States Grapple with the ACA’s Intellectual & Developmental Disabilities Provisions
When the Affordable Care Act (ACA) was passed, it included several provisions to address the healthcare needs of the 4.5 million Americans with intellectual and developmental disabilities (I/DD). In recent years, many states have begun transitioning to Medicaid managed care models in an effort to improve access to and coordination with community-based services for vulnerable populations, particularly for persons with I/DD. Yet questions linger for members of the I/DD community and their caregivers around how the range of both acute and long-term care services will be delivered successfully under these models, and how the ACA’s provisions will support the I/DD community in this transition.
Last month, the Alliance for Health Reform hosted a briefing at the U.S. Senate on “Intellectual and Developmental Disabilities in the ACA Era,” to outline strategies and examine resources for effective enrollment of people with disabilities into managed care plans. The briefing featured experts from the Centers for Medicare and Medicaid Services (CMS), the Autistic Self Advocacy Network, and KanCare. This is a critical issue for National Council members serving individuals with I/DD, particularly in states transitioning to these new models of care.
Why is there concern from the I/DD community about managed care? Many Americans with I/DD have traditionally received care through Medicaid fee-for-service models. Given that Medicaid finances more than 70% of the wide-range of services frequently accessed by individuals with I/DD – including those with co-occurring conditions – some members of the I/DD community worry Medicaid managed care models will not fully address the varying needs of this population, from long-term services to acute care. More specifically, the biggest concerns center around continuity of services, and how much experience managed care organizations have working with I/DD populations.
Why do states think transition to managed care will be beneficial? States adopting Medicaid managed-care models anticipate these new service-delivery models will lower costs and improve the quality of care. Individuals with I/DD often require high rates of care coordination. In an effort to support these needs, managed-care models provide states with an opportunity to move away from institutional-based care to community-based care with coordinated wrap-around services.
How do the ACA provisions protect services for people with I/DD? The ACA allows states to waive traditional Medicaid requirements. For example, states may provide services to individuals who would not otherwise meet Medicaid eligibility rules, cover non-Medicaid services, and adapt programs to the special needs of a particular geographic area or group of recipients. The ACA enhanced the 1915(i) waiver to enable states to target Home and Community-Based Services (HCBS) to particular groups of people and ensures the quality of these services. This waiver allows people with chronic conditions increased access to day treatment, psychosocial rehabilitation services, clinical services, and other partial hospitalization services. Other important waivers include 1915(k), 1915(b) and 1115 demonstrations for managed care. CMS even offers states specialized technical assistance around managed care.
The Alliance’s briefing featured a number of helpful resources for policy makers and community health organizations considering how transition to long-term managed care models will work. In particular:
- The National Council on Disability released the “Guiding Principles: Successfully Enrolling People with Disabilities in Managed Care Plans” for stakeholders working with state Medicaid offices in the development of Medicaid managed care plans.
- The Center for Health Care Strategies, Inc. provides information on the Medicaid waivers listed above in their policy brief “Structuring New Service Delivery Models for Individuals with Intellectual and Developmental Disabilities.”
- Medicaid.gov also makes information about long-term services and Medicaid available on their website, “Medicaid Managed Long Term Services and Support (MLTSS).”