Electronic Visit Verification (EVV)

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Electronic Visit Verification (EVV) is a tracking system that requires electronic verification of when a person receives Medicaid-funded personal care or home health services.  Many people with disabilities worry that EVV will violate their privacy and limit their independence.  They are particularly concerned about systems that use GPS, cameras, or other intrusive tracking systems.  They are concerned it could limit their ability to go out into the community and confine them to their homes.  

CMS held an EVV Stakeholder Open Door Forum on November 7, 2018 at 1-3 pm EST to get stakeholder feedback on EVV implementation.  transcript and audio recording are posted to the CMS Podcast and Transcripts website at https://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/PodcastAndTranscripts.html.

What is EVV?

The EVV requirement was included in the 21st Century Cures Act that passed at the end of 2016. These are services that require an in-home visit and support Activities of Daily Living, like bathing and dressing, or Instrumental Activities of Daily Living, like meal preparation, managing money, taking medication or shopping.  State Medicaid programs must implement EVV or they will get less federal Medicaid funding (called federal medical assistance percentage or FMAP).  

In 2018, Congress passed a bill delaying the implementation deadline for a year. States are now required to put EVV systems for personal care services in place by January 1, 2020.  Many questions and concerns remain about how to ensure that the privacy and civil rights of people receiving services are protected. A delay is an important step to give advocates more time to work with Congress, the Centers for Medicare and Medicaid Services, and the states to address the significant concerns with EVV and its potential impact on people with disabilities.  We will keep you updated on next steps.

How does it work?

EVV requirements were intended to reduce fraud and save money. The effects of EVV will depend on how it is used in each state. EVV systems verify the type of service performed, the person receiving the service, the date, location, person providing the services and the time the service begins and ends. Generally, it relies on a system to electronically verify the services provided, often accomplished by telephone or web-based device.  Methods of EVV include, for example, tracking a provider’s location at the start and end of each visit and sending that data to the state Medicaid agency.  Other methods require a provider to be in a pre-determined location at the start and end of each visit.

States decide how to implement EVV and are at different stages in the process.  

Concerns with EVV

Invasion of Privacy

  • People are concerned about how information about their whereabouts is gathered and how it’s protected.
  • EVV is seen by some as essentially a government tracking system for Americans with disabilities and seniors.
  • Some devices include additional privacy concerns, such a camera, that could further intrude on a person’s privacy. Geotracking used to verify service locations is also seen as infringing on fundamental privacy rights and liberties of people with disabilities. Should a person be required to regularly document every move and location just because they use personal assistance services?

Limits Independence

  • Continuous surveillance threatens to undermine consumer control and self-direction, and hurts the ability of people with disabilities to fully participate in the community.
  • Consumer-directed programs allow services to be delivered anywhere they are needed, like schools and workplaces. EVV typically requires workers to check in from the homes of clients. This can make people with disabilities feel trapped in their homes due to limitations of an EVV system.
  • EVV can require many daily, task-by-task electronic check-ins. Verification could constantly disruption routines, with clients and service providers potentially obligated to put aside other tasks and communications. It becomes a frustrating time suck for people with disabilities as well as the care provider.  If it’s too burdensome, it could aggravate the shortage of care workers who are crucial for the independence of people with disabilities.
  • The services covered by EVV are essential for people with disabilities to remain in their own homes in the community.  Medicaid generally is the only option for providing community services that help someone live in their own home and participate in community life.  If EVV limits access to these services, it could force people into an institution like a nursing home.  This could violate their right to live in the community under the Americans with Disabilities Act and the Supreme Court’s decision in Olmstead v. L.C..

Practical issues 

  • Not everyone has digital access or landlines that may be required by the EVV system their state.
  • Concerns about how EVV will work in in rural areas where internet access may be limited. 
  • In states with self-directed waiver programs there’s a concern that if a state dictates the type of EVV that the provider must use this will make the state a joint provider for purposes on the Fair Labor Standards Act, and could trigger overtime requirements.
  • The expense of purchasing EVV equipment could create an incentive for service provider agencies to stop serving Medicaid clients in a state.

Timing and next steps

EVV must be in place by

  • Jan. 1, 2020 for personal care service providers
  • Jan. 1, 2023 for home health care service providers

or the state will lose a percentage of its FMAP match, which means the state would get less federal funding for its Medicaid program.  There is an exception that allows a delay for a year if a state can show it has made a good faith effort to comply, and the delays were unavoidable. 

Congress required CMS to publish guidance to explain what states need to do.  On May 16, 2018, CMS published two pieces of guidance on EVV to help states implement their systems. 

There are still critical unresolved issues in how EVV should work, even with this guidance.

