Adequate Planning

Has the state allocated adequate time for planning

Before implementing managed LTSS for individuals with I/DD in 2016, Tennessee conducted an 18- month planning and discussion process with stakeholders, including individuals with I/DD and their families, groups who advocate on their behalf, and providers. (see pages 17 and 18 of Tenncare’s State Amendment 27 Request). The state continued to revise the program as it was implemented, based on stakeholder feedback. (see Amendment 37 request).

CMS and its consultant Truven Health Analytics developed a timeline for MLTSS program development

Has the state set clear goals including

• expanding home and community based services

  Federal law requires that people be able to get services in the least restrictive environment possible. Managed LTSS programs provide a mechanism to shift the balance of services from institutions such as nursing homes to people’s homes and other community settings. Nearly half of all MLTSS programs identify increasing access to HCBS as a goal. (See pages 17-18 of this report.)
  
  Rhode Island spells out goals for its dual eligible demonstration to include: increasing the proportion of individuals successfully residing in a community setting, and improving and maintaining enrollee quality of life and care. (See page 2 of the Memorandum of Understanding.)

• making the program person-centered

  CMS regulations effective March 2014 require LTSS programs to be person-centered. This means that the consumer drives the care planning process, selects the members of her care team, and has choice of services, providers and settings. In addition, her goals, preferences, strengths and needs drive the services she gets. (See pages 3029-3030 of the regulations.)

• covering a full range of LTSS in all settings

  LTSS should include all the non-medical social services needed to ensure consumers can live full lives with as much participation in employment, education and community activities as they choose. This should include assistance with daily activities and personal care, chores, transportation, provision of assistive technologies, rehabilitation, peer and recovery services, support for family caregivers, home modifications, and other nontraditional services, such as air conditioners or gym memberships, if needed. These services should be offered in settings including the consumer’s home, provider’s offices, group homes, assisted living facilities and nursing homes. There should be no waiting lists or caps on services. Massachusetts’ dual eligible demonstration is among the programs with very comprehensive coverage. (See pages 266-287 of the contract.)

• addressing the specific needs of the population to be enrolled, for example, employment supports for people with I/DD

Has the state worked with a planning team including

• state agency officials with expertise in LTSS, mental health, substance use disorders, aging, managed care, chronic diseases and physical, intellectual and developmental disabilities

  CMS guidance on MLTSS says: “States will be expected to demonstrate that they have coordination and communication processes in place with other state agencies that support the populations enrolled in the MLTSS program, such as the aged, those with physical, intellectual and developmental disabilities, those with chronic diseases, and those with mental health or substance abuse issues.” (See page 5 of the guidance.)

• consumers and consumer advocates with experience and expertise in LTSS for each of the populations to be enrolled

  Massachusetts’ dual eligible demonstration project for people with disabilities involved a broad range of stakeholders, including consumers and consumer advocates in the planning.

• LTSS stakeholders

  Rhode Island engaged a broad range of stakeholders over an extended period in planning its move to MLTSS. (See pages 28-30 of the state's proposal for its demonstration program.)

• hired LTSS experts, if needed, including those specializing in serving each of the populations to be enrolled
  

  California added staff with expertise in managed Medicaid and Medicare services for its dual eligible demonstration. (See page 2 of this report from the Center for Health Care Strategies.)

Has the state included these components in its preparations

CMS guidance on MLTSS discusses planning and preparation. (See pages 4-8 of the guidance.)

• plans for stakeholder and consumer engagement

  CMS guidance requires stakeholder engagement plans for both managed LTSS and dual eligible demonstrations covering planning and monitoring.

  Community Catalyst’s report, A Seat at the Table: Consumer Engagement Strategies Essential to the Success of State Dual Eligible Demonstrations, discusses what a robust plan looks like, including broad consumer membership on statewide oversight councils and workgroups, requirements for MCOs and other delivery systems to implement engagement strategies, and established timetables and mechanisms for collecting feedback from individual consumers.

• plans for education of and outreach to consumers, families and caregivers about LTSS changes, including what will change and how to navigate managed care

  CMS MLTSS guidance requires states to devise plans for educating prospective enrollees and their caregivers about “how their LTSS will change and the choices they will be able or required to make.” (See page 7 of the guidance.)

