States are increasingly turning to capitated Medicaid managed care programs to deliver long-term services and supports (LTSS) to individuals with complex needs. As of December 2023, 24 states have managed long-term services and supports (MLTSS) programs in place, up from only eight in 2004. States are hoping to achieve a number of goals with their MLTSS programs, including increasing access to home and community-based services, promoting care coordination, enhancing quality and beneficiary satisfaction, and mitigating cost growth.
In fall 2023, NASHP partnered with Arnold Ventures to design a two-year cross-state learning and technical assistance collaborative to support states in strengthening accountability and oversight in their MLTSS programs. To learn more about states’ activities, priorities, and promising practices in this area, NASHP staff conducted interviews with state officials and MLTSS staff from seven states: California, Illinois, Massachusetts, Minnesota, South Carolina, Texas, and Virginia. Additional data collection activities included conducting supplementary interviews with eight subject matter experts in MLTSS and reviewing publicly available resources and documentation related to states’ oversight approaches.
Participating states were selected to reflect diversity in geographic region and age of MLTSS program(s). Three states in the sample — Massachusetts, Minnesota, and Texas — have been operating a MLTSS program for more than 20 years. The other four states have had a MLTSS program in place for 10 or fewer years. All states, with the exception of California and Virginia, have created at least one separate MLTSS program targeted toward adults 65 and older or individuals dually eligible for Medicare and Medicaid (dual eligibles).
The following table provides a snapshot of the states and MLTSS programs selected for this project.
Key Characteristics of State Programs Covering MLTSS for Aged and Disabled Populations, as of December 2023
| State | Program Name | Start Date | Populations Enrolled | Estimated Enrollment |
|---|---|---|---|---|
| California | Medi-Cal — CalAIM (California Advancing and Innovating Medi-Cal) Initiative | 2023 | All Medicaid eligible populations, including individuals with LTSS needs, in select counties1 | 1.1 million (LTSS only) |
| Medicare Medi-Cal Plans (MMPs) | 2014 | Dual eligibles 21+ in seven counties | 370,4902 | |
| Illinois | HealthChoice (MLTSS) | 2016 | Dual eligibles 21+ | 64,799 |
| Medicare-Medicaid Alignment Initiative | 2014 | Dual eligibles 21+ | 90,000 | |
| Massachusetts | Senior Care Options | 2004 | Adults 65+, dual eligibles 65+ | 75,000 |
| Minnesota | Senior Care Plus | 2005 | Adults 65+ | 28,162 |
| Senior Health Options | 1997 | Dual eligibles 65+ | 46,706 | |
| South Carolina | Healthy Connections Prime | 2014 | Dual eligibles 65+ | 13,000 |
| Texas | STAR+PLUS | 1998 | Adults 65+, adults with disabilities | 578,158 |
| Dual-Eligible Integrated Care Demonstration | 2015 | Duals eligibles 21+ | 32,660 | |
| Virginia | Cardinal Care (formerly Commonwealth Coordinated Care Plus)3 | 2017 | Adults 65+, individuals with disabilities, dual eligibles 21+ | 300,000 |
Sources: NASHP Interviews with state officials and review of publicly available state documents.
References:
- Under CalAIM, Medi-Cal managed care plans (MCPs) became responsible for providing LTSS services that were traditionally provided under fee-for-service (FFS) in January 2023. California does cover skilled nursing facility care in its MLTSS program, but most personal care services (in-home supportive services) are provided under FFS.
- www.dhcs.ca.gov/services/Documents/MCQMD/Cal%20MediConnect/DualEligible-Special-Needs-Plan-Dashboard-Dec2023.pdf
- On October 1, 2023, Virginia Medicaid combined its two managed care programs of Medallion 4.0 and Commonwealth Coordinated Care Plus (CCC Plus) into Cardinal Care Managed Care. This number is an estimate of those individuals formerly enrolled in Commonwealth Coordinated Care Plus, which served adults and children with disabilities and individuals who received LTSS.
As Medicaid managed care arrangements continue to evolve to fit the needs of the changing population, state policymakers must continually adapt and refine their oversight processes to address the needs of a wide range of beneficiaries. State officials and national experts identified a number of key themes and challenges related to data monitoring, the use of payment to advance rebalancing, and the complexities associated with developing a comprehensive oversight structure responsible for monitoring multiple populations and benefits. This brief offers some insights and promising practices for state policymakers to consider as they work to strengthen accountability and quality in MLTSS programs.
Effective Oversight Requires Access to Meaningful Data
All states noted the importance of having access to meaningful data for oversight. Reliable and complete data is essential to monitoring plan performance, ensuring beneficiary access to quality care, and helping state policymakers evaluate how well their MLTSS plans are achieving their intended goals. States also need timely and accurate data to develop capitation rates to pay MLTSS plans.
While all states require managed care organizations (MCOs) collect and report utilization data on a regular basis, gathering real-time data to identify performance problems early can be difficult due to long lag times in claims processing, incomplete or inaccurate coding, and lack of compliance with billing policies. States described working closely with MCOs on a regular basis to improve the quality of their data collection and reporting.
