LTSS CHOICES

About this Series

This Spotlight is part of the AARP
Public Policy Institute’s LTSS Choices
initiative. This initiative includes

a series of reports, blogs, videos,
podcasts, and virtual convenings that
seeks to spark ideas for immediate,
intermediate, and long-term options
for transforming long-term services
and supports (LTSS). We will explore a
growing list of innovative models and
evidence-based solutions—at both the
national and international levels—to
achieve system-wide LTSS reform.

We recognize the importance of
collaborating and partnering with
others across the array of sectors,
disciplines, and diverse populations
to truly transform and modernize

the LTSS system. We invite new ideas
and look forward to opportunities for
collaboration.

For all questions and inquiries,
please contact Susan

at LTSSChoices@aarp.org.

 

For Americans with limited income and savings, the primary
way to access long-term services and supports (LTSS) is to
enroll in Medicaid, a public program that is run at the state
level but combines federal and state funding. Medicaid
accounted for 52 percent of all LTSS expenditures in the U.S.
in 2018." Historically, state Medicaid programs reimbursed
LTSS providers using a fee-for-service model; however,
increasingly states are shifting to a different financing and
delivery system to manage and provide these services for
Medicaid beneficiaries: contracting with Medicaid managed
care organizations (MCOs).

The growing reliance on MCOs to finance and deliver Medicaid
services posed unique challenges and prompted innovative
responses as states responded to the COVID-19 pandemic.
MCOs providing Medicaid managed LTSS (MLTSS) had to
address many care and coordination issues, including the
availability and use of telehealth, food distribution, paying
family caregivers, data tracking, addressing workforce needs,
and backup planning.

‘Molly O’Malley Watts, MaryBeth Musumeci, and Priya Chidambaram, “Medicaid Home and Community-Based Services
Enrollment and Spending,” Issue Brief, (San Fransisco: Kaiser Family Foundation, February 2020).

These percentages do not include the significant contribution made by informal caregivers, whose economic value is
estimated at approximately $470 billion. See Susan C. Reinhard, Lynn Friss Feinberg, Ari Houser, Rita Choula, and Molly
Evans, “Valuing the Invaluable 2019 Update: Charting a Path Forward,” Insight on the Issues, (Washington, DC: AARP,
November 2019).

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

The COVID pandemic severely tested the ability of states and their MLTSS plans to meet Medicaid
program requirements, but the pandemic response also prompted some potential improvements

to care. Some approaches and practices that states and their MLTSS plans put into place in both
institutional and home- and community-based settings (HCBS) during the pandemic are examples for
how MLTSS can enhance care as well as help address future public health emergencies.

This Spotlight examines the role played by MCOs delivering MLTSS during the pandemic, shining a light
on the efforts to meet the needs of individuals receiving LTSS in nursing homes and in their own homes.
As the disproportionate number of COVID-related deaths in nursing homes makes clear, individuals
receiving LTSS services are particularly vulnerable to the virus. This Spotlight presents some of the
“on-the-ground” experiences of MCOs and other stakeholders as the crisis unfolded. We explore the
challenges states and MCOs faced, efforts to meet the needs of recipients of MLTSS, and lessons learned.

Methodology

The following information and insights are based on interviews with more than 25 individuals, including state Medicaid
directors or their leads on LTSS in 6 states (Arizona, Florida, Pennsylvania, Tennessee, Virginia, and Wisconsin), a cross-
section of representatives from both national and local Medicaid MLTSS plans, national association representatives,
LTSS thought leaders, and consumer advocates. A standard list of questions, modified according to on the organization
represented by the individual, guided the interviews. This analysis does not represent a comprehensive inventory of
initiatives implemented to address the pandemic nationally, nor is it a scientific sampling representative of all state
Medicaid programs; however, the intentional cross-section of states and MCOs offers important insights into what
happened as the pandemic unfolded.

The Growth of Medicaid MLTSS

Many states are shifting to managed care as the delivery system for individuals who use Medicaid LTSS.
Historically, states operated Medicaid LTSS programs using a fee-for-service model, in which states paid
providers directly for services provided to Medicaid beneficiaries. Under managed care, states contract
with MCOs to provide care coordination and services to Medicaid beneficiaries through a capitated per-
member-per-month payment.

Currently, 25 states operate MLTSS programs, which is up dramatically from 8 states in 2004. Ten
states, including Pennsylvania and Virginia, have added MLTSS programs since 2012.3 Spending on
MLTSS increased more than six fold from $6.7 billion in 2008 to $43.6 billion in 2016.* In 2017, the year
for which the most recent data are available, approximately 1.8 million Americans were enrolled in an
MLTSS plan.* Today’s estimates suggest well over 2 million Americans are enrolled in a Medicaid MLTSS
plan, which accounts for recent expansions (such as those in Pennsylvania). Figure 1 presents the states
with at least one Medicaid MLTSS program.

3Elizabeth Lewis et al., “The Growth of Managed Long Term Services and Support Programs: 2017 Update,” (Washington, DC: Truven Health Analytics for Centers for Medicare & Medicaid Services,
January 2018).

