Mass Home Care Testifies Against Adult Foster Care Rate Cuts


The state’s Executive Office of Health & Human Services held a hearing on March 17th regarding a proposed rate cut to the Adult Foster Care program that would take effect April 20th and cut $2 milion from to the program by June 30, 2017, and another $10 million in FY 18.

Rep. Denise Garlick (D-Needham), the chair of the Mental Health committee, testified against the rate cuts, as did the Mass Council for Adult Foster Care programs.

Excerpts of the testimony from Mass Home Care are shown below:

Mass Home Care Testimony Regarding Adult Foster Care Rates

101 CMR 351.00

March 17, 2017

  1. Statutory Requirements for Rates

The Executive Office of Health & Human Services derives its rate setting authority pursuant to section 13C of chapter 118E of the General Law, where it states:

“The secretary of the executive office shall have the responsibility for establishing rates of payment for social service programs which are reasonable and adequate to meet the costs which are incurred by efficiently and economically operated social service program providers in providing social service programs in conformity with federal and state law, regulations and quality and safety standards…When establishing rates of payment for social service programs, the secretary of the executive office shall adjust rates to take into account factors, including, but not limited to: (i) the reasonable cost to social service program providers of any existing or new governmental mandate that has been enacted, promulgated or imposed by any governmental unit or federal governmental authority; (ii) a cost adjustment factor to reflect changes in reasonable costs of goods and services of social service programs including those attributed to inflation; and (iii) geographic differences in wages, benefits, housing and real estate costs in each metropolitan statistical area of the commonwealth and in any city or town therein where such costs are substantially higher than the average cost within that area as a whole.”  (emphasis added)

In reviewing  any social services rates, we should ask if the methodology to derive those rates produce  a rate which is “reasonable and adequate to meet the costs which are incurred by efficiently and economically operated social service program providers.”


  1. Are these rates Reasonable and Adequate?

Each  time a rate is determined for AFC, the methodology is changed and inconsistent with past rate-settings. For example, in 2003 the state used a method that calculated a daily rate based on the “average hours per day” of staff needed x an hourly rate.

In November of 2006, MassHealth transmitted a new Level II AFC rate set at $82.02 per day, with no methodology cited in the transmittal letter. Ibn 2017, that rate is being proposed cents higher: $82.06–and a cut from the current Level 2 rate of $85.18.

In the 2017 Notice of Public Hearing for these Adult Foster Care rates, EOHHS stated yet another  methodology for determining the AFC rates:

“AFC provider cost report data was reviewed and the proposed rates apply an efficiency standard for indirect costs at the 75th percentile among AFC providers. After these adjustments, the 60th percentile  of unit costs was taken to determine the proposed per diem rates. The proposed amendments to 101 CMR 351.00 also include the additional of code modifiers to determine utilization of medical leave of absence days, and nonmedical leave of absence days as well as changes to align the reporting requirements with other existing EOHHS rate regulations.”


EOHHS does not publish its working papers that the analysts use to reach the rates found in 101 CMR 351. Such working papers can be requested through a public records act request, but the calculations are not included in any document made public as part of the rate hearing process.            There is no consistent pattern or predictability to the methodology the state used to “build” rates for AFC that meet the statutory requirements of section 13C of Chapter 118E.

The following points can be made about this somewhat opaque methodology:

  1. These rates do not meet the standard of being “reasonable and adequate to meet the costs which are incurred by efficiently and economically operated social service program providers.” Instead, EOHHS has usedAFC provider cost report data,” which by definition refers to historical cost statements from prior fiscal years. It can be demonstrated by AFC provider cost reports from prior fiscal years that previous rate increases were neither reasonable nor adequate. In fact, the rate increases for the AFC program in the past, which produced costs reports, had been wholly inadequate and unresponsive to meet the costs incurred by efficiently and economically operated programs.


  1. The AFC program rates promulgated in December of 2006 were in effect until April of 2008, and in May of 2008 were slightly increased, but AFC programs went without another increase for 5.5 years. The rates established in December of 2013 were not changed for 3.33 years. The rate being suggested today is 4 cents higher than it was in FY 2006!

Massachusetts AFC Rates

  1. The AFC rate increases historically over the past decade have been untimely and inadequate. For example, after increasing by only 1.3% in May of 2008, the level 2 rate remained unchanged for 5.5 years without a rate hike, and in December of 2013, the level 2 rate rose by only 2.5%, and saw no change for the next 3.3 years. MassHealth is now proposed to cut the level 2 rate set in December of 2013 by -3.66%, reducing the level 2 rate to roughly the same rate it was granted in December of 2006—9.33 years ago! No human services program can operate a 2017 program based on 2006 rates. This erratic funding pattern, has seriously constrained AFC agency program delivery, because the program spending has to meet imposed budget limitations.

            A methodology that uses an “efficiency standard for indirect costs at the 75th percentile” appears to be entirely arbitrary and capricious when compared to the language found in Chapter 118E, section 13C. EOHHS estimates that these proposed rates will result in a loss to the AFC programs of $10,600,000 in FY 18. Because these rates are based on historically-restrained cost reports, the resulting rates bear no relationship to rates which are “reasonable and adequate to meet the costs which are incurred by efficiently and economically operated social service program providers.”


III. Do these rates take into account  existing or new governmental mandate that has been enacted, promulgated or imposed?

            EOHHS is taking testimony today on 28 pages of updated regulations to the Adult Foster Care program. These proposed regulations contain numerous new governmental mandates that will add to the complexity of managing the AFC program.

