Category Archives: Group Homes

Step Right Up! CMS Announces New Medicare-Medicaid ACO Model

Come one! Come all! Step right up to be one of the first 6 states to test the new Medicare-Medicaid Affordable Care Act (ACO) pilot program.

experiment

Let your elderly population be the guinea pigs for the Center for Medicare and Medicaid Services (CMS). Let your most needy population be the lab rats for CMS.

On December 15, 2016, CMS announced its intent to create Medicare/caid ACOs. Currently, Medicare ACOs exist, and if your physician has opted to participate in a Medicare ACO, then, most likely, you understand Medicare ACOs. Medicare ACOs are basically groups of physicians – of different service types – who voluntarily decide (but only after intense scrutiny by their lawyers of the ACO contract) to collaborate care with the intent of higher quality and lower cost care.  For example, if your primary care physician participates in a Medicare ACO and you suffer intestinal issues, your primary care doctor would coordinate with a GI specialist within the Medicare ACO to get you an appointment. Then the GI specialist and your physician would share medical records, including test results and medication management. The thought is that the coordination of care will decrease duplicative tests, ensure appointments are made and kept, and prevent losing medical records or reviewing older, moot records.

Importantly, the Medicare beneficiary retains all benefits of “normal” Medicare and can choose to see any physician who accepts Medicare. The ACO model is a shift from “fee-for-service” to a risk-based, capitated amount in which quality of care is rewarded.

On the federal level, there have not been ACOs specially created for dual-eligible recipients; i.e., those who qualify for both Medicare and Medicaid…until now.

The CMS is requesting states to volunteer to participate in a pilot program instituting Medicare/Medicaid ACOs. CMS is looking for 6 brave states to participate. States may choose from three options for when the first 12-month performance period for the Medicare-Medicaid ACO Model will begin for ACOs in the state: January 1, 2018; January 1, 2019; or January 1, 2020.

Any state is eligible to apply, including the District of Columbia. But if the state wants to participate in the first round of pilot programs, intended to begin 2018, then that state must submit its letter of intent to participate by tomorrow by 11:59pm. See below.

dual-acos

I tried to research which states have applied, but was unsuccessful. If anyone has the information, I would appreciate it if you could forward it to me.

Participating in an ACO, whether it is only Medicare and Medicare/caid, can create a increase in revenue for your practices. Since you bear some risk, you also reap some benefit if you able to control costs. But, the decision to participate in an ACO should not be taken lightly. Federal law yields harsh penalties for violations of Anti-Kickback and Stark laws (which, on a very general level, prohibits referrals among physicians for any benefit). However, there are safe harbor laws and regulations specific to ACOs that allow exceptions. Regardless, do not ever sign a contract to participate in an ACO without an attorney reviewing it. 

Food for thought – CMS’ Medicare/caid ACO Model may exist only “here in this [Obama] world. Here may be the last ever to be seen of [healthcare.gov] and their [employee mandates]. Look for it only in [history] books, for it may be no more than a [Obamacare] remembered, a [health care policy] gone with the wind…”

As, tomorrow (January 20, 2017) is the presidential inauguration. The winds may be a’changing…

All Medicare/Caid Health Care Professionals: Start Contracting with Qualified Translators to Comply with Section 1557 of the ACA!!

Being a health care professional who accepts Medicare and/ or Medicaid can sometimes feel like you are Sisyphus pushing the massive boulder up a hill, only to watch it roll down, over and over, with the same sequence continuing for eternity. Similarly, sometimes it can feel as though the government is the princess sleeping on 20 mattresses and you are the pea that is so small and insignificant, yet so annoying and disruptive to her sleep.

Well, effective immediately – that boulder has enlarged. And the princess has become even more sensitive.

boulder

On May 18, 2016, the Department of Health and Human Services (HHS) published a Final Rule to implement Section 1557 of the Affordable Care Act (ACA). Section 1557 of the ACA has been on the books since the ACA’s inception in 2010. However, not until 6 years later, did HSD finally implement regulations regarding Section 1557. 81 Fed. Reg. 31376.

