ARRM's Daily Dispatch

Competitive Workforce Factor: Where Are We Now?

UPDATE: Published December 18, 2019

CMS Approves the Competitive Workforce Factor

In an announcement today, the Minnesota Department of Human Services informed all counties and providers it has received approval from the federal Centers for Medicare and Medicaid Services to apply the 4.7 percent Competitive Workforce Factor to Disability Waiver Rate System framework rates. Yay!

Providers and support teams can now move forward projecting the rates for service agreements renewing on or after Jan. 1, 2020 with full confidence in how the the frameworks will be calculated.

As a reminder, the overall impact of this implementation is projected to be an average increase to DWRS rates of 4 percent, equivalent to more than $150 million dollars over the next four years. It is paramount to forecast the impact for your own organization by reviewing each agreement, as the Competitive Workforce Factor only applies to direct staffing costs. Find information and resources in the ARRM Training Archive.

The department is moving quickly to update the Rate Management System, which should take place this evening.

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Strong Minnesota representation at ANCOR DC Summit

By Sara Grafstrom, Director of State and Federal Policy

In mid-October, I, along with other ARRM members, had the opportunity to attend our national trade association ANCOR’s Public Policy Conference in Washington DC. Engaging on the Federal level is critical in the work that ARRM is doing to advance the priorities of our membership.

Along with a day full of important updates and information sharing between states, our Minnesota contingent was able to meet with all ten of the offices of our Congressional Delegation, share our priorities and let them know how they can be supporting Home and Community-Based Service providers back home.

ARRM and Minnesota provider representatives met with Sen. Tina Smith to discuss key issues.

Conference re-cap

The one-day conference session included speakers from CMS, Capitol Hill staffers and Medicaid experts, some of the timely information shared included:

• HCBS transition plans: CMS provided important updates, sharing that 18 states have had final approval of their plans with only 5 more states needing initial approval before all 50 states will have accomplished that milestone.

• Electronic Visit Verification (EVV): CMS also shared updates on the implementation EVV, letting attendees know that 20 states have submitted a good faith extension request with 12 being approved so far. They shared that they expect the majority of states to request an extension, but highlighted the fact that they have no authority to grant an extension beyond the one year. [Read the most recent news on Minnesota's EVV implementation on the members-only blog]

The keynote address featured Josh Trent from Leavitt Partners sharing what he considers to be the seven emerging trends in Medicaid, those include:

• Value-Based Payment trends continuing
• Increased Medicaid Coverage including states looking at Medicaid Expansion that had not participated in the past
• A lull in state innovation; many states looking at how to execute what is already in the pipeline
• External factors impacting Medicaid
  • Mergers and acquisitions
  • Health information technology
  • Increased scrutiny in private equity
• Focus on social determents of health
• Focus on high-cost populations
• Growth in MCO; both in growth and pressures put on them

There was also important information shared around the politics of getting things done in an election year and important strategies in engaging in the upcoming election. I will be taking this information back to ARRM to make sure that our strategies for 2020 are aligning in the most effective way forward.

Important issues to track

ANCOR is pursing three major pieces of legislation this coming year to provide support to Home and Community-Based Services. Those include;

• HCBS Workforce and Infrastructure Act: This grant program would allow states to choose three of the following areas to make improvements in: workforce stability, transportation, employment supports, no wrong door- single entry system and implementation of the HCBS Settings Rule. States would be required to solicit stakeholder input and submit plans to CMS with measurable objectives and annual milestones in the chosen areas. This legislation is focused on helping states update outdated HCBS systems and grow community services.

• SOCs for DSPs: States rely heavily on Standard Occupational Classification (SOC) data, including out state of Minnesota, when setting our rates through DWRS. Currently, there is no separate SOC for DSPs at the U.S. Bureau of Labor Statistics. This information is critical not only in rate setting, but in recognizing the DSP as a profession and helping collect accurate data on the workforce needs. While typically it falls to the Bureau of Labor Statistics (BLS) to establish to SOC, that only happens every ten years. This legislation will encourage the BLS to consider a SOC for DSPs.

