Background
Many states are enrolling Medicaid participants in capitated, risk-based managed care plans designed to coordinate all their care, including long-term services and supports (LTSS) if needed. In Medicaid-managed plans that cover both health care and LTSS, 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 care organizations (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.
Medicaid 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 living. Fixed payments to MCOs make Medicaid costs more predictable for state governments. But they may create incentives for plans to restrict access to services by people with costly health care and LTSS needs.
States hold MCOs accountable for controlling service use and providing quality care.
The principles and policies regarding managed care generally, as well as the demonstration programs for consumers who are eligible for both Medicare and Medicaid, can inform the design and implementation of Medicaid-managed LTSS 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 Medicaid-managed long-term services and supports (LTSS) plan without first receiving an assessment of their needs and preferences. They also need information about the range of options available to meet them.
Federal and state governments should ensure that Medicaid enrollees in managed care plans have a choice of providers and receive services in a timely manner.
States must ensure MCOs are accountable for quality and access to care and that managed LTSS is not used solely for cost containment.
States should not implement managed LTSS with a primary goal of cost containment. States choosing to implement or expand managed LTSS (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 payments, changes in eligibility, and consumer outcomes. The state should regularly provide this information to the public in easily readable form.
The Centers for Medicare & Medicaid 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 for more information on housing).