Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix G. Massachusetts Senior CARE Options

09/01/2013

  Element     Description/Notes  
State and Lead Agency Massachusetts MassHealth, Office of Long Term Care, Executive Office of Health and Human Services (EOHHS)
Program Massachusetts Senior Care Options
Inception 2004
Year LTSS Added None specified.
Medicaid Authority 1915(a)/(c)
# Enrolled 15,568 (2012)
Group Enrolled Seniors
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

The SCO is required to have the following staff designated to implement the SCO's quality program:

  • SCO Director--Oversees all activities by the SCO and its subcontractors, including but not limited to, coordinating with the SCO's QM director, medical director, geriatrician, and behavioral health clinician.
  • QM Director--An identified senior level director to oversee all QM and performance improvement activities.
  • Medical Director--A licensed medical director with geriatric expertise and experience in community and institutional long-term care who will be responsible for establishing medical protocols and practice guidelines to support the program.
  • Geriatrician--A licensed geriatrician who will be responsible for establishing and monitoring the implementation and administration of geriatric management protocols to support a geriatric model of practice.
  • Behavioral Health Clinician--A qualified behavioral health clinician, with expertise in geriatric service, who will be responsible for establishing behavioral health protocols and specialized support to PCPs and PCTs.
b. Staffing and processes for provider monitoring and associated reporting requirements.

MCOs are required to develop a written protocol that addresses credentialing, re-credentialing, certification, and performance appraisal processes for providers. The protocol must also include enrollee complaints and appeals, results of quality reviews, UM information, and enrollee surveys. The MCO must have a written protocol that includes:

  • Mechanisms for detecting under utilization and over utilization of services.
  • Resource utilization of services, including specialty and ancillary services.
  • Clinical performance measures on structure, process, and outcomes of care.
  • IDT performance, including resolution of SP disagreements.
  • Enrollee experience and perceptions of service delivery.
  • Timely access.
c. Staffing and processes for care coordinator monitoring and associated reporting requirements.

MCOs are required to have care coordinators (GSSCs) employed by ASAPs. GSSCs participate in the initial and ongoing assessments of enrollees and also arrange, coordinate, authorize and monitor LTSS. The GSSC also track the provision and functional outcomes of community long-term care services, according to the SP. The MCO is required to monitor the ASAP to ensure that the performance and qualification requirements of the GSSC are met.

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

The MCO is required to have an IT system that can adequately interface with the state's information systems.

e. CI investigation processes and associated reporting requirements.

MCOs are required to develop a protocol to address elder abuse/neglect that includes protocols for preventing, identifying, treating and reporting suspected abuse and neglect, of enrollees. The protocol should also address coordination between PCP and protective services.

The MCO is also required to deliver incident reports to the state on the next business day after the MCO receives incident notification.

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

SCOs must establish qualifications for a GSSC and provide a GSSC through a contract with 1 or more of the ASAPs designated by the state that operate in the SCOs service area. The GSSC is responsible for arranging, coordinating authorizing and monitoring the provision of appropriate community long-term care and social support services.

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

The MCO is required to have a system in place for timely acknowledgement and response of complaints and assistance to the enrollee. Enrollees have the right to file appeals regarding adverse actions taken by the MCO to deny, reduce, terminate, delay or suspend a covered service.

  • Enrollee may file an internal appeal within 60 days of the receipt of the written denial notice. Enrollee must exhaust internal appeal processes before they go to external appeal by the CMS Independent Review Entity. An enrollee may also request and external review by the State Board of Hearings.
  • On a monthly basis, the SCO must report the number and types of complaints filed by enrollees specifying how and in what timeframes they were resolved. The MCO must cooperate with the state to implement improvements based on the findings of these reports.
  • The SCO must report the number, types, and resolutions of appeals filed, including, for external appeals, whether the external review was by the CMS Independent Review Entity or by the State Board of Hearings.
h. Other.

None specified.

  1. LTSS Performance Measures Requirements
Percent of enrollees diagnosed with dementia who are receiving geriatric support services.
  1. PIP Requirements
The SCO must annually develop at least 2 specific PIPs in the Primary Care, long-term care, or behavioral health areas. The SCO must provide the state with reports on progress toward reaching established goals.
  1. EQRO Requirements
The SCO must also participate in annual external quality reviews conducted by the EQRO.
  1. Care Coordination Requirements
a. Assessment tool requirements.

Upon enrollment, and as appropriate thereafter, SCOs must perform initial and ongoing assessments using an assessment tool approved by the state. This process will identify all of an enrollee's needs. SCOs must record the results of all assessments in the Centralized Enrollee Record and communicate the results to the enrollee's provider network in a timely manner.

b. Care coordinator to LTSS member ratio requirement.

None specified.

c. Frequency and nature of LTSS member monitoring.

Upon enrollment, SCOs must perform initial and ongoing needs assessments needs at least once every 6 months and or whenever an enrollee experiences a major change. Enrollees who require complex care SCOs must perform assessments at least quarterly.

d. LTSS/acute care coordination requirements.