• Hospital Coverage for DSPs: Currently, Medicaid does not allow state waiver programs to pay for DSP supports while the person they support is in the hospital. For individuals that rely on their staff for communication, or may be experiencing mental health or anxiety symptoms, having their trusted support staff by their side can be the difference in a prolonged hospital stay. Legislation will simply allow all waivers to permit states to reimburse for DSP coverage in hospitals. This legislation will have no additional federal cost.

You never know where you'll catch members of Congress!

Congressional meetings

I, along with 13 other ARRM member representatives, were able to divide and conquer and meet with the offices of all ten members of our Congressional Delegation, including meeting in person with Senator Tina Smith and Congressman Pete Stauber (08), along with running into Congresswoman Angie Craig (02) at the elevator!

Rep. Pete Stauber met with constituents from Congressional District 8.

We educated staffers about Home and Community-Based Services and what is happening in Minnesota, with specific focus on the workforce crisis, as well as provided information on how they can support us, both at the state level and with the policies that ANCOR is championing.

The meetings provided us a great opportunity to further strengthen our relationships with our federal legislators, as well as hear directly from their offices about their priorities and how we can be better resources.

 

Don't forget to register for the Fall Business & Finance Forum, November 13, where Sara will cover these federal issues in greater detail, along with the full Legislative Agenda and additional timely topics for Minnesota Home and Community-Based Service providers.

The Latest on Electronic Visit Verification in Minnesota

By Sue Schettle, ARRM CEO

ARRM staff members have been getting a few questions about Electronic Visit Verification (EVV) so we thought we’d provide an update on where things stand. 

First, mark your calendar for an upcoming “Dial-In with DHS” that will focus on all-things EVV. Natasha Merz from DHS will be our presenter. The ARRM members-only webinar will be held at 10:00 a.m. on Friday, October 11. Watch for the login information in our Weekly Briefs and newsletters.  The webinar will also be recorded so you can watch it at a later time.

What EVV collects

Going into planning for the implementation of EVV, it’s important to note the information sought by regulators so you can assess the effectiveness of any potential system.

What information must the EVV system collect?

• Type of service performed
• Who received the service
• Date of service
• Location of service delivery
• Who provided the service
• When the service begins and ends

Who will be required to implement EVV

Not all services are going to be required to use EVV. Providers should review the list of personal care services and home health services to understand whether their business is affected. I’ve listed the services below.

In Minnesota, the personal care services that will be required to use EVV are: 

• CDCS direct support
• Crisis respite (in-home)
• Extended personal care assistance
• Homemaker-assistance with personal cares
• Independent community living support (in-person)
• In-home family support
• Personal care assistance
• Personal support
• Respite care services (in-home)
• Individual home support (in-person)

In Minnesota, the home health services that will be required to use EVV are:

• Home health aide
• Skilled nurse visits
• In-home occupational therapy
• In-home physical therapy
• In-home respiratory therapy
• In-home speech and language therapy

Minnesota is not expanding the services that are required to use EVV from “personal care services” and “home health services,” however, there are a number of waiver services that meet the CMS definition of “personal care services” that are required to use EVV.

If DHS added additional services that are subject to EVV, DHS will communicate these changes via eList and website updates. 

Timing and status in Minnesota

The national EVV implementation date is January 1, 2020, but the Minnesota Department of Human Services (DHS) has reported to ARRM it will be asking for a “Good Faith Delay” which could delay implementation of EVV here for 6-12 months, if approved.

One of the reasons DHS is asking for the delay is that it has not yet set up the exact state requirements for EVV, nor selected the state-provided EVV system. The department has selected to utilize a hybrid EVV model, meaning providers may use either the state-provided EVV system, or an alternative system of their choosing that meets state requirements.  With the hybrid model, providers may select an EVV system that works best for their business but also maintains accountability to the state by submitting data to an aggregator.

