National Association of State Directors of Developmental Disabilities Services Managed Care and Medicaid Authorities Overview * as of today NASDDDS Webinar November 30, 2017
It ain t the heat, it s the humility Medicaid and Managed - Yogi Berra Care Long Term Services and Supports can be complicated but key components make sense with a little time and discussion
Background and Objectives Managed Care in long terms services and supports, the basics Why now Medicaid authorities most often used in MLTSS Differences and considerations in people with I/DD Where this is happening Strong practices 3
Medicaid..a tiny refresher. Began in 1965 to pay for health care to welfare recipients All 50 states and DC participate but they do not have to Jointly administered by the states and the federal Centers for Medicaid and Medicare Services (CMS) Jointly funded by the states and federal government Feds "match" state contribution on an annually determined formula called the matching rate based on state's economic picture The Federal share is called Federal Financial Participation (FFP) or sometimes FMAP (Federal Medical Assistance Percentage) The state share is called state match 4
State/Federal Partnership Medicaid now is WAY more than it s original intent of health care for low-income individuals and now is the major source of financing for long term community supports and services*** The state operates Medicaid under its' State Plan and other authorities such as waivers The state can change coverage, eligibility and the scope and amount of services as needed The state submits State plan amendments (SPAs) or waiver applications covering different services which CMS reviews and approves 5 ***In 2013, Medicaid outlays for institutional and community-based LTSS totaled just over $123 billion, accounting for about 28 percent of total Medicaid service expenditures that year. (KFF.org)
Other Medicaid Tidbits 6 State plan services are an entitlement to anyone who is eligible based on meeting any specific eligibility criteria and what is called medical necessity (but waivers are different as we will see) Children, under the provisions of EPSDT *are entitled to ALL mandatory and optional services even if the state does not specifically cover them for adults such as: Autism treatments Dental care Personal care Training family on treatments Skilled nursing services * Early Periodic Screening, Diagnosis, and Treatment
Medicaid Services-a Refresher Continued Mandatory services In/outpatient hospital Physician, midwife, and nurse practitioner Nursing home Home health Screening and treatment (EPSDT) for kids under 21 Family Planning Rural health clinics, federally qualified health centers 7 Optional services Personal care ICF-IID Prescription drugs Therapies-OT/PT/Speech Targeted case management Mental Health Services Home and community-based State plan services 1915(i) State plan HCBS 1915(k) Community First Choice 1915(j) Self-directed Personal care Waiver options 1915(c) HCBS waiver 1115 Research and demonstration waiver 1902(a) voluntary managed care waiver 1915(b)(3) Freedom of Choice waiver 1915(b)(4) Selective contracting States can choose to cover these services but are not required to do so by federal regulations in order to participate in Medicaid EXCEPT FOR KIDS!!
What is a Waiver? A waiver means that the regular Medicaid rules are waived, that is, not applied The waivers allow for Medicaid to be used in ways that might otherwise not comport with certain regulations Waivers are typically intended to give states flexibility to serve new populations and/provide services in innovative ways 8
States Are Faced with Challenges Reduced state staff and infrastructure from recession and cutbacks Increased demand for services and supports without concomitant budget increases 10 Resource competition and direct support professional competition from related fields (seniors) Base funding needed each year is higher because I/DD supports are often life long rather than short term or stable appropriations Increased budget and legislative uncertainty at federal and state levels
Medicaid Today-and Growing 11
Demographics -Demand for Supports Increasing 12 Figure 1 The 65 and Over Population Will More Than Double and the 85 and Over Population Will More Than Triple by 2050 Number of Individuals 100,000,000 90,000,000 80,000,000 70,000,000 60,000,000 50,000,000 40,000,000 30,000,000 20,000,000 10,000,000 0 2012 2032 2050 Age 65+ Age 65-74 Age 75-84 Age 85+ SOURCE: A. Houser, W. Fox-Grage, and K. Ujvari. Across the States 2013: Profiles of Long-Term Services and Supports (Washington, DC: AARP Public Policy Institute, September 2012), http://www.aarp.org/content/dam/aarp/research/public_policy_institute/ltc/2012/across-the-states- 2012-full-report-AARP-ppi-ltc.pdf.
