WiHPCA News

By Hoven Consulting – WiHPCA’s Government Affairs Firm

The Legislature's Joint Finance Committee (JFC) finished its work on reshaping Gov. Tony Evers' 2021-23 state budget proposal. While the Finance Committee completed their work on time, it was a challenging budget process with numerous moving pieces, including split government, billions of dollars in federal COVID-19 relief aid, and a projected $4.4 billion state budget surplus. 

The budget bill must still be approved by the full Legislature and signed into law by Evers, who could also veto the legislation in part or in whole. However, both houses of the Legislature are likely to adopt the budget approved by JFC with minimal changes. 

While the Finance Committee did not include Medicaid Expansion in its spending plan, it did include over $1.5 billion in total funding the state’s Medicaid program and increased spending on several specific initiatives. Of potential interest to hospice and palliative care agencies, the committee approved increases for home health care, personal care, and direct care workers as follows:

• Home Health Care Skilled Nursing Services: Provide more than $1.4 million over the two-year budget cycle to increase Medicaid rates for home health care skilled nursing services by 10 percent. The rate boost would begin on January 1, 2022 and will support care offered by licensed practical nurses, registered nurses, and nurse practitioners in home health agencies.

• Direct Care Workforce Funding: Provide $53,835,800 in 2021-22 and $50,403,200 in 2022-23 to increase funding for the direct care workforce funding supplement.  

• Personal Care Reimbursement: Provide $18,904,300 in 2021-22 and $59,369,300 in 2022-23 to increase hourly rates paid for personal care services to $20.69 on January 1, 2022, and to $22.35 on January 1, 2023. 

Please find below an overview of additional Department of Health Services and Medicaid-related provisions included in the JFC-approved version of the budget bill:

Medicaid

• Medical Assistance Cost-to-Continue Estimate: Provide funding of $1.3 billion in 2021-22 and $1.25 billion in 2022-23. In addition, adjust the cost-to-continue re-estimate to provide $25,900,000  in 2021-22 and $51,400,000 in 2022-23, reflecting the impact of the Department's proposed rate increase to managed care organizations providing services under Family Care, PACE, and Partnership, subject to approval by the federal Centers for Medicare and Medicaid Services.  

• Nursing Home Reimbursement: Provide $82 million in 2021-22 and $170 million in 2022-23 to increase reimbursement rates paid to skilled nursing facilities and intermediate care facilities for individuals with intellectual disabilities. 

• Postpartum Eligibility Extension: Provide $2.5 million in 2022-23 to reflect the estimated cost of extending benefits, for women enrolled in MA as pregnant women, until the last day of the month in which the 90th day after the last day of the month that the end of the pregnancy falls, instead of the 60th day under current law.

• Outpatient Mental Health and Substance Abuse Services and Child-Adolescent Day Treatment Reimbursement: Provide $6.6 million in 2021- 22 and $13.2 million in 2022-23 for a 15% increase to reimbursement rates for outpatient mental health and substance abuse services. In addition, provide $1.3 million in 2021-22 and $2.6 million in 2022-23 for a 20% increase to reimbursement rates for child and adolescent day treatment services. 

• Medication-Assisted Treatment: Provide $1.2 million in 2021-22 and $2.4 million in 2022-23 to increase MA reimbursement rates for opioid treatment providers by 5% and increase rates for opioid-related patient evaluation and management provided by primary care providers by $5 per visit.

• MA Dental Reimbursement: Provide $15.4 million in 2021-22 and $30.8 million in 2022-23 to increase MA dental reimbursement rates by 40%. 

• Home Health Reimbursement Rate: Provide a budgeted sum of $473,300 as the state share of payments, and provide the matching federal share of payments, in 2021-22, and by a budgeted sum of $960,200, as the state share of payments and provide the matching federal share  of payments, in 2022-23, for the Department to increase the Medical Assistance rates paid for nursing care in home health agencies for dates of services beginning January 1, 2022. Specify that funding is to support licensed practical nurses, registered nurses, and nurse practitioners in home health agencies that are licensed under s. 50.49 of the statutes.

