Revision: March 16, 2023, 11:27 a.m.
Sen. Birdsell, Dist 19
Sen. Bradley, Dist 3
Sen. Whitley, Dist 15
Sen. Gannon, Dist 23
March 15, 2023
2023-1015s
05/10
Floor Amendment to SB 36-FN
Amend the bill by replacing all after the enacting clause with the following:
1 Statement of Findings. The general court hereby finds that:
I. The state of New Hampshire is ranked as having one of the fastest growing number of older adults in the country.
II. As the number of older adults increases, the need for long-term care will increase.
III. Pursuant to the federal Older Americans Act, New Hampshire is required to promote the development and implementation of comprehensive, coordinated, statewide system of long-term services and supports that is responsive to the needs and preferences of older individuals and their family caregivers.
IV. The federal Americans with Disabilities Act prohibits unnecessary institutionalization of individuals with disabilities.
V. RSA 151-E was established to provide Medicaid eligible elderly and chronically ill adults with a continuum of long-term care options.
VI. Despite these federal and state mandates, historically there has been a lack of investment in our state’s system and programs for older adults and adults with disabilities.
VII. Rebalancing New Hampshire’s systems to expand more home and community-based options will reduce the cost of providing services and allow our state to serve more people.
2 New Subdivision; Long-Term Care; System of Care for Healthy Aging. Amend RSA 151-E by inserting after section 21 the following new subdivision:
System of Care For Healthy Aging
151-E:22 Purposes. The purposes of this subdivision are to:
I. Build upon existing infrastructure to establish a comprehensive and coordinated system of care to ensure that older adults and adults with disabilities have access to and timely delivery of supports and services and to ensure that they have a meaningful range of options.
II. Reduce the cost of providing long-term care by expanding the availability of less costly home and community-based services.
III. Require the department of health and human services to expand and improve access to home and community-based services for older adults and adults with disabilities in alignment with New Hampshire’s state plan on aging, the federal Older Americans Act, Americans with Disabilities Act, and Medicaid law.
IV. The system of care referenced in this subdivision is meant to streamline access to long-term care supports and services and not intended to expand eligibility for any current Medicaid programs, including long-term care Medicaid or any home and community-based Medicaid waiver programs.
151-E:23 Statement of Policy. It is the policy of New Hampshire to establish and implement a comprehensive and coordinated system of care that promotes healthy aging and enables older adults and adults with disabilities to have a meaningful choice in care options, including the ability to receive the care they need in their homes and communities.
151-E:24 Definitions. In this subdivision:
I. “Disability” means a physical or mental impairment that substantially limits one or more major life activities.
II. “Home and community-based services” means a range of medical and supportive services provided to persons in their own homes or other community-based settings including, but not limited to, adult day programs, and assisted living.
III. “Long-term services and supports” means a variety of services provided in both facilities and community-based settings designed to meet a person's health or personal care needs to help them live as independently and safely as possible when they can no longer perform everyday activities on their own.
IV. “Older adult” means an individual who is 60 years of age or older.
V. “System of care” means:
(a) A comprehensive and coordinated delivery system for the provision of long-term services and supports to New Hampshire’s older adults and adults with disabilities.
(b) The system of care is intended to provide services to all older adults and adults with disabilities who require long-term services and supports.
(c) The system of care shall have the following characteristics:
(1) A comprehensive array of long-term services and supports including, but not limited to, personal care, homemaker services, transportation, meal delivery or preparation, emergency response systems, adult day care, and family caregiver support to enable older adults and adults with disabilities to remain independent and in the setting of their choice.
(2) An absence of significant gaps in services and barriers to services.
(3) Sufficient administrative capacity to ensure quality service delivery.
(4) Services that are consumer-driven, community-based, and culturally and linguistically competent.
(5) Transparent, with information made available and known to consumers, providers, and payers.
(6) A funding system that supports a full range of service options.
(7) A performance measurement system for accountability, monitoring and reporting of system quality, access and cost.
