Medicaid Managed Care: Integrating Health Care and Long-Term Services and Supports

Background

Many states are moving toward or expanding capitated, risk-based managed care for Medicaid enrollees who have long-term services and supports (LTSS) needs. These states are enrolling Medicaid beneficiaries in managed care plans that undertake to coordinate all their care, including LTSS if needed. Because these people often have one or more chronic conditions, they tend to use more health services than average. They often depend on nonmedical supports such as personal care to help with activities of daily livingADLs include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. . In Medicaid-managed LTSS, managed care organizations bear the financial risk by receiving a per-member, per-month rate.

Medicaid-managed LTSS provides many opportunities and challenges in care delivery and financing. The opportunities can include the use of care coordinators and better outcomes of care across multiple settings. Unnecessary hospital and nursing facility admissions, as well as medication mismanagement resulting from multiple parallel systems of care, may decline. States can hold managed care organizations accountable both for controlling service use and providing quality care. The fixed payments to managed care organizations make Medicaid costs more predictable for state governments. However, fixed payments may also create incentives for plans to restrict access to services for people who have costly health care and LTSS needs. And many plans have little or no experience providing LTSS to these high-need, high-cost populations. In light of the vulnerability of these groups and some plans’ limited experience, the principles and policies guiding managed care generally, as well as the test programs for dual-eligible beneficiaries, should also inform the design and implementation of Medicaid-managed LTSS (see Chapter 7, Private Health Plans: Managed Care; and Chapter 7, Health: Managed Care for Dually Eligible Medicaid Beneficiaries).

Medicaid Managed Care: Integrating Health Care and Long-Term Services and Supports: Policy

Goals of an integrated system

In this policy: FederalState

All Medicaid-managed long-term services and supports (LTSS) plans should offer, promote, and support consumer-directed care.

Care coordination should include knowledge of community supports (e.g., housing, transportation, and employment), a reasonable ratio of care coordinators to beneficiaries, standards for frequency of client contact, and specific and adequate reimbursement. Care coordinators should not be exclusively available by phone. There should be opportunity for beneficiaries to meet with their care coordinator/case manager in person as needed (see Chapter 9, Livable Communities, for more information on housing).

Conditions of enrolling in an integrated system

In this policy: FederalState

Federal and state governments should ensure that Medicaid beneficiaries in capitated plans receive timely access to LTSS.

No person should be enrolled in a Medicaid-managed LTSS plan without first receiving a conflict-free assessment of their needs and preferences and conflict-free counseling about the range of options applicable to their needs and preferences.

LTSS eligibility criteria

In this policy: FederalState

Individuals should not have to meet medical criteria to be eligible for LTSS.

Federal and state governments should prohibit waiver programs from making enrollment in a managed care plan a condition for receiving LTSS.

Role of hospital discharge-planning departments

In this policy: FederalState

Hospital discharge-planning departments should be required to help consumers obtain the array of equipment and services they need to meet their home-care needs following hospital discharge.

Discharge planners should inform consumers in advance of the costs of equipment and services, and available payment sources, including Medicare and Medicaid.

To effect a smooth transition for the consumer, the hospital discharge planner should be required to coordinate planning with the local Aging and Disability Resource Centers (ADRC) or other system with a single entry point; with the consumer’s family caregiver, if appropriate; and with the care manager, if the consumer is already enrolled in a Medicaid-managed LTSS plan and has a care manager in the community.

Monitoring and oversight

In this policy: FederalState

Centers for Medicare & Medicaid Services (CMS) should establish strong reporting and oversight requirements for states adopting LTSS managed care.

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

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