CMS Training for Program Developers

Consumer-Directed Services

States use a variety of approaches to including consumer-directed options into their MLTSS programs.

Tennessee provides an example of a state that requires the MLTSS vendor to contract with a consumer-direction support vendor.
For another example of a state that requires its MLTSS contractors to offer both a Fiscal/Employer Agent model and an Agency with Choice model, see provisions of the Texas Star+Plus contract.
For an example of a more explicit and directive contract language that includes, for example, a requirement that MLTSS contractors offer and document members' choices about consumer-directed services, see provisions of the Wisconsin contract.

Below are some key issues to consider when reviewing an MCO's provider network (see 42 CFR 438.206 for a complete list of requirements):

Adequate providers. One step in determining if a MLTSS contractor has established an adequate provider network is to review the LTSS your beneficiaries are using in the FFS environment and make sure these are well represented in the MLTSS contractor's provider network. This can ensure that the transition to managed care will yield similar access to services for consumers. Does the MLTSS contractor provider network include adequate access to skilled nursing facilities, home care providers, homemakers, etc.? Consider working with your Medicaid managed care counterparts to understand specific metrics that may be used to assess adequacy, understanding that these metrics may need to be adjusted for your target population.

Physical accessibility. Ensure that the offices of network providers are physically accessible to beneficiaries. A few examples of physical accessibility are (1) a provider should have an elevator if their office is on the second floor, or (2) a provider should have a ramp installed if there is a step up or down into their office.

Language access. Ensure that the provider network can accommodate your LTSS beneficiaries' language needs. This may include having providers in the network who speak languages other than English or providing access to interpreters as well as making sure providers can provide information to and communicate with beneficiaries' caregivers, beneficiaries with cognitive impairments, intellectual and/or development disabilities, and/or sensory impairments, e.g., by providing documents in braille or large print, and/or by providing access to sign language interpreters.

Geography. In some states, beneficiary travel distance and time standards are used in Medicaid managed care programs to document reasonable access within the provider network. Consider working with your Medicaid managed care colleagues to make sure you have appropriate provisions in your LTSS solicitations/contracts, understanding that your target population may require different time and distance standards than the general Medicaid population.

Hours of operations. The MLTSS contractor should ensure that providers have hours of operation that are appropriate for members. These hours should mirror those of commercial patients and/or of beneficiaries who have Medicaid FFS coverage.

O’Keeffe et al, 2010. UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMER 2010 EDITION. “Chapter 7: Participant-Directed Services and Supports.” U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, October 29, 2010.
Crisp, S., Doty, P., Flanagan, S., Smith, G., O’Keeffe, J., et al. (2009). Developing and Implementing Self-Direction Programs and Policies: A Handbook. Chestnut Hill, MA: National Resource Center for Participant-Directed Services.

This publication was developed to provide state staff, policymakers, service providers, program participants, and other stakeholders with a single comprehensive source of information about participant direction programs and policies.
Available as the full handbook at http://www.cashandcounseling.org/resources/handbook