Key Themes in Capitated Medicaid Managed Long-Term Services and Supports Waivers

Introduction
  1. CMS and Truven Health Analytics, The Growth of Managed Long-Term Services and Supports Programs:  A 2012 Update at 1 (July 2012), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/MLTSSP_White_paper_combined.pdf.

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  2. CMS, Guidance to States Using 1115 Demonstrations or 1915(b) Waivers for Managed Long-Term Services and Supports Programs at 1-2 (May 2013), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf.

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  3. Kaiser Family Foundation, Medicaid in an Era of Health & Delivery System Reform:  Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015  at 2-3 (Oct. 2014), available at https://www.kff.org/medicaid/report/medicaid-in-an-era-of-health-delivery-system-reform-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2014-and-2015/.

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  4. Id. at 29.

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  5. For examples of the important role that Medicaid HCBS play in beneficiaries’ daily lives, see Kaiser Commission on Medicaid and the Uninsured, Medicaid Beneficiaries Who Need Home and Community-Based Services:  Supporting Independent Living and Community Integration (March 2014), available at https://www.kff.org/medicaid/report/medicaid-beneficiaries-who-need-home-and-community-based-services-supporting-independent-living-and-community-integration/.

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  6. See, e.g., CMS MLTSS Guidance at 1 (noting that the “application of a capitated managed care model to long-term services and supports is new for many states, health plans, and providers”).

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  7. See generally Kaiser Commission on Medicaid and the Uninsured, Medicaid Long-Term Services and Supports:  Key Considerations for Successful Transitions from Fee-for-Service to Capitated Managed Care Programs (April 2013), available at https://www.kff.org/medicaid/issue-brief/medicaid-long-term-services-and-supports-key-considerations-for-successful-transitions-from-fee-for-service-to-capitated-managed-care-programs/; Kaiser Commission on Medicaid and the Uninsured, People with Disabilities and Medicaid Managed Care:  Key Issues to Consider (Feb. 2012), available at https://www.kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-care/; Kaiser Commission on Medicaid and the Uninsured, Examining Medicaid Managed Long-Term Service and Support Programs:  Key Issues to Consider (Oct. 2011), available at https://www.kff.org/medicaid/issue-brief/examining-medicaid-managed-long-term-service-and/; see also National Council on Disability, Medicaid Managed Care for People with Disabilities:  Policy and Implementation Considerations for State and Federal Policymakers (March 2013), available at http://www.ncd.gov/publications/2013/20130315/.

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  8. See generally CMS MLTSS Guidance.

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Background
  1. For a summary of CMS’s § 1115A demonstration authority, see Kaiser Commission on Medicaid and the Uninsured, State Demonstrations to Integrate Care and Align Financing for Dual Eligible Beneficiaries: A Review of the 26 Proposals Submitted to CMS, Appendix A (Oct. 2012), available at https://www.kff.org/medicaid/report/state-demonstrations-to-integrate-care-and-align/; for current information on the demonstrations, see Kaiser Commission on Medicaid and the Uninsured, Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared:  States with Memoranda of Understanding Approved by CMS (July 2014), available at https://www.kff.org/medicaid/issue-brief/financial-alignment-demonstrations-for-dual-eligible-beneficiaries-compared/.

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  2. Kaiser Commission on Medicaid and the Uninsured, Five Key Questions and Answers About Section 1115 Medicaid Waivers (June 2011), available at https://www.kff.org/health-reform/issue-brief/five-key-questions-and-answers-about-section/.

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  3. Kaiser Commission on Medicaid and the Uninsured, The New Review and Approval Process Rule for Section 1115 Medicaid and CHIP Demonstration Waivers (March 2012), available at https://www.kff.org/health-reform/fact-sheet/the-new-review-and-approval-process-rule/.

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  4. See generally Kaiser Commission on Medicaid and the Uninsured, Medicaid Long-Term Services and Supports:  An Overview of Funding Authorities (Sept. 2013), available at https://www.kff.org/medicaid/fact-sheet/medicaid-long-term-services-and-supports-an-overview-of-funding-authorities/.

