Health And Human Services Committee Briefing: June 25, 2020

On June 25, 2020 Maryland’s Health and Human Services Subcommittee gave an extensive briefing detailing the state and community response to the social service needs of Marylanders during COVID-19. Find updates from Maryland Department of Health, Behavioral Health Association of Maryland, Community Health Resources Commission, Mental Health Association of Maryland, and more below, or download the full presentation.

Tonya Zimmerman, Principal Policy Analyst
Maryland Department of Legislative Services

• Temporary Cash Assistance (TCA) Applications: 17,520 in April compared to 4,852 in March – 21 of 24 jurisdictions had more than double the applications.
• Prince George’s County had the largest increase, Baltimore City had fourth highest.
• Supplemental Nutrition Assistance Program (SNAP) Applications : 149,346 in April compared to 28,757 in March – 18 of 24 jurisdictions had more than double the number of applications.
• Baltimore City had the largest increase followed closely by Prince George’s County.

Q&A

Senator Adelaide Eckardt: Were you surprised that there wasn’t any more increased enrollment than appears in the charts?

Simon Powell: Not particularly, because you’re talking about percent change from the underlying number and enrollment in that area is fairly high anyway.

Tricia Roddy, Medicaid Director
Maryland Department of Health 

            Overview

• Medicaid has implemented temporary flexibilities designed to ensure safety of participants and providers during the COVID-19 pandemic.
• Most flexibilities are tied to

• • (1) Executive Orders and/or
  • (2) Waivers from the federal government.

• Federal Actions:

• • January 31, 2020: Public Health Emergency (PHE) declared (retroactive to January 27, 2020)
  • March 13, 2020: National Emergency (NE) declared
  • April 26, 2020: PHE extended for up to an additional 90 days. The current authority expires July 25.
  • Renewal: It is unclear if the PHE will be extended further.
• Staff have successfully shifted to a telework model. A limited number of team members remain on-site to complete mission critical tasks that cannot be performed remotely.

Telehealth Flexibilities 

•  Safety of Medicaid providers and participants is a priority.
• To prevent transmission and spread of COVID-19 disease, Medicaid implemented certain flexibilities with respect to delivery of services via telehealth, these include:

• • Permitting a participant’s home or any other secure location to serve as a telehealth originating site for purpose of the delivery of Medicaid-covered services;
  • Permitting reimbursement for audio-only health care services delivered by phone; and
  • Permitting the use of telehealth technology not compliant with HIPAA.
• Federal waivers permitting telephonic and non-HIPAA compliant technology sunset in tandem with the end of the federal PHE.
• Medicaid is evaluating which services may be appropriate for delivery via telehealth in a home setting on a permanent basis.

Eligibility and Enrollment

• Enrollment growth drivers include: Maintenance of effort (MoE) requirements, job losses, and special enrollment periods through the Maryland Health Connection tied to tax filing and COVID-19.

• • The majority of new enrollment is MAGI adults

• Maintenance of Effort (MoE) Requirements:

• • Families First Coronavirus Response Act (FFCRA) authorizes a 6.2% eFMAP during the PHE for states that comply with MoE–

• • • MoE: sunsets at the end of the month in which the PHE ends,
    • eFMAP: sunsets at the end of the quarter in which the PHE ends.

• • States may not terminate coverage for any beneficiary enrolled in Medicaid during the emergency period effective March 18, 2020, unless the beneficiary voluntarily requested to be disenrolled, or is no longer a resident of the state.
  • States may not reduce benefits for any beneficiary enrolled in Medicaid on or after March 18, 2020, through the end of the month in which the emergency period ends.
• Medicaid redeterminations have been suspended as a result.

