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TRANSCRIPT
Environmental Scan of
MLTSS Quality and Participant Direction Requirements in MCO Contracts
2013 National HCBS Conference
September 10th 2013
Today’s Presenters Pam Doty Office of the Assistant
Secretary for Planning and Evaluation (ASPE)
Pat Rivard Truven Health Analytics Casey DeLuca National Resource Center for & Participant-Directed Services at Suzanne Crisp Boston College
Introduction
• States are moving from fee-for-service to managed long-term supports and services
• Change in roles for quality oversight – MCOs responsible for monitoring and reporting
• One way to understand how states are delegating these responsibilities is through an environmental scan of state - MCO contracts
HHS’s Office of the Assistant Secretary for Planning and Evaluation (ASPE)
ASPE partnered with: Truven Health Analytics to conduct a quality-focused
environmental scan of MCO contracts. National Resource Center for Participant Directed
Services at Boston College to review language that states have used in MCO contracts related to participant direction
Environmental Scan
Conducted June-August 2013 by Truven
Health Analytics 17 state contracts with MCOs for Medicaid
MLTSS programs
Seventeen States/MLTSS Programs: Arizona Arizona Long-Term Care System Delaware Diamond State Health Plan-Plus Florida Long-Term Care Community Diversion Pilot Project Hawaii QUEST Expanded Access Illinois Integrated Care Program Kansas KanCare Massachusetts Massachusetts Senior Care Options Michigan Medicaid Managed Specialty Supports and Services Minnesota Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options New Mexico Coordination of Long-Term Services New York Medicaid Advantage Plus North Carolina MH/DD/SAS Health Plan Waiver Pennsylvania Adult Community Autism Program Tennessee TennCare CHOICES Texas STAR+PLUS Washington Medicaid Integration Partnership Wisconsin Family Care
Main Sources for Identifying Key
Elements of Quality for MLTSS CMS’ Guidance to States Using 1115 Demonstration
and 1915(b) Waivers MLTSS programs (May 2013) Quality Requirements for 1915(c) Home and
Community Based Services (HCBS) Waivers: Often imbedded in 1115 Terms and Conditions Combo Waivers- 1915a/c or 1915 b/c
Medicaid Managed Care Quality Requirements (CFR 438)
Environmental Scan
Developed Data Collection Tool Based on main sources for identifying key
elements of MLTSS Quality
Approach to scan Relied on the contracts’ tables of contents Used search function using appropriate
terminology for each quality element in the scan
MCO Staffing Requirements Quality Oversight and Reporting
16 contracts included language related to MCO staffing requirements for oversight/monitoring
Wide variety of requirements Examples include: QM unit distinct from other MCO departments MCO medical director responsible for overseeing quality MCO quality committee that oversees all quality functions MCO designated key executive staff responsible for quality
improvement - must notify state if any change in these key positions
Provider and Care Coordinator Monitoring and Reporting
All 17 states include contract language related to provider monitoring Most require that MCOs engage in credentialing and re-
credentialing of providers 11 states include contract language related to oversight of
care coordinators One state requires MCOs to collect evidence to
demonstrate that care coordination is being monitored Another state requires MCOs to describe how care
coordination standards will be monitored by the MCO
IT Requirements in Support of Quality
Monitoring and Reporting All 17 states include language in their
contracts related to IT requirements 5 states require MCOs to maintain an
information system that provides data on quality areas including service utilization, and grievances and appeals
Critical Incident Reporting and Investigation
14 states require MCOs to have critical incident reporting processes
Many specify critical incidents that MCOS must incorporate into their systems
Some states require MCOs to contact the state in the event of certain critical incidents (e.g., deaths, abuse, neglect, exploitation)
One state requires MCOs to determine whether any changes in MCO/provider policies or practices might prevent occurrence of similar incidents in the future
Mechanisms for Monitoring
Receipt of LTSS Services 10 states include contract language related to
mechanisms for monitoring receipt of community LTSS services. Examples of these requirements include: Real-time Electronic Verification System -
MCO alerted to late/no receipt of services Retrospective verification of service receipt
for which a provider has billed
Mechanisms for Handling Complaints,
Grievances, Appeals, and Associated Reporting
16 states include language in their contracts related to MCO mechanisms for handling complaints, grievances, and appeals
Requirements focus on: Record keeping State reports Review/analysis of data to make corrections or
implement improvements to address findings
LTSS Performance Measures (PMs)
13 states include language related to LTSS PMs Some PMs focus on processes
• response time to respond to referrals • timeliness of care plan development • timeliness of receipt of services • process for coordination of services • process for handling critical incidents
Some PMs focus on outcomes related to: • community retention rate • rate of preventable hospital admissions • rates of nursing facility and chronic hospital admissions
Performance Improvement Projects (PIPs)
17 states require MCOs to carry out 2-3 PIPs that
focus on clinical and non-clinical areas – CFR 438 requires “an ongoing program of performance
improvement projects that focus on clinical and nonclinical areas.”
