Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix D. Hawaii Quest Expanded Access


  Element     Description/Notes  
State and Lead Agency Hawaii Department of Human Services, MED-QUEST Division
Program QUEST Expanded Access (QExA)
Inception 2009
Year LTSS Added N/A
Medicaid Authority 1115
# Enrolled 44,600 (December 2011)
Subset using LTSS: 6,830
Group Enrolled Eligible individuals who are aged, blind, or disabled.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

The MCO is required to employ the following staff:

  • Licensed Medical Director to oversee the quality of care furnished by the MCO and to ensure care is provided by qualified medical personnel. The Medical Director shall address any potential quality of care problems and direct quality activities. The Medical Director shall work closely with the State Medical Director and participate in quarterly state meetings, Provider Advisory Board meetings and any committee meetings relating to the programs when requested by the state.
  • QM coordinator/director responsible for all QI activities. This person shall be a licensed physician or RN.
  • Grievance coordinator to oversee all member grievance system activities. This person shall also be responsible for the provider complaints, grievance and appeals system. The MCO may choose to delegate this function to the provider services manager.
  • Compliance officer responsible for all fraud and abuse detection activities, including the fraud and abuse compliance plan.
b. Staffing and processes for provider monitoring and associated reporting requirements.

The MCO is required to have a Credentialing Program Coordinator.

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

The MCO is required to have a service coordination manager who is a RN and is responsible for all service coordination activities and oversees the hiring, training and work of all health plan service coordinators.

The MCO must submit a Service Coordinator Report which includes performance reports regarding new members who have met with their service coordinator, received a HFA, and had a care plan developed. The report also includes performance reports about members who requested a change in service coordinators.

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

MCOs are required to be able to receive/transmit data files to the state via software provide by the state. MCOs are required to have and IT Director or CIO, and IT Manager, and IT staff.

e. CI investigation processes and associated reporting requirements.

MCOs are required to report all cases of suspected abuse to protective units of the state per state and federal statutes. MCOs shall ensure that its network providers report all cases of suspected abuse to the state as well.

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

None specified.

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

MCOs shall have a grievance system that is consistent with the requirements of the state to include an inquiry process, a grievance process, and appeals process and provide information to members on accessing the state's administrative hearing system. The MCO shall require that members exhaust its internal grievance system prior to accessing the state's administrative hearing system.

All policies and procedures for the MCO's grievance system must be reviewed and approved by the state. The MCO shall address, log, track and trend all expressions of dissatisfaction, regardless of the degree of seriousness or regardless of whether the member or provider expressly requests filing the concern or requests remedial action. An appeal may be filed when the MCO issues a notice of action to a health plan member.

For standard resolution of an appeal, the MCO shall resolve the appeal and provide a written notice of disposition as expeditiously as the member's health condition requires but no more than 30 days from the day the MCO receives the appeal.

MCOs shall establish and maintain an expedited review process for appeals. The MCO shall resolve an expedited appeal and provide written notice to the affected parties as expeditiously as the member's health condition requires but no more than 3 business days from the time the MCO received the appeal.

MCOs shall notify the state within 24 hours if an expedited appeal has been granted or if an expedited appeal timeframe has been requested by the member. After exhausting all grievance and appeal procedures available within the MCO and the state, the member may file a request for an external review of a MCO's final determination with the State Insurance Commissioner.

MCOs are required to submit Member Grievance and Appeals Reports to the state that includes the following information:

  • Number of grievances and appeals by type.
  • Type of assistance provided.
  • Administrative disposition of the case.
  • Overturn rates.
  • Percent of grievances and appeals that did not meet timeliness requirements.
  • Ratio of grievances and appeals per 100 members.
  • Listing of unresolved appeals originally filed in previous quarters.
h. Other.

None specified.

  1. LTSS Performance Measures Requirements
The MCO shall report institutional utilization data for members, by age and gender in the format and per the specifications prescribed by the state:
  • Rate of acute hospital admissions.
  • Rate of preventable hospital admissions (e.g., pneumonia, COPD, CHF, dehydration and urinary tract infection).
  • Rate of NF admissions.
  • Members discharged from a NF.
  • Members residing in NFs.
  • Rate of chronic hospital admission.

