The most exciting opportunity presented by an MCO model is the potential that MCOs will be incentivized to provide care at home and in the community instead of in more costly and restrictive institutional settings. For beneficiaries to benefit from this “rebalancing,” the array and duration of HCBS services provided by the MCO must be adequate to assist beneficiaries to achieve personal goals in areas such as community integration, meaningful relationships, employment/education opportunities, home environment, recreation, and health/welfare. The available menu of services must be person-centered in both its scope and its responsiveness to beneficiaries who vary widely in their age, capacities, ambitions, needs, and personal support networks. The benefit package must also make MCOs liable for the full range of LTSS services, including the cost of care provided in institutional settings.
- Contracts must state clearly that MCOs must provide Medicaid state plan services that are no more restrictive in amount, duration, and scope than the coverage provided in the Medicaid fee-for-service setting.
- If the MCO is also responsible for providing Medicare services, contracts must state clearly that MCOs must provide Medicare plan services that are no more restrictive in amount, duration, and scope than the coverage provided in the Medicare or Medicaid fee-for-service setting, whichever is more inclusive.
- MCOs must provide a detailed description for each of the various sub-populations to be served, and of the type of services available to meet their functional needs across the range of their life goals and needs. States must provide overarching documentation on how available LTSS services can meet the functional needs of all beneficiaries in the program.
- MCOs must be financially responsible for the full range of LTSS to ensure that there are no incentives to direct enrollees toward institutions instead of receiving support services while living in community-based settings. For example, MCOs must be at risk financially for nursing facility expenses because if nursing facility services are carved out from LTSS, MCOs would be financially rewarded for shifting complex enrollees with high care needs toward institutions where some other entity would be financially responsible for their care.
- The MCO benefit package must include comprehensive home and community-based services. MCOs should be required to provide these services in sufficient amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are furnished. HCBS must not be subject to arbitrary limits such as wait lists, enrollment caps, or geographic limitations.
- MCOs should be permitted and encouraged to provide alternative supports or services when appropriate to support the individual’s long-term care goals and needs. However, contracts must include baseline standards across all MCOs for enhanced and alternative services so individuals can understand the choices available to them, and the extent of services and treatments that are governed by MCO appeal rights.
- MCO benefit packages must include coverage for expenses related to care transitions and changes in beneficiary functional levels, such as moving expenses and home modifications needed for aging in place or after the acquisition of secondary conditions.
- MCOs must identify and support community-based “transition-out” programs to move enrollees when appropriate to community-based settings from nursing facilities and other institutions, and develop such programs where they don’t exist or exist only at a rudimentary level. Peer support should be an integral component of such programs.
- For enrollees with a desire to be employed, MCOs must provide services and supports needed to gain and maintain employment as an integral component of improved health, wellness, and independence. There should be a presumption of competitive, integrated employment that is appropriately supported, and Medicaid “buy in” opportunities must be extended to beneficiaries who would otherwise meet the eligibility income threshold but for employment income.
- Any carve out of specific subpopulations should only be for groups that already fully enjoy the benefits of coordinated and integrated care, under the administration of an entity that provides robust home and community-based services.
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