Below are highlights of unfunded regulatory mandates:

  • The regs add a Community Health Worker to the Multidisciplinary Professional Team. Although the reason for adding this staff position to the MPT is to give providers the opportunity to substitute a lower cost staff person for an RN or care manager visit, the fact is the new staff will come at a cost: there will be advertising, supervision, training and payroll/fringe costs to the agency.
  • The new regulations require AFC providers to become accredited. Although AFC providers support accreditation, this could be a time-consuming and expensive process, occurring as EOHHS cuts the program funds by $10.6 million annually.
  • AFC providers will be dealing with a new Third Party Administrator for prior authorization, which will increase costs for staff training, and staff time spent preparing and processing prior authorization requests. The EOHHS are falling, but administrative burden is rising.
  • New requirement for annual AFC authorizations for consumers to continue in program
  • The regulations add a new requirement for a new assessment to be performed when a member Transfer from one AFC provider to another.
  • Calculating medical and non-medical Leaves of Absence will become more administratively burdensome because they must be calculated on a consecutive 12 month period basis rather than a simple calendar year basis.
  • Expanded Policy Manuals: the regulations substantially increase the written list of policies and procedures that must now be developed as part of an AFC provider’s policy manual.
  • Expanded Plan of Care Requirements for level 2 members: New plan of care review requirements substantially increase the reporting and documentation requirements mandated for plan of care review for all level 2 members, with a new list of policies and procedures that must be in the plan, including an emergency file with list of required contents.
  • New preadmission procedures and activities that may or may not lead to prior approval. Instead of waiting for prior approval, the regulations require AFC providers to do a full workup on the applicant, right up to a move-in date—without any guarantee of approval by the Third Party Administrator.
  • New Staffing Qualification checks, in addition to already required licenses and certification verification, TB screenings and PS reporting, AFC agencies will now be responsible for pre-hire screening of Sex Offender Registry, OIG checks, checks, These new vetting and training requirements will drive up administrative and personnel costs and prolong the hiring process.
  • Expanded scope of first month staff orientation: such as basic first aid, CPR, emergency procedures, Heimlich maneuver, universal precautions, elder abuse and neglect, critical incident reports, techniques of providing safe personal care assistance, good body mechanics, human rights and non-discrimination, developmental needs of the member, reporting changes in conditions, relevant provisions of the affordable care act, etc.
  • AFC Backup Staff Coverage: As a new requirement, AFC providers must budget for professional and direct care backup staff to cover for illnesses, vacations or other reasons.  This would be an additional line item on AFC Cost Reporting.

The proposed rates do not meet the statutory requirements of providing for the reasonable costs of new government mandates. Given all the programmatic and  administrative changes, it is inconceivable that rates would be reverting to 2006 levels.

  1. Do these rates apply a cost adjustment factor to reflect changes in reasonable costs of goods and services of social service programs including those attributed to inflation?


The explanation of these new rates in the Hearing Notice makes reference to “indirect costs,” “code modifiers,” and “changes to align reporting requirements.” But there is no evidence that these programs, pursuant  to the section 13C requirements, have had any inflation cost adjustments. This has been the pattern for the past decade: long periods with no rate increase, followed my small adjustments, following by rate reductions.


  1. Conclusion

The evidence available suggests that EOHHS has backed into these rates based on a target spending figure for FY 17 and FY 18, by manipulating findings of cost reports that do not reflect the true scope of the current day AFC Program.   This random methodology fails to  address any of the statutory requirements in Chapter 118E for setting rates “which are reasonable and adequate to meet the costs which are incurred by efficiently and economically operated social service program providers,” or which “take into account factors, including, but not limited to: (i) the reasonable cost to social service program providers of any existing or new governmental mandate that has been enacted, promulgated or imposed,” or which take into account “a cost adjustment factor to reflect changes in reasonable costs of goods and services of social service programs including those attributed to inflation,” or which take into account “geographic differences in wages, benefits, housing and real estate costs in each metropolitan statistical area of the commonwealth and in any city or town therein where such costs are substantially higher than the average cost within that area as a whole.”

These rates are not in compliance with state law, and should be withdrawn and recalculated to account for the factors that are required for AFC programs that are “reasonable and adequate to meet the costs which are incurred by efficiently and economically operated social service program providers.”

We also request that all AFC providers be sent a copy of the analyst’s worksheets and methodology that were used to calculate the proposed rate.

Mass Home care thanks EOHHS for the opportunity to testify on these AFC budgetary cuts and proposed rates.





Mass Home Care’s Analysis of President Trump’s FY 18 Budget “Blueprint 3 16 17

Mass Home Care released an analysis of President Trump’s FY 18 “Budget Blueprint.” Here is the release:

Impact of President Trump’s FY 18 Budget Blueprint on Elders in Massachusetts

Mass Home Care 3/16/17

President Trump’s FY 2018 Budget Blueprint sent to Congress March 16th will result in:

  • major cuts in Medicaid enrollment (a drop of 306,000 Medicaid enrollees by 2026—many non-elders–  due to the impact of the American Health Care Act),
  • the loss of $140 million in fuel aid in FFY 18
  • $1.2 million in Older Americans Act funds for social services and meals in FFY 18
  • A loss of 81,317 in elder meals funding  ($609,884) in FFY 18
  • nearly $2 million in senior aide jobs in FFY 18
  • $16.5 million in Community Services Block Grants
  • the end of legal services corporation, and many other federal program noted below.

                                        [all figures based on 3.34% cut in DHHS funds, across the board, below  FFY 17 funds]

DISCLAIMER: The President’s ”Blueprint” budget is more of a press release than a detailed budget. The fact is, Congress is not even finished with the FY 17 budget, and Appropriations Committees will produce a final federal budget that may or not look much like the President’s plan. As in Massachusetts, the Governor submits a House 1 budget document usually in late January, and then after 5 months of deliberations by the General Cour, the final budget is produced—often very different than House 1.

The President’s “skinny” budget is a message to the Congress about the Trump Administration’s funding priorities. The budget contains very few individual program line-items, and many programs that impact the elderly—including funds for Older Americans Act and other aging programs within the Administration for Community Living (ACL) and Administration on Aging (AoA) are not specifically mentioned.

