Provider Quality, Quantity and Continuity

Does the state require MCOs to maintain a diverse and robust network of providers

For a broad discussion of network adequacy in managed care, see the National Health Law Program’s report, Network Adequacy in Medicaid Managed Care: Recommendations for Advocates.

• sufficient to ensure consumer access and choice

  Tennessee requires MCOs in its MLTSS program to contract with at least two providers of each non-residential, community based LTSS and enough providers to ensure consumers can get all services required in their care plan “in the amount, frequency, duration and scope” required. The state and plans track how quickly services are started, what services are used and any missed visits. Plans face fines if they don’t meet network benchmarks (See pages 192-195 and 337 of the contract.)

• experienced and credentialed in LTSS

  Illinois requires MCOs in its dual eligible demonstration project to have procedures that govern participation in LTSS networks, including rules on credentialing. (See page 18 of the Illinois readiness tool.)

• culturally and linguistically competent

  Minnesota's Senior Health Options contract requires MCOs to provide consumers with access to providers who are culturally and linguistically competent in the language and culture of the consumers, including for those who are deaf or use sign language. In addition, MCOs must work to expand the pool of providers who are culturally and linguistically competent. (See page 187 of the contract.)

• accessible for people with disabilities

  Illinois’ contract for its dual eligible demonstration project requires MCOs to visit network providers to assess Americans with Disabilities Act compliance. (See page 70 of the contract.)

• trained in independent living and recovery philosophies, person-centered planning and self-direction

  Illinois’ contract for its dual eligible demonstration project requires MCOs to manage provider networks focusing on issues that include independent living philosophy and cultural competence. MCOs must visit provider locations to assess this. (See page 70 of the contract.)

Does the state work to enhance provider networks by

• routinely assessing unmet consumer needs and requiring network expansion

  Tennessee requires MCOs in its LTSS program to track every instance in which a consumer does not receive LTSS due to inadequate provider capacity and to expand the network or face sanctions. (See pages 194-195 of the contract.)

  California's dual eligible demonstration project will track unmet LTSS needs as one measure of MCO quality. The state and CMS will monitor need and access to care through surveys, utilization data and complaints and, if necessary, require MCOs to expand their networks. (See pages 83-86 and 115 of the Memorandum of Understanding.)

• regularly testing network adequacy with secret shoppers

  Tennessee monitors the adequacy of MCO provider networks through the use of “secret shoppers” who “periodically phone providers listed on [provider enrollment] reports to confirm that the provider” is part of the MCO network as well as by monitoring consumer appeals. See page 190 of the contract.)

• implementing strategies to increase and improve retention of direct care staff

  Tennessee’s contract requires MCOs to help the state develop an “adequate qualified workforce for covered long-term care services” through strategies focused on expanding and retaining direct care staff. Those strategies may include partnerships with colleges, creation of a worker registry and establishment of incentives. Each MCO is required to report annually to the state on its workforce development efforts. (See page 195 of the contract.)

• requiring training for personal care workers

  Arizona requires aides to complete an Arizona Medicaid-approved training course and testing program, based on a core-competencies curriculum developed by the state. Independently registered aides and those providing care for self-directed enrollees are exempt from these requirements. (See page 6 of this report.)

• reviewing capitated rates to MCOs, and MCO payment rates to providers to ensure these are not barriers to robust networks

  CMS guidance on MLTSS recommends this. (See pages 8-9 of the guidance.)

During the transition to managed care, does the state minimize disruption by

• requiring MCOs to include current community providers and offer transition support

  Texas required plans to enroll current providers for the first three years of MLTSS. (See this Kaiser report, Examining Medicaid Managed Long-Term Services and Support Programs: Key Issues to Consider.)

  Ohio’s dual eligible demonstration project requires MCOs to contract with Area Agencies on Aging for care coordination for individuals over the age of 60. (See page 56 of the Memorandum of Understanding.)

• permitting consumers to continue seeing non-network providers for at least a year and requiring MCOs to pay those providers the full Medicaid fee-for-service rate

  Ohio’s dual eligible demonstration project Memorandum of Understanding requires plans to maintain services including personal care, nursing, attendant care, out of home respite and day care at the current level with current providers for a year. (See pages 63-64 of the Memorandum of Understanding.)

• requiring plans to allow exceptions to network requirements when needed by consumers

  Massachusetts requires MCOs in its dual eligible demonstration project to offer single-case out-of-network agreements to providers who are: currently seeing enrollees, not willing to enroll in the provider network, and willing to continue serving those enrollees at the network payment rate. This applies only in certain circumstances. (See page 61 of the contract.)

• maintaining contract provisions for transitions among managed care plans

  Arizona requires MCOs to coordinate when a consumer is changing plans. The plan from which a consumer is leaving must notify the new MCO and inform them of any special care needs, and the new plan must coordinate with the old plan to ensure services are not interrupted. The new contractor must continue all services in the consumer’s existing care plan for 90 days unless the consumer agrees to any change. The new MCO must also designate a transition coordinator to work with the consumer. (See pages 44 of the contract.)

• allowing consumers to get previously authorized services until a new service plan is implemented

  Massachusetts, in its dual eligible demonstration project for people with disabilities, requires MCOs to comply with this policy. During the transition period, MCOs must provide services at the same levels and pay providers the same rates as before the consumer became a member of the new MCO. (See page 53 of the contract.)