Caitlin Murray et al., “Medicaid Long Term Services and Supports Annual Expenditures Report: Federal Fiscal Years 2017 and 2018,” Mathematica, January 7, 2021.

5Ibid.; Lewis et al., “Growth of Managed.”

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

FIGURE 1: STATES WITH MEDICAID MLTSS PROGRAMS

No MLTSS Program wy MLTSS Program

 

Source: MACPAC, 2020, analysis of ADvancing States data, 2020.

Differences in Medicaid MLTSS Contracts

MLTSS programs vary significantly from state to state, differing in populations served, benefits covered,
and geographic reach, among other distinguishing characteristics. Some have mandatory enrollment,
while others are voluntary. Programs can also vary within a state, as some Medicaid agencies have
contracted for more than one MLTSS model depending on the population served and services delivered.
Most MLTSS programs serve older adults and people with physical disabilities, often excluding individuals
with an intellectual or developmental disability. The structure of each program affects the services an
MCO is responsible for providing, potentially narrowing or expanding the scope of benefits available.

Generally, state MLTSS programs fall into one of three categories:

Bl Medicaid LTSS-only plans provide Medicaid LTSS benefits only (not medical services), usually including both
institutional and HCBS services, although some are limited to managing only HCBS with limited financial risk for
institutional beneficiaries.

Bi Comprehensive Medicaid MLTSS plans deliver both LTSS and non-LTSS medical services. States may limit enrollment
only to beneficiaries of LTSS services or include all members of a population (e.g., all individuals over age 65

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

regardless of whether they require LTSS). Most states (21) employ this type of plan, according to a recent survey of
state Medicaid directors®

Bl integrated Medicaid and Medicare plans cover both Medicare and Medicaid benefits, including LTSS, for individuals
who are enrolled in both programs.

State Medicaid agencies contract with MCOs in administering their MLTSS program. The contracts
ensure that state and federal requirements are met, including parameters related to appropriate care
coordination, individualized assessment of need, and person-centered planning. Although all contracts
must include these core requirements, the specifics of the contract language differ, introducing another
element of variability among programs.

In assessing the role played by MLTSS plans during the COVID pandemic, it is important to consider the
core areas for which a plan is responsible as well as the variability among MLTSS programs across states.
Depending on a state’s MLTSS program structure, the services for which an MLTSS plan is responsible vary
significantly, ranging from an MLTSS-only health plan to a comprehensive Medicare and Medicaid plan
offering the full gamut of health care services. Even among MLTSS-only plans, there are wide variances in
services, as some plans limit coverage by carving out all or a portion of institutional services.’

Challenges States and MCOs Faced during COVID-19

Care coordination, real-time data, communication, access, and equipment all posed challenges as

state Medicaid agencies and MCOs sought to quickly respond to COVID. Establishing clear roles and
accountability for care in nursing homes was particularly important as the disproportionate death

toll on nursing home residents became clear. Since the beginning of the pandemic, roughly 184,000
residents and staff of nursing homes and other long-term care facilities have died of COVID,’ accounting
for nearly one-third of deaths attributable to the pandemic in the United States.°

Clearly establishing the responsibilities of state Medicaid agencies in addressing beneficiary needs
versus that of the MLTSS plan was a necessary first step. Although all states took the lead role, the
approaches in working with MLTSS plans differed. Some state agencies played a more central part in
directing the activities of MLTSS plans, while other states focused on removing barriers, providing
flexibilities, and addressing issues that would otherwise inhibit the ability of MLTSS plans to respond to
beneficiaries’ needs and meet plan contract requirements.

Despite their contractual relationship with nursing homes, MLTSS plans struggled to gain access to
nursing home residents, making it difficult to perform care coordination responsibilities. As nursing
homes facilities were locked down, care managers were unable to gain entry to the buildings. Not
only were plans unable to gain entry, they also found it difficult to reach appropriate personnel
inside. Further, the lack of direct observations that would otherwise have occurred during in-person
assessments became a problem: MLTSS plans did not have the technology in place—sometimes not

5Kathy Gifford et al., “A View from the States: Key Medicaid Policy Changes, Results from a 50 state Medicaid Budget Survey for State Fiscal Years 2019 and 2020,” Kaiser Family Foundation, San
Francisco, October 2019.

“Ibid.; Lewis et al., “Growth of Managed.” As an example, New York State received approval in December 2019 from the Centers for Medicare & Medicaid Services to limit the nursing home benefit
included in the partially capitated MLTSS plans to three months for enrollees who require long-term stays in nursing homes, moving reimbursement to fee for service.

8AARP Nursing Home COVID-19 Dashboard, Public Policy Institute, online at: https://www.aarp.or i/issues/caregiving/info-2020/nursing-home-covid-dashboard.html, accessed after update May
13, 2021.

 

®*Percentage calculation used data from Centers for Disease Control and Prevention Covid Tracker online at: https://covid.cdc.gov/covid-data-tracker/#datatracker-home, accessed on May 15, 2021.

