Providing incentives with capitated payments. A key feature that distinguishes MLTSS from traditional programs is how the Medicaid agency pays for services. In the traditional system, most LTSS services are paid on a fee-for-service reimbursement basis, meaning that an amount is paid to the provider each time an individual service is provided. In an MLTSS program, the state calculates the average cost of providing a group of services and pays the MLTSS contractor that amount each month for each member who is enrolled with the contractor. This is called a per-member-per-month (PMPM) payment, or capitation.
Stakeholders may express concern that capitation provides an incentive to skimp on care, and without adequate monitoring and quality improvement systems in place, "the MLTSS contractor may not provide all needed services. However, if properly designed, financial incentives in MLTSS programs can align the interests of beneficiaries, contractors, and the Medicaid program by re-calibrating the balance of services toward greater HCBS and less institutional care.
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.
