Element | Description/Notes |
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State and Lead Agency | Arizona Health Care Cost Containment System (AHCCCS) |
Program | Arizona Long-Term Care System (ALTCS) |
Inception | 1988-1989 |
Year LTSS Added | N/A |
Medicaid Authority | 1115 Research and Demonstration Waiver |
# Enrolled | 52,251 (May 2012) |
Group Enrolled | Elderly, physically disabled, and DD. |
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a. Staffing requirements for quality oversight/reporting.
The MCO is required to have the following key staff positions for quality oversight/reporting:
The MCO must ensure that the QM/QI Unit within the organizational structure is separate and distinct from any other units or departments (e.g., Medical Management or Case Management units). |
b. Staffing and processes for provider monitoring and associated reporting requirements.
MCOs are required to demonstrate that providers are credentialed and reviewed through the MCO's Credentialing Committee chaired by the MCO's Medical Director. The provider monitoring shall follow a documented process for provisional credentialing, initial credentialing, re-credentialing and organizational credential verification of providers who have signed contracts or participation agreements with the MCO. The MCO must submit a Credentialing Quarterly Report. |
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c. Staffing and processes for care coordinator monitoring and associated reporting requirements.
MCOs shall provide an annual Case Management Plan which outlines how all case management and administrative standards will be implemented and monitored by the MCO. The administrative standards shall include but not be limited to a description of the MCO's systematic method of monitoring its case management program. The plan shall also include an evaluation of the MCO's Case Management Plan from the prior year to include lessons learned and strategies for improvement. The MCO shall implement a systematic method of monitoring its case management program to include but not be limited to conducting quarterly case file audits and quarterly reviews of the consistency of member assessments/service authorizations (inter-rater reliability). The MCO shall compile reports of these monitoring activities to include an analysis of the data and a description of the continuous improvement strategies the MCO has taken to resolve identified issues. The MCO shall ensure adequate staffing to meet case management requirements. The MCO's case management plan shall also describe their methodology for assigning and monitoring case management caseloads. |
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d. IT requirements in support of quality monitoring and reporting.
The MCO must have a health information system that integrates member demographic data, case management information, provider information, service provision, claims submission and reimbursement and be capable of collecting, storing and producing information for the purposes of financial, medical and operational management. The MCO shall develop and maintain a HIPAA compliant claims processing and payment system capable of processing, cost avoiding and paying claims and must be adaptable to updates to meet changing policies as-needed. The MCO must include nationally recognized methodologies to correctly pay claims, able to assess and/or apply data related edits, and produce remittance advice related to payments and/or denials to providers. To record and track placement history and cost effectiveness studies, the MCO must have a CATS. MCOs are not required to enter service authorizations into the CATS. However, the MCO is expected to maintain a uniform tracking system in each member chart documenting the beginning and end date of services inclusive of renewal of services and the number of units authorized for services. |
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e. CI investigation processes and associated reporting requirements.
The MCO is required to track and trend member and provider issues which include investigation and analysis of quality of care issues, abuse, neglect and unexpected deaths. The resolution process must include:
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f. Mechanisms for monitoring receipt of community LTSS and associated reporting requirements.
None specified. |
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g. Mechanisms for handling complaints/grievances/appeals, and associated reporting requirements.
MCOs are required to have a written grievance system process for subcontractors, enrollees and non-contracted providers which define their rights regarding disputed matters with the MCO. The MCO's grievance system for enrollees includes a grievance process (procedures for addressing enrollee grievances), an appeals process, and access to the state's fair hearing process. The MCO shall also ensure that it timely provides written information to both enrollees and providers which clearly explain the grievance system requirements. The MCO will provide reports on the grievance system to the state. |
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h. Other.
None specified. |
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State has 32 Quality Standards for the contractors. LTSS-related quality measures include items such as structure and process for handling CIs both individual and systems-level; initiation of services; and, coordination of services with PCP. |
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MCOs are required to have an ongoing PIPs that focus on clinical and non-clinical areas that involve:
PIPs are mandated but MCOs may select additional projects based on opportunities for improvement identified by internal data and information. Each PIP must be completed in a reasonable time period so as to generally allow information on the success of PIPs in the aggregate to produce new information on quality of care every year. MCO must submit PIP baseline, re-measurement and final reports to the state. |
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The state contracts directly with the EQRO and submits all data to the EQRO. There is no direct coordination between the EQRO and MCOs. |
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a. Assessment tool requirements.
The MCO case manager must complete a UAT based on information from the strengths/needs assessment to determine the member's current LOC. |
b. Care coordinator to LTSS member ratio requirement.
Each case manager's caseload may not exceed a weighted value of 96 base on the following formula:
MCOs may assign a weighted value lower than those outlined. |
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c. Frequency and nature of LTSS member monitoring.
The MCO is required to initiate a SP for each member at the time of enrollment. The SP shall identify the immediate health care needs of each newly enrolled member with an action plan. The comprehensive SP must be developed within 60 calendar days from date of the initial medical service and contain all the required elements. The MCO case manager modifies and updates the SP when there is a change in the member's condition or recommended services. This will occur periodically as determined by the member, family, or provider. |
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d. LTSS/acute care coordination requirements.
MCOs must identify and facilitate coordination of care for all members during changes or transitions between MCOs, as well as changes in service areas, subcontractors, and/or health care providers. Members with special circumstances may require additional or distinctive assistance during a period of transition. Policies or protocols must be developed to address these situations. Special circumstances include members designated as having "special health care needs". If a member is referred to and approved for long-term care, the MCO must coordinate the transition with the assigned long-term care facility provider to assure that applicable protocols are followed for any special circumstances of the member, and that continuity and quality of care is maintained during and after the transition. |
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e. Risk assessment and mitigation requirements.
None specified. |
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The MCO is required to have a Dispute and Appeal Manager who will manage and adjudicate member and provider disputes arising including member grievances, appeals and requests for hearing and provider claim disputes. |
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None specified. |
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None specified. |
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The MCO is required to submit reports on member services/case management and credentialing.
The MCO's QM program shall be designed to achieve, through ongoing measurements and intervention, significant improvement sustained over time in the areas of clinical care and non-clinical care expected to have a favorable effect on health outcomes and member satisfaction. The MCO must:
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ACO = accountable care organization AHCCCS = Arizona Health Care Cost Containment System ALF = assisted living facility ALTCS = Arizona Long-Term Care System CATS = Client Assessment and Tracking System CHCQM = Certified in Health Care Quality and Management DD = developmental disability LOC = level of care PCP = primary care provider/physician SP = service plan |
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