HB 893-FN – AS AMENDED BY THE HOUSE
28Mar2007… 0751h
2007 SESSION
01/03
HOUSE BILL 893-FN
AN ACT relative to long-term care.
SPONSORS: Rep. Donovan, Sull 4; Rep. Emerson, Ches 7; Sen. Fuller Clark, Dist 24
COMMITTEE: Health, Human Services and Elderly Affairs
This bill:
I. Authorizes individuals eligible to receive Medicaid-funded nursing home services with the right to have their individual support plans developed through a person-centered planning process regardless of age, disability, or residential setting.
II. Maintains current eligibility criteria for nursing facility services which would change on July 1, 2007.
III. Requires that the department make publicly available an annual report on the availability of, need for, and quality of long-term care services in each county of the state.
IV. Requires that the department calculate accurate cost estimates of the full cost to the state of adequately funding long-term care services and to submit these estimates as an informational addendum with its budget request.
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Explanation: Matter added to current law appears in bold italics.
Matter removed from current law appears [in brackets and struckthrough.]
Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.
28Mar2007… 0751h
07-1117
01/03
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand Seven
AN ACT relative to long-term care.
Be it Enacted by the Senate and House of Representatives in General Court convened:
1 Long-Term Care; Purpose. Amend RSA 151-E:1, III to read as follows:
III. This chapter is [an initial] an essential step toward [incrementally] rebalancing the long-term care system and expanding choices available to recipients. It increases the continuum of care by adding mid-level care, including but not limited to, assisted living and residential care services. Through an acuity-based reimbursement system [and], a comprehensive needs assessment process, and an information and assistance process, it [encourages] provides those eligible for Medicaid nursing facility services the opportunity to [consider] choose more appropriate, less costly mid-level services and home and community-based care. In this way, the state intends to serve this increasing Medicaid eligible population more appropriately and more economically.
2 New Paragraph; Long-Term Care; Definition Added. Amend RSA 151-E:2 by inserting after paragraph VII the following new paragraph:
VII-a. “Person-centered planning” means a planning process to develop an individual support plan that is directed by the person, his or her representative, or both, and which identifies his or her preferences, strengths, capacities, needs, and desired outcomes or goals.
3 Long-Term Care; Eligibility for Nursing Services. Amend the introductory paragraph of RSA 151-E:3, I(a) to read as follows:
(a) Clinically eligible for nursing facility care because the person requires 24-hour care for one or more of the following purposes, as determined by registered nurses [employed by state or county government using] appropriately trained to use an assessment tool and employed by state government, county government, an independent case management agency, or a designee acting on behalf of the department:
4 New Paragraph; Long-Term Care; Assessment Tool. Amend RSA 151-E:3 by inserting after paragraph III the following new paragraph:
IV. For the purposes of the assessment performed pursuant to paragraph I, the registered nurse shall give substantial weight to clinical information provided by the applicant’s physician, including, but not limited to, diagnosis, prognosis, and plan of care recommendations.
5 Long-Term Care; Consumer Choice. Amend RSA 151-E:4 to read as follows:
151-E:4 Consumer Choice. A person who has been determined to be Medicaid eligible for nursing facility services in accordance with RSA 151-E:3 shall have the right to receive nursing facility services; however, the person shall be offered and may choose to receive services in a less restrictive setting if such services are available and do not result in costs to the state and counties in excess of the limitations set forth in RSA 151-E:11, II. Such choice shall be offered in accordance with state laws and federal regulations. The person shall have the right to have his or her individual support plan developed through a person-centered planning process regardless of age, disability, or residential setting. The department shall take into consideration the family and community supports available to the person, the family’s desire and ability to care for the person, and shall ensure that all consideration and support is offered to the family to maintain the person in home and community-based care. Nothing in this section is intended to require the provision of financial assistance or supports by a family member.
6 Long-Term Care; Information and Referral. Amend RSA 151-E:5 to read as follows:
151-E:5 Information and Referral. The department shall establish a system of community-based [focal points] information and referral resource centers that provide information and referral services to elderly and chronically ill adults. The information and referral network established under this section shall not be used for the purpose of political [or legislative] advocacy, but may inform and educate the general court regarding the extent of services available as well as the unmet needs in the community.
7 New Sections; Annual Report; Medicaid Waiver Program; Eligibility. Amend RSA 151-E by inserting after section 15 the following new sections:
151-E:16 Annual Report.
I. The department shall make publicly available an annual report, beginning on January 1, 2008, that quantifies the following information for all services provided to elderly or chronically ill adults by or through the bureau of elderly and adult services; such report to include data which is available, and if data is unavailable or incomplete, an explanation for such omission:
(a) The need for each service based on assessments done for applicants.
(b) The capacity available for providing each service.
(c) The unmet need for each service.
(d) The quality of the services provided.
(e) The ability of the existing system to meet service needs.
(f) The availability and effectiveness of consumer’s appeal rights to providers and managers of each of these long-term care services.
(g) The number of hours of each type of service included in the Medicaid waiver recipient’s plans of care, as approved by the bureau of elderly and adult services, which are not actually provided to the recipient.