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  5. For examples of specific HCBS, see CMS/Mathematica Policy Research, The HCBS Taxonomy:  A New Language for Classifying Home and Community-Based Services 4 Medicare & Medicaid Research Review  E1-E17 (2014), available at http://dx.doi.org/10.5600/mmrr.004.03.b01.

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  6. See generally Kaiser Commission on Medicaid and the Uninsured, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid:  15 Years After the Supreme Court’s Olmstead Decision (June 2014), available at https://www.kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years-after-the-supreme-courts-olmstead-decision/.

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  7. See generally Kaiser Commission on Medicaid and the Uninsured, How is the Affordable Care Act Leading to Changes in Medicaid Long-Term Services and Supports Today?  State Adoption of Six LTSS Options (April 2013), available at https://www.kff.org/medicaid/issue-brief/how-is-the-affordable-care-act-leading-to-changes-in-medicaid-long-term-services-and-supports-ltss-today-state-adoption-of-six-ltss-options/.

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  8. See generally id. 

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  9. 79 Fed. Reg. 2948-3039 (Jan. 16, 2014), available at http://www.gpo.gov/fdsys/pkg/FR-2014-01-16/pdf/2014-00487.pdf.

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  10. 77 Fed. Reg. 26828, 26855 (May 7, 2012), available at http://www.gpo.gov/fdsys/pkg/FR-2012-05-07/pdf/2012-10294.pdf.

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  11. CMS, Summary – Essential Elements of Managed Long Term Services and Supports Programs, available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/MLTSS-Summary-Elements.pdf.

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  12. CMS MLTSS Guidance at 1

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Key Themes
  1. New Mexico’s § 1115 MLTSS waiver was first approved in 2014, but converted from the state’s prior § 1915(b)/(c) authority.

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  2. CMS MLTSS Guidance at 9, 12.

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  3. Kaiser Commission on Medicaid and the Uninsured, Medicaid Home and Community-Based Services Programs:  2010 Data Update (March 2014), available at https://www.kff.org/medicaid/report/medicaid-home-and-community-based-service-programs/.

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  4. CMS MLTSS Guidance at 8.

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  5. New Jersey reports that it will implement the Miller Trust option to enable additional individuals to qualify for community-based LTSS, in lieu of the “217-like option” which had been approved by CMS as part of the state’s comprehensive waiver, but proved challenging to implement.  Kaiser Family Foundation, Medicaid in an Era of Health & Delivery System Reform:  Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015  at 17 (Oct. 2014), available at https://www.kff.org/medicaid/report/medicaid-in-an-era-of-health-delivery-system-reform-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2014-and-2015/.

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  6. CMS MLTSS Guidance at 9.

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  7. Tennessee’s MCO contracts includes financial incentives for meeting Money Follows the Person NF to community transition benchmarks.  Kaiser Commission on Medicaid and the Uninsured, Tennessee’s Money Follows the Person Demonstration:  Supporting Rebalancing in a Managed Long-Term Services and Supports Model (April 2014), available at https://www.kff.org/medicaid/issue-brief/tennessees-money-follows-the-person-demonstration-supporting-rebalancing-in-a-managed-long-term-services-and-supports-model/.

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  8. Kaiser Commission on Medicaid and the Uninsured, Long-Term Services and Supports in the Financial Alignment Demonstrations for Dual Eligible Beneficiaries (Nov. 2013), available at https://www.kff.org/medicaid/issue-brief/long-term-services-and-supports-in-the-financial-alignment-demonstrations-for-dual-eligible-beneficiaries/.

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  9. CMS MLTSS Guidance at 12.

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  10. For background on the Money Follows the Person program, see Kaiser Commission on Medicaid and the Uninsured, Money Follows the Person:  A 2013 State Survey of Transitions, Services, and Costs (April 2014), available at https://www.kff.org/medicaid/report/money-follows-the-person-a-2013-survey-of-transitions-services-and-costs/.

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  11. Person-centered planning focuses on the strengths, needs, and preferences of the individual beneficiary instead of being driven by the care delivery system.  See, e.g., Virginia Commonwealth University Partnership for People with Disabilities, A Closer Look at the Centers’ for Medicare and Medicaid Services’ Definition of Person-Centered Planning, available at http://www.medicaid.gov/mltss/docs/PCP-CMSdefinition04-04.pdf.

