Access to home- and community-based services (HCBS) has increased over the last few years. But, despite some of the spotlight that the current administration has shone on HCBS, there is still a lot of work to be done to unlock the full potential of these services.

“The reality of the funding aspect of Medicaid does not make it easy to run a business and to serve all the people that need to be served,” Mollie Gurian, VP of home-based and HCBS policy at LeadingAge, said at the organization’s annual conference in Chicago on Monday. “There have been some victories in this area and some of our state partners have made really big gains in advocating for increased financing for Medicaid programs — especially money that has flowed into states through the American Rescue Plan.”

When it comes to policy, Gurian believes a more full-picture approach needs to be taken by health care regulators and stakeholders.

“People who are surviving on Medicaid dollars are going to be challenged to compete with hospitals and even others in our own continuum,” Gurian said. “From a LeadingAge perspective, there’s also sort of a lack of focus on the continuum and big picture for long-term care and how we need all the pieces to fit together from a policy perspective. Policies you make in one area are ultimately going to trickle down and affect policies in other areas.”

In order to make some of the improvements to the HCBS landscape, LeadingAge believes the U.S. Centers for Medicare & Medicaid Services (CMS) needs to be doing its part.

For instance, in a recent proposed rule from CMS — which would require at least 80% of Medicaid reimbursement for home- and community-based services go toward worker compensation — the agency also proposed that states revamp their stakeholder groups and make sweeping changes to the way agencies document incident management reports.

While several of the proposals are seen as positive, others could potentially have adverse effects on HCBS providers.

“I used to work for a state Medicaid agency and, obviously, each state, their engagement and the way they take feedback from their stakeholder groups is a bit different,” Georgia Goodman, director of Medicaid at LeadingAge, said. “It’s a really onerous process for states to administer these stakeholder groups. I’m not saying they shouldn’t administer them. I’m saying making meaningful changes to how they administer them doesn’t come necessarily from a regulatory framework. It comes from a theoretical framework.”

Instead, CMS should be encouraging states to commit to hearing feedback from stakeholders, collecting that feedback and acting on that feedback appropriately.

“When thinking about who’s actually on those stakeholder groups and making wholesale changes to those groups, that may not result in the changes that CMS was actually seeking,” Goodman said.

CMS has also made it a point to make sure beneficiaries have their voices heard in terms of how they receive HCBS care. Goodwin and her colleagues share that sentiment, but CMS didn’t give the same space for providers.

“Beneficiaries should absolutely have a voice, but providers are an integral piece of this puzzle,” Goodwin said. “In managed care, many providers don’t have a voice. State Medicaid agencies regularly say, that through the managed care contracting process, there’s an opportunity for providers to demonstrate their value and to push back against onerous requirements. But in reality, we know that’s not necessarily the truth.”

Managed care companies, for instance, will often find a way to meet network adequacy requirements without penetrating into the community, bypassing the need to get feedback or input from larger providers, Goodwin explained.

In order to make it more of a fair deal for providers, LeadingAge is advocating for more providers when managed care companies contract with HCBS providers.

If there are large provider organizations in a certain market that a managed care company can contract with, they can meet those network adequacy requirements without really working with other providers.

In terms of the 80/20 rule, the main takeaway LeadingAge had was that the quality of care is not solely driven by direct care staff compensation.

There are several other factors like training, clinical supervisory oversight, personal protective equipment, transportation and many others that go into providing quality HCBS care.

“We believe CMS was pushing this as a mechanism in hopes that states would respond by increasing provider rates,” Goodwin said. “But, as you all know, there’s no control from CMS to actually influence those provider rates as that’s a fully legislative process.”

Looking ahead, Goodwin felt optimistic that members of Congress — particularly members of the House Committee on Energy and Commerce — understand the current worries from the HCBS industry.

In late October, the committee held a hearing on supporting access to Long-Term Services and Supports (LTSS).

“Everyone, including us, expressed a lot of support for the direct care workforce and how they need more money, but this is not the policy to do it,” Goodwin said. “It did seem like, in a heavily Republican but still bipartisan way, there was a lot of understanding about that. I think that we have a lot of support in Congress if CMS were to go forward with the rule to advocate against that being finalized.”

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