Friday, September 28, 2007
Congress included authority for these nursing home diversion grants in the most recent reauthorization of the Older Americans Act (OAA). These new provisions in the OAA complement the changes occurring in Medicaid to rebalance the long term care system.
The grants will help enable states to use existing OAA and state revenue funds in a more flexible manner so that a greater range of support options can be made available to individuals who are at high risk of nursing home placement. States receiving grants are Arkansas, Connecticut, Georgia, Illinois, Kentucky, Maryland, Michigan, Minnesota, New Hampshire, New Jersey, Vermont and West Virginia.
For more information, go to AoA's web site at http://www.aoa.gov/press/pr/2007/September/9_24_07.asp.
NCAL’s proposed changes to the guidelines’ chapter on assisted living facilities would:
· Promote “universal design” practices (e.g., appliances/storage areas/spaces that can be utilized by people with various types of disabilities);
· Make the recommended number of parking spaces more flexible;
· Facilitate designs that combine activity and dining areas; and
· Promote residents’ control of their environment, including artificial and natural lighting.
Changes to the AIA guidelines can be proposed and viewed at: http://www.fgiguidelines.org/. Many states and localities use the AIA guidelines to develop building codes and regulations. The 2006 edition of the guidelines featured a chapter on assisted living for the first time.
The self-directed PAS state plan option permits individuals to hire, fire, supervise, and manage employees of their own choosing, including, at the State's option, legally liable relatives, and to direct a budget from which the individuals purchase their PAS. States are required to assure safeguards to protect health and welfare of Medicaid beneficiaries under this option and to assure the financial accountability for funds expended for self-directed services. Participants must have sufficient supports to manage their workers and budgets and an individualized backup plan for critical contingencies and potential harm.
The benefit is not available to individuals who live in a home controlled by a provider of services not related to the individuals by blood or marriage. If PAS are provided as part of a package of services within a congregate living arrangement (e.g., in an assisted living arrangement), the State plan PAS would not be available.
States may permit individuals to choose to receive cash disbursements, on a prospective basis, to purchase personal assistance identified in their service plan. States may allow individuals to use the funds to acquire items that increase independence or substitute for human assistance.
The State Medicaid Director letter is available on CMS' web site at http://www.cms.hhs.gov/SMDL/SMD/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS1203243&intNumPerPage=10.
Friday, September 21, 2007
Issues with the CARE instrument identified by AHCA predominantly focuse on the need to set definitions and standards to improve tool clarity and accuracy. AHCA criticizes the inclusion of the certifying statement that requires clinicians to assure accuracy and truthfulness of their responses under penalty of substantial personal and organizational criminal, civil and administrative penalties for submitting information found to be false. The certifying statement requires all clinician involved in the assessment to sign, document the sections they coded and provide their professional license number. Click here to view the AHCA comments.
The proposed uniform patient assessment instrument is designed to measure difference in patient severity, resource utilization, claims analysis and outcomes for patients in acute and post-acute care settings. The instrument is a component of the Deficit Reduction Act (DRA) of 2005 that authorized the Post Acute Care Payment Reform Demonstration (PAC-PRD).
During the demonstration, the CARE instrument will collect patient information on acute hospital discharge and on admission and discharge to a post acute care setting. The instrument is intended to measure differences in medical conditions or predict outcomes like discharge to home or community, rehospitalization, and changes in functional and medical status.
Currently, Research Triangle International (RTI) is pulling together a list of providers wishing to volunteer to participate in the demonstration. The pilot will be rolled-out in January 2008.
Wednesday, September 19, 2007
The three year RAC post-payment medical review demonstration project began on March 28, 2005, in the three states with the highest Medicare expenditures: California, Florida, and New York. Connolly Consulting is the RAC responsible for New York, PRG Schultz for California, and HealthData Insights for Florida. While AHCA is not aware of any major problems with the RACs in Florida and New York State, nursing facility providers in California have reported problems with PRG-Schultz. These problems pertain to appeals, the quality of medical necessity reviews, the statute of limitations and the contingency payment aspect of the contract with the RAC. Accordingly, AHCA had brought these issues to CMS and the Hill.