The Final Rule became effective July 18, 2016. You are expected to be compliant with the rule’s notice requirements, specifically the posting of a nondiscrimination notice and statement and taglines within 90 days of the Final Rule – October 16, 2016. So you better giddy-up!!

First, what is Section 1557?

Section 1557 of the ACA provides that an individual shall not, on the basis of race, color, national origin, sex, age, or disability, be

  • excluded from participation in,
  • denied the benefits of, or
  • subjected to discrimination under

all health programs and activities that receive federal financial assistance through HHS, including Medicaid, most Medicare, student health plans, Basic Health Program, and CHIP funds; meaningful use payments (which sunset in 2018); the advance premium tax credits; and many other programs.

Section 1557 is extremely broad in scope. Because it is a federal regulation, it applies to all states and health care providers in all specialties, regardless the size of the practice and regardless the percentage of Medicare/caid the agency accepts.

HHS estimates that Section 1557 applies to approximately 900,000 physicians. HHS also estimates that the rule will cover 133,343 facilities, such as hospitals, home health agencies and nursing homes; 445,657 clinical laboratories; 1300 community health centers; 40 health professional training programs; Medicaid agencies in each state; and, at least, 180 insurers that offer qualified health plans.

So now that we understand Section 1557 is already effective and that it applies to almost all health care providers who accept Medicare/caid, what exactly is the burden placed on the providers? Not discriminating does not seem so hard a burden.

Section 1557 requires much more than simply not discriminating against your clients.

Section 1557 mandates that you will provide appropriate aids and services without charge and in a timely manner, including qualified interpreters, for people with disabilities and that you will provide language assistance including translated documents and oral interpretation free of charge and in a timely manner.

In other words, you have to provide written materials to your clients in their spoken language. To ease the burden of translating materials, you can find a sample notice and taglines for 64 languages on HHS’ website. See here. The other requirement is that you provide, for no cost to the client, a translator in a timely manner for your client’s spoken language.

In other words, you must have qualified translators “on call” for the most common 15, non-English languages in your state. You cannot rely on friends, family, or staff. You also cannot allow the child of your client to act as the interpreter. The clients in need of the interpreters are not expected to provide their own translators – the burden is on the provider. The language assistance must be provided in a “timely  manner. “Further, these “on call” translators must be “qualified,” as defined by the ACA.

I remember an English teacher in high school telling the class that there were two languages in North Carolina: English and bad English. Even if that were true back in 19XX, it is not true now.

Here is a chart depicting the number of non-English speakers in North Carolina in 1980 versus 2009-2011:

languages

As you can see, North Carolina has become infinitely more diverse in the last three decades.

And translators aren’t free. According to Costhelper Small Business,

Typical costs:
  • Interpreting may take place in person, over the phone or via video phone.
  • In-person interpreters typically cost $50-$145 per hour. For example, American Language Services offers interpreters starting at $100 per hour (or $125 for sign language) and a two-hour minimum is required.
  • Phone interpreters typically cost $1.25-$3 per minute. Language Translation, Inc. offers a flat fee of $1.88 per minute for phone interpreting, for example.
  • Video interpreters typically range from $1.75 to $7 per minute. For instance, LifeLinks offers video interpreting from $2.25 per minute for any language and $2.95 for sign language. A 15-minute minimum is common for phone or video interpreting.

It seems likely that telehealth may be the best option for health care providers considering the cost of in-person translations. Of course, you need to calculate the cost of the telehealth equipment and the savings you project over time to determine whether the investment in telehealth equipment is financially smart.

In addition to agencies having access to qualified translators, agencies with over 15 employees must designate a single employee who will be responsible for Section 1557 compliance and to adopt a grievance procedure for clients. Sometimes this may mean hiring a new employee to comply.

The Office of Civil Rights (“OCR”) at HHS is the enforcer of Section 1557. OCR has been enforcing Section 1557 since its inception in 2010 – to an extent.

However, expect a whole new policing of Section 1557 now that we have the Final Rule from HHS.

CMS Clarifying Medicare Overpayment Rules: The Bar Is Raised (Yet Again) for Health Care Providers

Have you ever watched athletes compete in the high jump? Each time an athlete is successful in pole vaulting over the bar, the bar gets raised…again…and again…until the athlete can no longer vault over the bar. Similarly, the Center for Medicare and Medicaid Services (CMS) continue to raise the bar on health care providers who accept Medicare and Medicaid.

