States contracting with health plans to operate as Medicaid managed care organizations (MCOs) is a growing phenomenon. So is the correspondingly sharp rise in MCOs administering services for elders and people with disabilities, under the formal name of managed long-term services and supports (MLTSS).

As a result, populations in skilled nursing care centers, and increasingly Medicaid beneficiaries in assisted living communities, are coming under the umbrella of a new world order for reimbursement, where health plans are the payer and the state acts as overseer.

It is in the assisted living space that this article will examine how managed care is having an impact on provider contracting, reimbursement, and care coordination.

A Trend With Legs
Although the idea of managed care replacing the traditional state-operated fee-for-service (FFS) Medicaid system is not something assisted living providers seek, it is a trend experts say has staying power as more states look to offload the management of Medicaid to MCOs and at the same time, presumably, save money.

“In assisted living, it is a little bit of a new phenomenon, but we have seen a rapid explosion of managed care in the LTSS arena over the last 10 years,” says Damon Terzaghi, senior director of Medicaid policy and planning for the National Association of States United for Aging and Disabilities (NASUAD). Currently, the NASUAD State Medicaid Integration Tracker lists 19 states as having implemented MLTSS programs.
“Given the emphasis and the rapid proliferation of these programs, we do expect that this is something that is here to stay. We think it is something that is iterative and evolves as states implement these programs,” he says.

What this means for the long term and post-acute care (LT/PAC) provider is a fascinating instance of “it depends.”

Some providers in some states look to the changes as an opportunity to get a step ahead of the competition in the related world of pay-for-performance contracting. A larger majority of providers wince at the mention of Medicaid managed care, complaining of lengthy payment delays, redundant surveys, and convoluted prior authorization demands from insurers who may or may not fully grasp the marketplace for high-acuity beneficiaries.

Easy Now, Say LT/PAC Advocates
Indeed, the LT/PAC profession wants the Medicaid managed care train to at least slow down for more assessment.

According to the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), there is a “limited pool of evidence” on what impact MLTSS is having, leaving questions about the pace and scale of states making the shift. AHCA/NCAL has asked the Centers for Medicare & Medicaid Services to protect Medicaid beneficiary access to quality care by stopping expansion of managed care “until more conclusive evidence concerning cost, quality, and outcomes is available.”

Between 2003 and 2014, nationwide enrollment in comprehensive risk-based managed care increased from 40 percent of Medicaid-eligible individuals to 61 percent, according to data compiled by AHCA/NCAL. By 2020, MCO enrollment is expected to account for nearly 85 percent of Medicaid beneficiaries.

Increasingly, states are transforming the payment and delivery of LTSS by shifting to MLTSS models. The number of states implementing MLTSS programs has increased significantly in recent years, from eight states with operational programs in 2004 to more than half of states either operating, developing, or considering MLTSS programs in 2017, the association says.

Experiences Are Varied
To say states are each as unique as a snowflake is a bit of an overstatement when it comes to reviewing the variation in how MLTSS affects assisted living providers across the nation. But, it’s not too far off, as some states like Arizona have had Medicaid managed care since Ronald Reagan was president, and others, like Iowa, have just recently made the plunge.

In listening to providers’ experiences in dealing with MLTSS in these two states, it is striking how they diverge in some ways and converge in others. The most obvious divergence is that Iowa has only been in the Medicaid managed care business since April 2016 (for all of its Medicaid beneficiaries) and has had more than a few hiccups in rolling out its program.

From her vantage point, assisted living operator Pat Giorgio, president, chief executive officer (CEO), and founder of Evergreen Estates in Cedar Rapids, Iowa, says the managed care transition has gotten off to a “very, very rough start,” partly driven by the fact that the state went 100 percent in for all components of the Medicaid program, from coverage for children through to LTSS.

“So, the three managed care companies that were selected were adjusting to payments to health care providers, to long term care, to HCBS [home- and community-based services] and mental health and the whole ball of wax from day one. Which in my opinion is the poster child for how not to roll out Medicaid managed care,” Giorgio says.

Growing Pains
The trouble for her three buildings specifically filtered back to a common theme that MCOs didn’t really understand the HCBS waiver program, or for that matter, Medicaid in assisted living communities in general. “I’m a small provider, but some of the bigger providers in the state, as well as your hospitals and mental health operators certainly, all had problems. It was just really rough and tough for awhile.”

While the situation has gotten better after the MCOs opened better communications with providers to air out issues, the fact that their de facto listening tour took place after implementation still irks Giorgio.

“It’s improved, but it is still in my opinion a really challenging environment for providers. I can tell you that without a doubt I have had to increase my full-time equivalent hours just to manage the paperwork. Not just submitting claims, but dealing with many different case managers,” she says.

Where Evergreen used to have one case manager that handled all three buildings, now it has 20. That, along with the additional hours of paperwork and bureaucratic issues, hasn’t resulted in an increase in reimbursement. “Obviously, that has a negative impact on the bottom line,” Giorgio says.

Beyond paperwork for her company, the Medicaid program itself is not giving people approvals for coverage as quickly as before, stretching out such decisions from two to three months to four to six, she says.

“That’s not on the back of the managed care companies, because they have nothing to do with it. Our departments of health and human services have to approve them, and I still today don’t have an answer as to why that process has slowed down. You would think that their workers would have less work since the managed care companies took over. It just intuitively doesn’t make sense.”

MCOs Respond to Invite
Giorgio relates that while MCOs understand health insurance, what they didn’t seem to grasp at the beginning is the underlying premise of HCBS, in which the beneficiary can be at home or can be in an assisted living or a special care community.

“It’s just getting them to understand the difference between what we can do in residential care and assisted
living versus what a family member who is an approved caregiver can do. There was a real disconnect.

They just simply didn’t understand, and we set up special meetings trying to get them to tour my buildings to make it better.”

The invitation to MCOs has turned into a best practice of sorts, Giorgio says, since the case managers were all on board to learn about LT/PAC. “The case managers from the MCOs are now becoming my best advocates because they understand what we do, and they understand that our reimbursement rate is low, but that we provide an important service,” she says.

Part of that service, and having the health insurers comprehend what assisted living facilities do, ties into the acuity levels of residents. Like a lot of people outside the LT/PAC field, MCO case managers had to be informed about just how serious resident conditions are.

“[You have to show them that] our residents are the ones who can no longer live at home safely. So, when they come to us in our communities, it’s because they are eligible for HCBS. They are not successful at home, like those with serious memory issues, not remembering to take their medications properly,” Giorgio says.

Educating the Plans
The point she makes to MCOs is that her communities are the next step from being in a skilled nursing center. But even the difference between skilled nursing and assisted living has caused confusion in the new Iowa system.

“A nursing facility for Medicaid reimbursement is paid double what is paid in assisted living. So, it immediately costs the MCO and the state twice as much if they go from our setting to a nursing facility,” Giorgio says.

During the managed care program’s rollout, MCO executives said they wanted to see an increase in the number of Medicaid recipients in assisted living and residential settings, not in nursing centers. “But the reality is that they’re having a really hard time discerning the difference between HCBS at home and HCBS in assisted living.”

For instance, she says, some Medicaid managed care case managers told her that they will ask a resident, “Can you prepare a meal?” And they might say, “Well no.” So, Giorgio says their follow-up question may be, “Can you make a peanut butter sandwich?”

“And if they say, ‘Well, yes, I can make a peanut butter sandwich,’ then the MCOs count that as a meal,” Giorgio says. “They then want to take away dollars for meal preparation from us, the number of meals that we provide. Because they believe they’re interpreting that as the resident is living in their own home. There’s just a disconnect between what services we’re providing and what MCOs think the clients can do for themselves,” she says.

From the regulator viewpoint on the Medicaid managed care rollout, Matt Highland, communications specialist for Iowa Medicaid Enterprise, admits there were “bumps along the way,” notably in claims processing, but since then a collaborative approach has helped to ease the problems.

“I think when you look at long term care, and the waiver program, by nature it is complicated. We have had training and onboarding with the MCOs focused on those issues,” he says.

The Arizona Experience
If the Iowa Medicaid program is on one extreme in the experience department when it comes to Medicaid managed care, the other end of the spectrum is Arizona. There, Heidi Capriotti, public information officer for the Arizona Health Care Cost Containment System (the Medicaid program in Arizona), says her state was the last to add Medicaid in 1982, but the first to have mandatory managed care for all beneficiaries, with some exceptions for Native Americans.

The strategic goal in Arizona when it comes to Medicaid managed care is cost-effectiveness and how to use quality metrics to monitor provider performance for its 1.9 million members, while bending the cost curve.

“We are always looking for ways to innovate in that space,” Capriotti says, referring to related value-based purchasing programs for select skilled nursing centers, hospitals, and clinics.

Assisted Living Provider Knows the Score
With 16 total MCOs operating across geographic- and service-based areas, the ballgame for assisted living providers in Arizona when it comes to managed care is well known, says Sean Mockbee, executive director of Sunshine Village in Phoenix, an 84-bed memory care facility that has up to 65 percent of its residents on Medicaid.

“I think it’s been over 30 years with managed care. So, honestly, I don’t know any different. You know, it’s what I grew up in,” he says.

The company also has Paseo Village, a 115-unit assisted living building where around half of the population is memory care and half assisted living and some other programming, including behavioral health. That building is nearly 80 percent Medicaid, Mockbee says.

His advice for those providers in states where managed care has not yet taken hold, or is about to, is to be cautious of the contracting issues that come with MCOs.

“The biggest part on the negotiations is the first contract,” Mockbee says. “It’s very hard to go in after the fact and say, ‘you know what, I got it wrong, I really need to increase it.’ They’re not going to let you. So, it’s that first contract that is the most important,” along with contracting for any type of new programming when that becomes advisable.

As for the impact of managed care on residents, the state in Arizona has control over the benefits each Medicaid beneficiary must receive, so one MCO from the next is basically on the same page in that regard. “The only real difference is case management,” Mockbee says. Some MCOs have better-trained, or more involved, case managers.

 “And that can change by just the person working for the health plan,” he says. That is because if there is a well-trained case manager on board, they are proactive in setting up communications with families and work with the assisted living staff more easily than a case manager who lacks these skills. “It just kind of creates that whole piece of the pie and makes it a little bit better versus if the case manager doesn’t come, doesn’t call, or doesn’t communicate,” Mockbee says.

Payment Not at Issue Here
A seemingly persistent complaint in some states with managed care is the lack of timely payment from MCOs, or any payment at all, along with trouble getting prior authorizations for care. But, again, the experienced Arizona stakeholders may have a leg up here as well.

“I would say luckily our system is pretty seasoned,” Mockbee says. “We’ve had payment problems. But once you learn it, and the plans kind of get on board with how to pay, it gets resolved. Yeah, I’ve heard horror stories out of many other states. Luckily here, you know, if you get a prior authorization and you bill, there are now online claim submissions and EFT [electronic funds transfer] payments. It’s a very quick process, and it’s pretty seamless.”

There may be some of those proverbial hiccups, but Mockbee says 98 percent of his Medicaid-based claims are paid by the various MCOs within a couple of weeks. “If you do your due diligence ahead of time and actually have the authorizations that match, it helps. You’ll get a lot of errors in authorizations, but it’s your business office manager who must stay on top of that. Or else you will have claims problems,” he says.

If there are disputes, each health plan has a grievance process that a provider should go through first. “We can escalate that up the channel if we need to. If it’s a real problem, there’s a grievance procedure that goes through the state, and they will get involved and make sure the health plan is doing what it’s supposed to do. But, you definitely have to exhaust all efforts inside that health plan first,” Mockbee says.

A Battle Royal in Ohio
If Iowa is a state in the midst of ironing out its Medicaid managed care system, and Arizona a state seemingly set with MLTSS, then there is Ohio. “This is a huge battle here,” says Pete Van Runkle, executive director of the Ohio Health Care Association (OHCA), which represents LT/PAC providers throughout the state and is an affiliate of AHCA/NCAL.

He says MLTSS has become one of the most significant issues in the ongoing two-year budget bill debate, which is the culmination of a fight to keep managed care from encroaching into the LT/PAC space any more than it has to.

Van Runkle explains that for the past three years the state has been conducting a managed care demonstration program, along with several other states, covering only the urban areas of Ohio, which amounts to 29 of 88 counties.

“And, so we’ve been dealing with that for three years, and members have been upset and uncomfortable with it for all of that time,” he says.

The program, which is called My Care Ohio, “has improved to a fair degree since it started, but we still receive a lot of complaints from members and have to work issues for them involving managed care plans,” he says.

With that as background, the heated budget battle focuses on Gov. John Kasich’s (R-Ohio) budget proposal to expand managed care statewide and only for Medicaid populations, not for people dually eligible for Medicare and Medicaid as the demonstration does. “This has been a bitter fight,” Van Runkle says. “We have highlighted this as one of the two major issues that we have to deal with, as we had to oppose [the governor’s proposal] based on what our members were telling us about their experiences.”

Objections Are Deep
So, what exactly are the problems with managed care for Ohio LT/PAC providers? According to an OHCA survey, the major issue is the timeliness and accuracy of MCO payments.

“When you submit a claim and the plan improperly denies it, or pays it at the wrong rate or pays it in some other fashion incorrectly, then the provider views that as not getting paid. That is how they see it,” Van Runkle says.

The survey also showed that the hassles in getting authorizations for services and the consequences of it is a significant issue, too. In addition, Van Runkle says transportation has been a huge problem.

“Although the plans have made some improvements, these plans have had instances where they send taxi cabs for people who have been in skilled nursing facilities.” He says this is because most appropriate transportation providers feel that the Medicaid rate paid by health plans is too low to make it worth their time.