Demand-Shortage of Caregivers 13 A labor shortage is worsening in one of the nation's fastest-growing occupations taking care of the elderly and disabled-just as baby boomers head into old age. Wall Street Journal April 15. 2013 75,000,000 60,000,000 45,000,000 30,000,000 15,000,000 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
Confronting Reality 14 Growth in public funding will slow Workforce will not keep pace with demand 75,000,000 60,000,000 45,000,000 30,000,000 15,000,000 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 The Waiting List People Waiting For Services Residential Capacity Growth Needed 76,677 RISP 2011 460,597 16.6%
Why States are Seeking Sustainable Change- Conclusion 15 We are facing decades of Tight Funding Workforce shortages More people who need support to live in the community We have to find a way to reach as many people as possible which means a service system that is Affordable Sustainable Supports people in community life
Efforts to Build a Sustainable Future Supporting Families AND Developing Innovative Supports Relationship based Expecting Employment Outcomes Building on Technology Focusing on Person Centered Planning Investing in Peer Networks 16 AND some states have implemented or are exploring managed care long term services and supports (MLTSS) P.S. The other efforts above can be accommodated through MLTSS
Some States are Implementing or Exploring MLTSS There is no one kind of MLTSS Program or System Generally, managed care Includes capitated payments, in which the managed care contractor accepts a set monthly amount to provide a package of services, as opposed to being reimbursed for each service provided. This is often referred to as per member per month Ask for authority to develop a defined network of providers, as opposed to freedom to choose any qualified provider under Section 1902 (Social Security Act, describing CMS authority) Selective contracting on part of Medicaid program, as opposed to giving an agreement to any qualified vendor People get some/all of Medicaid services from an organization(s) under contract with the state Medicaid agency. Instead of the state paying providers directly, an intermediary entity is responsible for managing care 17
Generally, Managed Care 18 Contractors can be local, regional or national MLTSS populations can include seniors, individuals with behavior support needs, people with physical disabilities or individuals with intellectual/developmental disabilities This says generally because the type of managed care service delivery model, purpose of the program and system is individually designed by the state in accordance with the federal authority.
Who Receives Managed Care Long Term Services and Supports? As of 2011, 74.2% of Medicaid recipients were enrolled in managed care for at least some services, but participation rates are much higher for acute, medical care than for long term services and supports There are far fewer people with I/DD in MLTSS than there are seniors and people with physical disabilities n 2004, only eight states had MLTSS programs (Saucier et al., 2012), but as of 2016, nineteen states have MLTSS programs and two more plan to launch MLTSS programs in 2017 or 2018 (Kruse and Ensslin, 2016). I/DD is carved out in many of these states. 19
Managed LTSS Care Including I/DD In MLTSS Arizona (1115) Michigan (b/c) Wisconsin (b/c) North Carolina (b/c) Kansas (1115) Tennessee (1115 roll out for I/DD began in July 2016) New Jersey (1115) Iowa (1115) 20 In Planning or Pre Implementation Stage Florida legislative exploration New York* (b/c) * pre-implementation (1115), I/DD rolling out soon New Hampshireexploring it down the road Other states are examining MLTSS to determine potential benefits
Where is MLTSS Twelve waivers use 1115 demonstration authority for MLTSS, one state (KS) uses combination 1115/1915(c) authority, and seven waivers use 1915(b)/(c) authority 21 While 1915(b)/(c) waivers are focused on MLTSS, 1115 MLTSS waivers often include additional features, such as other delivery system and financing reforms or eligibility or benefits provisions affecting other populations, as a result of the additional waiver and expenditure authorities available under 1115. *Kaiser Family Foundation