The President’s  FY 18 budget reflect deep cuts below current budget caps and sequestration levels as mandated by the Budget Control Act of 2011. The President does not outline any proposals for mandatory spending, such as Medicare and Social Security, or for federal revenue and tax proposals.

Older Americans Act (OAA) and Other Aging Programs

President Trump proposed funding the Department of Health and Human Services (DHHS), which houses the Administration for Community Living (ACL)  and its Administration on Aging, at $65.1 billion. This is a $12.6 billion cut (-16.2 percent) below current funding. But roughly $10 billion of the overall cut to HHS comes from rolling back recent funding increases for the National Institutes of Health and from eliminating other block-grant programs. That would leave a cut of around 3.34% to make in other DHHS programs. If those cuts were made equally across Older Americans Act programs, the state would lose around $1.21 million Older Americans Act-related federal funds. But the Blueprint contains no data on actual line item cuts.

President Trump wants to eliminate the Older Americans Act Title V Senior Community Services Employment Program (SCSEP), which is housed within the Department of Labor. Last year, Senate appropriators targeted SCSEP for a $34 million cut to its $434 million funding level, but the House lawmakers rejected that cut. The Trump budget would zero out the program entirely. This would result in a loss of $1.88 M to the Community Service Employment program in Massachusetts.

Within the federal Department of Housing and Urban Development (HUD), the President proposed cuts to rental assistance programs, which could include Section 202 Supportive Housing for the Elderly. HUD is slated for an 11.6 percent cut. The Section 202 program helps expand the supply of affordable housing with supportive services for the elderly. It provides very low-income elderly with options that allow them to live independently but in an environment that provides support activities such as cleaning, cooking, transportation, etc.

Other Key Programs Slated for Elimination

In addition to Senior Aides jobs, other programs on the chopping block that could affect services and support for older adults include the Corporation for National and Community Service (CNCS), which includes the Senior Corps programs such as Foster Grandparents and RSVP; the Low Income Home Energy Assistance Program (LIHEAP), which would cost Massachusetts $140.4 million in financial assistance for fuel costs; the Community Services Block Grant, which provides around $16.5 million in wrap-around services for older adults in many communities; and the Legal Services Corporation, which administers some elder justice programs.

Additionally, the budget would eliminate funding within HUD for the Community Development Block Grant (CDBG). This $3 billion cut would eliminate CDBG funding to states to use for a variety of programs including a small amount that a few states and communities direct toward shoring up senior nutrition programs such as home-delivered meals. However, this cut does not mean that the federal home-delivered meals program under the Older Americans Act was slated for elimination. Those details are not available in the current budget blueprint, but news reports of the CDBG cut have led to confusion among advocates and the public.  

As is shown below, Massachusetts gets $10.1 million for social services under the Older Americans Act. A 3.34% cut in these OAA funds would result in a loss of $337,340. The state receives $18.26 million for the elderly meals program—both at congregate meal sites and home-delivered meals. A 3.34% cut in meals funding would result in a loss of $609,884 in nutrition funding, or a loss of roughly 81,317 meals in FFY 2018.


The federal grant funds that came to the Executive Office of Elder Affairs in FY 17 total $36,412,065


Adult Foster Care Faces Cuts March 1st.


Cuts to Adult Foster Care Begin March 1st

The countdown to cuts is on.

On March 1, the Baker Administration will begin cutting as much as $5.6 million from the Adult Foster Care program. The cuts will continue through the last four months of the fiscal year.

“We are running out of time to protect the elderly and people with disabilities,” said Linda Andrade of the Mass Council on Adult Foster Care. “Adult Foster Care is one of the premier ‘community first’ programs in the Commonwealth. The population in need is growing, and our budget should be growing to meet that need.”

Next year, the program could lose as much as $22.6 million.

Adult Foster Care is a program that allows elderly and disabled people to move in with a host family that provides 24/7 support. The average cost per client is less than $21,000 a year. Comparable round-the-clock support at a nursing facility can cost up to four or five times more.

“Community programs like this one make programmatic sense and financial sense,” noted Al Norman of Mass Home Care. “It just makes no sense to cut back community programs that help keep people out of costlier institutions.”

“Individuals with disabilities want to live in a home, in the community,” added Gary Blumenthal, CEO of the Association of Developmental Disabilities Providers. “Adult Foster Care is one of the few round-the-clock care programs that takes place in a home setting. That is why consumers are attracted to it.”

Governor Baker used his executive powers to make $5.6 million in 9C cuts to this MassHealth service for low-income individuals. These cuts amount to a 9-percent rate cut for providers. The cuts will undermine the program and can harm those who receive Adult Foster Care services and support, including caregivers who receive visits and oversight.

Andrade, Norman and Blumenthal agreed that the Adult Foster Care program is on the verge of a crisis. Adult Foster Care providers have indicated that sizeable funding reductions to their individual programs may make this innovative cost-saving program impossible to operate.

“It is imperative that the governor rescind this 9C reduction or that the Legislature overturn this reduction in a FY 17 Supplemental Budget appropriation,” concluded Al Norman.

FACT SHEET FY17 9C Action –

MassHealth Adult Foster Care Program

(4000-0600, 4000-0700)


Cut Will Leave 12,000 Caregivers Without Support and Oversight


MassHealth will cut rates for Adult Foster Care (AFC) services by 10% effective March 1, 2017, reducing payments to AFC Providers by $5 Million in FY2017 and more than $20 Million in FY2018.


AFC makes it possible for 12,000 elders and younger adults with disabilities to live at home with full-time caregivers.

