Managed Medicaid Long-Term Care (MMLTC), also called Medicaid Managed Long-Term Services and Supports (MLTSS), is a way in which states can deliver Medicaid home and community based services (HCBS), as well as nursing home care, to persons who are elderly or disabled. With the Medicaid managed care delivery system, state Medicaid agencies contract with managed care organizations (MCOs), essentially private health insurance companies, who provide health care plans. For each program participant, a set monthly rate, formally called a capitation rate, is paid to the MCO to cover the services and supports included in one’s plan. In turn, program beneficiaries must utilize providers that are part of the MCO’s provider network.
The managed care delivery system for Medicaid long-term care programs is growing in popularity, as demonstrated by the increase in such programs across the states. In 2004, just 8 states utilized this type of delivery system, and in 2021, ADvancing States reported that 24 states had MLTSS programs. Within the states that offer MMLTC, many states have more than one managed long-term care program.
Some MMLTC programs only cover long-term services and supports, such as in-home personal care assistance, adult day care, and home health care, other programs offer Medicaid acute care (inpatient and outpatient hospital services, laboratory services, physician visits, etc.) and Medicaid long-term care, and still others streamline the benefits of acute care from both Medicaid and Medicare and Medicaid long-term care services for dual eligible persons (those eligible for both Medicaid and Medicare benefits). Some programs require mandatory enrollment, while others have optional enrollment.
While many states are turning to managed care for the delivery of Medicaid long-term services and supports, many states also still utilize a non-managed Medicaid long-term care delivery system. Also called Medicaid fee-for-service (FFS), this is the traditional delivery method of Medicaid benefits. It is becoming common for states to give a Medicaid beneficiary the option of choosing between a managed care program and a fee-for-service program.
Unlike with managed care, non-managed long-term care (fee-for-service) program participants are not limited to a network of care providers. They can see / receive services from any provider who accepts Medicaid, and the state pays providers directly for each service provided. This is in contrast to managed care in which the state pays a set monthly rate for each program participant to receive services and supports.
With both managed care and fee-for-service Medicaid, program participants can receive a variety of long-term home and community based services. These benefits are intended to help seniors and persons with disabilities to live at home or in the community, rather than require placement in a nursing home. Potential benefits vary based on the state and the managed care program in which one is enrolled. Examples of potential benefits include in-home personal care, homemaker services, adult day care, home health care, durable medical equipment, personal emergency response systems, home delivered meals, respite care, home / vehicle modifications, and non-medical transportation. Medicaid programs may also cover services and supports in assisted living residences or adult foster care homes. Many MMLTC programs also cover the cost of nursing home care.
For Medicaid Managed Long-Term Services and Supports, there are both pros and cons. If presented with a choice between managed care and fee-for-service, consider the following.
Pros
Reduced / Controlled Costs for States – Given that states pay a fixed monthly rate to a managed care organization for each program participant in a managed care program, the state knows its costs ahead of time and is better able to control its budget. With fee-for-service Medicaid, the state pays providers for each service provided, which makes it difficult to budget and control costs.
Increased Efficiency in Care Coordination / Delivery of Services and Supports – With managed care, the managed care organization coordinates all services for program participants. This is in contrast to fee-for-service Medicaid, in which a program participant may have several agencies coordinating all of their program benefits. Furthermore, some managed Medicaid long-term care programs include prescription drug benefits or Medicare benefits, allowing program participants to receive all of their Medicaid and Medicare benefits via one program. Care plans may also be shared via electronic health records (EHRs) for ease of communication between providers. All of this equates to program participants and their family members spending less time and effort in coordinating care.
Potential Additional Program Benefits – Some managed care organizations include services that are not usually available via non-managed Medicaid long-term care.
Some States Have Seen a Decrease in Waiting Lists for Long Term Care Services and Supports – Many states offer long-term services and supports for the elderly and disabled via 1915(c) home and community based services Medicaid Waivers, which limit the number of program participants. It is not uncommon for there to be a waitlist for long-term care services. While there may be a waitlist for some services via Medicaid managed long-term care programs, some states have been able to eliminate or decrease the number of persons waiting for services.
Cons
Program Participants are Limited to a Network of Providers – Program participants are only able to use providers who are in their managed care organization’s network of providers. Upon acceptance into a managed care program, one may have to switch their current providers, as program participants cannot use any provider that accepts Medicaid.
Sense that There is a Shift From a Patient Centered Approach to Being a Number – Some managed care beneficiaries may feel they are seen as a number, rather than as a patient. This could be reflected in the attitude of care providers and physicians towards program participants.
The following states have a Medicaid Managed Long-Term Services and Supports model for delivering program benefits.
Arizona
Arkansas
California
Delaware
Florida
Hawaii
Idaho
Illinois
Iowa
Kansas
Massachusetts
Michigan
Minnesota
New Jersey
New Mexico
New York
North Carolina
Ohio
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Virginia
Wisconsin
Indiana is implementing a MLTSS program, PathWays for Aging, which is expected to be active in the summer of 2024.
While the exact eligibility requirements for Managed Medicaid Long-Term Care Programs vary based on the state and the specific program, all programs have financial (income and asset limits) and functional (generally a Nursing Home Level of Care) eligibility criteria. See Medicaid eligibility criteria by state. For state specific questions, persons can contact the Medicaid agency in the state in which they reside. See contact information.