How a Medicaid MCO Achieved URAC Medicaid with LTSS Accreditation After Entering a State MLTSS Program — IHS Case Study

Last updated: April 2026

Organization Type: Medicaid Managed Care Organization

Program: Managed Long-Term Services and Supports (MLTSS) contract awarded by state Medicaid agency

Populations Served: Adults with physical disabilities, individuals with intellectual/developmental disabilities, and dual-eligible Medicare-Medicaid members

Engagement Duration: 16 months

Outcome: URAC Medicaid with LTSS Accreditation achieved

Key Challenge: Transitioning from standard Medicaid Health Plan operations to MLTSS-compliant infrastructure while simultaneously preparing for URAC's LTSS module — without disrupting ongoing member services or triggering state contract performance findings

Background

This Medicaid MCO had held URAC Medicaid Health Plan Accreditation for several years — a mature program with strong policy infrastructure and a history of clean surveys. When the organization was awarded an MLTSS contract by its state Medicaid agency, it entered genuinely new operational territory.

The MLTSS contract required the plan to manage long-term services and supports for three distinct populations: adults with physical disabilities receiving personal care attendant and home health services, individuals with I/DD receiving day habilitation and supported employment, and dual-eligible members in assisted living and skilled nursing facilities. None of these populations were meaningfully represented in the plan's prior Medicaid membership. The operations, provider network, care management protocols, and quality reporting infrastructure built for standard Medicaid acute care management were not designed for LTSS.

The state contract included a provision requiring the plan to obtain URAC Medicaid with LTSS Accreditation within 24 months of contract start. With 16 months remaining when the plan engaged IHS, the timeline was tight but achievable — provided the LTSS program infrastructure was built correctly from the beginning rather than retrofitted for accreditation.

The Challenge

The plan's leadership understood that its existing accreditation infrastructure was a starting point, not a foundation. URAC's LTSS module evaluates operational practices that simply did not exist in a standard Medicaid managed care organization. Key gaps identified in IHS's initial assessment:

  • No person-centered care planning infrastructure. The plan's care management system produced templated care plans designed for acute episodic care. There was no mechanism for generating individualized plans reflecting LTSS member goals, preferences, functional status, and community integration priorities — and no documentation audit trail that would satisfy URAC's LTSS module file review requirements.
  • Care coordination siloed by service type. Medical care management, behavioral health management, and LTSS service authorization operated in separate departments with no documented integration mechanism. URAC's LTSS standards require demonstrated coordination across all service types for each LTSS member — not parallel management tracks.
  • LTSS provider network built without URAC standards in view. The plan had credentialed and contracted personal care attendant agencies, adult day programs, and home health providers to meet state minimum network requirements. The network adequacy methodology — access standards, time-distance criteria, monitoring processes — had not been adapted for LTSS provider types. URAC's network management standards require documented methodology specific to each network segment, including LTSS.
  • No HCBS settings compliance documentation. Federal HCBS settings requirements under the ACA's Final Rule require that plans contracting with home- and community-based service providers ensure those settings meet community integration standards. The plan had not conducted or documented required HCBS settings assessments for any of its LTSS provider settings.
  • Grievance and appeals process not adapted for LTSS. The plan's existing grievance and appeals process was designed for clinical coverage disputes. LTSS members face distinct dispute types — service hour reductions, personal care attendant terminations, facility transition decisions — that require different processes, different documentation, and different resolution timelines. The existing process would not satisfy URAC's LTSS-specific requirements.
  • Quality reporting infrastructure measured nothing LTSS-specific. The plan reported HEDIS measures relevant to its standard Medicaid population. It had no infrastructure for tracking CMS MLTSS quality measures — falls risk screening rates, assessment and care planning compliance, successful transitions from long-term facility stays, or community integration rates. URAC's LTSS module requires quality measurement aligned with MLTSS outcomes, not just standard Medicaid HEDIS measures.

