MANAGED LONG TERM SERVICES AND SUPPORTS (MLTSS) James David Toews

What Is Managed Care? Way of paying for and delivering health care and/or long-term services and supports (LTSS) Generally, payer gives a managed care organization (MCO) a set (capitated) monthly payment per member, which the MCO uses to provide services and supports to its members Provide an array of services to members through an established network of contracted providers MCOs assume and manage some or all of the financial risk for their members –As such, they have a financial incentive to keep members healthy, and to coordinate members’ care 2

What Is Managed LTSS? Payer – typically the State Medicaid Agency (SMA) – contracts with an MCO to coordinate and provide LTSS May cover home and community-based services (HCBS) as well as institutional care May serve different populations: older adults, people with physical disabilities, and/or people with developmental/intellectual disabilities, or behavioral health needs. 3

CMS Authorities for MLTSS Social Security Act (SSA) Section 1115 demonstrations (for comprehensive or targeted Medicaid program redesign) SSA 1915(b) + (c) Medicaid waiver combinations Affordable Care Act (ACA) -- Integration and Financial Alignment demonstrations for dual eligibles through Centers for Medicare & Medicaid Services (CMS) Medicare-Medicaid Coordination Office (MMCO) 4

Where Are We Headed? MLTSS experience is limited, as is our evidence base Interest in MLTSS is growing rapidly –Duals’ Financial Alignment Initiative: 26 states submitted proposals to CMS o Six have been approved thus far (CA, IL, MA, OH, VA, WA); six have been withdrawn (AZ, HI, MN, NM, OR, TN) 5

Why Now? State budget deficits Growth in Medicaid spending Current LTSS spending trends are unsustainable ACA: Incentives to states to develop new service delivery and payment models –MMCO financial alignment, medical homes/health homes; 2014 Medicaid expansion Current system issues: –Fee-for-service incentives to maximize expensive services, institutional bias, inflexible service packages, little incentive for oversight, etc. 6

Potential Benefits of MLTSS More care coordination Improved integration between acute care and LTSS More flexible benefits packages Accelerated rebalancing through global budgets Improved community alignment Improved quality management 7

Challenges in MLTSS Limited experience Process is moving very quickly in some states –Are states ready? Are plans ready? Transitioning beneficiaries from fee-for-service to capitated systems Network adequacy What happens to existing community-based organizations and networks? Ensuring that important HCBS features are not lost in integration with acute care –Loss of focus on independence, community living, recovery 8

Challenges (continued) Meeting people’s needs Ensuring person-centered planning is the basis for service authorization and delivery. Ensuring service authorizations are made by qualified people Avoid compounding existing problems (e.g., lack of affordable housing) Quality and oversight Meaningful consumer engagement and participation 9

CMS MLTSS Guidance In summer 2013 CMS published MLTSS guidance for states based on best practices for establishing and implementing MLTSS programs –Also clarifies expectations of CMS from states using section 1115 demonstrations or 1915(b) waivers combined with another long term services and supports (LTSS) authority in an MLTSS program – Includes 10 key elements that CMS expects to see incorporated into new and existing state Medicaid MLTSS programs – Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdfhttp:// Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf Following are potential questions that stakeholders and advocates might use to decide if the 10 elements are addressed in your state’s proposal/plan 10

Element 1: Adequate Planning Did the state’s MLTSS planning team include key individuals with experience and expertise in LTSS? Were other relevant state agencies (e.g., state agencies on mental health, DD, aging, physical disabilities, etc.) on the planning team? In the state’s RFP, procurement or contract with MCOs, is there clear language requiring the MCO to include top level management and operational staff with LTSS experience in its organizational design? Prior to launch, does the state have a detailed written plan for education and outreach to consumers, providers, contractors, families, caregivers, community organizations and others about the roll-out of MLTSS? Was the education and outreach plan developed with close cooperation and input from stakeholder groups? Are there easily accessible consumer hotlines available during the MLTSS roll-out to answer questions and help resolve immediate confusion or complaints? Is there contractual language requiring MCOs to continue contracting with existing LTSS providers of MLTSS consumers for a minimum of 90 days but preferably 180 days, even at the pre-existing fee for service rate, if necessary? 11

Element 2: Stakeholder Engagement Did the state convene a formal stakeholder advisory group with cross- disability representation? Did the state assure easy access to advisory group meetings, including things like transportation, personal assistants, interpreters, etc.? Did the state present a MLTSS plan that was understandable (including its financial calculations) and was clear as to how the LTSS system would be specifically improved in the move to managed care, (e.g. more people would be diverted or moved from institutions, waiting lists would be reduced, more people would get consumer-directed supports, etc.)? Did the state summarize and post the concerns and recommendations made by stakeholders, including which ones were incorporated into the final design, and which ones were not and the reasons why? Did the state plan and implement a formal and specific role for stakeholders in monitoring the roll-out and implementation of MLTSS, including access to regular reports, data, and trend analyses? 12

