Push underway to fix state funding for elderly housing

Wednesday, September 6, 2017

Veto, rule change impacts nursing homes, assisted living

Advocates for the elderly and disabled in Missouri are pushing legislators and Gov. Eric Greitens for another special legislative session this month to address a controversial rule change in state funding primarily targeting the ailing and elderly.

The Missouri Assisted Living Association and the Missouri Health Care Association are among those pushing to have a special session of the Missouri General Assembly called to coincide with the annual veto session, slated for Sept. 13. At issue will be whether senior citizens threatened with losing funding for their assisted living or nursing home residency will be forced into other arrangements.

According to Jorgen Schlemeier, government affairs consultant for the Missouri Assisted Living Association and the Missouri Health Care Association, Gov. Greitens precipitated the current situation by changing rules and regulations to support his budget. In an effort to save $50 million, Greitens proposed changing the standard for how sick a person must be to receive state money supporting Medicaid benefits for in-home services or nursing home and assisted living.

Unlike past governors, Greitens proposed raising the Medicaid standard for qualifying for state support from the long-used 21-point threshold to 24 points. He filed a fiscal note with his budget statement, directing the legislature to cut provider rates for in-home and assisted living by 3 percent, and 3.5 person for nursing homes. Those impacted would be senior citizens, disabled veterans and babies.

"This is a horrible policy decision," Schlemeier said. "If we reassess you on a point system next year for sickness, if you havenít got sicker and not up to 24 points on scale, you can't get services for assisted living or nursing homes."

By calculation, the difference between 21 and 24 points would be 8,360 people. Schlemeier said Greitens calculated that all of these people would simply fall off eligibility, and not become more ill and re-qualify over time. In addition, he said one ambulance trip for a patient, let alone a day in the hospital, would eat up any savings the governor projected.

The state support for in-home and assisted living served as a preventative measure, keeping people out of hospitals. Without funding that helps people stay in these supported living facilities, those in declining health would be forced to try to live on their own.

Joyce Furnell, with Bristol Care in Sedalia, identified two people she knows who will be impacted by the changes. She pointed to Marietta, an 84-year-old who lives in Eldon.

"Marietta's Medicaid assessment says she has osteoporosis, hyper-thyroidism and problems with her knees," Strong said. "She has issues with mobility. She needs a walker, and needs help with that. She can't manage independent meal preparation. She requires assistance getting in and out of shower and drying off. She uses lift chair to get up. She sees her primary care physician for all her checkups. She takes 15 meds. She can't manage independently if she lived at home.

"She was denied funding for the assisted living program. Her assessment says she can't live on own. People are asking us 'Where do we go? We can't come to you. We cant go to skilled facility.' I have no answer for these families."

In another case, Furnell spoke about a man named Kevin, 60, who lives in Webb City. Kevin, who is classified as "borderline intellect," applied to live in a care facility on Aug. 1. He has been living at home, with some assistance from his sister. He has seizures, high blood pressure, and heart disease, cannot cook safely, cannot understand his need for medications or take them properly on his own. He will not bath or change his clothes unless asked.

"After July 15 [when the new regulations went into effect], Kevin was not eligible for service," Strong said. "He needs to qualify for state funding. Assisted living is reimbursed differently from skilled nursing. For us to have any Medicaid participation, he has to fall within 24 points. We assessed him at 21. He's not sick enough and not poor enough for Medicaid."

In addition, Greitens also moved to cut rates for private duty nursing by 6 percent. Schlemeier said that program allows parents to bring prematurely born babies home earlier and receive support at home that otherwise can only come from neonatal care at the hospital. The difference in dollars is $600 per day paid for private duty nursing vs. $6,000 per day in a hospital stay.

Likewise, Nikki Strong, executive vice president of the Missouri Health Care Association in Jefferson City, said nursing homes now average a per diem of $153 per day paid from Medicaid. "The state's portion is a sliver of that," she said. In contrast, a hospital stay costs $2,500 a day.

In the past 10 years, Strong said, legislators had never run into such a proposal, even with a Republican-led General Assembly. Greitens initially recommended placing the state funding threshold at 27 points. Lawmakers immediately tried to figure out ways to restore funding. In response to political push-back, Greitens submitted a budget amendment dipping into a one-time $50 million tobacco settlement to reduce some of the cuts.

"State Rep. Scott Fitzpatrick, R-Shell Knob, chairman of the House budget committee, said 'no way' on 27 points," Schlemeier said. "He dedicated general revenue to get the qualification back to 24 to buy points back. It wasn't enough to get back to 21."

Fitzpatrick suggested a circuit breaker where seniors under a certain income level would get a credit for the amount of property tax paid on property they owned. Another proposal was offered for renters.

Fitzpatrick's proposal won House approval. The Missouri Senate proposed its own solution, a temporary fix that Fitzpatrick did not like. The debate continued up until the last minute of the legislative session. Seeing no options, Fitzpatrick put the Senate's version up for a vote, and it passed.

"At that point, all is good," Schlemeier said. "We still had a point threshold of 21. We got half the rates back. But Gov. Greitens vetoed the bill and filed the rule to implement the cuts. That's what we're living under now."

Those impacted by the rule change had 30-days notice of the change, then another 30 days to appeal. With the rate cuts going into effect on July 1, the first people affected will see their 60-day window run out on Sept. 15. A fix coinciding with the veto session on Sept. 13 could head off the deadline.

Two methods are open to lawmakers for calling a special session. Greitens, who receiving significant pressure over the bill, could call it. Legislators could also force a session by petition, if 75 percent of both houses act. That method has never been used before, Schlemeier said, but is not out of the question this time.

He noted that State Sen. David Sate, R-Cassville, as a professional pharmacist, advocated for another funding mechanism to preserve the 21-point standard.

State Rep. Mike Moon, R-Ash Grove, said he voted against HCB 3, the Senate version, because he didn't like the Senate's temporary solution.

"Our population [impacted by the change] is middle class people who worked, tax abiding citizens who spent down their savings and outlived their resources," Strong said. "They've sold their homes and are living in our facilities. Veterans are a lot of our people. Now they're too ill and need our services. They prefer to stay in their communities. Likewise the disabled. They can't work. They're a little different from the population we serve."

"Sometimes we focus on financial impact and forget what's happening to our neighbors, like our friend's mother," Furnell said.

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