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

even telephones were available for individual residents—to conduct virtual visits with beneficiaries,
particularly at the outset of the pandemic. This inability to reach members also impacted efforts to
transition people out of nursing homes.

Other factors compounded the challenges plans faced. Amid the public health emergency and major
staffing challenges, nursing homes had to respond to multiple plan representatives/case managers
seeking assistance. Nursing home workers were often overwhelmed with an already severely strained
staff that didn’t have the spare resources necessary to facilitate plan and member interaction. Although
most individuals in nursing homes receive coverage through Medicaid, the number of members in

any one MLTSS plan in a particular facility can be relatively small depending on the number of MLTSS
plans under contract with a state. In addition, many residents were not covered by any Medicaid
MLTSS plans, instead receiving coverage through traditional Medicare or Medicare Advantage plans, or
through private pay. Thus, individual MLTSS plans often had only a small percentage of residents who
were members in any one facility.

The lack of reliable, real-time data to better manage the pandemic as it was unfolding was a
fundamental challenge. In the early days of the pandemic, states struggled to gather data on clusters
of COVID cases in nursing homes. Tennessee was the first state to mandate that its nursing facilities
report COVID case data, taking this step even before the Centers for Medicare & Medicaid Services
(CMS) required it. The lack of timely encounter data from the MLTSS plans sometimes made it difficult
to make urgent decisions in terms of redirecting resources. Without data-sharing, states were unable
to assess the pandemic’s impact on reimbursements to certain providers, such as those of adult day
services, that were suspended by COVID lockdowns. In addition, the lack of data and coordination
regarding the distribution of federal dollars and other resources, such as personal protective
equipment, made it more difficult for states to find gaps and respond quickly.

Efforts to Meet the Needs of Beneficiaries
Several themes emerged in meeting these challenges.

Clear, frequent communication was essential.

State Medicaid agencies took the lead in providing guidance and directing MLTSS plan efforts

during the pandemic, although how states played that role varied. States held regular meetings with
MLTSS plans on an individual and group basis as the pandemic unfolded, with many meetings daily,
particularly at the onset. Through regular communication, states shared the latest federal guidance
from the Centers for Disease Control and Prevention and other agencies, updates on pandemic-related
developments at the state and local levels, and state direction on priority MLTSS activities, including
regulatory flexibilities to address most pressing needs.

The frequent and clear communication allowed for refinement and improvement as states and MLTSS
plans handled concerns as they arose. States sought and responded to input from MLTSS plans. The
meetings also provided a forum for MLTSS plans to share what they saw happening on the ground.
MLTSS plans often gave advice from the vantage point of their clinical expertise. One plan with roots
in an academic health center had expertise on quarantining and telehealth. National plans shared
advanced intelligence on what they were seeing in other markets hit hard earlier on in the pandemic.
This iterative process evolved over time as states passed through the stages of the pandemic. For
example, Virginia’s health plans became increasingly proactive over time in recommending initiatives
to better meet the needs of members, such as additional meals for beneficiaries and certain medical
supplies (e.g., diapers) for patients returning from hospitals.

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

Plans supported nursing homes, responding to real-time needs.

The MLTSS plans identified several ways to address the barriers nursing homes faced. First and
foremost, at the early stage of the pandemic, there was a need for personal protective equipment (PPE),
and most of the plans surveyed detailed their efforts to make PPE available to nursing homes and other
providers. For example, one plan deployed unused stock of PPE from the medical facilities it owned to
distribute PPE to providers in its managed care markets.

Besides locating PPE, MLTSS plans implemented strategies to reach their members virtually, but there
was a particular awareness for not overwhelming an already incredibly strained nursing home staff.
State departments of health or state survey and certification agencies responsible for Medicare and
Medicaid facility oversight and licensing took direct responsibility for health and safety issues related
to nursing homes as the pandemic unfolded. In some instances, the responsible agency was outside the
department overseeing Medicaid programs.” Given the continual communication and direction from
these oversight agencies, and the ongoing pandemic pressures, state Medicaid agencies advised plans
not to overload nursing homes with unnecessary demands.

In Pennsylvania, MLTSS plans coordinated efforts by standardizing a schedule and a virtual process

for engagement to avoid overburdening nursing home staff. Several plans provided technology for

care managers to interact with beneficiaries in nursing homes. One plan sought to leverage the Federal
Lifeline program, a Federal Communications Commission program that provides discounts to low-income
consumers on monthly telephone and broadband Internet service, and supplemented these resources
where necessary to provide devices and WiFi for its nursing home residents. In addition to giving tablets

to nursing home beneficiaries in 11 states, another plan worked with nursing homes in one state to tie into
their electronic medical record system to assist in coordinating health care for members. Other plans noted
similar efforts to integrate with nursing homes’ clinical record systems to enhance care management.