“So, we are running into great, great difficulty getting ambulettes or the wheelchair vans for our people,” he says.

Rounding out the other stumbling blocks with managed care, at least for those answering the OHCA survey, is the care coordination activities of the MCOs. Survey takers cite the lack of communication on the part of MCO case managers when they are in their buildings. “They really don’t participate in planning care, not that we would really want them to, but they don’t. Nor do they really have any relationship with the patients. It is purely a paperwork activity they are doing because they have to,” Van Runkle says.

Gauging the True Aim of Managed Care
While assisted living and other providers keep a laundry list of complaints about their experiences with Medicaid managed care, the trend is running hot for states to turn some or all their Medicaid program management to managed care, be it national carriers like UnitedHealthcare or a Medicaid specialist like Molina Healthcare.

In breaking down the trend and provider uneasiness in more detail, Jeff Myers, president and CEO of the Medicaid Health Plans of America (MHPA), says it certainly is the case that managed care is moving into the LT/PAC arena, with the costliest and hardest populations to manage.

“You’re now seeing states really start to look at the aged duals, the intellectually and developmentally disabled duals and placing them into full-risk care, and obviously, that is the largest portion of the state’s Medicaid budget,” he says.

States like Pennsylvania and Virginia, for instance, are nearing or completing their request for proposals process after gaining waivers to implement MLTSS, adding to the mix of states entering managed care for their highest-acuity beneficiaries.

When asked why it has taken longer for states to tackle the MLTSS populations than other segments of Medicaid, Myers says the first barrier is the fact these people have not traditionally been in managed care, “and there’s always been a lot of trepidation for those that are most at risk when they are required or encouraged to move to a full capitated risk system.”

The second point, he says, is the general resistance among institutional providers to move toward a fully capitated model because they are concerned that that capitated model will somehow drive down money flowing through their system.

Technology Plays a Role
A third piece of the puzzle is how MCOs relate to LT/PAC providers. “It has been my experience here at MHPA that one of the challenges our plans have is the relative fragmentation in the institutional space,” Myers says. Despite there being large multi-state providers, the average owner of a nursing or assisted living center is much, much smaller.

“The fact that they are not highly centralized and that nursing homes have never gotten access to some of the IT [information technology] money that hospitals and others have gotten has made integration into a managed care environment kind of hard,” he says. “The plans generally, when they sign contracts with the state, have some form of quality hold back, and they need quality data that if you are a hospital or a doctor and have had access to the health information exchange money is relatively easy to provide.”

But LT/PAC providers may not have invested a lot in data management. “It’s much harder to do. And so, some of the integration between providers and Medicaid health plans just must do with what their data sets look like and how plans can get to that data set to make sure that money’s being exchanged fairly and encouraging a plan, encouraging the institutional providers to take some risks,” Myers says.

MCOs May Offer Volume
It is these factors and the above-all weight of thin Medicaid margins to begin with that leave nursing and assisted living operators with a fair amount of fear and loathing when it comes to managed care.

“But, I do believe that they’re going to find that managed care companies have an incentive to make sure that [LT/PAC providers] are financially viable, because that’s where the care gets provided,” Myers says.

The real question and possibly the real value for health plans and providers alike is how successful MCOs are at managing the full financial risk for the LT/PAC population. Myers says this will require nursing facilities to back up their advance in quality of care with hard and fast data to reap the rewards of additional outcomes-based payments for quality.

It is this optimistic tone that may eventually overcome the resistance of many providers serving elders and people with disabilities.

More Managed Care Flexibility Seen
As NASUAD’s Terzaghi says, it seems to be the nature of managed care that as the programs have matured, the tentacles of their reach have branched out far and wide.

“As states have included those populations, they [MCOs] have expanded even further, whether just to primary acute services for older adults and people with disabilities then into LTSS,” he says.

And in some cases, this includes populations with intellectual and developmental disabilities or traumatic brain injury that have been excluded from managed care in the past due to their complexity and challenging nature.

Without judging the value of Medi-caid managed care, Terzaghi says, there is real opportunity for flexibility in the health care system with the private plans, even if there are growing pains at times in getting there.

“The challenge is that a lot of providers tend to be wary of managed care. In many states the providers now must do individual rate negotiations with the managed care plans, which can be a little bit more challenging than dealing with statewide rate setters set by the legislature and the Medicaid agencies,” he says.

There also can be increased reporting requirements and data submission placed upon providers, especially because managed care plans are held to higher-quality review standards than that seen in FFS programs. But Terzaghi also sees light at the end of the tunnel, with the providers that do well on quality and outcomes in a solid position moving forward.

“When providers do stuff well and engage their plans proactively, they can see a boon from that,” he says.