2018 Brings Major Changes to HCBS for Veterans

Members | January 02, 2018 | by Peter Notarstefano

In 2018, the Veterans Health Administration plans on redrawing how they administer the referral and payment for long term services and supports.

Even though we have seen a positive move towards the use of community home health services by the Veteran’s Health Administration, there has been challenges in ordering and paying for adult day services, non-emergency transportation and hospice through the VA CHOICES program and the VA Extended Care budget. Also, the inconsistency in policy concerning utilization and payment of adult day services, and non-emergency transportation has also been a barrier for Veterans to obtain needed services.

For Adult Day Care, VA reimbursement rates are determined in 1 of 2 ways:

  1. Negotiated in an informal agreement
  2. Follow the rule for non-Medicare services in 38 CFR 17.56. §17.56

In the absence of a Medicare rate or Medicare waiver, payment will be the VA Fee Schedule amount for the period in which the service was provided. The VA Fee Schedule amount is determined by the authorizing VA medical facility, which ranks all billings (if the facility has had at least eight billings) from non-VA facilities under the corresponding procedure code during the previous fiscal year, with billings ranked from the highest to the lowest. The VA Fee Schedule amount is the charge falling at the 75th percentile. If the authorizing facility has not had at least eight such billings, then this paragraph does not apply.

The negotiated rate or contracted rates for adult day services results in different rates in different parts of the country. Rates for a full day range from $62.45 to $81.50, and higher payments do not correlate with the amount or quality of services provided. Some VA Medical Centers have discontinued paying for transportation to and from Adult Day Services. Many times the VA rate is the same as the Medicaid waiver rate. Some VA Medical Centers have limited adult day services to 2 days a week or limited the number of agreements with adult day providers to one provider per service area.

The good news is that the House Committee on Veterans’ Affairs passed the H.R. 4242: The VA Care in the Community Act, legislation to streamline VA’s community care accounts into one veteran-centric program that replaces the Choice Program, removing the current 30-day, 40-mile requirement to give veterans more timely access to community care. The VA Care in the Community Act would consolidate VA’s existing community care programs into one cohesive program and would modernize VA’s medical claims processing system to ensure that community providers can expect to be paid on time for the care they provide to veterans on VA’s behalf. It would further require VA to conduct periodic local capacity and market assessments to identify how gaps in care can be addressed through improvements to both internal and external capacity, standardize the rates VA pays to community providers and authorize VA to enter into provider agreements for needed care when contracts are not available or achievable. The Senate Committee has also moved legislation to reform VA’s community care programs.

Major Changes in 2018

In 2018, the Veterans Health Administration plans on redrawing how they administer the referral and payment for long-term services and supports. Instead of VA Medical Centers aligned by VA Service Networks, there will be a move to a Community Care Network that will consist of four area contracting regions. Health plans would be assigned by the Veterans Health Administration to establish networks of providers including Adult Day Centers, Home Care Agencies, Home Health agencies and Hospices. The Veterans Community Care Network Health plans would negotiate rates with providers.

The specific requirements for VA Provider agreements will depend on what legislation passes Congress and is signed by the President this year. Please share with me (pnotarstefano@LeadingAge.org) any opportunities and challenges that you are facing in providing home and community-based services for veterans. LeadingAge is working closely with the Veterans Health Administration on this issue.