This final rule has four major goals as envisioned by CMS, three of which have areas that LeadingAge members should take note of:

  1. Supporting states’ efforts to advance delivery system reform and improvements in quality of care for Medicaid and CHIP beneficiaries; 
  Network adequacy for long-term services and supports (LTSS)
  It is noted that managed care networks need to meet the needs of managed LTSS beneficiaries, including adequate capacity and expertise to provide access to services that support community integration, such as employment supports, and the provision of training and technical assistance to providers. As such four changes are made for states to:

  • Establish time and distance standards specifically for MLTSS programs, as well as other standards for LTSS provider types that travel to deliver services;
  • Ensure that network providers have capabilities to ensure physical access, accommodations, and accessible equipment for enrollees with physical and mental disabilities;
  • Maintain an appropriate network of LTSS providers that is adequate for the anticipated number of enrollees for the service area and sufficient in number, mix, and geographic distribution; and
  • Establish a credentialing and recredentialing policy that addresses all the providers, including LTSS providers, covered in their managed care program regardless of the type of service provided by such providers.

Quality rating system
  The rule establishes authority to develop and implement a Medicaid and CHIP quality rating system (QRS), similar to the QRS that exists for the Marketplace, to enable states to better measure and manage the quality of care and to assist consumers to shop for plans.
  Identification of enrollees with LTSS needs The state must implement mechanisms to identify persons who need LTSS and may use state staff, enrollment brokers, or health plan staff.  2. Strengthening the consumer experience of care and key consumer projections; 
  Provider directories
  Each health plan must make available in paper form upon request and electronic form, information about its network providers including items on cultural and linguistic capabilities and accommodations for people with disabilities. LTSS providers are on the list of provider types covered, as appropriate.
  Assessment and treatment plan for LTSS
  For each enrollee identified as needing LTSS services, a comprehensive assessment must be completed. Upon completion new requirements state that a treatment plan must be produced that is developed by an individual meeting LTSS service coordination requirements with enrollee participation, and in consultation with any providers caring for the enrollee; developed by a person trained in person- centered planning using a person-centered process and plan; and reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly, or at the request of the enrollee. This update puts real emphasis on the person-centered process and moves language away from treating conditions to meeting individual’s needs and goals.
  Choice counseling

States are required to provide choice counseling services for any new enrollee or for enrollees when they have the opportunity to change enrollment. CMS highlights that this is particularly important for those individuals needing LTSS. For individuals with LTSS needs additional beneficiary supports must be available including an access point for grievances and concerns with their health plan, education on grievance and appeal rights, and assistance in navigating the grievance and appeal process.

  3. Strengthening program integrity by improving accountability and transparency; and
  4. Aligning rules across health insurance coverage programs to improve efficiency and help consumers who are transitioning between sources of coverage. 
  Provider screening and enrollment
  State Medicaid and CHIP programs are required to screen and enroll all network providers who are not otherwise enrolled with the state to provide services to fee-for-service Medicaid beneficiaries. As done in Medicare fee-for-service and Medicaid fee-for-service, this standard requires that all providers in Medicaid, who order, refer, or furnish services under the managed care program, are appropriately screened and enrolled. The rule does not, however, require providers who participate in a Medicaid managed care plan’s network to also provide services to individuals enrolled in a state’s Medicaid fee-for-service program. Managed care plans will be able to execute temporary network provider agreements, subject to requirements, pending the outcome of the screening and enrollment process to support network development. 

Generally, the most relevant information for our members is the explicit inclusion of rules around managed LTSS programs as more and more states have and are moving towards this approach. Much of the requirements are ones that have previously existed in regulation or guidance for fee-for-service LTSS and other Medicaid managed care policies. It is clear that CMS is putting great emphasis on involving stakeholders in planning for LTSS programs and person-centeredness remains a vital component of both assessments and service planning.