Transcript Document
States, Dual SNPs and Medicaid
Managed LTC: High Complexity
Limits Widespread
Implementation
Muskie School of Public Service
Presented by Paul Saucier at the ACAP Medicaid Managed Care Policy
Summit
July 15, 2009
Washington, D.C.
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Muskie School of Public Service
Cutler Institute for Health and Social Policy
Acknowledgements
• ASPE Series on Special Needs Plans and
State Medicaid Programs (Prepared by
Thomson Reuters under contract to the
DHHS Office of the Assistant Secretary for
Planning and Evaluation) Hunter McKay,
Project Officer. Paul Saucier, Jessica Kasten
and Brian Burwell, Co-authors.
• Thomson Reuters technical assistance to the
Pennsylvania Office of Long Term Living,
Integrated Care Initiative.
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Why are states interested?
• Increase value in large and growing area of
state Medicaid budgets
– Better cost predictability
– Appropriate substitution
– Better accountability/quality focus
• Complement rebalancing efforts
• Medicare provider decisions impact LTC
• Win-win-win for consumers, payers, plans?
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MMLTC Enrollment Growth, 2004-2008
173,645
180000
160000
140000
120000
100000
80000
68,117
60000
40000
20000
0
2004
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2008
2004 figures from Saucier, Burwell, and Gerst, 2005. 2008 figures updated by Saucier.
Many states have engaged in serious
planning efforts
• Arizona, California (selected counties),
Colorado, Connecticut, Delaware,
Florida, Hawaii, Maryland,
Massachusetts, Michigan, Minnesota,
New Mexico, New York, Ohio, Oregon,
Pennsylvania, Rhode Island,
Tennessee, Texas, Vermont, Virginia,
Washington, Wisconsin
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10 have implemented MLTC outside
of PACE
• Arizona, California (selected counties),
Colorado, Connecticut, Delaware,
Florida, Hawaii, Maryland,
Massachusetts, Michigan, Minnesota,
New Mexico, New York, Ohio, Oregon,
Pennsylvania, Tennessee, Texas,
Vermont, Virginia, Washington,
Wisconsin
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Half of states with SNP contracts have
MLTC programs
Alabama
Massachusetts Tennessee
Arizona
Minnesota
Texas
California
New Jersey
Utah
Colorado
New Mexico
Washington
Idaho
New York
Wisconsin
Kentucky
Oregon
Puerto Rico
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Why haven’t more states included
MLTC in their SNP contracts?
• State capacity needs
• Dual eligibility issues
• Consumer and advocate perceptions of
MCOs
• Potential loss of position among HCBS
stakeholders
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State Capacity Needs
(MMC Capacity not Sufficient)
• Managing plans v. managing waiver
slots, providers
• Providing incentives v. direct role in
building community capacity
• Integrated care management v. waiver
services management
• Quality improvement v. assurances and
incident reporting
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Dual Eligibility Issues
• Degrees of integration
• Shifting federal policy
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Purpose and Population Example
This Contract……creates an
alternative delivery system for
acute and long-term care
services integrating Medicare
and Medicaid funding for
persons age 65 and over who
are Dually Eligible for Medicare
and Medicaid as well as those
who are eligible for Medicaid
only
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Due to increased budgetary
constraints, a desire to increase
efficiency and reduce
fragmentation of long-term
services, the State shall require
that most Medicaid recipients of
long-term care services…. enroll
in the State’s [name of initiative]
program.
Marketing Example
The MCO must submit all materials
for review, in a final format to the
STATE prior to receiving an
approval from the STATE, including
Medicare materials. The STATE and
CMS shall do a review of all
Medicare related materials. Upon
receiving STATE approval of
[program] material, the MCO is
responsible for submitting material
subject to CMS review, directly to
CMS for review. If CMS requires
changes to the STATE approved
material, the MCO shall submit a
copy of the final document to the
STATE.
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Contractor shall not distribute any
marketing or informational materials
intended for enrollees without first
obtaining approval from the
Department for Medicaid materials
and CMS for Medicare materials.
Care management example
The MCO must provide Care
Coordination/Case Management
services that are designed to
ensure access to and to
integrate the delivery of all
Medicare and Medicaid
preventive, primary, acute, post
acute, rehabilitation, and long
term care services, including
STATE plan Home Care
Services… and Elderly Waiver
services.
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The CONTRACTOR shall:
coordinate and collaborate with
Medicare Advantage plans for all
dually eligible Members who do
not elect to enroll with [the]
CONTRACTOR’s Special Needs
Plan..
MIPPA meets Medicaid
Medicare SNP Requirements
Medicaid Sec. 1915(c) Waiver
Requirements
Population: All Members
Population: Nursing Facility Certified
Eligible (NFCE) Members
Risk assessment (physical,
psychosocial and functional
needs). On initial enrollment,
and annually.
Level of Care Assessment (to
determine eligibility for waiver or
nursing facility services). When
a long term living need is
indicated, and at least annually
to recertify.
Care Plan (address all needs).
Individualized Service Plan (address
LTL needs).
Interdisciplinary Team manages
care.
Care Manager manages care.
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Source: Pennsylvania Office of Long Term Living, ICI Design Overview Draft
More Dual Eligibility Issues
• Challenging for state to capture savings
– Funding streams remain separate
– Substitution occurs, but who captures the
savings?
– Difficult to explain, and volatile federal
policy increases uncertainty for state
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Consumer and Advocate Perceptions
of MCOs
• Paternalistic, medical model of care will
roll back hard-won battles for social
model, self-direction
• Gatekeepers manage costs, not care
• Big on margin, small on mission
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Potential Loss of Position among
HCBS Stakeholders
• Who is managing waiver services today,
and what will their role be tomorrow?
• How will their relationship to state
government be altered?
• Is real partnership with MCOs possible?
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Catalysts for MLTC
• Clear and stable federal authority for
integration and aligned incentives
• Early stakeholder engagement, and
partnership building over time
• Explicit attention to consumer-centered
approach
• State infrastructure
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