July 18, 2023 – From the Desk of the National Association for Home Care & Hospice

On Monday, July 3, 2023, the National Association for Home Care & Hospice (NAHC) and Home Care Association of America (HCAOA) submitted a joint comment letter on the proposed Medicaid Access Rule. In our letter, we express support for many of the provisions in this proposed rulemaking. We specifically support and provide comments that we believe would strengthen and improve the following provisions:

• Access Reporting: 42 CFR §441.311(d);
• Payment Rate Transparency: 42 CFR §447.203(b)(1);
• Interested Parties Advisory Group: 42 CFR §447.203(b)(3)(ii)(6);
• State Analysis Required for Payment Restructuring and Access: 42 CFR §447.203(c);
• HCBS Quality Measure Set: 42 CFR §441.312;
• Strengthening Oversight of Person-Centered Plans:  §441.301(c)(3)(ii)(A);
• Incident Management System: 42 CFR §441.302;
• HCBS Grievance System: 42 CFR §441.301(c)(7); and
• Medicaid Advisory Committee and Beneficiary Advisory Group: 42 CFR §431.12.

We also provide recommendations that we believe would make the following provisions more effective and improve the ability to successfully implement:

• Definition of DCW: 42 CFR §441.302(k)(1)(ii);
• Reporting on Proportion of Payments to DCWs: 42 CFR §441.311(e); and
• Payment Rate Disclosure: 42 CFR §447.203(b)(3)(ii).

Unfortunately, the HCBS Payment Adequacy provision at 42 CFR §441.302(k)(3)(i) is the most impactful part of this rule and is untenable for our members. We provide significant analysis and detail to demonstrate why:

• The proposal lacks statutory authority;
• There is no data to support it;
• It contradicts CMS HCBS quality efforts;
• Existing policies do not support such a mandate;
• State rate models demonstrate inconsistency of the proposal with HCBS practices;
• Provider cost data also does not align with the proposal;
• Provider surveys indicate significant confusion and negative impacts for patients and caregivers;
• The mandate is administratively complex and would be extremely challenging to enforce;
• The proposal would create inequities within and across states;
• The proposed rule undermines state authority; and
• The proposed rule would disproportionately impact small and rural providers.

We believe that there are opportunities to implement regulations that improve the structure and outcomes of state HCBS reimbursements and offer an alternative proposal. We believe that our proposal would enhance HCBS payment methodologies in a way that:

• Provides more structure for state rate-setting processes;
• Creates a transparent approach that clearly delineates the components of a Medicaid reimbursement methodology;
• Supports and increases worker compensation;
• Maintains state flexibility and autonomy regarding provider rate setting;
• Preserves the ability to perform both required and supplementary administrative activities that are crucial to high-quality HCBS delivery; and
• Adheres to the statutory requirements regarding Medicaid payment adequacy found at Section 1902(a)(30)(A) of the Social Security Act.

NAHC and HCAOA look forward to ongoing discussions and collaboration with CMS, states, and other partners to strengthen and improve HCBS, increase wages for workers, and supports ongoing provider viability.

Each year,  National Association for Home Care & Hospice (NAHC) members and industry partners touch down in our nation’s capital to advocate with lawmakers for support of the care-in-the-home community. NAHC tracks critical legislative, regulatory, and policy issues that affect their members to ensure you’re prepared for the day.

Advocacy Day is where NAHC needs your help to advance policy by joining them for a day on Capitol Hill and participating in their grassroots efforts virtually through their online Action Center.

Advocacy Day participants will have the opportunity to meet with Members of Congress or their legislative staff to advance issues facing our growing and evolving industry. This is a chance to share your story with legislators and ask that they back policies to bolster your capacity to continue providing high-quality home-based care to patients and families. FREE REGISTRAION OPEN NOW!

Governor Tony Evers signed Senate Bill 70 – the Fiscal Year 2023-2025 budget bill – into law on July 5.  It is now 2023 Wisconsin Act 19.  This budget will spend nearly $99 billion over the next two fiscal years. 

