Of the estimated 1.5 million consumers with intellectual and developmental disabilities enrolled in Medicaid, approximately 358,508 consumers (25%) are enrolled in a managed long-term services and supports (MLTSS) program in 10 states. Of the current Medicaid I/DD MLTSS programs, the specialty vertical model operating in Arizona and Arkansas has seen a 250% growth from 2016 to 2019, according to our new analysis, Medicaid Managed Long-Term Care Models For The I/DD Population: An OPEN MINDS Market Intelligence Report.
Today, 22 states operate 26 Medicaid MLTSS programs, and 10 of those states include the consumer population with I/DD in those programs. There are four types of financing and delivery systems for the I/DD MLTSS programs—I/DD support services embedded in Medicaid acute care health plans, I/DD support services embedded in Medicaid LTSS health plans, specialty vertical managed care models for I/DD consumers, and consumer-driven models for I/DD support services. The model with the highest estimated I/DD enrollment is the I/DD support services embedded in LTSS health plans model that operates in Michigan, Tennessee, and Wisconsin—with approximately 164,834 consumers with I/DD. The specialty vertical model operating in Arizona and Arkansas is next with 157,528 consumers with I/DD.
While these models are very different, the implications for specialty service provider organizations serving the I/DD population in these states are similar. First, the contractual reimbursement arrangement shifts from a state or county entity to some type of managed care organization. And this shift brings with it the need to participate in managed care systems—with a need for prior authorization process, electronic health record (EHR) systems, data exchange/interoperability with other types of health/human service organizations, fee-for-service billing, and the ability to accept risk-based contracts. This market shift will bring the need for more capital for infrastructure and contracting—and with that, new competition from large provider consolidator organizations and from new private equity-funded for-profit organizations in the market space.
The key to planning for executive teams is to know your specific state markets and any likely changes in those markets. North Carolina, for example, is gearing up to implement the popular specialty vertical managed care model soon. Twelve states—Delaware, Hawaii, Illinois, Massachusetts, Minnesota, New Mexico, New York, Pennsylvania, Rhode Island, Tennessee, Texas, and Virginia—currently exclude their I/DD population from enrolling in MLTSS. These states may change the status quo not too far in the future as they seek better outcomes and see the models that have succeeded in the ten states with MLTSS for the I/DD population. Regardless of whether there is a current or pending I/DD MLTSS program in the state, it is worthwhile to develop relationships with the health plans in the market. Consumers with an I/DD are served by commercial, Medicare, and Medicaid plans—and there is an opportunity to diversify both service lines and payer mix with new relationships. This means that if the organization has not worked with managed care organizations in the past, assessing the organizational readiness for those relationships is key (for more on the elements of readiness, check out our Managed Care Competencies Assessment.
For more, check out these resources on the I/DD market landscape in our OPEN MINDS Circle Industry Library:
- Health Care Coverage For Consumers With An I/DD – The Trends & The Future
- The Changing Landscape For Autism & I/DD Services: An Executive Briefing
- For Success With The I/DD Population, Employment Matters
- The Intellectual & Developmental Disability Consumer Health Insurance Market: An OPEN MINDS Market Intelligence Report
- The Evolving Market For Consumers With Intellectual & Developmental Disabilities: An OPEN MINDS 2020 Market Intelligence Report
- Who’s Waiting & Why?
- A Holistic Approach With The I/DD Population Pays Off
- North Carolina Medicaid Managed Care Policy Paper: Behavioral Health I/DD Tailored Plan RFA Pre-Release
- Number Of People On I/DD HCBS Wait Lists Rose Nearly 12%
- Colorado Cuts I/DD Waiting List By 61% From 2013 To 2019
And to learn more about I/DD service delivery in the pandemic, join us on May 5 for the web briefing, Caring For Vulnerable Populations In A Social Distance World: Autism Service Providers Implement Virtual Care Delivery. The briefing is offered as part of the new OPEN MINDS Executive Blueprint For Crisis Management program, designed to help our Elite-level OPEN MINDS Circle subscribers navigate the business, operational, and culture changes of a market in turbulence.