Can help states to achieve budget stability by bending the cost curve over time and assist in predicting costs May assist in limiting states financial risk, passing part or all of it on to contractors by paying a single, fixed fee per enrollee Allows one or more, depending on the program design, entity to be held accountable for controlling service use and providing quality care Allows the potential to provide services to more people and create flexibility in service provision - - - - if done very carefully and all key components in place Opportunity for improved coordination and wellness Opportunity to target incentives to improve in home and family supports Potential to increase coordination across systems Potential Advantages of MLTSS 22
Potential Disadvantages of MLTSS Risk of services being seen as more medical in nature Commercial MCOs have limited experience in providing LTSS for people with I/DD even though this experience is increasing MCOs need for a level of profit margin runs risk of reducing service dollars if capitation and rate discussions not well thought out and negotiated. MCOs are less experienced in this for people with I/DD and their families receiving ongoing community based services. Care coordinators have less experience in working with people with I/DD and families as essential partners in non medical services, more frequent contact and over many years. Could take time to understand full community lives such as employment and life long learning. 23
Ask why managed care? Before Jumping into Managed Care States selecting managed care as a service delivery system for long term services must both have clear problem and goal identification and then ensure managed care is the tool most appropriate to address the problem and reach goals to provide the best supports to people. 24 Recent uses for MLTSS have included increasing budget predictability and improving communication among service providers for individuals, along service alignment and quality. Managed care is not the only means available to states to achieve these goals, so careful analysis is necessary to ensure that managed care is the proper approach. Before selecting managed care and, if managed care is selected, decide what outcomes are to be achieved before deciding on a Medicaid authority.
Medicaid Authorities for Managed Care 25 Section 1915(a) Waivers: allow states to establish managed care programs with voluntary enrollment Section 1915 (b) Waivers: States can apply for waivers to provide services through managed care delivery systems or otherwise limit people s choice of providers through mandatory enrollment. Concurrent Section 1915 (b)/1915 (c) Waivers: States can apply to simultaneously implement two types of waivers to provide services to seniors and people with disabilities, as long as all federal requirements for both programs are met.
Medicaid Authorities for Managed Care 26 Section 1115 Research & Demonstration Waiver: States can apply for program flexibility to test new and innovative approaches to financing and delivering Medicaid and CHIP, including managed care. Section 1915 (a) Authority: States can enter into contracts with organizations to provide services in the state plan; must be voluntary; only existing services and cannot limit contractors. Section 1932 (a) Authority: States may mandate enrollment in managed care. Certain groups are exempt. Rural areas must have a least 2 options.
Section 1915 (b) Managed Care Waivers 1915(b) Waivers are one of several options available to states that allow the use of Managed Care in Medicaid. When using 1915(b), States can apply for waivers to provide services through managed care delivery systems or otherwise limit people s choice of providers through mandatory enrollment. 1915(b)(1) - Implement a managed care delivery system that restricts the types of providers used to get Medicaid benefits 1915(b)(2) - Allows a county or local government to act as a choice counselor or enrollment broker in order to help people pick a managed care plan 1915(b)(3) - Uses savings that the state gets from a managed care delivery system to provide additional services 1915(b)(4) - Restricts number or type of providers that can provide specific Medicaid services (such as illness/disease management or transportation) In long managed care long term services and supports, it is most typical to see 1915(b)(3) used concurrently with 1915 (c) 27
Concurrent Section 1915 (b) and 1915 (c) Waivers 28 States can provide traditional supports (home health, personal care,, as well as HCBS services (community navigator, respite care and 1915 c-like supports) using a managed care delivery system. By combining a 1915 (c) with a 1915 (b), the managed care delivery system authority is used to either Mandate enrollment into a managed care arrangement which provides HCBS services or limit the number or types of providers which deliver HCBS services.