151-E:25 Duties of Commissioner of the Department of Health and Human Services. The commissioner of the department of health and human services shall:
I. Modify the policies and practices of the department of health and human services necessary to implement this subdivision, to the extent possible within existing statutory and budget constraints.
II. Coordinate the plans and activities of the commissioner with the bureau of elderly and adult services, the bureau of family assistance and division of long-term supports and services to implement the system of care and reduce duplication of efforts across divisions and bureaus within the department.
III. Develop a plan for full establishment and maintenance of a system of care. Such plan shall be reviewed annually and amended or modified as needed. It shall include sufficient detail to allow compliance with the reporting requirements of RSA 151-E:27 as applicable and shall address at least the following elements:
(a) System capacity, including workforce sufficiency.
(b) Federal funding participation, including but not limited to, Medicaid waivers and plan amendments.
(c) Changes to statutes, administrative rules, and structure of appropriations, and department policy, practice and structure.
(d) Projections of cost savings from increased service effectiveness and reductions in costly forms of care and use of such savings to close existing gaps in long term care services.
(e) Recommended modifications to law, practice, and policy to prepare for and accommodate the participation of privately funded service providers in the system of care.
(f) Changes to rates for the Choices for Independence program in accordance with section 1902(a)(30)(A) of the Social Security Act and requirements for Medicaid home and community-based waiver programs under section 1915(c).
IV. Beginning no later than January 1, 2025, begin adjusting rates for the Choices for Independence waiver consistent with the rate study, assuming funds are available. Any unspent funds allocated to the Choices for Independence program shall be non-lapsing and shall be used for service provision for the Choices For Independence program.
V. On or before September 30, 2024, submit a waiver request to the Centers for Medicare and Medicaid services or implement an alternative method to establish a robust presumptive eligibility process for Medicaid home and community-based waiver services, including a mechanism for third party participation.
VI. Improve functionality of the NH EASY system for individuals applying for services and provide additional trainings for professionals who frequently assist people applying for services and develop associated performance metrics.
VII. Ensure applications for Medicaid long-term services are user friendly and processed in a timely manner and develop performance metrics to measure these attributes.
VIII. On or before June 30, 2025, maintain an online portal for providers, case managers, navigators and other long-term care service providers to enable them to easily identify and access available long-term care services and supports for older adults and adults with disabilities. The portal functions required by this section may be assigned to an entity that has responsibilities in addition to those required by this section. The portal shall contain the following information:
(a) A current list of home and community-based care waiver service providers accepting new clients, including links to websites and contact telephone numbers, organized by region that is updated on a weekly basis.
(b) Non-Medicaid resources to support the cost of home and community-based services.
(c) Referral information for legal service organizations.
(d) Guidance regarding family navigation of hospital discharge protocols and options.
IX. On or before June 30, 2025, create a public facing online dashboard to track home and community-based waiver services data, including, but not limited to, results of any performance measurement assessments, waiver services authorized but not paid, current wait times for receiving waiver services and the number of people from institutionalized care into the community.
151-E:26 Person-Centered Counseling Program. The department shall:
I. Create a new person-centered counseling program in each contracted aging and disability resource center (ADRC) to provide support and assistance to persons living at home or in short or long-term institutional settings, including hospitals, to transition into community-based settings. The program shall include referrals and support to access, at a minimum, but not limited to: assistance with completing Medicaid applications, discharge planning, referrals and access to Title III-B and Title XX services and programs, referrals and access to community-based services, housing, and other supports and services to meet the needs of the individual and their family. These services shall not replace or duplicate targeted case management services described in RSA 151-E:17.
II. Increase operational capacity in each ADRC to enable the provision of person-centered counseling services for adults, including but not limited to, educating consumers about available community-based resources for long-term services and supports, assistance with completing Medicaid applications, and assistance with the transition to access such services.
III. Establish performance metrics for each contracted information and referral resource center to assess each office’s ability to provide the services contained in this section.
151-E:27 System of Care Implementation and Reporting Requirements.