  • A critical Community First innovation, AFC has contributed substantially to reducing utilization of nursing facilities and state-run institutions.
  • AFC is one of the few community options available to MassHealth members who need assistance with personal care and around-the-clock support and supervision.
  • AFC Provider Agencies provide education and coaching to lay caregivers – most often friends and family members without health care experience or training – so they have the support they need to provide care to elders and people with disabilities who have complex physical and behavioral health conditions.


The cut will:

  • Reduce the number of home visits by 50%, decreasing support for AFC caregivers, increasing the incidence of caregiver stress, and jeopardizing the health and safety of elders and people with disabilities. One of the most impactful features of the program, home visits ensure MassHealth members and their caregivers have regular and predictable access to a trusted care team (nurse and case manager) who understand the member’s health and social circumstances. AFC care teams help caregivers manage challenging behaviors and medical conditions, and can assess situations and act quickly when a member’s conditions change, preventing unnecessary health care costs. Consumers who are enrolled in AFC  are adults with intellectual disabilities/developmental disabilities, dementia, autism, behavioral health needs and/or are medically complex and many have co-mobidities.  AFC support provides the opportunity to manage individual situations, keep people stable at home and maintain program integrity through frequent visits.  The program serves people who would otherwise not be living in an independent apartment or who would be in a nursing facility or group home.
  • Undermine the ability of quality agencies to continue to operate across the Commonwealth. A 10% rate cut is decimating and unprecedented. AFC providers will not be able to absorb such losses.
  • Limit the Commonwealth’s capacity to provide care at home where people want to be, and jeopardize the savings that MassHealth realizes by supporting members in AFC. (Clinically comparable members are $85 p/day in AFC and ~$160 p/day in nursing facilities.) Without ongoing support from their care teams, some families will be unable to continue their around-the-clock commitment to caregiving at home and may elect more expensive out-of-home alternatives. This model works because of dedicated caregivers and because of the comprehensive support system and professional help that AFC Provider Agencies provide to those caregivers. AFC serves a complex and vulnerable consumer base.  Host families are trained and supported.  In a time of direct care worker shortages, this model of care offers a residential option for consumers and quality caregiving through host or natural family members who receive a modest monthly stipend.


Please Act Now to Reverse the 9C Cut to the AFC Program

and Keep Care at Home for 12,000 MassHealth Members

Here is the legislative language we are seeking to place in a supplemental appropriations bill before the March 1st cuts begin:


SECTION __. Chapter 133 of the acts of two thousand and sixteen is hereby further amended in Item 4000-0600 by adding after the words “in providing kosher foods” the following new language: —

“provided further, that the eligibility, staffing and rate requirements for the adult foster care program shall not be more restrictive than those in effect in fiscal year 2016; provided further, that not less than $5,600,000 shall be added to this item to maintain said eligibility, staffing and rate requirements;”

and by striking out the sum “$3,509,766,093” and replacing it with the following:–



               Press Release: For Immediate Use

                 Contact: Al Norman, 978-502-3794

          Elder Home Care Wait Lists To Begin In 26 Days

STATEWIDE—The Baker Administration has officially announced that starting September 1st, waiting lists for some elders will begin in the home care program. Massachusetts calls itself a “community first” state—but the doors to nursing facilities are wide open, while the entrance to home care will soon be limited. Mass Home Care predicts that the monthly caseload for elders will have to drop by 650 to 800 elders per month.

“Due to projected demand exceeding FY17 budgetary limitations,” the Administration said in a memo to Aging Services Access Points (ASAPs), “Elder Affairs will be implementing a managed intake process. This process will be effective as of September 1, 2016.”

The final Conference Committee budget for FY 17 home care items is roughly $3.5 million below FY 16 appropriations:

Line Item FY16 Budget FY 17 FINAL
9110-1500 ECOP $ 70,255,327 $70,548,399
9110-1630 HCPOS $104,595,483 $102,570,589
9110-1633 HC  CM $35,546,961 $33,795,743
TOTALS $210,397,771 $206,914,731

The maintenance budget for the enhanced home care program is around $74 million—so the total shortfall is closer to $7.5 million.

“This was an entirely predictable—and avoidable—outcome,” said Mass Home Care Executive Director Al Norman. “The General Court didn’t give home care enough funding to run a maintenance budget, and the Governor filed a supplemental budget that added more federal dollars—but  reduced the state share, setting up a wait list situation.”

According to the Executive Office of Elders Affairs, elders who have “a critical unmet need for meal preparation” will be put on a waiting list—regardless of where they live in the state. Every elder who applies for home care is assigned a “priority level” based on their need for service.

The state is also cutting off funding for the Intensive Care Management program, which helps seniors with behavior health reasons for resisting care. A pilot program approved by the General Court to provide up to $1 million to help seniors with income slightly over the home care eligibility limit has also been scrapped.

Mass Home Care has written an amendment to the Governor’s supplemental budget  to add $3 million in available federal  dollars for home care from the “Community First” Trust Fund.

“This is a manufactured crisis,” Norman concluded. “The state has federal dollars in its hands that could end this wait list before it happens.”

“We hope they act quickly—on September 1st we start turning some elders away.”

#                             #                                  #                                  #


“Rightsized” Budget for FY 17 Will Mean Elders On Home Care Wait Lists

Contact: Al Norman 978-502-3794

STATEWIDE: An elder rights group says that seniors  will be put on a wait list for home care as a result of cuts made in the final days of the FY 17 budget process.

“We need to reduce our caseload by 628 elders per month for the entire year,” explained Mass Home Care President Greg Giuliano. “The General Court left us roughly $4 million short of what we need to maintain our current home care programs.” Giuliano said the Conference Committee budget sent to the Governor produced an appropriation lower than  either the House or Senate versions of the budget. “Usually lawmakers compromise on a number between the high and low mark—but this year they went below the low mark—and guaranteed waiting lists.”