Convening a task force of nursing homes and other LTSS stakeholders, Arizona developed a plan for
prioritizing access by key oversight personnel (e.g., long-term care ombudsmen) to ensure entry during
the lockdown periods. It also made grant funding available to nursing homes to purchase IT equipment,
such as iPads, to support telehealth visits for care managers and family members.

MCOs also contributed clinical support to nursing homes. Clinical staff for one plan volunteered to
assist nursing homes in several states. Wisconsin engaged its MCOs to provide technical assistance on
behavioral health issues to surge facilities set up during the pandemic, as these facilities lacked the
expertise to care for individuals with behavioral health needs. MCOs in Tennessee collaborated with a
vendor to develop protocols for COVID units in nursing facilities and provided incentive payments to
nursing home units that met these protocols. These efforts by MLTSS plans to provide clinical and other
supports to nursing homes, and efforts to use IT solutions to assist with care management, represent
practices that could serve as blueprints in future health emergencies; they could also enhance care
more generally for MLTSS nursing home beneficiaries.

Plans were asked to focus on home and community-based services.

While states expected MLTSS plans to meet contract requirements and provide care management
and services for all beneficiaries, states asked plans to place particular focus on the needs of people
receiving HCBS during the pandemic. The Medicaid agency and its contracted MLTSS plans had the

°For example, in Pennsylvania, the Department of Health is a separate agency from the Department of Human Services, which houses the Medicaid program; in Florida, the state’s survey and
certification agency is part of the Agency for Health Care Administration, an umbrella agency that also includes the state’s Medicaid program.

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

primary responsibility for the health and safety of vulnerable individuals in HCBS settings—and the
direct care workforce on which they relied.

The top priority for MLTSS plans at the onset of the pandemic was helping to secure PPE for the direct
care workforce and other HCBS providers; however the HCBS workforce was not designated “essential”
in the federal distribution of PPE. Instead, MLTSS plans relied on their existing supply chains for PPE
and other necessary items, such as cleaning products.

Plans also faced issues interacting with members receiving HCBS: They needed to ensure that their care
managers did not further spread the infection, and beneficiaries were often reluctant to have outside
people enter their homes. Plans also faced reticence among staff in conducting in-home assessments
and care coordination, particularly during the initial stages of the outbreak.

To address this barrier to in-person meetings, MLTSS plans conducted immediate phone or virtual
outreach to members in HCBS to identify needs, reconfigure services as necessary, check availability
of staffing, test backup plans, and provide additional supports to members. For example, plans called
members to confirm they had necessities, like food and medicine, and arranged home delivery as
needed, and continued to make calls depending on the ongoing support needs identified. Plans saw the
required person-centered service plan, particularly the emergency backup plans, as key to identifying
the needs of consumers and addressing gaps in care during the pandemic.

Predictive analytical tools allowed several plans to monitor care and triage services for those most in
need. A Massachusetts plan leveraged its data and analytics to focus on two variables: the changing
needs of individuals and challenges in the provider network (e.g., monitoring closures and PPE needs).
By developing a dashboard that pulled from claims, electronic medical records, and social data, the
plan distributed information to 400 care managers three times a day to help manage the care of 40,000
members, including roughly 12,000 who were identified as top priority.

Plans gave significant attention to organizing and educating their workforces, especially as care
managers moved to conducting virtual visits. For example, one plan purchased ZOOM/DocuSign for all
care managers and conducted comprehensive training on person-centered virtual care management.
Likewise, because their personnel were on the front lines of interacting with consumers, MLTSS plans
continually updated staff about COVID-related protocols, including guidance safety protocols and how
to enter homes.

CMS emergency waiver flexibilities were critical.

The declaration of a Public Health Emergency in January of 2020 due to COVID allowed CMS to grant
waiver flexibilities, which greatly aided states and their MLTSS plans in providing HCBS services
during the pandemic. The waiver flexibilities included so-called Appendix K amendments to 1915(©)
HCBS waivers and 1115 demonstrations, and section 1135 waivers. Under these various authorities,
states gained administrative relief, made temporary modifications to Medicaid eligibility and benefit
requirements, relaxed rules to serve individuals with disabilities and older adults in their homes,
modified payment rules to support health care providers, and provided wider access to Medicaid-
covered services furnished via telehealth.": The Public Health Emergency is likely to remain in place
through the end of 2021,” thereby extending availability of the various flexibilities.

MEMS, “State Health Officials Letter 20-004 RE: Planning for the Resumption of Normal State Medicaid, Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Operations Upon
Conclusion of the COVID-19 Public Health Emergency,’ CMS, Baltimore, December 22, 2020.

“Letter to Governors from Norris Cochran, Acting Secretary of Health and Human Services, January 22, 2021.