Element 3: Enhanced Provision of HCBS Does the state’s MLTSS plan include concrete rebalancing benchmarks by year, and how they will be achieved (e.g., nursing home diversion, MFP, etc.)? Does the MLTSS plan require and set goals for increasing the number of consumers directing their own care and supports? Are the above written into clear contractual language for the managed care plans along with explicit language on their requirements to comply with ADA and Olmstead? 13

Element 4: Alignment of Payment Structures and Goals Are all LTSS services, both institutional and HCBS, carved into the plan? Do capitation rates set by the state for managed care plans incentivize higher payments for HCBS, and lower payments over time or penalties for high institutional utilization? Are capitation rates tiered in a way that promote HCBS for persons with complex needs, including rates that are high enough or can be achieved through rate exception processes? Does the state have a periodic evaluation strategy to see if its rate structures or capitation models are achieving the benchmarks described above in Element 3? 14

Element 5: Support for Beneficiaries Is there a mechanism to provide consumers with independent and conflict-free MLTSS enrollment assistance? If the plan consumers choose or are passively enrolled in is not satisfactory, do they have the right to choose another plan at any time? Is there an independent consumer rights agency or ombudsman available to help consumers understand their rights and to resolve problems? 15

Element 6: Person-Centered Processes Does each MLTSS plan solicit active participation of the consumers and/or designees in all aspects of designing an individualized service package? Does the consumer have meaningful choices between both medical and LTSS providers? Does the state require each MLTSS plan to offer self-direction, including the ability of the consumer to hire and fire support staff? Does the state encourage plans to use long-standing person- centered training and practice tools as the operating principle for integrated teams including both medical and LTSS personnel? 16

Element 8: Qualified Providers Does the state assure that plans have adequate networks of providers to meet the needs and choices of consumers, including HCBS providers able and willing to support individuals with complex needs? Does the state assure that MLTSS plans will contract with out- of-network providers to provide needed specialized services that are not available in-network? 17

Element 9: Qualified Providers Does the state have a rigorous system for reporting suspected abuse or neglect, tracking the status of investigations, and assuring abuse cases are resolved, with added protections for the consumer? In addition to helping consumers resolve individual complaints with MLTSS plans, does the consumer rights agency or ombudsman roll up complaints and report them as systemic issues, and does the state take action based on such reports? If service plans for consumers are cut or changed, are existing plans continued for the duration of an appeal either to the MCO or the state? 18

Element 10: Quality Does the state have specific and measurable outcomes for LTSS, acute care, and behavioral health that are tracked at both the state and MCO level? For LTSS, does the state track the movement and lengths of stay across both institutional and types of community settings at both the MCO and state level? (See rebalancing benchmarks under element #3) Does that state Medicaid agency have staff involved in MCO contract monitoring who have experience with aging and disability populations? Does the state require consumer participation in specific monitoring activities at both the MCO and state level? 19

A Few Key Resources CMS resources –Duals Financial Alignment Initiative: Medicaid-Coordination/Medicare-and-Medicaid- Coordination/Medicare-Medicaid-Coordination- Office/FinancialModelstoSupportStatesEffortsinCareCoordination.htmlhttp:// Medicaid-Coordination/Medicare-and-Medicaid- Coordination/Medicare-Medicaid-Coordination- Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html –Health homes: Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical- Assistance/Downloads/State-by-State-SPA-Matrix-7-23.pdfhttp:// Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical- Assistance/Downloads/State-by-State-SPA-Matrix-7-23.pdf –Innovation Center models by state ( –Medicaid MLTSS: Information/By-Topics/Delivery-Systems/Medicaid-Managed-Long- Term-Services-and-Supports-MLTSS.htmlhttp:// Information/By-Topics/Delivery-Systems/Medicaid-Managed-Long- Term-Services-and-Supports-MLTSS.html 20

A Few Key Resources (Continued) Center for Health Care Strategies LTSS resources: url_nocat5108/info-url_nocat.htm?type_id=1051 (includes resources on community integrations, duals, and MLTSS) url_nocat5108/info-url_nocat.htm?type_id=1051 Community Catalyst Duals resources: (Duals) (Integrated care) Kaiser Family Foundation Medicaid resources: (includes duals and LTSS) N4a Aging & Disability Exchange: (focuses on business capacity and integrated care) NASUAD State Medicaid Integration Tracker: National Senior Citizens Law Center resources on duals for advocates: