State Managed LTSS Programs

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Arizona

Arizona Long-Term Care System (ALTCS)

The Arizona Long-Term Care System is a program of Arizona's capitated Medicaid managed care system, a statewide 1115 Waiver program known as the Arizona Health Care Cost Containment System (AHCCCS).  Operating since 1989, ALTCS offers institutional and home and community-based services to people with a nursing facility level of care need.
 

ALTCS uses two blended capitation rates, one for duals (people covered under Medicare and Medicaid) and one for non-duals (Medicaid-only).  The plans are at risk for 50% of the extra cost if the proportion of members in institutions is higher than expected, and they must return 50% of the excess to the state if the proportion institutionalized is lower than expected.

More information

AHCCCS reports to CMS, including annual HCBS reports.
Archived HCBS quarterly reports from previous years (click on Resources/Reports folder)
 

Program documents

ALTCS EPD (Elderly & physical disabilities) contract with managed care organizations:
 
AHCCCS 1115 Waiver Application
 
AHCCCS 1115 Waiver Special Terms & Conditions:
 
See Sections 1000 (ALTCS Services & Settings), 1300 (Member-Directed Options), and 1600 (Case Management)
 
Needs assessment form:
 
AHCCCS Quality Assessment & Performance Improvement Strategy
 
Capitation rates for 2016:
 
 
 

Last modified Jan 14, 2019

California

Cal MediConnect

Cal MediConnect (CMC) is a capitated duals demonstration program for California adults eligible for both Medicare and Medicaid.  Enrollment began in 2014.  CMC operates in seven counties and is part of a larger initiative called the Coordinated Care Initiative (CCI).  Although LTSS is managed by health plans, the pre-demo structure of the LTSS system is largely maintained through managed care organization contracts with counties to provide In-Home Supportive Services.  Populations excluded from the demonstration include those receiving institutional or Waiver services for intellectual or developmental disabilities, as well as participants in certain other Waiver programs.
 
Aside from CMC, the other component of CCI is a mandatory Medicaid managed care program for people opting out of CMC.  In other words, dual beneficiaries in the seven counties can choose to continue receiving Medicare benefits in a fee-for-service arrangement, but their Medicaid benefits, including LTSS, will nonetheless be provided under a managed care model.  This component of CCI operates as part of California's 1115 Waiver.
 

The Medicaid portion of the Cal MediConnect capitation rate is a single, blended rate that varies by county and depends on the mix of members in the following four categories:  Institutionalized for more than 90 days, HCBS High, HCBS Low, and Communty Well/Healthy.

More information

CLPC & U.C. Berkeley evaluation of Cal MediConnect
 

Program documents

CMC contract with managed care organizations:
 
CMS Evaluation Report:
 
Supplemental quality reporting requirements:
 
CMC memorandum of Understanding with CMS:
 
CMC demonstration proposal to CMS:
 
CMS approval and special terms & conditions for California's 1115 Waiver:
 
1115 Waiver extension request 2015:
 
California Medicaid Managed Care Quality Strategy:
 
Cal MediConnect Capitation Rates:
 

Last modified Mar 5, 2019

Delaware

Diamond State Health Plan (DSHP) Plus

Diamond State Health Plan Plus is a Medicaid managed care program for seniors and people with physical disabilities that integrates LTSS with healthcare services.  It operates statewide as an 1115 Waiver and serves dual eligibles as well as people without Medicare coverage.  DSHP Plus has been in operation since 2012.
 

DSHP Plus has three capitation rate tiers:

  • NF/HCBS Dual, for people on both Medicaid and Medicare who receive LTSS either in institutions or in the community through HCBS Waivers.
  • NF/HCBS Non-Dual, as above except not covered by Medicare.
  • Community, for everyone else.

More information

 

Program documents

Contract with managed care organizations:
 
Waiver extension request:
 
Current approval document:
 
Original DSHP Plus Waiver application:
 
CMS Approval & Special Terms & Conditions for DSHP & DSHP-Plus:
 
Pre-Admission Evaluation (LTSS level-of-care assessment)
 
Quality Management Strategy:
 
Information on capitation rates:
 

Last modified Jan 30, 2019

Florida

Statewide Medicaid Managed Care (SMMC) Long-Term Care (LTC) Program

Florida's Statewide Medicaid Managed Care program provides long-term services and supports through a Long-Term Care program that has operated since 2013 as a combined 1915(b) and (c) Waiver program.   The LTC program is distinct from its Managed Medical Assistance (MMA) program, an 1115 Waiver program that delivers other healthcare services.  Enrollees are able to choose the same managed care organization to provide both types of services, allowing for potential integration of services.
 

