Comprehensive Reform

Background

The U.S. needs a system that provides universal access to a comprehensive range of health care services and long-term services and supportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. (LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. ). Consumers and their families need to be educated about their risk for needing LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. and the lack of coverage for LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. through MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). and health insurance. The public and private sectors can assist consumers as they consider all their options for financing LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. and choose among them.

Some resources already exist. Aging and Disability Resource CentersState-operated organizations that provide information about and access to all of the long-term services and supports available to older adults and people with disabilities. Also known as Single Point of Entry and No Wrong Door systems. (ADRCState-operated organizations that provide information about and access to all of the long-term services and supports available to older adults and people with disabilities. Also known as Single Point of Entry and No Wrong Door systems. ) and No Wrong Door (NWDState-operated organizations that provide information about and access to all of the long-term services and supports available to older adults and people with disabilities. Also known as Single Point of Entry and No Wrong Door systems. ) systems—also called single-entry points—provide education, guidance, and conflict-free advice about LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. options. They can also assist in making informed decisions. Programs can provide a wide array of supports that emphasize the maintenance of independence, dignity, autonomy, and privacy for individuals to maximize their physical and psychosocial potential.

Because the full cost of LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. benefits is too expensive for many Americans, financing provisions for LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. programs need to take affordability into account. These provisions must be sustainable for programs overall. A financing package needs to adequately address transition costs as a new program is phased in.

A new system needs strong consumer protection standards and enforcement mechanisms. State ADRCState-operated organizations that provide information about and access to all of the long-term services and supports available to older adults and people with disabilities. Also known as Single Point of Entry and No Wrong Door systems. /NWDState-operated organizations that provide information about and access to all of the long-term services and supports available to older adults and people with disabilities. Also known as Single Point of Entry and No Wrong Door systems. systems operate best with consumer and other stakeholder input and oversight. They are meant to provide conflict-free counseling and referrals to a comprehensive range of services. It is essential that the services and supports that consumers receive be largely self-directed, whether financed through private family resources or public programs. There is evidence that many consumers who receive a cash benefit manage their LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. more economically than those who receive benefits under an agency-administered model.

COMPREHENSIVE REFORM: Policy

COMPREHENSIVE REFORM: Policy

Comprehensive System

Federal policymakers should develop a comprehensive system for financing Long-Term Services and SupportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. (LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. ) that includes a new social insurance program Group insurance that serves a social purpose and is operated by the government. Individuals contribute to the program either directly or indirectly through their employer. Tax revenues may also be used to fund these programs. The program protects participants from large or sudden… to provide a basic level of LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. . The program should be designed to function seamlessly with a mix of other financing sources. Those sources should include private long-term care insurance, individuals' out-of-pocket expenditures, and MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. for individuals with low incomes.

The public and private sectors—including the Social Security Administration, the Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services, and health insurance carriers—should coordinate with each state's Aging and Disability Resources Centers/No Wrong Door systems to educate consumers and their families about their risk for needing LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. , the lack of coverage for LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. through MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). and health insurance, and all options for financing LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. . Doing so helps consumers understand their options and responsibilities and make informed choices that are best suited to their needs and circumstances.

New funding sources

The cost of a new social insurance LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. program should be paid for with premiums, individual contributions through cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. requirements, and general revenues.

LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. financing proposals should be evaluated on the extent to which they are progressiveIn taxation, a situation in which people with lower income pay a smaller percentage of their income than do people with higher income., broad-based, stable, affordable, and capable of growing with enrollment.

The federal government should finance LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. through a universal, comprehensive, and publicly administered program such as MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). or similar social insurance program Group insurance that serves a social purpose and is operated by the government. Individuals contribute to the program either directly or indirectly through their employer. Tax revenues may also be used to fund these programs. The program protects participants from large or sudden… of shared risk.

Progressive financing and low-income protections

Program participant cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for either community or institutional services should be modest. It should not favor one type of service over another. To protect people with low incomes, public funds should contribute to their cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. requirements.

