Ensuring Medicaid Managed Care Programs Meet Enrollees' Long-Term Services and Supports Needs

Background

Many states have implemented or are expanding capitated, risk-based managed care for Medicaid enrollees with long-term services and supports needs. These states are enrolling Medicaid beneficiaries in managed care plans that undertake to coordinate all their care, including long-term services and supports (LTSS) if needed. Because these beneficiaries 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 ofADLs or Activities of Daily Living are the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring. IADLs or Instrumental Activities of Daily Living are activities related to independent living and include preparing meals, managing money, shopping for… daily living. In Medicaid-managed LTSS, managed care organizations bear the financial risk of covering these often higher-need beneficiaries because the plan receives a per-member, per-month rate.

Medicaid-managed LTSS provides both opportunities and challenges in the financing and delivery of services. These 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 by people who have costly health care and LTSS needs. 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 also Chapter 7, Health - Private Health Plans: Managed Care; and Chapter 7, Health: Managed Care for Dually Eligible Medicaid Beneficiaries).

ENSURING MEDICAID-MANAGED CARE PROGRAMS MEET ENROLLEES’ LONG-TERM SERVICES AND SUPPORTS NEEDS: Policy

Oversight, enrollment, and consumer protections in an integrated system

In this policy: FederalState

No person should be enrolled in a Medicaid-managed long-term services and supports 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 Medicaid enrollees in managed care plans have a choice of providers and receive services in a timely manner.

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.

The Centers for Medicare & Medicaid Services should evaluate the relative merit of managed care and other models of 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 in person as needed (see also Chapter 9, Livable Communities for more information on housing).