Managed Long-Term Services and Supports

1. Medicaid Managed Long-Term Services and Supports Division of Medicaid and Long-Term Care Department of Health and Human Services

2. 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.

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. “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

10. “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

11. “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

12. “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

13. “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

14. “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

15. “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

16. “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

17. “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

18. 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

19. Now let us hear from you!