In February, CMS finalized the rule requiring providers to proactively investigate themselves and report any overpayments to CMS for Medicare Part A and B. (The Rule for Medicare Parts C and D were finalized in 2014, and the Rule for Medicaid has not yet been promulgated). The Rule makes it very clear that CMS expects providers and suppliers to enact robust self auditing policies.

We all know that the Affordable Care Act (ACA) was intended to be self-funding. Who is funding it? Doctors, psychiatrists, home care agencies, hospitals, long term care facilities, dentists…anyone who accepts Medicare and Medicaid. The self-funding portion of the ACA is strict; it is infallible, and its fraud, waste, and abuse (FWA) detection tools…oh, how wide that net is cast!

Subsection 1128J(d) was added to Section 6402 of the ACA, which requires that providers report overpayments to CMS “by the later of – (A) the date which is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due, if applicable.”

Identification of an overpayment is when the person has, or reasonably should have through the exercise of reasonable diligence, determined that the person received an overpayment. Overpayment includes referrals or those referrals that violate the Anti-Kickback statute.

CMS allows providers to extrapolate their findings, but what provider in their right mind would do so?

There is a six-year look back period, so you don’t have to report overpayments for claims older than six years.

You can get an extension of the 60-day deadline if:

• Office of Inspector General (OIG) acknowledges receipt of a submission to the OIG Self-Disclosure Protocol
• OIG acknowledges receipt of a submission to the OIG Voluntary Self-Referral Protocol
• Provider requests an extension under 42 CFR §401.603

My recommendation? Strap on your pole vaulting shoes and get to jumping!

The (Recent) History of PCS Rates and Why There Is Parity of Rates Between Home Health and Long Term Care Facilities

Think of this blog as a history lesson…

As I was preparing my Power Point for speaking at the NC Association of Long Term Care Facilities (NCALTCF), I ran across a number of interesting issues on which I could blog. If you are attending the annual NCALTCF conference September 8-10, this will be a prelude to a portion of my presentation. I will be speaking on September 8th.

I am reviewing the history of personal care services (PCS) rates, and I realize that a few years ago, the parity of PCS rates for home health care providers and long-term care facilities (LTCF) occurred. The issue? Why the parity? I am curious. I remember vividly the parity change in 2012. But, I wonder, why did it occur?

Home health care companies provide PCS to people within their own homes (obviously a much-needed and growing service). Long term care facilities (LTCF) provide PCS within a facility.

But LTCFs have higher overhead due to mortgage/rent, 24-hour staff, monthly bills, more regulatory compliance issues, a cafeteria or kitchen, etc. Whereas, a home health care company does not incur these expenses. Why NOT pay LTCF a higher PCS reimbursement rate?

The answer is…we did, in North Carolina. And the federal government found that we violated the Americans with Disabilities Act (ADA).

Here is the percentage breakdown of people receiving home health, assisted living, nursing homes, hospice, and day service centers, on a national basis in 2013, according to the Centers for Disease Control (CDC).

LTCF pie chart

 

Notice the green, home health section. Home health has grown at a very rapid rate since 2000. But assisted living (blue) is still predominant.

Back before 2010 and in an attempt to help adult care homes that provide assistance with dementia patients, the General Assembly provided an enhanced Medicaid rate for those facilities.

For decades, the Centers for Medicare and Medicaid (CMS) warned us that the ADA requires that Medicaid reimbursements apply equally to all, including those living in institutional facilities and those who live with family. CMS informed us that we were in violation of Olmstead v. L.C., a Supreme Court decision decided in 1999. In Olmstead, the Supreme Court decided mental illness is a form of disability and that institutional isolation of a person with a disability is a form of discrimination under Title II of the ADA. See Olmstead v. L.C., 527 U.S. 581 (1999) (Remember the Prince song?)

In 2010, Disability Rights filed a complaint with the federal government complaining about NC’s disparate PCS rates between LTCF and home health. In 2011, the US Department of Justice investigated and agreed with Disability Rights. NC was violating Olmstead by providing two different reimbursement rates.