Public Health

• Community Health Center Grants: Increase grant funding for federally qualified health centers (FQHCs) by $1,000,000 annually.  

• Grants to Free and Charitable Clinics: Increase grant funding for free and charitable clinics by $1,000,000 annually.  

• Lead Screening and Outreach Grants: Provide $50,000 annually to increase a grant for lead screening and outreach activities provided by a community based human service agency that provides primary health care, health education, and social services to low-income individuals in the City of Milwaukee, from $125,000 to $175,000. 

Community Based Behavioral Health

• Child Psychiatry Consultation Program: Provide $500,000 in 2022-23 to increase from $1,500,000 to $2,000,000 the funding for the child psychiatry consultation program.

• Medication-Assisted Treatment Expansion: Provide $500,000 in 2021-22 and $1,000,000 in 2022-23 in the Joint Committee on Finance supplemental appropriation for medication-assisted treatment.  

• Methamphetamine Addiction Treatment Grants: Provide $150,000 in 2021-22 and $300,000 in 2022-23 in the Joint Committee on Finance supplemental appropriation for training for substance use disorder treatment providers on treatment models for methamphetamine addiction.    

• Substance Use Disorder Treatment Platform: Provide $300,000 in 2022-23 in the Joint Committee on Finance supplemental appropriation for development of a substance use disorder treatment platform that allows for the comparison of treatment programs in the state.  

• Behavioral Health Bed Tracker: Provide $50,000 in 2021-22 and $20,000 in 2022-23 to expand the purposes of the current psychiatric bed tracking system to include information on the availability of space for peer run respite beds and crisis stabilization beds.  

Behavioral Health Trainee Provider Grants: Provide $250,000 in 2022-23 in the appropriation for treatment program grants to increase total funding for the program in that year to $750,000. Modify the program to: (a) specify that the Department may expend any available federal moneys received for this program; (b) require the Department to distribute a total of $750,000 per year, beginning in 2022-23; and (c) renumber the appropriation so that it is included as an appropriation under mental health and substance abuse services instead of under public health.

Earlier this year, WiHPCA fulfilled one of our main organizational goals for 2021 when we began quarterly meetings with the Division of Quality Assurance (DQA) at the Wisconsin Department of Health Services. In addition to building a positive relationship with an important regulatory agency that oversees the hospice and palliative care industry, the specific purpose of the meetings are to review and discuss survey deficiencies, examine avenues for improvement, and seek regulatory guidance from DQA.

The initial meeting held on March 11 was well attended and opened a great line of communication between WiHPCA members and DQA staff. The June 10 second quarter meeting was also successful and provided attendees with a wealth of important regulatory information. Please find below an overview of the June 11 meeting:

Survey Report:

• Number of surveys performed (Oct. 1, 2020-March 31, 2021)

i.      Number of complaint surveys – 14

ii.      Number of recertification surveys performed – 8

Complaint surveys topics – Top 5 concern areas:

iii.      Quality of Care and Treatment

iv.      Patient Rights

v.      Nursing Services

vi.      Admission/Transfer/Discharge Rights

vii.      Infection Control

Question and Answer Overview:

• Will the Public Health Emergency – and the associated COVID-19 waivers (CMS 1135) that apply to hospice care – remain in place until Dec. 31, 2021? While guidance continues to be sought, a 90-day extension of the public health emergency (PHE) was signed effective April 15, 2021. 
• • See: https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.  DQA will receive the same notice that providers receive related to an end date for the PHE or any changes to the waivers that occur prior to the end of the PHE. 
  • CMS provided this website for more information about 1135 waivers: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/1135-Waivers
• How many new hospice organizations have begun operations in Wisconsin in 2021?
• • One hospice newly licensed in 2021. The Hospice statewide directory is found here: https://www.dhs.wisconsin.gov/guide/hospice.htm.
• How many applications are pending approval?
• • There are currently two hospice applications pending approval.
• Does DQA plan to re-write hospice and facility interface documents or convene a task force to revise the interface in the near future?
• • Jessica Tomczak, the DQA Nurse Consultant for Hospice, is working on this project. Any ideas for updates can be e-mailed to her at: Jessica.Tomczak@dhs.wisconsin.gov.  
• Has there been any coordination of care issues with nursing homes or assisted living in general, or as it specifically relates to infection control?
• • F-774 - The hospice plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. 
  • F-774 was cited one time recently (May 2021) related to the Plans of Care for patients residing in Nursing Homes or Assisted Living Facilities not specifying which provider was responsible for which care areas on the Plan of Care.
• 1135 Waivers will continue through the Feds through 12/31.  This was confirmed through 20-003 for hospices.  We are working with the Biden Administration through NHPCO to look at extending some aspects such as telehealth visits past the PHE.  Will telehealth visits be codified through the state of WI for NP and physicians visits for our palliative care programs?
• • CMS response – Since the PHE is ongoing, CMS has not issued any further information regarding telehealth as it relates to Hospice.  We will update you if we receive any further guidance.
  • WI response – DHS established a temporary telehealth policy to ensure access to health services during the COVID-19 pandemic. The temporary policy flexibilities for telehealth services related to COVID-19 are not tied to the federal or state declaration of a public health emergency. DHS is in the process of drafting emergency and permanent telehealth rules.  The current policy will continue until emergency telehealth rules go into effect.  For Medicare certified providers, please follow the guidance from CMS.
• CMS recently changed their guidance in QSO-20-38-NH to allow to not routinely test staff that have been fully vaccinated.  They did reiterate that unvaccinated staff needed to be tested according to the percent positivity rate in their county.  DHS guidance in the past has been that all routine testing had to be performed a minimum of every 2 weeks.  We have not seen any adjustment to this DHS guidance (unless we missed it) allowing for NOT testing vaccinated staff, etc.  Are we correct in assuming that DHS is allowing this even though their previous guidance was more restrictive? 
• • DHS released updated testing guidance (see attached) on 6/9/21 to align with the guidance provided in CMS QSO Memo 20-38 revised 4/27/21.
  • The current DHS COVID-19: Nursing Home testing guidance links to the revised CMS QSO Memo -20-38 and recommends routine testing of unvaccinated staff based on the county positivity rate in the last week:
  • • Low – Positivity rate of < 5% - Once a month testing
    • Medium – Positivity rate of 5% - 10% - Once a week testing
    • High – Positivity rate of > 10% - Twice a week testing

First elected to the state Assembly in 2012, Representative Dan Riemer (D-Milwaukee) is serving his fifth term representing the 7th Assembly District, which includes portions of the cities of Milwaukee and West Allis, as well as the Village of West Milwaukee.

Rep. Riemer holds a law degree from UW-Madison and is a full-time lawmaker. He currently serves on the Assembly Health Committee, and during his time in the Legislature has worked on numerous health care-related proposals.

Rep. Riemer took a few minutes to talk with us about a handful of topical health care issues facing Wisconsin and what health care policy priorities he believes should be pursued during the 2021-22 legislative session:

Question 1

As a long-time member of the Assembly Health Committee and a legislator who has worked on numerous health care-related polices during your time in the Legislature, what do you believe are the largest health care-related challenges facing the state? In addition, what policy solutions do you believe are needed to address those challenges? Lastly, what key health care policy proposals is the Assembly Democratic Caucus focusing on for the 2021-22 legislative session?

Answer: The single biggest health care challenge facing Wisconsin is the failure to expand Medicaid. This would increase the number of Wisconsinites with health insurance, and lower health care costs for newly Medicaid-covered individuals between 100%-133% of the Federal Poverty Line. Medicaid provides better benefits than Affordable Care Act plans or other plans and provides Wisconsin’s government with over one billion additional dollars, some of which could be devoted to other health care priorities.

