ALABAMA NURSING HOME ASSOCIATION ANNUAL CONVENTION & TRADE SHOW Birmingham, Alabama September 20 23, 2010 1 Introduction CMS defines state long term care rebalancing as achieving a more equitable balance between the proportion of total Medicaid long term support expenditures used for institutional services such as nursing facilities and intermediate care facilities for the mentally retarded. Additionally, rebalancing includes community based supports under a State Plan and waiver programs. 2 Introduction SJR 84 created the Long Term Care Rebalancing Advisory Committee. The overall purpose of this Committee is to develop a vision for a better, more responsive long term care system and the policies to promote the new system. Many of the initiatives that will be discussed today resulted from the work of the Long Term Care Rebalancing Advisory Committee. 3 1
But they are designed to: Introduction Respond to input from individuals who desire to receive their long term care services in the community. Afford individuals a choice of where their long term care services will be provided. Comply with federal requirements such as MDS Section Q Return to the Community. Control the States long term care expenditures. 4 Introduction The primary goals of the long term care rebalancing initiatives are to ensure the following: The Five Rights for Long Term Care: Right patient; getting Right intervention; in the Right amount; in the Right location; for the Right length; of time Adapted from the Five Rights of Medication Administrator 5 Introduction The Alabama Medicaid Agency long term initiatives: Are not designed to eliminate nursing facilities for we realize that there will always be a need for the services provided by nursing facilities. Are not designed to transition all residents from nursing facilities since many residents cannot be safely maintained in the community. 6 2
Alabama PACE 7 What Is PACE? PACE (Program of All inclusive Care for the Elderly). The PACE program is a unique capitated managed care benefit for the frail elderly provided by a not for profit or public entity. The PACE program features a comprehensive medical and social service delivery system using an interdisciplinary team approach in an adult day health center that is supplemented by in home and referral services in accordance with participants needs. 8 History of PACE In 1971, a San Francisco Chinese American community developed an interdisciplinary team and adult day center model known as On Lok. On Lok Senior Services opened one of the first adult day centers in 1973. On Lok means Peaceful Happy Abode. There are currently 74 PACE programs operational in 30 states. Alabama is currently working to become the 31 st state to operate a PACE program. There are currently 19,000 20,000 participants in the PACE programs nationwide. 9 3
History of PACE (Continued) Other states operating PACE programs include: Arkansas, California, Colorado, Florida, Hawaii, Iowa, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Missouri, Montana, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Virginia, Washington, and Wisconsin. Illinois has a PACE program, but is not currently fully integrated. Illinois is considered a pre pay site that is Medicaid managed with no dual eligible capitation financing. 10 The State Plan The Medicaid State plan is the contract between the State and Federal government whereby the State agrees to administer the Medicaid Program in accordance with Federal law and policy. The State plan sets forth the scope of the Medicaid program, including groups covered, services furnished, and payment policy. A State Plan Amendment for PACE must be approved by CMS in order for the state to receive Federal matching funds. The Balanced Budget Act (BBA) established the PACE model of care as a permanent entity within the Medicare program and enables States to provide PACE services to Medicaid beneficiaries as a State option. The State plan must include PACE as an optional Medicaid benefit before the State and the Secretary of the Department of Health and Human Services (DHHS) can enter into program agreements with PACE providers. 11 The State Plan (Continued) Each state that elects PACE as a State Plan option can choose to develop just one or multiple sites in one or more geographic areas. States can limit the total number of PACE enrollees, although this decision should be made in recognition of PACE programs need to achieve adequate census in order to operate as efficiently and manage financial risk as effectively as possible. PACE reduces nursing home admissions and their related operational costs. Approximately $1.5 million in capital expenditures is needed to develop a PACE site with the capacity to serve 250 to 500 enrollees. This translates to about $5,000 per enrollee. 12 4
