July 24, 2015

CMS is incorporating specific MLTSS language into the recently released Medicaid managed care Notice of Public Rulemaking (NPRM). This is not only to recognize the importance of MLTSS as part of the overall practice and administration of LTSS within the managed care framework but also to enhance the historical rules/policies pertaining to acute managed care to have them benefit from lessons learned and best practices gleaned from the LTSS system. LTSS has historically been broad and flexible to meet specific state needs and this seems to be true of the LTSS section of this NPRM as well. CMS attempts to be evenly handed of providing flexibility to meet specific state needs and innovation while requiring core standards for the entire United States. However, areas such as services, benchmarks, and quality measures for LTSS are more difficult to quantify than acute services (e.g. metabolic measurements; disease life-span).

The overall content in the LTSS section is based on May 21, 2013 CMS guidance that provided ten key principles. The NPRM attempts to codify these principles. The specific focus on MLTSS is in this section but the requirements apply to all populations, not just those receiving LTSS. This is a major change in perspective from CMS: to look holistically at the individual and not be disease/disability/service support need specific.

Below you will find a brief analysis of the “ten key principles” of MLTSS:

Adequate Planning

There is a heavy emphasis on pre-planning especially for those individuals transitioning from FFS to Managed Care. States and MCO’s will need to add additional requirements for the current planning procedures to include LTSS and additional information material or amended information material must include LTSS.

Stakeholder Engagement

The stakeholder engagement process is to be separate from the Medical Care Advisory Committee (MCAC) and solely focused on MLTSS because it will require significant stakeholder involvement in the ongoing development, implementation, and daily management of MLTSS. Advocate groups will want more specificity in terms of membership and meeting requirements but this will be difficult to monitor due to the fact that it is difficult to operationalize the term ”involvement”. This has been an issue with the Community First Choice provisions where some states fully embraced the concepts while other states provided little opportunity for involvement.

Enhanced provision of Home and Community Based Services

With an emphasis on meeting all ADA and Olmstead requirements and all other pertinent state and federal requirements, these requirements are already included in most states’ requirements. A number of states are being challenged with their Olmstead compliance by the Department of Justice. The real issue with Olmstead compliance is with states’ appropriations and whether they are funding community services adequately to give real choice in residential setting.

Alignment of Payment Structures and Goals

This rule addresses the issue of aligning payment to MCOs to support goals of MLTSS to” improve the health of beneficiaries; support the beneficiary’s experience of care, support community integration of enrollees, and reduce costs.” CMS included this area to ensure this information is included in the annual program summary report but may prove to be a challenge for state funding to actually ensure these goals. This rule reads as a “pay-for-performance” requirement, providing terms such as “experience of care and “community integration” which can be overly vague.

Support for Beneficiaries

A possible major rule addition is the new cause for disenrollment for enrollees receiving LTSS. This could potentially have a serious impact to MCO operations and state administrations. The language states that if a state does not allow an individual to switch MCOs at any time then states should permit MLTSS enrollees to dis-enroll and switch to another MCO or FFS when the termination of a provider from their MLTSS network would result in a disruption of the enrollee in using that specific provider. An additional requirement, modeled after current administrative claiming rules and on enrollment broker services, describes the conditions to be met for a state to claim FFP for LTSS-specific services beneficiary support system activities. Cost must be supported by an allocation methodology that is in the state’s Allocation Plan; not supplementation; service must meet independence and conflict of interest provisions applicable to enrollment brokers and the initial contract or agreement for services be reviewed and approved by CMS which may be burdensome to state government in terms of time and CMS involvement if they do not approve the contract.

Person-Centered Processes

CMS is putting an emphasis on person centered planning and a comprehensive needs assessment and service planning. These changes requiring identification, assessment and treatment/service planning for individuals receiving LTSS enrolled in a MCO. This should have a big impact on the way MCOs do business; especially the way they do acute services. These rules, specifically addressing LTSS, but will impact all services. Traditionally, services have been top down from the state/provider to the beneficiary. Person centered planning means that the beneficiary is included at all aspects of the service planning process and is to incorporate his/her goals/aspiration services desires. This process can, at times, provide false expectations and MCOs must learn how to manage expectation but at the same time include the individual and their goals into the service planning process.

Comprehensive, Integrated Service Package

There is an emphasis on coordination and referral by MCOs when there are different contracts for specified services. This activity should be occurring but may require additional resources to really have service coordination and a service coordinator, as a meaningful activity that is meeting the stated goals.

Qualified Providers

CMS wants MCOs to ensure adequate capacity, expertise to provide services that support community integration (e.g. employment services and provision of training and TA to providers). This includes standards for when an individual travels to a provider and standards when the provider travels to the individual. The time/distance standards will be difficult to establish especially when there are large rural areas or in heavily trafficked areas. States may want to look at alternatives to the traditional time/distance standard to achieve the goal of timely services within one’s area. Accessibility should be within all state requirements now for any service, meeting the ADA standards.

Participant Protection and Quality

CMS is adding a contract standard that MCOs participate in state efforts to prevent, detect, and remediate all critical incidents. MCOs are required to have mechanisms to assess the quality and appropriateness of care provided to LTSS enrollees (including between settings of care and compared to stated goals in the person centered plan) and states must include the results of any rebalancing efforts by the MCO in its annual program. CMS will need to provide more clarification on what qualifies as a critical incident and what their requirements for assessing the quality and appropriateness of care would be as they are currently very vague on these efforts. There will be additional work for the state and MCO since it has been difficult to quantify quality in LTSS versus the acute system with its HEDIS measures.

Stakeholder Engagement in LTSS

CMS is proposing the MCO be required to have a stakeholder engagement process that is ongoing to solicit direct input on the enrollees’ experiences through the implementation of an advisory committee. This advisory committee will be made up of enrollees (not providers). MCOs are going to have to dedicate some staff and time to convene the advisory group and ensure it is a meaningful process.


Throughout the NPRM, there is increasing recognition of the growth of managed care and Managed Long Term Services and Supports (MLTSS). Some areas seem more aspirational without giving needed clarification and/or parameters. The proposed language will require in some instances: additional staff; IT changes; policy development and training; closer monitoring and ongoing quality assurance; and new reporting requirements.

Currently, a majority of MLTSS programs have been using the Fee-For-Service (FFS) definitions of LTSS and states use this specificity to help guide and measure outcomes which may have an impact on other nationwide assessment and quality measures because definitions vary significantly across states. The requirement for individuals to live the in setting of their choice also provide a challenge for states/MCOs when determining how broad this requirement is.

Interested parties have until 5pm on July 27 to submit comments on the NPRM. We welcome the opportunity to speak to you regarding your concerns or questions regarding the new Medicaid Managed Care rules. Please do not hesitate to contact us at info@

Marc Gold

About Marc Gold

Marc Gold, Senior Consultant, leads projects involving long-term services and supports including managed long-term services and supports. With nearly three decades of experience in directing long term services and supports policy, Marc was most recently an executive with the Texas Department of Aging and Disability Services as the special advisor on policy and leading Texas’s Olmstead efforts. There, he was responsible for interagency policy involving all of the Texas health and human services agencies, Texas’s Promoting Independence Initiative, the Money Follows the Person Demonstration, and the Balancing Incentive Program. Marc served on the National Academy of State Health Policy’s Long-Term Services and Supports advisory committee.