The General Assembly (GA) tackled the issue in 2012. The GA decreased the LTCF’s enhanced PCS rate to the home health’s rate in order to comply with federal law. Although there was a limit as to the number of hours of PCS per month, the GA wrote in an extra 50 hours per month for people suffering from dementia.

Disability Rights originally made the 2010 complaint to the federal government with honest, well-meaning intentions. Disability Rights wanted better care for the mentally ill. And Olmstead had wonderful results for the mentally ill. Now people suffering from mental illness can remain in their homes, if desired (although sometimes a legal battle is required).

But the unknown, unintentional consequence of Olmstead for the owners of LTCFs is that the PCS rate became paired with the home health PCS rate, which keeps declining. For example, prior to October 1, 2013, the PCS rate was $15.52 (now it is $13.88).

The federal minimal wage is $7.25. People who are paid minimum wage, generally, are not licensed professionals.

Most members of a LTCF staff are licensed. Many are certified nurse assistants (CNAs). Most are required to attend yearly continuing education classes. Should these CNAs and licensed professionals make only $6.00 more than minimum wage? Are not professional licensees worth more?

Not to mention…let’s talk about what LTCF staff actually does on a day-to-day basis. My Grandma Carson resides in a LTCF. Thankfully, she still lives in her own independent living house on the LTCF grounds because she can maintain her independent living, but many residents of LTCF cannot. LTCF staff assists in activities of daily living (ADLs), such as toileting, eating, ambulating, and grooming. When my great-grandmother could no longer feed herself, the wonderful staff at Glenaire in Cary, NC fed her. Should a person feeding an elderly person (and bathing and helping go to the bathroom) NOT be paid well-over minimum wage?

Well…the reimbursement rate may be $13.88 (a tad over $6.00 above minimum wage), but a PCS worker for a home health agency AND a LTCF does not earn $13.88/hour, they earn less. Companies are created to earn a profit. There is nothing wrong with earning a profit.

In fact, starting January 1, 2014, PCS workers in home health are now eligible for minimum wage. “ARE NOW ELIGIBLE.” As in, last year, PCS workers could have earned LESS than minimal wage.

In the future, I hope that health care providers who provide PCS services are paid more; I also hope that, in the future, the PCS rate increases. Someday, I will be the recipient of a PCS worker.

Adult Medicaid Group Homes: Forgotten Again?

In the wake of such tragedies such as the Colorado movie theatre last July, the Sikh temple in Wisconsin in August, Minneapolis in September, then the unthinkable massacre at the Connecticut elementary school in December, and, of course, the Boston bombing in April, you would think that mental health would be a top priority.

Instead, politicians across America are advocating gun laws.  Without commenting on gun control (as this is a Medicaid blog), mental health seems to be getting placed on the back-burner.

In the North Carolina budget passed by the Senate last week, mental health, in particular, group homes for adults with severe mental illnesses, again, was forgotten.  Whether on purpose or by accident, I have no idea.  But the fact remains a large part of metal health simply was not contemplated in the budget.

I am sure most of you remember the comedy of errors that occurred at the beginning of the year when the criteria for personal care services (PCS) was revised.  Basically in January 2013, the criteria to receive PCS became more stringent.

According to DMA, effective January 1, 2013, PCS “is available to individuals who has a medical condition, disability, or cognitive impairment and demonstrates unmet needs for, at a minimum three of the five qualifying activities of daily living (ADLs) with limited hands-on assistance; two ADLs, one of which requires extensive assistance; or two ADLs, one of which requires assistance at the full dependence level. The five qualifying ADLs are eating, dressing, bathing, toileting, and mobility.”

Prior to January 1, 2013, individuals who qualified for Medicaid special room and board assistance were automatically granted approval to receive PCS funding regardless of need. This applied for both in-home and facility-based services.

Due to the more stringent 2013 criteria, thousands of adults in group homes in NC who depended on Medicaid were no longer eligible.  Former Gov. Perdue was forced to shimmy around funds in order to keep these disabled adults from losing their homes.  The whole debacle created terror and stress for those disabled adults whose residences were threatened, for the families of the threatened disabled adults, for the group home executives who did not want to evict these disabled adults, and for any mental health advocate or person with empathy toward the mentally ill.