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

The telehealth flexibilities given to states and their MLTSS plans, particularly the ability to use
telephone and/or video conferencing to conduct assessments and coordinate care, represented one
of the top flexibilities noted by almost every plan and the state representatives interviewed. Although
not a substitute for face-to-face interactions, telehealth offered efficient access to beneficiaries who
otherwise might have been hard to reach during the pandemic. This was true despite several challenges
and constraints, including member access to devices and data, the lack of broadband in rural areas,
and technology platforms that are not always disability-friendly or easy for people with limited

prior exposure to navigate. Several plans noted initiatives to fill in gaps for beneficiaries lacking a
device, although most beneficiaries or their caregivers had access to a phone for assessment and care
coordination purposes. In Tennessee, plans used tablets that they provided to members as part of
their electronic visit verification (EVV) program for monitoring direct care workers, to provide care
coordination, and support members and family caregivers.

Other key waiver flexibilities included the following:

Hi increased use of paid family caregivers. To ensure a sufficient workforce, states paid certain family members, often
spouses, to provide services during the COVID pandemic. Based on an analysis by CMS, more than two-thirds of
states were granted the authority to expand the workforce in this way,'? and the states and plans interviewed echoed
the importance of adding this flexibility to meet the needs of individual, person-centered plans.

i Modifications to existing services or addition of new services. States often requested exceeding the existing service
limits included in a waiver or adding a new HCBS service during the pandemic. For example, one critical need was
the availability of food for beneficiaries isolated in their homes. Some states increased the number of meals an
individual could receive each day, or added home-delivered meals to the HCBS service package for the first time. CMS
reported that other services added to waivers included remote support services, live-in caregiver, medical respite,
assistive technology, wellness monitoring, and companion and homemaker services, among others.”

Mi Services provided in expanded settings. As COVID lockdowns impacted providers, such as adult day programs,
states sought alternative ways to provide services included in an individual’s person-centered services plans. This
workaround entailed providing actual services in a different setting or using remote technology to bring services
into the home or other venues. Several of the plans interviewed administered adult day care services virtually,
using existing network providers to lead, over a technology platform, physical, cognitive, and social activities
normally provided onsite at an adult day facility. This was a way to fill gaps in an individual’s service plan and help
maintain the provider network. A Wisconsin plan initiated several pilot programs to explore deploying technology for
community-supported living, daily living skills, and other wraparound services to people in their homes.

i Temporary, or one-time, direct rate enhancements. These helped defray the added costs incurred during the
pandemic and provided additional pay to the direct care workforce. To help keep providers afloat, states also
made retainer payments to providers, including adult day and other HCBS providers, that experienced significant
drops in patient volume due to the pandemic. Because many providers rely on Medicaid as their primary source of
revenue, suspension of services severely impacted their revenues and potentially put their businesses in jeopardy
of permanent closure. Retainer payments helped preserve these provider networks. States handled the enhanced

Disabled and Elderly Health Programs Group, Center for Medicaid and CHIP Services, “Innovations in Medicaid: State Home and Community Based Services (HCBS) Pandemic Response and
Unwinding COVID-Related Waivers” (presentation, ADvancing States Conference, Washington, DC, December 8, 2020).

“Ibid.

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

payments differently. Tennessee gave temporary targeted rate increases for home care workers, a specific rate
adjustment of $5 per hour for hazard pay for personal assistants supporting COVID patients, and retainer payments
for adult day providers. Virginia also provided hazard pay for personal attendants, and Florida offered retainer
payments for adult day providers. Arizona directed additional payments to nursing homes, assisted living facilities,
and HCBS providers. For the most part, MLTSS plans either served as conduits for the provision of these directed
payments or absorbed these costs as part of their capitation payment (with the expectation that these costs would
be factored in during the actuarial rate-setting process).

Waiver flexibilities proved to be an extremely important tool for MLTSS plans in fulfilling their core
responsibilities and, by most accounts, the plans adapted quickly to the changes allowed by the
waivers. For example, with telehealth, MLTSS plans ramped up almost overnight to incorporate virtual
visits into their practice. Over time, the plans also employed remote technology for the delivery of
services (such as adult day), to deliver support to family caregivers, and to address social isolation of
beneficiaries. Likewise, MLTSS plans utilized the backup service plans to integrate family caregivers
into an individual’s plan of care and tap existing provider networks to add services (e.g., additional
meals) to meet the special needs of beneficiaries during the pandemic in a timely fashion.

Some MLTSS plans engaged in initiatives beyond contractual requirements.

In some cases, MLTSS plans tackled well-known existing gaps in LTSS that became particularly

acute during the public health emergency. These effort in some cases went beyond basic contract
requirements to address issues like the workforce shortages plaguing nursing homes and HCBS. One
plan partnered with ADvancing States, the organization representing the nation’s 56 state and territorial
agencies on aging and disabilities and LTSS, to develop an IT infrastructure for the job registry Connect
to Care Jobs, which matched individuals to long-term care positions. In Wisconsin, MCOs and local
providers developed an online resource that matched providers experiencing shortages of workers with
those that were reducing staff (e.g., day programs) to help fill vacant positions."

