Many Medicaid members who prefer to live at home or in a community setting rely on managed long-term care plans to provide them with the necessary long-term services and supports (LTSS) to help them do so. These services are a vital element of their person-centered care plan, promote community integration, and may act as a potential preventative measure or delay utilization of more costly LTSS or institutional services. However, some plans may have vulnerabilities in their policies that leave Medicaid beneficiaries with less-than-acceptable services and standards of care.
In New York, the Medicaid Managed Long-Term Care (MLTC) plan gives Medicaid members who are chronically ill or disabled – and wish to stay in their homes or a community setting – access to LTSS, including home care, adult care, and physical therapy. A number of managed care organizations (MCO) administer the MLTC plan programs. A federal investigation found that some of these programs lacked rules, policies, guidelines, and regulations that resulted in them being non-compliant with their contracts.
The investigation by the New York State Office of the Inspector General uncovered that Medicaid members were not receiving the services and supports they were entitled to from the MCOs – and to whom the state was paying millions of dollars. These findings underscore that states should guarantee contracts for MLTC plans include requirements for policies, guidelines, and processes that will provide the appropriate services to members, manage utilization, and ensure the state’s funding is used appropriately.
At UMass Medical School, we have significant knowledge and experience in the area of LTSS and Medicaid – from creating policies and clinical guidelines to developing and implementing programs and evaluating results. Our team works with Medicaid agencies to make sure members are receiving the services and supports they are entitled to receive to remain in their homes or live in a community setting.
Medicaid programs need to evaluate upfront what needs to be in place in order for these programs to perform as required. By establishing a strong focus on close observation, regulation, and emphasis on following policy, Medicaid can be certain its members will receive the medically necessary, high-quality care in the setting of their choice as intended from MCO-managed plans.