Dr. Aliya Jones, Deputy Secretary
Behavioral Health Administration

            BHA Actions Taken

• Helping to expand and strengthen telehealth and telephonic options.
• Offering providers transition guidance to move from live to virtual service so they can stay open and connected to patients.
• Redirected grant funds to assist with Personal Protective Equipment (PPE) for health care workers.
• Supporting federal decisions to relax take-home medication requirements for stable patients in order to reduce foot traffic in treatment programs.
• Extending renewal deadlines for provider certificates and licenses.
• Developed PSAs on recognizing anxiety, stress, and depression.
• Developed Deaf and Hard of Hearing Communication guide.
• Developed a Recovery and Wellness Resource guide.
• Posting social media messages on mental health, substance use disorder, and problem gambling.
• Developed a Resource Guide on Intimate Partner Violence for providers and consumers.
• Developing a Resource Guide on Grief and Loss.
• We are working with the Maryland Institute Emergency Services System (MIEMSS) to provide 24-hour telehealth services for personnel working in skilled nursing and other long-term care facilities.
• In the process of developing a new program – A collaborative partnership focused on providing mental health support for first responders impacted by COVID19.

Enhanced Communications

• Weekly FAQs – responding to provider inquiries.

• • Since mid-March, 62 FAQs have been distributed.

• Weekly meetings with the Maryland Behavioral Health Authorities, the local managers of behavioral health services, to identify jurisdictional issues and offer including guidance on how to move from live to virtual services to keep providers operational and patients connected to needed services.
• Weekly or bi-weekly calls and webinars for opioid treatment providers, crisis service providers, residential recovery/substance use disorder treatment providers and recovery residence providers.
• Organized webinars for the Maryland Primary Care Program (MDPCP) for ambulatory care providers to help support the mental resilience of frontline physician providers.

• • Topics included: Building Resilience During Coronavirus Crisis, Workplace Anxiety, Stress Management During a Pandemic, COVID Survival for Providers, Stress and Self Care for Providers and Front-line staff, PCP Suicide Prevention Toolkit.
• Sharing daily guidance documents from CDC, SAMHSA, NASADAD, NASMHPD, ASAM, and other partners.

New Initiatives for Veterans and COVID-19 Survivors

• Developed a collaborative resource: Operation Roll Call, a program that offers veterans regular check-in calls and a chance to talk to someone who can offer support.

• • To date, 24 individuals have signed up.

• Partnered with NAMI to develop peer support groups and shared mental health supports with CovidCONNECT, the State’s new website for Marylanders who have recovered from COVID-19.

• • To date, there are 1,700 total enrollees.

Bernie Simons, Deputy Secretary, Developmental Disabilities Administration

• DDA is conducting weekly stakeholder webinars including webinars to support families during the pandemic.
• DDA created a COVID-19 toolkit and guidance for providers to support individuals in group homes.
• DDA created a COVID-19 webpage with resources and guidance for stakeholders.
• DDA operationalized Appendix K by providing guidance, FAQs, forms, and created easy to read at-a-glance fact sheets for Appendix K.
• DDA in partnership with the MDH Epidemiologist team created screening tools and checklists for group homes to prevent outbreaks.

Service Flexibility, Funding, and PPE

• Provider Retainer Payments.
• Additional funding and flexibilities for self directed services.
• Individual wellness checks by Coordinators of Community Services to ensure individuals are getting needed support during COVID-19.
• Go Team supports for Group Homes.

Information, Guidance and Resources 

•  Weekly stakeholder webinars, including webinars specifically for families.
• DDA related COVID-19 Toolkit.
• DDA COVID-19 webpage with resources and guidance specific to families, participants, direct support professionals, and providers.
• DDA Appendix K webpage with federal approval, guidance, FAQs, and forms.
• Created at-a-glance fact sheets on DDA’s Appendix K for stakeholders.

Service Flexibility and Support 

• On March 26, DDA submitted a federal waiver application (Appendix K) for all DDA Waivers including Family Supports, Community Supports, and Community Pathways with the following flexibilities:

• •  Telephonic and remote service options.
  • Increased rate for supporting people.
  • Exceptions to preauthorization requirements.
  • Automatically increase respite service hours.
  • Provided additional funding for staff supports in all Group Homes

• Alternative service delivery sites.
• Exceptions to site capacity.
• Staffing flexibilities to include hiring family members to provide services and exceptions to staff onboarding requirements.
• Provider Retainer Payments.
• Self-directed service additional funding and flexibilities

