Just as providers have adjusted to the alphabet soup of programs, initiatives, models, and laws impacting long term care, from ACOs and ACA to PQRS and PCMH, a new addition to the mix—MLTSS, or Managed Long Term Services and Supports—is causing heartburn. Fortunately, with planning, support, communication, and information, providers can feel healthy and even happy.
MLTSS refers to the delivery of long term care services and support through capitated Medicaid managed care programs. Traditionally, states have provided Medicaid benefits using a fee-for-service system. However, in the past 15 years, a growing number of states have implemented a managed care delivery system for these benefits.
Currently, about 50 million people receive Medicaid benefits through some form of managed care,
although most are children and adults under 65, and the number is increasing almost daily.
Depending on the state, participation in a Medicaid managed care program may be voluntary or mandatory. However, more states are requiring people to enroll in managed care, and more states are using MLTSS to expand home- and community-based services.

Programs Come In Many Packages

MLTSS may involve managed care organizations (MCOs) that provide most Medicaid benefits to people in exchange for a monthly payment from the state. They also may involve limited benefit plans that look like health maintenance organizations (HMOs) but provide only one or two Medicaid benefits (such as mental health or dental services), or primary care case managers who act as an individual’s primary care provider and receive small monthly payments for coordinating referrals and other medical services. The vast majority of states are using the HMO model to implement MLTSS.

States can implement a MLTSS system through a state plan or waiver authority. A waiver allows the state to waive certain federal rules to offer optional services and/or expand eligibility to a group of individuals that would not otherwise qualify for Medicaid. A state plan is a contract between a state and the federal government describing how that state administers its Medicaid program.

However, states must comply with federal regulations governing managed care delivery systems. These regulations include requirements for a managed care plan to have consumer protections, including a quality program, appeal and grievance rights, reasonable access to providers, and the right to change plans.

Movement Here To Stay

While some states already are waist-deep in Medicaid managed care, others are just dipping their toes in or still contemplating how to take the plunge.

Wherever a provider’s state stands today, Mike Cheek, American Health Care Association (AHCA) vice president of Medicaid and long term care policy, cautions, “You need to understand that Medicaid fee-for-service appears to be quickly going away. Close to 30 states have implemented or are planning to implement managed care for all of their Medicaid populations. If it’s not in your state now, it soon will be.

“You no longer will be paid by the state Medicaid agency. Instead, you will be paid by HMOs or other entities with whom you have contracts. These entities will drive how you’re paid, how often, how many referrals you receive, and how long residents will stay in your facility,” he says.

The move into Medicaid managed care is mostly nonpartisan. Although some Republican lawmakers may view it as a way to downsize government, says Cheek, the overarching issue is cost saving and moving patients into the setting with the lowest level of care as quickly as possible.

Nonetheless, how a state implements its Medicaid managed care program will help determine what challenges providers face as they begin to get involved.

Most Successful Ventures

The programs that have been most effective to date have employed a phased-in enrollment and implementation plan so that kinks and problems can be worked out before the program is rolled out on a widespread basis.

Another key to success is the development of quality metrics that involves providers up-front.
Whatever approach a state takes to MLTSS, says Cheek, the program must have improving access and quality—not just cost savings—as the primary goals.

Medicaid managed care won’t impact how facilities care for their residents, but it is likely to affect patient demographics and lengths of stay. Arizona Health Care Association Executive Director Kathleen Collins Pagels says, “Expect seismic shifts to less acute settings, including assisted living and home care. Also expect higher acuity of patients in both assisted living and skilled nursing.”

Start By Building Relationships

To succeed in the world of Medicaid managed care, Kansas Health Care Association Executive Director Cindy Luxem says, “It’s all about relationship building from the beginning. We’ve found that the providers who have the best relationships with their plans are ultimately successful.”

Fortunately, says Cheek, facility leaders already know how to do this. “The way you developed good relationships with hospitals, you can establish good relationships with managed care plan personnel," he says.

“I have regular meetings with managed care plan leadership,” says Pagels. “I bring them to tour facilities, and we have lunch with the team leaders there. This helps them understand what we do and our commitment to care.”

She adds, “We invite them to our meetings and participate in theirs. We share resources and education.”
While it is important to help plan leaders understand what you need from them, she stresses, it also is essential to know what they need and want from you. “Talk about their needs for network development and what services they need assistance with,” she says.

To truly understand Medicaid managed care, Pagels suggests, become an expert on the plan. “Understand the plan’s idiosyncrasies, strengths, and weaknesses,” she says. This information is easy to find.

“Start with your state association,” she suggests. It is a priority for staff there to assist their members in making these important connections, she says. There also is a great deal of information about plans, their history, scope, capitation rates, and more on their websites and on state Medicaid sites.