I. When preparing the biennial budget for the Choices for Independence program, the department shall prepare data showing the amount program provider rates would be increased to be in alignment with the rate plan as completed by the department.
II. The department shall review and propose rates for the Choices for Independence program in accordance with section 1902 (a)(30)(A) of the Social Security Act and requirements for Medicaid home and community based waiver programs under section 1915(c). The department shall provide a report to the house health, human services and elderly affairs committee and senate health and human services committee, the house finance committee, the senate finance committee and the joint legislative committee on health and human services established in RSA 126-A:13 on or before July 1, 2024. The focus of the rate study is to promote efficiency, economy, quality of care and access to services within New Hampshire’s Choices for Independence program. The rate study shall establish reimbursement methodologies utilizing the U.S. Centers for Medicare and Medicaid Services Market Basket Index as an inflation benchmark for rate-setting purposes. The department shall seek input from Choices For Independence beneficiaries, providers, and other stakeholders in regard to access to Choices For Independence services in future rate setting processes. Information regarding access to services shall be publicly documented and shall be considered in the subsequent rate-setting process.
III. On a biennial basis, the department shall perform a financial review to determine whether ADRC offices are receiving sufficient funding to maintain their operations and make legislative budget requests if additional funding is warranted.
IV. Beginning November 1, 2023, and annually thereafter, the department shall report to the governor, the state commission on aging established in RSA 19-P:1 and the joint legislative committee on health and human services established in RSA 126-A:13. The report shall provide detailed information regarding the status of the implementation of this subdivision.
V. Beginning in 2024, the report shall address the following:
(a) The total cost of Medicaid long-term care services and Choices for Independence program services.
(b) The extent to which the state's long-term care support and services systems are consistent with a system of care.
(c) A description of any actual or planned changes in department policy or practice or developments external to the departments that will affect implementation of a system of care.
(d) Any other available information relevant to progress toward full implementation of a system of care.
(e) The result of pilots regarding access with the counties.
(f) A review of options to enhance the system of care.
(g) Presumptive eligibility findings and recommendations for next steps.
(h) The status of changes to the NH Easy application system and any additional enhancements needed.
(i) The status of reimbursement rates and rate study.
VI. Beginning in 2025, the report shall also address the following:
(a) Identification of those actions which will be required to maximize federal and private insurance funding participation in the system of care, along with target dates for completion.
(b) Identification of changes to statutes, administrative rules, policies, practices, and managed care and provider contracts which will be necessary to fully implement the system of care.
(c) Identification of significant gaps in the array of long-term care supports and services for older adults and adults with disabilities, along with a description of plans to close those gaps.
VII. Beginning in 2026, the report shall also address the following:
(a) Projections of future demand for services in the system of care.
(b) Identification of shortfalls in workforce sufficiency affecting full implementation of the system of care and plans for addressing those shortfalls.
(c) Identification of specific plan amendments and other changes to the Medicaid system required for full implementation of the system of care and plans for making those changes.
(d) Numbers of older adults and adults with disabilities waiting services in various categories.
VIII. Beginning in 2027, the report shall also address the following:
(a) Detailed statistical information regarding older adults and adults with disabilities serviced, along with demographic characteristics, service need and provision, involvement in service systems, service funding sources, and placement or other site of service provision.
(b) Financial information, including but not limited to measures of cost-effectiveness, comparisons with other states with regard to levels of funding from federal, state, local, and private sources, and cost savings resulting from service coordination and effectiveness.
(c) An assessment of any influences external to the department of health and human services, including configuration of the private long-term care health care system, which may be affecting establishment of the system of care.
3 Appropriations; Department of Health and Human Services; System of Care for Healthy Aging.
I. For the purpose of developing a plan to establish and maintain the system of care for healthy aging as described in RSA 151-E:25, III, a sum not to exceed $50,000 for the biennium ending June 30, 2025, is hereby appropriated to the department of health and human services. The appropriation shall be nonlapsing and may be used to engage outside qualified and experienced vendors to assist in the production of the plan. In addition to the appropriation and notwithstanding RSA 14:30-a, the department may accept and expend matching federal funds without prior approval of the fiscal committee of the general court. The governor is authorized to draw a warrant for the general fund portion of said sum out of any money in the treasury not otherwise appropriated.
