No one expects lawmakers to allow the axe to fall, but 48 million beneficiaries and their doctors are looking on nervously.

Temporary reprieves have created a recurring problem that gets harder and harder to fix. A 1990s budget law called for automatic cuts to doctors if Medicare costs kept rising. Congress has issued so many waivers that a permanent fix would now cost more than $300 billion over 10 years.

In related news, home health agencies face a 2.3 percent cut in 2012, which would decrease funding by about $430 million. Kaiser Health News reports:

Home health advocates decried the cut, saying it would lead some agencies to close. The decreased funding, announced Monday, lowers the average base payment to home health agencies for a 60 days “episode of care” to $2,138 in 2012 from $2,192 in 2011. In 2006, the average reimbursement was $2,337, according to the National Association for Home Care and Hospice.

About half the cut in the payment rate in 2012 and 2011 was the result of a provision in the 2010 health law that lowered the fees.

“We have not seen the closures of agencies, but we are reaching that breaking point,” said Bill Dombi, an association vice president.

The health care industry is bracing itself for waves of retiring Baby Boomers, some of whom eventually will need long-term care. If a significant percentage of this huge cohort opts for home care, the lower rates of reimbursement for these agencies doesn’t bode well for providers.

• DADS added a new section to its web site: Culture Change in Texas Long-term Care.

• The MDS Privacy Act Statement is available in Spanish in the MDS 3.0 RAI Manual.

• “Effective for dates of service or dates of discharge (services) on or after October 1, 2013, Medicaid fee-for-service, Medicaid managed care, Primary Care Case Management (PCCM), family planning (Titles V, X, and XX), the Children with Special Health Care Needs (CSHCN) Services Program, and the Long Term Care (LTC) program will transition medical diagnosis and inpatient procedure coding from ICD-9-CM to ICD-10 code sets.”

• CMS has begun assessing the Texas Medicaid program using the PERM review process to measure payment accuracy in that program and CHIP. Click here for more information on what to expect during review process, and click here for an overview of PERM.

For more information on these more recent news alerts, see the main page.

Public Notice

HHSC issued an amended public notice of intent to seek a waiver from CMS to expand the STAR+PLUS program. An excerpt:

The waiver request, in its final form, is now available to the public, as described below. HHSC is publishing this amended notice to alert interested parties that the comment period will remain open to take comments on the waiver request until 5:00 p.m., August 31, 2011.

The waivers relate to the transition of all current STAR and STAR+PLUS areas, the inclusion of 28 additional counties effective September 1, 2011, and the phase-in of more counties effective March 1, 2012. The counties are listed in the table below.

The waiver request would allow expansion of Medicaid managed care throughout Texas by maintaining historic local contributions to Medicaid for hospitals currently receiving upper payment limit payments. If approved, acute care benefits will be administered statewide through managed care. Other Medicaid services and long-term services and supports will be available in specific counties.

Proposed Rules

HHSC proposes new Division 27 in Chapter 354, Subchapter A, §§354.1361 – 354.1364, Women’s Health Program (WHP). Among other things, the changes would restrict applicability of the proposed new division to the WHP and define the terms “affiliate,” “corporate entity,” “elective abortion,” “health clinic,” “HHSC,” “promotes,” and “Women’s Health Program.” See the Texas Register for details.

• On DADS’s Behalf

HHSC proposes to repeal Subchapter C, §§8.51 – 8.63, Life-Sustaining Treatment, in Chapter 8, Client Care–Mental Retardation Services, to remove rules regarding life-sustaining treatment in state supported living centers.

HHSC proposes new §9.229, concerning critical incident reporting, and amendments to §9.238, concerning level of care I criteria, and §9.239, concerning ICF/MR level of care VIII criteria, in Chapter 9, Mental Retardation Services–Medicaid State Operating Agency Responsibilities, Subchapter E, ICF/MR Programs–Contracting. The changes would require ICF/MR providers to report data related to critical incidents, which would help DADS report certain information to HHSC annually.

HHSC proposes to amend §49.1, concerning definitions, in Subchapter A, Definitions; an amendment to §49.12, concerning general requirements for participation, and the repeal of §49.19, concerning advertising and solicitation of clients, in Subchapter B, Contractor Requirements; and an amendment to §49.61, concerning sanctions, in Subchapter F, Sanctions and Terminations, in Chapter 49, Contracting for Community Care Services, which would remove references to solicitation from Chapter 49 and update references to Texas Department of Human Services to reflect agency name changes to DADS.

