LHCSA STAT REPORTS
SEPSIS INSTITUTE
HOSPICE CAP CUT
STARK FLEXIBILITY
With one month left to go, only 50 LHCSAs have submitted required statistical reports. The deadline is November 16 and includes the registration process.
HCA “Sepsis and Home Health Care” module featured in just-launched Sepsis Institute online learning platform.
MedPAC recently discussed a 20% cut to the hospice aggregate cap which would require an act of Congress. Adjusted by wage index, the proposal impacts providers with long lengths of stay.
The Dept. of Health and Human Services is proposing to relax several regulations (i.e. Stark Law, anti-kickback) in an effort to allow more collaboration.
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Your Source for HOME CARE News, Policy and Advocacy
UPCOMING PROGRAMS Compliance Experts Lead October 17 HCA Symposium Oct. 17 (Albany) PDGM Bootcamp for Clinical Managers and Quality Staff Oct. 23 (Fairport) Webinar: Immigration Law Compliance for Home Health, Hospice Oct. 30 2-3 p.m. Save The Date: 2020 Northeast Home Health Leadership Summit Jan. 28-30 (Boston) Registration for these and other programs are on HCA’s website at https://hcanys.org/eventseducation/ upcoming-events.
Vol. 4, Issue 36| October 15, 2019
Projected $4B State Deficit, Scrutiny of Fidelis Deal All Raise Risk Alarms for Medicaid Fiscals Adding to the pressure of an anticipated $4 billion state budget deficit next year are press reports that the federal government is scrutinizing state-negotiated Medicaid windfall funds from the sale of Fidelis to Centene. Specifically, the U.S. Centers for Medicare and Medicaid Services (CMS) has stated in a letter to state officials that the multi-billion-dollar deal is under review, putting Medicaid payments at possible risk. See DEFICIT p. 4
Judge Rules Against FI PMPM Change for Consumer Directed Services Late last week, a New York State Supreme Court judge ruled against the state Department of Health’s (DOH) change in reimbursement for administrative expenses of Fiscal Intermediaries (FIs) providing consumer directed services. See JUDGE p. 2
HCA Op-Ed, Growing Congressional Support on PDGM Bill “Say your employer takes 8 percent from your paycheck this week as a penalty for you possibly being late to work sometime next week, despite a long record of punctuality,” writes HCA President and CEO Al Cardillo in an op-ed for the Albany Times Union last week, setting up an analogy: “That’s what the federal government is doing for Medicare-covered home health services in 2020 with cuts of $1 billion nationwide,” referring to the so-called “behavioral adjustments” under the Patient Driven Groupings Model (PDGM). See PDGM p. 3
INSIDE $4B Deficit, Scrutiny of Fidelis Deal All Raise Risk Alarms....................1 HCA Op-Ed, Growing Congressional Support on PDGM Bill..................1 Judge Rules Against FI PMPM Change.................................................1 Member Hiring Announcement.......................................................3 HCA Announces Appointment of Paul Essner to HCA Board..................4 LHCSA Statistical Reports Due November 16......................................5 Discussions Continue on New CHHA-LHCSA-FI Cost Report..............6
New Sepsis Institute Features HCA Module................................................................6 MedPAC Weighs 20% Cut to Hospice Aggregate Cap.....................................................6 HHS Proposes Flexibilities in Stark, Anti-Kickback and CMP Rules ................................7 EVV Report Summarizes Stakeholder Responses........................................................8 PHHPC Acts on Home Care Applications......................................................................9 NGS’s Oct. Advisory Meeting Yields Key Home Health Updates..................................10 Medicare Appeal Thresholds Posted for 2020........................................................10 Health Care Resources..........................................................................................10
The Situation Report: the Home Care Association of New York State JUDGE from p. 1 The judge found that the policy: “constitutes a rule or regulation which could not be promulgated without first complying with SAPA (State Administrative Procedure Act) mandates.” SAPA requires that, prior to the adoption of a rule, an agency must submit a notice of proposed rule-making for publication in the State Register and provide for public comment. The judge ordered DOH to revert to the previous rate methodology utilized prior to the change. The decision did not address the merits of the case, however, and thus DOH can either appeal or issue a proposed regulation under SAPA to implement the per-member-permonth (PMPM) policy for administrative expenses. A return to the prior reimbursement structure also eliminates $150 million in state-and-federal-share Medicaid savings that the state was counting on under its PMPM policy change. This gap adds pressure to the Medicaid budget, creating the risk for a range of possible actions, like rate changes, to shore up funds, especially with forecasts of a multi-billion-dollar deficit next year. (See related p. story.) HCA is reaching out to DOH to learn if it will issue new guidance to address the court decision and will keep members informed.
