Last month, Republican Scott Brown defeated Democrat Martha Coakley for the late Ted Kennedy’s U.S. Senate seat in Massachusetts. During his campaign, Brown publicly opposed Barack Obama’s health care reform plan. Democrats interpreted his win as a consensus against reform as offered by Congress. Democrats in both houses of Congress considered trying to pass health care reform in smaller bills rather than one large bill. The proposed budget’s infusion of Medicaid funds is an attempt to compensate for lack of progress on reform. States that included extra funding in their budgets in anticipation of health care reform passing may appreciate the emergency funds.

According to the president’s secretary of Health and Human Services, Kathleen Sebelius, there will be a six-month extension of the Medicaid funding increase that was part of last year’s stimulus bill. The recession has sent more Americans to Medicaid, and some states have considered lowering payment rates to doctors and hospitals to make up for shortfalls.

The budget also calls for experiments to improve quality of care for the elderly with multiple chronic health issues and to find the most effective treatments for high-cost conditions.

FY 2011 federal funding for Texas includes $18.7 billion for coverage to low-income children and families and $2.5 billion for primary and preventive care at health centers. (Source)

CDSA for PHC:

DADS explains the responsibilities of the employer and CDSA when individuals enroll in PHC (which includes PHC, CAS, and FC) program and opt to go directly on the CDS option. DADS also released a letter that contains instructions for case managers. For other details, download the two-page letter.

NFs:

DADS revised the Nursing Facility Customized Power Wheelchair Authorization Form 3706 and form instructions to eliminate the need for information letters 08-12 (IL08-12), dated February 20, 2008; IL08-51, dated April 24, 2008; and IL08-98, dated August 1, 2008. (Letter)

HCS:

The Texas State Fire Marshal’s Office recently adopted the 2009 NFPA 101 Life Safety Code published by the National Fire Protection Association. HCS providers must ensure that a four-person residence is in continuous compliance with applicable provisions concerning Residential Board and Care Occupancies – Small Facilities of the 2009 NFPA 101 Life Safety Code. Download a copy of the code on this web page. Attached to the two-page letter is a Life Safety Code Certification form.

HCS, TxHmL, and CDSA:

DADS is making a change to recommended adaptive aid and minor home modification prior approval amount thresholds, effective February 1. (Letter) An excerpt:

“Adaptive Aid Prior Approval Cost Changes: Previously, prior approval recommendation was made for adaptive aids costs that met or exceeded $500. Prior approval is now recommended for adaptive aids costs that meet or exceed $1000.

“Minor Home Modification Prior Approval Cost Changes: Previously, prior approval recommendation was made for minor home modifications costs that met or exceeded $1000. Prior approval is now recommended for minor home modifications costs that meet or exceed $2500.”

Public Notices

HHSC awarded contract 529-10-0082-00001 to Stanley M. Stewart, on an emergency basis, to analyze and make recommendations on statewide implementation of the Texas Integrated Eligibility Redesign System and provide consultation and support to provide short- and long-term solutions for the administration of Supplemental Nutrition Assistance Program, in response to a U.S. Department of Agriculture directive. The contract’s value is $262,000.

HHSC intends to submit a request for waiver renewal for the STAR Program.

HHSC also intends to submit to CMS a request to amend the CLASS waiver, a Medicaid home and community-based services waiver program under the authority of Title XIX, §1915(c), of the Social Security Act.

For copies of the proposed waivers, please contact Christine Longoria by mail at Texas Health and Human Services Commission, P.O. Box 85200, mail code H-620, Austin, Texas 78708-5200, phone (512) 491-1152, fax (512) 491-1953, or by e-mail at Christine.Longoria@hhsc.state.tx.us.

See the relevant section of the Texas Register for more information.

Adopted Rules

On behalf of DADS, HHSC adopted an amendment to §60.12, concerning client eligibility criteria, in Chapter 60, Contracting to Provide Programs of All-Inclusive Care for the Elderly, to update the reference to criteria an individual must meet for nursing facility care. An excerpt:

“Currently, §60.12 contains references to §19.2409 (relating to General Qualifications for At-Risk Assessments and Medical Necessity Determinations) and §19.2410 (relating to Criteria Specific to a Medical Necessity Determination). These two sections have been repealed. The medical necessity criteria are now found in §19.2401 (relating to General Qualifications for Medical Necessity Determinations). The amendment also updates a reference to Texas Department of Human Services to DADS to reflect changes resulting from agency consolidations in 2004. ”

See the relevant section of the Texas Register for more information.

NFs:

DADS informed these providers of new application requirements in Form 3720-N. Provider Letter 08-01 notified NF licensees that all applicants for initial licensure or change of ownership with an effective date of June 1, 2008, or later, were required to complete a new section of the application, Item 10, about the applicant’s financial condition. (Letter)

The following modifications apply to license renewals that expire June 1, 2010, or later:

“Item 11 of the license application is being revised to add questions regarding the applicant’s continued compliance with minimum standards of financial condition; these additional questions will be Part 1 of the new Item 11.

“The current Item 11 will become Part 2 of the new Item 11. Not all license renewal applicants will be required to complete both parts.”

CLASS, CWP, and DBMD providers:

DADS announced its Employment Services Training and Technical Assistance Initiative and clarified to these providers the transportation requirements for Supported Employment (SE). (Letter)

The SE transportation requirements:

CLASS:

Provider Manual (PM) 5319 Supported Employment Services
Supported employment services must include any activity needed to sustain paid work, including supervision, training, and transportation.

DBMD:

Waiver application C1/C3 Supported Employment
The supported employment component includes services and supports, including supervision and training, essential to sustain paid work by an individual. When providing transportation, the provider must have a valid Texas driver’s license with proof of insurance.

