REGULATORY INTELLIGENCE YEAR-END REPORT - 2022 Health Policy Tracking Service - Issue Briefs Long-Term Care Funding and Insurance This Issue Brief was written by Louise W. Seiler, B.A., a contributing writer. 12/19/2022 I]. OVERVIEW Long-term care services include a broad range of services and supports that meet both the medical and non-medical needs of people with a chronic illness or disability, over an extended period of time. Non-medical, personal care comprises the most common type of long-term care, to provide help with everyday activities, also called 'activities of daily living" (ADLs), including bathing, dressing, grooming, using the toilet, eating, moving around, and transferring to or from a bed or chair. [FN2] The duration and level of long-term care will vary from person to person and often change over time. The Administration for Community Living (part of the U.S. Department of Health and Human Services (HHS)) provides statistics ('on average') to be considered. Someone turning age 65 today has almost a 70% chance of needing some type of long-term care services and supports in their remaining years. Women need care longer (3.7 years) than men (2.2 years). One-third of today's 65-year-olds may never need long-term care support, but 20 percent will need it for longer than 5 years. Overall, more people are using long-term care services at home, and for longer, than in facilities, on average receiving care at home for two years but for one year in facilities. [FNS] Long-term care services can be provided in a variety of settings, both institutional and home- or community-based. The National Center for Health Statistics (NCHS) reports that in 2016, over 8.5 million people in the United States received care provided by 4,600 adult day services centers, 12,200 home health agencies, 4,300 hospices, 15,600 nursing homes, and 28,900 assisted living and similar residential care communities. Further, NCHS found that in 2016 there were 286,300 participants enrolled in adult day services centers, 1,347,600 residents in nursing homes, and 811,500 residents in residential care communities. In 2015, about 4,455,700 patients were discharged from home health agencies, and 1,426,000 patients received services from hospices. [FN4] The proposition of getting long-term care is becoming more costly every year, according to the 2021 Genworth Cost of Care Survey, [FNS] dated January 31, 2022. Genworth has conducted the survey annually since 2004. The most recent report looks at the increasing cost trends that have occurred between 2020 and 2021. Over that time, care settings have seen increases in costs ranging from 1.96% for a semi-private room in a nursing home to 12.5% for home health care. Annual national median costs broken down by category, and total percentage increase between 2020 and 2021 are as follows: [FN6] * Assisted living facilities: $4,500 per month, up 4.65% ¢ Nursing home annual rates: private room, $108,405; semi-private room, $94,900, up 1.96% and 2.41%, respectively. * Home health aide: $27.00/hour, up 12.50% * Homemaker services: $26.00, up 10.64%; and + Adult day services, $78/day, up 5.41%. Why are costs rising? The report finds the core driver of cost increases to be supply and demand. Every day 10,000 baby boomers turn 65, according to the 2020 census. IFN7] Seven out of ten of them will require long-term care services at some point. Further, the level of care needed by this rapidly aging population has increased over the years. The high turnover rate and insufficient supply of professionals to meet the growing demand amplifies the growing need for care providers as workers weigh the risks of COVID-19 and opportunities in other fields of work. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. The costs of long-term services and supports (LTSS) have historically been covered by Medicaid, private insurance, personal savings, and direct unpaid care provided by friends and family members. The Associated Press-NORC Center for Public Affairs Research has conducted annual surveys since 2013 to investigate experiences and attitudes regarding long-term care. The surveys have revealed that a majority of American adults hold a number of misconceptions about the extent of the long-term care services that they are likely to need in the future, and the cost of those services. A majority of Americans 40 and older are unsure how they'll pay for long-term care, according to an AP-NORC Center survey. Key findings of surveys conducted in 2016 and 2018 include: ¢ Nearly 4 in 10 mistakenly expect to rely on Medicare to pay for their long-term care needs as they age. ¢ Only 17% are very or extremely confident that they will have the financial resources to pay for long-term care. ¢ 77% would prefer to receive care for themselves in their own home and 67% would prefer for their loved ones to receive care in a home setting. ¢ One-third say they have done no planning at all for their own long-term care needs. ¢ 72% support state-paid family leave programs to help Americans providing care to a loved one. ¢ 80% want employers to offer long-term care insurance as a workplace benefit. ¢ A majority support a number of policies to help Americans finance long-term care; tax breaks are especially popular. [FN8] While Medicaid pays for many long-term care services, eligibility and the extent of coverage vary from state to state. The federal Deficit Reduction Act N®! (DRA), which became law in 2006, significantly revised the extent of Medicaid coverage. This omnibus bill reduced spending for many federal programs, including long-term care. The legislation encouraged states to refrain from using federal Medicaid dollars to fund costly institutional long-term care and created incentives to redirect services to a more community-oriented setting. In addition, the DRA expanded the 'look-back" period for asset transfers from three years to five years, and makes individuals with home equity over $500,000 to $750,000 (as determined by each state) ineligible for coverage. States also must take into account all income of institutionalized spouses to meet the minimum monthly maintenance needs allowance for spouses remaining in the community. [FN10] How states deliver services-such as home care, assisted living, nursing home care, and supports for family caregivers-was assessed in a report compiled by AARP's Public Policy Institute, joined by the Commonwealth Fund and the SCAN Foundation. Released in 2020, the report examines key dimensions of LTSS system performance: (1) affordability and access, (2) choice of setting and provider, (3) quality of life and quality of care, (4) support for family caregivers, and effective transitions. States that rank highest overall-Minnesota, Washington, Wisconsin, Oregon, Vermont, California, and Connecticut-often do well in multiple dimensions but have opportunities to improve, the report found. Lagging states that scored in the bottom quartile overall (Mississippi, Nevada, Louisiana, Tennessee, Indiana, Arkansas, Oklahoma, Kentucky, South Carolina, Alabama, West Virginia, and Florida) have among the lowest median incomes and highest rates of both poverty and disability, and many are in the South. States that scored in the second or third quartiles have opportunities to improve, having scored in the top quartile on at least one dimension (e.g., Nebraska, Arizona, Ohio, Illinois, Alaska, and Texas). The report also found that a wide variation exists within dimensions and indicators, with low-performing states being markedly different from those that score high. Often, low-performing states have not adopted public policies to increase access to services, or that enable consumers to exercise choice and control. [FN11] Il. IMPACT OF COVID-19 ON LONG-TERM CARE The COVID-19 pandemic has hit long-term care facilities particularly hard, where residents and staff in nursing homes are at greatest risk of morbidity and mortality from COVID-19 infection. Nursing home residents constituted one-third to more than half of all deaths during the early waves of the COVID-19 pandemic. [FN12] Following this, widespread adaptation of infection prevention and control measures and the supply and use of personal protective equipment resulted in a significant decrease in nursing home infections and deaths. For nursing homes, the most important determinant of experiencing a COVID-19 outbreak in appeared to be community- transmission levels, although nursing home size and quality, for-profit status, and sociodemographic characteristics were also important. Use of visitation bans, imposed to reduce the impact of COVID-19 on residents, had to be balanced against their impact on the well-being of residents, friends and family, and staff. The successful rollout of primary vaccination has resulted in a sharp decrease in morbidity and mortality from COVID-19 in nursing homes. However, emerging evidence suggests that vaccine efficacy may wane over time, and the use of a third or additional vaccine 'booster' doses in nursing home residents restores protection afforded by primary vaccination. Ongoing monitoring of vaccine efficacy in terms of infection, morbidity, and mortality is crucial in this vulnerable group in informing ongoing COVID-19 vaccine boosting strategies. The impact of COVID-19 on nursing homes has been far-ranging and will likely endure for years to come. An overview of key considerations and the consequences of the pandemic on the provision of long-term care follows. Waivers of Regulations THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. Under Section 1135 of the Social Security Act, the HHS Secretary is authorized to waive certain Medicare, Medicaid, and Children's Health Insurance Program program requirements and conditions of participation once the President has declared an emergency through the Stafford Act IFN13] and the Secretary has declared a Public Health Emergency. President Trump issued such an emergency declaration on March 13, 2020, and the HHS Secretary issued a PHE on January 31, 2020, in response to the spread of COVID-19. As a result of this authority, CMS granted waivers to ease certain requirements for affected providers. The blanket waivers originally instituted at the onset of the COVID Public Health Emergency include: ¢ Telehealth services. CMS is now paying for more than 80 additional services supplied via telehealth, including initial nursing home and discharge visits. Providers also are now allowed to evaluate beneficiaries who have only audio phones. ¢ 3-Day Prior Hospitalization. CMS is waiving the requirement for a 3-day prior hospitalization for coverage of an SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period. ¢ Reporting Minimum Data Set. CMS is waiving the timeframe requirements for Minimum Data Set assessments and transmission. ¢ Pre-Admission Screening and Annual Resident Review (PASARR) waived. CMS is waiving 42 CFR 483.20(k) allowing states and nursing homes to suspend these assessments for new residents for 30 days. ¢ Physical Environment. Provided that the state has approved the location as one that sufficiently addresses safety and comfort for patients and staff, CMS is waiving requirements under 42 CFR 483.90 to allow for a non-SNF building to be temporarily certified and available for use by a SNF in the event there are needs for isolation processes for COVID-19 positive residents, which may not be feasible in the existing SNF structure to ensure care and services during treatment for COVID-19 are available while protecting other vulnerable adults. CMS will waive certain conditions of participation and certification requirements for opening a nursing facility if the state determines there is a need to quickly stand up a temporary COVID-19 isolation and treatment location. ¢ Patient rooms. CMS is also waiving requirements to temporarily allow for rooms in a long-term care facility not normally used as a resident's room, to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity. ¢ Resident Groups. CMS is waiving the requirements that residents can participate in-person in resident groups. This waiver would only permit the facility to restrict in-person meetings during the national emergency given the recommendations of social distancing. ¢ Training and Certification of Nurse Aides. CMS is waiving the requirements that a SNF not employ anyone for longer than four months unless they have met the training and certification requirements under 42 CFR 483.35(d), to assist in potential staffing shortages seen with the COVID-19 pandemic. Facilities must still ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. ¢ Physician Visits in Skilled Nursing Facilities/Nursing Facilities. CMS is waiving the requirement for physicians and non-physician practitioners to perform in-person visits for nursing home residents and allow visits to be conducted via telehealth options. ¢ Resident roommates and grouping. CMS is waiving the requirements in 42 CFR 483.10(e) (5), (6), and (7) solely for the purposes of grouping or cohorting residents with respiratory illness symptoms and/or residents with a confirmed diagnosis of COVID-19, and separating them from residents who are asymptomatic or tested negative for COVID-19. ¢ Resident Transfer and Discharge. CMS is waiving certain requirements to allow an LTC facility to transfer or discharge residents to another LTC facility for certain cohorting purposes. IFN14] The temporary waiver for Medicare's three-day hospital stay and other so-called 1135 waivers continued into January 2022, after the COVID-19 public health crisis designation was extended by HHS Secretary Xavier Becerra on October 15, 2021. [FN15] In addition to the 1135 waivers, on October 20, 2021, CMS also extended a waiver giving providers more time to comply with fire safety standards adopted prior to the pandemic. Since mid-2016, nursing homes have been required to meet standards included in the 2012 Life Safety Code and the 2012 Health Care Facilities Code, or use the National Fire Protection Association's 2013 Fire Safety Evaluation System (FSES) as an alternative. In a memo sent to state survey agencies, CMS officials said providers using FSES and operating under a time-limited waiver to correct certain deficiencies will have an additional two years to comply. The deadline is now November 1, 2023. In its continuing review of the COVID-19 blanket waivers issued early in the onset of the pandemic, in April 2022, CMS decided to end the waiver of training requirements for nurse aides along with 15 other waivers made available to skilled nursing facilities. IFN16] While acknowledging the benefits of regulatory flexibilities during the course of the pandemic, the agency cites concerns over resident care (e.g., abuse, weight loss, depression, pressure ulcers, etc.), and attributes such outcomes in part to the waivers. The terminated waivers were identified by CMS as those requirements that should be restored to address the risks to resident health and safety that are not related to infection control. The specified waivers will take effect in two groups, at 30 days and then 60 days from issuance of THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. the memorandum. Blanket waivers for hospitals and certain other entities will remain in effect to that those facilities can best manage surges in COVID infections. In addition to rescinding the waiver of nurse aide certification requirements, CMS is rescinding numerous allowances related to doctors being able to relinquish some obligations to nurse practitioners or other nonphysicians. It is also restoring some requirements for in- person physician visits that had given way to telehealth capabilities. Staff Cases and Deaths According to a report released on January 12, 2022 by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), deaths from COVID-19 among nursing home workers neared an all-time high in the first week of 2022. IFN17] Based on data from the Centers for Disease Control and Prevention (CDC), the report found that 67 COVID-related deaths occurred among nursing home staff in the week ending January 9. The all-time high of 69 was set in July 2020, six months before vaccines became available. Nationwide, nursing homes have experienced a surge in new COVID cases in recent weeks due to community spread among the general population. Last week, 32,061 nursing home residents tested positive for COVID-19 ? nearly doubling the previous week's numbers. Staff case counts hit their highest ever last week, reaching 57,253 ? more than double the previous staff case count record, set in December of 2020. Experts have repeatedly noted that COVID-19 cases in the surrounding community are a key indicator of outbreaks in nursing homes. Notably, thanks to high vaccination and booster rates among residents, although COVID-related deaths among nursing home residents have increased in recent weeks, the rate of deaths is 10 times lower than in December 2020 (0.60 vs. 5.68 resident deaths per 1,000 residents). Mandatory Vaccination of Staff and Residents January 4, 2022 Deadline. Long-term care staff must be fully vaccinated against COVID-19 by January 4 under a new healthcare worker vaccination rule issued by CMS that took effect November 5, 2021. [FN18] Broviders were required to establish a policy by December 5 ensuring that all eligible staff have received the first dose of a two-dose vaccine regimen, or a one-dose COVID-19 vaccine prior to providing any care, treatment, or other services by the January deadline. CMS said it will compel compliance with the new requirements through established survey and enforcement processes. Exemptions based on recognized medical conditions or religious beliefs, observances or practices will be allowed, but operators must develop their own processes for allowing those exemptions. President Biden Mandate. Prior to the CMS rule, President Biden announced on August 18, 2021, that he has directed all nursing homes to require their staff be vaccinated against COVID-19 or risk losing Medicare and Medicaid funding. IFN18] He also directed HHS to draft new regulations making employee vaccination a condition for nursing homes to participate in Medicare and Medicaid. The decision marked the first time President Biden threatened to withhold federal funds to get people vaccinated. Supreme Court Upholds Mandate. The U.S. Supreme Court on January 13, 2022, upheld the vaccine requirement for staff at all nursing homes and other federally funded healthcare facilities, in a 5-4 decision. IFN20] The Court lifted two injunctions blocking a CMS rule covering over 17 million workers, including staff at 15,000 nursing homes. The rule was announced on November 5 but blocked in 25 states by lower court injunctions. With the lifting of the injunctions, the rule is set to move forward. Under guidance issued by CMS, 100% of covered staff must have had at least one shot by January 27, 2022, and a second shot (if applicable) by February 28, with some enforcement discretion available. Second Booster Shots: Nursing home residents who received a second mRNA booster shot during circulation of the Omicron subvariants were much less likely to experience hospitalization and death from COVID-19 when compared to those who received a single booster dose, according to a new study reported by the CDC. IFN21] A second booster provided residents with 74% lower odds of severe outcomes, including hospitalization and death, and 90% protection against death alone over a 60-day period, the investigators reported. The study was conducted across 196 U.S. community nursing homes in 19 states, including 9,527 residents. Researchers concluded that the results support the importance of efforts to ensure the nursing home population is up to date on recommended COVID-19 vaccine booster doses, including the newly authorized bivalent COVID-19 vaccine. CMS Launches Tool to Compare Vaccination Rates. CMS is making it easier to check COVID-19 vaccination rates for nursing home staff and residents with a new feature on Medicare.gov. Announced on September 21, 2021, [FN22] the tool makes vaccination data available in a user-friendly format to help people make informed decisions when choosing a nursing home for themselves or a loved one, according to the agency press release. CMS and the CDC are also continuing to use this data to monitor vaccine uptake among residents and staff and to identify facilities that may need additional resources or assistance to respond to the pandemic. Medicare and Medicaid-certified nursing homes have been required to report weekly COVID-19 vaccination data for both residents and staff since May 2021, and CMS has been posting the information on the CMS COVID-19 Nursing Home Data website. Religious Exemption. Updated guidance issued by the U.S. Equal Employment Opportunity Commission (EEOC) on October 25, 2021, [FN23] requires employees and applicants to inform their employers if they want an exception to an employer's COVID-19 vaccine THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. requirement due to a sincerely held religious belief, practice, or observance. Title VII of the Civil Rights Act of 1964 requires employers to consider requests for religious accommodations, but they are not required to protect social, political, or economic views, or personal preferences of employees who seek exceptions to a COVID-19 vaccination requirement. The guidance also states that employers that demonstrate 'undue hardship" are not required to accommodate an employee's request for religious accommodation. The EEOC cautions, however, that the guidance answers COVID-19 questions only from the perspective of the EEO laws. Other federal, state, and local laws come into play regarding the COVID-19 pandemic for employers, employees, and applicants. Infection and Mortality Rates Drop in Nursing Homes. Data over the past year indicate that U.S. nursing homes are currently 'the safest places to be" for frail older adults, who are most susceptible to the virus. According to new data from the National Investment Center for Seniors Housing & Care (NIC), COVID-19 cases at skilled nursing facilities have declined 98% since mid-December (when vaccinations started). In fact, nursing home infections have accounted for just 0.3% of all cases in the U.S. since mid-May 2021. According to the NIC, the drop in nursing home cases has outpaced the drop in case counts among surrounding populations, which in some areas were on the rise, even as vaccines become more readily available. In December 2020, new nursing home fatalities accounted for about 74% of overall fatalities for older adults over 85 years of age. By April 2021, that share dropped to 28%. Currently, more fatalities are occurring in the general population of older adults over 85 years of age than in those living in nursing homes. [FN24] Funding for Nursing Facilities PRF funding On August 27, 2020, HHS announced that it has distributed nearly $2.5 billion of a planned $5 billion to nursing homes to support increased testing, staffing, and personal protective equipment (PPE) needs. IFN25] The funding allocation was made through the Health Resources and Services Administration (HRSA) as a targeted distribution from the $175 billion Provider Relief program funded through the bipartisan CARES Act and the Paycheck Protection Program and Health Care Enhancement Act. The distribution of almost $2.5 billion in additional funding to over 15,000 nursing homes nationwide supplements the $4.9 billion that was previously distributed to skilled nursing facilities, the agency said. The funding includes $8.5 billion in American Rescue Plan resources for providers who serve rural Medicaid, Children's Health Insurance Program or Medicare patients, and an additional $17 billion for Provider Relief Fund (PRF) Phase 4 for providers who can document revenue loss and expenses associated with the pandemic. The Phase 4 PRF payments will be based on lost revenues and expenditures between July 1, 2020, and March 31, 2021. F7*l On October 28, 2020, HHS, through the HRSA, announced it will distribute approximately $333 million in the first round of performance payments to 10,631 nursing homes. IFN27] The nursing homes are being recognized for demonstrating significant reductions in COVID-19 related infections and deaths between August and September. More than three fourths (77%) of eligible nursing homes qualified for payment. Overall, the nursing homes contributed to 5,000 fewer COVID-19 infections in nursing homes in September than in August. Against both the infection control and mortality criteria, 10,501 nursing homes, or 76 percent, qualified for payments and contributed to 1,200 fewer COVID-19 related nursing home deaths between August and September, HHS said. The $2 billion incentive funding plan was announced in August. It is divided into five performance cycles. This performance-based payment structure will reward nursing homes for keeping new COVID-19 infection and mortality rates among residents lower than the communities they serve, as analyzed against CDC data. Nursing homes will receive September quality incentive payments during the first week of November, and will have four more opportunities to receive additional incentive payments. [FN28] The HRSA made more than $560 million in PRF Phase 4 General Distribution payments to more than 4,100 providers across the country beginning February 24, 2022, HHS has announced. IFN28] With the announcement, nearly $11.5 billion in PRF Phase 4 payments has now been distributed to more than 78,000 health care providers across the United States that were affected by the COVID-19 pandemic. This is in addition to HRSA's distribution of American Rescue Plan (ARP) Rural payments totaling nearly $7.5 billion in funding to more than 44,000 providers since November 2021. Phase 4 payments have an increased focus on equity, including reimbursing a higher percentage of losses for smaller providers and incorporating bonus payments for providers who serve Medicaid, Children's Health Insurance Program (CHIP), and Medicare beneficiaries. Approximately 86 percent of all Phase 4 applications have now been processed. Remaining applications will continue to be processed throughout early 2022. Air Quality Upgrades. To reduce the spread of COVID-19, CMS is making funds available to long-term care providers looking to improve air quality. Facilities can apply for civil monetary penalty reinvestment funds to purchase portable fans and air room cleaners with HEPA filters to improve air quality, according to updated guidance released by the agency on February 2, 2022. [FN30] According to CMS, providers can request up to $3,000 per facility, including shipping costs. Facilities can consider a number of best practice options to improve air quality, according to the CMS, including the addition of ultraviolet germicidal irradiation (UVGI) to the heating ventilation, minimizing groups of people or visitors in small rooms, ensuring maximum outdoor air intake, and use of portable air cleaners. State Funding In Illinois, a $700 million Medicaid funding boost is coming to providers after Gov. J.B. Pritzker signed nursing home reform legislation on May 31, 2022, that ties the Medicaid increases to higher staffing levels. Under the law, Illinois will increase its $2.5 billion in annual THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. nursing home funding by roughly $700 million, with $100 million coming from the state and the rest from federal Medicaid and provider assessments. It also calls on nursing homes to meet at least 70% of federal staffing level guidelines in order to qualify for bonus reimbursements. Nursing homes' star ratings also will be taken into consideration for reimbursement increases. Providers and resident advocates both have hailed the reform measure. New York has also pushed ahead with legislation that ties funding to direct care at nursing homes. The state in February passed legislation that requires providers to spend a minimum of 70% of revenue on direct care - with at least 40% of that going to direct care workers. On August 3, 2022, New York Governor Kathy Hochul announced the launch of the Health Care and Mental Hygiene Worker Bonus ('HWB') program. Enacted in the FY 2023 New York State Budget, the program includes $1.3 billion allocated for the payment of recruitment and retention bonuses to certain health care and mental hygiene workers, including skilled nursing facilities. The program is a key initiative in the Governor's aim to increase the state's health care workforce by 20 percent over the next five years, according to the press release. [FN31] Bonuses will be awarded to eligible workers who make less than $125,000 annually and remain in their positions for at least six months. Disbursements will be commensurate with the number of hours worked and duration of service within designated vesting periods for up to a total of $3,000 per employee. The program is aimed at facilitating an incentive program for the purpose of recruiting, retaining, and rewarding health care and mental hygiene workers meeting specified eligibility requirements. Nursing homes short on workers in Minnesota could soon be welcoming hundreds of new certified nursing assistants to their ranks. [FN32] Governor Tim Walz on May 31, 2022, announced the state's Next Generation Nursing Assistant initiative surpassed its goal of recruiting 1,000 new workers with a total of 1,278 registered participants. The program, which opened in January, covers the cost of tuition, books, uniform and certification exam fees for those interested in pursuing a career as a CNA. The state is using $3.4 million in federal relief and $6.7 million in state money to fund the program. An additional $13.3 million has been proposed for the program for fiscal year 2024-2025. Of the total participants, 940 have enrolled in free training courses offered by the state or a private training provider. Additionally, 338 high school students are accessing training through their school district with the state paying for their certification exam. In Wisconsin, as many as 3,000 certified nursing assistants could find their way into Wisconsin nursing homes through a $6 million investment by the federal government into its workforce development program. [FN33] Governor Tony Evers and the Wisconsin Department of Health Services on Wednesday announced they are expanding the WisCaregiver Careers program to address the CNA shortage in the state's nursing homes. Originally launched in 2018 to help expand the healthcare workforce among Wisconsin's nursing homes, the program was revamped during the pandemic thanks to a $400,000 workforce grant from the state and is on track to reach its goal of training 500 new CNAs for employment by the end of June. The expansion this year is thanks to a $6 million investment from the CDC Nursing Home & Long-term Care Facility Strike Team program. The money will be used to support employee recruitment and success through retention bonuses, employer reimbursement, success bonuses and mentorships. While studies have found that high staffing levels in nursing homes are associated with higher care quality, current staffing standards in nearly every state remains severely low, according to one report. [FN34] Any analysis by the Kaiser Family Foundation examines federal and state standards and identifies changes to state minimum staffing requirements adopted since the onset of the COVID-19 pandemic. [FN35] The report found that five states (Arkansas, Connecticut, Massachusetts, New York, and Rhode Island) have permanently increased their minimum staffing requirements while at least two states (Oregon and South Carolina) have temporarily decreased their minimum staffing ratios to compensate for staffing shortages. Rhode Island adopted the largest increase: nursing homes went from a required 0.32 hours of direct care per resident, per day to 4.1 hours per resident day, data showed. By contrast, Florida decreased minimum staffing requirements for certified nursing assistants from 2.5 hours per resident day to 2. Additionally, four states (Colorado, Illinois, Massachusetts, and North Carolina) adopted laws or regulations that require increases to nursing home staff wages since the onset of COVID-19. At least three states (Michigan, North Carolina, and Ohio) adopted temporary increases or one-time bonuses to nursing home staff wages post-COVID. Other states have adopted or proposed Medicaid provider reimbursement rate changes that do not explicitly require corresponding increases in direct care staff wages. Staffing Shortages and Other Impacts Salary Increases and Turnover Rates. The national average hourly rate for nursing home RNs, LPNs, and CNAs increased between 9.38% to 11.15% in 2022 in a continued response to COVID-19 and ongoing staffing issues, according to the 2022-2023 HCS Nursing Home Salary & Benefits Report. IFNS6] RNs hourly rates rose sharply, increasing from 4.08% in 2021 to 11.08% in 2022. LPNs saw the lowest hourly rate increase of 9.38%, still nearly double the rate increase in 2021, and triple that of 2020. CNAs once again received another large hourly rate raise, with a 2021 increase of 7.13% and 11.15% in 2022. The national hourly rate for RNs was $34.58; the hourly rate for LPNs was $26.46; and the rate for CNAs was $16.87. Turnover rates again trended upwards, according to the study, along with a slight drop in the average number of RNs, LPNs, and CNAs reported per facility by participants. The turnover rate for RNs was 46.23%, for LPNs 41.33%, and for CNAs 54.81%. In a measure to attract new employees, 50.70% of respondents reported paying sign-on bonuses. The average sign-on bonus reported for RNs was $4,566; the average sign-on bonus for LPNs was $3,494; and for CNAs was $2,146. 1,283 nursing homes participated in the study and provided compensation data on 119,100+ employees, covering 46 management and 54 nonmanagement positions. Data in the study are effective as of March 2022. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. Federal Funding. Demands placed on the nation's nurses by COVID pandemic combined with retirements of an aging workforce have increased the need for nursing workers in the U.S. In fact, the U.S. Bureau of Labor Statistics projects that more than 275,000 additional nurses are needed from 2020 to 2030, and that employment opportunities for nurses will grow at 9 percent, faster than all other occupations from 2016 through 2026. To help address challenges in developing a skilled healthcare workforce, the U.S. Department of Labor (DOL) announced on October 3, 2022, an $80 million funding program through its Nursing Expansion Grant Program to support nursing training programs designed to expand the pipeline of nursing professionals while advancing equity and creating pathways for workers to fill these jobs and improve the nation's healthcare system. [FNS7] The grants will be administered by the department's Employment and Training Administration and emphasize training people from historically marginalized and under-represented populations to bring greater employment equity in underserved communities and improve healthcare workforce diversity, the agency noted. These grants also emphasize using research and evidenced-based practices, supportive services, sector strategies, and training that address barriers to becoming nurses, it said. Driven by partnerships between public and private sector entities, these grants will support organizations that use worker-centered industry strategies to train nursing instructors or create nursing professional career pathway programs. Applicants must propose training program models that attract workers, unions, worker organizations and employers while building partnerships with community- based organizations and training institutions, according to the press release. Funding to Address Health Care Workforce Burnout. The White House announced in January 2022 $103 million in grants to help curb healthcare worker burnout and staffing shortages. [FN38] Through three different programs, the funding will be given to 45 total winners, HHS said. Burnout has been named a top reason for nurse departures by an array of professional groups, especially connected to long-term care. The awards will fund evidence-informed programs, practices, and training, with a specific focus on providers in underserved and rural communities, according to the announcement. Just over $68 million will be granted to 34 providers through the Health and Public Safety Workforce Resiliency Training Program, $28.6 million will be granted to 10 grantees through the Promoting Resilience and Mental Health Among Health Professional Workforce program, and $6 million will be given to George Washington University through the Health and Public Safety Workforce Resiliency Technical Assistance Center. Each of the programs is tailored toward promoting mental health and reducing burnout among healthcare workers. The administration hopes the funding support will help improve the retention of healthcare workers. Operators Concerned About Surviving Financial Challenges According to a new survey from the American Health Care Association/National Center for Assisted Living, [FNS9] only a quarter of long- term care operators are confident they can last a year or longer, due to the financial challenges caused by the COVID-19 pandemic. Survey findings showed that 54% of nursing home operators reported they are currently operating at a loss, while 49% have had to make cuts due to increased expenses and lost revenue in 2021. The top three costs incurred by facilities due to COVID-19 are: additional pay for staff, hiring additional employees, and personal protective equipment (PPE). Additionally, 84% of respondents reported they're also losing revenue due to fewer post-acute patients coming from hospitals; 83% cited financial losses due to fewer residents seeking long-term care; and 37% said their losses are attributed to residents/patients moving out. The survey was based on responses from 616 nursing homes and 122 assisted living communities across the United States. $94B Losses Projected for Long-Term Care over 2020-2021. The COVID-19 pandemic has hit long-term care facilities especially hard financially. Additional costs for routine testing to hiring additional staff and purchasing personal protective equipment (PPE) have forced providers to dedicate extensive resources to fight the virus. The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) conducted an analysis and estimates that the long-term care industry will lose $94 billion over a two-year period (2020-2021). In 2020, nursing homes spent roughly $30 billion on PPE and additional staffing alone. Contributing to the losses is the drop in occupancy-going from 71% to 67% in just the last three months. The analysis also estimates that, without immediate assistance, over 1,600 nursing homes could close in 2021-about one tenth of the closures in 2020. [FN40] Occupancy Rates Post-COVID. According to one expert, skilled nursing operators seeing steep drops in occupancy since the start of the pandemic aren't expecting those numbers to rebound any time soon. 'For facilities that lost existing occupancy due to a COVID-19 outbreak, when coupled with a reduced incoming stream of residents, skilled nursing leaders expect it may be 18 months before their occupancy can recover to pre-COVID levels," Cory Rutledge, managing principal at CliftonLarsonAllen, told McKnight's Long-Term Care News. [FN41] Median occupancy rates for skilled nursing providers have fallen as low as 75% in each of the three most recently reported weeks, according to weekly occupancy data trends from the federal government's National Healthcare Safety Network's database. That's a drop from the 84.5% 2018 median occupancy rate CLA reported in its most recent SNF trends report. Visitation Rules for Nursing Homes THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. CMS, in collaboration with the CDC, issued updated guidance on March 10, 2021, for nursing homes to safely expand visitation options during the COVID-19 pandemic public health emergency. This latest guidance comes as more than three million doses of vaccines have been administered within nursing homes, following the U.S. Food and Drug Administration's (FDA) authorization for emergency use of COVID-19 vaccines. According to the updated guidance, facilities should allow responsible indoor visitation at all times and for all residents, regardless of vaccination status of the resident, or visitor, unless certain scenarios arise that would limit visitation for: ¢ Unvaccinated residents, if the COVID-19 county positivity rate is greater than 10 percent and less than 70 percent of residents in the facility are fully vaccinated; * Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated, until they have met the criteria to discontinue transmission-based precautions; or * Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine. The updated guidance also emphasizes that 'compassionate care" visits should be allowed at all times, regardless of a resident's vaccination status, the county's COVID-19 positivity rate, or an outbreak. Compassionate care visits include visits for a resident whose health has sharply declined or is experiencing a significant change in circumstances. At the same time, CMS continues to recommend facilities, residents, and families adhere to the core principles of COVID-19 infection control, including maintaining physical distancing and conducting visits outdoors whenever possible. This continues to be the safest way to prevent the spread of COVID-19, particularly if either party has not been fully vaccinated. N42! CDC Confirms Spread of Coronavirus by Asymptomatic Carriers Researchers with the CDC concluded that at least 50% of new coronavirus cases stem from asymptomatic carriers based on study reported in Jama last week. IFN43] The study found that 59% of all disease transmission came from asymptomatic individuals, comprising 35% from presymptomatic individuals and 24% from individuals who never developed symptoms. The researchers estimated that, based on their analytical model of multiple scenarios of proportions of asymptomatic individuals with COVID-19, and infectious periods, that transmission from asymptomatic individuals accounted for more than half of all transmissions. The findings suggest that identifying and isolating symptomatic COVID-19 patients alone will not control the spread of the disease; that measures such as wearing masks, hand hygiene, social distancing, and strategic testing of people who are not ill is essential in slowing the spread of COVID-19. The findings support an October study [FN44] that called on nursing homes to consider testing their workers more frequently than federal standards mandate (that are based on community positivity rates). Legislation Federal A proposal by four Democratic senators would provide nearly $1 billion to assist nursing homes with infection control and help manage COVID-19 care for residents. The legislation, called the COVID-19 Nursing Home Protection Act (2021 CONG US S 333), was introduced in the Senate on February 22, 2021, by Democratic Sens. Bob Casey (PA), Raphael Warnock (GA), Sheldon Whitehouse (RI), Richard Blumenthal (CT), and Cory Booker (NJ). It would send $750 million to states to establish nursing home strike teams and guarantee another $210 million for the Department of Health and Human Services to contract with Quality Improvement Organizations (QIOs) to provide infection control assistance to providers. The proposed support is a significant increase compared to what's been included in the House-proposed coronavirus relief package currently under review. That $450 million measure specifically calls for $200 million for ensuring skilled nursing facilities get sufficient help with COVID-related infection control measures through QIOs, and an allocation of $250 million to states for developing strike teams. Booker said in a statement that the strategies are aimed at 'giving states what they need - funding for "strike' teams to help address staffing shortages in nursing homes and assist with vaccinations in these settings." Senate Aging Subcommittee Chairman Bob Casey (D-PA) lists the American Health Care Association and Alzheimer's Association as two of the proposal's supporters. [FN45] Additional legislation: ¢ 2021 CONG US HR 5094, introduced August 24, 2021, the 'Nursing Home Workforce Support and Expansion Act of 2021," would provide additional funding to states and long-term care providers to hire and retain workers, to strengthen wages and benefits for long-term care workers. States would be required to use the money to provide wage subsidies to employees in post-acute and long- term care settings, student loan repayment or tuition assistance, guarantee affordable and accessible childcare and transportation assistance to eligible workers. ¢ 2021 CONG US HR 7744, introduced May 12, 2022, would extend beyond the COVID-19 emergency period, with certain modifications, the Emergency Declaration Blanket Waiver relating to training and certification of nurse aides to alleviate burdens imposed on staff of skilled nursing facilities and nursing facilities. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. ¢ 2021 CONG US HR 8021, introduced June 9, 2022, would authorize the Secretary of Health and Human Services to award grants to reduce barriers to immigrants becoming nurses or allied health professionals in the United States. ¢ 2021 CONG US HR 8022, introduced June 9, 2022, would address barriers immigrants and refugees face to entering the health care workforce. California * 2021 CAA.B. 279 (NS), introduced January 21, 2021, would prohibit the owner of a skilled nursing facility from ceasing to deliver or making significant changes to the nature of residential care services, or from transferring a resident to another facility, during any declared state of emergency relating to COVID-19, except if the owner files for bankruptcy. The bill would require, upon termination of the same type of state of emergency, the owner of an SNF to issue a 6-month advance notice of any proposed sale or termination of the licensed operation of the facility to each resident before the sale or termination goes into effect. The bill would also prohibit during the same type of state of emergency, any changes in all conditions for the sale of assets imposed by the Attorney General, except if the owner of an SNF files for bankruptcy. By expanding the requirements and prohibitions imposed on a licensee of an SNF, the failure to comply with would be a crime, this bill would impose a state-mandated local program. ¢ 2021 CA A.B. 523 (NS), vetoed by the governor October 6, 2021, would have required the department to make permanent the specified PACE program flexibilities instituted, on or before January 1, 2021, in response to the state of emergency caused by COVID-19 by means of all-facility letters or other similar instructions taken without regulatory action, with prescribed modifications, such as instead limiting a PACE organization's use of telehealth to specified services, including conducting assessments for eligibility for enrollment in the PACE program, subject to the federal waiver process. ¢ 2021 CAA.B. 1585 (NS), amended/substituted August 18, 2021, would revise the required qualifications for Infection Preventionists at skilled nursing facilities to require an IP to have primary professional training as a licensed nurse, medical technologist, microbiologist, epidemiologist, public health professional, or other health care related field. The bill would also require the IP to be qualified by education, training, clinical or healthcare experience, or certification, and to have completed specialized training in infection prevention and control. * 2021 CAA.B. 2546 (NS), amended/substituted May 19, 2022, would require the State Department of Public Health, the State Department of Social Services, and the State Long-Term Care Ombudsman, or their designee, to convene a working group to develop recommendations regarding best practices for public health officials and long-term care facilities, as defined, when developing policies, including certain visitation policies involving designated support persons, related to long-term care facilities during public health emergencies, as defined. Colorado ¢ 2022 CO H.B. 1199 (NS), introduced February 7, 2022, providing for 'compassionate care' visitation requirements in end-of-life situations and other circumstances. * 2022 CO S.B. 53 (NS), adopted June 8, 2022, concerning visitation rights at health-care facilities during pandemic. Florida 2022 FL S.B. 988 (NS), adopted April 6, 2022, the 'No Patient Left Alone Act'; requiring providers to allow clients to receive in-person visitors in end-of-life situations. Georgia ¢ 2021 GAH.B. 290 (NS), amended/substituted March 3, 2021, policy of hospitals and nursing homes during a declared public health emergency that limits patients' abilities to be visited by designated family members and friends. * 2021 GAH.B. 649 (NS), introduced February 26, 2021, visitation by essential visitors to patients to hospitals and residents in long- term care facilities. Hawaii ¢ 2021 HI H.B. 2394 (NS), amended/substituted February 9, 2022, appropriating moneys to provide one-time enhanced payments of fifteen per cent to any facility in the State licensed by Medicare to provide skilled nursing or intermediate care to Medicaid patients to assist with pandemic-related costs and lost revenues. ¢ 2021 HI S.B. 237 (NS), introduced January 22, 2021, raises the standard of care for the State's veteran homes, long term care facilities and nursing homes in response to the COVID-19 pandemic by describing requirements for care facility licensing and leadership, implementing standards of recordkeeping, creating protocols for emergencies and personal protective equipment, and establishes a hotline for complaints. ¢ 2021 HI S.B. 3236 (NS), amended/substituted April 29, 2022, appropriating funds to provide enhanced payments to state-licensed skilled nursing facilities, community care foster family homes, and expanded adult residential care homes that are caring for Medicaid patients, provided that the Department of Human Services obtains the maximum amount of federal matching funds available for this expenditure. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. Illinois ¢ 2021 IL H.B. 1830, introduced February 17, 2021, provides that a health care provider shall not be liable for civil damages for causing or contributing to the death or injury of an individual as a result of the health care provider's acts or omissions while providing or arranging health care in support of the State's response to COVID-19. ¢ 2021 IL H.B. 3147 (NS), adopted August 16, 2021, requires long-term care facilities and hospitals to facilitate at least one phone call or video call between a resident or patient and a family member of the resident or patient each day during a pandemic or other public health emergency. ¢ 2021 IL H.B. 5541 (NS), introduced January 31, 2022, creating the Long-Term Care Facility COVID-19 Mitigation Act to require long-term care facilities to conduct regular universal testing for all facility residents and staff and disclose all COVID-19 cases and deaths to facility residents, residents' family members, the Department of Public Health, and the federal CDC; provides that the Department of Public Health shall coordinate with local, State, and federal governments to establish COVID-19 alternate care sites with staffing; requires the Department to establish a commission to implement increased State oversight of facilities, provide additional staff resources and PPE for workers, and consider receivership for facilities with chronic public health violations. lowa ¢ 2021 IA H.F. 190 (NS), introduced January 22, 2021, relating to cross-over visitation between residents or tenants in a shared campus long-term care facility during a national public health emergency or public health disaster. ¢ 2021 IA S.F. 192 (NS), introduced February 1, 2021, creating a line of duty reimbursement for COVID-19 pandemic-related health care costs of qualified volunteer emergency services providers, providing an appropriation, and providing effective and applicability dates. * 2021 IA S.F. 507 (NS), introduced march 2, 2021, relating to long-term care facility and hospital practices including patient visitation and protections, and providing civil penalties. ¢ 2021 IA S.C.R. 5 (NS), introduced February 16, 2021, encouraging the United States Congress to provide flexibility to the states in determining visitation practices in nursing facilities. Kansas 2021 KS H.B. 2126 (NS), introduced January 25, 2021, providing immunity from civil liability for COVID-19 claims for adult care facilities. Maine 2021 ME H.P. 817 (NS), introduced March 18, 2021, to authorize and regulate visitation of essential caregivers at long-term care facilities. Massachusetts ¢ 2021 MA H.D. 2410 (NS), filed February 17, 2021, ensuring access to PPE for eldercare providers. ¢ 2021 MA S.D. 1550 (NS) and 2021 MA H.D. 3834 (NS), filed February 19, 2021, filed February 17, 2021, relative to infection control in nursing facilities, authorizing the Department of Health to use Civil Monetary Penalty monies to establish an Infection Preventionist training grant program for certified nursing facilities. Minnesota 2021 MN S.F. 2740 (NS), engrossed February 17, 2022, authorizing retired nurses to practice in long-term care settings, modifying training requirements for direct care staff in long-term care facilities, and establishing a temporary voluntary correction program for nursing homes. Mississippi * 2022 MS H.B. 764 (NS), engrossed February 2, 2022, the 'Mississippi Health Care Workers Retention Act of 2022'; to make an appropriation from the coronavirus state fiscal recovery fund to the state department of health; to provide that a portion of the funds shall be expended by the department for providing funds to Mississippi licensed hospitals, long-term care facilities, and certain other providers to provide premium pay to their Mississippi licensed/certified health care workers who are primarily devoted to mitigating or responding to the current COVID-19 public health emergency. * 2022 MS S.B. 2673 (NS), introduced January 17, 2022, the 'Mississippi Frontline Nurses and Health Care Workers Retention Act'; to provide the legislative findings and determinations regarding the importance and urgency of the act; to establish the 'Mississippi Frontline Nurses and Health Care Workers Retention Grant Program' in the Mississippi department of health and prescribe its components; to provide that a portion of the funds shall be expended by the department for providing funds to Mississippi licensed hospitals, long-term care facilities, and certain other providers to provide premium pay to their Mississippi frontline nurses and licensed/ certified health care workers providing bedside care who are primarily devoted to mitigating or responding to the current COVID-19 public health emergency. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -10- Missouri 2022 MO H.B. 2116 (NS), adopted June 30, 2022, relating to 'compassionate care" visitation rights of patients in end-of-life and other situations in health care facilities including hospitals, long-term care facilities and hospice facilities. New Hampshire ¢ 2021 NH S.B. 132 (NS), amended/substituted March 4, 2021, establishing a COVID-19 micro enterprise relief fund; requiring a COVID-19 needs assessment of nursing homes and long-term care facilities and making an appropriation therefor. ¢ 2021 NH S.B. 332 (NS), introduced January 5, 2022, establishing the long-term care retention stabilization program of 2022 for services provided by frontline workers employed by certain Medicaid providers, and contracted entities through the developmental services system. The program provides temporary stabilization funding to incentivize frontline workers to remain in or rejoin this workforce during the COVID-19 emergency. ¢ 2021 NH S.B. 413 (NS), introduced January 5, 2022, requiring an independent audit and needs assessment regarding COVID-19 preparedness at long term care facilities, nursing homes, and the New Hampshire veterans' home, and making an appropriation therefor. New Jersey * 2022 NJ A.B. 2570 (NS), introduced February 14, 2022, requiring licensed providers of long-term skilled nursing care to establish a permanent morgue for use in non-emergent periods and supplemental morgue space for use in public emergencies. ¢ 2022 NJ A.B. 4044 (NS), introduced May 16, 2022, requiring long-term care facilities to stock and provide COVID-19 antiviral treatments to residents. ¢ 2022 NJ S.B. 2520 (NS), introduced May 12, 2022, establishing the 'New Jersey No Patient Left Alone Act," requiring certain facilities to establish policies guaranteeing visitation rights for residents in hospice, long-term care, and veterans' home facilities. New York ¢ 2021 NY A.B. 3162 (NS), introduced January 22, 2021, and 2021 NY S.B. 2067 (NS), introduced January 19, 2021, establishes a temporary state commission to study and investigate the effects of the COVID-19 pandemic response on deaths in nursing homes; and providing for the repeal of such provisions upon expiration thereof. ¢ 2021 NY A.B. 6057 (NS), introduced March 5, 2021, directs the department of health to establish and implement an infection inspection audit and checklist on residential care facilities, nursing homes and long-term care facilities. ¢ 2021 NY A.B. 9928 (NS), amended/substituted May 20, 2022, establishing a frontline healthcare workers tax credit for clinical and non-clinical frontline healthcare workers and certain long-term care facility workers during the COVID-19 pandemic. ¢ 2021 NY S.B. 1783 (NS), adopted December 22, 2021, directs the department of health to establish and implement an infection inspection audit and checklist on residential care facilities, nursing homes and long-term care facilities. ¢ 2021 NY S.B. 2543 (NS), introduced January 21, 2021, provides for insurance reimbursement for expenses related to the provision of PPE for direct care workers, care recipients and an emergency inventory of a ninety-day supply of PPE for home- and community- based long-term care services. ¢ 2021 NY S.B. 6782 (NS), introduced May 17, 2021, establishing a frontline healthcare workers tax credit for clinical and non-clinical frontline healthcare workers and certain long-term care facility workers, including hospice care, during the novel coronavirus, COVID-19 pandemic. North Carolina ¢ 2021 NC H.B. 351 (NS), adopted September 10, 2021, Clifford's Law, directing the Secretary of the Department of Health and Human Services to establish visitation protocols for nursing homes, combination homes, and adult care homes, including family care homes, during declared disasters and emergencies and requiring these facilities to adhere to the established visitation protocols during declared disasters and emergencies when normal visitation policies are suspended or curtailed. ¢ 2021 NC S.B. 191 (NS), engrossed May 5, 2021, providing patient visitation rights in hospitals, nursing homes, hospice, and other care facilities will not be impacted during declared disasters and emergencies and directing the department of health and human services to impose a civil penalty for any violation of those rights. Ohio 2021 OH H.B. 120 (NS), adopted April 21, 2022, permits compassionate care visits in long-term care facilities during the COVID-19 state of emergency. Oklahoma * 2021 OK H.B. 1677 (NS), engrossed March 1, 2021, relating to long-term care, providing for designation of compassionate caregivers for long-term care facility and assisted living residents; requiring access to residents by certain people; providing precautions that THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -11- may be taken in certain situations; allowing revocation of compassionate caregiver status under certain circumstances; prohibiting elimination of visitation. ¢ 2021 OK H.B. 2566 (NS), introduced February 1, 2021, relating to long-term care, providing for visitation of residents in long-term care facilities; providing for health care provider access to residents of long-term care facilities; allowing restrictions by the State Department of Health; prohibiting unilateral elimination of visitation. * 2021 OK H.B. 3247 (NS), introduced February 7, 2022, preempting field of legislation relating to employment-related vaccination mandates; nullifying any federal statute, rule, or executive order relating to employment-related vaccination mandates; defining terms; creating employer liability for adverse events caused by vaccinations when such vaccinations are a condition of employment; providing for exception; providing for damages, costs, and attorney fees. * 2021 OK H.B. 3313 (NS), introduced February 7, 2022, making it unlawful for any medical entity in this state to deny visitation to COVID-19 patients, even when such patients are deemed to be in isolation from the general public and other patients. ¢ 2021 OK S.B. 674 (NS), introduced February 1, 2021, requiring certain coverage of health care services provided through telemedicine; prohibiting certain exclusion of service for coverage; requiring reimbursement; prohibiting application of certain deductible; requiring equivalence of copayment or coinsurance; prohibiting imposition of certain limits or maximums. ¢ 2021 OK S.B. 1518 (NS), amended/substituted February 28, 2022, regarding long-term care, eliminating the temporary emergency waiver for employment of noncertified nurse aides; stating requirements for training and competency evaluation program. Pennsylvania ¢ 2021 PA H.B. 208 (NS), introduced January 22, 2021, providing for the disclosure of communicable diseases in certain facilities during disaster emergencies. ¢ 2021 PA H.B. 368 (NS), introduced February 3, 2021, imposing duties on employers for the health and safety of employees relating to limiting exposure to COVID-19; and providing for right to bring own personal protective equipment, for notification of illness in the workplace, for whistleblower protection and for enforcement. ¢ 2021 PA H.B. 649 (NS), introduced February 24, 2021, providing for access to long-term care facilities for essential caregivers, for additional safety requirements for residents of long-term care facilities, for suspension of access for essential caregivers and for personal protective equipment for essential caregivers. * 2021 PA H.B. 996 (NS), amended/substituted May 4, 2021, providing for access to long-term care facilities for members of the clergy, for additional safety requirements for residents, for suspension of access for members of the clergy and for personal protective equipment for members of the clergy. ¢ 2021 PA H.B. 2325 (NS), introduced February 9, 2022, establishing the Long-Term Care Facility Employee Retention Grant Program to address staffing shortages caused by the COVID-19 pandemic. * 2021 PA S.B. 190 (NS), introduced March 23, 2021, providing for essential family caregivers in facilities, including hospice, during disaster emergencies. ¢ 2021 PA S.B. 385 (NS), amended/substituted June 8, 2021, providing for a long-term care facility ventilation grant program. South Carolina * 2021 SC H.B. 3227 (NS), introduced January 12, 2021, relating to rights of residents of long-term care facilities, so as to add the right of residents to communicate with persons by videotelephonic or web-based video communication technologies. ¢ 2021 SC H.B. 5018 (NS), introduced February 23, 2022, the 'No Patient Left Alone Act," to safeguard patient and resident visitation rights in certain health care facilities during declared disasters and emergencies in compassionate care situations including end-of-life situations. Tennessee 2021 TN H.B. 2535 (NS) and 2021 TN S.B. 2574 (NS), introduced February 2, 2022, requiring nursing homes and assisted-care living facilities to permit at least one family member or patient representative who meets certain conditions to visit a resident of the facility during end-of-life situations if a disaster, emergency, or public health emergency for COVID-19 has been declared. Vermont 2021 VT H.B. 595 (NS), introduced January 13, 2022, requiring long-term care facilities to allow residents to identify up to two individuals as their 'essential caregivers" who would have the right to visit the resident in the facility during a public health emergency. Washington ¢ 2021 WAH.B. 1196 (NS), amended/substituted February 3, 2021, relating to audio-only telemedicine. ¢ 2021 WAH.B. 1462 (NS), introduced February 2, 2021, relating to the total compensation for telemedicine services, including skilled nursing facilities. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -12- ¢ 2021 WA H.B. 2117 (NS), introduced February 9, 2022, ensuring a terminally ill patient's right to visitors. ¢ 2021 WA S.B. 5294 (NS), introduced January 20, 2021, concerning the creation of statewide epidemic preparedness and response guidelines for long-term care facilities. Wisconsin * 2021 WI A.B. 215 (NS), introduced March 31, 2021, visitation of a long-term care facility resident or hospital patient by an essential visitor or member of the clergy. ¢ 2021 WI S.B. 230 (NS), introduced March 24, 2021, visitation of a long-term care facility resident or hospital patient by an essential visitor or member of the clergy. Ill. MEDICAID FUNDING The Medicaid program is jointly funded by the federal government and states. The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP). FMAPs are used in determining the amount of Federal matching funds for State expenditures for assistance payments for certain social services, and State medical and medical insurance expenditures. The Social Security Act requires the Secretary of Health and Human Services to calculate and publish the FMAPs each year. Section 1905(b) of the Act specifies the formula for calculating Federal Medical Assistance Percentages. FMAP varies by state based on criteria such as per capita income. The regular average state FMAP is 57%. It ranges, however, from 50% in wealthier states up to 75% in states with lower per capita incomes (the maximum regular FMAP is 82%). FMAPs are adjusted for each state on a three-year cycle to account for fluctuations in the economy, and are published annually in the Federal Register. [FN46] States must ensure they can fund their share of Medicaid expenditures for the care and services available under their state plan. Recognized sources of funding for the state share of Medicaid payments include: * Legislative appropriations to the single state agency « Inter-governmental transfers (IGTs) * Certified public expenditures (CPEs) ¢ Permissible taxes and provider donations Before the CMS approves a state plan amendment, they must verify that state funding sources meet statutory and regulatory requirements so they can authorize federal financial participation (FFP) for the covered services. States can establish their own Medicaid provider payment rates within federal requirements. States generally pay for services through fee-for-service or managed care arrangements. Under fee-for-service arrangements, states pay providers directly for services. States may develop their payment rates based on: the costs of providing the service, a review of what commercial payers pay in the private market, and a percentage of what Medicare pays for equivalent services. Under managed care arrangements, states contract with organizations to deliver care through networks and pay providers. Approximately 70% of Medicaid enrollees are served through managed care delivery systems, where providers are paid on a monthly capitation payment rate. Payment rates are often updated based on specific trending factors, such as the Medicare Economic Index or a Medicaid-specific trend factor that uses a state-determined inflation adjustment rate. The methodologies for service rates are described in the Medicaid State Plan. To change the way they pay Medicaid providers, states must submit a State Plan Amendment (SPA) for CMS review and approval. Before the amendment's effective date, the state must also issue a public notice of the change. The notification is intended to widely inform providers and other stakeholders of changes to Medicaid payment rates. CMS periodically reviews SPA reimbursement methodologies for consistency with the Social Security Act and other federal statutes and regulations. States must 'assure that payments are consistent with efficiency, economy and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.' In support of President Biden's plan to improve the nation's nursing homes, CMS issued an informational bulletin on August 22, 2022, outlining actions for states to take to improve the safety and quality of care of residents. [FN47] Detailing actions that states can take using existing Medicaid authorities to drive better health outcomes for nursing home residents and improve staff pay, training, and retention efforts, the informational bulletin ? issued by CMS' Centers for Medicaid and CHIP Services (CMCS) ? also provides examples of current state Medicaid initiatives to support this work. To ensure nursing homes are adequately resourced and staffed, CMS is urging states to tie Medicaid payments to quality measures that will improve the safety and quality of care. 'We know that low wages for staff can contribute to frequent turnover and dangerous staffing shortages at nursing homes, so we encourage states to work with these facilities to find solutions for training and improving staffing," said Administrator Brooks-LaSure stated in a press release. [FN48] THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -13- In addition to the informational bulletin, CMS continues to encourage states strongly to achieve a more equitable balance between the share of spending and use of services and supports delivered in home and community-based settings relative to institutional care like nursing homes, the press release stated. As another key priority of the Biden-Harris Administration, CMS is committed to strengthening the availability of Medicaid-covered home- and community-based services (HCBS) as an alternative to institutional care. As a result of the American Rescue Plan, states are planning to invest $25 billion to expand, enhance, and strengthen HCBS, the largest investment ever in HCBS, the press release noted. An analysis of recent trends in nursing facilities compiled by the Kaiser Family Foundation IFN4S] finds that Medicaid is the primary source for most certified nursing facility residents, with more than six in ten (62%) residents-about 832,000 people-having Medicaid as their primary payer. States in the East, particularly the Southeast, have higher shares of residents with Medicaid as their primary payer than other states. The relatively high cost of care in the long-term care delivery system, that includes home- and community- based services, has led it to become the focus of attention from policymakers. Researchers drew on data from the federal On-line Survey, Certification, and Reporting system (OSCAR) and Certification and Survey Provider Enhanced Reports (CASPER) on nursing facility characteristics, staffing, and deficiencies, by state, from 2009 to 2016. Key findings include: ¢ The number of nursing facility beds has been fairly consistent since 2009, reaching 1.6 million certified beds in 2016 (with an average of 109 beds per facility). However, nursing facility occupancy rates declined slightly from 2009 to 2016, from 84% in 2009 to 81% in 2016. ¢ The share of nursing facilities that were for-profit increased slightly, from 67% in 2009 to 69% in 2016, while the share that were non- profit declined slightly from 26% in 2009 to 24% in 2016. ¢ On average, in 2016, residents' level of need for assistance with activities of daily living scored 5.8 on a scale from 3 to 9, and levels of need have been fairly stable since 2009. ¢ In 2016, total nursing hours (including RNs, LPN/LVNs, and NAs) averaged 4.1 hours per resident day, an increase from 3.9 in 2009, although there was wide state variation in average nursing hours per resident day. Nationwide, many of these hours are accounted for by non-licensed nursing care (i.e., nursing assistants). * Nursing facility deficiencies have declined between 2009 and 2016 (though there is still much state variation in rates of deficiencies). State Funding In support of President Biden's plan to improve the nation's nursing homes, CMS issued an informational bulletin on August 22, 2022, outlining actions for states to take to improve the safety and quality of care of residents. [FNSO] Detailing actions that states can take using existing Medicaid authorities to drive better health outcomes for nursing home residents and improve staff pay, training, and retention efforts, the informational bulletin ? issued by CMS' Centers for Medicaid and CHIP Services (CMCS) ? also provides examples of current state Medicaid initiatives to support this work. To ensure nursing homes are adequately resourced and staffed, CMS is urging states to tie Medicaid payments to quality measures that will improve the safety and quality of care. 