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Protecting the Rights of Low-Income Older Adults
2www.NSCLC.org
Medicaid Transformation: Managed Care &
Long Term Services and Supports
Gwen Orlowski, National Senior Citizens Law Center
January 23, 2014
The National Senior Citizens Law Center is a non-profit organization whose principal mission is to protect the rights of low-income older adults. Through advocacy, litigation, and the education and counseling of local advocates, we seek to ensure the health and economic security of those with limited income and resources, and access to the courts for all. For more information, visit our Web site at www.NSCLC.org.
What will be covered• What are Medicaid Managed Long Term
Services and Supports (MLTSS)?• Why are we talking about this now? What’s
going on nationally?• How can advocates make a difference?– A focus on Service Plans/Plans of Care
Assessments Case/Care Managers Prior AuthorizationGrievances Appealing Actions Fair
HearingsAid Paid Pending/Continued Benefits
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What are Managed Long Term Services and Supports• Managed care = delivery system for services• LTSS = institutional services and home and
community-based services (HCBS)• Examples of HCBS:
- case/care management - respite- home health aides - adult
day - personal care assistance - assisted living- chore services -
habilitation
Delivery System TransformationsTransition from:
Fee-for-Service (FFS)↓
Transition to:
Risk-based Managed Care
7www.NSCLC.org
Fee for service LTSS Managed LTSS
Medicaid managed LTSS: LTSS through capitated care
Beneficiary
CMS and State
LTSS Provider
DME
CMS and State
MCO
LTSS*
DME*Beneficiary
* If provider is part of network and service part of care plan
Delivery System Transformations– New Populations• Aged/Duals• Younger Adults with physical disabilities• Individuals with Intellectual and Developmental
Disabilities
– New Services • State Plan Carve Outs → Carved Back in (e.g.,
Personal Care & Adult Medical Day in NJ)• Long Term Services and Supports (26 states as of
2014)
Delivery System TransformationsWhat factors are driving the shift?
1. Consumers want to receive services in HCBS2. Medicaid expenditures for people who are aged and
disabled, including those in nursing homes, are disproportionately high and growing
3. Managed care purportedly improves access to good quality care, while at the same time containing or stabilizing cost
4. Rebalancing – shifting dollars away from institutions toward HCBS
10
Three initiatives driving rebalancing1. Medicare-Medicaid financial alignment demonstrations
(dual eligible demonstrations)2. States shifting to managed care:– Medicaid managed long-term services and supports
(MLTSS) through 1115, 1915(b) and 1915(c) waiver3. States are pursuing innovative improvements to LTSS
introduced in the Affordable Care Act:– Balancing Incentive Payment Program (BIPP)– Community First Choice Option
11
Growth of MLTSS in States• Number of States with MLTSS programs *
→ 8 states in 2004→ 16 states in 2012
→ 26 projected by 2014• MLTSS States as of 11/13**: AZ, CA, DE, FL,
HI, IL, KS, MA, MI, MN, NC, NE, NH, NJ, NM, NY, OH, PA, TN, TX, WA, WI
*The Growth of Managed Long-Term Services and Supports Programs: A 2012 Update – Truven Health Analytics/CMS (July 2012)**State Medicaid Integration Tracker, November 15, 2013, www.nasuad.org
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Growth of MLTSS in States• # of individuals receiving LTSS through MCOs: *
→ 105,464 in 2004→ 389,390 in 2012
• As of 2012, approx. ½ of the states →mandatory enrollment
• Corporate status, market share of members: – For Profit: 44%– Non-Profit: 32%– Public or Quasi-Public: 24%
13
Growth of MLTSS in States• Populations served:– Older Adults (CA, FL, MA, MN)– Older Adults and Adults with Physical Disabilities
(AZ, DE, HI, NM, NY, TN, TX, WA, WI)– States which include Adults with ID/DD (AZ, HI,
MI, NC, PA, WA, WI)• As of 2012, 8 states offered self-directed
options (AX, DE, HI, MA, MN, TN, TX, WA)(KS’s 1/1/14 date was delayed by CMS)
14
MLTSS Info Source #1: CMS Guidance• 10 Elements in May, 2013 CMS guidance:
Planning Strategies
Stakeholder Engagement Enhanced HCBS
Payment Alignment
Beneficiary Support
Person-centered Process
Comprehensive Service Package
Qualified Providers
Participant Protections
Quality
15
MLTSS Info Source #2: CMS Final Rule on Community Living Options
• Choice of service provider. • Private Rooms, roommate choice, lease
protections. • Heightened scrutiny for locations with
qualities of an institutional setting. • Grandfathering to protect beneficiaries
penalized by increased stringency of level of care (LOC) after modification.
16
MLTSS Info Source #2: Community Character• CMS proposed definition to community-character in
2012:– NSCLC Comments:
http://www.nsclc.org/wp-content/uploads/2012/07/comments-on-HCBS-state-plan-regs-NSCLC-7-2-12.pdf
– LeadingAge Comments: http://www.leadingage.org/uploadedFiles/Content/Members/HCBS/Home_Care_and_Home_Health/LeadingAge_Comments_on_Community_First_Choice_Option.pdf
17
Community character in MLTC waivers• New Jersey definition of community
character of HCBS:– Private, semi-private bedrooms, bathrooms – Access to food at any time– Ability to make decisions about daily activities,
including visitors and food– Privacy to visit with friends– Choice on how and when to spend time
18
Community character in Florida• Similar to New Jersey requirements• Differences include:– Resident may lock unit– Personal sleeping schedule– Choice of eating schedule
Choice of length of telephone calls
19
Lessons Learned? Stories from the trenches of Kansas and NJWhat happens when an individual’s services
are reduced? Or terminated altogether?• In NJ, Mr. L was on the TBI waiver for more than 10 years,
he was also HIV positive, had diabetes, and in 2009, had developed a seizure disorder. Since 2009, he has been assessed for and received 40 hours a week in personal care services. In November 2012, his new MCO reassessed Mr. L and determined that he needed on 8 hours per week of PCA services.
Now what?
20www.NSCLC.org
Assessment Process• Continuity of Care?• Service Plan/Plan of Care?• Who? Conflict-free?• Assessment tool• History of assessments –
can you access old tools?• Care-managers role?• What is a Prior
Authorization?
Is the MCO decision an “action”?• Any “action” gives rise to
Constitutionally protected due process rights• Grievance rights• Appeal rights
• Rights to a state fair hearing
• Aid paid pending/ Continued Benefits
What to think about
21
Where to begin?• What does the waiver say?
• §1115 Special/Standard Terms and Conditions• §1915(c) waivers → cms.gov
• Read the Contract• Care management; continuity of care; prior
authorizations and utilization review; readiness reviews, network adequacy, grievances/appeals/state fair hearing rights; conflict free care management
• Quality Data and Transparency
22
Contract Language: New JerseyPrior Authorization Prior Authorization Limitations:
In no instance shall the contractor apply prior authorization requirements and utilization controls that effectively withhold or limit medically necessary services, or establish prior authorization requirements and utilization controls that would result in a reduced scope of benefits for any enrollee.
Continuation of Benefits: The MCO shall continue benefits if:• The enrollee/provider files the appeal timely;• The appeal involves a service termination, suspension or reduction• The services were ordered by an authorized provider• If enrollee requests a FH, continues of benefits must be requested
within 10 days of action letter or intended effective date, whichever is later
23
Contract Language: KansasPrior Authorization In accordance with 42 CFR 438.420(b), the MCO must continue the
Member’s benefits currently being received, including the benefit that is the subject of the appeal, if all of the following are met:
• The Member or his or her representative files the appeal timely, meaning on or before the later of the following: within 10 days of the MCO mailing the notice of action or the intended effective date of the MCO proposed action;
• The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
• The services were ordered by an authorized provider; • The original period covered by the authorization has not expired; and • The Member requests an extension of the benefits.
24
Persistence:• Systems Advocacy
• Individual Advocacy
25
More info on MLTSS, Florida, NJ and NY waiver• NSCLC’s MLTSS page with resources from Eric
Carlson:– Summary on MLTSS Guidance– Special report on Florida’s LTC Managed Care
Program– Analysis of New York and New Jersey’s MLTSS
Program
Available at: www.nsclc.org/index.php/mltss