We hope you are having a restful summer as we begin to ramp up towards the 90th Texas Legislative Session next January. We expect prominent themes for the session to include topics such as increasing the healthcare workforce, hospice fraud, and tort reform.

And be sure to save the date for LeadingAge Texas Capitol Day on Tuesday, February 3, 2027, when members from across the state will gather at the Texas State Capitol to advocate for the future of aging services. Registration and additional details will be available this fall.

I've shared a brief advocacy update covering key state and federal developments, including healthcare workforce issues, hospice and home health policy, and LeadingAge Texas' recent testimony before the House Public Health Committee on strengthening the nursing pipeline and supporting long-term care providers.

National News:

LeadingAge Asks Members to Speak Up on Immigration Policy:
Following the Supreme Court's June 25 decision ending judicial protection for Haitian and Syrian Temporary Protected Status (TPS) holders, LeadingAge is urging providers to share how workforce disruptions are hitting their communities rather than let others define the narrative. This piece highlights members already speaking out and provides links to resources and toolkits for those ready to add their voice.

Department of Education's Public Service Loan Forgiveness Rule Struck Down by Courts:
On June 30, 2026, two federal district courts issued orders vacating the Department of Education's (ED) Public Service Loan Forgiveness (PSLF) final rule. Under the PSLF program, the Secretary of Education is required to forgive the remaining balance of federal student loans for borrowers who have made ten years of payments on their loans while working for a qualifying public service employer.  On October 31, 2025, ED issued a final rule revising what organizations qualify as public service employers by excluding certain nonprofits from PSLF eligibility for engaging in what the Department defines to be “substantial illegal activity”—which it defines, for example, as aiding or abetting violations of federal immigration law, engaging in gender-affirming care, supporting terrorism, or engaging in a pattern of illegal discrimination.  Following its issuance, the PSLF rule was subject to legal challenges in several federal district courts.  The U.S. District Court for the District of Columbia and the U.S. District Court for the District of Massachusetts issued orders on June 30, 2026 vacating the PSLF final rule.  Both opinions cited the rule as being contrary to law and exceeding the Secretary’s statutory authority under the Higher Education Act.  The rule was originally set to take effect on July 1, 2026.

Congress Passes Major Housing Reform Legislation, President's Signature Uncertain;
Following the landmark passage of the 21st Century ROAD to Housing Act by both chambers of Congress, the President cancelled the signing of the bill, demanding Congressional action instead on an unrelated pieced of legislation. In a statement from Katie Smith Sloan, president and CEO of LeadingAge, Sloan stated: "We urgently call on President Trump to reverse course on cancelling his signing of this legislation into law. Nothing, and certainly not an unrelated debate, should stand in the way of making momentous and bipartisan progress on housing in America." 

State News:

See LeadingAge Texas’ Testimony at House Interim Hearing on Healthcare Workforce:
The Texas Legislature is currently conducting interim hearings to study certain topics and prepare for the upcoming 90th session in 2027. The House Public Health Committee met on June 4th to discuss their interim charges, which included the “Texas Health Care Workforce”. LATX Director of Advocacy and Public Policy Noah Jones testified before the committee on the specific challenges facing long-term care nurses and advocated for increased supports for the nursing pipeline and improved retentions strategies. You can watch Noah’s testimony HERE (9:43:43).

Texas HHSC Issues Provider Letter for Emergency Plans for Assisted Living Facilities:
On July 6th, Texas HHSC published Provider Letter 2026-11 to inform assisted living facilities (ALFs) on the required emergency preparedness requirements implemented under HB 3595 (89R). 

The requirements of the bill are as follows:

• No later than January 1, 2026, an ALF must develop or revise emergency preparedness plans to meet the requirements of HSC §247.073, including:
  • designating an area or areas of refuge in the event of a power outage
  • maintaining safe temperatures in an area of refuge; and
  • reporting unplanned power outages of more than 12 hours to HHSC Complaint and Incident Intake (CII).

Please note that this provider letter DOES NOT require assisted living facilities to utilize power generators in the event of a prolonged outage. However, an ALF must include information on the type of onsite generator equipment or backup power source, if any, in their emergency preparedness plan. 

Click here to read the provider letter for the full list of emergency preparedness requirements.

I am Noah Jones, the new Director of Advocacy and Public Policy for LeadingAge Texas (LATX). I come to LATX after working with the Texas Counseling Association to pass important mental healthcare reforms in the 89th Texas Legislative Session. Before this I worked in the office of State Senator Royce West (D-TX). 

The 90th Texas Legislative Session is only 7 months away, and LATX is hard at work to ensure a successful effort for all not-for-profit aging services providers across the state. We expect prominent themes for the session to include topics such as increasing the healthcare workforce, Medicaid fraud, and tort reform. 

More than ever, we need the continued advocacy of our members to ensure the protection and promotion of aging services in Texas. You have the first-hand experience that can be invaluable to legislators and their staff as they create new policies which impact your work. If you want to become more involved with our public policy efforts, please email me at noah@leadingagetexas.org.

National News:

CMS’ Home Health and Hospice Moratorium

The Centers for Medicare and Medicaid Services (CMS) issued a moratorium on enrollment of new home health and hospice agencies. The Consolidated Appropriations Act of 2026 had language that prohibited hospices from using telehealth for face to face recertifications during a moratorium. CMS said in frequently asked questions (FAQs) published at the time of the announcement that hospices could continue to use telehealth for the face to face recertification during the moratorium, but did not provide further details on their legal analysis or how they were instructing their contractors at this time. This six-month effort is intended to prevent new bad actors from entering Medicare while the Centers for Medicare and Medicaid Services takes action to identify, investigate, and remove those already exploiting the system. Read LeadingAge's analysis regarding what non-profit, mission-driven agencies can expect here. 

LeadingAge Supported Hospice and Home Health Bill Advances Out of House Committee

On May 21, the House Ways and Means Committee marked up eight bills including the "Protecting Seniors and Stopping Fraudsters Act." (HR 8883) which was introduced on May 19 by Representative Beth Van Duyne (R-TX). The bill was passed out of Committee by a vote of 27-16. The vote was bipartisan; 3 Democrats voted yes on the bill. During the markup, Representative Linda Sanchez (D-CA) who introduced the Hospice Care, Accountability, Reform, and Enforcement (CARE) Act of 2026 along with Senator Mark Warner (D-VA), made several comments and asked questions underscoring differences between the two bills, particularly focused on the lack of payment reform policies in Representative Van Duyne’s bill. Representative Van Duyne emphasized the targeted nature of the policies in her bill and the desire to not increase burdens on legitimate providers. On May 20, LeadingAge submitted a letter for the record supporting this bill. 