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  12. CMS MLTSS Guidance at 8.

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  13. Id.

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  14. Kaiser Commission on Medicaid and the Uninsured, A Guide to the Medicaid Appeals Process (March 2012), available at https://www.kff.org/medicaid/issue-brief/a-guide-to-the-medicaid-appeals-process/.

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  15. CMS MLTSS Guidance at 10.

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  16. CMS, Medicare-Medicaid Coordination Office, Funding to Support Options Counseling for Medicare-Medicaid Enrollees (last modified June 5, 2014), available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FundingtoSupportOptionsCounselingforMedicare-MedicaidEnrollees-.html.

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  17. CMS MLTSS Guidance at 10.

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  18. Id.

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  19. Id. at 6.

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  20. Id. 

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  21. Id. at 13.

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  22. Id. at 15.

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  23. Id. at 6.

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  24. Id. at 15.

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  25. CMS, Modifications to Quality Measures and Reporting in § 1915(c) Home and Community-Based Waivers (March 2014), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Downloads/3-CMCS-quality-memo-narrative.pdf.

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  26. CMS, Testing Experience and Functional Assessment Tools, available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Grant-Programs/TEFT-Program-.html.  States with MLTSS waivers included in this brief and receiving TEFT grants include AZ and MN.

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  27. Kaiser Commission on Medicaid and the Uninsured, Long-Term Services and Supports in the Financial Alignment Demonstrations for Dual Eligible Beneficiaries (Nov. 2013), available at https://www.kff.org/medicaid/issue-brief/long-term-services-and-supports-in-the-financial-alignment-demonstrations-for-dual-eligible-beneficiaries/.

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  28. National Quality Forum, Quality Measurement for Home and Community-Based Services, available at http://www.qualityforum.org/ProjectDescription.aspx?projectID=77692.

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  29. National Quality Forum, 2014 Input on Quality Measures for Dual Eligible Beneficiaries (Aug. 2014), available at http://www.qualityforum.org/Publications/2014/08/2014_Input_on_Quality_Measures_for_Dual_Eligible_Beneficiaries.aspx.

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  30. National Council on Disability, Medicaid Managed Care for People with Disabilities:  Policy and Implementation Considerations for State and Federal Policymakers (March 2013), available at http://www.ncd.gov/publications/2013/20130315/.

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  31. NASUAD, National Core Indicators – Aging and Disabilities, http://nasuad.org/initiatives/national-core-indicators-aging-and-disabilities.

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  32. AARP et al., Is It Working?  Recommendations for Measuring Rebalancing in Dual Eligible Demonstrations and MLTSS Waivers, available at http://dualsdemoadvocacy.org/wp-content/uploads/2014/01/Rebalancing-in-MLTSS-and-Dual-Eligible-Demo_01.13.14.pdf; see also Disability Rights Education & Defense Fund and National Senior Citizens Law Center, Identifying and Selecting Long-Term Services and Supports Outcome Measures (Jan. 2013), available at http://www.nsclc.org/wp-content/uploads/2013/02/Guide-LTSS-Outcome-Measures-Final.pdf; H. Stephen Kaye, Center for Personal Assistance Services, University of California San Francisco, Selected Inventory of Quality-of-Life Measures for Long-Term Services and Supports Participant Experience Surveys (Dec. 2012), available at http://dredf.org/Personal-experience-domains-and-items.pdf.

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  33. Agency for Healthcare Research and Quality, Medicaid Home and Community-Based Services Measure Scan (July 2007), available at  http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/hcbsreport/index.htmll.

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  34. President’s Committee for People with Intellectual Disabilities, Managed Long-Term Services and Supports Report to the President 2012), available at http://www.acl.gov/NewsRoom/Publications/docs/PCPID_FullReport2012.pdf.

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  35. National Core Indicators, available at http://www.nationalcoreindicators.org/.

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  36. CMS MLTSS Guidance at 17.

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  37. Id. at 15.

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  38. Id. at 12.

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  39. Id. at 15.

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  40. Id. at 16.

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