Vision for Long-Term Services and Supports – LTSS and Ombudsman Program

Long term services and supports will be part of Medicaid Transformation.  This is an area of concern for many individuals with intellectual and developmental disabilities, as these services and supports are many times required for a lifetime.  

NC DHHS has published a concept paper entitled North Carolina’s Vision for Long-term Services and Supports under Managed Care, a point-in-time framework on a specific issue, discussing defined processes to assist Medicaid beneficiaries requiring long-term services and supports (LTSS) in services and care.  

Long-term services and supports are defined in the paper as “medical and non-medical programs and services provided in a variety of settings, including, but not limited to, nursing facilities, other group or private living settings, and the community; to people of all ages for a short or extended time to support their regaining or maintaining maximum health and independence when living with a chronic illness or disability.”  Although this definition seems to be quite broad, the estimate of the number of Medicaid beneficiaries included in the LTSS category is not high. Of the estimated 2 million people enrolled in Medicaid, NC DHHS projects that:

• Approximately 14,500 Medicaid-only beneficiaries using State Plan LTSS will enroll in Standard Plans;
• Approximately 30,000 Medicaid beneficiaries using LTSS with serious mental illness (SMI), serious emotional disturbances (SED), substance use disorder (SUD), intellectual and developmental disabilities (I/DD), and traumatic brain injuries (TBI) will enroll in behavioral health and I/DD Tailored Plans (BH I/DD TPs); and
• Approximately 62,000 remaining beneficiaries using LTSS will enroll in managed care.

This gives a projected total of 106,500 Medicaid beneficiaries using LTSS, Standard and BH/I-DD Tailored Plans combined.  According to the Appendix in this concept paper, 112,000 are projected to be under the BH/I-DD Tailored Plan, including individuals dually eligible for Medicare and Medicaid (down from an estimated 120,000 in the BH/I-DD TP concept paper published in November).  Given these numbers, it appears that more detail is needed about how these numbers match up and the crossover between the Standard and BH/I-DD Tailored Plans for individuals requiring long-term services and supports and intensive BH/I-DD services and supports.

Care management will play a central role in coordinating care for beneficiaries using LTSS.  The care management of LTSS beneficiaries will be conducted by individuals with experience in LTSS who are trained in the person-centered planning process.  The care management role will include on-going care management needs, general health need screenings, population health programs, transitional care management and care coordination for beneficiaries using LTSS.  Finally, the PHPs will be responsible for providing the capacity to focus on transitional care management.

Two additional pivotal roles in ensuring a seamless transition for beneficiaries are the enrollment broker and ombudsman programs.  For that reason, NC DHHS is focusing on the functions that these entities will provide. The role of the Enrollment Broker has been detailed already through a concept paper and RFP.  This concept paper also provides a little more detail about the ombudsman program that will be separate from NC DHHS.  

The Ombudsman Program will do the following for beneficiaries using LTSS:

• Serve as an access point for enrollee complaints and concerns,
• Provide education on enrollees’ grievance and appeals rights within the PHP, the Department fair hearing process, enrollees’ rights and responsibilities and additional resources available to enrollees outside of the managed care entity, and
• Assist enrollees in navigating the eligibility, enrollment and benefits, and grievance and appeals processes, including referrals to legal representation.

Finally, NC DHHS will require that all PHPs create a Member Advisory Committee.  That committee will include beneficiaries using LTSS and providers and PHPs involved in LTSS.  The Member Advisory Committee must meet at least quarterly.