Managed Care Panel

James David Toews
What Is Managed Care?
• Way of paying for and delivering health care and/or long-term
services and supports (LTSS)
• Generally, payer gives a managed care organization (MCO) a
set (capitated) monthly payment per member, which the MCO
uses to provide services and supports to its members
• Provide an array of services to members through an
established network of contracted providers
• MCOs assume and manage some or all of the financial risk for
their members
As such, they have a financial incentive to keep members healthy, and
to coordinate members’ care
What Is Managed LTSS?
• Payer – typically the State Medicaid Agency (SMA) –
contracts with an MCO to coordinate and provide
• May cover home and community-based services
(HCBS) as well as institutional care
• May serve different populations: older adults, people
with physical disabilities, and/or people with
developmental/intellectual disabilities, or behavioral
health needs.
CMS Authorities for MLTSS
• Social Security Act (SSA) Section 1115 demonstrations
(for comprehensive or targeted Medicaid program
• SSA 1915(b) + (c) Medicaid waiver combinations
• Affordable Care Act (ACA) -- Integration and Financial
Alignment demonstrations for dual eligibles through
Centers for Medicare & Medicaid Services (CMS)
Medicare-Medicaid Coordination Office (MMCO)
Where Are We Headed?
• MLTSS experience is limited, as is our evidence base
• Interest in MLTSS is growing rapidly
– Duals’ Financial Alignment Initiative: 26 states submitted
proposals to CMS
o Six have been approved thus far (CA, IL, MA, OH, VA, WA); six have
been withdrawn (AZ, HI, MN, NM, OR, TN)
Why Now?
State budget deficits
Growth in Medicaid spending
Current LTSS spending trends are unsustainable
ACA: Incentives to states to develop new service
delivery and payment models
– MMCO financial alignment, medical homes/health homes;
2014 Medicaid expansion
• Current system issues:
– Fee-for-service incentives to maximize expensive services,
institutional bias, inflexible service packages, little
incentive for oversight, etc.
Potential Benefits of MLTSS
More care coordination
Improved integration between acute care and LTSS
More flexible benefits packages
Accelerated rebalancing through global budgets
Improved community alignment
Improved quality management
Challenges in MLTSS
• Limited experience
• Process is moving very quickly in some states
– Are states ready? Are plans ready?
• Transitioning beneficiaries from fee-for-service to
capitated systems
• Network adequacy
• What happens to existing community-based
organizations and networks?
• Ensuring that important HCBS features are not lost in
integration with acute care
– Loss of focus on independence, community living, recovery
Challenges (continued)
• Meeting people’s needs
• Ensuring person-centered planning is the basis for
service authorization and delivery.
• Ensuring service authorizations are made by qualified
• Avoid compounding existing problems (e.g., lack of
affordable housing)
• Quality and oversight
• Meaningful consumer engagement and participation
CMS MLTSS Guidance
In summer 2013 CMS published MLTSS guidance for states based
on best practices for establishing and implementing MLTSS
Also clarifies expectations of CMS from states using section 1115
demonstrations or 1915(b) waivers combined with another long term
services and supports (LTSS) authority in an MLTSS program
Includes 10 key elements that CMS expects to see incorporated into new and
existing state Medicaid MLTSS programs
Following are potential questions that stakeholders and advocates
might use to decide if the 10 elements are addressed in your state’s
Element 1: Adequate Planning
• Did the state’s MLTSS planning team include key individuals with experience and
expertise in LTSS?
• Were other relevant state agencies (e.g., state agencies on mental health, DD, aging,
physical disabilities, etc.) on the planning team?
• In the state’s RFP, procurement or contract with MCOs, is there clear language
requiring the MCO to include top level management and operational staff with LTSS
experience in its organizational design?
• Prior to launch, does the state have a detailed written plan for education and
outreach to consumers, providers, contractors, families, caregivers, community
organizations and others about the roll-out of MLTSS?
• Was the education and outreach plan developed with close cooperation and input
from stakeholder groups?
• Are there easily accessible consumer hotlines available during the MLTSS roll-out to
answer questions and help resolve immediate confusion or complaints?
• Is there contractual language requiring MCOs to continue contracting with existing
LTSS providers of MLTSS consumers for a minimum of 90 days but preferably 180
days, even at the pre-existing fee for service rate, if necessary?
Element 2: Stakeholder Engagement
• Did the state convene a formal stakeholder advisory group with crossdisability representation?
