Confusion surrounding the provision of home- and community-based services under a final rule issued by the Centers for Medicare & Medicaid Services in 2014 may limit the ability of assisted living and memory care providers to serve Medicaid beneficiaries, leaders of the Senate Special Committee on Aging told CMS in a letter on Tuesday.
Sen. Susan Collins (R-ME), committee chairwoman, and Sen. Claire McCaskill (D-MO), ranking member, asked for clarification from the federal agency. Without it, some seniors who are or could be served in rural areas or settings such as continuing care retirement communities may need to move to more expensive and restrictive care settings than their needs require, the senators told Michael Nardone, director of the Disabled and Elderly Health Programs Group at CMS.
In an effort to enable Medicaid beneficiaries to receive services in settings that are integrated into the community rather than in skilled nursing facilities, CMS established new reimbursement criteria for HCBS settings via the 2014 rule. Certain settings are presumed ineligible for the Medicaid waiver program — including settings located in buildings in which inpatient institutional treatment is provided, settings in buildings on the grounds of or adjacent to a public institution, or settings that isolate individuals from the broader community — unless they meet a heightened standard of proof.
All states and all HCBS settings must be in compliance with the final rule by March 17, 2019.
Statewide transition plans in Delaware, Iowa, Kentucky, Ohio and Tennessee have received initial approval, and Tennessee’s plan has been approved.
“We are concerned about reports that the absence of guidance explaining CMS’ interpretation of the new requirements has led to a lack of clarity and created confusion among providers that ultimately limit their ability to serve Medicaid beneficiaries,” Collins and McCaskill wrote. “In particular, we seek more information regarding the criteria used for basing whether certain settings are presumed ineligible and how affected providers can complete the heightened scrutiny process to reverse such a determination, including for: (1) secured memory care units; (2) assisted living communities located in rural areas; (3) assisted living communities that are located in a separate or converted section, or on the campus of a nursing home.”
Many seniors, the senators wrote, prefer to live in CCRCs, also known as life plan communities, because skilled nursing services are readily available to them if they need them. “This can ease transitions for individuals with conditions that might not follow a predictable trajectory, and may allow married couples to live near one another in cases where needs differ,” they added, not specifically naming the entities.
The National Center for Assisted Living said it was pleased that the senators wrote to CMS.
“We applaud their leadership to honor the care needs and wants of assisted living residents,” NCAL Executive Director Scott Tittle said. “NCAL hopes additional guidance from CMS will bring much-needed clarity while recognizing assisted living as an integral part of the home and community.”
The final rule was a major topic when NCAL members met with members of Congress in May and also is a focus area as the group’s state leaders meet in the nation’s capital this week, where they are learning how to advocate for providers in front of members of Congress.
The Center for Excellence in Assisted Living, which counts among its members NCAL, Argentum, LeadingAge and the American Seniors Housing Association, has been serving as a resource to CMS as it provides additional guidance to states developing transition plans and determining whether certain senior living settings qualify to provide HCBS.
For additional information on the rule and additional perspective from NCAL, Argentum and LeadingAge, see “Senior living looks forward to additional HCBS guidance from CMS.”