Managed care organizations receive a single, blended capitation rate that depends upon the region of the state and the proportion of members expected to be institutionalized.  The proportion is calculated and then reduced to a targeted, lower percentage, and therefore the capitation payment is reduced, on the assumption that plans will work to divert people from institutional placement or transition them out of institutions.  MCOs that fail to achieve these targets must either lose money or reduce benefits.

More information

Monthly Medicaid enrollment reports (tab LTC has institutional and HCBS participants)
 

Program documents

SMMC LTC contract with managed care organizations:
 
Waiver renewal application (draft):
 
Waiver amendment request:
 
Original waiver application:
 
Waiver renewal approval letter:
 
Florida Comprehensive LTC Assessment:
 
Medicaid Comprehensive Quality Strategy:
 
Capitation rates for LTS and MMA services:

Last modified Jan 3, 2019

Hawaii

QUEST Integration

QUEST Integration is the latest incarnation of Hawaii's 1115 Waiver program for integrated, managed Medicaid services.  It has been in operation since 2013.  Previously, Hawaii had a separate program for Medicaid recipients receiving LTSS, which was known as QUEST Expanded Access, or QExA.  Enrollment is mandatory.
 

Capitation rates for QUEST Integration vary by age, gender, island of residence, and Medicaid eligibility group, such as Medicaid expansion, "Aged/blind/disabled" (ABD), and CHIP.  Two rates are used for the ABD category, according to whether the person is also covered under Medicare.  These are both blended rates, determined by stratifying members according to their LTSS needs and residential setting.

More information

QUEST Integration (and predecessors) reports to CMS and enrollment reports
 

Program documents

QUEST 2017 External Quality Review Report of Results
 
QUEST Integration Request for Proposals (includes contract language):
 
QUEST Integration Waiver Application:
 
QUEST Integration Waiver Extension Application:
 
QUEST Integration Waiver Temporary Extension Approval:
 
QUEST Integration Waiver Approval and Special Terms & Conditions:
 
QUEST Amendment Approval Letter:
 
Med-QUEST Quality Strategy Performance Measures:
 
LTSS assessment tools used by all plans:
 

Last modified Apr 4, 2019

Illinois

Medicare-Medicaid Alignment Initiative (MMAI)

MMAI is a capitated duals demonstration program for Illinois adults eligible for both Medicare and Medicaid.  It is offered in two regions of the state:  the greater Chicago area and Central Illinios.  The demonstration began enrollment in 2014 and is targeted to adults in the "Aged, Blind, and Disabled" Medicaid eligibility group.  People receiving Medicaid institutional or Waiver services for intellectual and developmental disabilities are excluded.
 

Capitation rates for MMAI depend on age group (working age versus elderly), region of the state (Greater Chicago versus Central Illinois), and LTSS recipiency and setting.  Prior to September 2016, the rate structure was as follows:

  • The Nursing Facility rate applies only after the first 90 days of institutionalization.  During the first 90 days, the prior capitation rate remains in effect.
  • The Waiver Plus rate applies to two categories of members receiving HCBS Waiver services:
    • Those within 3 months of transition out of an institution.
    • Those within 3 months of eligibility determination for HCBS or nursing facility, as long as the person remains in the community.
  • The Waiver rate is for all others on an HCBS waiver.
  • The Community Plus rate is for community residents not receiving HCBS Waiver services, for the first 3 months following return to the community after a nursing home stay of longer than 90 days.
  • The Community rate is for others not receiving HCBS Waiver services.

In September 2016, the rate structure was simplified to eliminate the "Plus" rate categories.  There is now one category for nursing home residents, a second for people on HCBS waivers, and a third for everyone else.

More information

 

Program documents

Contract with managed care organizations (2018, 2016 and 2013 versions):
 
CMS Evaluation Report:
 
Supplemental quality reporting requirements:
 
Memorandum of Understanding with CMS:
 
Demonstration proposal to CMS:
 
Illinois Medicaid Managed Care Quality Strategy:
 
MMAI Capitation Rates:
 

Last modified Mar 5, 2019

Iowa

IA Health Link

In 2016, Iowa transitioned to a new Medicaid managed care program known as IA Health Link.  The program, which operates under authority of Sections 1902(a) and 1915(b) of the Social Security Act, was approved by CMS in February 2016.  Managed home and community-based services are provided through 1915(c) Waivers operating concurrently.  The statewide program is mandatory for people in all Medicaid eligibility categories, with very limited exceptions, and includes participants in all 1915(c) Waivers.
 

Capitation rates for IA Health Link are based on Medicaid eligibility category, age, and gender; in addition, there are separate rate cells for people receiving LTSS.  For LTSS users, there are four blended capitation rates that include people receiving either institutional services or HCBS:

  • LTSS—Elderly, for people 65 or over in custodial care nursing homes or getting hospice care or Elderly Waiver services.
  • LTSS—Non-Dual or Pre-65, for those under 65 in custodial care nursing homes, non-duals of any age in skilled nursing facilities, people under 65 getting hospice services, and people on the Physical Disability Waiver, the Health and Disability Waiver, the AIDS Waiver, or the Brain Injury Waiver.
  • LTSS—Intellectual Disability, for people in institutions for people with intellectual disabilities or getting services through the Intellectual Disability Waiver.
  • LTSS—Children's Mental Health, for children institutionalized for mental health conditions or receiving services through the Children's Mental Health Waiver.

The blended rates are calculated according to the mix of institutional and community residents and then adjusted downward to reflect a target for rebalancing the system in favor of HCBS.  Although nominally intended to provide an incentive for MCOs to divert members from nursing home placement and transition them out, plans that are unable to meet those targets will find themselves shortchanged and perhaps unable to meet member LTSS needs.

More Information

IA Health Link Monthly Data Reports (includes HCBS & institutional LTSS recipients, as well as demographics and performance)
 

Program Documents

IA Health Link Contract Scope of Work:
 
IA Health Link application to CMS:
 
CMS approval letter:
 
Capitation rates:

Last modified Jan 9, 2019

Kansas

KanCare

KanCare is a statewide 1115 Waiver program for Medicaid services in Kansas. It was implemented in 2013 and initially approved for five years. After a one year extension, KanCare was approved for a five year renewal (KanCare 2.0) and implemented in January 2019. Home and community-based services are covered through 1915(c) Waiver programs that operate in parallel and are provided by managed care organizations.  These programs are in the process of being more fully integrated into KanCare.
 

KanCare members who receive LTSS fall into one of four capitation rate categories:

  • LTC, for people in institutional settings or receiving HCBS under the Frail Elderly or Physical Disability Waivers.
  • Waiver, for people receiving HCBS under the Autism, Technology Assisted, Traumatic Brain Injury, or Serious Emotional Disturbance Waivers.
  • DD Waiver, for people receiving HCBS under the Developmental Disability Waiver.

More information

KanCare monthly participant and expenditure reports (includes LTSS by setting & program)
 

Program documents

KanCare 2.0 Request for Proposals (and selected attachments):
 
KanCare Request for Proposals (includes contract language):
 
KanCare 2.0 and KanCare Waiver Applications:
 
Extension Approval Letter:
 
CMS Special Terms & Conditions for KanCare:
 
KanCare Quality Strategy :
 

Last modified Apr 4, 2019

Massachusetts
Massachusetts has two principal managed LTSS programs:  OneCare and Senior Care Options.  In the summer of 2018, the State proposed a Duals Demonstration -- 2.0, combining both programs. Information relevant to all programs is at the bottom of this page.

 

OneCare

OneCare is a capitated duals demonstration project for adults between the ages of 18 and 64 who are eligible for both Medicare and Medicaid.  It operates statewide.  Enrollment began in 2013.
 

Capitation rate categories for the Medicaid portion of OneCare are based on county of residence and a combination of residential setting, level of care need, and diagnosis, as follows:

  • The Facility-Based Care category applies to people institutionalized for longer than 90 days. 
  • Five "community" categories apply to community residents and the first 90 days of institutional residency (based on the most recent assessment prior to institutionalization): 
    • Very High Community Need is for people with an institutional level of need and a diagnosis of quadriplegia, ALS, muscular dystrophy, or respirator dependence. 
    • High Community Need is for others with an institutional level of need. 
    • Community Very High Behavioral Need is for those not in the above categories who have both a specified mental health diagnosis (schizophrenia, other psychosis, or episodic mood disorder) and a substance abuse diagnosis that is not in remission.
    • Community High Behavioral Need is for others with either a mental health diagnosis, from the list above, or a substance abuse diagnoses that is not in remission.
    • Community Other is for everyone else.

