Core Skills

Program Management

MLTSS program management is especially challenging given that the populations and services included within a MLTSS program may span multiple state government units. One person - the program manager - should have accountability for program operations and the authority to take independent or collective action when needed.   It is important to consider the key roles that a program manager may take in your program while you are making your hiring decision. The following are a few key attributes you should look for in a program manager:

• The program manager should have the ability to maintain an ongoing relationship with CMS for program design, implementation and monitoring.
  
  
• The program manager should have a critical understanding of the financial, contractual, and regulatory environment governing the MLTSS program as well as its relationship to other Medicaid, state, and federal policy, including Medicare. 
  
  
• A program manager should be able to advocate for resources and policy changes to improve program operations and assure compliance with applicable state and federal requirements. 
  
  
• The program manager should be a knowledgeable spokesperson with staff, other state program areas, and state leadership. 
  
  
• This position also should have a credible presence with external stakeholders, including CMS, program vendors, consumers, advocates, and state legislators.

Contract Management

The contract is the central document articulating what a state is purchasing from its MLTSS contractor(s) and the terms under which its performance will be evaluated.  The MLTSS contract is particularly complex in that it defines the relationship among entities that may not be accustomed to working together (e.g., hospitals, nursing facilities, HCBS, social services).  The development and negotiation of a contract combines legal, financial, policy, and program expertise.  Ongoing contract management requires both a focus on specific contract standards, reporting requirements, and a systems perspective on how contract components intersect and support one another when working as intended.  The following are a few key attributes you should look for in a contract manager:

• Contract managers should be able to distinguish isolated issues in need of easy remedy from violations suggesting more systemic performance problems.
  
  
• MLTSS states stress the value of contract managers who can work collaboratively with other units of state government, such as licensure, whose data often provide a fuller picture of how a vendor may be performing.
  
  
• Contract managers should be well-organized, well-versed in the terms of the contract, able to use and interpret data, and able to effectively communicate with vendors and program staff. 
  

Member Relations

Member relations includes the enrollment and member services functions. These functions are typically carried out by the contractor, but must be overseen at the state level by someone who is well grounded in program eligibility requirements, member rights and responsibilities and effective communication with beneficiaries through the use of plain language and other methods.  States stress the intensive nature of this function and the value of a hands-on manager who understands the cultural diversity of the service population and ways to engage community based organizations in building awareness and confidence in a new MLTSS program.  The person directing member relations at the state level should develop standardized protocols and training to ensure a uniform enrollment process at the local level, as well as effective mechanisms for soliciting, documenting, referring, and resolving member concerns and complaints. 

Provider Relations

Provider relations plays a very critical role in the early development of a MLTSS program in ensuring that there is an adequate network of qualified providers to deliver the range of LTSS covered.  While a state’s managed care vendor bears the ultimate responsibility for network adequacy, provider relations should serve an important “broker” role in recruiting the initial MLTSS provider network and helping to develop resources where gaps occur.  The provider relations position in some states also is responsible for credentialing MLTSS service providers that are not otherwise subject to state licensing requirements (e.g., direct care workers). 

Financial & Analytic

Depending on the federal waiver authority you choose, there also can be significant reporting of program financial and operational data required by CMS.  Most states contract for the specialized actuarial expertise required to establish rates for their MLTSS programs and rely on state licensing and/or insurance departments to oversee the financial performance of a vendor. States must develop specifications for collecting individual person-level encounter data for services included within MLTSS, including the design of systems for conducting quality control of submitted data and the routine analysis of that data. States with MLTSS programs stress the importance of having in-house capacity to track and trend service use and cost patterns for specific MLTSS product lines. They also stress that states with MLTSS programs underway should understand and act upon financial reports submitted by the MLTSS contractor.

Quality Management

Expertise is needed to design systems for detecting individual and system quality problems so that appropriate and timely action can be taken.  Early in the design of your MLTSS program, you will need to have expertise in quality management in order to identify the indicators against which you will monitor quality, which includes determining the sources of data that will be used to monitor performance and the benchmarks against which to compare your quality indicators.  Special skills are required for managing the quality of MLTSS programs given that the standard of care is not always clearly defined and poor outcomes often reflect cross-system, not individual provider failures.  These unique aspects of MLTSS programs suggest the importance of quality managers who:

• Understand the clinical complexity of care processes and the social determinants that often influence member outcomes. 
  
  
• Have strong analytical skills. There is also a strong analytic component to quality management in organizing, combining and stratifying data to assess quality by service, provider, and groups of members (e.g., those with similar clinical conditions such as diabetes) so that effective improvement interventions can be designed. 
  
  
• Understand the federal quality requirements that stem from the authority or combination of federal authorities used to implement the program.

 

 

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