(h) A summary of services provided to each recipient by type of service and by county.
(i) Length of time between the date of application and the date of eligibility determination and the length of time between the date of the eligibility determination and the date of service plan implementation.
(j) Number of denials and reasons for denial.
II. The annual report shall include data gathered by information and referral resource centers, or otherwise available to the state, that reflects the unmet needs of elderly and chronically ill adults in New Hampshire living in the community and the basis for the unmet need. The annual report shall provide the required information by county and for the entire state and shall include the input of providers and consumers in developing the county reports on need, capacity, and quality.
III. The department shall provide copies of the annual report to the speaker of the house of representatives, the president of the senate, the governor, the house and senate standing committees with jurisdiction over elderly services, and the state committee on aging.
151-E:17 Accurate Cost Estimates.
I. The department shall estimate and report the full cost to the state of adequately funding long-term care services at a level which ensures all eligible individuals the quality services which they need and for which they are eligible. The cost estimates shall include the cost to fund home and community-based, mid-level, and nursing facility care at a reimbursement level necessary to ensure that individuals who are eligible for Medicaid-funded long-term care services have access to quality services in all 3 settings, are able to live with dignity in a safe environment, and are able to exercise choice in their care setting. The department estimate shall be based on provider reimbursement rates that ensure a provider workforce that is sufficient to fully meet the needs of eligible consumers.
II. The department shall include the estimate required by paragraph I in the annual report required under RSA 151-E:16 and as an informational addendum to its budget submission.
151-E:18 Availability of Targeted Management Services. The department shall make available to and advise all Medicaid recipients who require a nursing facility level of care or are at risk of needing such care and who are patients in hospitals, rehabilitation hospitals, or nursing facilities of the availability of targeted case management services provided by independent case managers, to explore the feasibility of transitioning to home and community-based care.
151-E:19 Presumptive Eligibility.
I. The commissioner of the department shall establish a presumptive eligibility program to prevent unnecessary and costly institutionalization of individuals who are Medicaid eligible for nursing facility services and choose to receive services in less restrictive settings.
II. Pending verification of application information, the department shall authorize medical assistance in the interval between application and the final Medicaid eligibility determination if the department determines the applicant is likely to be eligible. Presumptive eligibility shall be made available at department district offices, information and referral resource centers, and other qualified providers. The presumptive eligibility period shall not include coverage of home or environmental modifications.
III. Presumptive eligibility authorizations shall be dependent upon a face-to-face interview of each applicant and review of a completed Medicaid application. The department district offices, information and referral resource centers, and qualified providers shall perform the face-to-face interview within 20 business days of a request for medical assistance. The department district offices, information and referral resource centers, and qualified providers shall assist the applicant in completing the application within 5 business days of the face-to-face interview and the department shall review the application for presumptive eligibility within 5 business days of completion of the application.
IV. The presumptive eligibility period begins on the date the department determines the applicant likely meets the eligibility criteria and ends on the date eligibility is verified or the individual is determined ineligible.
V. The Medicaid applicant shall acknowledge in writing the uncertainty of continuing service coverage beyond the presumptive eligibility period and the potential for financial responsibility for costs incurred in the event of a determination of Medicaid ineligibility.
VI. If an applicant is determined ineligible for Medicaid, the department shall promptly notify the applicant and the applicant’s providers of the finding and the immediate termination of service coverage authorization. In such a case, the department shall use non-Medicaid funds to pay for any waiver services which the applicant has already received. In the event an application was filed with fraudulent intent, the department shall be entitled to reimbursement of funds expended on behalf of the applicant.
VII. The commissioner of the department shall adopt rules, pursuant to RSA 541-A, relative to:
(a) A process to determine presumptive eligibility.
(b) A definition of a qualified provider.
(c) Content and format of forms required under this section.
8 Repeal. The following are repealed:
I. 2005, 175:22, relative to eligibility for nursing services, is repealed.
II. 2005, 175:25, III, relative to a prospective effective date.
9 Effective Date.
I. Section 8 of this act shall take effect June 30, 2007.
II. The remainder of this act shall take effect July 1, 2007.
LBAO
07-1117
Amended 05/21/07
HB 893 FISCAL NOTE
AN ACT relative to long-term care.
FISCAL IMPACT
The Department of Health and Human Services states this bill, as amended by the House (Amendment #2007-0751h), will have an indeterminable fiscal impact on state and county expenditures, and state revenue in FY 2008 and each year thereafter. This bill will have no fiscal impact on county and local revenue or local expenditures.
