The U.S. Government Accountability Office (GAO) has found “significant problems” with the managed long-term supports and services (MLTSS) covered by Medicaid and implemented through contracts with managed care organizations. The GAO made the discovery in a recent review of six states.
In the report, which was released publicly on December 16, the GAO recommended a national oversight strategy for MLTSS programs – a recommendation that the Department of Health and Human Services (HHS) did not agree with. The Centers for Medicare & Medicaid Services (CMS), which would monitor such programs, is part of HHS.
“HHS commented that such a step was not necessary, because CMS has strategies to enhance oversight in LTSS and managed care more generally,” the report said. “Our work indicates that relying primarily on a general approach to oversight has not been effective and has allowed significant problems with quality and access in MLTSS to go undetected by CMS and persist for years.”
LTSS includes a range of health care, personal and supportive services and can be provided in institutional settings such as nursing facilities or home- or community-based settings, the GAO noted. LTSS accounts for about a third of total Medicaid spending, according to the report, and a growing number of states have opted to use a managed care delivery model to provide the services.
The number of states with MLTSS programs grew from eight in 2004 to 26 in 2020; under these arrangements, states contract with managed care organizations to provide “a specific set of covered services in return for a fixed periodic payment per beneficiary – typically per member per month.” Under MLTSS arrangements, MCOs are also responsible for care management, which can cover health assessments, care planning and service authorization, among other things.
For its report, the GAO examined three components of MLTSS: the care management provided to MCO beneficiaries, state oversight of MCO care management, and CMS oversight of state implementation of requirements for MLTSS.
To assess state oversight, the GAO reviewed the documentation of state MLTSS monitoring for six states – Arizona, Florida, Iowa, New York, Texas and Virginia – which together served 50% of Medicaid beneficiaries in MLTSS programs in 2018, the most recent year for which data was available. CMS oversight was evaluated through reviewing federal regulations and CMS documents and interviewing agency officials.
The report found that all six states identified “significant problems with MCO care management, though states may not be identifying the full extent of the problems.” Specifically, problems ranged from assessment and care planning compliance to insufficient care coordination.
States identified these problems through tools such as operational reviews and external quality reviews — and in Arizona, Florida, Iowa, Texas and Virginia, the states found problems occurring over multiple years.
But because the selected states collected inconsistent data, did not gather certain data, or infrequently reviewed their MLTSS programs, they have more care management problems, according to the GAO.
The MCOs themselves are starting to send new contracts to skilled nursing facilities as old contracts expire, and some of the agreements have raised red flags for Chad Bogar, the founder and CEO of the law firm sb2 Inc. He told SNN last month that some of the contracts do not provide steps for care plans or care continuation, even if they are required to do so by master contracts with the state.
The GAO report pointed out that CMS issued new managed care rules in May 2016, with several provisions related to MLTSS care management that need to be included with state contracts with MCOs. But states varied in how they responded to MCO care management issues, and some of the data collection and other practices did not help.
For example, the GAO found that five of the six states did not require MCOs to report the number of MLTSS beneficiaries that had a decrease in services, while three of the six states did not collect data on the nature of expedited appeals. And while Virginia required MCOs to report the number of beneficiaries with an increase or decrease in services, it could not aggregate the data due to “MCO reporting inconsistencies.”
Meanwhile, Arizona conducts operational reviews of MCOs “a minimum of every three years,” while Virginia has not formally reviewed MCO care management since the MCOs started providing services in 2017.
And federal oversight was not much better, according to the GAO report.
“We found that CMS has not systematically overseen whether states have effectively implemented requirements for monitoring their managed care programs, which may have allowed problems in MLTSS programs to persist,” it noted.
The agency has also failed to monitor whether states effectively implemented two beneficiary protection requirements: state beneficiary support systems and MLTSS stakeholder advisory groups. One way it could have done that would be through state reports required under the 2016 final rule, but that requirement has not actually been implemented, the GAO noted.
“States are to begin submitting the reports after CMS issues guidance on the reports’ content and format,” the report said. “However, as of July 2020 — over 4 years since the final rule was issued — CMS had not issued that guidance, so states have not begun submitting them. CMS officials told us they were developing the guidance and a new reporting tool for the reports, which they hoped to release in early 2021.”
But the agency has not implemented other procedures for overseeing the effectiveness of state monitoring programs.
CMS, for its part, told the GAO that it uses other methods for overseeing state MLTSS programs, such as reviews when states seek to extend their programs and making use of external quality reviews and information that states periodically report. It also pointed to “routine contacts” with states and MCOs, with “episodic input” from stakeholders.
The GAO’s assessment of that methodology was blunt.
“We found that CMS’s oversight approach was not effective in detecting and resolving MLTSS access and quality problems,” the report said. “CMS officials told us they had become aware of problems in multiple MLTSS programs and had engaged with the states to resolve them. In several of these cases, however, CMS officials learned of the problems after receiving complaints from beneficiaries, family members or other stakeholders, or through media reports—and not through their regular oversight methods.”