State News:

LeadingAge Texas Testifies for Improved Nursing Pipeline and Supports

The Texas Legislature is currently conducting interim hearings to study certain topics and prepare for the upcoming 90th session in 2027. The House Public Health Committee met on June 4th to discuss their interim charges, which included the “Texas Health Care Workforce”. LATX Director of Advocacy and Public Policy Noah Jones testified before the committee on the specific challenges facing long-term care nurses and advocated for increased supports for the nursing pipeline and improved retentions strategies.

Monday, June 2nd marked the end of an eventful and highly productive 89th Legislative Session. LeadingAge Texas worked tirelessly on issues impacting non-profit aging services providers, and continued investments were made as a result. All of our high-priority bills crossed the finish line.

Thanks to your advocacy and support, LeadingAge Texas members helped pass legislation to preserve longstanding charitable tax exemptions, increase Medicaid reimbursement, modernize the continuing care retirement community statute, and guarantee due process for facility survey determinations.

Considering the number of bills and the significance of these bills, this has been our most successful session in over 25 years.

Below is a list of LeadingAge Texas priority bills sent to the Governor’s desk:

SB 1 | General Appropriations Bill for Fiscal Years 2026 – 2027
The budget includes approximately $533M (all funds) to increase Medicaid reimbursement to nursing facilities. 

HB 2525 | Preserve Charitable Tax Exemptions for Charitable Organizations Serving the Elderly
Creates a new pathway to charitable tax exemption (4% test), and new definitions of charity tailored to senior housing, for nonprofit organizations who have provided charitable housing and services in Texas for at least 20 years, or who are under common control of a nonprofit organization that has provided charitable housing and services for the last 20 years.

SB 457 | Ensuring Transparency in State Funds for Nursing Homes
Adds an additional $12/day to the Medicaid base rate and ensures that at least 80% of funds for patient care expenses are spent on patient care expenses, instead of shareholder dividends.

SB 1522 | Modernization of the Continuing Care Retirement Community (CCRC) Statute
Updates the CCRC statute to clarify that a care continuum may exclude skilled nursing, or may include skilled nursing  via a third-party, without jeopardizing licensure,. The bill also increases consumer protection by requiring disclosure by unlicensed communities that charge upfront fees, by prohibiting advertisement as a CCRC without licensure, and by affording the TDI Commissioner greater oversight into land ownership of a CCRC.

SB 2269 | Ensuring Due Process for Long-Term Care Communities During the Survey Process
Guarantees that a decision made by MPRO (Michigan Peer Review Organization) during the Informal Dispute Resolution (IDR) process is binding and cannot be dismissed by the Health & Human Services Commission (HHSC) with regard to state citations and resulting state remedies.

HB 3595 | Preserving Regional Flexibility for Emergency Preparedness Planning
Codifies emergency preparedness requirements that afford communities the opportunity to craft region-conscious protocols to ensure the health and safety of senior Texans.

We look forward to continuing the conversation with members during our upcoming 89th Legislative Session Recap on July 8, from 10–11 am (Virtual). During this session, we’ll take a deeper dive into the legislative proposals LeadingAge Texas helped negotiate, the issues we defended against and tracked throughout the session, and what the implementation process will look like.

Thank you for your continued support and advocacy on behalf of nonprofit aging services providers across Texas. Your engagement throughout this session made a real difference.

If you have any questions or would like to learn more, please contact Emiliano Romero, Director of Advocacy & Public Policy, at emiliano@leadingagetexas.org.

Over the past 69 years, older Texans and their families have relied on Lutheran Sunset Ministries for a range of critical services, including nursing home care. Our roots in Clifton are deep: begun by Lutheran congregations in 1954, generations of families have called our ministry home.

Our ability to continue serving our rural community is threatened by a proposed staffing requirement issued by the Centers for Medicare and Medicaid Services (CMS) on September 1, 2023, as part of the Biden Administration’s focus on ensuring quality care in nursing homes. We share that goal, and as demonstrated by our history, are committed to providing the type of care we ourselves would want to receive. No mandate from a government authority has been needed to meet that mission.

Over 90% of Texas nursing homes would fail to meet the proposed standards. We could not. Already, there are times when, due to staffing needs, we are forced to limit admissions. 

CMS’ proposal – an across-the-board staffing hours per resident day (HPRD) requirement – comes at a time of unprecedented workforce shortages. By CMS’ own estimates, an additional 12,639 RNs and 76,376 nurse aides are needed to meet this requirement. Particularly for providers in rural areas, this is impossible. 

Last year, the Texas Center for Nursing Workforce Studies released data showing over 15,000 qualified nursing school applications were not offered admission in 2021. On average, Texas turns away more than 10,000 qualified applications each year from its nursing programs. There is not a quick solution to this shortage.

For nurse aides, we have increased pay 30% since the pandemic and still can’t hire enough nurse aides. It’s just too difficult to compete with other sectors. 

Licensed Vocational Nurses (LVN) are also crucial to the delivery of our care. Yet, CMS’ mandate completely ignores LVNs, as if they have nothing to offer. That could not be further from the truth. The requirement should be a hybrid that includes these vital and caring professionals. 

Then there is the financial impact of the proposal, which CMS does little to address but estimates will cost over $4 billion to implement in the first year alone (other estimates are higher, as much as $7 billion). For our ministry, it would cost us a million dollars to comply. Nursing homes, unlike other businesses, are funded through Medicare and Medicaid, and for more than a decade that funding has been woefully inadequate in Texas. 

Over half of our nursing home residents are on Medicaid; we cannot charge the state more to cover these additional expenses. We would have to increase the rates of our private pay residents by two thousand dollars a month to cover this additional cost. Families cannot afford it and shouldn’t have to shoulder that burden. 

If this mandate is allowed to be implemented as proposed, it could further limit access to care by affecting more than just nursing homes. The broader healthcare system will be disrupted and reshuffling the limited number of care workers available between settings won’t solve the problem. 

