Originally Published in our Fall 2024 Newsletter.

On August 21, 2024, several administrators of Medicaid-contracted home care companies that are members of the Rhode Island Partnership for Home Care offered comments at a public hearing related to the proposed State Plan Amendment (SPA) issued by Rhode Island’s Health and Human Services Secretary Richard Charest to the U.S. Centers for Medicare and Medicaid Services (CMS) on July 31, 2024 related to State Fiscal Year 2025 (SFY25) rate increases for Medicaid-contracted home care providers.

Home care providers contracted with the state’s Medicaid Program expressed several concerns with the SPA as proposed because it reduces the outlay of the rate increases as expressed in the September 1, 2023 “Social and Human Service Programs Review” report by the Rhode Island Office of the Health Insurance Commissioner (OHIC). Subsequently, it was intended by the Rhode Island General Assembly to adopt the report’s recommendations in order to substantially raise home care worker wages for those that care for Medicaid beneficiaries. Collectively, as leaders within Rhode Island’s home care industry delivering quality care to our most vulnerable, homebound population, the Rhode Island Partnership for Home Care expressed the following concerns:

Elimination of the PressGaney Survey Requirement: Approximately twelve years ago, the Rhode Island Department of Health eliminated the requirement for licensed home care providers and licensed home nursing care providers to utilize the services of PressGaney to survey their Medicaid clients and their staff. This survey was used to measure satisfaction and quality of continuity of care. However, the survey used by the Rhode Island Department of Health was generic to all healthcare providers and asked required questions specific to healthcare services rendered in a facility-based setting. Those questions asked are not applicable to home care. The rate enhancement connected to this survey is tied to worker wages applicable to the S-5125, S-5125-U1 and S-5130 codes. Eliminating this enhancement will reduce the wage tied to these workers. Just because newer home care providers contracted with the Medicaid Program are ineligible to participate in a defunct program, it should not be at the financial penalty of “grandfathered” providers and their employees.

Suspension of the Staff Training Verification Documentation Requirement: Over a decade ago, an Assistant Administrator for Family and Children Services at the Rhode Island Executive Office of Health and Human Services (EOHHS), who is now no longer employed within EOHHS, informed contracted home care providers that they no longer needed to submit documentation verifying annually that employees are receiving inservice training. Instead, said documentation would need to be provided to a surveyor upon request during a site visit. Contracted home care providers were last required to submit this documentation to EOHHS directly in 2013. All Medicaid-contracted home care providers are in compliance with this staff training requirement as a result and should not be penalized for any changes in enforcement of this policy.

Creation of Disparity with the National Accreditation Requirement: On May 6, 2024, the Rhode Island Department Health enacted several amendments to the operating regulations for licensed home care providers and licensed home nursing care providers. Licensed providers are required to be certified by a national accrediting organization, such as the Community Health Accreditation Partner (CHAP), the Accreditation Commission for Health Care (ACHC) or The Joint Commission. Contracted home care providers with an existing national accreditation status should not be penalized for compliance. Moreover, newly contracted home care providers within the first two years of licensure should not benefit from an adjustment to a new base rate without meeting this regulatory requirement. As such, the Medicaid Program should maintain the current rate enhancement that subsidizes the costs for initial national accreditation status and renewal (e.g. application fees, surveyor fees, continuing education fees, quality assessment and quality improvement expenses) and maintain the state accreditation enhancement until May 5, 2026 or when the last of the remaining nine contracted providers becomes nationally accredited.

Continuation of the Behavioral Health Training Program: While this rate enhancement remains as a separate requirement within the SFY25 budget as enacted, EOHHS has not made an announcement on the continuation of the training program beyond the grant’s no cost extension expiring on December 31, 2024. To date, over 600 home care employees working with Medicaid beneficiaries have completed this program and are benefiting from its subsequent wage increase as prescribed within the SFY25 budget as enacted. However, class rollouts of the limited number of offerings provided by Rhode Island College, the only institution currently authorized by EOHHS to offer such training, have constrained contracted providers’ ability to attain and sustain minimum staffing levels of those that have completed this training. To resolve this issue, the Rhode Island Partnership for Home Care is pursuing a three-way agreement with Rhode Island College, as the current and only EOHHS-preferred vendor for the training program and the Rhode Island Partnership for Home Care Foundation, an entity of the Rhode Island Partnership for Home Care that is the highest-volume producer of quality education programs for the home care and hospice industry in Rhode Island. This way, we can act as a third-party fiscal intermediary in order to financially-sustain the program and expand the number of “seats” available per year for CNAs and homemakers within the employ of Provider Members of the Rhode Island Partnership for Home Care that want to participate in the program.

Differentiation of Pediatric Services Provided by Nurse Classification: The SPA as proposed does not have a reimbursement rate differentiation between services provided by a registered nurse (RN) and a licensed practical nurse (LPN) for pediatric private duty nursing (PDN) services applicable to the T-1000 code and its modifiers. Thus, the Rhode Island Partnership for Home Care is seeking to have the Medicaid Program include T-1000 and its respective modifiers in an amended SPA to CMS for Provider Members of our association.

Specification of Skilled Care Rates: The T-1001 nursing assessment and X-0043 nursing and therapy visits billing rates are inequitable based on time in the home, delivery of skilled care services and treatment and competitive market pay rates to nurses and therapists. Skilled visits are more time intensive and may require specialization to address the specific clients’ needs over a nurse conducting a nursing assessment once every two months. Per the appropriation by the General Assembly in the SFY25 budget as enacted, T-1001 will reimburse at $187.55 per visit on October 1, 2024. This includes the 0.12% annual cost inflation factor (CIF) adjustment for SFY25. X-0043 will reimburse at only $154.14 per visit with the inclusion of the CIF. There is an inequity for the T-1001 visit reimbursement as Medicaid beneficiaries requiring skilled care have more complex assessments than those beneficiaries receiving only personal care or homemaking services. With this said, the Rhode Island Partnership for Home Care recognizes that total Medicaid spending in State Fiscal Year 2023 (SFY23), as the last completed state fiscal year with available total spend data as of the August 21, 2024 public hearing, T-1001 total expenditure was $686,956.37 and X-0043 total expenditure was null. However, there has been no public reporting by EOHHS that there is an anticipation of zero X-0043 expenditures through either fee-for-service (FFS) or any of the managed care organizations (e.g. Neighborhood Health Plan of Rhode Island, Tufts Health Plan Rhode Island, United Healthcare) within the most completed fiscal year, State Fiscal Year 2024 (SFY24) or the current fiscal year, SFY25. The Rhode Island Partnership for Home Care is pursuing for its Provider Members that EOHHS adjust the reimbursement rate for X-0043 to cover the costs for sending a nurse or therapist to cover a skilled visit and create a T-1001 modifier to differentiate nurse assessments for personal care/homemaking beneficiaries and skilled care beneficiaries.

Unfortunately, EOHHS recently rejected all public appeals to readjust the rate increases back to those approved by the General Assembly for SFY25. The proposal is currently under CMS review. Members of the Rhode Island Partnership for Home Care will receive further information on this matter and guidance as how they can respond and benefit for their respective company.