A Home Care Owner’s Guide To The Final Medicaid Access Rule

Are you worried about the future of your Medicaid home care agency? Or what to do about your existing Medicaid clients? We’ve got all of your thoughts, questions, and answers. 

The 80/20 Rule is “creating a complex compliance environment for home care providers across the country who want to care for people who need it most. Medicaid has been the quintessential payer source for senior care services and I anticipate that many providers will think more carefully about taking on more clients (or pull out of the Medicaid business completely),” shares Julio Barea, head of sales. 

In this article, we’ll go over:

• The Medicaid Access Rule (as it stands today)
• The dialogue around the rule
• What you can do today

The Medicaid Access Rule

The Ensuring Medicaid Access Rule was finalized by CMS to improve access to quality care via Medicaid. This only impacts Medicaid business. We’ve written about the rule before, read more here to learn about the details. 

One of the most important provisions—and most contested—was the 80/20 Rule. This means that 80% of the reimbursement rates must go toward caregiver wages. There are, of course, several noted exceptions, including:

• Caregiver training
• Travel costs
• PPE 

READ MORE FROM POLSINELLI: The 80/20 Rule is Here: 

CMS Finalizes HCBS Care Worker Payment Requirements

Although this is a significant change, there is a 6-year period before providers are subject to this new operating model. 

The 80/20 Rule is not the only component of the Medicaid Access rule, though. Let’s dive into the other parts:

• The rule establishes a Beneficiary Advisory Council (BAC) consisting of Medicaid beneficiaries (and their families).
• The rule also requires states to publish all fee-for-service Medicaid fee schedule payment rates on a public website.
• The rule also ensures that states create an advisory group to guide payment rates for relevant services (required to meet every 2 years). 

READ MORE From CMS: Ensuring Access to Medicaid Services Final Rule (CMS-2442-F)

The Dialogue Around The Rule

Many industry stakeholders across the country shared their concerns over the 80/20 Rule. Here are a few:

HCAOA shared: “Most providers will curtail services, while many will leave the Medicaid space entirely. 80/20 will only serve to reduce access, particularly in rural and underserved communities, contradicting the purported goal of the rule.”

Transcend Strategy Group (with BAYADA) shared: “There are 56 (you read that right) Medicaid programs. This one-size-fits-all approach doesn’t take into account the different requirements and regulations in each state, let alone the different reimbursement rates they offer for HCBS. How will such a broad and unfunded mandate align with 56 programs?”

“We’ve spoken to many of our customers about the current home care landscape and many are reconsidering their options when it comes to their revenue mix. Private pay, VA, and LTCI are a few to focus on as we find out more about where the rule lands in the future,” Barea added. 

“On the other side of this rule, this is a great time for investors looking to add home care agencies into their portfolio or expand their footprint.” 

What Home Care Providers Can Do Today

Although the rule doesn’t go into effect today, there are a number of things you and your team can do today to be prepared ahead of the rule being implemented. 

• Expand your payer source mix. The VA, as an example, is not only a great opportunity to give back to people who served your community, but their rates are good across the board. 
• Optimize your operations. Whatever happens, looking for new and innovative strategies to make your operations and resources more efficient can’t hurt. This creates a situation that forces your agency to be creative. Think: ‘How can we do more with what we already have?’ This will help you identify gaps, opportunities, and ways to reallocate resources to fill more urgent or helpful functions. 
• Add new services. There hasn’t been a better time to look at adding new services to your agency.

READ MORE: Breaking Down the Different Methods of Home Care Delivery: 

Agencies, Registries, Virtual Marketplaces and Consumer-Directed Models

Moving Forward In Home Care With The Final Medicaid Access Rule

While not all people agree on the direction this rule took, there are several important changes that will positively impact care. Some of those include rate transparency, the advisory groups that give seniors a voice in program changes, and—at least—plenty of time to work on operations before implementation begins. 

Even if we’re only looking at the 80/20 Rule, this presents an important opportunity to reevaluate your home care agency’s operations. This means looking at your payer mix: are you relying too heavily on Medicaid or one payer for all of your clients? Now’s the time to look around at the bigger picture. 

If you’re looking for an agency management system that can help your agency navigate the 80/20 Rule (along with the rest of the Ensuring Medicaid Access Final Rule), check out CareTime today.