As I have done for many years through legislation, Governor Evers has also repeatedly proposed Medicaid expansion. The Assembly Democratic Caucus has again made this a priority, as have Democrats in the State Senate. The time has come for the Republican majority in the Wisconsin Legislature to agree. That’s the simple solution to our biggest health care challenge.

Question 2

The cost of healthcare continues to rise, for both individuals and employers. In fact, a recent survey by the Kaiser Family Foundation and the Purchaser Business Group on Health found that 85 percent of large employers believe the government must take a bigger role in managing healthcare costs and coverage. Another survey found that 55 percent of small business owners say the cost of providing health insurance to their employees is the biggest challenge they face. What types of policies or future legislation do you believe are necessary to help drive down the overall costs of health care?

Answer: In addition to Medicaid expansion, which will reduce what Wisconsin’s taxpayers and government must pay for health care for a large sector of our population (a form of lowering costs), I strongly support other measures to lower the overall cost of healthcare in Wisconsin.  One step that I support would be to require that the Wisconsin State Employee Health Plan (WSEHP) be used as the vehicle by which all government employees obtained health insurance. 

A careful analysis of WSEHP by University of Wisconsin-Madison La Follette Professor of Economics John Mullahy and others compared the WSEHP’s experience in Dane County vs. Wisconsin’s other 71 counties. The study showed that  when a very large percentage of the employees in a county are offered a choice among competing health care plans, they have incentives to enroll in the lower-cost plans, because while higher-cost plans are always available, they must pay a modest additional premium to enroll in higher-cost plans. Given the choices, health care premiums and costs are held down.

If WSEHP served as the vehicle for enabling all government employees to obtain health insurance in the same way, it should be possible to replicate much of WSEHP’s unique success in Dane County in constraining health care premiums and costs.  One of the benefits of this is that, as the Dane County story suggests, it is not only the WSEHP and those it helps obtain health insurance for who experience reduced costs.  The model’s incentives put pressure on the competing plans to become more cost effective in general, which helps private employers as well.

Question 3

Skilled home health care offers a wide range of health care services, which are provided by skilled non-physician practitioners, such as nurses in a patient’s home. Not only does skilled home health offer patients with greater convenience, increased quality of life, and better outcomes, it is also typically less expensive than care delivered in a hospital or other facility. Unfortunately, despite the many benefits of home health care, the Wisconsin Medicaid reimbursement rate for home-based skilled nursing has not been increased in over a decade. With that in mind, would you support increasing the Medicaid reimbursement rate for home health skilled nursing services by 10 percent?

Answer:  I certainly would be concerned if the current Medicaid reimbursement rate for home health skilled nursing services is resulting in a reduction in the number of providers or the quality of care.

This is not an issue, however, that I know much about. I would welcome the opportunity to learn more.

 

The views and opinions expressed in this interview are those of the individual that was interviewed and do not necessarily reflect the official policy or position of the organization.

Governor Tony Evers has called a special session of the legislature to take up a proposal to expand the Wisconsin Medicaid program, which would capture an extra $1 billion in federal funds and cover more than 90,000 additional Wisconsin residents under the program.

The legislation would also use $850 million of the additional federal dollars for numerous economic development-related projects and transfer the rest to the state’s budget stabilization fund.

The Republican-controlled Legislature has said they would immediately gavel out the special session without taking up the proposed legislation.

As you know, the WiHPCA has launched a Legislative Key Contact Program, which can be a highly effective grassroots advocacy tool to help build and nurture strong on-going relationships between WiHPCA members and lawmakers in Wisconsin. Ultimately, the program can help us help shape new policies important to our members.

We are happy to report the program is live on the WiHPCA website and members can easily and quickly sign-up as a Key Contact.

As a Key Contact, you can help influence the legislative process at both state and federal levels by cultivating relationships with elected officials. By taking advantage of existing relationships and making contact with members of the Wisconsin Legislature and the Wisconsin Congressional  Delegation, you can help us educate lawmakers on industry issues and influence legislation.

