Managed care carve-out for certain long-term care clients narrowed, advanced

A bill that would change the reimbursement structure for skilled nursing services provided to certain long-term care Medicaid recipients in Nebraska was narrowed and given first-round approval March 25.

LB1091, as introduced by Lincoln Sen. Eliot Bostar, would require the state Department of Health and Human Services to provide a carve-out from Nebraska’s Medicaid managed care program for services and supports for long-term care clients with special needs.

The measure would require those services instead to be administered and reimbursed through a Medicaid fee-for-service or other delivery system authorized under state or federal law. It also would prohibit a skilled nursing facility from being required to enroll in an MCO as a condition of eligibility to provide such services.

The department would be required to amend Medicaid managed care contracts, including revisions to enrollment processes, no later than six months after the bill’s effective date.

Bostar said the measure would align special needs long-term care services with the current reimbursement structure for other services that are funded and managed through a fee-for-service model. He said the change would impact fewer than 150 Nebraska Medicaid beneficiaries.

“This is simple legislation meant to deliver the [highest] quality of care to the most vulnerable … long-term care clients in the state,” Bostar said.

A Health and Human Services Committee amendment, adopted 46-0, would change the department’s rule-making obligation under the bill to discretionary rather than mandatory.

It also would remove a requirement that DHHS implement the bill’s provision in a way that would not increase state General Fund expenditures above the projected costs that would have been incurred for such individuals if services were provided through the Medicaid managed care program.

Bostar said the amendment would provide “budget neutrality” and allow the department to continue providing services outlined in current regulations for special needs long-term care clients.

Gering Sen. Brian Hardin, chairperson of the committee, said the proposal seeks to ensure that vulnerable long-term care patients in the state receive consistent, specialized care from their providers.

He said the current method of coverage for long-term clients with special needs disrupts care, destabilizes providers and subjects clients to a service delivery model that does not work well for people with intensive, ongoing medical needs.

Sen. Jason Prokop of Lincoln also supported LB1091 and the committee amendment. He noted that long-term care clients with special needs — such as those with traumatic brain injuries, spinal cord injuries or other neurological conditions — often require highly specialized care and complex services that do not fit neatly into a traditional managed care system.

Since the state’s transition to managed care in 2017, Prokop said, providers have struggled to continue providing services to long-term care clients with special needs due to increased MCO denials for admissions and continuation of medically necessary care.

“When the right care is provided at the right time, outcomes improve and long-term costs decrease,” Prokop said. “[Returning] this narrow and highly specialized population to the fee-for-service structure that already exists within Medicaid … restores a system that better serves medically complex Nebraskans.”

LB1091 advanced from general file on a vote of 46-0.