Home Health & Hospice Week

HHAs must pay for entire day of adult day care, plus transportation, under test project.

Details about the medical adult day care demonstration project have emerged, and they're making some home care providers think twice about getting involved.

The Centers for Medicare & Medicaid Services is soliciting applications for the demonstration, in which Medicare home health patients could receive a portion of their plan of care services in an adult day care facility. (See next article, for more details about the project.)

Unwelcome surprise: CMS took many home care providers unawares in the July 18 special Open Door Forum on the demo, which drew 360 callers. Under the project, HHAs must pay day care facilities for the entire day of day care when a patient receives a plan-of-care-covered service that day, explained Armen Thoumaian, CMS project officer for the demo. That includes transportation to and from the facility, Thoumaian said.

CMS won't allow the day care facility to bill either the patient or any other third party for that day of service, Thoumaian stressed. The same goes for transportation services, he said in response to a question from an Almost Family Inc. representative attending the meeting.

CMS' "interpretation that [the] HHA is responsible for purchasing the entire day of services runs counter to my impression of the statute," Bob Wardwell of the Visiting Nurse Associations of America said in the forum.
 
The Medicare Modernization Act is clear that day care facilities can't receive duplicate payments for services rendered as part of the home health plan of care. But nowhere does the law indicate that the HHA must pay for the entire day of care, including many services not on the POC, said Wardwell, a former CMS top official. "I see lots of complications."

CMS wanted to encourage an "innovative mix of services" to be proposed by prospective applicants, Thoumaian responded.

Demo HHAs Will Need Volume

HHAs may face quite a financial struggle to pay for an entire day of day care every time they visit a patient in the facility under the 95 percent PPS rate, callers predicted.
 
"What is their incentive to participate?" one adult day care center caller from Oklahoma asked. HHAs may need to see a significant volume - perhaps 20 patients a day - in the facility to make up for the reduced payment rate and day care fees, the caller suggested.

HHAs most likely will work out a per diem arrangement with day care facilities, expected Ann Howard with the American Association for Homecare.

Benchmarks: CMS found day care costs ranging from about $40 to $70 per day, depending on region, facility and services offered, Thoumaian offered.

Besides the financial implications, home care providers may be worried about their liability under such an arrangement, Wardwell pointed out. They may fear they'll be on the hook if an accident occurs at the day care facility, for example.

That's exactly why CMS prefers that the HHAs and day care facilities have common ownership and control, Thoumaian said.

This revelation "could put a real crimp in recruitment" for the demo, Wardwell warns.

"Being responsible for the full cost of a day in medical adult day care will certainly discourage HHAs from participating in the demo," Howard tells Eli.

One beneficiary caller pointed out how difficult it was to find HHAs participating in the homebound demonstration (see Eli's HCW, Vol. XIII, No. 41) and voiced fears the same could happen with the day care demo. The homebound demo enrolled only one patient in its first few months.

Other hurdles to demo participation include: