A growing number of state Medicaid agencies are planning to launch or expand programs that offer risk-based contracts to managed care organizations (MCOs) to provide long-term services and supports (LTSS)—and, in some cases, acute and primary care—to older adults and people with disabilities. Because these individuals often have one or more chronic health conditions, they tend to use more health services than younger people and people without disabilities. In addition, they often depend on other services and supports such as personal care to perform activities of daily living, such as bathing and eating.
In risk-based managed care arrangements, state Medicaid agencies pay their contracted MCOs a predetermined monthly per-member rate and the MCOs bear financial risk for providing all covered services within the rate. These fixed payments make Medicaid costs more predictable for state governments, but they may create incentives for plans to restrict access to services for individuals who have costly health care needs. This potential risk highlights the importance of state oversight to ensure that MCOs comply with all contract requirements—including the provision of all LTSS required to provide optimal care to their enrollees.
AARP Policy Institute conducted a study to determine the specific capacities that state Medicaid agencies need to monitor the performance of managed LTSS (MLTSS) programs. It sought to identify promising practices in state oversight as well as the monitoring capacities that should be in place when states begin to implement new or expanded MLTSS programs. Lessons were drawn from oversight practices in eight states that have many years of experience operating and overseeing MLTSS: Arizona, Massachusetts, Minnesota, New Mexico, New York, Tennessee, Texas, and Wisconsin.
February 20, 2014
The Government Accountability Office (GAO) released a new report
citing how Medicaid spends a third of their funds on a small sect of high-expenditure Medicaid beneficiaries. The report, Medicaid: Demographics and Service Usage of Certain High-Expenditure Beneficiaries
, found that states spent 31.6% of all Medicaid expenditures on 4.3% of the Medicaid population. Furthermore, the report stated that certain characteristics, such as residing in a long-term care facility, contributed to individuals being deemed high-expenditure Medicare beneficiaries.
May 29, 2013
A new report
from the Urban Institute, funded by the Robert Wood Johnson Foundation, interviewed health care stakeholders in eight states to determine if Medicaid managed care programs were prepared for the imminent influx of beneficiaries resulting from the Affordable Care Act's (ACA) Medicaid expansion. Researchers found that managed care programs generally possess a strong organizational and operational structure that would permit them to readily absorb new beneficiaries. In an effort to mitigate the negative implications of churn, the study also found that some states will choose to offer private plans similar to those of Medicaid. One challenge addressed by the report was the ability of each state's health information technology to uptake a vast increase of new enrollees and eligibility processes.
September 24, 2012
The Medicaid program is both a federal and state effort to finance health insurance coverage for certain categories of low-income individuals and serves as a source of coverage for about 67 million individuals. Medicaid enrollment and spending have increased astronomically over the past decade and states are beginning to turn to managed care to provide services to Medicaid beneficiaries. Because states have such flexibility in implementing Medicaid managed care programs, there exists wide variation in terms of the scope of services they provide and the populations they enroll in managed care.
The Affordable Care Act (ACA) requires that all states expand eligibility for Medicaid to nonelderly individuals whose income does not exceed 133 percent of the federal poverty level (FPL); this expansion is estimated to result in the enrollment of an additional 7 million individuals in 2014. States that choose to provide Medicaid services to newly eligible individuals may do so through managed care arrangements.
In response to requests from Senator Jay Rockefeller (D-West Virginia) and Representative Henry Waxman (D-California), the Government Accountability Office (GAO) released
August 29, 2012
Medicaid paid for nearly half of the nation’s $263 billion long-term care expenditures in 2010. Federal law discourages individuals from artificially impoverishing themselves in order to establish financial eligibility for Medicaid. Specifically, those who transfer assets for less than fair market value during a specified time period before applying for Medicaid may be ineligible for coverage for long-term care for a period of time. The Deficit Reduction Act (DRA) extended the look-back period to 60 months and introduced new requirements for the treatment of certain types of assets, such as annuities, in determining eligibility. States are responsible for assessing applicants’ eligibility for Medicaid, the criteria for which varies by state.
