The Centers for Medicare & Medicaid Services (CMS) recently finalized the Ensuring Access to Medicaid Services rule. The rule is meant to be a significant step in reforming Medicaid’s framework to improve both access to and quality of care. It addresses many aspects of Medicaid services, from payment structures to quality assessments and stakeholder engagement. Yet, it’s not without controversy. In particular, the 80-20 provision has sparked dialogue within the homecare sector. Here we’ll explain what’s included in this new rule and explore the implications for homecare agencies. 

Overview of the Final Rule  

According to CMS, the goal of this rule is to increase access to care and quality of care, and improve health outcomes for Medicaid beneficiaries across fee-for-service (FFS) and managed care delivery systems, including home- and community-based services (HCBS). To increase transparency and accountability, the rule addresses the following key areas: 

  • Enhanced Payment Transparency: States must make Medicaid fee-for-service (FFS) payment rates publicly available and regularly update them. This aims to ensure that payment rates are sufficient to attract enough providers to offer quality care. 
  • Direct Care Worker Compensation (“80-20” Provision): At least 80% of Medicaid payments for personal care, homemaker, and home health aide services must go directly to compensating direct care workers. This controversial provision looks to improve wages and reduce turnover among caregivers, although it’s sparked debate about its impact on agency operations, especially for smaller providers. 
  • Advisory Groups: The establishment of advisory groups, including direct care workers and beneficiaries, is mandated to consult on Medicaid operations and payment rates. This inclusion aims to ensure that a wide range of stakeholders can have a say in how Medicaid services are administered. 
  • Quality and Incident Management: The rule requires states to report on quality measures for HCBS and to establish incident management systems to track and address issues in care delivery. This will help maintain high standards of care and ensure quick responses to any service failures. 
  • Grievance Systems: States must implement grievance procedures for Medicaid beneficiaries, enabling them to file complaints on the adequacy of person-centered planning and service compliance. This supports beneficiaries in having a direct channel to express dissatisfaction and seek resolutions. 
  • Reporting and Performance Metrics: There are new mandates for states to report on various performance metrics, such as the timeliness of service delivery and the effectiveness of their HCBS programs, enhancing accountability and program evaluation. 

Controversy Surrounding the “80-20” Provision  

While the “80-20” provision has been celebrated for its potential to improve compensation for caregivers, it has also been met with significant concern from homecare agencies. These agencies worry about the financial feasibility of dedicating such a large portion of Medicaid reimbursements directly toward homecare worker wages.  

Some within the industry fear it could lead to operational difficulties and possibly force smaller providers out of business. 

“The negative impacts to patient access nationally will be swift and severe.” said Jason Lee, CEO of the Home Care Association of America, in remarks released by the association. “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 proposed rule.” 

Even though this provision is meant to improve the caregiver shortage challenges that have long plagued the homecare industry, many believe that it will do the opposite. The Home Care of Assocaiation of America stated, “The imposition of this rule will only serve to further hamper our efforts to recruit and retain the caregiving workforce… it will force providers to cut the supports that they currently pay for out of their own pockets: services such as training, career advancement, supervision, and oversight and recognition programs.” 

Yet, not everyone sees this provision as bad news. David Grabowski, PhD, professor of healthcare policy at Harvard Medical School, expressed how he believes this provision will decrease turnover and improve care in McKnights Senior Living. “Currently, there is a long waiting list in most states for HCBS,” Grabowski said. “The hope is that this policy will translate to hiring more workers and paying existing workers higher wages. This should lead to shorter wait times and more comprehensive care for Medicaid recipients.” 

Homecare providers who anticipate that the 80-20 provision will negatively impact their business should not panic just yet. Experts expect that there will be a four-year “runway” to become compliant with the rule, and within those four years there is expected lobbying and even perhaps legal action that may take place. 

A Shift for Medicaid 

Regardless of whether those within the homecare industry view these changes as beneficial or harmful, one thing remains true: the Ensuring Access to Medicaid Services rule is a landmark shift in Medicaid administration. As many have stated, the intentions for this rule are positive, and most agree that we must improve caregiver compensation, service quality, and stakeholder involvement. Our hope at HHAeXchange is that as implementation unfolds, there will be ongoing dialogue between CMS, homecare providers, caregivers, and beneficiaries to address the valid concerns that exist, and ensure the rule fulfills its goal of enhancing Medicaid services effectively. 

For more detailed information and updates on the rule, stakeholders are encouraged to visit the CMS official page on the Ensuring Access to Medicaid Services final rule here