Proposed rule changes to ARChoices, a Medicaid program that includes in-home and community-based services for adults with physical disabilities and seniors, could affect local residents and businesses, an in-home health care agency representative said.
In 2016, the Arkansas Department of Human Services consolidated two Medicaid waiver programs (Alternatives for Adults with Physical Disabilities, for those 21 to 64 years old with a physical disability, and ElderChoices, for seniors 65 or older) into one program, ARChoices.
After the consolidation, DHS began using a new assessment system for potential beneficiaries. Prior to the consolidation, a DHS nurse would meet with applicants to the program and determine how many hours of home care they required. After the programs were joined, DHS switched to resource utilization groups, or RUGs, an algorithm which DHS said would assign hours more fairly and subjectively.
Soon after the implementation of the RUGs algorithm, Kevin de Libon, a lawyer with Legal Aid of Arkansas, a nonprofit which provides legal services to low-income Arkansans, filed suit with the agency on the behalf of several ARChoices beneficiaries whose benefits were reduced due to the RUGs algorithm.
“This was really devastating, because we had a lot of people come to us at Legal Aid, who had been getting eight hours a day of care, and now, really, the maximum you could get was five and a half,” de Libon said, adding that those who needed IV or respirator care could get up to six hours under the RUGs assessment. “You can have cerebral palsy, be totally limited, but be stable so that you don’t need one of those few kind of treatments, so the maximum you could get was five and a half hours of care.”
He said the cut in benefits had negative health consequences for ARChoices beneficiaries.
“It meant people were lying in their own feces; going without meals because their caregiver didn’t have time to make it; getting shut in more than they would have to normally; going without range of motion exercises to prevent muscle deterioration; they were getting bed sores because they couldn’t be turned often enough. Really awful stuff,” de Libon said.
A judge barred DHS from using the algorithm in May due to DHS not warning beneficiaries their benefits could be reduced. DHS then enacted an emergency rule which allowed them to continue using the RUGs algorithm. However, the judge in the suit held them in contempt of court for the continued use of the algorithm, saying the enactment of the rule was a manufactured emergency, according to the Arkansas Times.
Since then, DHS has set to work proposing new rules which they say will make the assessment process for beneficiaries more fair and uniform. However, local in-home care providers say these new rules could hurt beneficiaries and the businesses that support them.
“We want to think that the state made a mistake, you know? Because it’s so detrimental [to our clients],” said an in-home health care agency representative who asked that their name and business be withheld. “I would like for the public to know what’s going on and for this to be postponed until it can be studied and see if anything can be changed and still save money for the state.”
Grady Tracy, administrator for Champagnolle Landing Senior Wellness Center, said although they don’t cater to in-home patients, they do deliver meals to homebound seniors, which he said could potentially be affected by the new rule changes.
“We will have people at Champagnolle Landing, that come to the senior center, that live in the community, that will be impacted,” Tracy said. “We do deliver home meals to people that receive ARChoices, so when we get there we may know some of the impact. We may see some of the impact. … Arkansas is still considered one of the highest in the nation for senior food insecurity.”
The rule changes range from altering program applicants’ assessment process to changing the services care providers may provide and who may be a caregiver. For example, one rule change would disallow relatives from being compensated by Medicaid for providing care to their family members.
In a visit to El Dorado recently, Gov. Asa Hutchinson said reactions to that particular rule change have been less than positive and that the state would reconsider it after the public comment period ended Nov. 7.
“There’s a chance that will be adjusted,” Hutchinson said. “[The rule] hopefully will be adjusted.”
Marci Manley, chief deputy of communications for the Arkansas DHS, said the public comment period was enlightening and that DHS is now working on revising the rules that were set forth before the comment period.
“We take the feedback provided in the public comment period seriously, and we are currently working on a revised final rule, which we hope will address many of the concerns from stakeholders while weighing the responsibilities we have as a state agency,” Manley said.
The new assessment process increases the amount of questions an applicant will be subject to from 286 to 400. A registered nurse from a private company called Optum will conduct that assessment. Then, using that assessment, DHS will determine whether a person is eligible. A DHS nurse will also visit the applicant to determine a plan of care for them.
Hard budget caps have also been added by the new rules. Based on the level of care they need, people in the program will be placed into one of three budget categories: intensive, intermediate and preventative. Those needing intensive care will have a budget of $30,000 worth of services per year; intermediates will have $20,000 a year; and preventatives will get $5,000 per year. An algorithm will determine which budget category a person fits into.
