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Shaping policy, sharing solutions, strengthening communities

Managed Long Term Services and Supports or Mangled LTSS?

Virginia Network of Private Providers Fall Conference 2014

ANCOR is… A national nonprofit trade association advocating and supporting

• Over 1200 private providers of services and supports to
• Over 1,00,000 people with disabilities and their families
• And employing a workforce of over 800,000 direct

support professionals and other staff

The American Network of Community Options and Resources

Vision: Advancing excellence in supports and services ~ Leading the way to communities of choice. Mission: To inform, educate and network service providers to safeguard, develop, grow and extend their capacity to support the choices of people with disabilities.

Future Uncertainties

• State Budget Instabilities
• Congress is struggling with multiple

life-changing reforms such as health reform, immigration, environmental disasters, and wars

• Uncertain political climate – move to

social extremes

• Health Reform - Medicaid Reform -

Managed Care, Exchanges, Expansion, Duals

• Changes to Federal Rules -

Companion Care, Employment, new HCBS Rule

• Less Money: Federal, state, and

local deficits

• Workforce Issues - DSPs
• DOJ Olmstead Enforcement

$56.65 Billion Public Funds

Braddock, et.al., Coleman Institute and Dept. of Psychiatry, University of Colorado, 2013. http://stateofthestates.org

Federal Spending on Medicaid and Medicare is Unsustainable

States Can’t Make Up the Difference

Prevalence of Cognitive Disability in US

Braddock, et.al., Coleman Institute and Dept. of Psychiatry, University of Colorado, 2013. http://stateofthestates.org

People with disabilities account for the largest share of Medicaid spending

SOURCE: KCMU and Urban Institute estimates based on data from FY 2008 MSIS and CMS-64, 2011.

Enrollees Expenditures on benefits

Children 20% Elderly 25% PWDs 43% Adults 13% Children 49% Elderly 10% PWDs 15% Adults 25%

Total = $318 billion Total = 59.5 million FY 2008

HCBS Waiver Waitlists

Workforce is Shrinking

15,000,000 30,000,000 45,000,000 60,000,000 75,000,000 2000 2005 2010 2015 2020 2025 2030

Source: U.S. Census Bureau, Population Division, Interim State Population Projections, 2005

Females aged 25-44 Individuals 65 and older

Larson, Edelstein, 2006

DSP Wages are Below Federal Poverty Level

Most People Are Supported in <6 Person Settings

Braddock, et.al., Coleman Institute and Dept. of Psychiatry, University of Colorado, 2013. http://stateofthestates.org

More People with I/DD Live with Family Caregivers than in our Publicly Funded System

Why Would States Look at Managed Care?

• Allows State officials achieve budget stability over time

through capitation

• Limits states’ financial risk, passing part or all of it on to

contractors by paying a single, fixed fee per enrollee

• Allows one entity to be held accountable for controlling

service use and providing quality care

MLTSS DEFINITION

• Managed Long Term Services and Supports (MLTSS) refers to

an arrangement between State Medicaid programs and contractors through which the contractors receive capitated payments for LTSS and are accountable for quality, cost and

• ther standards set in the contracts
• Capitation can be for all services or selected services
• Contractors can be local, regional or national
• LTSS populations include persons with age-related, physical or

intellectual/developmental disabilities. Many of these also have serious mental illness.

SOURCE: KCMU/HMA Survey of Medicaid Managed Care, September 2011.

October 2010

WY WI WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH NV NE MT MO MS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL PCCM only (12 states) MCO only (16 states and DC) No MMC (3 states) MCO and PCCM (19 states)

Almost all states operate comprehensive Medicaid managed care programs

STATES WITH MLTSS GREW FROM 8 TO 16 Between 2004 TO 2012

Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs. May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.

19 STATES HAVE MLTSS PROGRAMS in 2014 10 States are Projected to Move to MLTSS in the Next Year

Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs. May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.

States Including IDD Populations in 2012

Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs. May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.

