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Medicaid. Managed Long-Term Services and Supports. Division of Medicaid and Long-Term Care Department of Health and Human Services.
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Medicaid Managed Long-Term Services and Supports Division of Medicaid and Long-Term Care Department of Health and Human Services
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.
Let’s break it down . . . What is Medicaid? • Medicaid is a state and federal partnership program that covers medical care and long-term services and supports for low-income individuals. • Medicaid is health insurance • Nebraska’s contract with the federal government to provide Medicaid is called the State Plan.
Let’s break it down cont’d. What are traditional medical services included in the State Plan? Examples include: • Hospital services • Physicians’ services • Mental health and substance use disorder services (also known as behavioral health services) • Pharmacy services • Durable medical equipment and medical supplies • Dental services • Radiology • Lab work • Therapies • Visual care services
Let’s break it down cont’d. What are traditional long-term services and supports included in the State Plan? Examples include: • Nursing facility services • Home health care • Hospice care • Personal Assistance Service (PAS)
Let’s break it down cont’d. Other long-term services and supports included because of a “waiver” to the State Plan include: • Aged and Disabled Waiver Services, including services such as- -Assisted Living -Home Care/Chore -Home-Delivered Meals -Personal Emergency Response Systems -Respite Care • Traumatic Brain Injury Waiver Services, including- -Assisted Living
Currently, clients who need long-term services and supports have their long-term care needs and medical care delivered (paid for) by Medicaid through a system called Fee for Service (FFS) • Client sees provider • Provider bills Medicaid • Medicaid pays retrospectively • Quality of care is not monitored • Coordination of care is not provided
The managed care delivery system is different: • Nebraska Medicaid contracts with a managed care organization (MCO) • The MCO contracts with providers to participate in its provider network • Nebraska Medicaid pays the MCO a “per member per month” (PMPM) payment for each enrolled client • Out of this money, the MCO pays its network providers for the care and services they provide clients • The MCO must cover the care and services in the benefits package in the same amount, duration, and scope as FFS • The MCO can place appropriate limits on the care or services based on medical necessity or utilization control • What constitutes medical necessity cannot be more restrictive than what is used in FFS
The MCO also – • Assigns a Primary Care Provider (PCP) if the client doesn’t choose one within the MCO’s provider network • Provides case management • Offers disease management • Can offer substitute or value added services
Nebraska Medicaid is developing a managed care program for the delivery of long-term services and supports with a targeted implementation date of 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.
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 -Planned client and provider outreach, education, and transition -Rapid identification and resolution of MLTSS problems
“Essential Elements” cont’d • 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 -State website with current information about the MLTSS program initiative -Managed care organization stakeholder advisory committees
“Essential Elements” cont’d • Enhanced Provision of Home and Community- Based Services (HCBS) -Services provided in the most integrated setting possible • Alignment of Payment Structures and Goals: -Encourage the delivery of community-based care • Support for Beneficiaries -Independent, conflict-free eligibility determination and functional assessment processes -Availability of independent ombudsman program
“Essential Elements” cont’d • Person-centered processes -Person-centered service planning process that promotes: *Use of self-determination principles *Active engagement of the client and individuals of their choice *Service plan reflects the client’s or caregiver’s needs and preferences
“Essential Elements” cont’d • 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 -Provider support during transition to MLTSS
“Essential Elements” cont’d • 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 -Mandatory managed care organization reports related to the critical elements of MTLSS 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 • Develop Request For Proposal (RFP) to post in 2014 to procure the managed long-term services and supports managed care organization • Obtain CMS approval of waivers and amendments to the Medicaid State Plan as necessary
MLTSS Website Address: http://dhhs.ne.gov/medicaid/Pages/MLTSS.aspx
Now let us hear from you! Email Comments and Questions to DHHS.MedicaidMLTSS@nebraska.gov Address to which surveys can be sent: Attn: Julie Docter DHHS P.O. Box 95026 Lincoln, NE 68509-5026