Although there is a long history of efforts to improve the coordination of Medicaid and Medicare while controlling costs, the evidence base supporting current efforts is relatively slim. States have targeted different populations such as aged and disabled, adults with disabilities, people with intellectual or developmental disabilities, acquired brain injury, or autism. There is variability in the degree of financial integration, and programs that incorporate Medicare must contend with the freedom of consumers to opt-out. Many programs were implemented without a baseline assessment or a contemporaneous comparison group. Thus, much of the knowledge base derives from descriptive studies.

Despite this dearth of knowledge, trends are emerging providing an opportunity to examine state programs more closely. Twenty-three states have turned to Managed Care Organizations (MCOs) to provide Medicaid financed Managed Long-Term Services and Supports (MLTSS) as a way to control costs and shift the locus of care away from institutional settings, while three additional states are planning to implement similar programs. These programs, under the authority of CMS, vary by design and population coverage, however they all share a common goal of improving the coordination between Long-Term Services and Supports (LTSS) and physical and behavioral health care.  

Most medical or health care services are financed by Medicare, while most LTSS is paid for by state Medicaid programs. States have made significant efforts to transition care for people with disabilities from institutional to home and community-based settings using what are referred to as ‘waiver programs.’ Although waiver program clients typically have a high burden of chronic conditions in addition to physical and intellectual disabilities, these programs exert little control over the medical care that clients need, leading to a lack of coordination. MLTSS programs seek to address this problem by integrating the financing of medical care and LTSS under one risk contract. The hope is that MCOs will be incentivized to improve medical management as well as serve people in the least restrictive and preferred environment. 

States have used several different approaches to implement MLTSS programs. One effort, sponsored by CMS, is the Financial Alignment Demonstration program. In this model, dually eligible consumers can enroll in a single plan that provides the benefits of both Medicaid and Medicare. Other states are using the waiver process to integrate financing and delivery of LTSS and medical care covered by Medicaid, but do not make direct changes Medicare. In these programs, states will typically require Medicare managed care plans to coordinate with Medicaid MLTSS plans even though the financing remains separate. Such arrangements may align incentives to improve care and quality of life, but investments by one plan might result in savings to a competitor. 

To learn more about this topic, AcademyHealth Long-Term Services and Supports Interest Group will host an upcoming webinar sponsored by LTQA. Join us on Thursday, May 3rd from 2:30pm to 4:00pm Eastern for a webinar entitled, Managed Long-Term Services and Supports: The Potential for Medicaid Managed Care to Integrate Acute and Long-Term Care.” During this webinar, presenters will provide a national overview of MLTSS programs. The webinar will feature leaders of two state programs: Tennessee, which has a long track record of Medicaid managed care and was an early adopter of MLTSS, and Pennsylvania, which is launched the first phase of its MLTSS program in January, 2018. 

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