More information

Monthly enrollment reports (includes LTSS participants by setting)
 
Demonstration proposal to CMS:
 
2018 Capitation Rates:
 
2017 Capitation Rates:
 
2016 Capitation Rates:
 
 

Senior Care Options

Senior Care Options (SCO) is a voluntary managed care plan for dual eligibles at least 65 years of age.  SCO has been in operation since 2004 under a 1915(a) and (c) Waiver program known as the Frail Elder Waiver.
 

Capitation rates are based on residential setting (community versus institutional, with the institutional rate only applying after the first 90 days), Medicare coverage (dual versus non-dual), region of the state (greater Boston area versus elsewhere), and a combination of level of need and diagnosis, as follows:

  • For community residents (and institutional residents during the first 90 days, who retain their pre-institutional rate), there are three levels:
    • Nursing home certifiable.
    • Not nursing home certifiable, but with a diagnosis of Alzheimer's, other dementia, or chronic mental illness.
    • Everyone else.
  • There are also three levels for institutional residents, depending on level of acuity.  The lowest, which is greater than all of the community rates, is also applied to the first 90 days after a person has been transitioned from an institution back to the community.

More information

 

Program documents

Contract with managed care organizations:
 
Waiver application from 2014 (link to CMS)
 
For 2014 capitation rates, see Appendix E of the Contract.
 
 

Duals Demonstration -- 2.0

This next generation duals demonstration would combine OneCare and Senior Care Options while maintaining the distinct population focus, service package, eligibility, and competency requirements of each of the current programs. 
 

More information

 

program documents

Final Concept Paper, August 2018
 

 

General information on Managed LTSS in Massachusetts

 
Managed Care Quality Strategy: 

Last modified Apr 29, 2019

Michigan

MI Health Link

MI Health Link is a capitated duals demonstration program for adults eligible for both Medicare and Medicaid.  It operates in ten counties in the Lower Peninsula and the entire Upper Peninsula.  Enrollment began in 2015.
 

Capitation rates are determined by region of the state, age group (working ages versus elderly), LTSS utilization, and residential setting.  There are two tiers for nursing home residents, with a lower rate for privately owned facilities and a higher rate for publicly owned facilities.  These rates take effect only after the first three months of institutionalization; the rate assigned prior to institutionalization is used until then.  There are two rates for community residents, one for those with a nursing home level of care need and the other for everyone else.   For people transitioning out of a nursing home after a stay of three months or longer, a supplemental capitation payment is made during the third month following transition.

More information

 

Program documents

Contract with managed care organizations:
 
Supplemental quality reporting requirements:
 
Quality Withold Analysis Results Year 1 (2015-2016):
 
Memorandum of Understanding with CMS:
 
Demonstration proposal to CMS:
 
1915(c) Waiver Amendment Application:
 
Assessment instrument for level of care determination:
 
MI Health Link Capitation Rates:
 

Last modified Mar 5, 2019

Minnesota

Minnesota Senior Health Options (MSHO) and Senior Care Plus (MSC+)

Minnesota Senior Health Options is a voluntary managed care program for dual-eligible (Medicare and Medicaid) seniors.  It has been in operation since 1997 under the combined authority of Sections 1915(a) and (c) of the Social Security Act.
 
Minnesota Senior Care Plus began operation in 2005 as a successor to a prior 1115 Waiver program.  It is a 1915(b) program operating in parallel with the state's 1915(c) Elderly Waiver.  All Minnesota seniors receiving Medicaid services are enrolled in MSC+, except those dual eligibles opting to participate in MSHO.
 

The capitation rate structure for both programs is unlike that used in other states, in that the managed care organizations are paid only a Basic Care rate for institutionalized members, which is lower than the payments for community-resident members.  Rather than paying plans a higher rate for institutionalized members, the state supplements the community-resident capitated payment to account for the risk that any given member will be institutionalized.  After 180 days of institutionalization, the member's nursing home services become the responsibility of the state agency.  The MCOs, therefore, is at risk for a large payout for any member who becomes instutionalized, and thus have a strong financial incentive to divert members from from nursing home placement and transition them back to the community as soon as possible.

There are essentially three tiers of payment:  the Basic Care rate for all members regardless of  LTSS utilization, which is supplemented by a Nursing Facility Add-On rate for all community residents and additionally supplemented by an Elderly Waiver Add-On rate for those receiving HCBS through the Waiver.  These rates vary by gender, age group (65-74, 75-84, and 85+), and whether the person is also covered under Medicare.

More information

Managed care enrollment reports (includes LTSS participant data for both programs)

 

Program documents

Contract with managed care organizations for both programs:
MN Department of Human Services contract page
 
Annual Evaluation Reports to CMS:
 
Memorandum of Understanding with CMS:
 
Proposal to CMS:
 
MSC+ 1915(b) Waiver Renewal Application:
 
MSC+ 1915(b) Waiver Approval Letter:
 
 1915(c) Elderly Waiver application (concurrent with both MSHO & MSC+):
 
Comprehensive Quality Strategy:
 
Information about Minnesota's MnCHOICES web-based LTSS assessment system (scroll down to "MnCHOICES Content" for instruments)
 
Capitation rates for both programs are available in plan-specific contracts for MSHO/MSC+ (see last page)
 

Last modified Jan 30, 2019

New Jersey

New Jersey Comprehensive Waiver

In 2014, New Jersey began providing Medicaid managed long-term services and supports through its FamilyCare Comprehensive Demonstration (formerly Comprehensive Waiver) program, which has operated since 2012 under the authority of Section 1115 of the Social Security Act.  Participation is mandatory for nearly all populations.
 

Capitation rates for people receiving LTSS vary by Medicare coverage (dual versus non-dual) and by residential setting.  There is one tier for people receiving HCBS and another for people in nursing homes.  Enhanced rates apply to people in what are termed special care nursing facilities.  Capitation rates for non-LTSS recipients depend on eligibility category and age group.

More information

 

Program documents

Contract with managed care organizations:
 
NJ Comprehensive Waiver 1115 Application:
 
NJ Comprehensive Waiver Annual Report:
 
Request for Waiver Amendment:
 
Draft Waiver Renewal Application 2016:
 
CMS Special Terms & Conditions:
 
Description of assessment tool for personal care services:
 
Managed Care Quality Strategy:
 
For capitation rates, see Section C of the contract with managed care organizations, above.
 
 
 
 
 
 

Last modified Feb 7, 2019

New Mexico

Centennial Care

In 2014, New Mexico implemented a new, statewide 1115 Waiver program to deliver most Medicaid services, including LTSS, via an integrated managed care system.  Participation in Centennial Care is mandatory for most populations.  Home and community-based services for people with developmental disabilities are carved out.
 

More information

 

Program documents

Annual Reports:
 
Request for proposals and contract with managed care organizations:
 
Amended contract with managed care organizations, 2016:
 
Centennial Care 2.0 Waiver Renewal Application:
 
Centennial Care 1115 Waiver Application:
 
CMS Approval and Special Terms & Conditions:
 
Managed Care Quality Strategy:

Last modified Feb 7, 2019

New York

Fully Integrated Duals Initiative (FIDA)

The Fully Integrated Duals Initiative is a capitated duals demonstration program, which began operation in New York City and part of Long Island in 2015.   The program is targeted to people who need LTSS, whether in an institutional or community setting.  HCBS participants must need those services for a minimum of 120 days to be eligible. 
 
Although the FIDA program excludes people receiving services from the state developmental disabilities agency, a separate managed LTSS duals initiative (FIDA -- Intellectual and Developmental Disabilities) was launched for that population in 2016 (see below). 
 

One blended capitation rates applies to members who are "nursing-home certifiable," regardless of residence.  Another rate applies to community residents who are not nursing-home certifiable.

More information

 

Program documents

Contract with managed care organizations:
 
Information on uniform LTSS assessment tool (UAS-NY)
 
Managed Care Quality Strategy:
 
 

Fully Integrated Duals Initiative—Intellectual and Developmental Disabilities (FIDA-IDD)

FIDA-IDD is a voluntary (opt-in only) duals demonstration program for people living in New York City or on Long Island who have intellectual or developmental disabilities (I/DD) and receive either institutional services or HCBS through specific programs.  Enrollment began in 2016.
 