Implementation

DHS expects to implement EVV after a state-selected verification system is made available to providers. The department states is will provide ample notice via email, provider communications and updates to the DHS EVV webpage, well before the deadline for providers to implement EVV (ARRM will also assist in sharing these notifications).  DHS will select an EVV vendor through a request for proposals, although has not yet published the RFP.

Additionally, new 2019 legislative changes supported by ARRM ensure that providers will be reimbursed the full rate for services even if Minnesota is subject to a federal financial penalty related to the timing of EVV implementation.

To ensure you receive important updates on implementation, please sign up for the eList service on the DHS webpage for EVV.

CMS Denies 7th Year of Rate Banding in MN

ARRM learned late last week that CMS has officially denied Minnesota’s legislative mandated request for a 7^th year of banding within the Disability Waiver Rate System.

With this announcement, banding will officially end at the close of 2019. Individuals who currently have banded rates will see banding come off their rate on a rolling basis through 2020 as their service authorizations are renewed.

Below, please find the official announcement from DHS. If you have any questions, please feel free to contact Sara Grafstrom at [email protected] or Ken Bence at [email protected].

With the end of banding confirmed, this raises the importance of completing the "pre-exception" rate exception process for individuals with banded rates (more from the latest Friday's With DHS webinar here) ARRM will send out more information to members outlining additional educational offerings and training throughout the year to continue to prepare members for the end of banding. 

Banding end-date decision by the Centers for Medicare & Medicaid Services

On Jan. 23, 2019, the federal Centers for Medicare & Medicaid Services (CMS) notified DHS it was unable to approve the waiver amendment to add a seventh year of banding in 2020.

Background

Implementation of the Disability Waiver Rate System included a rate-stabilization period, also referred to as “banding,” in which the amount rates could change were tied to historical rates for people and providers who had services in 2013.

The 2017 Minnesota Legislature approved a seventh year of banding (through Dec. 31, 2020) contingent on federal approval from CMS. DHS submitted a waiver amendment to update the rate stabilization (banding) schedule by adding an additional year of banding per the 2017 legislative requirements.

What does this mean?

For DWRS framework services with a start date of Jan. 1, 2020, or later, rates will not be banded to an individual or weighed average historic rate. All rates will be at the Rate Management System framework rate for the service. This change will occur on a rolling basis as service authorizations either renew or change.

How does this affect lead agencies and providers?

DHS will include the changes in the Rate Management System within the MnCHOICES Support Plan application. Also, as previously communicated by DHS, lead agencies, service providers, service recipients and DHS will begin to identify people with banded service rates who may receive rate exceptions. See guidance and additional information at https://mn.gov/dhs/partners-and-providers/news-initiatives-reports-workgroups/long-term-services-and-supports/disability-waiver-rates-system/

National EVV Stakeholder Call

The Centers for Medicare and Medicaid Services (CMS) is holding a national stakeholder call on Electronic Visit verification happening on November 7 (details below). CMS is required to hold this stakeholder discussion as part of the EVV delay bill advocated for by ANCOR in late July. CMS will share previously submitted feedback as well as take additional feedback as part of the call.

Also, note CMS has established a specific EVV email account dedicated to EVV input and questions, [email protected]. 

Electronic Visit Verification (EVV) Stakeholder Open Door Forum

November 7, 2018

1:00 pm -3:00 pm Eastern Time (12:00 - 2:00 pm Central Time)

Conference Call Only

Participant Dial-In Number: 1-(800)-837-1935

Conference ID: 33979177

Please see www.medicaid.gov/medicaid/hcbs/guidance/... for a number of resources, including the statutory language requiring EVV usage, and implementation materials issued by CMS to-date based on that statute. 

 *Please note – In an effort to reach as many stakeholders as possible, CMS will post a transcript and audio recording to the Podcast and Transcripts website at www.cms.gov/Outreach-and-Education/Outreach/... for downloading. There will also be two business days of the Encore presentation for those who were unable to join the call.