II. For the purpose of developing and implementing the online portal, dashboard, and data collection systems described in RSA 151-E:25, VIII and IX, a sum not to exceed $100,000 for the biennium ending June 30, 2025, is hereby appropriated to the department of health and human services. The appropriation shall be nonlapsing and may be used to engage outside qualified and experienced vendors to assist in the production of the dashboard and data collection. In addition to the appropriation and notwithstanding RSA 14:30-a, the department may accept and expend matching federal funds without prior approval of the fiscal committee of the general court. The governor is authorized to draw a warrant for the general fund portion of said sum out of any money in the treasury not otherwise appropriated.
III. For the purpose of enabling the department to complete the reporting requirements described in RSA 151-E:27, a sum not to exceed $150,000 for the biennium ending June 30, 2025, is hereby appropriated to the department of health and human services. The appropriation shall be nonlapsing and may be used to engage outside qualified and experienced vendors to assist in the production of reports in 2024 and 2025. In addition to the appropriation and notwithstanding RSA 14:30-a, the department may accept and expend matching federal funds without prior approval of the fiscal committee of the general court. The governor is authorized to draw a warrant for the general fund portion of said sum out of any money in the treasury not otherwise appropriated.
4 Appropriation; Department of Health and Human Services; Person-Centered Counseling Program. The sum of $1,197,600 for the biennium ending June 30, 2025, is hereby appropriated to the department of health and human services for the purpose of funding the person-centered counseling program established in RSA 151-E:26. Said funds shall be nonlapsing. In addition to the appropriation and notwithstanding RSA 14:30-a, the department may accept and expend any federal funds available for the purposes of the counseling program without prior approval of the fiscal committee of the general court. The governor is authorized to draw a warrant for the general fund portion of said sum out of any money in the treasury not otherwise appropriated.
5 System of Care and Peer-Centered Counseling; Staffing; Classified Positions Established.
I. The following classified positions are established in the department of health and human services to support the person-centered counseling program established in RSA 151-E:26:
(a) Program Specialist III (Labor Grade 23, Step 5); and
(b) Program Specialist IV (Labor Grade 25, Step 5).
II. The sum of $190,000 for the biennium ending June 30, 2025, is hereby appropriated to the department of health and human services for the purpose of funding the positions established in paragraph I. In addition to the appropriation and notwithstanding RSA 14:30-a, the department may accept and expend matching federal funds without prior approval of the fiscal committee of the general court. The governor is authorized to draw a warrant for the general fund portion of said sum out of any money in the treasury not otherwise appropriated.
III. The commissioner of health and human services, to the extent possible, shall fill available vacant classified positions as necessary to implement the system of care for healthy aging established in section 2 of this act, including additional staffing to perform rate setting, streamlining of application process, creation and maintenance of public facing dashboard and online portal for providers, updating of performance measures and other required activities.
6 Personal Care Services; Definition of Personal Care Services Provider. Amend RSA 161-I:2, XII to read as follows:
XII. "Personal care services provider" means a person who:
(a) Is selected by:
(1) The eligible consumer;
(2) The eligible consumer's legal guardian;
(3) The eligible consumer's representative; or
(4) A person granted power of attorney by the eligible consumer; and
(b) Is employed by a home health agency or other qualified agency to provide personal care services; and
(c) Is not:
(1) The eligible consumer's legally responsible relative, except as authorized pursuant to RSA 161-I:3-a;
(2) The eligible consumer's legal guardian, except as authorized pursuant to RSA 161-I:3-a;
(3) The eligible consumer's representative; or
(4) A person granted power of attorney by the eligible consumer, except as authorized pursuant to RSA 161-I:3-a.
