Introduction
Through a partnership with Arnold Ventures, 10 states participated in the National Academy for State Health Policy (NASHP)’s MLTSS Learning Collaborative, with some of these states receiving monthly technical assistance and site visits. The goal of the project was to create a forum and provide support for states to explore, develop, and/or strengthen policies and strategies to improve care for individuals enrolled in Medicaid managed long-term services and supports.
What do MLTSS and D-SNPs Mean?
Managed long-term services and supports (MLTSS) is a service delivery method where states partner with managed care organizations (MCOs) to provide MLTSS for individuals with complex health and social service needs. As of July 2025, 25 states have a MLTSS program. Through their contracts with MCOs, states hope to achieve a wide variety of outcomes in their MLTSS programs, such as increased access to and enhanced quality of home and community-based services, better care coordination, and cost-containment.
Dual-Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage plan specifically designed to support individuals who qualify for both Medicare and Medicaid. To operate within a state, each D-SNP must establish a State Medicaid Agency Contract (SMAC) with the respective state Medicaid agency. These contracts allow states to include specific provisions aimed at enhancing care coordination and quality of care, generate potential cost savings, and require integration between Medicare and Medicaid services.
During the MLTSS collaborative, state leaders engaged through roundtables, monthly calls, and site visits. States received technical assistance from Altarum Medicare-Medicaid Services for States (AMMS), and they shared information with each other on strategies to improve MLTSS quality and oversight. These strategies included care coordination, contract management and oversight, and stakeholder engagement, especially for dually eligible Medicare-Medicaid populations.
Technical assistance for states extended to understanding and improving care coordination between Medicaid and D-SNPs. This brief outlines snapshots of these state innovations and lessons learned.
State Innovations Can Address Key Care Coordination Challenges
A benefit of MLTSS is care coordination across the continuum of services and supports for Medicaid enrollees, which can be a key driver of individual access to, experience, and quality of care and services. While care coordination requirements vary by state, common elements include:
- Health risk assessments, required to be completed a certain time after enrollment, which can help inform the development of person-centered care plans.
- Person-centered care plans, created in consultation with and focused on enrollees’ needs, goals, and preferences.
- Interdisciplinary care teams, often consisting of enrollees, providers, family members, and support professionals, such as care coordinators.
Many states face challenges in providing high-quality care coordination. Several report difficulties reaching and engaging members with complex needs, including people with behavioral health conditions, intellectual and developmental disabilities, dementia, or people experiencing homelessness. Workforce shortages and high care coordinator turnover rates can also make it difficult for states to hire and retain care coordinators. To address these challenges, states shared several innovative strategies:
- California’s Enhanced Care Management program is a statewide Medi-Cal managed care benefit designed to address coordination challenges for difficult-to-reach populations, such as people experiencing homelessness, substance abuse disorder, or transitioning from incarceration. This service provides intensive coordination services to address both clinical and non-clinical needs of members by building trusting relationships and meeting members wherever they are. Members are assigned one care manager who coordinates all health and health-related care and can provide additional connection to community supports.
- Minnesota partnered with its managed care plans to develop a Care Plan Audit Protocol, an intensive process where plans, under state supervision, examine assessments and care plans created for members to evaluate their care planning and coordination processes for MLTSS and 1915(c) home and community-based (HCBS) waiver enrollees. This process also allows the state to identify larger trends and common problems, and it builds in incentives to reward high-performing plans.
- Virginia‘s 2025 D-SNP state contract and its Medicaid managed care contract, Cardinal Care Managed Care, address care manager workloads by encouraging plans to hire care management “extenders” who assist with administrative tasks such as filing paperwork. If plans choose to hire an extender, their corresponding case manager receives a 20 percent increase in their allowed staffing ratio.
Effective Contract Management Depends on State Oversight and Accountability Tools
State contract management and oversight is crucial in the development of a robust MLTSS program. However, state administrative capacity, data management and analytic experience, and the establishment of quality metrics and a rate methodology can pose challenges. When developing a contract management strategy, states can consider the following approaches:
- Prescriptive versus less prescriptive contract language: States can set clear expectations and requirements to hold plans accountable, while also allowing flexibility for innovations (e.g., dictating staffing levels for care coordination by Health Risk Assessment score levels versus allowing health plans to set).
- Readiness review frequency: This review can vary from a “one-and-done” review to periodic, ongoing readiness reviews by target areas (e.g. states can identify areas such as network adequacy for specific provider types at regular intervals).
- Staff oversight structure: To ensure maximum efficacy, states can assign one staff person per each plan contract who can act as a liaison with other state agencies and use contractors to supplement staff capacity. Additionally, quarterly or more frequent meetings between health plans and Medicaid and other state agency subject matter experts can break down both internal and external siloes (e.g. tapping into and including experts from the Aging Agency and or Disability Agency, depending upon meeting agenda focus).