For more information about each rule proposed on DADS’ behalf, see the Texas Register.

Withdrawn Rules

HHSC has withdrawn proposed amendments to §§48.6002, 48.6040, 48.6050, and 48.6078 which appeared in the July 1, 2011, issue of the Texas Register (36 TexReg 4098).

Adopted Rules

HHSC adopted amendments to §355.723, Reimbursement Methodology for HSC and TxHmL programs, which establishes the reimbursement methodology.

HHSC adopted amendments to §355.7103, Rate-Setting Methodology for 24-Hour Residential Child-Care Reimbursements, to delete the rate end date currently in the rule.

HHSC adopted the repeal of §355.8052, Medicaid Inpatient Hospital Reimbursement; and adopted new §355.8052, Medicaid Inpatient Hospital Reimbursement, which describes the new prospective payment system applicable to Medicaid inpatient hospital payments.

HHSC adopted new §355.8055, Reimbursement Methodology for Rural and Certain Other Hospitals, which describes the Medicaid methodology for reimbursing rural hospitals, rural referral centers, sole community hospitals, and critical access hospitals.

HHSC adopted an amendments to §355.8061, Payment for Hospital Services, to reorganize and clarify subsection (a)(2) and to change Medicaid payment methodology in two areas: (1) non-emergency services provided in an emergency department (ED); and (2) imaging services.

HHSC adopted amendments to §355.8551, concerning the dispensing fee for Medicaid pharmacy services reimbursement, to remove the reimbursement rate component fee amounts for the pharmacy dispensing fee, clarify terms in the dispensing fee formula, and add definitions for the components of the formula.

HHSC adopted the repeal of §370.47, State Kids Insurance Program (SKIP) to abolish it and allow children of qualifying state employees to enroll in the Children’s Health Insurance Program.

Finally, HHSC adopted amendments to §372.956, concerning the expedited Supplemental Nutrition Assistance Program (SNAP) application process; and the repeals of §§372.1201 – 372.1204, concerning finger-imaging requirements. The changes remove references to the finger-imaging requirement for Temporary Assistance to Needy Families and SNAP households from HHSC’s rule base in compliance with recent legislative direction.

For more information on each adopted rule, see the Texas Register.

• On DADS’s Behalf

HHSC adopted an amendment to §48.6026, in Chapter 48, Community Care for Aged and Disabled, to require an HCSSA contracting with DADS to provide CBA services to maintain licensure in the licensed home health services category and permit the provider to maintain licensure in the personal assistance services category to provide CBA personal care tasks that do not require nurse delegation or supervision, including the assignment of health maintenance activities. See the Texas Register for details

• Providers still have time to submit the 2011 Home Health and Hospice Care Nurse Staffing Survey, extended to August 31, 2011. Providers will find materials for Texas Center for Nursing Workforce Studies at this web site. When ready to begin the survey, go to this web page.
• The CLASS Basic Job Skills Training is scheduled for September 6 – 7, 2011 in Austin, Texas. To register, go to the this web page.
• The CLASS provider manual has been revised and is posted at the this web page.
• Providers may register for the one-day CDSA Annual Quality Improvement Training for CDSAs with DADS contracts. The session will be held on September 8, 2011 10 a.m. to 3:30 p.m. in the William H. Travis Building, 1701 N. Congress Avenue, Room 1-111, Austin, Texas. DADS asks attendees to complete this registration form (PDF) and send to linda.clowdus@dads.state.tx.us no later than September 1.

CDSA for CBA:

DADS has proposed to create two categories of personal assistance services in the CBA Program. The letter also outlines operational procedures for CDSAs. An excerpt:

PAS Category I is proposed to include tasks delegated by a registered nurse (RN) to an unlicensed attendant, health maintenance activities, and extension of therapy.

PAS Category II is proposed to include tasks that do not require delegation by an RN, such as assistance with activities of daily living, cleaning, laundry, shopping, escort, and protective supervision.

The proposed consumer directed services (CDS) service rates for PAS Categories I and II will remain the same as the current CDS CBA rate. The proposed financial management services (FMS) fee for CBA is lower than the current CBA FMS monthly fee. The rate packet for the proposed rates is available on the Health and Human Services Commission (HHSC) Rate Analysis webpage at http://www.hhsc.state.tx.us/rad/rate-packets.shtml.

