Efforts to Enhance the Availability and Quality of - National ...


Efforts to Enhance the Availability and Quality of - National ...

Efforts to Enhance the Availability andQuality of Managed Long-Term CareOnline ResourceL&M Policy Research, Muskie School of Public Service& Thomson ReutersHHSM-500-00009I/T0001September 12, 2011

Agenda1. Background2. Project Team3. Project Summary2


Background• National enrollment in Medicaid ManagedLong Term Services and Supports (MLTSS)programs has more than tripled since 20042009 enrollment was estimated at 250,000, up from68,000 in 2004• Fifteen states have implemented one or morestate-designed MLTSS program• Thirty states have implemented PACE or pre-PACE programs• Eight states have demonstrated ability to takeMLTSS programs to scale with multi-region orstatewide programs4

States with MLTSS ProgramsImplemented one or morestate-designed MLTSS programImplemented multi-region orstatewide MLTSS program5

Background (cont.)• As states consider options for improving theirLTSS systems, some will want to implementexpanded HCBS options within existing ornew managed care delivery systemsCMS has worked with a number of states tofashion waiver and Medicaid state plan strategiesthat use multiple federal authorities concurrentlyIncreasing state interest and expanded federalauthorities have created a need for technicalassistance tools addressing Medicaid authoritiesand program implementation issues in MLTSS6

Project Team

Our Team• L&M, women‐ andminority‐owned, 8(a)firm located inWashington, D.C., bringsexpertise in:• Public and private healthcare issues• Qualitative andquantitative healthresearch methods• Health servicesmanagement andoperations• Health policydevelopment andprogram evaluation• Consumer research andtesting• The University ofSouthern Maine MuskieSchool of Public Servicesbrings experience in:• Evaluating state SNPcapabilities and creatingHCBS care managertraining modules –haspreviously worked withCMS on such projects• Developing materialsand displays inaccordance with 508regulations allows for astreamlineddevelopment processand economies• Thomson Reuters’Community LivingSystems group is anationally‐recognizedleader in:• LTC research,particularly the deliveryof HCBS• Thomson has worked ontechnical assistanceprojects from stateMedicaid HCBSprograms anddevelopment of qualitytraining modules forCMS8

Our TeamLisa Green, Ph.D.L&M Policy ResearchProject DirectorMargaret Johnson, M.B.A.L&M Policy ResearchProject ManagerL&M Policy ResearchJudy Dey, Ph.D.Rachel DolinThomson ReutersPaul Saucier, M.A.Content expertMuskie SchoolMaureen Booth, MRPSue Ebersten, MPACrystal FrenchTAP members9

TAP MembersMary Pat FarkasCamille DobsonCarrie SmithCheryl PowellRobin CooperMonica Deignanand Charles JonesMichael FitzpatrickWendy Fox‐GrageDiane JusticeCorrine Altman MooreCynthia WoodcockMike CheekTechnical Advisory PanelTAP Chairperson – Division of Integrated Health Systems, CMSDivision of Integrated Health Systems, CMSDivision of Integrated Health Systems, CMSFederal Coordinated Health Care Office, CMSThe National Association of State Directors of DevelopmentalDisabilities ServicesDivision of Long‐Term Care, Office of Family Care at theWisconsin Department of Health ServicesNational Alliance on Mental IllnessAARP Public Policy InstituteNational Academy for State Health PolicyMassHealthThe Hilltop InstituteNational Association of States United for Aging and Disabilities10

Project Summary

Purpose• In order to provide consistent technicalassistance to states regarding thedevelopment of MLTSS program, CMS hasengaged L&M Policy Research and ourpartners to design an online curriculumThe primary purpose is to offer states guidance onrelevant federal authoritiesThe tool will also provide broader resources tosupport program development, including• A checklist of key program development issues• Sample contract language from existing programs12

MLTSS Defined• The following definition of MLTSS guided thedevelopment of the resource:MLTSS includes prepayment to a contractor for apackage of long-term services in the form of a fullor partially capitated payment• The contractor is accountable for providing a definedset of services and meeting quality standards within theamount of the prepaymentMLTSS is present in a range of models, includingthose that include Medicaid services alone andthose that include both Medicaid and Medicareservices for Medicare-Medicaid beneficiaries13