But the program will not succeed without strong member participation, so please take a few moments to read more about it – and learn how simple it is to “enlist” and participate as a Key Contact. The time commitment is minimal and your responsibility as a key contact depends on your level of comfort and willingness to engage.

Remember, lawmakers are often eager to hear input from their constituents, and as an expert in your field, you can make a real difference in the policy process as a Key Contact. CLICK HERE to sign-up by filling out and submitting a brief online survey.

There is no question that members of WiHPCA are experts and leaders in Wisconsin’s hospice and palliative care industry. With that in mind, it is rewarding when our members are acknowledged in the media or other public forums for their relentless work and dedication to caring for patients with terminal and life-limiting illness. Not only does it recognize the hard work of our members, but it also helps educate the public on the importance of hospice and palliative care.

We are pleased to report that Rita Hagen, WiHPCA Board member and Executive Director of Hospice Alliance, penned an article – “COMMUNITY: Understanding Hospice Alliance's palliative care” – that was recently printed in the Kenosha News. Please CLICK HERE to read Rita’s article, which provides a tremendous overview of palliative care/Supportive Care Management and how it benefits individuals living with serious illness.

The U.S. Treasury last week issued guidelines for state and local governments on how they can access their share of the $350 billion in COVID-19 aid for state, local, tribal, and territorial governments included in the American Rescue Plan Act (ARPA).

It was also announced the state of Wisconsin will receive $700 million less in ARPA funding than originally anticipated – from and an anticipated $3.2 billion to an actual $2.5 billion. In addition, the direct federal funding to the state will be split into two payments a year apart. The reduction in funding is due to improvements in the state’s unemployment rate, which has returned close to pre-pandemic levels.

Governor Tony Evers (D) who has full control over the allocation of the federal aid had planned to put $700 million toward the state’s ongoing response to the pandemic and $2.5 billion toward economic recovery. That will now need to be revisited with less funding coming into Wisconsin.

Evers, along with Wisconsin U.S. Senator Tammy Baldwin (D) has sent a letter to the Biden Administration asking Treasury to reconsider the split payment approach.

The newly released rules provide guidance on allowable uses of the federal relief funding. The federal government’s funding objectives for the relief aid includes:

• Support urgent COVID-19 response efforts to continue to decrease spread of the virus and bring the pandemic under control.
• Replace lost revenue for eligible state, local, territorial, and Tribal governments to strengthen support for vital public services and help retain jobs.
• Support immediate economic stabilization for households and businesses.
• Address systemic public health and economic challenges that have contributed to the inequal impact of the pandemic.

State and local governments may use these funds to:

• Support public health expenditures, by, for example, funding COVID-19 mitigation efforts, medical expenses, behavioral healthcare, and certain public health and safety staff.
• Address negative economic impacts caused by the public health emergency, including economic harms to workers, households, small businesses, impacted industries, and the public sector.
• Replace lost public sector revenue, using this funding to provide government services to the extent of the reduction in revenue experienced due to the pandemic.
• Provide premium pay for essential workers, offering additional support to those who have and will bear the greatest health risks because of their service in critical infrastructure sectors.
• Invest in water, sewer, and broadband infrastructure, making necessary investments to improve access to clean drinking water, support vital wastewater and stormwater infrastructure, and to expand access to broadband internet.

Within these overall categories, recipients have broad flexibility to decide how best to use the funding to meet the needs of their communities.

For more information, please visit the U.S. Treasury website.

The Joint Finance Committee, the state Legislature’s budget writing committee, has begun voting to reshape Governor Tony Evers’ $91 billion state budget bill proposal. The most significant action the GOP-controlled committee took was the approval (along party lines) of a motion to pull more than 380 items from Evers’ two-year spending plan for the state. The items removed from the legislation were either non-fiscal policy items or provisions included by the governor that are opposed by the Republican majority in the Legislature.

More specifically, the motion removed the following health care-related items from the 2021-23 budget bill:

• Full federal Medicaid expansion
• Creation of a state-based Health Insurance Exchange
• Legalization of medical marijuana
• Raising to 21 the minimum age to purchase tobacco products

By removing the provision to expand Medicaid, Wisconsin is declining $1.6 billion in additional federal aid over the next two years, including $1 billion in American Rescue Plan Act (ARPA) funding for each state that approves Medicaid expansion. Proponents of the measure say expanding Medicaid eligibility would not only save the state money, but also provide health coverage to over 90,00 additional people.

Republicans who control the Legislature oppose Medicaid expansion, pointing to the lack of a coverage gaps between BadgerCare eligibility and eligibility for subsidies to purchase private coverage in the health insurance marketplace. They also believe expansion could put Wisconsin is a tough fiscal position in the future if the federal  government decides to reduce Medicaid contributions made to states. 

The Joint Finance Committee will continue to meet during the month of May to take further action on the budget bill. However, they are not expected to address major spending items, including Medicaid issues until next month.

Although much of the focus in the State Capitol is on development of the 2021-23 state budget bill – the $91 billion two-year spending plan for the state – lawmakers are also acting on stand-alone, non-budget legislation, including many that impact the delivery of health care in Wisconsin. Legislation of interest to health care professionals across the state that have been introduced and are currently being considered by the Legislature’s Health Committees include the following:

• Assembly Bill 66 - Relating to community health center grants and making an appropriation.
• Assembly Bill 86 - Relating to providing complementary and alternative health care practitioners with exemptions from practice protection laws, requirements and prohibitions for individuals who provide complementary and alternative health care services.
• Assembly Bill 184 - Relating to application of prescription drug payments to health insurance cost-sharing requirements.
• Assembly Bill 281 - Relating to registration of pharmacy technicians.
• Assembly Bill 290 - Relating to reimbursement of pharmacist services under the Medical Assistance program.
• Assembly Bill 295 / Senate Bill 308 - Relating to licensing and regulation of pharmacies and remote dispensing sites under the pharmacy practice law and the practice of pharmacy.
• Assembly Bill 296 - Relating to funding for free and charitable clinics and defining telehealth.
• Senate Bill 337 - Relating to prohibiting businesses from discriminating against customers due to vaccination record.
• Senate Bill 340 - Relating to reimbursement rates for behavioral treatment services under the Medical Assistance program.
• Senate Bill 342 - Relating to prohibiting the state or other governmental entities from discrimination based on whether the person has received a COVID-19 vaccine.

For a full list of bills currently being considered by the Assembly and Senate Health Committees, CLICK HERE to view Assembly bills and HERE to view Senate bills. You bill be able to read the bills in full and track their status as they move through the legislative process.

WiHPCA is committed to strengthening the relationship between hospice and palliative care professionals and key government policymakers that impact our industry through regulation and legislation. Engaging with lawmakers and regulatory organizations and sharing your professional expertise with them can have a significant influence on the development of polices that impact hospice and palliative care in Wisconsin.

In addition to WiHPCA’s grassroots advocacy efforts in the State Capitol, we have created an exciting opportunity for members to regularly engage with the Division of Quality Assurance (DQA) at the Wisconsin Department of Health Services. 

In fact, on Thursday, June 10, WiHPCA is holding its second quarterly meeting with DQA. Please REGISTER TODAY for this unique opportunity. This webinar will not be recorded. Please plan to participate in the webinar and take advantage of live Q&A.

The purpose of the quarterly meetings – which are tentatively scheduled to be held every three months during the second week of the month – is to review and discuss survey deficiencies, examine avenues for improvement, and maintain a strong, ongoing dialogue between our members and DQA.

A more detailed agenda, a summary of questions, and other related materials will be sent to registrants prior to the meeting.

If you are interested in submitting a question for the June 10 meeting, please do so no later than close of business on Wednesday, May 26.