Then Much of the Gov’s Plan Put Back In, Along with Changes
From Forbes McIntosh, Government Policy Solutions, WALA Lobbyist
The Wisconsin Legislature’s Joint Finance Committee last Wednesday voted to delete (remove) much of what Gov. Scott Walker had proposed in his recommended 2015-17 state budget proposal. However, the Committee then added back many of those same provisions along with other parameters for DHS to follow in creating the final plan. The Committee also required the Department of Health Services (DHS) to “consult” with consumers, advocates and stakeholders prior to developing its final Waiver request (reform plan), which a summary of the plan is to be completed and delivered to the Joint Finance Committee by April 1, 2016 for approval or denial. In short, while there are changes to to the Governor’s proposed Family Care and IRIS restructuring plan, both big and small (see below) – a plan to restructure Family Care and IRIS will be submitted to CMS in 2016 and implementation could begin as early as January 1, 2017.
Existing MCOs. While they did not get everything they wanted in the budget, they will be able to exist and compete under the new proposal and they will not have to offer the Family Care benefit statewide. County-based MCOs now have a path to operate as an HMO.
New MCO \ IHA Entrants. While they did not get everything they wanted in the budget, they got a lot – and this budget proposal will allow them to compete and grow in the newly restructured LTC managed care system.
LTC Providers will be happy that the “prohibition on claw-back schemes” is maintained and that “any willing provider \ return to home” provisions are maintained for at least 3-years after the new Family Care is implemented. The bad news for LTC providers is that after the initial 3-years (or at a later time identified by DHS) managed care organizations (or as they will be called in the future IHAs – Integrated Health Agencies) may have the authority to move people out of their homes in assisted living or other licensed residential settings based on whether that provider is in our out of the IHA’s network. Further, the budget provides the authority of IHAs “allowing for audits of providers, in order to improve accountability in the provision of services.” As providers know, audits are expensive and time consuming – and this budget provision does not limit how many audits can be required to occur.
The final package of items approved includes:
Long-Term Care Changes and Statewide Expansion of Family Care and IRIS
The LTC adopted a motion that incorporates Gov. Scott Walker’s statewide Family Care expansion. But in addition to requiring the Wisconsin Department of Health Services (DHS) to submit the waiver request to the federal Centers for Medicare and Medicaid Services, the JFC budget motion also requires the DHS waiver request to include the following components:
- Integration. Specify that MA-funded long-term care consumers receive both long-term care and acute care services, including Medicare-funded services to the extent allowable by CMS, from integrated health agencies (IHAs).
- Statewide vs. Regions.
- Increase the size of regions currently served by managed care entities, such that each region has sufficient population to allow for adequate risk management by IHAs.
- Specify that there shall be no less than five regions.
- Require multiple IHAs in all regions of the state.
- MCOs Now IHAs. Require IHAs to make available a consumer-directed option under the long-term care program, under which the IHA would assist individuals in developing individualized support and service plans, ensure that all services are paid according to the plan, and assist enrollees in managing all fiscal requirements, and which shall include, but is not limited to, the ability to select, direct and/or employ persons offering any of the services currently available under the IRIS program, and the ability to manage, utilizing the services of an IHA serving as a fiscal intermediary, an individual home and community-based services budget allowance based on a functional assessment performed by a qualified entity and the availability of family and other caregivers who can help provide needed support.
- Provider Audits. Modify the state’s long-term care programs, including allowing for audits of providers, in order to improve accountability in the provision of services.
- Open Enrollment. Establish an open enrollment period for the state’s long-term care programs that coincides with the open enrollment period for the Medicare program.
- Independent Actuarial Study. Require that rates paid to IHAs be set through an independent actuarial study.
- Any Willing Provider. Preservation of the current “any willing provider” requirement for long-term care providers for a minimum of three years after the implementation date of the program in each region.
In addition, the approved motion makes the following changes regarding the Family Care proposal:
- Requires that DHS consult with consumers, advocates and stakeholders prior to developing its final waiver request.
- Request DHS to submit a summary of the plan associated with the waiver request to the Joint Finance Committee by April 1, 2016.
- Specify that a long-term care district, defined under s. 46.2895 of the statutes, is permitted to operate a health maintenance organization.
- Specify that long-term care advisory committees are responsible for review and assessment of the self-directed service option.
- Specify that language under 46.2895 of the statutes relating to tribal or band long-term care districts shall be maintained until a waiver for the provision of tribal long-term care services from CMS is approved and implemented.
In other LTC provisions, the omnibus motion:
- Keeps Aging and Disability Resource Centers (ADRCs) intact.
- Requires DHS to evaluate the functional screen and options counseling for reliability and consistency among ADRCs.
- Requires DHS to study the integration of income maintenance consortia and aging and disability resource centers for any efficiencies that may be gained by their merger.
Children’s Community Options Program
- Adopts the governor’s proposal regarding Children’s Community Options Program – with a few modifications.
Children’s Long-Term Care Services
- Adopts the governor’s proposal to provide a 3% annual increase to the Children’s Long-Term Care Services program.
MA Reimbursement of Nursing Homes
- Provides 1% acuity increase for MA reimbursements to nursing homes beginning in 2016-17.
- Direct DHS to study the labor region methodology and to propose changes to labor region methodology “such that any proposed labor region methodology results in adjustments to direct care costs that reflect labor costs for nursing homes in each county no later than July 1, 2016.”
Exempt IMDs and County-Operated Nursing Homes from Bed Assessment
- Exempt county government-owned institutions for mental disease (IMDs) and state-only licensed facilities from the nursing home bed assessment.
County-to-County Nursing Home Bed Transfers
- Require DHS to develop a policy that specifies procedures for applying for, and receiving approval of, the transfer of available, licensed nursing home beds among counties.
Healthy Aging Grants
- Provide $200,000 GPR in one-time funding each year of the biennium for a grant to a private, nonprofit group for various activities relating to training, disease prevention or health promotion in healthy aging.
Transfer Prior Authorization Staff from the Office of the Inspector General to the Division of Medicaid Services
- Transfer 2.75 GPR positions and 8.25 FED positions from the Office of the Inspector General (OIG) to the Division of Medicaid Services, effective March 31.
See the budget papers below that are referenced in the omnibus motion:
- Paper #356. Long-Term Care Changes.
- Paper #357. ADRCs and Long-Term Care Advisory Councils.
- Paper #358. Statewide Expansion of Family Care and IRIS
- Paper #359. Children’s Community Options Progam.
- Paper #360. Dementia Care Specialists.
- Paper #361. Children’s Long-Term Care Services.
- Paper #362. MA Reimbursement for Nursing Homes.