CBA and HCSSA:

DADS has proposed to create two categories of personal assistance services in the CBA Program. (Letter)

–  The Department of Assistive and Rehabilitative Services, Medicaid Infrastructure Grant and the Social Security Administration are co-hosting a Ticket to Work event on July 12, 2011, from 9 a.m. to 5 p.m. at the Crowne Plaza located at the Reliant Center, 8686 Kirby Drive, Houston, Texas. See the PDF attachment for more information: Ticket on the Road

–  See the MDS web page for the latest notifications and updates.

–  DADS will hold a public work session on Tuesday, July 12, 2011, at 9 a.m. in the John H. Winters Building Public Hearing Room, 701 W. 51st St., Austin, Texas. DADS asks providers to complete and return this form (DOC) by 9 a.m. on Monday, July 11, 2011.

–  The Texas Center for Nursing Workforce Studies invites providers to participate in the 2011 Home Health and Hospice Care Nurse Staffing Survey to assess the size and effects of the nursing shortage in licensed and certified home health and hospice agencies in Texas. Providers may access more information at the WS HHCNSS website: http://www.dshs.state.tx.us/chs/cnws/hhcnss.

Providers may begin the 2011 Home Health Care Nurse Staffing Survey at this link:  http://2011HHCNSS.questionpro.com.

See the news alert page for details about each update.

For details about each news alert, see the main link.

With the U.S. population growing grayer, job prospects for home health aides — and every worker providing health care to seniors, for that matter — are quite rosy. As the 78 million baby boomers live longer with more chronic illnesses, the country will face a shortage of professionals trained to meet the special needs of the elderly.

“Are we ready for the baby boomers growing older?” asks Iveris Martinez, a gerontologist and assistant professor at Florida International University’s medical school. “The consensus is no. We simply don’t have enough health professionals with specialty training in geriatrics.”

It’s not just the elderly who will be affected by this shortfall, however. Experts predict that fewer medical practices will accept new patients and people will face longer waits to see physicians — if they see them at all. Instead, more nurse practitioners and physician assistants will provide front-line care.

Geriatric physicians are in short supply, but that may change when the field of geriatrics grows as a result of the retirement boom.

The Dallas Morning News reports that budget writers are grappling with potential unintended consequences while figuring out which services to cut. For instance, cutting kidney dialysis treatment may cause an increase in hospital patients with severe renal disease. An excerpt:

Medicaid, a state-federal program, covers poor children, pregnant women, disabled adults and the elderly in nursing homes. Texas’ GOP leaders have proposed cuts of 29 percent, a much larger reduction than most programs would see as lawmakers try to write a balanced budget without raising taxes or exhausting their rainy-day money.

The program’s price tag grew rapidly in the current two-year cycle because Congress temporarily enhanced federal matching money to help recession-ravaged states cope with swelling rolls. But now, GOP leaders say, the beast must be tamed.
…
While a huge share of the cuts will come out of care providers’ fees, there are figures pulled out of the air for new efficiencies, savings generated by new outcomes-based payment models and cuts to the adult recipients’ so-called optional services. Details are to come later.

Lawmakers face a dilemma. Cutting Medicaid services to save money may cause patients to delay treatment and, at the same time, cause physicians to stop taking Medicaid patients.

A related story on Politico suggests home care may lessen the sting of some service reductions. For patients in nursing facilities who don’t need round-the-clock care, home care is a less expensive option.

DBMD:

HHSC approved new payment rates for Employment Assistance and Supported Employment in the DBMD waiver program effective, February 1, 2011: Employment Assistance $33.44; Supported Employment $33.44. (Letter)

NF Administrators, Social Workers, and Rehabilitation Therapy staff:

DADS clarified the provision of specialized services to Medicaid-eligible nursing facility residents and Preadmission Screening and Resident Review (PASRR).  To be eligible for specialized services, a Medicaid recipient must: be Medicaid eligible for NF care; reside in a Medicaid-certified NF; and have an approved PASRR. (Letter)

Home Health Agencies Seeking Medicare Certification:

DADS seeks clarification from these providers on three questions previously published in PL #07-17. (Letter)

Hospice Agencies Seeking Medicare Certification:

DADS seeks clarification from these providers on three questions previously published in PL #07-17. (Letter)

CBA, CWP, and MDCP providers:

HHSC approved new payments for these providers, effective February 1, 2011. See the new rates at the HHSC Payment Rates site. (Letter)

HCS and TxHmL:

HHSC approved new per diem payment rates HCS and TxHmL providers, effective February 1, 2011. Click on the links to access the rates, and download the letter here.

