A new AARP report documents how the recession continues to have negative impacts on state programs for older individuals and adults with physical disabilities even as demand for publicly funded services has grown. (See: http://www.aarp.org/health/health-care-reform/info-10-2010/health-panel-10201.html.) States have used many administrative tools to curtail expenditures, and resources—including staff—are stretched thin. According to the 50-state study, 31 states cut aging and disability services programs (non-Medicaid) in FY 2010, and 28 states were expecting to cut these programs in FY 2011.
Major revenue sources—personal income, corporate, and sales taxes—for 2011 are expected to be below pre-recession levels for most states, according to the report. States are also contending with increasing service demands, forcing many to impose new limits on non-Medicaid long-term services and supports (LTSS). The study found that states are “holding steady” with Medicaid LTSS because funding from the ARRA stimulus funds requires them to maintain eligibility. However, many states expect they will need to make additional cuts in LTSS when the funds phase down and expire in June 2011.
The report also found that many states are using the economic downturn as an opportunity to shift services from institutional to non-institutional settings. The Affordable Care Act provides states with new opportunities to expand home and community-based services, yet many states are reluctant to commit to these programs until further federal guidance is issued.
Monday, January 24, 2011
Tuesday, January 18, 2011
NCAL & AHCA Commend CMS for Proposing Earliest Possible Date To Implement Part D Co-pay Legislation
The National Center for Assisted Living (NCAL) and the American Health Care Association (AHCA) last week formally commended the Centers for Medicare & Medicaid Services (CMS) for proposing to implement Sec. 3309 of the Affordable Care Act on Jan. 1, 2012. As noted in their letter to CMS Administrator Donald Berwick, M.D., CMS is proposing the earliest possible implementation date allowable under wording in the health reform statute. Sec. 3309 is the result of a five-year campaign by NCAL, AHCA, and other national organizations. (See: http://www.ahcancal.org/ncal/advocacy/Letters/LetterCMSonProposedPartDImplementation.pdf.)
The letter to Dr. Berwick was in response to a proposed rule published by CMS on Nov. 22, 2010. In the proposed rule, CMS estimates that Sec. 3309 will eliminate cost sharing under the Medicare Part D prescription drug program for an estimated 600,000 dual eligible beneficiaries receiving home and community-based (HCB) services (including those living in assisted living communities). Sec. 3309 will bring needed financial relief to this vulnerable group of very low-income seniors and people with disabilities and improve their medical care. It also will also create parity in Part D cost sharing requirements between dual eligible beneficiaries in institutional and HCB settings. For more information, contact NCAL Senior Policy Director Karl Polzer at kpolzer@ncal.org.
The letter to Dr. Berwick was in response to a proposed rule published by CMS on Nov. 22, 2010. In the proposed rule, CMS estimates that Sec. 3309 will eliminate cost sharing under the Medicare Part D prescription drug program for an estimated 600,000 dual eligible beneficiaries receiving home and community-based (HCB) services (including those living in assisted living communities). Sec. 3309 will bring needed financial relief to this vulnerable group of very low-income seniors and people with disabilities and improve their medical care. It also will also create parity in Part D cost sharing requirements between dual eligible beneficiaries in institutional and HCB settings. For more information, contact NCAL Senior Policy Director Karl Polzer at kpolzer@ncal.org.
Monday, December 6, 2010
CMS Proposes Earliest Possible Date To Implement Medicare Part D Co-pay Legislation
The Centers for Medicare & Medicaid Services (CMS) has proposed implementing legislation that will eliminate Medicare Part D cost sharing for dual eligible beneficiaries in assisted living and other home and community-based (HCB) settings on January 1, 2012 – the earliest possible date allowable under Sec. 3309 of the Affordable Care Act (ACA).
Over the past several years, NCAL has led of a coalition of almost 40 national organizations urging passage of the Part D co-pay legislation and has been urging CMS to implement Sec. 3309 as soon as possible. Under the original Part D law, dual eligibles (those covered by both Medicare and Medicaid) in institutional settings had no cost sharing while a similar population living in community-based settings, including assisted living communities, was required to make co-payments. Assisted living residents average 8-10 medications and those on Medicaid often have difficulty affording their Part D co-payments. Sec. 3309 will eliminate Part D cost sharing for dual eligibles in HCB settings covered under Medicaid waivers, a 1915(i) state plan amendment, or under a Medicaid managed care plan.