The State Plan Amendment for PACE The State plan amendment is submitted to CMS describing the nature and scope of the PACE program, and that it is made available to individuals who meet the medical and financial criteria for the PACE program. The State plan amendment covers three major components: 1. Clinical and financial eligibility and post eligibility treatment of income requirements for PACE enrollees. 2. An overview of the methodology used to calculate the Medicaid capitated payments. 2. Procedures for processing Medicaid enrollments and disenrollment in the State s Management Information System. 13 PACE Definitions Contract year means the term of a PACE program agreement, which is a calendar year, except that a PACE Organization s (PO) initial contract year may be from 12 to 23 months, as determined by CMS. Medicare beneficiary means an individual who is entitled to Medicare Part A benefits or enrolled under Medicare Part B, or both. Medicaid participant means an individual determined eligible for Medicaid who is enrolled in a PACE program. Medicare participant means a Medicare beneficiary who is enrolled in a PACE program. PACEstands for Programs of All inclusive Care for the Elderly. PACE center means a facility operated by a PO where primary care is furnished to participants 14 PACE Definitions (Continued): PACE organization (PO) means an entity that has an agreement with Medicaid and CMS to operate a PACE program. PACE program agreement means an agreement between a PO, CMS, and the State administering agency for the operation of a PACE program. Participant means an individual who is enrolled in a PACE program. Servicesinclude both items and services. State administering agency means the State agency responsible for administering the PACE program agreement. Trial period means the first 3 contract years in which a PO operates under a PACE program agreement, including any contract year during which the entity operated under a PACE demonstration program. 15 5
PACE Services The PACE service package must include all Medicare and Medicaid covered services, and other services determined necessary by the interdisciplinary team for the care of the PACE participant. Primary Care (including doctor and nursing services) Hospital Care Medical Services Prescription Drugs Nursing Home Care Emergency Services Home Care Physical therapy Occupational therapy Adult Day Care Recreational therapy Meals Dentistry Nutritional Counseling Social Services Laboratory/X ray Services Social Work Counseling Transportation 16 PACE Services (Continued) PACE programs provide social and medical services in accordance with the participant s needs. An interdisciplinary team, consisting of professional and paraprofessional staff, assesses participants needs, develops care plans and services (including acute care services and when necessary, nursing facility services) which are integrated for a seamless provision of total care. The PACE interdisciplinary team has more flexibility to implement care plans that respond to each individual s unique needs than it would under a state s Home and Community based Services Medicaid waiver. 17 What Pace is not PACE is not a Continuing Care Retirement Community. Continuing Care Retirement Communities (CCRC) are designed for seniors who are currently living independently but want the security of being cared for when needed as they grow older. 18 6
CCRC Sometimes referred to as Life Care Communities, CCRC encompass a long term care contract for independent living, assisted living, skilled nursing and certain ti healthcare services at one location. Residents usually begin in an independent living residence, transfer to assisted living, and if declining health dictates, move to an onsite skilled nursing facility. Residents enjoy an independent lifestyle with the knowledge that if they become sick or frail, their needs will continue to be met. 19 CCRC (continued) Residents must be capable of living independently when they move in. CCRC provides a continuum of care that includes housing, services, and health care. The CCRC offers the residents access to coordinated social activities, dining services and health care when and if the course of aging raises the need. 20 CCRC (continued) Residents commonly pay an entry or buy in fee to join the community with a monthly fee paid thereafter. The resident enters into a contractual agreement between the resident and the CCRC that guarantees the services. Monthly fees may cover the following: Meals Transportation Housekeeping services Laundry services Health monitoring Emergency call monitoring Utilities Social activities Security 21 7
CCRC (continued) There is no Medicare or Medicaid payment until the person requires skilled nursing services or nursing facility services and meets the medical and financial criteria for the Medicare and Medicaid programs. Section 1919 of the Social Security Act states, Contracts for admission to a State licensed, registered, certified, or equivalent Continuing Care Retirement Center or life care community, including services in a nursing facility that is a part of such a community, may require residents to spend on their own care resources declared for the purposes of admission before applying for medical assistance. 22 CCRC (continued) CCRC are highly regulated in some states, but no federal agency oversees retirement communities. There are about 25 communities that are designated as Active Adult Communities, Independent Living Communities, CCRCs, or Assisted Living Communities in the State of Alabama. 23 Specific Roles The PACE program will be a three way agreement between CMS, Medicaid, and the PACE Organization. Mercy Medical in Daphne, Alabama will be the first PACE Organization in Alabama. The Role of CMS (Centers for Medicare & Medicaid Services) The Federal Agency that will determine if the PACE Organization is in compliance with Federal Regulations to operate a PACE Program in Alabama. The Role of Alabama Medicaid Agency, or its designee The State Administering Agency (SAA) has administrative authority and is charged with the responsibility of operating the PACE program. The Role of the PACE Organization The PACE provider is solely responsible for all needs of the recipient, once that individual is enrolled in the PACE program. 24 8