The contract specifies the following care coordination performance measures:

  • New members who have met with their service coordinator.
  • New members received an assessment and had a care plan developed.

The MCO must use the following performance standards to monitor the success of program implementation and must improve its performance measure outcomes from year to year. The state will set and provide the MCO with the performance standards annually on the following 3 levels:

  • Minimum--Minimal expected level of performance.
  • Goal--A reachable standard for a given performance measure.
  • Benchmark--Ultimate standard to achieve.

The MCO must show demonstrable and sustained improvements toward meeting the state set performance standards. The state will require corrective action plans and may impose sanctions on the MCOs that do not meet the minimum performance standards and do not show significant improvement.

  1. PIP Requirements
Contract does not require LTSS-related PIPs.
  1. EQRO Requirements
MCOs are required to:
  • Collaborate with the EQRO to assess the quality of care and services provided to members and identify opportunities for health plan improvement.
  • Provide all requested program-related documents and data to the EQRO.
  • Submit any corrective action plan(s) that address identified issues requiring improvement, correction or resolution to the state and the EQRO.

The EQRO will perform an annual independent review of the quality outcomes, timeliness of, and access to, services provided by the MCO that includes:

  • Validation of PIPs.
  • Validation of HEDIS performance measures required by the state.
  • A review to determine the MCO's compliance with standards established by the state which requires a state quality strategy relating to access to care, structure and operations and quality assessment and improvement.

The EQRO will also perform the following optional activities:

  • Administration and reporting the results of the CAHPS® 3.OH Consumer Survey. The survey will be conducted annually, administered to an NCQA-certified sample of members enrolled in each MCO and analyzed using NCQA guidelines. The EQRO will provide an overall report of survey results to the state.
  • Administration and reporting of the results of the provider satisfaction survey. The EQRO will assist the state in developing a survey tool to gauge PCPs' and specialists' satisfaction in areas such as how providers feel about managed care, how satisfied providers are with reimbursement, and how providers perceive the impact of health plan UM on their ability to provide quality care. The EQRO will provide the state with a report of findings including the raw data broken down by island. If the health plan scores low in certain areas, the state will require that the health plan initiate corrective action plans to resolve these areas of concern. The results of the provider survey will also be made available to providers.
  1. Care Coordination Requirements
a. Assessment tool requirements.

The MCO shall use a standardized form developed by the MCO and have a process for conducting and completing the HFA. The process and HFA form shall be submitted to the state for review and approval.

b. Care coordinator to LTSS member ratio requirement.

Each service coordinator's caseload cannot exceed 1,880 hours annually (FTE in the state is 2,080 hours--1,880 hours assumes 90% productivity).

  • For non-NF LOC members, service coordinators may have up to 750 members (1:750). The assumption is that service coordinators will devote approximately 2.5 hours annually to each member in this category (1,880 hours/750 members = 2.5 hours).
  • For NF LOC members residing in the community, service coordinators may have up to 50 members (1:50). The assumption is that service coordinators will devote approximately 37.6 hours annually to each member in this category (1,880 hours/50 members = 37.6 hours).
  • For NF LOC members residing in an institutional setting, service coordinators may have up to 120 members (1:120). The assumption is that service coordinators will devote approximately 15.7 hours annually to each member in this category (1,880 hours/120 members = 15.7 hours).
  • For members choosing self-direction, service coordinators may have up to 40 members (1:40). The assumption is that service coordinators will devote approximately 47 hours annually to each member in this category (1,880 hours/40 members = 47 hours).

If a mixed caseload is assigned to a care coordinator, the following formula shall be used in determining the service coordinator's mixed caseload:

  • Number of non-NF LOC members X 2.5 hours +
  • Number of NF LOC members residing in the community X 37.6 hours +
  • Number of NF LOC members residing in an institutional setting X 15.7 hours +
  • Number of members choosing self-direction X 47 hours = 1,880 hours or less.
c. Frequency and nature of LTSS member monitoring.