SCOs must ensure linkages among the PCP, the PCT, and any appropriate acute, long-term care, or behavioral health providers to keep all parties informed about utilization of services. SCOs must ensure that the PCP or the PCT integrates and coordinates services including protocols for:

  • Individualized POC.
  • Generating or receiving referrals and recording and tracking the results of referrals.
  • Providing or arranging for second opinions.
  • Sharing clinical and individualized POC information.
  • Determining conditions and circumstances under which specialty services will be provided.
  • Tracking and coordination of enrollee transfers from 1 setting to another.
  • Obtaining and sharing individual medical and care planning information among the enrollee's caregivers in the provider network.
e. Risk assessment and mitigation requirements.

SCOs must have protocols which address monitoring and risk assessment mechanisms to identify enrollees at risk of hospitalization for pneumonia, dehydration, injuries from falls, skin breakdown, loss of informal caregiver, and history of non-compliance with treatment programs. In addition, SCOs must develop monitoring and risk assessment mechanisms that assist the PCP or PCT to identify enrollees at risk of institutionalization. SCOs may contract with ASAPs to conduct risk assessment activities regarding non-medical service needs for enrollees without complex care needs.

  1. Ombudsman (Function) Requirements
SCOs must employ ESRs trained to answer enrollee inquiries and concerns and be available to enrollees to discuss and provide assistance with resolving complaints. SCOs must compile and analyze all complaints at least annually must include an examination of frequency by type of complaint and the satisfaction or dissatisfaction of enrollees with complaint resolution.

In addition, SCOs are required to provide information to enrollees regarding contacting an external Ombudsman.

  1. Quality-Related Financial Incentives
None specified.
  1. Experience of Care/ Satisfaction Feedback Requirements
The SCO must administer an annual survey to all enrollees and report the results to the state. The survey must include:
  • Quality and performance indicators including:
    • Information on enrollee satisfaction;
    • Availability, accessibility, and acceptability of services;
    • Information on health outcomes and other performance measures.
  • Information about enrollee appeals and their disposition.
  • Member experience of care.

The SCO must conduct 1 survey or focus group with each of the following groups:

  • Non-English speaking enrollees to assess their experience with the contractor's ability to accommodate their needs.
  • Persons with PD to assess their experience with the SCOs ability to meet their needs.
  • Enrollees from a minority ethnic group served by the SCO to assess their experience with the SCO's ability to provide culturally sensitive care and support to family members and caregivers of enrollees.
  • Family members and significant caregivers of enrollees to assess the SCO's ability to support family members and significant others.
  1. LTSS Quality Review
SCOs are required to produce the follow reports:
  • Clinical data including specific HEDIS measures and state specific measures regarding preventive medicine, acute and chronic disease, and enrollees diagnosed with dementia.
  • Complaints and appeals.
  • Disenrollment rate.
  • Annual report of voluntary enrollment rate and reasons.
  • Annual reports on rates of preventable hospitalizations, admissions and discharges from nursing homes facilities.
  • Community health service utilization in units and per 1,000 enrollees for services such as personal care, hospice and adult day care.
  1. Other
GSSC--SCOs must establish qualifications for a GSSC and provide a GSSC through a contract with 1 or more of the ASAPs designated by the state that operate in the SCOs service area. The GSSC is responsible for the following activities:
  • As a member of the PCT, participate in Initial and Ongoing Assessments of the health and functional status of enrollees.
  • Arrange, coordinate and authorize the provision of appropriate community long-term care and social support services.
  • Monitor the appropriate provision and functional outcomes of community long-term care services.
  • Track the appropriate provision and functional outcomes of community long-term care services.
  1. Other
SCOs must conduct an evaluation of the effectiveness of health promotion and wellness activities for enrollees on each anniversary of the start date of the contract, specifying the costs, benefits, and lessons learned. SCOs must also implement improvements based on the evaluation, including, as appropriate, continuing education programs.
  1. Other
SCOs must ensure access to 24-hour emergency services for all enrollees, whether they reside in institutions or in the community.
  1. Other
Program Initiatives--The SCO must have and comply with written protocols and a reporting system to:
  • Minimize unnecessary or inappropriate hospital admissions.
  • Ensure that enrollees who are admitted to an institution receive the Interdisciplinary Discharge Planning and implementation processes that begin at the point of admission to the hospital or NF.
  • Provide cancer screening services, and the provision of appropriate follow-up services.
  • Provide DM activities (for enrollees identified with CHF, COPD, diabetes).
  • Manage the care for enrollees identified with dementia.
  • Prevent, identify, and treat alcohol abuse.
  • Prevent and treat abuse and neglect of enrollees and report incidents and actions taken.
ASAP = aging services access points
CHF = congestive heart failure
CI = critical incident
CMS = Centers for Medicare and Medicaid Services
COPD = chronic obstructed pulmonary disease

DM = disease management
EOHHS = Massachusetts Executive Office of Health and Human Services
EQRO = external quality review organization
ESR = Enrollee Service Representative
GSSC = Geriatric Support Services Coordinator

HEDIS = Health Effectiveness Data and Information Set
IDT = interdisciplinary team
IT = information technology
LTSS = long-term services and supports
MCO = managed care organization

NF = nursing facility
PCP = primary care provider/physician
PCT = primary care team
PD = physical disability
PIP = performance improvement project

POC = plan of care
QM = quality management
SCO = senior care organization
SP = service plan
UM = utilization management

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