The core home care line items in the final FY 17 budget are lower than FY 16 appropriations

Line Item FY16 GAA FY 17 Gov FY 17 House FY 17 Senate FY 17 FINAL
9110-1500 ECOP $ 70,255,327               0 $  74,345,122              0 $70,548,399
9110-1630 HCPOS $104,595,483 $158,143,535 $101,485,589 $158,143,536 $102,570,589
9110-1633 HC  CM $35,546,961 $  51,482,919 $   33,795,743 $  52,557,919 $33,795,743
TOTALS $210,397,771 $209,626,454 $209,626,454 $210,701,455 $206,914,731

Elder Home Care begins FY 17 facing a shortfall that translates into 349 elders per month in the enhanced home care program, and 279 elders per month in basic home care, for a total of 628 elders per month in FY 17 who will not receive needed services.

The Governor vetoed language that would require MassHealth to apply for two state plan amendments that would bring in more than $20 million in new federal revenue that could be used for home care services. Giuliano said this veto “leaves federal dollars on the table at a time we are cutting elders off home care.”

Although lawmakers agreed to a $1.075 million home care expansion for the “near poor” who are slightly over the program’s income cap, Giuliano said he is concerned that advocates will have to fight to make the program happen.

Waiting lists for home care have been a chronic problem for the elderly, Giuliano said. In FY 2013, for example, as many as 2,000 elders were on a wait list for home care for much of the program year.

“We say Massachusetts is a ‘community first’ state, Giuliano said, “but in most parts of the state there is no wait to get into a nursing facility. These home care cuts send exactly the wrong message to families.” Nursing home use has dropped more than one-third since the year 2000 Giuliano said,  largely due to home care services, but access to home care too often is sporadic.

“We can keep 5 or 6 elders in home care for the cost of one person in an institution,” Giuliano said, “so closing off home care is financially a bad deal for taxpayers.”

Mass Home Care said it will urge lawmakers to restore the cuts in home care funding through a supplemental budget, restore the state plan amendment language cut by the Governor, and push for implementation of the $1 million ‘near poor’ home care pilot project.

                             #                 #                 #                 #


              PRESS RELEASE: MAY 26, 2016
contact: Al Norman 978-502-3794
​STATE HOUSE–​In one of its final budget votes of Thursday night around 9 pm, the State Senate approved on a voice vote an amendment that increases funding for the state’s elder home care program by just over $1 million, to create a program for elders whose income is just over the limits allowable ​under current eligibility guidelines.
The amendment allows the Executive Office of Elder Affairs to admit elders whose annual income is between $27,015 and $31,066. This includes seniors who “​(i) are unable to afford sufficient unsubsidized home care for their needs; (ii) pose a risk of higher-cost state-provided care in a nursing facility should they be ineligible for home care; or (iii) lose home care eligibility as a result of a spouse’s death;”

Al Norman, the Executive Director of Mass Home Care, said the Senate action “will provide some much needed relief to ‘near poor’ seniors who cannot pay the full cost of home care services on their limited income.” Norman said elders who qualify for this program will pay for some of the cost of their care on a sliding fee basis.

“When we keep an elder living independently at home, we are also saving the taxpayers the cost of keeping them in an institution,” Norman said.

Norman credited Senate President Stan Rosenberg for guiding the amendment to its final passage. “The President has taken a personal interest in looking after the well-being of our seniors.” Norman said.

The measure now goes to a Joint Conference Committee to work out the final provisions of the budget.

Here is the text of the amendment adopted this evening by the Senate:

Further EHS 469.2

Home Care Rates

Ms. Jehlen, Ms. L’Italien, Ms. Lovely and Ms. Chang-Diaz moved that the amendment be amended by striking out the text in its entirety and inserting in place thereof the following:-

the proposed new text be amended, in section 2, in item 9110-1633, by inserting after the word “provided”, in line 5, the following words:- “, that the secretary of elder affairs shall develop a pilot program to provide home care services to certain persons whose annual income exceeds, by 15 per cent or less, the current income eligibility limit based on regulations promulgated by the secretary; provided further, that such persons may include those who:


(i) are unable to afford sufficient unsubsidized home care for their needs; (ii) pose a risk of higher-cost state-provided care in a nursing facility should they be ineligible for home care; or (iii) lose home care eligibility as a result of a spouse’s death; provided further, that an amount not to exceed $1,075,000 shall be used for the pilot program which shall be allocated between items 9110-1630 and 9110-1633; provided further, the secretary shall report to the house and senate committee on ways and means not later than February 1, 2018 on: (a) caseload and expenditures made from the pilot program; (b) projected cost effectiveness from the piloted population including, but not limited to, estimated savings from reduced medical costs, avoided nursing facility admissions and cost sharing by recipients; and (c) the estimated fiscal impact and cost benefits of expanding home care to all eligible persons whose annual income exceeds the current income eligibility by 15 per cent or less; provided further”; and

in said section 2, in said item 9110-1633, by striking out the figure “$51,482,919” and inserting in place thereof the following figure:- “$52,557,919”.



CONTACT: Al Norman, 978-502-3794


STATEWIDE–“Too many of our seniors face stressful situations, from health challenges to financial difficulties to emotional strain.” So says the Senate Ways & Means Committee in its FY 17 state budget, which was released by Senate Chairwoman Karen Spilka (D-Ashland) on May 17th. “By 2030, 1 in 4 Massachusetts residents will be over the age of 60.”

The Committee’s budget provides a total of $287.7M for elder affairs, a $4.3M increase over the FY 2016 funding level. But within that total, certain programs, like home care, actually sustained a cut in funding below  FY 16 appropriations. Home care dropped by $771,817 in all three budget proposals issues thus far in the State House: the Governor’s budget in January, the House budget in April, and now the Senate budget in May.

The Senate Ways & Means budget acknowledged “demographic shifts in our population,” but the senior budget is having its own “stressful situation.”