FIDA-IDD has two blended capitation rates, based on age but not residential setting or level of service need:  one is for people between the ages of 21 and 49 and the other is for ages 50 and older.

More information

 

Program documents

Contract with managed care organizations:
 
Supplemental quality reporting requirements:
 
Memorandum of Understanding with CMS:
 
 
 
 
 

Last modified Apr 4, 2019

Ohio

MyCare Ohio

MyCare Ohio, a program for "duals" covered under both Medicare and Medicaid, has two components:  (1) a capitated duals demonstration project that integrates Medicare and Medicaid benefits and (2) a Medicaid-only managed care component for people who choose to continue their Medicare coverage on a fee-for-service basis.  The program was launched in 2014 and operates in 29 Ohio counties.  The Medicaid-only component operates under authority of an 1915(b) Waiver.  People receiving LTSS related to intellectual or developmental disabilities are excluded from the program.
 

Capitation rates depend on age group (18-44, 45-64, and 65+), region of the state, whether Medicare benefits are included in the rate (duals demo versus Medicaid-only plan), and the level-of-care need and setting.  The Waiver/NFLOC rate is for people meeting the nursing home level of care criteria who are either eligible for or receiving HCBS Waiver services or have resided in a nursing home for longer than 100 days.  The Community Well rate is for others.  For people getting the Community Well rate prior to placement in a nursing home, the (lower) Community Well rate remains in effect for the first 100 days in the nursing home.  For people on the NFLOC rate who transition to Community Well, the NFLOC rate remains in effect for three months.

More information

Ohio Medicaid monthly caseload reports (includes MyCare LTSS participants by setting)
 

Program documents

Contract with managed care organizations (see also Provider agreement, below):
 
Annual CMS Evaluation Report:
 
Supplemental quality reporting requirements:
 
Memorandum of Understanding with CMS:
 
Demonstration proposal to CMS:
 
Approved 1915(b) Waiver proposal for the Medicaid-only component:
 
Provider agreement:
 
 
For capitation rate information, see Appendix E of the MyCare Ohio Provider Agreement, above.

 

Last modified Apr 5, 2019

Rhode Island

Integrated Care Initiative & Rhody Health Options (RHO)

Rhode Island implemented the first phase of its Integrated Care Initiative (ICI) in 2013.  Operating under a Section 1115 Waiver, a managed care program known as Rhody Health Options (RHO) was launched to provide Medicaid benefits, including LTSS, to two populations:  Medicaid beneficiaries receiving LTSS and other Medicaid beneficiaries who are also covered by Medicare ("duals").  In the second phase of the program, launched in 2016, a capitated duals demonstration program expanded upon RHO, thus allowing the state to provide duals with integrated Medicare and Medicaid services.
 

In the duals demonstration (Phase II of the ICI), there are two capitation rates for the Medicaid component:  a blended Waiver/LTC rate for people on HCBS waivers or in nursing homes for longer than 90 days and a Community (non-LTSS) rate for everyone else.

More information

Program participant & expenditure data (see "State Expenditures for Long-Term Supports and Services under Managed Long Term Care")
 

Program documents

RHO contract with managed care organizations:
 
1115 Waiver Extension Application:
 
CMS Special Terms & Conditions for the 1115 Waiver:
 
Duals Demonstration (Phase II) Proposal Solicitation:
 
Duals Demonstration (Phase II) Three-Way Contract:
 
Supplemental quality reporting requirements:
 
Duals Demonstration (Phase II) Memorandum of Understanding with CMS:
 
Duals Demonstration (Phase II) Proposal to CMS:
 
Duals Demonstration (Phase II) capitation rate information:
 
Managed Care Quality Strategy:

Last modified Apr 5, 2019

South Carolina

Healthy Connections Prime

Healthy Connections Prime is South Carolina's duals demonstration project, which began offering integrated Medicare and Medicaid services, including LTSS, to elderly adults (65+) eligible for both programs in 2015.  Begun on a voluntary (opt-in) basis, passive (opt-out) enrollment in the program began in April 2016, initially in one region of the state but later extending statewide.  People living in institutional settings are excluded, but participants in all Waiver programs are included, including those for people with intellectual and developmental disabilities.
 

