PROVIDENCE – Deep within the weeds of the proposed FY 2017 state budget, there are some interesting choices in language reflecting changes in policy in some of the specific items in the R.I. Executive Office of Health and Human Services expenditures, related to the future Medicaid budget, that a number of health care advocates have shared with ConvergenceRI.

Question: Why is the state, in Article 7, under subsection (f), labeled “Integrated Care Initiative – Enrollment,” apparently attempting to make managed care enrollment mandatory under Rhody Health Options.

Currently, seniors can opt out of enrolling in the Medicaid option offered by Neighborhood Health Plan of Rhode Island, a policy that has been in place since implementation of Rhody Health Options was begin in the fall of 2013. Yet, under the proposed budget, enrollment would now become mandatory.

Such a move may not be allowed by the Centers for Medicare and Medicaid Services, according to some advocates. A state that makes enrollment mandatory has to provide a choice of at least two plans, under regulation 42 CFR 438.52. With Rhody Health Options, the only option currently provided is Neighborhood Health Plan of Rhode Island.

Question: What is the intended result, in Article 7, under subsection (i), labeled “Federal Financing Opportunities,” which states: “The EOHHS proposes to review Medicaid requirements and opportunities under the U.S. Patient Protection and Affordable Care Act of 2010 and various other recently enacted federal laws and pursue any changes in the Rhode Island Medicaid program that promote service quality, access and cost-effectiveness [emphasis added] that may warrant a Medicaid State Plan Amendment or amendment under the terms and conditions of Rhode Island’s section 1115 Waiver, its successor or any extension thereof. Any such actions the EOHHS takes shall not have an adverse impact on beneficiaries or cause an increase in expenditures beyond the amount appropriated for state fiscal year 2017.”

On its face value, it appears the language would give the R.I. Executive Office of Health and Human Services the capability to make changes, including budget cuts, without having to seek any legislative approval, according to advocates.

A similar kind of “the sky’s the limit” clause appears in Article 9, on Page 126 of the budget document. It states that the R.I. EOHHS is broadly empowered to: “identify and implement fiscal controls within the overall budget of the office of health and human services, as needed, to achieve the full savings enacted in the FY 2016 appropriations act under the Reinventing Medicaid Initiative.

Question: Does this language permit the R.I. EOHHS to make budget cuts at will, without the approval of the R.I. General Assembly, in order to achieve the projected “Reinventing Medicaid” budget savings?

More questions
Questions: What are the numbers for patients in nursing facilities that have been transitioned back to the home or community-based settings that have been achieved by the Rhody Health Options program begun in November of 2013, as compared to transitions from the previous programs? Can the results be measured as a way of providing accountability around costs, efficiencies and outcomes, as a way of providing evidence-based metrics about the success of the program?

Some background. One of the initial premises of the Rhody Health Options program under the Integrated Care Initiative was that there would be as many as 3,000 residents in nursing homes that would be able to be transitioned back to the community, according to projections offered by the R.I. EOHHS in 2013.

The expectation was that Neighborhood Health Plan of Rhode Island, the contractor, would be able to leverage its expertise in case management services to support these transitions.

This work was based on the programs that grew out of the initial Global Waiver in 2009, with the major goal of re-balancing long-term care spending by increasing access to home and community-based long term care, and decreasing reliance on nursing facility care.

Toward that end, a Nursing Home Transition Program was developed by R.I. EOHHS, so that beneficiaries in nursing facilities who had the desire and potential to be discharged to home or community-based settings would be identified and given assistance in making that transition. Services to support these transitions included the arrangement of home care services and equipment, and home modifications.

In 2011, Rhode Island received a Money Follows the Person Demonstration grant, and that program worked in conjunction with the Nursing Home Transition Program.

Surprising answers
The answers may be surprising to many: in 2015, there were 94 total transitions, with 46 transitions managed by Neighborhood Health Plan, 23 through the Money Follows the Person program and 13 through the Nursing Home Transition Program, according to reports by the R.I. EOHHS.

The remaining 48 transitions were managed by the Office of Community Programs at R.I. EOHHS.

When the 2015 total of 94 transitions is compared to the total number of transitions in 2010, 2011 and 2012 – 128, 138 and 149 respectively, before Neighborhood Health Plan was involved – the evidence appears to show that the overall effect that Neighborhood Health Plan had on the number of people being transitioned from nursing facilities to the community was to decrease those numbers.