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MLTSS Implementation Plans in North Carolina and New Hampshire

This week, our In Focus reviews two recently released papers outlining North Carolina’s and New Hampshire’s plans to implement Medicaid managed care long-term services and supports (MLTSS). The North Carolina Department of Health and Human Services released “North Carolina’s Vision for Long-term Services and Supports under Managed Care” on April 5, 2018, and is accepting comments through April 27. The New Hampshire Department of Health and Human Services released its “Implementation Plan for Medicaid Care Management – Nursing Facility/Choices for Independence Services” on March 6, 2018, and is accepting comments through May 4, 2018. Both states are anticipated to release requests for proposals (RFPs) for integrated Medicaid managed care services in the next several months.

North Carolina

North Carolina is in the process of transitioning approximately 1.9 million Medicaid members from a predominantly fee-for-service system to managed care (to read our In Focus on North Carolina’s proposed design for Medicaid managed care, click here). As part of this effort, the state released “North Carolina’s Vision for Long-term Services and Supports under Managed Care” in April 2018. The concept paper focuses on Medicaid Prepaid Health Plan (PHP) requirements for the 14,500 Medicaid-only enrollees utilizing State Plan LTSS who will be transitioned to managed care in the first phase of the plan, targeted for July 1, 2019.

MLTSS Transition Phases

While the concept paper focuses on PHP requirements in phase 1 of the transition to MLTSS, the state briefly outlines all three phases of the transition. Phase 1 includes 14,500 Medicaid-only members using State Plan LTSS; phase 2 includes 30,000 members using LTSS with serious mental illnesses (SMI), serious emotional disturbances (SED), intellectual and developmental disabilities (I/DD), and traumatic brain injuries (TBI); and phase 3 includes the remaining 62,000 beneficiaries who use LTSS. Those members transitioned in phase 1 will be enrolled in standard plans, while those enrolled in phase 2 will be enrolled in Behavioral Health and Individuals with Developmental Disabilities Tailored Plans (BH I/DD TPs).

Phase 1 MLTSS Integration and Covered Benefits

The state anticipates PHPs will provide integrated physical and behavioral health services, as well as LTSS for the Medicaid-only members transitioned in phase 1. PHPs will cover all State Plan LTSS, which includes home health, personal care, hospice, home infusion services, durable medical equipment, and nursing facilities for up to 90 days. All services will be covered under a single capitation rate that will not differentiate between institutional and community-based populations to encourage treatment in the most cost-effective settings. The rate methodology will include rate categories and risk adjustment to avoid penalizing PHPs with higher-need members. LTSS will generally be excluded from cost sharing.

PHP Selection and Assignment

To mitigate issues for members as they transition from fee-for-service to managed care environment, the state is contracting with an enrollment broker, which will provide counseling to members about their plan options. The state released the competitive procurement for the broker in March. Members who do not select a plan within a 60-day window will be auto-assigned to a PHP based on a methodology that prioritizes existing provider relationships. While all Medicaid members will have 90 days to change plans after enrollment, enrollees who use LTSS will be allowed to switch PHPs at any time.

Network Adequacy and Performance

PHPs will be required to contract with at least one nursing facility accepting new patients in every county in applicable service regions, as well as contract with at least two non-nursing facility LTSS providers in each county. The state released a draft quality strategy in March that will be used to assess PHP performance, and the state will include quality metrics that are specific to those with LTSS needs. The state will review PHPs’ Quality Assessment and Performance Improvement programs annually.

Estimated Medicaid Managed Care Enrollment

While not specific to MLTSS, the report includes an appendix that outlines the anticipated enrollment phase-in schedule. This appendix, developed in February 2018, appears below.

Timeline

As previously mentioned, a request for proposals for integrated Medicaid managed care services is anticipated to be released in the next several months, and the state is targeting July 1, 2019, to launch managed care. However, the release of the RFP and the subsequent launch is dependent on several factors, including Waiver approval from the Centers for Medicare & Medicaid Services (CMS) and key legislation passing the General Assembly, which gathers next month for a short session. Last week, Department of Health and Human Services Secretary Mandy Cohen told the Joint Legislative Oversight Committee CMS has approved the 1115 Waiver that authorizes the program, and the state is awaiting formal notification.

New Hampshire

New Hampshire is in the process of expanding their Medicaid Care Management (MCM) program to include LTSS provided under their Choices for Independence (CFI) Waiver and those provided by nursing facilities (NFs). The CFI waiver provides home and community-based services (HCBS) to approximately 4,000 individuals who meet nursing facility level of care, are age 65 and older or ages 18-64 and blind or disabled. The state’s “Implementation Plan for Medicaid Care Management – Nursing Facility/Choices for Independence Services” reflects state law requirements to move forward with the LTSS carve-in of CFI/NJ services to managed care by July 1, 2019.

Services Covered and Enrollment

Managed care organizations (MCOs) will be responsible for managing comprehensive acute and behavioral health services, as well as LTSS which include CFI HCBS for MCM members. CFI HCBS waiver program services include personal care, adult medical day services, supported employment and housing, home-delivered meals, and other services. Blended capitation rates are being “weighed and considered in the actuarial rate setting process.”

Maximus, the state’s current enrollment broker, will provide MCO choice counseling to newly eligible individuals. The state will auto-assign individuals who do not select a plan within 30 days of initial enrollment period. The auto-assignment methodology will seek to maintain current provider relationships. Members cannot disenroll from an MCO without approval from the state, regardless of their LTSS needs.

Network Adequacy and Quality

The state will establish time, distance, and availability standards to assess network adequacy. New Hampshire’s existing MCM Quality Strategy will expand its quality measures to include those that measure improved health outcomes for CFI/NF members. MCOs will have additional reporting requirements related to LTSS, such as member qualify of life surveys for CFI members.

PACE

New Hampshire is also implementing a Program for All-Inclusive Care for the Elderly (PACE) for individuals eligible for Medicare and Medicaid, anticipated to go live by December 2019.

Timeline

The state anticipates releasing an RFP for integrated managed care services “on or about May 30, 2018.” MCOs will assume responsibility for member care beginning July 1, 2019, but will not assume full capitated risk for NF/CFI services until December 31, 2019. The state is in the process of amending its existing 1915(c) and 1915(b) waivers to add MLTSS, and anticipates federal approval will take six to nine months.

Source: New Hampshire Department of Health and Human Services, “Implementation Plan for Medicaid Care Management – Nursing Facility/Choices for Independence Services,” released March 6, 2018.

North Carolina’s Vision for Long-term Services and Supports under Managed Care: https://files.nc.gov/ncdhhs/documents/LTSS-Vision_ConceptPaper_FINAL_20180405.pdf

Implementation Plan for Medicaid Care Management – Nursing Facility/Choices for Independence Services: www.dhhs.nh.gov/ombp/medicaid/documents/mltss-implementation-plan.pdf

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