Volume 4, No. 36 October 15, 2019
The Situation Report is a weekly publication of the Home Care Association of New York State (HCA). Unless otherwise noted, all articles appearing in The Situation Report are the property of the Home Care Association of New York State. Reuse of any content within this newsletter requires permission from HCA. Al Cardillo President and CEO acardillo@hcanys.org Roger L. Noyes Director of Communications, Editor of The Situation Report rnoyes@hcanys.org Rebecca Fuller Gray Executive V ice President for Clinical and Program Affairs rgray@hcanys.org Patrick Conole Vice President, Finance & Management pconole@hcanys.org Andrew Koski Vice President, Program, Policy & Services akoski@hcanys.org Alyssa Lovelace Director for Policy and Advocacy alovelace@hcanys.org Lauren Ford Director of Program Research, Development and Policy lford@hcanys.org Laura Constable Senior Director, Membership & Operations lconstable@hcanys.org Celisia Street Director of Education cstreet@hcanys.org Mercedes Teague Finance Manager mteague@hcanys.org Jenny Kerbein Director of Governance & Graphic Design jkerbein@hcanys.org
http://nehomehealthsummit.com Home Care Association of New York State (HCA) 388 Broadway, 4th Floor, Albany, NY 12207 Tele: 518-426-8764; Fax: 518-426-8788; Website www.hcanys.org
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Billi Wilson Manager, Meetings & Events bwilson@hcanys.org Teresa Brown Administrative Assistant tbrown@hcanys.org
The Situation Report: the Home Care Association of New York State
Volume 4, No. 36 October 15, 2019
PDGM from p. 1 He further describes the inherent faults of the “behavioral adjustment” cuts that ride along with PDGM, urging action on a bill to curtail those cuts: H.R. 2573/S.433. You can read the op-ed in its entirety at https://www.timesunion.com/opinion/article/Viewpoint-Cuts-tohome-health-care-providers-are-14510184.php. The opinion pages are just one method for leveraging action on this important bill that has been extensively summarized for the membership. HCA and our government-affairs team have worked vigorously over the past few weeks to gain co-sponsorship from New York’s Congressional Delegation on this bipartisan, commonsense measure. We thank the offices of Reps. Brian Higgins, Grace Meng, Anthony Brindisi, Thomas Suozzi, Sean Patrick Maloney and Yvette Clarke for signing on. Many others have signaled they will do so as well, but we need your support to provide further momentum. If your Representative has not yet signed on as co-sponsor, please join over 800 of your colleagues who have written Congress on this bill using our Phone2Action platform at https://p2a.co/fwWNZT0. HCA expects the final home health prospective payment system rule to be posted later this month, at which time we will immediately alert the membership. (The rule includes PDGM.) Our comments and upcoming education opportunities – including our October 23 PDGM Bootcamp for Clinical and Quality Managers – are posted to a special PDGM page on our website at https://hca-nys.org/pdgm-resourceseducation-and-advocacy.
HIRING: Clinical Assessment Managers (RNs) VNSNY is hiring Clinical Assessment (UAS) Managers to join our team. Use your clinical skills to assess member needs and identify solutions that promote high quality health care services. Option to work in any of the following counties: Monroe, Dutchess, Onondaga, Ulster, Orange, Oneida, Putnam, Delaware, Otsego, Sullivan, Rockland, Madison, Herkimer. We offer: flexible schedules, comprehensive training and ongoing support, competitive pay rates, great benefits (for full time) and telework opportunities. Qualifications:
Current license to practice as an RN in NYS (BSN preferred) Minimum six months of utilization review or care management experience at a Managed Care Organization or discharge planning experience required Demonstrated success with conflict management skills Knowledge of Medicaid or Medicare regulations required
Apply full time: https://jobs.vnsny.org/job/brooklyn/rn-uas-assessment-upstate-new-york-counties/1238/13316863 Apply per Diem: https://jobs.vnsny.org/job/brooklyn/rn-uas-assessments-per-diem-upstate-new-york-counties/1238/12539568 VNSNY is the nation’s largest not-for-profit home- and community-based health care organization. For 125 years, VNSNY has been committed to meeting the health care needs of New Yorkers with compassionate, high-quality home health care. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, members, and clients from before birth to the end of life.
