MACPAC Recommends Payment Policies for HCBS Workforce Support

ALEXANDRIA, Virginia & WASHINGTON—At its September public meeting, the Medicaid and CHIP Payment and Access Commission (MACPAC) released draft recommendations for Medicaid payment policies intended to support the home- and community-based services (HCBS) workforce.

“The Secretary of the Department of Health and Human Services (HHS) should direct the Centers for Medicare & Medicaid Services (CMS) to require states to report, on a biannual basis, hourly wages paid to home- and community-based services workers who provide the following services: personal care, home health aide, homemaker and habilitation,” the draft recommendation said. “States should report descriptive statistics on hourly wages for each service, including mean, median and range. For each service, these data should be disaggregated by worker characteristics determined by HHS, including but not limited to: by licensed nurses and all other direct care workers, and by rural versus urban settings.”

“In previous MACPAC public meetings, staff discussed findings from a compendium of HCBS authorities, federal and state interviews and a technical expert panel that explored strategies to ensure that HCBS payment rates are adequate to attract and retain a sufficient workforce,” said a written statement on MACAC’s website. “During this session, staff presented a draft recommendation to promote the HCBS workforce for commissioner consideration and a future commission vote.”

The recommendations made by MACPAC recieved pushback from some in the home health industry. The National Alliance for Care at Home (the Alliance) said that the recommendations should be more centered on solutions rather than data.

“We are concerned about the draft recommendation MACPAC discussed during today’s meeting,” the Alliance said. “Rather than seeking to address the root cause of low worker wages, MACPAC’s recommendation instead focuses on collecting additional information that would further describe the issue. This approach increases administrative burden on states and providers without actually proposing solutions to this problem.”

The Alliance added it appreciates MACPAC’s interest in addressing issues related to worker pay in HCBS and that it urges MACPAC and its commissioners to recommend structural changes to federal Medicaid law and regulations that mandate payment policies ensuring access to HCBS through livable wages for direct care workers. 

The Alliance also said CMS should be given the authority to require states to perform comprehensive rate studies at least every five years that:

• Use generally accepted accounting practices to develop a payment methodology that assures continued adequacy of each component of the rate model
• Establish a rate model that includes individualized components for core provider cost drivers as well as a livable wage for workers
• Submit a copy of the rate review report and recommendations with any waiver renewal or state plan amendment and make the report publicly available on their website
• Require states to justify any variance between the report recommendations and the actual established payment rates
• Disapprove rate methodologies that do not clearly account for all statutory and regulatory requirements of delivering services as well as demonstrating that the rates are sufficient to support a livable wage for workers

“Our members are committed to improving the lives and livelihoods of direct care workers because beneficiaries depend on them,” the Alliance said. “We call on MACPAC to ensure that states and the federal government are equal partners in this critical endeavor.”