CWP:

Waiver application C1/C3 Supported Employment
Supported employment includes services and supports, such as supervision and training, essential to sustain paid work by an individual in an integrated setting, and includes transportation to and from the job site as a component of this service.

CBA, HCSSAs, and ICMW HCSSAs:

DADS requires HCSSAs to attempt to purchase all items listed on the individual service plan from Medicare, Medicaid, or other third-party resources before requesting authorization for these items through the CBA and ICMW programs. The two-page letter includes a four-page chart, “Community Based Alternatives and Integrated Care Management Waiver List of Adaptive Aids/Medical Supplies.”

DADS will no longer require CBA and ICMW HCSSAs to provide proof of denial from the TMHP for adaptive aids and medical supplies that acute care Medicaid would never approve.

During his campaign, Brown publicly opposed President Barack Obama’s health care reform plan. Democrats interpreted his win as a consensus against reform as offered by Congress.

Kaiser Health News has a round-up of stories from several news sources.

“Unease would be a gentle word in terms of the attitude of my colleagues toward certain provisions of the Senate bill,” House Speaker Nancy Pelosi told NPR.

House Minority Leader John Boehner said, “Listen, our goal is to stop this monstrosity. And we’re working with our members so that we don’t find ourselves in a position where they’re able to pick off a few of our members and to get this bill passed.”

During an ABC News interview last week, the president implied that he may try to push through popular features of the health care reform bill separately, but a health policy expert doesn’t think this strategy will work, either. “Each one of those pieces has barbs attached to it,” Jeff Goldsmith told NPR. “You can say that health insurance reforms are really very popular across a broad spectrum, but then when you put them in — you know, like eliminating pre-existing conditions or lifetime caps — not only do you not have the health plans at the table, but [opponents] are going to come at you hammer and tongs.”

The current health care reform bill would cut Medicare, despite reports that doctors are reducing Medicare patient loads or dropping Medicare altogether. Groups like the American Medical Association, the American Hospital Association, and the American Nurses Association endorse the health care reform bill.

HHSC will hold a public hearing on February 16, 2010, at 1:30 p.m., in the Lone Star Conference Room of HHSC, Braker Center, Building H, located at 11209 Metric Boulevard, Austin, Texas, to receive comment on proposed Medicaid payment rates for the following:

• Augmentative Communication Devices
• Vagal Nerve Stimulators
• 2010 Annual Healthcare Common Procedure Coding System (HCPCS) Updates
• Bath and Bathroom Equipment
• Certified Nurse Midwife (CNM) Services in a Birthing Center
• special fee review and medical policy changes that are part of the project known as Change Order Request (COR) 79
• “E” Codes (Wheelchairs and Similar Equipment)
• Mastectomy and Breast Reconstruction Services
• Quarterly Medicaid Fee Reviews
• Vision Nonsurgical Services
• Vision Surgical Services

See the relevant section of the Texas Register for details.

1) Providers have requested face-to-face HCS billing guidelines training. Consequently, staff from DADS Billing and Payment Unit will provide half-day training on the recent changes to the billing guidelines, to be conducted in multiple waiver contract areas together with scheduled billing and payment reviews until the spring 2010.

Training in Dallas will be held at Dallas Metrocare Services at 1380 Riverbend Drive, Dallas, Texas, in Room 319 on January 25, 2010, from 1 p.m.-4 p.m. The session is limited to 60 participants and only two representatives from each contract. Call Brenda Cosens (214) 743-1256 to reserve your place.

2) The HSC Case Management Transition Initiative web site, which provides HCS providers, MRA staff, individuals served in the HCS program, legally authorized representatives, and others with information, is available here.

To read previous news alerts, visit this page and scroll down.

An excerpt:

“To restore budget neutrality, the Congress should require the Secretary to fully offset increases in inpatient payments due to hospitals’ documentation and coding improvements. To accomplish this, the Secretary must reduce payment rates in the inpatient prospective payment system by the same percentage (not to exceed 2 percentage points) each year in 2011, 2012, and 2013. The lower rates would remain in place until overpayments are fully recovered.”

Among other things, MedPAC recommends Congress increase payment rates for acute inpatient and outpatient prospective payment systems; update physician services payments next year by one percent; eliminate an update to payment rates for skilled nursing facility services, eliminate the market basket update next year to home health; and eliminate an update to payment rates for long term care hospital rates for next year.

NF and Rehab Services providers:

To expedite review and approval/disapproval process for Rehabilitation Authorization Requests, DADS will no longer return approvals by fax for Physical Therapy /Occupational Therapy and Speech, effective February 1. DADS will only return faxes for reasons (Exceptions to Requests) listed in the two-page letter.

CDSAs for the CWP:

The CDS option will be available for individuals in CWP who use personal assistance services, residential habilitation; or respite (in-home and out-of-home), effective January 25, 2010. Visit the CWP web page, and download the three-page letter.

Jonathan Blum, director of CMS’s Center for Medicare Management, said the report “contains some welcome news and yet another warning sign. Health care spending as a percentage of GDP is rising at an unsustainable rate. It is clear that we need health insurance reform now.”

According to the report, health care’s share of the GDP grew to 16.2 for 2008, up .3 percent from 2007.

The recession naturally caused people to spend less on health care, and impacted their ability to buy private insurance. Spending on hospital care grew 4.5 percent in 2008 to $718.4 billion. Nursing home and home health spending grew a combined 11.1 percent. Private insurance spending was lower: 2.6 percent in 2008, down from 5.6 percent in 2007.