	Background

		Prevalence and Characteristics of Medicaid Managed Long- Term Services and Supports Programs

States’ increasing use of managed care for Medicaid beneficiaries  needing long-term services and supports is a significant change from how  states have historically met the needs of these vulnerable populations. CMS uses these elements to review and approve states’ MLTSS  programs. In addition to state-specific requirements, states with MLTSS programs  are also subject to broader quality requirements that apply to all Medicaid  managed care programs. A beneficiary can file an appeal in response to an MCO’s  decision to, among other things, reduce services, terminate services, or  deny payment for services. A beneficiary can file a grievance with an MCO to express  dissatisfaction about any matter not covered by appeals. Selected States Used Multiple Methods to Oversee MLTSS Care, and Varied in the Extent to Which They Used Beneficiary Appeals and Grievances to Monitor Access and Quality

		Selected States Used a Range of Methods, Including External Reviews, to Oversee MLTSS Access and Quality

The six states we reviewed used a range of methods to oversee MLTSS  beneficiaries’ access to and quality of care. Reviews of provider networks: Officials in all six states reported  conducting their own assessments of MLTSS provider networks or  requiring MCOs to report on their MLTSS provider networks. Selected States Varied in the Extent to Which They Used Appeals and Grievances to Monitor Beneficiaries’ Concerns about MLTSS Access and Quality

The six states we reviewed varied in the extent to which—and how—they  used appeals and grievance data to monitor beneficiaries’ concerns about  quality and access in their MLTSS programs. While CMS has specified certain parameters for state oversight of  MLTSS, the agency did not always require the six selected states to  report the information needed to monitor this oversight. CMS’s 2013  guidance for MLTSS programs highlights the 10 elements that it deems  essential for developing and maintaining high-quality programs, which  CMS uses when reviewing or approving state MLTSS programs. In our review of the reporting required of our  selected states, however, we found that CMS did not require all states to  report on certain areas related to those key elements—namely network  adequacy, that is, the sufficiency in the number and types of long-term  care providers serving beneficiaries in the managed care plans; critical  incidents, which are events or situations that cause or may cause harm to  a beneficiary’s health or welfare, such as abuse, neglect, or exploitation;   and appeals and grievances. As a result, we found cases where state  reporting did not allow CMS to assess state adherence with federal  guidance and oversight of MLTSS access and quality. CMS did not require three of our six selected  states—Arizona, Minnesota, and Tennessee—to regularly report  information on network adequacy, but it did require Delaware,  Kansas, and Texas to report such information. Critical incidents reports. For example, CMS used the  same, or similar, statement to indicate that all states should report on  quality assurance efforts: “Identify any quality assurance and monitoring  activities in the quarter.” In response to this, we found that four states  reported general descriptions of their planned and ongoing quality  assurance activities for MLTSS or their comprehensive managed care  programs as a whole, and often repeated the same or similar information  in subsequent quarterly reports. The Centers for Medicare & Medicaid  Services’ (CMS) Onsite Review of  KanCare. external quality review, CMS does not have one consistent approach for  monitoring MLTSS programs. However, any gaps in  reporting requirements, and gaps in state reporting from what CMS has  required, may mean that CMS does not always have the data to monitor  key aspects of MLTSS access and quality among selected states and  may be unable to reliably detect state or MCO practices that do not meet  CMS’s guidance. Conclusions

Using managed care to deliver long-term services and supports offers  states an opportunity to allow Medicaid beneficiaries with significant  health needs to live and receive care in the setting of their choice, expand  access to home and community-based care, and provide such care at a  potentially lower cost than institutional care. Recommendation

To improve CMS’s oversight of states’ MLTSS programs, we recommend  that the Administrator of CMS take steps to identify and obtain key  information needed to oversee states’ efforts to monitor beneficiary  access to quality services, including, at a minimum, obtaining information  specific to network adequacy, critical incidents, and appeals and  grievances.
Why GAO Did This Study

Twenty-two states use MLTSS programs to provide care for Medicaid beneficiaries who need long-term support. Using managed care to deliver long-term services and supports can be a strategy for states to expand home- and community-based care, which many beneficiaries prefer, and to lower costs. However, given the potential vulnerability and needs of beneficiaries in these programs, oversight is crucial to ensure their access to quality care.
GAO was asked to review states' implementation and CMS's oversight of MLTSS programs. In this report, GAO (1) described how selected states monitored MLTSS access and quality, and (2) examined the extent to which CMS oversees MLTSS access and quality in selected states.
GAO reviewed federal regulations, guidance, and internal control standards. For six states selected for variation in location, program size and duration, and other factors, GAO reviewed reporting requirements, reports to CMS, and other documents. GAO also reviewed data from these states on beneficiary appeals and grievances from 2013 through 2015—the most recent data available—and interviewed state and CMS officials.

What GAO Found

In Medicaid, long-term services and supports are designed to promote the ability of beneficiaries with physical, cognitive, or mental disabilities or conditions to live or work in the setting of their choice, which can be in home or community settings, or in an institution such as a nursing facility. States are increasingly delivering such services through managed care, known as managed long-term services and supports (MLTSS). In MLTSS, as with most Medicaid managed care programs, states contract with managed care organizations (MCO) to provide a specific set of covered services to beneficiaries in return for one fixed periodic payment per beneficiary. In addition, beneficiaries have the right to appeal an MCO decision to reduce, terminate, or deny their benefits, or file a grievance with an MCO regarding concerns about their care.
The six states GAO reviewed—Arizona, Delaware, Kansas, Minnesota, Tennessee, and Texas—used a range of methods for monitoring access and quality in MLTSS programs. To oversee beneficiaries' care, GAO found that states used—to varying levels—external quality reviews, beneficiary surveys, stakeholder meetings, and beneficiary appeals and grievances data. For example, while all six states used external quality reviews and beneficiary surveys, GAO found that states varied in the extent to which—and how—they used appeals and grievances data to monitor beneficiaries' concerns about quality and access in their MLTSS programs.
The Centers for Medicare & Medicaid Services (CMS)—the federal agency responsible for overseeing Medicaid—did not always require the six selected states to report the information needed to monitor access and quality in MLTSS programs. CMS primarily relied on its reviews of state-submitted reports to monitor MLTSS programs for compliance with federal regulations and state-specific reporting requirements, and what states are required to report to CMS can vary by state. Although CMS highlighted certain elements that it deemed essential to developing and maintaining high quality MLTSS programs in its 2013 guidance, GAO found that CMS did not require all selected states to report on these elements—namely, provider network adequacy; critical incidents, which are events that may cause abuse, neglect or exploitation of beneficiaries; and appeals and grievances. CMS did not require three of the six states that GAO reviewed to regularly report on network adequacy or provide summaries of critical incidents. Further, although CMS requires all selected states to report on their quality assurance efforts, GAO found that states often report general descriptions of their planned and ongoing quality assurance activities for MLTSS or their entire comprehensive managed care programs. Consequently, state reporting did not always provide CMS with information needed to assess state oversight of key elements. Gaps in reporting requirements may mean that CMS does not always have information needed to monitor key aspects of MLTSS access and quality among selected states and it may not be able to reliably detect state or MCO practices that do not meet CMS's guidance.

What GAO Recommends

GAO recommends that CMS take steps to identify and obtain information to oversee key aspects of MLTSS access and quality, including network adequacy, critical incidents, and appeals and grievances. HHS concurred with GAO's recommendation.