  Florida uses an independent enrollment broker and conducts outreach in partnership with community providers and its Aging Resource Centers. To facilitate the transition of enrollees, it conducted public information meetings in each of the state's 11 geographic regions. It requires plans to offer a website for enrollee information. (See pages 28-30 of Florida’s 1915(b) waiver.)

• plans for education of providers, contractors and community organizations

  CMS guidance (page 7) advises states to provide educational sessions to help community based organizations understand MLTSS and the process of transitioning LTSS to managed care, as well as to prepare them to answer questions from consumers.

  Devising a communications strategy for this purpose is discussed in detail in the Center for Health Care Strategies’ A Communications Work Plan to Engage Stakeholders in Medicaid Managed Long-Term Services and Supports Program Development.

• Information technology (IT) systems

  CMS guidance on MLTSS says states should “develop information technology systems, data collection, and health information technology processes” to facilitate management of the program. (See page 5 of the guidance.)
  
  South Carolina’s dual eligible demonstration uses a web-based record to track intake, assessment and care planning activities and track compliance with federal regulations. (See page 15 of the contract.)

• plans for state management of program, including staff training

  The Center for Health Care Strategies discusses key elements of this process for dual eligible demonstrations in Building State Capacity to Implement Integrated Care Programs for Medicare-Medicaid Enrollees.

• plans for oversight including independent ombudsman and state monitoring

  CMS guidance says each MLTSS program must have an independent ombudsman or advocate. (See page 10 of the guidance.) CMS also requires states to provide CMS with a description of how they will oversee the program. (See pages 4-5 of the guidance.)

  For additional resources on oversight, see AARP's Keeping Watch: Building State Capacity to Oversee Medicaid Managed Long-Term Services and Supports.

• plans for rapid identification and resolution of problems including state hotline
  

  Kansas and MCO officials held daily teleconferences with Medicaid providers and consumers to help troubleshoot problems as they arose in the days before rollout of its managed care program and for weeks afterward. However, Kansas has struggled to fix many problems with its program.

• transition plan from fee for service to managed care for providers and consumers, including phase-in starting with low-need consumers

  Consumers need continuity of care as they switch from a fee for service to managed care system. Massachusetts’ transition plan for its dual eligible demonstration included four enrollment phases over one year (three of which are described here) starting with consumers who have the lowest acute needs.  The demonstration also includes requirements to protect existing care routines and provider relationships. See pages 65-66 of the contract.

• draft quality strategy

  CMS guidance requires states to develop a draft quality strategy as they begin moving toward managed LTSS, as a step toward a comprehensive quality initiative for the program. (See pages 6, 15-17 of the guidance.)

Has the state assessed the readiness of each managed care organization (MCO) to ensure they have the following

For a more detailed discussion of MCO readiness issues, see Community Catalyst’s report, The Dual Eligible Demonstration Projects: State and Health Plan Readiness.

• consumer hotline

  Many states require MCOs to maintain hotlines or call centers. Illinois’ contract with its dual eligible demonstration MCOs requires them to maintain call centers that are open at least 12 hours a day and address a full range of concerns in each consumer’s primary language. (See pages 96-99 of the contract.)

• LTSS expertise in leaders, line staff and contractors

  CMS guidance on MLTSS says: "States must require that MCOs have comprehensive LTSS training, experience, and expertise incorporated into their MLTSS operations and management, including care and disease management staff. This must extend to any subcontractors that MCOs might employ to deliver services under their MLTSS contracts." (See page 5 of the guidance.)

  California’s readiness review for its dual eligible demonstration requires MCOs to have a policy and procedure to train all staff on LTSS, and to have LTSS agency staff train MCO staff about LTSS programs. (See pages 28, 31 of the readiness review).

  Texas officials interview a sample of service coordinators to determine whether they have received adequate training. Service coordinators are tested on their response to specific scenarios. (See the AARP Public Policy Institute’s report on network adequacy.)