When nursing homes close, where will residents in our community go for the care they need? Instead of ineffective new rules, the administration should invest in serious solutions to tackle the aging services workforce crisis. We are sharing the very real impact this rule will have on rural communities like ours, as well as solutions with the Centers for Medicare and Medicaid. Together, we can get it right! 

Below is a list of bills sent to the Governor LeadingAge Texas advocated for: 

“We deeply appreciate the investments made in senior care this session. We understand difficult decisions are made when preparing budget proposals. This funding will help address some of the challenges not-for-profit aging services providers have expressed for more than a decade, but particularly over the last two years, “ said George Linial, president & CEO of LeadingAge Texas. “Caregivers in nursing homes have done a remarkable job caring for residents throughout the pandemic. The financial impact of COVID-19, an unprecedented workforce shortage and record-high inflation isn’t sustainable. These initial investments will help ensure older Texans have continued access to high-quality care.”

Rodney Rueter, LeadingAge Texas Board Chair and CEO of Lutheran Sunset Ministries said, “Not-for-profit providers are thrilled to see nursing homes prioritized in the budget. Our ministry is dedicated to serving seniors that rely on Medicaid for their care but underfunding poses a real threat to our mission. This investment is a step in the right direction. It will allow us to begin to recognize and reward the incredible commitment of our staff and continue providing dignified and compassionate care to our rural community."

SB 1 and HB 1, the base budgets filed by Senator Joan Huffman and Representative Greg Bonnen last week, make critical investments to prioritize Texas seniors and the caregivers serving them.    

The 2024 – 2025 budget proposals include: 

• Approximately $400M to increase support for nursing homes. 
• $32M to increase support for nursing programs and repayment programs.

Contact: Alyse Meyer
alyse@leadingagetexas.org | 512- 467-2242 x105

Advocacy in Washington, D.C. 
Like anyone who cares about America’s older adults, LeadingAge is gratified that the Biden Administration is prioritizing long-term care—and our policy experts are moving quickly to ensure that your needs and perspective are part of discussions in Washington, D.C.

Still, we were incredibly disheartened that the White House chose to wrongly paint all nursing homes with the same negative brush in its rhetoric. We know, as you do, that many nursing homes, including the thousands of communities within LeadingAge’s membership, are bastions of quality care and quality of life. Throughout the pandemic and even before, you have continued to serve older adults and families despite this country’s indifference towards and outdated approach to long-term care. 

The Administration should acknowledge the deep commitment to care and quality demonstrated every day by so many nursing homes across the country—and we have sent a letter to President Biden and members of his Administration to share both our disappointment on your behalf, and a roadmap for next steps we can take together. 

In the letter, we outlined three immediate ways the Administration can best support millions of residents, family members, and frontline staff in nursing homes across the country: 1) address the dire staffing crisis, 2) take an evidence-based approach to quality improvement, and 3) fund quality care. 

We need a broad, multi-departmental strategy to increase staffing levels and transparency. We need to compensate frontline professionals fairly and address price gouging by temporary staffing agencies. We need ways to expand the pipeline of direct care professionals, including changes in immigration. We need to separate out the high-performing, high-quality providers from those that should be closed. We need to reward the best providers who continuously improve quality of care, as so many LeadingAge member nursing homes have despite the many challenges wrought by the COVID pandemic and long-standing system inadequacies.

Not all nursing homes are the same; and we’re fighting hard to ensure that the Administration understands that nonprofit and mission-driven nursing homes operate with financial transparency and open communication. As we said in our letter to the President: “It’s long past time for a clear-eyed, fact-based approach to ensure older Americans and families can access the quality nursing home care they deserve.”

Nonprofit and mission-driven nursing homes like yours must be at the table for the urgent and necessary discussions in coming weeks and months. LeadingAge requested an initial meeting with the White House to begin those conversations. 

Media Outreach and Public Communications 
LeadingAge is also pursuing action with the media and the public. President and CEO Katie Smith Sloan has already issued two statements on the White House announcement and State of the Union. You’ve probably seen some of the coverage in the trades (Skilled Nursing News, ‘Stop Blaming Nursing Homes’: Biden’s Proposed Reforms Garner Mixed Reactions ; McKnight’s Long-Term Care News, Providers decry major ‘crack down’ without major funding) and national press (Associated Press, Biden to launch ambitious overhaul of nursing home quality; The New York Times, Biden will lay out new nursing home protections in his State of the Union speech).

In addition, LeadingAge released a statement to coincide with our letter to the Administration, and are reaching out to key media outlets to be sure your voice is heard.

Supporting Your Community
While most Americans don’t follow the day-to-day of national politics, many of your residents and families may have heard some of the recent rhetoric about “cracking down” on nursing homes. We want everyone who is part of a LeadingAge member community to know that their nursing home and the thousands of others that are part of LeadingAge have no tolerance for bad care. Katie penned a letter to your residents and family, which we invite you to distribute as you think best.

All of us at LeadingAge are proud to represent nursing home providers like you. Thank you for everything you do each and every day.

First, submit comments online and select HB 145. Comments are accepted until the hearing is adjourned so please do this ASAP. I encourage you to share a few talking points about your community but you may also copy and paste this message: 

Long-term care communities have been on the frontline of COVID-19 for the last 18 months. As a non-profit organization with a longstanding history in our community, we remain dedicated to providing the highest quality services and care to the older Texans we serve. We face many challenges as we continue to protect both residents and staff from COVID-19. The pandemic has devastated our communities and staff. Filling direct-care staff vacancies and other essential positions is one of the biggest challenges we are facing today. 

We ask House Appropriations Committee and the Texas House to prioritize long-term care by directing ARPA funds to strengthen the Long-Term Care workforce by investing ARPA funds in the following areas: 

1. Recruiting  and  hiring  qualified  staff.
2. Off-setting the cost of using temporary staffing agencies to adequately staff.
3. Staff retention programs to include frontline staff bonus, hero pay.
4. Long-term care nursing student loan repayment assistance program for candidates who meet eligibility criteria for application, including full-time employment by a long-term care facility. 
5. Free training and testing for CNAs.
6. Provide greater access and scholarships to LVN to RN Bridge Programs.

Reach out to your State Representatives and Chair of the House Appropriations Committee today asking them to make sure long-term care and the long-term care workforce receives support in this bill.