Relationship of Catholic Health East to Mercy Medical It should be noted that Catholic Health East (Mercy Medical s parent organization) currently operates six PACE programs with three more under development. This the largest number of sites owned and operated by any single provider within the country. 25 Medical Eligibility PACE provides a cost effective, community based model of care for older adults who meet institutional nursing home eligibility requirements. Financial Eligibility PACE serves disabled individuals whose income is not greater than 300% of the SSI Federal Benefit Rate (FBR). Section 710 of the Omnibus Appropriations Act of 1998 permits states to cover PACE enrollees under institutional groups and rules similar to those that apply under home and community based services waivers. This means that States can elect to cover PACE enrollees under the special income level group (also known as the 300 percent group). States can also apply other institutional rules to PACE enrollees, such as spousal impoverishment and post eligibility treatment of income. 26 Dual Eligible Population PACE serves the dual eligible population as well as Medicare only and Medicaid only recipients. Eligibility to enroll in a PACE program is not restricted to an individual who is either a Medicare beneficiary or Medicaid recipient. Target Population (Age Requirement) PACE will serve recipients 55 years of age or older living in the designated PACE service area. 27 9
Enrollment Limits and Enrollment Agreement Mercy Medical will serve a maximum of 300 enrollees. Enrollment in PACE is voluntary. Enrollment continues as long as desired by the PACE participant, regardless of change in health status, until death or voluntary or involuntary disenrollment. A participant s enrollment in the program is effective on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement. The PACE provider must submit the signed Enrollment Agreement signature page to the Alabama Medicaid Agency (AMA) within two days of the effective date of enrollment. The AMA then enrolls the individual into PACE on the effective date of enrollment. 28 Service Area The initial PACE site will be in Mobile and Baldwin Counties. Licensure TBD 29 PACE Reimbursement The PACE provider will receive a monthly capitation rate from Medicare and Medicaid for each eligible enrollee. The provider will assume full financial risk for participants care without limits on amount, duration, or scope of services. The PACE provider will receive monthly capitation payments from the Alabama Medicaid Agency. The payments will be automatically generated by the Medicaid Management Information System (MMIS) based on individuals that are enrolled in the program. 30 10
The Code of Federal Regulations 42 CFR Part 460 includes guidance in the following areas: PACE and the Provider PACE Application PACE Regulations Provider Responsibilities Staffing Marketing Enrollment Agreement Complaints & Grievances Appeals Process Disenrollment Post Eligibility Enrollment Process 31 The Code of Federal Regulations 42 CFR Part 460 includes guidance in the following areas: Review of the PACE Provider Application Organizational Summary Legal entity Service area Transitional care during termination Non profit status Organized under state law Organizational structure Governing body Participant Advisory Committee (PAC) 32 Patient Rights The Code of Federal Regulations 42 CFR Part 460 includes guidance in the following areas: Bill of Rights Explanation of rights Restraints Grievance and appeal process 33 11
More About PACE The development of a PACE program in Alabama is one of five successful strategies approved on March 31, 2010, by the Long Term Care Rebalancing Advisory Committee pursuant to Senate Joint Resolution 84. Interest in implementing a PACE program in other geographical locations in Alabama has been communicated to members of the LTC team. Currently, the PACE Program is scheduled to go live October 2011 in Mobile and Baldwin Counties. 34 Resources to learn more about PACE Code of Federal Regulations 42 CFR Part 460 www.gpoaccess.gov National PACE Association www.npaonline.org 35 Contact Information Marcia Edwards, Administrator LTC Project Development/Program Support Unit Telephone: 334 242 5040 Toll Free: 1 800 362 1504 Fax: 334 353 4182 Email: marcia.edwards@medicaid.alabama.gov or Ginger Wettingfeld, Associated Director LTC Project Development/Program Support Unit Telephone: 334 242 5018 Toll Free: 1 800 262 1504 Fax: 334 353 4182 Email: ginger.wettingfeld@medicaid.alabama.gov 36 12
