How States Provide Long-Term Services and Supports to Children in Medicaid Managed Care

For years, states have used managed care delivery systems to help control costs and improve health care and outcomes for adult Medicaid beneficiaries with complex health care needs. Now, more than a dozen states are using managed care to provide long-term services and supports (LTSS) to children and youth with special health care needs (CYSHCN).

LTSS are costly for federal and state governments to deliver. Nationally, public LTSS spending exceeds $242 billion annually. Medicaid is responsible for about $145 billion or 60 percent of these expenditures and LTSS currently accounts for 30 percent of all Medicaid spending. Annual Medicaid spending per enrollee is more than 12-times higher for children who use LTSS ($37,084) compared to those who do not ($2,863).

LTSS encompass a range of medical and non-medical services provided to people who are chronically ill or disabled. They typically include services such as nursing facility care, home nursing services, and home- and community-based services, such as in-home nursing care. LTSS often provide support for daily living activities, including eating, dressing, and maintaining personal hygiene. CYSHCN who receive LTSS are typically children with significant health care conditions and may need LTSS services over their childhood, and perhaps for the rest of their lives. Their LTSS needs may change as they grow and mature. Some CYSHCN receive care in a nursing home facility due to their extensive medical and/or behavioral health care needs and limitations in available community-based services.

Until now, few national reports have explored how states are redesigning their programs to include children in state Medicaid managed long-term services and supports (MLTSS). In early 2018, the National Academy for State Health Policy (NASHP) analyzed state Medicaid managed care programs nationwide that provide LTSS for children. NASHP reviewed state contracts to identify which pediatric populations were covered, how the programs were structured, and what approaches states used when evaluating the quality of LTSS and requirements for cross-agency collaboration.

This new NASHP issue brief and its accompanying chart highlight strategies that states have used to implement MLTSS and identify key contract language that helped states establish these programs.

Currently, one-quarter of states (14 states) provide MLTSS to children through 17 Medicaid managed care (MMC) programs. In some cases, states have more than one MMC program to serve specific groups of Medicaid enrollees. In contrast, 24 states provide 39 MLTSS programs to adults. The CYSHCN that states enroll in their MLTSS programs vary across the country. Most enroll children who receive Supplemental Security Income, are enrolled in Medicaid as the result of foster care placement, and/or are enrolled in 1915(c) HCBS waivers. Nearly all provide these services as part of a comprehensive set of physical, behavioral, and LTSS benefits.

There are a number of ways that states can ensure that MLTSS programs serve the unique needs of children, including instituting specific network adequacy requirements for LTSS providers, implementing new or adapting existing quality measurement strategies for children receiving LTSS, and requiring coordination between managed care organizations, LTSS state agencies, and community-based partners.

Using MMC to provide LTSS to children is an emerging trend that is likely to expand as managed care becomes the dominant delivery system for all Medicaid enrollees and services. This issue brief includes strategies states may consider in implementing MLTSS for children including family engagement, preparing LTSS providers, and designing programs to meet the specific needs of children. As states implement new delivery system models and respond to new federal rules, NASHP will continue to monitor the delivery of MLTSS services to children and identify promising practices.