Humana thanks the Virginia Department of Medical Assistance Services (DMAS) for the opportunity to provide suggestions for the use of increased home and community-based services (HCBS) funding available under the American Rescue Plan Act (ARPA). Humana is a longtime partner of the Commonwealth, currently serving more than 980,000 Medicare, commercial, and Tricare members. Through their community and provider relationships, infrastructure, and data capabilities, we believe that managed care organizations (MCO) are well positioned to be strong partners of the Commonwealth in the implementation of the enhanced HCBS funding. In addition to providing coverage of HCBS services, MCOs forge partnerships and operate programming aimed at supporting members receiving HCBS services and their caregivers and addressing social needs like social isolation. Programmatic recommendations you may want to consider are as follows:

Recommendation 1: Promoting Access to Waiver Services

Humana supports the use of enhanced HCBS funding to shorten the waitlist for the Developmental Disabilities waivers, particularly for those members who are deemed to have Priority Level One Needs. In addition, we encourage DMAS to consider expanding waiver eligibility to allow more members to benefit from waiver services.

We also support the use of federal medical assistance percentage (FMAP) funding to provide short-term services that can provide a bridge until members on the waitlist can receive waiver services. For example, members and their caregivers may benefit from receiving training on seeking employment, expanded transportation to access employment and community services, and enhanced supports for transitions from institutional settings into the community. MCOs can assist in arranging and providing those bridge services that fall within the scope of managed care services.

Recommendation 2: Support Workforce Development and Increase Reimbursement Rates

The National Center for Health Workforce Analysis estimates that from 2015 to 2030, the need for more direct care workers may increase by 48%.[i] The enhanced HCBS funding made available under ARPA creates an opportunity for DMAS to address workforce shortages and the increased demand for direct care workers. Humana supports the use of increased funding on activities designed to build and retain this essential workforce. These activities include, but are not limited to:  

• Increasing payments and developing career opportunities for direct care providers:
  • In addition to the increased reimbursement rates that will take effect on July 1, 2021, Humana supports a further increase in reimbursement rates for both agency-directed care and consumer-directed care (e.g., increased reimbursements for eligible family caregivers).[ii] An increase in reimbursement rates can be coupled with higher wages or paid leave benefits or overtime for these agency or consumer-directed employees to further promote staff retention.
  • Humana supports career development and growth opportunities for HCBS direct care providers. For example, we offer continuing medical education opportunities for our network providers. Specifically, Humana supports funding pilot projects to develop competency-based curriculums and certification processes to encourage career growth among HCBS direct care providers.
• Trainings and payments to relative/family caregivers:
  • Given the role spouses and parents play to support loved ones during this pandemic, Humana supports extending the flexibilities instituted under the COVID-19 public health emergency that allow spouses and parents of children under the age of 18 to be reimbursed for consumer-directed services.^{[iii], [iv]}
  • Humana supports providing additional trainings to relative caregivers to better equip them to serve members receiving HCBS services. For example, we maintain online caregiver resources and toolkits designed provide caregivers with tips on how to prevent burnout and support their loved ones. For example, DMAS may work with MCOs and providers to offer caregiver trainings and supports that emphasize how caregivers can safely support members in HCBS settings and avoid preventable hospitalizations and emergency department visits.
  • Humana supports the use of available funds to provide personal protective equipment and other necessary equipment to family caregivers to promote their personal safety as they provide essential care for their relatives during the COVID-19 public health emergencies. In 2020, Humana donated approximately 24 million masks to provider groups and community-based organizations across the country, recognizing personal protective equipment as essential tools to reduce the risk of transmission and promote maintenance of daily activities. 
  • Humana is committed to leveraging value-based payment models to increase access and improve quality of care. Working with MCOs, the Commonwealth can develop incentive payment models for providers to recruit and retain direct care providers.
  • Building on the work of the Department of Health Professionals Advisory Committees and leveraging electronic verification visit data, we suggest exploring the use of available funds to obtain more data on the HCBS workforce. Tracking trends in the HCBS workforce can help the Commonwealth identify potential operational efficiencies, workforce shortages, and training opportunities. Detailed data will allow MCOs, agencies, and members to develop targeted solutions for recruiting and retaining staff. ^[v]

Recommendation 3: Reconnecting Members to Essential Supports and Services

Social isolation, exacerbated by the COVID-19 public health emergency, has a profound impact on the health and well-being of HCBS members, particularly those without access to adult day care and those who live at home. Through our enterprise population health strategy, Bold Goal, Humana has contributed to national research on the effects of social isolation on overall health and quality of life and implemented various initiatives in our Bold Goal communities across the country to measurably reduce the impact of social isolation among our memberships. Based on this experience, Humana supports DMAS’ efforts to reduce social isolation among HCBS members and reconnect them to essential services and supports. We suggest that DMAS explore the following use of the available HCBS funding:

• Promoting enhanced local programs to re-engage members in their community:
  • Humana supports DMAS’ collaborative efforts with MCOs and community-based partners to address social isolation through reinvigorated in-person programs focused on reconnecting HCBS members to their communities, social supports, SDOH resources, and rehabilitative programs. In addition, we encourage DMAS to explore leveraging the available funding to increase access to transportation services to connect members with those services they may have missed during the COVID-19 public health emergency. Transportation is a significant barrier to members living more fulfilling, independent lives. In a 2019 study conducted by Humana’s Bold Goal, we found that 32.7% of our surveyed Medicare members who expressed feeling “lonely or isolated” also reported having transportation barriers.
• Investing in assistive technology to mitigate isolation:
  • We support the use of this funding to provide assistive technology to mitigate isolation that resulted from COVID-19, particularly among those members not eligible for waiver services or for members who are on a waiver waitlist. Through this technology, DMAS may promote the creation of peer and social support groups for HCBS members and caregivers. Through a pilot of ours that offers social support to socially isolated members, we achieved a 21% reduction in loneliness (measured using the UCLA 3-Item Loneliness Scale), a three-day average increase in physically healthy days, a five-day average increase in mentally healthy days, and 54.7% of participating members reporting feeling less lonely.
• Meeting members where they are to promote re-engagement with routine care:
  • To promote reconnecting members to essential services, DMAS may consider the use of a mobile unit, especially in rural areas of the Commonwealth. Mobile health units alleviate health disparities in vulnerable populations, including members receiving HCBS, by offering urgent care, preventative health screenings, and chronic disease management to members within their own communities. Humana supports prioritizing services targeted towards members with active gaps in care who may have deferred routine care during the COVID-19 pandemic. Further, we support equipping this mobile unit with telehealth capabilities to connect members to timely and appropriate care.