In addition, Governor Evers issued a veto message that specifies 51 separate line-item vetoes he made to this budget bill.  The Governor’s budget and veto message may be viewed here: https://doa.wi.gov/budget/SBO/2023-25%20Veto%20Message%20FM.pdf

The following provision that Governor Evers fully vetoed will likely be of interest to WiAHC:  DHS and Managed Care Organization Reporting Requirements:  Require DHS to include information regarding (a) executive leadership salaries and (b) amounts retrieved by the state under the contractual risk corridors, in the publicly available financial summaries for Family Care, Family Care Partnership, and PACE managed care organization. Require DHS and Family Care, Family Care Partnership, and PACE managed care organization (MCO) to track and annually report to the Legislature’s Joint Finance Committee total authorized and total provided care plan hours by service category and MCO.

A summary of all the WiAHC budget highlights are included (HERE).

By Hoven Consulting – WiAHC’s lobbying firm

• Fiscal Year 2023-2025 State Budget Update – Department of Health Services

On June 15, the Legislature’s Joint Finance Committee (JFC) approved Fiscal Year 2023-2025 funding levels for the Department of Health Services (DHS).  The approved DHS budget increased spending by $3.1 billion overall during the biennium. The budget bill will still need to be approved by the JFC and the legislature and signed by the Governor before it becomes law.

In part due to WiAHC’s advocacy, JFC approved a continuation of the 5% Home and Community Based Services (HCBS) rate increase that was initially funded by federal American Rescue Plan Act (ARPA) funds.  

The following are highlights of the approved DHS budget:

Medicaid/Medical Assistance

Elder and Disability Services

Public Health

The DHS budget was adopted by the committee on a party line vote of 11-4. While these items will be included in the Legislature's budget proposal, they will only be enacted if the budget bill is passed by both the Assembly and Senate and the bill is signed by Governor Evers.

• Fiscal Year 2023-2025 State Budget Update – Department of Safety and Professional Services (Occupational Credentialing)

On June 8, the Legislature’s Joint Finance Committee (JFC) held a committee meeting and approved the Fiscal Year 2023-2025 budget for the state Department of Safety and Professional Services (DSPS).  This agency is responsible for occupational credential processing, the state’s electronic Prescription Drug Monitoring Program, as well as other matters.  In recent years, DSPS has struggled with processing a backlog of applications for new and renewed occupational credentials. 

During this meeting, committee Republicans proposed funding the following:

The committee approved this funding package and did not approve an alternate funding package advanced by committee Democrats.   

During this committee meeting, committee Democrats criticized GOP JFC members for not including funding for more credential processing staff, bearing in mind the ongoing credential processing backlog at DSPS.  JFC Republicans responded by noting that the agency will improve its output with fewer employees due to the increased use of technology. 

The DSPS budget was also adopted by the committee on a party line vote of 11-4. While these items will be included in the Legislature's budget proposal, they will only be enacted if the budget bill is passed by both the Assembly and Senate and the bill is signed by Governor Evers.

• Professional Advisory Bodies Rule Changes - Update

In January 2023, WiAHC Board Chair Jayne Thill wrote to Deb Standridge, the Department of Health Services’ (DHS) Deputy Secretary, requesting that the DHS eliminate an outdated administrative rule relating to professional advisory bodies for home health care agencies in their biennial rules review.  Specifically, this would bring Wisconsin’s regulations in line with federal regulations by eliminating professional advisory bodies but maintaining governing bodies along with regulatory oversight for ensuring the quality of care and patient safety. 

WiAHC made this request since federal regulations eliminated professional advisory committees in 2017, as home health agencies are already overseen by a governing body pursuant to federal regulations.  They are also overseen by governing bodies in Wisconsin administrative rules.  In 2017, the federal Centers for Medicare & Medicaid Services (CMS) also put in place federal regulations requiring home health agencies to implement ongoing quality assessment and performance improvement (QAPI) programs.  Essentially, CMS replaced professional advisory committees in federal regulations with the creation of the QAPI program.

