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?