Insurers that manage long-term care and supports for individuals with disabilities in their home or community will have to assure that beneficiaries can interact with their community and make more of their own life choices.
A new final rule for state programs in home and community-based services takes effect January 1, and states must submit plans to the Centers for Medicare & Medicaid Services by March, starting with an assessment of settings where residents live.
Patricia Nobbie, program specialist for special programs at the Center for Disability and Aging Policy in HHS' Administration for Community Living, said that CMS has changed its focus from "what an institutional setting is to what an individual's experience is in a home- and community-based setting."
The challenge will be to determine what differentiates a setting that isolates people who receive home- and community-based services funding from those in the community who do not receive HCBS funding, she said at a conference sponsored by America's Health Insurance Plans (AHIP). Settings that isolate people would be those that provide most services onsite in places where residents have limited interaction with the broader community.
"For MCOs, this affects what you might include or not include in your networks for serving people who are receiving HCBS," she said. It is complicated because every state is different, with several different waivers serving different populations, and service definitions are not necessarily consistent across states.
MCOs should review their guidelines, professional standards, training requirements, reimbursement rates, licensure and certifications for different types of settings and services, standards of practice.
"If you are considering contracting with a state as a deliverer of long-term services and supports, these are the things that you will have to look at prior to writing a contract with the state and make sure that the things that you are putting in the contract are compliant with rule," Nobbie said.
CMS has also offered a description of what a person-centered planning process looks like. It is more than a care plan, extending the support and services to a person beyond their clinical and medical needs to social, environmental and community-based supports, such as where they want to live, if they want to have a job, be near family and friends, and how their goals for life will be tracked.
"We're trying to get away from a service-driven life," she said.
Also taking effect in January is a Labor Department rule that extends minimum wage and overtime protections to those who provide essential home care assistance, such as home health and personal care aides and certified nursing assistants. Some states or MCOs may assume roles as joint employers.
Bruce Darling, president and CEO of the Center for Disability Rights, said that it is important to pay a good wage to healthcare workers attending residents at home or in the community. States could include the cost of services as part of their contracts.
"Plans are the crossroads in which money comes from the state and out to attendants. Plans will need to make sure that attendant hours are paid for," he said.
For example, in New York, many MCO contracts don't look like they are employers, Darling said. But there are mechanisms to pay for overtime.