Appendix K: A Potential Opportunity for Expanding Home and Community Based Resources for Frail and Disabled Florida Seniors

What is Appendix K? 
In response to the COVID crisis, Appendix K is one important mechanism states have for ensuring that frail and disabled seniors requiring a nursing home level of care have access to the home and community-based services (HCBS) needed to stay safely at home. In Florida, HCBS are provided to a limited number of low- income disabled adults under what is referred to as the “Long-Term Care (LTC) Waiver.” Click here for more information on the LTC Waiver.
 
Appendix K can be used by states during the COVID-19 emergency to increase the number of people who can enroll in the LTC Waiver, lift budget and service limitations, add services, change provider qualifications, raise provider rates, and make other changes to improve access to services. Like other Medicaid Programs, the state receives roughly 66% federal match funding (referred to as FMAP) for all LTC Waiver expenditures. (Note, the FMAP was raised from 60% during the crisis.)
 
Does Florida Already Have an Appendix K? 
YES. Florida has received approval of Appendix K submissions for each of the state’s Medicaid waiver programs providing HCBS, including the Long-Term Care Waiver for severely disabled adults needing a nursing home level of care. Florida requested and received important flexibilities for the LTC Waiver, including: temporarily waiving licensure requirements to allow adult day care staff to provide services in the enrollee’s home and providing retainer payments to Adult Day Care Centers that were closed due to the crisis.
 
In contrast to other states, Florida has not (yet) ask for increased services, supplemental pay for frontline workers, or increased waiver slots so that more people could enroll in the LTC waiver. See link for more information.
 
Can Florida ask for and Receive Additional Funding and Flexibilities? 
YES. States are encouraged to submit additional requests to the federal agency reviewing Appendix K requests.
 
Can states get extra funding for frontline home health workers? 
YES. A number of states have used Appendix K to get supplemental payments for front line workers who take care of waiver enrollees. Here are examples:

• Increase rates up to 50% subject to department approval. ND, UT
• Increase in rates in quarantine situations; increase up to 50% of previous rate. AK
• Increase rates 8% or 13%, depending on the service. CO
• Increase rates up to 15%. NE
• Increase rates up to 50% of maximum rate, if beneficiary or household member tests positive for COVID-19, or has been advised to self-quarantine. MA
• Increased rates in certain geographic areas; increase of up to 50% of previous rate. KY
• Flexibility to adjust provider rates, with add-on not to exceed 25% of previous rate. WA
• Increase rate for institutional respite services to match the institutional rate for designated waiver. MS

 
Click here for more information about specific state utilization of Appendix K. See also, here for Kaiser Family Foundation Appendix K tracker.
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Can states increase the number of people who can receive HCBS? 
YES. Two states, Utah and Maryland, requested and received permission through Appendix K to raise their waiver cap. In Florida, the LTC waiver enrollment is currently capped at approximately 65,000 and there is a waiting list of over 50,000.
 
In contrast to the LTC waiver benefit, which provides needed home health services and supports in one’s home, Florida’s Medicaid nursing home benefit is not a “capped” benefit.  In other words, if someone meets the financial and medical eligibly standards for HCBS, they can go into a nursing home without first being placed on a waitlist.
 
What are relevant points regarding Florida's need to increase the number of LTC Waiver slots?

• A number of individuals on the waiting list are at increased risk of COVID-19 given their age, poverty and medical conditions, and they are also at risk of having unmet daily needs due to a caregiver’s infection. 

 

• The cost of a Nursing Facility in Florida is four (4) times the cost of long-term care services under the waiver. [i]

 

• As of April 2020, there are 59,180 are waiting for the Medicaid LTC Waiver. [ii]

 

• National studies show that risk of nursing facility entry increases where caregivers are under emotional, physical or financial strain.[iii]

 

• The primary variable that moves a person up the waitlist and into services is a finding that the caregiver is in crisis.

 

• Most caregivers are either older adult spouses or grown children over the age of 50.

• Increase in LTC waiver slots will have the dual benefit of supporting older adults at home now (so that they do not flood beleaguered nursing facilities) and supporting older adults residing in nursing facilities so that they can return to their communities with assistance and avoid exposure to the virus. 

 

[i] As of June 2019, the Nursing Facility rate was $6,119 and the HCBS rate was $1,650. The Statewide Medicaid Managed Care LTC rate paid managed care entities 44.6% of the Nursing Facility rate ($3,599.81), LTC Capitation Rates and Related Services - Budget Estimate Detail, obtained from AHCA by Justice in Aging. (JIA).
 
“Florida has been falling behind on funding home- and community-based services in recent years. In 2013, the state had a waiting list of nearly 50,000 for state- and Medicaid-funded home- and community-based services. The most current waiting list, from February 2019, is 71,650, an increase of nearly half. A 2017 AARP Long-Term Services and Supports Scorecard listed Florida as 49th among the 50 states and the District of Columbia in providing support to family caregivers.” http://silversolutionscoalition.org/wp- content/uploads/2019/09/CoalitionIssueBrief.pdf
 
[ii] https://fcoa.starchapter.com/images/other/waitlistreport_042020.pdf
 
[iii] For example, see J. Wolff et al, Long-Term Nursing Home Entry: A Prognostic Model for Older Adults with a Family or Unpaid Caregiver, JAGS 2018

For more information or questions please contact Miriam Harmatz, harmatz@floridahealthjustice.org, or Melissa Lipnick,  lipnick@floridahealthjustice.org. May 26, 2020. 

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