Medicaid program managers are trying to turn their long-term care (LTC) benefits system upside down.
Officials in Washington and in the states are trying to help a higher percentage of Medicaid LTC benefits users get their care at home, or in some reasonably home-like setting rather than in a hospital or nursing home.
The effort could have wide-ranging, difficult-to-predict effects on many different aspects of long-term care planning, including what kinds of LTC arrangements are available — inside and outside “the home”; what kinds of LTC planning services consumers expect; and what holders of private long-term care insurance (LTCI) experience when their private LTCI benefits run out.
Regulators at the Centers for Medicare & Medicaid Services (CMS) hope a new “home and community-based services” settings final rule will “maximize opportunities for individuals to have access to the benefits of community living and the opportunity to receive services in the most integrated setting,” according to Pat Nobbie, a policy specialist at the Administration for Community Living. She gave a presentation on the regulations in July at a conference organized by the National Association of Councils on Developmental Disabilities.
Medicaid program managers have also prepared another, similar presentation explaining the regulations.
Here’s a look at what private LTC planners might want to know about the new Medicaid home and community-based services regulations and new, related “person-centered” LTC planning guidance.
1. The new Medicaid home and community-based service final rule is a little sister of the CLASS Act.
The drafters of the Patient Protection and Affordable Care Act of 2010 (PPACA) included one ultra-controversial LTC section — the Community Living Assistance Services and Supports (CLASS) Act. The CLASS Act was supposed to create a voluntary, premium-supported LTC benefits program. Anyone with a job — even employed people who were already severely disabled — could have signed up for the program. Actuaries at CMS blocked implementation of the CLASS Act program, saying they knew of no practical way to make the program financially viable.
Congress eventually repealed the CLASS Act provision, but other, lesser-known PPACA LTC provisions survived.
See also: But Wait, There’s More!
States’ Medicaid programs pay the nursing home bills for about 60 percent of U.S. nursing home residents.
One part of PPACA, PPACA Section 2601, is supposed to encourage states to spend more for their LTC money on various types of home care and community-based care, such as adult day care services, and less on nursing home care. The section affects how federal and state Medicaid program officials run home and community-based services programs under several parts of Section 1915 of the Social Security Act.
CMS published the final rule implementing PPACA Section 2601 in January, after publishing several batches of draft regulations and reviewing 2,000 public comments.
PPACA and the regulations may reshape LTC providers by limiting which ones can bill Medicaid for home and community-based services.
Above: The late Sen. Ted Kennedy, the father of the CLASS Act. (AP photo/Toby Jorrin)
2. CMS pulled back from plans to shun assisted living facilities, but the final rule could still cause headaches for entities that try to provide multiple levels of care, or entities that try to care for people with dementia in a home-like setting.
Originally, when CMS published drafts of the new regulations, it was thinking about excluding assisted living facilities (ALFs) from access to Medicaid home care benefits programs.
ALFs, residents and consumer groups protested. CMS ended up saying that an apartment in an ALF may qualify as a “home.” But, apparently in response to regulator and consumer group hostility toward institutional care, CMS has created a complicated definition of “home.”
Entities apparently will have a hard time getting an apartment classified as a home if it’s in an ALF that’s in the same building as a nursing home. If, however, an ALF shares a building with apartments for seniors who are still capable of living on their own, the apartment in the ALF will probably fit the CMS definition of “home.”
If an LTC services provider owns or controls a “residential setting,” then an apartment in the provider’s ALF might count as if an ALF if it has a lockable door, residents have a choice of roommates, residents have the freedom to decorate their living units, residents can eat whenever they want, and residents can have visitors whenever they want.
3. The new regulations could expand demand for LTC planners, managers and advocates.
Entities are supposed to use “person-centered service plans” to document the care options available and the consumer’s needs and preferences.
LTC programs and entities have been trying to use a person-centered approach for years, but PPACA now makes that the law. The implementing regulations set formal requirements for the services. In the Medicaid LTC benefits area, the regulations give consumers the right to invite anyone they want to “person-centered planning meetings.”
Now, for example, a state is supposed to use an independent agent to evaluate whether a consumer is eligible for LTC benefits.
4. The U.S. Department of Health and Human Services (HHS) — the parent of CMS — is making person-centered planning training a major focus.
You may have thought HHS was too busy setting up the PPACA public exchange system and keeping Medicare solvent to think much about person-centered LTC planning, but the Assisted Living Federation of America (ALFA) says the Administration for Community Living is helping each HHS agency do as much as it can to promote person-centered planning and consumer self-direction.
The Administration for Community Living is also developing a person-centered counselor training program for state LTC benefits program advisors.
HHS Secretary Sylvia Mathews Burwell (File photo)