In proposed rules published in the Nov. 22 Federal Register, the agency states: “We believe it is important to provide this benefit at the earliest possible date, since it will provide assistance to an estimated 600,000 beneficiaries a year. In proposing an effective date, we considered the administrative impact on States, and we believe that even the earliest possible effective date will provide States with adequate time for implementation.” See http://edocket.access.gpo.gov/2010/pdf/2010-28774.pdf. NCAL will be submitting comments to CMS on the proposed rule supporting implementation of Sec. 3309 of the ACA on Jan. 1, 2012.
Over the past several years, NCAL has led of a coalition of almost 40 national organizations urging passage of the Part D co-pay legislation and has been urging CMS to implement Sec. 3309 as soon as possible. Under the original Part D law, dual eligibles (those covered by both Medicare and Medicaid) in institutional settings had no cost sharing while a similar population living in community-based settings, including assisted living communities, was required to make co-payments. Assisted living residents average 8-10 medications and those on Medicaid often have difficulty affording their Part D co-payments. Sec. 3309 will eliminate Part D cost sharing for dual eligibles in HCB settings covered under Medicaid waivers, a 1915(i) state plan amendment, or under a Medicaid managed care plan.
In proposed rules published in the Nov. 22 Federal Register, the agency states: “We believe it is important to provide this benefit at the earliest possible date, since it will provide assistance to an estimated 600,000 beneficiaries a year. In proposing an effective date, we considered the administrative impact on States, and we believe that even the earliest possible effective date will provide States with adequate time for implementation.” See http://edocket.access.gpo.gov/2010/pdf/2010-28774.pdf. NCAL will be submitting comments to CMS on the proposed rule supporting implementation of Sec. 3309 of the ACA on Jan. 1, 2012.
Wednesday, November 3, 2010
Proposed Changes to SNF/NF Conditions of Participation Regarding Hospice
On October 22, CMS released a proposed rule entitled “Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services” which can be found at http://edocket.access.gpo.gov/2010/pdf/2010-26395.pdf.
In the rule, CMS proposes that long term care (LTC) facilities (that is, SNFs and NFs) that choose to arrange for the provision of hospice care through an agreement with one or more Medicare-certified hospice providers would have in place a written agreement with the hospice that specifies the roles and responsibilities of each entity.
To have your comments included in AHCA’s comment document to CMS, please send them to Lyn Bentley at lbentley@acha.org by December 6.
Background
Under current regulations, a LTC facility may choose to have a written agreement with one or more hospice providers to provide hospice care to a Medicare eligible resident who wishes to elect the hospice benefit. However, if the facility chooses not to contract with a Medicare-certified hospice to provide hospice services for the resident who wishes to elect the benefit, the LTC facility is responsible for assisting the resident in transferring to a facility that will arrange
for the provision of such services, as requested by the resident.
CMS states in the proposed rule that “there is a lack of clear regulatory direction regarding the responsibilities of providers in caring for LTC facility residents who receive hospice care from a Medicare-certified hospice provider, which could result in duplicative or missing services.” CMS believes this problem would be remedied by a regulatory requirement for a written agreement between the hospice and the SNF/NF which would specify what services each provider will provide. Per CMS, beneficiary health and safety could be endangered by a lack of coordination between hospice and LTC providers.
CMS states that “the language in this proposed rule was crafted to mirror the hospice final rule [June 5, 2008 hospice final rule (73 FR 32088) “Medicare and Medicaid Program: Hospice Conditions of Participation”] as much as possible to ensure that both entities are held equally responsible for the written agreement.”
Provisions of the Proposed Rule
• As previously stated, CMS is proposing that LTC facilities may either arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospice providers or not arrange for such services and assist a resident in transferring to a facility that will arrange for the provision of these services when the resident requests such a transfer.
• The proposed rule “…seeks to clarify the role of the LTC facility and the Medicare-certified hospice by requiring clear delineation [in the agreement] of each provider's responsibility for maintaining continuity of care.” The agreement requirements would apply even when the hospice and SNF/NF are under common ownership and/or control. The signatures of authorized representatives of the hospice and the LTC facility would be required.
• The LTC facility would be required to ensure that the hospice services meet professional standards and principles that would apply to individuals providing services in the facility, and the timeliness of the services. “Timeliness of services'' means that the facility “…would be required to ensure that, from the time the resident elected the hospice benefit until the services were terminated, the Medicare-certified hospice would provide hospice services meeting the resident's needs in a timely manner, without any delay in the provision of services for the resident.”
