The 114th U.S. Congress has considered legislation on improving access to Adult Day Services more than any other Congress. LeadingAge is proud of their member's advocacy work on adult day services, as well as the increasing important role of adult day services for the care of older adults and persons with disabilities. Members of Congress are seeing for themselves when they visit an adult day program and hear the stories of the participants and their caregivers. 

The list of legislation that improve access to adult day services:

 

  • Representative Lee Zeldin introduced H.R. 2460, which would ensure that 70% or more service connected disabled veterans are able to receive Adult Day Health Care at no cost to the veteran and their family by defining the program as a reimbursable treatment option through the VA. This would expand this great option of care for our veterans.This bill has strong bipartisan support in Congress, with over 45 cosponsors.  The text of the bill states that "the Secretary shall enter into an agreement under section 1720(c)(1) of this title or a contract with each State home for payment by the Secretary for adult day health care provided to a veteran who is eligible for, but does not receive, nursing home care pursuant to subsection (a).

 

  • Adult Day Achievement Act  HR263 The bill would provide grants to adult day programs providing life enhancing services like rehabilitation therapy and social supports to people with neurological conditions or diseases including MS. Adult day programs also help families by offering caregivers respite from caregiving duties. 

 

 

  • Medicare Adult Day Services Act HR 1383 introduced by Rep Linda Sanchez[CA-38]The bill has 15 cosponsors. The legislation amends title XVIII (Medicare) of the Social Security Act to: (1) cover certified adult day services furnished in a certified adult day services center 

 

 

  • H.R.4212  Community-Based Independence for Seniors Act of 2015 introduced by Rep Linda Sanchez[CA-38] (introduced 12/10/2015)      The bipartisan bill has 12 Cosponsors Related Bills: H.R.2704 / S704

 

 

  • LeadingAge is pleased that on February 25, 2016, the House Veterans Affairs Full Committee voted and approved H.R.4591 -- Department of Veterans Affairs Purchased Health Care Streamlining and Modernization Act to go to the full House of Representatives for a vote. The bill creates Veterans Care Agreements for small providers (gross annual revenue of the provider in the year preceding the year in which the provider enters into the Veterans Care Agreement does not exceed $11 million cap, with the exception of a $27 million cap for skilled nursing facilities, as amended), such as physician practices, adult day centers, small skilled nursing homes, and home health providers that would reduce the onerous requirements in Veterans Administration contracts that tend to discourage contractors from contracting with the VA. There is a similar Senate bill (S2000) that creates provider agreements that only covers extended care providers, the House bill covers physician practices. The bill did not include a cap that limited the use of provider agreements to small providers. 

 

 

  • Sen. Jon Tester D-MT introduced S.2633, a bill to improve the ability of the Secretary of Veterans Affairs to provide health care to veterans through non-Department health care providers, and for other purposes. The bill was referred to the Committee on Veterans' Affairs. Sec. 1703B of the legislation establishes Veterans Care Agreements. These Agreements to furnish care would be enacted if it is not feasible to furnish hospital care, medical services, or extended care at facilities of the Department of veterans Affairs or under contracts. The VA may furnish such care and services by entering into agreements under this section with eligible providers that are certified under subsection( c )

 

 

CMS Released a new Home and Community-Based Services (HCBS) toolkit to help providers and states improve Medicaid Integrity. The new HCBS toolkit on the Medicaid Program Integrity Education (MPIE) website helps promote better HCBS billing practices. 

This new toolkit:

  • Reviews HCBS service areas while addressing common errors and improper payments.
  • Gives providers information on how to create, review, and update person-centered plans for HCBS as well as addressing common errors and improper payments.
  • Provides an overview of the self-directed care option including ideas to avoid common errors and improper payments.

 

Provide any suggestions, ideas, or feedback on how you are using the toolkit materials and the outcome.

Remember, education is the key to program integrity!

The Toolkit includes the Understanding Your Role as a Provider newsletter, which provides information about Medicaid home health services, waiver programs, centered plans of care, and durable medical equipment.

There are 3 toolkits contained within this HCBS toolkit:

 

  • Toolkit 1 provides a general overview of home and community-based services and additional information about common errors and improper payments in durable medical equipment, habilitation waivers, and personal care services.  
  • Toolkit 2 provides an overview and additional resources that focus on person-centered care plans as it pertains to common errors and improper payments.
  • Toolkit 3 contains information regarding common errors and improper payments in self-directed home and community-based care.