METHODOLOGY
The Department states section 3 of the bill proposes to expand the universe of individuals who can administer the assessment tool for determining clinical eligibility for HCBC services. When nurses administering the tool are employed by the state (which includes employment by the county) or are under contract with the state, the state receives a 75% federal match for payment of the nurses. The increased match is allowable because the nurses are supervised by the state. The increased match is not permitted for nurses employed by other entities such as independent case management organizations. Accordingly, those nurses could only be paid using the traditional 50% federal match, thus there would be a decrease in Federal Financial Participation (FFP). In order to make clinical eligibility assessment possible by third parties, Department information technology would need to be available at different sites. At a minimum, such third parties would need access to the Options computer system. The approximate cost for providing such access to third parties is not known at this time. The Department states section 4 of the bill directs the Department to give ‘substantial weight' to clinical information, but no definition for 'substantial weight' is provided. Accordingly, the Department assumes that there will be an increase in administrative appeals by applicants who are denied assistance when they believe the Department did not give 'substantial weight' to clinical information provided. It is not possible to quantify the increase in appeals, but it would demand resources at the Administrative Appeals Unit as well as legal resources from Bureau of Elderly and Adult Services. Nurses would be the primary witness for the Department, resulting in less time spent by the nurses assessing clinical eligibility. Section 6 of the bill directs the Department to collect information regarding services and unmet needs. While the Department does not currently have data available to satisfy the intent of section 6, a project is already underway to obtain such data for various purposes. Assuming the result of this project proves sufficiently similar to the directive in section 6 of the bill, the Department will not require additional resources to comply with the section.
Section 7 of the bill directs the Department to publish a report annually commencing on January 1, 2008 containing certain data, some of which is not currently available. The Department assumes for purposes of this fiscal note that the intent is to develop data about HCBC, not all forms of long-term care. Accordingly, the Department would rely upon data currently supplied by providers on a quarterly basis which would need to be compiled manually by Department staff. In order to ensure accuracy of the data and compile a report, the Department would require an audit team consisting of two staff (a Registered Nurse, LG 28 and a Program Specialist IV. LG 25) to work one full day per week exclusively on this audit. In that time, the team could review 25% of all the approximately 2,500 HCBC cases. There would also be a one-time cost to develop a home-grown database to manage all the information mined by the audit team. Section 7 also directs the Department to produce accurate cost estimates for the operation of long-term care coverage. There is currently no data available upon which to base such estimates for HCBC or mid-level care, only nursing home data exists. The Department will need to get providers of HCBC and mid-level care to commence reporting on the type of information nursing homes currently provide. An audit team would then need to review the cost reports from all three types of providers in order to provide an estimate based on provider reimbursement rates that ensure a provider workforce that is sufficient to fully meet the needs of eligible consumers. Section 7 further directs the Department to advise certain individuals who are in hospitals, nursing homes, or rehabilitation facilities of the option of receiving long-term care in the community instead of a facility. The Department assumes for purposes of this fiscal note, that it can create a pamphlet that employees of these facilities (such as discharge planners) can give to patients. It is not possible to estimate precisely how many pamphlets would meet this need, however, the Department can safely estimate 7,500 pamphlets based on the approximate number of individuals served in these settings in 2006. The cost of copying a tri-fold pamphlet is estimated at $2,472.
Section 7 of the bill also directs the Department to provide presumptive eligibility for Medicaid for individuals seeking HCBC services. The bill does not designate which applicants would be appropriate for presumptive eligibility in favor of letting the Department set criteria in administrative rules. The Department cannot project how many individuals would qualify for presumptive eligibility. For purposes of this fiscal note, the Department assumes that 50 applicants per month will be granted presumptive eligibility out of the approximately 300 to 350 applicants for Old Age Assistance (OAA) related Medicaid processed each month by Division of Family Assistance. In the ordinary course, the Department has 90 days (approximately 3 months) within which to determine someone eligible for Medicaid long-term care. In order to process claims during the presumptive period, the Department would need approximately $451,050 up front (50 individuals X average HCBC Monthly Cost of $3,007 X 3 months). The Department assumes that the intent is to pay for services during the presumptive period using state dollars, without federal matching funds under Medicaid. If the intent is to use a state and federal funding mix, the state will need to pursue a section 1115 waiver because federal Medicaid funds may only be used to provide presumptive eligibility for pregnant women and children under age 19. Offering presumptive eligibility would also require the Department to process every claim on such individuals twice. Once during the presumptive period during which claims will be paid with state-only dollars, and a second time once eligibility had been determined, so that federal dollars could be supplanted to the state fund from which the service was originally paid.
The Department states additional processing will demand additional transactions by workers as well as modifications to several computer systems, including but not limited to New HEIGHTS and the MMIS. The estimated cost of these modifications to New HEIGHTS is approximately $375,000. The approximate cost to the current MMIS (AIM) is $168,000, but this does not consider modifications that will need to be made to the new MMIS, Pharmacy Benefit Manager, or MDSS. It is not clear from the bill if county funds are intended to be used during the presumptive period. The bill provides that the state would bear the financial responsibility for services paid for during the presumptive eligibility period when the individual ultimately is not eligible for Medicaid. If individuals ultimately are not proven to be eligible for Medicaid, the bill permits the Department to pursue recoupment if there is evidence of fraud. Rule changes would be necessary to carry this out, as well as the potential of additional employees in the Office of Special Investigation which is the Departmental unit responsible for pursuing welfare frauds. The Department states it has seen no substantiation of the assertion that delay in processing applications results in increased placements in nursing facilities over HCBC, and accordingly is not able to factor these potential savings into the fiscal impact.