The CMS is about to release a sweeping proposed rule that could fuel a major expansion of Medicaid managed long-term care for elderly and disabled beneficiaries.
The Medicaid managed-care industry hopes the new rules will create more uniformity in state programs, while patient advocates hope the rules will strengthen beneficiary choices, transparency, and quality oversight and protections.
The rule, which was just reviewed by the Office of Management and Budget, will update federal regulations issued in 2002 governing Medicaid managed-care organizations. In addition to a section on managed long-term care, it's also expected to address network adequacy and access to providers, rate-setting and greater standardization of quality metrics across states.
The rule is overdue because Medicaid managed-care enrollment has soared by 48% to 46 million beneficiaries, according to Avalere. By the end of this year, Avalere estimates that 73% of beneficiaries will receive services through managed-care plans.
There is particular interest in the long-term-care part of the upcoming rules. Managed long-term care “was just getting started in 2002, so it wasn't addressed in the last update of these regulations. We're very much looking forward to what these regulations have to say,” said Meg Murray, CEO of the Association for Community Affiliated Plans, which represents not-for-profit safety net Medicaid plans.
Medicaid is the largest single payer for long-term nursing-home care, and the Congressional Budget Office has estimated that Medicaid annual spending on long-term care will increase from $60 billion to more than $100 billion in 2023.
Traditionally, state Medicaid programs paid long-term-care providers on a fee-for-service basis even as they moved more nondisabled beneficiaries into managed care. But as of 2014, 26 states were using managed long-term care, up from eight in 2004, according to the CMS. The number of beneficiaries in managed long-term care has grown from 105,000 in 2004 to 389,000 in 2012.
The states hope having private plans manage services for these expensive elderly and disabled beneficiaries will lead to cost savings and better coordination of care, including a shift from institutional settings to home- and community-based care.
Patient advocates say well-managed care could be an improvement but they fret about disruptions in care for these vulnerable patients and about private plans stinting on care to improve their bottom lines.
Some experts hope the new CMS rules will encourage more states to implement managed long-term care because there currently are wide variations in quality of nursing home care. Across the country, 39% of nursing homes certified by Medicare or Medicaid have one- or two-star ratings on the CMS' five-star quality-rating system, with some states having an even higher share of their facilities with low scores, according to a May report from the Kaiser Family Foundation.
When state Medicaid programs implement managed long-term care, “There is a real incentive for plans to move beneficiaries to higher-star facilities or help a facility improve its star rating,” said Jeff Myers, CEO of Medicaid Health Plans of America.
Currently, the structure of managed long-term-care programs varies widely from state to state and there are limited federal quality standards for these programs, said Kip Piper, a Washington-area consultant.
Advocates for beneficiaries have been worried about reported reductions in services under managed long-term care compared with fee-for-service, according to the Medicaid and CHIP Payment and Access Commission, which conducted site visits last summer in five states with managed long-term-care programs.
Long-term-care providers are worried about being excluded from Medicaid plans' networks. “We will be looking for provisions that guarantee access to and choice of long-term-care providers, as well as protections for long-term-care providers that will mitigate potential disruptions to delivery of services,” said Greg Crist, a senior vice president at the American Health Care Association, which represents nursing homes and assisted living facilities.
Advocates hope the CMS will require state Medicaid programs to have independent ombudspeople looking out for the best interests of beneficiaries in managed long-term care, said Rhonda Richards, senior legislative representative for AARP, a senior advocacy group.
Other possible beneficiary protections could include requiring states or managed-care insurers to allow enrollees to disenroll or change plans if their long-term-care providers leave the plan's network, according to the Kaiser Family Foundation. Another potential provision could be strengthening state oversight requirements regarding physical accessibility of healthcare services and sites.
In addition to the long-term-care provisions, a new report from Avalere Health predicted that the CMS' new Medicaid managed-care regulations also will cover:
