FMLA & Short-Term Disability

SESCO Management Consultants

• The Family and Medical Leave Act (FMLA) entitles eligible employees of employers with at least 50 employees to take up to 12 weeks of unpaid, job-protected leave in a 12-month period for specified family and medical reasons. The employer may elect to use the calendar year, a fixed 12-month leave or fiscal year, or a 12-month period prior to or after the commencement of leave as the 12-month period. FMLA contains provisions on employer coverage; employee eligibility; maintenance of health benefits during leave; job restoration after leave; notice and certification of the need for leave; and protection for employees who request or take FMLA leave.
  
  
• Short-Term Disability (STD) is offered by private insurance companies to offer partial wage replacement while an employee is out of work due to a policy specific covered medical condition. STD does not provide job protection or maintenance of health benefits.
  
  
• Because FMLA and STD serve different purposes, it is common for an employer to run FMLA and STD leave concurrently with each other when the reason for the need for FMLA relates to the employee’s own health condition. In fact, doing so is recommended so an employee may not take STD leave after FMLA leave has been exhausted. If the employee’s health condition is a FMLA-qualifying “serious health condition”, it will likely also be covered by STD.
  
  
• When an employee’s need for FMLA leave relates to anything other than the employee’s own medical condition, STD will rarely be an option because that need will not be a covered benefit under the STD policy.
  
  
• There is much to consider in determining FMLA eligibility and administering FMLA leave. Please do not hesitate to contact us with specific questions.

If you are not a retainer client, contact us to learn about our services by calling 423-764-4127 or click here.

How The Sausage Gets Made: Inside CMS’ Home Health Payment Rulemaking Process

Home Health Care News | By Joyce Famakinwa

Every year, industry stakeholders anticipate the U.S. Centers for Medicare & Medicaid Services’ (CMS) release of the home health proposed payment rule and the final rule.
 
The final rule’s provisions and updates determine what the Medicare home health landscape will look like for the foreseeable future, but sometimes providers aren’t well-versed on the ins and outs of the rule-making process.
 
On an annual basis, there are several steps that CMS routinely goes through to put together the home health proposed payment rule.
 
It begins with the annual inflation update, otherwise known as the market basket index.
 
“That process to get to the proposed rule has two main elements to it,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told Home Health Care News. “One of them is to look at what the formula is for determining the annual inflation update, and that examines a variety of cost elements and the weight given to those cost elements.”
 
Periodically, there’s a rebasing of the market basket index, and a revision to the weights given to each element, according to Dombi.
 
“That would entail examining what the inputs are, and then what the sources of those inputs might be,” he said. “CMS uses a combination of numbers from the cost report and Bureau of Labor Statistics data.”
 
This first step is for CMS to determine whether it will stick with its most recent formula or make adjustments.
 
Data is then sent to an outside firm that CMS uses to forecast what the inflation rate was estimated to be for the particular year. This year CMS likely used data from the third or fourth quarter of 2022, Dombi noted.
 
“The forecasting methodology is employed to say, ‘Okay, if this is what the trends look like, this is what the inflation in cost will be during 2024,” he said. “It really is a prediction of inflation costs.”
 
Budget neutrality adjustment — which has received industry pushback after the switch to the Patient-Driven Groupings Model — is also a big factor when it comes to the proposed rule and the proceeding final rule.
 
Achieving budget neutrality is a fairly complex process, health care policy expert Lisa Grabert told HHCN.
 
“CMS has rules that they have to follow [regarding] budget neutrality, and they’re given some flexibility in how they can achieve that,” she said.

Read Full Article

Medicare to Pay for At-Home Dementia Care Coordination

MedScape | By Alicia Ault
 
Under a new Medicare pilot program that will begin in 2024, the federal government will pay clinicians to coordinate at-home dementia support services, including respite care for family members.
 
A Department of Health & Human Services (HHS) initiative, part of the aim of the Guiding an Improved Dementia Experience (GUIDE) program is to help Medicare beneficiaries with dementia stay in the community for as long as possible. It is estimated that there are 6.7 million Americans living with Alzheimer's disease or some other form of dementia, said HHS.
 
The program is voluntary and will be open to Medicare-enrolled clinicians and other providers who can assemble an interdisciplinary care team and meet the program's participation criteria.
 
"Our new GUIDE Model has the potential to improve the quality of life for people with dementia and alleviate the significant strain on our families," said HHS Secretary Xavier Becerra, in a statement.
 
"Not only is dementia care management a proven way to improve the quality of care and quality of life for those living with Alzheimer's and other dementia, but now we know that it would also save the federal government billions of dollars," Robert Egge, Alzheimer's Association chief public policy officer and Alzheimer's Impact Movement (AIM) executive director, said in a statement.
 
Egge cited a recent analysis commissioned by AIM that found that dementia care management would save the federal government nearly $21 billion over 10 years.
 
"People living with dementia and their caregivers too often struggle to manage their health care and connect with key supports that can allow them to remain in their homes and communities," said Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure, in the HHS statement.
 
"Fragmented care contributes to the mental and physical health strain of caring for someone with dementia, as well as the substantial financial burden," she said, adding that Black, Hispanic, Asian American, Native Hawaiian, and Pacific Islander populations have been especially disadvantaged.
 
The GUIDE Model will provide new resources and greater access to specialty care to those communities, said Brooks-LaSure.
 
Care teams that seek to participate in the GUIDE model must have a care navigator who has received required training in dementia, assessment, and care planning.
 
The teams also must have a clinician with dementia proficiency as recognized by experience caring for adults with cognitive impairment; experience caring for patients aged 65 years old or older; or specialty designation in neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology, or geriatric neurology.
 
Medicare beneficiaries will be eligible if they are not residing in a nursing home; are not enrolled in hospice; and have a confirmed dementia diagnosis.
 
Beneficiaries who receive care from GUIDE participants will be placed in one of five "tiers," based on a combination of disease stage and caregiver status. Beneficiary needs, and care intensity and payment, increase by tier.
 
GUIDE teams will receive a monthly, per-beneficiary amount for providing care management and coordination and caregiver education and support services. They can also bill for respite services — up to an annual cap — for Medicare beneficiaries who have an unpaid caregiver.
 
Clinicians seeking to participate in GUIDE can apply beginning in the fall. The program will run for 8 years beginning July 1, 2024.

Read Full Article

Medicaid Access Regulation: State Medicaid Agency Comments & Fact Sheet

NAHC and our partners with the Partnership for Medicaid Home-Based Care (PMHC) and the Home Care Association of America (HCAOA) are pleased to publish the attached fact sheet outlining concerns included in comment letters submitted by state Medicaid agencies regarding the Medicaid access rule’s 80-20 provision.

Several states expressed serious concern with the 80 percent direct compensation proposal, citing lack of data from CMS to support and implement the proposal, potential exacerbation of existing workforce shortage issues especially in small and rural communities, adverse impacts on affordability, and lack of agency authority to implement the policy, amongst other issues. The fact sheet also includes a link to a compilation of all the comments submitted by state government agencies and their representative organizations (which is also attached for reference). The document is intended to be a quick way to educate policymakers on concerns with the proposal, using the arguments put forward by a bipartisan group of government agencies responsible for administering the programs.

See Attached Fact Sheet