 

 

CAST Patron Selfhelp Community Services is working hard to reduce isolation among older New Yorkers who rarely or never leave their homes and who are likely to be depressed and have serious chronic conditions.

Home Health Care News describes Selfhelp’s Virtual Senior Center as its “most innovative approach to helping homebound seniors.” The program offers live, interactive classes, and exchanges for older adults in New York City, Chicago, Baltimore, and San Diego. Homebound participants interact with the outside world using 22-inch touchscreen all-in-one computers loaded with an easy-to-use interface and group video chat. 

“We bring the activities of senior centers … to seniors who are isolated and living at home,” says CAST Commissioner Stuart Kaplan, chief executive officer of Selfhelp. “One of the benefits that we have found is that once somebody starts using the center, they form their own chatrooms and start social interactions outside the classroom, which further combats isolation. The majority of seniors who are participating are now talking to each other and using other adaptations.”

Currently, over 250 participants use the Virtual Senior Center. Selfhelp has found that engaging with the program provides many benefits for participants:

  • 97% of participants said the Virtual Senior Center improved their quality of life. 
  • 51% of participants reported that engagement with the program improved their health status. 

The Virtual Senior Center is only one illustration of Selfhelp’s shift to providing services wherever an older adult lives. Kaplan describes Selfhelp’s approach as “blended care” that integrates housing and health care. 

“We espouse that we are living at the intersection of social housing, affordable housing, and health care,” says Kaplan. “Technology is one aspect that fits within the blended services and ultimately should fit into a payment system of bundled payments.”

President Obama signed the PACE Innovation Act (PIA) into law on Nov. 5, 2015. The new law will allow the Centers for Medicare & Medicaid Services (CMS) to develop pilot projects based on the successful PACE Model of Care. On Oct. 21, the PACE Innovation Act of 2015 (S. 1362) was approved by the U.S. House of Representatives.

The PACE Innovation Act of 2015 (S. 1362) was introduced in the U.S. Senate by Sen. Tom Carper (D-DE) and Sen. Patrick Toomey (R-PA), passed with bipartisan support. 

The PACE Innovation Act would allow CMS to develop pilot programs designed to bring the PACE model to more populations -- including younger individuals, people with multiple chronic conditions and disabilities, seniors who do not yet meet the nursing home level of care standard, and others.

Currently, the PACE model is limited to those aged 55 and older who meet state-specified criteria for needing a nursing home level of care. Today, there are 114 Programs of All-Inclusive Care for the Elderly (PACE) in 32 states.

LeadingAge praises Reps. Chris Smith (R-NJ) and Earl Blumenauer (D-OR) and Sens. Tom Carper (D-DE) and Pat Toomey (R-PA) for their leadership in moving forward this important legislation.

S. 1362 is the companion bill to the Smith-Blumenauer PACE Innovation Act of 2015 (H.R. 3243), which was introduced on July 29 by Rep. Christopher Smith (R-NJ), Rep. Earl Blumenauer (D-OR), Rep. Kevin Brady (R-TX), and Rep. Jim McDermott (D-WA). 

The U.S. Department of Health and Human Services (HHS) awarded a 5 year, $12 million cooperative agreement to expand supportive services to Holocaust survivors in the United States to the Jewish Federations of North America (JFNA). 

About 130,000 Holocaust victims reside in the United States, and about 25% are impoverished. 

Securing basic amenities, such as affordable housing, long term services and supports, and nutritious meals can be a serious concern for thousands of frail Holocaust survivors.  

As time passes, the consequences of advanced aging are compounded by the physical and emotional horrors they endured during the war. 

The number of Holocaust survivors turning to community agencies has intensified. Agencies project that the number of requests for help, as well as the intensity of services required, will hold steady through 2020 and remain significant until 2025. 

The goal of this program is to achieve measurable outcomes in advancing innovations in the delivery of person-centered trauma-informed supportive services and improving the nation's overall capacity to provide services in this way. 

We are pleased that Kathy Greenlee, assistant secretary for aging, the U.S. Senate and House Appropriations Leadership, and the bipartisan leaders in the Congress, especially Sen. Ben Cardin (D-MD), Sen. Mark Kirk (R-IL), Rep. Debbie Wasserman Schultz (D-FL) and Rep. Ileana Ros-Lehtinen (R-FL), have all made a commitment to help Holocaust survivors through the federal funding of this project. 

LeadingAge looks forward to work with the Jewish Federations of North America (JFNA) and their other partners, such as Selfhelp Community Services on the implementation of this important program. 