Approach• Technical assistance will be provided in theform of an online resourceIt will be highly accessible for end users and can beupdated as policy and practice continue to evolveLinks to the resource can be included on other Websites where state officials are likely to look forassistance• The resource will be asynchronous, whichmeans that the user will not interact with otherpersons in real timeThe user will access the material at whatever timehe/she chooses, at whatever pace is comfortable,and to the desired depth15

Key Elements of Instructional Design• Within the limits of an asynchronous offering,the resource will be designed as an interactivelearning experience for the user, incorporatingprinciples of adult education and bestpractices in technology-enhanced learning• Features will include:Brief (2 to 3 minute) video vignettes to highlight keypoints within the curriculum;Knowledge checks in key areas; andA case study that challenges the user to apply theknowledge from the module16

Learning Objectives• After using the resources, users should:Understand the major MLTSS program designchoicesUnderstand the federal Medicaid authoritiesavailable to implement an MLTSS program, andwhich authorities to invoke to best accommodatethe design choicesUnderstand how managed care contracting differsfrom FFS reimbursement, and how this changesthe demands on state agencies in terms of theskills and organizational relationships needed toeffectively manage programs17

Outline of Online Resource• Unit 1: Overview and LearningObjectives• Unit 2: MLTSS Basics• Unit 3: Universal Features Commonto All MLTSS ProgramsStakeholder engagementPerson-centered approachQuality management systems18

Outline of Online Resource (cont.)• Unit 4: Program Design ChoicesTarget populationsCare coordinationOptions for including MedicareCovered servicesProvider networksEnrollmentConsumer-directed servicesFinancial incentives• Unit 5: Federal Authorities• Unit 6: Organizational Capacity andCompetencies19

TimelineConvene TAPCurriculumDevelopmentOnline ResourcePhase 1:Preparation*OnlineResource Phase2:DevelopmentOnlineResourcePhase 3:TestingMarch 2011 andNov. 2011June 2011‐Sept.2011July 2011‐Sept.2011Oct. 2011Nov. 2011‐Dec.2011* Reviewing draft content, drafting video scripts, liningup speakers, etc.20

Beta Testing• We will begin beta testing in November and areseeking volunteers• If you are interested, please fill out our form afterthis presentation21

Contact UsMargaret Johnson, M.B.A.Senior ResearcherL&M Policy Research, LLCP.O. Box 42026Washington, D.C. 20015Phone: 720.215.6589Fax: 202.688.2936mjohnson@lmpolicyresearch.com22

Managed Long-Term Services and Supports:Structures and Safeguards to Ensure a Person-Centered Approach to CareMary Pat Farkas, Technical DirectorDivision of Integrated Health SystemsDisabled and Elderly Health Programs GroupCenter for Medicaid, CHIP, and Survey & Certification

Medicaid - Long-Term Services and Supports• Medicaid covers over 40% of all LTSS• LTSS represents about 1/3 of all Medicaid spending• Most individuals get LTSS thru Fee-for-Service• Institutional mandatory /HCBS optional2

LTC Expenditures by PayerPrivateInsurance7.2%Other Private2.7%Other Public2.6%Out-of-Pocket18.1%Medicaid48.9%Medicare20.4%3

Long-Term Services and Supports (LTSS) inMedicaid• LTSS = $115B in 2009 (32% of total Medicaid)• Institutional LTSS (nursing facility) remains theentitlement• HCBS spending was $51.1B in 2009• Not all populations have equal access to homeand community-based services (HCBS)• Systems are fragmented and complex tonavigate4

The Affordable Care Act (ACA)• Supports most integrated settingappropriate– Offers new or improved HCBS StatePlan options– Offers new option for integrating andlinking services– Offers enhanced FMAP (“match”) tohelp States modify delivery systems5

