The Home and Community-Based Services (HCBS) Utilization Review/Utilization Management (UR/UM) Webpage

About the HCBS UR/UM webpage:

The Department is excited to share a new webpage dedicated to HCBS Utilization Review/Utilization Management.

This webpage will be the landing page for resources related to Children's Extensive Supports, Children's Home and Community-Based Services, Health Maintenance Activities, Over Cost Containment, and Supported Living Services reviews conducted by Telligen.

This webpage will be replacing the resources on the Long-Term Services and Supports (LTSS) training webpage. Case Managers can find information regarding upcoming Telligen Office Hours, Telligen Tip Sheets, Procedure Code Modifier list and more.

This page includes information about:

• Purpose of the HCBS UR/UM program
• Telligen office hours
• Training materials
• Forms and templates
• Memos and guidance
• Program contacts

We hope you'll bookmark the HCBS UR/UM webpage and use it as a handy reference.

The Potentially Dire Long-Term Impact Of Home Health Agency Closures

Home Health Care News | By Patrick Filbin

Back in October, Hospice and Home Care of Juneau closed after 20 years in business.
 
A month earlier, Trinity Health At Home in Springfield, Illinois, shut its doors and laid off 60 employees.
 
At the start of the new year, Oahu Home Healthcare announced it was shutting down, leaving just eight at-home care agencies on the most populated island in Hawaii.
 
More and more, small- to medium-sized providers are shuttering permanently due to staffing constraints and margin pressures. Home health insiders believe that this trend is troubling not just for providers in jeopardy, but for the industry as a whole.
 
“The industry got a reprieve this year from CMS,” Mike Dordick, the president of McBee Associates, told Home Health Care News. “If that doesn’t happen again, you’re going to start to see not just small agencies close, you’re going to see some of the large players say, ‘There’s no point in serving these rural markets and some of these areas because we’re losing money.’”
 
McBee Associates is a health care services and consulting firm that works with providers in a wide range of states. In 2019, prior to the pandemic, Dordick told HHCN that he believed there would be about a 30% reduction in the number of providers over the next several years.
 
Of course, the public health emergency changed projections. It gave providers financial stability and “masked” some of the financial troubles that were inevitable, Dordick said.
 
In the first quarter of 2019, there were 9,624 home health providers that filed at least one claim with CMS, according to McBee’s data. In the first quarter of 2022, that number was at 8,670, a 10% reduction.
 
That reduction is partly due to mergers, and partly due to closures.

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Debt Ceiling Fight Looms Over Medicare, Medicaid

Axios | Peter Sullivan
 
House Republicans don't have much of a path to get major health care changes passed with a Democratic Senate and president, with one possible exception: the debt ceiling fight. 
 
Why it matters: It's not clear which spending cuts House Republicans will push for in exchange for expanding the government's borrowing authority later this year — but at least some say health care programs like Medicare and Medicaid should be on the table. 

• Others, mindful of how the mere talk of entitlement cuts has brought political repercussions, are saying they want to steer clear of the programs. 

What they're saying: "We're going to have to look at the whole board," conservative Rep. Barry Loudermilk (R-Ga.) told Axios, including mandatory spending like Medicare and Medicaid. "The easiest to start with is discretionary, but the main driver of the national debt is the mandatory."

• "Everything's on the table," he added. 
• Asked about entitlement reform, Speaker Kevin McCarthy told reporters Thursday that "as Republicans we will always protect Medicare and Social Security," but did not get into specifics. (He also did not mention Medicaid).
• "We will protect that for the next generation going forward, but we are going to scrutinize every single dollar spent," he added. 

What to watch: Rep. Morgan Griffith (R-Va.), a Freedom Caucus member who is also on the Energy and Commerce Committee, said any changes to Medicare would not take place immediately.

• "Anytime we talk about those cuts people always panic," he told Axios. "Nobody needs to panic. If we're going to do something, it will be out in the future years a long way out and people will understand it and will have time to adjust for it."
• He cited the possibility of raising the Medicare eligibility age from 65 to 67 as one possible change, while keeping it lower for people who had careers doing manual labor and have trouble continuing to work later in life. 

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Blood Test for Early Alzheimer’s Detection

One of the first stages of Alzheimer’s disease involves formation of toxic aggregates, called oligomers, of the protein amyloid beta (Aβ). These oligomers can start to form more than a decade before symptoms appear and before other known disease markers form. The ability to detect these oligomers would permit early disease diagnosis. This would make strategies to intervene before irreparable brain damage occurs possible.

An NIH-funded research team led by Valerie Daggett at the University of Washington developed a method to detect toxic Aβ oligomers in patients’ blood. They tested the assay, called the soluble oligomer binding assay (SOBA), on nearly 400 banked human blood plasma samples. Results appeared on December 13, 2022, in the Proceedings of the National Academy of Sciences.

Toxic Aβ oligomers have a structure known as an alpha sheet that isn’t normally found in proteins. Alpha sheets tend to bind to each other. SOBA takes advantage of this distinct structural feature. The researchers designed a synthetic alpha sheet molecule to bind to the alpha sheets in Aβ oligomers. They showed that their designed molecule, called AP193, bound to the subset of Aβ with alpha sheets but not to other, non-toxic forms of Aβ.

Aβ oligomers normally reduce signaling in cultured neurons. Adding AP193 prevented this reduction in signaling. AP193 might thus form the basis for future therapeutic strategies.

When the team applied SOBA using AP193 to a cerebrospinal fluid sample from a person with Alzheimer’s disease, they detected Aβ oligomers. They did not detect oligomers in cerebrospinal fluid from a person who had no cognitive impairment.

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