MLTSS plans also addressed areas of social determinants of health such as housing and food needs
experienced by HCBS beneficiaries. Food became a priority as vulnerable individuals isolated in their
homes. As noted above, states responded by adding or increasing the number of home-delivered meals
provided to HCBS beneficiaries. National MLTSS plans leveraged contracts with national grocers to
supply food to members in need. A Massachusetts plan provided cash to its HCBS beneficiaries to buy
necessities such as food and household products; this plan also collaborated with the Massachusetts
state government to temporarily house COVID-positive, marginally housed individuals in six hotels
across the state.

Lessons Learned: Replicating Successes and Making Improvements

These experiences shed light on needed improvements as MLTSS plans and states prepare for future
public health emergencies. At the same time, some interventions initiated in the height of the crisis
can strengthen the LTSS system, representing clear improvements that states and MLTSS plans should
consider adopting permanently.

Wisconsin supplemented its efforts at the state level with a quadrant structure that teamed MCOs and fiscal intermediaries with local providers and other LTSS stakeholders in four areas of the
state. The goal of this structure was to help MCOs and other stakeholders respond more rapidly to specific challenges at the local level given diverse needs of the urban southeast versus those of the
more rural areas of Wisconsin. In addition to job matching, the state reported that this framework helped to quickly identify local sources of PPE either from the MCO or local providers and allocate
this supply to providers with PPE shortages.

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

The innovations plans made to connect with members and provide care management are among

the practices that could be replicated in future health emergencies. These successes, especially the
expanded use of telehealth, should also be embraced as permanent solutions for enhancing ongoing
care coordination for MLTSS beneficiaries. Other improvements that could have long-term benefits
include stronger protocols for accessing nursing home residents and integration with an institution’s
medical record to better manage overall care. Medical record integration is a particular asset for plans
managing the full range of both Medicaid and Medicare benefits.

MLTSS plans saw themselves as an important resource and partner to states in managing the health
care crisis. Particularly in serving vulnerable beneficiaries through HCBS, the plans were a relatively
nimble resource that states could deploy to meet the ever-changing needs presented by the pandemic.
These supports included provision of PPE, guidance on the ground as the pandemic unfolded, rapid
transition to virtual assessments and care management, and implementation of other flexibilities to
serve HCBS beneficiaries. Plans introduced new technological tools to assist in the provision of services,
and tapped into additional resources—going beyond the basic contract requirements.

The following are among the other important takeaways that deserve attention as states, MCOs and
public health experts evaluate the pandemic response with a view toward lessons learned.

Clearly Defined Roles

There is a need to assess the proper role of state public health officials and Medicaid programs in
overseeing the safety and health of residents in nursing homes and other institutional facilities. In

states with MLTSS plans, the assessment should include the appropriate role of MLTSS plans in serving
beneficiaries in these institutions. New Jersey is already tackling this issue. There, legislators established
the Task Force on Long-Term Care Quality and Safety to address improvements in nursing home
resident and staff safety, quality of care and services, person-centered care, and workforce engagement
and sustainability, among other issues. The task force is also charged with exploring reforms to increase
the use of Medicaid managed care to drive improvements in quality and oversight of nursing homes."

Enhanced Clinical Support

MLTSS plans also have significant clinical expertise to share; as previously noted, there are examples
of MCOs providing crucial on-the-ground support to states as the crisis unfolded in nursing homes.
Pennsylvania established the Regional Response Health Collaborative, a partnership between state
government agencies and 10 health care systems. This collaborative provided clinical and operational
supports, and an educational platform for long-term care providers such as nursing homes, assisted
living and personal care homes, as they responded to the COVID-19 pandemic.” Although this effort
did not involve MLTSS plans, this and other models for potential engagement of clinical expertise and
personnel in support of long-term care providers should be explored.

Strengthening Provider Contracting

In the aftermath of the pandemic, strengthening the provider contracting provisions could enhance the
quality of care on an ongoing basis and in the event of another public health emergency. MLTSS plans

16NJ A 4481, State Legislation, “Establishes New Jersey Task Force on Long Term Care Quality and Safety.” Enacted September 2020, httos://www.njleg.state.nj.us/bills/Bill View asp?BillNumber=A4481.

"Regional Response Health Collaborative,” Department of Human Services, accessed May 18, 2021, https://www.dhs.pa.gov/coronavirus/Pages/RRHCP.aspx#:~:text=The%20Regional%20
Response%20Health%20Collaborative,Pennsylvania%20and%20the%20Jewish%20Healthcare

 

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

can use their financial leverage to incentivize nursing home care improvement and preparedness. This
may include incentives to nursing homes that have implemented best practice protocols for infection
control, or other pay-for-performance metrics related to resident safety and quality. Ultimately, plans
may wish to explore limiting their networks to exclude nursing homes that do not meet minimum
standards of care.

Embracing Telehealth

For beneficiaries receiving HCBS services, states and their MLTSS plans introduced numerous
interventions and policy changes to address the significant barriers posed by the pandemic. None was
more important than the major acceleration in the use of telehealth. Telehealth successfully supported
assessments and care coordination and introduced potentially new models of delivering services
virtually. Many MLTSS plans used telehealth and IT software to provide real-time support to family
caregivers and help case managers identify and assist individuals at risk of mental and physical health
decline due to social isolation.

