Under the provisions of the 21st Century Cures Act, states were mandated to implement EVV for Medicaid personal care services by January 1, 2020.
However, in May 2019, the Centers for Medicare & Medicaid Services (CMS) announced states could apply for a Good Faith Effort (GFE) exemption and defer EVV implementation for up to one year as long as they could demonstrate they made a good faith effort to comply and encountered unavoidable delays. With the exception of Tennessee, all states applied for a GFE exemption and received approval from CMS.
Earlier this year, Applied Self-Direction, an organization that provides practical expertise for self-direction programs, hosted a webinar examining the reasons behind states’ delays to EVV implementation. The ASD webinar and the CMS-issued approval letters were both released before the onset of the COVID-19 pandemic. While delays were already apparent before COVID-19, due to the challenges posed by the virus, many states have delayed their implementation efforts altogether. Some states, such as Florida, are not requiring providers to submit claims through the EVV system, though they must continue to verify the delivery of services using EVV to the fullest extent possible. In this blog post, HHAeXchange will take a closer look at those challenges with insights from our team of dedicated homecare experts.
To examine the reasons behind states’ delays in EVV implementation, Applied Self-Direction (ASD) completed an in-depth review of all the GFE approval letters published by CMS, which are available here on the CMS website.
With 49 states and DC receiving approvals for GFE exemptions, there was clearly a universal need for additional time in order to implement EVV. Note, however, that requesting and receiving an extension does not mean that these states haven’t already started implementing, or don’t plan to implement, EVV before January 2021.
ASD members were polled as to whether they felt the states they were assigned to would be fully implemented by the new deadline. Below are their responses:
The varying responses from Financial Management Services (FMS) providers reflect the fact that states face different challenges in implementing EVV and some may be more impacted by certain obstacles than others.
In their requests to CMS for GFE exemptions to delay EVV, states were required to list their reasons for needing an extension. ASD analyzed the reasons cited in the CMS-issued approval letters and found the following to be the most commonly noted:
Prolonged RFP Process
Competing State Priorities
Provider Engagement and Training
Stakeholder Engagement and Training
Responding to Stakeholder Feedback
Accommodating Unique Issues of Self-Direction
Adjusting to Guidance Released by CMS
Complexity of Coordinating with Numerous Agencies
Issues Identified in Implementation
Coordinating with FMS Providers
Negotiations with Unions
Implementing a New Waiver
ASD members also reported their concerns regarding issues reported by the states:
According to the GFE letters, 21 states cited a prolonged RFP process as a main reason for delay. ASD noted obstacles such as protests prior to awarding a contract; the need to incorporate stakeholder feedback; the volume of questions from potential vendors, prolonged contract negotiations, and veto of a budget bill as contributing factors.
ASD noted that states that have yet to begin the RFP process should expect delays. Completing an RFP process is an early step in EVV implementation, and future complications are bound to arise, such as those involving technology.
Among all of the states that cited concerns about technology in their letters to CMS, the most common technology issue reported was “system interoperability”.
According to the Cures Act, the term ‘interoperability’ means health information technology that – “(A) enables the secure exchange of electronic health information with, and use of electronic health information from, other health information technology without effort on the part of the user; “(B) allows for complete access, exchange, and use of all electronically accessible health information for authorized use under applicable State or Federal law; and “(C) does not constitute information blocking as defined in section 3022 (a).”
The need for custom configuration was also noted by a handful of states. “Every state Medicaid Agency is designed to support the unique needs of their specific stakeholder populations, and is governed not only by federal laws but also state-specific legislation,” said Kimberly Glenn, Senior Vice President of Government Health Plans at HHAeXchange. “This allows each state agency to select vendors and systems to better serve their members, but also brings with it some difficulties for integration and interoperability. Successful integration in one state in no way means that same configuration will be a simple plug and play solution for the next state, especially given only a handful of EVV systems have been deployed at the state level to date.”
