Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix B. Delaware Diamond State Health Plan-plus


  Element     Description/Notes  
State and Lead Agency Delaware Department of Health and Social Services, Division of Medicaid and Medical Assistance
Program Diamond State Health Plan-Plus (DSHP-Plus)
Inception April 1, 2012
Year LTSS Added 2012 (LTSS added to DSHP)
Medicaid Authority 1115 Demonstration
# Enrolled 4,800
Group Enrolled Elderly, persons with PD, persons with HIV/AIDS, children, and Medicare-Medicaid enrollees.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

The MCO must employ QM staff with experience working with the long-term care population. The MCO must designate a QM coordinator who is either the MCO's medical director or a person who directly reports to the medical director. This individual is responsible for the:

  • Development and implementation of the quality strategy.
  • Interface and support of the EQRO.
  • Development of the MCO's annual written quality strategy (including objectives, scope, specific activities, and methodologies for continuous tracking, provide review and focus on health outcomes).
  • Monitoring of the quality of care that MCO members receive and the review of all potential quality of care problems.
  • Oversight of the development and implementation of continuous assessment and improvement of the quality of care provided to members.
  • Clinical or health service areas to be monitored.
  • Specification of quality indicators that are objective, measurable, and based on current knowledge and clinical experience for priority areas selected by the state and MCO.
  • HEDIS standard.
  • MCO's QM committee.

The MCO also must have a QM Committee that assists the coordinator in carrying out the quality strategy. The MCO must have policies and procedures that clearly define the roles, functions, and responsibilities of the QM committee and medical director. The Committee will have oversight responsibility and input on all QM activities.

b. Staffing and processes for provider monitoring and associated reporting requirements.

MCOs must have written policies and procedures which include selection and retention of providers, credentialing and re-credentialing, and non-discrimination requirements. The MCO must have written policies and procedures for determining and assuring that all providers with which it contracts are licensed by the state or meet business participation criteria and are qualified to perform their services.

The MCO also must have written policies and procedures for monitoring its providers and for disciplining providers who are found to be out-of-compliance with National Medical Practice and Credentialing Standards.

c. Staffing and processes for care coordinator monitoring and associated reporting requirements.

None specified.

d. IT requirements in support of quality monitoring and reporting.

MCOs must maintain a health information system that collects, analyzes, integrates, and reports data. The system must provide information on areas including, but not limited to, utilization, and grievances and appeals, and disenrollment for other than loss of Medicaid eligibility. The MCO must collect data on member and provider characteristics as specified by the state, and on services furnished to members through an encounter data system or other methods as specified by the state.

e. CI investigation processes and associated reporting requirements.

MCOs are required to develop and implement a CI reporting system for incidents that occur with its members related to the provision of covered services. CIs shall include:

  • Unexpected death of a member.
  • Suspected physical, mental or sexual abuse and/or neglect of a member.
  • Theft or financial exploitation of a member.
  • Severe injury sustained by a member.
  • Medication error involving a member.
  • Inappropriate/unprofessional conduct by a provider involving a member.

MCOs regularly identify, track, review and report (within 24 hours) CIs to the state. MCOs review and analyze CIs to identify and address potential and actual quality of care and/or health and safety issues. MCOs require providers involved in a CI to conduct an investigation and submit a report within the timeframe specified by the MCO. MCOs shall review provider reports and follow-up as necessary to ensure that an appropriate investigation was conducted and corrective actions were implemented within applicable timeframes. MCOs submit monthly reports to the state regarding all CIs.

f. Mechanisms for monitoring receipt of community LTSS and associated reporting requirements.

MCOs must have processes to identify utilization problems and undertake corrective action. MCOs must have policies and procedures to verify that services were provided and report findings to state.