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Volume 4, No. 36 October 15, 2019
The Situation Report: the Home Care Association of New York State
DEFICIT from p. 1 Meanwhile, other media reports indicate that the Medicaid Global Cap has been subjected to budget maneuvers as a way of deflecting possible overruns, calling into question what future financial liabilities will be. Fidelis-Centene funds As the 2019-20 state budget negotiations headed to a close this past spring, the Cuomo administration finalized a change in insurance law, approved in the final budget, to leverage $2 billion in state-accrued windfall profits from the Fidelis-Centene sale as a result of the Fidelis conversion to for-profit status. The vast majority of these Medicaid funds have been dedicated as investments mostly for the institutional sector. Throughout the past legislative session, HCA and a coalition of 21 community provider associations joined forces on a multi-part advocacy campaign to press legislation (A.7977A/ S.6376) which would dedicate a proportionate share of these health care transformation funds to community-based care, including home care and hospice. The bill’s Assembly sponsor, Health Committee Chairman Richard Gottfried, stood with the coalition at a press conference earlier this year and he expressed strong backing for the bill which, ultimately, did not receive the support needed from all quarters to gain momentum and pass both houses. A projected multi-billion-dollar deficit, the uncertain fate of Fidelis funds, and continued scrutiny of
Medicaid expenditures altogether create an environment of extreme risk for home care, hospice and Managed Long Term Care (MLTC) going into these next phases of state budget planning for the coming year. Of additional concern are signals from state officials that MLTC funding is specifically in the crosshairs, including concerns about MLTC funding growth raised by State Budget Director Robert Mujica at a recent presentation to the state’s Business Council. These major fiscal and political developments all mingle with the state’s high-stakes proposal to extend New York’s 1115 Medicaid waiver and Delivery System Reform Incentive Payment (DSRIP) program at a requested federal investment of $8 billion. The waiver focus adds yet another revenue variable and set of budgetary assumptions that further complicate the budget outlook for 2020. It is unclear to what degree the state’s future Medicaid forecasting hinges on approval of the waiver. Within this high-risk environment, HCA’s government affairs, advocacy and executive teams have been leading dozens of local-district meetings with state lawmakers, as well as central Legislative and Division of Budget staff, to outline our major concerns, profiles of home care system finances, and Medicaid cost-savings proposals to set the stage for the coming budget and legislative session. Please stay tuned for further information on how you can engage with your elected officials in preparing for the upcoming state legislative session.
HCA Announces Appointment of Paul Essner to HCA Board HCA welcomes Paul Essner, CDP, CLU, ChFC, Principal, TSG Financial, A Division of Risk Strategies, to the HCA Board of Directors. Mr. Essner is newly appointed by the Board, filling the open seat held by Roni Glaser. Mr. Essner brings to the HCA Board 26 years of experience in financial planning, employee benefits, corporate and personal financial planning and individual insurance. HCA looks forward to Mr. Essner’s contributions to the work of the Board and to HCA’s mission on behalf of home and community-based care. HCA greatly thanks Ms. Glaser for her contributions to the Board and her outstanding and continuing contributions to HCA and the entire HCA membership.
