States encouraged to maintain health benefits for temporary census workers

The Acting Director of the Center for Medicaid and CHIP Services (CMCS) encouraged states, to the extent permitted under the law, to exclude temporary income from employment in the 2020 Decennial Census when determining eligibility for public benefit programs. A new bulletin provides guidance on existing flexibility under state plans for modified adjusted gross income (MAGI) based systems and non-MAGI based systems. This includes the option of submitting a state plan amendment (SPA) to CMS (CMCS Bulletin, July 3, 2019).

Census workers and health benefits

The Census provides low-income individuals with an opportunity for employment and skills training. Many of these workers are eligible for Medicaid or in a household with Medicaid or CHIP eligible individuals. One element of successful recruiting efforts by the Census Board is ensuring the continued availability for Medicaid and CHIP coverage for workers and their families. During previous censuses, state Medicaid and CHIP agencies have been encouraged to ensure that temporary census workers and their families do not lose eligibility due to temporary census income. Previously, states were able to disregard temporary census income for all Medicaid and CHIP eligibility groups, but a move to a MAGI-based methodology no longer permits the use of income disregards. The bulletin describes existing authorities that may be used to exclude or minimize the impact from temporary census employment.

Existing State Plan Options

Under section 1902(e)(14)(D) of the Social Security Act, for non-MAGI populations, states may disregard in whole or in part, temporary census income and many states have already elected to disregard temporary census income for multiple eligibility groups in their state plan. States wishing to apply disregards of temporary census income for the first time or wish to add or modify the non-MAGI groups affected must submit an SPA to CMS.

Under MAGI-based methodologies, temporary census income is taxable as employment income and Medicaid and CHIP regulations prohibits the use of income disregards and this prohibition cannot be waived. States may elect under 42 C.F.R. §435.603(h)(3) to use a reasonable method for determining a prorated portion of reasonably predictable changes (RPC) to income as they do for fluctuating income such as from seasonal work or self-employment. States with approved RPC methodology for seasonal work may include temporary census income within its scope such that a new SPA submission would not be necessary. States that do not have an existing state plan authority to implement an RPC methodology may elect to do so through an SPA, although the methodology cannot be limited only to temporary census income.

Parents and Other Caretaker Relatives may retain specific coverage protections due to increased earned income through Transitional Medical Assistance (TMA). TMA is a required eligibility protection that states must apply, even under increased earnings due to temporary census employment. If census employment income triggers a transition to TMA, the Medicaid agency would redetermine the individual’s eligibility when census employment ends.

CMS is offering technical assistance on the options and requirements included in the informational bulletin as well as assistance on submitting the required state plan amendments.

Kusserow on Compliance: Meeting nursing home compliance program legal mandates

The November 28, 2019 deadline approaches for skilled nursing facilities and nursing homes to adopt and implement an effective compliance and ethics program as a condition of participation in the Medicare and Medicaid programs. At that time, state survey agencies will begin assessing facility compliance with implementation of an effective compliance and ethics program. Yet, the OIG continues to find major problems with that health care sector. The OIG recently reported that posthospital extended care services or Medicare beneficiary coverage must be preceded by an inpatient stay in a hospital for not less than three consecutive calendar days. The OIG found that CMS improperly paid 65 of the 99 skilled nursing facility (SNF) claims sampled by the OIG.  Projecting from its sample, the OIG estimated that CMS improperly paid $84 million for SNF services over a two-year period.

Those nursing homes that followed the OIG guidance will have little problem in meeting the new mandate, but those who did not have only months to come into compliance. Organizations trying to catch up should consider having a compliance expert perform a gap analysis to identify elements needed for the compliance program and how be able to evidence program effectiveness. A gap analysis should provide a “road map” and step-by-step plan for bringing a facility into compliance with the mandates. Those that have already implemented a compliance program should consider having an effectiveness evaluation conducted by experts to verify that the program will meet mandated standards.