The trainwreck of the adult PCS group homes only occurred 4-ish months ago.

Yet, lawmakers, seemingly, failed to address the recurrent problem of funding for group homes for adults with severe mental illnesses, who are no longer eligible for PCS, in last week’s budget passed by Senate.

Wednesday afternoon (if you work downtown, then you know what I am talking about) a group of protesters rallied outside the General Assembly clad in blue shirts, holding signs saying, “Save Group Homes!” and “Disaster Relief! Save my Home!,” and some simply said, “Help!”

The Senate’s budget failed to provide funds for approximately 1,450 people living in 6-person group homes.  Each group home resident currently receives $16.14 a day, or about $6,000 a year, from the state program.  The fear is that group homes are so underfunded as it is that any amount, no matter how small, of decreased funds would drive the group homes out of business, forcing residents onto the street.

In general, group homes are not huge money-makers for the owners.  The workers at a group home make approximately $9-10/hour.  Group homes must be staffed 24/hours/day and 365/days/year.  The group homes must use the state-funded money to staff the home, keep up the maintenance of the home, feed all the residents and care for all the residents, plus all overhead (i.e., electricity, heat/air conditioning, any extras for the residents, such as TVs or cable, blankets, etc.).  Plus group homes must provide a small, monthly stipend for the residents in order for the residents purchase medicine (co-pays) and personal hygiene products.

Logically there must be SOME profit in group homes in order for anyone to want to run a group home.  But the profit is minimal.

Similar to the low Medicaid reimbursement rates to physicians, causing physicians to not accept Medicaid, any sort of cut to group home funding (including the residents not qualifying for PCS due to the new criteria and without special funding to cover the difference), group homes will inevitably close.  You simply cannot expect a person to keep a group home open when no profit is made.  Just as if you cannot expect a doctor to accept Medicaid patients if no profit is made.

So, is the State of North Carolina saving money by not providing additional funding to those PCS recipients who no longer qualify for PCS? Hey, the Medicaid budget goes down, right? But what happens to those adults with severe mental illnesses when, because of the lack of PCS funds, the group homes either close or turn out those residents who no longer qualify for PCS?

In a perfect world, I guess the families of the adult Medicaid recipients would take them in and all would be fine.  But I gather there is a reason that these recipients are in a group home and not with family.

No, since this is not a perfect world, most of these adults with severe mental illnesses, without a group home, would be homeless and, eventually, if not immediately, would be hospitalized at a much higher price that a group home.

So these adult Medicaid recipients are stable in a group home. Well-cared for. Most likely, have relationships with the staff and other residents.  But because of the new PCS criteria and the fact that the NC budget does not provide funding for Medicaid residents that no longer qualify for the PCS funding, we will uproot the adults with severe mental illness, send them into the world, expect them to be ok, and, then, later, pay much more money to the hospitals that are forced to take in these Medicaid recipients due to whatever issues caused the hospitalization.

Hmmmm….at least the Medicaid budget is lower.

NC Health Care Providers Who Accept Medicaid: Thank you!

How about a big “Thank you” to our North Carolina health care providers accepting Medicaid?

Many providers continue to accept Medicaid despite the fact that the state is conducting Medicaid audits, the providers feel harassed by the state, the providers are terrified that they have to pay back hundreds of thousands of dollars for health care services actually rendered to Medicaid recipients, the providers are forced to wait months post-services rendered to receive Medicaid reimbursements, and the reimbursements are so much lower than the overhead costs.

Why?  Why do health care providers undergo so much emotional and financial strain to provide health care services to Medicaid recipients?  I believe that health care providers who dedicate services to Medicaid recipients truly understand and believe that the Medicaid population deserves and needs quality health care.  These providers understand that most providers will not undergo the mental and financial stress needed to meet all the Medicaid criteria and documentation. So these providers feel a sense of duty to Medicaid recipients.

And to those health care providers who accept Medicaid in NC: “Thank you.”

