A growing number of states have decided to expand their Medicaid managed care programs to encompass Long-Term Services and Supports (LTSS). From 2004 to 2012, the number of states with Medicaid managed LTSS (MLTSS) programs doubled from eight to 16, and ten more states are projected to implement MLTSS programs by 2014.1 As states move their LTSS from a fee-for-service (FFS) environment to managed care, the nature of the state's quality oversight enterprise must ensure the compliance of the managed care organizations (MCOs) with whom they contract.
Under FFS, the state's quality focus is on monitoring providers (institutional providers, as well as those delivering home and community-based services (HCBS) and ensuring that the health and well-being of those served is safeguarded. The state's focus under managed care is monitoring the managed care entities to make certain that they meet contractual obligations for addressing the needs of their enrolled members. In the managed care environment, the first line of quality oversight is delegated to the MCO.
Among other obligations, the MCO must demonstrate to the state that:
- person-centered plans, based on comprehensive assessments, are developed with members;
- service plans meet members' needs and are responsive to their wishes for how services and supports will be delivered;
- services in the plan are actually delivered;
- services are coordinated (including health services);
- providers are responsive to members' changing needs and circumstances; and
- providers and the MCO address emerging member risk and critical events experienced by members.
In addition, Medicaid managed care regulations2 require a further set of quality activities for the MCO not imposed in the FFS environment--Performance Improvement Projects (PIPs), an independent annual compliance review, as well as independent validationof the MCOs performance measures and PIP methodologies/results.
Through a combination of the CFR 438 Medicaid managed care regulations and recent guidance on the essential elements of MLTSS programs,3 the Centers for Medicare and Medicaid Services (CMS) provides states with expectations for quality oversight in MLTSS. CMS specifies what states must do. But, it is primarily at the states' discretion as to how they will implement CMS' requirements.
In this study, we explore how several states have designed their quality monitoring and improvement programs for MLTSS. We focus on the early adopters of MLTSS as well as those programs that are presently considered "established." As the findings of this report will demonstrate, states take somewhat different approaches to MCO oversight and we explore them in more detail below.