EVV Delayed At Federal Level

On Monday, President Trump signed a bill delaying the implementation of new Electronic Visit Verification requirements for the states by one year. The national association ANCOR worked to build a bi-partisan coalition of Senators and Representatives to draft and pass the legislation out of congress.

What does the EVV delay entail?

From the ANCOR statement announcing the signed bill:

"States now have until January 1, 2020, to begin compliance with the EVV law. States can also apply for a good-faith extension that would extend the deadline until January 1, 2021. In addition, the legislation signed into law this week mandates that input from the public is solicited to help ensure the thoughtful implementation of the EVV requirement."

What does this mean for Minnesota and ARRM Members?

While delayed, states are continuing to push forward with EVV implementation to avoid potential issues with falling out of compliance, although now have additional time to seek input from the public, and providers, care staff and importantly, people receiving services. The immediate reaction from the Minnesota Department of Human Services (DHS) is to take a step back and reassess its approach and timelines.

On the advocacy side, many organizations have been looking at legislation to give specific direction to DHS to ensure providers aren't harmed by the eventual implementation of EVV. This includes a bill introduced during the 2018 Legislative Session which defined what EVV is, what services it would apply to, and required the Commissioner to ensure that there is at least one system available for providers to use that would not be an additional cost to them.

As ARRM has previously reported, while the EVV requirement legislation was originally created specifically with addressing perceived issues in PCA and home health aid services in mind, the rumblings from federal and state regulators was that a form of requirements would likely be extended to most or all HCBS waiver services. 

Medical Marijuana: What you need to know

Recently an ARRM member raised a question regarding medical marijuana in an AFC/CRS program. This question has been raised in the past.  Although in this case the county involved felt the issue was only with dispensing the medical marijuana, the issue may include having the medical marijuana on site where federal funds are used to provide services.  Below is the information ARRM received most recently. The strongest piece of advice to ARRM members is to obtain legal advice when making decisions in this area.

Information from DHS Licensing

The Centers for Medicare and Medicaid Services (CMS) has said federal law prohibits federally certified providers from dispensing medical marijuana, because marijuana is classified as a Schedule One controlled substance and that classification renders the manufacture, distribution, or possession of marijuana a criminal offense. These providers may be at risk of federal action, such as losing federal reimbursement for allowing residents to use medical cannabis. The U.S. Department of Justice (DOJ) also issued a memo in August 2013 (the Cole memo) which states there is no guarantee, safe harbor, or immunity of any kind, and federal authorities have every authority to prosecute marijuana offenses. 

Whether federal authorities would actually pursue enforcement action against a provider when a state has authorized medical cannabis is unclear, so the actual risk to a provider is unclear. Regardless, in light of this position from CMS about federally certified providers, and the DOJ Cole memo, we believe the same analysis holds true for DHS-licensed providers receiving Medicaid waiver funds.

Seek legal advice

All DHS-licensed providers who receive Medicaid funding for services they provide are strongly encouraged to obtain legal advice about the impact of state law authorizing the use of medical cannabis by an individual on the provider’s federal funding and compliance with other federal laws that are obligated to follow. This information contained in this article is not legal advice, and should not be relied upon as legal advice. Readers are directed to consult with a lawyer of their own choosing for legal advice.

BREAKING: CMS issues Electronic Visit Verification guidance

ARRM learned today the Centers for Medicare and Medicaid Services (CMS) issued long awaited guidance to states and stakeholders regarding Electronic Visit Verification (EVV) requirements. While there are still questions remaining, ARRM’s review of the information provided shows CMS does not expect EVV to be required in traditional group homes.

It does appear that EVV will be required for any service being provided in an individual’s home when personal cares are being provided to the person. This would include at least some unit-based HCBS services.

ARRM will continue to work with Minnesota Department of Human Services officials as they interpret and utilize the guidance issued by CMS. ARRM will provide updates as more information is received. Use the links in the release from ANCOR to access the letter from CMS providing guidance as well as a document of FAQs.

