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Medicaid

Division of Medicaid and Long-Term CareDepartment of Health and Human Services

Managed Long-Term Services and Supports

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Nebraska Medicaid is in the process of developing a statewide Medicaid

managed care program for the delivery of long-term services and supports. The targeted implementation date is

July 2015.

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Let’s break it down . . .

What is Medicaid?• Medicaid is a state and federal partnership

program that covers medical care and long-term services and supports for low-income individuals.

• Medicaid is health insurance• Nebraska’s contract with the federal government

to provide Medicaid is called the State Plan.

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Let’s break it down cont’d. What are traditional medical services included in the State Plan? Examples include:• Hospital services• Physicians’ services• Mental health and substance use disorder services (also known as behavioral health services)• Pharmacy services• Durable medical equipment and medical supplies• Dental services• Radiology• Lab work• Therapies• Visual care services

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Let’s break it down cont’d.

What are traditional long-term services and supports included in the State Plan? Examples include:• Nursing facility services• Home health care• Hospice care• Personal Assistance Service (PAS)

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Let’s break it down cont’d.Other long-term services and supports included because of a “waiver” to the State Plan include:• Aged and Disabled Waiver Services, including services such as-

-Assisted Living-Home Care/Chore-Home-Delivered Meals-Personal Emergency Response Systems-Respite Care

• Traumatic Brain Injury Waiver Services, including--Assisted Living

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Currently, clients who need long-term services and supports have their long-term care needs and medical care delivered (paid for) by Medicaid through a system called Fee for Service (FFS)• Client sees provider• Provider bills Medicaid• Medicaid pays retrospectively• Quality of care is not monitored• Coordination of care is not provided

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The managed care delivery system is different:• Nebraska Medicaid contracts with a managed care organization

(MCO)• The MCO contracts with providers to participate in its provider

network• Nebraska Medicaid pays the MCO a “per member per month”

(PMPM) payment for each enrolled client• Out of this money, the MCO pays its network providers for the care

and services they provide clients• The MCO must cover the care and services in the benefits package in

the same amount, duration, and scope as FFS• The MCO can place appropriate limits on the care or services based

on medical necessity or utilization control• What constitutes medical necessity cannot be more restrictive than

what is used in FFS

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The MCO also –• Assigns a Primary Care Provider (PCP) if the client

doesn’t choose one within the MCO’s provider network

• Provides case management• Offers disease management• Can offer substitute or value added services

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Nebraska Medicaid is developing a managed care program for the delivery of long-term

services and supports with a targeted implementation date of July 2015.

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Managing long-term services and supports will enable Nebraska Medicaid to accomplish the following goals for clients who use long-term services and supports: • Improve client health status and quality of life by better

coordination of medical care, behavioral health care, and community-based services and supports.

• Promote client choice and use of the right services and supports at the right time in the right amount.

• Increase client access to responsive, quality services and supports.

• Use financial resources wisely to sustain Nebraska Medicaid.

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Centers for Medicare and Medicaid Services (CMS) “Essential Elements” of Effective Managed Long-Term

Services and Supports (MLTSS) Programs:

• Adequate Planning and Transition Strategies-Thoughtful and deliberative planning process -Planned client and provider outreach, education, and transition-Rapid identification and resolution of MLTSS problems

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“Essential Elements” cont’d• Stakeholder Engagement

-Stakeholder input in program design, implementation, and monitoring

*State established advisory group*Broader public input by means of local town hall-type meetings and web-based input

-State website with current information about the MLTSS program initiative

-Managed care organization stakeholder advisory committees

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“Essential Elements” cont’d• Enhanced Provision of Home and Community- Based

Services (HCBS)-Services provided in the most integrated setting

possible• Alignment of Payment Structures and Goals:

-Encourage the delivery of community-based care• Support for Beneficiaries

-Independent, conflict-free eligibility determination and functional assessment processes

-Availability of independent ombudsman program

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“Essential Elements” cont’d• Person-centered processes

-Person-centered service planning process that promotes:*Use of self-determination principles*Active engagement of the client and individuals of their choice*Service plan reflects the client’s or caregiver’s needs and preferences

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“Essential Elements” cont’d• Comprehensive, Integrated Service Package

-Physical and behavioral health care, dental care, and pharmacy will be included in the benefits package-Comprehensive needs assessment

• Qualified Providers-State specified provider network composition and access requirements-Provider support during transition to MLTSS

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“Essential Elements” cont’d• Client Protections

-Statement of client rights-Critical incident reporting system-Complaints process-Appeal rights

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“Essential Elements” cont’d• Quality

-Comprehensive Medicaid managed care quality strategy that is integrated with other relevant State quality initiatives and includes quality measures-Mandatory managed care organization reports related to the critical elements of MTLSS such as network adequacy; client health and functional status; and appeal actions-Measurement of key experience and quality of life

indicators

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Next Steps for MLTSS Implementation

• Continue outreach to clients, family members, advocates, providers and other stakeholders to solicit input on the design and implementation of MLTSS; hear concerns; answer questions

• Develop Request For Proposal (RFP) to post in 2014 to procure the managed long-term services and supports managed care organization

• Obtain CMS approval of waivers and amendments to the Medicaid State Plan as necessary

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MLTSS Website Address:http://dhhs.ne.gov/medicaid/Pages/MLTSS.aspx

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Now let us hear from you!

Email Comments and Questions to DHHS.MedicaidMLTSS@nebraska.gov

Address to which surveys can be sent:Attn: Julie DocterDHHSP.O. Box 95026Lincoln, NE 68509-5026