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Growth in MLTSS:
Implications for Social
Determinants of Health and
Community Based
Organizations
Joe Caldwell, Ph.D.
Director of Long-Term Services and Support Policy
National Council on Aging
Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 2
Background
NCOA leads the Disability & Aging Collaborative
▪ Informal coalition of more than 40 national aging and disability groups
working together to advance LTSS policy
▪ One of the first successful efforts to bring together aging and disability
organizations
Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 3
Disability and Aging Collaborative and
• American Association on Health and Disability
• AARP
• ACLU
• ADAPT
• AFSCME
• Alliance for Retired Americans
• Altarum Institute
• ANCOR
• The Arc of the United States
• Association of University Centers on Disabilities
• Autism Speaks
• Autism Society of America
• Autistic Self Advocacy Network
• Bazelon Center for Mental Health Law
• Caring Across Generations
• Center for Medicare Advocacy
• Center for Public Representation
• Community Catalyst
• Dana & Christopher Reeve Foundation
• Disability Rights Education & Defense Fund
• Easter Seals
• Families USA
• Jewish Federations of North America
• Justice in Aging
• Leading Age
• Lutheran Services in America
• National Association of Area Agencies on Aging
• National Association of Councils on Developmental Disabilities
• National Academy of Elder Law Attorneys
• National Association for Home Care and Hospice
• National Committee to Preserve Social Security and Medicare
• National Council on Aging
• National Council on Independent Living
• National Consumer Voice for Quality Long-Term Care
• National Disability Rights Network
• National Health Law Program
• National PACE Association
• Paralyzed Veterans of America
• Paraprofessional Healthcare Institute
• SEIU
• United Spinal Association
• VNAA –Visiting Nurse Associations of America
Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 4
Growth of Medicaid Managed LTSS
• Under Medicaid Managed Long-Term Services and Supports (MLTSS)
Programs, state Medicaid agencies provide capitated payments to managed
care organizations to provide long-term services and supports.o Most often in combination with acute and behavioral health services
o In some states integrated with Medicare for dually eligible individuals
• In 2007 (Lewis et al., 2018):
o 24 states operated MLTSS programs
o Enrollment in MLTSS programs more than doubled, from 800,000 in 2012 to 1.8 million in 2017
o States often operate multiple MLTSS programs (41 programs in the 24 states)
o Most common populations served are older adults (33 programs in 2017) and adults with physical
disabilities (30 programs in 2017).
Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 5
States with MLTSS Programs Active or In Development
Source: NASUAD (2018) Medicaid Integration Tracker
Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 6
Implications for Social Determinants of Health
• Reasons states have reported moving to MLTSS:
o Rebalancing LTSS from institutional to HCBS
o Reducing waiting lists for HCBS
o Improved care coordination
o Improved quality
o Budget predictability and containing costs
• Plans respond to what States put into the contracts
• Plans can provide added supplemental benefits and services
• Capitated payments provide plans with enhanced flexibility versus
traditional Medicaid
Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 7
Implications for Community Based Organizations
• Be actively engaged early in the process as states consider MLTSS and
maintain ongoing engagement
o Opportunities to work with the State Medicaid agency to shape development of
programs, goals, and contract language
• 2016 Medicaid Managed Care Rule required:
o States and each managed care entity to establish stakeholder advisory groups for
design, implementation and oversight of LTSS
o State and managed care stakeholder groups must be engaged in the development of
the quality and performance improvement strategy, performance improvement plans,
and annual state managed care program assessment reports
Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 8
Implications for Community Based Organizations
• Increasingly CBOs are contracting with MCOs
o Aging and Disability Business Institute:▪ https://www.aginganddisabilitybusinessinstitute.org/
o HCBS Business Acumen Center: ▪ http://www.hcbsbusinessacumen.org/
Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 9
Quality Measurement
• Quality measurement in MLTSS can drive desired outcomes:
o What gets measured gets done
o Can be tied to payment through incentives or penalties/withholds
o Can be tied to quality improvement projects
o Allow consumers to compare plans and make informed choices
• Significant gaps in HCBS related measures that have been developed
and endorsed by the National Quality Forum (NQF)
o NQF Workgroup on HCBS quality
o Significant work being done to develop HCBS measures▪ HCBS Experience of Care Survey (CAHPS) endorsed by NQF
▪ University of Minnesota RTC on HCBS Outcome Measures developing HCBS survey measures
▪ CMS contract with Mathematica developing measures for MLTSS, Duals, HCBS
□ Measure being considered related to falls risk, assessment, and plan of care
Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 10
National Core indicators –Aging and Disability
• Partnership between NASUAD, HSRI, and participating stateso Currently 15 states participating
o Not all MLTSS specific, but some states are beginning to use NCI-AD as performance measures to compare plans
o Quality indicators in HCBS domains, including: service planning, rights, community inclusion, choice, health and care coordination, safety and relationships.
• Measures in NCI-AD related to falls and management of chronic conditions:o Do you (or somebody else) have concerns about you falling or being unstable?
o Has somebody talked to you or worked with you to reduce your risk of falling or being unstable? This could be a professional, family member, or a friend.
o Questions about unmet needs for home modifications (i.e. grab bars, bathroom)
o Do you have chronic conditions? Do you know how to managed that chronic condition?
Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 11
Example from Texas 2015 NCI-AD Report
Source: NASUAD (2018) Medicaid Integration Tracker
12©2018 Aetna Medicaid
Proprietary and Confidential
MLTSS & CBO Partnerships
Alan Schafer, RN, Senior Director, LTSS May 23, 2018
13©2018 Aetna Medicaid
Proprietary and Confidential
| At Aetna Medicaid we believe in…
Improving every life we
touch
as good stewards to those we
serve.
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Proprietary and Confidential
Our members are at the center of everything we do
Aetna at a glance:
50,000 employees
23.5 million medical members
$61 billion revenue
160 years of national
and international experience
3rd largest managed care organization
in the U.S.
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Aetna Medicaid overview
30years of managed care
experience
Leader in managing medically complex populations at the local, community-
based level by integrating physical health, behavioral health, and social
economic status of members
3 millionmembers across 15
states
Over
23successful
implementations in the
last 2 years
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Proprietary and Confidential
©2018 Aetna Medicaid
Proprietary and Confidential 16
Populations we serve
17©2018 Aetna Medicaid
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Physical, behavioral, and social integration
Fully integrated care encompassing physical
health, behavioral health and social and cultural
concerns of members
Strong provider partnerships and alliances
with community based organizations
Interdisciplinary care teams that include the
member and family
Leveraging technology to ensure care team has
a view of the whole person
Physical
health
Behavioral
health
Social and
cultural
issues
We have leading edge medical management
capabilities that focus on:
18©2018 Aetna Medicaid
Proprietary and Confidential
Respected
Community
Organization
Competence
with the
Population
Visionary
Leadership
| Choosing Partner Organizations
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Proprietary and Confidential
Nimble
Governance
Collaborative
Partner
Ability to
Comply with
Regulatory
Requirements
| Choosing Partner Organizations
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Proprietary and Confidential
Case management delegation
LTSS provider network contracting
Care Transitions
Initial health risk assessments
Locating hard to reach members
Waiver applications
Waiver service coordination
NF to community transitions
| Creating CBO Partnerships in our MLTSS States
Nationally recognized, locally focused
AZ
TX
FL
IL
OH
MI
NY
NJ
VA
CA
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Proprietary and Confidential
| Learning Lessons
Flexible model designs
Communication, problem solving
System access, security
Data sharing and reporting
Shared policies and procedures
Delegation oversight
Regulatory audits
CBO clinical expertise/staffing
Training
Value based reimbursement
We put the members we serve at the center of everything we do
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We believe that fundamental change requires increased
collaboration
Thank You
Alan Schafer
Senior Director, LTSS
22
Our Long and Winding Road to CDSME Reimbursement under MLTSS
May 23, 2018 NCOA Center for Healthy Aging Annual Meeting
VIRGINIA DEPARTMENT FOR AGING AND REHABILITATIVE SERVICES (DARS)
TIMELINE: CDSME IN VIRGINIA
• 2005: Introduced by Virginia Department of Health
• March 2010: VA receives a 2-year grant from Administration on Aging
• September 2012: VA receives a 3-year grant from Administration for Community Living (ACL)
• August 2016: VA receives a 2-year grant from ACL
DARS is the lead state agency. Area Agencies on Aging lead at the local level.
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Provides and advocates for resources and services to improve the employment, quality of life, security, and independence of older Virginians, Virginians with disabilities, and their families.
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• Statewide Medicaid managed long term services and support programs serving approximately 210,000 individuals with complex care needs.
• Integrated delivery model across the full continuum of care.
• Care management at the heart of the CCC Plus.
• Focuses on improving quality, access and efficiency.
COMMONWEALTH COORDINATED CARE PLUS(CCC PLUS)
DMAS/DARSCOLLABORATION
• Early grant activities: Post card mailing to older Medicaid beneficiaries, helped organize and host statewide meeting
• Invited DARS to meetings with MCO’s: Opportunities to orient MCOs to CDSME
• Supported DARS/MCO discussions in 2015 to explore ER utilization study
• In the CCC Plus RFP: Strongly encouraged MCOs to partner with DARS to offer CDSME services as an enhanced member benefit to beneficiaries under the MLTSS program.
TIMELINE: VIRGINIA PREMIER HEALTH PLAN (VPHP)/DARS COLLABORATION
6/16: Invitation from VPHP, subsequent meeting and presentation. VPHP sends letter of intent to DARS the same day
8/16: DARS begins Scope of Work draft
10/16: Conference call with Virginia Premier to discuss Scope of Work. Referrals to be made through No Wrong Door electronic tools
12/16-1/17: Planning discussions with Virginia Premier
Months of back and forth on contract wording
VIRGINIA PREMIER HEALTH PLAN (VPHP/DARS COLLABORATION
4/17: Fully executed contract with VPHP.BAA has also been finalized and executed
BUT, several issues to be resolved:• Signed consent • Routing referrals to AAA subcontractor• Agreement on handling referrals to CDSME
“satellite” AAAs
Winter/Spring 2018: Training and refresher training for VPHP and AAAs
Finally, on May 1, 2018 the referral system goes live!
VPHP/DARS CONTRACT BASICS
• Coordination by DARS of referral and billing processes
• Programs delivered by Area Agencies on Aging
• Electronic referrals from Virginia Premier using Virginia’s No Wrong Door technology
• Virginia Premier reimburses DARS based on member workshop attendance
• DARS contracts with AAAs and reimburses based on member attendance
QUESTIONS?
April HolmesCoordinator of Prevention Programs
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