Concurrent Section 1915 (b) and 1915 (c) Waivers 29 Used to implement a mandatory or voluntary managed care program that includes waiver HCBS in the managed care contract. The 1915(c) waiver allows a state to target eligibility and provide HCBS services. The 1915(b) then allows a state to mandate enrollment in managed care plans that provide these HCBS services, and to exercise other 1915(b) options, such as selective contracting with providers. 1915(b)(3) - Use the savings that the state gets from a managed care delivery system to provide additional services
Section 1115 Demonstrations 30 Section 1115 of the Social Security Act gives the Secretary of HHS authority to approve experimental, pilot, or demonstration projects that promote objectives of the Medicaid and CHIP programs including managed care. Purpose: to give States additional flexibility to design and improve programs, is demonstrate and evaluate policy approaches such as: Managed care Expanding eligibility to individuals not otherwise Medicaid or CHIP eligible Providing services not typically covered Using innovative service delivery systems that improve care, increase efficiency, and reduce costs. Demonstrations must be budget neutral to the Federal government, which means that during the course of the project Federal Medicaid expenditures will not be more than Federal spending without the waiver.
Waivers and Authorities 31 Section 1915 (a) Authority: States can enter into contracts with organizations to provide services in the state plan; Must be voluntary; only existing services and cannot limit contractors. Used to authorize voluntary managed care programs on a statewide basis or in limited geographic areas implemented through CMS Regional Office approval of the managed care contract. The state has the ability to use passive enrollment with an opt-out within this authority.
Please Remember 32 But first---determine what does the state want to accomplish through managed care? What problem does the state believe managed care might solve?
Managed Care Cycle 33 Stakeholder Engagement Goals Identification Data Analysis, Program Design and Authority Dev Internal State Infrastructure: Alignment and Partnerships Provider identification and Capacity Assessment Payment Development Detailed Policy and Procedure Development Readiness Assessment and Program Implementation Quality Oversight and Performance Improvement
Two important learning documents Establishing Expectations for Managed Care Long Term Services and Supports 1. CMS Guidance for Managed Care Long Term Services and Supports - 10 Key Elements 34 1. National Council on Disability- 20 Principles for Managed Care
1. Adequate Planning and Transition Strategies 2. Stakeholder Engagement 3. Enhanced Provision of HCBS (ADA/Olmstead) CMS Guidance for Managed Care 10 Key Elements 4. Alignment of Payment Structures with MLTSS Programmatic Goals 5. Support for Beneficiaries 6. Person-centered Processes 7. Comprehensive and Integrated Service Package 8. Qualified Providers 9. Participant Protections/States Oversight 10. Quality CMS Guidance to States Using 1115 Demonstrations or 1915 (b) Waivers for Managed Long Term Services and Supports Programs: http://www.medicaid.gov/medicaid- CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf 35
April 2016 CMS Managed Care Final Rule-Modernized for MLTSS Beneficiary Protections Modernizing and Quality Improvement Codification of elements contained in the May 2013 CMS Guidance for Managed Long-Term Services and Supports Programs Adds language live or work in the setting of their choice HCBS must comply with the HCBS rule, including settings, person centered planning, and other provisions For LTSS, discusses choice of provider, community integration, self determination Stakeholder engagement Increased actuarial soundness and payment provisions Changes in the medical loss ratio *May be timeline changes in some areas to provide states more implementation time 36
Planning, Design & Implementation: IDD, Seniors, and People with Physical Disabilities are not the same- Having the Conversation It is important to help others understand the differences in supports when discussing the program design Focus Seniors Comfort, quality, and keeping/building connections in remaining years of life I/DD - Getting and Keeping a Good Life Length of Service Seniors- Averages 3-5 years but hopefully can be more I/DD - up to 60 years or more Community Supports Seniors- Many people have friends, family, relationships from spiritual community, clubs, etc. to rely on, focus is on helping people stay connected to those relationships I/DD - need to build and maintain relationships and supports throughout life 37 Takes honest conversations on why managed care, types of services, costs, support coordination
Planning, Design & Implementation: IDD, & Seniors, and those with Physical Disabilities are not the same- I/DD state systems view Primary Services and Supports Seniors - medical care, home health and personal assistance Support to keep family relationships and socialization IDD habilitation(learning) and growing over a lifetime, finding and keeping a job, supporting families, in home supports Family Care Giving Seniors In the later years of life I/DD - Begins at birth and continues through a lifetime 38 Takes honest conversations on why managed care, types of services, costs, support coordination
Considerations & Cautionary Notes: Readiness is Key Conduct a Careful Readiness Assessment- Take Time Stakeholder engagement should start as soon as possible and continue throughout the managed care development and implementation cycle Identify program goals-what do we want to achieve and why (even before determining Medicaid authority) Assumptions about savings should be tested 39 It isn t just about enough physicians, psychiatric hospitals or home health agencies it s about employment services, supported or shared living, respite, and supports to families. Health is important but it isn t the main service used by most adults with I/DD. And people are in services longer.
