• COVID-19 relief. We support additional legislation that will provide funds and other relief for aging services.
• Support liability protection. We will continue to work with a coalition of national associations and state association partners to enact state civil liability protections for assisted living providers relating to COVID-19 claims. Nearly half the states have enacted some sort of protections (but many not including assisted living providers), and we are still advocating for broad protections on the federal level.
• Vaccine mandates and booster shot distribution. We support and advocate for an adequate budget to enable seamless implementation of rapid, efficient distribution of vaccines and boosters to all aging services professionals including all employees of life plan communities. We encourage HHS to implement consumer education programs to encourage immunization.
• Professionalize the Workforce. We support treating LTSS professionals with respect and dignity. LTSS settings must feature greater standardization of competency-based training requirements and education needed to prepare the frontline workforce to deliver quality care.
• Behavioral Health: Geriatric Social Worker Education, Recruitment and Retention Program. We support the inclusion of expanded programs to recruit, educate, and retain geriatric social workers that encourage more social workers to join and specialize in the aging services field.
• IMAGINE Proposal. We propose the creation of an aging-forward immigration system that would engage foreign-born workers to address the workforce crisis faced by many nursing homes and aging services providers.

Executive Branch

• Office of State and Community Energy Programs (SCEP.) We support the implementation of the Inflation Reduction Act and its energy efficiency goals for residential housing programs, and encourage the SCEP to work together with aging services providers to facilitate the adoption of energy-saving technologies and equipment.
• Integrated MA benefits. We support ongoing flexibility for Medicare Advantage plans to add or amend benefits and policies that improve access to services or deliver a more integrated approach to care (e.g., adding new supplemental benefit – home delivered meals during the pandemic) and doesn’t add administrative burden to providers.
• Various COVID-19 Mitigation Efforts. As in all other areas of aging services, we support and advocate for: distribution of testing materials; vaccine distribution; extension of the Public Health Emergency; prioritization and delivery of personal protective equipment; streamlined Provider Relief Fund reporting; among many others.
• Regulatory waivers. We advocate that CMS continue 1135 regulatory waivers to allow providers the flexibility to focus their resources on preparing for and responding to COVID-19 outbreaks in their communities and that additional flexibilities be considered.

ACTIONS YOU CAN TAKE NOW

• Let your Representative and Senators know you support legislation that enhances access to assisted living.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies impact assisted living.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support more opportunities to create and sustain assisted living.

ADDITIONAL RESOURCES

• NCAL Report 2022: States Continue Strengthening Assisted Living Regulations
• AHCA/NCAL Assisted Living Regulatory Review 2022
• JAMDA: The Imperative to Reimagine Assisted Living
• ASHA: State of Seniors Housing 2021
• ASPE Compendium of Residential and Assisted Living Regulations and Policy
• JAMDA – The Need to Include Assisted Living in Responding to the COVID-19 Pandemic
• Nursing Outlook: Comparing Residential Long-Term Care Regulations Between Nursing Homes and Assisted Living
• CDC – Characterization of COVID-19 in Assisted Living Facilities – 39 States

LeadingAge Advocacy Goals

• Advocate for permanent changes to Medicare, Medicaid, and commercial payer telehealth policy based on lessons learned from the coronavirus pandemic.
• Ensure all aging services providers are included in future permanent telehealth expansions.
• Permanently remove Medicare’s restrictions of patients’ homes as an originating site for audio-only, synchronous audio-only, and asynchronous biometric remote patient monitoring (RPM) and for individuals with chronic conditions living independently, and for individuals with chronic conditions living independently but helped by home health clinicians. Also, promote the use of synchronous audio-video telehealth in skilled nursing homes and assisted living communities.
• Create an equitable payment policy for the post-pandemic era that balances providers’ costs with patient protections.
• Promote the adoption of interoperable electronic health records, including funding and technical support.
• Promote the use of standards-based health information exchange between aging services providers and their partners including primary/acute care providers and payers.
• Ensure equitable internet connectivity for all aging services providers and older adults, including in affordable housing where Wi-Fi access should be federally funded.
• Promote policies that support the use of technology to reduce social isolation.
• Promote the LeadingAge proposed “Telehealth Demonstrations” to expand professionals eligible for certain telehealth interventions, such as Chronic Disease Management and Complex Chronic Conditions to include home health nurses, care managers, and clinical social workers at home health agencies that use RPM technologies to manage chronically ill populations, under the supervision of a physician. Such codes are under-utilized by physicians. Similarly, there are opportunities for therapists, pharmacists, and staff at other types of home-based care providers, etc., to provide appropriate interventions using the appropriate modalities of telehealth.

Health IT Incentives:

Secure government funding for the Office of National Coordinator (ONC) at the U.S. Department of Health and Human Services (HHS) to:

• Establish electronic health record (EHR) Interoperability Certification Criteria/Program relevant to LTPAC, but aligned, where possible, with the acute care certification program.
• Establish health IT education and training for staff in LTPAC providers, similar to the Regional Extension Centers (RECs) that supported small physician practices.
• Fund technical assistance resource centers to provide technical assistance for LTPAC providers, similar to the RECs that supported small physician practices.
• Direct financial incentives for LTPAC Providers (SNFs/NFs, home health, hospice, long-term acute care hospitals (LTACHs), in-patient rehabilitation facilities (IRFs) to:
  • Upgrade to interoperable EHR technology;
  • Upgrade their infrastructure and broadband connectivity;
  • Subscribe and connect to health information exchange entities or networks, and add technically competent staff to support the use;
  • Conditional Sustainable Use financial incentives/payment modifiers that, tied to quality measures, would be impacted by effective exchange of health information with partners for the next five years.

Broadband:

• Extend the subsidized broadband connectivity rates for health care providers in rural areas to additional aging services providers by amending the Social Security Act (as was done in the 2015 Rural Connectivity Act, which added nursing homes to the definition of healthcare providers).
• Create funding opportunities for congregate affordable low-income housing providers to collectively apply for and receive broadband internet connectivity to the building and to their residents’ units, to ensure equitable access to services.

THE ISSUE

Massively increased flexibilities, particularly in the Medicare program, to utilize technology to deliver all types of care became an essential lifeline for our health care system during a time of unparalleled challenges and strains. If there is any “silver lining” to the coronavirus pandemic, it has been an increase in the use of technology to deliver appropriate and timely care to keep people safe, healthy, and well-connected.

The ability to use telehealth during this emergency was vitally important to protect staff and patients’ health, but also to expand the reach of overextended health care personnel. Waivers in Medicare rules that allow the home to be an originating site of care expand the types of technology that can be used for telehealth visits (e.g., Facetime and even audio-only in some cases) and expand the types of providers that can bill for telehealth services are all massive changes from the pre-pandemic state of play.

The question now is how to capitalize on the progress made during the pandemic, which in many ways has served as the “demo” of telehealth that many have asked for in the past. Concerns for the future include how to make sure that telehealth is incorporated into practice in an equitable, cost-effective (for both the government and providers), and accessible way. What is clear is that we need to continue moving forward.

In addition to making permanent many of the pandemic flexibilities, aging services providers need to adequately pay their appropriate trained staff, like therapists and nurses. These staff can either deliver interventions, including therapy via telehealth (both synchronous virtual visits as well as asynchronous RPM) under a physician-approved care plan, or can assist a remote physician during an asynchronous telemedicine visit. Moreover, providers need support to maintain and upgrade technology. Hence, they need adequate reimbursement from all payer sources to sustain and maintain the investments they already made in delivering care via telehealth.

Broadband investment, especially in rural and underserved areas, is critical to making sure telehealth is an accessible service nationwide – including in affordable senior housing communities, many of which lack connectivity and where federal investment in wireless internet capability is imperative. Continued investment in broader health IT to support information management and the secure exchange of health information are also critically important and need to be inclusive of aging services providers.

Finally, those providers who treat patients in their own home – like home health and hospice as well as PACE – who have not been able to take full advantage of the affordable internet connectivity like their other healthcare peers in rural areas, or telehealth in the past, or even the expanded telehealth flexibilities, need to be included.

ADVOCACY ACTION 2023

118^th Congress

Click here to see the full list of technology and telehealth legislation LeadingAge is following in Congress.

• Keeping key pandemic flexibilities.

We support keeping the following pandemic flexibilities in place permanently:

• • Permanently removing the geographic restrictions on telehealth;
  • Allowing the home to be an originating site of care beyond the public health emergency;
  • Permanent expansion of the providers who can furnish telehealth services in both the physical and mental health ;
  •  Continued flexibility in the type of modality allowable for video-audio connections (e.g., allowing the use of FaceTime or other smartphone technology) to utilize all tools available, including audio-only, to deliver telehealth services as appropriate and look to work with Congress on the intersection of accessibility and privacy (e.g., HIPAA concerns).
• Hospice face-to-face recertification. We support allowing the hospice face-to-face recertification to take place via telehealth on a permanent basis.
• Prevent a telehealth “cliff” after the end of the PHE. While we support the expansion of telehealth based on the experience of providers and patients during the pandemic, it is critically important that there not be a “cliff” where the flexibilities suddenly end, potentially cutting off access.
  Advancing Telehealth Beyond COVID-19.

We support the House-passed bill, the Advancing Telehealth Beyond COVID-19 Act of 2022 (H.R. 4040), which would extend key Medicare telehealth flexibilities that were granted during the COVID-19 Public Health Emergency until at least December 31, 2024. Specifically, the bill provides that certain flexibilities continue to apply until December 31, 2024, if the emergency period ends before that date. The bill allows:

• Beneficiaries to continue to receive telehealth services at any site, regardless of type or location (e.g. the beneficiary’s home);
• Occupational therapists, physical therapists, speech-language pathologists, and audiologists to continue to furnish telehealth services;
• Federally qualified health centers and rural health clinics to continue to serve as the distant site (i.e., the location of the health care practitioner);
• Evaluation and management and behavioral health services to continue to be provided via audio-only technology; and
• Hospice physicians and nurse practitioners to continue to complete certain requirements relating to patient recertifications via telehealth.