For more information about meeting the standards of these new mandates, Tom Herrmann may be reached at thermmann@strategicm.com or at (703) 535-1410.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: CMS announced updates to nursing home ratings

CMS announced updates in April 2019 to Nursing Home Compare and the Five-Star Quality Rating System. Its purpose is to provide tools for consumers to compare quality between nursing homes. This comes in advance of the November 28, 2019 deadline for skilled nursing facilities and nursing homes to have implemented an effective compliance and ethics program as a condition of participation in the Medicare and Medicaid programs. The new tools announced have been created to help consumers, their families, and caregivers compare nursing homes and identify areas they may want to ask about when looking at nursing home care. Nursing Home Compare has a quality rating system that gives each nursing home a rating between 1 and 5 stars and those with 5 stars are considered to have above average quality and nursing homes with 1 star are considered to have quality below average. There is also a separate rating for each of the following three factors:

 

  1. Health Inspections include findings on compliance to Medicare/Medicaid health and safety requirements from onsite surveys conducted by state survey agencies at nursing homes.
  2. Staffing Levels are the numbers of RNs available to care for patients in a nursing home at any given time.
  3. Quality Measures for care are based on resident assessment and Medicare claims data.

 

The April 2019 changes include revisions to the inspection process, enhancement of new staffing information, implementation of new quality measures, and lifting of the “freeze” on the health inspection ratings instituted in February 2018 to hold up the star rating score until all nursing homes were surveyed at least once under the new survey process. In April, users of the site will be able to see the most up to date status of a facility’s compliance, which is a very strong reflection of a facility’s ability to improve and protect each resident’s health and safety. CMS is also setting higher thresholds and evidence-based standards for nursing homes’ staffing levels, recognizing that nurses have the greatest impact on the quality of care nursing homes deliver. As such, CMS is assigning an automatic one-star rating when a Nursing Home facility reports no RN is onsite. In April 2019, the threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to one-star will be reduced from seven days to four days. The new Update includes:

 

  • changes to the quality component to improve the identification of quality differences among nursing homes, raising expectations for quality, and incentivizing continuous quality improvement;
  • adding measures of long-stay hospitalizations and emergency room transfers;
  • removing duplicative and less meaningful measures;
  • establishing separate quality ratings for short-stay and long-stay residents; and
  • revising the rating thresholds to better identify the differences in quality among nursing homes making it easier for consumers to find the information needed to make decisions.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Meeting sanction checking mandates

As the HHS Inspector General, I created what is now referred to as the List of Excluded Individuals and Entities (LEIE) that was followed by OIG compliance guidance documents which call for checking employees, physicians, vendors, and contractors against the LEIE. The OIG considers all claims and costs associated with an excluded party as potentially false and fraudulent and can lead to significant financial penalties and more. The OIG Special Advisory Bulletin on the Effect of Exclusion provides very useful information in assessing this risk area. CMS mandates, as a condition of enrollment, providers may not employ or contract with individuals or entities that are excluded from participation in any federal health care program and call for checking not only against the LEIE, but also the General Service Administration’s (GSA) Excluded Parties List System (EPLS), now part of the System for Award Management (SAM). CMS further called upon State Medicaid Directors to establish their own sanction data base and requires providers to check it on a monthly basis. To date, 40 states have moved to establish their own Medicaid sanction lists with other states in the process of doing the same. This has increased the sanction screening burden exponentially, not only for the compliance office but other departments as well. HR often has responsibility of sanction checking new hires and periodically current employees. Procurement is also affected because they handle the screening of vendors and contractors. The Medical Credentialing Office must ensure checking on physicians who have been granted staff privileges.  Other federal sanction databases worth screening are maintained by the DEA and FDA, as well as the Department of the Treasury Office of Foreign Assets Control (OFAC) Terrorist Watch List.

Daniel Peake, of the Compliance Resource Center (CRC), works with clients to provide a variety of CRC services that includes providing sanction checking services, as well as the investigation and resolution of potential hits. He noted that the time and resources necessary for developing and maintaining a search engine, along with regularly collecting and updating sanction information from many databases is not very cost effective. This high cost of using internal resources to develop and manage the sanction checking has resulted in the great majority of health care entities subscribing to a vendor service that provides a search engine to their established databases. Vendors can afford the high cost of maintaining the currency of the data because they amortize the costs over many clients. The problem is that that vendor quality, cost, and reliability can vary enormously.  From experience, he offered the following tips for those considering a vendor:

 

Tips on choosing a vendor search engine service

  1. Know the cost up front with a fixed rate, not based upon per click searches.
  2. Contract should permit cancelling without cause at any time, if dissatisfied.
  3. Ensure vendor has liability insurance ($ 1 to 3 million preferably).
  4. Determine other services included (e.g. policy templates, regulatory updates, etc.).
  5. Determine how much “help desk” assistance is available to resolve potential hits.

 

For more information, contact Daniel Peake at (dpeake@complianceresource.com) (703-236-9854).

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.