Section 2401: Community First Choice Option• Effective October 1, 2011• Adds Section 1915(k) to Medicaid• Optional State Plan benefit for attendant careand related supports, including self-direction• Eligible individuals must have income at orbelow 150% Federal Poverty Line (FPL) ormeet institutional level of care (LoC)• Includes 6% enhanced Federal match• Notice of Proposed Rulemaking publishedFebruary 22, 2011 – CMS 2337-P6

Section 2402: Removing Barriers to HCBS• Section 1915(i)• State option offer HCBS as a State plan benefit• Eliminates the link between HCBS and institutionallevel of care• Relies on needs-based criteria• Some modifications made through the ACAeffective October 1, 2010 including addition of“other” services• States cannot waive statewideness or capenrollment7

Section 2403: Money Follows the Person• Provides for the extension and expansion ofMoney Follows the Person through 2016• Offers States substantial resources andadditional program flexibilities to remove barriers• More States have recently been awarded MFPgrants• CO, FL, ID, ME, MA, MN, MS, NV, NM, RI, TN,VT, WV received an additional $4.3B• By April 2011, CMS expects to have at least 42States and the District of Columbia participating8

Section 2701: Adult Health Quality Measures• Requires development of a core set of qualitymeasures for Medicaid adults• Due January, 2012• States voluntarily report status annually• Establishes a Medicaid Quality MeasurementProgram to test emerging, evidence-basedmeasures including testing of the initial core set9

Section 2703: Health Homes for Individualswith Chronic Conditions• Effective January 1, 2011• Enables States to offer “Health Homes” to individualswith certain chronic conditions including mental health,substance use, asthma, diabetes, heart disease,obesity, other conditions• Health Home providers will coordinate all primary,acute, behavioral health and long term services andsupports to treat the “whole-person”.• Enhanced Federal match (90%) available for first 8quarters10

Section 10202: Balancing Incentive Program• Effective October 1, 2011• Offers enhanced Federal match to States that makestructural reforms to increase nursing home diversions andaccess to HCBS– 2% if less than 50% LTSS spending in non-institutionalsettings– 5% if less than 25% LTSS spending in non-institutionalsettings• States must implement structural changes including “nowrong door–single entry point system,” conflict-free casemanagement, and core standardized assessments11

Section 6407: Home Health Face to Face EncountersUnder Medicare• Effective 1/1/2010• Requires face to face encounter by aphysician before certification of need forHome Health services or Durable MedicalEquipment (DME)• Medicare home health regulation finalized• Medicaid NPRM issued early 201112

Provisions to Improve Care Coordination forDually Eligible Individuals (Medicare, Medicaid)• Section 2601 – 5 Year period for certain Medicaidwaivers that include dually eligible beneficiaries• Section 2602 –Establishes Federal Coordinated HealthCare Office (FCHCO)• Promote effective integration of care across Medicareand Medicaid• 8.8 m enrollees; 40% of total Medicaid spending (15 %enrollees), 36% of Medicare spending (21% enrollees)• Up to 15 states to receive up to $1M each to developmodels of integration13

Newly Eligible Individuals throughExpansion Programs• Estimated 16 million newly covered individuals• Health Insurance Exchanges, Medicaid,Children’s Health Insurance Program (CHIP)• 50% are likely to be served through Medicaid• An estimated 5.4 million people currentlyuninsured with a mental disorder, includingthose with substance use disorders, will gaincoverage14

Rebalancing - Long-Term Services & Supports(LTSS)• Opportunities for States:– Focus on consumer– Provide more choice for HCBS options as alternatives toinstitutional care– Managed long-term services and supports (MLTSS)– Improve quality of care in each setting– Control costs– Coordinates all care for beneficiaries (primary, acute, behavioralhealth, and LTSS)15

Key Considerations for MLTSS• Develop State Goals/Vision for MLTSS• Engage Stakeholders• Promote person-centered approaches to care planning and self-direction• Use a uniform assessment tool• Provide conflict free case management• Flexible benefits – not a one-size fits all• Promote true integration of primary, acute, behavioral health and LTSS• Support care management strategies and linkages to improve outcomes and healthstatus• Encourage multi-disciplinary approach to care• Assure health and welfare standards for beneficiaries• Improve quality measurement in each setting• Consider performance incentives to support goals• Develop rate-setting expertise to assure sound rates• Strengthen State Oversight16