The bill also delays implementation of certain in-person evaluation requirements for mental health telehealth services until January 1, 2025, or the first day after the end of the emergency period, whichever is later.

• Reimbursement for home health telehealth visits. We support legislative efforts that allow virtual visits to be reimbursed under the Medicare home health benefit with appropriate guardrails.
• PACE and telehealth. We support legislation that would allow audio-only diagnoses that are made via telehealth to be used for purposes of determining risk adjustment to payments for PACE and Medicare Advantage programs.
• Housing and technology. We support federal funding for the installation and service fees for wireless broadband internet in all HUD-assisted senior housing communities units.
• Meaningful use. Aging services providers were not included in previous funding efforts that supported health care providers’ transition to electronic health records (EHR) systems that contain the medical and treatment histories of patients. We will continue to advocate for funding and payment incentives, including incentives tied to quality, to assist aging services providers in accessing EHR technology that is interoperable with that of their physician and hospital partners and peers and encourage the bi-directional exchange of information.
• Nursing homes and telehealth. We support legislation that allows all nursing homes to use telehealth models to improve care.
• Affordable rural internet connectivity for aging services providers. We support legislative action aimed at expanding the scope of the 2015 Rural Healthcare Connectivity Act to include home health, hospice, and other aging services providers in the home and community. Such action would allow all aging services providers to take advantage of lower internet connectivity costs offered to acute care and nursing homes.

Executive Branch

• CMS commissioned study on telehealth services. HHS announced in a December 2021 research report massive increases in the use of telehealth helped maintain some health care access during the COVID-19 pandemic. The report also provides insights into telehealth visits conducted in 2020, which increased 63-fold from approximately 840,000 in 2019 to 52.7 million. Additionally, the report found: specialists such as behavioral health providers saw the highest utilization relative to other providers; telehealth services were accessed more in urban areas than rural communities; and Black Medicare beneficiaries were less likely than White beneficiaries to utilize telehealth. In light of this report, LeadingAge encourages CMS to improve health equity in telehealth services as highlighted by the COVID-19 PHE and to expand access among underserved populations.
• CMS 1135 waivers. LeadingAge will continue to advocate for a review of telehealth and technology 1135 waivers to see which can be made permanent without Congress, including utilization of telehealth for hospice routine home care visits and flexibility in licensure requirements in the Medicare and Medicaid program.
• Remote patient monitoring. LeadingAge will work to ensure that all appropriate aging services providers can utilize and bill for asynchronous remote patient monitoring, which is critical for individuals with chronic conditions who our providers serve to enhance their service.
• Advocate for the creation of claims codes or modifiers to document hospice virtual visits: Hospice providers are utilizing telehealth for routine home care during the pandemic. We will advocate for the creation of claims codes or modifiers that will allow for the analysis of these encounters for a variety of purposes including quality measurement.
• Advocate for the use of data from new claims codes documenting home health virtual visits. Home health providers are allowed to use virtual visits as part of their documented plan of care. We will advocate for the analysis of the recently created G-Codes for these encounters for a variety of purposes including quality measurement.
• Advocate for allowing home health nurses to bill for services. Therapists and other appropriately licensed professionals are allowed to use telehealth and home health agencies to bill for such services beyond the pandemic. Remote patient and medication adherence monitoring improve chronic care management, reduce hospitalizations, hospital stay, and readmissions, and consequently cost. Chronic care management reimbursement codes currently exist for physicians, physician assistants, and nurse practitioners, but are woefully underutilized. We will advocate for the creation of claims codes or modifiers that will allow the appropriate staff at home health agencies to perform, and for agencies to bill for, a variety of appropriate chronic care management and therapy interventions approved by a physician’s plan of care using telehealth, including remote patient and medication adherence monitoring technologies.
• Make demonstrations inclusive of telehealth. New and current CMS Innovation Center (or Innovation Center) demonstrations should include waivers to allow for the broad utilization of telehealth and technology. We will advocate for the Innovation Center to continue to build the evidence for the role these areas will continue to play in healthcare delivery.
• Video-based Mental Health Visits. The Calendar Year (CY) 2023 Medicare Physician Fee Schedule has codified the continued coverage of video-based mental health visits for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) on a permanent basis.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know your views on eliminating barriers for the expansion of telehealth services in the Medicare program.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies related to technology and not incorporating telehealth models in Medicare affect older adults.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know your views on technology and telehealth for older adults.

Resources

• LeadingAge Center for Aging Services Technologies

LeadingAge Advocacy Goals

• Propose and support LTSS reforms for older adults that include key provisions: low-income seniors must have housing and housing must include services as needed; new financing approaches must be considered, and communities must be prepared to include increasing numbers of older adults.
• Promote equitable LTSS financing reform to ensure that people at all economic levels are able to access services when they need them.
• Support the evolution of an aging-services continuum that builds on both the lessons of COVID and current successes and helps providers keep moving toward systems and services consumers want.
• Create policies that recognize that the consumer long-term care experience involves using many types of services; policies should enable consumers to transition to different types of services within the continuum.
• Identify and create solutions to enhance provider access to high-quality aging and LTSS options for middle-income individuals.
• Support and complement the work of family caregivers.

THE ISSUE

In 2018, 52 million people aged 65 and older lived in the U.S., 16% of the population. In 2026 the oldest baby boomers will turn 80. The older population in 2030 is projected to be more than twice as large as 2000, growing from 35 million to 73 million and representing 21% of the U.S. population. (Older Americans 2020: Key Indicators of Well-Being (agingstats.gov) Complicating the increasing numbers of older people, are economic declines in the over-65 group. Older individuals did not fare well economically during the pandemic, for example. Even with the relatively large 2023 cost of living increase in Social Security, many older adults will face financial hardship.

The demographic trends are evolving in a changing environment that includes climate change, pandemics, changes in housing and transportation patterns, rapid technology advancements, evolving attitudes toward work, and growing inequity based on race, gender, age, income, and geography.

The Coronavirus pandemic hammered home the fact that the nation’s aging and long-term care services are not where they should be. COVID’s differential impact on older people put into crisp clarity the fact that we must take steps to ensure a safe, high-quality range of choices for people who need functional supports as they age.

The pandemic further had deleterious effects on the economic status of many in the nation, especially those in lower wage tiers. Most people in the United States do not save or plan for their own likely future need for LTSS, and the federal government has yet to offer a program.

Family caregivers provide much of that care, and LTSS insurance has shown limited success. Medicare does not cover ongoing LTSS needs. Medicaid finances some LTSS for people who have very limited incomes and assets, and for those whose health and LTSS expenditures drive them into poverty. But Medicaid, too, will emerge from the pandemic badly battered, needing to provide more services to more people.

Individuals at the top of the income spectrum may be able to self-finance care. Those in the vast and increasing “middle market” have few options to meet their LTSS needs. While many LTSS benefit proposals have been discussed, few address financing. Increasingly, states—disappointed with the lack of federal attention—are discussing LTSS financing proposals of their own.

While most people prefer to remain in place, at least until they need extensive supports, few reform proposals to date have taken into account that many low-income people have no real options to receive extensive services in any place other than a nursing home. The administration’s caregiver support proposal offers more substantial supports to help people stay in the community.

LTSS reform proposals typically focus on benefit plans and financing. They must also take into account housing and age-ready communities. To receive home and community-based services, individuals must have a home. Any viable LTSS reform proposal must start with provisions to provide housing for people who qualify for public housing but do not receive it, and proposals must ensure that people in that housing have the ability to receive some services that help them remain in the community. Finally, proposals should address the infrastructure of communities across the country to ensure they support aging and multigenerational populations.

ADVOCACY ACTION 2022

118^th Congress

Click here to see the full list of LTSS finance reform legislation LeadingAge is following Congress.

• Comprehensive LTC Financing Reform. We support equitable, flexible long-term care financing reform. It must include a strategy to cover the expenses that assures viability. This may include payroll deductions, similar to the Washington State Long-Term Care program. We support front end or catastrophic proposals and we support public private partnerships to cover the costs. In the 117^th Congress we supported the WISH (Well-Being Insurance for Seniors at Home) Act and are ready to work with Congress on similar proposals.
• Expansions in existing programs. We support bills that would expand access to home and community-based or residential services, make more low-income senior housing available, and support the LTSS workforce.
• Educating policymakers. We will continue to build awareness of the need for LTSS after age 65 and promote proposals to address these needs, especially proposals that include a financing strategy, housing plus services, and community infrastructure building. We will work with any Members of Congress interested in these ideas.

Executive Branch

• Encourage federal agencies (e.g., HHS, Treasury, OMB, White House) to continue developing and supporting LTSS financing reform proposals and conversations.
• Supplemental Benefits. We support efforts to encourage plans to include supplemental benefits that include some home and community-based services as well as targeted services and supports for those with chronic illness. We advocate for these benefits and their corresponding eligibility requirements to be clearly communicated to beneficiaries. We seek to ensure providers of all sizes have an opportunity to be part of these networks.
• Medicaid Managed Care and LTSS. Monitor Medicaid managed care regulations relating to LTSS.
• New Models of Integrated Care. Engage the Center for Medicare and Medicaid Innovation in further development of new demonstration projects or models that will allow post-acute providers and/or LTSS providers to be accountable and financially at-risk for the care of a population or an episode of care.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know that you support meaningful LTSS financing and infrastructure reform.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand the importance of LTSS financing and infrastructure reform.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support programs that create a sustainable LTSS financing system and accompanying infrastructure development.

ADDITIONAL RESOURCES

• Special Issue of Generations, “The Financing of Long-Term Care: An American Conundrum,” April 2019.

LeadingAge Advocacy Goals

• Advocate for the availability of aging services across the continuum in Medicare and Medicaid.
• Ensure that regulations governing the Medicare and Medicaid programs promote high-quality care and are not burdensome to providers.
• Oppose block grant and per capita cap policies in Medicaid.
• Ensure that state Medicaid rates paid to nursing homes are sufficient to cover the costs of care.
• Ensure appropriate reimbursement to provide quality end-of-life care.
• Advance policy that promotes the availability of HCBS across funding streams, including Medicare and Medicaid.
• Advance managed care arrangements, reimbursement, and operational policies that enable aging services providers to meet their mission of serving older adults.