In a joint letter to the Senate Chairwoman, a group of 20 elder agencies, including Mass Home Care, applauded the  Senate’s messaging about the need for state residents to “continue to care for each other.”

“We agree,” the advocates said, “that ‘demographic shifts in our population’ are challenging our families today—and will become more challenging as our elder population rises 46% by the year 2035. We also agree that ‘intergenerational support systems’ are key to dealing with the social transformations that threaten the ability of older persons to live in the ‘least restrictive setting’ appropriate to their needs—one of the missions of the MassHealth program (Ch. 118E,s.9).”

“A ‘strong and resilient Commonwealth’ includes strong and resilient seniors,” the letter continued. “Just this past week, two new reports—one from the BCBSMA Foundation on LTSS, and a second from the Elder Economic Security Commission—underscore the growing demand for long term services for seniors, and the financial insecurity that many older households face.”

“According to the Medicaid Public Policy Institute, nearly 70% of people turning age 65 will need some level of LTSS in their lifetime, with 40% of people needing services for more than 2 years and 16% of people needing over $100,000 in services. Data from Truven Health Analytics reveals that if Massachusetts spent in FY 13 the same % share of its total LTSS spending as Oregon spent on home and community based services (78.9%) that same year, it would have shifted $850,910,425 into community care.”

In response to the Senate budget, Mass Home Care is supporting 4  budget amendments:

  • An amendment filed by Senator Joan Lovely (D-Salem) that would equalize the rates between two separate home care management rates (the Enhanced Community Options program and the Community Choices program) that essentially have the same scope of care management services. Care managers who serve elders in one account, also serve elders in the other account interchangeably. The only difference is that ECOP people are not on MassHealth. But the clients in both programs are clinically at the nursing facility level of care.  The FY 16 rate for  ECOP care management is $215.90. The rate for Community Choices is $275. Every time an ASAP care management goes out on an ECOP visit, the ASAP is paid $59.10 less than a Choices client. The projected cost of this rate equalization for FY 17 is $5.02 million based on projected caseload.
  • An amendment filed by Senator Barbara L’Italien (D-Andover) This language allows EOEA to write regulations to provide home care services to those “near poor” elders whose annual income does not exceed more than 15% above the current income limits (elders with incomes between $27,015 and  $31,066). It allocates a capped pool up to $2.7 million for such applicants. If this ‘near poor’ fund was split between the basic home care program and the enhanced home care program, EOEA could provide services to 276 elders per month in the basic home care program, and 165 elders per month in the enhanced home care program for the full fiscal 2017 year. This would slow down the progression towards nursing facilities for a total caseload of  441 frail elders per year. This “near poor” fund is capped, and EOEA would report to house and senate ways and means on the caseload attributed to this fund.
  • An amendment filed by Senator Michael Moore (D-Millbury) which would add $1.75 million to the line item which  pays for the operations and staffing at the 26 Aging Services Access Points (ASAPs). The staff in this line item are mostly frontline care managers and RNs. A 2015 independent salary study of 1,305 ASAP care managers  and RNs concluded that workers in the home care system are being paid “below market rate salaries.” The care management turnover rate is 20% per year. This funding would  mitigate the “low salary/high turnover” syndrome that causes employees to leave the elder services field, and bring this account level with where it stood in FY 16—which is the same as where it stood in FY 11.
  • An amendment filed by Senator Barbara L’Italien that would add spouses to the list of family members who can be paid under MassHealth to provide personal care services. This amendment has been unanimously passed by the Senate twice in the past year, only to die on the budget Conference Committee. The amendment would require the Executive Office of Health and Human Services to file a MassHealth state plan amendment to allow payment to spouses. The federal government has 4 ways to allow this to happen: a 1915c waiver amendment, or a 1915i, 1915j or 1915k state plan amendment—all options under the Affordable Care Act. Research from the California personal assistance services program, where spouses have been paid as caregivers since the mid 1990s,  demonstrates that the use of spouses as caregivers has had no adverse financial impact on Medicaid costs. Spouses are cheaper to use than other caregivers, because they do not have to be paid for routine tasks that spouses normally provide for one another, as described below. The Veterans Administration also allows vets to have their spouse as a paid caregiver, including in Massachusetts.



Lawmakers Propose 26 Measures To Improve Economic Security of Elders

for further information contact: Al Norman 978-502-3794

BEACON HILL, MA. In mid-May, the Elder Economic Security Commission, established under the FY 2014 state budget, issued iTs 56 page report to the public, containing 26 recommendations for action ranging from increasing retirement income, and affordable housing, to health care and long term services and supports.

The Commission was tasked with examining the strategies to increase the economic security of older adults, and to help older residents remain living in their communities. The Commission assessed older adult’s current level of economic security, identified policies and programs to assist elders, and assessed what additional funding was needed to increase elder economic security. The legislative co-chairs of the Commissoner were Rep. James O’Day (D-W.Boylston) and Sen. Patricia Jehlen (D-Somerville). Mass Home Care’s seat on this Commission was filled by Linda George, former CEO of Boston Senior Home Care.

Among the recommendations from this Commission are the following:

  • Raise the income eligibility for home care and the Enhanced Community Options Program to 300% of the federal poverty level as a wrap around to the MassHealth program
  • Amend MassHealth regulations to allow spouses to be paid caregivers under PCA abd AFC programs.
  • Amend the MassHealth regulations to allow PCA consumers to receive care if they require cueing and supervision.
  • Expand funding for Options Counselor/Family services Counselors working with the Aging Services Access Point Network.
  • Expand funding for Benefit Enrollment Specialists available within the Aging Services Access Point Network.
  • Extend the earned income tax credit for working people over age 65 (eliminate the age cap), increase the amount singles without children can receive, and increase the percentage of the federal credit that the state credit is based upon.
  • Create a state line item to provide a supplement to the federal Low-Income Heating Program.
  • Increase the income limits for MassHealth for people 65 and over from 100% of the federal poverty limit to 135% of the FPL, and raise the MassHealth asset limits for seniors from current $2,000 for a single person to $13,440 for a single person.
  • Create an Elder Affairs line item for the support of a geriatric mental health partnership
  • Enable the Secretary of Elder Affairs to implement a universal Community Living Assistance and Supports (CLASS) insurance program for home and community-based long term supports and services.