Managed LTSSStates with Managed LTSS:• Build on existing managed care experience• Offers consumers more choice and better coordinated care• Can provide more benefits & choice then FFS• Better management of LTSS spending• Can provide more cost effective system• Improve quality of care measurement in each setting andacross settings• Move to full integration of Medicare and Medicaid services17

States with MLTSS• Arizona – 1989 under 1115 offered statewide on mandatory basis• Texas – 1998 under 1915(b)(c) offered regionally on mandatory basis• Wisconsin – 2000 under 1915(b)(c) regionally on voluntary basis• Hawaii – 2009 under 1115 offered statewide on mandatory basis• Tennessee – 2010 under 1115 offered statewide on mandatory basis• Minnesota – 2005 under 1915(a) &1915(b)(c) offered regionally on voluntary• New Mexico - 1997 under 1915(b) offered statewide on mandatory basis18

The Foundation for a Redesigned Service SystemPersonCenteredIntegrationIndividualControlQuality

Person-CenteredPersonCenteredThe following provisions explicitly or implicitly require astrong person-centered approach:– Community First Choice Option– Removing Barriers to HCBS – both in 1915(i) andSecretarial rulemaking– Quality Measurement– Health Homes for Individuals with ChronicConditions– Balancing Incentive Program– Money Follows the Person– Home Health – Face to Face Encounters20

Individual ControlIndividualControlThe following provisions allow for or explicitlyrequire self-direction options and maximizeindividual control:– Community First Choice Option– Removing Barriers to HCBS – both in 1915(i)and Secretarial rulemaking– Quality Measurement– Health Homes for Individuals with ChronicConditions– Balancing Incentive Program– Money Follows the Person21

QualityThe following provisions include explicit qualityrequirements:Quality- Community First Choice Option- Removing Barriers to HCBS – both in 1915(i)and Secretarial rulemaking- Quality Measurement- Health Homes for Individuals with ChronicConditions- Balancing Incentive Program- Money Follows the Person- Provisions related to individuals duallyeligible for Medicare and Medicaid22

IntegrationIntegrationThe following provisions promote or require improvedintegration and strong coordination:– Community First Choice Option– Removing Barriers to HCBS – both in 1915(i) andSecretarial rulemaking– Quality Measurement– Health Homes for Individuals with Chronic Conditions– Balancing Incentive Program– Money Follows the Person– Provisions related to individuals dually eligible forMedicare and Medicaid23

Additional IncentivesOpportunities for EnhancedFederal Matching AssistancePercentage (FMAP):– Health Homes– Balancing Incentives– Community First Choice Option– Money Follows the Person24

State Plan Services and HCBS Waivers• In addition to the new opportunitiesafforded under the ACA, Statesmay still use traditional State PlanServices and HCBS waivers todesign strong systems of care25

CMCS Assistance to States• Continuing serious budget concernsfor States• Secretary Sebelius’ February 3, 2011Letter to Governors - committed tohelp States implement effective costcontrol– Modify benefits– Manage services for high costenrollees– Purchase drugs more effectively– Assure program integrity26

For More InformationCMS: www.cms.hhs.gov http://www.healthcare.gov/CMCS Updates: https://www.cms.gov/AboutWebsite/EmailUpdates/list.aspCMS: Community Services and Long-Term Supportshttp://www.cms.gov/CommunityServices/01_Overview.asp#TopOfPageState Medicaid Director Letters http://www.cms.gov/SMDL/SMD/list.asp#TopOfPageMFP Technical Assistance Website http://mfp-tac.com/CFC NPRM http://edocket.access.gpo.gov/2011/pdf/2011-3946.pdf1915(c) NPRM After April 19, 2011, the regulation can be accessed athttp://www.access.gpo.gov/su_docs/fedreg/frcont11.html27

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