I/DD Care Could Be Disrupted by Medicaid Managed Care

Summary of Medicaid Managed Care May Create Disruptions in Care for ID/DD Populations, an article by the American Health Care Association (AHCA).

According to the American Health Care Association, Medicaid managed care may create disruptions in I/DD care. States across the U.S. continue to expand the use of managed care for Medicaid programs, and individuals with I/DD are being considered for participation. However, state managed care experience has typically included only children and healthy adult populations. A lack of familiarity with Long-Term Services and Supports (LTSS) and I/DD populations may result in less access and quality of care for a large number of beneficiaries.

As managed care further penetrates our health care models, we must consider numerous issues that may impact I/DD populations:

Uncertainty Concerning Effect on Quality and Outcomes

There is limited research on the effects of managed care on reducing costs and improving outcomes. Most current research measures process rather than outcomes. So measuring the impact of Medicaid managed care on beneficiaries is challenging. Quality measures vary across states and plans. In turn, comparing quality across plans and measuring the difference in quality between managed care and fee-for-service creates additional challenges.

Lack of Adequate State and Plan Readiness Review Procedures

Many Managed Care Organizations (MCOs) have a lack of experience with Medicaid managed care, especially I/DD populations. While states have requirements ensuring beneficiary needs are met, there is little information available about the processes used to verify and validate these requirements.

Unclear Beneficiary Resources for Managed Long-Term Services and Supports Education

Managed Care has created some confusion and uncertainty for many beneficiaries. This can be challenging for individuals with I/DD or low health literacy.

Unnecessary Prior Authorization Requirements and Challenging Independent Grievance and Appeals

MCOs may employ utilization management tools and other protocols in making coverage determinations which may inappropriately emphasize cost rather than quality of care. Beneficiaries and providers must have sufficient avenues to appeal decisions made by an MCO and to file complaints about issues or concerns with an MCO’s operations.

Barriers to Access

MCOs often experience difficulty recruiting providers willing to accept lower rates. According to a Kaiser Family Foundation survey, over two-thirds of managed care states reported that beneficiary access to specialists is a challenge, which is particularly problematic for the needs of the ID/DD population.

Coordination of Care

MCOs vary significantly in their approaches to designing and implementing care coordination models which can create confusion for providers attempting to adhere to care coordination requirements for multiple organizations. In addition, case managers play a critical role in ensuring that individuals with ID/DD receive the full range of services and supports needed. Under managed care arrangements, case managers have an incentive to limit the scope and level of services to contain costs, which may create a conflict of interest.

Mixed Medicaid Budgetary Research Findings

Researchers have found that state Medicaid managed care initiatives have no effect on overall Medicaid spending. States with more generous Medicaid reimbursement prior to MLTSS implementation realized greater cost savings, primarily due to reductions in provider reimbursement rates rather than managed care plan practices. In addition, the administrative costs of contracting with MCOs can be significant.

Need for Stakeholder Engagement and Transparency

The level of collaboration among state officials and other stakeholders vary significantly across states. Beneficiaries, providers and other stakeholders must have sufficient opportunity to prepare and respond to a state’s decision to develop and/or modify an existing MLTSS program. Intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) and home and community based (HCB) waiver group homes must be among the stakeholder groups consulted.

Increased Administrative Complexity

Lack of uniformity in plan policies and standards creates administrative burden for both providers and beneficiaries, which can result in delays in beneficiary care and provider reimbursement.