• training for MCO staff in independent living, recovery philosophies

• training for MCO staff in self-direction and person-centered planning

  Massachusetts is offering trainings for MCO staff and providers. Topics scheduled so far include independent living, self-determination, and the recovery model; behavioral health, recovery and peer supports; cultural competency with a focus on both disability and race and ethnicity.In Tennessee’s managed LTSS program for individuals with I/DD, MCO Support Coordinators are required to complete person-centered planning training requirements (see page 10-11 of Tennessee’s Amendment 27 Application).

  In Tennessee’s managed LTSS program for individuals with I/DD, MCO Support Coordinators are required to complete person-centered planning training requirements (see page 10-11 of Tennessee’s Amendment 27 Application).

• financial solvency

  Massachusetts requires its Senior Care Options MCOs to maintain enough reserves to provide to enrollees all covered services for at least 45 calendar days if the plan became insolvent. (See page 56 of the contract.)

  California spells out detailed requirements for solvency of MCOs in its dual eligible demonstration, including net assets, reserves and working capital. (See pages 86-89 of the Memorandum of Understanding.)

• above average quality ratings from the Centers for Medicare and Medicaid Services and the National Committee for Quality Assurance

  CMS will not allow MCOs in the dual eligible demonstration to enroll auto-assigned consumers if the MCOs score fewer than three stars for three or more consecutive years on Medicare ratings. CMS bars MCOs under sanction for enrollment or marketing violations from participation. (See pages 3-7 of the guidance. We recommend against states contracting with MCOs that have below average ratings or are under sanction.)

• consumer engagement plan

  CMS guidance says states must ensure MCOs “maintain effective systems for engaging participants” including advisory boards. See page 7 of the guidance. Community Catalyst’s A Seat at the Table: Consumer Engagement Strategies Essential to the Success of State Dual Eligible Demonstrations recommends a more robust engagement strategy. Community Catalyst spells out how plans can implement a robust engagement plan in this tool.

• Americans with Disabilities Act (ADA) compliance plan

  In their contracts with MCOs for their dual eligible demonstrations, Illinois and Massachusetts both require the MCOs to designate an ADA compliance officer and establish and annually update a work plan to achieve and maintain ADA compliance. (See pages 68-69 of the Illinois contract.)

• compliance plan for mental health and addiction parity

  Massachusetts’ contract for MCOs in its dual eligible demonstration project explicitly requires MCOs and providers to comply with the federal parity law, and includes detailed requirements on behavioral health services. (See pages 36-39 of the contract).

• strategies to address racial and ethnic disparities

  For recommendations, see Community Catalyst’s report: Miles to Go: Progress on Addressing Racial and Ethnic Health Disparities in the Dual Eligible Demonstration Projects.

• compliance plan for federal standards on cultural and linguistic competence

  Arizona’s MLTSS contract requires MCOs to carry out a Cultural Competency Plan that addresses all settings and services, and complies with requirements for people with Limited English Proficiency. MCOs must also annually submit an assessment of the plan’s effectiveness. (See page 152 of the contract.)

• robust networks of skilled, culturally competent community providers

  New Mexico’s MLTSS contract with MCOs requires them to develop and implement a Cultural Competency/Sensitivity Plan to ensure the MCO “provides both directly and through its network providers and subcontractors, culturally competent services to its members” and participates in the state’s efforts to “promote the delivery of services in a culturally competent manner to all Members, including those with limited English proficiency and diverse cultural and ethnic backgrounds.” (See pages 13, 139, and 293 of the contract.)

• ongoing plans for consumer and provider education about managed LTSS

  Massachusetts, in its dual eligible demonstration, requires MCOs to provide ongoing education for providers about best practices in delivery of LTSS and other services to maximize independent living and enrollee self-reliance, availability and range of services, including behavioral health, community based services and LTSS services, person-centered planning processes and cultural competency, maximizing independence and functioning of enrollees through health promotion and prevention and assisting enrollees to maximize their involvement and decision-making about their care. (See pages 69-70 of the contract.)

  In Ohio’s  capitated dual eligible demonstration project, the state will work with Aging and Disability Resource Networks, the Ohio Senior Health Insurance Information Program (OSHIIP) and “other local partners to ensure ongoing outreach, education and support to beneficiaries” in making enrollment decisions that best meet their needs.  (See page 8 of the Memorandum of Understanding.)