None specified in main contract.

d. LTSS/acute care coordination requirements.

The MCO is responsible for coordinating the primary, acute and long-term care services for all members and ensuring the continuity of care. The MCO shall use a patient-centered, holistic, service delivery approach to coordinating member benefits across all providers and settings.

e. Risk assessment and mitigation requirements.

The MCO shall provide members with services that are appropriate to their medical and LOC needs. Upon enrollment, the MCO shall conduct a face-to-face HFA to determine the health and functional capability of each member and the appropriate strategies and services to best meet those needs. The HFA shall take into consideration the health status (including but not limited to medication management, risk for falls, history of ER visits), environment, available supports, medical history, and social history of each member.

  1. Ombudsman (Function) Requirements
The state provides and oversees the activities of the ombudsman program available to all members to assure access to care, to promote quality of care and to strive to achieve member satisfaction.
  1. Quality-Related Financial Incentives
The state has developed a program to make financial payment incentives to MCOs for meeting established performance and quality goals. The state pays a financial incentive using HEDIS measurements or measures that have been audited by a vendor selected by state. MCO may be eligible for payments if performance exceeds state benchmarks for annual HBA1C testing, biennial lipid profiles testing and biennial retinal exams.

MCOs may also be eligible for performance incentive for personal assistance services if the MCO:

  • Increases the number of members receiving personal assistance services.
  • Increases the number of members receiving HCBS per the annual thresholds.
  • Increases its HCBS provider network.
  • Does not have a waiting list.
  1. Experience of Care/ Satisfaction Feedback Requirements
None specified.
  1. LTSS Quality Review
Each year, the MCO must submit the following reports to the state in accordance to state requirements:
  • Evidence of the MCO's ability to expand capacity for personal assistance services.
  • Evidence of the MCO's ability to expand capacity for HCBS.

The MCO shall annually report the need for assistance with ADLs for all members, by age and gender, and place of residence. This data will be collected in accordance with the MDS, and will include the number of members per 1,000 needing limited assistance and number of members per 1,000 needing extensive or total assistance with mobility, transfer, dressing, eating, toilet use, personal hygiene, or bathing.

Each year, the MCO must submit a QAPIP description to the state which includes program goals, objectives, work plan, timetables for implementation and accomplishments. The report must include the previous year's QAPIP report along with UM program and evaluation reports.

The MCO must also submit annually a QAPIP Evaluation, which details the activities during the previous year, analysis of the strengths and areas of improvement, a discussion of incorporating the strengths into the MCO's practices and a corrective action for each area of improvement.

Semi-annually, the MCO must report performance measure statistics according to state requirements. On an annual basis, the MCO must report an evaluation of the performance measure activity from the previous calendar year.

The MCO must submit the following reports related to LTSS utilization:

  • Long-Term Care Services Report, which include performance measures on transfers to and from NF and community settings, acute care hospital administrations, access to ER services and those receiving supports through HCBS and institutional setting.
  • Personal Assistance Services Report, which include names of members assessed to need personal assistance services and those assessed who are receiving the service.
  • HCBS Report, which include members assessed to need HCBS and those assessed who are receiving the service.
ADL = activity of daily living
CAHPS = Consumer Assessment Health Care Providers and Systems
CHF = congestive heart failure
CI = critical incident
CIO = Chief Information Officer

COPD = chronic obstructed pulmonary disease
EQRO = external quality review organization
ER = emergency room
FTE = full-time equivalent
HCBS = home and community-based services

HEDIS = Health Effectiveness Data and Information Set
HFA = Health and Functional Assessment
IT = information technology
LOC = level of care
LTSS = long-term services and supports

MCO = managed care organization
NCQA = National Committee on Quality Assurance
NF = nursing facility
PCP = primary care provider/physician
PIP = performance improvement project

QAPIP = Quality Assessment and Performance Improvement Plan
QExA = QUEST Expanded Access
QI = quality improvement
QM = quality management
RN = registered nurse

UM = utilization management

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