Medicaid-Managed Care Programs and Long-Term Services and Supports Needs

Background

Many states are enrolling 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. participants in capitated, risk-based managed care plans designed to coordinate all their care, including 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. ) if needed. In 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. -managed plans that cover both 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. , managed care organizations bear the financial risk of covering high-need participants at high risk for acute health care. The plan receives a per-member, per-month rate regardless of the number of services needed. Managed 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. can help with cost containment. Still, states must ensure managed care organizations (MCOs) are also accountable for quality and access to care. States hold MCOs accountable for controlling service use and providing quality care.

Because MCOs have a financial incentive to keep costs low, they use care coordinators to manage care to prevent or reduce unnecessary hospital and nursing facility admissions. Care coordination can also reduce the medication mismanagement that often results in an individual receiving treatment from multiple care systems.

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. participants tend to use more health services than average because they frequently have one or more chronic conditions. Often, they also need personal care to help 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.  

Fixed payments to MCOs make 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. costs more predictable for state governments. But they may create incentives for plans to restrict access to services by people who have costly 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. needs.

The principles and policies regarding managed care generally, as well as the demonstration programs for consumers who are eligible for both 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 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. , can inform the design and implementation of 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. -managed 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. plans (see also Private Health Plans: Managed Care and Managed Care for Dually Eligible Medicaid Beneficiaries).

MEDICAID-MANAGED CARE PROGRAMS AND LONG-TERM SERVICES AND SUPPORTS NEEDS: Policy

MEDICAID-MANAGED CARE PROGRAMS AND LONG-TERM SERVICES AND SUPPORTS NEEDS: Policy

Oversight, enrollment, and consumer protections in an integrated system

No person should be enrolled in a 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. -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. ( 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. ) plan without first receiving an assessment of their needs and preferences, as well as information about the range of options available to meet them.

Federal and state governments should ensure that 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. enrollees in managed care plans have a choice of providers and receive services in a timely manner.

States should not implement managed 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. with a primary goal of cost containment. States choosing to implement or expand managed 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. (known as MLTSS) should do so with the financial commitment to maintain or improve access to services, consumer choice, and quality of care. They should make every effort to preserve provider-user continuity.

States should develop uniform, robust metrics and work with plans to collect and monitor provider payment, changes in eligibility, and consumer outcomes. The state should regularly provide this information to the public in readable form.

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 should evaluate the relative merit of managed care and other service models.

Care coordination should include knowledge of community supports (e.g., housing, transportation, and employment), a reasonable ratio of care coordinators to program participants, standards for frequency of consumer contact, and specific and adequate reimbursement. Care coordinators should not be exclusively available by phone. There should be opportunity for program participants to meet with their care coordinator in person as needed (see also Livable Communities).