Scott Tittle

Delays by the Centers for Medicare & Medicaid Services in issuing additional guidance on its 2014 final rule related to home- and community-based services may mean that assisted living communities are excluded from providing such services to older adults through Medicaid waivers, thereby thwarting the efforts to promote resident choice and engagement that the rule seeks to foster, National Center for Assisted Living leaders told the government agency on Tuesday.

NCAL’s letter to Mike Nardone, director of CMS’ Disabled and Elderly Health Programs Group, follows one that Sens. Susan Collins (R-ME) and Claire McCaskill (D-MO), chairwoman and ranking member, respectively, of the Senate Special Committee on Aging, sent to Nardone on Sept. 6.

Without additional clarification, Collins and McCaskill told Nardone, some seniors who are or could be served in rural areas or settings such as continuing care retirement / life plan communities may need to move to more expensive and restrictive care settings than their needs require. Leaders of NCAL and other organizations representing senior living providers, who share the senators’ worries, praised them for the effort at the time.

“Nothing has really changed — and that’s our concern,” NCAL Executive Director Scott Tittle told McKnight’s Senior Living, explaining the reason for the new letter, which he signed with NCAL Senior Director of Policy Lilly Hummel.

“States are developing their transition plans right now, and some have even been approved,” Tittle continued. “But we’re still lacking clear guidance on a number of issues that will be critical in determining whether certain assisted living communities will be able to participate in this program.”

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 comply with the final rule by March 17, 2019.

CMS last issued guidance on the rule in April, shortly after Tennessee’s statewide transition plan received final approval. Since then, plans in Delaware, Idaho, Iowa, Kentucky, Ohio and Pennsylvania have received initial approval.

Tittle and Hummel asked Nardone for a timeline of when further guidance will be released and specified that stakeholders need more information about:

  • Operationalizing resident-centered care for those with dementia;
  • The criteria needed for assisted living communities to overcome a heightened scrutiny review for HCBS settings that are co-located with or adjacent to an institutional setting (as could be the case at CCRCs);
  • The process that CMS would use for heightened scrutiny reviews; and
  • How to operationalize CMS’ April guidance on new construction.

NCAL also urged CMS officials to visit assisted living communities “to ensure that forthcoming guidance reflects the current preferences of AL residents and the true nature of AL communities.” Those visits should include communities that offer memory care services, those that are co-located with a nursing center and those in rural areas, Tittle and Hummel said.

“We’ve been working with other stakeholders to push CMS on this and want to engage in a dialogue with them before the end of the year,” Tittle said.

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