Can Managed Care Turn the Tide for Complex Populations? Heather Howard RWJF State Health and Value Strategies Princeton University National Association of Medicaid Directors 2016 Fall Conference November 8, 2016

Growth in Medicaid Managed Care: Including for Populations with Special Health Care Needs Medicaid managed care has gone from covering 2.7 million beneficiaries in 1991 to more than 50 million beneficiaries today. States have expanded Medicaid managed care programs to include: populations with special health care needs, such as children in foster care, persons with disabilities, seniors, and new adult expansion populations under the ACA more services, such as long-term services and supports and/or behavioral health services. The growth in managed care is due to both the growth of Medicaid And the increasing penetration of managed care. Today Managed care is the predominant form of service delivery in Medicaid. Since 1991, the managed care penetration increased from about 10% to almost 80%! As the number of Medicaid beneficiaries enrolled in managed care has grown substantially - the services included in these managed care contracts have increased as well. I’ll get back to the definition of LTSS shortly.

39 States contract with Medicaid MCOs Nationally half of all Medicaid beneficiaries get their care through comprehensive managed care plans called ‘MCOs’ - paid on a risk-basis. MCOs are what we used to call “HMOs”. 39 states have these types of contracts in place for at least some of their Medicaid beneficiaries – often primarily children, non-elderly, non-disabled adults – but increasingly including other populations with special health care needs. Almost another 30 percent of Medicaid beneficiaries are enrolled in other forms of managed care – plans with less risk or covering a narrower set of services.

Long-term Services and Supports (LTSS) Definition of LTSS in Medicaid managed care: “Services and supports provided to beneficiaries of all ages who have functional limitations and/or chronic illnesses that have the primary purpose of supporting the ability of the beneficiary to live or work in the setting of their choice, which may include the individual’s home, a worksite, a provider‐owned or controlled residential setting, a nursing facility, or other institutional setting.” LTSS include home and community-based services, primarily non‐medical in nature, and focused on functionally supporting individuals in the community The rule creates a new definition for LTSS that specifically applies to Medicaid managed care.

States with MLTSS Programs, 2005-2013 Between 2005 and 2013, the number of states with Managed LTSS programs – either independently or as part of comprehensive managed care programs almost doubled. As you can see, most of the growth has been in states that include MLTSS services in comprehensive managed care programs (the green). And the trend for more MLTSS continues beyond 2013 – the latest available national statistics. Other states – like VA –are starting new MLTSS programs now. Source: CMS: Medicaid Managed Care Trends and Snapshots 2000 – 2013

Managed LTSS: Challenges Populations with complex needs receiving different types of services from a different set of providers Unique aspects of patient-centered care in LTSS Lack of standardized measures and benchmarks for measuring plan performance with managed LTSS

Managed LTSS: Challenges Heterogeneity of LTSS population creates small cohorts and presents monitoring and measurement challenges Small, independent LTSS providers serving small numbers of patients makes measurement even more complicated Limited state and provider experience with risk-based payments or performance incentives for MLTSS

Managed LTSS and the Rule States must systematically engage stakeholders in planning and oversight of MLTSS programs. Requires that enrollees with LTSS needs are involved in person-centered treatment and service planning. Enrollees needing LTSS must be allowed to disenroll from a Medicaid plan if their institutional, employment, or residential provider leaves the enrollee’s plan. Also creates new federal standards for medical necessity, network adequacy, care coordination, and quality of care with LTSS in mind. Medical Necessity in the rule - “the prevention, diagnosis, and treatment of an enrollee’s disease, condition, and /or disorder that results in health impairments and disability; the ability for an individual to achieve age-appropriate growth and development; the ability for an enrollee to attain, maintain, and retain functional capacity; and the opportunity for an enrollee receiving long term services and supports to have access to the benefits of community living, to achieve person centered goals, and live and work in the setting of their choice.” States must develop and implement time and distance network adequacy standards for MLTSS programs, including for providers that travel to the enrollee to render services. Expands requirements for identification, assessment and service planning to enrollees with LTSS needs and requires service planning to be conducted in a person‐centered manner. Plans must have mechanisms to assess the quality and appropriateness of care to enrollees with special health care needs and plans providing LTSS have additional quality assessment and performance improvement requirements.

MLTSS Considerations Not the ‘easy’ populations or services in Medicaid, but the most in need and most expensive Questions to consider What are the challenges unique to Managed LTSS programs? What do states need to think about in building these programs? How do you monitor quality of LTSS being delivered? How does the Medicaid rule play into all this?

Heather Howard Director, RWJF State Health and Value Strategies Lecturer in Public Affairs, Princeton University Woodrow Wilson School of Public and International Affairs (609) 258-9709 heatherh@princeton.edu