Information, Guidance and Resources

• The DDA has worked in partnership with the MDH Epidemiologist team to create screening tools, guidance, and checklists for group homes to prevent outbreaks.
• On April 10, Heather Saunders, Nursing Program Consultant from the Office of Antimicrobial Resistance and Healthcare Associated Infection in MDH conducted training on the use of PPE and Dr. Kenneth Feder the Epidemic Intelligence Service Officer for the Centers for Disease Control and Prevention assigned to MDH presented on COVID-19 concerns and answered questions.
• On April 17, the DDA conducted a webcast with Dr. Feder “Responding to Outbreaks of COVID-19 in Homes for People with Developmental Disabilities” where Dr. Feder walked providers through prevention scenarios to help with outbreaks.
• On April 24, the DDA shared guidance on the Go Teams program provided by Dr. Timothy Chizmar, State EMS Medical Director, MIEMSS.
• The DDA is sharing national best practice information and guidance to all providers as they look to reopen.

Q&A

Senator Delores Kelley: I am particularly concerned about reports regarding the lack of cumulative reporting of the nursing home illnesses and deaths that are Covid-19 related. I’m also concerned about the lack of broadband coverage to do telehealth in rural areas.

Robert Neall: Regarding assisted living, a lot of the large sophisticated ones have done testing on their own. The smaller ones do not have medical personnel on site, so we are working on a testing strategy to go through that the way we did with nursing homes. As far as telehealth, we did a lot of this because we had to. I think we will take a step back and see if this is good for the long haul.

Senator Pam Beidle:  Regarding the nursing home numbers. How can the deaths in nursing homes go down? I understand the number of patients affected will go down, can you explain how this number could decrease?

Robert Neall: I’ve asked that same question Pam, and I’m going to get to the bottom of it and I’ll give you a call when I find out.

Senator Guy Guzzone: What can you tell me about the creative thinking that you guys are doing and use of CARES dollars. I understand what’s going on with the Medicaid money and such, but in terms of helping our provider community? What kind of things have you been spending money on putting money aside for?

Robert Neall: I’d like to be able to itemize it for you and circulate it to you and the committee. We have been using that money. It is money that we can plug into things that are natural gaps in what we’re trying to do.

Senator Guy Guzzone: Are you thinking of ways of possibly reimbursing providers for things that were not considered or normal parts of their efforts because of dealing with Covid.

Robert Neall: That’s part of it. I’m assuming gaps and lapses will be brought to our attention for consideration.

Senator Jim Rosapepe: How are we doing in terms of PPE? What are your expectations on where we will be in the next couple of months?

Robert Neall: We are in very good shape. I have not stopped procuring PPE, we have perhaps even a year’s worth. I hesitate to even estimate how much we have, but I’ve continued to procure it. We are trying to be fully prepared for a second wave.

Senator Malcolm Augustine: Regarding Home and Community Based Options Waiver. Has anyone been able to get off of the waiting list?

Tricia Roddy: Waiting lists are still in place. They are operating as they always have been during this time period.  The protections that we have put in place have allowed them to go into the nursing homes if they need nursing home care. In the event that they are disenrolled they are allowed to go back into those Home and Community Based Waiver programs.

Senator Melony Griffith: Where are we at with the IT system transition? What is going out the door to providers?

Robert Neall: We are making significant progress. We are happy to get back to you on those.

Michelle Farr Executive Director
Social Services Administration, Department of Human Services 

COVID-19 Services Briefing: Child Welfare, SNAP, TCA and TDAP – Parent Resources Developed during Covid-19 Pandemic

Supporting Families – Community Outreach

• Governor’s Office of Crime Prevention, Youth and Victim Services

• • Report abuse/neglect video

• Partnerships and Collaborations

• • Maryland Department Education and Office of Childcare
  • MD Parent Teacher Association
  • Maryland Chapter of American Academy of Pediatrics and the Maryland Academy of Family Physicians
  • Maryland Chapter of the National Association of Social Workers
  • Support to our provider community