THE ISSUE

Medicare and Medicaid are critical revenue sources for most aging services providers and provide coverage to older adults who need post-acute care and/or long-term services and supports. These programs provide coverage to more than 100 million Americans, including millions of older Americans. The COVID-19 pandemic has underscored just how critical Medicare and Medicaid are and has unearthed challenges providers and consumers alike face as they interact with both. As detailed in other sections of these policy priorities, many provider types interact with Medicare and/or Medicaid differently and have their own needs. Across the board, however, preserving, strengthening, and improving these systems are vital to realizing an aging services system that meets the needs of every older adult. To achieve that, LeadingAge supports specific policy actions from both Congress and the executive branch as described below.

ADVOCACY ACTION 2022

118^th Congress

Click here to see the full list of Medicare and Medicaid legislation LeadingAge is following in Congress.

• Medicare home health reimbursement. We continue to support legislative efforts that seek to ensure transparent and evidence-based approaches to Medicare reimbursement in the Patient-Driven Groupings Model.
• Reimbursement for home health telehealth visits. We support legislative efforts to allow Medicare reimbursement of virtual home health visits, with appropriate guardrails and visit equivalency between in-person and virtual visits.
• Sequestration: We support an extension of the Medicare sequestration moratorium.
• Keeping key pandemic flexibilities: Support making key pandemic related telehealth provisions a permanent part of the Medicare program: permanently removing the geographic restrictions on telehealth; allowing the home to be an originating site of care beyond the public health emergency; and permanent expansion of the providers who can furnish telehealth services in both the physical and mental health arenas.
• Medicaid FMAP. We support an increase in the general Federal Medical Assistance Percentage for long-term care services to ensure states have the funds needed to sustain these services.
• Benefit categories. We ask Congress to revise Medicaid and put HCBS (including waiver and state plan services and PACE) on equal footing with nursing homes and make HCBS a mandatory Medicaid benefit.
• Protecting access to Medicaid HCBS. We support making permanent key provisions that ensure access to HCBS, including the federal spousal impoverishment protections for Medicaid HCBS and the Money Follows the Person program (as included in Build Back Better).
• Adult Day Coverage under Medicare. We believe Congress should amend the Medicare program to make adult day services available to beneficiaries (e.g., FFS and managed care).
• Medicaid rates. We will continue to work with state partners and members to ensure that state Medicaid rates paid to aging services providers are sufficient to cover the costs of care.
• New models of integrated care. Engage the Center for Medicare and Medicaid Innovation in the further development of a new demonstration or model(s) that would allow post-acute providers and/or LTSS providers to be accountable and financially at-risk for the care of a population or an episode of care.
• Prepare for unwinding of the PHE: work with members on the impacts of the impact of the unwinding of the Medicaid provisions tied to the public health emergency and work with CMS as needed to advocate for member needs.
• Advance Medicare Advantage reforms. LeadingAge will also support efforts to revise Medicare Advantage law to reduce administrative burden on providers and create some minimum expectations of plans as they contract with providers to ensure a more even playing field.
• Observation Stays. We support the reintroduction of the Improving Access to Medicare Coverage Act that would mandate that all time spent in a hospital, regardless of admission status, would count toward the 3-day qualifying stay required for SNF services under the Medicare benefit. The waiver of the 3-day stay requirement during COVID reinforces the lack of rationale for this restriction on Part A eligibility.

Executive Branch

• Rules, guidance, other federal policy documents. We will work with CMS on Medicaid and Medicare rules and guidance documents relevant to providers across the continuum—nursing homes, PACE, home health, hospice, HCBS waiver services.
• Regulatory waivers. We advocate that CMS continue 1135 regulatory waivers to allow providers the flexibility to focus their resources on preparing for and responding to COVID-19 outbreaks in their communities and that additional flexibilities be considered. We advocate for making permanent certain waivers (e.g., the 3-day stay) to expand beneficiaries’ access to care despite geographical barriers or workforce insufficiency.
• Accelerated and advance payment program. We will continue to monitor the accelerated and advance payment program repayment to ensure repayment will not deleteriously impact providers’ finances.
• Extend administrative flexibility. Support continuation of the Public Health Emergency 1135 Blanket Waivers that CMS put in place during the pandemic allowing providers the flexibility to focus their resources on preparing for and responding to COVID-19 outbreaks in their communities and that additional flexibilities be considered.
• IMPACT Act. We will participate in the Medicare unified post-acute prospective payment system technical expert panel to provide the voice of LeadingAge members regarding possible future payment system design. This includes advocacy to slow the pace of model development work of the Department of Health and Human Services and the Centers for Medicare and Medicaid Services to reflect relevant data collection not skewed by the experiences of the COVID-19 pandemic.
• Telehealth. We continue to advocate for revisions to CMS guidance documents to broaden access to telehealth services for PACE participants and Medicare Advantage enrollees. In addition, we ask CMS to encourage state Medicaid agencies to make telehealth available as a meaningful option for Medicaid HCBS providers unable to deliver in-person services.
• Protect Medicaid financing. We oppose any Medicaid waiver or rulemaking that reduces federal funding to the program, as these could ultimately jeopardize HCBS access. To that end, CMS should not approve and/or rescind waivers that allow per capita caps/block grant financing, work requirements, and unnecessary coverage/enrollment barriers.
• Innovation Center models. We will closely monitor CMMI action to ensure that home and community-based services of all types are included as part of the proposed LTSS Innovation Fund and in other models.
• Transportation and Medicaid. We support the maintenance of current rulemaking that assigns non-emergency medical transportation (NEMT) as a mandatory Medicaid benefit.
• Supplemental Services under Medicare Advantage. We will encourage CMS to continue broadening HCBS availability in Medicare Advantage and work with plans on implementation.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know that you support the expansion and preservation of Medicare and Medicaid for older adults.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies impact providers and residents.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support more opportunities to create and sustain Medicare and Medicaid.

LeadingAge Advocacy Goals

• Ensure appropriate reimbursement methodology and rates for home health services across payers.
• Advocate for reasonable home health and home care regulations to allow quality, community-based care without unnecessary burdens.
• Work for meaningful inclusion of home care services in Medicare Advantage supplemental benefits with efficient processes and fair payment.
• Promote a vision for the future of home health services and their role in the continuum of post-acute, long-term, and end-of-life care including making home health more accessible to people whose condition may not improve but could avoid decline with appropriate services.

THE ISSUE

Home health services are a vital component of the health care continuum, both as an important discharge destination for hospitals as well as providing care and therapies in the community that prevent hospitalizations. In 2019, 5.2 million Medicare beneficiaries received home health services with more than 7 million episodes and nearly 442,000 Medicaid beneficiaries received Medicaid-funded home health services. However, the staffing crisis has forced many agencies to decline new referrals knowing they do not have the staff to adequately serve new patients. Compounding these issues is the growth of Medicare Advantage enrollment and the often inadequate payment home health agencies receive from MA that make supporting these beneficiaries nearly impossible.

2022 was a year of contradictions in the home health space. The public at large and policymakers continued their rallying cries, which have gotten louder since the onset of the COVID-19 pandemic, to increase access to care in the home and community. On the other hand, policymakers also continued their drumbeat regarding overpayment to Medicare home health.  The interpretation of the Bipartisan Budget Act of 2018’s requirements regarding budget neutrality and ensuing permanent prospective payment adjustments and proposed and looming temporary retrospective payment adjustments looms large over LeadingAge home health members and those they serve. Though our advocacy in 2022 helped to forestall monumental proposed payment cuts, the future is still uncertain with regards to payment and as a result, access to care to the critically vulnerable populations our members serve every day. Additionally, CY2023 will bring the start of the home health value-based purchasing program and the new OASIS-E. Home health members are experiencing workforce shortages, as are all LeadingAge provider members. Unlike retail or other business sectors, aging services providers cannot raise their prices. They are reliant on Medicare and Medicaid dollars to provide high-quality care. We will continue to advocate for policies that allow both the goal of expanded home and community-based care and appropriate reimbursement to co-exist.

Home health agencies must be recognized and reimbursed for their capabilities to coordinate and collaborate with other care providers, ensuring that the patient receives appropriate, high-quality care regardless of the setting or location in the evolving health care delivery system.

ADVOCACY ACTION 2023

118^th Congress

Click here to see the full list of home health services legislation LeadingAge is following in Congress.

• Home health reimbursement. We continue to support legislative efforts that seek to ensure transparent and evidence-based approaches to Medicare reimbursement in the Patient-Driven Groupings Model.
• Reimbursement for telehealth visits. We support legislative efforts that allow virtual visits to be reimbursed by Medicare with appropriate guardrails and visit equivalency between in-person and virtual visits.
• Reinstate Medicare rural add-on payments. We support legislative efforts that would make permanent the add-on for services to rural patients which expired in 2022.
• Expand clinician roles and responsibilities. We support legislative efforts to expand the authority of advanced practice nurses, physician’s assistants, occupational therapists, and other members of the interdisciplinary care team to meet the growing needs of older adults seeking home health services.
• Supporting the home care workforce. We support legislative efforts to ensure that home care workers earn at least a living wage and have opportunities for professional development. We support efforts to increase the pool of qualified applicants domestically and internationally.
• Advance Medicare Advantage reforms. LeadingAge will also support efforts to revise Medicare Advantage law to reduce administrative burden on providers and create some minimum expectations of plans as they contract with providers to ensure a more even playing field.
• Create innovation in the Medicare and Medicaid home health benefits. LeadingAge supports opportunities to reform, enhance, and expand home health benefits.
• Meaningful use. Aging services providers were not included in previous funding efforts that supported health care providers’ transition to electronic health records (EHR) systems that contain the medical and treatment histories of patients. We will continue to advocate for funding and payment incentives, including incentives tied to quality, to assist aging services providers in accessing EHR technology that is interoperable with that of their physician and hospital partners and peers and encourage the bi-directional exchange of information.

