Disabled individuals receiving long-term support are losing services as they transition from fee-for-service to managed Medicaid, according to research by the National Council on Disability, a federal agency that advises the White House and Congress on issues affecting Americans with disabilities.
Historically, managed-care arrangements have excluded people with disabilities who use long-term services and supports because of their complex needs. Now, however, some states are moving this population to managed care.
For decades, 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.
For the past two years, the NCD has hosted 10 community forums around the country with over 650 people sharing experiences with managed Medicaid. The audiences were made up of beneficiaries, advocates, providers, state government agency workers, and managed care organizations. The report is built on feedback heard at the events.
Overwhelmingly, disabled beneficiaries said they lost access to care. Participants reported that MCOs frequently deny long-term care services and supports that were previously provided by the Medicaid FFS system.
“The impression is that some MCOs are very strategic in their denials and that other plans might just be careless, but the way it plays out for people in MLTSS plans is the same—services are cut substantially without notice and explanation,” NCD said.
Managed care beneficiaries should receive a written notice and an opportunity for a hearing before coverage is denied but participants at the forums reported that often services are being terminated during the authorization period (usually 60 to 90 days), while the individual's appeal is pending, and due process protections are not being considered under Medicaid managed care, NCD said.
“The CMS must clearly emphasize to states the expectation that authorized long-term services and supports services continue pending appeal,” NCD said.
Much of the tension is based on the belief that many managed-care companies expanding into the managed long-term services and supports market have a limited understanding of the services and the people they serve, NCD said.
Most managed care companies are used to contracting for acute health care services that are highly regulated and licensed. They are not used to contracting for services that are more tailored to the individualized needs of the long-term services and supports recipient, according to the agency.
There is no nationally endorsed set of measures for these services and that has resulted in inequality from state to state, NCD said.
It's unclear if a proposed rule released last summer by the CMS that aims to overhaul managed Medicaid will address all of the concerns raised.
A CMS spokesman didn't immediately return a request for comment.
Jeff Myers, CEO of Medicaid Health Plans of America, thought the study was an important one because it gives voice to disabled enrollees.
“Of course there are and will be shortcomings, but I feel that this [report] is an indictment of the prior fragmented FFS model, not the evolving model of care coordination inside an MCO model.”