Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Endnotes: Citations, Additional Information, and Web Addresses

10/29/2010

  1. Paul Saucier is the author of this chapter.

  2. Categorical groups eligible for SSI include those age 65 or older, and children and adults under age 65 who meet SSI disability criteria.

  3. Kaye, N. (2005). Medicaid Managed Care: Looking Forward, Looking Back. Portland, ME: National Academy for State Health Policy.

  4. Saucier, P., Burwell, B., and Gerst, K. (2005). The Past, Present and Future of Managed Long-Term Care. Prepared by Thomson Reuters and the University of Southern Maine Muskie School for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging, and Long-Term Care Policy. Available at http://aspe.hhs.gov/daltcp/reports/mltc.htm#section1.

  5. CMS. National Summary of Medicaid Managed Care Programs and Enrollment as of June 30, 2008.Available at http://www.cms.hhs.gov/MedicaidDataSourcesGenInfo/downloads/08Trends508.pdf.

  6. CMS. Number of Managed Care Entity Enrollees by State as of June 30, 2008. Available athttp://www.cms.hhs.gov/MedicaidDataSourcesGenInfo/downloads/08MCE-%20Enrolleesf508.pdf.

  7. Kaye, N. (2005), op. cit.

  8. The 11 states operating MLTC outside of PACE are Arizona, California, Florida, Hawai’i, Massachusetts, Minnesota, New Mexico, New York, Texas, Washington, and Wisconsin. Tennessee has received Federal permission to implement an initiative scheduled to begin in 2010.

  9. Evaluations of early MLTC programs have found consistently that hospital and nursing home use decreases and community services increase. For a review of the literature, see Saucier, P., Burwell, B., and Gerst, K. (2005), op. cit.

  10. Saucier, P., and Fox-Grage, W. (2005). Medicaid Managed Long-Term Care. Washington, DC: AARP, Public Policy Institute. Available at http://www.aarp.org/health/medicare-insurance/info-2005/ib79_mmltc.html.

  11. If a state has made the policy decision to cover persons who meet certain financial or other criteria, capping enrollment could upset advocates and raise valid issues related to equity. If a state can get Federal financial participation for all eligible persons, they would of course prefer this, but because the Office of Management and Budget puts an overall cap on expenditures, the state must either cap enrollment or pay costs only with state dollars once the expenditure limit is reached.

  12. The requirements for a §1115 waiver can lead to enrollment caps, which are politically difficult and can strain relations with contractors. Capping per person costs can be done easily by setting the capitation rate to not exceed the per person cap.

  13. For more on Medicaid rate setting in PACE, see National PACE Association (2009). Pace Medicaid Rate-Setting: Issues and Considerations for States and PACE Organizations. Available at http://www.npaonline.org/website/navdispatch.asp?id=2871.

  14. The Affordable Care Act amended §1915(h) of the Social Security Act.

  15. Behavioral services include mental health and substance abuse services.

  16. CMS. (2009). Providing Long Term Services and Supports in a Managed Care Delivery System. Enrollment Authorities and Rate Setting Techniques: Strategies States May Employ to Offer Managed HCBS, CMS Review Processes and Quality Requirements. Available at http://www.cms.hhs.gov/CommunityServices/Downloads/ManagedLTSS.pdf.

  17. Ibid. CMS may consider the inclusion of HCBS in a stand-alone §1915(a) contract in those cases where the state operates an approved section §1915(c) waiver or §1915(i) State Plan benefit for the same population served through the contract, in the same geographic region as the contract, containing the same services offered through the contract, and the costs of such services may be included in contract payments. These HCBS would be expressly contained in the managed care contract, and the individual need not be enrolled in a §1915(c) HCBS waiver or be receiving services through a §1915(i) HCBS State Plan program. Because this is a voluntary vehicle, an individual must be able to have the option to receive the services through another Medicaid approved authority in the state (i.e., State Plan or HCBS waiver).

  18. Ibid.

  19. Adults age 17 years, 9 months and older are eligible.

  20. For an overview of the Federal Special Needs Plan authority, see Saucier, P., Kasten, J., and Burwell, B. (2009). Federal Authority for Medicare Special Needs Plans and their Relationship to State Medicaid Programs. Prepared by Thomson Reuters for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. Available at http://aspe.hhs.gov/daltcp/reports/2009/leghist.htm.

  21. To date, there are no known MLTC programs invoking this authority.

  22. 42 CFR 441.302. Available at http://law.justia.com:80/us/cfr/title42/42-3.0.1.1.10.7.html.


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