Kelly Wilson

I need to preface this post by stating, I am in no way an opponent of, nor a critic of the long-range vision of the Statewide

, or at least what I interpret it to be. A program developed to maximize LTC funds and provide care and services to those who need it, something I and so many others advocate for. It is in this capacity and as a volunteer board member of FALA, the Florida Assisted Living Association, that I meet with many owners and administrators from Miami Dade, Broward, Palm Beach, Treasure Coast and areas around the state. Hundreds of these assisted living providers are gravely concerned about their ability to continue serving the SMMC residents in their facilities without going under.

Florida Long Term Care Managed Care

A $1 bill can only be stretched so far, 100 pennies still have only a $1 value, 1+1 simply does not = 3, 4 or 5. Perhaps somewhere, planning early on in this rather large and complicated undertaking, there was a simple miscalculation.

When considering the ginormous task of developing and implementing such a program, it seems obvious to expect that adjustments would be needed along the way and there have been several. Striving for clearly defined roles and responsibilities with a process for execution and deadlines, the wheel, AHCA has instructed and re-instructed its many cogs, DOEA, ADRC’s, CARES, DCF, Choice Counseling and Contracted LTC Plan Providers on a few occasions.

 

Florida Medicaid

How much grease does it take to keep all these wheels turning? Apparently, more than there is……and the wheel squeaking to nearly a standstill is that of the participating ALF, assisted living providers.

The ALF’s fall under HCBS providers, these assisted living facilities are housing and providing 24/7 care and services to thousands of SMMC recipients. They receive inadequate reimbursement amounts and with payment delays it is becoming more difficult to cover costs for resident care. This brings to mind UCR, used by insurance companies determining allowable and covered fees, usual, customary and reasonable. Anyone familiar with assisted living costs would likely agree on a figure of $3100 as UCR and a range, low to high $2600 to $5800+.  The ALF providers who are primarily serving these SMMC recipients are receiving an average of $700 – $900 monthly room and board rates from residents who often have limited social security income. They receive a median of $35-$38 per day from the LTC plan providers. It is simple math and the numbers do not add up to meet the costs of standard operations and delivering quality care. I operated a six bed facility 15 years ago and participated in Diversion, which back then paid at a comparable rate of $1000 – $1200.

 

Assisted Living in FloridaYou must understand what assisted living is, take George, a pleasant 82 yo gentleman, whose only income is $975 monthly SS, his hard earned savings was pilfered by a distant relative a few years ago. Diabetic and hypertensive, George has impaired vision and is a little forgetful. A stroke 3 years ago left him with left sided weakness, at risk for falls he needs a little help safely getting in and out of bed, his recliner, onto the toilet and to walk any distance. He takes pills 3 times a day, which he cannot manage or remember. The assisted living with staff provide George a safe home with the social, emotional and assisted services and support he needs 24/7. Often all inclusive of laundry, cleaning, meals that meet his no added sugar or salt diet, activities, medication assistance, coordination of health & medical care, managing prescriptions, arranging or providing transportation and daily personal care assistance with showering and hygiene. George has been a resident for nearly two years, happy and thriving, this is home and family for him. Just as in your home, you need income and a budget in order to keep the lights on, the water running and the food on the table. It is no different for the ALF providers who have staffing, compliance requirements and operational costs that must be met to maintain quality care standards.

If tomorrow, even 50% of these assisted living facility providers said they could no longer accept any SMMC recipients as residents because of the current contracted payment rates, there would be a crisis. If an individual is unable to remain at home safely and receive services, what alternative is there? Paying the cost of nursing home care when the resident does not require skilled services will further drain the program. The less restrictive, home like environment option of assisted living has been a highly cost effective alternative to the nursing home.

Dollars and sense, the public record reflects that capitated rates vary by the 11 regions and include a Certified Non-HCBS Rate and a Certified HCBS Rate with other calculations intended to transition a small percentage of appropriate residents from skilled nursing homes into ALF settings. There is a blended payment from AHCA to the LTC plan providers based on the number of plan participant’s enrolled. In this managed care model, the LTC plans in turn have contracts in place with SNF’s, ALF’s and other home and community based providers to deliver services intended to meet the client needs / level of care. As mentioned, the rates differ by region and though I am not a mathematician, the capitated rates used for calculating blended payments, (unclear of the exact amount), to the LTC plans simply do not add up, especially when meeting Medicaid rates to the Non-HCBS facilities. We won’t even drift into addressing the problem of resident’s who currently reside in many facilities who have been parked on a waitlist for months, or years. This broken system has placed a large strain on the infrastructure of the industry.

We will begin Florida’s Legislative Session in January 2016 and the discord continues, from the expansion of Medicaid aka as closing the gap, gun laws and the Governor’s proposed budget. Gov. Rick Scott Budget

Long Term Care Funding

As various agencies and providers tasked with their SMMC roles and responsibilities are feeling the squeeze, this issue simply cannot be ignored. Though everyone is looking for funding, the immediate need is to provide a “patch” for the Assisted Living Facility providers with a fair, reasonable increase to the reimbursement rate. The LTC plans should also have no ability to mandate negotiated room & board rates and to make deductions from their contracted payments to providers. Why, when we already know these facilities are paid below average amounts, would such a restriction or limitation be in place? The success of the SMMC program hinges on the ability to deliver services and provide affordable care options of which assisted living is that continum of care. Providing the adequate financial resources necessary to cover fair & reasonable costs for each SMMC recipient in assisted living will ensure that thousands under the LTC plan can remain safely in place, receiving the care and services they deserve.

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