• Did the state assure easy access to advisory group meetings, including things
like transportation, personal assistants, interpreters, etc.?
• Did the state present a MLTSS plan that was understandable (including its
financial calculations) and was clear as to how the LTSS system would be
specifically improved in the move to managed care, (e.g. more people would
be diverted or moved from institutions, waiting lists would be reduced,
more people would get consumer-directed supports, etc.)?
• Did the state summarize and post the concerns and recommendations made
by stakeholders, including which ones were incorporated into the final
design, and which ones were not and the reasons why?
• Did the state plan and implement a formal and specific role for stakeholders
in monitoring the roll-out and implementation of MLTSS, including access to
regular reports, data, and trend analyses?
Element 3: Enhanced Provision of HCBS
• Does the state’s MLTSS plan include concrete
rebalancing benchmarks by year, and how they will be
achieved (e.g., nursing home diversion, MFP, etc.)?
• Does the MLTSS plan require and set goals for
increasing the number of consumers directing their
own care and supports?
• Are the above written into clear contractual language
for the managed care plans along with explicit
language on their requirements to comply with ADA
and Olmstead?
Element 4: Alignment of Payment Structures and Goals
• Are all LTSS services, both institutional and HCBS, carved into
the plan?
• Do capitation rates set by the state for managed care plans
incentivize higher payments for HCBS, and lower payments over
time or penalties for high institutional utilization?
• Are capitation rates tiered in a way that promote HCBS for
persons with complex needs, including rates that are high
enough or can be achieved through rate exception processes?
• Does the state have a periodic evaluation strategy to see if its
rate structures or capitation models are achieving the
benchmarks described above in Element 3?
Element 5: Support for Beneficiaries
• Is there a mechanism to provide consumers with independent
and conflict-free MLTSS enrollment assistance?
• If the plan consumers choose or are passively enrolled in is not
satisfactory, do they have the right to choose another plan at
any time?
• Is there an independent consumer rights agency or ombudsman
available to help consumers understand their rights and to
resolve problems?
Element 6: Person-Centered Processes
• Does each MLTSS plan solicit active participation of the
consumers and/or designees in all aspects of designing an
individualized service package?
• Does the consumer have meaningful choices between both
medical and LTSS providers?
• Does the state require each MLTSS plan to offer self-direction,
including the ability of the consumer to hire and fire support
• Does the state encourage plans to use long-standing personcentered training and practice tools as the operating principle
for integrated teams including both medical and LTSS
Element 8: Qualified Providers
• Does the state assure that plans have adequate networks of
providers to meet the needs and choices of consumers,
including HCBS providers able and willing to support individuals
with complex needs?
• Does the state assure that MLTSS plans will contract with outof-network providers to provide needed specialized services
that are not available in-network?
Element 9: Qualified Providers
• Does the state have a rigorous system for reporting suspected
abuse or neglect, tracking the status of investigations, and
assuring abuse cases are resolved, with added protections for
the consumer?
• In addition to helping consumers resolve individual complaints
with MLTSS plans, does the consumer rights agency or
ombudsman roll up complaints and report them as systemic
issues, and does the state take action based on such reports?
• If service plans for consumers are cut or changed, are existing
plans continued for the duration of an appeal either to the MCO
or the state?
Element 10: Quality
• Does the state have specific and measurable outcomes for LTSS,
acute care, and behavioral health that are tracked at both the
state and MCO level?
• For LTSS, does the state track the movement and lengths of stay
across both institutional and types of community settings at
both the MCO and state level? (See rebalancing benchmarks
under element #3)
• Does that state Medicaid agency have staff involved in MCO
contract monitoring who have experience with aging and
disability populations?
• Does the state require consumer participation in specific
monitoring activities at both the MCO and state level?
A Few Key Resources
CMS resources
Duals Financial Alignment Initiative:
Health homes:
Innovation Center models by state
Medicaid MLTSS:
A Few Key Resources (Continued)
Center for Health Care Strategies LTSS resources: (includes resources on community
integrations, duals, and MLTSS)
Community Catalyst Duals resources: (Duals) (Integrated care)
Kaiser Family Foundation Medicaid resources: (includes
duals and LTSS)
N4a Aging & Disability Exchange: (focuses on
business capacity and integrated care)
NASUAD State Medicaid Integration Tracker:
National Senior Citizens Law Center resources on duals for advocates:

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