LTSS Choices

The Role of Medicaid Managed Long-Term Services and Supports during the COVID-19 Pandemic

Published October 15, 2021

For people with limited income and savings, the primary source for financing their long-term services and supports (LTSS) is Medicaid. Historically, state Medicaid programs reimbursed LTSS utilizing a fee-for-service model. However, increasingly states are shifting to a different financing and delivery system to manage and provide these services; they are contracting with Medicaid managed care organizations (MCOs). Of course, MLTSS programs vary significantly from state to state, and the structure of each state’s program affects the services an MCO is responsible for providing.

This report, based on interviews with a range of stakeholders in six states, examines the role played by MCOs providing Medicaid Managed Long-Term Services and Supports (MLTSS) during the COVID pandemic, which severely tested the ability of the states and their MLTSS plans to meet Medicaid program requirements. However, the pandemic response also revealed potential improvements to care. Some approaches and practices put into place in both institutional and home and community-based settings (HCBS) during the pandemic provide examples for enhancing care for MLTSS beneficiaries as well as addressing future public health emergencies.

The authors find the COVID-19 pandemic posed tremendous challenges for MLTSS plans, as it did for the entire health care system, particularly with respect to beneficiaries residing in nursing homes. MLTSS plans experienced similar barriers to entry as others did when these institutions were under lockdown – despite their contractual relationships and accountability to care for their members. Several did, however, report some successes in working around these constraints. MLTSS plans also played a key role in reaching HCBS beneficiaries, partnering with states to implement a number of Medicaid flexibilities that were permitted by CMS during the pandemic.

The authors identify the following eight takeaways that deserve attention as states, MCOs and public health experts evaluate the pandemic response with an eye towards lessons learned.

Clearly defined roles

There is a need to assess the proper role of state public health officials and Medicaid programs in providing oversight of safety and health of residents in nursing homes and other institutional facilities; the assessments should include the role of MLTSS plans in states where they operate.

Enhanced Clinical Support

There were several examples where MCOs provided crucial on-the-ground support and clinical expertise to states as the crisis unfolded in nursing homes. Models for potential engagement of clinical expertise and personnel in support of long-term care providers should be explored.

Strengthening Provider Contracting

MLTSS plans can use their financial leverage to incentivize nursing home care improvement and emergency preparedness, such as incentives to nursing homes that have implemented best practice protocols for infection or other pay-for-performance metrics.

Embracing Telehealth

During the pandemic, telehealth successfully supported assessments and care coordination and introduced potentially new models of providing services virtually, many of which are here to stay. Still, there is no substitute for a face-to-face visit. Assessing the right balance and cost-effectiveness between in-person and telehealth should be ongoing.

Evaluation of Waiver Flexibilities

The increased use of paid family caregivers was a particularly important resource for MLTSS plans as they worked to fill gaps in an individual’s person-centered service plan. Similarly expanded services, such as home delivered meals, may warrant continuation beyond the pandemic.

Data Tracking

The importance of data to track the spread of COVID cannot be emphasized enough; it was critical to the ability of states and their MLTSS plans to make informed and quick decisions to keep services functioning and protect the health and safety of staff and LTSS recipients. Where there were gaps in data, however, responses were hindered. An assessment is needed to identify the critical gaps in data experienced during the COVID pandemic to ensure the infrastructure and functionality are in place to better manage future public health emergencies.  

Emergency Back-Up Plans

One of the first things states and MLTSS plans should do now is review their emergency back-up plans, some of which are designed for severe weather or other emergencies, and update them based on the lessons learned from the COVID pandemic.

HCBS Workforce is ‘Essential’

If faced with future public health emergencies of this kind, it is critical that the overall federal response recognizes HCBS beneficiaries and their workforce in the same way it recognizes staff and residents in nursing homes and other congregate settings.



The Role of Medicaid Managed Long-Term Services and Supports during the COVID-19 Pandemic

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Suggested Citation

Nardone, Michael, and Susan C. Reinhard. The Role of Medicaid Managed Long-Term Services and Supports during the COVID-19 Pandemic. Washington, DC: AARP Public Policy Institute, October 2021.


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