Cost-effective private duty steps up to the Medicaid personal care plate
HCFA lets states pick Medicaid personal care providers
States can now pick private duty agencies to provide personal care that is reimbursed by Medicaid, if they choose to follow the optional rule from the Health Care Financing Administration (HCFA) in Baltimore.1
By eliminating the requirement that personal care services be supervised by a registered nurse, the rule opens up Medicaid-reimbursed personal care services to agencies other than skilled nursing providers and expands the benefit to cover locations outside the home.
Removing the RN supervision requirement would mean states could turn to a private duty agency to provide the care, rather than a Medicare-certified agency, says Marc Catalano, RN, BSN, president of Catalano’s Nurses Registry in Hialeah, FL. "There are a lot of more cost-effective methods of providing personal care than the classical Medicare home health agency.
"The rule simply says that the state would have the right to determine who could provide the [personal care] service," he continues. "That gives the state a lot of flexibility that they don’t currently have under today’s laws."
The final rule, published in the Sept. 11 Federal Register, defines covered services as assistance with eating, bathing, dressing, personal hygiene, activities of daily living, toileting, and taking medications.
About 30 states already offer Medicaid coverage for personal care services, many through waiver programs. Waiver programs target a group of people in the state who need a specific type of service, while the regular Medicaid benefit is more limited because it applies to a broad population.
"We only allow so many units of the regular program service," one state Medicaid official tells Private Duty Homecare. "The services provided through the waiver program are above the normal program limits." The rule, therefore, should have little effect on existing waivers, she says.
Agencies providing Medicaid services under the optional personal care rule do not have to be Medicare-certified, says Deborah McNeal Arrindell, executive director of the Home Care Aide Association of America in Washington, DC. Providers do have to meet state licensing requirements, however.
HCFA left it entirely up to the states to develop their own requirements, including provider qualifications and mechanisms for quality assurance. States also decide on the rate of reimbursement based on the funds they receive from the federal government.
This long leash for the states, along with the removal of the RN supervision requirement, concerns the association, says Arrindell. "We believe that given there are no minimum quality standards established under this law for providers of care, that eliminating the requirements for supervision without establishing minimal quality standards will leave a lot of Medicaid recipients vulnerable to poor care or abuse."
The association wrote at great length to HCFA about this, she says. "We had asked that there be some quality assurance standards, minimal standards of training, or testing. We believe in the absence of any federal minimal requirements, states could establish programs without any standards or could require that individual Medicaid recipients determine whether or not a personal care attendant is qualified."
This is not likely under the current government focus on fraud and abuse, says Sharon Newton, RN, CDMS, assistant director of state programs for Outreach Health Services in Garland, TX.
"I don’t think the states are going to leave it carte blanche’ and open-ended they are going to set their minimum standards."
If states, by chance, do not have set standards for agencies or for personal care attendants, agencies should work with their state home care associations to put some in place, she says. "[Standards should be established] so agencies don’t get a bad name."
In removing the RN supervision requirement, HCFA was trying to be responsive to the disability groups that wanted consumer-directed care, Arrindell says.
"While some individuals’ conditions may dictate a need for nurse supervision, many individuals receiving personal care services are either capable of directing their own care or have needs that are not based on a medical’ condition," the rule says.
"We believe it’s fine for people to self-direct their care but that the state needs to be responsible for ensuring the competency of caregivers," says Arrindell.
Most agencies already take responsibility for the competency of their staff, Newton says. Although she supports having an RN do the initial client assessment, she adds, "You don’t have to have an RN by your name to provide some services well."
In the rule, HCFA does allow states to continue RN supervision if they so choose. States can make the "determination of when supervision of personal care services is necessary and what type of professional is qualified to supervise the personal care attendant."
Arrindell says she doesn’t know if states that offer Medicaid personal care programs requiring RN supervision will change their programs. "I think it will be interesting to see if the [rule] does change them. I would think that it might."
HCFA expects the rule to increase the demand for personal care services. "We believe this effect will be viewed as beneficial to providers of personal care services," the rule explains. "If the increase in demand for such services is sufficient, the number of providers of personal care services may increase."
The rule would offer more opportunity for providers if states decide to offer the option, says Gayla Sasser, executive director of the Tennessee Association for Home Care in Nashville. "It would certainly be helpful to the Tennesseans who would like to stay home for their long-term care needs. Now, their choice is basically a nursing home unless they can [qualify for] one of the Medicaid waivers in one of the four counties [that offer them.]"
A new provision in the rule allows states to reimburse for personal care services provided at locations such as assisted living facilities and adult day care centers; this may help business, too.
The number of states that take advantage of the provision, though, depends on the amount of control they can keep on the cost of the care, Catalano says. "The whole idea of giving the state flexibility is to give the state options that can help contain costs not increase them."
Since the rule opens up Medicaid personal care to private duty agencies that don’t offer skilled nursing, the provider list may become more competitive.
"The field might become watered down," Newton says.
However, Private duty agencies shouldn’t worry about a shift in private pay to Medicaid personal care reimbursement, Catalano adds. People who qualify for Medicaid, he explains, seldom can afford private pay services.
The rules of the road
States that elect to offer the services under the rule must, at least, cover the services in the home.
While states have the option of providing personal care in places such as adult day care and assisted living facilities, there are some exceptions to the site of care. For example, individuals are not eligible for the personal care program if they are an inpatient or resident of a hospital, nursing facility, or intermediate care facility for persons with mental disabilities, except for services that are not required to be provided by the facility.
In addition to being furnished in a home or other location, HCFA says the personal care services must be:
- authorized for an individual by a physician in accordance with a plan of treatment or (at the state’s option) otherwise authorized for the individual in accordance with a service plan approved by the state;
- provided by a qualified individual who is not a member of the individual’s family. HCFA defines a qualified individual as someone who is not a "legally responsible adult."
Reference
1. 62 Fed Reg 47,895 (Sept. 11, 1997).
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