State Medicaid directors need greater flexibility and faster federal approval to maintain or establish new managed long-term supports and services (MLTSS) programs in Medicaid. A growing number of states are implementing such programs, from 8 states in 2004 to 16 states in 2012. “A strong and effective federal-state partnership with clearly aligned goals is critical to the success of these efforts,” says an interesting report from the National Association of Medicaid Directors (NAMD).

Medicaid pays for a large proportion of the nation’s long-term care services: 35.6 percent of all home health care, 31.8 percent of nursing home care, and 52.6 percent of other personal and residential long-term care, according to the latest Actuarial Report on the Financial Outlook for Medicaid from the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary (OACT).

Medicaid ends up paying for such a large proportion of long-term care services because they typically are not covered in full by Medicare or private plans, and because many Medicaid enrollees – the elderly and disabled – are the main consumers of long-term care. The National Association of Medicaid Directors says long-term care beneficiaries are six percent of the Medicaid population but account for almost half of total Medicaid spending.

Medicaid Managed Long-Term Supports and Services:

Medicaid long-term supports and services (LTSS) includes nursing home care, home health care, personal care, adult day care, and home and community-based services (HCBS).  Medicaid LTSS benefits are thus a broad, complex array of medical services and social supports.

Several state Medicaid agencies – most notably, Arizona, Florida, Hawaii, Massachusetts, Minnesota, New Mexico, Tennessee, Texas, and Wisconsin – have extensive experience in the successful use of managed care approaches to increase access and quality, control spending, improve outcomes, and offer member-centered, consumer-driven models for Medicaid long-term supports and services.  In contrast to unmanaged fee-for-service, managed LTSS can take several forms but typically involves the state Medicaid agency contracting with a specially skilled health plan to coordinate Medicaid long-term care services on a risk basis, with accountability for access, quality, and outcomes.

Recommendations from State Medicaid Directors:

The recommendations, addressed to the CMS Center for Medicaid and CHIP Services (CMCS), were organized into four main policy principles:

1. Faster, more predictable federal review of managed long-term care programs in Medicaid.

CMCS should give states authority to make certain changes without going through a federal approval process, and should agree on different levels of federal review for different types of changes to their programs. “As with any new program or change, states must have the authority to respond quickly to unanticipated situations or to implement more efficient and effective policies and procedures,” the report says.

2. Maintain existing state flexibility to design and implement manage Medicaid long-term care, in coordination with national goals.

Medicaid directors suggested CMCS preserve existing policies that allow states to determine rates, incentives, penalties, standards for networks and access to care, and state contract requirements with health plans and providers.

3. Maintain state flexibility to define stakeholder engagement process.

Federal policies should not determine what quality and performance information states must share to help Medicaid members make decisions about health plans. States should maintain that authority, the report says, because “states must strike a careful balance with state statutes that protect certain proprietary information and detailed financial data from health plan entities.”

4. Ensure collaboration between states and the federal government in developing quality improvement and performance measures.

Nationally developed measures should be consistent with state measures. The NAMD report lists several guidelines for those measures, including point that fee-for-service payment model indicators are not appropriate for managed care, and that quality measures should not assume Medicaid can affect outcomes from Medicare services – except for integrated care programs involving people eligible for both Medicaid and Medicare.

Learn More:

The Kaiser Commission on Medicaid and the Uninsured last year released a guide for states contemplating whether to create a Medicaid managed long-term care program.

The Center for Health Care Strategies offers a range of helpful resources on improving Medicaid long-term supports and services.


Kip Piper is a Medicaid, Medicare, and health reform consultant, speaker, and author.  For more, visit  Follow on Twitter at @KipPiper and connect with Kip on LinkedIn.