Considerations Regarding Managed Care, People with Disabilities

Considerations Regarding Managed Care, People with Disabilities and 1115 Waivers. Information Bulletin # 352 (2/2012)

As discussed in the last Information Bulletin, the AARP and NASUAD recently released report “On the Verge: The Transformation of Long-Term Services and Supports” pointed out that 12 states already have Medicaid Managed Long Term Services and Supports (MMLTSS) and another 11 states report plans to implement managed care LTSS in 2012 and 2013.

Here are some points that advocates might want to consider about managed care for people with disabilities.

1. There should be a “blended rate” per person with a disability. That is, your state should enter a contract to pay the managed care entity the same rate per person whether the person is in the community or in a nursing home, a state center or an ICF-MR. This gives the managed care entity an incentive to provide services in the community.

2. Blended rates contain assumptions, based on your state’s previous year’s data regarding the numbers of people receiving LTSS services in the community and in a nursing home.

3. Publish and mandate “performance requirements,” e.g., what must be in an assessment and care plan. Make sure services in a care plan are actually developed and provided in the community within 15-30 days of the assessment and agreed on care plan.

4. Require Quality Improvement Reports [QIOs], conducted by separate, outside, independent contractors to evaluate the managed care entity’s performance. CILs are a natural for this.

5. Make sure that appeal rights and clearly delineated, especially with regards to type and amount of community-based services.

6. Build into the contract with the managed care entity both carrots and sticks, i.e., if there is too high an admission rate to institutions with managed care, penalize them via the capitation rate. Similarly, if they serve more people in the community than was anticipated, reward them the same way.

7. Build in specific incentives to keep people in the community with home and community-based services, including self-direction, relatives being paid for personal assistance services.

8. Do no permit “carve outs” regarding location of service. That is, the managed care company should be fully and entirely responsible for both institutional and community-based services for as long as a person is MA eligible. In managed-care parlance, there should be no “risk corridors” whereby the State assumes payment of institutional care if the person is instititutionalized for a specific number of days. This should give managed care companies a financial incentive to serve persons with adequate and appropriate community-based services.

9. Do not permit “carve outs” based on type of disability. If managed care is good and proper for some people with disabilities, it can and should serve people with any disability.

10. Every disabled person who is currently on MA, regardless whether s/he is in the community or in an institution should be part of the managed care program and capitation rate.

11. Require the managed care entity to have a “transition out” program for persons already institutionized. The capitation rate could include one-time transition costs to ensure people already institutionalized received the start-up items they require.

12. We know that many people with disabilities go directly from an acute care hospital to an institution without being offered any real choice and without adequate and appropriate community-based services being offered. Therefore, make sure the managed care contract has a requirement that the managed care entity and the hospitals must enter an agreement to ensure hospitals do not continue dumping people with disabilities in nursing homes.

We know that many advocates are vehemently against managed care for people with disabilities. The purpose of this Information Bulletin is not to advocate for or against MMLTSS. Rather, since 23 states have left or are leaving the station, we think there should be some public dialogue.

Special thanks to Leslie Hendrickson for his time, insights and suggestions.

Steve Gold, The Disability Odyssey continues

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