I heard a story today of a health care provider who deserves this “Thank you,” and more. When the Personal Care Services (PCS) criteria changed this past January 1, 2013, many of the provider’s clients no longer qualified to receive PCS under Medicaid.  Did that stop the provider from providing the needed PCS?  No.  Is the provider paid for its services?  No.  But this provider was dedicated to its clientele.

So when 80-year-old Dorothy (obviously, I have changed the names), who suffers from late-stage breast cancer, dementia, and Rheumatoid arthritis was told that she no longer met the PCS criteria, she was terrified.  But this provider continues, even today, to provide Dorothy the care she needs.

The provider is not reimbursed for helping Dorothy.  But the provider feels a sense of duty.  Do you turn your back on someone in need because the General Assembly changed the PCS requirements?  Or do you continue to help the person you have cared for for so many years and hope that the government will somehow right the injustice?

Interestingly, this same provider is undergoing two Medicaid audits for a total of approximately half a million in alleged recoupments.  The provider was forced to hire an attorney and defend the Medicaid reimbursements it has received for years of providing quality health care service to the Medicaid population.  Instead of getting a “Thank you,” the state has audited and claimed that the provider must pay back almost half a million dollars, even though the provider provided all the services for which it billed.

Yet this provider, not only provides all the services for which it bills Medicaid, but when Medicaid drops Dorothy (and thousands of others) from the Medicaid program, this provider goes above and beyond its call of duty and provides services knowing that Medicaid will never reimburse it.

Maybe this provider should not be audited. Maybe the Medicaid system should be audited for all the services for which this provider is not paid.  Or maybe  this provider, and many others, deserve a simple:”Thank you.”

General Assembly Back: Medicaid PCS Issue is HOT

NC legislators are back at work as of noon today (January 30, 2013). The most pressing issue in Medicaid? Personal Care Services (PCS).

In 2012, when the Medicaid rules changed (The rules didn’t change in 2012. The rules were determined to change in 2013) as to who could receive PCS, thousands of adults receiving PCS in adult care homes, suddenly, did not meet the criteria for PCS. Thousands of Medicaid recipients would no longer receive PCS; therefore, many group homes would go bankrupt.

Just to show the great breadth of this problem: The Office of Administrative Hearings (OAH) received 15,000 appeals this month from Medicaid recipients no longer eligible to receive PCS.

Expect to see a bill with a fix to the group home issue in the House Appropriations Committee on Thursday.

Mt. Gilead Group Home Closes Doors: So Many Questions Remain

Last week, a Montgomery County adult care home was forced to close down, causing dozens of adult, Medicaid recipients to be without health care or housing.

Owners Amy and Larry Patton had called the Department of Health and Human Services (DHHS) previously and informed DHHS that the slow Medicaid reimbursements were going to close down their facility.

There is very little information from the Pattons regarding the reasons the group home had to close, except for their complaints to DHHS regarding slow Medicaid reimbursements. It appears that they removed all valuable items from the Mt. Gilead, North Carolina group home, such as TVs and refrigerators, in the middle of the night. Employees came in the morning to find everything gone.

The residents and families of the residents in the adult care home are outraged, and rightly so. They should be outraged. But are they outraged at the correct people/companies?

As a Medicaid attorney, I see health care providers struggling every day to make payroll.  The health care providers depend heavily on Medicaid reimbursements (a) being provided, and (b) being timely. If these Medicaid payments fail to come or fail to come timely, the health care provider, like any other business, is forced to close.

I have no evidence that Pattons were not receiving their Medicaid payment except for the complaint they made to DHHS regarding timeliness.  There may have been more complaints.  We will probably never know.

But it is a fact that there are health care providers in North Carolina which are not receiving Medicaid payments.  In 2011, due to the Affordable Care Act (ACA) NC General Assembly passed Session Law 2011-399, which codified DHHS’ authority for pre-payment reviews.  A pre-payment review places the health care provider in a situation that few providers are capable of overcoming. Basically, the Agency stops the medicaid payments to the provider until the provider can prove in 3 consecutive months that the provider can document a 70% accuracy rate based on the Agency’s standards.