On May 18, Governor Evers approved a document – a “statement of scope” – for a biennial review of administrative rules intended to repeal obsolete state administrative rules.  This document includes a provision that would effectively remove professional advisory bodies from the home health care portion of state administrative rules.  The approval of the “statement of scope” is the first step in the regulatory process.  WiAHC will provide future updates in this newsletter.

• WiAHC Spring Conference

WiAHC held its 2023 Spring Conference at the Best Western Premier Waterfront Hotel and Conference Center in Oshkosh from June 1-2.  This event featured a combination of general sessions and breakout sessions of interest to all those who work in Wisconsin’s home health care industry.  Leading subject matter experts from Wisconsin and throughout the nation presented at this event.  In addition, WiAHC was fortunate enough to host two state legislators at this conference – Representative Lori Palmeri (D-Oshkosh) and Senator Dan Feyen (R-Fond du Lac).  Rep. Palmeri serves on the Assembly Committee on Mental Health and Substance Abuse Prevention and Sen. Feyen is the Assistant Majority Leader in the state Senate. 

Ascension at Home Together with Compassus recently opened their doors to State Senator Andre Jacque (R-DePere), hosting the veteran lawmaker at their Sturgeon Bay, WI office.

Compassus is a national leader in providing high-quality, compassionate, person-centered care to individuals wherever they call home. Their continuum of post-acute care services ensures patients and their families have the support they need to address current and future health needs.

Led by WiAHC Board Chair and Compassus Regional Quality Director Jayne Thill, the Compassus team (including Donna Moens, Executive Director; and Marla Wills, Director of Clinical Services) spent over an hour with Sen. Jacque discussing the value of home health care for patients, the mission of WiAHC, and the regulatory and legislative challenges faced by the home health industry. Much of the discussion focused on the growing workforce shortage in the health care sector and how it is impacting home health.

WiAHC thanks Jayne and her dedicated team for hosting Sen. Jacque and participating in WiAHC’s

legislative advocacy outreach program. Our advocacy efforts aim to connect members with their local state lawmakers to advocate for programs and policies that improve the delivery of home health care, support home health professionals, and enhance home health services provided to patients.

For more information on local legislator visits to your agency, please contact wiahc@badgerbay.co.

Although most of the activity the State Capitol is currently focused on the 2023-25 state budget bill – the state’s two-year spending plan – lawmakers are still working on stand-alone legislation, some of which could impact WiAHC members and the home health care community in Wisconsin. Fortunately, the WiAHC Government Affairs Team – headed by Tim Hoven and Nathan Butzlaff from Hoven Consulting – closely monitor and lobby on legislative proposals important to WiAHC.

However, you can also track the bills WiAHC is lobbying on during the 2023-24 legislative session. Please CLICK HERE to review WiAHC’s legislative activity on the state of Wisconsin’s Eye on Lobbying website. 

Medicare Home Health has endured a series of massive cuts to the reimbursement structure and providers are expecting additional cuts to be announced in this year’s rulemaking by the Centers for Medicare & Medicaid Services (CMS). These cuts will have devastating, long-term repercussions on access to care for patients, and it is estimated that more than half of Medicare-certified home health agencies will be operating with negative margins as a result of these cuts.

It is crucial for Congress to intervene and tell CMS to stop these additional cuts. The 7.85% permanent cut finalized in 2022 equates to more than $1 billion in cuts annually starting in 2024 and continuing in perpetuity. This will result in devastating, long-term repercussions for home health patients and their providers.

To maintain access to home health care services and prevent harm to the Medicare patients across Wisconsin that depend on essential health care provided in their homes, it’s critical for WiAHC members to urge Congress to fix the potential chaos created by CMS by passing the Preserving Access to Home Health Act of 2023 (S. 2137), which is being authored by Senators Debbie Stabenow (D-MI) and Susan Collins (R-ME).