'We know that low wages for staff can contribute to frequent turnover and dangerous staffing shortages at nursing homes, so we encourage states to work with these facilities to find solutions for training and improving staffing," said Administrator Brooks-LaSure stated in a press release. [FNS1] In addition to the informational bulletin, CMS continues to encourage states strongly to achieve a more equitable balance between the share of spending and use of services and supports delivered in home and community-based settings relative to institutional care like nursing homes, the press release stated. As another key priority of the Biden-Harris Administration, CMS is committed to strengthening the availability of Medicaid-covered home- and community-based services (HCBS) as an alternative to institutional care. As a result of the American Rescue Plan, states are planning to invest $25 billion to expand, enhance, and strengthen HCBS, the largest investment ever in HCBS, the press release noted. Nursing facilities in Illinois and Florida expect to see increases in Medicaid funding thanks to budgetary actions in those states. In Illinois, legislators approved an annual $700 million funding increase for nursing homes with the aim of increasing staffing levels and improving quality of care. The bill heads to Governor J.B. Pritzker, who is expected to sign the legislation. [FNS2] 1, Florida, nearly 700 nursing homes are in line for additional help with the ongoing workforce crisis, thanks to several key actions by lawmakers this legislative session. In all, lawmakers directed $293 million for increases to nursing homes in the state's fiscal year 2022-23 budget, which begins July 1. 'N®*! Florida's $112 billion state budget for the 2022-2023 fiscal year was approved April 4, 2022. Lawmakers included a 7.8% increase in Medicaid funding for nursing homes. Governor DeSantis said the hope is that the increase will allow nursing homes to increase hourly pay rates for certified nursing assistants. Lawmakers also loosened staffing standards in a bill (2022 FL H.B. 1239(NS)) that allows nursing homes to lower the amount of direct nursing care requirements from 2.5 hours a day to 2 hours a day. Long-Term Care Services and Supports (LTSS) THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -14- The Medicaid program allows for the coverage of Long-Term Care Services through several vehicles and over a continuum of settings that include Institutional Care and Home- and Community-Based Long-Term Services and Supports. As states face rising Medicaid costs and continuing fiscal pressures, state Medicaid programs are increasingly considering risk-based contracting with managed care organizations (MCOs) to provide LTSS to those enrollees. While the fixed payment structure helps make Medicaid costs more predictable for states, they may create incentives for plans to restrict access to services for individuals who have costly health care needs. This potential risk highlights the importance of state oversight to ensure that MCOs comply with all contract requirements-including the provision of all LTSS required to provide optimal care to their enrollees. This potential risk highlights the importance of state oversight to ensure that MCOs comply with all contract requirements-including the provision of all LTSS required to provide optimal care to their enrollees. Institutional Long-Term Care Medicaid covers certain inpatient comprehensive services as institutional benefits as authorized in the Social Security Act. These include hospital services, Intermediate Care Facilities for People with Mental Retardation (ICF/MR), nursing facilities, Preadmission Screening & Resident Review (PASRR), inpatient psychiatric services for individuals under age 21, and services for individuals aged 65 or older in an institution for mental diseases. Features of institutional benefits include: ¢ Residential facilities that assume total care of the individuals who are admitted. * Comprehensive care including room and board. « Comprehensive service is billed and reimbursed as a single bundled payment. ¢ Institutions must be licensed and certified by the state, according to federal standards. ¢ Institutions are subject to survey at regular intervals to maintain their certification and license to operate. * Eligibility for Medicaid may be figured differently for residents of an institution, and therefore access to Medicaid services for some individuals may be tied to need for institutional level of care. Home- and Community-Based Long-Term Services & Supports Home- and community-based services (HCBS) provide opportunities for Medicaid beneficiaries to receive services in their own home or community. These programs serve a variety of targeted populations groups, such as people with mental illnesses, intellectual disabilities, and/or physical disabilities. CMS is working in partnership with states, consumers and advocates, providers, and other stakeholders to create a sustainable, person-driven long-term support system in which people with disabilities and chronic conditions have choice, control, and access to a full array of quality services that assure optimal outcomes, such as independence, health, and quality of life. [FNS4] The Kaiser Family Foundation (KFF) has released its latest analysis of Medicaid funding for seniors and people with disabilities who rely on long-term services and supports (LTSS) to handle activities of daily living and the direct care workers who provide these services. FN5] As the primary source of funding for home and community-based services (HCBS), state Medicaid programs have faced long-standing challenges related to the aging population, workforce shortages, and an insufficient supply of affordable, accessible housing, the report points out. All of these challenges pre-dated and have been intensified by the pandemic. At the same time, existing financing sources have been insufficient to meet the need for HCBS. In an October 2021 poll, 18% of adults said that they or a family member need new or additional support from paid nurses or aides beyond what they currently receive. Cost is the most common reason cited by people who have not received needed support. Private insurance and out-of-pocket spending account for small shares of HCBS financing compared to Medicaid and Medicare coverage is limited to short-term post-acute (and not long-term) care. Although Medicaid finances the majority of HCBS, the optional nature of most aspects of Medicaid HCBS eligibility and benefits results in substantial variation across states. State Medicaid programs must cover LTSS in nursing homes, while nearly all HCBS are optional. States have made significant shifts in addressing this historical bias toward institutional LTSS, with spending on HCBS surpassing spending on institutional care for the first time in FY 2013. HCBS accounted for 59% of LTSS spending in FY 2019, the highest share to date For additional information on HCBS funding and policies, see Health Policy Tracking Service, Long-Term Care: Home- and Community- Based Services, a service of Thomson Reuters. Waivers Waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and the Children's Health Insurance Program (CHIP). There are four primary types of waivers and demonstration projects: * Section 1115 Research & Demonstration Projects: States can apply for program flexibility to test new or existing approaches to financing and delivering Medicaid and CHIP. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -15- ¢ Section 1915(b) Managed Care Waivers: States can apply for waivers to provide services through managed care delivery systems or otherwise limit people's choice of providers. ¢ Section 1915(c) Home- and Community-Based Services Waivers: States can apply for waivers to provide long-term care services in home and community settings rather than institutional settings. * Concurrent Section 1915(b) and 1915(c) Waivers: States can apply to implement two types of waivers to provide a continuum of services to the elderly and people with disabilities, as long as all federal requirements for both programs are met. Medicaid Enrollment and Spending Growth; COVID-19 Implications Since March 2020, the COVID-19 pandemic and its economic impact have had significant implications for Medicaid spending and enrollment. To provide broad fiscal relief to states while preventing coverage losses during the pandemic, Congress passed the Families First Coronavirus Response Act (FFCRA) early in the pandemic to provide a 6.2 percentage point increase in the federal Medicaid match rate (FMAP) for states that meet certain 'maintenance of eligibility" (MOE) requirements, including a continuous enrollment requirement. According to a recent report by the Kaiser Family Foundation, [FNS6] these provisions have driven Medicaid enrollment to record highs and contributed to declines in the uninsured rate. Medicaid spending has also increased, though fiscal relief from the enhanced FMAP met or exceeded the state costs of the additional enrollment through in every state, KFF estimates. The KFF brief analyzes Medicaid enrollment and spending trends for state fiscal years 2022 and 2023, based on survey data provided by state Medicaid directors. When the public health emergency (PHE) expires, the enhanced FMAP will continue through the end of the quarter and states must meet MOE requirements through the end of the month. The PHE was recently extended to mid-January 2023. Key survey findings include the following: ¢ Enrollment growth: Following a sharp increase the previous year, Medicaid enrollment growth slowed in FY 2022 (to 8.4%) and is projected to decline (-0.4%) in FY 2023, based largely on the assumption that the PHE and the related MOE requirements would end by mid-FY 2023. ¢ Spending growth: State Medicaid agencies expect total Medicaid spending (including both federal and state funds) to reach a peak growth rate of 12.5% in FY 2022 and slow to 4.2% in FY 2023. Enrollment growth was identified as the primary driver of FY 2022 expenditure growth; slower enrollment growth is expected to result in a lower total spending growth rate in FY 2023. States reported that the state (nonfederal) share of Medicaid spending grew by 9.9% in FY 2022 but projected a sharper growth rate of 16.3% in FY 2023 based on the assumption that the fiscal relief would expire by mid?FY 2023, shifting the state and federal spending shares even though total Medicaid spending growth is expected to slow. While state economic conditions have improved and COVID-19 vaccines and boosters are broadly available, uncertainty remains about the trajectory of the pandemic. State officials responsible for the unwinding of the continuous enrollment requirement and for overall state budgeting also face planning and operational challenges due to the uncertainty of the PHE duration. Since the enhanced FMAP will expire at the end of the PHE, state spending will increase to replace the expiring federal funds. Transportation Services, Non-Emergency CMS has delayed consideration of a rule that would make it optional for states to cover non-emergency transportation services, as part of a larger bid to cut $143 billion from Medicaid. According to a regulatory agenda included in the White House budget, a new deadline in late 2021 has been set for a proposed rule allowing states to opt out of the coverage. Such transportation services-often used for dialysis, doctor visits, or physical therapy-have been mandatory since Medicaid's inception. CMS, however, has granted states such as Indiana and lowa waivers to cut back on the offering. Medicaid vs. Long-Term Care Insurance Long-term care insurance is expensive. In 2017, the national averages for long-term care expenses ranged from $47,840 for a full- time home health aide to over $100,000 for a private room in a nursing home. A study conducted by researchers at the Center for Retirement Research at Boston College examines the options that single individuals over 65 face, and the value of purchasing long- term care insurance. The main funding sources for long-term care are Medicare, private LTC insurance, and Medicaid. Medicare covers short-term stays for noncustodial care, for up to 100 days. Private long-term care insurance is purchased by few single individuals in the U.S., only about 13%. For those that are uninsured, Medicaid bears much of the cost of skilled nursing care once an individual's assets have been exhausted and the means test is met. The researchers found that while the risk of needing long-term care is greater than research previously indicated, average stays are shorter. Using monthly rather than annual figures, they pointed out that 50% of men and 39% of women don't stay in a skilled nursing facility longer than three months: the average nursing home stay for a man is less than a year; for women, 17 months. With the availability of Medicare and Medicaid, and lower chances that one will endure an expensive, long illness that will bankrupt them, the investigators concluded that 'rational, far-sighted, well-informed" single people would be smart to avoid paying long-term care insurance premiums. [FNS7] Dual-Eligible Special Needs Plans Provide Insurance Vehicle for Providers THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -16- Researchers at the ATI Advisory, a healthcare research and consulting firm, examine an approaching regulatory transition that would give skilled nursing providers an opportunity to participate in and offer special needs plans designed for dual-eligible individuals. Some 81% of nursing home residents are 'dual eligibles" ? dually eligible for both Medicaid and Medicare coverage. The report by the ATI Advisory, with the support of the SNP Alliance, studied opportunities for the CMS to support and facilitate smooth transitions for states and dual eligibles, out of the Medicare-Medicaid Plan (MMP) Model. '"N®8! The MMP Model was implemented in 2013 by the CMS to better integrate Medicare and Medicaid at the administrative, financial, and clinical levels, and allow states to share in Medicare savings. The MMP model has been tested in ten states across eleven programs with varied results, but generally, strong stakeholder support, according to the report. The report examined ways states can blend successful elements of the MMP model into quickly growing Dual-Eligible Special Needs Plans, or D-SNPs. D-SNPs are the largest of the special needs plans, covering about 4.4 million of more than 11 million dually eligible beneficiaries. Enrollment in D-SNP plans has grown dramatically in recent years, increasing from 1,833,000 in 2016 to 4,385,000 in 2022. Nearly all D-SNPs are currently offered by major insurance providers and managed care companies. The report looks at the potential of financial reward for providers who can manage the risk that comes with being an insurer and managing participants' quality outcomes. Recent Legislative Activity Califomia ¢ 2021 CAA.B. 2079 (NS), amended/substituted August 17, 2022, would require, no later than July 1, 2023, the establishment of a direct patient-related services spending, reporting, and rebate requirement for skilled nursing facilities; would require that a minimum of 85% of a facility's total non-Medicare health revenues from all payer sources in each fiscal year be expended on residents' direct patient-related services; would require a facility to report total revenues collected from all revenue sources, along with the portion of revenues that are expended on all direct patient-related services and nondirect patient-related services; would require the State Department of Health Care Services to conduct an audit of the financial information reported by the facilities. If a skilled nursing facility fails to comply with the direct patient-related services spending requirement, the bill would require the facility to issue a pro rata dividend or credit to the state and to all individuals and entities making non-Medicare payments to the facility for resident services; would impose sanctions, as specified; would also authorize the department to withhold certain certification from a licensed skilled nursing facility for failure to fully disclose information. * 2021 CAA.B. 2823 (NS), amended/substituted June 13, 2022, providing for Medi-Cal beneficiary maintenance needs: home upkeep allowance and transitional needs allowance for Medi-Cal patients residing in a long-term care facility. Connecticut 2022 CT S.B. 195 (NS), amended/substituted April 26, 2022, to increase to fifty thousand dollars the minimum amount of assets that may be retained by the spouse of an institutionalized Medicaid beneficiary. Delaware 2021 DE S.B. 109 (NS), engrossed June 24, 2021, relating to Medicaid reimbursement rates for home health-care services. District of Columbia 2021 DC L.B. 825 (NS), adopted June 28, 2022, to approve, on an emergency basis, Modification Nos. 15, 16, and 17 to Contract No. CW63144 with Consumer Direct District of Columbia, LLC to provide Vendor Fiscal/Employer Agency Financial Management services and support broker services to Medicaid participants enrolled in the District's Medicaid Home and Community-Based 1915(c) waivers and to authorize payment for the goods and services received and to be received under the contract. Hawaii ¢ 2021 HI H.C.R. 42 (NS), introduced February 22, 2021, and 2021 HI S.C.R. 41 (NS), introduced February 23, 2021, urging the department of human services to study the feasibility of increasing payment to Hawaii's Community Care Foster Family Homes (CCFFH) and expanded adult residential care homes (e-arch) for Medicaid recipients. ¢ 2021 HI H.C.R. 46 (NS), introduced February 23, 2021, requesting the Department of Human Services to study the feasibility of increasing the Medicaid reimbursement payment rate for Hawaii's community care foster family homes and expanded adult residential care homes for Medicaid recipients. ¢ 2021 HI H.B. 2394 (NS), amended/substituted February 9, 2022, appropriating moneys to provide one-time enhanced payments of fifteen per cent to any facility in the State licensed by Medicare to provide skilled nursing or intermediate care to Medicaid patients to assist with pandemic-related costs and lost revenues. ¢ 2021 HI H.R. 37 (NS), introduced February 23, 2021, requesting the Department of Human Services to study the feasibility of increasing the Medicaid reimbursement payment rate for Hawaii's community care foster family homes and expanded adult residential care homes for Medicaid recipients. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -17- ¢ 2021 HI S.R. 4 (NS), adopted April 5, 2022, requesting the Department of Human Services to study the feasibility of increasing the Medicaid reimbursement rates for community care foster family homes, expanded adult residential care homes, and other types of home- and community-based service care providers and services. ¢ 2021 HI S.B. 3236 (NS), amended/substituted April 29, 2022, appropriating funds to provide enhanced payments to state-licensed skilled nursing facilities, community care foster family homes, and expanded adult residential care homes that are caring for Medicaid patients, provided that the Department of Human Services obtains the maximum amount of federal matching funds available for this expenditure. * 2022 HI S.B. 3236 (NS), approved July 7, 2022, to help preserve the financial viability of nursing facilities, community care foster family homes, and expanded adult residential care homes in the State by providing a one?time enhanced payment to state?licensed skilled nursing facilities, community care foster family homes, and expanded adult residential care homes that are caring for Medicaid patients. Illinois ¢ 2021 IL H.B. 1422 (NS), introduced February 17, 2021, makes a technical change in a section concerning Medicaid payment rates for nursing facility and ICF/DD services in nursing facilities. ¢ 2021 IL H.B. 3899 (NS), introduced February 22, 2021, amends the Medical Assistance Article of the Illinois Public Aid Code; provides that the Department of Healthcare and Family Services shall implement no later than July 1, 2021 a reimbursement system that uses the Medicare PDPM nursing component rate and takes into account transparency, accountability, actual staffing as reported under the federally required Payroll Based Journal system, changes to the minimum wage, adequacy in coverage of the cost of care, quality star rating, staffing star rating, and a quality component that rewards quality improvements. ¢ 2021 IL H.B. 4443 (NS), introduced January 21, 2022, declaring that all changes to the existing nursing facility direct care reimbursement rate methodologies and to the bed assessment and collection procedures must be approached with caution, executed deliberately, and held to the highest of standards in order to protect nursing facility residents from disruption in care, protect workers from lost wages and jobs, and protect providers from the increased instability within the industry. Provides that a Nursing Facility Oversight Committee (Committee) shall be named by the 4 legislative leaders to oversee, assess, and provide direction to the Department of Healthcare and Family Services as it relates to long-term care services. * 2021 IL S.B. 110 (NS), adopted July 9, 2021, provides that, in applying the regional wage adjuster component of the Medicaid RUG-IV 48 reimbursement methodology, no adjuster shall be lower than 0.95. ¢ 2021 IL S.B. 1040 (NS), introduced February 25, 2021, makes a technical change in a Section concerning Medicaid payment rates for nursing facility and ICF/DD services in nursing facilities. ¢ 2021 IL S.B. 3116 (NS), introduced January 11, 2022, and 2021 IL H.B. 443 (NS), filed January 10, 2022, declaring that all changes to the existing nursing facility direct care reimbursement rate methodologies and to the bed assessment and collection procedures must be approached with caution, executed deliberately, and held to the highest of standards in order to protect nursing facility residents from disruption in care, protect workers from lost wages and jobs, and protect providers from the increased instability within the industry. Indiana ¢ 2022 IN S.B. 316 (NS), introduced January 11, 2022, requiring: (1) the office of the secretary of family and social services; (2) an entity that has contracted with the office of the secretary; and (3) a person that has contracted with an entity; to contract with the area agencies on aging as the primary provider to perform specified long term services and supports programing for certain Medicaid applicants, enrollees, and recipients. ¢ 2022 IN S.B. 407 (NS), introduced January 12, 2022, and 2022 IN H.B. 1194 (NS), introduced January 6, 2022, would require the office of the Secretary of Family and Social Services (office of the secretary) to apply to the United States Department of Health and Human Services for a Medicaid waiver or state plan amendment to implement, not earlier than January 1, 2024, a fee for service integrated care model program for specified category of Medicaid recipients. lowa ¢ 2021 IA H.F. 447 (NS), introduced February 9, 2021, relating to the evaluation of Medicaid-managed care long-term services and supports. ¢ 2021 IA H.F. 2202 (NS), adopted June 13, 2022, relating to Medicaid program reporting requirements, eliminating the monthly budget maximum or cap for individuals eligible for the Medicaid home- and community-based services brain injury waiver. ¢ 2021 IA H.F. 2512 (NS), introduced February 23, 2022, relating to long-term services and supports provided under the Medicaid program. ¢ 2021 IA S.F. 154 (NS), introduced January 25, 2021, relating to reimbursement of hospitals for days awaiting placement through private insurance and the Medicaid program. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -18- ¢ 2021 IA S.F. 190 (NS), introduced January 28, 2021, relating to long-term services and supports provided under the Medicaid program. ¢ 2021 IA S.F. 379 (NS), introduced February 16, 2021, relating to reimbursement rates for Medicaid long-term services and supports providers. Louisiana ¢ 2022 LA H.B. 1012 (NS), adopted June 18, 2022, providing for non-emergency medical transportation services within the Medicaid program. ¢ 2022 LA S.R. 38 (NS), enrolled May 2, 2022, requesting the Louisiana Department of Health to study programs implemented in other states or through Medicaid waiver programs to evaluate options for delaying institutionalization for frail elders. Maine ¢ 2021 ME H.R. 40 (NS), introduced January 11, 2021, resolved, to ensure appropriate personal needs allowances for persons residing in long-term care facilities. ¢ 2021 ME S.R. 292 (NS), introduced March 10, 2021, to Increase MaineCare Reimbursement Rates for Services Provided by Direct Care Workers. Maryland ¢ 2022 MD S.B. 743 (NS), introduced February 7, 2022, establishing the Affordable Assisted Living Enhanced Care Pilot Program to establish affordable assisted living enhanced care residences for the provision of enhanced care to eligible adults who are at least a certain age; prohibiting a residence selected for the Pilot Program from being prohibited from admitting into the residence certain individuals who are not eligible for the Pilot Program; and generally relating to the Maryland Medical Assistance Program and the provision of assisted living services. * 2022 MD S.B. 863 (NS), introduced February 7, 2022, requiring the Maryland Medical Assistance Program to increase the reimbursement rate for Program long-term services and supports by a certain percentage; requiring a provider agency to pay a minimum wage to certain personal care aides and to submit cost reports to the Maryland Department of Health; and authorizing the Department to take enforcement actions. Massachusetts ¢ 2021 MA H.D. 1538 (NS), draft/request, February 9, 2021, for the purpose of ensuring a living wage for nursing facility direct care staff, MassHealth shall annually fund a living wage rate add-on for direct care staff of licensed nursing homes, including, but not limited to, certified nurse aides, housekeeping, laundry, dietary, plant operations, and clerical staff. Funds shall cover a living wage, and associated payroll benefits and related employee costs. ¢ 2021 MA S.D. 771 (NS), draft/request, February 5, 2021, increasing the personal needs allowance for residents of long-term care facilities. * 2021 MA S.D. 1524 (NS), filed February 17, 2021, increasing the personal care allowance for long-term care residents. ¢ 2021 MA S.D. 1771 (NS), filed February 18, 2021, relative to stabilizing the Commonwealth's nursing facilities by recognizing inflationary costs in adjusting nursing home allowable resident care base year costs, recognizing current labor and resident care costs in setting Medicaid rates, and other. ¢ 2021 MA S.D. 1788 (NS), filed February 18, 2021, relative to the nursing home quality jobs initiative, ensuring a living wage for nursing facility direct care staff, MassHealth shall annually fund a living wage rate add-on for direct care staff of licensed nursing homes, including, but not limited to, certified nurse aides, housekeeping, laundry, dietary, plant operations, and clerical staff. Funds shall cover a living wage, and associated payroll benefits and related employee costs. MassHealth shall, subject to appropriation, adjust the annual living wage add-on with an inflation adjustment consistent with the annual unadjusted Skilled Nursing Facility Market Basket Update as established by the Centers for Medicare & Medicaid in the Medicare Skilled Nursing Facility prospective payment system rule. Minnesota * 2021 MN S.F. 984 (NS), introduced February 15, 2021, personal care assistance program modification. ¢ 2021 MN S.F. 2103 (NS), introduced March 15, 2021, establishing a funding mechanism for the programs for all-inclusive care for the elderly (PACE) program. ¢ 2021 MN S.F. 3195 (NS), introduced February 17, 2022, modifying nursing facility payment rates, elderly waiver rates, and payment rates for customized living services provided under certain disability waivers. Missouri 2022 MO H.B. 2727 (NS), introduced February 22, 2022, modifying provisions for public assistance benefits, including for residents of skilled nursing facilities. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -19- Nebraska ¢ 2021 NEL.B. 101 (NS), adopted 4-21-2021, relating to the Medical Assistance Act; to change the limitation on addition of long-term care services and supports to the Medicaid managed care program. ¢ 2021 NE L.R. 145 (NS), introduced May 12, 2021, to study the adequacy of current aged and disabled Medicaid waiver assisted-living provider rates. New Hampshire 2021 NH S.B. 149 (NS), amended/substituted June 3, 2021, regarding Medicaid spend-down requirements, automated pharmacy systems for long-term care and other residential facilities, and blanket CMS waivers for health care during a declared emergency. New Jersey ¢ 2022 NJ A.B. 4012 (NS), introduced May 16, 2022, requiring Medicaid fee-for-service coverage of managed long term services and supports when beneficiary is pending enrollment in managed care organization. * 2022 NJ A.B. 4701 (NS), introduced October 3, 2022, providing a supplemental appropriation of $3.6 million to the Department of Human Services to increase the adult medical day care Medicaid per diem rate by four percent from $86.10 to $89.54. Adult medical day care services provide medically necessary services in an ambulatory care setting to individuals who are nonresidents of the facility, and who, due to their physical or cognitive impairment, require such services to support their community living. ¢ 2022 NJ S.R. 97 (NS), introduced August 8, 2022, urging the Centers for Medicare and Medicaid Services to increase access to skilled nursing facility and home office data. ¢ 2022 NJ S.B. 2821 (NS), introduced June 9, 2022, requiring Medicaid and NJ FamilyCare managed care organizations to offer patient-centered medical home model or other alternative payment model to primary care providers. * 2022 NJ S.B. 2936 (NS), introduced June 27, 2022, providing Medicaid coverage for certain home visitation program services under certain circumstances. New York ¢ 2021 NY A.B. 1060 (NS), introduced January 7, 2021, authorizes the commissioner of health to adjust medical assistance rates of payment for certified home health agencies, managed long-term care plans, hospices, long-term home health care programs, licensed home care services agencies and other entities for recruitment, training and retention of direct care workers for services in shortage areas and by shortage disciplines. ¢ 2021 NY A.B. 9944 (NS) and 2021 NY S.B. 8806 (NS), introduced April 19, 2022, providing that transportation management brokers contracted with the department of health shall not have responsibility for services provided to enrollees of Medicaid managed long-term care plans or a Program of All-Inclusive Care for the Elderly (PACE). ¢ 2021 NY S.B. 2542 (NS), amended/substituted April 23, 2021, relating to the definition of the 'look-back period" for the determination of eligibility of an individual for medical assistance benefits. * 2021 NY S.B. 4965 (NS), introduced February 19, 2021, relating to the automatic enrollment and recertification simplification for Medicaid eligible recipients in Medicaid managed care and long-term care plans. ¢ 2021 NY S.B. 5345 (NS), introduced March 2, 2021, authorizes one or more demonstration projects that permit a managed long-term care plan to enroll persons that are permanently placed in a nursing home in rural areas. ¢ 2021 NY S.B. 5374 (NS), amended/substituted January 4, 2022, and 2021 NY A.B. 6329 (NS), amended/substituted December 29, 2021, enacting provisions to provide minimum wages for home care aides; requiring at least 150% of minimum wage or other set minimum; directing the commissioner of health to set regional minimum rates of reimbursement for home care aids under Medicaid and managed care plans. Ohio ¢ 2021 OH H.B. 572 (NS), introduced February 15, 2022, requiring the Departments of Aging and Medicaid to establish programs to provide payment to residential care facilities that have one or more residents who are Assisted Living waiver recipients or meet other criteria. ¢ 2021 PA H.B. 2067 (NS), introduced November 9, 2021, further providing for State participation in cooperative Federal programs; in public assistance, further providing for income for the community spouse, for medical assistance payments for institutional care, for medical assistance payments for home health care, for other medical assistance payments and for medical assistance benefit packages and coverage, copayments, premiums and rates; providing for the Office of Independent Medical Assistance Director. Oklahoma ¢ 2021 OK H.B. 2119 (NS), amended/substituted March 29, 2021, relates to nursing facility reimbursement; providing for enhanced FMAP payments when certain funds are made available. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -20- ¢ 2021 OK H.B. 3480 (NS), introduced February 7, 2022, recalculating Medicaid long-term care facility reimbursements and modifying direct-care-staff-to-resident ratio requirements. Pennsylvania * 2021 PA H.B. 1693 (NS), amended/substituted February 7, 2022, providing for a notice of legal representation for medical assistance. ¢ 2021 PAS.R. 288 (NS), adopted June 21, 2022, directing the Joint State Government Commission to conduct a study of long-term care facilities' impact relating to Medicaid funds in the Commonwealth. Rhode Island ¢ 2021 RI H.B. 7615 (NS), introduced March 2, 2022, increasing the daily rate of payments to nursing facilities by twenty percent (20%) for single occupancy rooms to include private bathrooms. ¢ 2021 RI H.B. 7860 (NS), introduced March 4, 2022, relating to medical assistance, requiring the executive office of health and human services to adjust, once every three (3) years the per diem reimbursement to nursing facilities, by taking into consideration increases in direct and indirect care costs. * 2021 RI S.B. 2306 (NS), introduced February 15, 2022, would provide for Medicaid home care, home nursing care and hospice base rate adjustments for services delivered by professionals and paraprofessionals to meet the increasing demand for services for medically complex and rural patients and to meet the need to grow and sustain the workforce. Tennessee 2021 TN H.B. 2347 (NS), introduced February 2, 2022, and 2021 TN S.B. 2463 (NS), introduced February 3, 2022, requiring the comptroller of the treasury, in conjunction with the bureau of TennCare and the department of health, to study the use of temporary staffing provided by healthcare staffing agencies in long-term care facilities; requires that the study examine the effects that costs of temporary staffing have upon the TennCare program and upon assisted-care living facilities, and practices that may improve the quality of long-term care for residents while reducing costs to the TennCare program. Vermont 2021 VT H.B. 153 (NS), engrossed March 25, 2021, to establish an annual inflation factor to be applied to the Medicaid rates for providers of home- and community-based service providers. It would also direct the Department of Vermont Health Access and the Department of Disabilities, Aging, and Independent Living to study the Medicaid reimbursement rates paid to home- and community- based service providers (including hospice), their adequacy, and the methodologies underlying the rates. Washington ¢ 2021 WAH.B. 1275 (NS), introduced January 19, 2021, relating to nursing facility Medicaid rate rebasing, inflation, and case mix. * 2021 WA H.B. 2060 (NS), introduced January 20, 2022, and 2021 WA S.B. 5866 (NS), introduced January 14, 2022, relating to Medicaid long-term services and supports eligibility determinations completed by federally recognized Indian tribes. * 2021 WA S.B. 5311 (NS), introduced January 20, 2021, adjusting the skilled nursing Medicaid rate methodology to provide an annual inflationary adjustment. ¢ 2021 WA S.B. 5866 (NS), adopted March 31, 2022, concerning Medicaid long-term services and supports eligibility determinations completed by federally recognized Indian tribes. Wisconsin 2021 WI A.B. 774 (NS), introduced December 9, 2021, and 2021 WI S.B. 726 (NS), relating to limitation of estate recovery for the cost of long-term care Medical Assistance to only a recipient's probate estate. IV. HOME- AND COMMUNITY-BASED SERVICES FUNDING Home- and community-based services (HCBS) provide opportunities for Medicaid beneficiaries to receive services in their own home or community. These programs serve a variety of targeted populations groups, such as people with mental illnesses, intellectual disabilities, and/or physical disabilities. CMS is working in partnership with states, consumers and advocates, providers and other stakeholders to create a sustainable, person-driven long-term support system in which people with disabilities and chronic conditions have choice, control, and access to a full array of quality services that assure optimal outcomes, such as independence, health, and quality of life, "N° Many patients prefer HCBS because they provide them with the freedom to remain in their homes or communities instead of institutions. In addition, many studies indicate that HCBS offer significant savings for insurers as compared to institutional settings. Federally funded Medicaid support, in the form of Medicaid waivers and direct personal assistance services (PAS), provides another significant reason for the rising popularity of HCBS. Section 1915(c) of the Social Security Act [FN60] offers states a federally supported alternative to providing long-term care services in institutional settings by allowing them the option to waive Medicaid provisions in order THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -24- to offer individuals HCBS. PAS allow Medicaid beneficiaries receiving personal care or HCBS to supervise, manage, and personalize their care. Baby boomers may be more willing to receive long-term care outside the home than was commonly thought, however, according to a LeadingAge poll released in March 2019. IFN61] More than 1,200 older adults between age 60 and 72 participated in the poll, which asked them about late-life care preferences. Up to 40% of respondents would want to live somewhere other than their current home or apartment if they had a physical disability that required them to need help with daily activities, the survey found. Earlier studies and surveys reported that the majority (76% or more) of adults say they want to stay in their own home. These earlier studies do not target older baby boomers and they do not ask for separate responses depending on whether the impairment is physical or cognitive. Asked what would be important if they were in a position of needing help with daily activities, being safe was ranked the most important consideration, higher even than being around family or friends. About 14% of the respondents indicated they would move to a place that is staffed to provide healthcare along with the help with daily activities in the presence of a physical disability. That number swelled to 42% if help was required due to dementia. While most people (over 60%) want to live with their spouse or partner if they need help due to a physical or cognitive disability, becoming a burden on family members was cited as the biggest worry among participating baby boomers. Affordability was seen as the biggest challenge to purchasing care among all respondents. Kaiser Health News reports that nearly every state reported actions to increase the use of HCBS settings for people needing long-term care. The report surveyed individual states, and found that 42 took actions in FY 2016 to move and keep more people who require long- term care services in home or community settings, including 23 states that opted to expand their Program of All-Inclusive Care for the Elderly (PACE). PACE provides comprehensive medical and social services to certain frail, elderly individuals who qualify for nursing home care but, at the time of enrollment, can still live safely in the community. The majority of participants served by PACE are dually eligible for both Medicare and Medicaid. More than 45,000 older adults are currently enrolled in more than 100 PACE organizations in 31 states, and enrollment in PACE has increased by over 120% since 2011. On May 28, 2019, CMS finalized a rule to update and modemize PACE. This rule-the first major update to the PACE since 2006- reflects updates based upon best practices in caring for frail and elderly individuals, according to the agency's fact sheet. [FNE2] The final rule revises and updates the requirements for the PACE program under Medicare and Medicaid, including: ¢ Strengthening protections and improving care for PACE participants; and ¢ Providing administrative flexibility and regulatory relief for PACE organizations. The changes provide greater operational flexibility, remove redundancies and outdated information, and codify existing practice, the fact sheet states. Post-Hospital Rehabilitation at Home Researchers in Boston studied the feasibility of rehabilitation at home (RAH) as an option for skilled nursing facility (SNF) level care. IFNE3] The group researched whether the cost of care and safety and experience of patients could be improved by shifting the site of care to the patient's home, and found that patients have better experiences with lower costs under the model. The study was conducted using a pilot trial where 10 participants were randomly assigned to RAH or traditional SNF care. The results indicated that the median cost of care for patients receiving RAH was $8,404, compared to $9,215 for the SNF residents. At-home patients also saw an increase in their activities of daily living, such as personal hygiene and feeding themselves. The findings signal that a shift in post-acute care, away from SNFs and toward home-based services, could help lower costs, provide greater functional status improvement, and a better patient experience, although more research is needed. Health Outcomes: Study Funding for Medicaid HCBS versus institutional care is widely regarded as beneficial. However, according to a study reported in Health Affairs, [FN64] little is known about the outcomes of these services, especially for racial and ethnic minority groups, whose members tend to use the services more than whites do, and for people with dementia who may need high-intensity care. Using national Medicaid claims data on older adults enrolled in both Medicare and Medicaid, investigators found that overall hospitalization rates were similar for HCBS and nursing facility users, although nursing facility users were generally sicker as reflected in their claims history. Among HCBS users, blacks were more likely to be hospitalized than non-Hispanic whites were, and the gap widened among blacks and whites with dementia, according to the researchers. The study also found that, conditional on receiving HCBS, Medicaid HCBS spending was higher for whites than for nonwhites, and higher Medicare and Medicaid hospital spending for blacks and Hispanics did not offset this difference. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -29- The study's findings suggest that HCBS needs to be carefully targeted to avoid adverse outcomes and that the racial/ethnic disparities in access to high-quality institutional long-term care are also present in HCBS. Policy makers should consider the full costs and benefits of shifting care from nursing facilities to home and community settings and the potential implications for equity. For additional information on HCBS funding and policies, see Health Policy Tracking Service, Long-Term Care: Home- and Community- Based Services, a service of Thomson Reuters. National Strategy to Support Family Caregivers The HHS has released a National Strategy to Support Family Caregivers to assist those who care for seriously ill family members. The strategy contains nearly 350 actions that the federal government plans to take to support caregivers in the comping year, as well as 150 recommendations that the state or local communities or the private sector could take. The HHS sub-agency Administration for Community Living (ACL) spearheaded the development of the strategy. The strategy was developed jointly by the advisory councils created by the RAISE Family Caregiving Act and the Supporting Grandparents Raising Grandchildren Act, with extensive input from the public, including family caregivers and the people they support. It will be updated in response to public comments and will evolve with the caregiving landscape, the ACL noted. The actions called for in the strategy document center around five principal objectives: ¢ Increasing awareness of and outreach to family caregivers ¢ Advancing partnerships and engagement with family caregivers ¢ Strengthening services and supports for family caregivers ¢ Ensuring financial and workplace security for family caregivers, and ¢ Expanding data, research, and evidence-based practices to support family caregivers. Annually, nearly 53 million people assist family members or other loved ones in maintaining health, quality of life, and independence due to aging, disability, or a chronic health condition, according to ACL. Replacing the work of family caregivers with paid services would cost an estimated $470 billion each year, the agency indicated. 'At some point in our lives, most of us will either be a family caregiver or need one. Many of us will experience both," Acting ACL Administrator and Assistant Secretary for Aging Alison Barkoff in an announcement. 'This strategy presents a vision, along with recommendations for achieving it. Bringing that vision to life will require contributions and commitments from every sector, every level of government ? and all of us ? and ACL is proud to help lead that work." [FN65] Recent Legislative Activity Federal * 2021 CONG US HR 5514, introduced October 8, 2021, to improve extended care services by providing Medicare beneficiaries with an option for cost-effective home-based extended care under the Medicare program. «2021 CONG US HR 6149, introduced December 7, 2021, to develop and test an expanded and advanced role for direct-care workers who provide long-term services and supports to older adults and people with disabilities in efforts to coordinate care and improve the efficiency of service delivery. ¢ 2021 CONG US HR 7158, introduced March 18, 2022, to authorize the Secretary of Veterans Affairs to enter into contracts and agreements for the payment of care in non-Department of Veterans Affairs medical foster homes for certain veterans who are unable to live independently. California ¢ 2021 CAA.B. 523 (NS), vetoed by the governor October 6, 2021, would have required the department to make permanent the specified PACE program flexibilities instituted, on or before January 1, 2021, in response to the state of emergency caused by COVID-19 by means of all-facility letters or other similar instructions taken without regulatory action, with prescribed modifications, such as instead limiting a PACE organization's use of telehealth to specified services, including conducting assessments for eligibility for enrollment in the PACE program, subject to the federal waiver process. * 2021 CAA.B. 2548 (NS), amended/substituted May 19, 2022, would require the Department of Aging to establish and administer a 3- year Healthier Homes - Age in Place Nursing Pilot Program in the Counties of Contra Costa, Fresno, Orange, Riverside, Sacramento, San Diego, Shasta, and Sonoma. The program would provide grant funds to qualified nonprofit organizations that specialize in resident services for the purposes of hiring one full-time registered nurse and one full-time community health worker to work at 3 senior citizen housing developments in each county to provide health education, navigation, coaching, and care to residents. ¢ 2021 CA A.B. 2823 (NS), amended/substituted March 28, 2022, providing for Medi-Cal beneficiary maintenance needs: home upkeep allowance and transitional needs allowance. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -23- ¢ 2021 CA S.B. 171 (NS), adopted September 23, 2021, requires the State Department of Health Care Services to implement activities and expenditures to enhance, expand, or strengthen home and community-based services (HCBS) under the Medi-Cal program, as specified. ¢ 2021 CA S.B. 281 (NS), adopted September 30, 2022, requires the department to provide services consistent with the Money Follows the Person Rebalancing Demonstration for transitioning eligible individuals out of an inpatient facility who have resided in that setting for fewer than 60 days until January 1, 2026, and to cease providing those services commencing January 1, 2027. Connecticut * 2022 CT H.B. 5193 (NS), introduced February 23, 2022, to require ninety-day notice to residents of rent increases exceeding five per cent, limit fee increases, prohibit residents who contracted for assisted living services from being forced to pay for a higher level of skilled nursing care or move except under certain circumstances and provide certain exceptions to notice periods for change of residency. ¢ 2022 CT H.B. 5227 (NS), amended/substituted April 26, 2022, establishing a community ombudsman program to respond to complaints regarding home and community-based long-term care services and supports, in programs administered by the Department of Social Services. ¢ 2022 CT H.B. 5339 (NS), amended/substituted April 5, 2022, expanding access to the state-funded portion of the Connecticut home- care program for the elderly by reducing copayments and increasing asset limits. Delaware ¢ 2021 DE H.C.R. 110 (NS), adopted June 29, 2022, establishing the long-term care and memory care task force, to study and make findings and recommendations to best address the needs of residents in nursing facilities, intermediate care facilities for individuals with disabilities, assisted living facilities, and memory care units within these facilities. ¢ 2021 DE S.C.R. 44 (NS), adopted May 20, 2021, creating an aging-in-place working group to develop recommendations related to home and community based services. Florida ¢ 2022 FL H.B. 1569 (NS), filed January 11, 2022, requiring Social Services Estimating Conference to develop specified information relating to home-based & community-based Medicaid waiver program. * 2022 FL S.B. 646 (NS), introduced January 11, 2022, deleting the requirement that a portion of the punitive damages awarded for claims brought under part II of ch. 400, F.S., relating to nursing homes, and part | of ch. 429, F.S., relating to assisted living facilities, be deposited into the Quality of Long-Term Care Facility Improvement Trust Fund. ¢ 2022 FL S.B. 1704 (NS), introduced January 18, 2022, requiring the Social Services Estimating Conference to develop specified information related to the home-based and community-based Medicaid waiver program. Hawaii ¢ 2021 HI H.C.R. 46 (NS), introduced February 23, 2021, requesting the Department of Human Services to study the feasibility of increasing the Medicaid reimbursement payment rate for Hawaii's community care foster family homes and expanded adult residential care homes for Medicaid recipients. ¢ 2021 HI H.R. 37 (NS), introduced February 23, 2021, requesting the Department of Human Services to study the feasibility of increasing the Medicaid reimbursement payment rate for Hawaii's community care foster family homes and expanded adult residential care homes for Medicaid recipients. ¢ 2021 HI S.C.R. 10 (NS) and 2021 HI S.R. 4 (NS), introduced March 3, 2022, urging the department of human services to study the feasibility of increasing payment to Hawaii's community care foster family homes and expanded adult residential care homes for Medicaid recipients. ¢ 2021 HI S.C.R. 41 (NS), introduced February 23, 2021, urging the Department of Human Services to study the feasibility of increasing payment to Hawaii's community care foster family homes (CCFFH) and expanded adult residential care homes (e-ARCH) for Medicaid recipients. ¢ 2021 HI H.B. 491 (NS), introduced January 25, 2021, and 2021 HI S.B. 838 (NS), introduced January 22, 2021, allows the executive office of aging to relax the thirty-hour employment requirement for qualified caregivers under the Kupuna Caregivers Program during a state-declared state of emergency; adds the option of Kupuna caregiver-directed services to the Kupuna caregivers program; includes assisting the care recipient and caregiver with the enrollment process as the duty of a coach; allows funds under the Kupuna Caregivers Program to be issued to the care recipient's financial management service provider. ¢ 2021 HI S.B. 59 (NS), introduced January 21, 2021, requires operators of adult residential care homes, assisted living facilities, long- term care facilities, nursing homes, and community care facilities to establish and implement infectious disease control and prevention training and other related protocols; requires the Department of Health to ensure compliance with infectious disease control and THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -24- prevention training programs prior to the issuance or renewal of a license; authorizes the Department of Health to conduct random audits to determine compliance with infectious disease control and prevention training program or course. ¢ 2022 HI S.B. 3236 (NS), approved July 7, 2022, to help preserve the financial viability of nursing facilities, community care foster family homes, and expanded adult residential care homes in the State by providing a one?time enhanced payment to state?licensed skilled nursing facilities, community care foster family homes, and expanded adult residential care homes that are caring for Medicaid patients. Illinois ¢ 2021 IL H.B. 4578 (NS), introduced January 21, 2022, creating the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act. Requires the Director on Aging, in consultation with the heads of other appropriate State agencies, to develop jointly with the Family Caregiving Advisory Council (Advisory Council) a Family Caregiving Strategy (Strategy); requires the Director to submit the Strategy to the Senate Subcommittee on Long-Term Care and Aging and to the House Workforce Development Subcommittee, and to other State agencies responsible for carrying out family caregiver programs. ¢ 2021 IL S.B. 1977 (NS), adopted August 20, 2021, requires the Department of Healthcare and Family Services to apply for all available federal funding to promote community inclusion and integration for persons with disabilities, regardless of age, and older adults so that those persons have the option to transition out of institutions and receive long-term care services and supports in the settings of their choice. Indiana 2022 IN S.B. 392 (NS), introduced January 11, 2022, providing that home health agencies may enter into cooperative agreements to carry out the following activities: (1) To form and operate, either directly or indirectly, one or more networks of home health agencies, hospitals, skilled nursing facilities, physicians, and other health care providers and to arrange for the provision of health care services through such networks. (2) To contract, either directly or through such networks, with the office of the secretary of family and social services, or the office's contractors to provide: (A) services to Medicaid beneficiaries; and (B) health care services in an efficient and cost-effective manner on a prepaid, capitation, or other reimbursement basis. (3) To undertake other managed health care activities. lowa 2021 IA H.F. 2202 (NS), adopted June 13, 2022, relating to Medicaid program reporting requirements, eliminating the monthly budget maximum or cap for individuals eligible for the Medicaid home- and community-based services brain injury waiver. Kentucky * 2022 KY H.B. 651 (NS), introduced February 28, 2022, to require the Cabinet for Health and Family Services to ensure that home and community-based waiver programs provide certain services, including attendant care or non-skilled in-home care services across all waiver programs, skilled nursing visits for adult day health care and home health care providers, participant-directed services, and RN specialized respite; require the cabinet consolidate all home and community-based waiver application processes under the Department for Medicaid Services, including the Michelle P. waiver provider application process; require the cabinet to apply for and implement a Medicaid state plan benefit to establish health homes to coordinate care for people with Medicaid who have chronic conditions. ¢ 2022 KY S.B. 100 (NS), adopted February 7, 2022, establishing the right to designate an essential caregiver to visit a resident in- person at long-term care facilities, assisted-living communities, and state mental hospitals; requiring the Cabinet for Health and Family Services to promulgate administrative regulations to establish conditions for essential caregiver visitation. Maine ¢ 2021 ME H.P. 1043 (NS), introduced April 8, 2021, to encourage family care of aging adults. ¢ 2021 ME S.P. 191 (NS), adopted May 3, 2022, to continue funding for home-delivered meals for homebound seniors and to address the growing demand. Maryland 2022 MD S.B. 28 (NS), adopted May 29, 2022, for the purpose of altering the required contents of the home- and community-based services waiver submitted by the Maryland Department of Health to CMS; requiring the Department to send an application to a certain number of individuals each month, if the Department maintains a waiting list or registry for the waiver; requiring the Department to apply to CMS for an amendment to the home- and community-based services waiver. Massachusetts ¢ 2021 MA H.D. 2507 (NS), filed February 17, 2021, establishing a livable home modification grant program. ¢ 2021 MA H.D. 2522 (NS), filed February 17, 2021, increasing awareness of community-based PACE programs for older adults. ¢ 2021 MA S.B. 2873 (NS), introduced June 9, 2022, relative to the program of all-inclusive care for the elderly (PACE), a person seeking admission to a long-term care facility paid for by MassHealth shall receive pre-admission counseling for long-term care THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -25- services, which shall include an assessment of community-based service options including but not limited to PACE, pursuant to CFR Part 460.60. A person seeking care in a long-term care facility on a private pay basis shall be offered pre-admission counseling. ¢ 2021 MA S.D. 757 (NS), draft/request, February 5, 2021, directing the administration to amend the Frail Elder Home and Community- Based Waiver to permit eligible older adults to choose to reside in Certified Assisted Living Residences. * 2021 MA S.D. 1476 (NS), filed February 17, 2021, to increase awareness of community-based PACE programs for older adults. Missouri 2022 MO H.B. 2727 (NS), amended/substituted April 26, 2022, relating to payments for home care in licensed skilled nursing facilities. Minnesota * 2021 MN S.F. 671 (NS), introduced February 4, 2021, modifying payment rates for home health services and home care nursing services. ¢ 2021 MN S.F. 2306 (NS), introduced March 25, 2021, human services rates for services under elderly waiver and disability waiver modifications. ¢ 2021 MN S.F. 2786 (NS), engrossed March 23, 2022, provisions and appropriation for nursing home and assisted living facility employee bonuses. New Jersey * 2022 NJ A.B. 3999 (NS), introduced May 16, 2022, establishing requirements for incentive-based value payment system for home health agencies and health care service firms. ¢ 2022 NJ A.B. 4012 (NS), introduced May 16, 2022, requiring Medicaid fee-for-service coverage of managed long term services and supports when beneficiary is pending enrollment in managed care organization. ¢ 2022 NJ S.B. 2650 (NS), introduced May 16, 2022, providing gross income tax deduction for senior citizens for certain medical expenses for in-home care or care in assisted living and long-term care facilities and funeral expenses. ¢ 2022 NJ S.B. 2936 (NS), introduced June 27, 2022, providing Medicaid coverage for certain home visitation program services under certain circumstances. New Mexico 2022 NM H.B. 175 (NS), amended/substituted February 7, 2022, making an appropriation to the aging and long-term services department to engage in a pilot project consisting of community-based and culturally appropriate outreach campaigns related to Alzheimer's Disease and other forms of dementia in tribal, rural and underserved communities in the state. New York ¢ 2021 NY A.B. 1060 (NS), introduced January 7, 2021, authorizes the commissioner of health to adjust medical assistance rates of payment for certified home health agencies, managed long-term care plans, hospices, long-term home health care programs, licensed home care services agencies and other entities for recruitment, training and retention of direct care workers for services in shortage areas and by shortage disciplines. ¢ 2021 NY A.B. 1137 (NS), introduced January 7, 2021, requires contracts with home care service providers to provide sufficient resources to ensure compensation to a qualified workforce providing high quality care. ¢ 2021 NY A.B. 1342 (NS), introduced January 8, 2021, makes assisted living programs eligible for access funding under the vital access provider program. ¢ 2021 NY A.B. 2588 (NS), introduced January 19, 2021, relates to a moratorium on new licensed home care service agency approvals. ¢ 2021 NY A.B. 3626 (NS), introduced January 28, 2021, enacts the 'independent senior housing resident freedom of choice act' to authorize persons in independent housing, shelters and residences to receive services they could otherwise receive if they resided in a private residence. ¢ 2021 NY A.B. 6329 (NS), introduced March 16, 2021, relating to fair pay for home care aides under Medicaid and managed care plans. * 2021 NY A.B. 9542 (NS), introduced March 16, 2022, establishing a state-level program of all-inclusive care for the elderly for persons 55 years of age or older, qualifying for nursing home levels of care who wish to remain in their community. ¢ 2021 NY S.B. 5374 (NS), amended/substituted January 4, 2022, and 2021 NY A.B. 6329 (NS), amended/substituted December 29, 2021, enacting provisions to provide minimum wages for home care aides; requiring at least 150% of minimum wage or other set minimum; directing the commissioner of health to set regional minimum rates of reimbursement for home care aids under Medicaid and managed care plans. ¢ 2021 NY S.B. 5839 (NS), introduced March 19, 2021, relates to a moratorium on new licensed home care service agency approvals. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -26- ¢ 2021 NY S.B. 6526 (NS), adopted July 16, 2021, amends the definition of social adult day services to include community or home settings which are pursuant to a person-centered service plan. ¢ 2021 NY S.B. 6664 (NS), amended/substituted March 2, 2022, establishing a state-level program of all-inclusive care for the elderly for persons 55 years of age or older, qualifying for nursing home levels of care who wish to remain in their community. North Carolina ¢ 2021 NC H.B. 727 (NS), introduced April 29, 2021, establishing a licensure by accreditation process for adult care homes; exempting adult care homes that are licensed by virtue of accreditation from routine inspections and the star rating program for assisted living facilities; and appropriating funds for an assisted living accreditation grant program and for a comparison of resident outcomes in accredited versus non-accredited adult care homes. ¢ 2021 NC H.B. 777 (NS), introduced May 4, 2021, appropriating funds for expansion of the project caregiver alternatives to running on empty (project C.A.R.E.) program, for caregivers of persons with dementia. ¢ 2021 NC S.B. 191 (NS), adopted October 15, 2021, the No Patient Left Alone Act, providing patient visitation rights will not be impacted during declared disasters and emergencies and directing the department of health and human services to impose a civil penalty for any violation of those rights. Ohio ¢ 2021 OH H.B. 572 (NS), introduced February 15, 2022, requiring the Departments of Aging and Medicaid to establish programs to provide payment to residential care facilities that have one or more residents who are Assisted Living waiver recipients or meet other criteria. ¢ 2021 OH H.B. 744 (NS), introduced November 9, 2022, regarding self-direction in certain Medicaid home- and community-based services waiver programs. Oklahoma 2021 OK S.B. 1577 (NS), amended/substituted February 28, 2022, regarding long-term care, designating Oklahoma Health Care Authority as state administering agency for PACE program agreements. Pennsylvania 2021 PA H.B. 2293 (NS), amended/substituted June 30, 2022, providing for temporary health care services agencies, including long- term care nursing facilities and personal care homes or assisted living residences. Rhode Island ¢ 2021 RI H.B. 7347 (NS), introduced February 4, 2022, requiring health insurance plans to provide coverage for accessible residence modifications, when those modifications are determined to be medically necessary, but only after a physician makes a determination that absent the accessible modifications, that the patient would have to move into a long-term care residential facility. ¢ 2021 RI H.B. 7446 (NS), introduced February 11, 2022, providing for Medicaid home care, home nursing care and hospice base rate adjustments for services delivered by professionals and paraprofessionals to meet the increasing demand for services for medically- complex and rural patients and to meet the need to grow and sustain the workforce. This act would support the state's long-term care rebalancing goals by keeping high-acuity or high medical necessity patients out of skilled nursing facilities and hospitals and remain safe at home and in the community with highly trained and stable long-term services and support. ¢ 2021 RI H.B. 8137 (NS), introduced April 13, 2022, allowing assisted living facilities to provide medical/skilled nursing care services to residents in an assisted living setting, as their care needs change, rather than requiring transition to a skilled nursing facility when full- time skilled services are required for the resident. ¢ 2021 RI S.B. 2206 (NS), introduced February 8, 2022, requiring insurance coverage for medically necessary residence modifications that would otherwise require the patient to enter a long-term care facility. * 2021 RI S.B. 2306 (NS), introduced February 15, 2022, would provide for Medicaid home care, home nursing care and hospice base rate adjustments for services delivered by professionals and paraprofessionals to meet the increasing demand for services for medically complex and rural patients and to meet the need to grow and sustain the workforce. Tennessee ¢ 2021 TN H.B. 2347 (NS), introduced February 2, 2022, and 2021 TN S.B. 2463 (NS), introduced February 3, 2022, requiring the comptroller of the treasury, in conjunction with the bureau of TennCare and the department of health, to study the use of temporary staffing provided by healthcare staffing agencies in long-term care facilities; requires that the study examine the effects that costs of temporary staffing have upon the TennCare program and upon assisted-care living facilities, and practices that may improve the quality of long-term care for residents while reducing costs to the TennCare program. ¢ 2021 TN S.B. 582 (NS), filed February 9, 2021, changes from February 1 to January 15, the date by which the bureau of TennCare must report to the general assembly a separate accounting of long-term expenditures for nursing facility services, home and THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -27- community-based services made under the CHOICES long-term healthcare program, and employment and Community First CHOICES services. Vermont 2021 VT H.B. 153 (NS), introduced January 29, 2021, relating to Medicaid reimbursement rates for home- and community-based service providers. V. MEDICARE FUNDING Medicare Part A covers medically necessary skilled nursing care in a skilled nursing facility for a limited time, provided certain conditions are met. It does not cover custodial care if it is the only kind of care needed. Generally, skilled care is available for up to 100 days, following hospitalization. On July 29, 2022, CMS released a final rule updating Medicare payment policies and rates for skilled nursing facilities for FY 2023. [FNE6] The agency finalized a 2.7% increase, or approximately $904 million hike in Medicare Part A payments. CMS explains that the estimate reflects a $1.7 billion increase resulting from the 5.1% update to the payment rates, which is based on a 3.9% SNF market basket increase plus a 1.5 percentage point market basket forecast error adjustment and less a 0.3 percentage point productivity adjustment (as required by law), as well as a negative 2.3% (or $780 million decrease) in the FY 2023 SNF PPS rates as a result of the recalibrated parity adjustment, which is being phased in over two years. CMS acknowledged that since implementation of the Patient Driven Payment Model (PDPM) in FY 2020, its initial data analysis showed an unintended increase in payments of approximately 5% or $1.7 billion per year. As with past case-mix classification model transitions, the agency conducted the data analysis to recalibrate the parity adjustment in order to achieve budget neutrality under PDPM. In its fact sheet, CMS said it recognizes that the COVID-19 public health emergency (PHE) provides a basis for taking a more cautious approach in order to mitigate the potential negative impacts on the nursing home industry, such as facility closures or disproportionate impacts on rural and small facilities. Therefore, after considering the stakeholder feedback received, and to balance mitigating the financial impact on providers of recalibrating the PDPM parity adjustment with ensuring accurate Medicare Part A SNF payments, CMS is finalizing the recalibration of the PDPM parity adjustment factor of 4.6% with a two-year phase-in period that would reduce SNF spending by 