According to NC Gen. Stat. 108C-7, the prepayment review can only last up to 12 months, at which time the provider will, most likely, lose its ability to serve Medicaid recipients if it is unable to meet the documentation requirements.

But 12 months without Medicaid payments will wipe out a health care provider.

Surprisingly, NC Gen. Stat 108C-7 does not allow a health care provider to appeal. No due process.

Now I have no evidence that the Pattons were subject to a pre-payment review. I have no evidence that the Pattons were not receiving Medicaid payments.  But for a group care home to close its doors when the owners were not new to Medicaid (they also owned two other group homes in Guilford County), unexpectedly and without providing help to its Medicaid recipients is mysterious.

These were people trying to help Medicaid recipients.  They owned 3 group homes. I question whether the Pattons, like so many other health care providers, were subject to pre-payment review with no appeal rights.

NC Group Home Residents Lose Medicaid Funds: May Lose Homes

NC residents who live in Medicaid-funded group homes suffer mental illnesses or developmental disabilities.  Group homes allow the residents a home-like atmosphere and 24/7 health care and personal care services, such as help with toileting, bathing, and eating.

The federal government informed NC that the state was using the wrong eligibility criteria for Medicaid recipients receiving personal care. Personal care services (PCS) is a paraprofessional service that covers the services of an aide in the recipient’s private residence or group home to assist with the recipient’s personal care needs that are directly linked to a medical condition.

To fix the eligibility problem pointed out by the feds, the General Assembly set up a $39.7 million fund to pay for adult care homes, but group homes were unintentionally excluded. If the legislators did not use the word “only” in the legislation, most likely, group homes would have been covered. But in “only” covering adult care homes, group homes were excluded.

The result of the General Assembly’s oversight is that approximately 1400 people may be homeless starting January 1, 2013.

Despite an outcry from the General Assembly for Purdue to call a special session, Purdue refused. Instead, last week, Purdue announced that she was moving $1 million dollars within the Department of Health and Human Services to pay for group homes through January 2013. This allows the group home residents one extra month before Medicaid funding is gone.

The General Assembly organizes January 9th, but is not scheduled to conduct business until January 30, 2013….the day Medicaid funding will cease for the group homes.

 

20,000~ Medicaid Recipients: Homeless, January 1, 2013

Literally THOUSANDS of mentally disabled, NC Medicaid recipients may be on the streets of NC come January 1, 2013. Perdue claims that her last act as governor will be to prevent this to happen. But can she? No. Not alone.

Due to recently passed federal legislation, The Center for Medicare and Medicaid Services told North Carolina last year that personal care services (such as assistance with daily ADL‘s like eating, bathing, and toileting) must be reimbursed at the same rate for Medicaid patients who live in private homes and for those in group homes. It is estimated that the change in the reimbursement rate would cause $414 million less payments to group homes caring for Medicaid recipients suffering from mental illness. The result of this massive cut in Medicaid payments to group homes will cause most group homes in North Carolina to go bankrupt, resulting in all the Medicaid recipients residing at the group home to be put out on the street.

Group homes must abide by extremely stringent state and federal laws to keep their doors open.  Therefore, group homes are exceedingly expensive to run. Not to mention that group homes must have 24-hour, 365 days/year employees. The cost to run a group home is staggeringly higher to run than a private home. It is illogical why the government would pay a private home and a commercial group home the same Medicaid rate. In a private home, the people live at the home; therefore private homes do not need to pay for numerous employees to work 24-hour, 365 days/year. Yet, due to federal legislation, Medicaid will reimburse group homes the same as private homes.

Can we stop this tomfoolery? It is up to the state legislators. While they relax for Christmas vacation, come New Year‘s approximately 20,000 adult Medicaid recipients may be on the street.  While legislators sip hot toddies with a roof over their heads, 20,000 will be freezing in the middle of winter, homeless, during one of the coldest months of the year. Action is needed. State legislators have advised Perdue to fund these group homes will alternative funding. However, Perdue has stated this is impossible due to the language of statutes. What is needed? A special session! Make the legislators come back for a special session. If the legislators get to ring in the New Year with a roof over their heads, don’t the residents of North Carolina’s group homes deserve the same?