How does the MLTC Medicaid model impact seniors?

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Ben Mandelbaum, Chief Operating Officer of LTC Consulting Services and Senior Planning Services
Ben Mandelbaum, Chief Operating Officer of LTC Consulting Services and Senior Planning Services

Medicaid provides long-term care to more than 4.6 million seniors and 3.7 million people with disabilities. Contrary to popular opinion, however, Medicaid-sponsored long-term care is not specifically for the poor, although Medicaid is a healthcare safety net for low-income citizens. 

The reason is long-term is so expensive that very few Americans, even affluent ones, can fully afford the care they require.

Medicaid has undergone a significant shift recently in the way seniors and the disabled are approved and receive this care, due in part to the large influx of Medicaid applicants with the retirement wave of the baby boomers. The most significant change to Medicaid in recent years was the implementation of the Managed Long-Term Care (MLTC) model. 

With their many years of experience in assisting seniors and facility owners with Medicaid-sponsored long-term care, Senior Planning Services, a tri-state area Medicaid planning company, would like to discuss and shed light on the topic.

Underestimating Managed Long-Term Care (MLTC):

What is MLTC? Managed Long Term Care plans are private insurance companies that are paid a monthly premium by the Medicaid program to provide nursing home, assisted living and home care coverage to people who need long-term care because of a chronic health condition or disability.

The MLTC plans provide an assessment and decide what level of care is needed and how many hours of home care a Medicaid recipient will receive if they are not in an institutional setting. They arrange for care by a network of providers that the plan is in contract with; this process in the past was carried out by the Medicaid office and is now delegated to the private insurance companies.

MLTC is not a new Medicaid program, but rather a new Medicaid delivery system. It is designed to improve the quality of long-term care for individuals who need health services and caregiver assistance, increase efficiency between healthcare providers, streamline the process, and cut cost to the government.

The old system: Medicaid FFS (Fee For Service):

Why the change to MLTC? What was wrong with the old Medicaid model? Well, under the old Medicaid FFS (Fee For Service) model, there were two primary problems:

  1. Medicaid was widely taken advantage of and abused. The FFS model offered too many loopholes that prevented balanced budgeting by the federal and state governments. Some seniors were recommended services that they didn't necessarily need or placed in nursing homes when they may have been better off in a community setting. This resulted in services out-of-sync with the needs of the consumer — often providing too much of an unnecessary service and too little of a necessary one. 

  1. Under the FFS system, all of the services were distinct and billed individually and a consumer, therefore, could receive services from multiple providers under different networks with limited or no coordination between them. This unhealthy, perhaps inculpable, consumer trend coupled with a lack of centralized oversight pushed the ball even farther over the edge.

These avoidable Medicaid claims cost the federal and state governments billions of wasted dollars. If left unchecked, these flaws would have caused Medicaid to cease to exist in the foreseeable future. There was a pressing need for a system overhaul to take place so that Medicaid would continue to function into the future and that the holes in the system be immediately repaired.

The MLTC difference:

Under MLTC, providers are offered financial incentive by the Centers for Medicare & Medicaid Services to offer exactly the services needed by the individual and prevent unnecessary, costly nursing home and hospital admissions. The plans integrate all of the long-term health needs of an individual across several different locations in order to ensure that they're receiving the best possible care, but are less likely to provide unnecessary or unwanted interventions. This successfully tackles the first problem with old system, namely, providers recommending excessive services.

To solve the second loophole, that of overlapping services, the process is now streamlined with each consumer being assigned a service coordinator. The designated service coordinator ensures that all providers for any given recipient are working in sync and improving consumers' health. The program has also designed a "flat rate" fee for every member in the program. For that fee, the providers have to provide all the services needed by each individual enrolled in the plan.

On a daily basis, the way the new system operates in many states is that once a senior is approved for Medicaid, they will choose an MCO (Managed Care Organization) of their choice. Once the senior has enrolled in an MCO, the provider must reach out to the senior's designated service coordinator in order to begin billing for that recipient. In order to determine the amount of time the senior can receive care, a nurse will come down and carry out an individualized assessment. This process enable everyone enrolled in the program to receive the customized services they need, while at the same time freeing up funding for those that require additional services. 

MLTC Benefits:

MLTC's benefits include nursing home care, assisted living, adult day health care, home health services provided at home, specialty health appointments, personal care needs like bathing and getting dressed and even meal delivery.

At its core, the MLTC model is designed to provide all the services an ill or disabled individual needs. There comes a point where family members simply can't provide all the help needed, and that's when MLTC steps in to fill in the gaps. A patient's physical needs, social needs, and medical needs are all taken into consideration under the terms of the plan. Depending on the type of care selected, MLTC plans may cover only the long-term care services or all of the services associated with Medicaid. More information can be found here.

  • How Does MLTC Affect Patient Care? MLTC coordinates all the different elements of patient care and ensure that no matter where they might be, the patient is receiving the same quality of services. Each provider who accepts payment through MLTC must meet a certain set of standards in order to continue providing services. These standards ensure quality of patient care. 
  • How does MLTC affect consumer choice of nursing homes and other services? Like any insurance program, the MLTC model has limitations based on the nursing homes and providers that are covered by the program. There is, however, a good selection of options available under each plan. These nursing homes and providers are carefully monitored to ensure that they are providing the quality of care that each patient deserves. While a patient's first-choice nursing home might not always be on the list, there will be nursing homes available that will fit their needs. 

The ultimate goal of the changes to the system, as explained by the Health Care Education Project, was threefold: Improve the quality of care, address issues that can cause poor health, and reduce costs across the program. The MLTC model covers all of the services needed by each individual enrolled in the plan, keeping all of the patient's needs under the same umbrella of service. In the future this should lead to higher-quality services that address all of the health needs of each individual while still reducing the costs associated with the program.

Ben Mandelbaum is chief operating officer of LTC Consulting Services and Senior Planning Services, with offices in New Jersey, New York, Pennsylvania and Connecticut.

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