• Written agreements would need to define:
1) the services to be provided by hospice and the SNF/NF, respectively, in accordance with the care plans;
2) how the facility and hospice would communicate; and
3) conditions under which the facility would need to contact the hospice immediately (including significant changes in condition/status; clinical complications that would alter the care plan; need for transfer for any condition not related to the terminal condition; or resident death).
• Agreements would have to include the following provisions:
1) the hospice assumes responsibility for determining the appropriate course of hospice care, including changing the level of services, if necessary;
2) the facility provides 24-hour room and board and meets the resident's personal and nursing care needs in coordination with the hospice.
3) delineation of the hospice's responsibilities, including providing medical direction and management of the hospice care; nursing; counseling; social work; medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services necessary for care of the terminal illness and related conditions; as well as bereavement services to LTC facility staff.
4) requirement that facilities report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the facility becomes aware of the alleged violation.
5) facility designation of a member of the facility's interdisciplinary team to be responsible for working with hospice representatives to coordinate care provided. The rule outlines responsibilities of the interdisciplinary team
6) Each resident's written plan of care would include both the hospice plan of care and the services provided by the SNF/NF.
Specific Feedback to CMS
In addition to the specific provisions of the proposed rule, CMS requests feedback on the following two issues:
1) How LTC facilities can provide orientation for hospice staff who provide occasional coverage for a member of the identified hospice interdisciplinary group that is quick and efficient, but sufficient to protect residents who receive hospice care.
2) CMS efforts to mirror existing hospice requirements notwithstanding, some differences occur. For example, the proposed rule would require that the facility report all alleged violations by hospice personnel to the hospice administrator immediately when the facility becomes aware of the alleged violation. However, the hospice is required in the June 2008 hospice final rule to report these same violations within 24 hours of the hospice becoming aware of the alleged violation. CMS is requesting feedback on whether the differences between the requirements that are found in the proposed rule would create a barrier to forming agreements between LTC facilities or interfere in coordination of residents' care between LTC facilities and hospices.
To view the rule in its entirety, go to http://edocket.access.gpo.gov/2010/pdf/2010-26395.pdf. To have your comments included in AHCA’s comment document to CMS, please send them to Lyn Bentley at lbentley@acha.org by December 6.
In the rule, CMS proposes that long term care (LTC) facilities (that is, SNFs and NFs) that choose to arrange for the provision of hospice care through an agreement with one or more Medicare-certified hospice providers would have in place a written agreement with the hospice that specifies the roles and responsibilities of each entity.
To have your comments included in AHCA’s comment document to CMS, please send them to Lyn Bentley at lbentley@acha.org by December 6.
Background
Under current regulations, a LTC facility may choose to have a written agreement with one or more hospice providers to provide hospice care to a Medicare eligible resident who wishes to elect the hospice benefit. However, if the facility chooses not to contract with a Medicare-certified hospice to provide hospice services for the resident who wishes to elect the benefit, the LTC facility is responsible for assisting the resident in transferring to a facility that will arrange
for the provision of such services, as requested by the resident.
CMS states in the proposed rule that “there is a lack of clear regulatory direction regarding the responsibilities of providers in caring for LTC facility residents who receive hospice care from a Medicare-certified hospice provider, which could result in duplicative or missing services.” CMS believes this problem would be remedied by a regulatory requirement for a written agreement between the hospice and the SNF/NF which would specify what services each provider will provide. Per CMS, beneficiary health and safety could be endangered by a lack of coordination between hospice and LTC providers.
CMS states that “the language in this proposed rule was crafted to mirror the hospice final rule [June 5, 2008 hospice final rule (73 FR 32088) “Medicare and Medicaid Program: Hospice Conditions of Participation”] as much as possible to ensure that both entities are held equally responsible for the written agreement.”
Provisions of the Proposed Rule
• As previously stated, CMS is proposing that LTC facilities may either arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospice providers or not arrange for such services and assist a resident in transferring to a facility that will arrange for the provision of these services when the resident requests such a transfer.
• The proposed rule “…seeks to clarify the role of the LTC facility and the Medicare-certified hospice by requiring clear delineation [in the agreement] of each provider's responsibility for maintaining continuity of care.” The agreement requirements would apply even when the hospice and SNF/NF are under common ownership and/or control. The signatures of authorized representatives of the hospice and the LTC facility would be required.