Netsanet Kibret, Executive Director
Family Investment Administration, Department of Human Services

Assisting TDAP Customers Remotely

The TDAP population in the best of circumstances, often faces physical, mental, and/or financial barriers to travel. As a result, disability advocacy efforts were already designed to meet people where they are. The Disability Benefits Advocacy Project vendor has historically designed efforts to prevent office presence as well as integrating new efforts in light of COVID. The efforts include:

• paperless operations
• remote screenings, outreach and case development
• continued office presence to intercept mail
• increased phone and mail outreach
• partnership between the vendor and SSA to perform remote hearings
• enhanced efforts for medical record development
• collaborative efforts with SSA to identify potential barriers within SSA’s modified service delivery and address accordingly

Pandemic-EBT – Who is Eligible?

• Households with children who are eligible to participate in free and reduced-price meals (FARMS).
• All children in Community Eligible Provision (CEP) regardless of whether they had elected to participate in FARMS.
• Benefits were calculated at the daily rate of $5.70 based on the number of days that the schools were closed due to COVID-19- related school closures.

Q&A

Senator Delores Kelley: Are we doing any training for teachers to help them understand what the department needs or what the regulations are?

Michelle Farr: I have brought that concern up. We partner very closely with the Board of Education. We have two ways in which we can respond to a concern. We have more high-risk which are CPS investigative referrals and then we have alternative response referrals.

Stephanie Cooke: The reports made by teachers and education staff are having a lot of contact with the children. The difference would be between what the finding is. Some mental health professionals and law enforcement tend to report allegations that the department would have evidence that there has been abuse and neglect, which is not the same as the fact that there are risk factors in the family.

Elizabeth Chung, Chair
Community Health Resources Commission

CHRC Background & Mission 

1. Expand access to health care in underserved communities;
2. Support projects that serve low-income Marylanders, regardless of insurance status; and
3. Build capacity of safety net providers.

Impact of CHRC Grants

• 266 grants totaling $77.7 million.
• More than 488,000 Marylanders served.
• Statewide impact- projects in all 24 jurisdictions.
• Address Social Determinants of Health (SDOH).
• Federally Qualified Health Centers, local Health Departments, free clinics and outpatient behavioral health providers.

CHRC as Steward of Public Funds 

• Current portfolio of 71 open grants; $17.5 million in funds managed.
• Prioritize projects that yield quantifiable outcomes, i.e., clinical outcomes and cost-savings.
• Grantees are held accountable for performance and achieving goals and outcomes.

Supporting Safety Net Providers During COVID

1. Provide relief for current grantees.

·         Permit reporting extensions and extend grant end dates for up to 12 months from March 5, 2020.

·         Re-allocate up to 25% of remaining grant funds for COVID-related activities/response.

2. Issue COVID Emergency Funding Relief Call for Proposals.

Mark Luckner, Executive Director
Community Health Resources Commission

COVID-19 Emergency Relief Call for Proposals 

• 66 proposals received, requesting a total of $2.8 million in funding requests.
• $1.46 million in federal CARES Act funding made available to CHRC from the Maryland Department of Health.

COVID-19 Emergency Relief Call for Proposals 

• Telehealth (expansion / creation of services)
• Laptops
• HIPAA Compliant Software
• Video services (Zoom)

2. Procurement of PPE
3. Infection control measures

·         Sanitization / deep cleaning of facilities

·         Equipment for minimization of aerosolized saliva (Dental)

4. Physical & social distancing

·         Purchase of equipment

COVID-19 Emergency Relief Call for Proposals Awards

Applicants evaluated on an 80-point scale.

• Priorities and key review criteria:

• • Serve vulnerable populations;
  • Address Social Determinants of Health;
  • Health disparities and health equity
• Commissioners awarded 45 applicants a total of $1.3 million in funding on June 23, 2020.
• CHRC staff is in the process of contacting every applicant.

CHRC monitoring of COVID grantees

• CHRC takes seriously its responsibility as fiscal steward of public resources (COVID RFP supported with federal funding)
• September 2020- Interim progress reports due.
• January/February 2021- Final grantee reports due (expenditures up to December 2020 are allowable under federal funding guidelines).