Adequate financing and reserves

Some tax revenues for a new LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. program should be earmarked to an LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. trust fund. This would build adequate reserves to cover later generations. The new LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. program should require some maintenance of states' current spending on LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. to help defray the federal government's costs.

Essential features of an LTSS social insurance program

The federal government should create some type of public social insurance benefit. It should be within MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). or in a new public program that provides some level of coverage to protect consumers who need LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. .

Benefits should be designed to enable consumers to choose services they consider most appropriate for their needs.

Strong federal and state oversight should be provided to ensure the equitable treatment of all people eligible to receive services. People must have equal access to services regardless of payer.

Care management should be used to coordinate health care and LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. for people who need both types of services. Care management should be conflict-free, multidisciplinary, and available to all, regardless of payer.

The system should build on states' experiences or require state and local agencies to have a major role in running any new program.

States should be required to implement a single point of entry for LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. to determine financial and program eligibility and authorize services promptly.

Assessments to determine eligibility for services should measure the need for assistance caused by functional limitations and the need for assistance with activities of daily livingSkills necessary for daily care of oneself such as bathing and showering, personal hygiene and grooming, toilet hygiene and self-feeding. and instrumental activities of daily livingSkills necessary for daily care of oneself such as bathing and showering, personal hygiene and grooming, toilet hygiene and self-feeding. without regard to whether the person being assessed has family who can assist with the care. It should also measure the need for long-term nursing services, medical management, and supervision due to cognitive and other mental impairments and behavioral problems.

Federal and state governments should consistently apply a standardized assessment to determine consumer's needs.

A full range of home and community-based services should be provided to delay or prevent institutionalization and help to control overall LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. costs. These services include but are not limited to personal care in the home, case management, respite care, adult day services, accessible transportation, and supportive housing A setting for long-term services and supports that includes board and care homes, assisted living facilities, and group homes that provide or arrange for services and help with activities of daily living (see separate entry) in a residential setting. .

Consumer-directed LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. should always be available, promoted, and supported, regardless of payer or provider. Federal and state agencies should offer consumers the option of a cash payment to select and manage their LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. .

Services from all providers should be designed and delivered in a way that promotes independence.

The program should not provide financial incentives to use one type of care over another.

If federal and state governments use capitated payment systems, they should require strong consumer protection standards. Capitated ratesA payment system used with managed care organizations (MCO) that provide health care. The MCO is paid a fixed amount for each enrollee and bears at least part of the financial risk for the cost of providing care. must be sufficient to meet the needs of those served and allow consumers to choose the services that best meet their needs.

Intermediate steps for comprehensive reform

Until a comprehensive national LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. program is implemented, intermediate steps should be taken:

  • States should implement affordable LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. programs for those who do not meet MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets.'s eligibility requirements but who still cannot afford LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. .
  • Coordination among LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. programs —and between the health care and LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. systems for people who need services from both—should be improved.
  • Services in consumer-preferred settings—primarily the home and community—should be expanded. Services that support family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. ' ability to continue providing care should be included in the expansion.

Oversight

The federal and state government should conduct regular, thorough, and consistent oversight. Oversight should include evaluation of consumer outcomes to the extent feasible.

They should ensure quality of care and quality of life for all consumers. The rights of the consumer should be protected in all LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. settings.

Consumer focus

Consumers and their family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. , as appropriate, should be the focus of all LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. programs and services.

LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. consumers, including those from diverse communities, should participate in all aspects of program development, implementation, and oversight.

Consumersto the extent they are capableor their caregivers or legal representatives should have the option to make decisions about the LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. they receive and manage their own services and supports.

Coordination with other health programs

MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). coverage of health services for those with chronic illnesses and disabling conditions should be improved (see also Chronic-Care Coordination and Accountable Care Organizations). Medical care management should be used to coordinate health care and LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. for people who need both types of services. Care management should be conflict-free, multidisciplinary, and available to all, regardless of payer.

Covered services should be fully portable so people can receive them in a wide range of settings.

The effects of integrating other public LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. programs, such as state-funded and Department of Veterans Affairs programs, into a new system should be carefully considered to ensure that program changes enhance participant access. Existing programs should receive adequate federal funding to ensure veterans' access to LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. .

