HOUSE OF REPRESENTATIVES

H.R. NO.

153

TWENTY-SEVENTH LEGISLATURE, 2013

 

STATE OF HAWAII

 

 

 

 

 

HOUSE RESOLUTION

 

 

Requesting the department of HUman services to study the rights and due process requirements regarding complaints, grievances, and appeals across care settings for medicaid nursing facility level of care clients who receive home and community based services.

 

 

 


     WHEREAS, effective February 1, 2009, Medicaid members who were 65 years or older or of any age with a disability were enrolled in the QUEST Expanded Access (QExA) Program.  As of January 2013, there were 45,363 elderly and disabled individuals in the QExA Program per Department of Human Services and Med-QUEST Division statistics; and

 

     WHEREAS, many of these elderly and disabled individuals are determined to be at a certified nursing home level of care, i.e., skilled nursing level of care, intermediate care facility level of care, or sub-acute level of care, as certified by Hawaii's Peer Review Organization through a standardized DHS 1147 Form; and

 

     WHEREAS, one of the stated goals of the QExA Program is to increase the percentage of certified nursing home level of care clients in home and community based services as a least restrictive care option to nursing home institutions; provided that those members who desire, or no longer can be safely serviced in their home, may also choose to receive home and community based services in community care foster family homes, expanded residential care homes, or assisted living homes with the QExA managed care plan acting as the payor of services with an assigned case manager; and

 

     WHEREAS, all community care settings that provide 24-hour care for QExA clients at nursing facility level of care, including community care foster family homes, expanded care homes, and assisted living facilities must comply with all applicable federal regulations; and

 

     WHEREAS, Hawaii's statewide percentage of the nursing home level of care population receiving home and community based services has increased from 40.2 percent in 2008 to 64.9 percent in 2012; and

 

     WHEREAS, the Med-QUEST Quality Strategy sets an increase of five percent per year for clients receiving their care in a home and community based services setting as a target for the QExA Program; and

 

     WHEREAS, Hawaii's remaining QExA members at certified nursing facility level of care receive their care in an institutional setting with the QExA managed care plan acting as the payor of services with an assigned case manager; and

 

     WHEREAS, the Legislature finds that certified nursing facility level of care recipients are considered the most vulnerable population within the Medicaid managed-care populations, and these individuals' rights to due process and to quality care are protected by strict federal regulations especially in regards to the expansive complaints, grievance, and appeals processes as clearly stated in the Balanced Budget Act of 1997, 42 C.F.R. Part 438; and

 

     WHEREAS, in addition to the far reaching federal regulations specified in 42 C.F.R. Part 438, the Centers for Medicare and Medicaid Services has organized assurances for quality of care into a Home and Community Based Services Quality Framework that focuses attention on participant-centered desired outcomes, including participant rights and responsibilities and participant outcomes and satisfaction; and

 

     WHEREAS, the Legislature finds that the Centers for Medicare and Medicaid Services receives quarterly and annual reports from the Med-QUEST Division, which include details of compliance with the Balanced Budget Act of 1997, 42 C.F.R. Part 438, Subparts A, C, D, and F as part of the Centers for Medicare and Medicaid Services' oversight of the Hawaii QUEST Expanded Section 115 Demonstration Waiver; now, therefore,
     BE IT RESOLVED by the House of Representatives of the Twenty-seventh Legislature of the State of Hawaii, Regular Session of 2013, that the Department of Human Services is requested to conduct a study on the level of compliance with certain regulatory requirements in health care settings that provide care for Medicaid nursing home level of care individuals enrolled in the QExA Program; and

 

     BE IT FURTHER RESOLVED that the scope of the study is requested to include compliance with the regulatory requirements of the:

 

     (1)  Balanced Budget Act, 1997, 42 C.F.R. Part 438, Subparts A, C, D, and F;

 

     (2)  Applicable Department of Human Services, Med-QUEST Division, and QExA current contract requirements;

 

     (3)  Med-QUEST Quality Strategy; and

 

     (4)  Med-QUEST Quality Standards; and

 

     BE IT FURTHER RESOLVED that the scope of the study is requested also to include information on whether all certified nursing level of care clients are informed of, and have their rights regarding complaints, grievances, and appeals fully protected, implemented and reported as required in the community setting for home and community based services clients who are living in their private homes if serviced by case management agencies, community care foster family homes, expanded residential care homes, or assisted living facilities; and

 

     BE IT FURTHER RESOLVED that the Department of Human Services is requested to include in the report of its study a review:

 

     (1)  Of case management agency contracts to insure that all certified case management agencies are in compliance with federal regulations, QExA contracts, the Med-QUEST Division Quality Strategy, the Med-QUEST Division Quality Standards, and applicable state regulations;

 

     (2)  On whether QExA-contracted Medicaid providers who provide 24-hour care to QExA clients in home and community based settings are in compliance with federal requirements, current QExA contracts, the Med-QUEST Division Quality Strategy, the Med-QUEST Division Quality Standards, and applicable state regulations;

 

     (3)  Of the Department of Human Services Social Service Department contract with Community Ties of America to insure that their scope of service regarding compliance monitoring processes within any care setting as designated per contracts that service Medicaid QExA nursing facility level of care clients are in compliance with federal requirements, current QExA contracts, the Med-QUEST Division Quality Strategy, the Med-QUEST Division Quality Standards, and applicable state regulations;

 

     (4)  On whether the federal regulations, current QExA contract, the Med-QUEST Division Quality Strategy, and the Med-QUEST Division Quality Standards are applicable across all other institutional nursing facilities, such as free standing long term care facilities or hospital-based long term care facilities that provide 24-hour care at the skilled nursing level, intermediate care facility, or sub acute nursing level of care for Medicaid QExA clients; and

 

     (5)  Of the notification and implementation processes of member rights for Hawaii's Medicaid QExA clients at certified nursing home level of care across all care settings in regards to due process concerning complaints, grievance and appeal processes, as well as a review of the protection and implementation of contracted provider's rights to their grievance and appeal processes who provide 24-hour home and community based services; and

     BE IT FURTHER RESOLVED that the Department of Human Services is requested to submit its study report, including findings and recommendations, and any necessary implementing legislation needed to bring state and federal regulations into alignment in regards to home and community based services to the Legislature no later than 20 days prior to the convening of the Regular Session of 2014; and

 

     BE IT FURTHER RESOLVED that certified copies of this Resolution be transmitted to the Director of Human Services, Administrator of the Med-QUEST Division, Administrator of the Social Services Division, and Administrator of the Adult and Community Care Services Branch.

 

 

 

 

OFFERED BY:

_____________________________

 

 

Report Title: 

QUEST Expanded Access; Nursing Home Level of Care