The plan had 16 months to the contractual accreditation deadline. URAC's review process requires a sustained operational compliance period — policies cannot be drafted and immediately submitted as evidence of compliant practice. Every gap identified above required remediation with sufficient lead time to generate look-back evidence before the application submission date.

The IHS Approach

IHS structured the engagement in four phases, sequenced to the operational lead time required by each gap category. The non-negotiable constraint throughout was the look-back period: evidence of compliant LTSS operations had to be generating before the application window — not assembled in the weeks before submission.

Phase 1: Standard-by-Standard Gap Analysis (Months 1–2)

IHS conducted a standard-by-standard review of the plan's current operations against both the core URAC Medicaid Health Plan standards and the LTSS module requirements. Because the plan had prior URAC accreditation, the core standards review was focused on verifying continued compliance and identifying any drift from accreditation-cycle documentation — a routine finding in organizations that have held accreditation for several years without active maintenance.

The LTSS module review was more intensive. IHS mapped each LTSS standard domain to existing operational infrastructure, identified what was absent entirely versus what existed in a non-compliant form, and categorized each gap by remediation timeline. Gaps requiring new technology or workflow design — person-centered care planning infrastructure, LTSS quality reporting — were flagged as Month 1 priorities. Gaps requiring policy development and training — HCBS settings compliance, LTSS grievance and appeals — were categorized for Month 2–3 completion. Gaps requiring sustained operational practice before evidence generation — cross-service care coordination documentation, LTSS network adequacy monitoring — were structured for Months 3–10, with monitoring built in.

The gap analysis produced a remediation calendar mapped to the 16-month deadline, identifying the latest date by which each gap category had to be remediated to generate sufficient look-back evidence before the application submission window.

Phase 2: LTSS Program Infrastructure Development (Months 2–8)

IHS provided policy and procedure templates for all LTSS module standard areas. The plan's clinical, compliance, and operations teams adapted these to their specific state contract requirements, population mix, and existing system infrastructure. IHS reviewed all finalized documentation before implementation.

Key deliverables developed in this phase:

  • Person-centered care planning policy and procedure — defining the individualization requirements, member participation documentation, functional assessment integration, goal-setting process, and plan review frequency for each LTSS population segment
  • LTSS care coordination protocol — documenting the integration mechanism between medical care management, behavioral health, and LTSS service coordination, including shared care plan access, cross-service communication requirements, and escalation pathways
  • HCBS settings compliance procedure — defining the assessment methodology, documentation requirements, and remediation process for LTSS provider settings that do not meet federal community integration standards
  • LTSS network adequacy methodology — time-distance standards, access monitoring processes, and gap analysis procedures for each LTSS provider type in the plan's network
  • LTSS grievance and appeals policy — adapted processes for service hour reduction disputes, personal care attendant termination appeals, and transition decision grievances, with documentation requirements and resolution timelines
  • LTSS quality measurement framework — defining the metrics, data sources, reporting frequency, and quality improvement process for CMS MLTSS quality measures relevant to the plan's enrolled populations

Policy development ran in parallel with operational implementation. Policies that were finalized but not yet operationally implemented had no evidentiary value for the look-back review. IHS tracked implementation dates for each policy and built the remediation calendar around confirmed go-live dates rather than policy approval dates.

Phase 3: Mock Review (Month 12)

At month 12, IHS conducted a structured mock review simulating URAC's documentation review and validation process for the LTSS module. The mock review audited:

  • A sample of care management files for LTSS-specific documentation — person-centered care plan individualization, cross-service coordination notes, functional assessment integration, and goal documentation
  • HCBS settings assessment documentation for a sample of LTSS provider settings
  • Network adequacy monitoring records for each LTSS provider type
  • Grievance and appeals case files for LTSS-specific dispute types
  • Quality reporting documentation demonstrating active MLTSS measure tracking

The mock review identified three categories of findings. First: person-centered care plans for the I/DD population were individualized in content but lacked consistent documentation of the member's participation in the planning process itself — a specific URAC LTSS standard requirement. Second: HCBS settings assessments had been completed for home health and personal care settings but had not been initiated for supported employment settings. Third: the LTSS quality reporting framework was tracking the correct metrics but reporting at a quarterly frequency; the plan's quality committee meeting minutes did not demonstrate active review and action on LTSS metrics between reporting cycles.