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LHCSA Statistical Reports Due November 16 With one month to go, only 50 of 1,300 LHCSAs have submitted reports HCA reminds members that the 2018 Licensed Home Care Services Agency (LHCSA) Statistical Report is due November 16. So far, fewer than 50 out of about 1,300 LHCSAs have submitted reports. Agencies that wait until the last week to download the software and the report may encounter system delays and wait times for support. Support personnel will not be available on the deadline date of November 16, 2019. The Statistical Report includes the paperwork needed to complete the registration process required for all LHCSAs. Those who don’t send in the registration form by November 16 will face fines and not be allowed to operate in 2020 until they become registered. Repeat violations may result in your license getting revoked. All LHCSAs are required to submit these reports even if they don’t bill Medicaid, including LHCSAs that are exclusively Fiscal Intermediaries. The Health Commerce System (HCS) has a Dear Administrator Letter outlining changes to the report from prior years and technical information. Only those assigned the HCS Administrator Role will be allowed to submit the report, so make sure your HCS assignments are accurate and up to date. The 2018 LHCSA Statistical Report and the 2018 Assisted Living Program (ALP)-LHCSA Statistical Report will use the state DOH developed Universal Data Collection System (UDCS) platform, which must be downloaded from the HCS and installed on a user’s computer. The software has changed, so users must download it anew. Also, if you downloaded the software last year, you must uninstall the old software and install the new software. For assistance with Healthcare Financial Data Gateway permissions, send an e-mail to HCStatRpts@health.ny.gov. LHCSAs serving ALP have a separate report. ALP LHCSAs that exclusively serve ALP patients will not need to enter information on the 2018 LHCSA Statistical Report but will need to complete and submit the 2018 ALP LHCSA Statistical Report. However, ALP LHCSAs that also serve the community must submit the LHCSA statistical report regarding the patients in the community and, separately, the ALP LHCSA statistical report regarding their patients in the Assisted Living Program. Questions can go to HCStatRpts@health.ny.gov; please cc Andrew Koski at akoski@hcanys.org with any inquiries sent to the Department so that we can track questions or concerns from the field and further assist or facilitate answers.
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Discussions Continue on New Cost Report For CHHAs, LHCSAs and FIs At a third installment of the state’s Cost Report Workgroup, HCA and colleague associations continued to press fundamental issues with a draft cost report that the state Department of Health (DOH) is planning to adopt for most home care providers, including non-hospital-based Certified Home Health Agencies, Licensed Home Care Services Agencies (LHCSAs) and Fiscal Intermediaries (FIs). The new cost report would be a major expansion of the existing obligations as well as an extension to some LHCSAs and FIs who have never been required to submit such reports. Last week, HCA outlined some of the core issues that remain unresolved, impracticable or burdensome with the Department’s proposal. For these reasons, we again reasserted our position that the cost report should not be released in 2020 (based on 2019 data), as DOH has proposed, especially since agencies have not, to date, collected much of the data in the format required by the cost report. We are calling for a 2021 reporting cycle using 2020 data instead. Many items remain unresolved and HCA will continue pressing our position at the next series of meetings which are being held on October 17 and October 24. While the Department says it is still planning a 2020 implementation, HCA and HCA provider/FI members on the workgroup will continue to press for changes and an implementation delay. For more information, including a review of the proposed cost report, contact Andrew Koski at akoski@hcanys.org or (518) 810-0662; or Patrick Conole at pconole@hcanys.org or (518) 810-0661.
New Sepsis Institute Online Learning Platform Features HCA Module Sepsis Alliance this week formally launched a new online learning platform, The Sepsis Institute (TSI), debuting a new training module for home care presented by HCA President and CEO Al Cardillo and HCA Board Member Amy Bowerman, RN, Executive Director of Senior Network Health Managed Long Term Care plan and the Director of Quality Improvement and Privacy Officer for Visiting Nurse Association of Utica and Oneida County. TSI (https://www.sepsisinstitute.org) provides health care professionals across the continuum of care with high quality, evidence-based sepsis education and training to improve diagnosis and outcomes for the millions who are harmed by sepsis every year in the U.S. The HCA-featured Sepsis and Home Health Care module, designed specifically for home health professionals nationally, covers sepsis risk factors, identification, screening methods (SIRS, qSOFA), HCA’s Adult Sepsis Screening tool, treatment and more.