Considerations & Cautionary Notes: Readiness is Key-state I/DD perspectives 40 Conduct a Careful Readiness Assessment- Take Time Provider Networks- There is already a network of service providers known by many families, consumers and the DD state agency. Keeping continuity and availability of these providers within the new MCO networks takes support and intentional planning. Small providers are the most creative and the most at risk - no cash flow or I.T. system and will need support Stakeholders in I/DD are accustomed to having a meaningful seat at the table, strong voice and close connections with the state I/DD agency. People with I/DD and families are the heart of the system and need to be involved early and ongoing LTSS providers in I/DD may need assistance with billing when switching to new systems More data is needed in MLTSS for quality improvement, trends, network development and tracking in HCBS services. Infrastructure is needed as well as I/DD expertise at the state level Communicate everything, all the time. Rumors or hearing information from the grapevine can be inaccurate and scary.
Stakeholder Engagement At the beginning, families and people with I/DD need to hear how managed care will be adapted to Deliver support services What needs to be improved During development What we are looking to keep What we are collectively looking to improve Review of draft policies, contracts On going how is it working: feedback, listening sessions, ongoing engagement MCOs must have stakeholder engagement expectations 41
Stakeholder Engagement cont. Transparency means Sharing metrics/outcomes along the way. (EQRs can be hard to decipher) Working together to identify population specific and MCO specific data to review & opportunities for improvement A seat at the table in policy development, not just review, for home and community based services enhancements Statewide groups are good; local groups with state involvement keep people involved and participating The voices of individuals and families directly impacted should have the highest priority, throughout the each step of the managed care life cycle The engagement with stakeholders must be meaningful, ongoing, and must impact policy, quality improvement and implementation over time 42
Data Needed, Always and Ongoing 43 Data needs in MLTSS are rigorous, need capacity at the provider, MCO and state level to obtain, track and trend data. This is as basic as encounters and billing, tracking who is specifically authorizing services, authorization and utilization patterns to, with employment for example, as specific as the number of employment providers in each zip code, the support needs of individuals working, number of work hours, wages, and types of jobs. The data are needed to meet the purpose of the program and identified outcomes.
Tools to Encourage Integrated Settings-Contracts, Manuals, Rate Setting 44 Make integrated services more cost effective - build incentives for community based services in the capitation rate Keep institutions in the capitation rate, ICF/DD and nursing homes-where are biggest cost savings otherwise? Make expectations about self determination, community integration, work clear in the MCO contracts School to work transition Service approvals based on desired outcomes, not just an assessment Employment expectations In home supports and supports to families Use manuals to communicate policies about roles and responsibilities i.e. case management/support coordination
Integration Expectation Example- Employment 45 The priority for meaningful integration must be imbedded in each MLTSS element (design, implementation, financing and oversight), including explicit expectations for integrated work. This can be, for example, put directly into the contract as the purpose of the program and otherwise woven throughout policies and manuals. E.g. At intake and assessment, employment should be primary for children in transition and all working-age adults; transportation to a job must be addressed in plan. Employment should be a mandatory service in the MCO service and the preferred service, with a reference to policy or other binding expectation. This prioritization is especially important if services other than employment are provided. Note: This also means that state infrastructure with I/DD expertise is needed to monitor service provision and improvement strategies
MLTSS State Tools to Encourage Integrated Settings- Contracts, Manuals, Rate Setting Build expectations into provider qualifications Measure the delivery and outcomes of services for integration value In family homes with support In own homes In shared living Age appropriate for children and adults Employment outcomes Integration regardless of medical or behavioral support needs People with trachs, g-tubes, ventilators, medical frailty People with behavioral reputations; criminal offenders 46