The Long-Term Care Statistics Branch at the National Center for Health Statistics (NCHS) disseminated information from the 2014 National Study of Long-Term Care Providers survey in their publication, QuickStats: Percentage of Adult Day Services Center Participants, by Selected Diagnoses -- National Study of Long-Term Care Providers, United States, 2014. 

Their findings helps us better understand the medical needs of the individuals served in adult day services centers.

Diseases in Adult Day Services

Of the 6 diagnoses tracked in the 2014 survey for Adult Day Services, participants had the following diseases: 

  1. 44% had cardiovascular disease. This was the most common diagnosis among adult day services center participants
  2. About 30% of adult day services center participants had a diagnosis of Alzheimer's disease or other types of dementia
  3. 30% had diabetes
  4. approximately 25% had an intellectual or developmental disability
  5. 25% had depression 
  6. 10% had severe mental illness. This was the least common diagnosis 

This information reinforces the importance of adult day services, as a means to care for individuals in the community who are high risk of needing more costly institutionalization.

LeadingAge submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the fiscal year (FY) 2016 Medicare Hospice Proposed rule (CMS-1629-P) to address the following sections of the rule:

 

  • Proposed Routine Home Care Rates and Service Intensity Add-On Payment.
  • Proposed FY 2016 Hospice Wage Index and Rate Update Transition Period.
  • HQRP Reconsideration and Appeals Procedures for the FY 2016 Payment Determination and Subsequent Years.
  • Clarification Regarding Diagnosis Reporting on Hospice Claims

 

Proposed Routine Home Care Rates and Service Intensity Add-On Payment 

LeadingAge recommends that CMS: 

 

  • Develop a reimbursement methodology that reflects the actual costs of caring for individuals with different diagnosis related to the terminal illness as well as individuals that receive higher cost treatments. 

  • Allow sufficient time for Hospice providers, CMS and the Medicare Administrative Contractors to prepare and test the new payment system to assure the required infrastructure and information systems are in place to effectively and efficiently implement the proposed Routine Home Care Rates and Service Intensity Add-On Payments. 

  • Clarify how hospice days will be counted for beneficiaries in existing hospice episodes that continue thru October 1, 2015, and beyond.

  • Annually propose additional refinements to the Routine Home Care Rates and Service Intensity Add-On Payments that may be needed based on new data collected. Stakeholders should be given the opportunity to submit comments on these proposed payment changes through the rulemaking process. 

  • Give Hospices the opportunity to provide additional RN and SW services approved by the patient’s physician to provide more than 4 hours of RN/SW time, and receive payment for these additional service hours.

  • Develop criteria that would warrant payment for additional hours per day. 

  • Allow RNs and SWs be paid for telephone communication with the hospice beneficiary as part of the Service Intensity Add-on. 

  • Increase their oversight of hospice providers not providing the services required under the Hospice Conditions of Participation, and are exhibiting inappropriate practices highlighted by the Office of Inspector General and the Medicare Payment Advisory Commission. 

  • Include the Service Intensity Add-On payment for a hospice provider’s care of patients residing in SNF/NFs.

  • Give stakeholders adequate time to assess and comment on any changes to the SIA payments.

 

Proposed FY 2016 Hospice Wage Index and Rate Update Transition Period 

LeadingAge recommends that CMS: 

 

  • Support a change in statute to address the additional labor costs for hospice providers that occur in rural and frontier areas, similar to the rural add on given to home health providers.

  • Analyze the impact of the change in wage index area delineation especially on labor costs for hospices in rural and frontier areas.

 

HQRP Reconsideration and Appeals Procedures for the FY 2016 Payment Determination and Subsequent Years

LeadingAge recommends that CMS: 

 

  • Clarify what information would be included on the HQRP website, and at what point in the process could the hospice correct erroneous information related to hospice compliance reports. 

 

Clarification Regarding Diagnosis Reporting on Hospice Claims 

 

LeadingAge recommends that CMS: 

 

  • Complete a Regulatory Impact Analysis of the financial impact of requiring hospices to have their coders include codes unrelated to the terminal illness on the hospice claims. Stakeholders should be given the opportunity to submit comments on the Regulatory Impact Analysis of the financial impact of requiring hospices to have their coders include codes unrelated to the terminal illness on the hospice claims.

  • Provide more details on the process of how the hospice will differentiate the diagnosis related to terminal illness from the diagnosis not related to the terminal illness.

  • Work with stakeholders to determine what constitutes "terminal illness" and "related conditions."

  • Increase oversight of hospices using fraudulent and unethical coding practices, and hold them accountable.

 

LeadingAge appreciates all of the hospice members that joined us on conference calls to share their expertise on the ramifications of the proposed rule and helped us develop our comments to CMS. 

Earlier this year the Centers for Medicare and Medicaid Services (CMS) provided an opportunity for physicians and health systems to get a glimpse of the future of health care reimbursement, and essentially “test drive” it before it becomes a reality. 

They did this by creating a current procedural terminology (CPT) code for chronic care management (CCM) services that will provide physicians with additional reimbursement if they meet certain requirements. 

In CliftonLarsonAllen’s view, the concept of this CPT code is directly in line with the desired evolution of health care to manage the health of a population of people.

Reimbursing for care management

CMS has long recognized that care management is a critical component to primary care services that, when delivered effectively, will lead to improved health and reduced spending for Medicare beneficiaries. Until January 1, 2015, however, the reimbursement system did not effectively reimburse physicians for care management services that took place outside of a traditional face-to-face visit. 

Physicians and other practitioners are now eligible to be reimbursed for non-face-to-face care coordination activities by using CPT code 99490 when they meet specific eligibility criteria. The total reimbursement for these care coordination activities would amount to about $43 per eligible beneficiary per month. 

While this may not sound significant on the surface, it can add up. At the same time, the motivation for the reimbursement -- rewarding effective care management -- can lead to improved patient outcomes and experiences.

Qualifying for reimbursement

In order to qualify for the additional reimbursement, physicians and the Medicare beneficiary receiving the service must meet specific criteria. A high level overview of those requirements is as follows:

  1. At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional must be spent on care management per calendar month.
  2. The beneficiary must have two or more chronic conditions that are expected to last at least 12 months or until the death of the patient.
  3. The chronic conditions put the patient at significant risk of death, acute exacerbation or decomposition, or functional decline.
  4. A comprehensive care plan must be established for the patient, and this plan must be implemented, monitored, and revised as necessary.
  5. The patient must have access to the physician or other qualified member of the health team 24 hours per day, 7 days per week.
  6. The patient must be informed that CCM services will be provided, and sign a consent form to authorize sharing of medical information with other providers.

CMS has provided an example of the types of chronic conditions that could potentially allow the use of CPT code 99490. They include:

  • Alzheimer’s disease and related dementia.
  • Arthritis.
  • Asthma.
  • Cancer.
  • Diabetes.
  • Depression.
  • Hypertension.
  • Chronic obstructive pulmonary disease.

Who is eligible to bill for services?

To support the implementation of care coordination activities, CMS provided exceptions to Medicare’s “incident to” rules that allows certain clinical staff to provide CCM services under the general supervision -- rather than direct supervision -- of the billing physician. 

According to CMS, physicians and the following practitioners are eligible to bill for CCM services:

  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified nurse midwives

Business case considerations

In any transformation it is important to understand not only the clinical requirements and benefits, but also the impact on the organization from a reimbursement and financial perspective.

To evaluate the business case for considering CCM services, we completed an analysis that assumes a patient panel size of 2,000 patients. Of that total patient population, we assumed 35% were Medicare beneficiaries, and that 33% of those Medicare beneficiaries would be eligible for CCM services due to multiple chronic conditions and meeting the CMS criteria. 

Based on these assumptions, about 231 patients would be eligible to receive CCM services, for which the practitioner delivering those services would receive reimbursement of just over $118,000 on an annual basis.

The team assembled to provide CCM services would have to spend a minimum of 20 minutes per month for each patient, or just under 80 hours per month on the 231 patients.

What should you do?

CCM services represent a real opportunity for those willing to embrace the health care transition taking place. While there are many details to understand and processes to implement, one thing is for sure -- CMS has created an opportunity for practitioners to be reimbursed for non-face-to-face care coordination services.

So what must be done in order to capitalize on these opportunities? Using our illustration above, it would be impossible to expect physicians to dedicate 80 hours per month to direct care coordination activities. Transitioning to the CCM model of care will require rethinking how care is delivered and moving away from physician-led care to physician-led care teams.

CLA has extensive experience in analyzing the reimbursement implications associated with CCM services and physician-led clinical care teams. We have the operational expertise to guide your organization through assessment to implementation. If you want to learn more and are ready to take the next steps, CLA can help your organization make this important transformation.

Read more.

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