The Preserving Access to Home Health Act of 2023 not only seeks to reverse these damaging Medicare home health cuts, but it also instructs the Medicare Payment Advisory Commission (MedPAC) to analyze the Medicare Home Health Program comprehensively. MedPAC's review would encompass aggregate trends under Medicare Advantage, Medicaid, and other payers.

We need you to tell your members of Congress to act NOW and require CMS to stop additional cuts to home healthcare in 2024. Remember, these cuts will threaten the ability of 3.2 million Medicare beneficiaries to receive life-saving clinical care in the home each year. It is time to prioritize the health and well-being of our elderly, disabled, and chronically ill patients and ensure that they have access to the care they need and deserve.

Of course, when advocating for home health with your members of Congress, it is important to ensure your message is both compelling and clearly presented. Thankfully, our national partner, the National Association for Home Care and Hospice (NAHC), has made connecting with your elected representatives as easy as a few clicks on your computer or mobile device.

Simply CLICK HEREto contact your federal lawmakers on the Preserving Access to Home Health Act of 2022. All you need to do is fill in your name and contact information and hit SEND.

WiAHC is happy to remind members about and provide links to the latest articles and information on the home health care industry from Home Health Care News and other publications:

·       Study: Shortages Force 89 Percent of Home Care Agencies to Turn Away Care

McKnights Home Care – By Adam Healy | June 26, 2023

MissionCare Collective, parent organization of myCNAjobs, a job placement, career tools and training site for caregivers, released a study Friday revealing that a vast majority of home care providers have been forced to turn away care because of workforce shortages. Findings from the study indicate that 89% of providers have had to deny care because of the workforce crisis. On average, small- and mid-sized care providers refuse 510 care hours each month, the study said. Also, a majority have seen problems surrounding recruitment and retention worsen in the past six months. Read More…

·       Lawmakers Seeking to Block Home Health Medicare Cuts

Home Health Care News – By Andrew Dolan | June 22, 2023

The Preserving Access to Home Health Act of 2023 was introduced Thursday. Its largest objective is to prevent further cuts to home health payments in 2024 and beyond. The bill, if passed, would also strip the Centers for Medicare & Medicaid Services (CMS) of some of its payment-rate setting power and force the The Medicare Payment Advisory Commission (MedPAC) to consider Medicare Advantage (MA) payment rates in its reports. Read More…

·       NAHC: Medicaid Unwinding May have Affected Thousands of Home Care Patients

McKnights Home Care – By C. Max Bachmann | June 14, 2023

Officials with the Department of Health and Human Services (HHS) said Tuesday they have urged states to adopt flexibilities to minimize Medicaid coverage loss during the unwinding of the continuous enrollment provision. Between 8 million and 24 million people could lose Medicaid coverage during the 12-month unwinding period, according to data from KFF. The concern, CMS and home care providers say, is not that these beneficiaries are no longer eligible, but rather that procedural roadblocks are stopping them from receiving coverage. Read more…

·       Home Health Care A ‘Perfect Storm’ Of Complexity For Dealing With ACA Compliance

Home Health Care News – By Patrick Filbin | June 8, 2023

Within all of health care, home health agencies are among the most likely to be audited by the IRS for non-compliance with the Affordable Care Act (ACA). That’s true, in part, because of the number of hourly employees and data collection issues in the industry. To avoid scrutiny, agencies need to rigorously check their compliance records and understand what is being asked of them by the federal government, according to compliance experts. Read more…

Home Health Care News, which is part of the Aging Media Network, is a leading source for news and information covering the home health industry.

WiAHC leaders met with State Senator Andre Jacque (R-DePere) in Sturgeon Bay. The meeting was hosted by Jayne Thill and her team at Ascension at Home Together with Compassus.  The meeting highlighted the benefits of home health care for patients, as well as the challenges the home health care industry faces.

