Participant-Directed Services in Managed Long-Term Services and Supports Programs: A Five State Comparison. 3.2. State Requirements for Participant-Directed Managed Long-Term Services and Supports


How states communicate their requirements for PD-MLTSS varies. Three states (Arizona, Massachusetts, and Texas) relied less on specific contract language regarding the development and management of PD-MLTSS. Two states (Arizona and Texas) indicated they have developed detailed policy and procedure manuals or handbooks. Those states without specific contract language reported that it was quicker and easier to make changes to manuals or handbooks than it was to contracts. Tennessee and New Mexico indicated having contract language outlining the MCOs responsibilities related to allowing someone to choose PD-MLTSS. Tennessee currently has the most detailed requirements regarding the development and management of PD-MLTSS. The PD-MLTSS section of Tennessee's contract is approximately 35 pages and covers all aspects of the program including policies, procedures, forms, processes, and reporting. The following are common state requirements (see Appendix B, Table B2: State Requirements for PD-MLTSS, for more information):

  • Four of the five states require the MCO to offer PD-LTSS to all enrollees: Four of the five states (except Massachusetts) include specific language in their MCO contracts requiring MCOs to offer the PD-MLTSS option to all members at the time of enrollment and during reassessments. The fifth state (Massachusetts) prefers to avoid detailed documents and communicates its expectations orally to the MCOs. Massachusetts state officials feel this allows for a better exchange of ideas. New Mexico is implementing a policy that when someone is new to long-term care community-based services, they must first go into the agency-based benefit for 120 days and then they have the opportunity to choose participant direction. The State's rationale for this is new enrollees need time to adjust to all of the changes and choices associated with being a new MLTSS recipient. MCOs are required to document in the case file that participant direction was offered, whether the member chose to self-direct, and if the member selected employer authority, or employer and budget authority (if available). All of the five study states offer PD-MLTSS as a voluntary option and allow transitioning back to agency-based services any time the member desires. Tennessee goes farther by requiring MCOs to report the number and percent of those electing the participant-directed option, including the date referred to the FMS Agency.

  • The majority of the states require person-centered processes: Arizona, New Mexico, and Tennessee all indicated requiring person-centered processes. Under its new Centennial Care program, New Mexico ensures person-centeredness is met through a new assessment regime tool called the Comprehensive Needs Assessment (CNA) for its budget authority option. Every participant will be assessed at the proper time for his/her specific needs. The CNA will then generate an individual budget amount tailored to each participant's specific needs instead of the current practice of categorizing the individual as having low, medium, or high needs.

  • Tennessee was the only state with enrollment targets for PD-MLTSS: All of the states indicated optimism that PD-MLTSS enrollments would increase in the future. Texas state respondents believed that the expansion of PD-MLTSS to 164 mostly rural counties of the state would result in higher numbers of persons self-directing. It will be interesting to monitor this as one of the Texas MCO respondents made the observation that there are fewer participants self-directing in the rural areas of the state. The MCO respondents believed that the majority of participants in these rural counties speak Spanish and prefer using the local agencies and agency workers where Spanish is also the primary language. Respondents in Arizona hoped the expansion of its Agency with Choice option would increase participant direction enrollments. New Mexico indicated the expansion of its Medicaid program under the Section 1115 will increase enrollment in Centennial Care. Tennessee specifies increased enrollments as a quality benchmark in its contracts with MCOs (see Appendix C, Tennessee Enrollment Targets and PD-MLTSS Performance Measures, for Tennessee's enrollment targets).

  • Training for members and direct service workers are available in each state but few require it: Each MCO interviewed conveyed having both member and direct service worker training available (and provides the training at the request of the member). Only Tennessee requires member and direct service worker training as conditions of eligibility in their program. In Arizona, member training is not required; however, direct service worker training is mandatory and includes Universal Precautions and Health Insurance Portability and Accountability Act privacy regulations. Additional training materials are available in the Arizona participant manual. Most state contracts stipulated the state is to review and approve training curriculum, but most trainings are conducted by the MCO and not the state.

  • All the states require that PD-MLTSS participants have a back-up plan: Current PD-MLTSS programs require the development of a participant back-up plan to address instances when regularly scheduled workers are not available to provide critical services for the member. This requirement is conveyed to MCOs either in language found in the Request for Proposal (RFP), formally executed contracts, state Medicaid manuals, or state policies and procedures. Lack of precision in these documents, however, can lead to some role confusion as to who is responsible. For example, Tennessee's contract has the responsibility for creating a back-up plan assigned to the MCO service coordinator, FMS agency, and the participant. The detailed requirements for implementing back-up plans may also be a deterrent to expanding PD-MLTSS in some states. For example, Arizona goes so far as to require the MCO case manager to dispatch a back-up agency worker within two hours to provide a self-directing member services if the member notifies them that their worker is not available. As of the date of this research, this requirement is based on an Arizona state law. While ensuring that participants have adequate back-up plans is an important support for PD-LTSS, states need to be mindful that such a requirement does not either serve as a deterrent to case managers in presenting the option or make the responsible entity (e.g., the MCO, the FMS, or the state), that is held responsible to ensure back-up, look like "joint employers" of home care workers for purposes of the Fair Labor Standards Act.

  • Three of the five states have specific reporting requirements related to PD-MLTSS: New Mexico, Tennessee, and Texas all require specific PD-MLTSS reports related to enrollment. Beyond enrollment, state requirements for PD-MLTSS reports vary. Tennessee currently has the most extensive set of PD-MLTSS performance indicators (see PD-MLTSS Quality Monitoring section). New Mexico reported that it will also have an extensive PD-MLTSS report under Centennial Care and is in the process of developing this in its PD-MLTSS workgroup. While Arizona does not require specific reports, it does have the ability to generate PD-MLTSS reports from the information provided by the MCOs.

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®