2.3%, or approximately $780 million, in FY 2023 and 2.3% in FY 2024. In addition, the final rule includes updates for the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program for FY 2023 and future years. And, in order to mitigate instability in SNF PPS payments due to significant wage index decreases that may affect providers in any given year, CMS is finalizing a permanent 5% cap on annual wage index decreases to smooth year-to-year changes in providers' wage index payments. Quality measures: For FY 2018 and FY 2020, CMS introduced four new quality and resource use measures for skilled nursing facilities, in accordance with the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). Three new claims-based measures, effective in FY 2018, included discharge to community, Medicare spending per beneficiary, and potentially preventable 30- day post-discharge readmission measure for skilled nursing facilities. A fourth, assessment-based measure was added for FY 2020, and will cover drug regimen reviews conducted with a follow-up for any identified issues. Quality Reporting Program (QRP): The SNF QRP applies to freestanding SNFs, SNFs affiliated with acute care facilities, and all non- CAH swing-bed rural hospitals. Beginning with fiscal year 2018, and each subsequent year, if an SNF does not submit required quality data, their payment rates for the year are reduced by 2% for that fiscal year. Application of the 2% reduction may result in an update that is less than 0.0 for a fiscal year and in payment rates for a fiscal year being less than such payment rates for the preceding fiscal year, according to the memo. Penalties will begin October 1 (the start of fiscal 2018) for skilled nursing facilities that don't submit quality data. In FY 2020, CMS adopted two new quality measures to assess how health information is provided by the SNF at the time of transfer or discharge. The two measures are: 1) Transfer of Health Information to the Provider-Post-Acute Care and 2) Transfer of Health Information to the Patient-Post-Acute Care. On October 28, 2020, CMS announced that new skilled nursing facility performance data, featuring six additional measures, [FN67] is now on the Nursing Home Compare website. The updated SNF Quality Reporting Program (QRP) data was published during the October 2020 quarterly refresh of the site. The updates include quality data from January 1, 2019, to December 31, 2019, for quality assessment data, and from October 1, 2017, to September 30, 2019, for claims-based measures. Starting October 2020, the six new measures being publicly reported are: ¢ changes in skin integrity post-acute care: pressure ulcer/injury, ¢ drug regimen review conducted with follow-up for identified issues, * application for IRF functional outcome measure: change in self-care, * application for IRF function outcome measure: change in mobility, THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -28- * application for IRF functional outcome measure: change in discharge self-care score, and ¢ application of IRF functional outcome measure: discharge mobility score. CMS noted that the October 2020 refresh of the QRP data on the Nursing Home Compare/Care Compare sites is the last scheduled refresh of the data until January 2022. SNF Value-Based Purchasing Program (VBP) CMS began rewarding SNFs with incentive payments based on their quality measure performance on October 1, 2018. The program currently scores SNFs on an all-cause measure of hospital readmissions, and in the future, will transition to a measure of potentially preventable hospital readmissions. As required by statute, the program reduces SNFs' Medicare payments by 2%, then redistributes 60% of those funds as incentive payments. In the final rule, the SNF VBP Program is changing the name of the program's measure to the 'Skilled Nursing Facility Potentially Preventable Readmissions after Hospital Discharge" (SNFPPR) measure, and also includes an update to the public reporting requirements to ensure that CMS publishes accurate performance information for low-volume SNFs. Currently under the VBP program, SNFs automatically lose 2% of their Medicare reimbursements, which they can win back by sufficiently reducing hospital readmissions. In some cases, the highest-performing operators can actually take in more than the cut amount. The first round of results, however, saw 73% of the nation's more than 15,000 nursing homes lose at least some amount of money, with just 27% pulling in a bonus payment. MedPAC Proposal: A proposal offered by the Medicare Payment Advisory Commission to replace the current value-based purchasing program for skilled nursing facilities with a more equitable, value-incentive model would benefit both providers and residents, according to a leading healthcare policy expert, McKnight's reports. IFN68] MedPAC on June 15, 2021, delivered its annual report to Congress on issues affecting the Medicare program and the healthcare delivery system. The recommendation to eliminate the current SNF VBP with an alternative incentive model that rewards providers more evenly based on the quality of care they provide was approved unanimously by the commission in April. Flaws of the current VBP program include: assessing SNF performance based on a single outcome measure (hospital readmissions); not fully distributing all withheld funds; no accounting for social risk factors in payment; and the rewards are too small to encourage all providers to improve quality of care, commissioners have said. In contrast, the proposed replacement would score SNFs based on multiple performance measures focused on patient outcomes, distribute all withheld funding each year to providers, and account for social risk factors. 'The proposed SNF VIP model addresses all of these flaws by incorporating a range of quality measures, building in strategies to ensure reliable results, distributing rewards across all facilities, accounting for differences in patients' social risk factors and distributing the entire provider-funded pool of dollars," Harvard's David Grabowski, Ph.D., told McKnight's Long-Term Care News on June 16. The commission in the past has also argued the switch would ultimately result in more equitable payments across SNFs with different mixes of patients. The change would be budget neutral if adopted. On January 13, 2022, MedPAC voted for recommendations to cut skilled nursing facilities' base pay by 5% in 2023 and freeze rates for physicians and physical therapists. [FNES] SNF spending would decline $2 billion next fiscal year, for a total of $10 billion in federal savings over the next five years. In making the expected recommendation for a 5% SNF cut, MedPAC noted that Medicare margins had increased for 2022 to 16.5% without accounting for added federal coronavirus relief. With the relief incorporated, margins hit 19.2%. Panel staff said the median margin for SNFs operating 'relatively' efficiently was 22.8%. Home Health Payment Rates On November 4, 2022, CMS filed a final rule [FN70] setting forth routine updates to the Medicare home health payment rates for calendar year (CY) 2023. The rule also finalizes a methodology for determining the impact of the difference between assumed versus actual behavior change on estimated aggregate expenditures for home health payments due to the change in the unit of payment to 30 days and the implementation of the Patient Driven Groupings Model (PDGM) case-mix adjustment methodology. It also finalizes a corresponding permanent prospective adjustment to the CY 2023 home health payment rate. The reassignment of certain diagnosis codes under the PDGM case-mix groups is also finalized in the rule and establishes a permanent mitigation policy to smooth the impact of year-to-year changes in home health payments related to changes in the home health wage index. The rule also finalizes recalibration of the PDGM case-mix weights and updates the low utilization payment adjustment thresholds, functional impairment levels, comorbidity adjustment subgroups for CY 2023, and the fixed-dollar loss ratio used for outlier payments. Additionally, the rule discusses comments received on the future collection of data regarding the use of telecommunications technology during a 30-day home health period of care on home health claims. Changes to the Home Health Quality Reporting Program requirements, changes to the expanded Home Health Value-Based Purchasing (HHVBP) Model, and updates to the home infusion therapy services payment rates for CY 2023 are also finalized. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -29- The regulations are effective on January 1, 2023. Civil monetary penalties Effective February 3, 2017, HHS has updated its regulations to reflect required annual inflation-related increases to CMPs, pursuant to the Federal Civil Penalties Inflation Adjustment Act Improvement Act of 2015. Skilled nursing providers will face slightly fines for noncompliance, the first time that CMPs were adjusted since 1987. The adjusted civil penalty amounts apply to civil penalties assessed on or after February 3, 2017, when the violation occurred after November 2, 2015. If the violation occurred prior to November 2, 2015, or a penalty was assessed prior to September 6, 2016, the pre-adjustment civil penalty amounts in effect prior to September 6, 2016 will apply. As published in the Federal Register, [FN71] the rule includes a chart that lists the updated civil monetary penalties and the penalty amounts administered by all the agencies in HHS. Coronavirus (COVID-19) Response Older adults and people who have severe chronic medical conditions like heart, lung, or kidney disease seem to be at higher risk for more serious COVID-19 illness, according to the CDC. Older people may be twice as likely to have serious COVID-19 illness. This means that most people with Medicare are at higher risk. IFN72] In response, CMS expanded Medicare coverage of healthcare needs related to COVID-19. They include: * Coverage of lab tests for COVID-19. Beneficiaries pay no out-of-pocket costs. ¢ All medically necessary hospitalizations are covered. This includes if you're diagnosed with COVID-19 and might otherwise have been discharged from the hospital after an inpatient stay, but instead you need to stay in the hospital under quarantine. ¢ Although there's no vaccine for COVID-19, if one becomes available, it will be covered by all Medicare Prescription Drug Plans (Part D). * If you have a Medicare Advantage Plan, you have access to these same benefits. Medicare allows these plans to waive cost-sharing for COVID-19 lab tests. * Telehealth: Medicare has temporarily expanded its coverage of telehealth services to respond to the current public health emergency. According to Medicare.gov, 'these services expand the current telehealth covered services, to help you have access from more places (including your home), with a wider range of communication tools (including smartphones), to interact with a range of providers (such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social worker). During this time, you will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings. This will help ensure you are able to visit with your doctor from your home, without having to go to a doctor's office or hospital, which puts you and others at risk of exposure to COVID-19." ¢ Medicare pays for 'virtual check-ins"-brief, virtual services with your established physician or certain practitioners where the communication isn't related to a medical visit within the previous 7 days and doesn't lead to a medical visit within the next 24 hours (or soonest appointment available). ¢ Medicare also pays for you to communicate with your doctors using online patient portals without going to the doctor's office. ¢ If you live in a rural area, you may use communication technology to have full visits with your doctors. The law requires that these visits take place at specified sites of service, known as telehealth originating sites, and get services using a real-time audio and video communication system at the site to communicate with a remotely located doctor or certain other types of practitioners. Medicare pays for many medical visits through this telehealth benefit. CMS has established new codes to allow providers to properly bill for services related to the diagnosis and treatment of COVID-19. Additionally, nursing homes and hospitals have been instructed to review their infection control procedures. Additionally, to limit the transmission of COVID-19 in nursing homes, facilities are required to restrict visitation of ai! visitors and non- essential care personnel, except for certain compassionate care situations, such as an end-of-life situation. Health care workers and CMS and state agency surveyors are excepted. [FN73] Coverage of Vaccine CMS Administrator Seema Verma said the agency is coming up with a plan to make sure Medicare beneficiaries were covered once a coronavirus vaccine is developed. [FN74] LS. officials have said they expect private insurers to cover the cost of a vaccine with no co- pay for patients. Under the Affordable Care Act, most health plans are required to cover certain preventive services, such as vaccines, without cost-sharing. The CARES Act, signed into law in March, also requires free COVID-19 immunizations approved for emergency use. Verma said CMS would ensure the fees Medicare pays for administration of the vaccine are appropriate, taking into account some of the complexities of the coronavirus vaccine, including that it will likely require two doses. Normally, it would take Medicare between one and three years to ensure it is paying adequately for a new treatment. Moratorium on Medicare Sequestration Cuts Extended THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -30- On April 14, President Biden signed legislation extending the moratorium on Medicare sequestration, after the U.S. House of Representatives passed the Medicare Sequester Relief Act, which extended mandated 2% Medicare cuts to healthcare providers until the end of 2021. The Partnership for Home Healthcare said the extension will give providers additional breathing room as they continue to battle fallout from the COVID-19 pandemic and adapt to the new Patient Driven Grouping Model (PDGM) payment system. 'While the COVID-19 crisis has underscored the value of care delivery in the home, providers continue to struggle with the impacts of the 4.3% PDGM payment cut that took effect in 2020 and again in 2021," Joanne Cunningham, executive director of the Partnership, said. 'The sequestration moratorium provided by Congress has been incredibly valuable to the home health sector due to the challenges of providing care during the (public health emergency), coupled with the PDGM payment cuts this year and last. The continued relief will help stabilize the delivery of home care to Medicare's most vulnerable seniors," In March of 2020, Congress temporarily halted the 2% Medicare cuts until the end of last year as part of the Coronavirus Aid Relief and Economic Security (CARES) Act. It extended them again until March 31. A few days before the cuts were to take effect again, the Senate voted overwhelmingly to extend them further. Sequestration was part of the Budget Control Act of 2011. The cut is imposed on the 80% allowed charge that healthcare providers received directly from Medicare. '"N7®! Medicare Advantage Denials Released on April 27, 2022, a new report from the Office of the Inspector General of the Department of Health and Human Services has found that Medicare Advantage organizations (MAOs) have improperly denied or delayed services to beneficiaries. [FN76] The OIG investigation was prompted by annual audits conducted by CMS that have highlighted widespread and persistent problems related to inappropriate denials of services and payment. The OIG has accused MAOs of sometimes delaying or denying Medicare Advantage beneficiaries' access to services, even though the requests met Medicare coverage rules. Examples of health care services involved in denials that met Medicare coverage rules included advanced imaging services (e.g., MRIs) and post-acute facility stays (e.g., inpatient rehabilitation), the report stated. The report also found that MAOs reversed some of the denied prior authorization and payment requests that met Medicare coverage and MAO billing rules. Often the reversals occurred when a beneficiary or provider appealed or disputed the denial, and in some cases MAOs identified their own errors. The OIG noted that the findings provide an opportunity for improvement and recommend that CMS: ¢ issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews; * update its audit protocols to address the issues identified in the report, such as MAO use of clinical criteria and/or examining particular service types; and * direct MAOs to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors. Avoidable and costly billing errors during the intake and admissions process result in skilled nursing providers leaving millions of reimbursement dollars on the table, according to two leading billing and reimbursement experts. [FN77] They presented several findings from a cross-sectional study of long-term care providers between 2019 and 2020 during the LeadingAge Illinois Annual Meeting & Expo. Their study found that, on a monthly basis, claims denials by Medicare Advantage plans averaged from 8% to 10%. On average, providers were able to get that down to 3% to 5% and typically let the rest go, after several unsuccessful attempts to appeal the denials. Findings also showed that 80% of denials happen because of information not being gathered correctly, or an incorrect health plan being entered into the billing system during the intake and admissions process. Applying the denial data to a 90-SNF sample of providers in the Ohio Aging Services Network having a net patient revenue of $2 billion, leaving 5% on the table equals $10 million in uncollected claims. Making sure the intake and admission process is error free is essential for providers, according to Steven R. Wermuth, health policy consultant for Strategic Health Care. Key documentation providers need includes the patient's health plan information, hospital discharge plan, and health plan provider portal. Identifying carve outs where rates can be adjusted in the health plan is really critical, added Elizabeth McLaren, vice president of reimbursement and community-based services for Covenant Living Communities and Services. Providers were also encouraged to use the clearinghouse (which checks to ensure claims get processed correctly) to fix any errors that pop up on the EMR and CMS's Triple Check process. The speakers also said providers must analyze claims data after receiving payment, compare and assess any differences, and keep a record of differences. Payment Rates The growth of Medicare Advantage's market penetration represents a major threat to skilled nursing providers, McKnight's reports. IFN78] Some providers find themselves clearing less per resident day through MA plans than they do in state Medicaid programs. Speaking at the 2021 Legislative and Regulatory Conference hosted by the National Association for the Support of Long Term Care, a panel of nursing home and senior living executives called for more oversight in the face of the continuing shift. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -31- 'This transfer of risk from the government to Part C Medicare Advantage plans ... threatens our financial stability," Phil Fogg, Jr., CEO and president of Marquis Companies said. The increased preference of beneficiaries for MA coverage has been eating away at skilled nursing's bottom line for years now. In 2020, about 39% of all Medicare beneficiaries enrolled in Medicare Advantage plans, a 9% increase over 2019. While the Congressional Budget Office has estimated that the MA share will hit 51% by 2030, Fogg noted that MA shares have already hit 63% in the Western U.S., where Marquis is based. National HealthCare Corporation CEO and inside director Stephen F Flatt says the rise of Medicaid Advantage helped undermine the company's growth model, with MA payments 12% to 25% below Medicare Part A levels. In half the states where National HealthCare operates, after netting out ancillary expenses from Medicare Advantage per diem, Medicaid is a better payer from a margin perspective, Flatt added. In the case of MA patients who can't pay their co-pays, providers are left holding even more of the cost. Flatt has seen per- patient day MA payments come in at $180 in states where Medicaid pays $220 per patient day. In addition to low rates, MA payers continue to push for even shorter lengths of stay and create excess paperwork with routine audits. In its eastern Tennessee operations, which have a 52% MA penetration, National HealthCare facilities had 860 post-payment audits in a single year that resulted in an error rate of less than 8%, netting the insurer just $60,000, Flatt said. And while the managed care system has long been touted as delivering benefits for high-quality providers, with payments affected by quality outcomes, Flatt said, 'I've not seen any of that. We've been told blatantly by the MA companies, we don't care what your star rating is, there's really no interest in rehospitalization rates. It's, "Here's the rate. Here's the patient. Take it, or we'll find somebody else." Dementia Care Medicare Advantage (MA) plan enrollees with dementia report worse care experiences than enrollees with other chronic conditions, a new study finds. IFN79] As reported by McKnight's, [FN80] investigators examined MA consumer service assessment surveys. Study participants had Alzheimer's Disease and related dementias (ADRD) and had used nursing home, home health, or inpatient services within the last three years. When analyzed, the data showed that dementia patients were more likely to report lower scores for needed care and customer services when compared with MA recipients without ADRD. Notably, beneficiaries with dementia were also twice as likely to be excluded from the performance measures surveys, either because they weren't eligible or didn't respond. This undercounting may result in MA plans not being held accountable for their outcomes, the researchers wrote. Researchers also found that respondents who did not use proxies to complete their assessment forms reported worse outcomes than those whose proxies filled out the forms. The investigators also looked at whether people with dementia who enrolled in MA special needs plans (SNPs) experienced improvements in care. SNPs are designed for patients with complex care needs, such as dementia. Despite rapid SNP enrollment growth, they found no significant care improvements for these enrollees. The researchers proposed possible reasons for the discrepancies in care. Based on prior research, MA beneficiaries tend to be admitted to lower-quality care settings than those in traditional Medicare. Barriers to care such as prior authorizations and narrow networks may also contribute to additional burdens on these patients when compared to healthier enrollees. And, there is evidence that these enrollees face challenges in selecting the right plan, potentially leading to lower-rated care experiences, the researchers wrote. Policymakers must design performance measures that more equitably include beneficiaries who have serious health conditions and functional and cognitive decline, and who require proxies to report on their care experiences, researchers recommended. State Performance Standards Every year, CMS conducts a formal assessment of each State Agencies' (SAs') performance relative to measures included in the State Performance Standards System (SPSS) program. CMS works with the SAs to strengthen oversight so that the care provided in nursing homes and/or by providers and suppliers is of the highest quality, according to the guidance cover letter. [FN81] In April 2018, CMS launched an initiative to evaluate the SPSS process and identify ways to improve how we monitor and ultimately the SA performance. Through this FY 2020 guidance, the agency begins implementing changes to the SPSS. According to CMS, these changes reflect the use of improved, current datasets with consistent and objective oversight. For example, since implementing the new long term care survey process in 2017, CMS now has more robust data to monitor and improve performance. The resulting updates to the SPSS aim to enable CMS and SAs to address areas of concern more effectively, and ultimately improve beneficiary safety and the quality of their care. Below is a summary of the changes for the 2020 fiscal year: ¢ Established State Performance Indicators to help identify the underlying causes for inadequate performance in one or more of the scored performance measures. * Added the ability to include state specific measures, to tailor the program and address state-specific issues. ¢ Improved the process by which the program operates. For example, for some performance issues, SAs will be given 18 to 24 months to make correction. CMS will also be leveraging centralized data sources and hubs to access data and avoid redundant or duplicative data reporting. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -32- ¢ Included a new measure for cases where immediate jeopardy is cited that indicates if the survey agency delivered the IJ template at the exit conference, per Appendix Q of the State Operations Manual. ¢ CMS also plans to significantly enhance oversight of how SAs handle complaints and facility-reported incidents (FRIs), including how each state prioritizes reports of abuse or neglect, the timeliness of the investigation of reports, and the quality of these investigations. « Abuse and neglect: CMS has included some updates in the SPSS guidance to strengthen oversight in this area. In addition, to ensure that SAs respond to allegations in a timely and thorough manner, CMS will be revising policies for SAs to investigate complaints and FRIs in Chapter 5 of the State Operations Manual. CMS will update the SPSS guidance once those revisions take place. Three-Day Hospitalization Rule Medicare beneficiaries must have inpatient status at a hospital for three consecutive days to qualify for coverage of subsequent skilled nursing care. Currently, many beneficiaries spend extended periods of time in a hospital under observation stay status, which does not count toward that three-day threshold. In a rule issued on August 16, 2013, CMS clarified hospital inpatient status, which is likely to boost the number of seniors receiving Medicare coverage for skilled nursing services. The final CMS rule clarified when inpatient status should be conferred, triggering Medicare Part A coverage: 'We are specifying that for those hospital stays in which the physician expects the beneficiary to require care that crosses two midnights and admits the beneficiary based upon that expectation, Medicare Part A payment is generally appropriate," the rule states. 'Conversely, we are specifying that hospital stays in which the physician expects the patient to require care less than two midnights, payment under Medicare Part A is generally inappropriate." This rule is expected to increase Medicare reimbursements to hospitals for inpatient stays by $220 million annually, CMS estimated. The final rule appears in the August 19, 2013 Federal Register. [FN82] The increasing use of hospital observation stays has resulted in increased costs for Medicare beneficiaries, as they are classified and billed as outpatient care. Patients pay a copayment of 20% for outpatient care (under Medicare Part B), compared to a fixed deductible of $1,200 for inpatient care (under Part A). Federal Court Gives Patients Right to Appeal Rule A three-judge federal appeals court panel in Connecticut ruled on January 25, 2022, against a frustrating and confusing rule that left hundreds of thousands of Medicare beneficiaries without coverage for nursing home care, and no way to challenge a denial. [FN83] The ruling came in response to a 2011 class-action lawsuit eventually joined by 14 beneficiaries against the Department of Health and Human Services. It will guarantee patients the right to appeal to Medicare for nursing home coverage if they were admitted to a hospital as an inpatient but were switched to observation care, an outpatient service. The court's decision applies only to people with traditional Medicare whose status was changed from inpatient to observation. Observation care is a classification designed for patients who are not well enough to go home but still need the kind of care they can get only in a hospital. Without a three-day inpatient stay, beneficiaries are ineligible for Medicare's nursing home benefit. So, if they need follow-up care in a nursing home after leaving the hospital, they can face charges of about $290 a day, the average national cost of nursing home care, according to a 2021 survey. Also, since observation care is categorized as outpatient treatment, even if the patient is on a hospital ward, they can get stuck with significant copays under Medicare rules. Medicare patients who were switched from inpatient to observation status after January 1, 2009, will be able to file appeals for nursing home coverage and reimbursement for out-of-pocket costs. Bipartisan Legislation to End Requirement Representatives Joe Courtney (CT-02), Glenn "GT' Thompson (PA-15), Susan DelBene (WA-01), and Ron Estes (KS-04) re-introduced the bipartisan Improving Access to Medicare Coverage Act of 2021, legislation to fix an arbitrary Medicare policy that excludes coverage of skilled nursing care for certain patients, resulting in exorbitant and unexpected out-of-pocket costs. Sherrod Brown (D-OH) plans to introduce a companion bill in the Senate in the coming days, according to the press release. [FN84] Under current Medicare policy, a beneficiary must have an 'inpatient" hospital stay of at least three days for Medicare to cover skilled nursing care. Hospitals are increasingly holding patients under 'observation status"-an 'outpatient' designation. Under outdated Medicare rules, patients who receive hospital care on 'observation status" do not qualify for the benefit of skilled nursing care, even if their hospital stay lasts longer than three days and even if their care team prescribes it. The Improving Access to Medicare Coverage Act of 2021 would ensure Medicare covers this doctor-recommended, post-acute care even after the pandemic concludes by counting the time spent under 'observation status" towards the requisite three-day hospital stay for coverage of skilled nursing care. Coronavirus (COVID-19) Waiver In response to the Coronavirus outbreak, CMS is waiving the 3-day hospitalization rule for those people who need to be transferred as a result of the effect of a disaster or emergency. During the COVID-19 public health emergency (PHE), an SNF has the option to THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -33- apply the 3-Day Prior Hospitalization waiver in order to furnish Medicare Part A services without a qualifying hospital stay, or to obtain an additional 100-day benefit period without a 60-day break in spell of illness (Benefit-Period waiver) if certain conditions are met. In addition, for certain beneficiaries who recently exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period. N®l On June 26, 2020, the agency released updated guidance [FN86] on the SNF benefit period waiver for providers. The guidance explains that the benefit waiver period would not apply to beneficiaries that receive ongoing care in the SNF that is 'unrelated to the emergency." CMS explained in an MLN Matters article: 'For example, if the patient has a continued skilled care need (such as a feeding tube) that is unrelated to the COVID-19 emergency, then the beneficiary cannot renew his or her SNF benefits." It added that in that situation would fall under continued skilled care in the SNF 'rather than the emergency that is preventing the beneficiary from beginning the 60 day "wellness period." When making determinations, a SNF resident's ongoing skilled care is considered to be emergency-related unless it is altogether unaffected by the COVID-19 emergency itself, CMS explained. The temporary waiver for Medicare's three-day hospital stay requirement will continue at least into January 2022 after the COVID-19 public health crisis designation was extended by HHS Secretary Xavier Becerra on October 15, 2021. [FN87] Overpayments CMS likely overpaid about $84 million for posthospital extended care services during a two-year period, according to a report issued by the HHS Office of the Inspector General on February 14, 2019. IFN88] in a sampling of 99 skilled nursing facility claims, OIG found that CMS improperly paid 65 of the claims, where the '3-day rule" was not met. Based on that sample, the OIG estimated that the federal government improperly paid more than $84 million for SNF services from 2013 to 2015. Under federal law, to be eligible for coverage of posthospital extended care services, a Medicare beneficiary must be an inpatient in a hospital for not less than 3 consecutive calendar days before being discharged from the hospital. OIG attributes the improper payments to the absence of a coordinated notification mechanism among the hospitals, beneficiaries, and skilled nursing facilities to ensure compliance with the 3-day rule. It noted that hospitals did not always provide correct inpatient stay information to SNFs, and SNFs knowingly or unknowingly reported erroneous hospital stay information on their Medicare claims to meet the 3-day rule. SNFs used a combination of inpatient and non-inpatient hospital days to determine whether the 3-day rule was met. In addition, because CMS allowed SNF claims to bypass the Common Working File (CWF) qualifying stay edit during our audit period, the SNF claims were not matched with the associated hospital claims that reported inpatient stays of less than 3 days, the report found. OIG recommends that CMS ensure that the CWF qualifying inpatient hospital stay edit for SNF claims is enabled when SNF claims are processed for payment. In addition, CMS should require hospitals to provide beneficiaries a written notification of the number of inpatient days of care provided during the hospital stay and whether the hospital stay qualifies subsequent SNF care for Medicare reimbursement so that beneficiaries are aware of their potential financial responsibility before consenting to receive SNF services. CMS should also require SNFs to obtain a written notification from the hospital and retain it as a condition of payment for their claims, OIG states in the report. Further, CMS should educate both hospitals and SNFs about verifying and documenting the 3-day inpatient hospital stay relative to supporting a Medicare claim for SNF reimbursement. Long-term Care Hospitals Researchers find that Medicare could save about $4.6 billion per year-with no harm to patients-by not allowing hospital discharges to long-term care hospitals (LTCHs). LTCHs began in the 1980s as a regulatory carve-out from normal payment rules for a few dozen specialty hospitals. LTCHs treated patients with tuberculosis and chronic diseases and could earn far more money than traditional hospitals and nursing homes, if they cared for patients who stayed with them for an average of 25 days. Since then, the number of LTCHs has ballooned to over 400 and annual Medicare spending of $5.4 billion in 2014. For years, analysts and policymakers have questioned the value of these hospitals. Several analyses have suggested that Medicare may be overpaying for LTCH services. [FN89] A recent study, covering 1990 to 2014, took a close look at what happened to patients as new LTCHs opened across the country in places that had none. The researchers, at the Massachusetts Institute of Technology, Stanford University, and the University of Chicago, found that when an LTCH opened, the odds increased that very sick patients leaving a normal hospital would end up going next to an LTCH, generating increasing costs for Medicare and for the patients themselves. Without the LTCH, the patients would have received care at skilled nursing facilities (SNFs)}-post-acute care facilities that provide medically similar care but are paid significantly less. The researchers found that 'substitution to LTCHs leaves patients unaffected or worse off on all measurable dimensions." [FN90] LTCHs offer no benefit when it comes to patients' chances of dying or going home within 90 days. Shared Savings Program The Medicare Shared Savings Program was established by the Affordable Care Act (ACA). IFN91] The Shared Savings Program is a key component of the Medicare delivery system reform initiatives included in the ACA and is a new approach to the delivery of health care, according to CMS. [FN92] Congress created the program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. Eligible providers, hospitals, and suppliers may participate in the program by creating or participating in an Accountable Care Organization (ACO). ACOs are groups THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -34- of doctors and other health care providers who voluntarily work together with Medicare to provide high quality service to Medicare beneficiaries. To fulfill the intent of the ACA, the program aims to improve beneficiary outcomes and increase value of care by providing better care for individual, better health for populations, and lowering growth in expenditures. The Shared Savings Program rewards ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Participation in an ACO is purely voluntary. A study published in JAMA found that, for ACOs entering in 2012, participation in the Medicare Shared Savings Program was associated with a 9% differential reduction in post-acute spending by 2014. The study, using fee-for-service Medicare claims, found that the spending reductions were driven by discharges to facilities, length of facility stays, and acute inpatient care. The reductions were smaller for later entrants and similar for ACOs with and without financial ties to hospitals, the report says. Researchers concluded that participation in the MSSP has been associated with significant reductions in spending without deterioration in quality of care. 