Advocacy Roundup
Policy and coverage developments affecting ventilator users: CMS finalizes its Access Rule, the Biden administration seeks $150 billion for home and community-based services, and insurers tighten access to home ventilators.
CMS Finalizes New Rule for Home and Community-Based Services
The Centers for Medicare and Medicaid Services (CMS) have finalized a new rule, "Ensuring Access to Medicaid Services," or the Access Rule, aimed at strengthening home and community-based services for individuals with disabilities. This rule entails setting minimum payment thresholds for direct care providers, mandating states to annually reassess the needs of recipients, and implementing other measures to bolster the direct support professional workforce. It is a response to the increasing trend of individuals with disabilities residing in community settings rather than institutions.
Under the measure, at least 80% of Medicaid payments for homemaker, home health aide and personal care services must go toward compensation for direct care workers as opposed to administrative overhead with limited exceptions. States will also have to report on a standardized set of quality measures, as well as how they establish and maintain their waiting lists and the timeliness of service delivery.
Biden Administration Calls for Significant Increase in Funding for Home and Community-Based Services
In his State of the Union address last month, President Biden called for a large increase in funding for home and community-based services. "Imagine a future with home care and eldercare, and people living with disabilities can stay in their homes and family caregivers can finally get the pay they deserve," he said in the speech.
He followed this up by including $150 billion over 10 years for home and community-based services in his budget request for 2025. Budget requests are largely just a wish list of a president's priorities, however. It will fall on Congress to determine what will ultimately be included in the federal budget for the upcoming year.
Insurer Delays and Denials Hamper Patients Seeking Home Ventilators, According to Report
According to a recent report by the Associated Press, some physicians and patients are finding that insurers are imposing greater challenges on patients seeking to acquire home mechanical ventilation. Insurance rejections have become more common for patients, particularly those with advanced cases of chronic obstructive pulmonary disease, according to Chuck Coolidge, Chief Strategy Officer for VieMed, a respiratory equipment provider.
Dr. Lisa Wolfe, a professor at Northwestern's Feinberg School of Medicine, attributes the rise in coverage problems to technological advancements that have made ventilators easier to use, resulting in their expanded use for conditions that are not immediately life-threatening. She suggests that insurers may be responding to this increased utilization. Federal spending on ventilators through Medicare surged from approximately $3 million to nearly $269 million between 2009 and 2017, as reported by the U.S. Department of Health and Human Services Office of Inspector General. Read more here.