MedPAC Weighs 20% Cut to Hospice Aggregate Cap Reduction, aimed at cost rebalancing, would require Congressional action At its recent October meeting, the Medicare Payment Advisory Commission (MedPAC) discussed significant changes to the hospice aggregate cap. Any such changes would require an act of Congress. MedPAC says a cap reduction – including a simulated 20 percent cut to the cap, as discussed at the meeting – is intended to align payments, especially in cases where hospices with long lengths of stay are most responsible for cap overages and for margins that are “out of balance.” Continued on next page
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Continued from previous page The 2020 aggregate cap is $29,965. According to MedPAC, 12.7 percent of hospices exceed the cap (2016 data), and those hospices have margins of 20.2 percent and 12.6 percent before and after return of the cap overages, respectively. MedPAC’s slide presentation (see https://hca-nys.org/wp-content/uploads/2019/10/hospice-october-2019-forpublic.pdf) simulates a 20 percent reduction to the cap and its impact for providers based on their share of stays over 180 days. According to MedPAC’s analysis, this simulation results in more hospices exceeding the cap – 26 percent – using 2016 data (assuming no behavioral change from 2016) with a 3.2 percent impact to all providers on an overall average basis. However, sorting the data by length of stay (i.e., share of stays over 180 days), the lowest three quintiles of providers for 180-plus lengths of stay would see no impact or a negligible impact, while the fourth and fifth highest quintiles for 180-plus lengths of stay saw a 4.5 percent and 15 percent impact, respectively. Notably, these calculations also include a wage adjustment, which is not accounted for under the current cap, as a way of “improving equity across providers,” says MedPAC, given MedPAC’s analysis that the cap is stricter in some areas with higher wage index ratios. Hospice payment and regulatory compliance have been under the federal government’s microscope. If embraced by Congress and implemented by the U.S. Centers for Medicare and Medicaid Services (CMS), this proposal on the aggregate cap would have a far-reaching impact on providers and services. Yet many more details are needed to gauge the precise effect on New York’s hospice community, which has substantially lower average lengths of stay than the national average. Also, 74 percent of New York hospices are operating at losses on net patient revenue, and New York labor costs are higher than many other states under what remains a distorted wage-index methodology for hospice and home health alike. HCA is a member of the Hospice Advisory Council of the National Association for Home Care and Hospice (NAHC) which has been closely examining and responding to payment and reimbursement issues like this one. In this venue, and in our collaboration with the Hospice and Palliative Care Association of New York State (HPCANYS), HCA will conduct further analysis and action steps should MedPAC make a formal recommendation to Congress in this area.
HHS Proposes Flexibilities in Stark, Anti-Kickback and Civil Monetary Penalty Rules Proposals offer potential new collaboration opportunities but also risks for home care and hospice The Trump Administration has announced new proposed rules to change the regulations promulgated under the federal Stark Law, anti-kickback statute and Civil Monetary Penalties. These laws generally prohibit inducements or payments that lead to unnecessary utilization in government programs. The proposed changes, the Administration says, offer new flexibilities and safe-harbor provisions for arrangements among providers that may otherwise currently be impeded by existing regulations at a time when providers seek to collaborate under value-based and other models of care. In announcing the proposed changes, the U.S. Department of Health and Human Services (HHS) outlined several scenarios that may be aided by the new flexibilities and safe-harbor provisions allowing collaboration,
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such as: the sharing of services like data analytics; arrangements whereby hospitals may provide care coordinators in service to physicians for discharged patients; or a hospital donating cybersecurity software for use by physicians that refer patients to the hospitals. HCA will be examining the proposed rule closely for possible applicability to home care, hospice and Managed Long Term Care (MLTC). A quick glance at the proposal raises at least a few scenarios that present concerns as well as possibilities. As an example, the proposed rule discusses certain limited activities of home health agency staff who may be placed in a hospital to assist with the hospital’s discharge planning work. Another scenario highlighted in HHS’s press release involves the possible permissibility of a physician practice providing a smart pillbox to patients without charge, noting “the [physician] practice could also provide a home health aide to teach the patient and the patient’s caregiver how to use the pillbox” – an example that potentially aggravates existing major concerns by HCA and members about the cross-over of non-home care entities into home care’s jurisdictional boundaries. The rules have not yet been posted to the Federal Register. A link to the draft rules are posted here: https:/ /www.hhs.gov/sites/default/files/oig-nprm.pdf and https://www.hhs.gov/sites/default/files/cms-starklaw-nprm.pdf. Comments will be due in 75 days from the postings in the Federal Register. HCA will provide further analysis and reaction as we examine the proposals more closely.
