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AOTA Comments on Medicaid Program

AOTA Comments on Medicaid Program

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Published by: Il Dc on Jul 16, 2011
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07/16/2011

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July 5, 2011Centers for Medicare and Medicaid ServicesDepartment of Health and Human ServicesAttention: CMS-2328-PBaltimore, MD 21244-1850
RE:
 
CMS-2328-PAOTA comments on proposed rule on the Medicaid Program: Methods for AssuringAccess to Covered Medicaid Services, Federal Register, May 6, 2011.
Dear Sir or Madam:The American Occupational Therapy Association (AOTA), the national professional associationrepresenting the interests of more than 140,000 occupational therapy practitioners appreciates theopportunity to comment on this proposed rule which has the potential to have a major impact onaccess to appropriate services – and appropriate providers of these services -- for children andadults who are Medicaid beneficiaries.Because occupational therapists and occupational therapy assistants provide services to peopleacross the lifespan with a focus on wellness, prevention, rehabilitation, and maintenance of existing function, AOTA is particularly interested in any changes that will have a direct impacton the ability of children, adults, seniors and individuals with disabilities and chronic conditionsto receive the supports and services they need to function as independently as possible.Occupational therapy places a major focus on providing individualized supports and services inthe least restrictive environment. Occupational therapy practitioners have a holistic perspective,in which the focus is on adapting the environment to fit the person, and the person always is anintegral part of the therapy team.Occupational therapy services typically include an individualized evaluation, during which theindividual/family and occupational therapist work together to determine the person’s goals. OTsand OTAs provide customized interventions to improve the person’s ability to perform dailyactivities and reach specific goals. All efforts include an outcomes evaluation to ensure that theappropriate goals have been established and are being met and – if needed -- to make changes tothe intervention plan. Occupational therapy services may include: comprehensive evaluations of the individual’s home and other environments (e.g., workplace, school); recommendations for adaptive equipment and training in its use; as well as guidance and education for familymembers and caregivers.AOTA provides the following specific comments both to (1) offer its support for the innovativekey concepts embedded in this proposed rule; and (2) to offer specific recommendations whichAOTA believes will assist the Department to strengthen the eventual final rule.
 
AOTA supports the Centers for Medicare and Medicaid Services (CMS) efforts to make statesmore accountable for ensuring sufficient access to quality services for beneficiaries of all ages.However, AOTA asserts that the Department must be very clear as it defines the terms“sufficient access” and “quality” and that these definitions fit all categories of beneficiaries. For example, the population of individuals with whom OTs work, too often face the obstacle of avery narrow definition of medical necessity which either limits or even prohibits access to theservices and supports they need to live in the community. Effective monitoring and enforcementof state actions is a critical key to the success of any effort to ensure that people get access to theservices they need.While AOTA and other providers realize that states are facing budget deficits, we are extremelyconcerned with the emphasis-- actually almost the acceptance as fact-- that additional ratereductions are the key part of this effort. Currently more and more providers are being forced outof the Medicaid program because of ongoing rate cuts in both the Fee for Service (FSS) andmanaged care structures. AOTA strongly believes – and has data to back up the fact -- that OTservices help keep people of all ages become and remain more independent, productive and lessdependent on the health care system. We are extremely concerned with the impact that the focuson rate cuts will have on beneficiaries’ access to critically needed OT services and supports.AOTA has always supported provisions that allow more beneficiary and stakeholder input intostate actions – actions that will have a direct impact on both beneficiaries and those who providethem with services and supports.However, it appears in this proposed rule that beneficiary and stakeholder input mostly will berelated to any State Plan Amendments (SPA) which reduce or restructure payment rates. Thisemphasis on more rate reductions is of major concern. Also of major concern, however, is theneed to ensure that beneficiaries and providers who– though they may have the right to participate in the process– may not be fully educated as to all the potential outcomes of a SPAand what changes in provider rates will really mean to them as beneficiaries. In addition, their  participation must not be last minute and must not be viewed by the state as pro-forma. Theremust be proper notice and the input of stakeholders must be considered.AOTA questions why the provisions of this proposed rule apply only to state FFS Medicaid anddo not apply to managed care arrangements. The Preamble states that “managed care entities aresubject to separate access review procedures”…..and that “the Department is currentlyundertaking a review of states managed care access standards”. At a time when over 70 percentof the Medicaid population is enrolled in some form of managed care, and when managed carerestrictions have been extremely problematic for children and adults with disabilities and chronicillness, it certainly appears to AOTA that any focus on protecting access to needed servicesshould include managed care. In addition, in relation to rate setting, too often in managed care itis the very low capitation rates, along with very limited definitions of “medical necessity” thatlimit individuals with disabilities and chronic illness from access to the services they need to liveas independently as they can in the community – for their whole lives.One final comment related to rate setting refers to the statement that some states develop rates on“a review of the amount paid by commercial payers in the private market”. When it comes to the

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