The Commission’s report concludes that “Massachusetts older adults are among the most economically insecure in the nation…63% of the state’s retired elder households lacked the income required to meet the costs of their basic daily needs. 81% of African-American senior households and 91% of Hispanic senior households have incomes insufficient to meet their daily needs.”



 Mass Home Care Part of End-of-Life Care Coalition

BOSTON, May 12, 2016—Mass Home Care is one of the statewide groups that is participating in a new coalition to help people of all ages to make their wishes know about end of life care.

Eighty-five percent of Massachusetts residents believe that physicians and their patients should talk about end-of-life care – but only 15 percent have actually had such conversations, according to a new statewide survey by the Massachusetts Coalition for Serious Illness Care.

Strikingly, even those respondents facing serious illness are reluctant to plan ahead with their care team. Only 25 percent of respondents facing such afflictions reported talking with their physician about end-of-life care.

In addition, although the vast majority of people will eventually encounter medical situations in which they are unable to make decisions for themselves:

  • Almost half of the population (46 percent), including most men, people of color, and those without college education, have not discussed their wishes for serious illness care with others.
  • Most respondents (55 percent) have not named a health care agent (or proxy) to make such decisions.

“These findings are a wake-up call for all of us, clinicians and patients alike,” said Atul Gawande, M.D., M.P.H., co-chair of the Coalition, executive director of Ariadne Labs, a joint center of Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, and author of the New York Times bestseller, Being Mortal: Medicine and What Matters in the End.

“People have priorities in their lives besides just living longer,” said Dr. Gawande. “They have goals and aims for the quality of their life, too. This survey shines a light on the need to ask people about what those priorities are– and then to ensure that they are honored.

“This is about how you want to live, not just about how you want to die,” Gawande said. “When clinicians don’t talk to people about their priorities for serious illness care, care can become misaligned with what matters to them. And the result is suffering.”

The landmark survey’s findings were  shared at the Coalition’s inaugural Summit at the Kennedy Library in Boston.

The Coalition’s goal is “for everyone in Massachusetts to be cared for in accordance with their own goals and preferences, at every stage of health care and illness,” said Maureen Bisognano, co-chair of the Coalition and former President and CEO of the Institute for Healthcare Improvement. “We have to have the will to build a system where clinicians feel comfortable raising these conversations with their patients. And people feel comfortable raising it with their clinicians.”

But there is work to be done to achieve that goal, according to the survey. One-third of Massachusetts residents who had a loved one die in the past year said patient preferences were not fully followed. And one-fifth described the end-of-life care they witnessed as only fair or poor.

“None of us should be satisfied until people across the Commonwealth feel much more comfortable to express their wishes, and clinicians have the time and skills to really understand, so they can respect those wishes,” said Bisognano.

But the survey shines light on reasons for hopefulness, too. When respondents do name a health care agent, 85 percent talked to their agent about their wishes if faced with serious illness.

“There are people doing incredible work in this area in Massachusetts,” said Andrew Dreyfus, another Coalition founding member and President and CEO of Blue Cross Blue Shield of Massachusetts. “They are joining the Coalition to give these matters the focused attention they deserve. And to help make Massachusetts a national leader in serious illness care, just as we have been a national leader in so many other important areas of health care. This is the right time. And this is the right community in which to do it.”

“We want to make this conversation easier to have,” explained coalition member Al Norman of Mass Home Care. “People want their health care to be consistent with their values and wishes. The best way to do that is to tell family and practitioners what you want in advance—because when the time comes—you may not be able to have that conversation yourself.”





Contact: Al Norman/978-502-3794/


On April 14, 2016, the $15.4 billion MassHealth program announced a major “restructuring” campaign designed to create “a sustainable, robust” health care program for its 1.8 million members. This process is the culmination of roughly a year of “intensive design and stakeholder engagement,” according to state officials.

MassHealth accounts for almost 40% of the Commonwealth’s budget. The Administration of Governor Charles Baker has made overt moves to swap out the current fee-for-service payment model, which they says results in “fragmented, siloed care,” and replace it with a managed care delivery system experiment which places large hospital and physician networks, known as “Accountable Care Organizations,” in control of funding.

The instrument to make this change is a large federal 1115 waiver to support MassHealth restructuring. Financing for the current waiver ends June 30, 2017 with $1 billion in federal support. State law (Chapter 224) requires MassHealth to adopt alternative payment methodologies for promotion of more coordinated and efficient care. ACOs would represent for MassHealth a more “integrated” model of care. In ACO models, the health care providers are accountable for the cost and quality of care. MassHealth also has a number of existing managed care organizations (MCOs) already providing care for the low-income population. In most cases, these MCOs will  remain the insurer, pay claims and will work with ACO providers to improve care delivery. Integrated care  means bringing behavioral health (BH) and long term services and support (LTSS ) under the control of the ACO, and strengthening links with social services.

