The §1915(a) authority allows states to create voluntary managed care programs without a waiver or a Medicaid State Plan amendment. It does not allow selective contracting, which means that states cannot engage in competitive procurement of contractors under this authority. The state may, however, define the contractors qualifications and offer contracts to all who meet them, and participating contractors may limit specific providers when they create their networks. This authority can also be used to waive comparability and to limit a program geographically.
|TABLE 8-3. New Mexico Coordination of Long-Term Services (CoLTS)|
|Target Group||Older persons and persons with physical disabilities. Enrollment is mandatory.|
|Scope of Medicaid Capitation||Most Medicaid services, including primary and acute health care and long-term care services (institutional and HCBS). Behavioral services are carved out to a separate managed care organization.|
|Authorities||Concurrent §1915(b) and (c) waivers. New Mexico is the latest state to implement an MLTC program, and has used the (b)(c) combination to create a mandatory, statewide program that includes primary and acute health care and long-term services in one package.|
|More information is available at: http://www.nmaging.state.nm.us/COLTS_overview.html.|
This authority alone is not sufficient to create an MLTC initiative because without a concurrent §1915(c) waiver or a §1915(i) State Plan benefit, it limits the state to offering existing State Plan services and using regular State Medicaid Plan financial eligibility criteria. However, §1915(c) waiver services can count as services offered under the State Plan.17 Services not expressly contained in the approved §1915(c) waiver or in the§1915(i) State Plan amendment for which payment is made under the contract, may be provided as in lieu of services at the states election.18
Thus, states that offer many long-term services through their State Plan or existing §1915(c) waivers may find this authority adequate for establishing an MLTC program--as does Pennsylvania, which uses the §1915(a) authority to operate a program for adults with autism. See Table 8-4 for an example of the use of this authority.
|TABLE 8-4. Pennsylvania Adult Community Autism Program (ACAP)|
|Target Group||Adults (age 21+) with Autism Spectrum Disorder who require an Intermediate Care Facility (ICF) level of services, but can live in a community setting. Enrollment is voluntary.|
|Service Area||Four counties.|
|Scope of Medicaid Capitation||Primary care, ICF level of services in the community, and behavioral services. Acute care and pharmacy are carved out.|
|Authorities||Section 1915(a) authority. Pennsylvania operates this program without waivers. Although the §1915(a) authority does not authorize selective contracting, only one contractor to date has met the required qualifications and is the sole vendor.|
|More information is available at: http://www.dpw.state.pa.us/ServicesPrograms/Autism/.|