How to Gauge Quality HCBS

Under contract with CMS's Center for Medicaid and CHIP Services and the Medicare-Medicaid Coordination Office, Mathematica is developing reliable and valid quality measures for people with disabilities and older adults receiving long-term services and supports (LTSS) in institutions or home- and community-based settings. LeadingAge members that operate non-emergency transportation, home care, adult day services and case management services have served Medicare-Medicaid (dual) enrollees and Medicaid beneficiaries for many years. The move towards increasing the use of mandated quality measures that will eventually determine utilization and reimbursement is continuing, and it is important for all of us to comment on how states will gauge the strength and performance of HCBS systems. LeadingAge submitted comments on the questions asked by Mathematica concerning the measure concepts. The questions included:

LeadingAge stressed the following in our comments on measures for Medicare-Medicaid (dual) beneficiaries and Medicaid beneficiaries using home and community-based services: 

• Don’t assume that Medicaid beneficiaries with intellectual/developmental disabilities; physical disabilities, mental health diagnosis and frail elders all have the same rates of success in the rebalanced Medicaid delivery system in a state. In the Money Follows the Person Program, 63% of the persons transitioned to the community were under 65. Only 37% of the persons transitioned to the community through MFP were older adults. So a state may have successfully provided access to HCBS for the ID/DD population, it may have poor outcomes  for older adults receiving HCBS. 
• It is important to collect data that reflects rural areas within a state and urban areas since the access to non-emergency transportation, home care, adult day services and case management services may be limited in these areas. 
• It is also important not to access the data in all waivers and state plans as though they were the same. Benefits and eligibility levels vary. Unlike a 1915(c) waiver, a 1915 ( i ) establishes separate additional needs-based criteria for individual HCBS. 

LeadingAge recommended defining HCBS based on provider type. Services provided by an assisted living center under a 1915 ( c ) Medicaid waiver  differ from an adult day health program or personal care program. Measures should take into account the diversity of scope of services provided within HCBS.