Rapid Response Podcast: The 80/20 Rule with David Totaro of BAYADA Hearts For Home Care

 In Podcasts, Preparing for the Future

On Monday, April 22, 2024, the Centers for Medicare & Medicaid Services (CMS) released the final Medicaid Access Rule, a 1,000+ page set of regulations. It covered many topics and providers are still examining the nuances of what the rule will mean for the 56 Medicaid programs and the home- and community-based services (HCBS) they provide to beneficiaries.

Transcend hosted David Totaro of BAYADA Hearts for Home Care for a rapid response podcast to start to understand the consequences of the rule, and specifically the 80/20 portions that have had home care providers so concerned for the last year. We talked through some of the finer points, made a few predictions, and shared ways home-based care advocates could get involved.

At a high level, David walked us through some key points:

  • Understanding the 80/20 rule. At the core, it mandates that 80% of payments for HCBS should be passed through to the bedside caregiver. CMS did make some tweaks to these proposals, such as including payroll taxes, training expenses and RN supervisors who provide direct patient care in the 80%, and allowing agencies to not have to include mileage reimbursement in their calculations. Even with these tweaks, providers are concerned that they will face operating deficits if the 80/20 portion of the rule goes into effect. CMS extended the glide path to implementation for this portion from 2028 to 2030, giving time for programs and Medicaid to prepare.
  • Beyond the 80/20 Component. The rule had many other key features that affect HCBS, like quality reporting, hardship exemptions and several others. It will take some time to fully analyze all of the components and understand how they’ll affect home care.
  • Unintended Consequences. There are 56 (you read that right) Medicaid programs. This one-size-fits-all approach doesn’t take into account the different requirements and regulations in each state, let alone the different reimbursement rates they offer for HCBS. How will such a broad and unfunded mandate align with 56 programs?
  • The Impact on Providers. Providers, both large and small, are feeling the pressure. With razor-thin margins, the 80/20 rule threatens to force many to reduce services or shut their doors entirely. The ripple effect is anticipated to be felt most keenly in rural and underserved areas. This may be a true access issue in the years to come.
  • An Admirable but Shortsighted Goal. Everyone in the HCBS community agrees that bedside caregivers need to be paid more, full stop. But margins are already very thin for agencies and this approach doesn’t recognize that. With a white-hot labor market added into the mix, you have a recipe for closures and service area condensing.
  • Counterintuitive Thinking. It frustrates many providers that HCBS saves money over the alternatives, but CMS continues to under-invest in these programs. Patients and beneficiaries want to be at home, as opposed to an institutional setting, and keeping them in the community has been a proven way to save taxpayer dollars.
  • Light at the End of the Tunnel? But wait, there’s hope! Legislative action is underway, with proposed bills aiming to halt or modify the rule. Advocacy efforts are in full swing, urging Congress to reconsider the one-size-fits-all approach and seek more sustainable solutions.

What you can do next.

Only time will tell how this affects home-based care, but one thing is for certain – power lies in our collective voices. Whether you’re a caregiver, an administrator or simply passionate about home-based care, there are ways to make a difference. Reach out to your representatives, stay informed, and join the movement for change. Signing up for BAYADA Hearts for Home Care’s action alerts or alerts through a NAHC or Home Care Association of America membership is a great way to affect meaningful change and keep up to date.

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