Executive Branch

• Patient-Driven Groupings Model (PDGM). We will provide feedback to CMS on member’s experience to accuracy and adequacy of PDGM.

• Home Health Value Based Purchasing: We will monitor the roll out of HHVBP and engage with CMS as needed to help our members with the requirements of this new payment system.
• OASIS-E: We will work with members on the rollout of OASIS-E and engage with CMS as needed on our members’ needs.

• Home Health CY2024 rule: We will review and provide comments on the CY2024 Medicare home health wage rule.
• IMPACT Act. Continue advocacy to slow the pace of the Medicare unified post-acute prospective payment system model development work of the Department of Health and Human Services and the Centers for Medicare and Medicaid Services to reflect relevant data collection not skewed by the experiences of the COVID-19 pandemic.
• Advocate for the use of data from new claims codes documenting home health virtual visits. Home health providers are allowed to use virtual visits as part of their documented plan of care. We will advocate for the analysis of the recently created G-Codes for these encounters for a variety of purposes including quality measurement.
• New models of integrated care. Engage the Center for Medicare and Medicaid Innovation in the further development of a new demonstration or model(s) that would allow post-acute providers and/or LTSS providers to be accountable and financially at-risk for the care of a population or an episode of care.
• Quality measures. We will promote activities to establish quality measures that are evidence-based and accurately reflect quality care. We ensure home health agencies are not negatively impacted under the Home Health Value-Based Payment program or Home Health Quality Reporting Program payments.

• Survey and certification. We call on CMS to improve consistency and accuracy in the survey and certification process including education and oversight of state surveyors and accrediting bodies. We will propose alternatives focused on a collaborative approach to quality improvement and utilization of enforcement remedies that reflect a just culture.
• Medicare Care Compare. We will provide feedback on the additions or changes to the Medicare Care Compare site to ensure important information is clearly displayed and consumers are not misled by icons and formatting that prioritize information that does not accurately capture home health quality information.
  Medicare Advantage supplemental services. We will encourage CMS to continue broadening the home-based care availability in Medicare Advantage and work with plans on implementation.

• MedPAC: We will monitor and engage with MedPAC as needed regarding their home health recommendations including a proposal to adjust and lower home health payment and anticipated future recommendations about the home health payment system writ large.
• MACPAC: We will monitor and engage with MACPAC as needed regarding their recommendations around Medicaid Home Health.
• Family caregiving: LeadingAge recognizes the critical role family caregivers play in the care of older adults in the community. We will continue to monitor and engage on the U.S. Department of Health and Human Services, Administration of Community Living’s (ACL) National Strategy to Support Family Caregivers.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support the home health legislative priorities.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies impact home health services.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support more opportunities to provide home health services.

ADDITIONAL RESOURCES

• LeadingAge Center for Managed Care Solutions and Innovation
• Home Health Topics
• CY2023 Proposed Home Health Rule Comments
• Response to CMS Managed Care RFI
• BPC Report on Home Health Benefit Improvements

LeadingAge Advocacy Goals

• Promote a vision for the future of hospice and palliative care services and their role in the continuum of post-acute, long-term, and end-of-life care including advocating for meaningful benefit reform to enable this vision.
• Ensure appropriate reimbursement to provide quality end-of-life care.
• Promote access to and use of appropriate palliative and end-of-life care in all health and long-term care settings.
• Work for reasonable hospice regulations and oversight to allow quality, home and community-based care without unnecessary burdens.
• Support the development of policies that support hospice and palliative care providers in their efforts to support their communities as they recover from the trauma of the Coronavirus pandemic through their grief and bereavement programs.
• Work for meaningful inclusion of home care services in Medicare Advantage supplemental benefits with efficient processes and fair payment.

THE ISSUE

2022 marked the 40^th anniversary of Congressional enactment of the Medicare Hospice Benefit. It is a benefit that when done correctly provides holistic supportive care for terminally ill patients and their families. But, as recent reporting has highlighted, distressing trends are occurring in hospice ranging including fraud. These bad actors as well as the number of Medicare dollars being spent on hospice increasing will lead to enhanced scrutiny from policymakers. While some of this scrutiny will be warranted, advocacy will be essential to ensure that LeadingAge member hospices are not swept up in a regulatory environment that makes it even more difficult for them to operate and reduces access for patients and families.

In addition, hospice and palliative care organizations are focused on opportunities that would facilitate the transition to value-based payment, the continuing demonstration of the “carve in” of hospice to the Medicare Advantage program and continued regulatory pressures including how to promote quality care via a revised survey process and continued pressure from audits. Community-based palliative care continues to find its footing given the realization by payers and patients alike that an extra layer of support at any point during the course of a serious illness promotes quality and reduces unwanted utilization.

Hospice members are experiencing workforce shortages, as are all LeadingAge provider members. Unlike retail or other business sectors, aging services providers cannot raise their prices. They are reliant on Medicare and Medicaid dollars to provide high-quality care. The need for robust advance care planning and a workforce trained in palliative care principles was, unfortunately, underscored during a pandemic that took a disproportionate toll on older adults and those with serious illness. Palliative care professionals, especially in inpatient settings, were in high demand and this skillset needs to be ingrained into health care professionals’ training.

Moving forward, the role of bereavement and grief supports services will be critical to communities as they recover from trauma. Finally, if as anticipated, one result of this pandemic is a surge in the desire for home-based care, hospice and community-based palliative care providers have a large role to play in supporting high quality care at home.

ADVOCACY ACTION 2023

118^th Congress

Click here to see the full list of hospice and palliative care legislation LeadingAge is following in Congress.

• Hospice Benefit Reform: work on changes to the hospice benefit that will promote access to care, reduce bad actors, promote sustainable reimbursement, and ensure the viability of high-quality providers into the future.
• Supporting the home care workforce. We support legislative efforts to ensure that home care workers earn at least a living wage and have opportunities for professional development. We support efforts to increase the pool of qualified applicants domestically and internationally.
• Advance Medicare Advantage reforms. LeadingAge will also support efforts to revise Medicare Advantage law to reduce administrative burden on providers and create some minimum expectations of plans as they contract with providers to ensure a more even playing field. This will be important to hospice providers as they prepare for a “carve in” and engage in other service lines.
• Telehealth: We support allowing hospice face-to-face recertification to take place via telehealth on a permanent basis and allowing utilization of telehealth in routine home care when clinically appropriate
• Advance care planning: We support expanding access to advance care planning in the Medicare program through elimination of statutory barriers and inclusion of more clinical professionals in payment.
• Training in hospice and palliative care: We support investments in training in hospice and palliative care across all disciplines.
• Advocate for robust community-based grief and bereavement supports: Advocate for the development of policies that support hospice and palliative care providers in their efforts to support their communities as they recover from trauma (e.g., expanded funding for community grief and bereavement programs, development of standards to measure what constitutes a “good’ bereavement program).
• Expanded use of nurse practitioners and physician assistants in hospice: We support seeking a legislative fix that would allow nurse practitioners and physician assistants to certify the terminal prognosis as clinically appropriate. We also support seeking a legislative fix to the statute that does not allow for PAs to provide face-to-face encounters. We also seek to provide clarity around the role of physician assistants in hospice.
• Expand access to hospice respite care: we support expanding access to hospice respite care through allowing respite to occur in the home.
• Promote access to palliative and concurrent care: support efforts that would allow beneficiaries to access community based palliative care and concurrent care earlier in their trajectory of illness.
• Meaningful use. Aging services providers were not included in previous funding efforts that supported health care providers’ transition to electronic health records (EHR) systems that contain the medical and treatment histories of patients. We will continue to advocate for funding and payment incentives, including incentives tied to quality, to assist aging services providers in accessing EHR technology that is interoperable with that of their physician and hospital partners and peers and encourage the bi-directional exchange of information.

Executive Branch

• Hospice and Medicare Advantage: We will continue to engage with the Center for Medicare and Medicaid Innovation (CMMI) on the Value-Based Insurance Design (VBID) Model – Hospice Track on improvements to the model and provide education for our members.
• New models of payment and integrated care: LeadingAge will continue to engage CMMI to shape care and payment models that offer integrated care delivery and create opportunities within existing and new models for hospice and palliative care providers to play a meaningful role that ensures a share of the financial gains achieved. We will also monitor the implementation of ACO Reach and other models that encourage early admission to hospice.
• Quality measure development: We will continue to work with CMS and their contractors on the development of Hospice Outcomes and Patient Evaluation (HOPE) tool development and engage in other quality improvement activities.
• Advocate for the creation of claims codes or modifiers to document hospice virtual visits: Hospice providers are utilizing telehealth for routine home care during the pandemic. We will advocate for the creation of claims codes or modifiers that will allow for the analysis of these encounters for a variety of purposes including quality measurement.
• Advocate for use of chaplain codes in documenting hospice visits: Three codes were recently authorized for use to Medicare claims to document chaplain visits. We will advocate for the documentation of these codes in claims for hospice services as well as advocating for the inclusion of chaplains as an eligible professional for purposes of the Hospice Visits in Last Days of Life (HVLDL) Measure.
• Advocate for change in definition of a hospice “day”: For both continuous home care and the visits in the last days of life measure, advocate for the addition of a modifier that allows hospices to indicate when the service has occurred over the course of 2 days.
• Oversight reforms: We will engage with the CMS Center for Clinical Standards and Quality and the Center for Program integrity as well as the Office of Inspector General as they consider oversight reforms.

• Survey and Certification. We will also actively contribute to the development of statutory requirements in the Consolidated Appropriations Act, 2021 in creating a Special Focused Program for hospices. We call on CMS as part of this development process to improve consistency and accuracy in the survey and certification process including education and oversight of state surveyors and accrediting bodies. We will propose alternatives focused on a collaborative approach to quality improvement and utilization of enforcement remedies that reflect a just culture.