• The LTC facility would be required to ensure that the hospice services meet professional standards and principles that would apply to individuals providing services in the facility, and the timeliness of the services. “Timeliness of services'' means that the facility “…would be required to ensure that, from the time the resident elected the hospice benefit until the services were terminated, the Medicare-certified hospice would provide hospice services meeting the resident's needs in a timely manner, without any delay in the provision of services for the resident.”
• Written agreements would need to define:
1) the services to be provided by hospice and the SNF/NF, respectively, in accordance with the care plans;
2) how the facility and hospice would communicate; and
3) conditions under which the facility would need to contact the hospice immediately (including significant changes in condition/status; clinical complications that would alter the care plan; need for transfer for any condition not related to the terminal condition; or resident death).
• Agreements would have to include the following provisions:
1) the hospice assumes responsibility for determining the appropriate course of hospice care, including changing the level of services, if necessary;
2) the facility provides 24-hour room and board and meets the resident's personal and nursing care needs in coordination with the hospice.
3) delineation of the hospice's responsibilities, including providing medical direction and management of the hospice care; nursing; counseling; social work; medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services necessary for care of the terminal illness and related conditions; as well as bereavement services to LTC facility staff.
4) requirement that facilities report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the facility becomes aware of the alleged violation.
5) facility designation of a member of the facility's interdisciplinary team to be responsible for working with hospice representatives to coordinate care provided. The rule outlines responsibilities of the interdisciplinary team
6) Each resident's written plan of care would include both the hospice plan of care and the services provided by the SNF/NF.
Specific Feedback to CMS
In addition to the specific provisions of the proposed rule, CMS requests feedback on the following two issues:
1) How LTC facilities can provide orientation for hospice staff who provide occasional coverage for a member of the identified hospice interdisciplinary group that is quick and efficient, but sufficient to protect residents who receive hospice care.
2) CMS efforts to mirror existing hospice requirements notwithstanding, some differences occur. For example, the proposed rule would require that the facility report all alleged violations by hospice personnel to the hospice administrator immediately when the facility becomes aware of the alleged violation. However, the hospice is required in the June 2008 hospice final rule to report these same violations within 24 hours of the hospice becoming aware of the alleged violation. CMS is requesting feedback on whether the differences between the requirements that are found in the proposed rule would create a barrier to forming agreements between LTC facilities or interfere in coordination of residents' care between LTC facilities and hospices.
To view the rule in its entirety, go to http://edocket.access.gpo.gov/2010/pdf/2010-26395.pdf. To have your comments included in AHCA’s comment document to CMS, please send them to Lyn Bentley at lbentley@acha.org by December 6.
Monday, November 1, 2010
New OSHA SST Inspection Directive
The Occupational Health & Safety Administration (OSHA) has issued its 2010 site specific targeting (SST) directive. Inspection criteria include:
• The primary inspection criteria using the 2009 Data Collection Initiative will target healthcare facilities in SIC code 805 (which includes long term care) with a Days Away, Restricted or Transferred (DART) rate at or above 16.0, or a Days Away From Work, Injury and Illness (DAFWII) case rate at or above 13.0 (only one of these criteria must be met.) 300 of the highest rated DART and DAFWII facilities will be surveyed under SST-10.
• A secondary inspection list will be created for healthcare facilities reporting DART rates of 13.0 or greater but less than 16.0, or a DAFWII case rate of 11.0 or greater but less than 13.0.
• As in past years, surveys of nursing and personal care facilities will focus on ergonomic stressors; exposure to blood and other potentially infections materials, as well as tuberculosis; and slips, trips, and falls. When additional hazards come to the attention of the compliance officer, the scope of the inspection may be expanded to include those hazards.
• When conditions indicate that a General Duty Clause citation relating to ergonomics may be warranted, the Area Office will contact the Regional Ergonomics Coordinator.
To view the directive in its entirety, go to http://www.osha.gov/OshDoc/Directive_pdf/CPL_02_10-06.pdf.
• The primary inspection criteria using the 2009 Data Collection Initiative will target healthcare facilities in SIC code 805 (which includes long term care) with a Days Away, Restricted or Transferred (DART) rate at or above 16.0, or a Days Away From Work, Injury and Illness (DAFWII) case rate at or above 13.0 (only one of these criteria must be met.) 300 of the highest rated DART and DAFWII facilities will be surveyed under SST-10.
• A secondary inspection list will be created for healthcare facilities reporting DART rates of 13.0 or greater but less than 16.0, or a DAFWII case rate of 11.0 or greater but less than 13.0.