Contact Barb Turner [email protected] with questions.

Weekly Legislative Update: Policy Bill Moves Forward, ARRM acts on 7% rate reduction

Session is in full swing and moving very rapidly. Below, please find a summary of the top headlines and developments from this week.

7% Rate Reduction: As ARRM informed members earlier this week, DHS sent a letter to legislators informing them that part of Minnesota’s waiver amendment was rejected. Specifically, CMS will not allow rates that received the automatic inflationary adjustment to also receive the 7% in rate increase that providers received since 2013. ARRM understand the magnitude of this issue and has been working diligently with many different groups and stakeholders to find a solution. We will keep members informed as things move quickly and how they can play a role in advocacy efforts.

February Forecast Released: Updated budget projections for the state show a surplus of $329 million. This of course is a drastic improvement to the nearly $200 million deficit that was projected in the November forecast. ARRM released a statement from CEO Sue Schettle on the forecast and the impact of the need to act as a result of the decision from CMS. Read it here.

Best Life Alliance/DWRS Legislation: The Best Life Alliance bill was introduced in the Senate and House this week, (SF 2889/ HF 3191). The bill as written moves the automatic inflationary date from every five years to every two years and invests the 7% in rate adjustments that have been received since 2013 into the framework.

The bill is scheduled for a hearing in the Senate Human Services Reform Finance and Policy Committee on Monday, March 5^th. During that hearing we anticipate the bill will be amended with a potential solution to the 7% rate reduction notice that DHS informed legislators about earlier this week. I will provide a full analysis of that hearing, and any amended language next week.

ARRM’s Policy Bill: ARRM’s Policy Bill (HF 2911/SF 2483) was heard in the Senate Human Services Reform Finance and Policy Committee on Monday. Barb Turner presented the bill, along with our chief author, Sen. Paul Utke (02). During the hearing we were able to successfully amend the bill to extend the deadline for the licensing moratorium exception for un-licensed settings by one year; as well as account for what happens if you have an open bed as of May 30^th, 2017 in a setting that you would like to have licensed. The bill was laid over until more clarity is provided as to whether there will be an omnibus bill this session or bills will travel independently.

Looking ahead, our policy bill is tentatively scheduled for a hearing on Tuesday, March 8^th in the House Health and Human Service Policy Committee.

Meeting with new MDH Commissioner: On Thursday, ARRM CEO Sue Schettle, along with members Don Priebe (Homeward Bound) and Rod Carlson (Living Well Disability Services) were able to meet with the new Commissioner of the Minnesota Department of Health, Jan Malcom. The meeting was very productive in efforts of informing Commissioner Malcom of what is working on our end when it comes to dealing with abuse and fraud; as well as being able to talk in specifics about ICF services. ARRM looks forward to continuing to grow our relationship with the Department of Health.

Looking Ahead: Next week will be a week filled with legislative hearings as ARRM continues to push our Policy bill forward and deal with the 7% rate reduction. Please watch your emails for Action Alerts that may come out early next week and reach out to me with any questions you may have.

--Sara Grafstrom, Director of Member Advocacy and Government Relations

Updates on Waiver Amendments

Minnesota submitted a set of amendments on the disability waivers to DHS earlier this summer. CMS is delaying approval of these amendments, which would allow implementation of items from the 2015 and 2016 legislative sessions. The delay is due to CMS placing additional expectations on Minnesota in regards to public comment.  In ARRM’s opinion, the additional expectations would not enhance the process and actually could make it seem less transparent.

ARRM has submitted a letter to Mike Nardone, Director of the Disabled and Elderly Health Programs Group at CMS in Baltimore, with a copy to Ralph Lollar, Director of the Division of Long Term Services and Supports. The letter states ARRM’s position on the additional public comment requirements and encourages CMS to proceed with approval of the amendments.
ARRM will keep members up to date on the progress of the most recent set of waiver amendments.