Managed Care and Integrated Services

Part of LeadingAge's 2021 Policy Priorities
 

LEADINGAGE ADVOCACY GOALS

  • Pursue new payment model demonstration(s) that give post-acute and long-term service and support providers the opportunity to lead by accepting both the financial risk and rewards of the model.
  • Identify and advocate for the inclusion of basic rights or protections for providers in managed care programs that ensure beneficiary access to services and provider viability, and opportunities to streamline administrative requirements between plans and providers.
  • Support and advocate for policy initiatives and models that take a more holistic and integrated approach to address the needs of older adults and align incentives for all participating providers.
  • Medicare Advantage flexibilities: Support the initiatives to make permanent those regulatory waivers and flexibilities given to Medicare Advantage plans during the public health emergency that improved beneficiary access to needed services and medications, simplified provider payment, and streamlined or eliminated utilization management requirements.  
  • Support efforts to ensure supplemental benefit offerings are clearly communicated to beneficiaries and caregivers; provide beneficiaries access to a broad array of quality providers of these services and consistency in benefits year-over-year.
  • Pursue broad reimbursement policies that ensure adequate funding for aging services providers across payers and actuarial soundness. Advocate for policies to ensure that payments/reimbursements under Medicare and Medicaid managed care plans adequately cover the services provided and offer opportunities for providers to enter into contracts with alternative payment methodologies that reward performance and outcomes

LeadingAge members are saying:

  • “I actually had a [major national plan] representative tell me that they purposely harass providers that are not in their network, by taking payments back, requiring them to resubmit information, etc. It’s a way to force providers into their MedAdvantage network at reduced payment rates. How do companies like this get these government contracts?”
  • “We’re looking at setting up our own I-SNP and/or C-SNP because we think we can manage the care better.”
  • “Our affordable housing has a service coordinator but plans seem reluctant to delegate their care coordination responsibilities for their members in our building.”
  • “My plans don’t negotiate how much they pay us. They just give us a contract and say take it or leave it.”
  • “Prior authorization for skilled care can take as much as 90 days. The person is long gone by then.”
  • “How can adult day providers contract with MA plans for these new supplemental services?”
  • “We contract with 5 different plans and they each have their own set of rules for prior authorization, reimbursement and credentialing. Keeping it all straight, requires a lot of staff resources that I don’t really have. Is there anyway to standardize contracts across these payers?”

THE ISSUE

Aging services providers in many parts of the country have reached a tipping point where managed care – Medicare Advantage (MA), Medicaid managed care, and CMMI payment reform initiatives — is the dominant payer. Under these programs, providers often face inadequate payments on top of increased expectations and administrative burden of these contracts (often presented as a take it or leave it), all of which in turn is threatening their viability and beneficiary access. MA plans are embracing their ability to expand supplemental benefits into home and community-based services as well as some broader non-medical services to help chronically ill individuals manage their conditions. These benefits play an important role in delivering a more holistic approach to addressing beneficiaries’ needs but only if they can still access these benefits from an array of quality providers and not just the large provider organizations.

During the COVID-19 pandemic, plans were given certain regulatory waivers that allowed more nimbleness in addressing plan beneficiaries’ needs. While some new benefits were added (e.g. in-home meal delivery) to address situations resulting from COVID-19, other plans did not take advantage of flexibilities, such as their ability to eliminate prior authorization requirements, which resulted in slowing hospital discharges to post-acute care during the pandemic. The Center for Medicare and Medicaid Innovation (CMMI) has been expanding its deployment and testing of advanced alternative payment models. In recent years, these models have created opportunities for physicians to lead these models. Post Acute and Long Term Services and Supports (PA-LTSS) providers have largely been excluded from leading and taking on financial risk under these models. As a result, these providers have seen little to no financial benefit by participating in existing models as partners. Those providers interested and able to accept financial risk are increasingly pursuing the development of Special Needs Plans. LeadingAge has actively engaged CMMI around developing new models that allow PA-LTSS providers to accept both full financial and clinical risk as well as models that allow them to phase into taking on increasing levels of financial risk and delivery reform through other models.