MassHealth is finishing up work on a 5-year Delivery System Reform Investment Program (DSRIP) funding request to the federal government. To access the DSRIP funding, the Feds require the state to come up with matching funds for the new DSRIP investment, which will be financed through a $250 million increase in the existing assessments on hospitals. The hospitals will receive a $250 million annual increase in MassHealth payments, resulting in no net impact to hospitals as a class

The DSRIP proposal will include investments to support providers who sign on for ACO model; funding for BH and LTSS Community Partner (CP) organizations; formal partnerships between ACOs and CPs; funds for more flexible services;  investments in health care workforce development, improved accommodations for members with disabilities; and a major expansion of the treatment for Substance Use Disorder for addressing the opioid crisis

At the center of the “restructuring” plan are the ACOs. To be an ACO, providers must show they can coordinate care and partner with Community Partners, including primary, specialty, behavioral, acute, and community-based care. The ACO must have relationships with other providers to coordinate/ integrate care effectively. ACOs will be able to choose to create an integrated ACO/MCO entity or enter into ACO contracts with other MCOs; some ACOs may choose to contract directly with MassHealth.

MassHealth has also been working to improve program integrity, especially for LTSS, like  home health service. Home health spending grew last year by $170M, or 41%, and over 80% of growth was driven by providers new to the Commonwealth since 2013. As part of its increased oversight of the home health industry, MassHealth has referred 12 home health providers to the Attorney General’s office for fraud, and imposed a  moratorium on new home health providers,  and added clinical prior authorizations for home health services.

In addition, MassHealth is attempting to “passively enroll” its members into managed and accountable care models. In its FY 17 budget, the Baker Administration sought authority to involuntarily enroll seniors in FFS into Senior Care Options (SCO) plans. But the House thus far refused to grant this power. The SCO plan by statute must provide for voluntary enrollment.

MassHealth’s timeline calls for pilot ACOs to launch by the end of calendar 2016, with a full roll out of ACOs, BH/LTSS Community Partners and DSRIP by October 2017.

In the LTSS field, the focus is on the relationships between the new ACOs and the new “Community Partners.” (CPs). The ACO plan calls for increased LTSS integration and linkages to social services in ACO models through “explicit requirements for partnering with LTSS Community Partners.” The state will encourage ACOs to “buy” LTSS care management expertise from existing community-based organizations, like the 26 statewide Aging Services Access Points (ASAPs) vs. “building” their own assessment and care coordination capacity. MassHealth plans to invest in infrastructure and capacity to overcome fragmentation amongst community-based organizations.

The State will certify who becomes  a LTSS CP. The ACOs will refer to BH, LTSS and social service providers, to help assess “social determinants of health,” ranging from housing stabilization, income supports, nutrition and utility assistance. These new certified CP will have to demonstrate expertise in care coordination and assessments and infrastructure/ capacity. MassHealth says that the CPs “can be providers but self-referrals monitored.” This process is not defined yet, but the goal is presumably to mitigate any conflict of interest between the assessment process and the direct service providers. ACOs themselves will not be allowed to have any direct or indirect financial ownership interest in a CP. In addition, LTSS CPs must demonstrate expertise across multiple populations with disabilities, such as those with physical disabilities, developmental or intellectual disabilities, brain injuries, the elderly, etc.

Certified CPs and ACOs will both be able to get direct DSRIP funding. Social service providers will receive DSRIP funding from funds given to ACO designated for flexible services to address social determinants of health. The funding for both is contingent on ACOs and CPs formalizing arrangements for how they work together. MassHealth is not requiring ACOs to partner with CPs, but instead trying to use financial incentives to make this happen. But advocates for LTSS have pushed for a formal requirement that ACOs use LTSS CPs to provide an “independent agent” for members as a consumer protection against health providers self-referring to the services they own. Such a formal relationship has been available for years by statute in the Senior Care Options (SCO) plan, and the One Care plan—the state’s first two integrated managed care experiments.

The stated goals of the Community Partners initiative are as follows:

  • Create explicit opportunity for ACOs and MCOs to leverage existing community-based expertise and capabilities to best serve consumers with LTSS and BH
  • Break down existing silos in the care delivery system across BH, LTSS and physical health
  • Ensure care is person-centered, and avoid over-medicalization of care for LTSS
  • Preserve conflict-free principles including consideration of care options for consumers and limitations on self-referrals
  • Make explicit and scalable investments in community-based infrastructure within an overall framework of performance accountability
  • Create a certification process for BH and LTSS Community Partners
  • Encourage ACOs/MCOs and Community Partners to formalize how they work together, especially for care coordination and performance management

A CP must be a community-based organization with extensive and broad expertise in BH and/or LTSS in a geographic region. A CP can be a direct service provider but will have a limit on self-referrals. A LTSS CP must have competencies to work with at least 3 subpopulations with disabilities, and meet other criteria, such as strong relationships with social service organizations, IT infrastructure for data capture and maintenance, quality measurement and reporting, electronic encounter/billing capacity. MassHealth will encouraging formation of new entities and partnerships to be CPs, with the explicit goal of overcoming fragmentation and siloes that hinder care integration. The state will promotes entities to come together to serve the continuum of members, such as elders, adults and children with physical disabilities, and members with brain injury, ID/DD, mental illness, and SUD. LTSS CPs may receive DSRIP funding for MCO members if formal arrangements in place.

Certified Community Partners (CPs) must be certified by EOHHS, will be expected to develop infrastructure and meet performance requirements, and a  portion of their DSRIP funding will be contingent on meeting quality/process metrics and ACO/MCO review of performance. At the consumer level, the “Certified” LTSS Community Partners will offer LTSS expertise across multiple populations, conduct independent assessments, advise members on their care options, provide LTSS care coordination, and offer linkages to social services. The CPs will refer to/partner with Adult Foster Care, Personal Care Attendant, Adult Day Health,  and other providers, as well as social service providers.

“This is a very ambitious restructuring,” said Dan O’Leary, President of Mass Home Care . “The key for us will be the role of the ‘conflict free agent’ in conducting assessments and care planning. Since this is a program being managed by large health care providers, we need to ensure that the consumer’s long term supports needs are fully recognized and addressed , and that they have an independent agent on their team to preserve open choice of services and providers.”

“Ensuring the consumer’s needs are met with the right care and services in the right place will be a major challenge,” O’Leary said.