“Share this information with your entire team. Teach staff from the bottom up what they need to know to work effectively with the managed care plans,” says Pagels.

Sign On The Dotted Line?

The contract between the managed care plan and the provider cements the relationship. “You will be paid under the terms of the contract,” says Cheek. “The volume of referrals you get and how long residents stay will be driven by the contract. What you’re paid may be set by the contract.”  Some states, such as Tennessee, have made contracting easier by setting Medicaid rates so that providers don’t have to negotiate them with plans. (For a contract checklist, see box on right.)

Transparency is key to an effective contract, says Jesse Samples, executive director of the Tennessee Health Care Association. “Almost everything you need to know is in this agreement—including the specific responsibilities of the plan and the provider,” Samples says.

It is important to have legal counsel review a contract before finalizing it, says Luxem. This can help identify areas where language is unclear and requires clarification. She adds, “This can save you a great deal of heartache and money down the road.”

Luxem gives the example of a provider that accidentally submitted billing for only $31 per day per resident, and the plan refused to pay more after the mistake was uncovered. “The contract says that the provider would receive the state-approved amount or the amount the provider submits, whichever is less. It took months to straighten this out,” says Luxem. “These are the kinds of problems that can occur with a new contract for a new program.”

Revisit and review contracts annually, suggests Pagels. “You have to stay on top of this, as the plan doesn’t necessarily have an incentive to do this. Inclusions and exclusions can cost you significant dollars.” She says that the contract must be reasonable for both parties.

“If you generate a contract that you think is extraordinary, you may get personal satisfaction from that, but you may never get a referral from the plan.”

Samples cautions that providers shouldn’t expect to do a lot of negotiating on their managed care contracts. “Unlike Medicare Advantage plans where you can decline to sign a contract you’re uncomfortable with, contracts on the Medicaid side are more standard. However, if you have questions or concerns about issues outside of payment—such as issues relating to quality or performance measures, your state association may be able to help.”

Managed Care And Culture Change

Long term care facilities have put tremendous resources into culture change in recent years, and Medicaid managed care plans need to understand that the concept of person-centered care is linked inextricably to long term care.

The good news, says Pagels, is that plans actually understand—and appreciate—culture change and its impact on promoting quality care.

However, she says, “It is helpful to understand what measures plans use to assess quality and make sure there is a common language. Make sure they understand what is being measured.” She adds, “Sometimes it is essential to help plans understand what we do and how we work in our regulatory environment.”

Luxem notes that person-centered care incentives are included in her state’s pay-for-performance initiative. “I believe that more states will demand that plans pay attention to quality measures that focus on person-centered care. This will position AHCA members well, because we already are focused on Baldrige criteria and quality and performance measurement,” she says.

Show How Culture Change Relates To Outcomes

Samples suggests that there is still a learning curve regarding managed care and culture change. “There is an opportunity to bring plans into the fold and educate them about person-centered care and how it relates to quality, outcomes, and cost-effectiveness.” Samples says. “When you bring them to the table on this, they are more likely to incorporate this information into their contracts and the collaborative process.

“In addition to educating plans about culture change, you should help them understand all aspects of long term care and the challenges you face from an operational standpoint. If you want successful program implementation, all of the players have to be on board with the different components that make up the total package,” he says.

According to Tony Marshall, senior director of reimbursement at the Florida Health Care Association, Medicaid managed care plans don’t have any incentive to lean toward or away from culture change.
“They aren’t in the business of managing care. Their job is to help you case-manage and review services to determine if a patient can be moved from the nursing home in a quicker, more efficient manner,” he says. Nonetheless, Medicaid managed care plans do have an interest in quality, although they are more focused on outcomes.

“In our state, managed care plans monitor survey data but try to avoid duplicating the survey process. They are looking at the underlying survey and quality metrics related to issues such as falls, and they are interested in how your facility ranks in relation to other providers,” Marshall says.

Florida actually mandated in its state law that Medicaid managed care plans would not duplicate the survey process. This was a lesson state leaders learned from talking to their counterparts from states that had taken the managed care plunge before them. “We heard about one state where providers got surveyed by every single plan they contracted with. We wanted to avoid this excessive burden on our providers,” Marshall says.

Maintaining Census, Expanding Services

As a goal of Medicaid managed care is to keep patients in nursing center beds for as few days as possible, maintaining census in this environment will present a new challenge for facilities.

“Providers will have to make sure that plans see them as worthy of referrals. You want to establish yourself with the plans so that you can become a preferred provider and receive more referrals,” says Cheek.
This requires documenting low rates of readmission and antipsychotic use, low staff turnover, and “other data points to show you offer stable, quality health care that maximizes functioning.”

At the same time, Cheek suggests looking to start or grow robust post-acute services and considering ways to diversify. “Think about adding respite services and end-of-life care, offering assisted living, providing adult day care, or delivering in-home services,” he says. He also recommends becoming part of a long term care provider network to secure more referrals.