Thank you, 
 
Alyse Meyer
Vice President of Advocacy
(512) 467-2242 ext. 105

Our priority legislation, SB 6, the Pandemic Liability Protection Act, passed on third reading in the House on Monday and now returns to the Senate for action on the changes made to the bill in the House. If the Senate approves the amendments made in the House, then the bill will head to the Governor for signature. Because it cleared both chambers by a supermajority, SB 6 becomes law upon the Governor’s signature.
 
SB 6 provides liability protection for doctors, healthcare providers, and healthcare facilities during the declared COVID-19 public health emergency. 
 
All core elements of our bill remain intact. Protections apply to care rendered to known or suspected COVID patients and to care affected by the pandemic. Conduct is governed by gross negligence or a willful and wanton standard. The statute protects healthcare providers who operated in good faith. Liability protections are retroactive to March 13, 2020, when Governor Abbott declared COVID a public health emergency. Legislative findings were added to counter the anticipated constitutional challenges to the retroactivity of the bill.

The willful and wanton standard in the Pandemic Liability Protection Bill mirrors the standard that applies in Good Samaritan law and in Texas’ emergency care protections which have been in force in our state since 2003.

The COVID bill does not provide unchecked liability protection. It simply broadens the current emergency room standard to COVID patients and situations where the defendant proves that COVID was the producing cause of the care rendered.

SB 6 does not protect bad actors who are grossly negligent, engage in willful misconduct or are consciously indifferent to their patient’s welfare and safety. Instead, it protects all those who put their safety at risk when working in a healthcare setting if they make a good faith effort to provide appropriate medical care.

The higher gross negligence standard is triggered only when the pandemic disease was a producing cause of the injury or death. Conversely, the burden falls on the plaintiff to disprove the defense by a preponderance of the evidence. Specifically, they must show that the diagnosis or treatment of the pandemic disease or reasonable suspicion of infection was not a producing cause of the injury or death.
 
The triggered protections for future man-made or natural disasters were removed in the House committee. However, SB 6 immediately triggers protections for future pandemics upon the declaration of the Governor or President of the United States.
 
Our COVID liability protections are part of a broader pandemic omnibus bill that safeguards businesses, schools, churches, and non-profits, who made a good faith effort to abide by a set of local, state, or federal guidance during the COVID outbreak.
 
In January, Governor Abbott declared pandemic liability protection an emergency, giving the bill priority status. The Lieutenant Governor and House Speaker signaled their support early. Even still, we had to fend off repeated attempts to water down the protections and single out particular healthcare providers.
 
Opponents asserted that the gross negligence standard should apply when the lawsuit is filed instead of when the alleged gross negligence occurred. The proposed revision would have had the result of delaying a lawsuit until after the Governor lifted his emergency declaration, and in so doing, nix the gross negligence protections from any COVID suit. Nursing home advocates made several efforts to exclude long-term care facilities from liability protections.  Last-minute efforts were also made to limit the time frame of the protections specifically for nursing and assisted living facilities. None of the challenges or amendments succeeded. 
 
Even the day the bill reached the House floor, Chairman Leach was fighting off proposed amendments to water down the bill’s effectiveness. Ultimately, SB 6 passed the House with the language that emerged from House Judiciary and Civil Jurisprudence Committee with the lone exception of an amendment that clarifies the bill does not create a new cause of action.
 
Congratulations to the many people who made this victory possible, starting with Senate and House sponsors Kelly Hancock and Jeff Leach. These men had an open-door policy, sat through many negotiating sessions, made thoughtful edits, and stuck to their principles in delivering a thoughtful and effective piece of legislation. 
 
Thank you to the legal teams from TMA, THA, and Texas Civil Justice League for helping us craft the bill and reach a consensus. Kudos to TAPA General Counsel Brian Jackson, who helped craft, fine-tune, and negotiate the bill and serve as our principal resource witness. 
 
Thank you to our advocate Brian Yarbrough for working with the authors and shepherding the bill through the legislative process and to Billy Phenix for working to ensure conflicting liability language in other bills did not become Texas law. 
 
Thank you for the input from our many witnesses, from the nursing home community, and from TAPA board member Dr. Liam Fry, who explained the need for and real-life implications of our COVID bill in committee testimony. 
 
And lastly, thank you to our board members and stakeholders who guided us and trusted us to navigate a contentious legislative process. 
 
We anxiously await the final enactment of the 2021 Pandemic Liability Protection Act.

There are an estimated 3.5 million people in Texas age 65 and older; they make up approximately 12.3 percent of the total Texas population of 28.7 million. 80% of all US COVID-19 deaths are among people 65+—a death rate at least 90 times higher than 18-29 year olds. About 1% of the U.S. population live in nursing homes and other long-term care settings, but represent 40% of COVID-19 deaths, according to the COVID Tracking Project.

Additionally, aging services and long-term care providers have been disproportionately impacted by the coronavirus pandemic. Learn more about the impact of COVID-19 on older Texans and the providers serving them by reading our Long-Term Care Situation Report detailing COVID-19 response and impact statistics.

Funding Strategies to Support COVID-19 Response and Access to Quality Care

COVID-19 has exacerbated the ongoing financial challenges faced by non-profit long-term care providers. Federal funding relief at the on-set of the pandemic served as a lifeline for providers but resources are falling short. Aging services providers continue to face exponential expenses due to routine testing, PPE, staffing, cleaning and other ongoing costs, while revenues have fallen substantially for many due to limitations on short-term admissions.

Medicaid remains an essential source of reimbursement for long-term services and supports in Texas – covering 62% of nursing home residents. The current strategy for financing Medicaid isn’t sustainable, and continues to strain our state budget. Additionally, the nursing home payment methodology is overcomplicated increasing administrative burden, and lacks incentive to improve care. It does not distinguish high quality providers from those struggling to meet minimum standards of care. Greater efficiency and long-term cost savings may be achieved by better targeting state resources.

Recommendations:

• The Texas Legislature should examine long-term care facility funding and current expenditures to determine any additional financial support needed to ensure facilities are able to comply with current regulations, and have access to critical resources like PPE, testing, staffing, and infection control supplies.
• The Texas Legislature may recognize the heroic efforts of critical frontline aging services workers by leveraging federal CARES Act relief funding to finance a frontline employees hazard pay program.
• LeadingAge Texas supports a Medicaid payment system in Texas nursing homes that promotes accountability, rewards quality with a focus on direct-care staffing and patient outcomes, drives toward systemic improvement across the field, and centers regulation on patient-care instead of paperwork. These types of reforms will help providers meet the costs of recruiting, training and retaining qualified staff, as well as other essential operations to ensure quality clinical care and quality of life for the people they serve.
• New programs focused on workforce development and strengthening existing programs like the Nursing Facility Direct-Care Staff Rate Enhancement program will help improve recruitment and retention by directly allocating dollars to direct-care staff wages and benefits. 

SB 146 | Support Initiatives to Strengthen the Long-Term Care Workforce

Before the COVID-19 pandemic, Texas faced a shortage in its long-term care workforce that threatened quality care and patient safety. The pandemic has exacerbated the threat and it is critical that the Legislature act now to strengthen the long-term care workforce and protect the most vulnerable Texans. 

Working in long-term care is highly rewarding, but recruiting and retaining qualified staff is difficult even in the absence of a virus that poses an extreme risk to providers and the seniors they serve. COVID-19 has made it even more challenging, as the pandemic has devastated long-term care facilities. Due to COVID-19, recent reports have described nursing homes as the most dangerous job in America.

In 2017, the Texas Department of State Health Services reported that direct-resident-care Registered Nurses (RNs) had the highest position vacancy rates in the state (18.9%). Comparatively, RNs in hospitals had a vacancy rate of 8.1%. Certified Nursing Assistants (CNAs) produced the highest overall median facility turnover rate among nursing staff at 65.5%. To compare, CNAs also had the highest turnover rate among nursing staff in hospitals (34.1%).

Recommendations:

• Support SB 146 (Powell), a student loan repayment program available to nurses who work in long-term care will produce more opportunity for new graduates, improve quality care for aging Texans, and generate long-term cost savings for the state.
• The Texas Legislature should work to promote CNA programs and other employment opportunities in long-term care by encouraging partnerships between providers and K-12 schools through new and existing models like PTECH. 

SB 270 | Prevent Financial Abuse of Nursing Facility Residents by Responsible Parties

Many nursing home residents’ funds are managed by third parties, usually their children, because the residents lack the cognitive ability to manage their own financial affairs. This arrangement exposes residents to abuse and exploitation, as some responsible parties improperly divert or steal residents’ funds that are needed to pay for their long-term care.

Under federal law, nursing homes cannot require a third party to commit their own funds to pay for the resident’s care. As a result, when a responsible party unlawfully uses a resident’s funds and fails to pay for their care and services, the nursing home’s ability to pursue the perpetrator is limited by issues of legal standing. Without legislation giving providers a clear right to pursue responsible parties that have diverted resident funds, residents are susceptible to eviction and lawsuits.

Recommendation:

• Support SB 270 (Perry) that grants nursing homes legal standing to stop financial exploitation by a responsible party and pursue resident funds from the responsible party to pay for long term care services provided. 

HB 249 & HB 663 | Preserve Non-Profit Affordable Senior Housing & Encourage New Development

By 2030, nearly 1 million Texans will be 85 and older. As our population rapidly ages there is a growing need for housing options for low-income seniors. Additionally, the integration of healthcare and supportive services in affordable senior housing communities is a cost-effective strategy allowing seniors to age independently and avoid costlier settings like nursing homes.

The Low Income Housing Tax Credit Program administered through the Texas Department of Housing & Community Affairs has become one of the only funding sources for existing and new affordable senior housing communities. LeadingAge Texas supports measures that make this program more accessible to housing providers that support seniors’ ability to age in place and remain independent in both urban and rural neighborhoods.

Recommendations:

• Support HB 249 (Cortez) which will remove barriers that highly qualified regional and/or national nonprofits face when competing for funding in Texas by amending the “non-profit” definition.
• Support HB 663 (Cortez) which will help many existing affordable housing developments to avoid either falling into disrepair, or being converted to market rate housing because they are currently ineligible for the At-Risk SetAside due to a technical issue in statute.

Streamline Regulations across Aging Services to Improve Access & Choice for Older Texans

Older Texans want to receive services in the setting of their choice. Aging services providers are limited in the types of services they are able to offer due to a fragmented regulatory framework that unnecessarily impedes access. Especially, in underserved rural communities. As the delivery of aging services continues to evolve and encourage models that promote “aging in place”, regulations and licensure requirements should be updated to reflect this change. Streamlining regulations to encourage multiple service-types in the same location will enable providers to better serve aging Texans.

Recommendation:

• Support regulatory reform to improve access to home and community based services like respite and adult day by leveraging resources in existing service models like assisted living and nursing homes. Many nursing home and assisted living providers are well equipped to provide quality services to older Texans that live outside the facility. However, current regulation prohibits these types of services and requires separate licensure.

Improve Service Delivery under STAR+PLUS Medicaid Managed Care

Long-Term Care providers have struggled to meet the administrative demands of STAR+PLUS since carved into the program in 2015. While improvements have been made through collaboration between the Health and Human Services Commission, Managed Care Organizations (MCOs), and the provider community, ongoing issues continue to strain staff resources and divert attention from actual patient-care.

Recommendation:

• Support measures that streamline administrative processes under managed care, encourage alternative payment models to incentivize quality, distinguish high performing providers, and create metrics that measure health plan performance specific to Medicaid beneficiaries in nursing homes.

Continue to Defend Tort Reform Provisions

In 2003, medical liability reforms were passed to protect both providers and patients. These reforms have successfully reduced lawsuits and liability costs increasing the number of quality providers who specialize in geriatric medicine and aging services.

Recommendation:

• Continue to support these medical liability reforms to ensure adequate access to high-quality care.

Voting Synopsis

There are several options available to voters who are quarantined/isolated, such as in a long-term care facility, to allow them to vote differently than in-person voting on or before the day of the election. Read more

Voting Information for Residents and Long-Term Care Facilities

Click here to view voting information from the Office of the State Long-Term Care Ombudsman, Issued September 15, 2020.

Additionally, LeadingAge Texas has created this short informational guide to assist your families and residents in voting during the 2020 election. 

November 3, 2020 is the date of this year’s general election.  LeadingAge Texas has created this short informational guide to assist your families and residents in voting during the 2020 election. 