What Can Be Accomplished - Aligning Payment Structures with Goals- cont. *State Spend sufficient time on capitation methodology. Capitation in MLTSS)is unique for people with I/DD. In past, capitation often relied primarily on what was spent in past year(s), plus regulatory changes & basic demographics. To drive innovation, realistically predict costs, reached desired outcomes & achieve rebalancing over time, capitation should not look solely at factors listed above and include Desired policy changes, valued outcomes e.g. in home supports, crisis support to prevent out of home placement, employment, early intervention, aging caregivers,, youth transition, alignment with HCBS settings rule and based on the state s demographic data. MLTSS capitation in I/DD is relatively new. Extensive data is needed to develop actuarially sound capitation rates, especially those predicated with all factors. If state does not have robust data system and analytics readily available, more time needed to pull data for first capitation (and ongoing). The new CMS Managed Care rules heighten expectations for actuarially sound rates and capitation requirements. 47
Aligning Payment Structures with Goals and Network Sufficiency Rate setting- decide which components will be retained by state vs. what authority MCOs will have: When state sets rates, may be more guarantees for core service expectations, but will MCO sign contract without flexibility? Can there be balance-state sets rate for some services especially when MLTSS for I/DD begins? 48 Does state provide rate guidelines for desired outcomes such as HCBS employment & in home support, or does MCO have full ability to design rates as long as enough providers in network and meet benchmark expectations? Defining strong network adequacy standards and monitoring regarding LTSS outcomes. Networks must include robust HCBS services. Network oversight to ensure rate structure supports desired outcomes, such as increase in home based support, supportive living, supports to families, employment Network development and oversight can/should reach beyond traditional adequacy. More than about sufficient doctors, hospitals, therapists (while important!), day programs and group homes. Should be specific about desired & needed services to achieve program's purpose based on data (e.g. x # of families need respite in x area, x providers needed to meet need for employment, x # of providers needed for aging caregivers) Should be reviewed, approved and monitored by the state staff with I/DD expertise.
Keeping Strong Support Coordination People with I/DD and their families (and others such as advocates, providers, and state I/DD staff) can fear losing the true essence of support coordinators. Care management is better known in managed care and is only newly beginning to contain elements known in the I/D community MCOs need specific training, contract expectations, ongoing mentoring, outlined in policies and manuals, clinical practice guidelines, monitoring, etc. to enhance the skills and individual and family expectations of support coordinators/case managers A support coordinator is a person who person who: Does not work for a provider (conflict free) Develops a relationship with the person and family over time Develops the individual plan with them Conducts on-going oversight (checks in) to make sure services are delivered and are achieving outcomes Is available for ad hoc problem solving 49
Support Coordination 50 AZ introduction to case management: The case manager must Foster a person-centered approach Maximize member/family self-determination promote the values of dignity, independence, individuality, privacy and choice. Support the member to have a meaningful role in planning and directing their own care to maximum extent possible. Facilitate access to non-altcs services available throughout the community Advocate for the member and/or family/significant others as the need occurs Assist members to identify their goals and provide information about local resources that help transition to greater self-sufficiency in the areas of housing, education and work Case management begins with a respect for the member s preferences, interests, needs, culture, language and belief system
Qualified Providers 51 Basics are certification, licensing, background checks, credentialing (for clinical services), credentialing agencies MCOs and providers need training in disability specific areas, history and values base, person centered processes, I/DD vs. behavioral health, self direction Assure training of non-certified direct support professionals; establish a core curriculum Keep small providers and the rich network of HCBS agencies known in the community Providers need training in billing, encounters, coding & other insurance-based knowledge Involve people with disabilities and families as trainers Ensure people with disabilities and family members are on boards of non-profits and steering policy committees of for profit MCOs
Acute, Behavioral Health & LTSS Coordination 52 There are potential benefits- more coordinated discharge planning to prevent illness, promote wellness across home and other environments when framed around values of community living. MCOs, acute health providers and case managers need a unique set of skills/understanding. Families and people with disabilities highly active in planning and interventions, and the valued roles of direct support professionals. There are opportunities in LTSS to better coordinate with behavioral/mental health care; polypharmacy, trauma informed care, linking mental health supports for overall support plan. Won t stop the hot potato between systems, but it can reduce it. MCO providers may need training in supporting people with complex needs in community and family homes and with a different role on the support team.