De Libon said with the new budget caps, beneficiaries may not be able to pay for all the services DHS determines they are entitled to. In-home care providers currently charge Medicaid $18 an hour for services provided; at that rate, the caps would be reached before year’s end for those entitled to the maximum hours of care.
An algorithm will also determine where a person ranks in need for care in different activities of daily living (ADLs). ADLs are activities such as eating, bathing, grooming, using the bathroom, housekeeping, shopping and other related tasks. A person will be eligible for between five and 45 minutes of care in each ADL.
“They’ll add all that up and determine how many hours a day you get,” de Libon said. “So it operates in two ways. That latter one, they call that the Task and Hour Standard, that one can say you need eight hours a day of care. But you could be put into a budget category where you can’t afford to buy eight hours of care, where your budget will only allow you to buy four hours a day of care, or six hours a day of care. So, you see, it’s switching out one algorithm based system for another; one set of complexities for a different set of complexities. So now people are going to have to figure out what budget category they’re in, why they’re in that category and not another one and then they’re going to have to figure out how many hours a day of care they’re entitled to, why they’re entitled to that amount and not more or less and how many hours of that which they’re entitled to they can actually buy based on their budget.”
Manley said DHS received some public comments regarding the budget caps and assessment process, but that they have no plans to alter either of those at this time.
People currently in the ARChoices program will have their benefits grandfathered in for a year, so current beneficiaries will not be immediately affected by the budget caps. DHS has also made allowances for those whose situations change in the first year of the new rules, so that if they go over budget they will still receive all the care they are eligible for. Situation changes could include the death of a caregiver or release from a long-term facility, de Libon said.
One of the biggest changes in the new guidelines is a 21.7 percent funding cut for assisted living facilities, under the LivingChoices Medicaid program. Care providers worry that the cut could cause closures of assisted living facilities.
“This came from a meeting that assisted living people were in: they said their budget has been cut so drastically that they won’t be able to stay in business,” the in-home care agency representative said.
The Arkansas Times reported that at a public hearing for the rule changes, assisted living providers said the rule changes would be detrimental to the level of care people can be provided with and their health outcomes.
Manley said DHS is working to find a solution that both DHS and assisted living providers find acceptable.
“DHS recognizes the rate change for assisted living facilities … could pose a challenge to some providers,” Manley said. “Assisted living facilities receive two separate streams of funding for Medicaid clients. Every Medicaid client in assisted living must pay an amount for room and board that is calculated on the federal SSI (supplemental security income) rate … DHS is not proposing any changes to this amount. In addition, Medicaid pays the facility a daily rate for the care provided to the client by the facility. Under the proposed rule, this daily rate would decrease by an average of 21.7 percent.”
Additionally, the services a caregiver may provide have also been changed by the new rules. The in-home care provider said that under the new rules, unless an ARChoices beneficiary lives alone, they will not be allowed to receive help from a care provider with housekeeping; some will no longer be entitled to help with meal preparation; and all forms of companionship will be eliminated from people’s plans of care.
“You have a little old lady that has no one, the highlight of their day is that caregiver coming and visiting with them,” the in-home care representative said. “This program was designed for those people that meet nursing home criteria, but if they had just a little bit of help they could stay home rather than go to the nursing home.”
Manley said DHS has received public comments about the changes to the types of tasks caregivers may assist clients with and who may be a caregiver and that they are considering what changes may need to be made based on those comments.
“We believe that these changes incorporate our responsibility to ensure the health and safety of program participants, while allowing them an opportunity for services in the community and at home rather than an institution. At the same time, we have worked to balance those priorities with our responsibilities to the federal government’s requirements and the responsibility we have in ensuring we use taxpayer funds responsibly. Each of those factors were considered when developing the proposals,” Manley said.
The new rules were up for public comment for thirty days through Nov. 7. The rules must still be approved by a legislative committee before they become official. Manley said the revised rules would be finalized later this week. Most of the rule changes will go into effect on Jan. 1, though Manley said the funding cuts to assisted living facilities may be phased in over time.
To read the proposed rule changes, visit https://medicaid.mmis.arkansas.gov/General/Comment/Comment.aspx.
Caitlan Butler can be reached at 870-862-6611 or [email protected].