Texas has four avenues for casting an election ballot:  

1. Election Day Voting
2. Early Voting 
3. Absentee Voting 
4. Curbside Voting at Polling Location

Election Day Voting

Tuesday, November 3, is the date of the 2020 general election.  Voters may follow the traditional approach to casting a ballot by driving to the voting location on that day.  

Early Voting

Governor Greg Abbott announced an extension of early voting beginning on October 13 thru October 30.   

Absentee Voting
Texas is An Absentee Ballot (not mail-in ballot) State

Part of the confusion around mailing a ballot is in the difference between a mail-in-ballot and an absentee ballot.  Mail-in-elections are conducted when all voters automatically receive the ballots.  Six states in the United States currently have their entire election conducted by a mail-in-ballot process.  Texas is not one of those states.  

Texas, like most states, follows an absentee ballot approach for voting by mail.  A voter must request an absentee ballot ahead of the election.

The Texas League of Women Voters has compiled this video and website explaining the process of requesting and acquiring an absentee ballot.  

Texas voters can qualify for mail-in ballots only if they are in one of these categories:

• 65 years or older
• Have disability or illness
• Out of the county on Election Day and during early voting
• Confined in jail

The Texas election code defines disability as a “sickness or physical condition” that prevents a voter from appearing in person without the risk of “injuring the voter’s health.”  The Texas Supreme Court earlier this year ruled that a lack of immunity to the new coronavirus does not qualify a voter to apply for a mail-in ballot. 

The League of Women Voters suggests these tips for requesting an absentee ballot:

• If you check "Disabled" - DO NOT WRITE IN YOUR DISABILITY.
• Avoid any confusion by election officials and sign both your application and ballot in the same way.
• Have a ballot mailed to the address where you actually are.
• Include your contact information in case there is a problem with your application.
• Mark the annual box for voters 65 years of age or older and voters with a disability.

Some key dates for requesting an absentee ballot and voting by mail:

• Oct. 5 is the last day to register to vote.
• Oct. 13 is the first day of early voting in-person.
• Oct. 23 is the last day to submit an application to vote by mail.
• Nov. 3 at 7 p.m. is the deadline to receive an absentee ballot, if not postmarked
• Nov. 4 at 5 p.m. is the deadline to receive an absentee ballot postmarked Nov. 3

Some confusion is also surrounding whether Texas will allow absentee ballots to be dropped off at polling locations.  Texas does not allow drop off ballots at polling locations.  The Texas election code does not allow counties to implement drop boxes for mail-in ballots.  

Those looking to vote by mail without the mail being involved can head to their county's elections office to hand-deliver their ballots instead of mailing them.  Voters will not, however, be allowed to hand-deliver a ballot to a polling location. It must be the election office. 

Ballots brought to the office will be accepted up until 7 p.m. on Election Day, which is November 3. Ballots must be brought to the office by the voter with one of the state’s accepted forms of photo ID.  The voter will then sign off on their submission. 

If someone who had planned to vote by mail now wishes to vote in person, though, they can simply bring their empty ballot to a polling place, surrender it, and then cast a new ballot.  

Curbside Voting

A final option for voters that are ill or disabled is to vote curbside.  Curbside voting is available to voters who are sick or are physically unable to enter the polling place. Curbside voting is allowed from October 13-30 (early voting) and on November 3.  Voters will go to their polling location and request an election officer bring a ballot to their car for curbside voting.  For more information on curbside voting, or voting with a disability, see Vote Texas information in this link.  

Centers for Medicare & Medicare Services
Department of Health and Human Services
Attn: CMS-2393-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850

Re: Comments by LeadingAge Texas on Proposed Rule CMS-2393-P – Medicaid Program; Medicaid Fiscal Accountability Regulation

Please accept this letter of comment on the recently proposed rule, Medicaid Fiscal Accountability Regulation, Proposed Rule CMS-2392-P. LeadingAge Texas advocates for approximately 200 of Texas' finest retirement housing communities, assisted living facilities, continuing care retirement communities, nursing homes, and home and community based services providers. Over 30,000 older Texans reside in LeadingAge Texas-member communities. Thousands more are served through home health services, adult day care centers, and other community out-reach services. LeadingAge Texas members are sponsored primarily by community-based nonprofit civic, religious, fraternal, and other mission-driven organizations.

LeadingAge Texas urges the Centers for Medicare and Medicaid Services (CMS) to withdraw or substantially delay implementation of Proposed Rule CMS-2392-P due to its potential impact on supplemental payment programs. Specifically, the Quality Incentive Payment Program (QIPP) in Texas.

A majority of LeadingAge Texas members serving Medicaid beneficiaries participate in QIPP as both private and public nursing homes. Currently, over 800 nursing homes are enrolled in the program. Over the last three years, QIPP has encouraged quality improvement by awarding nursing homes that meet certain quality metrics with incentive payments. Those incentive-based payments have allowed Texas nursing homes to reinvest in direct-resident care and achieve sustainable quality improvement. Lastly, QIPP has made critical Medicaid funds available to nursing homes financially strained due to historic underfunding.

We believe CMS is taking an aggressive approach that would have major implications for thousands of Texans and the providers that serve them. Additionally, these proposed changes were developed without consultation or collaboration with Congress, state Medicaid agencies, the provider trade associations representing nursing homes, and other Medicaid providers that would be adversely affected. Instead of making changes to the supplemental payment rules without comprehensive data to realize the impact, CMS should take a more data-driven and iterative approach before making such major changes to these critical programs.

Restrictions on Sources of IGTs to Tax Revenue Only
CMS should withdraw this portion of the proposed rule. The proposed rule attempts to limit the source of IGTs to tax revenues only. Federal law and longstanding CMS policy allows NSGOs to use revenues derived from various sources including inpatient and outpatient hospital care to make intergovernmental transfers (IGTs) to cover the nonfederal share of supplemental payments. Such funds are no less public due to their source. This change would cause a major dilemma creating a significant budget gap, diversion of funds from other priorities, or cuts to the Medicaid program. Lastly, the preamble misinterprets Congressional intent and CMS’s own longstanding interpretation of the 1991 Voluntary Contribution and Provider-Specific Tax Amendments law as a vehicle to abruptly cut federal spending to supplement inadequate Medicaid rates for long term care services.