There is no doubt that many of these telehealth innovations are here to stay. Still, states and

MLTSS plans must evaluate the cost-effectiveness of these tools in providing high-value services to
beneficiaries. While electronic devices can provide a mechanism for staying in contact with individuals,
there is no substitute for a face-to-face visit. Assessing the right balance between standard in-person
care and using telehealth should be ongoing and a focus once the pandemic has subsided.

Evaluation of Waiver Flexibilities

States will have to decide if some of the waiver flexibilities that proved successful during the pandemic
should be adopted as ongoing policy. The increased use of paid family caregivers was a particularly
important resource for MLTSS plans as they worked to fill gaps in an individual’s person-centered
service plan. Considering the potential to continue this policy should be part of the evaluations in
which states engage post-pandemic. Similarly expanded services, such as home-delivered meals, may
warrant continuation. CMS will also need to decide what it will allow once the public health emergency
has officially ended.

Data Tracking

The importance of data to track the spread of COVID cannot be overemphasized. Data tracking was
critical for states and their MLTSS plans to make informed and quick decisions to keep services
functioning and protect the health and safety of staff and LTSS recipients. CMS released its first tranche
of data on nursing home deaths several months into the pandemic,** but many states moved earlier in
compiling their own information. Similarly, managed care claims and encounter data helped identify
gaps in service delivery and providers at risk of shuttering due to declining patient volumes.

Gaps in data, however, hindered responses. Once PPE and emergency funds started to flow to
individual providers within a state, there was no mechanism to track these resources and determine
unmet needs. An assessment is required to identify the critical gaps in data experienced during the
COVID pandemic, to ensure the infrastructure and functionality are in place to better manage future
public health emergencies.

8CMS, “Nursing Home COVID-19 Data and Inspection Results Available on Nursing Home Compare,” News Release, CMS, Baltimore, June 4, 2020, https://www.cms.gov/newsroom/press-releases/
nursing-home-covid-19-data-and-inspections-results-available-nursing-home-compare

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

Emergency Backup Plans

The pandemic also reinforced the importance of having a detailed emergency backup plan to continue
to support operations during crises. Florida Medicaid officials noted that contract amendments
implemented just prior to the pandemic strengthened requirements on implementing an emergency
management plan. These amendments were instituted in response to hurricanes and other emergencies
Florida has experienced in recent years, but the state felt they were helpful in responding to the COVID
pandemic. An MLTSS plan in Texas said it felt better prepared to deal with COVID given its experience
dealing with prior emergencies and the critical actions required to focus on the needs of beneficiaries.
That said, the COVID pandemic was a unique phenomenon that challenged everyone’s preparations for
emergencies. One plan noted that, although it had an emergency service plan, some time had passed
since it had been activated, and the plan did not prepare workers for the COVID pandemic. One of the
first actions states and MLTSS plans should take is to review these emergency backup plans and update
them based on lessons learned.

Designating the HCBS Workforce As “Essential”

As the pandemic unfolded, public officials and the media paid a significant amount of attention to the
plight of individuals residing in nursing homes and other congregate settings—and the need to provide
these institutions with PPE and other financial resources. This focus was appropriate given that these
individuals were at significant health risk and the facilities in which they were housed were often
understaffed and overwhelmed. While the millions of Americans who rely on Medicaid HCBS services,
including those served through MLTSS plans, are also an extremely vulnerable population, they did
not receive the same initial attention. The HCBS direct care workforce charged with caring for these
individuals is often exceedingly fragile, but these workers were not always deemed as “essential” when
federal resources, such as PPE, were distributed.

Fortunately, state Medicaid programs, with assistance from MLTSS plans, did place significant emphasis
on assisting these beneficiaries and supporting the workforce upon which they depend. If faced with
future public health emergencies, HCBS beneficiaries and their workforce must be recognized as an
important part of the overall federal response. The additional resources for Medicaid HCBS services
contained in the recently approved American Rescue Plan” indicate that this is a lesson already learned
from the COVID pandemic.

Conclusion

The COVID-19 pandemic posed tremendous challenges for MLTSS plans, as it did for the entire health
care system, particularly with respect to beneficiaries residing in nursing homes. MLTSS plans were
unable to enter these institutions when they were under lockdown—despite contractual relationships
and the need to be accountable for the care their members received. However, several plans reported
some successes in working around these constraints. MLTSS plans also played a key role in reaching
HCBS beneficiaries, partnering with states to implement several Medicaid flexibilities permitted by CMS
during the pandemic.

Overall, the state survey respondents said the MLTSS plans were a valuable partner during this
challenging time and were a resource that assisted in responding quickly to challenges on the ground.

°CMS, “State Medicaid Director Letter, SMD# 21-003 RE: Implementation of American Rescue Plan Act of 2021 Section 9817: Additional Support for Medicaid Home and Community-Based Services
during the COVID-19 Emergency,” CMS, Baltimore, May 13, 2021.

