While long-term living facilities may face some challenges as a result of eventual healthcare reform legislation, two provisions in the House-approved bill could be beneficial by helping consumers obtain the resources needed to finance care and by providing supplemental payments to help facilities cover the cost of caring for Medicaid beneficiaries.

As approved by the House of Representatives November 7 and sent to the Senate, the Affordable Health Care for America Act (HR 3962) follows recommendations from the Medicare Payment Advisory Commission (MedPAC) to “encourage payment accuracy that more accurately reflects the costs of services provided,” according to the bill’s summary. It imposes a market basket freeze for the second, third, and fourth quarters of next year.

The summary also states that “nursing home transparency provisions provide regulators and families additional information on nursing home ownership and control, and more information on nursing home staffing and quality through Nursing Home Compare.”

In addition, tougher penalties would be imposed on nursing homes “that fail to provide adequate care to their residents and improved training for nursing home staff to increase quality of care,” the document adds.

However, recognizing the disparity between Medicare and Medicaid reimbursement rates, the bill provides for supplemental payments to nursing facilities with high percentages of Medicare and Medicaid residents that are efficiently and transparently operated and that provide quality care. A total of $6 billion would be available for such payments over the period 2010 through 2013.

The measure also directs the Medicaid and CHIP Payment Access Commission (MACPAC) to study the adequacy of Medicaid payments to nursing facilities and provide recommendations to Congress by December 31, 2011.

That provision was met with enthusiastic support by the American Health Care Association (AHCA), whose president, Bruce Yarwood, said it “represents a first step in acknowledging the nation’s chronic Medicaid underfunding crisis,” which he contended “shortchanges seniors’ nursing home care more than $4 billion annually.”

Yarwood said that “stability must be brought to the Medicaid program in order to protect the care of nursing home patients, and the jobs of frontline caregivers vital to the provision of quality care.”

The bill codifies the recalibration factor included in the FY2010 payment rule from the Centers for Medicare & Medicaid Services (CMS) for Medicare payments to skilled nursing facilities. It provides a “budget neutral” adjustment within the payment system to “improve payment accuracy” for nontherapy ancillary services and therapy services, directs the Department of Health and Human Services (HHS) to analyze payments for nontherapy ancillary services for inclusion in a future SNF case mix reclassification system, and creates an “outlier” payment for nontherapy ancillary services.

“The 23.9 billion, 10-year cuts contained in the (bill), coming on top of cuts of up to $16 billion to Medicare-funded nursing home care just put into effect by CMS October 1, will further destabilize our sector at a time when most governors across America are being forced to cut or freeze seniors’ Medicaid benefits and services,” Yarwood said. “Taken together, our sector, our patients, and our workforce face an unprecedented cumulative threat that can only be resolved by significantly reducing the level of Medicare cuts contained in this new bill.”

Yarwood said AHCA would continue its efforts to reduce those cuts as the health reform legislation continues its journey through the Senate and to President Obama for his signature.

“Because facilities devote a full 70 percent of operating expenses to wages, benefits, and other labor costs, Medicare and Medicaid funding stability from Washington equates to staffing stability and quality care locally,” he said. “The bottom line is that the steep Medicare cuts in the House bill will mean lost jobs in addition to compromised eldercare.”

However, the measure includes provisions long sought by the long-term care industry that will make it easier for Americans to finance long-term care.

The bill includes language, similar to that included in major legislation under consideration in the Senate, that would establish a national, voluntary insurance program to facilitate community living services and supports.

Those provisions come from the Community Living Assistance Services and Supports (CLASS) Act (HR 3001), which would provide individuals with a financing alternative for long-term services and supports that does not force them to become impoverished in order to be covered by Medicaid.

Working adults would be automatically enrolled in the program, unless they choose to opt out. Employees of companies that choose not to participate could enroll by another mechanism established by the government, such as mail-in coupons. Premium payments would be placed in a “Life Independence Account” on behalf of each eligible beneficiary and managed by HHS as a new insurance program.

Benefits would be paid out of a trust fund consisting of enrollees’ premiums and interest earned on its balances. Monthly premium amounts would be determined by HHS with the objective of maintaining solvency for 75 years. Those below poverty and full-time students would pay nominal premiums.

To qualify for benefits, individuals would have to be at least 18 years old and have contributed monthly premiums for at least five years. Eligibility will be limited to:

• Individuals who are unable to perform two or more activities of daily living, such as eating, bathing, dressing, or transferring.

• Individuals who have an equivalent cognitive disability that requires supervision or hands-on assistance to perform those activities, such as traumatic brain injury, Alzheimer’s disease, multiple sclerosis, or mental retardation.

People would receive benefits when they present a functional limitation of this type that is expected to last for a continuous period of more than 90 days. Individuals would receive a cash benefit based on the degree of disability or impairment, but payments would average no less than $50 per day.

The CLASS Act provisions would work in conjunction with other long-term services and programs such as Medicaid. It would not replace the need for basic health insurance or for long-term coverage through Medicaid or private long-term care insurance. It is intended to supplement this coverage by providing a mechanism to pay for nonmedical expenses that allow a person with a disability to remain independent. However, if an eligible person chooses to move into an institutional facility, CLASS Act benefits would be used to defray those associated expenses.

Robert Gatty

Robert Gatty has more than 40 years of experience in journalism, politics and business communications and is the founder and president of G-Net Strategic Communications based in Myrtle Beach, South Carolina. He can be reached at bob@gattyedits.com.