 

Guidance - Key Issues

What’s Covered by EVV requirements?

  • CMS has defined the services covered by EVV requirements very broadly.  It includes any service that provides assistance with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs) where the is an in-home visit. 
    • The name of the service does not matter.  Some states include personal care services bundled together in other community based services, like in-home supports or respite.  All of these services are covered if they provide assistance with ADLs or IADLs in the home.  This could apply even to Medicaid-funded medical supplies that require an in-home visit for set-up. 
    • Even with the guidance, questions still remain.  For example, if a person is picked up from their home by their personal care attendant, but the service happens somewhere else, is EVV required?  Or if only part of the services take place in the home, does that mean only that part of the visit needs to be verified?
  • Personal care services that either start or end in the individual’s home are subject to EVV.
    • EVV does not require states to capture each location as a person through the community.
    • Capturing the location in which the service is started and stopped is enough.
  • Services not covered by EVV requirements:
    • Personal care services that are provided to residents of an institution, including a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or an institution for mental diseases
    • Personal care services that do not require an in-home visit.
    • Personal care services provided in congregate residential settings that are staffed 24-hours a day, like a group home.
    • Personal care services provided in a Program of All-Inclusive Care for the Elderly (PACE) program.

Privacy and Independence

  • EVV does not require a state to track all of a person’s locations, but the guidance does not say that a state should not do this.  States can track additional information beyond the minimum requirements in the law, so people with disabilities, their family members and service providers may still worry about their privacy and autonomy. 
  • Global positioning services (GPS) are not required but are allowed.
  • States are encouraged but not required to select EVV systems that support self-directed models.

Stakeholder input

  • States are required to get stakeholder input in developing their EVV system.
  • This should include individuals and their families, including family caregivers and individuals with self-directed services, if applicable and organizations that represent the interests of individuals receiving these services.

Training

  • The guidance recommends, but does not require, that beneficiaries receiving personal care Services (PCS) and home health care services (HHCS), and their families, are educated about the changes that will take place with the implementation of EVV.

Deadline and Decrease of Funds

  • The guidance came out in mid-May 2018, almost six months after it was required by the law.  
  • The law allows CMS discretion to give states an extra year to implement EVV for personal care services. CMS says they’ll work with states on an individual basis to see if they made good a faith effort and faced unavoidable delays in providing EVV.  
  • In many states, the legislative activity and budgeting cycle for this year has already ended, making it hard to plan for an EVV system that meets the requirements of the law and includes necessary flexibility and accommodations.  
  • States can send information to CMS starting in July 2018 if they think they won’t be ready.

What you can you do?

Get involved as EVV is rolled out in your state!  The law requires input from stakeholders including from participants and family caregivers.  A successful state EVV system will require meaningful stakeholder engagement and training.

Bills extending the deadline for implementing EVV for personal care services for a year have passed in Congress. The delay is an important step.  However, there are still significant concerns about EVV.   Stakeholders should continue to work with their state, as well as Congress and CMS to limit the ways the EVV system burdens people receiving personal care services and the people providing care services. 

Share your questions and concerns with CMS at the CMS EVV mailbox (EVV@cms.hhs.gov).

Resources

NCIL’s EVV Task Force Statement of Principles and Goals 

Electronic Visit Verification and Self-Direction: A Consumer Perspective

Applied Self-Direction EVV Resources Webpage

Resources by CPR with the Georgia Council on Developmental Disabilities

CPR’s feedback to CMS for Nov. 7th Stakeholder call

CCD Comments on CMS Electronic Visit Verification Compliance Survey (12/3/18)

National Association of States United for Aging and Disabilities (NASUAD) Report on EVV

Health Management Associates Report on State Readiness for EVV (2017)

Delay Sought for Medicaid Caregiver Check-In Mandate (Disability Scoop 5/30/18)

Stop EVV Coalition Webpage

CMS EVV Guidance

Letters Expressing Concerns about EVV 

Consortium for Citizens with Disabilities (CCD) Long-Term Services and Supports (LTSS) Task Force Letter (9/28/18)

Letter from the National Council on Independent Living (NCIL) (6/4/18)

Letter from CCD to CMS Administrator Verma (5/17/18)

U.S. Representative DeGette’s letter to CMS on the effects of EVV on self-directed services (4/24/18)

WA State Letter to Congress on EVV challenges (2/12/18)

National Association of State Directors of Developmental Services (NASDDDS) Letter to CMS (4/4/18)

National Association of States United for Aging and Disabilities (NASUAD) Letter to CMS (4/23/18)

Agencies and Association Speak Out on EVV in Louisiana      

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