Effective Advocacy Strategies in Managed Care for Long-Term Services and Supports
Central Jersey Legal Services, through the expertise of Gwen Orlowski, provides insight into consumer advocacy strategies within the Managed Long-Term Services and Supports (MLTSS) system. Explore cases highlighting challenges faced by individuals, emphasizing the importance of effective advocacy to protect their rights and access to appropriate care.
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Advocacy Strategies: Managed Care Gwen Orlowski Central Jersey Legal Services gorlowski@lsnj.org
Central Jersey Legal Services Keeping the promise of justice for all. Serving low-income residents of Union, Middlesex, and Mercer Counties
What we will cover today: Overview of Managed Long-Term Services and Supports (MLTSS) New Jersey Experience Consumer Advocacy: Effective Strategies Using the 2014 Person-Centered Planning Rules Appeals and Fair Hearing Strategies Role of the Ombudsman in Wisconsin
Story #1 HCBS waiver participant s PCA hours are reduced by from 36 hrs/wk to 18 hrs/wk after MCO nurse shows up at house with little notice Participant speaks Portuguese She is a recently widowed and 85 Nurse/Care Manager, who she has never met before, is 40 something year old man
Story #2 Young adult with TBI is placed in a nursing home with no special TBI services and all PT/OT therapies are cut within weeks the MCO seems unfamiliar with TBI NF and HCBS services Prior to MLTSS, NJ had TBI waiver and SCNF TBI units All but 1 TBI special nursing facility dropped out of Medicaid after July 1, 2014, and that NF won t admit this client MCO won t provide network info about HCBS providers, and then says none will take client because he needs ADL assistance
Story #3 NF resident wants to return home and is told by her MCO care manager that she can t she needs too many hours of service and no provider agency can cover weekends Resident still maintains affordable apartment MCO care manager never discusses self-direction MCO says cost cap budget is proprietary No Notice of Action is provided to Resident
Managed Long-Term Services and Supports MLTSS
MLTSS LTSS Delivery System = Managed Care Managed Care Other Health Care Services (i.e. PCP, Acute, Behavioral Health) Case or Care Management is Key Mechanisms include: 1915(c) HCBS waivers combined with 1915(b) waivers 1115 Demonstration Waivers 1115 Demonstration Waivers with 1915(c) HCBS Waivers
MLTSS can includes: Institutional Services HCBS Nursing Home Assisted Living Adult Day Personal Care Assistant Home-Delivered Meals PERS Home Modifications
Why or Why Not Managed Care? Purported Benefits Arguments Against Incentive to deny or reduce services State trying to relieve itself of responsibility MCOs are not culturally attuned to Medicaid protections Not accountable to private citizens (i.e. claims of proprietary protections) Stability in state budgets Better care coordination Ability to offer supplemental benefits Fewer silos Better quality control
MLTSS: Common Problems Inadequate or inappropriate service plans Including reductions/terminations during transition to MLTSS Cost thresholds for HCBS Sometimes also for nursing facility services. Caregiver are forced to provide services Natural supports should be voluntary Poor assessment tools Often developed by MCO and applied contrary to law
MLTSS: New Jerseys Experience 1115 Comprehensive Waiver: CMS approved October 2, 2012 Includes MLTSS among other changes to Medicaid program Implementation of MLTSS was delayed until July 1, 2014 MLTSS Steering Committee 4 Workgroups (i.e. Assessment to Appeals and Quality Measures) Four 1915(c) HCBS waivers were transitioned into MLTSS 12,000 waiver recipients were reassessed in 1st6 months No prohibition or state review of adverse service changes Weak data reporting requirements in STC
MLTSS: New Jerseys Experience New PCA Functional Assessment Tool New PCA tool wasn t implemented until Jan. 1, 2015 Lack of transparency around tool initially Summer 2015: State webinar to advocate/families Grievances, Appeals, and Access to State Fair Hearings Standardized Notice of Action. . .but!!! Continuation of Services until outcome in MCO Appeals (automatic) and in Fair Hearings (must be requested) VERY CONFUSING 3 stage appeal process Strong Special Terms and Conditions and Contract Provisions