Contract language is vague - difficult to tell whether there are any LTSS-related PIP requirements
2 states clearly articulated LTSS-specific PIP requirements
External Quality Review Organization
-EQRO-
17 states include language regarding the role of an EQRO Validation of performance measure data and
PIP (CFR 438 requirement) Most states require MCOs to cooperate with
the EQRO
Care Coordination Requirements
Assessment Tools 14 states require MCOs to use either a state
assessment form or a form approved by the state to determine member needs and/or LOC eligibility
Care Coordinator /Member Ratio 6 states include contract language to establish
caseload ratios Frequency/Nature of Member Monitoring 10 states specify time requirements related to
face-to-face visits & phone contacts
LTSS-Acute Care Coordination
16 states include clauses requiring LTSS-acute
care coordination Examples include: Integrated care teams that includes all disciplines Written policies and procedures to ensure
coordination Written operational agreements with hospitals,
long-term care facilities, and drug/alcohol treatment programs to facilitate transitions of care
Risk Assessment and Mitigation
Nine states include requirements related
to risk assessment and mitigation including: Risk categories (ex. risk of
institutionalization or hospitalization) Mitigation requirements Risk agreements
Ombudsman- Like Functions
8 states reference:
• Availability of a state ombudsman program, or • Require MCOs to have ombudsman-like functions
such as a member advocates 4 states reference external ombudsman programs 1 state established a state ombudsman office for
MCO enrollees 3 states require MCOs to employ member advocates
to work with members as needed
Experience of Care/
Satisfaction Feedback 9 states include language requiring MCOs to conduct
experience of care/satisfaction surveys or focus groups • Contract language not specific enough to
determine if feedback mechanisms focus on LTSS Some states assume this responsibility or employ an
independent vendor for this purpose 2 states require focus groups in addition to surveys
Quality Reports
16 states include language related to LTSS quality reports Some states require quarterly reports and others require
annual reports Some examples of the information/data that MCOs must
report to the state include: • Critical incidents • Results of member satisfaction/ experience of care surveys • Performance data for specific performance measures • Complaint, grievance and appeal reports • Late and missed provider visit reports
Financial Incentives for Performance
Nine states include financial incentives for
performance in MCO contracts 4 states have established an incentive pool from which
MCOs may earn payments based on performance o Some withhold portion of MCOs capitation rate to fund
the pool One state has a Quality Challenge Award to reward MCOs
that demonstrate superior clinical quality, service delivery, access to care, and/or member satisfaction
One state has established awards for MCOs showing improvement over the previous fiscal year
Observations/Word of Caution
Wide diversity in quality requirements For the same quality requirement
– some very prescriptive – others left to discretion of MCO
MCO contracts may not present a full description of the quality requirements
State practices may vary to the extent to which contract quality requirements wholly represent quality practices in each state.
Review of Participant Direction in MLTSS
What is Participant Direction?
What
When Who
How
Participant controls
Essential Elements of Participant Direction
Choice, Control, & Flexibility
Information & Assistance
Financial Management
Services
Specific Quality Assurance & Improvement
Strategies
CMS Position CMS supports self-direction (SD) in both fee-for-
service and the managed care system
“States that offer SD … are expected to continue….”
“States that do not currently offer SD…should consider providing the opportunity…within MLTSS
program”
-May 2013
States Reviewed
HI
WA
OR
CA
NV
ID
MT
WY
AZ
CO
NM
TX
OK
KS
NE
SD
ND MN
IA
MO
AR
LA
MS
TN
KY
IL
WI
MI
IN
WV
AL GA
FL
SC
NC
VA
PA
DC
MD
DE
NJ
RI
MA
NH
VT
ME
OH
CT
AK
NY
Arizona Long-Term Care System
States Reviewed
HI
WA
OR
CA
NV
ID
MT
WY
AZ
CO
NM
TX
OK
KS
NE
SD
ND MN
IA
MO
AR
LA
MS
TN
KY
IL
WI
MI
IN
WV
AL GA
FL
SC
NC
VA
PA
DC
MD
DE
NJ
RI
MA
NH
VT
ME
OH
CT
AK
NY
Massachusetts Senior Care
Options (SCO)
States Reviewed
HI
WA
OR
CA
NV
ID
MT
WY
AZ
CO
NM
TX
OK
KS
NE
SD
ND MN
IA
MO
AR
LA
MS
TN
KY
IL
WI
MI
IN
WV
AL GA
FL
SC
NC
VA
PA
DC
MD
DE
NJ
RI
MA
NH
VT
ME
OH
CT
AK
NY
Coordination of Long-Term Services
(CoLTS)
States Reviewed
HI
WA
OR
CA
NV
ID
MT
WY
AZ
CO
NM
TX
OK
KS
NE
SD
ND MN
IA
MO
AR
LA
MS
TN
KY
IL
WI
MI
IN
WV
AL GA
FL
SC
NC
VA
PA
DC
MD
DE
NJ
RI
MA
NH
VT
ME
OH
CT
AK
NY
TennCare CHOICES
States Reviewed
HI
WA
OR
CA
NV
ID
MT
WY
AZ
CO
NM
TX
OK
KS
NE
SD
ND MN
IA
MO
AR
LA
MS
TN
KY
IL
WI
MI
IN
WV
AL GA
FL
SC
NC
VA
PA
DC
MD
DE
NJ
RI
MA
NH
VT
ME
OH
CT
AK
NY
STAR+PLUS
Domain Review Degree of flexibility Employer and/or Budget Authority
Available supports Information & Assistance (I&A) Financial Management Services (FMS)
Quality within the participant-directed design Reporting Benchmarks Satisfaction
General Findings Contract with multiple MCOs Include elders & adults with disabilities MCOs are required to introduce the participant-
directed option in four state contracts Offer participant-directed personal attendant
services Require person-centered practices 4 of the 5 state contracts included all the essential
elements of participant direction
Federal Authorities
3 of the 5 states use 1115 1 state uses 1915 (b)/(c) 1 state uses 1915 (a)/(c)
Employer and Budget Authority
4 of the 5 states specify employer authority in their contracts
2 states allows for a flexible individual budget 1 state allows individual budgets with restrictions Restrictions confined to employment related purchases
Information and Assistance
In 3 states, the MCOs manage I&A internally 1 state created a new function to manage the day-
to-day supports provided to participants and coordinate activity with MCO case manager and FMS
FMS 4 of the 5 states require approval of the provision
of FMS vendors 3 states delegate the selection and legal
arrangement between the MCO and FMS 1 state executes the legal agreement in the form of
a three-way contract 1 State Medicaid Agency directly contracts the
FMS 3 states specify models of FMS (Agency with
Choice and Fiscal/Employer Agent)
Quality
4 of the 5 states require the MCO to submit quality assurance and improvement plan prior to implementation
3 of the states require specific participant direction reporting requirements
Only 1 state applies specific participant direction performance indicator Establishes enrollment targets
Quality
4 of the 5 states require back-up plans specific to participation direction
1 state adds an electronic visit verification (EVV) system to verify services were delivered
2 state contracts required the administration of member satisfaction surveys
Observations
There is wide diversity in participant direction requirements
Commitment to participant direction is related to the state’s expectations and guidance in contracts
3 of the 5 states use policies and procedures for day-to-day operations rather than contractual language
Observations 1 state presents detailed information about every
element of participant direction 1 state is completely silent on participant
direction, however there is a robust program within the managed care system
Thorough contracts include language specifying the details of the four essential elements and should include language on participant engagement
QUESTIONS?