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As the state of New Hampshire embarks on a gap analysis of its home- and  community-based services system, one senior living organization leader is cautioning against a “Hunger Games” scenario that pits one setting over another.

The nonprofit Human Services Research Institute and the University of New Hampshire’s Center on Aging and Community Living are conducting an assessment and gap analysis of the state’s HCBS system, with a goal of providing recommendations for improvements that promote community integration, independence and a robust system of long-term services and supports for older adults and people living with disabilities. 

Through public forums, the organizations will look at the availability of HCBS services across the state, use rates for those services, HCBS provider capacity, nursing facility usage, and the experiences and preferences of those using HCBS services. 

Brendan Williams, president and CEO of the New Hampshire Health Care Association, said that the COVID-19 pandemic led to historic federal and state resources for Medicaid programs, including providing that care in assisted living communities through HCBS waivers. But assisted living’s role in the state’s “fragile long-term care system” must be recognized, he added.

“While the influx of funding for in-home care has been a positive, assisted living is a very rare Medicaid option, given low state payments,” Williams said. “If assisted living is to be a meaningful Medicaid option, as much attention must be paid to it as is being paid to in-home care.”

He added that although NHHCA supports HCBS, he’s wary of any “Hunger Games” scenario where any long-term care setting could be disadvantaged over another.

“We view the system as fragile and interdependent,” Williams said. 

New Hampshire passed a state budget in June that gave providers a 3% increase in Medicaid payments. It began in July, with additional raises coming in January. A portion of those increases were targeted at the Choices For Independence, or CFI, waiver program, which provides almost 3,800 individuals from the Granite State with help at home or in a small community setting, according to the New Hampshire Bulletin

Chris Kelliher, the administrator at the Villager Assisted Living Home in Goffstown, NH, said that assisted living operators are looking for an increase in CFI rates that comes closer to covering their costs. Those rates will be announced by the state in December and will go into effect in January.

The operator of the small assisted living community said all residents move into the community as paying with private funds, but once they run out of resources and turn to Medicaid or the CFI waiver, he accepts that payment, knowing he will lose approximately $500 every month per resident.

“It does put places in a precarious position,” he said, adding that he has an almost two-year waiting list. “It’s a big gamble that a lot of facilities take when they do CFI. A lot of facilities aren’t willing to gamble, because they’re gambling on their future.”

Assisted living operators, Kelliher said, aren’t asking for an “astronomical” rate increase, just something closer to the private-pay rates.

Using funding from the Centers for Medicare & Medicaid Services’ Money Follows the Person Demonstration Expansion award, the state plans to evaluate its long-term services and supports system, including the CFI waiver. A final report is expected in June.