Transitioning to Managed Long-Term Services and Supports
CMS and Truven Provide Guidance and Suggestions
June 21, 2013 09:08 AM
On May 21, the Centers for Medicare & Medicaid Services (CMS) issued guidance to states and other stakeholders on the implementation of managed long-term services and supports (MLTSS). CMS also issued analysis by Truven Health Analytics (Truven) on observations of and suggestions for long term services and supports (LTSS) providers and managed care organizations (MCOs) implementing MLTSS.
In the following brief, the National Council on Medicaid Home Care, a NAHC affiliate, reports on CMS’s analysis of what it deemed the “essential elements” of MLTSS programs, and general observations and recommendations that Truven had for LTSS providers implementing MLTSS.
Essential Element #1: Adequate Planning
States must have adequate planning with regards to the design of the MLTSS program, MLTSS readiness and MCO readiness evaluation, and oversight regarding implementation and transition.
On the program design front, states are encouraged to execute “a thoughtful and deliberative planning process” to establish a framework for a “clear vision for the program.” This includes getting stakeholder input, educating the stakeholders, determining implementation readiness, and implementing “safeguards and oversight mechanisms” for transitioning to and ongoing maintenance of MLTSS.
States need to demonstrate to CMS that they have sufficient “coordination and communications processes” among state agencies that deal with the beneficiaries of MLTSS, such as aged beneficiaries, in addition to those that have: chronic diseases, mental health issues, substance abuse issues, developmental disabilities, intellectual disabilities, and physical disabilities.
States also should ensure that those developing the MLTSS program have education and expertise in LTSS services and delivery systems, managed care, and the likely beneficiary population. CMS notes that some programs have built in training time in this regard.
MLTSS Readiness and Education
States must have plans in place to assess the readiness of stakeholders involved. The state must ensure that the MCOs staff, both with regard to operations and management, have sufficient “training, experience, and expertise” in MLTSS. Additionally, states must submit to CMS in their initial proposals their plans for educating all stakeholders about MLTSS.
Implementation and Transition Oversight
States must have plans for troubleshooting problems that arise during MLTSS implementation, including means for consumer support. States must also have a quality strategy for the MLTSS program. Also, states must implement policies which reduce the risk to beneficiaries during the transition period from fee-for-service (FFS) LTSS to MLTSS.
Essential Element #2: Stakeholder Engagement
States must provide CMS with strategies to engage stakeholders, whereby the states will incorporate public opinion in MLTSS design. For example, states must set up an MLTSS stakeholder advisory group, including LTSS stakeholders such as enrollees, families, caregivers, providers, and community-based organizations. States must also offer “broader public input” opportunities beyond the advisory group, such as events/meetings with virtual input mechanisms for those unable to attend in person.
Implementation and Oversight
States must inform CMS how specifically stakeholders are involved in implementation of MLTSS. States must incorporate “stakeholder input processes” which include participant feedback and communication, and advisory committees. States must also submit to CMS education and outreach plans to show how stakeholders can provide feedback regarding implementation.
States should also provide information sessions for community-based organizations (CBOs) regarding MLTSS, and must require MCOs to implement systems to effectively engage MLTSS beneficiaries.
States must have plans for constant communication with stakeholders before and during implementation. This includes creating and maintaining a state webpage focused on MLTSS.
Essential Element #3: Enhanced Provision of Home and Community Based Services
States must make certain that the MLTSS program operates in compliance with all applicable laws, as well as any state Olmstead plan. States must also require that MCOs provide MLTSS “in the most integrated setting possible.” States are also “encouraged” to provide supports which enable workforce participation like personal assistance services, peer support services, and supported employment. Non-institutional MLTSS must comply with home and community based setting requirements governing 1915(c) Home and Community Based Services Waivers, 1915(i) State Plan Home and Community Based Services and 1915(k) Community First Choice.
Essential Element #4: Alignment of Payment Structures and Goals
Alignment of Rate-setting with MLTSS Objectives
States must provide payment rates that promote MLTSS and home and community-based services. States must also provide payment rates which promotes “adequate” participation of both MCOs and providers.