VENTILATOR DEPENDENT RESIDENTS 37 Introduction: The Alabama Medicaid Agency will pay nursing facilities a supplemental fee for service payment for care provided to ventilator dependent and/or qualified tracheostomy residents who are eligible for Medicaid benefits. The supplemental fee for service payment will promote quality care and ensure the health and safety of Medicaid recipients that are ventilator dependent and/or a qualified tracheostomy resident. 38 Definitions: Ventilator Dependent Resident A resident who is on mechanical ventilation necessary to sustain life and who requires the care by and monitoring of a Registered Nurse or Licensed Practical Nurse 24 hours a day and routine interventions by a duly licensed respiratory therapist, or 39 13
Qualified Tracheostomy Resident A resident who (1) has a tracheostomy, (2) receives oxygen therapy, and (3) requires the care and monitoring of a Registered Nurse or Licensed Practical Nurse 24 hours a day and routine interventions by a duly licensed respiratory therapist. This definition does not cover a resident with a tracheostomy who receives only occasional monitoring or suctioning. 40 Admission Criteria: Limited to ventilator dependent and/or qualified tracheostomy residents. The ventilator dependent d resident and/or qualified tracheostomy resident must meet the current nursing facility level of care criteria established by Medicaid. 41 All of the following criteria must be present in order for a resident to be considered ventilator dependent: The resident is not able to breathe without a volume ventilator with a backup. The resident uses the ventilator t seven days per week. The resident has a tracheostomy. The resident requires daily respiratory therapy intervention, i.e., oxygen therapy, tracheostomy care, chest physiotherapy or deep suctioning. These services must be available 24 hours a day. The resident must be medically stable and not require acute care services. 42 14
The resident will also be considered ventilatordependent if all of the above requirements were met at admission but the resident is in the process of being weaned from the ventilator. This does not include C PAP or Bi PAP. 43 Criteria for Tracheostomy Residents: All of the following criteria must be present in order for a resident to be considered for qualified tracheostomy care: The resident is not able to breathe without the use of a tracheostomy. The resident requires daily respiratory therapy intervention, i.e., oxygen therapy, tracheostomy care, chest physiotherapy, or deep suctioning. These services must be available 24 hours a day. The resident must be medically stable and not require acute care services. 44 Ventilator dependent or qualified tracheostomy resident who is in the process of being weaned from being ventilator dependent or needing qualified tracheostomy treatment shall continue to be considered a qualified ventilator dependent resident until the weaning process is completed. A Registered Nurse or Licensed Practical Nurse must be readily available and have primary responsibility of the unit. 45 15
Enrollment Requirements: All nursing facilities that desire to receive a supplemental feefor service payment for providing services to ventilatordependent and/or qualified tracheostomy Medicaid residents must execute an Addendum to the current Nursing Facility Provider Agreement with the Alabama Medicaid Agency. The nursing facility must complete an enrollment application to serve ventilator dependent and/or qualified tracheostomy residents. The application should include the number of beds designated to serve ventilator dependent residents and/or qualified tracheostomy residents. 46 Nursing Facility Participation Requirements Nursing facilities must meet all of the requirements as delineated in Alabama Medicaid Agency Administrative Code Chapter 10, Long Term Care and Chapter 22, Nursing Facility Reimbursement. 47 The nursing facility that desires to receive a supplemental fee for service payment for ventilator dependent and/or qualified tracheostomy residents must: Be enrolled as a Medicaid certified facility. Meet all of the federal and state regulations governing nursing facilities. Meet the federal and state physical plant requirements and all life safety standards for nursing facilities including, an alternate power source to prevent interruption of the ventilator in the event of a power outage. 48 16
