Protecting the Rights of Low-Income Older Adults
January 23, 2014
Medicaid Transformation:
Managed Care &
Long Term Services and Supports
Gwen Orlowski, National Senior Citizens Law Center
www.NSCLC.org
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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
Grievances
Case/Care Managers Prior Authorization
Appealing Actions
Fair Hearings
Aid Paid Pending/Continued Benefits
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
home health aides
personal care assistance
chore services
-
respite
adult day
assisted living
habilitation
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Delivery System Transformations
Transition from:
Fee-for-Service (FFS)
↓
Transition to:
Risk-based Managed Care
Medicaid managed LTSS: LTSS
through capitated care
Fee for service LTSS
CMS and
State
LTSS
Provider
Managed LTSS
CMS and
State
LTSS*
MCO
Beneficiary
DME
DME*
Beneficiary
* If provider is part
of network and
service part of care
plan
www.NSCLC.org
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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 Transformations
What factors are driving the shift?
1. Consumers want to receive services in HCBS
2. 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
Three initiatives driving
rebalancing
1. 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) waiver
3. States are pursuing innovative improvements to LTSS
introduced in the Affordable Care Act:
– Balancing Incentive Payment Program (BIPP)
– Community First Choice Option
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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%
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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)
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MLTSS Info Source #1: CMS
Guidance
• 10 Elements in May, 2013 CMS guidance:
Planning
Strategies
Beneficiary
Support
Stakeholder
Engagement
Person-centered
Process
Quality
Enhanced HCBS
Participant
Protections
Comprehensive
Service Package
Payment
Alignment
Qualified
Providers
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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.
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MLTSS Info Source #2: Community
Character
• CMS proposed definition to community-character in
2012:
– NSCLC Comments: http://www.nsclc.org/wpcontent/uploads/2012/07/comments-on-HCBSstate-plan-regs-NSCLC-7-2-12.pdf
– LeadingAge Comments:
http://www.leadingage.org/uploadedFiles/Content/
Members/HCBS/Home_Care_and_Home_Health/Le
adingAge_Comments_on_Community_First_Choice
_Option.pdf
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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
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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
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Lessons Learned? Stories from the
trenches of Kansas and NJ
What 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?
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What to think about
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
www.NSCLC.org
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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
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Contract Language: New Jersey
Prior 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
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Contract Language: Kansas
Prior 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.
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Persistence:
• Systems Advocacy
• Individual Advocacy
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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
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Contact:
Gwen Orlowski, gorlowski@nsclc.org
www.NSCLC.org
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