This week, our In Focus comes from Senior Consultant Rachel Patterson, who provides an overview of Chapter 3 of the Medicaid and CHIP Payment and Access Commission (MACPAC) June 2018 Report to Congress on Medicaid and CHIP, which examines the growing role of managed care in long-term services and supports (LTSS). Chapter 3 includes research conducted by teams including HMA Principals Sarah Barth and Karen Brodsky regarding network adequacy for home and community-based service (HCBS) and Principals Sarah Barth, and Sharon Lewis and Senior Consultant Rachel Patterson regarding enrollment of people with intellectual and developmental disabilities (ID/DD) into MLTSS.
MACPAC has undertaken a series of activities to better understand LTSS and managed long-term services and supports (MLTSS), including research on state adoption, goals, federal regulations, implementation, operation, outcomes, and emerging trends – as well as issues MACPAC will continue to monitor related to MLTSS.
MLTSS Penetration Grows
Medicaid is the largest payer of LTSS programs, MACPAC notes, and the use of MLTSS by Medicaid has grown substantially in recent years. In 2004, only eight states had MLTSS programs; by January 2018 that number had grown to 24. Furthermore, the scope of MLTSS continues to expand, with eight states now offering MLTSS programs to individuals with intellectual and developmental disabilities (ID/DD). Many states also operate multiple programs; as of January 2018, 24 states had 41 different MLTSS programs. About 1.8 million people are enrolled in an MLTSS program.
States typically turn to MLTSS for four primary reasons, MACPAC says:
- Rebalancing of LTSS spending, i.e., increasing the amount of funds going to home and community-based services (HCBS) instead of institutional care;
- Care coordination and quality;
- Reductions of HCBS waiting lists and improved access to care;
- Budget predictability and cost control
MLTSS Operational Issues
But whether LTSS is delivered through MLTSS or fee-for-service, MACPAC finds, the “programs face common challenges.” MACPAC notes, for example, that the number of individuals on HCBS waiting lists nationally topped 656,000 in 2016, adding that there is high turnover and shortages among direct support workers.
Initial implementation, procurement, and contracting periods are critical for beneficiaries, MACPAC says, because of the danger of care disruptions. Engagement of beneficiaries, advocates, and providers also plays a key role in successful transitions to MLTSS, MACPAC says, as does adequate training to address the shift providers must make from fee-for-service to managed care payments and contracting.
Research conducted by HMA on behalf of MACPAC found that every MLTSS program studied had existing HCBS network adequacy standards in place, including the following:
- Continuity of care standards beyond federal time requirements;
- Time and distance metrics;
- Criteria defining a minimum number of providers by type or the reporting of the number of HCBS providers by geography;
- Reporting requirements for gaps in service;
- Any willing provider provisions;
- Provider payment rates equal to at least Medicaid fee-for-service rates;
- Single case agreement provisions
These standards are evolving as states gain experience with MLTSS. For example, stakeholders expressed a preference for the gaps in service standard, which requires reporting and/or tracking of missed HCBS visits and gaps or delays from the time of service authorization to service delivery.
Furthermore, as states figure out what’s working in term of network adequacy requirements, they are using the reprocurement process to implement changes, MACPAC says.
The Future of MLTSS
MLTSS is expected to continue to evolve, MACPAC notes, as existing programs mature and as more states transition to MLTSS.
Areas to watch include the growing enrollment of individuals with ID/DD into MLTSS, better understanding of how states are aligning MLTSS with dual-eligible special needs plans (D-SNPs), the adequacy of federal and state oversight efforts, and research comparing the cost and quality of MLTSS compared to fee-for-service models.
MACPAC notes, for example, that historically individuals with ID/DD have been excluded from MLTSS programs for several reasons, including a lack of provider familiarity with MLTSS programs, stakeholder skepticism, and challenges in achieving cost savings.
But that’s changing as more states consider MLTSS. Research by HMA conducted on behalf of MACPAC finds that the keys to successful program rollout includes slow, incremental transitions by region or eligibility group; and stakeholder engagement to address community concerns.
HMA also found that ID/DD-specific provisions in MLTSS contracts “are more prevalent for separate programs designed for people with ID/DD than for programs that include other populations receiving LTSS.” Often these provisions are tied to underlying policy goals. Tennessee, for example, requires case managers to receive training on cultural competency, family supports, dignity of risk, transition planning for youth, and other areas. Other states require MLTSS staff to have ID/DD-specific training, have specific stakeholder engagement requirements, or include ID/DD specific quality provisions.
The chapter also explores MLTSS and design characteristics, including the managed care authority chosen by the state, contract type (comprehensive or LTSS only), covered populations, mandatory or voluntary enrollment, geographic reach, inclusion of institutional services, number of participating plans, types of plan (for-profit, non-profit, and public entities), payment policies, and integration with Medicare benefits. The chapter also goes into detail on the federal requirements for MLTSS, including Medicaid authorities available and what they allow and federal regulations and guidance on MLTSS.
The MACPAC June Report to Congress is available at: https://www.macpac.gov/publication/june-2018-report-to-congress-on-medicaid-and-chip/