Payment Incentives/Penalties and Oversight
States must provide performance-based financial incentives and/or penalties to achieve the goals of the MLTSS program. States must also have policies and procedures to oversee and evaluate payment structures to ensure they are in furtherance of the goals of the MLTSS program.
Essential Element #5: Support for Beneficiaries
States must provide counseling on MLTSS options to potential participants and caregivers. To ensure that such counseling is “conflict-free” and independent, it cannot be provided by a health plan, service provider, or those making determinations of eligibility. States must also ensure that an ombudsman or other independent advocate is available to help participants navigate MLTSS, including assisting to resolve beneficiary/MCO issues. At the very least, states must also permit beneficiaries to disenroll from an MLTSS program or to switch to an alternative MLTSS or FFS program, when provider termination from the network would disrupt the beneficiary’s residence or employment.
Essential Element #6: Person-Centered Process
States must require MCOs to use state approved, person-centered needs assessments. The needs assessments must include elements such as: health status, treatment needs, employment, social and transportation needs, preferences for care, back-up plans in cases where caregivers are unavailable, and support networks.
Also, states must require MCOs to implement a person-centered service planning process, such as those found governing Community First Choice (CFC), 1915(i) and 1915(c) authorities. An interdisciplinary team of both professionals and non-professionals will be a key component of this process. Such team members include those chosen by the beneficiary, and also must have “adequate knowledge, training, and expertise around community living and person-centered service delivery.”
States offering self-direction under FFS LTSS are required to continue offering this under MLTSS, while those that do not offer self-direction under FFS LTSS are encouraged to consider it in their transition to MLTSS.
Essential Element #7: Comprehensive, Integrated Service Package
CMS “expects” the MCO capitation payment from states will include behavioral health, physical health, and LTSS (both institutional and non-institutional) services. States must justify any “carve-outs” by explaining “how the goals of integration, efficiency, appropriate incentives and improved health and quality of life outcomes will otherwise be achieved.”
Authorization, reduction, modification, or termination of services by the MCO must be based on an up-to-date assessment of needs that supports such action.
States should also ensure that services are provided towards beneficiaries that are transitioning between care settings.
Essential Element #8: Qualified Providers
States must require that MCOs have a network of providers qualified in LTSS who can provide all services under the MCO contract, and who meet the state’s certification, credentialing, and licensing requirements. States should also encourage the incorporation of existing LTSS providers in the FFS model to the MCO networks in the MLTSS model.
Network Composition and Access Requirements
CMS “expects” states to incorporate language regarding coordination and continuity of care in a transition plan. CMS states that this plan may include honoring existing service plans.
Meaningful Provider Qualifications, Credentialing, and Training Requirements
States must develop credentialing requirements and provider qualifications for MLTSS providers. States are also advised to develop qualifications, credentialing, and training requirements for providers that are not licensed or certified for MCOs to use when constructing MLTSS networks. Provider qualifications must include criminal background, abuse registry, and clearance check components.
Provider Support during MLTSS Transition
States must have plans to support providers during their MLTSS transitions. States must also provide requisite training, including how to develop the needed administrative capability to support MLTSS.
Participant Contract Termination Protection
State contracts with MCOs must include provisions that protect the beneficiaries when these contracts are terminated. Such provisions must address provider and participant notification, and rules prohibiting new enrollments during the termination phase.
Essential Element #9: Participant Protections
States must create a statement of participant rights, which in turn is honored in the MCO contracts. States must make sure that enrollees are educated on their rights.
Safeguards to Prevent Abuse and Neglect
States must also have a mechanism to “identify, report, and investigate” incidents of abuse and neglect during MLTSS delivery, as well as a mechanism for process improvement. States must also determine if they need to modify their incident reporting systems.
The mechanisms to prevent fraud and abuse, in addition to the roles and responsibilities of the parties, must be enumerated in the MCO contracts. Both the providers and MCO staff must be trained and educated on these policies and procedures. Beneficiaries and their families must also be educated on fraud and abuse.
