Four Ethos-Supported Amendments to S. 2202
TOP PRIORITY: Amendment #23 Senator L’Italien/ Regarding Transfers Of Home Care Funding
Background: This amendment strikes section 132 in its entirety, because it is punitive to elders, creates major instability in the home care program, and will trigger statewide waiting lists.. The SWMs language proposed in section 132 makes a few technical edits to the original section 130 in S 2190, but this section is still unworkable and breaks continuity of care for thousands of elders who are “aging in place” and are not asking for a change.
This section allows EHS to forcibly disenroll as many as 9,900 elderly MassHealth members who are being managed in the capitated state home care program. It instead forcibly enrolls them in a Senior Care Options (SCO) plan they did not choose or request. It also requires EOEA to transfer funds from the home care purchased services account (9110-1630) to the SCO program.
This would suddenly disinvest roughly $37 million in home care service dollars, leaving the home care program unable to serve new applicants. SWMs adds new language saying that funds would not be transferred if it results in a home care waiting list—but it is not clear when and how such funds would be transferred, which would affect when a waiting list would be declared. It is not clear why lawmakers would want to put the home care program at risk of a waiting list—which a transfer of this size would clearly trigger.
The SWMs language allows funds to transfer in the reverse: from SCOs back to home care but this is a symbolic gesture, since the passive enrollment is going from home care to SCOs. Even if 33% of those forced to enroll in SCOs chose to return to home care, there would still be a loss to home care of roughly $24.3 million. This section turns the home care program into a funding silo only for people above MassHealth income eligibility levels, which encourages care fragmented by funding source. This section says some elders would not be passively enrolled into SCO based on undefined “level of acuity or continuity of care.” Any elder who is nursing facility level of care already attracts federal match, so moving them from a home care per member per month capitated program to a SCO managed care program generates no new federal match. It is not clear if this transfer includes elders in the Frail Elder Waiver (FEW).
Every elder in the home care program has chosen to be in the home care program. They should not be forced to leave the home care program. This rob-Peter-to-pay-Paul transfer will irreparably harm the home care program which has been in existence since 1973. When elders transfer to SCOs, SCOs are immediately paid a monthly capitation; they do not need to be further compensated. The home care program would never build back its caseload to pre-transfer levels—because no more Medicaid members would be enrolled in home care, year after year.
This wholesale transfer of members could increase costs to the Commonwealth, because of the cost structure of the SCO program. Home care transfers are unlikely to be coded by SCOs as members who are “well,” and the cost per client in a SCO plan is likely to increase beyond the cost of Basic home care services, which is currently only $3,729 a year.
Section 132 is unworkable, will cause waiting lists that the General Court has worked hard to avoid, and pushes thousands of frail older people into plans they did not choose. The SCO program already has a ‘critical mass’ that generates significant profits for the SCOs.
Amendment # 24 Senator L’Italien/ Regarding Financial Eligibility for Medicaid
Background: This amendment makes changes to Section 130 in three ways.
The first way is to seek a federal waiver to allow people on Medicare (who will also be on MassHealth) to be forcibly enrolled (ie, “passively enrolled”) in the Senior Care Options (SCO) program. We support the current federal protection in Medicare which guarantees a Medicare beneficiary has access to traditional Medicare if, for any reason, they do not wish to be in a managed care plan. People who are enrolled in Medicare Advantage plans cannot be passively enrolled. SCOs are Medicare Advantage Part C plans, so they cannot passively enroll members. Based on the state’s experience in the One Care program, large passive enrollment campaigns result in very significant “opt outs” by enrollees. Seniors will do better in SCO plan if they voluntarily choose it.
Choice: The federal government has given Medicare beneficiaries important rights regarding their ability to choose how they receive their Medicare benefits The Senate report on healthcare emphasizes the importance of protecting consumer rights. Senate legislation should not undercut these Medicare protections.
Parity: No other Medicare beneficiaries or LTSS users are being asked to give up their right to choose whether or not to participate in a managed-care arrangement. Seniors should not be singled out in this way. The same freedom on choice considerations should apply to seniors as those that apply to younger people with disabilities.
Success of SCO: The success of the senior care options program is based on a number of factors. A great deal of its success is predicated on the enrollment process. SCO plans meet with each prospective member to inform them about the plan and talk to them about its benefits. Since no one can be enrolled unless they sign an enrollment form, seniors who enroll in SCO are more involved in their care, and participate with their health care providers in the development and implementation of their personalized plan of care. The experience with One Care is instructive here. We believe that large scale passive enrollments of people into managed care plans can be counter-productive for the members and the plans. We should support and extend the success of SCO by conducting more vigorous outreach and voluntary enrollment. We support significant growth and expansion of SCO. The question is how that gets accomplished, and how fast.
MassHealth has invested a lot of money in the new Third Party Administrator, which is intended to address cost, program integrity, and to generate the kind of LTSS utilization data that is critical to appropriate management and oversight of these programs. One consideration that is critical to the success of managed care is the question of the right capitation for LTSS.. Again, we should learn from the One Care experience. In SCO, some high cost users of LTSS self-select out of SCO. The current MassHealth SCO capitation is completely insufficient to pay for the care of this group. That must be addressed as part of SCO expansion, but we need to give the TPA an opportunity to begin reporting. We believe that the TPA will find that seniors in the Home Care Program overall have more appropriate utilization of state plan LTSS by virtue of having an ASAP care manager to assist them, even though ASAPS do not have access to authorization information about Home Care Program consumers for many LTSS services.
