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Lawmakers hear proposal to raise targeted HCBS provider rates amid workforce, rural access concerns
Summary
Agency officials told the House appropriations panel that North Dakota’s in‑home provider rates lag regional benchmarks; they proposed targeted rate increases for specific HCBS services, citing provider recruitment challenges, higher client acuity and shifting service mixes that require nurse involvement and 24‑hour supports for some clients.
Nancy Nicholas Meyer and Division of Medical Services director Sarah Achor explained to the Human Resources Appropriations panel that provider wages and agency reimbursement for many in‑home and HCBS services have not kept pace with regional benchmarks and rising demands.
Achor summarized Medicaid obligations and long‑term care policy context before returning the floor to Meyer for HCBS specifics. Sarah Achor noted that Medicaid is an entitlement program that requires federal compliance and federal match; she said states can limit waiver slots but not generally deny eligible individuals access to Medicaid services.
Meyer described several cost drivers and the division’s targeted rate proposal. She told lawmakers that a relatively small subset of waiver clients — about 16% of participants — accounts for roughly 40% of waiver costs because they need 24‑hour or medically complex in‑home services. She also described a rising prevalence of behavioral health and substance use needs among waiver recipients, which increases training and staffing requirements for providers.
Decision package and proposed rate changes (as presented): - Total targeted rate increase request: about $5.3 million total funds ($3.5M general fund, $1.7M federal match). The package includes agencies and SPED where applicable. - Proposed new agency 15‑minute unit rates (examples discussed): homemaker/chore/personal care/respite/support services grouped to $9.40 per 15 minutes; companionship and supervision at $9.10 per 15 minutes; nurse‑delivered services (nurse education/extended personal care) elevated to a proposed $19.71 per 15‑minute unit.
Why it matters: Committee members asked how those increases would translate to employee wages and whether they would improve provider recruitment in rural service deserts. Meyer said agency rates do not directly equal worker pay but that agencies reported paying direct caregivers roughly in the mid‑teens per hour; higher agency reimbursement is intended to help agencies offer competitive wages and retain staff.
Committee dialogue and clarifications: Representative Stevens asked how the revised rates would move North Dakota relative to neighboring states; staff said the proposal narrows the gap but a comprehensive regional rate study would better estimate rank. Representative Murphy asked if individuals may provide services as independent contractors; staff confirmed family caregivers and independent QSPs may enroll but noted agency arrangements and required program enrollment procedures.
Ending: Lawmakers acknowledged the complexity of balancing wage competitiveness, provider accountability and program costs. The department emphasized that improved rates for preventive and less‑intensive services could reduce higher‑cost institutional placements over time and asked the committee to consider the targeted increases as a workforce‑stabilization strategy.