Essential Element #10: Quality
All states must develop a quality strategy for managed care that includes MLTSS and the key elements of this guidance, and is integrated with other relevant quality initiatives, such as the Adult Health Quality Program, Balancing Incentive Program (BIP), Community First Choice, Health Homes, and Money Follows the Person (MFP). The quality strategy must also include a mechanism for continuous quality improvement.
States must use their existing LTSS quality strategy as a foundation for developing their MLTSS quality strategy, and modify accordingly.
States must also collect person-level encounter data to further quality oversight and monitoring. States must use their external quality review process to assess MLTSS quality.
States must establish MCO reports that relate to MLTSS, including components such as call monitoring, complaint and appeal actions, disenrollment, fraud and abuse reporting, network adequacy, participant health and functional status, quality of care performance measures, service plans and service plan revisions, timeliness of assessments, and utilization data. These requirements must be enumerated in the MCO contract.
The states, contractors, and/or MCOs must maintain measure quality of life indicators and maintain data on quality of life as it relates to MLTSS. The state must analyze this data and make it available to the public.
Truven interviewed stakeholders regarding their transition to MLTSS. The following is a quick synopsis of Truven’s findings, with an emphasis placed on Truven’s findings as they relate to LTSS providers.
LTSS providers had varying levels of preparedness for the business transition to managed care, which was a result of many factors, including: 1) time of implementation; 2) the presence/absence of contractual protections of the existing provider network in state/MCO agreements; 3) the scope of the MLTSS program; and 4) the degree of technical assistance that the state provided. Given the transition to MLTSS, LTSS providers need more business acumen, specifically in contract negotiations with MCOs. LTSS providers also receive little to no technical support from the states. Finally, LTSS providers fear that they will not be able to partake in the MLTSS transition given their lack of infrastructure and knowledge.
Specific Challenges Faced by LTSS Providers
According to Truven, LTSS providers face the following challenges in transitioning to MLTSS:
A more complex contracting process;
A need to focus more on risk during contract negotiations;
An increased focus on accurate pricing;
More complex contracts;
Novel billing practices;
Licensing and credentialing requirements;
The increased importance of prompt payment as a vehicle for financial viability; and
Enrollment and disenrollment tracking
Truven also gave the following suggestions, many of which are relevant to LTSS providers:
CMS could require states to provide technical assistance to LTSS providers;
CMS should encourage states to develop “neutral forums” where LTSS providers and MLTSS contractors can educate each other and share information;
CMS should encourage states to provide reasonable timelines so that LTSS providers will be able to successfully prepare for their transitions to MLTSS;
MCOs and LTSS providers should conduct practice billing sessions for optimal training and compliance;
CMS/State MLTSS agreements should all include continuity of care provisions;
States could allow high-performing LTSS providers to become MLTSS contractors;
States could encourage MCOs to use LTSS specific, uniform billing practices;
States should provide contract negotiation technical support to small LTSS providers; and
MCOs could/should have a staffed LTSS specialist.
In its recent guidance, CMS recognized MLTSS as something “many states are pursuing or considering” and as “a service delivery option that could increase the breadth, availability, and quality of LTSS available to those who require them.” Through its guidance documents, CMS is sending a multi-faceted message to stakeholders. First, CMS is recognizing that MLTSS is the future of Medicaid, and a major effort that needs structure, support and oversight. In addition, CMS is communicating that it is continuing to work with stakeholders in that transition. Specifically, CMS is sending a message to the states that one of the main focuses on Medicaid reform should be home and community based services (HCBS).
That said, home health providers can look to CMS’ MLTSS guidance as a basic framework to smooth their transitions to MLTSS. Home health providers are encouraged to keep abreast of MLTSS developments on CMS’ website, and to contact the Council with any questions or concerns.
For CMS’ guidance, click here. For Truven’s analysis, click here.
For additional documents released by CMS and Truven, click here
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