!Transparency! CMS Waiver Approval Process Research Goals - 1115 Contract Website Reporting requirements Quarterly Public Reports (Kansas) Track Appeals and FHs Track reductions and terminations in 1styear Capitated Rates and Cost Cap Thresholds Amounts paid to providers Standardized Assessments and criteria for service authorizations Quality Measures and Performance
Consumer Advocacy Strategies Using Person-Centered Planning Rules and the Appeals/Fair Hearings Processes to Win
2014 Person Centered Planning Rules Rules are part of the Centers for Medicare and Medicaid (CMS) 2014 HCBS settings rule HCBS Settings Rule State Transition Plans Up to 5 years PCP rules Effective March 17, 2014 PCP rules apply to*: 1915(c) HCBS waivers and 1115 demonstration waivers 1915(i) state plan HCBS benefits *1915(k) Community First Choice 2012 PCP rules
Rule in 3 Parts The Person Centered Planning Process The Person Centered Written Plan The Plan is Reviewable and Subject to Change
The Planning Process Consumer leads the planning process Must be timely Occur at times and locations convenient to LTSS consumer Include people chose by LTSS consumer Consumer empowered informed choices MCO Information and Support = Informed Choice Must offer informed choices regarding services and supports Cultural Competency and Language Access
The Written Service Plan Must reflect Identified Need & Preferences Plan must reflect strengths and preferences Plan must reflect goals and desired outcomes Services and Supports important to meet needs identified through assessment of functional need
Assessment of Functional Need Medically Necessary vs Functional Need Tool should measure TOTAL need: beware the assessment service plan Advocacy Goal: Standardized, transparent assessment tool that is person-centered in design and in application (i.e. MNChoices incorporates quality of life domains)
The Written Service Plan Must include Paid & Unpaid Services and Supports, as well as Providers NOTABLY: Natural Supports are unpaid supports that are provided voluntarily.
The Written Service Plan Must be finalized and agreed to, with the written informed consent of the LTSS consumer But LTSS consumers still have their appeal and fair hearing rights: Constitutional Due Process Protections
Plan is Reviewable & Subject to Change At least every 12 months When the LTSS consumer s circumstances change At the request of the LTSS consumer
Resources: A Right to Person Centered Planning http://justiceinaging.org/wp- content/uploads/2015/04/FINAL_Person- Centered_Apr2015.pdf Q&A: Person Centered Planning Changes http://www.healthlaw.org/publications/browse- all-publications/q-a-person-centered-planning- changes
Grievances, Appeals and Fair Hearings Did the MCO engage in an ACTION? If yes before, after, instead of, at the same time Internal MCO Appeal State Fair Hearing If no MCO grievance (e.g., rudeness by customer service rep)
What is an MCO Action? Denial or limited authorization of a requested service Reduction, suspension, or termination of previously authorized service Failure to provide services in a timely manner MCO must give written NOTICE OF ACTION
Right to Continuation of Services Right is incorporated into both the Medicare Fair Hearing regulations and the Medicaid Managed Care Some issues around prior authorization periods (proposed regs may fix) State work-a-around: Kansas and New Jersey
MCO Appeals Right to an expedited appeal Right to in-person or in-writing Right to case file, including medical records Right to introduce evidence & make arguments
Medicaid Fair Hearing Right to examine Medicaid file Right to offer evidence and make legal arguments Right to cross-examine witnesses
Resources What s in a Notice? How Notices of Action Protect Consumers in Medicaid Managed Long Term Services and Supports. http://justiceinaging.org/wp-content/uploads/2015/02/Advocates-Guide-for- Notices-in-Medicaid-Managed-LTSS.pdf Medicaid Managed Care Rules: Key Considerations for Aging Advocates. http://justiceinaging.org/wp-content/uploads/2015/06/Medicaid-Managed- Care-Proposed-Rule_Key-Considerations-for-Aging-Advocate
Turn it over to Heather - Thank you! gorlowski@lsnj.org