• Medicare Care Compare. We will provide feedback on the additions or changes to the Medicare Care Compare site to ensure important information is clearly displayed and consumers are not misled by icons and formatting that prioritize information that does not accurately capture hospice quality information.
• Hospice wage rule: We will review and provide comments on the FY 2023 Medicare Hospice wage rule.
• MedPAC: We will monitor and engage with MedPAC as needed regarding their hospice recommendations including a proposal we support to wage adjust and lower hospice aggregate cap and anticipated future recommendations about the hospice payment system writ large.
• Family caregiving: LeadingAge recognizes the critical role family caregivers play in the care of older adults in the community. We will continue to monitor and engage on the U.S. Department of Health and Human Services, Administration of Community Living’s (ACL) National Strategy to Support Family Caregivers

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know that you support quality hospice and palliative care.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies impact hospice and palliative care.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support more opportunities to provide quality hospice and palliative care services.

ADDITIONAL RESOURCES

• Nonprofit Hospice Services: Where Mission and Community Meet
• Hospice Medicare Margins: Analysis of Patient and Hospice Characteristics, Utilization and Cost
• Opportunities to Strengthen CMS Oversight of Hospice Providers (GAO)
• FY2023 Hospice Wage Index Rule Comments

LeadingAge Advocacy Goals

• Advocate for Medicare and Medicare Advantage(MA) policies and reforms that ensure beneficiary access to equitable care and services, preserve aging service providers’ viability and identify ways to streamline administrative requirements.

• Create value-based opportunities for aging service providers within risk-based models including MA.
• Seek opportunities for aging service providers and housers to be meaningful participants in CMMI models.
• Oppose efforts that expand managed care organizations’ influence within the Medicare program.
• Pursue new payment model demonstration(s) or opportunities within existing Center for Medicare and Medicaid Innovation (CMMI) models that give post-acute and long-term service and support providers the opportunity to lead by accepting both the financial risk and rewards of the model.
• Support and advocate for policy initiatives and models that take a more holistic and integrated approach to addressing the needs of older adults and align incentives for all participating providers.
• Support initiatives to make permanent those regulatory waivers and flexibilities given to Medicare Advantage plans during the public health emergency that improved beneficiary access, simplified provider payment, and streamlined or eliminated utilization management requirements.
• Support efforts to ensure supplemental benefit offerings are clearly communicated to beneficiaries and caregivers.
• Pursue broad reimbursement policies that ensure adequate funding for aging services providers across payers and actuarial soundness. Advocate for policies to ensure that payments/reimbursements under Medicare and Medicaid managed care plans adequately cover the services provided and offer opportunities for providers to enter into contracts.

THE ISSUE

Aging services providers in many parts of the country have reached a tipping point where managed care—Medicare Advantage (MA), Medicaid managed care, and CMMI payment reform initiatives—is the dominant payer. Medicare Advantage enrollment reached 48% nationally in 2022, but the rates can vary regionally, with penetration rates as high as 80% in some areas of the country. Under these programs, providers often face inadequate payments on top of increased expectations and administrative burden of these contracts (often presented as a take it or leave it), all of which is threatening the viability of aging services providers and beneficiary access. MA plans are embracing their ability to expand supplemental benefits into home and community-based services as well as some broader, non-medical services if structured flexibly.

During the pandemic, plans were given regulatory waivers that allowed more nimbleness in addressing plan beneficiaries’ needs. While some new benefits were added (e.g., in-home meal delivery) to address situations resulting from COVID-19, other plans did not take advantage of flexibilities, such as their ability to eliminate prior authorization requirements, which resulted in slowing hospital discharges to post-acute care at points throughout the pandemic. On a parallel track, the Center for Medicare and Medicaid Innovation (CMMI) has been expanding its deployment and testing of advanced alternative payment models over the past decade. In October 2021, CMMI published a new strategic direction for its next decade of work, which aims to move all providers into value-based models and beneficiaries into accountable care relationships by 2030. Post-Acute Care and Long-Term Services and Supports (PAC-LTSS) providers have largely been excluded from leading and taking on financial risk under these models though there are some limited opportunities within the new ACO REACH program announced in 2022. As a result, these providers have seen little to no financial benefit by participating in existing models as partners. With no ability to lead a CMMI model, interested providers, who are able to accept financial risk, are increasingly pursuing the development of their own provider-led Special Needs Plans. LeadingAge has actively engaged CMMI around developing opportunities for PAC-LTSS.

 ADVOCACY ACTION 2022

118th Congress

Click here see the full list of managed care legislation LeadingAge is following in Congress.

LeadingAge will pursue legislation to preserve access to care for beneficiaries, ensure financial viability of providers, reduce their administrative burden when contracting with plans, establish some minimum expectations of plans related to their interactions with providers, and ensure compliance and enforcement of MA requirements to ensure a more even playing field for providers.

• Pursue repeal of non-interference clause or other legal barriers, which prevents CMS from establishing rate floors and/or goals for value-based payment adoption by MA/SNP plans for post-acute care providers.
• Establish MA whistleblower/compliance line: Expand current or create new MA complaint and compliance line allowing providers to report issues with plans. This offers another layer of protection for beneficiaries.
• Support efforts to ensure beneficiaries’ ability to return to Medigap with guaranteed issue: Allow Medicare beneficiaries who enroll in MA plans to return to FFS and a Medigap plan with guaranteed issue as long as they have continuous coverage so beneficiaries don’t lose this option once enrolled in MA.
• Support efforts to protect CMMI program and funding: We seek to preserve the ability of the Center for Medicare and Medicaid Innovation to test new care delivery and payment models where aging services providers can play a meaningful role.
• Support for efforts to expand Medicare benefits: There have been efforts to expand the standard Medicare benefit to include services such as vision, hearing and dental, which would provide more parity with services offered through MA plans. LeadingAge supports efforts to include services that have a direct impact on health care outcomes for Medicare beneficiaries through a more holistic approach to addressing needs and are proven to reduce other care costs.  

Executive Branch

• Seek regulatory reforms of the MA requirements to ensure necessary protections as this becomes the predominant model: Identify and pursue new language to be included in the Medicare and Medicaid managed care regulations, including the Medicare Managed Care Manual, that clarifies certain provider rights and plan obligations in their interactions with providers, assures beneficiary access to medically necessary services, and seeks to streamline and/or standardize required elements of participation in these programs to reduce administrative burden.
• Ensure Provider Payment Adequacy: Pursue efforts to have CMS establish a provider rate floor that plans must pay unless the plan can negotiate a pay-for-performance or other value-based arrangement with the provider. Alternatively, HHS could require plans to pass along a certain percentage of any rate increase received by the plans annually.
• Ensure access to quality providers within MA plans: Pursue regulatory changes adding provider quality as a factor in determining a plan’s network adequacy in an effort to preserve a beneficiary’s ability to select high quality providers for their care.
• Prohibit provider exclusions due to size: Pursue an any willing provider clause that would allow all providers to participate in plan networks if they are willing to accept contract terms and wish to be in network. This would prevent plans from excluding small providers due to size.
• Administrative Simplification: Seek changes to require HHS to establish a single electronic clearinghouse/portal (e.g., support National Provider Directory) that can be used by plans and providers for credentialing, prior authorizations, and other health information exchange to streamline administrative tasks.
• Ensure Provider Payments Adjust for Cost of Living, Inflationary increases and/or new regulatory requirements. Require plans to have a clause in their contracts that requires them to adjust payment rates to reflect external pressures, such as updating rates in accordance with inflation and other factors similar to the Medicare FFS payment rule process.

• Limit egregious audit reviews by health plans resulting in excessive administrative burden to get paid: Establish parameters for the number and type of claims that can be audited and limit the timeframe in which a plan can retroactively seek repayment so that these decisions are made timely.
• Establish timely prior authorization timelines for plans or require plans to staff their PA process 24/7/365 with qualified personnel. Establish and enforce penalties for plans who do not meet the required timeframes resulting in care delays.
• Dual Integration: Support and pursue efforts to both clinically and financially integrate care and services for dual eligible to better address their needs.
• Supplemental benefits: We support efforts to encourage plans to include supplemental benefits that include some home and community-based services as well as targeted services and supports for those with chronic illness. We seek to ensure providers of all sizes have an opportunity to be part of these networks.
• COVID-19 regulatory waivers: We support ongoing flexibility for Medicare Advantage plans to add or amend benefits or amend policies as long as it benefits the enrollee by improving access to services or delivering a more integrated approach to care.
• MA Regulatory Updates: Monitor Medicare Advantage annual proposed rules governing MA policies and payments.
• Medicaid Managed Care and LTSS: Monitor Medicaid managed care regulations relating to LTSS.
• New models of payment and integrated care: LeadingAge will continue to engage CMMI to shape care and payment models that offer integrated care delivery and create opportunities within existing and new models for post-acute providers, housers and/or LTSS providers to play a meaningful role that ensures a share of the financial gains achieved.

ADDITIONAL RESOURCES

• LeadingAge Center for Managed Care Solutions & Innovations resources
• Managed Care Member Community on MyLeadingAge
• Integrated Services White Paper
• Comments on CMS Request for Information on Medicare Advantage

LeadingAge Advocacy Goals

(Note: Life Plan Communities (LPCs), also known as Continuing Care Retirement Communities (CCRCs), are multi-level provider systems where independent living, assisted living, memory care, and nursing home care can be found on the same campus.  Many include home care, home health, hospice, and palliative care as well.  It is critical to note that these communities respond to local need, are regulated by some states, and are not federally regulated as a comprehensive entity; however, SNFs that are a part of LPCs are regulated by CMS, as are ALs on a state level. We work closely with LeadingAge state partners to support relevant state-specific advocacy for LPCs.)

