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Best Practices and Innovations in Medicaid Managed Long-Term Services and Supports (MLTSS): By: Sarah Swanson, Denise Rozell, John Tschida AUCD Webinar, 2020 Presenters: Denise Rozell, JD Director of Policy Innovations Association of

  1. Best Practices and Innovations in Medicaid Managed Long-Term Services and Supports (MLTSS): By: Sarah Swanson, Denise Rozell, John Tschida AUCD Webinar, 2020

  2. Presenters: Denise Rozell, JD Director of Policy Innovations Association of University Centers for Disabilities Sarah Swanson , MPH Assistant Professor Community and Family Resource Coordinator UNMC Munroe-Meyer Institute John Tschida, MA Interim Director Association of University Centers for Disabilities

  3. Two Policy Briefs:

  4. Background: States Historically Have Managed Medicaid Home and Community Based Services (HCBS) Medicaid Waiver Programs Medicaid (non-medical services) Medicaid (medical services) Physical Therapy Home & Vehicle Modifications Occupational Therapy In-home care Applied Behavioral Analysis Job Coaching Hospital services Independent Living Skills Training Mental Health Respite Durable Medical Equipment

  5. N Background: e w State contracts with Managed Care Organization to Manage Services Medicaid (non-medical services) Medicaid (medical services) Physical Therapy Home & Vehicle Modifications Occupational Therapy In-home care Applied Behavioral Analysis Job Coaching Hospital services Independent Living Skills Training Mental Health Respite Durable Medical Equipment

  6. Current Picture: Source: http://www.advancingstates.org/initiatives/managed-long-term-services-and- supports/mltss-map (2020)

  7. MLTSS Growth: Year Number of states implementing MLTSS tripled 8 2004 2018 24 Source: Truven, 2018 Year Number of state MLTSS programs more than doubled 19 2012 41 2017 Source: MACPAC, 2018

  8. Individuals with IDD are No Longer Carved Out (Excluded)

  9. Why are States Moving to MLTSS? Medicaid expenditures are becoming one of the largest budget lines for states and the aging population is adding urgency to state efforts to reform LTSS. Sources: Health Management Associates, National Committee for Quality Assurance, 2017 • MLTSS can provide states budget predictability. • MLTSS will improve care coordination and make things simpler for the recipient. • MCOs will provide services that support the whole person and improve the individual’s quality of life. • MCOs can provide services that Medicaid cannot. • MCOs can help transition individuals in nursing or institutional setting to home and community based settings. • MLTSS will reduce Medicaid expenditures.

  10. A Problem or An Opportunity?

  11. Roles and Contracting Processes Change Before Managed Care State Medical Providers Community Based Org. States contract directly with providers After Managed Care State MCO Medical Providers MCO Community Based Organizations States contract with Managed Care Organizations (MCOs). MCOs in turn, contract with both medical and non-medical providers States are responsible for monitoring and holding MCOs accountable…

  12. New Services or Innovations: In many states, managed care is viewed as the chief vehicle for transforming the delivery of Medicaid services to beneficiaries with disabilities and chronic illnesses, and states are using the contracts with MCOs to influence service delivery and drive systems change.

  13. Social Determinants of Health: Critical to Improving Health Outcomes “There is growing recognition among policymakers that integrating health care with social supports and services is critical to improving broad population health, advancing health equity, and reducing health care spending.” Source: https://www.chcs.org/topics/soc ial-determinants-of-health/

  14. Role of the AUCD Network in MLTSS Implementation

  15. Opportunities for the AUCD Network: Inform and Involve Stakeholders

  16. Role of AUCD Network

  17. Opportunities for the AUCD Network: Contract with the MCOs UCEDDs and LENDs are uniquely positioned… If you can help the MCO meet with required performance measures

  18. Opportunities for the AUCD Network: Research and Evaluation

  19. Opportunities for the AUCD Network: Build a Solid Framework • Involving Stakeholders • Building a “Single Entry Point/No Wrong Door” • Training to Community-Based Organizations on how to Contract with MCOs • Developing Ombudsmen Programs