Protections Rights and Responsibilities 53 Private MCOs are new at supporting I/DD individuals and their families and Medicaid agencies do not generally have all specific rules, statutes, policies and work that has been completed by state agencies with I/DD stakeholders and improved over decades. Encourage Medicaid agency to reference I/DD statute, rule and policy binding by MCO contract or otherwise preserve these, such as: Right to most integrated settings Fair compensation for labor Right to own property Need to have and right to contact Human Rights Committee Need to have Program Review Committee Right to presumptive competency Right to be free from excessive medications and review of medications if used to modify behavior Freedom from abuse, neglect and mistreatment And more!
Quality Comprehensive- This is likely to take more access to data than expected Incident management Reporting; monitoring; trending individuals, providers, case managers and MCOs Evaluate Support Coordination Participant Feedback Utilization who is receiving supports and where, underserved, targeted areas? Review and trend grievances, complaints, appeals, claims, provider monitoring, incidents, quality of care concerns, outcomes, PIPS, and compliance data The oversight of the MCOs quality by the State is as important as the MCO s system Including stakeholders in review of the data and seeking both conclusions and recommendations on an ongoing basis is essential 54 States must require quality metrics to ensure an ongoing oversight of plan progress toward outcomes. States should retool their mandatory Medicaid managed care quality management requirements to include more home and community based services from acute and health related measures.
Support Family Caregivers Good information and communication Services that include supports to families Peer support and information Family engagement in policy development implementation and MLTSS oversight Families as trainers of MCO staff Consider paying family caregivers Consider a warm line for families or other ways to keep families informed when MLTSS first rolls out Consider have family networks, family information centers or another family group review written materials about MLTSS for clarity before state sends out written documents 55
State s Role State staff with expertise in I/DD as well as managed care Ensuring that people with disabilities and families have access to information about the plans and a problem resolution process Ensuring that statutes, rules, policies-everything that stakeholders developed over the decades are kept and followed Conducting oversight and monitoring of MCOs Public reporting on the performance of MCOs Policy development and implementation with stakeholders Data and trend analysis for quality improvement 56
State s Role Monitoring feedback from program participants through complaint systems, hotlines, consumer surveys & outreach sessions with stakeholders Oversight of MCOs Operational and financial reviews Network plan approval and oversight Review outcomes data AND more Seek continuous innovation The state I/DD role changes but does not lessen 57 State Oversight MCO Quality Strategy
More State Agency Tools 58 The state agencies (Medicaid and I/DD) has many tools to shape the design and performance expectations of MCOs. From how the RFP is written, to the contract, values based services, quality metrics, strong reporting practices, data expectations, specific communication, stakeholder feedback and strong procurement, MCOs will have clear direction and expectations. Policies, manuals, clinical practice guidelines, performance measurement specific to long term services and supports Policies and Manuals are developed in conjunction with stakeholders Performance Improvement Projects (PIPs) that are nonclinical and focus on community based measures such as employment, supports to families shared living, etc. Provider network plan that is based on MCO data analysis, approved and monitored by the state Payment incentives and purchasing (after some experience under the belt)
CMS, OIG and GAO Emerging Priority Areas 59 Financial Accountability Fraud, Waste and Abuse Prevention OIG Audits EVV implementation Focus on Abuse, Neglect and Exploitation Continued emphasis on HCBS regulation implementation Conflict of interest requirements At least 14 states are working to ameliorate issues of identified conflict Person-centered planning expectations CMS placing increased emphasis on meaningful person-centered planning Quality Improvement Strategies New flexibilities in 1115 demonstration waivers
Measuring Progress 60 Managed care is more than a financing mechanism. Defining quality outcomes for people with disabilities, seeking opportunities for integration, and supporting more people and their families in the community= Progress.