EVV Report Summarizes Stakeholder Responses State expects to submit request for one-year delay in personal care implementation, from 2020 to 2021 The state Department of Health (DOH) today issued a report summarizing stakeholder input on the implementation of federally required Electronic Visit Verification (EVV). EVV, as extensively reported, is a requirement of the federal 21st Century CURES Act mandating that states, like New York, institute EVV for all Medicaid-funded personal care and home health care. The personal care requirement begins January 1, 2020. EVV for home health is scheduled for January 1, 2023. However, the state today reiterated its plan to seek a delay on the personal care implementation date under a “good-faith-effort” waiver, allowed by the U.S. Centers for Medicare and Medicaid Services (CMS). The Department says it plans to pursue this one-year delay (to 2021) in an application that will be sent by November 30. The report issued today is a culmination of provider surveys and ten listening sessions held throughout the state. According to the report, DOH received 146 responses to its provider survey. Over 1,000 attendees participated in the listening sessions. Among the concerns collected from each were: privacy and security issues with EVV technology, accessibility and availability of EVV in internet “dead zones” and other technical matters, training issues, cost of implementation, and more. DOH says that 46 of 146 provider respondents said they already have EVV in place. One question mentioned in the report, among several raised by HCA, concerns whether providers are already compliant with EVV if they meet the separate existing state requirement for use of Verification Organizations
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(applicable in cases where a provider has Medicaid revenue exceeding $15 million). Another issue in the report, also raised by HCA, is funding: “Provider stakeholders requested that the state fund or offset the cost of implementation and maintenance … as the current reimbursement system, may not provide funding for these systems,” the reports states. The state’s report is largely a compilation of feedback, concerns and questions. As such, it does not provide new answers to many of these or other issues. As a next step, the state is formulating EVV implementation options. It will also issue an EVV Request for Information for responses from vendors. More information, including the report and additional updates, are on the state’s EVV website at https://www.health.ny.gov/health_care/medicaid/redesign/evv/. The federal EVV website is at https://www.medicaid.gov/medicaid/hcbs/guidance/electronic-visit-verification/index.html. HCA will continue to press our core recommendations, EVV cost estimates and calls for funding, including those recommendations outlined in an eight-point “EVV Principles” document shared with the state earlier this summer (see https://hca-nys.org/wp-content/uploads/2019/10/EVV-Principles_070819.pdf).
PHHPC Acts on Home Care Applications The Public Health and Health Planning Council (PHHPC) acted on a number of home care applications at its October 10 meeting. The agenda and supporting documents are at https://www.health.ny.gov/facilities/ public_health_and_health_planning_council/meetings/2019-10-10/index.htm. PHHPC approved the following applications:
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A change of ownership by a Certified Home Health Agency (CHHA).
An existing Licensed Home Care Services Agency (LHCSA), with a site in Rockland County and a site in the Bronx, seeking to acquire a LHCSA in Albany that serves 11 counties.
A for-profit LHCSA requesting approval to convert to a not-for-profit corporation.
An entity seeking to obtain licensure as a LHCSA that will serve five counties under an exception to the existing LHCSA moratorium. The applicant will serve patients with implanted intrathecal pain pumps who suffer from severe, chronic pain and spasticity.
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NGS’s Oct. Advisory Meeting Yields Key Home Health Updates HCA Vice President for Finance and Management Patrick Conole participated in a home health advisory meeting last week with the state’s Medicare Administrative Contractor (MAC), National Government Services (NGS), which yielded important technical updates for the home health membership. The purpose of the meeting (for provider representatives in NGS’s Jurisdiction 6) is to discuss important MAC issues, information or developments, and for HCA and colleagues to pose questions or concerns. HCA has prepared a detailed memo with updates from the meeting at https://hca-nys.org/wp-content/uploads/2019/10/101119NGSHomeHealthMemo.pdf. These updates include: audit and reimbursement issues; top reason codes for claim denials and tips from the Medicare regulations to avoid denials; Comprehensive Error Rate Testing (CERT) results; NGS education with a focus on the Patient Driven Groupings Model (PDGM); new online functionalities; and other important items.
Medicare Appeal Thresholds Posted for 2020 The U.S. Centers for Medicare and Medicaid Services (CMS) has announced the annual adjustment in the “amount in controversy” threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The 2020 amounts will be $170 (up from $160 in 2019) for ALJ hearings and $1,630 (up from $1,600 in 2019) for judicial review. More information is at https://www.govinfo.gov/content/pkg/FR-2019-10-07/pdf/2019-21751.pdf.
Health Care Resources
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“Maternal and Child Home Visiting Program: HHS Determined That States Generally Met the Maintenance of Effort Requirement,” by the U.S. Government Accountability Office https://www.gao.gov/assets/710/701431.pdf
“Medicare: Spending on Certain Disposable Wound Care Devices in Home Health,” by the U.S. Government Accountability Office https://www.gao.gov/assets/710/702041.pdf