Advocacy Home and Community Based News Testimony

Response to RFI Rescue Plan Act

Dignity Alliance Massachusetts’ Response to the Request for Information American Rescue Plan Act Home and Community-Based Community HCBS Initiatives

May 2021 (See Glossary for description of abbreviations)

Download the DA American Rescue Plan RFI.docx

Access to Services and Supports and Community Integration

  1. Amendments to the Frail Elder Waiver to Support New Services
    • Add Residential Services to the Frail Elder Waiver including:  (1) Assisted Living, (2) Shared Living, and (3) Personal Care Homes
    • Add Mental Health Outreach Teams/Mobile Mental Health Services/Crisis Response Teams  
    • Add Consumer Direction to the Frail Elder Waiver for Companion, Homemaker, Personal Care, Home Health Aide, Supportive Home Care Aide, Chore, and Transportation
  2. Advocate for the establishment of a 1915i Waiver to expand access to Home and Community Based services
    • Increase capacity in the ECOP or Basic Program: Address the copay levels to make it more affordable to people and establish a formal mechanism to address co-pay disparity
    • Propose initiatives to support individuals with dementia or Alzheimer’s disease and their caregivers
    • Add new program targeted to elders with a diagnosis of dementia or Alzheimer’s, but who are not at a nursing facility level of care and extend a service array appropriate for the scenario.
    • Add Persons under age 60 with a diagnosis of Alzheimer’s Disease and Related Disorders
    • Add New Alzheimer’s/Dementia Coaching Service to Support Caregivers
  3. Amend the Community First Trust Fund to require that all FMAP the state earns through the American Rescue Plan will be deposited into this fund
    • The new funding the state receives as FMAP must then be used to support home and community-based services
  4. Informed Choice
    • Recruit and support a cadre of In-Reach Coordinators who are responsible for ensuring all individuals in designated nursing facilities make an informed choice whether to remain in the facility. Coordinators must provide each resident in nursing facilities (not only those who have requested community services) education, information, and participation in community activities necessary to allow each resident to make an informed choice, including the provision of necessary accommodations to their disability and the impact of their institutionalization. Coordinators will offer peer support, program visits, and direct experiences with community living arrangements. Coordinators would be expected to meet with all individuals in nursing facilities at least monthly, connect them to former nursing facility residents who successfully transitioned to the community, discuss community living opportunities, assist in applying for HCBS waivers or other Medicaid services, and lead transition planning and be responsible for coordinating all transition activities. There would be enough Coordinators to serve all individuals in at least 100 nursing facilities.
  5. Transition to the Community
    • Provide expanded HCBS waiver funding and services for 1,000 individuals currently in nursing facilities (or at imminent risk of being admitted to a nursing facility), including persons who need intensive behavioral and nursing supports, through the MFP Residential (700) and Community Living Waivers (300). To address the long-term cost implications of this initiative, require a concomitant reduction in nursing facility capacity through either the closure or downsizing of specific facilities.
  6. Housing
    • Develop a major new initiative to fund home modifications consistent with MFP waiver service descriptions, and one-time purchase of DME for persons in, or at serious risk of being admitted to, nursing facilities.
    • Recruit and support a cadre of Housing Coordinators who will assist in applying for housing vouchers, subsidies, and residential support services, with a priority on individuals in nursing facilities who have enrolled in MFP waivers (Community Living waiver) but are waiting placement. Housing Coordinators would locate community housing; obtain funding for transition to the community; coordinate the transition to the community; and provide or arrange transportation to community settings.
    • Assign state agency responsibility for contracting and managing residential service providers for older adults, as DDS, DMH, and MRC do for persons with disabilities. Agency would have the responsibility and capacity to determine eligibility; provide service coordination; operate an incident and risk management program; develop provider standards; approve budgets; manage contracts; assess provider qualifications and oversee service providers; perform quality assurance; collect/report data; and provide IT capacity for service delivery.
  7. Nursing Facility Transformation
    • Provide grants and technical assistance to nursing facilities to transform their business model or at least develop and operate new integrated residential settings and supports. One-time grants would be awarded on a competitive basis to nursing facility providers that were committed to developing and operating residential settings for individuals with disabilities or older adults who needed intensive nursing supports. The grants would include specific metrics and outcomes concerning the number of new settings; the design, size, location, and operation of the settings consistent with the HCBS Settings Rule; and the number of individuals transitioned from nursing facilities to these settings. Technical assistance grants would be made to entities with the experience and capacity to mentor, support, and guide nursing facilities in the transformation process, including developing new business models, training staff, and implementing transitions.
  8. Long Term Care System Transformation Plan
    • Fund a study by a qualified entity to analyze the Commonwealth’s long term care system, its reliance on congregated settings like nursing facilities, and barriers to community living for persons who otherwise are admitted to nursing facilities. The study would include a blueprint with recommendations for transforming the long-term care system and substantially downsizing its nursing facility bed capacity. A similar study was conducted by the Manatt Group for New Jersey and by Milliman Inc. for California.