Changes to Definition of Non-State Government Owned or Operated
CMS should defer to states regarding the definition of a unit of government. Currently, the term “non-state government owned or operated” (“NSGO”) refers to a nursing facility (“NF”) that is “owned or operated” by a non-state government entity. This allows a non-state government entity, such as a public hospital, the ability to operate a nursing facility it leases instead of owns. In addition, it allows the NSGO entity to contract with an experienced management company to run the day-to-day operations of the facility.

By creating a new definition of “non-state government provider” CMS is infringing on a fundamental reserved right of states to organize their governmental structures as they see fit. This intrusion into the operation and administration of state government violates the very basis of the Medicaid program -- the federal-state partnership and the federalism principles on which it rests. The rule would undermine the efforts of state and local governments to deliver public health care services more efficiently and effectively, and penalize those that have reduced their reliance on taxpayer support.

Calculating Supplemental Payments
The proposed rule would make substantial changes to how states calculate non-DSH supplemental payments but does not provide data supporting such changes. Instead, it proposes to limit the types of data used (e.g., from within the last two years) and the methodologies states can employ to calculate supplemental payments. It also requires states to submit extensive data to CMS on quarterly and annual bases, which would be used to inform future decision making on supplemental payments and upper payment limits. CMS should collect the data needed for this section of the proposal, perform analyses and propose changes according to those findings.

As proposed, the Medicaid Fiscal Accountability Regulation would drastically impact QIPP, potentially eliminating it altogether. These changes could result in access to care issues for Texas nursing facility residents, especially in rural areas of the state. LeadingAge Texas appreciates the opportunity to submit comments on behalf of not-for-profit nursing home providers in Texas, and is committed to working with CMS to develop Medicaid financing strategies that are transparent and sustainable long-term.

CMS should not move forward with the proposed changes impacting supplemental payments without first examining the full impact on both patients and providers, and gathering the data needed to make such changes responsibly. The proposed rule should be delayed or withdrawn until CMS has the necessary information and data to fully consider the impact of implementation. Additionally, it should consult with Congress, Medicaid state agencies and the healthcare provider associations impacted.

Respectfully,

George Linial
President/CEO
LeadingAge Texas

George Linial, CAE, CASP
President & CEO, LeadingAge Texas

We are thrilled to announce that yesterday, May 29, Governor Abbott signed HB 3329 (Assisted Living services) into law! We’d like to thank all LeadingAge Texas members for your involvement this session. Your advocacy makes a difference! As you know, there is always more work to be done. We look forward to continuing our efforts this interim.

In the meantime, don’t hesitate to contact me at alyse@leadingagetexas.org with any questions. 

Alyse R. Meyer
Vice President, Advocacy
LeadingAge Texas
512-467-2242  x105 
@advocate4aging

HB 3329 (Frank) related to services permitted in Assisted Living Facilities was voted out of committee unanimously and will head to the full Texas House for a vote. 

SB 1491 (Perry) related to civil liability against a responsible payor who misappropriates a nursing facility resident's funds was also voted out of committee unanimously and will head to the full Texas Senate for a vote. 

HB 3111 (Klick) and SB 2300 (Powell) creates a student loan repayment program for nurses in nursing homes. Both bills were heard in committee this week. We provided testimony in support along with AARP and the Texas Nurses Association. 

HB 1050 (Hughes) creating a statewide nursing home provider tax was scheduled for a hearing on Monday, April 15th in the Senate Finance Committee. LeadingAge Texas has been engaged on this bill and continues to work with the bill author to ensure LeadingAge Texas member communities and residents are not harmed by this tax. We continue to advocate for strong quality ties and transparency.

As bills gain traction we will be sending Calls to Action to LeadingAge Texas members asking you to contact your state legislators to voice our position on bills. For more information contact Alyse Meyer at  alyse@leadingagetexas.org. 

For the latest updates follow me on twitter @advocate4aging.

Alyse R. Meyer
Vice President, Advocacy
LeadingAge Texas
512-467-2242  x105 

Representative Klick, a registered nurse, understands the strain student debt places on making career choices in nursing. “We have some good news for nursing students. As a nurse, I know the dilemma facing new graduates entering the field. We want to pursue our passion of caring, but we also have a student debt that is hard to overcome. This bill will create a loan assistance program for nurses that want to care for our elderly. For many nurses, this can be the difference in pursuing their dream of working with older Texans.”

A 2014 analysis conducted by the National Student Nurses Association showed that the average debt burden of a nurse with a bachelor’s degree is $30,000, a figure that has risen steadily over the last several years.

Contrary to some perceptions, entry level nurses are not paid at the same level as doctors or pharmacists. Nurses with student loans are less likely to take positions in nursing homes and long-term care facilities because the pay is often not as competitive as hospitals and private-practice settings.

A 2018 report by Forbes magazine found that student debt prevented 80% of borrowers from saving for retirement, 56% from buying a home, 42% from buying a car, and 50% from contributing to charity, according to the report. More than 85% said student loan debt was a major source of stress, and one in three said such debt is the biggest stress in their lives.

LeadingAge Texas, which represents 200 non-profit aging services organizations in Texas, sees the bill as a unique opportunity to recruit nurses into a quickly evolving field. “As Texas’ population ages, the demand for nurses in long-term care has never been higher and opportunities for professional development are endless. HB 3111 will give nursing homes the boost they need to attract the next generation of talent,” said George Linial, President & CEO of LeadingAge Texas.

According to the Texas Center for Nursing Workforce Studies, encouraging younger nurses to remain in the profession is critical. An aging nurse workforce is a significant challenge for Texas healthcare. In 2015, 39.8% of RNs in the state were 50 years or older.

“We cannot have a viable healthcare system in Texas unless we find ways to encourage our nursing graduates to pursue caregiving for our aging population,” says Klick.  “Millennials and Generation Z start their careers with significant debt. This bill can help eliminate some of that burden if a nursing student pursues a career in long-term care where Texas is seeing the most need. Once these nurses see the difference they make in the lives of aging Texans, our hope is they will pursue a lifelong career in this field.”

Alyse Meyer
LeadingAge Texas
512-467-2242
alyse@leadingagetexas.org

Dozens of bills have already been filed impacting aging services and long-term care. LeadingAge Texas is analyzing and monitoring those bills to ensure our members and the seniors they serve are not negatively impacted. Click here to access a list of bills LeadingAge Texas is currently tracking. 