Flexible, innovative, and efficient administration

A reformed LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. system must have an administrative structure capable of meeting the needs of diverse and growing numbers of beneficiaries.

 

Access to home-and community-based services

Eligibility for services should be based on how LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. relate to an individual's functional needs, chronic illness, and medical conditions.

MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant).'s potential role in meeting MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries' LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. and medical needs should be reexamined and expanded to assist people who depend on family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. . It should include improved home health careA Medicare benefit provided in an individual’s home. Eligibility requires that an individual be under the care of a physician who authorizes all services and certifies that the person is homebound  and in need of intermittent skilled services. and skilled-nursing facility benefits, personal care designed to help people with ADLs, adult day care, and other caregiver support services, such as assessment of caregiver needs, education and training, and respite care.

Improved MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. benefits should serve as an LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. safety net for vulnerable populations with low incomes and few assets and for those who become impoverished because of medical or LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. needs.

Services provided through the Older Americans Act and Social Services Block Grants should receive adequate funding because they are important to the home and community-based LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. system.

Conflict-free care management should be available through public agencies to help individuals and their families access the full range of LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. .

 

Long-term care insurance (LTCI)

LTCI should be subject to stronger consumer protections and greater standardization so that consumers can make informed comparisons among policies.

 

Phased-in coverage

A comprehensive new program can be introduced gradually. The program should cover people who currently need services and build an adequate program for future generations through a range of financing resources.

 

Appropriate services

Unnecessary institutionalization should be avoided. Home and community-based services—such as home careA range of services provided in the home, including health-related care, personal care, and supportive services., conflict-free care management, personal care, respite care, adult day services, and supportive housing A setting for long-term services and supports that includes board and care homes, assisted living facilities, and group homes that provide or arrange for services and help with activities of daily living (see separate entry) in a residential setting. —should be utilized to control the costs associated with LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. (see also Home and Community-Based Services).

In order to help control LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. costs, federal and state governments should use a standardized assessment in a consistent manner to determine the program participant's needs. The assessment should inform the service plan in addressing the person's goals and needs. Longitudinal information from this assessment should be used to evaluate consumer outcomes and monitor quality of care. A universal core of assessment items should be developed and implemented across health care and LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. systems so that consumer outcomes can be tracked.

 

Data collection

Federal and state governments should ensure that standardized systems collect data on service use, costs, and quality, particularly for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. and MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant).. Accurate and timely LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. data are central to evaluating services and consumer outcomes and making sound policy decisions regarding the cost-effective allocation of financial resources.

 

Fraud and abuse

Federal and state governments should adequately fund MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. fraud and abuse units. They should also investigate and prosecute providers in any services and supports setting who defraud MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. or abuse program participants.

 

Conflict-free care management

Conflict-free care management should ensure effective and efficient coordination of high-quality consumer services.

 

Risk-sharing

Financial incentives should be aligned. Appropriate protections should be in place to ensure that individuals receive the LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. they need at an appropriate cost. Costs should not be inappropriately high and must provide value for the government, consumers, families, taxpayers and be efficient and effective. Costs should also not be so inappropriately low that they result in poor-quality care, insufficient care, not enough care, etc. Organizations and governmental agencies that provide any care management should share the financial risk of cost overruns and the financial rewards of effective cost containment. These include managed long-term services and supportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. , also known as MLTSS, health maintenance organizations, and social health maintenance organizations.

Effective governmental oversight (e.g., periodic audits and look-back surveysA survey of a sample of nursing facilities conducted by the federal government to determine if the state agency correctly performed its survey, i.e., to determine whether the type and level of deficiencies identified by both surveys are consistent. ) must be in place to help prevent conflicts of interest within the care-management system.

 

Private payments

Social insurance program Group insurance that serves a social purpose and is operated by the government. Individuals contribute to the program either directly or indirectly through their employer. Tax revenues may also be used to fund these programs. The program protects participants from large or sudden… payments should be supplemented by private payment, as long as cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. requirements do not unduly burden people with low incomes.