Managed Care Plan Infrastructure

Integration of long term services and supports (LTSS) into the array of services provided by health plans that are primarily medical managed care organizations (MCOs) brings the risk that services, and the management of these services, will revert to a medical or clinical model, reversing gains in the social model of providing care.  In a medical model the strong role of consumer choice in designing and directing home and community-based services could be diluted.  Managed care’s utilization control tools could direct beneficiaries and prioritize resources to perceived clinical/medical needs and fail to give weight to priorities of consumer direction, individual preferences, social needs, and life goals.  To help protect against this risk, MCOs delivering LTSS should demonstrate financing, administrative, and care coordination infrastructures that treat LTSS services on an equal footing and as an equal partner with acute medical services.

  • The MCO must have leadership and management roles dedicated solely to LTSS that are filled by key personnel with demonstrated experience and expertise in LTSS management and systems issues.
  • Service authorization decisions must be made by personnel with specific expertise in LTSS and not just medical or clinical expertise.  Experience with and understanding of the complex and distinct needs of sub-populations of LTSS beneficiaries are also necessary.
  • The MCO must have structures and procedural safeguards to ensure that HCBS services are delivered on an equal footing with medical services. For example, particular HCBS models of practice for various populations (such as recovery in mental health, and independent living for people with various disabilities) should not be overridden by medical approaches to care in which medical providers have final authority over HCBS related decisions.
  • MCO governance structures must include beneficiaries who use a range of LTSS.
  • MCOs must commit to maintaining and further developing and supporting LTSS provider networks that are effectively integrated within beneficiary communities.
  • MCO interdisciplinary care teams must include individuals with expertise in the availability, provision and coordination of LTSS.
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