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 rule is overdue because Medicaid enrollment has soared 48% to 46 million beneficiaries over the past four years, according to Avalere. By the end of this year, about 73% of beneficiaries will receive services through managed-care plans.
Medicaid is the largest single payer for long-term nursing-home care, and the Congressional Budget Office has estimated that Medicaid spending on long-term care will increase from $60 billion a year to more than $100 billion by 2023.
Traditionally, state Medicaid programs paid long-term-care providers on a fee-for-service basis even as they moved more non-disabled 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 LTC grew from 105,000 in 2004 to 389,000 in 2012.
The states hope private plans will lead to cost savings and better coordination of care, including a shift from institutional settings to home- and community-based care.
But patient advocates fret over care disruptions and the potential for private plans to stint on care to improve their bottom lines.
Across the country, 39% of nursing homes have low one- or two-star ratings on the CMS' five-star quality rating system, according to a May report from the Kaiser Family Foundation.
But when state Medicaid programs implement managed LTC, “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.
The CMS rule review also is expected to address network adequacy and access to providers, rate setting and greater standardization of quality metrics across states.