Expand Eligibility

  1. Extend Post Eligibility Treatment of Income (PETI) to PACE Members
    • PETI allows an individual, who has been determined medically and financially eligible for HCBS and is receiving services through the waiver, to remain on the Frail Elder Waiver even if they have an increase in income. The excess income is contributed to the cost of the individual’s care and spent down to 300% of the FBR rather than forcing the enrollee to spend all the way down to $542. This policy, implemented by MassHealth for individuals receiving services through FEW, should be extended to PACE members.
  2. Change the Frail Elder Waiver Formula to Allow Individuals with Incomes Above Program’s Limits to Keep Income Below the 300% FPL
    • Change the Frail Elder Waiver formula for persons whose income is over the 300% federal poverty level (FPL) income cap from a deductible to a premium. Regulations currently require anyone with income over 300% FPL (currently $2349/month) to pay a deductible – to private, outside medical vendors – that leaves the participant with only $522/month in income to live on (to pay for heat, electricity, food, etc.). Instead, allow participants to pay – directly to MassHealth – a premium in the amount of every dollar of income that exceeds 300% FPL. Leaving people with the full $2349 to use for living expenses would enable more people to afford to stay at home, preventing unnecessary institutionalization.


  1. Cash and Counseling Demonstration
    • Cash and Counseling may prove to be a valuable option for a portion of the consumer population and a demonstration pilot is warranted. The preservation of the current bargaining unit, as well as PCAs’ fundamental right to collectively bargain, must be ensured throughout any such demonstration. Any new Cash & Counseling pilot should also include an objective pay schedule that is further codified in the collective bargaining agreement, the continued use of the PCA new hire orientation to ensure all PCAs receive consistent information regarding their rights and responsibilities, and the continued ability of consumers to use surrogates for limited employer tasks such as for physical signatures if they are otherwise able to manage the program effectively and fully on their own.
    • Implement a Cash & Counseling demonstration, through a 1915( j) waiver to enable PCA employers to have a “flexible budget” within their allotted PCA hours that allows them to pay a premium rate above $15.75 per hour for difficult to fill shifts, and structure the demonstration in a manner that permits compliance with existing collective bargaining contracts. Budget flexibility would allow PCA employers to pay up to $25 or more per hour to attract qualified PCAs. Further, the program would be designed to be accountable but not overly so. Flexibility of this nature will address the problem and hold on to the workforce that seems to be slipping away. This demonstration fits within the requirements of the RFI definition of HCBS and will not supplant state spending but will ”enhance, expand or strengthen.” In addition, it addresses MassHealth’s strategic area of HCBS workforce development, including recruitment and retention strategies.
  2. Provider Rate Enhancement to Support the Home Care Aide Workforce
    • The American Rescue Plan and the 10% bump in federal matching support for MassHealth’s HCBS offers a critical opportunity to better support recruitment and retention of Massachusetts’ home care workforce. Accordingly, we support both targeted rate increases that explicitly support direct care worker wages as well as the allocation of federal funding to support one-time pandemic premium pay bonuses. Such premium pay should include progressive adjustments based on income and be reflective of home care hours worked throughout the pandemic. MassHealth PCAs would be paid adjusted bonuses directly, while private home care employers should receive restricted grants that are explicitly conditioned on passing along these premium pay bonuses. Final implementation of such bonuses requires impact bargaining with labor organizations representing these workforces.
    • A 7% rate increase for Home Care POS and ECOP rates, effective as soon as possible, which would be coordinated with:
      • Immediately transitioning 1/1/21 rate add-on payments to targeted rate increases to support direct care worker wages
      • Updating of the Mandatory Minimum Compensation Mandate in Homemaker/PC homemaker contracts
      • Agreement to adjust rate again accordingly for 1/1/22 minimum wage increase
      • EOEA/EOHHS commitment to re-instituting Massachusetts Direct Care Worker assistant (CNA) rate adjustments to be managed ladder, and for all Personal Care Attendant (PCA) and certified nursing for coordination with Homemaker, Personal Care Homemaker, and Home Health Aide rate increases
      • Impact to ASAP Case Management rates and SCO reimbursement will also be considered as EOEA/EOHHS develops their implementation proposal for this initiative

Technology & Infrastructure

  1. Build Technology Capacity for Consumers and Staff
    • Support Staff training and capacity to provide Telehealth to consumers, as well as training, devices, and internet access for consumers
  2. Enhance Data Integration and Sharing
    • Establish an initiative to connect the ASAP network with appropriate Admission / Discharge / Transfer (ADT) notification systems to improve care coordination between HCBS providers and health care systems.


ADTAdmission / Discharge / Transfer
ARPAAmerican Rescue Plan Act
ASAPAging Service Access Point
CNACertified Nursing Assistant
DDSMassachusetts Department of Developmental Services
DMHMassachusetts Department of Mental Health
ECOPEnhanced Community Options Program
EOEAMassachusetts Executive Office of Elder Affairs
EOHHSMassachusetts Executive Office of Health and Human Services
FMAPFederal Medical Assistance Percentage
FEWFrail Elder Waiver
FPLFederal Poverty Level
HCBSHome and Community-Based Services
ITInformation Technology
MFPMoney Follows the Person
MRCMassachusetts Rehabilitation Commission
PCPersonal Care
PCAPersonal Care Attendant
PETIPost Eligibility Treatment of Income
POSPurchase of Services
RFIRequest for Information
SCOSenior Care Organization