Medicaid is the largest payor for long-term services and supports (LTSS) for older adults and persons with disabilities (American Health Care Association [AHCA], 2013; Medicaid and CHIP Payment and Access Commission [MACPAC], 2020). Due to the complexity of needs in this population, care coordination is necessary to optimize delivery of care. This complexity of care and the need to decrease costs have prompted the development of Managed Long-Term Services and Supports (MLTSS) in many states to improve access, quality, and efficiency of care, as well as facilitate person- and family-centered care and improve care coordination (AHCA, 2013; Tuck & Moore, 2019). States in greater numbers are transitioning their LTSS from a fee-for-service payment model to MLTSS, where the state receives a capitated payment to provide LTSS to eligible persons (Tuck & Moore, 2019). Due to lower health care costs with community-based care, MLTSS programs are incentivized to expand home and community-based services (HCBS) and gain the added benefit of greater community inclusion (Tuck & Moore, 2019). In addition, with the focus on HCBS, many MLTSS have worked to transition participants from high-cost institutional settings back to the community. For example, New Mexico reduced the percentage of persons residing in nursing facilities from 18.7% in 2011 to 14.3% in 2015 (Moore & Smith, 2018). The number of people who need LTSS is expected to increase as the aging population grows. With this increased need for LTSS looming, states are again looking for opportunities to rebalance Medicaid LTSS toward less restrictive, lower cost, community-based care (Archibald et al., 2018).
At the same time, after decades of trying to engage federal and state policymakers to attend to persons who receive both Medicaid and Medicare (i.e., dual eligibles), advocates and providers are hopeful that change is possible. Growing consensus prevails that providing quality care for dually eligible older adults and persons with disabilities requires not only efficiency in terms of cost, but also in the delivery of care. Therefore, it is believed that MLTSS programs may address cost and quality of care to this population who typically have complex health care needs and disproportionate Medicaid and Medicare expenditures (MACPAC, 2020).
Dually eligible older adults and persons with disabilities are a heterogeneous group. However, this group is twice as likely to be in fair or poor health and have cognitive or mental impairment compared to individuals receiving Medicare alone or with private insurance (Medicare Payment Advisory Commission [MedPAC] & MACPAC, 2018). Dually eligible individuals also leverage a higher cost burden, particularly to state Medicaid budgets. Of the separate programs Medicare and Medicaid, dually eligible individuals represent 20% of all Medicare recipients but account for 34% of Medicare expenditures. Compared to those on Medicaid only, 15% of beneficiaries are dually eligible and account for 32% of all Medicaid expenditures (Medicare–Medicaid Coordination Office, 2020). Of the 20% of the fee-for-service dually eligible individuals who use Medicaid-covered institutional LTSS, they accounted for 34% of Medicare spending and more than 53% of total Medicaid spending in 2013 (MedPAC & MACPAC, 2018) (Figure 1). As these numbers demonstrate, Medicaid is the primary payor for LTSS, which are largely unavailable through private insurance or Medicare (Watts et al., 2017).
Dual-eligible beneficiaries as a share of Medicare and Medicaid recipients and spending for the calendar year 2013.
Note. FFS = fee for service; Duals = dually eligible individuals.
LTSS provide coverage to help dually eligible older adults and persons with disabilities meet their daily self-care and household needs (Watts et al., 2017). However, Medicaid LTSS cover most critical services, such as person-centered care planning; HCBS, such as home care; respite care; and caregiver training and support (Johnson et al., 2020; Tuck & Moore, 2019). Funding for capitated Medicaid LTSS that increase access to HCBS rather than long-term institutional care came from the §1115 MLTSS waivers (Watts et al., 2017). States can use several Medicaid authorities to implement MLTSS, including section 115 waivers or combining 1912(C) HCBS waiver authority with Section 1915(a), Section 1915(b), or Section 1932 managed care authorities (MACPAC, 2018).