Dr. Kathryn Fiddler, Vice President of Population Health
Peninsula Regional Health System

Dr. Charles Dolan
Salisbury Fire Dept. and SWIFT Program Advisory Board Member

Salisbury-Wicomico Integrated FirstCare Team (SWIFT)

• Mobile Integrated Healthcare-Community Paramedicine Program

• •  Collaboration between Peninsula Regional Health System and the Salisbury Fire Department, began in October of 2017.
  • Staffing: SFD Paramedic and PRHS Nurse Practitioner with community health team members.
  • Patient Population: Medically Underserved, High Utilizers of 911 and ER.
  • Goals: Reduce acute care visits by providing primary care and referral to services by visiting patients where they reside.

• Outcomes in 2019: Enrolled over 40 patients, reduced acute care/ER visits by 58%, and a 56% reduction in acute care dollars.

• •  Program Expansion in 2020-2021:

• • • Expansion into Wicomico County
    • Use of telemedicine and remote patient monitoring
    • Use of Nurse Practitioner and Paramedic to respond on low level 911 calls to reduce ER visits for non- emergent conditions
• COVID-19 pandemic programmatic disruption due to inability to visit and interact with patients at the capacity.

Kevin Lindamood, President and CEO
Healthcare for the Homeless

Telehealth and People We Serve 

1. The undeniably real circumstances of the people we serve

2. The importance of telehealth

3. Audio telehealth vs. video telehealth

4. The definition of “originating site” broadly as a home setting

5. Critical need to ease telehealth restrictions permanently and to include Federally Qualified Health Centers (FQHCs)

11 Shelters Tested Universally in Baltimore

1. Partnerships among Baltimore Homeless Services, Baltimore City Health Department, Health Care for the Homeless, Hospital Partners

2. From 25 to 350 residents

3. Positivity range from 55% to 0%

4. High risk of asymptomatic spread

5. Strong relationship between speed of response and rate of spread

6. Universal testing warranted in all congregate facilities

Connection Between Housing and Health Care

1. Homelessness was already a public health emergency

2. Success of public-sector COVID response: De-concentration, isolation

3. Need for same urgency to move people into permanent housing

4. Structural racism and housing policy

5. Recommendation: Policies that recognize housing as a human right and public health intervention

Housing (Un)availability and (Un)affordability 

• Maryland has a shortage of 137,602 affordable rental-housing units for families earning less than 50% of area median income (AMI) and a shortage of 118,810 units for families earning less than 30% of AMI.
• The average price of a two-bedroom fair market rent unit in Maryland is $1,237 per month, while the average amount that households at 30% AMI have available for rent is $741 (2019).
• In Baltimore, over 20% of all households spend more than half their income on housing.
• Maryland has just 33 affordable housing units per 100 households earning 30% AMI or less.

Impending Mass Eviction Crisis… Absent Further Action

• Evictions and foreclosures will resume on July 25.
• Rent delinquency rate in June 2020 of 30.4%: Almost one-third of renters in Maryland are not able to pay the rent.
• An enormously disparate impact on Black communities ravaged by COVID-19.
• Baltimore City procured $13 million in federal assistance, but 3x this amount is needed to avoid massive COVID-related evictions.

Q&A

Senator Jim Rosapepe: How does testing work? How do you get people tested? How do you get the results back to them?

Kevin Lindamood: In addition to the shelter based testing, we are testing every day at our clinic. Our outreach workers are active in the community. If somebody has symptoms or has been exposed we can test someone and trigger transportation to isolation. Many communities have isolation hotels and motels.

Senator Jim Rosapepe: Are you encouraging homeless people without symptoms to get tested?

Kevin Lindamood: In the beginning no, because testing was so limited. Now if someone tells us they are concerned we will get them tested.

