5 LTSS ombudsman market secrets

Sellers of private long-term care insurance (LTCI) may wish that private savings and private LTCI were paying for most long-term care (LTC) services in the United States — but you may also wish that the Tooth Fairy were putting diamond rings under your pillow every night. That’s not what’s happening.

Someday, private LTCI might pay for a majority of U.S. LTC services.

Today, all private insurers combined pay only about 11 percent of LTC bills, according to the Robert Wood Johnson Foundation. Residents and their families pay about 22 percent. Medicaid and other public programs pay about 67 percent.

But one point about “public programs” that observers often miss is that the government buys most of the acute health care, LTC and plan administration services it uses from outside vendors, through procurement processes that are often announced on state or local community procurement websites.

Even if a government agency, or a big, formidable nonprofit agency that might as well be a government agency, is providing the services, that outside agency might hire outside subcontractors.

If nothing else, few of the agencies are using robots, or government-owned slaves, to staff their programs. They bring in independent contractors or hire people to do the work required by the contracts.

Traditionally, Medicare paid for some home health care services. Medicaid paid for nursing home care for the (wink wink) indigent. (More accurately: For the truly needy, along with people with skilled Medicaid planners.) States set up “long-term care ombudsman” offices to help consumers handle problems with nursing homes.

In recent years, the federal government has pushed state Medicaid managers to shift from providing long-term care through nursing homes to providing “long-term services and support” (LTSS) that still pay for some nursing home care, but also pay for home care, home-based respite care for family caregivers, and adult daycare services. Because those LTSS programs are operating more like insurance companies, and often use private companies to manage people’s use of care, the Centers for Medicare & Medicaid Services (CMS) requires them to set up LTSS ombudsman programs — programs that focus on helping consumers resolve problems with the new LTSS system.

In other words: The new Medicaid managed LTSS programs need the public plan equivalent of claim advocates.

In the past year, for example, the Ohio Department of Medicaid has been talking about hiring a provider organization to help people who are starting to use the state LTSS system know where to go for help.

The Louisiana Department of Health and Hospitals has been talking about hiring an independent LTSS ombudsman for managed care for people with intellectual and developmental disabilities.

The New York State Department of Health solicited bids for a statewide managed LTSS ombudsman program.

For some ideas about what LTCI specialists should consider when thinking about ombudsman opportunities, read on.

1. An LTSS mindset

When you see a request for proposals (RFP) for an LTSS ombudsman program, rather than an LTCI customer service program, you know you’re not dealing with people who live to close sales.

The LTCI specialists who even want to consider looking at ombudsman RFPs are probably the ones who naturally enjoy learning about the care facilities and home care providers in their area and are already spending a fair amount of their time helping consumers cope with billing problems, claim problems and decisions about where to get care.

See also: Real acronyms: LTC or LTSS?