Most health plans are familiar with Long-Term Services & Supports (LTSS), but they may not understand how much operational pressure LTSS can place on an organization.
A care management program that performs well for a traditional Medicaid population can struggle when members require ongoing support services, caregiver coordination, community resource integration, and long-term service planning. Provider networks that appear adequate during contracting can face capacity constraints in practice. Reporting structures that satisfy compliance requirements may leave leadership with limited visibility into service delivery issues.
None of these challenges are unique to LTSS, but LTSS populations tend to bring them to the surface quickly.
As states continue to invest in Managed Long-Term Services & Supports (MLTSS) programs and as demand for long-term care grows, health plans are taking on more responsibility for some of Medicaid’s most complex and resource-intensive populations. Medicaid remains the nation’s primary payer for long-term care services, and just a few years ago, more than 30% of $597.6 billion total federal and state Medicaid spending was dedicated to long-term care.¹
Many teams are asking, can our organization identify risk early enough? Can care managers coordinate across medical, behavioral, social, and community-based services? Can members access approved services when they need them? Can our leadership accurately measure performance? The answers to these questions determine whether an LTSS program performs as intended.
LTSS Puts Pressure on Every Operational Function
LTSS populations require a different level of coordination than many traditional Medicaid populations.
Members often have chronic conditions, disabilities, functional limitations, behavioral health needs, caregiver dependencies, and social needs that influence their health outcomes. Supporting those members requires more than medical management. It takes coordination across multiple services, providers, vendors, community organizations, and state programs so much so that LTSS touches nearly every operational area within a health plan.
Care management teams need clear processes for coordinating services across settings. Network teams need visibility into provider capacity and access challenges. Quality teams need reliable performance data. Member services teams need the knowledge and resources to support complex member situations. Technology teams need systems capable of connecting clinical, operational, and social data in ways that support action.
When one of those areas is underdeveloped, LTSS exposes the weakness, which is why organizations expanding into LTSS discover that existing programs ask more changes of them than expected.
Workforce Shortages Are Becoming a Member Access Issue
One of the biggest challenges affecting LTSS programs today is workforce availability.
Demand for long-term care services continues to grow as the population ages. At the same time, provider organizations across the country continue to face staffing shortages. According to recent reporting from Axios, approximately 70% of seniors will require some form of long-term care before the end of their lives, while long-term care providers continue to struggle with workforce shortages and caregiver availability.²
For health plans, this issue extends beyond provider contracting.
A provider may be contracted and credentialed while still lacking sufficient staff to deliver services consistently. A service authorization may be approved while members wait weeks for care to begin. A network may satisfy adequacy requirements while certain geographic areas experience persistent access challenges.
For Medicaid MCOs with significant LTSS exposure, workforce contraction intersects directly with access standards and quality metrics. Contractual network compliance will not insulate plans from real-world staffing shortages.
Organizations that rely exclusively on traditional network oversight find themselves reacting to problems after they have already affected members. Stronger LTSS programs monitor provider capacity, missed visits, staffing trends, service delays, complaints, and utilization patterns together rather than treating each as an isolated metric.
LTSS Often Requires a Different Care Management Model
One of the most common assumptions health plans make is that existing care management programs can be expanded to support LTSS populations with only modest changes.
Sometimes that works for a limited population. More often, teams find that their workflows, staffing models, reporting structures, and technology were designed around different member needs.
Clearlink encountered this challenge while supporting a regional health plan preparing to serve multiple high-need populations, including Aged Blind and Disabled (ABD), dual-eligible, LTSS, Long-Term Care (LTC), Severely Mentally Ill (SMI), Intellectual and Developmental Disabilities (IDD), and foster care populations.
The organization initially believed minor operational changes and additional subject matter expertise would be enough to support the expansion. A comprehensive assessment revealed broader needs across care management operations, reporting, technology infrastructure, training, population health strategy, and clinical workflows.
The resulting roadmap addressed gaps in areas such as risk identification, community resource integration, staff education, reporting capabilities, clinical platform readiness, and care coordination processes. By implementing those changes, the organization strengthened its readiness for complex populations and ultimately doubled membership while tripling associated revenue through the addition of several new populations, including MLTSS members.
