Participant-Directed Services in Managed Long-Term Services and Supports Programs: A Five State Comparison. 3.1. General Program Characteristics


Four (Arizona, New Mexico, Tennessee, and Texas) of the five study states integrate medical (primary and acute), community-based LTSS, and institutional long-term care (intermediate care and skilled nursing facilities). Three of the states (Arizona, Tennessee, and Texas) also include behavioral health services. As noted in Appendix B, Table B1: State PD-MLTSS Program Overview, all five states offer an employer model and three states (New Mexico, Tennessee, and Texas) also offer a budget authority model. The following describes the states' extant environments and general program design elements:

  • The majority of the states use Section 1115 waivers to implement PD-MLTSS: Perhaps because of its flexibility, three states (Arizona, Tennessee, and Texas) currently use Section 1115 to demonstrate innovation while maintaining budget neutrality. While New Mexico currently uses Sections 1915 (b) [Managed Care Waiver] and (c) [Home and Community-Based Services Waiver], they recently received approval to implement PD-MLTSS under Section 1115 and will begin to do so in January 2014. Massachusetts uses Sections 1915 (a) and (c) to offer voluntary participation.

  • All five states contract with multiple MCOs: As described in Appendix B, Table B1: State PD-MLTSS Program Overview, each state currently contracts with between two and five MCOs. In four states (Arizona, Massachusetts, New Mexico, and Tennessee), the MCOs are not-for-profit and for-profit organizations. All the current MCOs contracted with Texas are for-profit organizations.

  • All five states enroll elders and adults with disabilities in PD-MLTSS while four of the five carve out individuals with intellectual developmental disabilities (IDD): Only one of the state programs (Arizona) includes individuals with IDD in PD-MLTSS. What also makes Arizona unusual is that the state Developmental Disability Operating Agency is the MCO for the IDD population. Arizona's Medicaid program for people with IDD operates under a Section 1115 waiver that enables the Arizona Health Care Cost Containment System (AHCCCS) to be both the single state Medicaid agency and a state-operated, statewide managed care plan. A recent review indicates that this arrangement has worked well for the IDD population in Arizona.15

  • Three of the five states offer both employer and budget authority PD-MLTSS: Arizona and Massachusetts only offer the employer authority model of participant direction while New Mexico, Tennessee, and Texas offer both employer and budget authority. Although Tennessee and Texas meet CMS requirements for offering budget authority, the budget authority model in both states operates under a number of restrictions. In Tennessee, budget authority is listed as an option but is used to a limited degree. In Texas, budget authority is limited to employment supportive items (e.g., fax machines, worker bonuses, health insurance, vacation pay, etc.). Among the five study states, only New Mexico currently offers a budget authority model as it is traditionally defined. In New Mexico, a participant who wants to self-direct their personal care attendant and is eligible under the state's Coordinated Long Term Services program transitions to the Mi Via waiver. Services offered in Mi Via include homemaker, chore, respite, Personal Assistance Services, etc. New Mexico will continue to offer both employer authority and budget authority options under its new MLTSS program, Centennial Care, as the Personal Care Option and Self-Directed Community Benefit, respectively. New Mexico IDD self-directing participants are carved out of Centennial Care and will continue to receive services under Mi Via.

  • The five states vary in the types of services that can be self-directed by members: Two states (Massachusetts and Tennessee) define personal attendant services or personal care services as eligible to be directed by members. Texas offers more expanded options to include personal attendant and respite as well as nursing, physical therapy, occupational therapy, and speech or language therapy. Arizona allows members to self-direct certain skilled services. In addition to members directing their personal attendant services or personal care services, New Mexico's budget authority option allows participants to purchase both traditional Medicaid services and supports (e.g., adult day care, supportive employment, etc.) and Participant-Delegated Goods and Services (e.g., transportation, technology, household appliances, etc.).

  • Some states have adjusted the Nurse Practice Act (NPA) to accommodate PD-MLTSS: Arizona, Tennessee, and Texas reported changes to the state NPA. Arizona indicated that its board of nursing modified the NPA so that a PD-MLTSS member could hire a non-skilled attendant to perform a limited set of non-invasive tasks. Arizona also indicated that there were no plans to extend this exemption, nor does the exemption apply for persons receiving PD-MLTSS under an Agency with Choice model. Texas reported a similar type of exemption for members in PD-MLTSS that met certain criteria. Tennessee indicated that, with primary care physician (PCP) approval, PD-MLTSS members could delegate medication management. New Mexico respondents conveyed that while New Mexico's NPA was not amended for persons in PD-MLTSS, there was a NPA provision for "certified medication aides" so if a PD-MLTSS member needed medication management assistance, his/her aide could perform this service provided they were certified.

  • The numbers of participants who direct their own services vary in each state, however, in the majority of states, the number of PD-MLTSS participants is small and represents a very small percentage of MLTSS program members: Across the five states, the number of members reported enrolled in PD-MLTSS ranged from 300 (Arizona) to approximately 4,600 (Massachusetts). Currently, PD-MLTSS is available statewide in Arizona, Massachusetts, New Mexico, and Tennessee with PD-MLTSS becoming a statewide option in Texas beginning in 2014. The estimated PD-MLTSS take-up rates ranged from a low of 1.2% (Arizona) to a high of 24% (New Mexico). Most states did not have readily available information regarding how participant direction take-up rates in MLTSS compared to fee-for-service programs. This is an area for future research, comparing take-up rates for PD-LTSS before and after the advent of MLTSS. One state that had this information was Texas, where the participant direction take-up rate in its fee-for-service program was 8.2% (approximately 9,200 people out of an approximate 112,000) while it was only 2.5% in its MLTSS program (approximately 3,000 people out of an approximate 122,000). Part of the explanation for this difference is participant-directed is concentrated in the IDD waiver programs and this population is carved out of MLTSS in Texas. Texas expects the numbers of PD-MLTSS to grow as the state expands MLTSS to an additional 164 (mostly rural) counties in 2014.

View full report


"5LTSS.pdf" (pdf, 320.58Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®