There are four capitation rate tiers in Healthy Connections Prime:

  • NF1, for people residing in nursing facilities for more than 3 months and meeting the nursing home level-of-care criteria.
  • H1 (HCBS), for people getting HCBS and meeting nursing home or specific Waiver level-of-care criteria.
  • H2 (HCBS+), an enhanced rate for the first three months after a person transitions from NF1 to an HCBS waiver.

  • C1 (Community) for everyone else

More information

Monthly enrollment data reports include LTSS participants by setting
 

Program documents

Contract with managed care organizations:
 
Supplemental quality reporting requirements:
 
Memorandum of Understanding with CMS:
 
Demonstration proposal to CMS:
 
Capitation rates:
 

Last modified Mar 5, 2019

Tennessee

TennCare CHOICES

TennCare is Tennessee's statewide, mandatory Medicaid managed care system.  It has operated since 1994 as an 1115 Waiver program.  In 2010, long-term services and supports were added to the mix of managed care services under the name TennCare CHOICES, which serves adults with physical disabilities and seniors needing LTSS.  People receiving services related to intellectual and developmental disabilities are currently excluded from CHOICES, but a companion managed LTSS program, Employment and Community First (ECF) CHOICES, has been developed for this population.
 

Capitation rate categories for TennCare CHOICES depend on level of care need (nursing home level, regardless of whether the person resides in a nursing home or in the community, versus non-nursing home level), Medicare coverage status (dual versus non-dual), and region of the state.

More information

 

Program documents

Contract with managed care organizations:
 
TennCare 1115 Waiver Extension Request:
 
CMS Approval and Special Terms & Conditions:
 
Level-of-care determination instrument (PAE):
 
Quality Assessment Strategy:
 
Capitation rate information and annual Actuarial Review of the TennCare Program
 
 

Last modified Apr 5, 2019

Texas

STAR+PLUS

STAR+PLUS is a manged LTSS and acute healthcare program that has operated in Texas since 1998.  Originally run as a 1915(b)/(c) Waiver program, STAR+PLUS became part of the state's 1115 Waiver, known as the Texas Healthcare Transformation and Quality Improvement Program, in 2012.  The program expanded its scope to become statewide in 2014.  Enrollment is mandatory for adults and voluntary for children in select Medicaid eligibility categories.  Texas also launched a duals demonstration program in 2015 in six counties, allowing adult STAR-PLUS members who are also eligible for Medicare to receive integrated, managed Medicare and Medicaid services.
 

STAR+PLUS has three capitation rate categories:  Nursing Facility, HCBS (has nursing home level-of-care need), and Other Community Care (receives LTSS only through the state plan).  Rates also depend on Medicare coverage (dual versus non-dual) and region of the state.

More Information

 

Program Documents

STAR+PLUS contract with managed care organizations:
 
Duals demonstration three-way contract:
 
Supplemental quality reporting requirements:
 
1115 Waiver extension application:
 
1115 Waiver approval and special terms & conditions:
 
Duals demonstration memorandum of understanding with CMS:
 
Duals demonstration proposal to CMS:
 
Texas Managed Care Quality Improvement Strategy:
 
STAR+PLUS capitation rate information

Last modified Mar 5, 2019

Vermont

Choices for Care

Choices for Care is a long-term services and supports program that was launched in 2005 with the goal of providing home and community-based services and institutional services on an equal basis.  Originally operated under its own 1115 Waiver, Choices for Care was integrated into Vermont's managed care 1115 Waiver, which is known as Global Commitment to Health, in 2015.  The program provides services to adults with physical disabilities and seniors needing LTSS.  Enrollment is mandatory. 
 
Vermont's model for managed care is unique.  Rather than contracting with commercial or non-profit managed care organizations, the Vermont Medicaid agency runs its managed care programs through a separate state agency, the Department of Vermont Health Access, which serves in the role of a managed care entity.  Thus, there is no contract with an outside entity; instead, the language typically found in managed care contracts is embedded in state regulations.  Although Choices for Care was originally a fee-for-service program, with the integration into the Global Commitment Waiver, Vermont has promised CMS to "ensure a managed LTSS plan for a comprehensive care model is developed that promotes the integration of home and community based services, institutional, acute, primary and behavioral health care."
 

