NC

February 18, 2008 Department of Health & Human Services Centers for Medicare & Medicaid Services Attention: CMS-2229-P P.O. Box 8016 Baltimore, MD 21244-8016 RE: CMS-2229-P Medicaid Program; Self-Directed Personal Assistance Services Program State Plan Option (Cash and Counseling) The Association for Home & Hospice Care of North Carolina is the largest and one of the oldest state associations in the nation representing the nurses, social workers, therapists and aides that serve more than 200,000 Medicare/Medicaid beneficiaries across the state. Thank you for the opportunity to review the Consumer Directed Personal Assistance Services (PAS) Proposed Rule. Please accept the following comments and recommendations. General Comments ~ We recognize the value of preferences and choice, as they are foundations of person- centered care. A Self-Directed Personal Assistance Services (PAS) Medicaid option may be a viable alternative for some Medicaid recipients, such as a young disabled individual (i.e., spinal cord injury individual who is medically stable, with good cognition, and financially savvy). We also recognize the value of appropriate regulated oversight that offers support and protection to agencies and the consumers they serve. Literature contends that an individual self-directing his/her preferences and needs leads to increased satisfaction, but may not lead to lower overall costs. Specifically, creating a new or adding to the existing oversight infrastructure will add additional costs to the programs. Thoughtful and balanced consideration is warranted on this issue. Specifically addressing the following: ? Federal Comparability ~ It is critical that the proposed Medicaid option does not create obstacles and barriers to care. Specifically, individuals who chose the agency model for their personal care should not be put at a disadvantage by having stricter criteria or more burdensome requirements than those offered to consumers directing his/her own care. The Federal comparability requirements should not be waived between agency PCS and family/private arranged PCS. ? Viability of the Home Care Infrastructure ~ The majority of the Medicaid recipients would not be appropriate for consumer directed care; and the migration of those for whom the self-directed option is appropriate, would further stress the viability of the home care infrastructure. The challenge is the creation of a model that sustains a viable traditional provider base for those who could not self-direct as well as for those who are appropriate for self-direction and choose it. The sustaining of traditional models is especially important in rural areas or difficult to serve areas. If these agencies cannot remain viable, then the option for traditional use consumers would no longer exist. ? Critical Mass ~ The majority of agencies currently providing personal care services (PCS) under the Medicaid option provide it at or above their margin, i.e., at a loss. And many struggle to maintain a sufficient critical mass to break even on the program. Decreasing the number of eligibles in the program will have a direct correlation to increased agency costs and the need for States to increase the in-home aide rates in the traditional models. Providers may not be able to accept patients where they are operating at a loss. This would limit access, especially in rural communities, and force patients into a more expensive option, such as a skilled nursing facility (SNF) or would delay hospital discharges. ? Migration to Private Pay ~ We have seen a migration of agencies to serving predominately or only private pay clients due to the low Medicaid reimbursement rates and the cuts in service hours. As an agency?s critical mass drops, the agency?s costs increase forcing the agency to make business decisions that create access issues for Medicaid recipients and prematurely force beneficiaries into more costly alternatives. Specific comments to the proposed regulations are attached. Thank you for the opportunity to comment on this proposed rule. We appreciate CMS? continued open dialogue through the teleconferences and Open Door forums. As related to the Consumer Directed Care proposed rule, careful consideration is warranted due to the seriousness and extent of the changes. Providers may not be able to accept patients where they are operating at a loss. This would limit access, especially in rural communities, and force patients into a more expensive option, such as a skilled nursing facility (SNF) or would delay hospital discharges. Should you require clarifications on any of our comments please contact Tracy Colvard, Director of Government Relations & Public Policy via phone at 919-848-3450, or via email at tracycolvard@homeandhospicecare.org. Sincerely, Timothy R. Rogers Chief Executive Officer Board Member, National Association for Home Care & Hospice ATCH - AHHC's Formal Comments