Quality in Managed Long-Term Services and Supports Programs. Executive Summary

11/01/2013

As of 2012, 16 states had managed long-term services and supports (MLTSS) programs for Medicaid beneficiaries. This is an exploratory study of how eight of these states implemented Medicaid MLTSS quality oversight in their programs. The eight state MLTSS systems studied are: Arizona Long-Term Care System (ALTCS); Michigan Managed Specialty Supports and Services; Minnesota Senior Care Plus and Minnesota Senior Health Options; North Carolina 1915(b)/(c) Medicaid Waiver for Mental Health/ Developmental Disabilities/Substance Abuse Services; Pennsylvania Adult Community Autism Program; Tennessee CHOICES in Long-Term Care; Texas STAR+PLUS Program; and Wisconsin's Family Care.

Under fee-for-service (FFS), the state's quality assurance focus is on monitoring long-term services and supports (LTSS) providers, including nursing facilities and intermediate care facilities for persons with intellectual disabilities as well as home care agencies and other home and community-based services (HCBS) providers, to ensure that the health and well-being of service recipients is safeguarded. When states contract with managed care organizations (MCOs) to assume responsibility for delivering all (or almost all) LTSS to MLTSS plan members, the state's quality assurance focus shifts to monitoring how well the MCOs meet their contractual obligations for meeting the needs of their enrolled members. Thus, in the MLTSS environment, states delegate the first line of quality oversight--the monitoring of service providers--to the MCOs.

The Centers for Medicare and Medicaid Services (CMS) has issued regulations requiring MLTSS MCOs to perform certain quality activities and through a combination of regulations and policy guidance, CMS has also specified what the federal Medicaid agency expects from states with respect to quality oversight of MCOs. However, states have considerable discretion as to how to meet these CMS requirements. This study describes similarities and differences in state approaches among eight states whose MLTSS programs had progressed beyond the initial start-up phase by the summer of 2013 when the case study research was conducted.

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