By Hoven Consulting – WiAHC’s lobbying firm

• Update on the FY2023-2025 State Budget

On May 2, the Legislature’s Joint Committee on Finance voted to remove over 500 budget items included in Governor Tony Evers’ Fiscal Year 2023-2025 budget request from further consideration by the committee.  However, it is important to note that even though certain budget items from the Governor’s budget request remain in the budget bill after this vote, a majority of committee members will still need to vote separately to approve including those budget items in the committee’s version of the budget bill.  Those votes will occur at committee meetings on various dates in the future, as the committee considers different state agency budgets.  In addition, the Joint Committee on Finance is able to offer their own budget amendments to different state agencies.   

However, on May 2, the Joint Committee on Finance did not vote to remove funding for the following budget items likely of interest to WiAHC:

On May 23, the Joint Committee on Finance voted on the budget for the Higher Educational Aids Board (HEAB), which includes funding for the nurse educators program.  While an amendment was offered to increase the nurse educators program by $5 million per year – for a total of $10 million per year –that amendment unfortunately failed.  It's important to note that demand for nurse educator program funds has been less than anticipated.  That could be the reason why this amendment failed.  However, the committee did not modify the existing annual $5 million for this program.  In addition, HEAB anticipates that there will be unspent funds – at least $1.5 million – from Fiscal Year 2022-2023 that will be carried over to FY2023-2024.  Therefore, if Governor Evers signs the budget bill, the nurse educator program will be funded at least at a $6.5 million level in FY2023-2024.

• WiAHC Supports Bills Addressing Occupational Credentialing

WiAHC has decided to support the following bills that attempt to streamline the occupational credentialing process:

• Assembly Bill 144/Senate Bill 158:  In order to help expedite the occupational credentialing process for new college graduates in the health care field, these bills would require the state Department of Safety and Professional Services to grant preliminary occupational credentials to those who have recently completed the requirements to obtain a health care credential, submitted a license application, and have been engaged by a health care employer. 
• Assembly Bill 143/Senate Bill 160:  These bills would help reduce processing delays for individuals applying for occupational credentials to be occupational therapists, occupational therapy assistants, advanced practice nurse prescribers, and certain other health care professions by no longer requiring such applicants to take a “statutes and rules” exam.  Instead, such applicants may need to affirm that they have read and understood the statutes and rules that apply to the applicants’ practice.
• Senate Bill 193/Assembly Bill 204:  This bill changes the two-year renewal period for health and business occupational credentials to four-year renewal periods. 

·       Federal COVID-19 Public Health Emergency Ends

On May 11, 2023, the federal COVID-19 Public Health Emergency ended.  With the end of this emergency, there are changes in the response to COVID-19.  COVID-19 vaccines will continue to be provided free of charge to individuals until the government supply is depleted.  The state-funded Say Yes! COVID Test program will continue to provide free at-home antigen tests through May 2023, as supplies allow.  Eventually, however, all tests (antigen or PCR) will no longer be provided free of charge – individuals may have purchases reimbursed by insurance plans or may need to purchase them out-of-pocket.  COVID-19 antiviral treatments, such as Paxlovid, will continue to be free to patients until the federal stockpile has been depleted.  In addition, DHS will continue to operate its free-of-charge COVID-19 treatment telehealth service through December 31, 2023.

·       Governor Calls Special State Assembly Election

On May 5, Governor Tony Evers called a special general election for the 24th Assembly District on July 18, 2023.  If a special primary election is needed, it will occur on June 20, 2023.  This vacancy was created by the election of then-state Representative Dan Knodl (R-Germantown) to the 8th Senate District, which was previously held by longtime state Senator Alberta Darling (R-River Hills).  The 24th Assembly District includes portions of Waukesha and Ozaukee Counties, including the communities of Germantown, Menomonee Falls, and Grafton.