7 Personal Care Services; Authorization of Legally Responsible Relative. Amend RSA 161-I:3-a to read as follows:
161-I:3-a Authorization of Legally Responsible Relative, Guardian, or Person Granted Power of Attorney. The department may authorize reimbursement to a legally responsible relative, a guardian, or a person granted power of attorney by the eligible consumer, who provides personal care to an eligible consumer with special health care needs residing at home. Such reimbursement shall occur only when the department determines that the needs of the eligible consumer, the unavailability of appropriate providers or suitable alternative care services, and cost efficiencies make utilization of a legally responsible relative, guardian, or person granted power of attorney by the eligible consumer, for the provision of such services necessary and appropriate. Reimbursement shall be limited to care that is medically necessary due to specific health needs and shall not be made for care generally expected and provided by a legally responsible relative, guardian, or person granted power of attorney by the eligible consumer. The department shall not authorize reimbursement to a legally responsible relative, guardian, or person granted power of attorney by the eligible consumer, until a plan and rules adopted pursuant to RSA 541-A, are reviewed and approved by the oversight committee on health and human services, established in RSA 126-A:13.
8 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 [information and referral] aging and disability resource centers that provide information and referral services to [elderly and chronically ill adults] older adults and adults with disabilities. The [information and referral] aging and disability resource center network established under this section shall not be used for the purpose of political advocacy, but may inform and educate the general court regarding the extent of services available as well as the unmet needs in the community.
9 New Section; Personal Care Services; Financial Eligibility for Adult Home and Community-based Care Waiver Programs. Amend RSA 167 by inserting after section 4-e by the following new section:
167:4-f Financial Eligibility.
I. Financial eligibility for Medicaid adult home and community-based waiver programs shall include the following resource limits:
(a) For married individuals, revert to the standard in place prior to the passage of the federal Affordable Care Act, so that only the resources in the name of the applicant, and not the resources in the name of the applicant’s spouse are counted for purposes of determining Medicaid resource eligibility; and
(b) For single individuals, establish a resource disregard of $6,000, which would have an effective resource limit of $7,500.
II. Department of Health and Human Services; Resource Disregard Enhancement Authority; Rulemaking. Pursuant to RSA 161:4-a, the department of health and human services shall enter into rulemaking, subject to the Centers for Medicare and Medicaid Services (CMS) approval as necessary, to revert the resource standard for married persons prior to the passage of the Affordable Care Act and increase the resource disregard to a maximum of $6,000 for individuals seeking nursing facility services or home and community based care under state waivers established under section 1915(c) of the Social Security Act.
10 Department of Health and Human Services; Eligibility for Assistance. Amend RSA 167:4, I(b) to read as follows:
(b) To the extent permissible under federal law, in the case of an applicant for public assistance or medical assistance who has made an assignment or transfer of assets to an individual for less than fair market value within [60] 36 months, or for up to 60 months if deemed necessary by the department based upon case specific information or extenuating circumstances, or in the case of transfers of real estate, or transfers of assets to a trust or portions of a trust that are treated as assets disposed of by the individual within [60] 36 months, or for up to 60 months if deemed necessary by the department based upon case specific information or extenuating circumstances, immediately preceding the date of application or while the application is pending, or in the case of a recipient of public assistance or medical assistance who makes such an assignment or transfer while in receipt of the assistance, the assistance sought shall only be granted or continue to be granted in accordance with rules establishing restrictions and eligibility criteria for such cases as adopted by the commissioner of the department of health and human services under RSA 541-A, subject to applicable federal regulations and waiver approval, if any, and review by the oversight committee on health and human services, established in RSA 126-A:13. The oversight committee on health and human services shall make a report to the legislative fiscal committee which shall have final approval authority.
11 Effective Date. This act shall take effect July 1, 2023.
2023-1015s
AMENDED ANALYSIS
This bill expands the state's systems of care for healthy aging, increases access to home and community based services, establishes person-centered counseling programs through aging and disability resource centers, and makes appropriations to the department of health and human services for these purposes.