- Tools for accountability: States can align reporting with program goals and establish both incentives and penalties to ensure quality of care (e.g. tie to care transitions from hospital inpatient stays and longevity living in the community for specific populations).
State Snapshots
California’s Department of Health Care Services created a series of internal and external dashboards to approve efficiency on how the agency receives data. This enables a faster data turnaround time, allowing for early identification of potential administrative and operational issues. Additionally, the automated data processing helps prevent delays, enabling the Department to review data more promptly for anomalies and trends.
Massachusetts’s Executive Office of Health and Human Services worked with the Centers for Medicare and Medicaid Services (CMS) to develop a contract management tracker. The purpose of this tracker is to gather additional data each month outside of the normal compliance reporting information. Massachusetts has used these data to facilitate conversations and identify trends such as approved/denied service determinations, appeals/grievances, marketing issues, among others. As an outcome of this tracker, Massachusetts created an “issue” tracker within its system to easily view active/closed issue cases and generate annual reports.
Virginia’s Department of Medical Assistance Services (DMAS) originally structured its plan contract oversight among various departments. This resulted in compliance monitoring being buried within structural hierarchies. In response, the Department created a new Office of MCO Compliance and Monitoring to promote coordination and to elevate the visibility and importance of holding health plans accountable. Additionally, Virginia established a 360-degree performance review with their MCOs that focus on a variety of performance areas. This resulted in a more holistic review of MCO performance across multiple domains.
Meaningful Engagement Uses Dual Eligible Perspectives to Improve Programs
Dual-eligible populations — members enrolled in both Medicare and Medicaid — can provide states with insights about program gaps and areas for improvement because of their lived experiences. Building a robust stakeholder engagement and feedback system helps ensure states effectively serve these individuals, who typically face high needs, costs, and a complex health care and service delivery system. States interested in improving their engagement with dual-eligible populations can consider the following:
- Identify and work collaboratively with “Champions for Engagement”: States can work closely with plans or other trusted community partners (such as community- or faith-based organizations) to develop communication strategies specific to the communities with whom they are looking to engage.
- Meet people “where they are”: To promote engagement, states can consider hosting in-person events at familiar community locations alongside or co-hosted by community partners. Accommodations, such as transportation, interpretation services, and food, can remove barriers to engagement.
- Create permanent or ongoing communication channels: States can promote continuous feedback and communication with their members by forming standing councils, meetings, or health plan advisory boards.
- Operationalize feedback and “close the loop” with stakeholders: When possible, it is important for states to not only hear feedback but to also operationalize and consider feedback in the development of policies and programs. By “closing the loop,” states can follow up with stakeholders to communicate their work to address concerns and promote future engagement.
Engagement with these sometimes hard-to-reach populations takes concerted effort, but several states have successfully fostered this communication and feedback to improve programs:
- California‘s Medicare and Medi-Cal Ombudsperson Program contracts with legal aid and advocacy organizations to provide support, answer questions, and handle complaints from dual-eligible members. Regular meetings between the state and ombudspersons create an important feedback mechanism to identify and resolve common issues and system-wide problems faced by members.
- Massachusetts‘ One Care Implementation Council provides ongoing feedback to improve the program and provide accountability and transparency. Although supported by the state, the council and meetings are led by One Care members. The state notes that the council’s feedback has generated concrete changes to the One Care program, such as modified care coordination contract language with One Care health plans.
- Idaho recently conducted statewide outreach and stakeholder meetings to engage diverse populations, including Spanish-speaking, refugee, and tribal communities. Idaho also works to improve communication through state branded FAQs and flyers that are designed to share complex information in an easy-to-read format.
- Indiana has leveraged several stakeholder engagement strategies to inform the development and receive early feedback on their newly implemented PathWays for Aging Program. These include office hours for specific populations, webinars, public meetings, advisory groups, and in-person discussions on populations of focus, facilitated by community partners.
Conclusion
Care coordination, contract management and oversight, and stakeholder engagement are a few of the core pillars to any MLTSS program. Care coordination provides enrollees with a continuum of care across often-complex health and social service systems. Contract oversight is critical to ensure efficacy and stewardship of public dollars. Equally important is stakeholder engagement that informs the life cycle of these polices from development to implementation. Many states in the learning collaborative are working to better integrate and improve care for dually eligible members with Medicare and Medicaid coverage. As states’ Medicaid managed care programs evolve, it is important to tie these policies to outcomes that are informed by stakeholder engagement, robust data and quality measures, and enforced through strong state oversight and contract management.
Acknowledgments
NASHP would like to express our gratitude to Arnold Ventures for its support and partnership in this work. We would also like to thank Altarum Medicare-Medicaid Services for States (AMMS) and the state officials for sharing their time and expertise with us through their participation in NASHP’s Learning Collaborative. Additionally, the authors wish to thank the state officials and NASHP staff who reviewed this brief.
