Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix E. Illinois Integrated CARE Program

09/01/2013

  Element     Description/Notes  
State and Lead Agency Illinois Department of Healthcare and Family Services (HFS)
Program Integrated Care System Program
Inception May 1, 2011
Year LTSS Added Since inception.
Medicaid Authority 1915(c)
# Enrolled 39,487 (as of August 2013)
Group Enrolled Aged, Blind Disabled who are:
  • Age 19 and older.
  • Non-Medicare eligible older adults and adults with disabilities receiving Medicaid (case numbers beginning with 01, 91, 02, 92, 03, 93) including all HCBS waiver enrollees.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

MCOs are required to have a full-time QM Coordinator who shall be a licensed clinician and will be responsible for directing the activities of the QI staff in monitoring and auditing the MCO's health care delivery system to meet the state's goal of providing health care services that improve the health status and health outcomes of enrollees. The MCO shall also have a Medical Director who is responsible for managing the MCO's quality program. The Medical Director shall also attend all quarterly QA meetings.

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

The MCO shall engage in credentialing and re-credentialing of providers, monitor providers and include a plan for provider review in the QA plan. The MCO shall credential providers in accordance with NCQA credentialing standards as well as applicable HFS, state and federal requirements. Re-credentialing shall occur every 3 years.

MCOs shall perform QA evaluations of provider practices, which shall include monitoring of enrollee accessibility to ensure linguistic and physical accessibility. MCOs shall support providers in achieving accessibility.

The MCO QA plan shall include plan for provider review. The written description shall document how physicians and other health professionals will be involved in reviewing quality of care and the provision of health services and how feedback to health professionals and MCO staff regarding performance and enrollee results will be provided.

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

MCOs shall have a full-time Care Coordination and DM Program Manager who shall be a RN licensed, or other professional as approved by the state. The Care Coordination and DM Program Manager will direct all activities pertaining to Care Management and Care Coordination and monitor the utilization of enrollees' physical health and behavioral health treatments.

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

Not specific to quality.

e. CI investigation processes and associated reporting requirements.

MCOs are required to have a formal process for reporting incidents that may indicate abuse, neglect or exploitation of an enrollee. This will include training of all employees on the signs of abuse and neglect and what to do if suspected and information on the appropriate reporting agency. The MCO shall provide the state with its protocols for reporting suspected abuse and neglect at the Readiness Review.

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 establish and maintain a procedure for reviewing grievances registered by enrollees. All grievances shall be registered initially with the MCO and may later be appealed to the state. The MCO's procedures must:

  • Be submitted to the state in writing and approved in writing by the state.
  • Provide for prompt resolution.
  • Assure the participation of individuals with authority to require corrective action.

MCOs must have a Grievance Committee for reviewing Grievances registered by its enrollees and enrollees must be represented on the Grievance Committee. At a minimum, the following elements must be included in the Grievance process:

  • Informal process to handle grievances internally.
  • Formally structured grievance system compliant with federal regulations, including an expedited process.
  • Formally structured grievance committee that includes an enrollee.
  • Final decision can be appealed to the department.
  • Summary of grievances, responses and decisions submitted to the state quarterly.
  • Enrollee can appoint someone to represent them throughout the grievance process.

The MCO shall have a full-time Compliance Officer who shall oversee the MCO's compliance plan and the complaint, grievance and fair hearing process, and ensure and verify that fraud and abuse is reported in accordance with the federal guidelines.

h. Other.

None specified.

  1. LTSS Performance Measures Requirements
Several performance measures address LTSS including hospital admissions due to urinary tract infections and bacterial pneumonia, pressure ulcers and community retention rate for long-term care and HCBS enrollees.
  1. PIP Requirements
MCOs are required to conduct PIPs that are focused on health outcomes and enrollee satisfaction. The MCO must submit PIPs to the state for approval.
  1. EQRO Requirements
MCOs are required to cooperate with the process conducted by the EQRO. MCOs shall address the findings of the external review through its QA Program by developing and implementing performance improvement goals which shall be documented in the next quarterly report submitted by MCO following the EQRO's findings.
  1. Care Coordination Requirements
a. Assessment tool requirements.

MCOs are required to use DON tool to determine eligibility (LOC) for NF and HCBS waivers for individuals with disabilities, HIV/AIDS, brain injury, supportive living and the elderly.

b. Care coordinator to LTSS member ratio requirement.

Caseloads of Care Coordinators shall not exceed the following standards:

  • 50:1 High risk enrollees identified as needing intensive Care Management services.
  • 250:1 Moderate risk enrollees identified as needing supportive Care Management services.
c. Frequency and nature of LTSS member monitoring.

