Meeting the Challenge in Payer Relations

The importance of payers outside of traditional Medicare continues to grow for home medical equipment (HME) suppliers, and the American Association for Homecare (AAHomecare) is playing a growing role in coordinating efforts to ensure sustainable reimbursements and patient access across a wide range of payers. Since I joined the AAHomecare team in May 2016 to develop a comprehensive payer relations program, the opportunities to protect HME interests in this area have increased.

The Medicaid beneficiary population has grown by 26% since the 2010 Affordable Care Act broadened eligibility for states expanding Medicaid programs and funded efforts to raise awareness of the program. However, as the number of enrollees has grown to 72 million Americans, states have looked for ways to keep program costs down, and HME is among the areas that budget officials have looked to for savings.

The 2016 Cures Act, which limited aggregate federal Medicaid reimbursement for HME to what Medicare would have allowed for those items, raised the stakes further—especially as the Centers for Medicare & Medicaid Services (CMS) suggested that states could simply cut rates on a wide range of HME HCPCS codes to match Medicare reimbursement. Working with HME stakeholders nationwide, AAHomecare educated state Medicaid officials, legislators and other government officials on their options to meet Cures Act requirements without reflexively matching Medicare rates. These efforts were extraordinarily successful: Advocates prevented or limited rate cuts in 30 states in 2018 and were able to largely hold the line for 2019.

In addition to protecting Medicaid reimbursements across a wide swath of the country, this campaign allowed the association to develop relationships with state officials and leaders of state and regional associations; we also worked to develop messaging about how sustainable home medical equipment rates can improve patient outcomes and limit the need for costly clinical interventions.

Today, we’re building on those successes by proactively working to establish rate floors for HME Medicaid to keep prices stable in the future. We’re partnering with HME stakeholders in Florida, Indiana, New Hampshire, North Carolina, Texas and Virginia to advocate for rate floor legislation. In California, where leaders of the California Association of Medical Products Suppliers limited proposed cuts that could have reduced rates by nearly 60% in some cases, we are supporting efforts to repeal a 2011 state law that established an additional 10% Medicaid cut.

Budget pressures and a sizable Medicaid population mean the HME community will need to stay vigilant for years to come. Fortunately, our success in forestalling cuts the past two years has given providers and advocates a blueprint to work from.

MCO Outreach & Oversight Remain Priorities

While protecting Medicaid reimbursement rates is a linchpin of our work, we are actively engaged with other payers. As states increasingly rely on managed care organizations (MCOs) to administer their Medicaid programs, AAHomecare has established relationships with leaders at several of these organizations. A fall 2019 face-to-face meeting with CareCentrix executives, for example, allowed us to share feedback from the provider community on several claims processing issues that were subsequently addressed by the company. More recently, we were able to convince CareCentrix to reconsider plans to withhold payments to providers on positive airway pressure devices for patients with copay balances of more than 180 days. By building relationships with multiple individuals at these MCOs and staying in regular communication, we’ve earned a level of credibility as representatives of the provider community, which has helped resolve issues in a timely fashion.

We are also looking to strengthen state level oversight and establish quality standards for Medicaid MCOs, and to access data from state Medicaid authorities and MCOs to gain understanding of the broad fiscal and patient-outcome impacts of reimbursement cuts. 

This effort, led by AAHomecare’s newly formed Payer Relations Council, will include further developing our Freedom of Information Act request process to get claims data from states and MCOs. This data will help us demonstrate how HME supports better patient outcomes and helps keeps health care costs down. These efforts will also supplement and improve our capabilities in obtaining data from CMS and could have wide-ranging impacts on how we make the case for HME at the federal and state level.

In addition, we’ve worked with TRICARE to smooth consolidation and transition of regional administrators and to make sure that suppliers serving TRICARE patients received the same relief afforded to Medicare suppliers under the Cures bill. We’ve also helped prevent sole source arrangements in North Carolina and South Carolina, and we continue to educate officials in California, Ohio, Michigan and Florida about the benefits of keeping open network access for HME. In Tennessee, we worked with mobility stakeholders to secure a separate Medicaid benefit for complex rehab technology wheelchairs and accessories—and we are looking for opportunities to replicate that success in other states.

Sharing Best Practices & Expanding the Playing Field

AAHomecare’s State Legislative and Regulatory Workgroup has developed a comprehensive toolkit bringing together insights, best practices and sample legislative language as a resource for leaders at state and regional HME associations to use in their engagements with legislators, regulators, MCOs and other payers. This toolkit will continue to evolve as we learn what works in our payer relations advocacy across the nation. 

In addition to developing strategies to engage MCOs and other payers on a broad range of issues, the Payer Relations Council is working on developing stronger messaging on the value of HME and home-based care to help ensure payers and state officials understand HME’s role in the care continuum. The council is also exploring value-based care models for homecare and ways to position our industry to utilize that approach with a range of payers.

Formally bringing together more than two dozen highly experienced HME leaders allows us to expand the playing field, impacting more states and adding outreach and oversight for Medicare Advantage plans to our agenda for 2020 and beyond. We have an incredible opportunity to unite our industry’s advocacy work across a broad and important spectrum of payers over the next few years, and we can’t afford to waste it. I’m confident we’re moving in the right direction, and I’m excited about what we will accomplish together.