Ensure that a Registered Nurse or Licensed Practical Nurse has primary responsibility for the unit and is readily available at all times. Ensure that in house respiratory services are provided by a licensed Respiratory Therapist 24 hours a day for ventilatordependent residents and/or qualified tracheostomy residents. Provide a program of initial training and ongoing in service training for direct care staff. 49 Ensure that any attempts to wean a resident be documented in the resident s record. The nursing facility must notify the Medicaid Agency within 14 days from the date the resident is successfully weaned and is no longer in need of either ventilator t care or qualified tracheostomy t treatment. t t No additional reimbursement will be issued to the provider after the resident has been successfully weaned for 14 days and is no longer in need of either ventilator care or qualified tracheostomy treatment. Ensure that physician visits are conducted in accordance with the federal regulations for nursing facilities. 50 Maintain separate staffing records for the Respiratory Therapy staff that provides care for the ventilatordependent and/or qualified tracheostomy residents. Report any change of condition, such as weaning from ventilators, transfers, discharges, re hospitalizations and deaths. Make available the resident record for review by the Medicaid Agency every three months to determine if the resident continues to meet the ventilator dependent and/or qualified tracheostomy care criteria. 51 17
Not accept a ventilator dependent and/or qualified tracheostomy resident if any of the following situations exists: Termination of the nursing facility s Medicaid certification is imminent; or The nursing facility is a Special Focus Facility, under review by CMS, the Alabama Department of Public Health, or the Alabama Medicaid Agency. 52 Nursing Facility Quality Standards: The nursing facility must meet the following quality standards established by the Alabama Medicaid Agency: Staffing levels that correlate with the number of ventilator dependent residents. Respiratory therapy staff available in house 24 hours a day employee or contractual. Staff knowledge. At least one full time professional staff member who has completed a course in the care of ventilator dependent and tracheostomy individuals. 53 Ongoing training. All staff providing care to ventilator dependent and tracheostomy residents must receive training in the provision of ventilator care and tracheostomy care by a Respiratory Therapist or a physician who is a Board Certified Pulmonologist. Annual in service training conducted by qualified professionals. 54 18
Documentation. Written admission and discharge criteria specifying the medical requirements the resident must meet. A written weaning program. Admission, transfers and discharge policies. 55 Access to other services, including specialty and ancillary services. Physical plant requirements. The presence of an alarm system. Suitable power supply for ventilators including an alternate power source. 56 Quality of Care: Each nursing facility must ensure that the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing are provided to the resident, in accordance with the comprehensive assessment and plan of care. 57 19
Limitations: The Alabama Medicaid Agency will not limit participation to any nursing facility who desires to provide services to ventilator dependent or qualified tracheostomy residents unless the following conditions exist: Termination of the nursing facility s Medicaid certification is imminent; or The nursing facility is aspecial Focus Facility, under review by CMS, the Alabama Department of Public Health or the Alabama Medicaid Agency; or 58 The nursing facility does not meet the requirements established by the Department of Public Health and the Medicaid Agency to serve residents who are ventilatordependent or in need of qualified tracheostomy services. The Medicaid Agency will not pay for changes to the physical plant in order for the nursing facility to provide services for ventilator dependent or qualified tracheostomy residents. 59 Reimbursement and Payment Limitations: The nursing facility daily per diem rate will continue to be made in accordance with Chapter 22, Nursing Facility Reimbursement of the Alabama Medicaid Administrative Code. The request for additional reimbursement for a ventilatordependent or qualified tracheostomy resident must be submitted to the Alabama Medicaid Agency in writing for prior approval. Each request must include the most current Minimum Data Set (MDS) resident assessment and attending physician documentation of the medical condition of the ventilatordependent or qualified tracheostomy resident. 60 20
The nursing facility will be reimbursed the daily per diem rate determined for the nursing facility plus an additional daily payment for the ventilator dependent or qualified tracheostomy y resident. The supplemental fee for service payment will be $120 and indexed annually in accordance with the cost of living increases as prescribed. The total payment to the nursing facility will be the daily per diem rate plus the supplemental fee for service payment. 61 Costs for supplies directly associated with providing ventilatordependent or qualified tracheostomy care and salary, benefits, and payroll taxes or contract expenses associated with engaging respiratory therapists shall be excluded as allowable costs. No additional amount above the current nursing facility rate will be allowed for the resident until it is determined that both the resident and the nursing facility meet the requirements described in this chapter and prior authorization is issued by the Medicaid Agency. The supplemental fee for service payments will be approved for 12 month intervals. 62 If you have further questions regarding contact: Marilyn F. Chappelle, Director Long Term Care Division, 334 242 5009 E mail: marilyn.chappelle@medicaid.alabama.gov 63 21