None specified.

d. LTSS/acute care coordination requirements.

MCO are required to establish a community-based ICT for those enrollees identified as requiring Care Management services. The ICT shall consist of an assigned Care Coordinator, community liaison, provider service representative, and have the support of the MCO's medical staff. ICT strategies will include:

  • Conducting outreach and education about the development and purposes of the enrollee Care Plan.
  • Assigning a Care Coordinator who has experience most appropriate to support enrollee.
  • Using motivational interviewing techniques.
  • Explaining alternative care options.
  • Educating enrollee and caregivers about available resources.
  • Developing an enrollee Care Plan.
  • Providing the enrollee with a copy of the enrollee Care Plan.
  • Coaching the enrollee to have constructive conversations with the enrollee's PCP.

If an enrollee is receiving medical care or treatment as an inpatient in an acute care hospital on the effective date of enrollment, the MCO is required to assume responsibility for the management of such care and shall be liable for all claims for covered services from that date. For hospital stays that would otherwise be reimbursed under the Medicaid Program on a per diem basis, the MCO's liability shall begin on the effective date of enrollment. Notwithstanding the foregoing, for hospital stays that would otherwise be reimbursed under the Medicaid Program on a DRG basis, the MCO will have no liability for the hospital stay.

e. Risk assessment and mitigation requirements.

The MCO shall have as a goal that an enrollee has an enrollee Care Plan for HCBS Waiver services that allows the enrollee to have choice while also protecting the enrollee's safety. When a situation arises that requires negotiated risk for an enrollee, the MCO will work with the enrollee to make the enrollee aware of potential risks and make appropriate referrals if safety is a concern.

All enrollees are to be stratified as low to no risk, moderate risk or high risk. The MCO is required to conduct outreach to all enrollees categorized as high risk and moderate risk to conduct a risk assessment on these enrollees.

MCOs are required to incorporate the results of the risk assessment into the enrollee Care Plan. Enrollee Care Plans that include negotiated risks shall be submitted to MCO's Medical Director for review. Negotiated risks shall not allow or create a risk for other residents in a group setting.

The MCO's goals, benchmarks and strategies for managing the care of enrollees in its traditional DM programs shall be incorporated in and included as part of the Care Management program. The MCO shall use population and individual-based tools and real-time enrollee data to identify an enrollee's risk level. These tools and data shall include, but not be limited to, the following:

  • HRQ;
  • Predictive Modeling and CORE;
  • Surveillance Data.
  1. Ombudsman (Function) Requirements
None specified.
  1. Quality-Related Financial Incentives
The state has established an incentive pool from which MCOs may earn payments based on its performance with respect to specific quality metrics. To fund the pool, each month the state withholds a portion of the MCOs capitation rate. The MCO will not be eligible to receive any incentive pool payments if it fails to meet a minimum performance standard. (There are financial sanctions if performance data, PIPs or information on improvement efforts are not submitted.)
  1. Experience of Care/ Satisfaction Feedback Requirements
None specified.
  1. LTSS Quality Review
Reporting for enrollees in NFs and enrollees receiving HCBS waiver services include:
  • Maintenance in or movement to community living.
  • Number of hospitalizations and length of hospital stay.
  • Falls resulting in hospitalizations.
  • Behavior resulting in injury to self or others.
  • Enrollee non-compliance of services.
  • Medical errors resulting in hospitalizations.
  • Occurrences of pressure ulcers, weight loss, and infections.
  1. Other
The MCO is not entitled to any enrollment until the state is satisfied that MCO is ready to provide services to enrollees in a safe and efficient manner.
  1. Other
MCOs are required to provide clinical practice guidelines and best practice standards of care for coordination of community support and services for enrollees in HCBS waivers; community reintegration and support; and long-term care residential coordination of services.
AIDS = Acquired Immunodeficiency Syndrome
CI = critical incident
CORE = Consolidated Outreach and Risk Evaluation
DM = disease management
DON = determination of need

DRG = diagnosis-related group
EQRO = external quality review organization
HCBS = home and community-based services
HFS = Illinois Department of Healthcare and Family Services
HIV = Human Immunodeficiency Virus

HRQ = Health Risk Questionnaire
ICT = Integrated Care Team
IT = information technology
LOC = level of care
LTSS = long-term services and supports

MCO = managed care organization
NF = nursing facility
PIP = performance improvement project
QA = quality assurance
QM = quality management

RN = registered nurse

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