Health officials in Gov. Ron DeSantis’ administration have said federal approval of more than $1.1 billion in increased federal Medicaid funds for home and community-based services is “imminent.” But the state won’t say how it plans to distribute the majority of those funds to the direct service providers who care for the elderly and people with intellectual and developmental disabilities.
The ambiguity comes when Medicaid direct service providers are struggling to keep up with new increased minimum wage requirements and attract a future workforce willing to assist with daily activities that can keep patients living in the community, not in institutional care.
At press time, the Centers for Medicare and Medicaid Services still had not signed off on Florida’s proposal to spend $1.1 billion in additional federal funds. The DeSantis administration took advantage of the temporary 10% increase in federal matching funds Congress made available to states to bolster the infrastructure for home and community-based services under the American Rescue Plan. A state plan review shows Florida wants to target about 66% of the new funding, or about $622 million, for increased payments to the home and community-based service providers that care for about 108,000 people.
Most of those people are enrolled in either the iBudget program, designed for people with developmental and intellectual disabilities, or the statewide Medicaid-managed long-term care waiver program, which is meant for older adults who qualify for nursing home placement.
While home and community-based service providers offer similar services to those two groups, direct care providers generally work with Medicaid iBudget clients, or they work with long-term care clients.
Both Medicaid waiver programs allow people to get help with daily living activities, such as bathing, preparing meals and eating. Having those services delivered to them at home can keep the Medicaid beneficiaries from being institutionalized.
How the state plans to divide the money between the two waiver programs and the direct care providers at the heart of the programs isn’t clear.
The Agency for Health Care Administration did not respond to questions from Florida Politics regarding how much of the $622 million for enhanced payments would be used for iBudget providers and how much would be used in the long-term care program. Moreover, AHCA didn’t say whether it would use the Medicaid managed care organizations to disburse the funds to direct care providers who work with managed long-term care clients.
Florida Medicaid officials have submitted three different documents to the Centers for Medicare and Medicaid Services explaining how the state plans to use the additional federal dollars. The documents don’t indicate how the enhanced federal funding will flow from the state’s coffers to the direct care providers who work with the Medicaid waiver clients.
In a July document summarizing the state’s proposal to use federal dollars, Florida Medicaid Director Tom Wallace said the state will direct $356 million in one-time stipends to home and community-based service waiver providers. But there are no criteria the providers must follow for the distribution of funds. The document indicates providers can set their criteria.
Another $266 million in new federal funding will be directed to all home and community-based service providers to recruit and retain workers. But again, there is no additional information.
“Suffice to say, a lot of people are very, very interested,” Jim DeBeaugrine, a former secretary at the state Agency for Persons with Disabilities turned lobbyist, told Florida Politics.
DeBeaugrine said state Medicaid officials should meet with all home and community-based service providers who work with waiver clients and have what he called “good, old-fashioned communication.”
“At the end of the day, that’s just good business practice,” DeBeaugrine said.
A candid conversation would help the state avoid any potential wrangling over the distribution of the funds, which could slow things down.
“There’s an urgency to this and the urgency is not based on future need as much as it’s based on past damage that has occurred that nobody could help,” DeBeaugrine said.
Bishop Grady Villas in Orlando offers a variety of services that are covered by the iBudget waiver program for people in Central Florida. Executive Director Kevin Johnson said 39 percent of the positions he needs to operate the organization are vacant, forcing him last month to make the difficult decision to cut off services to new clients. The decision, ironically comes at a time when the state is increasing funding for the iBudget program and taking people off the waitlist.
Johnson has, since 2008, relied on outside fundraising in order to bolster the state Medicaid reimbursement rates and increase salaries for his staff.
On average, Johnson has for the last five years collected an average $600,000 annually through fundraising. Johnson was able to raise $750,000 in 2020, but the COVID-19 pandemic, he said, has been a game changer.
“It’s been a growing problem, but now it’s just a whole different job market, people have higher expectations. Local employers are more competitive. For us, that’s the biggest challenge. Also, the work we do is frontline. People were concerned about exposure during the pandemic. People were worried about vaccination.”
Because the organization is understaffed it has paid overtime to those who staff on board overtime. In September it became too much and Johnson decided to stop taking new clients.
While Johnson said he has the available funding in his budget to make special payments to staff he said he doesn’t want to jump the gun making payments before final CMS approval. Additionally he doesn’t want to make payments before understanding what qualifies for the increased federal reimbursement.
“It’s a concern not knowing and waiting, because you can only wait so long,” he said.”The flip side is as much as it can be a Band Aid to this problem right now, it’s not going to be a solution without further commitment from the Legislature to fund increased rates. And, of course, the support of the governor to allow those to proceed as well.”
Tyler Sununu, president and CEO at Florida Association of Rehabilitation Facilities, agrees. Sununu says his top priority for the upcoming 2022 legislative Session is to convince lawmakers to increase payments for services such as adult day care, residential habilitation and other home and community based services provided to clients on the iBudget program.
Meanwhile, communication with the Medicaid managed care industry also has been lacking. Florida contracts with Medicaid-managed care plans for the delivery of long-term care services.
Once enrolled in the program, people can access long-term care benefits meant to keep them out of nursing homes. A Department of Elder Affairs document shows the list of home and community-based services people can access include, among other services, adult companion care, adult day care, assistive care services, attendant care, behavioral management, care coordination, and case management, homemaker services, and occupational, physical, respiratory, and speech therapies.
But the state doesn’t pay those providers directly. Instead, it pays the Medicaid-managed care organization a monthly rate to coordinate all the enrolled health care needs and contract with the provider network to deliver them. Managed-care plans get the monthly rate for every Medicaid enrollee in the plan.
Florida Association of Health Plans President and CEO Audrey Brown said, to date, the Agency for Health Care Administration hasn’t contacted her organization regarding the increased funding for home and community-based service providers. Brown said she did not know whether the state would earmark the enhanced funding to the Medicaid managed care organizations and direct the plans to disburse the money or whether the state would pay the licensed home and community-based service providers directly.
“We do not yet know the exact mechanism for the additional payments, but that may be a decision point by the federal government, or AHCA may still be considering and has not yet made a determination. If the health plans are asked to act as a pass-through, they will operationalize accordingly, as we do for other directed payment programs,” Brown said in a statement.
But she added she “would not characterize the fact that the mechanism hasn’t been specified yet as anyone not being forthcoming.”
Brown said Medicaid-managed care organizations had been asked in the past to distribute enhanced payments to certain providers. The health plans can update their systems and get the payments out to the direct care providers.
But Brown acknowledged that the “more notice in advance” the managed care organizations have to make the system changes, the better.
“The last thing that we, as the plans, want, is any friction over the timing or receiving of these payments,” she said.