More information

 

Program documents

Choices for Care Regulations established by the Vermont Dept. of Disabilities, Aging and Independent Living:
 
1115 Waiver extension applications for Global Commitment to Health:
 
CMS Approval and Special Terms & Conditions for Global Commitment to Health:
 
Comprehensive Quality Strategy:
 
Service assessment & authorization instruments:
 
Choices for Care Data Reports (includes LTSS participation by setting)

Last modified Apr 5, 2019

Virginia
Virginia's Commonwealth Coordinated Care Plus (CCC Plus) is the state's Medicaid managed care program that was launched in 2017 for people on Medicaid who are elderly, have disabilities, use 1915(c) Waiver services, or live in institutional settings. The State's first dual demonstration program for adults who were covered under both Medicare and Medicaid, Commonwealth Coordinated Care (CCC), was launched in 2014 for people on both Medicare and Medicaid. It was terminated at the end of calendar year 2017, after which participants were transitioned to the CCC Plus program.
 

Commonwealth Coordinated Care Plus

Commonwealth Coordinated Care Plus (CCC Plus) is a mandatory managed care program for Medicaid recipients who are elderly, have disabilities, receive 1915(c) Waiver services, or live in institutional settings.  People receiving 1915(c) Waiver services for developmental disabilities are included in the program, but the Waiver services themselves are carved out.  The program was phased in regionally, with the first participants enrolled in August 2017 and statewide implementation completed in January 2018.  It operates under a combined 1915(b)/(c) Waiver authority.
 

More information

 

Program documents

Contract with managed care organizations:
 
Approved Waiver applications:

 

Commonwealth Coordinated Care

This was Virginia's first dual demonstration program for adults who were covered under both Medicare and Medicaid.  Participants in certain 1915(c) Waiver programs, including those for people with intellectual and developmental disabilities (I/DD), were excluded from the program, along with residents of institutional facilities for people with I/DD, state mental hospitals, and residential treatment facilities. CCC was available only in select regions of the state. 
 

Capitation rates for CCC depend on age (working ages versus elderly), level of service need (two categories), and region of the state.  People who are meet the eligibility for nursing home level of care are assigned one rate, whether they are institutionalized (after the first 20 days) or receiving HCBS under either the Elderly Waiver or the Disability with Consumer Direction Waiver.  Everyone else, including nursing home residents during the first 20 days, is assigned a lower rate.

Program documents

Contract with managed care organizations:
 
Supplemental quality reporting requirements:
 
Memorandum of Understanding with CMS:
 
Demonstration proposal to CMS:
 
Capitation rate information:
 

General information on Managed LTSS in Virginia

 
Managed Care Quality Strategy:
 
Uniform assessment instrument:
 

Last modified Apr 3, 2019

Wisconsin

Family Care & Family Care Partnership

Wisconsin operates two main managed LTSS programs:  Family Care, which operates as a combined 1915(b) and (c) Waiver program, and Family Care Partnership ("Partnership" for short), which operates under a 1932(a) Waiver combined with a 1915(c) Waiver.  Partnership has been in operation since 1996, and Family Care since 2000.  Both are voluntary programs for non-elderly people with physical or developmental disabilities and elderly people needing LTSS.  Family Care is a managed LTSS program that does not include primary care, while Partnership includes all LTSS and healthcare services (including Medicare-paid services if the person is dually eligible).  Eligibility for the Partnership program is limited to people determined to have a "nursing home level of care" need.  Family Care has a broader functional eligibility criterion, requiring that the person need personal assistance but not be nursing-home eligible.
 

Family Care has two capitation rate tiers, a blended rate for members with a nursing home level-of-care need, regardless of residential setting, and a rate for those without a nursing home level-of-care need.  Partnership, whose participants all have a nursing home level-of-care need, has a single, blended capitation rate that applies to all members.  In both programs, managed care organizations get a one-time Relocation Incentive Payment (of $1,000 as of 2015) for each member they transition out of a nursing home.

More information

 

Program documents

Contract with managed care organizations (both programs):
 
Waiver applications:
 
Level of need screen and assessment tool:
 
Individual Service Plan template:
 
Capitation rates & actuarial reports for both programs
 
Family Care, Partnership, and PACE member survey results:
 
Family Care, Partnership, and PACE Enrollment Data
 
Medicaid Managed Care Quality Strategy:

Last modified Apr 4, 2019