Congress, in the Tax Relief and Health Care Act of 2006, mandated an expansion of the program to all states no later than January 1, 2010. At this time, the claim RACs in the demonstration are being expanded. The New York claim RAC is being expanded to include the claims submitted to the Massachusetts fiscal intermediary (FI) plus the claims submitted to Mutual of Omaha (a national FI) from providers in New York and Massachusetts. The Florida claim RAC is being expanded to include the claims submitted to the South Carolina FI plus the claims submitted to Mutual of Omaha (a national FI) from providers in FL and SC. The California claim RAC is being expanded to include the claims submitted to the Arizona Medicare Administrative Contractor plus the claims submitted to Mutual of Omaha (a national FI) from providers in California and Arizona. There is no change to the MSP RACs at this time.
Currently, in the new states, the RAC can only perform CODING reviews (not medical necessity reviews) and only on HOSPITAL claims (not SNF claims, physician claims, etc). This will change in the spring when CMS allows the RACs to perform medical necessity reviews and to review more claim types.
CMS has indicated that the claims data from Mutual of Omaha in the 6 states plus the claims data the Massachusetts FI and South Carolina FI have already started flowing to the RACs. Hospitals from the 6 states who submit their claims to Mutual of Omaha and hospitals who submit their claims to the FI in Massachusetts and South Carolina (SC) could start to see medical record request letters and overpayment demand letters starting in mid to late September. CMS has encountered some technical issues in Arizona and their claims data has not yet started to flow. CMS indciates that it may be several more months before the agency gets all the Arizona claims flowing to the RAC.
CMS Issues Guidance on Requirements for Tamper-Resistant Prescription Paper Exempting Nursing Facilities and Certain Other Health Institutions
On August 17, CMS issued guidance which interprets this new requirement as not applying to nursing facility services and ICFs/MR services and other institutional and clinical services such as inpatient and outpatient hospital services, hospice, physician, dental, renal dialysis, laboratory and X-ray services and not applying when the prescription is communicated by the prescriber to the pharmacy electronically, verbally or by fax or when a managed care entity pays for the prescription. The guidance can be found at:
· State Medicaid Director Letter: http://www.cms.hhs.gov/SMDL/downloads/SMD081707.pdf
State Health Policymakers Backgrounder: http://www.cms.hhs.gov/DeficitReductionAct/Downloads/Tamper.pdf
Since AHCA/NCAL had questions that were not addressed by the August 17 guidance, we requested CMS to provide additional clarification. On September 12, CMS posted several answers to Frequently Asked Questions (FAQs) designed to respond to AHCA/NCAL’s questions and assist states in implementing the requirement, which is effective October 1, 2007. CMS confirmed that nursing facilities will not be affected by the requirement; CMS concluded that a written order prepared in an institutional setting where the doctor or medical assistant writes the order into the medical record and then the order is given by medical staff directly to the pharmacy is considered “tamper resistant” so long as the patient never has the opportunity to handle that written order. Although the institutional exemption to the new tamper-proof rule does not apply to assisted living facilities, CMS’ FAQs reiterates that non-written prescriptions – e-prescriptions, prescriptions transmitted to a pharmacy by fax, and prescriptions communicated by telephone – are not subject to the requirement. CMS' FAQs also addresses concerns about whether the prescribing physician had to personally fax the prescription in order for the exemption to hold; with regard to these non-written prescriptions, CMS clarifies that “a nurse or administrative staff person who is authorized to act on the prescriber’s behalf may phone the pharmacy the order, send the order by facsimile, or electronically transmit the order to the pharmacy.”