Glenn continued, “To succeed in this space, EVV vendors will have to provide some degree of configuration but cannot be a completely customizable offering. In order to achieve this balance and avoid technology issues, businesses should look to vendors with open API interfaces, powerful business rules engines, and a strong and thorough test plan. From the State’s end, the challenge lies in the availability of resources and a timeline often governed by federal deadlines. Early adoption is critical to not only allow for proper testing and configuration, but also to engage stakeholders and increase buy-in to reduce provider abrasion.”
Fourteen states were challenged by balancing EVV implementation with competing state priorities, such as:
Other CMS/Medicaid Initiatives, including Medicaid Expansion, CMS Corrective Action Plan (CAP) recommendations
Managed care transitions
Technology investments, including modernization of Medicaid Management Information System (MMIS)
Response to other issues such as natural disasters and the opioid crisis
These obstacles are also closely related to staffing and budget limitations, ASD noted.
Among states that were held back in their EVV implementation by budget limitations, several noted that their funding hinged on state legislation. The overall start-up and maintenance costs of EVV implementation can be difficult for states to predict, and for some is still unknown.
Many states said they needed more time to proactively conduct outreach to providers, while in other states, providers were slow to implement EVV or needed more time for training to address technical issues and other problems. The nature of provider issues seems to vary in states and is heavily dependent on their chosen EVV implementation model.
Nine states cited various idiosyncratic state processes that have drawn out EVV implementation, such as:
Lengthy RFP/project approval process
Mandatory timeframe for budget approval
Promulgation process for regulations
Several states needed additional time to gather feedback from stakeholders to inform EVV implementation and to train them to participate in EVV. Outreach to participants has been time-intensive and often requires a more hands-on approach than expected. In New Jersey, for example, the state specifically sought more time to allow outreach to individuals who self-direct their services.
When states engage stakeholders, they often learn new information that may cause delays in implementation. Several states had already engaged stakeholders for feedback and needed to delay implementation to allow time to respond to stakeholder issues such as concerns around onboarding, training, or policy, and changes to EVV business requirements.
For example, in New York, the state sufficiently demonstrated that it had made a good faith effort to comply with EVV requirements of the 21st Century Cures Act by completing a statewide environmental scan and issuing a Request for Information (RFI).
“Through these and other stakeholder engagement activities, such as regional listening sessions and the creation of an EVV webpage and email inbox, the State published a summary of the feedback in an EVV Stakeholder Convening Report,” said Andrew Segal, former Director of the Division of Long Term Care in New York State. “In its Good Faith Effort exemption request to CMS, the State cited unavoidable delays in implementing its EVV system, including additional time needed to conduct a survey and three rounds of follow-up to adequately assess providers´ EVV awareness and implementation status, and ensure the State is able to obtain input from a full range of stakeholders.”
ASD has heard that some states are implementing EVV in traditional services before rolling out to self-directed programs. Therefore, they expect some states to encounter additional delays as they roll-out EVV with self-direction programs in the coming year. Additional delays related to self-direction may include the need to develop an alternate EVV solution as a result of CMS’s August 2019 guidance on web-based electronic timesheets, additional software testing and training required, and implementing workaround for self-directed individuals who do not have access to cell phones and/or computers.
Seven states noted “staffing limitations” such as staff turnover, competing priorities for a small staff, limited budget to make new hires, and staff vacancies as delays to EVV implementation. In some states, there may only be one or two people focused on EVV, which indeed poses a challenge.
While implementing EVV takes time, the benefits are worth it. In addition to Cures Act compliance, states that successfully implemented EVV have achieved a reduction in fraud, waste, and abuse; streamlined operations; improved member care, and more.
If you still have questions about EVV, HHAeXchange is here to help. We are the leading homecare management platform with the most advanced EVV capabilities in the market. To learn more about HHAeXchange can help you meet your state’s EVV deadline, schedule a demo.
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