Providers: Get detailed contracts when entering Medicaid managed care systems, AHCA guidance urges

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Long-term care providers should be cautious adopters as Medicaid managed care programs grow in scope and number, according to a new report and toolkit from the American Health Care Association. 

Only 16 states currently have Medicaid managed care in place for long-term services and supports, but this number will increase to 27 as the Affordable Care Act is fully implemented in 2014, the AHCA analysis states. Report author Mike Cheek, AHCA vice president for Medicaid and Long-Term Care Policy, developed guidance for providers and advocacy organizations based on his analysis of existing managed long-term services and supports (MLTSS) programs. The advisory documents are attached as Appendix B and Appendix D to the toolkit.

“The documents are designed to help providers design or enhance new or current MLTSS programs in their states,” Cheek told McKnight's. “Appendix B includes a checklist of major contractual points that nursing facilities should consider and review in Medicaid Managed Care Contracts. In addition, Appendix D gives an advocacy framework that providers can use, depending on their state's MLTSS design. These are intended to ensure continued access to high quality services."

The contracting checklist addresses many of the potentially problematic areas described in the report, such as rate setting, quality oversight and plan exits.

Medicaid managed care is typically administered through capitated payments to a managed care organization (MCO) that is supposed to pay for all contracted care for beneficiaries. However, there have been no nationwide or multi-state analyses to check whether capitation rates for MLTSS have been adequate — and on the state level, the rates have in some cases not been adequate.

In Wisconsin, insufficient MLTSS capitation contributed to eight of nine MCOs in the state running deficits in 2009, according to the AHCA report. The contracting guidelines encourage providers to ask for detailed documentation of what rates will be paid, and when. Providers are also advised to define whether notice is required if the plan or facility becomes insolvent.

Other checklist items include asking whether survey compliance impacts participation, defining reporting requirements, and ensuring that conditions for plan termination are specific.

Appendix D lays out AHCA's positions on issues such as statewide versus regional implementation and whether participation of nursing facilities should be mandatory.

Click here to access the toolkit.

Click here for the report.