AOTA Comments on Medicaid Program

8/6/2019 AOTA Comments on Medicaid Program

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July 5, 2011

Centers for Medicare and Medicaid ServicesDepartment of Health and Human Services

Attention: CMS-2328-P

Baltimore, MD 21244-1850

RE: CMS-2328-P

AOTA comments on proposed rule on the Medicaid Program: Methods for Assuring

Access to Covered Medicaid Services, Federal Register, May 6, 2011.

Dear Sir or Madam:

The American Occupational Therapy Association (AOTA), the national professional association

representing the interests of more than 140,000 occupational therapy practitioners appreciates the

opportunity to comment on this proposed rule which has the potential to have a major impact onaccess to appropriate services – and appropriate providers of these services -- for children and

adults who are Medicaid beneficiaries.

Because occupational therapists and occupational therapy assistants provide services to people

across the lifespan with a focus on wellness, prevention, rehabilitation, and maintenance of existing function, AOTA is particularly interested in any changes that will have a direct impact

on the ability of children, adults, seniors and individuals with disabilities and chronic conditions

to receive the supports and services they need to function as independently as possible.

Occupational therapy places a major focus on providing individualized supports and services in

the least restrictive environment. Occupational therapy practitioners have a holistic perspective,in which the focus is on adapting the environment to fit the person, and the person always is anintegral part of the therapy team.

Occupational therapy services typically include an individualized evaluation, during which theindividual/family and occupational therapist work together to determine the person’s goals. OTs

and OTAs provide customized interventions to improve the person’s ability to perform daily

activities and reach specific goals. All efforts include an outcomes evaluation to ensure that theappropriate goals have been established and are being met and – if needed -- to make changes to

the intervention plan. Occupational therapy services may include: comprehensive evaluations of

the individual’s home and other environments (e.g., workplace, school); recommendations for

adaptive equipment and training in its use; as well as guidance and education for familymembers and caregivers.

AOTA provides the following specific comments both to (1) offer its support for the innovative

key concepts embedded in this proposed rule; and (2) to offer specific recommendations which

AOTA believes will assist the Department to strengthen the eventual final rule.



AOTA supports the Centers for Medicare and Medicaid Services (CMS) efforts to make states

more accountable for ensuring sufficient access to quality services for beneficiaries of all ages.However, AOTA asserts that the Department must be very clear as it defines the terms

“sufficient access” and “quality” and that these definitions fit all categories of beneficiaries. For

example, the population of individuals with whom OTs work, too often face the obstacle of a

very narrow definition of medical necessity which either limits or even prohibits access to theservices and supports they need to live in the community. Effective monitoring and enforcement

of state actions is a critical key to the success of any effort to ensure that people get access to the

services they need.

While AOTA and other providers realize that states are facing budget deficits, we are extremely

concerned with the emphasis-- actually almost the acceptance as fact-- that additional ratereductions are the key part of this effort. Currently more and more providers are being forced out

of the Medicaid program because of ongoing rate cuts in both the Fee for Service (FSS) and

managed care structures. AOTA strongly believes – and has data to back up the fact -- that OTservices help keep people of all ages become and remain more independent, productive and less

dependent on the health care system. We are extremely concerned with the impact that the focuson rate cuts will have on beneficiaries’ access to critically needed OT services and supports.

AOTA has always supported provisions that allow more beneficiary and stakeholder input into

state actions – actions that will have a direct impact on both beneficiaries and those who provide

them with services and supports.

However, it appears in this proposed rule that beneficiary and stakeholder input mostly will be

related to any State Plan Amendments (SPA) which reduce or restructure payment rates. Thisemphasis on more rate reductions is of major concern. Also of major concern, however, is the

need to ensure that beneficiaries and providers who– though they may have the right to participate in the process– may not be fully educated as to all the potential outcomes of a SPA

and what changes in provider rates will really mean to them as beneficiaries. In addition, their

participation must not be last minute and must not be viewed by the state as pro-forma. Theremust be proper notice and the input of stakeholders must be considered.

AOTA questions why the provisions of this proposed rule apply only to state FFS Medicaid and

do not apply to managed care arrangements. The Preamble states that “managed care entities aresubject to separate access review procedures”…..and that “the Department is currently

undertaking a review of states managed care access standards”. At a time when over 70 percent

of the Medicaid population is enrolled in some form of managed care, and when managed carerestrictions have been extremely problematic for children and adults with disabilities and chronic

illness, it certainly appears to AOTA that any focus on protecting access to needed services

should include managed care. In addition, in relation to rate setting, too often in managed care itis the very low capitation rates, along with very limited definitions of “medical necessity” that

limit individuals with disabilities and chronic illness from access to the services they need to live

as independently as they can in the community – for their whole lives.

One final comment related to rate setting refers to the statement that some states develop rates on

“a review of the amount paid by commercial payers in the private market”. When it comes to the



needs of individuals with disabilities and chronic conditions, too often the fact is that access to

needed rehabilitation or habilitation services and supports is extremely limited in the privatemarket. This was the major motivation behind the enactment of the Family Opportunity Act

(FOA), which as a state option, allows families with incomes above the set Medicaid level and

who have a child with a disability to buy into the Medicaid program so that their child can have

access to the full range of services available through the EPSDT program. A foundationalcomponent of the FOA is to allow families with children with disabilities to keep these children

at home where they belong – not forcing them into institutional care. AOTA also asserts that any

changes to the Medicaid program and “access” must not have a negative impact on EPSDT.

The proposed rule for the Medicaid Program: Home and Community-Based Services (HCBS)

Waivers placed a great deal of emphasis on person-centered planning. CMS took a very proactive and positive position stating that “through this proposed rule, we include expectations

that each individual within the waiver, regardless of target group (people with intellectual and/or

developmental disabilities, individuals with physical, sensory, or mental health disabilities; andindividuals who are facing health problems and disabilities due to the aging process.) has equal

access to the services necessary to meet their unique needs”. As the Department finalizes the proposed rule, Medicaid Program: Methods for Assuring Access to Covered Medicaid Services,

AOTA strongly urges the Department to consider the requirements in the HCBS proposed rule.

AOTA strongly supports the Medicaid program. It is a program that has been a life line for

millions of individuals of all ages. AOTA also recognizes that the nation is facing a fiscal crisis – as are the states – but any changes to the program must ensure that “access” is appropriate for

each individual beneficiary and not defined based on the needs of those with the lowest level of

health care needs. Focusing mainly on lowering already inadequate reimbursement rates can onlyhave a negative impact on millions of beneficiaries with high health care needs

AOTA recommends a strong focus on effective monitoring and enforcement of this rule. The

success of any new initiative relies heavily upon the effectiveness of the monitoring and

enforcement of these rules to ensure that people have access to the supports and services theyneed in the community. The final regulations must provide for the Department to exercise timely

and meaningful oversight over SPA compliance. While almost every state is facing a budget

crisis and while some states may be eager to move forward in innovative ways, other states may

not be of the same mind set. If you have any questions, please feel free to contact AOTA FederalAffairs Department directly at [email protected]. Thank you for your consideration of our comments.

Sincerely:

Tim Nanof

Federal Affairs Manager American Occupational Therapy Association

[email protected]

Documents

AOTA Comments on Medicaid Program