Section II: State Policy and Operational Considerations
Rate-setting for Medicaid MLTSS programs is a complex undertaking. The resources in this section can help states understand the policy and operational considerations that may influence the rate-setting process. Issues addressed include: steps for collecting, analyzing, and validating data; strategies for mitigating risk for states and managed care plans; and approaches for engaging managed care plans and other stakeholders in developing or refining rate-setting approaches.
Developing Capitation Rates for Medicaid Managed Long-Term Services and Supports Programs: State Considerations (January 2016, CHCS) This brief identifies themes from the experiences of states at the forefront of MLTSS that other states may want to consider as they seek to improve rate-setting and risk-adjustment methods, including efforts that promote services in home- and community-based settings.
Trust but Verify: Tennessee’s Approach to Ensuring Accurate Functional Status Data in its Medicaid Managed Long-Term Services and Supports Program (August 2016, CHCS) This brief describes how TennCare’s robust approach to collecting and validating data on enrollees’ functional status can help other states to advance strategies for MLTSS program rate setting.
Engaging Managed Care Plans in Rate Setting for Medicaid Managed Long-Term Services and Supports Programs (August 2016, CHCS) This brief describes state approaches for involving managed care plans in rate-setting activities, opportunities for plans to support these activities, and potential implications of MLTSS rate-setting policy decisions on participating managed care plans and other stakeholders.
Risk Mitigation Strategies in Medicaid Managed Long-Term Services and Supports Programs: Options for States (August 2016, CHCS) This brief explores the challenges in rate setting for MLTSS programs that may result in risk to overpayments and underpayments, and describes the most common financial risk mitigation strategies that states have employed to protect both the state from overpayment and managed care plans from excessive financial losses.
Rate-Setting Strategies to Advance Medicaid Managed Long-Term Services and Supports Goals: State Insights (August 2016, CHCS) This webinar highlights state considerations, and Tennessee and Wisconsin’s approaches for using rate-setting to advance MLTSS program goals, including: (1) helping more people to live in the community; and (2) adjusting risk appropriately based on MLTSS cost drivers, including functional status.
Considerations for a National Risk-Adjustment Model for Medicaid Managed Long-Term Services and Supports Programs (September 2016, CHCS) This brief examines considerations in developing a nationally available risk-adjustment model for MLTSS programs that can be used by states. It also explores research needed to develop a robust model that predicts expected LTSS costs as accurately as possible.