Increasingly, states are using managed care as a strategy to improve care coordination and address costs for this high-need population (MACPAC, 2020). Twenty-four states operated Medicaid MLTSS programs as of 2019, up from eight states in 2004 (MACPAC, 2020) (Figure 2). States are now working to align MLTSS with Medicare managed care for individuals who are dually eligible. Dually eligible individuals require better care coordination, particularly high-cost individuals who receive many services without enough attention to the coordination or quality of those services. Care coordination is a critical component of MLTSS with an emphasis on coordination between medical and behavioral health services (Johnson et al., 2020). The need for care coordination requires states to grow their pool of qualified care coordinators. Care coordinators are often social workers, lay persons trained in care coordination, or gerontologists. Nurses may also serve as care coordinators.
State adoption of managed long-term services and supports programs (MLTSS), June 2019.
Source: Medicaid and CHIP Payment and Access Commission (2020; in the public domain; permission is not required).
There is also a growing focus on measuring quality of life as well as quality of care. Many dually eligible individuals need access to more integrated primary, acute, and behavioral health care and LTSS, with special attention to blending health and social services to address long-standing negative effects due to their social determinants of health. Support and engagement of family caregivers, when available, are essential for this model to work.
Persons who receive Medicare and Medicaid need coherence between these programs in terms of rules and procedures. The creation of the Medicare–Medicaid Coordination Office under the Affordable Care Act was a major step forward in this effort (Feng, 2018). One of the most significant demonstration projects emerging from the Medicare–Medicaid Coordination Office is known as the Financial Alignment Initiative (FAI) Demonstration, which was implemented in 13 states, although Virginia and Colorado ended their demonstrations in 2017 (Feng, 2018; Musumeci, 2013). The FAI Demonstration is a federal–state partnership to develop service and payment models that better integrate care and align financial incentives across Medicare and Medicaid programs. Currently, if a state invests resources to improve care of people who are on Medicaid but also on Medicare, the state may incur Medicaid costs, whereas the federal government saves money. States may enter into an agreement with the Centers for Medicare & Medicaid Services (CMS), which allows states to share in any savings that accrue to Medicare as a result of improved quality and lower costs (Johnson et al., 2020). MLTSS are funded using new mechanisms from the Affordable Care Act. Currently, more than one third of states (n = 22) operate Medicare–Medicaid integrated care models with demonstrations under the FAI Demonstration authorized by the Affordable Care Act, giving states the opportunity to pursue innovative financing and integration approaches for dually eligible populations (Johnson et al., 2020).
In addition, states can integrate the care for dually eligible populations through Dual-eligible Special Needs Plans (D-SNPs) (Johnson et al., 2020; Kruse et al., 2020). In D-SNPs, first offered in 2006, clinician and hospital services are provided by a Medicare Advantage Plan with Medicaid paying for the Medicare cost sharing, LTSS, long-term care, and often behavioral health services (Tuck & Moore, 2019). D-SNP enrollment was >2.1 million as of January 2018, in 41 states, Puerto Rico, and the District of Columbia (Tuck & Moore, 2019). However, there is significant room for growth with >12 million people eligible for Medicare and Medicaid (Johnson et al., 2020).
The initial demonstration states that remain active (n = 11) are experimenting with MLTSS to focus resources across Medicaid and Medicare to improve care and the quality of care coordination while reducing costs for both programs (Feng, 2018). The plans receive a prospective blended rate for all primary, acute, and behavioral health and LTSS. Under this capitated approach, states and the CMS can share savings. Some states are exploring a managed feefor-service financial alignment model that does not involve capitation. In the fee-for-service model, the state is responsible for care coordination and the delivery of fully integrated Medicare and Medicaid benefits. The state receives a retrospective performance payment if a target level of Medicare savings is achieved (Walls et al., 2013). It takes time to build capacity for this multipronged approach to serve these populations and an infrastructure to integrate Medicare and Medicaid services along with financing with the intention to better align Medicare and Medicaid to integrate primary, acute, and behavioral health and LTSS for dually eligible persons (Feng, 2018). Preliminary research suggests that fee-for-service financial alignment models are effective at protecting consumer choices and continuity of care (Saucier et al., 2013).