To enhance their data monitoring and oversight capabilities, several states noted the advantages of having a data dashboard to help identify patterns, trends, and areas for improvement. Illinois described using two dashboards to monitor performance: a population-specific dashboard that includes data on metrics such as care plan completion and care transitions and an internal-performance dashboard to examine differences in care and utilization by race, ethnicity, and region. The state uses these data to identify gaps in care and develop performance improvement activities to address quality problems and disparities in access. California recently updated its publicly accessible Medi-Cal Long Term Services and Supports Dashboard, which reports utilization and demographic data by counties and managed care plans. The state intends to eventually include data relevant to its efforts to promote access to more home- and community-based services (HCBS) for LTSS beneficiaries.
Using MLTSS to Incentivize Rebalancing
One chief goal for states’ MLTSS programs is to “rebalance” or shift spending away from institutional care to more HCBS. Encouraging the provision of HCBS should lead to more people receiving the services and support they need at home rather than in more costly nursing facilities. To achieve this goal, states report using various strategies, including paying MLTSS plans a blended per-member-per month capitation rate, implementing financial incentives to transition enrollees from institutional facilities to community settings, and requiring plans to report on rebalancing-related quality metrics to measure progress.
Five of the seven states (California, Illinois, Virginia, South Carolina, and Texas) are using blended capitation rates to pay Medicaid managed care plans in at least one of their MLTSS programs. A blended capitation rate combines all MLTSS costs, including nursing facilities and HCBS, into one per-member per-month payment. The payment is the same regardless of whether the beneficiary receives care in a nursing facility or in a community setting. Blended capitation rates provide a strong incentive for MCOs to provide care in a less costly community setting.
To assess their progress toward “rebalancing,” states are monitoring and developing quality metrics to evaluate the level of community integration, transitions, and use of nursing homes. For example, Massachusetts, as part of its data-driven oversight strategy, now requires MCOs to report how many beneficiaries have been in the hospital for 10, 20, and 30 days or more. Tracking measures like these help states identify which MCOs may need additional support transitioning individuals who are receiving care in institutions to home- and community-based settings. Interviews with experts revealed that the availability of measures to assess rebalancing, as well as quality of care delivered by MLTSS plans, has improved in recent years, but more work needs to be done to adequately ensure that beneficiaries receive the services they need.
States are also creating distinct financial incentive initiatives to encourage the provision of more HCBS by MLTSS plans. Two states in the sample (Illinois and Virginia) offer rewards or bonuses to MCOs that successfully transition individual members from a nursing facility to community living. Under Virginia’s Discrete Incentive Transition Program, plans can earn up to $7,500 for every member who has resided in a nursing facility for one year or longer who is successfully transitioned to a community setting. In Illinois, as part of the state’s Community Transitions Initiative, MCOs receive incentive payments after they transition members living in nursing or mental health facilities to supportive housing or community living.
Leveraging MLTSS to Integrate Benefits and Services for High-Risk Populations
States are increasingly leveraging Medicaid managed care to not only integrate new services and benefits for beneficiaries but also to serve more high-risk populations such as individuals with behavioral health conditions and persons with intellectual and developmental disabilities. Furthermore, the Centers for Medicare and Medicaid Services and federal policymakers have been encouraging states to align their MLTSS programs with Medicare managed care for individuals dually eligible for both programs. As noted by interviewed experts and state officials, overseeing care delivery and payment for such a broad range of services and populations is challenging and requires significant state resources, staff time, and expertise.
To achieve efficiencies and enhance their MLTSS oversight capabilities in this complicated landscape, states described a number of strategies:
- Texas recently revamped its monthly MCO meetings to include representatives from multiple departments involved in managed care oversight (e.g., utilization review, quality improvement, and claims) to improve communication and information sharing across teams.
- California created an office of Medicare Innovation and Integration to better support and advance the development of innovative care models for Medicare and Medicaid beneficiaries.
- Virginia reorganized functional responsibilities related to compliance and oversight to allow staff more time to identify “big picture” trends, issues, and problems that affect multiple plans.
- Minnesota, which has been fully integrating Medicare and Medicaid benefits for dually eligible beneficiaries since 1997, implemented a redesign of its annual care plan audit for each MCO.
Next Steps
On March 21, 2024, NASHP and Arnold Ventures convened a virtual summit with state leaders to discuss MLTSS oversight best practices, key challenges, and priorities for the future. NASHP is also hosting a 15-month technical assistance opportunity to troubleshoot challenges and identify solutions to implementing a robust MLTSS oversight strategy. During this learning collaborative, three states will participate in regular calls with NASHP and each other to share best practices, learn from subject matter experts on oversight-related topics, and receive in-person site visits tailored to their specific needs.
Acknowledgements
NASHP would like to express our gratitude to Arnold Ventures for its support and partnership in this work. We would also like to thank the state officials and national experts who participated in interviews and shared their time and expertise with us.