• Identify and advocate for federal financial protections and supports that stabilize and strengthen the unique expense and revenue streams of the LPC model, such as insurance cost cap protections; cash flow protection loans; liability mitigation and protections; bankruptcy protections; in addition to all the financial relief and protections that are sought for all aging services providers mentioned in these policy priorities.
• Support the LPC model on a federal and legislative level by proactively seeking opportunities to educate lawmakers on its unique strengths and challenges.
• Pursue broad reimbursement policies that ensure adequate funding for nursing home care across payers and actuarial soundness. Advocate for policies to ensure that payments/reimbursements for Medicare and Medicaid services, including those delivered through managed care, adequately cover the services provided.
• Support legislative efforts to ensure that LPC staff earn at least a living wage and have opportunities for professional development. We support efforts to increase the pool of qualified applicants domestically and internationally.
• Pursue all advocacy goals and initiatives that serve to benefit segments of the LPC service portfolio, including affordable housing, assisted living, nursing homes, HCBS, hospice, palliative care, and managed care.
• On a state and federal level, identify opportunities to improve the regulatory environment for LPCs that seek to diversify their service portfolios to include alternative care options such as HCBS, continuing care at home, early admissions programs, Medicare Advantage and adult day programs.
• Engage in legislative opportunities on a state and federal level that address consumer protection advocacy efforts that impact LPCs.
• Raise legislators’ awareness of the increasing need for behavioral and mental health supports and services, as well as whole-person wellness, for older adults in congregate community settings.
• Advocate for Life Plan Communities to have all the resources needed to fight the COVID-19 pandemic, including staff, testing, PPE, and vaccines/boosters.
• Oppose federally mandated staffing ratios in nursing homes (or any other setting) unless there are assurances that requirements are tied to characteristics and needs of consumers, providers are reimbursed to cover the cost of additional staff, and Congress and the executive branch takes steps to ensure that enough applicants are available to be hired. In addition, any federal requirement would have to include waivers when a provider can demonstrate they have exhausted all resources available and still cannot meet the minimum.

THE ISSUE

The Life Plan Community (LPC), in many instances, is a representative, micro- cross-section of the aging services continuum of providers. Operating in an increasingly competitive and nuanced environment, LPC providers are adopting a two-pronged strategy of consolidation and diversification to survive and thrive. Already, the LPC model required of its operators a proficiency and versatility in disparate and differently regulated aging services, including independent living, assisted living, nursing homes, and memory care. Some LPC providers have expanded their portfolios into home and community-based services, hospice, and palliative services, managed care programs, adult day programs, and affordable housing.

While facing many of the issues that all aging services providers face—COVID-19, workforce shortages, behavioral and mental health program gaps, inadequate Medicare/ Medicaid reimbursement, and others—Life Plan Communities further struggle with the financial sustainability of their operations because of their multi-faceted nature. Some LPCs have eliminated services, downsized or closed their nursing homes, consolidated with other providers, or pursued corporate restructuring or bankruptcy filings.

ADVOCACY ACTION 2023

To review the full array of Congressional and Executive Branch advocacy action that affects Life Plan Communities, see individual service line policy priorities.

118^th Congress

Click here to see the full list of life plan community-related legislation LeadingAge is following in Congress.

• Strengthen the workforce: Support CNA training, geriatric grant programs, grants to recruit and retain direct care workers, and immigration reforms that will increase the supply of Life Plan Community workers.
• Professionalize the Workforce: We will work with the administration to fill in details of the workforce provisions of the platform’s caregiving proposal to treat LTSS workers with respect and dignity. LTSS settings must feature greater standardization of competency-based training requirements and education needed to prepare the frontline workforce to deliver quality care.
• Support liability protection. We will continue to work with a coalition of national associations and state association partners to enact state civil liability protections for aging services providers relating to COVID-19 claims. Nearly half the states have enacted some sort of protections, and we are still advocating for protections on the federal level.
• Telehealth: We support legislation to improve access to telehealth services in nursing homes.
• COVID-19 relief: We support immediate House and Senate introduction of legislation that will provide ongoing funds to support vaccines, tests, therapeutics, and other relief for aging services.
• Address barriers to providing nursing home services. We support legislation that would mandate all time spent in a hospital, regardless of admission status, count toward the three-day qualifying stay required for SNF services under the Medicare benefit.  The waiver of the three-day stay requirement during the COVID pandemic reinforces the lack of rationale for this restriction on Part A eligibility.
• Geriatric social worker education, recruitment, and retention program. We support the inclusion of expanded programs to recruit, educate, and retain geriatric social workers to encourage more social workers to join and specialize in the aging services field.
• Community program to address caregiver needs. We will work with the Biden administration to fill in details of the workforce provisions of the platform’s caregiving proposal to treat LTSS workers with respect and dignity. LTSS settings must feature greater standardization of competency-based training requirements and education needed to prepare the frontline workforce to deliver quality care.
• Adult day coverage under Medicare: We believe Congress should amend the Medicare program to make adult day services available to beneficiaries (e.g., FFS and managed care).

Executive Branch

• Office of State and Community Energy Programs (SCEP.) We support the implementation of the Inflation Reduction Act and its energy efficiency goals for residential housing programs, and encourage the SCEP to work together with aging services providers to facilitate the adoption of energy-saving technologies and equipment.
• COVID-19 policies, guidance, and resources. We will work with HHS to provide feedback on members’ needs for addressing COVID-19, including the need for financial assistance.
• Various COVID-19 mitigation efforts. As in all other areas of aging services, we support and advocate for: distribution of testing materials; vaccine distribution; extension of the Public Health Emergency; prioritization and delivery of personal protective equipment; streamlined Provider Relief Fund reporting; among many others.
• Survey and certification. We call on CMS to improve consistency and accuracy in the survey and certification process.
• Regulatory waivers. We advocate that CMS continue 1135 regulatory waivers to allow providers the flexibility to focus their resources on preparing for and responding to COVID-19 outbreaks in their communities and that additional flexibilities be considered.
• Alternative Payment Models: We engage in activities geared toward the development of alternative payment models, such as the Unified Post-Acute Care Prospective Payment System Technical Expert Panel.

ACTIONS YOU CAN TAKE NOW

• Let your Representative and Senators know you support legislation that enables relevant components of Life Plan Communities to provide high quality, consumer-responsive services.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies impact Life Plan Communities.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support more opportunities to create and sustain high quality Life Plan Community services.

ADDITIONAL RESOURCES

• LeadingAge Ziegler 200 2022 Edition

• Ziegler: Sponsorship Transitions White Paper
• CliftonLarsonAllen: Senior Living Trends Report 2021
• Love and Company: Senior Housing Trends 2021-22 White Paper

• CARF 2022 Financial Trends and Ratios Report

• NIC Notes: Six Key Drivers Shaping the Future of Senior Living Article (July 2022)

• International Council on Active Aging White Paper: Funding the New Wellness Model

• Senior Housing News: Senior Housing Trends 2022 Article
• Senior Housing News: Stability Ahead for LPCs July 2022 Article

• ASHA: State of Seniors Housing 2021

• Love and Company: Senior Housing Trends 2021-22 White Paper

• CARF 2022 Financial Trends and Ratios Report

• NIC Notes: Six Key Drivers Shaping the Future of Senior Living Article (July 2022)

• International Council on Active Aging White Paper: Funding the New Wellness Model

• Senior Housing News: Senior Housing Trends 2022 Article
• Senior Housing News: Stability Ahead for LPCs July 2022 Article

• ASHA: State of Seniors Housing 2021

THE ISSUE

The Life Plan Community (LPC), in many instances, is a representative, micro- cross-section of the aging services continuum of providers. Operating in an increasingly competitive and nuanced environment, LPC providers are adopting a two-pronged strategy of diversification and consolidation to survive and thrive. Already, the LPC model required of its operators a proficiency and versatility in disparate and differently regulated aging services, including independent living, assisted living, nursing homes, and memory care. Some LPC providers have expanded their portfolios into home and community-based services, hospice, and palliative services, managed care programs, adult day programs, and affordable housing.

While facing many of the issues that all aging services providers face—COVID-19, workforce shortages, behavioral and mental health program gaps, inadequate Medicare/ Medicaid reimbursement, and others—Life Plan Communities further struggle with the financial sustainability of their operations because of their multi-faceted nature. Some LPCs have eliminated services, consolidated with other providers, or pursued corporate restructuring or bankruptcy filings.

ADVOCACY ACTION 2022

To review the full array of Congressional and Executive Branch advocacy action that affects Life Plan Communities, see individual service line policy priorities.

117^th Congress

Click here to see the full list of life plan communities legislation LeadingAge is following in the 117th Congress.

• Telehealth: We support legislation to improve access to telehealth services in nursing homes.
• COVID-19 relief: We support immediate House and Senate introduction of legislation that will provide funds and other relief for aging services.
• Vaccine mandates and booster shot distribution. We support and advocate for an adequate budget to enable seamless implementation of rapid, efficient distribution of vaccines and boosters to all aging services workers, including all employees of Life Plan Communities. We encourage HHS to implement consumer education programs to encourage immunization.
• Support liability protection. We will continue to work with a coalition of national associations and state association partners to enact state civil liability protections for aging services providers relating to COVID-19 claims. Nearly half the states have enacted some sort of protections, and we are still advocating for protections on the federal level.
• Strengthen the workforce: Support CNA training, geriatric grant programs, grants to recruit and retain direct care workers, and immigration reforms that will increase the supply of Life Plan Community workers.
• Professionalize the Workforce: We will work with the administration to fill in details of the workforce provisions of the platform’s caregiving proposal to treat LTSS workers with respect and dignity. LTSS settings must feature greater standardization of competency-based training requirements and education needed to prepare the frontline workforce to deliver quality care.
• Address barriers to providing nursing home services. We support legislation that would mandate all time spent in a hospital, regardless of admission status, count toward the three-day qualifying stay required for SNF services under the Medicare benefit.  The waiver of the three-day stay requirement during the COVID pandemic reinforces the lack of rationale for this restriction on Part A eligibility.
• Geriatric social worker education, recruitment, and retention program. We support the inclusion of expanded programs to recruit, educate, and retain geriatric social workers to encourage more social workers to join and specialize in the aging services field.
• Community program to address caregiver needs. We will work with the Biden administration to fill in details of the workforce provisions of the platform’s caregiving proposal to treat LTSS workers with respect and dignity. LTSS settings must feature greater standardization of competency-based training requirements and education needed to prepare the frontline workforce to deliver quality care.
• Adult day coverage under Medicare: We believe Congress should amend the Medicare program to make adult day services available to beneficiaries (e.g., FFS and managed care).

