Patient advocates are praising a section of the CMS' proposed Medicaid managed-care rule related to long-term care. But health plans and states are sharply critical of provisions imposing new credentialing requirements on long-term care providers and allowing beneficiaries to opt out of managed care if their provider is not in a health plan's network.
The CMS included in the proposed rules a provision requested by patient advocates that allows beneficiaries enrolled in managed long-term care services and supports to switch plans or switch to fee-for-service Medicaid if their provider is out of network. Health plans blasted that provision.
“Simply allowing the individual to disenroll from the managed-care plan to fee-for-service will undermine the use of managed-care plans in the Medicaid program, and may cause adverse effects to the managed-care entity,” Aetna said in its public comments on the rule.
“We believe that disenrollment is not the best first option for beneficiaries receiving” long-term services and supports, Medicaid Health Plans of America said in its comments. “Rather, we believe that plans should have the opportunity to engage in single case agreements with the relevant provider before disenrollment is considered the option for the beneficiary.”
Medicaid is the largest 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 currently to more than $100 billion in 2023.
Traditionally, state Medicaid programs have 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.
States hope having private Medicaid plans manage services for the expensive population of elderly and disabled beneficiaries receiving long-term care services will lead to cost savings and better coordination of care, including a shift from institutional settings to home- and community-based care.
The proposed Medicaid managed care rule covers long-term services and supports, or LTSS. The rule defines LTSS, and lays out policies to protect beneficiaries and ensure access to care.
The rule defines LTSS as services and supports provided to beneficiaries of all ages who have functional limitations and/or chronic illnesses, and that have the primary purpose of supporting the ability of the beneficiary to live or work in the setting of their choice. Those settings may include the person's home or an institutional setting.
The definition was largely embraced by patient advocates, who generally support the goals of managed long-term care but are wary about the method and pace of moving disabled beneficiaries into managed-care plans and about plans' ability to serve these vulnerable, high-needs people.
“We support CMS' proposed definition of LTSS … as one that emphasizes the person-centered goals of LTSS rather than list off specific services,” the Disability Rights Education and Defense Fund said its public comments on the proposed rule. “We believe the breadth of this approach is needed and best supports a potential evolution of managed-care delivery of LTSS in ways that will meet the actual and most urgent and vital needs of Medicaid enrollees with long-term needs.”
Justice in Aging, an advocacy group for low-income seniors, was enthusiastic about proposed training for managed-care organizations and network providers on community-based services. “For care coordination to truly be effective, at a minimum, the care coordinators, case managers and (managed-care plan) staff leading the interdisciplinary team need a clear understanding of the community-based supports network,” the group said in its comments.
But state Medicaid agencies expressed concern about a proposal requiring states to establish credentialing and recredentialing policies for individual and organizational providers participating in their managed-care programs, including those caring for Medicaid beneficiaries receiving LTSS services. Medicaid LTSS providers include personal attendants, peer counselors, outpatient treatment centers, residential treatment centers, and group homes.
“There are no existing credentialing criteria that could be utilized to address entities and individuals that are not licensed by the state and may not be certified under current rules or requirements,” the Arizona Health Care Cost Containment System, the state's Medicaid agency, said in its comments. The rule “would impose a significant burden on the state and also serve as a disincentive for individuals to work in these types of positions, potentially creating access to care concerns,” Arizona's Medicaid agency says.
The National Association of Medicaid Directors agreed. “It is operationally unfeasible for the CMS to require credentialing for all LTSS provided in Medicaid,” the group said in its comments. It noted that many in-home providers of LTSS services are family caregivers.