  20. Opportunities for the AUCD Network: Best Practices • Support to Family Caregivers • Technology Innovations • Strategies to Build the Direct Workforce • Employment Supports • Accessible Housing

  21. Opportunities for the AUCD Network: Pilot New Models and Programs New Programs/Models Focus Limited in their services but offer Support Waivers budget predictability for states Set budget and a set number of slots. Take on risk but share in savings Provider-led Models Provider-led organizations who Accountable Care are responsible for the quality and Organizations the cost of care for its members

  22. Take Away Message: I. Medicaid Managed Care- It’s Here to Stay “Don’t fight it. Get onboard and shape it.” II. People with Disabilities, and Families Need to Be Informed and Involved “UCEDDs and LENDs can lead the charge” III. Opportunity for New Innovations “States are using MLTSS to transform systems. Be involved and learn from what has already been done, but be creative and create new programs.” IV. Opportunities for Contracting with MCOs “Know the Performance Measures. They dictate payment. Payments dictate priorities.”

  23. Two Policy Briefs:

  24. What’s happened since? • Number of states with MLTSS about the same • But the numbers are growing: people in MLTSS plans grew 63% from 2016 to 2020. • Overall, spending on LTSS is increasing. 24 A U C D Association of University Centers on Disabilities

  25. What’s happening now? • Expansion of MLTSS in states that have it – PA: Expansion of Community HealthChoices statewide. – NJ: Transitioned coverage of long-term residential services for substance use disorder treatment from fee-for-service to managed care. – NY: Experimenting with multiple models, especially for IDD population. – ID, IL, TN: Expansions in geography or population. 25 A U C D Association of University Centers on Disabilities

  26. What’s happening now? • Delays elsewhere – NC: Department of Health and Human Services (DHHS) announced the statewide transition to managed care will be suspended. • ‘Medicaid Transformation’ is the law, but there’s disagreement on how/whether to implement it. 26 A U C D Association of University Centers on Disabilities

  27. What’s Next? 27 A U C D Association of University Centers on Disabilities

  28. 28 A U C D Association of University Centers on Disabilities

  29. Pennsylvania Waiver • Expand habilitation service settings to private homes; • Allow for remote habilitation therapy and counseling, assessments, and service coordinator meetings through phone or videoconferencing; • Modify provider qualifications to allow more flexibility reassigning staff; • Relax staffing ratios and number of individuals served due to staffing shortages; and • Make retainer payments for personal assistance services for 15 days when the individual is hospitalized or absent from home due to COVID-19. https://nashp.org/states-modify-medicaid-home-and-community- based-waivers-to-respond-to-covid-19/ 29 A U C D Association of University Centers on Disabilities

  30. Why is this happening? • States are looking to preserve access to services. • Reducing regulatory burden. • Increasing flexibility (e.g. telehealth or in- home service authorizations). • In some cases, capitalizing on increased federal payments (FMAP). 30 A U C D Association of University Centers on Disabilities

  31. Budget Trouble Is Here • NY: 1.5% Medicaid provider rate cuts went into effect last week, affecting home care and other LTSS services. • VA: Medicaid population has grown by 30,000 since COVID outbreak. (AP, 5/21) 31 A U C D Association of University Centers on Disabilities

  32. Budget Trouble Is Coming • LTSS demand high; need is growing. • State and federal budgets strapped next year. • Main state budget expenditures: K-12 education and health care. • Main sources of income: property, sales, and income taxes. 32 A U C D Association of University Centers on Disabilities

  33. MLTSS Expansion? • Will states look to MLTSS for savings? • Disability organizations and experts need to be engaged. • Programs succeed with diverse stakeholder participation. 33 A U C D Association of University Centers on Disabilities

  34. Questions? 34 A U C D Association of University Centers on Disabilities

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