We kicked off the month by holding the LeadingAge Texas Advocacy Workshop & Capitol Day where members from across the state gathered to meet with legislators and staff to advocate for our field and the priorities we are focused on. 

LeadingAge Texas Members meet with legislators and staff at the 2019 Advocacy Workshop & Capitol Day.

We provided testimony to both the Senate Committee on Finance and the House Committee on Appropriations highlighting the need to: improve Medicaid reimbursement to quality nursing home providers, strengthen the Direct-Care Staff Rate Enhancement to help increase staff wages and benefits for front-line staff, and streamline administrative processes in STAR+PLUS managed care to contain costs and focus on patient care. 

Our policy team is working to visit every legislative office and has been successful working with key leadership including the Governor and Lt. Governor's offices. We've voiced support of bills that promote aging services and have worked to address concerns in bills that affect our members.

We encourage members to get involved and advocate for your organizations and the people you serve. Look for "Action Alerts" that ask you to contact your legislators and make your voice heard.

For the latest updates follow me on twitter @advocate4aging.

Alyse R. Meyer
Vice President, Advocacy
LeadingAge Texas
512-467-2242  x105 

Morningside Ministries, a not-for-profit organization in San Antonio, Texas, that provides senior housing and care services, closed its Chandler Estate nursing home rather than risk lowering the quality of care under pressure from the state’s Medicaid system.

The nursing home is slated to lock its doors this month, according to the San Antonio Express-News. And Morningside isn’t the only nonprofit to be faced with this kind of choice, according to George Linial, president and CEO of LeadingAge Texas.

Non-profits in Texas and elsewhere are facing particular pressure in the skilled nursing space. It’s a phenomenon Linial has seen firsthand.

“I do know there have been a number of not-for-profit nursing homes that have been bought out by for-profits, and part of that is that it’s hard for most not-for-profits,” he said. “Many of them are run independently… and they cannot make ends meet.”

Medicaid Falls Short

They aren’t helped by Medicaid reimbursements in the state, which are among the lowest in the country, Linial said.

“The not-for-profits that are providing great care are exiting from the Medicaid program,” he told Skilled Nursing News. “They’re reducing the number of Medicaid clients they serve because they’re unwilling to compromise on the quality of care they provide.”

This issue of care quality is exacerbated by the low Medicaid rates, which do not differentiate between nursing homes of high quality and those that provide subpar care, Linial said.

“As costs have continued to increase, the reimbursement rates have not kept up,” he elaborated. “I think from LeadingAge Texas’ perspective, there’s very little difference between payment for really great nursing homes and ones that are really struggling to provide good care. They’re getting reimbursed about the same.”

This plays into Texas’ struggles in providing long-term services and supports (LTSS). The AARP’s LTSS Scorecard ranked the state 35th overall among the U.S. states, but it ranks particularly poorly in quality of life and quality of care, at No. 46.

Those results are linked to the state’s poor Medicaid reimbursement rate, Linial said. With inadequate reimbursement, nursing homes can’t improve their staffing levels, pay staff better, or make improvements that are related to care quality, he told SNN.

Texas’ Medicaid program does have an initiative that gives rewards for better staffing, but this also lacks sufficient funding to address the problem in the state, Linial noted.

LeadingAge Texas advocated for legislation that would have linked Medicaid funds to hitting quality outcomes in 2017, but neither the Senate nor House bill made it through the state’s legislative process, Linial said.

Problems Old and New

Linial estimates that it’s been about 25 years since Texas reimbursed nursing homes for what their actual costs were. In addition, Texas has now included nursing facilities in managed care for Medicaid for almost three years, which has created a different set of billing problems; some nursing homes have had to hire additional billing people to deal with payment issues instead of direct care staff, Linial said.

It doesn’t add up to a positive result for non-profit operators.

“Virtually everyone who has been in the Medicaid program have either reduced the number of clients that they’ve served or have gotten out of the business completely, have gone completely off of Medicaid because they can’t afford it,” he said. “It’s hard for me to come up with a good number because it’s going on for a number of years.”

Written by Maggie Flynn

LeadingAge needs your help to expand and preserve affordable housing for low-income seniors! The House unanimously passed a housing modernization bill in February (HR 3700). Now, the Senate needs to do the same.

Send your lawmakers an email message today and urge them to quickly pass HR 3700, the Housing Opportunity and Modernization Act. To show their support for HR 3700, Senators should be asked to cosponsor the Senate version of this bill, S 3083. Because HR 3700 already passed the House, the fastest way to get affordable senior housing program improvements in place is for the Senate to pass the identical House bill, HR 3700. Take Action Now We’ve provided you with a sample letter for your convenience. You can also call your lawmakers. Contact the Capitol switchboard at (202) 224-3121.

Talking Points

• Pass the affordable housing modernization improvements in the House-passed Housing Opportunity Through Modernization Act, HR 3700. This bill passed unanimously in February by a vote of 427 – 0.
• Show support for HR 3700 by cosponsoring S 3083, an identical bill introduced in the Senate by Senators Robert Menendez (D-NJ), Tim Scott (R-SC), Chris Coons (D-DE) and Roy Blunt
  (R-MO).
• The legislation would:

• Modernize the ability of administrators to project-base housing choice vouchers by allowing the project-basing of up to 30% of the agency’s vouchers (rather than today’s 20% of the agency’s voucher budget) when the vouchers are used to house elderly and/or disabled households, veterans, and people who are homeless; and, erase the cap on the number of project-based vouchers used in a single senior housing community;
• Streamline the calculation of tenant income for purposes of rent setting by simplifying calculation of medical expense deductions and increasing standard senior deduction;
• Allow project sponsors / owners to rely on determinations of income conducted for other federal means-tested public assistance programs such as Medicaid and the Supplemental Nutrition Assistance Program (food stamps); and,
• Base tenant rents on prior-year income instead of projections of future income.

LeadingAge thanks you for your support on this important issue. Your voice is very important.

Be The Voice and Join the Seniors Action Network Today!

Excerpt:

With the backdrop of the Texas Capitol, Governor Greg Abbott and Lieutenant Governor Dan Patrick were sworn into office as the state’s top-elected Texas officials. The ceremony marks the end of the Perry-era in Texas politics, spanning three decades, including 14 years as Texas governor. In November, voters supported a Republican sweep in all statewide offices and increased the Republican margins in both chambers of the Texas Legislature.

Members, click here to read more!