Provider Networks - Key Considerations

Network Development

Establishment of an MLTSS program will not solve service access issues related to a lack of providers, at least in the short term. MLTSS may serve as a tool to improve quality and target high-performing providers by establishing network development benchmarks in plan contracts. The provider network established by the MLTSS contractor must provide the long-term services and supports that are included in the MLTSS program’s covered services. The network of a traditional managed care entity includes primary and acute care providers but may not include LTSS, so managed care entities may need to develop their network to provide the LTSS covered services. Depending on the covered services in the program, the providers that managed care contractors will most likely need to add to their network for LTSS are:

Personal assistance service providers
Homemaker/chore service providers
Supported and shared living providers
Family support
Respite
Fiscal intermediaries for consumer-directed services
Adult day care centers
Residential service providers including adult foster care providers
Meals support providers
Employment support providers
Other LTSS providers that do not intersect with acute care providers

Network Adequacy

One particularly difficult requirement in developing any Medicaid managed care provider network is ensuring network adequacy. This is especially true in LTSS since managed care contractors may not currently have LTSS providers in their network. The network must include providers able to meet the beneficiaries' needs. Network adequacy is determined by looking at many factors, including whether there are adequate numbers of providers; provider offices have adequate and appropriate staffing; and providers have reasonable hours of operation, provide appropriate language access, and are within an appropriate geographic distance from consumers. To safeguard against situations when the provider network can not accommodate beneficiaries' needs due to capacity constraints, consider including provisions in your managed care contracts that allow beneficiaries to access out-of-network providers.

Provider Qualifications

As required in all Medicaid managed care, the state is expected to ensure adequate qualifications and credentials of all service providers. For LTSS, the state should establish the minimum provider qualifications for providing direct beneficiary services, for example, setting expectations for an “RN” for skilled nursing providers, an “LPN” as the minimum standard for home care services, or a BS/BA in Social Work or equivalent work experience to qualify to be a case manager or care coordinator.

It may not be appropriate to require specific credentials for some support services, such as transportation and meal providers. In these situations, the MLTSS contractor should rely on other methods, such as past performance considerations, references, licensure, etc., to provide assurances of the provider’s ability to deliver services to your target population.

Provider Training

The state may want to require specific training to address major goals, areas of concern, and/or target populations included in your MLTSS program. For example:

Florida requires an annual training for all social workers on issues related to frail elders, member abuse, exploitation and neglect, and Alzheimer’s disease and related disorders.
In Texas, the MLTSS contractor is required to train service providers on requirements of the contract, the special needs of the beneficiaries, covered services and provider responsibility for providing these services, inpatient hospital services, processes for making referrals and coordinating non-MLTSS covered services, quality assurance and performance improvement plans, and program policies and procedures.

These trainings should be completed at appropriate intervals and serve to ensure uniformity in knowledge about the selected topic areas across the network providers.

Integration with Medicare