Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix C. Florida Long-term CARE Community Diversion Pilot Project

09/01/2013

  Element     Description/Notes  
State and Lead Agency Florida Department of Elder Affairs
Contract covering 2012 through August 2013
Program Long-Term Care Community Diversion Pilot Project
Inception 1998
Year LTSS Added 1998
Medicaid Authority 1915(a)/(c)
# Enrolled 19,283 (as of April 2012)
Group Enrolled Frail elders age 65 and older who are eligible for nursing home care.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

MCOs shall have a designated individual with a degree in Health Information Management or equivalent program and with a CPHQ designation responsible for the MCO's QA program.

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

MCOs are required to monitor the subcontractor's performance on an ongoing basis and conduct formal reviews according to a periodic schedule established by the state consistent with industry standards or state MCO laws and regulations. The MCO shall identify deficiencies or areas for improvement. The MCO and the subcontractor must take corrective action where deficiencies or areas for improvement are found.

The MCO is required to have a credentialing and re-credentialing process with written policies and procedures, and a description of its policies and procedures for selection and retention of providers following the state's policy for credentialing and re-credentialing.

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

For enrollees in an assisted living or NF, the MCO is required to ensure coordination with the medical, nursing, or administrative staff designated by the facility to ensure that the enrollees have timely and appropriate access to the MCO's providers and to coordinate care between these providers and the facility's providers.

For those enrolled in the MCO's Medicare Advantage Plan, the MCO must have protocols to ensure that all acute care services and long-term care services are coordinated. The enrollee's case manager must coordinate with the PCP, as well as the enrollee or other appropriate person, in the development of acute and long-term care plans. The MCO must ensure that all subcontractors delivering services covered by the contract agree to cooperate with the goal of an integrated and coordinated service delivery system for the enrollee.

When enrollees elect to remain in the Medicare FFS system, the MCO must establish protocols to ensure that services are coordinated to the maximum extent feasible for these enrollees. The case manager must actively pursue coordination with the enrollee's PCP and other care providers.

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

MCOs shall maintain a health information system that collects, analyzes, integrates, and reports data so the federal requirements are met. The system must provide information on areas including but not limited to utilization, grievances and appeals, and disenrollment for other than loss of Medicaid eligibility.

e. CI investigation processes and associated reporting requirements.

MCOs are required to implement a systematic process for incident reporting and shall require all subcontractors to comply with this process. The MCO is required to notify the state within 48 hours of an occurrence of an incident that may jeopardize the health, safety and welfare of an enrollee or impair continued service delivery. Additionally, the contractor shall immediately report knowledge or reasonable suspicion of abuse, neglect, or exploitation of a child, aged person, or disabled adult to the appropriate authorities. The MCO shall maintain an incident log that shall be available for inspection by the state and shall submit an incident report to the state for every member for whom an incident has occurred. Reportable conditions include, but are not limited to:

  • Closure of subcontracted facilities due to license violations.
  • Contractor or subcontractor financial concerns/difficulties.
  • Loss or destruction of enrollee records.
  • Compromise of data integrity.
  • Fire or natural disasters.
  • Critical issues or adverse incidents that affect the health, safety, and welfare of enrollees.

In the incident log, the MCO shall include a brief summary of the problem(s) and proposed corrective action plans and timeframes for implementation within a reasonable time after the incident is reported.

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

MCOs shall contact enrollees at least once a month by telephone or face-to-face. MCOs must ensure the review of the care plan is performed through face-to-face contact with the enrollee at least every third month. The care plan review must address the adequacy and appropriateness of services and determine that services furnished are consistent with the nature and severity of the enrollee's needs.

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

The MCO shall develop, implement, and ensure that its subcontractors have established grievance procedures to process and resolve client dissatisfaction with or denial of service(s), and address complaints regarding the termination, suspension or reduction of services, as required for receipt of funds. These procedures, at a minimum, will provide for notice of the grievance procedure and an opportunity for review of the subcontractor's determination(s). The MCO shall also have a description of grievance and appeals process in the Enrollee Handbook, along with the toll-free number to submit a grievance or appeal. The MCO is also responsible for maintaining a case record which shall include documentation of the discussion of the procedures for filing complaints and grievances.

h. Other.

None specified.

  1. LTSS Performance Measures Requirements
None specified.
  1. PIP Requirements
The focus of PIPS varies dependent upon issues identified by MCO and approved by the state. MCOs perform 2 PIPs:
  • 1 PIP must be a statewide collaborative PIP coordinated by the EQRO.
  • 1 PIP must address deficiencies identified by the MCO through monitoring, performance measure results, member satisfaction surveys, or other similar means.
  • Populations selected for study under the PIP must be specific to the enrollees in the MCO.
  1. EQRO Requirements
MCOs are required to participate with the EQRO on all performance measure validation activities including a site visit and submission of requested documentation. The MCO may work with the EQRO on statewide collaborative PIPs.
  1. Care Coordination Requirements
a. Assessment tool requirements.

MCOs are responsible for long-term care planning and annual face-to-face reassessments using a state form.

b. Care coordinator to LTSS member ratio requirement.

None specified. However, MCOs must have sufficient staff to conduct daily business in a manner that provides service delivery to the enrollees.

c. Frequency and nature of LTSS member monitoring.

MCOS are required to contact enrollees at least once a month either by telephone or face-to-face. MCOs are also required to review the care plan through face-to-face contact with the enrollee at least every third month.

d. LTSS/acute care coordination requirements.

For those enrolled in the MCO's Medicare Advantage plan, the MCO must have protocols to ensure that all acute care services and long-term care services are coordinated. The enrollee's case manager must coordinate with the PCP, as well as the enrollee or other appropriate person, in the development of acute and long-term care plans. The MCO must ensure that all subcontractors, delivering services covered by the contract, agree to cooperate with the goal of an integrated and coordinated service delivery system for the enrollee.

When enrollees elect to remain in the Medicare FFS system, the MCO must establish protocols to ensure that services are coordinated to the maximum extent feasible for these enrollees. The case manager must actively pursue coordination with the enrollee's PCP and other care providers to the maximum extent feasible for enrollees in Medicare FFS.

e. Risk assessment and mitigation requirements.

None specified.

  1. Ombudsman (Function) Requirements
None specified.
  1. Quality-Related Financial Incentives
None specified.
  1. Experience of Care/ Satisfaction Feedback Requirements
The MCO shall conduct an enrollee satisfaction survey during a specified time each year. The sampling for the survey must be a statistically significant sample of members having received long-term care services during the report period.

The MCO is required to send a copy of the survey to the state for approval. The survey shall include, but is not limited to 13 CAHPS-like questions that assess care management, satisfaction with the plan, and ALF services. The MCO shall submit the enrollee satisfaction survey results to the state. The MCO shall include an attestation statement signed by an authorized representative that addresses the validity, reliability, and whether any bias was uncovered in the survey. The attestation must describe how the validity and reliability were statistically or otherwise established and must include the measures the provider took to ensure the independence of the survey and the trust of the respondent.

  1. LTSS Quality Review
The MCO is required to report LTSS expenditures by service.
ALF = assisted living facility
CAHPS = Consumer Assessment Health Care Providers and Systems
CI = critical incident
CPHQ = Certified Professional in Healthcare Quality
EQRO = external quality review organization

FFS = fee-for-service
IT = information technology
LTSS = long-term services and supports
MCO = managed care organization
NF = nursing facility

PCP = primary care provider/physician
PIP = performance improvement project
QA = quality assurance

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