The MCO must employ sampling methods and operational procedures to verify with its members whether services billed to the MCO by providers were actually received. The MCO must submit a report to the state detailing the results of its sampling. The MCO must collect all health care related criminal conviction information from the MCO's network providers and immediately report this information to the state. For each case of suspected fraud and abuse, following the MCO's investigation, the MCO must report to the state the following: provider's name source of the complaint, type of provider, nature of the complaint, and approximate range of dollars involved.

g. Mechanisms for handling complaints/grievances/appeals, and associated reporting requirements.

MCOs are required to establish internal grievance procedures so members (or providers acting on their behalf) may challenge the denial of coverage. MCOs must have a system in place for members that includes a grievance process, an appeal process, and access to the state‘s Fair Hearing system. The MCO must ensure that the individuals who make decisions on grievances and appeals were not involved in any previous level of review or decision-making and have the appropriate clinical expertise as determined by the state.

MCOs must establish and maintain an expedited review process for appeals when the MCO determines that taking the time for standard resolution could seriously jeopardize the member‘s life or health, or ability to attain, maintain, or regain maximum function. The MCO must address each grievance and resolve each appeal, and provide notice as expeditiously as the member's health condition requires within state established timeframes.

MCOs are required to maintain records of grievances and appeals and must review the information as part of the state quality strategy. MCOs are required to follow all state-specified grievance and appeal data requirements. MCOs must provide the state with quarterly reports documenting the number and types of grievances and appeals registered by members and providers and the status or disposition of grievances/appeals including:

  • Grievance rate by medical nature of grievance.
  • Number of provider complaints by nature of complaint and resolution.
  • Number of families or caregivers of enrolled children with special health care needs from whom MCO has received a written complaint regarding accessibility or quality of services specified in the child's care plan.
  • Number of appeals by medical nature of appeal and outcome.
  • Analysis that identifies trends and/or patterns for administrative use and review including any corrective action taken as a result of the analysis.
h. Other.

None specified.

  1. LTSS Performance Measures Requirements
None specified.
  1. PIP Requirements
PIP requirements are general in nature with no specifications on MLTSS.
  1. EQRO Requirements
The state contracts with independent, external evaluators to examine the quality of care provided by MCOs. The state also designates an additional outside review agency to conduct an evaluation of the program and its progress toward achieving program goals.

MCOs are required to cooperate with any external quality or independent assessment of its performance which has been authorized by or performed by the state. Independent assessments shall include reviews of:

  • Access to care, quality of care, cost effectiveness, and effect of case management.
  • The MCO's QA procedures, implementation of the procedures, and the quality of care provided.
  • Consumer satisfaction surveys.

MCOs must identify, collect and provide any data or medical records to be reviewed by the independent assessors as requested. The monitoring and evaluation of MCOs will be conducted through periodic review of:

  • Data and/or narrative reports describing clinical and related information on health services and outcomes of health care for the enrolled populations.
  • Evaluation of encounters.
  • On-site visits and inspection of facilities.
  • Staff and member interviews.
  • Appointment scheduling logs, ER logs, denial of services, and other areas that will indicate quality of care delivered to members.
  • Medical records review of all quality strategy procedures, reports, and recommendation and corrective actions.
  • Staff and provider qualifications.
  • Grievance procedures and resolutions.
  • Requests for transfer between PCPs within contractor's network.
  1. Care Coordination Requirements
a. Assessment tool requirements.

None specified.

b. Care coordinator to LTSS member ratio requirement.

The MCO must maintain case manager staffing ratios of:

  • 1:120 for NF members.
  • 1:60 for members receiving HCBS (own home or assisted living).
  • 1:30 for members receiving services under the MFP program.
c. Frequency and nature of LTSS member monitoring.

Case managers are responsible for ongoing monitoring of the services and placement of each member assigned to their caseload in order to assess the continued suitability and cost effectiveness of the services and placement in meeting the member's needs as well as the quality of the care delivered by the member's service providers.

Member placement and services must be reviewed on-site with the member present within the following timeframes:

  • At least every 180 days for a member in an institutional setting (this includes members receiving hospice services and those in uncertified institutional settings).
  • At least every 90 days for a member receiving HCBS.
  • At least every 90 days for a member residing in an alternative residential setting.
  • At least every 90 days for a community-based member receiving acute care services only.

Acute care service monitoring for these members may be conducted on-site, via telephone or by certified letter. However, an on-site visit with the member must be completed at least once a year. MCOs may develop standards for more frequent monitoring visits of specific types of members/placements at their discretion but may not determine members to need less frequent visits.

d. LTSS/acute care coordination requirements.

Case managers are expected to use a person-centered approach regarding the member assessment and needs taking into account covered services and other needed community resources as applicable. Case managers are expected to provide coordination across all facets of the service system in order to determine the efficient use of resources and minimize any negative impact on members and assist members to identify their independent living goals and provide them with information about local resources that may help them transition to greater self-sufficiency in the areas of housing, education and employment.

e. Risk assessment and mitigation requirements.

None specified.

  1. Ombudsman (Function) Requirements
MCOs are required to employ at least 1 member advocate to work with members and providers to facilitate the provision of benefits. The advocate is responsible for making recommendations to MCO management regarding any changes needed to improve the care provided or the manner in which the care is delivered. The person must have the authority needed to carry out these tasks. The advocate will:
  • Investigate and resolve access and cultural sensitivity issues identified by the MCO, state, providers, advocate organizations, and members.
  • Monitor MCO formal and informal grievances with the grievance personnel to look at trends or major areas of concern.
  • Coordinate with schools, community agencies and state agencies providing services to members.
  • Recommend policy and procedural changes to MCO management including those needed to ensure/improve member access to care and quality of care.
  • Function as a primary contact for member advocacy groups and work with these groups to identify and correct member access barriers.
  • Participate in local community organizations to acquire knowledge and insight regarding the special health care needs of members.
  • Analyze systems functions through meetings with staff.
  • Provide training and educational materials for MCO staff and providers to enhance their understanding of the values and practices of all cultures with which the MCOs interact.
  • Provide input to MCOs on how provider changes affect access and quality/ continuity of care, and develop plans to minimize potential problems.
  • Review all informational material to be distributed to members.
  • Assist members and authorized representatives obtain medical records.
  1. Quality-Related Financial Incentives
The state, in conjunction with the MCO, will develop a system of incentives for reaching health care outcome objectives in certain key areas to be defined by the state and MCO. These outcome objectives include childhood immunizations, prenatal care, birth outcomes, pediatric asthma, and behavioral health care. MCOs are required to submit on a periodic basis objective numerical data and/or narrative reports describing clinical and related information on health services and outcomes of health care for enrolled populations. The state, the EQRO, and the MCO will also cooperate in the collection of data in order to provide accurate reports that can be used by the state to create new millennial outcome measures for the health and wellness of all residents of the state.
  1. Experience of Care/ Satisfaction Feedback Requirements
The contract specifies that MCOs must survey their members on at least an annual basis to determine satisfaction with MCO services but does not indicate whether the survey must include satisfaction with LTSS services.
  1. LTSS Quality Review
MCOs must provide the state with utilization, QA, financial and member satisfaction/complaint data on a regular basis and provide reports on long-term care, behavioral health and children with special health care needs, including information on expenditures, enrollment, access, quality of care, modality of care, and length of stay.
AIDS = Acquired Immunodeficiency Syndrome
CI = critical incident
DSHP-Plus = Diamond State Health Plan Plus
EQRO = external quality review organization
ER = emergency room

HCBS = home and community-based services
HEDIS = Health Effectiveness Data and Information Set
HIV = Human Immunodeficiency Virus
IT = information technology
LTSS = long-term services and supports

MCO = managed care organization
MFP = Money-Follows-the-Person
MLTSS = managed long-term services and supports
NF = nursing facility
PCP = primary care provider/physician

PD = physical disability
PIP = performance improvement project
QA = quality assurance
QM = quality management

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