CHARLES D. BAKER
Governor

KARYN E. POLITO
Lieutenant Governor

MARYLOU SUDDERS
Secretary

July 19, 2017

The Commonwe alth of Massachusetts Executive Office of Health and Human Services One Ashburton Place, Room 1109
Boston, Mass achusetts 02 108

Tel: (617) 573- 1600
Fax: (6 17) 573-1891
www .mass.gov/ eohhs

Mr. Brian Neale
Director, Center for Medicaid and CHIP Services Centers for Medicare and Medicaid Services 7500 Security Blvd.
Baltimore, MD 21244

Dear Director Neale:

In anticipation of the Center for Medicare and Medicaid Services' issuance of guidance regarding Section 12006 of Public Law 114-255, the 2151 Century Cures Act (CURES), I am writing regarding the electronic visit verification (EW) program.

The Massachusetts Medicaid Program (MassHealth) has a longstanding commitment to administering personal care and home health programs that support and strengthen the principles of independent living and consumer choice.  Since 1974, Massachusetts' MassHealth Personal Care Attendant (PCA) Program has been at the forefront of efforts to support independent living.  Today, the PCA Program serves approximately 33,000 MassHealth Members who employ over 44,000 personal care attendants (PCAs) .  Our PCA program is based on consumer direction, community living and a fundamental belief that people with disabilities understand their needs best. Massachusetts recognizes the benefits of EW; and, we are working with our stakeholders to implement an EW system that meets the requirements of the CURES Act, strengthens  program integrity, and preserves independent living and consumer direction .

Prior to implementation, there are several areas that we seek federal flexibility in order to meet the needs of our state and be in conformance with federal law.  These areas include:

1. EVV requirements within a self-directed program. EW systems and requirements should not restrict consumers to their homes or to a given location and should support consumers living fully with in the community. We seek CMS

guidance allowing states to implement EW in a manner consistent with those principles.  In Massachusetts, for example, consumers receiving MassHealth PCA services direct when and where services are needed.  We are working closely with our stakeholders to design an EW solution that ensures consumer control and flexibility.

We request confirmation that EW requirements for state Medicaid programs will preserve the flexibility required to support self-directed programs.

2.  Alternatives for MassHealth members without access to technological resources. In some cases, MassHealth members do not have access to internet, cell phone service, or other forms of technology needed to effectively utilize EW.

Massachusetts seeks flexibility to define EW requirements and to make appropriate alternatives available to consumers with limited telephone, internet or cellular access.

3.   Safeguarding  privacy and data. Many EW solutions rely on gee-location to record the service start time and location, as well as the service end time and location.  Although gee-location may enhance program integrity, MassHealth members and personal care attendants have raised legitimate concerns about potential privacy implications related to the collection of these data.  We share these concerns.   In implementing EW, MassHealth will take all reasonable measures to ensure appropriate safeguards and restrictions are in place regarding the use of any consumer data, and shall comply with all applicable state and federal laws for the safeguarding of consumer privacy and data.
We seek CMS reaffirming state obligations to protect consumer privacy and data. Given the magnitude of the task of implementing EW across the spectrum of personal
care and home health services provided under state Medicaid programs, coupled with
the statutory requirement that EW be implemented for PCA services in 2019, we seek implementation guidance as soon as possible.

Additionally, we seek responses to the following specific questions:

1.	We interpret the CURES Act EW requirement to apply to Medicaid Personal Care Attendant and Home Health programs as well as to 1915(c) HCBS waiver services. Is our interpretation consistent with CMS?

2.	Does the CURES Act EW requirements extend to circumstances in which the member resides in a provider operated setting and personal care is only a component of a larger waiver service (i.e. part of a bundled service)? For example, is the use of EW required for residential habilitation waiver services
(i.e. group homes) in which the waiver participant resides in a provider operated
setting and receives multiple types of assistance from the provider, such as

nursing oversight and medication management, in addition to assistance with personal care? If bundled personal care services fall under the CURES Act EW requirement, are states required to implement EW for those services by January 1, 2019, or is there an extended time period for integrating them into EW?

3.	Does the CURES Act EW requirement apply to personal care services delivered to members residing in the home of a provider-compensated caregiver such as under an Adult Foster Care (AFC) program?

4.	Does enhanced funding for EW technology required under the CURES Act extend both to EW technology provided by the state as well as state costs associated with the acceptance and integration of data from provider-owned systems?   In addition, would federal enhanced funding extend to reimbursements made to individual PCAs for the cost of data used on their personal devices associated with  an EW application?

Massachusetts appreciates CMS' attention and additional guidance regarding this matter.  Thank you.
Sincerely,	

cc:		Daniel Tsai, Assistant Secretary for MassHealth and Medicaid Director Elizabeth Cahn Goodman, DrPH, JD, MSW, Chief of Long Term Services and Supports, MassHealth