Local MR authorities, TxHmL, and CDS agencies:

DADS implement new cost ceilings for TxHmL, effective September 1, 2010 (letter):

TxHmL, HCS, MR authorities, and CDSAs:

DADS will no longer notify the provider, MRA, or CDSA of the approval or denial of an individual’s enrollment, transfer, or termination of services by mail, fax, or e-mail. Notification will continue to be mailed to the individual’s address listed in the CARE system. (Letter)

CDSAs:

DADS issued this letter to provide guidance for revising CDS employer budgets related to rate reductions in several programs. An excerpt:

Service Plan Changes

For service plan changes for CBA and CWP out-of-home respite, DADS case managers will be requesting from the CDSAs, in writing, the total amount of funds and number of units of out-of-home respite used from the beginning of the individual service plan period through January 31, 2011. Case managers will use this information to update the service plan and Service Authorization System (SAS) Service Plan and Service Authorization records.

For HCS and TxHml, CDS service authorizations have been automatically converted to the new rates by the CARE system. Therefore, CDSAs do not need a new service authorization from the HCS or TxHmL service coordinators before adjusting the CDS budget workbook.

CDS Employer Budget Workbooks Adjustments

The CDS employer will not be required to complete a new budget workbook to adjust for the February 1, 2011 rate decrease. The employer or CDSA may write in the authorized changes on the current budget workbook. On page 2 of the budget workbook, mark through the old rate and write in the new rate and the re-calculated amount remaining for that service in the current year budget. Both the employer and the CDSA representative must sign a new approval page (page 1) and write “rate decrease” on the new approval page. If there is a decrease in an employee’s hourly pay or benefits, the CDS employer must complete a new Form 1730, Wage and Benefits Plan.

Program for the All-Inclusive Care for the Elderly providers:

DADS informed the PACE organizations of procedural changes for processing enrollments, disenrollments and any changes in a participant’s Medicaid/Medicare status. Effective February 1, 2011, the DADS Community Services regional staff will begin entering data into the Service Authorization System for PACE participants. (Letter)

Program of All-Inclusive Care for the Elderly Organizations:

DADS informed these organizations about a recent change in the LTC Online Portal. DADS implemented version 3.0 in October, and this version includes an edit that won’t allow the MN/LOC assessment to be completely entered into the LTC Online Portal if the physician answers N (no) to question S7a, which must be answered for the initial enrollment only:

“Did an MD/DO certify that this individual requires nursing facility services or alternative community based services under the supervision of an MD/DO? ”

Download the letter for more information.

NF contractors:

DADS provided guidance for NFs related to routine handling of funds associated with Incurred Medical Expenses. (Letter)

1.  Last month, DADS announced to external stakeholders that the HCS Billing Guides would be opened for review and suggestion. Because of difficulty in accessing the document for revision, the Billing and Payment department has produced a Microsoft Word version of the current June 1, 2010, guidelines for editing. DADS asks stakeholders to submit requests no later than January 3, 2011. See the news alert section for contact information.

2.  DADS issued a correction for HCS providers and MR authorities. An excerpt:

Error Correcting an IPC

If a Service Coordinator (SC) returns an IPC to the provider for any reason, the IPC will remain in “Returned to Provider” status until the provider takes some action in CARE to send the IPC back to the SC for review. An IPC is not available for billing while in “Returned to Provider” status.

An IPC may be returned to a provider by the SC if the SC:

• did not receive a hard copy of the IPC within the required time frame,
• was not notified or did not participate in the IPC meeting on or before the IPC effective date, or
• determines the units of service on the hard copy of the IPC do not match the units of service in CARE.

3.  DADS announced a tentative award to Sandata Technologies to pilot use of an electronic visit verification system for documenting certain services in DADS Region 9, and the pilot will impact  personal assistance services and in-home respite in the CBA program, residential habilitation and in-home respite in the CLASS program, in-home respite and adjunct services in the MDCP, the PHC program, and CAS. See the news alert section for details.