Executive Branch

• COVID-19 policies, guidance, and resources: We will work with HHS to provide feedback on members’ needs for addressing COVID-19, including the need for financial assistance through Provider Relief Funds.
• Various COVID-19 mitigation efforts. As in all other areas of aging services, we support and advocate for: distribution of testing materials; vaccine distribution; extension of the Public Health Emergency; prioritization and delivery of personal protective equipment; streamlined Provider Relief Fund reporting; among many others.
• Survey and certification: We call on CMS to improve consistency and accuracy in the survey and certification process.
• Regulatory waivers: We advocate that CMS continue 1135 regulatory waivers to allow providers the flexibility to focus their resources on preparing for and responding to COVID-19 outbreaks in their communities and that additional flexibilities be considered.
• Alternative Payment Models: We engage in activities geared toward the development of alternative payment models, such as the Unified Post-Acute Care Prospective Payment System Technical Expert Panel.

ACTIONS YOU CAN TAKE NOW

• Let your Representative and Senators know you support legislation that enables relevant components of Life Plan Communities to provide high quality, consumer-responsive services.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies impact Life Plan Communities.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support more opportunities to create and sustain high quality Life Plan Community services.

ADDITIONAL RESOURCES

• LeadingAge Ziegler 200 2021
• CARF 2021 Financial Trends and Ratios Report
• Sodexo Survey Review: Dining Services Staffing Shortages
• Savant Wealth Management Survey Review: Retirement Plans of High Net Worth Individuals
• International Council on Active Aging Forum Report: Wellness Attracts the Middle Market
• PositiveAging Continuing Care at Home Webinar
• National Investment Center 2020 Investment Guide
• State of Seniors Housing (ACHA/LA)
• International Council on Active Aging White Paper: Creating a Path Towards the Next Normal in Senior Living

LeadingAge Advocacy Goals

• • • Federal and state regulatory and payment policies must recognize and accommodate challenges facing rural providers, including the special challenges rural providers face resulting from the Coronavirus pandemic—staffing, access to PPE, lack of affordable housing.
    • Ensure that rural aging services organizations have the financial resources to be able to hire and retain enough high-performing staff at all levels, especially given the impact of the Coronavirus pandemic on the health of frontline workers.
    • We oppose federally mandated staffing ratios in nursing homes (or any other setting) unless there are assurances that requirements are tied to characteristics and needs of consumers, providers are reimbursed to cover the cost of additional staff, and Congress and the executive branch takes steps to ensure that enough applicants are available to be hired. In addition, any federal requirement would have to include waivers when a provider can demonstrate they have exhausted all resources available and still cannot meet the minimum.
    • Promote policies that address the lack of affordable transportation for staff in rural areas and that support older persons’ mobility and independence.
    • Support improving access to affordable broadband in rural and frontier communities so that aging services providers can better reach the people they serve and provide additional services to older adults.
    • Support increased Medicaid funding and Medicare rural add-ons for aging services.
    • Replicate programs and models that hold promise.

THE ISSUE

Rural aging services providers face the same financing and policy challenges that all other providers face, but these challenges are magnified by distance and loss of population. All these challenges are exacerbated by the Coronavirus pandemic and its devastating toll on workers, older adults, and rural economies. Transportation, housing, workforce shortages, care coordination, telehealth, technology, and internet challenges, along with inadequate public financing, raise significant public policy challenges in a normal year and extraordinary challenges as we move through the pandemic. As populations shift to urban areas, these problems are exacerbated. Moreover, these problems magnify the challenge of delivering and administering vaccines to protect against Coronavirus. And yet our nonprofit nursing homes and low-income housing and life plan communities form the backbone of many rural areas, providing care, services, and employment. Many have closed over the past two years. If they close, communities—and the older adults remaining in them—face losing, in many cases, the only nursing home within driving distance. Transitioning residents to distant nursing homes means family members cannot visit as frequently or as easily. Further, when a nursing home closes, the community suffers economically, including the loss of jobs.

ADVOCACY ACTION 2023

118^th Congress

Click here to see the full list of rural services legislation LeadingAge is following in Congress.

• Rural Internet access: We support legislation to help improve high-speed internet access in rural areas.

• Workforce. We support legislative efforts to ensure that home care workers earn at least a living wage and have opportunities for professional development. We support efforts to increase the pool of qualified applicants domestically and internationally.

• Medicaid reimbursement.  We support permanently increasing the Federal Medical Assistance Percentage (FMAP) for all aging services/long-term care providers. We would like to see these increases, at least in part, reimburse aging services providers at a level that allows them to pay workers a living wage, and ensure that the appropriate percentage of provider reimbursement goes directly to pay direct care professionals.
• Critical Access Nursing Homes. We support a proposal to create a federally recognized Critical Access Nursing Home, similar to the Critical Access Hospital program to prevent additional closures of nursing homes in rural areas (and potentially other areas with minimal access) and ensure that community residents have access to the care they need close to home.
• Vaccine distribution.  We support the efficient distribution of vaccines and boosters to all aging services professionals.  We encourage HHS to continue to develop and implement consumer education programs to encourage immunization.
• Telehealth: We support legislation to improve access to telehealth services across the continuum of aging services.
• Reinstate CNA training programs within SNFs: We support repealing the CNA training “lock-out” and reinstating training programs when SNFs are in compliance.

Executive Branch

• Staffing ratios. We oppose federally mandated staffing ratios in nursing homes (or any other setting) unless there are assurances that requirements are tied to characteristics and needs of consumers, providers are reimbursed to cover the cost of additional staff, and Congress and the executive branch takes steps to ensure that enough applicants are available to be hired. In addition, any federal requirement would have to include waivers when a provider can demonstrate they have exhausted all resources available and still cannot meet the minimum.
• COVID-19 policies, guidance, and resources: We will work with HHS to provide feedback on members’ needs for addressing COVID-19, including the need for financial assistance.
• Various COVID-19 mitigation efforts. As in all other areas of aging services, we support and advocate for: distribution of testing materials; vaccine distribution; extension of the Public Health Emergency; prioritization and delivery of personal protective equipment; streamlined Provider Relief Fund reporting; among many others.
• Survey and certification: We call on CMS to improve consistency and accuracy in the survey and certification process.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know that you support preserving and enhancing services for older adults in rural areas.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies impact services in rural areas.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support more opportunities to preserve and enhance services for older adults in rural areas.

ADDITIONAL RESOURCES

• • • • Rural Health Information Hub

LeadingAge Advocacy Goals

• Aging services organizations must lead the way in fighting ageism and supporting the dignity and agency of older adults, particularly as older adults remain at greater risk from the impacts of COVID — in the community as well as in congregate settings.
• Promote actions to address abuse and neglect and expand support for programs developed by aging services organizations to fight elder abuse and neglect.
• Support robust funding for programs that protect older persons in the community from abuse and neglect resulting from the social and economic impacts of COVID, including adult day, PACE, senior centers, and other programs that can identify and intervene to prevent abuse and neglect.
• Support adoption of the patient safety model for identifying, addressing, and reporting elder abuse in congregate settings and HCBS programs.
• Advocate to include abuse identification and training in educational requirements for nursing home and assisted living administrators, geriatricians, physicians, social workers, and RNs.
• Examine ways to incorporate abuse prevention training for home care, case managers, service coordinators, and residential counselors.
• Increase grant funding for training and hiring aging services employees at all levels.
• Collaborate with the Global Ageing Network to coordinate the response to elder abuse and neglect.
• Promote equity in access to elder justice programs.

THE ISSUE

Elder abuse is estimated to affect one in ten older adults; these include our residents, our clients, our tenants, and the people waiting to be served by LeadingAge members. The COVID pandemic has exacerbated conditions that underlie abuse: isolation, increased reliance on potentially abusive caregivers, fear and loss of independence, along with the increased difficulty that programs designed to prevent elder abuse have experienced.  Elder abuse directly affects providers of aging services when the people we serve are victimized by financial exploitation and physical and psychological abuse. LeadingAge has been a leader in affirmatively addressing elder abuse in the broader community, as well as in our settings. Leading the fight against elder abuse is part of our ethical obligations and underscores our mission to be the trusted voice for aging, our vision of an America freed from ageism, through our promise to inspire, serve, and advocate.

ADVOCACY ACTION 2023

118^th Congress

Click here to see the full list of elder justice legislation LeadingAge is following in Congress.

• Elder abuse related legislation. We will provide education and assistance to address elder justice issues to House and Senate committees and work with Members of Congress concerned about these issues.

Executive Branch

• ACA Reinvestment Grants: We support the use of CMS fines to help train direct care workers in culture change.
• Elder Justice Coordinating Council: We will provide guidance on integrating work done by LeadingAge providers with Council activities at the local, state, and federal level.
• CMS Training: We will engage with CMS on training in abuse prevention.

ACTION YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know that you support elder justice programs.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies address elder justice concerns.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support elder justice programs and policies.

ADDITIONAL RESOURCES

• • Harry and Jeannette Weinberg Center for Elder Justice
  • LeadingAge Minnesota Safe Care for Seniors
  • Frameworks Institute: Talking Elder Abuse A FrameWorks Communications Toolkit
  • Federal Administration on Community Living
  • National Center on Elder Abuse

LeadingAge Advocacy Goals

• • We support the House and Senate introduction of legislation that will provide funds and other relief for aging services.
  • Achieve LTSS financing reform to ensure that individuals with dementia and family caregivers have access to care and services.
  • Aging services organizations must be able to hire and retain a sufficient number of high-performing staff at all levels to meet the needs of individuals with dementia and, specifically, to staff memory care services.
  • Ensure full funding for federal programs under the Older Americans Act and financing for Medicare and Medicaid services for people with dementia.
  • Advocate for full funding for research into treatments and a cure for dementia with particular attention to African Americans (in trials).