Experiences like this are common because LTSS often requires organizations to rethink how care management functions across the enterprise rather than within a single department.
Read the Full Case Study: Prepared Population Health Management
LTSS is Becoming Increasingly Relevant to D-SNP Strategy
Health plans pursuing D-SNP growth are also finding that LTSS considerations show up during planning and implementation.
Many dual-eligible members rely on LTSS services, creating additional coordination requirements across Medicare, Medicaid, state programs, community-based organizations, providers, and vendors.
Clearlink supported a government program-focused MCO with approximately 400,000 members during the design and launch of a new D-SNP product. The engagement included Model of Care development, application support, implementation planning, vendor integration, operational readiness activities, and ongoing program support.
Part of that work involved helping the organization understand how the new D-SNP program would interact with state dual-eligible initiatives and LTSS programs while also preparing internal teams for new operational responsibilities. The project ultimately resulted in a successful D-SNP launch and a two-year Model of Care approval.
Read the Full Case Study: D-SNP Product Design & Delivery
The broader lesson applies well beyond a single organization. Product strategy and operational strategy become difficult to separate when complex populations are involved. Program performance is heavily influenced by what happens after implementation, when care managers, providers, vendors, and members begin interacting with the program every day.
Questions Worth Asking Before Taking on Additional LTSS Risk
Health plans considering LTSS expansion often benefit from stepping back and asking themselves a few practical questions.
- Can our organization identify high-risk members early and consistently?
- Can care managers coordinate medical, behavioral, functional, and social needs through documented workflows rather than individual workarounds?
- Can our leadership accurately measure service delivery, provider capacity, member outcomes, and operational performance?
- Can our current technology support the level of coordination, reporting, and visibility required for LTSS populations?
- Does our provider network have sufficient capacity to support members beyond what contractual reports indicate?
These questions aren’t supposed to serve as tough roadblocks, slowing growth. They are simply realistic, meant to help organizations see where additional investment, process improvement, or operational support may be required before growth occurs.
LTSS Rewards Operational Discipline
LTSS programs depend on thousands of small operational decisions happening correctly every day.
Care plans need to be updated. Services need to be delivered. Assessments need to be completed. Members need to be supported. Data needs to be accurate. Providers need timely communication. Leadership needs visibility into what is working and what is not.
To perform well in LTSS, an organization must understand how their operational model functions in practice, not just how it appears on paper.
That level of visibility becomes increasingly important as membership grows, workforce pressures continue, and states place greater expectations on managed care organizations serving complex populations.
Clearlink helps organizations strengthen that foundation through clinical and operational management consulting, delegated care management program design and operationalization, LTSS and D-SNP program support, Model of Care development, technology assessment, workflow design, implementation services, and ongoing operational advisory support.
For health plans taking on LTSS responsibility, operational readiness is an ongoing effort to align people, processes, technology, and strategy around some of the most complex members in healthcare.
Need some help preparing for or optimizing your LTSS program? Get in touch with our team to learn more about our capabilities and experience with health plans like yours.
Frequently Asked Questions
What are some emerging trends in long-term services and supports?
Several trends are shaping LTSS programs, including workforce shortages, continued growth in home- and community-based services, greater integration between Medicare and Medicaid programs, increasing demand for caregiver support, and expanded use of analytics to identify members who may need intensive intervention. Health plans are also paying more attention to provider capacity as a complement to traditional network adequacy monitoring.
What capabilities are most important when preparing for LTSS population growth?
Organizations should evaluate care management workflows, risk stratification processes, provider network capacity, reporting infrastructure, staff training, clinical technology platforms, and community resource integration. Plans often find that supporting LTSS populations requires stronger coordination across departments than other Medicaid populations.
How does LTSS affect D-SNP program planning and operations?
Many dual-eligible members rely on LTSS services, which means D-SNP programs often need processes that support coordination across Medicare benefits, Medicaid programs, community services, care management teams, and state requirements. Successful programs address those operational relationships early in the planning process rather than after implementation.
Sources
1. Long Term Services & Supports, Medicaid.gov
2. The Growing Long-Term Care Dilemma, Axios