Services offered by MLTSS include functional screening assessments to determine a person's need for services and to assist in developing a person-centered plan of care. Each participant in MLTSS is required to have an initial assessment within a specified time period, typically within 90 days of enrollment, and an annual reassessment thereafter (Tuck & Moore, 2019). Based on these assessments, organizations administering MLTSS must provide or arrange for all required services and supports to address a person's health care needs. These services and supports include conducting risk assessments, coordinating HCBS and in-home services, developing a person-centered plan of care, engaging a care team, supporting and connecting participants to services, supporting adherence to the plan of care, and performing transition planning. In addition, the majority of MLTSS programs provide transportation for appointments, provide caregiver support coordination of behavioral health care, coordinate social services, assist with scheduling provider appointments, provide referrals based on a person's plan of care, and serve as a single point of contact for care coordination (Tuck & Moore, 2019).
The spread of MLTSS has been damped by some significant challenges. Several MLTSS programs have found it difficult to find and retain appropriately trained case managers who understand both Medicaid and Medicare benefits (Johnson et al., 2020; MACPAC, 2018). In addition, some states have effective nursing home lobbies that have shown strong opposition to legislation supporting the transition to MLTSS (Allen, 2017; MACPAC, 2018).
There are also market forces that challenge the success of MLTSS. As in any service sector, direct care workers are difficult to find and retain. An increase in wages has been necessary in 24 states implementing MLTSS (Gifford et al., 2018). However, it is not just wages that challenge meeting the needs of persons participating in MLTSS. Hiring and retaining direct care workers is further limited by poor benefits, limited career advancement opportunities and training, and high rates of work-related injuries (Gifford et al., 2018). Other market forces that challenge the success of MLTSS include lack of accessible and affordable housing, limited capacity of community-based providers, and reimbursement issues (Gifford et al., 2018). Now that states are gaining experience in MLTSS, states are turning their focus toward program outcomes. This focus on outcomes has been complicated by limited baseline data and limited targeted quality measures. Tracking eligible participants' denials of care by MLTSS providers is essential to identify patterns of these denials within and among populations or providers. Appeals to denials of care data should also be included as a quality outcome measure. The use of Ombudsman for MLTSS should be consistently implemented across states. In addition, better quality and encounter data are needed for improved monitoring and oversight of MLTSS (MACPAC, 2018).
Implications for Nurses
Despite these challenges, MLTSS are expanding in Medicaid-only and dually eligible populations. With further evaluation based on participant and quality data, innovations in this model will continue to occur. It is innovation that is needed to meet the needs of the dually eligible population. This population presents with complex health and social needs. Holistic assessment and care planning optimize the potential benefit of services. Gerontological nurses are well qualified to perform such assessments and work with the entire care team to develop the plan of care. With their understanding of functional needs and physical and mental health resources, nurses engaged with this population are ideal to tackle the innovations required to holistically address the needs of this population within the constraints of state and federal funding agencies.
With the growing complexity of older adults living in the community and receiving MLTSS, new models of care delivery are needed that optimize the contributions of all care team members and provide adequate oversight and support from RNs and advanced practice nurses (APNs) (Young & Siegel, 2016). One example of how nurses can positively influence the outcomes for dually eligible older adults enrolled in MLTSS is by increasing nurse delegation to support unlicensed personnel to perform medical/nursing tasks in the home. Home care and nursing delegation are significant needs, particularly when moving dually eligible individuals from long-term care settings back into the community.
Telehealth can also expand access to quality care, by providing expert consultation to providers in communities where geriatric expertise is limited and by providing direct service to homebound older adults and their caregivers (Young & Siegel, 2016). APNs are particularly well-positioned as a valuable resource for this model of care to address the comprehensive physical and emotional care needs of this population in a holistic and cost-effective way (Naylor et al., 2018).
The complexity and cost of care required by persons on Medicaid or dually eligible for Medicaid and Medicare have precipitated innovations by states to develop care models that meet the needs of their Medicaid and dual-eligible populations. The implementation of MLTSS has been one innovation that is gaining traction in states based on the success of baseline assessments, individualized care planning, and care coordination. RNs and APNs are key stakeholders in the outcomes of MLTSS in their states. There are opportunities for APNs to provide expert primary care to this complex population. Nurses in primary care can practice chronic disease management and encourage self care. Nurses in home care can train family caregivers and unlicensed personnel to provide care in the home. In addition, APNs and RNs need to monitor the quality of MLTSS programs and engage with oversight organizations as needed to assure persons enrolled in MLTSS receive the care they need.
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