Laura Howell, Executive Director
Maryland Association of Community Services, Developmental Disabilities Service Community

Pandemic Toll on Community Services for People with Developmental Disabilities

• 95,000 Marylanders with intellectual and developmental disabilities (IDD)
• Almost 18,000 use supports funded by DDA to live and work in the community, provided by community providers
• 200 community providers, the vast majority are nonprofit
• Community providers are funded with state and federal funds through a Medicaid waiver

Funding Loss

• CMS allows a certain number of days when the provider can be paid when someone is in the hospital or rehabbing in a nursing facility or on vacation with their family – these are called residential “retainer days”
• Loss of DDA provider “retainer “ (bed hold) day payments.
• Prior to pandemic: 30 retainer days reimbursed at 100% of rate.
• Permanent Change: 18 retainer days, reimbursed at 80% of rate.
• Federal rule triggered the reduction in days that federal matching funds can be used.
• MDH has options to address this issue, and has not indicated that they will be taking action to address this devastating change.
• For people who are more likely to have a lot of stays in hospitals or nursing facilities, this equals a 3% rate cut for their residential services.

How are other states handling DD funding during the pandemic?

• PA – just allocated $260 million for COVID-related costs for DD services.
• IL – is using state-only dollars to pay providers for day services until September 1, when they reopen, to ensure they can support people.
• DC – has an unlimited number of cycles of retainer days because providers “would not survive” if they only had 18 retainer days in one year (as MD now does).

How vulnerable will State leaders allow dd services to become?

• Community providers were vulnerable going into the pandemic.
• Governor Hogan vetoed important legislation that would have provided some stability through the State’s major systems change.
• We have no predictability in whom we will be able to support, and what the rules will be moving forward; and
• We have no sense of financial stability

• • Minimum wage
  • Budget cuts

Dan Martin, Senior Director of Public Policy
Mental Health Association of Maryland, Community Behavioral Health Association

Lori Doyle, Director of Public Policy
Community Behavioral Health Association of Maryland

• 68 member organizations providing mental health and/or substance use disorder services. Members include:

• • community-based providers and clinics
  • hospitals
  • local health departments

• CBH members:

• • serve approximately 170,000 individuals annually in Maryland
  • employ almost 13,000 individuals
  • are located in every jurisdiction in the state
  • provide a full range of services for youth and adults

Our Members’ Services

• Outpatient treatment (mental health and addiction, including MAT)
• Housing and day programs
• Crisis beds
• Case management
• Supported employment
• Assertive Community Treatment

COVID Impact

• ASO Relaunch

• • End of estimated payments
  • Reconciliation of six months of payment
  • Payment recoupment

• Proposed policy and budget changes

• • Threatened loss of 4% mandated rate increase for FY 21
  • End of telehealth expansion as of July 25
  • Comprehensive regulatory rewrite
  • Start-up of MDH rate study
• 173 organizations responded.
• Billable encounters down by an average of 14%.
• 40% of providers have suspended or eliminated admissions due to safety concerns/requirements.
• More than 1 in 5 have laid off or furloughed staff.
• More than half are providing non-reimbursed services and supports.
• Median COVID costs were $25,000 and continue to accrue.
• Only 35% of providers were able to secure supplemental funding.
• ASO handles authorizations and claims payment for the PBHS.
• New vendor (Optum) started on Jan. 1 but the authorizations and claims payment systems were dysfunctional.
• MDH allowed estimated payments to providers based on 2019 claims payments.
• Optum system is expected to go live soon – estimated payments will end and reconciliation begins.
•  MDH allowed flexibility to use various platforms – including telephonic – as programs closed due to safety, social distancing, crowd size requirements. Flexibility ending July 25.
• 40% downturn in billable encounters lessened to 14% (on average).
• Survey data shows both clients and practitioners embrace telehealth.
• Telehealth flexibility ending but crowd size/safety restrictions have not.
• SB 502 allows provision of mental health services in client homes.
• Part of the 2017 HOPE Act.
• Meant to address 25 years of financial neglect.
• FY 21 was 3rd installment (3% from HOPE plus 1% for minimum wage).
• Rising suicide and overdose deaths.
• Need a robust network of community providers.

To better understand what these extensive updates mean for your business, please feel free to reach out to us directly at (410) 337-0500.