The Government Accountability Office (GAO) was asked to...
August 28, 2012
Long-term and post-acute care providers and officials from the Office of the National Coordinator (ONC) for Health Information Technology recommended that Electronic Health Records (EHRs) design requirements focus on longitudinal care plans, transitions of care and patient assessments during a roundtable discussion held in May. A report summarizing
the roundtable discussion stated that federal health officials should offer long-term care providers incentives to adopt Stage 3 Meaningful Use criteria for EHR.
August 10, 2012
The National Association of Medicaid Directors sent
a letter to the Centers for Medicaid and CHIP Services (CMCS) Director Cindy Mann including recommendations on how to improve federal policies and procedures regarding managed long term supports and services programs.
June 6, 2012
The Congressional Budget Office presents
the long-term budget outlook under two scenarios in a new report. These scenarios embody different assumptions regarding future policies governing federal revenues and spending. The first, the extended baseline scenario, reflects the assumption that current laws generally remain unchanged and that lawmakers will allow changes that are schedule under current law to occur, forgoing adjustments routinely made in the past that have boosted deficits. The second, the extended alternative fiscal scenario, incorporates the assumptions that certain policies that have been in place for a number of years will continue and some provisions of law that might be difficult to sustain for a long period will be modified.
These two scenarios span a wide range of possible policy choices. The report focuses on the next 25 years and gives special focus to outlays for major health care programs.
Under both scenarios, the report estimates that total outlays for federal health care programs will grow much faster than the gross domestic product (GDP), increasing from 5.4 percent of the GDP in 2012 to nearly 10 percent in 2037. National health care spending is also expected to rise. Health care expenditures is expected to increase to almost one-quarter of the GDP by 2037. CBO suggested that key factors contributing to this growth in spending have been the emergence of new medical technologies, rising personal income, and the expanding scope of health insurance coverage.
October 17, 2011
The United States Government Accountability Office (GAO) released a report
, "Long-Term Care Hospitals: CMS Oversight is Limited and Should Be Strengthened," which recommends that the Centers for Medicare & Medicaid Services (CMS) strengthen its oversight of long-term care hospital (LTCH) survey activities and improve data collection on quality of care. LTCHs specialize in the provision of care to individuals with multiple or chronic conditions. CMS does currently collect data on the quality of care at LTCHs, but the GAO argues that the data are limited for several reasons. First, CMS does not have detailed data on survey results conducted by The Joint Commission (TJC) prior to 2009. Second, CMS does not currently collect data on LTCH quality measures regarding health care delivery because LTCHs are not required to report them. However, under the ACA, LTCHs will be required to make such reports beginning in 2014.
March 9, 2011
The Patient Protection and Affordable Care Act (ACA) has the potential to help States reorient their systems of long-term care. The goal is to move away from nursing homes and institutional care and toward a greater emphasis on home- and community-based services. This will enable States to both meet a broad range of needs and support family caregivers. The report
, "How The Affordable Care Act Can Help Move States Toward A High-Performing System Of Long-Term Services and Supports," published by Health Affairs, outlines five key characteristics of a high-performing system of long-term services and supports. The paper describes an emerging "scorecard" that could help measure states' progress toward this goal. Finally, the Health Affairs piece highlights aspects of the ACA which will support the creation of such a high-performing system for the disabled and those with chronic conditions.
February 23, 2011
More than 40% of the U.S. population has one or more chronic condition. Although the likelihood of having a chronic disease increases with age, approximately half of working-age Americans has at least one chronic condition. The prevalence of chronic diseases is increasing in both the elderly and non-elderly populations, with a significant increase in the number of people with multiple chronic diseases. Increased spending on chronic diseases in Medicare is a significant driver of the overall increase in Medicare spending over the last twenty years. Nevertheless, given the high cost of treating chronic diseases, the Affordable Care Act (ACA) includes many provisions to encourage chronic disease management as part of the overall emphasis on improving the efficiency of health care.