  THE ISSUE

  One in ten people age 65 or older has dementia and another two in ten has mild to moderate cognitive impairment. Though the incidence of dementia is decreasing, the increase in the sheer number of older adults means the number of people with dementia will rise. Today, approximately 5.8 million Americans live with Alzheimer’s disease or another form of dementia. By 2050, with the projected increased aging of the population, and the fact that people are living longer with chronic conditions, the number is expected to grow to nearly 14 million. The number of people affected by dementia rises considerably when the 16 million unpaid family caregivers are taken into account. All memory care residents, most nursing home residents, and large numbers of people served by other LeadingAge providers, live with dementia.

  People over 65 are at very high risk of severe COVID, with 80% of COVID deaths occurring in that age group. A subset of older individuals, people with dementia, are at even higher risk of severe COVID and death.  In June 2020 the Wall Street Journal reported that 15,000 more Americans with dementia died than would have been expected during the first four months of the pandemic. People with cognitive impairments have additional difficulty with public safety measures like wearing a mask and keeping social distance. Isolation and loneliness, a problem for the healthiest people, is compounded in those with dementia.

  Since the beginning of the pandemic memory care providers faced the same challenges as other residential care providers—only worse. They need more staff to be able to enforce safety measures; more staff means more PPE and more testing.  Yet they have run into the same PPE and testing supply and cost challenges.  Residents and staff need access to vaccines and boosters.

  Government at all levels must attend to the COVID-related needs of informal and formal providers of care to people with dementia.  Further, it is essential that programs serving individuals with Alzheimer’s disease and other dementias be fully funded and that funding is concurrently provided to support diagnosis, care coordination, and research into treatments and a cure.

  ADVOCACY ACTION 2023

  118^th Congress

  Click here to see the full list of Alzheimer’s and dementias legislation LeadingAge is following in the Congress.

  • COVID-19 relief: We support immediate House and Senate introduction of legislation that will provide continued relief for aging services.
  • Build Back Better:  We support the House-passed Build Back Better legislation, particularly provisions related to HCBS expansions, workforce supports, and additional HUD 202 homes.
  • Appropriations for research: We seek fiscal year 2023 appropriations to support federal spending on Alzheimer’s research and to support Alzheimer’s and dementia-related programs of the Administration on Community Living – HHS.
  • Bipartisan Task Force: We support the work of the Bipartisan Congressional Task Force on Alzheimer’s Disease and will provide help to inform its work.

  Executive Branch

  • Vaccine and booster distribution. We support the continued rapid, efficient distribution of vaccines to all individuals over age 65. We encourage HHS to implement consumer education programs to encourage immunization.
  • Personal Protective Equipment. We advocate to HHS and the Administration to prioritize nursing homes and aging services providers in the distribution of personal protective equipment to help limit transmission of COVID-19 and protect the staff providing care to vulnerable older adults.
  • Required Provider Reporting. We will continue to work with HRSA on streamlined reporting processes for Provider Relief funds.
  • Distribution of testing materials. We call on the Administration to ensure that all aging services providers have adequate COVID-19 testing materials and that nursing homes specifically have the testing resources needed to comply with CMS requirements.
  • We will track Alzheimer’s related activities of the Administration for Community Living – HHS, including the Alzheimer’s Disease Programs Initiative, the National Alzheimer’s and Dementia Resource Center, and the National Alzheimer’s Call Center.
  • Alzheimer’s Advisory Council. We will monitor the implementation of the Advisory Council on Alzheimer’s Research, Care, and Services, which is run by the Assistant Secretary for Planning and Evaluation – HHS. The council includes all federal agencies that work with dementia and meets quarterly to discuss programs that impact people with Alzheimer’s disease and other dementias and update the National Alzheimer’s Plan.
  • Family Caregiver Council. We monitor the implementation of the RAISE Family Caregiver Council, which is run by the Administration for Community Living – HHS and is charged with developing a national family caregiving strategy.
  • Alzheimer’s Research Summit. We will continue to monitor the implementation of the recommendations of the 2020 Virtual National Research Summit on Care, Services, and Supports for Persons with Dementia and their Caregivers to identify policy levers and proposals.

  ACTIONS YOU CAN TAKE NOW

  • Visit the Advocacy Action Center to let your Representative and Senators know that you support programs and policies that help people with dementia and their family caregivers.
  • Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies impact services for people with dementia.
  • Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know you support research and program to address the needs of people with dementia and their families.

   

LeadingAge Advocacy Goals

• Seek confirmation from the federal government that it will not pursue civil or criminal actions against providers if they allow the use of medical cannabis pursuant to state laws and regulations.
• Support federal legislation or regulations to prohibit any federal agency interference with state medical cannabis laws.
• Work with state LeadingAge affiliates, as requested, to support legislation at the state level to enact medical cannabis statutes and regulations that will allow older adults to access it under appropriate circumstances to alleviate pain and other symptoms of disease.

THE ISSUE

Medical cannabis is legal in 37 states and the District of Columbia. Under federal law, marijuana remains in Schedule I of the Controlled Substances Act and is illegal. There is no clarity from the federal government or agencies on whether they will pursue enforcement activities against those using medical cannabis pursuant to state laws allowing it.

ADVOCACY ACTION 2023

118th Congress

Click here to see the full list of medical marijuana legislation LeadingAge is following in  Congress.

Executive Branch

• Medical Cannabis Guidance: We will explore options for regulatory guidance or a memorandum from federal agencies discouraging any civil or criminal enforcement of medical cannabis usage in states where it is legal.
• Cannabidiol (CBD) Guidance: Now that CBD is legal after the passage of the 2018 Farm Bill, we will monitor the Food and Drug Administration’s (FDA) progress on issuing regulations/guidance on the use of CBD in Medicare- and Medicaid-financed settings.
• How Marijuana is Scheduled Under Federal Law: In October 2022 President Biden directed the Secretary of Health and Human Services (HHS) and the Attorney General to initiate a process to review how marijuana is scheduled under federal law.  We will monitor activity by HHS and the Department of Justice and participate in aspects of the process that are open to the public, including submission of comments, in support of our advocacy goals.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know your views on the legal use of medical cannabis by older adults.
• Host a Coffee Chat with Congress in your community to help your Members of Congress understand how policies related to medical cannabis affect older adults.
• Mobilize with the Advocacy Champions toolkit and let your Representative and Senators know your views on medical cannabis for older adults.

ADDITIONAL RESOURCES

• • Map of States that Allow Medical and Recreational Cannabis
  • FDA Regulation of Cannabis and Cannabis-Derived Products, Including Cannabidiol (CBD)
  • FDA Regulation of Cannabis and Cannabis-Derived Products, Including Cannabidiol (CBD): Communication & Regulatory Resources

LeadingAge Advocacy Goals

• Maintain current nonprofit tax status for our members as 501(c)(3) exempt organizations.
• Enhance Low Income Housing Tax Credit program to broaden its availability for use in developing affordable housing for seniors.
• Support charitable deductions through tax deductions.
• Support the deductibility of medical expenses at 7.5% of adjusted gross income.
• Support tax credit incentives that help aging services providers continue to recover from COVID-era expenses and that promote the utilization of innovative technologies to improve the well-being of older adults and the communities in which they live.

THE ISSUE

Federal tax laws have various incentives to support charitable institutions, such as allowing individuals to deduct charitable contributions and a certain amount of medical expenses from their tax returns, encouraging investment in housing through tax credits, and incentivizing other activities such as installation of energy efficient systems. Tax-exempt organizations rely on these mechanisms to support their philanthropic outreach and their ability to address low-income housing needs.

ADVOCACY ACTION 2023

118th Congress

Click here to see the full list of tax policy legislation LeadingAge is following in Congress.

We will support and advocate for tax changes that will positively impact members.  Those efforts will include the introduction of bills similar to those introduced in the prior Congress on the following topics:

• Low-Income Housing Tax Credits: We support the efforts that would increase state LIHTC allocations by 50%, provide a 50% basis boost for LIHTC communities that serve households with extremely low incomes in at least 20% of their apartments, lower the bond financing threshold from 50% to 25% to make more efficient use of existing Private Activity Bond resources and significantly expand rental housing production, encourage the development of more accessible LIHTC units, and support replacement of the current right of first refusal with a purchase option to facilitate the ability of nonprofits to maintain ownership/control of housing credit properties beyond Year 15.
• Charitable Contributions: We support efforts, such as this bill from a prior Congress, to maintain the incentive for and encourage charitable giving and provide for an “above-the-line” income tax deduction for charitable contributions and thus likely would improve the expected decline in charitable giving because of the increase in the amount of the standard deduction.
• Medical Expense Tax Deduction: We support maintenance of the current standard that allows deduction of unreimbursed medical expenses that exceed 7.5% of adjusted gross income, versus a higher threshold that would negatively impact seniors.

Executive Branch

• TCJA: We will continue to monitor efforts and/or guidance to provide clarity on tax changes as a result of the 2017 Tax Cuts and Jobs Act (TCJA).
• Employee Retention Credit: We support and will monitor the full implementation of the Employee Retention Credit (ERC) to offset the unprecedented rise in the workforce costs, both during and after the COVID-19 pandemic, for aging services providers. We advocate that the ERC be extended to include the 2022 tax year for aging services providers who continued to be faced with overwhelming labor costs related to the pandemic; we also advocate that the redemption of the ERC not be a part of cost-reporting for the calculation of Medicare or Medicaid reimbursement.
• Inflation Reduction Act: We support and will monitor the full implementation of the Inflation Reduction Act to include the not-for-profit aging services sector across the entire continuum of providers, and especially for those providers that serve older adults in rural, disadvantaged and economically suppressed regions.

ACTIONS YOU CAN TAKE NOW

• Be ready to contact Congress if legislation on tax issues is addressed this year.
• Continue social accountability efforts to document how your organization gives back to the broader community and fulfills its responsibilities as a tax-exempt entity.

ADDITIONAL RESOURCES

• • Low Income Housing Tax Credit Basics
  • Charitable Giving – Independent Sector