SCOs have worked with voluntarily enrollment (as the SCO law requires) because motivated members follow health protocols (like screenings and flu shots). With voluntary enrollment, the SCO plan has time upfront to conduct a major assessment at enrollment. Passively enrolled members are often hard to locate and serve. Thirdly, many of the people who do not voluntarily join a plan do not follow medical advice. These members can impact the SCO plan’s Medicare Star ratings on quality measures. An analysis should be done on the cost implications of Medicaid assuming the health care costs of these Medicare patients. For these reasons, we recommend that the first sentence of this section be deleted. We should continue the voluntary enrollment mode for SCOs, and continue to do outreach and education for seniors about the advantages of the SCO program.
The second change in this section allows a Medicare beneficiary who does not have roughly $28,000 to pay for 135 days in a nursing facility to be prospectively enrolled in the SCO plan. We support the idea of giving such individuals advance access to integrated care and keeping them from spending down and needing institutional care. This is essentially what the home care program has done over the years: it works with some elders who are not yet financially eligible for home care, and who never need to go onto MassHealth because the home care program addresses their LTSS needs.
The third part of this section allows the state to claim federal matching funds for the same kind if Medicare status—but it says nothing about such people being able to enroll in the home care program. The proposed amendment allows such Medicare members to choose between a SCO and the state home care program. Currently the language in section (i) and (ii) are not the same: section (i) allows prospective enrollment in a SCO plan, section (ii) only allows the state to claim FFP for an enrollee in home care. We want both these clauses to be merged into one, so that a Medicare beneficiary can go into either a SCO or home care program. and federal reimbursement will be available regardless of which plan the consumer chooses.
Amendment #9 Senator Cyr: Regarding Coordinated Care Protocols in Public Housing
Background: There are a number of LTSS care coordination mechanisms currently in place to provide coordination of care for people who reside in public housing—and they are similar to the care coordination that would happen in a person’s home. Care coordination services should be available to consumers regardless of their address. Section 133 confuses the role of a health plan gatekeeper with that of a housing landlord. Housing entities do not have the expertise or function to be “passively enrolling” people into health plans based on their address. The SCO plan should be an informed choice the consumer makes based on their best interests, not part of their housing decision. If they enroll in a SCO or other managed care plan, their care will be coordinated, regardless of their address. This section creates an overlay for care coordination protocols that is redundant. Programs like SCO, One Care, ACOs, and state home care all have existing mechanism for care coordination. It is already possible for specific public housing sites to be a “clustered care” site for home care services. Coordinated care teams do not need to be residence-based. Thousands of seniors today are being care managed in the community in their private homes, and in public housing units. This pilot project does not address an unmet need or service gap. Housing authorities should not be in the business of passively enrolling their tenants into health and LTSS plan. Residents in a housing authority should not have their choice of health plans narrowed by having to accept the managed care plan preferred by their landlord.
This amendment offers language that requires coordination of care protocols to be developed at public housing sites. ASAPs today can work with local housing authorities to create such protocols and memorandums of agreement. The language that allows housing authorities to make health care plan decisions for their tenants has been deleted. Consumers should have free choice of any SCO or other health plans that serve their communities, not just the two plans chosen by their landlord.
Amendment # 13 Senator Jehlen: Improving Access to Home and Community-Based Counseling
BACKGROUND: In its 2013 Cost Trends Report, the Health Policy Commission found that “For post-acute care, Massachusetts has a higher rate of discharge from hospitals to nursing facilities relative to the national average, suggesting an opportunity to manage post-acute care more efficiently. For LTSS, there are opportunities to deliver more supports in home- and community-based settings, expanding options for patients to receive care in their preferred setting while potentially achieving savings over time…This continued transition is especially important for MassHealth, which is the predominant payer for LTSS in Massachusetts.” A 2017 LTSS state scorecard published by AARP concluded that the top-ranked state in the nation had 4.1% of its nursing facility residents as “low care” needs. In Massachusetts 11% of people in nursing facilities have low care needs. Massachusetts ranks 23rd in the nation in this measure.
This amendment creates a “community rule out” provision in Medicaid statute. Medicaid would not pay for a nursing facility bed unless the patient had been offered a community options counseling, or had waived their right to have one. Despite the fact that since 2006 Massachusetts has had a requirement that consumes like to need nursing facility care should be offered a free, pre-admission counseling session, most hospitals and discharge planners are unaware of the provisions of Ch. 118E, s. 9. Other states, like Oregon and New Jersey, have enforced this pre-screening counseling by making it a required part of the discharge process. In New Jersey’s law, which has been in place since 1988, all persons who will become eligible for Medicaid within six months following NH admission must be assessed or Medicaid will not pay. It provides the legal framework for the state to claim a federal match for the salaries of staff performing PAS for almost all people entering a NH for a projected long stay. 80% of Hospital PAS assessments done within 24 hours. Rest are done within 72 hours (the policy). A study of the New Jersey law by Rutgers in 2006 found a high satisfaction with their return to the community. Most patients returned home, and most were alive and remained in the community for the full year studied.