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

But there is room for improvement; an ongoing analysis of the pandemic response could not only
strengthen readiness for future public health crises but also identify pandemic-driven responses that
should remain as improvements to the LTSS system.

Clearly, the experience in nursing homes during the pandemic calls for an assessment of what can be
done to ensure the health and safety of residents in similar health emergencies going forward. This
assessment should examine the roles and responsibilities of federal and state governments, nursing
homes, and MLTSS plans and include an analysis of how the federal COVID relief dollars provided by
Congress were spent. Specifically, understanding how those dollars flowed, how they were used, and
to what effect is fundamental to future policies. Likewise, the use of data, telehealth, supports for the
direct care workforce, emergency backup plans, and such CMS waiver flexibilities as paying family
caregivers are among the issues that should be assessed. Such a review would not only help prepare the
long-term care system for future emergencies but also pave the way for an improved system of care for
those individuals relying on Medicaid and MLTSS.

 

Acknowledgments

The authors express their gratitude to the members of the LTSS Choices team, particularly Carrie
Blakeway Amero and Harriet Komisar. We also appreciate the thoughtful contributions of Elaine Ryan,
Evelyn Liebman, Dorothy Siemon, Brian Posey, Diana Noel, and Megan O’Reilly. Finally, we thank all
those who agreed to interviews. Their names and organizations are listed in the appendix, with their
permission.

 

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LTSS CHOICES: THE ROLE OF MEDICAID MANAGED LTSS DURING THE COVID-19 PANDEMIC

Appendix. Experts Interviewed, 2021, Alphabetically by Organization

HB ADvancing States - Camille Dobson, Deputy Executive Director

WH Altarum - Michael Monson, CEO and President

BB AmeriHealth Caritas - Sharon Alexander, President, LTSS Solutions

Hi Anthem - Rachel Turner Chinetti, Senior Director, Specialized Populations & Programs

BB Arizona Health Care Cost Containment System - Jami Snyder, Director

BB Association for Community Affiliated Plans - Christine Aguiar Lynch, Vice President of Medicare and MLTSS

Bi ATI Advisory - Allison Rizer, Principal

BB ATI Advisory - Anne Tumlinson, CEO

MB Bureau of TennCare - Patti Killingsworth, Chief of LTSS Division

Bl Centene Corporation - Jennifer Burnett, Senior Director, PA Health and Wellness

Mi Centene Corporation - Laura Finkelstein Chaise, Vice President, Long-Term Services and Supports and Medicare-Medicaid
Plans

BB center for Health Care Strategies - Alexandra Kruse, Associate Director, Integrated Care, State Programs

Mi Center for Health Care Strategies - Nancy Archibald, Associate Director, Integrated Care, Federal Programs

Hi commonwealth Care Alliance - Christopher D. Palmieri, President & CEO

HB Commonwealth Care Alliance - Michelle Herman Soper, Vice President of Policy Development (Former Vice President of
Integrated Care, Center for Health Care Strategies)

BB Disabled and Elderly Health Programs Group, Center for CHIP and Medicaid Services at CMS - Barbara Edwards, Former
Director

Ml Florida Agency for Health Care Operations - Eunice Medina, Former Bureau Chief, Medicaid Plan Management Operations

MB inclusa Inc. - Kris Kubnick, Chief Member Experience Officer

Mi Independent Care Health Plan - Margaret Kristan, Vice President, Long-Term Care and Community Inclusion

HH Inland Empire Health Plan (IEHP) - Ben Jéuregui, Behavioral Health & Care Management Support Services Manager

HH inland Empire Health Plan (IEHP) - Shelly LaMaster, Director of Integrated Care

BB Long Term Quality Alliance - Mary Kaschak, Executive Director

Hi Molina Health Care Plan - Michelle Bentzien-Purrington, Vice President, MLTSS and SDOH Innovation

Mi Pennsylvania Health Law Project - Laval Miller-Wilson, Executive Director

Mi Pennsylvania Office of Long-Term Living - Kevin Hancock, Principal, Health Management Associates, Former Deputy

BB Speire Health Care Strategies - Tom Betlach, Partner

Hi United Healthcare Community & State - Michelle Martin, Senior Policy Director, Long Term Services and Supports

BB United Healthcare Community& State - Jillian Hamblin, Vice President, Long Term Care Programs

HB UnitedHealthcare Community & State - Kate Paris, Vice President, Policy & Influence

BB UnitedHealthcare Community Plan Tennessee - John Madondo, Executive Director, LTSS and Complex Care

MB UPMC Health Plan - Brendan Harris, Vice President, Community HealthChoices

Wi Virginia Department of Medical Assistance - Tammy Whitlock, Deputy Director for Complex Care

Wi Virginia Department of Medical Assistance Services - Karen Kimsey, Director

Hi Wisconsin Department of Health Services - Kiva Graves, Director, Bureau of Quality and Oversight, Division of Medicaid
Services

https://doi.org/10.26419/ppi.00152.001

 

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