Early States with Strong MLTSS for Individuals with IDD

• Arizona since late 1980s ALTCS 1115
• Michigan since 1998 – 1915 b & c with

network of pre-paid capitated MCOs with strong values and person centered planning in regulations

• Wisconsin since 1999 – 1915 b & c Family Care

for LTSS only with self directed option

Eight States Include People with IDD

• Arizona
• Hawaii
• Indiana
• Michigan
• North Carolina
• Pennsylvania
• Washington
• Wisconsin
• Delaware

Seven in all HCBS and ICF settings Delaware does not enroll people already in IDD HCBS Settings Hawaii and Washington don’t include HCBS/ICF but provide all

• ther services in MLTSS Settings

Pennsylvania is for now

• nly adults with autism

Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs. May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.

New States Emerging Since 2012

• Florida
• Illinois
• Kansas
• Louisiana
• New Hampshire
• New Jersey
• New York
• Ohio
• Tennessee
• Texas
• Virginia
• Illinois has submitted an MTLSS 1115 that

will include all populations

• New Hampshire includes IDD in 2014
• KanCare Implemented in 2013. Includes

IDD in 2014. CMS approved a waiver that ultimately continues an IDD waiting list

• New Jersey implements MLTSS 1115

waiver

• New York DISCOs
• Tennessee promotes IDD in 2014
• Texas passed legislation 2014

Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs. May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.

States with Self-Direction in MLTSS

Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs. May 2013; Truven Health Analytics,

• Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.

MLTSS examples include a diverse range of program models

Acute Care Services LTSS without Acute: Pennsylvania Adult Community Autism Program OR Arizona Long Term Care System Behavioral Health Services LTSS without Behavioral Health: New Mexico Coordinated Long Term Services OR LTSS with Behavioral Health: TennCare CHOICES Medicare Services Medicaid-funded Services Only: New York Managed Long Term Care OR Medicaid- and Medicare- funded Services: Minnesota Senior Health Options Populations Adults of All Ages and Levels of Care: Hawaii QUEST Expanded Access OR Older Adults with Institutional Level of Care Needs Only: Florida Nursing Home Diversion Contractors National Contractors: Texas Star+Plus OR Local Contractors: Wisconsin Family Care Partnership Payment Methods Full-Risk Capitation: Massachusetts Senior Care Options OR Partial-Risk Capitation: Wisconsin Family Care

Non-Clinical Outcomes of LTSS

• Just now emerging
• Different from medical managed care programs
• No current consensus
• No actuarial data

States Must Identify Non-Clinical Outcomes in Contracts

• Advocate for state to hold managed LTSS entities

accountable to achieve certain outcomes.

• Insist on state incentivizing achievement of
• utcomes by managed LTSS entities/providers.
• Ensure that outcomes are meaningful to people

with disabilities and measureable.

Possible Outcomes To Consider

• Percentage of Participants with jobs
• Number of hours Participants are engaged in volunteer

work

• Participants’ independence and social skills
• Satisfaction and quality of life indicators
• Stable housing
• Transportation available when desired
• Free from abuse and neglect

A Word about Employment

Butterworth, John, Frank A. Smith, Allison Cohen Hall, Alberto Migliore, Jean Winsor, Daria Domin, and Jamie Cuilla Timmons. "StateData: The National Report on Employment Services and Outcomes." Www.statedata.info. Institute for Community Inclusion, Winter 2012.