All three findings were remediable within the remaining four months before application submission. IHS provided specific corrective action guidance for each.

Phase 4: Application, Validation Review, and Accreditation Decision (Months 13–16)

IHS prepared the URAC application, organized evidence uploads across both the core Medicaid standards and the LTSS module, and supported the plan's team through the documentation review phase. The updated URAC program's 50%-plus reduction in document upload requirements streamlined this phase compared to prior versions of the program.

URAC issued two Requests for Information during the documentation review — both related to the LTSS module. The first sought additional documentation of the member participation process in care planning for the dual-eligible population. The second requested clarification on how the plan's LTSS network adequacy methodology accounted for geographic variation in LTSS provider density in rural areas of the service area. IHS drafted both responses with supporting documentation within the required response windows.

The plan achieved URAC Medicaid with LTSS Accreditation at month 16 — within the state contract deadline with two months to spare.

Outcomes

  • URAC Medicaid with LTSS Accreditation achieved within the state contract deadline. The 16-month engagement timeline, structured around the look-back period constraints, produced accreditation two months ahead of the contractual requirement.
  • LTSS program infrastructure built to sustain compliance through the accreditation cycle. Because the operational infrastructure was built to URAC standards from the outset — rather than retrofitted for the survey — the plan entered its accreditation cycle with compliant operations rather than documentation assembled to pass a one-time review.
  • Zero core standards deficiencies. The plan's prior URAC accreditation history and the Phase 1 core standards review prevented any drift into non-compliance. The URAC survey found no deficiencies in the core Medicaid Health Plan standard domains.
  • Two LTSS module RFIs resolved without conditional findings. Both RFIs were resolved within the response window with documentation that fully addressed the reviewers' concerns. Neither resulted in conditional findings or required a corrective action plan.
  • State contract retention secured. Accreditation within the contractual deadline removed a material contract compliance risk that had been flagged at the plan's board level since MLTSS contract award.

IHS Perspective

The challenge this organization faced is increasingly common as state MLTSS programs expand. Plans that have held URAC Medicaid Health Plan Accreditation for years — and know how to operate within that framework — enter MLTSS contracts believing their accreditation infrastructure gives them a head start on the LTSS program. It gives them a foundation for the core standards. It gives them almost nothing for the LTSS module.

The LTSS module evaluates a genuinely different kind of care management. Person-centered planning for an adult with I/DD who wants to live independently in the community is structurally different from acute care management for a Medicaid member with diabetes. Network adequacy for personal care attendant agencies in rural counties is structurally different from physician network adequacy analysis. HCBS settings compliance is a federal regulatory framework that most health plan compliance teams have never worked with. Organizations that try to apply standard Medicaid accreditation frameworks to these requirements consistently generate the same gaps: templated care plans, siloed coordination, missing LTSS network methodology, undocumented HCBS settings assessments.

IHS approaches URAC Medicaid with LTSS Accreditation engagements by building the LTSS program infrastructure correctly first — then documenting it for accreditation. The reverse approach, building documentation for a survey that doesn't reflect actual operations, produces accreditation without sustainability. URAC's multi-year accreditation cycle means organizations that take this shortcut face a worse problem at renewal than they faced at initial accreditation.

Thomas G. Goddard, JD, PhD — former Chief Operating Officer and General Counsel of URAC — leads all IHS URAC accreditation engagements. That experience shapes how IHS reads URAC standards: not as a compliance checklist, but as a description of what a well-run MLTSS plan actually looks like operationally.

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