• As in past years, surveys of nursing and personal care facilities will focus on ergonomic stressors; exposure to blood and other potentially infections materials, as well as tuberculosis; and slips, trips, and falls. When additional hazards come to the attention of the compliance officer, the scope of the inspection may be expanded to include those hazards.
• When conditions indicate that a General Duty Clause citation relating to ergonomics may be warranted, the Area Office will contact the Regional Ergonomics Coordinator.
To view the directive in its entirety, go to http://www.osha.gov/OshDoc/Directive_pdf/CPL_02_10-06.pdf.
Wednesday, October 27, 2010
Employers given one-year reprieve on reporting health plan costs
The Internal Revenue Service (IRS) recently announced a one-year delay in implementing a requirement under the Affordable Care Act that employers report the aggregate cost of employee health coverage on a Form W-2. The IRS says it will not enforce the reporting requirement in 2011, when it was previously set to go into effect.
Many employers, particularly those with self-insured health plans, have expressed concerns that it will be difficult to comply with the new requirement. According to IRS Notice 2010-69: “The Treasury Department and the IRS have determined that this relief is appropriate to provide employers with additional time to make any necessary changes to their payroll systems or procedures in preparation for compliance with the reporting requirement.” The IRS notice can be found at:
http://www.irs.gov/pub/irs-drop/n-2010-69.pdf.
Many employers, particularly those with self-insured health plans, have expressed concerns that it will be difficult to comply with the new requirement. According to IRS Notice 2010-69: “The Treasury Department and the IRS have determined that this relief is appropriate to provide employers with additional time to make any necessary changes to their payroll systems or procedures in preparation for compliance with the reporting requirement.” The IRS notice can be found at:
http://www.irs.gov/pub/irs-drop/n-2010-69.pdf.
Thursday, October 21, 2010
HHS Waivers Allow “Mini Med” Health Plans To Continue
The Department of Health and Human Services (HHS) has established a process under which group health plans or insurers may apply for waivers from the new restrictions on health plan annual limits (and lifetime limits) established under recently enacted health reform legislation. For plan or policy years beginning on or after September 23, 2010, interim regulations require no dollar limits on certain “essential benefits” and health plan annual coverage limits of no less than $750,000 with the amount rising to $2 million two years thereafter.
The waivers in part are intended to allow “limited benefit” plans or “mini med” plans, which typically have annual limits far below levels that the new rules allow, to continue to be offered until 2014 when new insurance market rules and other major coverage expansion reforms come into place. These plans tend to have lower premiums. In sub-regulatory guidance, HHS’ Office of Consumer Information and Insurance Oversight states: “These group health plans and health insurance coverage often offer lower-cost coverage to part-time workers, seasonal workers, and volunteers who otherwise may not be able to afford coverage at all.” Long term care providers are among the types of employers that offer these mini med plans to employees. Waiver applications must include “a brief description of why compliance with the interim final regulations would result in a significant decrease in access to benefits for those currently covered by such plans or policies, or significant increase in premiums paid by those covered by such plans or policies, along with supporting documentation.”
More information about the waiver process, the regulations, and a list of approved waivers can be found at: http://www.hhs.gov/ociio/regulations/patient/index.html. A sample of a waiver application prepared by the law firm Greenberg Traurig, LLP, is available at: http://www.ahcancal.org/ncal/advocacy/Documents/OutlineSampleWaiverApplication.pdf.
The waivers in part are intended to allow “limited benefit” plans or “mini med” plans, which typically have annual limits far below levels that the new rules allow, to continue to be offered until 2014 when new insurance market rules and other major coverage expansion reforms come into place. These plans tend to have lower premiums. In sub-regulatory guidance, HHS’ Office of Consumer Information and Insurance Oversight states: “These group health plans and health insurance coverage often offer lower-cost coverage to part-time workers, seasonal workers, and volunteers who otherwise may not be able to afford coverage at all.” Long term care providers are among the types of employers that offer these mini med plans to employees. Waiver applications must include “a brief description of why compliance with the interim final regulations would result in a significant decrease in access to benefits for those currently covered by such plans or policies, or significant increase in premiums paid by those covered by such plans or policies, along with supporting documentation.”
More information about the waiver process, the regulations, and a list of approved waivers can be found at: http://www.hhs.gov/ociio/regulations/patient/index.html. A sample of a waiver application prepared by the law firm Greenberg Traurig, LLP, is available at: http://www.ahcancal.org/ncal/advocacy/Documents/OutlineSampleWaiverApplication.pdf.
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