Two State Scenarios

• Kansas
• New Jersey

Kansas Experience

• January 2012 – All Medicaid Services to be

put under Managed Care

• February 2014 – IDD included

Kansas Consumer Experience

• The GOOD: additional services for underserved; MCOs care

coordinators friendly and try to be helpful; comprehensive assessments; nursing, nutritional and behavioral specialists to assist; and value added benefits

• The NOT SO GOOD: loss of local providers - medical/surgical

services; medication authorizations and auto-assigned PCP; confusion

• ver TCM role and MCO care coordinator; communication –

automated lines, authorization to speak with MCO, enrollment packets; lack of knowledge of I/DD services; receiving bills for medical services not paid by MCO; delays in medical procedures - prior authorizations; it’s all about medical outcomes

Kansas Provider Experience

• The GOOD: potential service growth - underserved waiting list; most

providers being paid timely during 180 day continuity of care period; no service reductions or rate changes during 180 day continuity of care period; desire of MCOs to work on employment issues

• The NOT SO GOOD: Have to deal with three entities instead of one;

increased administrative overhead costs; credentialing/contracting; MCO Lack of experience in I/DD services – waiver rules, etc.; capacity to serve 1,400 on underserved list; it’s all about medical

• utcomes

New Jersey Experience

• NJ CMW demonstration 1115 (a) was

approved effective 10/1/12 - 6/30/17 to:

– Implement statewide health reform and expand current managed care programs to include managed long term services and supports and expand home and community based services (HCBS) to some populations.

New Jersey Experience

Enables NJ to expand Medicaid eligibility and coverage options for people who needed HCBS but who were ineligible for Medicaid due to income.

• Gives NJ broad authority to modify rules for efficiency while

providing quality care.

• Combined four existing HCBS waivers:

1. Global Option (GO) for Long Term Care; 2. AIDS Community Care Alternatives Program (ACCAP); 3. Traumatic Brain Injury (TBI); and 4. Community Resources for People with Disabilities (CRPD).

• Stakeholder meetings
• Readiness testing
• Exclusion of 1915 c HCBS IDD waiver
• IDD waitlist is entitled to support services
• Comprehensive provision of services
• Self-Directed

New Jersey Experience

MLTSS Evaluations

• Florida’s Medicaid Waiver & Long Term Care

– Georgetown Health Policy Institute

• An Independent Evaluation of the Integrated Care

Program, Findings from Baseline Year Two

– UIC Department of Disability and Human Development (May 2014)

• More evaluations of MLTSS programs that include

people with I/DD are needed

Plan Ahead: The Future will look different from today

Additional Resources

http://www.medicaid.gov/mltss/ http://www.ncd.gov/publications/2013/20130315/ http://en.wikipedia.org/wiki/Managed_care http://www.kancare.ks.gov/ http://www.state.nj.us/humanservices/dmahs/home/mltss.html

About the Presenter

Diane McComb works with the American Network of Community Options and Resources (ANCOR) as the Liaison to State

• Associations. Concurrently, she also works with Delmarva Foundation, a CMS QIO like entity, providing technical expertise on

disabilities, self-direction, individual budgets, and community waiver programs. Prior to her current work she was appointed by Maryland’s governor as the Deputy Secretary of the Maryland Department of

• Disabilities. In that position she oversaw the development of the Maryland State Disability Plan, covering a wide array of issues

including children and families, long term services and supports, employment and training, housing, technology, Medicaid, transportation, and emergency preparedness. She was instrumental in initiating numerous policy shifts that resulted in increasing consumer-directed supports and other levels of consumer involvement in program evaluation and quality improvement. She was the CEO of a statewide association of community organizations that support people with disabilities and their families for sixteen years. During that time, she was the principal legislative advocate on behalf of Maryland’s programs and was a leader in the very strong collaborative growth of disability programs experienced in the state. The first decade of her career was devoted to building a community agency that supported people with developmental disabilities and their families, including many who were deinstitutionalized. Her career gives her unique perspective having been the director of a private community agency, the CEO of a statewide provider advocacy organization, and as a cabinet level governmental official. She brings her extensive knowledge of the disability community, her demonstrated track record of innovative problem solving, and lifelong commitment to creating improved capacity in the systems that empower individuals with disabilities to achieve their personal and professional goals in communities where they live. She holds an MSEd from the Johns Hopkins University in Severe and Profound Disabilities and has a long history working as an advocate for persons with disabilities and nonprofit management. She can be reached at dmccomb@ancor.org