'Spending reductions were more consistent with clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital- wide initiatives by ACOs or use of preferred SNFs." [FN9S] A recent study finds that providers taking part in the Medicare Shared Savings Program saved money by transferring care away from skilled nursing facilities and other settings to physician services. [FN] Conducted by the consulting firm Leavitt Partners and the Duke-Margolis Center for Health Policy, the study examined data from the program, which rewards providers for better coordinating care. Researchers found that money spent on SNFs, as well as what's spent on ambulance services and durable medical equipment, decreased between 2013 and 2016. Money spent on physician services in accountable care organizations, meanwhile, increased. Researchers concluded that ACOs can shift spending in ways that reduce overall costs, and that a need for further understanding of how ACOs have made these changes, which could help the healthcare system rein in costs, and that this tactic may be pursued by other ACOs as a strategy to achieve greater reductions in overall spending without compromising quality. Hospital Readmissions On October 1, 2012, Medicare began fining nearly two-thirds of hospitals that have high numbers of patients who are readmitted within 30 days of discharge for heart attacks, heart failure, and pneumonia. The readmission penalties, estimated to cost the average hospital about $125,000 per year, are part of an Affordable Care Act initiative aimed at improving quality and lowering government costs. Some experts believe that the penalty is still low enough that hospitals will opt to pay it rather than change readmission policies. However, others believe the initiative holds opportunity for nursing homes because it encourages hospitals to partner with quality post- acute providers as a means of reducing readmissions. 'We are also spreading our wings a little and reaching outside the hospital, to the extent that we can, to make sure patients are getting the ongoing treatment they need,' Nancy Foster, the American Hospital Association's vice president for quality and safety, told the Associated Press. Currently, readmission penalties are capped at 1% ofa hospital's Medicare payments for the first year but will eventually rise to 3% under the ACA. IFN95] Hospital discharge planners may direct patients to higher-quality long-term care facilities in the future, under ideas being considered by MedPAC. Current rules prohibit hospitals from directing patients to specific nursing homes. Almost half of skilled nursing residents had five or more higher-quality facilities available in their area that they were not directed to by their hospital, and just under 15% of residents were discharged to the facility with the highest quality rating within a 15-mile radius, according to members at the September MedPAC meeting. That's compared to the 46.8% of residents that may have missed out on going to a higher-rated quality provider. Members point out that encouraging patients to choose higher-quality facilities could boost care outcomes while lowering costs and readmissions. '*N%l Therapy Coverage Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical and occupational therapy, and speech- language pathology services. The Balanced Budget Act of 1997 imposed an arbitrary limit on the annual amount of Medicare coverage available for beneficiaries receiving outpatient therapy services. Two distinct caps were placed on therapy services. Since 1997, Congress acted 16 times to prevent this policy from taking effect by creating a temporary 'exceptions process" which gives beneficiaries permission to go beyond the cap and maintain Medicare coverage. In February 2018, with passage of the 2018 tax reform bill, the therapy caps were repealed. Medicare law no longer limits how much Medicare pays for medically necessary outpatient therapy services in a calendar year. An analysis commissioned by the American Occupational Therapy Association found that nearly 6 million Medicare beneficiaries used outpatient therapy services in 2015. IFN97] Rehabilitative care often allows older Americans to maintain their independence and remain at home rather than go to a nursing home or other long-term care facility. In the 2022 Physician Fee Schedule, CMS finalized a 15% payment reduction for physical and occupational therapy assistants, and extended temporary telehealth services under Medicare, added during the COVID-19 pandemic. The agency announced the final rule on November 2, 2021. The final rule confirms the 15% payment cut for outpatient occupational therapy services and outpatient physical therapy services that are provided, in whole or in part, by a physical therapist assistant or occupational therapy assistant. New payment modifiers applied to claims on those services, however, could minimize the blow, providers previously theorized. The new regulations become effective Jan. 1, 2022. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -35- The final rule also confirmed that certain services added to the Medicare telehealth services list will remain at least through December 21, 2023, to give federal health officials additional time to evaluate whether to retain them permanently. The rule also removes the geographic restrictions and added the beneficiary's home as a permissible originating site for telehealth services when used for diagnosis, evaluation, or treatment of mental disorders. The rule also requires that for these services there must be an in-person, non- telehealth service with the physician or practitioner within six months prior to the initial telehealth service. The federal government will be required to establish frequency guidelines for subsequent in-person visits. The finalized rule also limits the use of audio-only telecommunications systems to mental health services furnished by practitioners who have the capability to furnish two-way, audio/video communications, but where the beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology. CMS issued three final rules on November 2, including one focused on home health's pay increase that also touched directly on further nursing home policy. The rule also finalizes revisions to infection control requirements for nursing homes in the Medicare and Medicaid programs, including extending mandatory COVID-19 reporting requirements through December 31, 2024. It also incorporates into regulation several existing Medicare provider enrollment policies; and finalizes certain survey and enforcement requirements for hospice programs to implement provisions of the Consolidated Appropriations Act, 2021. A fact sheet on the final home health rule notes that it codifies expansion of the Home Health Value-Based Purchasing (HHVBP) Model and updates Medicare's home health PPS and home infusion therapy services payment rates for calendar 2022. As part of the new physician fee schedule rule, beginning January 1, 2022, CMS will pay $30 per dose for the administration of the influenza, pneumococcal, and hepatitis B virus vaccines. The agency will also continue a $40 per dose pay rate for administering COVID-19 vaccines until the end of the year when the current public health emergency is declared over. The rates will then be recalculated to align with pay rates for other Part B preventive vaccines, officials said. [FN98] An analysis of the proposed 2023 Physician Fee Schedule IFN9S] released by the Centers for Medicare & Medicaid Services on July 7, 2022, reveals additional payment cuts for nursing homes. While this year's proposed payment cuts appear to be milder than the 2022 and 2021 rules, changes to Current Procedural Terminology (CPT) codes and other details would add up substantially, according to Cynthia Morton, executive vice president of the National Association for the Support of Long-Term Care. 'Our initial analysis shows that rehab therapy services for seniors in nursing homes and other settings where Part B rehab therapy is provided are being reduced by CMS ranging from 3% to 6%," Morton told McKnight's Long-Term Care News. [FN100] Morton also expressed concern that there was no consideration of staff shortages and the rates therapy providers must pay to hire. The 2023 fee schedule conversion factor proposed by CMS is $33.08 for each relative unit, a slight decline from the 2022 factor of $34.61. The government previously boosted the rate as a reflection of COVID operating conditions, but that expired this year. The fee schedule also redefines participation and benefits of provider participation in accountable care organizations, makes some adjustments to covered telehealth services and expands slightly the types of dental services covered by Medicare. In addition, it would recategorize nursing homes as high-risk facilities, forcing new owners to be fingerprinted and undergo background checks. Maintenance therapy. |n 2013, a settlement agreement was approved in the case of Jimmo v. Sebelius, to ensure that more nursing home residents receive coverage for skilled therapies that help them maintain critical functions and the quality of life. At issue was the inappropriate use of the 'improvement standard" under which a claim would be denied due to the beneficiary's lack of restoration potential, even though the beneficiary did in fact require a covered level of skilled care in order to prevent or slow further deterioration in his or her clinical condition, N10") According to a fact sheet on the Jimmo v. Sebelius settlement agreement issued by the CMS, [FN102] providers must sufficiently document the need for skilled care in order to obtain Medicare coverage for so-called 'maintenance therapy." CMS never established an 'improvement standard" that said Medicare payments would be withheld for treatment given strictly to maintain, rather than improve, a resident's condition, the agency states in the fact sheet. Therefore, the settlement in Jimmo did not eliminate the improvement standard or otherwise expand Medicare coverage. In determining whether a particular maintenance treatment is eligible for Medicare coverage, providers must demonstrate that the needs of the resident can only be met through skilled rather than nonskilled care, the document says. 'Any Medicare coverage or appeals decisions conceming skilled care coverage must reflect this basic principle," according to the fact sheet. 'In this context, it is also essential and has always been required that claims for skilled care coverage include sufficient documentation to substantiate clearly that skilled care is required, that it is in fact provided, and that the services themselves are reasonable and necessary, thereby facilitating accurate and appropriate claims adjudication." [FN103) Under terms of the Jimmo settlement, Medicare beneficiaries receiving skilled care for chronic conditions no longer have to show improvement in order to have the care covered. Many providers, however, are still refusing to provide needed treatment, claiming that Medicare will not cover it. For about 30 years, home health agencies and nursing homes that contract with Medicare have routinely terminated the Medicare coverage of a beneficiary who has stopped improving, even though nothing in the Medicare statute or its regulations says improvement is required for continued skilled care. Under the settlement, the federal government agreed to update Medicare rules to require that Medicare cover skilled care as long as the beneficiary needs skilled care, even if it would simply maintain the beneficiary's current condition or slow further deterioration. CMS agreed to educate providers and its own contractors about inappropriate use of the 'improvement standard" under the settlement agreement. Many therapists and facilities, however, are still hesitant about billing for services that help chronically ill patients receive THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -36- maintenance therapies. The Center for Medicare Advocacy and Vermont Legal Aid allege that CMS has failed to comply with the settlement terms; that CMS's education campaign was insufficient. The agency hosted just one provider call on Jimmo, a lawyer for the Center for Medicare Advocacy says; although more than 3,000 people participated, only 18 were able to ask questions. [FN104] On February 1, 2017, a federal District Court [FN105] approved a corrective statement to be used by CMS to disavow the use of an 'improvement standard" for Medicare coverage of physical and occupational therapy and other skilled care. Advocates for seniors say coverage is often mistakenly denied simply because the beneficiary reaches 'a plateau" and is no longer making progress. The beneficiaries' lawyers argued that the effort had failed and additional steps were necessary. U.S. District Court Judge Christina Reiss in Vermont agreed, and approved most of the suggestions for further actions proposed by the government last month and added two more proposed by the advocates. Under the order, CMS must provide a new website devoted to the 2013 settlement that will include information on how claims should be handled, as well as a simple explanation that improvement is not a criterion for coverage. The website, unveiled in August 2017, includes wording of Medicare manual revisions to restate a 'maintenance coverage standard" for both skilled nursing and therapy services. The statement the judge accepted was largely written by the plaintiffs' lawyers and says, in part, that 'The Medicare program will pay for skilled nursing care and skilled rehabilitation services when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met)." The judge also told the government to hold a second training session on the policy for claims processors, appeals judges and others and even told them how to describe it to avoid any misunderstanding. But she rejected the plaintiffs' arguments that they should help develop the training and other messages so that the government would not repeat past mistakes. These measures must be completed by September 4, 2017. [FN106] 2022 Revisions On June 29, 2022, CMS released updated guidance for nursing home surveyors as part of the Phase 2 and 3 Requirements of Participation. [FN107] The update clarifies specific regulatory requirements and provides information on how compliance will be assessed. In addition, CMS is revising its guidance to State agencies, to strengthen the management of complaints and facility reported incidents. Key changes include: ¢ Abuse and Neglect: clarifies compliance, abuse reporting, including sample reporting templates, and provides examples of abuse that, because of the action itself, would be assigned to certain severity levels. ¢ Admission, Transfer, and Discharge: clarifies requirements related to facility-initiated discharges. * Mental Health/Substance Use Disorder (SUD): addresses rights and behavioral health services for individuals with mental health needs and SUDs. * Nurse Staffing (Payroll-Based Journal): uses payroll-based staffing data to trigger deeper investigations of sufficient staffing and added examples of noncompliance. ¢ Resident Rights: imports guidance related to visitation from memos issued related to COVID-19, and makes changes for additional clarity and technical corrections. ¢ Pharmacy: addresses unnecessary use of non-psychotropic drugs in addition to antipsychotics, and gradual dose reduction. * Infection Control: requires facilities have at least a part-time Infection Preventionist, and meet the needs of the facility. The IP must physically work onsite and cannot be an off-site consultant or work at a separate location. IP role is critical to mitigating infectious diseases through an effective infection prevention and control program. ¢ Arbitration: clarifies existing requirements for compliance when arbitration agreements are used by nursing homes to settle disputes. ¢ State Operations Manual Chapter 5: clarifies timeliness of state investigations, and communication to complainants to improve consistency across states. There are no new regulations related to resident room capacity. However, CMS is highlighting the benefits of reducing the number of residents in each room given the lessons learned during the COVID-19 pandemic for preventing infections and the importance of residents' rights to privacy and home-like environment. Accountable Care Organizations Accountable care organizations (ACOs) have been set up to provide incentives to healthcare organizations, including long-term care providers, to provide quality care for less money. They are designed around healthcare providers banding together to provide care to 5,000 or more beneficiaries. The program allows an ACO to partake in any shared savings resulting from high-quality efficient treatment. Organizations are required to follow a series of rules to qualify. Research from Avalere finds that the actual net savings from Medicare accountable care organizations under the Medicare Shared Savings Program has fallen far short of projections, by over $2 billion. The MSSP was enacted as part of the Affordable Care Act in 2010. At the time, the Congressional Budget Office estimated that the MSSP would produce $1.7 billion in savings to the federal THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -37- government from 2013 to 2016. However, the MSSP increased federal spending by $384 million over that time period. Researchers found, however, evidence that individual ACO performance may improve as they gain years of experience with the program: ACOs in their fourth performance year produced net savings to the federal budget totaling $152 million from 2013 to 2016. These results suggest that the CBO's initial projections may not have taken into account the time it takes for ACOs to gain experience with the program and to start to produce consistent savings. [FN108] Recent Legislative Activity Federal ¢ 2021 CONG US HR 4890 and 2021 CONG US §S 2576, introduced July 30, 2021, to establish a program to allow qualified group practices to furnish certain items and services at qualified skilled nursing facilities to individuals entitled to benefits under part A and enrolled under part B of the Medicare program to reduce unnecessary hospitalizations. ¢ 2021 CONG US HR 5312 and 2021 CONG US §S 2777, introduced September 21, 2021, to authorize the Secretary of Health and Human Services to make adjustments to payment rates for skilled nursing facilities under the Medicare program to account for certain unique circumstances. * 2021 CONG US §S 2048, introduced June 15, 2021, to count a period of receipt of outpatient observation services in a hospital toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare. * 2021 CONG US §S 2694, introduced August 20, 2021, the 'Nursing Home Improvement and Accountability Act of 2021," to improve care furnished and to support the workforce in skilled nursing facilities under the Medicare program and in nursing facilities under the Medicaid program, would require nursing homes to meet minimum staffing standards but receive additional Medicaid funds to support workforce and care improvements. Hawaii 2021 HIH.C.R. 18 (NS) and 2021 HI H.R. 16 (NS), introduced March 3, 2022, urging the United States Congress and Hawaii's congressional delegation to support legislation establishing Medicare for all, to cover long-term care among other medical services. New Mexico 2022 NM S.B. 138 (NS), adopted March 8, 2022, providing that receipts of a hospice or nursing home from payments by the United States government, or any agency thereof, or from a Medicare administrative contractor for medical and other health and palliative services provided by the hospice or nursing home to Medicare beneficiaries pursuant to the provisions of Title 18 of the Social Security Act may be deducted from gross receipts. Vi. LONG-TERM CARE INSURANCE Private Long-Term Care Insurance Costly long-term care expenditures can be avoided through the purchase of long-term care insurance, which has been a popular option for many. The industry, however, has faced financial challenges in recent years and many insurers have decided to discontinue offering individual policies. With the rising and often overwhelming costs of long-term care, some form of long-term care insurance has become an increasingly attractive option for many Americans. A recent survey, however, reveals that many individuals mistakenly believe that Medicare or their health insurance will cover long-term care expenses. The Life and Health Insurance Foundation for Education, also known as the LIFE Foundation, released a survey in November 2009 to coincide with Long-Term Care Insurance Awareness Month. The survey revealed that nine out of 10 Americans do not have a practical plan to pay for the expenses associated with long-term care. According to the survey results, 23% of respondents said they would rely on family or friends for assistance, while 20% would rely on their health insurance. Sixteen percent claimed that they will use Medicare to cover their long-term care expenses, 13% contend that their savings will cover long-term care costs and 11% responded that Social Security benefits will be their primary source of funding. Only 10% of Americans would rely on long-term care insurance, while 7% plan to depend on Medicaid. Genworth Financial's annual 'Cost of Care" report on the cost of nursing homes, adult day cares, home health aides, and similar services found that long-term care coverage is becoming more and more unaffordable for middle-class families. IFN109] The report found that the average cost for a private room in a nursing home is over $106,900 per year. However, many have found that assisted living facilities tend to be more affordable with a yearly average of $54,000. The Department of Health and Human Services reports that at least 70% of individuals over the age of 65 will need long-term care at some point during the remaining years of life. The likelihood of women needing long-term care is even higher since women have a longer life expectancy than men. In 2017, long-term care insurance companies paid out $9.2 billion in claim benefits to some 295,000 individuals, according to the American Association for Long-Term Care Insurance. In 2016, total claims amounted to $8.65 billion paid to 280,000 individuals. The THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -38- Association conducts an annual study of claims paid to policyholders who have a traditional, health-based long-term care insurance ;_., [FN110] policy. A study conducted by researchers at the Center for Retirement Research at Boston College examines the options that single individuals over 65 face, and the value of purchasing long-term care insurance. The main funding sources for long-term care are Medicare, private LTC insurance, and Medicaid. Medicare covers short-term stays for noncustodial care for up to 100 days. Private long-term care insurance is purchased by few single individuals in the U.S., only about 13%. For those that are uninsured, Medicaid bears much of the cost of skilled nursing care once an individual's assets have been exhausted and the means test is met. The researchers found that while the risk of needing long-term care is greater than research previously indicated, average stays are shorter. Using monthly rather than annual figures, they pointed out that 50% of men and 39% of women don't stay in a skilled nursing facility longer than three months: the average nursing home stay for a man is less than a year; for women, 17 months. With the availability of Medicare and Medicaid, and lower chances that one will endure an expensive, long illness that will bankrupt them, the investigators concluded that 'rational, far-sighted, well-informed" single people would be smart to avoid paying long-term care insurance premiums. [FN111] A 60-year-old male purchasing new long-term care insurance coverage can find coverage for under $2,000 a year providing nearly $400,000 in benefits at age 90 according to a cost analysis just conducted by the American Association for Long-Term Care Insurance. Married couples often benefit from a significant spousal discount, Slome explained. According to AALTCI studies, married couples or older adults living together purchase the majority of long-term care insurance policies the Association director notes. It is cheaper for individuals to purchase a long-term care policy when they are younger. The cost to a 55-year-old female is $7,224 a year for premiums linked benefit long-term care insurance, but that cost jumps to $13,048 a year by age 65. [FN112] Currently only 10% of long-term care costs are paid for by long-term care insurance. Individuals are encouraged to select policies that have annual increases in benefits because the cost of care is inevitably going to get higher. Note: For a discussion of Medicaid funding vs. long-term care insurance, see section III. MEDICAID FUNDING, above. State Programs Leaders in other states are watching how the state of Washington handles its long-term care insurance initiative, a first among state- run benefit programs. Called the 'WA Cares Fund," the program was approved by lawmakers in 2019. It mandates a 0.58% payroll deduction used to help pay for nursing care and other long-term care services and supports for those who need it. The benefit has a lifetime limit of $36,500, intended to cover a year's worth of home care at 20 hours a week. Contributions will begin July 1, 2023, and benefits will become available July 1, 2026. To be eligible for WA Cares Fund benefits, an employee must have worked and contributed to the fund for a total of 10 years without an interruption of five or more consecutive years; or contributed three of the last six years at time of application, having worked at least 500 hours per year. One must also need help with activities of daily living. To address certain concerns raised by the public, the legislature made improvements to the program in 2022. The changes include: People near retirement earn partial benefits for each year they work; workers who live out of state, workers on non-immigrant visas, and military spouses can opt out; and veterans with a 70% or higher service-connected disability can opt out. IFN113] Tax Credits and Deductions for Long-Term Care Insurance Although more Americans are purchasing long-term care insurance, the cost of such policies is prohibitive for many individuals. In fact, the high cost of long-term care insurance is the reason most people give for not purchasing it. In order to encourage individuals to acquire long-term care insurance and to offset a portion of the cost, federal and state legislators have promoted plans to provide tax credits to compensate for long-term care insurance premium payments. The federal government offers a tax deduction for qualified long-term care policies to the extent that the premiums (along with other unreimbursed medical expenses) exceed 7.5% of an individual's adjusted gross income, and the individual itemizes income tax deductions. Nearly half the states in the U.S. offer tax deductions and other incentives for the cost of long-term care insurance premiums, as of 2022. Recent Legislative Activity Federal * 2021 CONG US HR 7107, introduced March 16, 2022, to expand the use of retirement plan funds to obtain long-term care insurance. ¢ 2021 CONG US HR 7203, introduced March 24, 2022, to repeal the direct payment requirement on the exclusion from gross income of distributions from governmental plans for health and long-term care insurance. «2021 CONG US § 377, introduced February 23, 2021, to promote and protect from discrimination living organ donors; prohibiting discrimination against donors by long-term care and certain other insurers. ¢ 2021 Cong US S 24715, introduced July 21, 2021, the 'Long-Term Care Affordability Act," would amend the Internal Revenue Code of 1986 to expand the use of retirement plan funds to obtain long-term care insurance, and for other purposes. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -39- California ¢ 2021 CAA.B. 2604 (NS), adopted September 25, 2022, requires that a lower-cost option of a long-term care insurance policy to provide protection against inflation that automatically increases benefit levels by, at a minimum, either 3% each year over the previous year, or a fixed amount each year equal to 5% of the original benefit levels, but authorizes a policy or certificate to be certified if it automatically increases benefit levels by 1% each year over the previous year if the policyholder or certificate holder meets specified criteria. The bill also requires policyholders and certificate holders to be offered various options, if applicable, if a premium increases, including the option to reduce the daily benefit, as specified. «2021 CA S.B. 41 (NS), adopted October 6, 2021, would establish the Genetic Information Privacy Act, requiring a direct-to-consumer genetic testing company, as defined, to provide a consumer with certain information regarding the company's policies and procedures for the collection, use, maintenance, and disclosure, as applicable, of genetic data, and to obtain a consumer's express consent for collection, use, or disclosure of the consumer's genetic data, as specified; prohibits disclosure of a consumer's genetic data to any entity that is responsible for administering or making decisions regarding long-term care and other insurance products. Connecticut ¢ 2022 CT H.B. 5389 (NS), adopted May 24, 2022, concerning a study to use captive insurance companies to reduce premium rate increases for Connecticut partnership long-term care insurance policies and peer-to-peer car sharing. ¢ 2022 CT S.B. 62 (NS) and 2022 CT S.B. 68 (NS), introduced February 15, 2022, establishing a tax credit for premium payments for certain long-term care insurance policies. * 2022 CT S.B. 409 (NS), introduced March 10, 2022, to: (1) Establish a study regarding an alternative pool for long-term care policyholders; (2) require a public hearing concerning premium rate increases in excess of ten per cent; (3) require notice to individuals of the risk of premium increases prior to the purchase of a long-term care policy; and (4) implement a tax credit for individuals purchasing long-term care policies. Delaware ¢ 2021 DE H.B. 111 (NS), adopted June 15, 2021, relating to discrimination by life, disability, or long-term care insurers based on pre- exposure prophylaxis medication to prevent HIV infection. ¢ 2021 DE H.B. 229 (NS), adopted July 30, 2021, adopts the Interstate Insurance Product Regulation Compact, to promote and protect the interest of consumers of individual and group annuity, life insurance, disability income, and long-term care insurance products; develop uniform standards for insurance products covered under the Compact; establish a central clearinghouse to receive and provide prompt review of insurance products covered under the Compact; give appropriate regulatory approval to those product filings and advertisements satisfying the applicable uniform standard; improve coordination of regulatory resources and expertise between state insurance departments regarding the setting of uniform standards and review of insurance products covered under the Compact; and create the Interstate Insurance Product Regulation Commission. District of Columbia 2021 DC L.B. 202 (NS), introduced April 1, 2021, to prohibit insurance companies from factoring the use of pre-exposure prophylaxis in decisions related to the issuance of disability, life, or long-term care insurance policies. Florida ¢ 2022 FL H.B. 1099 (NS), adopted April 6, 2022, prohibiting insurers under long-term care and other policies from declining or limiting coverage and discriminating against persons based solely on their status as living organ donors. ¢ 2022 FL S.B. 1026 (NS), introduced January 11, 2022, prohibiting insurers under long-term care insurance policies, among others, health maintenance organizations, and prepaid health clinics under specified policies from declining or limiting coverages and discriminating against persons based solely on their status as living organ donors, and from precluding insureds or subscribers from donating organs. Georgia 2021 GA H.B. 115 (NS), filed January 26, 2021, would prohibit long-term care and health insurers from using information derived from genetic testing for any nontherapeutic purpose in the absence of a diagnosis of a condition related to such information. Hawaii ¢ 2021 HI H.B. 489 (NS), introduced January 25, 2021, and 2021 HI S.B. 836 (NS), introduced January 22, 2021, requires the thirty-day lapse or termination notices for long-term care policies to be sent by certified mail, priority mail, or commercial delivery service, or other method of delivery requiring proof of delivery. ¢ 2022 HI H.B. 2112 (NS), approved May 27, 2022, to adopt the 2019 revisions to the National Association of Insurance Commissioners' Credit for Reinsurance Model Law to conform to the requirements of the bilateral agreements on insurance (including long-term care insurance) and reinsurance between the United States and the European Union and between the United States and the United Kingdom. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -40- ¢ 2021 HI S.B. 2032 (NS), amended/substituted April 28, 2022, requiring direct-to-consumer genetic testing companies to adhere to certain requirements pertaining to the collection, use, and disclosure of genetic data; prohibiting disclosure of a consumer's genetic data to any person offering health insurance, life insurance, or long-term care insurance, or to any employer of the consumer without the prior express consent of the consumer. Illinois 2021 IL H.B. 1466 (NS), engrossed April 4, 2022, amending the Illinois Insurance Code, making a technical change in a section relating to long-term care insurance. Indiana 2022 IN S.B. 95 (NS), amended/substituted January 7, 2022, prohibiting an insurer that issues a policy of life insurance, disability insurance, or long-term care insurance from taking certain actions with respect to the coverage of individuals who are living organ donors; specifies that certain actions constitute an unfair and deceptive act and practice in the business of insurance when taken against a living organ donor by an insurer. Kentucky 2022 KY H.B. 502 (NS), amended/substituted March 8, 2022, prohibiting a direct-to-consumer genetic testing company from disclosing a consumer's genetic data to any entity offering health insurance, life insurance, or long-term care insurance, or to any employer of the consumer without the consumer's written consent. Louisiana 2022 LA H.B. 307 (NS), adopted May 25, 2022, prohibiting long-term care and other insurers from denying or conditioning certain policies based on the policyholder's status as a living organ donor. Maine ¢ 2021 ME H.P. 800 (NS), introduced March 11, 2021, relating to the use of genetic information by long-term care and other insurers. ¢ 2021 ME S.R. 374 (NS), introduced March 18, 2021, to classify employee health insurance as a fixed cost for MaineCare reimbursement in nursing homes. Maryland 2022 MD H.B. 866 (NS), adopted May 29, 2022, prohibiting direct-to-consumer genetic testing companies from disclosing, without the consumer's written consent, consumer's genetic data to long-term care and other insurers. Massachusetts * 2021 MA H.D. 2190 (NS), filed February 16, 2021, relative to long term care insurance tax credit. ¢ 2021 MA S.D. 582 (NS), draft/request, February 3, 2021, relative to long-term care insurance consumer protections. ¢ 2021 MA S.D. 707 (NS), draft/request, February 4, 2021, an Act for greater fairness in insurance policies, providing that if a policy, contract, certificate, or agreement offered, issued, delivered, or renewed, whether or not in Massachusetts, that provides, backs up, reinsures, or funds, in whole or in part, life insurance, health insurance, annuities, accident insurance, long term care insurance, or disability insurance coverage for any Massachusetts resident contains a provision that reserves discretionary authority to the insurer, or an agent of the insurer, to determine eligibility for benefits or coverage, to interpret the terms of the policy, contract, certificate, or agreement, or to provide standards of interpretation or review that are inconsistent with the laws of this state, that provision is void and unenforceable. ¢ 2021 MA S.D. 2070 (NS), filed February 19, 2021, expanding insurance options available through the group insurance commission; establishing a plan of long-term care insurance on such terms and conditions as the commission deems to be in the best interest of the commonwealth and its employees. Michigan ¢ 2021 MI H.B. 5997 (NS), introduced April 12, 2022, providing penalties for bad-faith denials by insurers, including long-term care insurers. ¢ 2021 MI S.B. 584 (NS), introduced June 30, 2021, prohibiting insurers from denying or limiting insurance to living organ donors. Minnesota ¢ 2021 MN H.F. 285 (NS), introduced January 25, 2021, and 2021 MN S.F. 463 (NS), introduced January 28, 2021, providing for expansion of long-term care insurance income tax credits. ¢ 2021 MN H.F. 1829 (NS), engrossed May 25, 2022, prohibiting organ or bone marrow donor discrimination by long-term care and other insurers. ¢ 2021 MN H.F. 1983 (NS), introduced March 8, 2021, life insurance policy sale allowed to convert to long-term care insurance policies. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -41- ¢ 2021 MN H.F. 4031 (NS), engrossed March 30, 2022, life insurance policy authorization allowed for coverage that provides long-term care. ¢ 2021 MN H.F. 4439 (NS) and 2021 MN S.F. 4182 (NS), introduced March 21, 2022, prohibiting a direct-to-consumer genetic testing company from disclosing a consumer's genetic data to any entity offering health insurance, life insurance, or long-term care insurance or to any employer of the consumer without the consumer's written consent. ¢ 2021 MN S.F. 2817 (NS), introduced February 3, 2022, prohibiting a direct-to-consumer genetic testing company from disclosing a consumer's genetic data to any entity offering long-term care insurance or to any employer of the consumer without the consumer's written consent. ¢ 2021 MN S.F. 3338 (NS), adopted May 22, 2022, requiring life insurance policies that provide coverage permission for long-term care be authorized in certain instances. ¢ 2021 MN S.F. 3978 (NS), introduced March 14, 2022, modifying the inflation protection requirements for policies qualifying for the state long-term care insurance credit; providing a phaseout for the credit. Missouri 2022 MO S.B. 912 (NS), introduced January 5, 2022, would cap rate increases for long-term care insurance policies at the lesser of the consumer price index or five percent, measured annually. New Mexico 2022 NM S.M. 26 (NS), introduced February 7, 2022, requesting the Office of Superintendent of Insurance to conduct and complete a comprehensive study on long-term care insurance and its affordability. New Jersey 2022 NJ S.B. 2650 (NS), introduced May 16, 2022, providing gross income tax deduction for senior citizens for certain medical expenses for in-home care or care in assisted living and long-term care facilities and funeral expenses. New York ¢ 2021 NY A.B. 2408 (NS), introduced January 19, 2021, provides a personal income tax deduction for long-term care insurance riders. ¢ 2021 NY A.B. 3123 (NS), introduced January 22, 2021, provides that health insurance contracts and policies for long term care shall be renewable unless there is nonpayment of premiums. ¢ 2021 NY A.B. 3167 (NS), introduced January 22, 2021, requires insurers that issue contracts providing long term care benefits to maintain records of policies cancelled due to increased premiums. ¢ 2021 NY A.B. 4191 (NS), introduced February 2, 2021, provides for an increased personal income tax deduction for medical expenses incurred by a New York taxpayer to include medical insurance premiums and long-term care premiums. ¢ 2021 NY A.B. 4514 (NS), introduced February 4, 2021, prohibits insurers from selling policies of insurance which duplicate existing coverage relative to long term health care policies. ¢ 2021 NY A.B. 5827 (NS), introduced February 26, 2021, requires long-term care insurance carriers who propose to raise long term care insurance premiums to obtain prior approval of the superintendent of financial services. ¢ 2021 NY A.B. 6034 (NS), introduced March 4, 2021, prohibiting ownership or control of managed long-term care plans by health maintenance organizations or insurers. ¢ 2021 NY A.B. 6320 (NS), introduced March 12, 2021, raising tax credits for long-term care insurance from twenty percent to fifty percent. ¢ 2021 NY A.B. 6321 (NS), introduced March 12, 2021, relating to refunds of excess long-term care insurance credits. ¢ 2021 NY A.B. 6631 (NS), introduced March 23, 2021, grants a state personal income tax deduction for retirement plan distributions used to purchase long-term care insurance. ¢ 2021 NY A.B. 6683 (NS), introduced March 25, 2021, eliminates the cap on the maximum amount and the gross income requirement for the long-term care insurance credit. ¢ 2021 NY A.B. 6730 (NS), introduced March 29, 2021, provides for transparency in long term care insurance rates. ¢ 2021 NY A.B. 6991 (NS), introduced April 19, 2021, relating to tax credits for premiums paid for long-term care insurance. ¢ 2021 NY A.B. 7903 (NS), introduced May 28, 2021, establishes a state-level program of all-inclusive care for the elderly for persons 55 years of age or older, qualifying for nursing home levels of care who wish to remain in their community. ¢ 2021 NY A.B. 8618 (NS), introduced January 10, 2022, increase in long-term care insurance policy rates. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -42- ¢ 2021 NY A.B. 9354 (NS), introduced February 23, 2022, establishing the 'Interstate insurance product regulation compact' to regulate certain insurance products among member states and to promote and protect the interest of consumers of individual and group annuity, life insurance, disability income and long-term care insurance products. ¢ 2021 NY A.B. 9837 (NS), introduced April 19, 2022, prohibiting insurance companies, including long-term care insurers, from discriminating based on genetic predisposition. ¢ 2021 NY S.B. 1162 (NS), amended/substituted February 2, 2021, requires New York state to develop and implement a plan for the distribution of COVID-19 medical countermeasures in a manner that prioritizes those communities serving the most vulnerable residents of the state, including in long-term care facilities. ¢ 2021 NY S.B. 1525 (NS), introduced January 12, 2021, provides for a personal income tax credit for ten percent of the cost of long- term health care insurance premiums. ¢ 2021 NY S.B. 2526 (NS), introduced January 21, 2021, relates to payments for home- and community-based long-term care services; provides that funds appropriated to compensate for minimum wage requirements shall not be subject to managed care risk adjustment on insurers. ¢ 2021 NY S.B. 3700 (NS), introduced January 30, 2021, establishes the 'Interstate insurance product regulation compact' to regulate certain insurance products among member states and to promote and protect the interest of consumers of individual and group annuity, life insurance, disability income and long-term care insurance products. * 2021 NY S.B. 4327 (NS), amended/substituted May 23, 2022, requiring a written statement from an insurer, corporation, health maintenance organization or fraternal benefit society as to the anticipated good faith increases of premium rates for a long-term care insurance policies or certificates over the next ten years and include a graphic demonstration illustrating past premium rate increases for such policies or certificates over the last ten years. * 2021 NY S.B. 4328 (NS), introduced February 3, 2021, requiring the superintendent of financial services to make public any rate filing or application submitted by long term care insurance carriers who propose to raise long term care insurance premiums. ¢ 2021 NY S.B. 4933 (NS), introduced February 18, 2021, provides that the tax credits for long-term health care insurance shall be up to $1,000 of the premiums paid for each policy of such insurance. ¢ 2021 NY S.B. 5531 (NS), introduced March 10, 2021, requires insurers which issue contracts providing long term care benefits to maintain records of policies cancelled due to increased premiums. ¢ 2021 NY S.B. 5731 (NS), introduced March 17, 2021, prohibits insurers from selling policies of insurance which duplicate existing coverage relative to long-term health care policies. * 2021 NY S.B. 6442 (NS), introduced April 28, 2021, eliminates the cap on the maximum amount and the gross income requirement for the long-term care insurance credit. North Carolina 2021 NC H.B. 71 (NS), amended/substituted June 3, 2021, The Living Donor Protection Act, to protect living donors from potential insurance discrimination by long-term care and other insurers. Ohio 2021 OH H.B. 188 (NS), adopted April 6, 2022, prohibiting insurers from discriminating against living organ donors. Pennsylvania ¢ 2021 PA H.B. 168 (NS), introduced January 14, 2021, further providing for disclosure and performance standards for long-term care insurance. ¢ 2021 PA H.B. 2751 (NS), introduced July 13, 2022, providing for use of genetic information for insurance purposes by health insurers, life insurers, and long-term care insurers. ¢ 2021 PAS.B. 125 (NS), introduced January 26, 2021, providing for use and restrictions in using genetic information for insurance purposes. ¢ 2021 PA S.B. 1291 (NS), introduced June 16, 2022, providing for genetic information privacy and setting penalties for violations; prohibiting disclosure of a consumer's genetic data without written consent to long-term care and other insurance entities. Rhode Island * 2021 RI H.B. 7752 (NS), amended/substituted June 23, 2022, and 2021 RI S.8. 2746 (NS), amended/substituted June 21, 2022, clarifying and updating the long-term care insurance statute. ¢ 2021 RI H.B. 7778 (NS), introduced March 3, 2022, updating the long-term care insurance statute so that it is in conformance with the latest version of the National Association of Insurance Commissioners model. South Carolina THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -43- ¢ 2021 SC H.B. 4537 (NS), introduced January 11, 2022, to prohibit issuers of long-term care insurance policies from discriminating against living kidney donors. ¢ 2021 SC H.B. 4832 (NS), adopted May 16, 2022, to require long-term care insurers to provide notice of proposed premium rate increases to policyholders. * 2021 SC H.B. 4839 (NS), amended/substituted March 1, 2022, to prohibit issuers of long-term care insurance policies, among others, from discriminating against living organ donors. * 2021 SC S.B. 121 (NS), introduced January 12, 2021, to enact the 'long-term care tax credit act' so as to allow a state individual income tax credit of fifteen percent of the total amount of premiums paid by a taxpayer pursuant to a long-term care insurance contract, not to exceed two thousand dollars in a taxable year for each individual, and to prohibit a double benefit. Tennessee ¢ 2021 TN H.B. 2851 (NS), introduced February 2, 2022, and 2021 TN S.B. 2074 (NS), introduced January 31, 2022, adding life insurance and long-term care insurance to the types of insurance for which an insurance provider is prohibited from denying coverage or varying the premiums, terms, or conditions of coverage on the basis of an individual's genetic information. ¢ 2021 TN 8.B. 2074 (NS), filed January 27, 2022, adding life insurance and long-term care insurance to the types of insurance for which an insurance provider is prohibited from denying coverage or varying the premiums, terms, or conditions of coverage on the basis of an individual's genetic information. Vermont 2021 VT S.B. 247 (NS), introduced January 13, 2022, prohibiting discrimination based on an individual's genetic information in relation to long-term care and other insurance coverage and the provision of social and medical services. Virginia * 2022 VA H.B. 421 (NS), adopted April 11, 2022, prohibiting any person from refusing to insure, refusing to continue to insure, or limiting the amount or extent of life insurance, disability insurance, or long-term care insurance coverage available to an individual or to charge an individual a different rate for the same coverage based solely and without any additional actuarial risks upon the status of such individual as a living organ donor. Virgin Islands 2022 VI LEGIS 8594 (2022), approved August 8, 2022, to implement revisions that were made to the National Association of Insurance Commissioners' Credit for Reinsurance Model Law, relating to insurance including long-term care insurance policies. Washington * 2021 WAH.B. 1438 (NS), adopted May 10, 2021, expanding eligibility for property tax exemptions for service-connected disabled veterans and senior citizens by modifying income thresholds for eligibility to allow deductions for common health care-related expenses, including long-term care insurance. * 2021 WAH.B. 1913 (NS), introduced January 11, 2022, replacing the long-term services and supports trust program with affordable and optional long-term care insurance coverage. West Virginia ¢ 2022 WV H.B. 4777 (NS), introduced February 15, 2022, State Living Donor Protection Act, prohibiting an insurer from declining or limiting coverage on a person under any life insurance policy, major medical coverage policy, disability insurance policy, or long-term care insurance policy solely due to the status of that person as a living organ donor. ¢ 2022 WV S.B. 623 (NS), introduced February 14, 2022, State Living Donor Protection Act, setting forth prohibited acts related to insurance coverage for living organ donors. Vil. Partnership Programs The Long-Term Care Partnership Program is a federally supported, state-operated initiative that allows individuals who purchase a qualified long-term care insurance policy or coverage to protect a portion of their assets that they would typically need to spend down prior to qualifying for Medicaid coverage. Once an individual purchases a partnership policy and uses some or all of the policy benefits, the amount of the policy benefits used will be disregarded for purposes of calculating eligibility for Medicaid. This means that they are able to keep their assets up to the amount of the policy benefits that were paid under their policy or coverage. For example, ina state that chooses to participate in the Long-Term Care Partnership Program, once you have used part or all of your maximum lifetime benefit, your assets would be protected up to the amount paid under the policy. You would not need to spend those assets before qualifying for that state's Medicaid program. Long-term care insurance partnerships are joint ventures between state Medicaid programs and private insurance providers. The Deficit Reduction Act of 2005 enables states to pursue public-private partnerships to create affordable long-term care insurance coverage THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -44- for moderate-income Americans. Similar pilot partnerships were started in the early 1990s in four states-California, Connecticut, Indiana, and New York-but the Omnibus Budget Reconciliation Act of 1993 curtailed the development of additional state partnership programs. The Deficit Reduction Act lifted these restrictions, allowing other states to pursue similar initiatives. In response to these new laws, the Center for Health Care Strategies, a nonprofit organization, selected 10 states-Arkansas, Colorado, Georgia, Michigan, Minnesota, Oklahoma, Ohio, South Dakota, Texas and Virginia-to participate in a partnership project supported by the Robert Wood Johnson Foundation. Under the plan, the selected states were to encourage consumers to buy private long-term care insurance policies by creating special eligibility rules under Medicaid for the consumers should they eventually exhaust their long-term private policy benefits and require additional coverage. The plan's proponents stated it would create a mutually beneficial relationship between consumers, Medicaid programs and the private insurance industry. [FN114] However, in a 2007 report examining the four partnership pilot programs set up in the early 1990s, the GAO concluded that such partnership programs are unlikely to result in Medicaid savings and may actually increase spending. [FN115] Additionally, the impact of such programs was minimal because about 80% of surveyed policyholders would have purchased long-term care policies without the availability of the partnership program. Vill. ALTERNATIVE AND SUPPLEMENTAL FUNDING SOURCES As a hedge against the potential costs for long-term care, seniors are finding long-term care insurance to be an expensive alternative, and one that may never pay out, if long-term care services aren't needed. Chances are about 50-50 that those reaching the age 65 in the next year or two will eventually need long-term care, according to federal government estimates cited in a Vanguard white paper. However, 26% of those turning 65 between 2015 and 2019 will eventually incur long-term care costs of more than $100,000, and 15% of retirees can expect to pay over $250,000. One alternative to long-term care insurance has been gaining popularity: life insurance policies with 'accelerated death benefit" (ADB) riders. Under such plans, you are able, under certain circumstances, such as the need to go into a nursing home, to get access to a portion of the policy's death benefit before you die. Then, upon your eventual death, the remainder of the death benefit is paid out to your beneficiaries. [FN116] Besides hybrid financial service products that combine the benefits of life insurance, or an annuity, with long-term care insurance, Jamie Hopkins, Director of Retirement Research at Caron Wealth suggests other types of deferred income annuities. Qualified longevity annuity contracts (QLACs) can help retirees meet their long-term care funding needs, he says. Hopkins points out that there's a large variety of annuities on the market and not all of them will be suitable for funding long-term care expenditures. However, deferred annuities, QLACs, 1035 exchanges, and hybrid long-term care annuity products can be strategically utilized to help fund long-term care expenditures. For example, one way to help fund long-term care expenditures is to stagger or layer on deferred annuities, enabling the retiree to create various levels of income for different periods of retirement, he says. These specialized, but limited, deferred annuities can help retirees avoid required minimum distributions at age 70?, increase their retirement income, provide a hedge against longevity risk, and provide a source of long-term care funding. The QLAC is a powerful tool for long-term care funding because it can be purchased inside of an IRA or 401(k), where most retirees house their retirement savings, he says. Additionally, the rules allow the QLAC to stay in the IRA without payments until age 85, at which time payments must begin. However, this can provide a very nice income source for retirees to help fund long-term care expenditures. Another strategy is to use a so-called hybrid or linked benefit contract, which combines long-term care coverage with an annuity into one product. [FN117] In addition to accelerated life insurance payments, states have begun to investigate alternative methods for individuals to pay for long- term care expenses, including innovative financing methods and universal care initiatives. Recent Legislative Activity Federal 2021 CONG US HR 5137, introduced August 31, 2021, to create senior health planning accounts funded by the proceeds of the sale or assignment of life insurance contracts. Colorado * 2022 CO H.B. 1247 (NS), adopted April 25, 2022, concerning requirements for additional supplemental payments for nursing facility providers, and making an appropriation. * 2022 CO H.B. 1333 (NS), adopted April 25, 2022, concerning an increase in the minimum wage for nursing facility employees. ¢ 2022 CO S.B. 200 (NS), approved June 1, 2022, concerning a grant program to improve access to health care in rural communities, including expansion of access to long-term care and recovery care in skilled nursing facilities. Connecticut THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -45- 2022 CT H.B. 5334 (NS), amended/substituted April 6, 2022, and 2022 CT S.B. 174 (NS), amended/substituted March 23, 2022, to study long-term care needs to ensure adequate resources are allocated. Georgia 2021 GA H.R. 1276 (NS), filed April 4, 2022, creating the Long-Term Services and Supports Trust Fund; to authorize the dedication of certain revenues to be deposited into such fund; to provide for limitations; to provide for assessment, administration, and implementation. Hawaii ¢ 2021 HI H.B. 311 (NS), adopted May 28, 2021, extends the nursing facility sustainability program to 2024; specifies that the nursing facility sustainability fee limit is 5.5 per cent of overall net patient service revenue; removes the per resident daily maximum fee of $20 for each facility; specifies that facilities that meet certain exceptions shall pay a reduced daily fee in comparison to other participating facilities; allows nursing facilities sixty days to pay the nursing facility sustainability fee. ¢ 2021 HI H.B. 977, 2021 HI H.B. 978, 2021 HI $.B. 1131, and 2021 HI S.B. 1132 (NS), introduced January 27, 2021, continues the nursing facility sustainability program for two additional years; appropriates funds out of the nursing facility sustainability program special fund for fiscal years 2021-2022 and 2022-2023. ¢ 2021 HI S.C.R. 104 (NS) and 2021 H.C.R. 120 (NS), introduced March 12, 2021, urging the Department of Human Services to convene a working group to explore creation of a sustainability fund for the community care foster family home and expanded adult residential care home programs. ¢ 2021 HI S.B. 820 (NS), amended/substituted March 5, 2021, extends the nursing facility sustainability program to 2024; specifies that the nursing facility sustainability fee limit is 5.5 per cent of overall net patient service revenue; removes the per resident daily maximum fee of $20 for each facility; specifies facilities that meet certain exceptions shall pay a reduced daily fee in comparison to other participating facilities; allows nursing facilities to pay assessed fees within 60 days, instead of 30 days. Idaho 2022 ID S.B. 1287 (NS), introduced February 9, 2022, establishing a rural nursing loan repayment fund to be administered by the state department of health and welfare, to pay for the educational debts of nurses in rural and underserved areas of the state that demonstrate a need for assistance in nurse recruitment and retention and the expenses of administering the rural nursing loan repayment program, which expenses shall not exceed ten percent (10%) of the annual appropriation by the legislature. Maine 2021 ME H.P. 654 (NS), adopted May 2, 2022, to provide incentives to unemployed workers to become part of the caregiver workforce. Minnesota ¢ 2021 MN S.F. 556 (NS), introduced February 4, 2021, constitutional amendment creating a dedicated fund for long-term care services; tax levy on individuals with income not taxed for social security to fund long-term care services; revenues dedication; legislative implementation directive. * 2021 MN S.F. 3338 (NS), engrossed March 29, 2022, to authorize in certain instances life insurance policies that provide coverage for long-term care. New Jersey ¢ 2022 NJ A.B. 4012 (NS), introduced May 16, 2022, requiring Medicaid fee-for-service coverage of managed long term services and supports when beneficiary is pending enrollment in managed care organization. ¢ 2022 NJ S.B. 1139 (NS), introduced January 31, 2022, and 2022 NJ A.B. 2766 (NS), introduced February 28, 2022, providing corporation business tax credit to long-term care facilities that pay for the training and certification of certified nurse aide. New York * 2021 NY A.B. 4656 (NS), amended/substituted April 29, 2022, establishing a residential demonstration program for persons with advanced neurodegenerative needs to provide medical, social, and residential care to persons with dementia, significant cognitive disease or behavior disturbances. ¢ 2021 NY A.B. 10031 (NS), introduced April 29, 2022, establishing a quality incentive program for managed care providers. ¢ 2021 NY S.B. 8903 (NS), introduced April 27, 2022, establishing a state-level program of all-inclusive care for the elderly. Rhode Island 2021 RI H.B. 7282 (NS), introduced February 2, 2022, creating a four-year pilot program to provide scholarships to certified nursing assistants employed in certain high needs fields, including in long-term care and hospice facilities. Vermont THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -46- ¢ 2021 VT H.B. 30 (NS), introduced January 7, 2021, relating to the study and design of a long-term care trust fund. ¢ 2021 VT S.B. 206 (NS), adopted May 11, 2022, relating to planning and support for individuals and families impacted by Alzheimer's Disease and related disorders. Washington * 2021 WAH.B. 1323 (NS), adopted April 21, 2021, relating to the long-term services and supports trust program. ¢ 2021 WA S.B. 5234 (NS), introduced January 15, 2021, repealing the long-term services and supports trust program and the premium assessment on wages. West Virginia 2021 WV H.B. 2653 (NS), introduced February 23, 2021, providing a tax exemption for income from a qualified retirement plan used to pay for long-term care. IX. VETERANS The Department of Veterans Affairs (VA) pays for long-term care services for service-related disabilities and for certain other eligible veterans, as well as other health programs such as nursing home care and at-home care for aging veterans with long-term care needs. The VA also pays for veterans who do not have service-related disabilities, but who are unable to pay for the cost of necessary care. Co-pays may apply depending on the veteran's income level. The VA has additional programs to help veterans stay in their homes: * The Housebound Aid and Attendance Allowance Program provides cash to eligible veterans with disabilities and their surviving spouses to purchase home- and community-based long-term care services such as personal care assistance and homemaker services. The cash is a supplement to the eligible veteran's pension benefits. ¢ Veteran Directed Home and Community Based Services program-developed in 2008 for eligible veterans of any age, provides veterans with a flexible budget to purchase services. Counseling and other supports for veterans are provided by the Aging Network in partnership with the Veterans Administration. ¢ Program of Comprehensive Assistance for Family Caregivers-ofiers enhanced clinical support for Family Caregivers of eligible Veterans. Veterans may be eligible for this clinical program if they: Sustained or aggravated a serious injury (or illness) in the line of duty in the active military, naval or air service during any service era. Among other applicable eligibility criteria, an eligible Veteran must: Have a single or combined service-connected disability rating by the Department of Veterans Affairs (VA) of 70% or more; and be in need of personal care services (requiring in-person personal care services) for a minimum of six continuous months based on any one of the following: o An inability to perform an activity of daily living. o Aneed for supervision or protection based on symptoms or residuals of neurological or other impairment or injury; or o Aneed for regular or extensive instruction or supervision without which the ability of the Veteran to function in daily life, would be seriously impaired. [FN118] Additional government funding is being distributed to help keep veterans, as well as other seniors, in their homes and out of institutionalized long-term care facilities. As authorized under the Affordable Care Act, nearly every state receives funding to establish Aging and Disability Resource Centers (ADRCs), meant to be a 'one-stop shop" for elderly and disabled individuals who want to receive care in their homes and communities, rather than a long-term care facility. On the rural front, VA Secretary David Shulkin told a public forum in Montana on August 21, 2017, that his agency will propose changes to make it easier for rural areas to receive funding to build nursing homes for veterans. He noted that rural areas are often bypassed, under existing agency guidelines, for awarding grants for veterans' homes. Montana veterans and lawmakers have been seeking funding for a veterans' home for the southwestern part of the state; this year the proposed home ranked 57th on the agency's priority list and the VA only funded the top 13, Shulkin explained. The agency will work to propose regulatory changes to ensure that some of the money goes specifically to rural areas, "79! Recent Legislative Activity Federal * 2021 CONG US HR 6332, introduced December 20, 2021, to direct the Secretary of Veterans Affairs to improve long-term care provided to veterans by the Department of Veterans Affairs by identifying current and future needs for both institutional and non- institutional long-term care of veterans based on demographic data and availability of services, from both VA and non-VA providers. ¢ 2021 CONG US §S 1965, introduced June 8, 2021, to direct the Secretary of Veterans Affairs to improve long-term care provided to veterans by the Department of Veterans Affairs. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -47- ¢ 2021 CONG US S 4169, introduced May 10, 2022, to require the Secretary of Veterans Affairs to carry out a pilot program to provide assisted living services to eligible veterans, and for other purposes. Florida 2021 GA S.R. 383 (NS), adopted April 1, 2022, creating the Senate Study Committee on the Restoration of Veterans Nursing Facilities. Georgia 2021 GA S.R. 383 (NS), introduced January 25, 2022, creating the Senate Study Committee on the Restoration of Veterans Nursing Facilities, whereas the Department of Veterans Affairs has identified the need for Georgia to provide skilled nursing facilities for 1,975 veterans and the two Georgia War Veteran Homes are only capable of supporting less than 500 veterans. Hawaii ¢ 2021 HI H.B. 1893 (NS), filed January 21, 2022, requiring the transfer of the Daniel K. Akaka state veterans' home to the Hawall Health Systems Corporation and then to the Department of Health as part of the Oahu Regional Health Care System. Extends the date of the transfer of the Oahu Regional Health Care System to the Department of Health by 1 year. ¢ 2021 HI S.B. 237 (NS), introduced January 22, 2021, raises the standard of care for the State's veteran homes, long term care facilities and nursing homes in response to the COVID-19 pandemic by describing requirements for care facility licensing and leadership, implementing standards of recordkeeping, creating protocols for emergencies and personal protective equipment, and establishes a hotline for complaints. Maine 2021 ME S.P. 719 (NS), adopted March 31, 2022, to fund and support the veterans homes in Caribou and Machias and require legislative approval for the establishment and closure of veterans homes. Massachusetts 2021 MA H.B. 5106 (NS), adopted August 4, 2022, providing for and amending provisions related to boards of trustees for each state- operated veterans' home, a veterans' homes council, a department of veterans' services, office of veterans' homes and housing within the department, and the office of veteran advocate to ensure the health, well-being and safety of residents of state-operated veterans' homes and access to equitable, high quality and competent care for veterans across all regions of the commonwealth. New Jersey 2022 NJ S.B. 2520 (NS), introduced May 12, 2022, establishing the 'New Jersey No Patient Left Alone Act," requiring certain facilities to establish policies guaranteeing visitation rights for residents in hospice, long-term care, and veterans' home facilities. New York 2021 NY A.B. 6874 (NS), introduced April 13, 2021, relating to directing the state director of veterans' affairs to submit a plan to the veterans' affairs commission for the provision of services to service-disabled veterans, including long-term care options. North Carolina 2021 NC H.B. 772 (NS), introduced May 4, 2021, directing the Department of Health and Human Services, in collaboration with the Department of Military and Veterans Affairs, to examine the state's delivery of long-term care to veterans and determine what improvements can be made to ensure exemplary services moving forward. Ohio 2021 OH S.B. 160 (NS), adopted June 14, 2022, to require certain entities to inform veterans and their spouses about available health care benefits, to require the Department of Medicaid to inform a veteran who applies for Medicaid about the county veterans service commission, and to name this act the Veteran Information Act. Oklahoma ¢ 2021 OK H.B. 3928 (NS), introduced February 7, 2022, relating to State Veterans Homes at Sulphur and Ardmore; authorizing Oklahoma Veterans Commission to renovate the home at Sulphur to provide specialized long-term care services; permitting Oklahoma Department of Veterans Affairs to obtain certain designations to provide advanced services and care; prohibiting admission for person dishonorably discharged from military service. * 2021 OK S.B. 1598 (NS), introduced February 7, 2022, authorizing the State Veterans Home of Sulphur to specialize in services supporting the long-term care needs of veterans who require both nursing home care and specialized cognitive care. Washington ¢ 2021 WAH.B. 1733 (NS), adopted January 27, 2022, establishing voluntary exemptions to the long-term services and supports trust program for certain populations identified in the long-term services and supports trust commissions 2022 recommendations report, specifically including exemptions only for veterans with a service-connected disability of 70 percent or higher, the spouses or domestic THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -48- partners of active duty service members, persons residing outside of Washington while working in Washington, and persons working in the United States under a temporary, nonimmigrant work visa. ¢ 2021 WAH.B. 2012 (NS), introduced January 17, 2022, establishing an exemption from the payment of premiums to the long-term services and supports trust program based on certain veterans benefits. West Virginia 2022 WV H.B. 4572 (NS), introduced February 8, 2022, authorizing long term care facilities to increase their number of beds on certificate of need by 5% so long as those beds are filled by veterans. X. PRISON INMATES Prisoners, for the most part, age faster and have more health problems than the general population, according to various studies. And once a prisoner is released, those health issues become even harder to manage. The Marshall Project reported that the number of inmates 55 and older had quadrupled between 1995 and 2010. The American Civil Liberties Union projected that by 2030 one-third of all inmates in the nation will be older than 55. N10 As the number of elderly prisoners increases, states are looking for cost-effective ways to provide their long-term care. Providing health care to an aging prison population is becoming a large and growing cost for states. Of the 2.3 million adults in state and federal prisons, about 246,000 are 50 or older, according to the National Institute of Corrections, and that the U.S. currently spends more than $16 billion annually caring for these aging inmates, [FN121] and their numbers are projected to grow dramatically in the next 15 years. Not only do inmates develop debilitating conditions at a younger age than people who are not incarcerated, but caring for them in the harsh environment of prisons is far more expensive than it is on the outside. Some states have tried to contract with private nursing homes to care for some of their elderly and disabled inmates under so-called 'medical parole" programs. Such programs allow prisoners to receive care outside of a prison while remaining in state custody. But few private facilities have been willing to accept them. Likewise, courts and communities have tended to resist so-called 'compassionate release," which cuts short the sentences of elderly or dying inmates so they can spend their last days on the outside. In 2012, Connecticut tried a different approach. Instead of attempting to place prisoners in nursing home beds next to someone's elderly parent, the state asked the commercial nursing home industry to provide a facility that would accept a steady stream of prison inmates and patients from the state mental hospital who required long-term nursing care. 60 West, a 95-bed, single-story facility in Connecticut is the first facility in the country to receive approval from the CMS for federal nursing home funding for paroled inmates. In December, 2016, the privately-owned facility under contract with the state was granted certification for eligibility for federal funding. As reported in Connecticut Health I-Team, [FN122] ailing inmates who qualify for nursing home-level care, and, who the state deems not to be public safety risks, are referred to 60 West. Medicaid covers half the cost of their care, saving the state about $5 million annually. A handful of states are interested in following Connecticut's lead: Michigan is seeking industry proposals for a similar arrangement, and Kentucky and Wisconsin are considering doing the same. In other states, however, officials may lack the political will to take on residents who don't want convicts in their midst. And even in Connecticut, it remains to be seen how far the state can take its plan, given the public backlash it already has experienced. Recent Legislative Activity New Hampshire 2021 NH H.B. 1335 (NS), introduced January 5, 2022, revising the criteria necessary for determining if an inmate qualifies for medical parole and revises the membership of the adult parole board. XI. Conclusion Recent studies have shown that Medicaid long-term care spending is expected to continue to rise which will put a greater burden of long-term care costs on federal and state governments. At the same time, federal and state governments continue to struggle to contain COVID-19 infections and deal with the extraordinary costs resulting from the pandemic. As a result, states will likely continue to pursue other means to offset Medicaid long-term care spending, such as long-term care partnership programs and increased funding for home- and community-based services. As increasing numbers of Americans consider private long-term care insurance, a number of states have considered legislation to regulate long-term care insurance practices and standards, and rein in ballooning premiums. © Copyright Thomson/West - NETSCAN's Health Policy Tracking Service [FN2] THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -49- . U.S. Department of Health and Human Services, Administration on Aging, "What is Long-Term Care?", https:/Avww.nia.nih.gov/health/ what-long-term-care (last visited 11-30-2022). [FN3] . How Much Care Will You Need?, LongTermCare.gov, https://acl.gov/ltc/basic-needs/how-much-care-will-you-need (last modified 02-18-2020). [FN4] . Lauren Harris-Kojetin et al., "Long-Term Care Providers and Services Users in the United States, 2015-2016," National Center for Health Statistics, Vital and Health Statistics, Series 3, No. 43 (February 2019), https://stacks.cdc.gov/view/cdc/76253. [FN5] . "Cost of Care Survey," Genworth (Jan. 31, 2022), https://(www.genworth.com/aging-and-you/finances/cost-of-care.html. [FN6] . Genworth Cost of Care Survey, Summary of 2021 Survey Findings (Feb. 7, 2022), https://pro.genworth.com/riiproweb/productinfo/ pdf/131168.pdf. [FN7] . "2020 Census Will Help Policymakers Prepare for the Incoming Wave of Aging Boomers," United States Census Bureau (Dec. 10, 2019), https:/Avww.census.govilibrary/stories/2019/12/by-2030-all-baby-boomers-will-be-age-65-or-older.html. [FN8] . 'Long-Term Care in America: Expectations and Preferences for Care and Caregiving," AP-NORC Center for Public Affairs Research (2016), http:/Avww.longtermcarepoll.org/PDFs/LTC 2016/AP-NORCLong Term Care_2016.pdf; Long-Term Care in America: Increasing Access to Care," AP-NORC Center for Public Affairs Research (2018), https://apnorc.org/wp-content/uploads/2020/02/ APNORC_LTC_Trend_2018_report.pdf. [FN9] . Pub. L. 109-171 (Feb. 8, 2006). [FN10] . Jeffrey S. Crowley, Health Policy Institute, Georgetown University, "Medicaid Long-Term Services Reforms in the Deficit Reduction Act," April 2006, www.kff.org. [FN11] . "Advancing Action, 2020: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers," AARP, The Commonwealth Fund, and The Scan Foundation (Sept. 24, 2020), http:// www.longtermscorecard.org/2020-scorecard/preface. [FN12] . Adam H. Dyer et al., "Managing the Impact of COVID-19 in Nursing Homes and Long-Term Care Facilities: An Update," NIH National Library of Medicine, PubMed.gov (Sept. 2022), https://pubmed.ncbi.nlm.nih.gov/35922016/. [FN13] . Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. ?? 512175207. [FN14] . COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (fact sheet), CMS.gov (Apr. 3, 2020), hitps:// www.cms.gov/files/document/covid19-emergency-declaration-health-care-providers-fact-sheet. pdf. [FN15] . Public Health Emergency: Renewal of Determination That a Public Health Emergency Exists, U.S. Department of Health & Human Services, Office of the Assistant Secretary for Preparedness and Response (Oct. 15, 2021) https:/Avww.phe.gov/emergency/ news/healthactions/phe/Pages/COVDI-150ct21.aspx?cm_ven=ExactTarget&cm_cat=COVID-19+Update+2#13&cm_pla=All +Subscribers&cm_ite=extended&cm_Im=1343767647&cm_ainfo=&&&&&. [FN16] THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -50- . Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers, Centers for Medicare & Medicaid Services (Memorandum, Apr. 7, 2022), https:/Awww.cms.gov/files/document/qso-22-15-nh-nltc-Isc.pdf. IFN17] . Report: Nursing Homes See Spike in New COVID Cases Due to Omicron Community Spread, AHCA/NCAL (Jan. 12, 2022), https:// www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/Report-Nursing-Homes-Cases-Jan122022. pdf. [FN18] . CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule (FAQs), CMS.gov (Nov. 4, 2021), https:/Avww.cms.gov/ files/document/cms-omnibus-staff-vax-requirements-2021 .pdf. [FN19] . Jeremy Diamond and Tami Luhby, "Biden says US will require nursing homes get staff vaccinated or lose federal funds," CNN.com (Aug. 18, 2021), https:/Avww.cnn.com/2021/08/18/politics/nursing-homes-federal-funding/index.html. [FN20] . Kimberly Marselas and James M. Berklan, "Breaking: CMS vaccine mandate upheld," McKnight's Long-Term Care News (Jan. 13, 2022), https:/Avww.mcknights.com/news/breaking-cms-vaccine-mandate-upheld/?utm_source =newsletter&utm_medium=email&utm_campaign=MLT_Weekly_20220114&hmSubld=GVkrCKLYrEM1&hmEmail=nluXS2jdOJOtlG- OxiMnyzlZDo7e_i8h0&email_hash=4d7f9620032317303f7753d76be9a357 &mpweb=1 326-2457 7-249238. The decision is available at https:/Avww.supremecourt.gov/opinions/21pdf/21a240_d18e.pdf. [FN21] . Kevin W. McConeghy et al., "Effectiveness of a Second COVID-19 Vaccine Booster Dose Against Infection, Hospitalization, or Death Among Nursing Home Residents - 19 States, March 29?July 25, 2022," CDC, Morbidity and Mortality Weekly Report (Sept. 30, 2022), https:/Avww.cdc.gov/mmwr/volumes/71 /wr/mm7139a2.htm#contribAff. [FN22] . CMS Launches New Medicare.gov Tool to Compare Nursing Home Vaccination Rates, CMS.gov (Press Release, Sept. 21, 2021), cms.gov/newsroom/press-releases/cms-launches-new-medicaregov-tool-compare-nursing-home-vaccination-rates. [FN23] . EEOC Issues Updated COVID-19 Technical Assistance, U.S. Equal Employment Opportunity Commission (Press Release, Oct. 25, 2021), https:/Awww.eeoc.gov/newsroom/eeoc-issues-updated-covid-19-technical-assistance-0. [FN24] . Beth Mace and Omar Zahraoui, "Nursing Homes Are Now Safe, But Data Raises Questions," N/C (June 2, 2021), https://blog.nic.org/ nursing-homes-are-now-safe-but-data-raises-questions. [FN25] . Trump Administration Announces the Distribution of $2.5 Billion to Nursing Homes for COVID-19 Relief Funding, HHS.gov (Aug. 27, 2020), https:/Avww.hhs.gov/about/news/2020/08/27/trump-administration-announces-2-5-billion-to-nursing-homes-for-covid-1 9-relief- funding.html. [FN26] . HHS Announces the Availability of $25.5 Billion in COVID-19 Provider Funding, HHS.gov (Sept. 10, 2021), https://Awww.hhs.gov/about/ news/2021/09/10/hhs-announces-the-availability-of-25-point-5-billion-in-covid-19-provider-funding.html. [FN27] . Trump Administration Distributes Incentive Payments to Nursing Homes Curbing COVID-19 Deaths and Infections, HHS.gov (Press Release, Oct. 28, 2020), https:/Avww.hhs.gov/about/news/2020/1 0/28/trump-administration-distributes-incentive-payments-to-nursing- homes-curbing-covid-19-deaths-and-infections.html. [FN28] . A state-by-state breakdown on incentive payments from this first cycle is available at: https:/Awww.hhs.gov/sites/default/files/provider- relief-fund-nursing-home-quality-incentive-payment-allocations.pdf. HHS will update this data to capture all recipients as payment disbursements continue. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -51- [FN29] . HHS Distributing $560 Million in Provider Relief Fund Payments to Health Care Providers Affected by the COVID-19 Pandemic, HHS.gov (Feb. 24, 2022), https:/Awww.hhs.gov/about/news/2022/02/24/hhs-distributing-560-million-provider-relief-fund-payments- health-care-providers-affected-covid-19-pandemic.html. [FN30] . Nursing Home Visitation Frequently Asked Questions (FAQs), CMS.gov (Feb. 2, 2022), https:/Awww.cms.gov/files/document/nursing- home-visitation-faq-1223. pdf. [FN31] . Governor Hochul Launches Health Care Worker Bonus Program, governor.ny.gov (Press release, Aug. 3, 2022), https:// www.governor.ny.gov/news/governor-hochul-launches-health-care-worker-bonus-program. [FN32] . State of Minnesota Surpasses Goal of Recruiting 1,000 Certified Nursing Assistants-Walz-Flanagan Budget to Move Minnesota Forward proposes additional funding to continue the initiative, March 29, 2022, https://mn.gov/governor/news/#/detail/appld/1/ id/523325. [FN33] . Gov. Evers and DHS Announce Expansion of WisCaregiver Careers Program, May 18, 2022, https://content.govdelivery.com/ accounts/WIGOV/bulletins/317fd16. [FN34] . State Nursing Home Staffing Standards, Summary Report, The National Consumer Voice for Quality Long-Term Care, https:// theconsumervoice.org/uploads/files/issues/CV_StaffingReport.pdf. [FN35] . MaryBeth Musumeci, Emma Childress, and Belle Harris, "State Actions to Address Nursing Home Staffing During COVID-19," KFF (Issue Brief, May 16, 2022), https:/Awww.kff.org/medicaid/issue-brief/state-actions-to-address-nursing-home-staffing-during-covid-19/. [FN36] . Nursing Home Caregivers Receive Double Digit Pay Increases in 2022, Hospital & Healthcare Compensation Service (Press Release, July 2022), https:/Avww.hhcsinc.com/press/NewsReleaseNH2022.pdf. [FN37] . US Department of Labor Announces $80M Funding Opportunity to Help Train, Expand, Diversify Nursing Workforce; Address Shortage of Nurses, U.S. Department of Labor (News Release, Oct. 3, 2022), https://www.dol.gov/newsroom/releases/eta/ eta20221003. [FN38] . Biden-Harris Administration Awards $103 Million in American Rescue Plan Funds to Reduce Burnout and Promote Mental Health and Wellness Among Health Care Workforce, HHS.gov (Press Release, Jan. 20, 2022), https:/Avww.hhs.gov/about/news/2022/01/20/biden- harris-administration-awards-103-million-american-rescue-plan-funds-reduce-burnout-promote-mental-health-wellness-among-health- care-workforce.html. [FN39] . Survey of Nursing Homes and Assisted Living Providers Shows Long Term Care Industry Still Facing Serious Economic Crisis (Fact Sheet), American Health Care Association/National Center for Assisted Living (June 2021), https:/Awww.ahcancal.org/News-and- Communications/Fact-Sheets/FactSheets/Financial-Survey-June-2021 pdf. [FN40] . "Long Term Care Faces Worst Financial Crisis in Years; Closures Loom Without Additional Funding," AHCA NCAL (Feb. 11, 2021), https:/Avww.ahcancal.org/News-and-Communications/Press-Releases/Pages/Long-Term-Care-Faces-Worst-Financial-Crisis-In-Years;- Closures-Loom-Without-Additional-Funding.aspx. [FN41] . Danielle Brown, 'Operators Worried It Might Be 18 Months Before Skilled Nursing Occupancy Recovers,' McKnight's Long-Term Care News (July 13, 2020), https:/Avww.mcknights.com/ THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -52- news/operators-worried-it-might-be-18-months-before-skilled-nursing-occupancy-recovers/? utm_source=newsletter&utm_medium=email&utm_campaign=MLT_Weekly_20200717&hmSubld=GVkrCKLYrEM1&hmEmail=nluxS2jdOJ0tlG- OxiMnyzlZDo7e_i8h0&email_hash=4d7f9620032317303f7753d76be9a357 &mpweb=1326-10387-249238. [FN42] . "CMS Updates Nursing Home Guidance with Revised Visitation Recommendations," CMS.gov (Press Release, Mar. 10, 2021), https:// www.cms.gov/newsroom/press-releases/cms-updates-nursing-home-guidance-revised-visitation-recommendations. [FN43] . Michael A. Johansson, PhD et al., "SARS-CoV-2 Transmission from People Without COVID-19 Symptoms," JAMA Network (Jan. 7, 2021), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774707. [FN44] . Justin Blackburn, PhD, et al., "Community Coronavirus Disease 2019 Activity Level and Nursing Home Staff Testing for Active Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Indiana," JAMDA (Oct. 28, 2020), https:/Awww.jamda.com/article/ $1525-8610(20)30930-0/fulltext# . [FN45] . Danielle Brown, "Senators' $1B would more than double House-proposed funding to help nursing homes," McKnight's Long-term Care News Feb. 24, 2021), https:/Avww.mcknights.com/ news/senators-1b-would-more-than-double-house-proposed-funding-to-help-nursing-homes/? utm_source=newsletter&utm_medium=email&utm_campaign=MLT_DailyUpdate_20210226&hmSubld=GVkrCKLYrEM1&hmEmail=nluxS2jdOJO OxiMnyzlZDo7e_i8h0&email_hash=4d7f962003231 7303f7753d76be9a357 &mpweb =1326-15709-249238. [FN46] . Tables displaying federal financial participation matching rates for each of the 50 states and territories are available at http:// aspe.hhs.gov/health/fmap.htm. [FN47] . Medicaid nursing facility payment approaches to advance health equity and improve health outcomes, CMCS Informational Bulletin from Daniel Tsai, Deputy Administrator and Director, Center for Medicaid and CHIP Services (Aug. 22, 2022), https:// www.medicaid.gov/federal-policy-guidance/downloads/cib08222022. pdf. [FN48] . CMS Encourages States to Use Medicaid Payments to Nursing Homes to Drive Better Health Outcomes for Residents, Improve Staffing, CMS.gov (Press Release, Aug. 22, 2022), https:/Awww.cms.gov/newsroom/press-releases/cms-encourages-states-use- medicaid-payments-nursing-homes-drive-better-health-outcomes-residents. [FN49] . Charlene Harrington et al., "Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016, Kaiser Family Foundation (Apr. 3, 2018), https:/Awww.kff.org/medicaid/report/nursing-facilities-staffing-residents-and-facility-deficiencies-2009- through-2016/. [FN50] . Medicaid nursing facility payment approaches to advance health equity and improve health outcomes, CMCS Informational Bulletin from Daniel Tsai, Deputy Administrator and Director, Center for Medicaid and CHIP Services (Aug. 22, 2022), https:// www.medicaid.gov/federal-policy-guidance/downloads/cib08222022. pdf. [FN51] . CMS Encourages States to Use Medicaid Payments to Nursing Homes to Drive Better Health Outcomes for Residents, Improve Staffing, CMS.gov (Press Release, Aug. 22, 2022), https:/Awww.cms.gov/newsroom/press-releases/cms-encourages-states-use- medicaid-payments-nursing-homes-drive-better-health-outcomes-residents. [FN52] . Peter Hancock, "Lawmakers OK bill to drive $700M into Medicaid-funded nursing homes to boost staffing, care," The State Journal- Register (Apr. 8, 2022), https:/Avww.sj-r.com/story/news/state/2022/04/08/illinois-bill-would-drive-700-million-nursing-homes- advances/9510576002/. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -53- [FN53] . Christine Jordan Sexton, "Gov. DeSantis: ?A lot of nursing homes will be very, very happy' after 2022 Session," Florida Politics (Mar. 15, 2022), https://floridapolitics.com/archives/508342-ron-desantis-a-lot-of-nursing-homes-will-be-very-very-happy-after-2022-session/. [FN54] . CMS Medicaid and CHIP Program Information, http:/Avww.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term- Services-and-Support/Long-Term-Services-and-Support.html. [FN55] . Molly O'Malley Waits et al., Medicaid Home & Community-Based Services: People Served and Spending During COVID-19, KFF (Mar. 4, 2022), https://www.kff.org/report-section/medicaid-home-community-based-services-people-served-and-spending-during- covid-19-issue-brief/. [FN56] . Elizabeth Williams, "Medicaid Enrollment & Spending Growth: FY 2022 & 2023," KFF (Oct. 25, 2022), https:// www.kff.org/medicaid/issue-brief/medicaid-enrollment-spending-growth-fy-2022-2023/?utm_campaign=KFF-2022- Medicaid&utm_medium=email&_hsmi=231113687&_hsenc=p2ANqtz-99RXQzvMPEgRQ2okYI6- sLqPn4SENluy8jrKpCHds5_1uscWUcSNTZgt61608j/2ONMW5QrNtqk- osqS6qx925pRq6NQA&utm_content=231113687&utm_source=hs_email. [FN57] . Leora Friedberg et al., "Long-Term Care: How Big a Risk?", Center for Retirement Research at Boston College (Nov. 2014, No. 14-18), http://crr.bc.edu/briefs/long-term-care-how-big-a-risk/. [FN58] . What's Next? Retaining the Successes of the Medicare-Medicaid Plan (MMP) Model, ATI Advisory (Oct. 2022), https:// www.snpalliance.org/wp-content/uploads/2022/10/Retaining_Success_MMP_ATI_SNPA_10.22.pdf. [FN59] . CMS Medicaid and CHIP Program Information, http:/Avww.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term- Services-and-Support/Long-Term-Services-and-Support.html. [FN60] . 42 U.S.C.A. ? 1396n. [FN61] . 'How Do Older Baby Boomers Envision Their Quality of Life If They Need Long-Term Care Services?", LeadingAge (March 2019), https://leadingage.org/sites/default/flles/HOW DO OLDER BABY BOOMERS ENVISION_FINAL.pdf. [FN62] . Programs of All-Inclusive Care for the Elderly (PACE) Final Rule (CMS-4168-F) (Fact sheet), CMS.gov Newsroom (May 28, 2019), https:/Avww.cms.gov/newsroom/fact-sheets/programs-all-inclusive-care-elderly-pace-final-rule-cms-4168-f. [FN63] . David M. Levine et al., "Skilled Nursing Facility Care at Home for Adults Discharged from the Hospital: A Pilot Randomized Controlled Trial," Journal of Applied Gerontology (Mar. 10, 2022), https://journals.sagepub.com/doi/10.1177/07334648221077092. [FN64] . Rebecca J. Gorges, Prachi Sanghavi, and R. Tamara Konetzka, "A National Examination of Long-Term Care Setting, Outcomes, And Disparities Among Elderly Dual Eligibles," Health Affairs Vol. 38, No. 7 (Research Article, July 1, 2019), https:/Avww.healthaffairs.org/ doi/abs/10.1377/hithaff.2018.05409?journalCode=nhithaff. [FN65] . 2022 National Strategy to Support Family Caregivers, Administration for Community Living (Oct. 3, 2022), https://acl.gov/ CaregiverStrategy?j=1686276&simc_sub=695435281=6707_HTML&u=37877024&mid=5150085758&jb=0. [FN66] THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -54- . Fiscal Year (FY) 2023 Skilled Nursing Facility Prospective Payment System Final Rule (CMS 1765-F), CMS.gov (July 29, 2022, Fact sheet), https:/Avww.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2023-skilled-nursing-facility-prospective-payment-system-final-rule- cms-1765-f. [FN67] . Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Public Reporting, CMS.gov (Oct. 28, 2020 update), https:// www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualitylnits/Skilled-Nursing-Facility-Quality- Reporting-Program/SNF-Quality-Reporting-Program-Public-Reporting. [FN68] . Danielle Brown, "A win-win:' Med PAC officially makes recommendation to replace SNF VBP with new incentive model," McKnight's Long-term Care News (June 17, 2021), https://www.mcknights.com/news/a-win-win-medpac-officially-makes-recommendation-to- replace-snf-vbp-with-new-incentive-model/. [FN69] . Bridget Early, "MedPAC Recommends Pay Freeze for Physicians, Upsetting AMA," inside Health Policy (January 14, 2022), https:// insidehealthpolicy.com/daily-news/medpac-recommends-pay-freeze-physicians-upsetting-ama. [FN70] . 87 FR 66790-01, filed Nov. 4, 2022, 2022 WL 16699445(F.R.). [FN71] . Annual Civil Monetary Penalties Inflation Adjustment, Health and Human Services Department, 82 Fed. Reg. 9174 (Feb 3, 2017). 2017 WL 446303. [FN72] . Medicare & Coronavirus, Medicare.gov, https:/Awww.medicare.gov/medicare-coronavirus. [FN73] . For details, see Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (Revised), CMS Center for Clinical Standards and Quality/Quality, Safety & Oversight Group (Memorandum, QSO-20-14-NH, Mar. 13, 2020), https:/Avww.cms.gov/files/document/qso-20-14-nh-revised.pdf. [FN74] . Elise Reuter, 'CMS promises a plan for Medicare to cover coronavirus vaccine, MedCity News (Oct. 13, 2020), https:// medcitynews.com/2020/10/cms-coming-up-with-a-plan-for-medicare-to-cover-a-coronavirus-vaccine/. [FN75] . Diane Estabrook, "Medicare sequestration moratorium officially extended," McKnight's Long-term Care News (April 15, 2021), https:// www.mcknightsseniorliving.com/home/news/home-care-daily-news/medicare-sequestration-moratorium-officially-extended/. [FN76] . Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care, U.S. Department of Health and Human Services, Office of Inspector General (Apr. 27, 2022), https:// oig.hhs.gov/oei/reports/OEI-09-18-00260.asp. [FN77] . Danielle Brown, 5-23-22, "Missing or wrong data at admissions costs SNFs millions," McKnight's Long-Term Care News (May 23, 2022), https:/Awww.mcknights.com/news/missing-or-wrong-data-at-admissions-costs-snfs-millions/. [FN78] . Kimberly Marselas, "As Medicare Advantage drives rate lower, fed-up CEOs embrace strategies that limit carriers' influence," McKnight's Long-term Care News (Apr. 26, 2021), https:/Avww.mcknights.com/news/as-medicare-advantage-drives-rate-lower-fed-up- ceos-embrace-strategies-that-limit-carriers-influence/. [FN79] THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -55- . David J. Meyers et al., "Comparing the care experiences of Medicare Advantage beneficiaries with and without Alzheimer's disease and related dementias," Journal of the American Geriatrics Society (Apr. 29, 2022), https://agsjournals.onlinelibrary.wiley.com/doi/ abs/10.1111/jgs.17817. [FN80] . Alicia Lasek, "MA enrollees with dementia report poor quality of care: study," McKnight's Long-Term Care News (May 9, 2022), https:// www.mcknights.com/news/clinical-news/ma-enrollees-with-dementia-report-poor-quality-of-care-study/. [FN81] . Fiscal Year 2020 State Performance Standards System Guidance, Center for Clinical Standards and Quality, Quality, Safety & Oversight Group, Centers for Medicare & Medicaid Services (Oct. 17, 2019), https:/Awww.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/AdminInfo-20-02-ALL. pdf. [FN82] . The final rule is available at https:/Avww.federalregister.gov/articles/2013/08/19/2013-18956/medicare-program-hospital-inpatient- prospective-payment-systems-for-acute-care-hospitals-and-the. [FN83] . Susan Jaffe, "Medicare Patients Win the Right to Appeal Gap in Nursing Home Coverage," KNN (Jan. 28, 2022), https://khn.org/news/ article/observation-care-medicare-patients-win-right-to-appeal-gap-in-nursing-home-coverage/. [FN84] . Reps. Courtney and Thompson Lead Bipartisan Introduction of Legislation to End Surprise Bills, Improve Affordability and Outcomes for Medicare Patients, Press Release, U.S. Congressman Joe Courtney (June 1, 2021), https://courtney.nhouse.gov/media-center/press- releases/reps-courtney-and-thompson-lead-bipartisan-introduction-legislation-end. [FN85] . COVID-19 Emergency Declaration-Health Care Providers Fact Sheet, CMS.gov (Mar. 13, 2020), https:/Avww.cms.gov/files/ document/covid19-emergency-declaration-health-care-providers-fact-sheet.pdf. [FN86] . Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19), MLN Matters Number $E20011 (June 30, 2020), https:/Awww.cms.gov/files/document/se2001 1. pdf. [FN87] . Public Health Emergency: Renewal of Determination That a Public Health Emergency Exists, U.S. Department of Health & Human Services, Office of the Assistant Secretary for Preparedness and Response (Oct. 15, 2021) https:/Avww.phe.gov/emergency/ news/healthactions/phe/Pages/COVDI-150ct21.aspx?cm_ven=ExactTarget&cm_cat=COVID-19+Update+2#13&cm_pla=All +Subscribers&cm_ite=extended&cm_Im=1343767647&cm_ainfo=&&&&&. [FN88] . "CMS Improperly Paid Millions of Dollars for Skilled Nursing Facility Services When the Medicare 3-Day Inpatient Hospital Stay Requirement Was Not Met," U.S. Department of Health and Human Services Office of Inspector General (Audit (A-05-16-00043), Feb. 14, 2019), https://oig.hhs.gov/oas/reports/region5/51600043.asp. [FN89] -Margot Sanger-Katz, "How to Tame Health Care Spending? Look for One-Percent Solutions." The New York Times (Aug. 27, 2018), https:/Avww.nytimes.com/201 8/08/27/upshot/rising-health-care-costs-economists-propose-small-solutions. html. [FN90] -Liran Einav, Amy Finkelstein, Neale Mahoney, "Long-Term Care Hospitals: A Case Study in Waste," the National Bureau of Economic Research (Aug. 31, 2018), http:/Awww.nber.org/papers/w24946. [FN91] . Patient Protection and Affordable Care Act, Pub. L. No. 111-148, ? 3022. [FN92] THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -56- . Centers for Medicare & Medicaid Services, "Shared Savings Program, https:/Avww.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/sharedsavingsprogram/index.html. [FNS3] . Changes in Postacute Care in the Medicare Shared Savings Program, The JAMA Network (April 2017), http://jamanetwork.com/ journals/jamainternalmedicine/article-abstract/26014 1 8?resultClick=1. [FN94] . David B. Muhlestein, et al., "Medicare Accountable Care Spending Patterns: Shifting Expenditures Associated with Savings," The American Journal of Accountable Care (March 2018), http:/Avww.ajmc.com/journals/ajac/2018/2018-vol6-n1/medicare-accountable- care-spending-patterns-shifting-expenditures-associated-with-savings?p=2. [FN95] . 'Medicare's hospital readmission penalties kick in," McKnight's Long-Term Care News & Assisted Living (Oct. 1, 2012), http:// www.mcknights.com/medicares-hospital-readmission-penalties-kick-in/article/261588/?7DCMP=EMC-MCK_Weekly. [FN96] . Emily Mongan, "MedPAC mulls bigger role for hospital discharge planners," McKnight's Long-term Care News (Oct. 6, 2017), http:// www.mcknights.com/news/medpac-mulls-bigger-role-for-hospital-discharge-planners/article/697867/. [FN97] . Megan O'Reilly and Andrew Scholnick, "Medicare Beneficiaries Needing Outpatient Therapy Face Higher Costs in 2018," AARP (Jan. 23, 2018), https://blog.aarp.org/20 18/01 /23/medicare-beneficiaries-needing-outpatient-therapy-face-higher-costs-in-201 8/. [FN98] . Danielle Brown and James M. Berklan, "CMS finalizes therapy pay cuts in 2022 Physician Pay Rule, and extends COVID reporting period," McKnights Long-Term Care News (Nov. 2, 2021), https:/Avww.mcknights.com/ news/breaking-cms-finalizes-therapy-pay-cuts-in-2022-physician-pay-rule-and-extends-covid-reporting-period/? utm_source=newsletter&utm_medium=email&utm_campaign=MLT_Weekly_20211112&hmSubld=GVkrCKLYrEM1&hmEmail=nluXS2jdOJOtlG- OxiMnyzlZDo7e_i8h0&email_ hash=4d7f9620032317303f7753d76be9a357 &mpweb=1326-2295 1 -249238. [FN99] . Calendar Year (CY) 2023 Medicare Physician Fee Schedule Proposed Rule (Fact Sheet), CMS.gov (July 7, 2022), https:// www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule. [FN100] . Kimberly Marselas, "More nursing home cuts buried deep in CMS physician pay schedule," McKnight's Long-Term Care News (July 12, 2022), https:/Awww.mcknights.com/news/more-nursing-home-cuts-buried-deep-in-cms-physician-fee-schedule/. [FN101] . Jimmo v. Sebelius Settlement Agreement Fact Sheet, Centers for Medicare and Medicaid Services, https:/Awww.cms.gov/medicare/ medicare-fee-for-service-payment/SNFPPS/downloads/jimmo-factsheet.pdf. [FN102] . The "Jimmo v. Sebelius Settlement Agreement Fact Sheet" is available at htfps://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/SNFPPS/Downloads/Jimmo-FactSheet. pdf. [FN103] . Tim Mullaney, "Medicare coverage of 'maintenance therapy' determined by need for skilled care, CMS clarifies in Jimmo document," McKnight's Long-Term Care News & Assisted Living (April 16, 2013), http:/Awww.mcknights.com/medicare-coverage-of-maintenance- therapy-determined-by-need-for-skilled-care-cms-clarifies-in-jimmo-document/article/288953/?7D CMP=EMC-MCK_Weekly. [FN104] . Kimberly Marselas, "Room for improvement," McKnight's (Aug. 5, 2016), http:/Avww.mcknights.com/news/room-for-improvement/ article/514332/. [FN105] THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -57- . Jimmo v. Burwell, Case No. 5:11-cv-17 (Vt. D.C. Feb. 1, 2017), https://kaiserhealthnews.files.wordpress.com/201 7/02/reiss-jimmo- decision-0201 17.pdf. [FN106] . Susan Jaffe, "Judge Accepts Medicare's Plan to Remedy Misunderstanding on Therapy Coverage," Kaiser Health News (Feb. 3, 2017), http://khn.org/news/judge-accepts-medicares-plan-to-remedy-misunderstanding-on-therapy-coverage/. [FN107] . Updated Guidance for Nursing Home Resident Health and Safety (fact sheet), CMS.gov (June 29, 2022), https://www.cms.gov/ newsroom/fact-sheets/updated-guidance-nursing-home-resident-health-and-safety. [FN108] . Josh Seidman et al., "Medicare Accountable Care Organizations Have Increased Federal Spending Contrary to Projections That They Would Produce Net Savings," Avalere (press release, Mar. 29, 2018), http://avalere.com/expertise/managed-care/insights/medicare- accountable-care-organizations-have-increased-federal-spending-con. [FN109] . "Genworth Cost of Care 2004-2021," Genworth (Feb. 7, 2022), hitps://Awww.genworth.com/aging-and-you/finances/cost-of-care/cost- of-care-trends-and-insights.html. [FN110] . "Long Term Care Insurance Industry Paid $9.2 Billion in Claims in 2017," American Association for Long-Term Care Insurance (Jan. 17, 2018), http:/Avww.aaltci.org/news/long-term-care-insurance-association-news/long-term-care-insurance-industry-paid-9-2-billion-in- claims-in-2017. [FN111] . Leora Friedberg et al., "Long-Term Care: How Big a Risk?", Center for Retirement Research at Boston College (Nov. 2014, No. 14-18), http://crr.bc.edu/briefs/long-term-care-how-big-a-risk/. [FN112] . Linked Benefit Price Index 2022, American Association for Long-Term Care Insurance, https://www.aaltci.org/linked-benefit-price- index-2022/. [FN113] . About the WA Cares Fund, WA Cares Fund, https:/Awacaresfund.wa.gov/about-the-wa-cares-fund/ (last visited Apr. 22, 2022). [FN114] . 'Ten States Selected to Participate in Long-Term Care Partnership Expansion Project," Center for Health Care Strategies, May 14, 2007, www.chcs.org. See also Robert Wood Johnson Foundation, "Long-Term Care Partnership Expansion: A New Opportunity for States," May 2007, www.rwjf.org. [FN115] . U.S. Government Accountability Office, "Long-Term Care Insurance: Partnership Programs Include Benefits That Protect Policyholders and Are Unlikely to Result in Medicaid Savings," Report GAO-07-231, May 2007, www.gao.gov. [FN116] -Mark Hulbert, "New ways to pay for long-term care could help seniors-and their heirs," MarketWatch (Oct. 5, 2018), https:// www.marketwatch.com/story/new-solutions-for-financing-long-term-care-could-help-seniors-and-their-heirs-2018-10-05. [FN117] . Jamie Hopkins, "Annuities Offer Long-Term Care Funding Flexibility," Forbes (Oct. 1, 2019), https:/Avwww.forbes.com/sites/ jamiehopkins/2017/10/17/annuities-offer-long-term-care-funding-flexibility/438e902b82529. [FN118] . VA Caregiver Support Program, Program of Comprehensive Assistance for Federal Caregivers (PFAFC), U.S. Department of Veterans Affairs, https:/Awww.caregiver.va.gov/support/support_benefits.asp (last visited Dec. 12, 2022). [FN119] THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -58- . Matt Volz, "VA seeks to funnel more nursing home money to rural areas," The Washington Post (Aug. 21, 2017), https:/Avww.washingtonpost.com/national/health-science/va-seeks-to-funnel-more-nursing-home-money-to-rural- areas/2017/08/21/733ae44c-86c0-11e7-96a7-d178cf3524eb_story.html?utm_term=.18106b62a31b. [FN120] . Maura Ewing, "When Prisons Need to Be More Like Nursing Homes," The Marshall Project (Aug. 27, 2015), https:// www.themarshallproject.org/2015/08/27/when-prisons-need-to-be-more-like-nursing-homes#.BCn6gEpHV. [FN121] . "For Aging Inmates, Care Outside Prison Walls," PEW Charitable Trusts (Aug. 12, 2014), http:/Avww.pewtrusts.org/en/research-and- analysis/blogs/stateline/2014/08/1 2/for-aging-inmates-care-outside-prison-walls. [FN122] . Adam Wisnieski, "Model' Nursing Home for Paroled Inmates to Get Federal Funds," Connecticut Health I-Team (April 25, 2017), http://c-hit.org/2017/04/25/model-nursing-home-for-paroled-inmates-to-get-federal-funds/. Produced by Thomson Reuters Accelus Regulatory Intelligence 27-Jun-2023 THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -59-