MedicaidMedicaid

Division of Medicaid and Long-Term CareDivision of Medicaid and Long-Term CareDepartment of Health and Human ServicesDepartment of Health and Human Services

Managed Long-Term Managed Long-Term Services and SupportsServices and Supports

Nebraska Medicaid is in the process of developing a statewide Medicaid

managed care program for the delivery of long-term services and supports. The targeted implementation date is

July 2015.

Managing long-term services and supports will enable Nebraska Medicaid to accomplish the following goals for clients who use long-term services and supports: •Improve client health status and quality of life by better coordination of medical care, behavioral health care, and community-based services and supports.•Promote client choice and use of the right services and supports at the right time in the right amount.•Increase client access to responsive, quality services and supports.•Use financial resources wisely to sustain Nebraska Medicaid.

What is Managed Care?Managed care is a health care delivery system organized to manage:• Cost• Use/Utilization• Quality

Usual Medicaid requirements not required of managed care:• Comparability• Freedom of Choice• Any Willing Provider

What is Managed Care? cont’d.

• Must cover the services in the benefits package in the same amount, duration, and scope as Fee-for-Service Medicaid

• Can place appropriate limits on a service based on medical necessity or utilization control

• What constitutes medical necessity cannot be more restrictive than what is used in Fee-for-Service Medicaid

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What is Managed Care? cont’d.• At-risk capitation payment: Managed care organization is

paid a per member per month (PMPM) amount and must manage delivery and payment of a defined scope of Medicaid benefits. The Managed Care organization:-Authorizes services-Assigns Primary Care Provider (PCP)-Maintains a network of providers-Pays claims-Offers case management and disease management-Can offer substitute or value added services

What are examples of long-term services and supports?

• Nursing facility services• Personal Assistance Service (PAS)• Home health services• Home and community-based waiver services such as:

-Assisted Living-Home Care/Chore-Home-Delivered Meals-Personal Emergency Response Systems-Respite Care

Centers for Medicare and Medicaid Services (CMS) “Essential Elements” of Effective

Managed Long-Term Services and Supports (MLTSS) Programs:

• Adequate Planning and Transition Strategies-Thoughtful and deliberative planning process -Technical assistance from CMS-Planned client and provider outreach, education, and transition-Coordination and communication with other state agencies

“Essential Elements” cont’d• Adequate Planning and Transition Strategies (cont’d)

-Program staff with expertise in managed care, LTSS services and delivery systems, and the needs of the clients who use them

-Effective information technology systems, data collection, and health information technology processes

-Readiness reviews -Rapid identification and resolution of MLTSS problems

“Essential Elements” cont’d

• Adequate Planning and Transition Strategies (cont’d)-Quality strategy-State oversight before, during, and after transition to MLTSS

• Stakeholder Engagement-Stakeholder input in program design, implementation, and monitoring

*State established advisory group*Broader public input by means of local

town hall-type meetings and web-based input

“Essential Elements” cont’d

• Stakeholder Engagement (cont’d)

-State website with current information about the MLTSS program initiative

-Managed care organization stakeholder advisory committees

• Enhanced Provision of Home and Community- Based Services (HCBS)

-Services provided in the most integrated setting possible

“Essential Elements” cont’d

• Alignment of Payment Structures and Goals-Encourage the delivery of community-based care

-State oversight and evaluation of payment structures to evaluate:

*Whether or not the structures are supporting the goals of the MLTSS program

*Whether or not the structures are allowing client access to quality providers

“Essential Elements” cont’d• Support for Beneficiaries

-Independent, conflict-free eligibility determination and functional assessment processes-Availability of independent ombudsman program

•Person-centered Processes-Standardized, person-centered and state-approved instrument to assess client needs-Person-centered service planning process that promotes:

*Use of self-determination principles*Active engagement of the client and individuals of their choice

“Essential Elements” cont’d

• Person-centered Processes (cont’d)-Service plan reflects the client’s or caregiver’s needs and preferences

• Comprehensive, Integrated Service Package-Physical and behavioral health care, dental care, and pharmacy will be included in the benefits package-Comprehensive needs assessment

• Qualified Providers-State specified provider network composition and access requirements

“Essential Elements” cont’d

• Qualified Providers (cont’d)-Minimum provider qualification and credentialing requirements -Provider support during transition to MLTSS

• Client Protections-Statement of client rights-Critical incident reporting system-Complaints process-Appeal rights

“Essential Elements” cont’d

• Quality-Comprehensive Medicaid managed care quality strategy that is integrated with other relevant State quality initiatives and includes:

*Quality measures*Representative, statistical sampling methodology where applicable *Mechanisms for the tracking and aggregation of data, remediation and systems improvement efforts

“Essential Elements” cont’d

• Quality (cont’d)-Use of State External Quality Review (EQR) process-Adequate State oversight and monitoring-Mandatory managed care organization reports related to the critical elements of MLTSS such as network adequacy; client health and functional status; and appeal actions-Measurement of key experience and quality of life

indicators

Next Steps for MLTSS Implementation

• Continue outreach to clients, family members, advocates, providers and other stakeholders to solicit input on the design and implementation of MLTSS; hear concerns; answer questions

• Establish a Stakeholder Advisory Council• Develop Request For Proposal (RFP) to post early 2014 to

procure the managed long-term services and supports vendor• Obtain CMS approval of waivers and amendments to the

Nebraska Medicaid State Plan as necessary

Now let us hear from you!