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Volume 13 Number 26 News: Medicaid State health care officials have asked the federal government to pull an interim final rule on case management and targeted case management (TCM), saying the rule went beyond congressional intent and would result in loss of services, such as transitional help, to Medicaid beneficiaries. "Case management is a vital service for Medicaid consumers," the American Public Human Services Association and the National Association of State Medicaid Directors wrote in their Feb. 4 joint public comment. "This sweeping interim final rule restricts the ability for Medicaid funds to be used to ensure that the most vulnerable citizens receive timely and appropriate access to care. It will also require tremendous administrative action to restructure programs throughout the country, without assuring a clear outcome of program improvements." The two organizations said the rule released Dec. 4, 2007 (72 Fed. Reg. 68077) went beyond the Deficit Reduction Act of 2005, and they asked the Department of Health and Human Services to withdraw it. "Especially, we ask that HHS remove all provisions from the interim rule that are not expressly authorized by the DRA," they said. APHSA also released a chart comparing enacted DRA regulations and the proposed provisions in the interim final rule. The rule has come under fire from key Senate Democrats, who have urged HHS to revise it (see related item in this issue a0b5x7m3q7 'Inappropriate' State Billing
The Centers for Medicare & Medicaid Services said it issued the "Optional State Plan Case Management Services" to clarify situations in which Medicaid would pay for referral services to specific, or targeted groups of Medicaid beneficiaries. CMS was concerned about "inappropriate" state billing of Medicaid that had been discovered by the Government Accountability Office.
The rule said Medicaid payment would not be available for direct services a Medicaid beneficiary received, including counseling that a case manager may provide and performance of diagnostic tests, both of which may be covered under another Medicaid service category. Also excluded are transportation or escort services, day care services, and other medical, social, educational, and other services to which eligible individuals have been referred (No. 231 HCDR 12/3/07 a0b5m3u8b1 The interim final rule included a 60-day public comments period ending Feb. 4. The rule is scheduled to take effect March 3.
Transition From Institutions to Communities
Among APHSA and NASMD concerns, they said, was the potential reduction of states' ability to help Medicaid beneficiaries transition from institutions, such as nursing homes, back to live in their communities.
Currently, payment is available for such transitional services for 180 days for individuals who have lived in an institution for more than 180 days. However, the interim final rule cuts the time limit to services provided within the last 60 days. The rule further states that payment for such services to individuals who have lived in an institution for less than 180 days will be available only during the last 14 days of an institutional stay.
APHSA and NASMD said the time-frame in either case does not provide enough time to help individuals find housing services. The 14-day time allotment does not give case managers enough time complete a "comprehensive assessment" of the beneficiary's needs and obtain appointments. The letter said that setting appointments with psychiatrists and mental health providers can take "several weeks," for instance.
The letter also addressed the requirement that case managers bill Medicaid in 15-minute increments. The groups said that such billing standards would not work for case management services because "the case manager must be available whenever the individual is in need of support, not just for routine, scheduled meetings as with a doctor or other direct service provider."
Exclusion of Other Programs' Services
The TCM definition excludes activities that constitute the administration of foster care programs or other nonmedical programs, CMS said in a Nov. 30, 2007, press release. Examples include guardianship, legal services, and special education services not included in individualized education plans or family services plans. TCM also does not cover services that are integral components of another Medicaid program.
APHSA and NASMD questioned the exclusion of services provided under these other programs, saying that the DRA law "imposes a much narrower standard that outlines specific services that case managers cannot charge to the Medicaid program."
Estimated Saving 'Discrepancy'
Whereas CMS has said the estimated savings from implementing the rule would be $1.28 billion over five years, APHSA and NASMD said there is a "discrepancy between [that calculation and] the Congressional Budget Office's initial projection of $760 million over five years based on the DRA."
In issuing the interim final rule in 2007, CMS cited GAO audit examples of "inappropriate" billing of Medicaid for TCM services, which it said contributed to increased spending for the services, up 76 percent between 1999 and 2003, from $1.7 billion to $3 billion.
CMS said that GAO had attributed the increase to "a growing trend among states to hire consultants to assist in administering their Medicaid programs."
Moratorium Bills Introduced
Although CMS has said the interim final rule will take effect March 3, Sen. Norm Coleman (R) and Rep. Keith Ellison (D), both from Minnesota, have introduced legislation for a one-year moratorium until April 1, 2009.
Ellison introduced H.R. 5173 on Jan. 29. The legislation was referred to the House Committee on Energy and Commerce. Coleman introduced S. 2578 the next day. The Senate bill was referred to the Senate Committee on Finance.
Coleman wrote a "Dear Colleague" letter Jan. 25 that echoed the concerns of APHSA and NASMD. He said delaying the rule's implementation would allow CMS time to "review the original intent of DRA provisions," which he wrote "excludes direct delivery of certain underlying medical, educational, or social services, all the while prominently iterating that many case management services remain allowable, legitimate Medicaid expenses."
CMS spokeswoman Mary Kahn told BNA Feb. 7 that CMS does not comment on pending legislation. She added, "We will proceed with the rule unless Congress directs us to do otherwise."
Kahn said that submitted public comments would soon be posted on the CMS web site.
APHSA and NASMD's comment is available on the Web. A comparison of the proposed final rule and DRA provisions is available. CMS's public comments website is available.
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