“You can’t be just one kind of provider anymore,” Luxem agrees. “You must offer skilled care, as well as other services such as adult day care, assisted living, and respite care if you want to move successfully in the future.” Plans, she says, increasingly will be seeking providers that offer a variety of services and can move patients seamlessly from one care setting to another.

Diversity is the way of the future, says Samples. “If you are a provider with access to the entire continuum, you not only are attractive to health plans but to potential staff.” He adds that this is the right thing to do for patients as well.

“If someone can get his or her needs met in a community setting, that is where that person should be. But it is advantageous for patients to be able to stay in the same system when they need skilled care,” Samples says.

Payment Paradox

“‘How do we get paid?’ is a question most providers have when it comes to Medicaid managed care,” says Luxem. That can take a while to sort out.

“We quickly discovered that some systems we had set up for billing in the state were more progressive than what the plans had. [The managed care] systems were not set up to handle our case-mix system, where rates can change frequently,” she says.

The newer the state and the plans are to Medicaid managed care, the more likely providers may experience payment delays and glitches. “We have experienced our own history of problems with timely payments over the years, particularly with new plans coming in,” says Pagels. “You need to manage your cash flow with this in mind.”

Fortunately, facility leaders can do more than cross their fingers and hope for the best. Pagels advises providers: “Invest in your business office. Make sure they have the training and support necessary to work effectively with the Medicaid managed care plans. Take opportunities to get involved with people at the plans who work with payments and understand appeals and grievance processes.”

Another key to ensuring prompt payment is to establish patients’ Medicaid eligibility as early as possible. “Some providers have run into payment delays because eligibility wasn’t approved in a timely manner. This makes it difficult to move into managed care,” says Luxem.

Planning Ahead

Providers need to be patient and be prepared to educate plans as necessary. “Some plans have had difficulty understanding how payment works for special services such as ventilator care,” says Luxem. The onus is on providers to watch these issues carefully and alert the plan immediately if they see problems.
Planning is key, agrees Marshall. “We anticipated that receiving payments in a timely manner might be a challenge. We had the benefit of putting language in our state statutes to ensure timely payments,” he says. Specifically, they included a provision that plans have to pay claims with sufficient information within 10 days. However, Marshall notes, while the statutes require plans to meet payment standards, there are no penalties for a failure to do so.

“From our perspective, plans aren’t trying to delay payment, but there was inadequate readiness review to test the claims processes," says Marshall, referring to a review process designed to focus on elements that include assessment procedures, care coordination, and staffing.

"And, unfortunately, most plans are not long term care-oriented, so they are unfamiliar with our payment systems,” Marshall says.

Marshall suggests some other efforts that may help improve payment in a Medicaid managed care world.
For instance, he suggests that states consider development of a uniform claims form process, standards for electronic funds transfer, and provider-plan workgroups to address payment issues on the front end.
Marshall also suggests that others learn a lesson from his state: “We included a provision to have a technical advisory workgroup, but we didn’t include a time frame for it, and it disappeared. This really needs to be a continuous process for ongoing dialogue to deal with challenges and situations as they arise.”

Work on payment issues should begin as soon as the ink is dry on the contract, Marshall stresses. “Have office staff work with their counterparts at the plan immediately. Allow sufficient time for training. Have plans come to the facility and participate in multiple trainings on the front end,” he says. Plans are more than willing to participate in meetings with providers. Take advantage of opportunities to interact, share information, and put processes in place during the transition period, Marshall says.

Ultimately, plans want to do the right thing for providers, Marshall says. “Our plans have gone above and beyond in their efforts to get payments to providers. They’ve even chosen to provide overpayments just to ensure that providers have the necessary cash flow.”

Suit Up, Get Ready

Like it or not, Medicaid managed care is here to stay, and, as Cheek observes, the days of traditional fee-for-service are numbered in most states. J. Emmett Reed, CAE, Florida Health Care Association executive director, adds, “Managed care is sweeping the country. It’s not a matter of if it will hit your state, it’s a matter of when.”

For providers in states yet to embrace Medicaid managed care, Reed suggests they reach out to colleagues in states where it already is up and running.

“One thing our membership did when we heard the managed care drum beating is have a group travel to other states and meet with their association leaders to talk about how managed care is affecting them,” he says.

By taking this proactive approach, Reed and his members were able to implement safeguards up front to avoid common glitches, have a strong role in developing statutes that protect providers, and enable problems to be solved almost before they happen.

States like Florida, Kansas, Tennessee, and Arizona are proof that with strong relationship building, providers can make Medicaid managed care plans partners in quality care.

“This is how we conduct our business,” says Pagels. “We navigate this journey and continue to seek common ground and the best ways to care for our patients.” ■