LeadingAge NY Seeks Changes in 1115 Waiver Concept Paper

Following up on a prior letter criticizing the omission of long term care (LTC) from the State's $17 billion Medicaid waiver concept paper , LeadingAge NY wrote to the State's Medicaid Director recommending specific modifications to address the needs of older adults and strengthen the LTC system. LeadingAge NY's letter is available here. As described in more detail below, we recommended that the State include in each element of the waiver dedicated funding and initiatives tailored to the needs of older adults and individuals with disabilities who need LTC services.

The State's waiver concept paper proposes to the Centers for Medicare and Medicaid Services (CMS) a new Medicaid 1115 waiver to succeed the Medicaid Redesign Team (MRT)/Delivery System Reform Incentive Payment (DSRIP) Waiver. It focuses on health disparities and health care delivery issues highlighted and intensified by the COVID-19 pandemic. The waiver concept paper includes the following initiatives:

Creation of Health Equity Regional Organizations (HEROs), coalitions to lead planning activities, support data analytics, and create partnerships to promote health equity.
Creation of Social Determinants of Health Networks (SDHNs), independent provider associations (IPAs) of community-based organizations that would contract with managed care organizations (MCOs) or providers to perform social determinants of health (SDH) interventions.
Promotion of “advanced value-based payment (VBP) models,” especially global arrangements that utilize pre-payment of the total cost of care and protect providers against fluctuations caused by disasters like a pandemic. VBP would also include SDHNs that would accept a targeted budget to reach HERO goals. Waiver funding would be provided in addition to regular MCO premiums to conduct interventions that promote better care for populations with health disparities. These might include, for example, a substance use disorder bundle, children in foster care bundle, and maternity bundle. The MRT Waiver's VBP Roadmap would be updated to create a menu of options for enhanced services.
Social care assessments (like the Uniform Assessment System (UAS) community health assessments) would be provided for all Medicaid beneficiaries.
Plan premiums would be adjusted based on social care acuity, and quality measures would be stratified based on social care acuity.
Expanded supportive housing and other housing supports would be implemented through HEROs, SDHNs, and MCOs and funded through VBP arrangements and direct payment via HEROs.
Provision of funding to hospitals and other health care facilities to develop strategies to respond to the next pandemic or mass disruption of health services.
Funding of workforce training to ensure a cross-trained workforce that is able to respond to a large influx of patients.
Reinvestment in Workforce Investment Organizations (WIOs) to address workforce needs, including recruitment and retention, career pathways, advanced VBP, overcoming implicit bias, apprenticeships, and standardization of training.

The Medicaid Director, Brett Friedman, elaborated on the State's plans in a presentation to the Public Health and Health Planning Council. His slides are available here. A detailed summary of the concept paper developed by our attorneys at Hinman Straub is available for LeadingAge NY members here.

LeadingAge NY's most recent letter providing feedback on the waiver called for a multi-pronged workforce strategy and policies and investments to revitalize the LTC system in the wake of the pandemic, guided by the following principles:

Promote Access and Choice: Medicaid beneficiaries should have an array of options suitable to varying levels of acuity and need, lifestyle preferences, and geographies.
Maintain a Well-Qualified, Appropriately Compensated, and Ample Workforce: Medicaid rates should support recruitment, retention, and career development of the LTC workforce by enabling payment of competitive wages. Our laws and regulations must also optimize available personnel by allowing them to practice at the top of their scopes and by supporting cross-continuum certifications.
Drive Quality and Value: Our policies should incentivize the delivery of high-quality, person-centered care through financial incentives that are reliable, timely, additive, and non-punitive.
Strengthen Integration: Our policies should support integration and coordination along the continuum of long-term services and supports and among the primary, acute, post-acute, and LTC sectors so that older adults can transition seamlessly from one setting to another.
Target High-Priority SDH for Older Adults: The waiver should address SDH for older adults through strategies tailored to their unique needs and preferences. It should expand and make effective use of existing community programs and services that serve older adults, rather than spend precious resources on new layers of administration and build new programs from the ground up.

To carry out this vision using the priorities and framework outlined in the concept paper, our recommendations included, among other items, the following:

HEROs: Ensure that HEROs include on their governing bodies Managed Long Term Care (MLTC)/Program of All-Inclusive Care for the Elderly (PACE) plans and Area Agencies on Aging (AAAs), as well as LTC providers representing the continuum of LTC, and require the HEROs to assess and address the needs of their regions’ older adults and others who require LTC services and their caregivers;
SDH: Address SDH utilizing existing infrastructure, and provide adequate funding to support them. In addition, we recommended that the waiver engage AAAs, existing community-based health care providers, senior centers, other non-medical service providers, and affordable senior housing providers; make targeted investments to delay the need for higher levels of care among older adults and slow the growth rate of public expenditures; and support unpaid, informal caregivers through training, respite services, and peer and emotional support. We also recommended the dedication of funding to partnerships of LTC providers, MLTC/PACE plans, and community services to support transitions of care along the acute/post-acute/LTC continuums and transitions from nursing homes to the community.
VBP: Recognize that unique VBP arrangements must be tailored for MLTC and for PACE and that new financial resources must be provided, especially in light of the State’s decision to pay premiums at the bottom of the actuarial rate ranges.
Supportive Housing: Ensure that funding for supportive housing is allocated to affordable senior housing with services.
Pandemic Response Redesign: As part of the pandemic response redesign:
- Provide financial incentives for nursing homes to enable the operation of more homelike and smaller facilities (e.g., Green House and small house models).
- Fund enhanced medical care and palliative care in nursing homes to enable nursing homes to retain residents and avoid hospitalization and accept discharged hospital patients earlier in their recovery.
- Support staff-intensive models, like Comfort First, for nursing home residents with dementia who present high supervision and social engagement needs and high risks for transmission of COVID-19.
Workforce Investment: Ensure that investments in WIOs and facility-based staff enable providers to pay competitive rates, offer work-related supports, and promote recruitment and retention of LTC staff, not just training to enhance the skills needed for VBP.
Integration of Care: Invest in technologies and strategies that promote integration and smooth transitions along the care continuum. In addition, seek a waiver of the home and community-based services (HCBS) conflict of interest rule to enable integration and coordination of long-term services and supports, while promoting greater choice of providers and care management for consumers.

LeadingAge NY continues to advocate for a Medicaid waiver that supports older adults and people with disabilities who need LTC services.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8838