Monday, September 17, 2007
Recently, the Institute for Community Inclusion (ICI) released an issue brief to explain the effects of recent changes to the federal, and some state, minimum wage laws on DD services changes. Specifically, the brief addresses the wage effects on public benefits, such as Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medicare, and Medicaid; and advises developmental disabilities (DD) services providers to collaborate with Work Incentives Planning and Assistance (WIPA) project leaders and Community Work Incentives Coordinators (CWICs) to gain expertise on benefit issues for their clients.
To access the issue brief, which contains links to WIPA projects, CWICs and other resources, go to http://www.communityinclusion.org/article.php?article_id=203.
Wednesday, September 12, 2007
In addition, the report points out important gaps that could hinder the ability of key stakeholders to effectively execute their responsibilities as follows:
- State and local jurisdictions that will play crucial roles in preparing for and responding to a pandemic were not directly involved in developing the National Response Plan;
- Relationships and priorities among actions in the Plan and Strategy are not clearly described;
- Performance measures focus on activities that are not always linked to results;
- Insufficient information is provided about how the documents are integrated with other key related plans; and
- No process is provided for monitoring and reporting on progress.
The GAO made two recommendations as follows:
- DHS and HHS develop rigorous testing, training, and exercises for pandemic influenza to ensure that federal leadership roles and responsibilities are clearly defined, understood, and work effectively; and
- The Homeland Security Council set a time frame to update the National Response Plan, involve key nonfederal stakeholders, and more fully address the characteristics of an effective national strategy.
DHS and HHS concurred with the GAO report and recommendations. To access the report, go to
Thursday, September 6, 2007
The recent study comes to the same basic conclusion stating: Unless Congress and HHS take action in response to the matters for congressional consideration and recommendations to the Secretary that we presented in our July 2002 report -- namely that Congress consider requiring the Secretary to improve public notification and input at the federal level and that the Secretary provide for an improved process--it appears likely that HHS will continue to approve waivers for comprehensive Medicaid demonstrations without adequate opportunity for public input. HHS disagreed with the GAO's conclusion.
To access the GAO report, go to http://www.gao.gov/new.items/d07694r.pdf.
To read all three updates, go to http://www.ahca.org/members/operate/life-safety/index.htm and scroll down to the heading "Fire Safety."
On August 21, 2007, President Bush, along with the President of Mexico and
the Prime Minister of Canada, announced the release of the North American Plan for Avian and Pandemic Influenza. The plan outlines how the three countries will work together to prepare for and manage outbreaks of highly pathogenic avian influenza and pandemic influenza. The North American Plan provides a framework to accomplish the following:
* Detect, contain, and control an avian influenza outbreak and prevent transmission to humans;
* Prevent or slow the entry of a new strain of human influenza into North America;
* Minimize illness and deaths; and
* Sustain infrastructure and mitigate the impact to the economy and the functioning of society.
To acccess the North American Plan for Avian and Pandemic Influenza, go to:
Wednesday, September 5, 2007
This year, as in past years, the need to immunize health care workers is receiving a lot of attention. Two CDC advisory committees recommend that all health care workers receive annual influenza immunizations. A helpful toolkit relating to immunizing health care workers in long term care is available on AHCA’s Web site at http://www.ahca.org/flu/immunization_toolkit_041115.pdf.
Since October 2005, Medicare certified nursing facilities are required to offer influenza vaccine annually to all residents unless contraindicated. Nursing facilities also are required to provide education to residents or their legal representatives on the benefits and risks of influenza vaccination. (Pneumococcal vaccine is also required unless contraindicated.)
For up-to-date information on influenza immunization and the 2007-2008 influenza season, access the National Influenza Vaccine Summit’s Web site at http://www.preventinfluenza.org. Along with providing general information on influenza, the National Influenza Vaccine Summit has a Web site to track dosage availability. The Influenza Vaccine Availability Tracking System (IVATS) was developed to address the difficulty health care providers may experience when trying to determine which wholesale distributors or manufacturers have influenza vaccine in stock, for sale, or on order. To visit IVATS, go to www.ama-assn.org/ama/pub/category/16919.html.