ADVOCACY ACTION 2021

117th Congress

  • Preserve and improve the Affordable Care Act including preserving funding for the Center for Medicare and Medicaid Innovation and supporting refinements to CMMI’s work.
  • Community-based ISNPs: We support legislation similar to the Community Based Independence for Seniors Act of 2019 to establish a community-based ISNP demonstration program.
  • Proposals to Expand Medicare: We anticipate a variety of proposals to be introduced similar to Medicare for All and other similar proposals to expand who is eligible for services, the type of services covered by Medicare, and other service delivery reforms for the program. To date, LeadingAge has been neutral on these efforts and will continue to evaluate legislation on these topics as introduced.
  • Improving Seniors’ Timely Access to Care Act: LeadingAge continues to lend our support to legislation that seeks to eliminate unnecessary prior authorization practices that limit seniors timely access to medically necessary care while streamlining approval processes for providers and ensuring plan accountability for timely decisions.

Executive Branch

  • Updating Managed Care Regulations to Ensure Necessary Protections as this Becomes the Predominant Model: Identify and pursue new language to be included in the Medicare and Medicaid managed care regulations, including the Medicare Managed Care Manual, that clarifies certain rights of providers, obligations of plans in their interactions with providers, improves beneficiary access to medically necessary services and seeks to streamline and/or standardize required elements of participation in these programs to reduce administrative burden.  Revisit Medicare Advantage and Medicaid managed care regulations to identify ways to streamline common processes across plans such as prior authorization and credentialing and establish some provider protections to ensure actuarially sound rates, beneficiary access to providers, appeals and grievance procedures that give providers standing, and a hotline for providers when issues cannot be resolved with the plans.  
  • Supplemental Benefits: We support efforts to encourage plans to include newly-available supplemental benefits that include some home and community-based services as well as targeted services and supports for those with chronic illness. We advocate for these benefits and their corresponding eligibility requirements to be clearly communicated to beneficiaries and their caregivers. We seek to ensure providers of all sizes have an opportunity to be part of these networks. 
  • COVID-19 regulatory waivers: We support ongoing flexibility for Medicare Advantage plans to add, amend benefits or amend policies as long as it benefits the enrollee by improving access to services or delivering a more integrated approach to care, (e.g., adding new supplemental benefit – home-delivered meals during the pandemic) and doesn’t add administrative burden to providers (e.g. suspend prior authorization requirements for SNF level of care). 
  • Coverage for COVID-19 Vaccine: We advocate for CMS to maintain a position that Medicare Advantage and Medicaid managed care plans must cover the COVID-19 vaccine as a standard benefit with no out of pocket cost to the beneficiary, once available. 
  • MA Call Letter: Monitor Medicare Advantage Call Letter and annual regulatory changes.
  • Medicaid Managed Care and LTSS: Monitor Medicaid managed care regulations relating to LTSS.
  • New Models of Payment and Integrated Care: We look forward to working with the Administration to implement its proposed 4-year demonstration to test innovative models of post-acute and LTSS delivery, that employ new LTSS workers, and extend benefits to individuals at-risk of qualifying for Medicaid (near duals). We will continue to engage theCenter for Medicare and Medicaid Innovation in the further development of a new demonstration or model(s) that would allow post-acute providers and/or LTSS providers to be accountable and financially at-risk for the care of a population or an episode of care.
  • IMPACT Act: We will participate in the Medicare unified post-acute prospective payment system technical expert panel to provide the voice of LeadingAge members regarding possible future payment system design. This includes advocacy to slow the pace of model development work of the Department of Health and Human Services and the Center for Medicare and Medicaid Services to reflect relevant data collection not skewed by the experiences of the COVID-19 pandemic.

 

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ACTIONS YOU CAN TAKE NOW

  • Host a Coffee Chat with Congress in your community to help your members of Congress understand how managed and integrated care policies impact providers’ and older adults’ access to needed services.
  • Mobilize with the Advocacy Champions toolkit and let your representatives and senators know you support approaches to health coverage and managed care that enables aging services providers to play a central role.

 ADDITIONAL RESOURCES