Comprehensive Integrated Service Package

• Does the state require MCOs to provide or coordinate a full range of services for physical health, behavioral health, and LTSS, including peer and recovery services

  Arizona’s ALTCS program includes all these services. (See pages 42-60 of Arizona's ALTCS contract.)

  Tennessee’s Medicaid program, TennCare, hires managed care companies to manage this full range of services. (See pages 44-53 of the contract.)

  CMS guidance on MLTSS says: “MCOs must provide, and/or coordinate the provision of, all physical and behavioral health services and LTSS (including institutional and non-institutional)... as this can promote service integration, increase efficiency, avoid cost shifting and disincentives to the provision of services, and enhance health outcomes and quality of life.” (See pages 11-12 of the guidance.)

• If the state carves out services from MCO control, does the state provide justification and routinely assess whether this harms consumers or violates their right to care in an integrated setting

  CMS guidance on MLTSS says: “The state will be expected to justify service ‘carve-outs’ and explain how the goals of integration, efficiency, appropriate incentives and improved health and quality of life outcomes will otherwise be achieved.” (See page 12 of the guidance.)

• Do consumers get needed supports to transition among care settings, including among home, hospital and nursing home

  Tennessee’s MLTSS contract requires MCOs to ensure transitions work for the consumer, with a focus on helping consumers remain in or return to the community. These include: for consumers who are in a nursing home, the MCO care coordinators are required to work with nursing home staff to facilitate a return to community living if possible; and for consumers who are hospitalized, the MCO must screen the consumer for needed LTSS services and work with hospital discharge planners to set up those services prior to discharge. The MCOs must also work with providers to help sustain community living and avoid unnecessary nursing home stays. (See pages 29 and 110-124 of the contract.)

• Does the state set a medical loss ratio that requires MCOs to spend at least 85 percent of premiums on services and supports

  Ohio has set a medical loss ratio (MLR) of 85-90 percent for its dual eligible demonstration MCOs. South Carolina, Illinois, Rhode Island and New York have set 85 percent MLRs for their dual demonstration MCOs. (For example, see page 138 of the Ohio contract.)

• Does the state prohibit waiting lists or caps on services

  South Carolina’s dual eligible demonstration Memorandum of Understanding says the program will eliminate waiting lists for those who qualify for HCBS waiver services. (See page 15 of the Memorandum of Understanding.)