Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix I. Minnesota Senior CARE Plus and Minnesota Senior Health Options


  Element     Description/Notes  
State and Lead Agency Minnesota Department of Human Services
Program Minnesota Senior Care Plus (MSC+)
Minnesota Senior Health Options (MSHO)
Inception 2005 (MSC+)
1997 (MSHO)
Year LTSS Added N/A
Medicaid Authority 1915(b)/(c) (MSC+)
1915(a)/(c) (MSHO)
# Enrolled 11,995 (April 2012) (MSC+)
36,128 (April 2012) (MSHO)
Group Enrolled Elderly (MSC+).
Elderly eligible for both Medicaid and Medicare Parts A & B (MSHO).
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

None specified.

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

The MCO must submit annually a report to the state that includes a complete list of participating providers including name, specialty, and address. The MCO will provide information about the qualifications of MH and chemical dependency providers.

  • The MCO shall adopt a uniform credentialing and re-credentialing process and comply with that process consistent with state regulations and current NCQA "Standards and Guidelines for the Accreditation of Health Plans".
  • For organizational providers, including NFs, hospitals, and Medicare certified home health care agencies, the MCO shall adopt a uniform credentialing and re-credentialing process and comply with that process consistent with state regulations.
c. Staffing and processes for care coordinator monitoring and associated reporting requirements.

The MCO must provide a description of the Case Management System to include:

  • A document describing how case management is being provided for community and nursing home members by county and population group including whether it is provided through contracts with local agencies or tribes, clinic or provider care systems, community agencies, health plan staff or other arrangements or through a combination of such arrangements.
  • The most recent SNP model of care as submitted to CMS.
  • Lists and descriptions of entities providing Care Coordination and Case Management contractors, duties of such entities or subcontractors, contracting and delegation arrangements.
  • A description of Care Coordination and/or Case Management screening and assessment tools, timelines and follow-up processes.
  • A description of use of protocols for management of chronic conditions including procedures for communication with clinics and physicians.
  • A description of use of Nurse Practitioners in the care of NF residents if applicable.
  • A description of the MCO's oversight and training of subcontractors and Care Coordinators/Case Managers, qualifications and caseloads/ratios of Care Coordinators/Case Managers.
  • Changes and updated descriptions provided annually.
d. IT requirements in support of quality monitoring and reporting.

The MCO must operate an information system that supports initial and ongoing operations and QAPIP. The MCO must maintain a health information system that collects, analyzes, integrates, and reports data, and can achieve the following objectives:

  • Collect data on enrollee and provider characteristics, and on services furnished to enrollees.
  • Ensure that data received from providers is accurate and complete by:
    • Verifying the accuracy and timeliness of reported data;
    • Screening or editing the data for completeness, logic, and consistency;
    • Collecting service information in standardized formats to the extent feasible and appropriate.
  • Make all collected data available to the state and CMS upon request.
e. CI investigation processes and associated reporting requirements.

None specified.

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.

The MCO must have a Grievance System in place that includes a grievance process, an Appeal process, an expedited Appeals process and access to the state Fair Hearing and Expedited Hearing Decision system. The overall system must:

  • Assure compliance with Medicare and Medicaid requirements.
  • Preserve enrollees' access to all appropriate levels of Medicare and Medicaid appeals.
  • To the extent possible, integrate both processes to make the system easier to navigate for the MSHO enrollee.
  • MCO must maintain and make available upon request by the state its records of all Grievances, DTRs, Appeals and state Fair Hearings to include the following reports:
    • Quarterly electronic report of all oral and written Grievances;
    • Quarterly DTR of Service Notice report;
    • Quarterly electronic report of all oral and written Appeals.

The Grievance System must meet requirements of state statutes. Any proposed changes to the Grievance System must be approved by the state prior to implementation.

h. Other.

None specified.

  1. LTSS Performance Measures Requirements
None specified.
  1. PIP Requirements
Each year, the MCO is required to submit a written description of the PIP the MCO proposes to conduct to the state for review and approval. The proposal must be consistent with the CMS protocol entitled "Protocol for Use in Conducting Medicaid External Quality Review Activities, Conducting Performance Improvement Projects" and state requirements. The new PIP proposal must include steps 1-7 of the CMS protocol and must be targeted to the MCO's senior populations.

Each year, the MCO must produce an interim report for each current PIP to include any changes to the project(s) protocol steps 1-7, and steps 8 and 10 as appropriate. Upon completion of each PIP, the MCO must submit a final written report to the state for review and approval. The report must include any changes to protocol steps. Each completed project must have a separate report.

The MCO is required to work with the state on developing PIPs for seniors. PIP topics should address the full spectrum of clinical and non-clinical areas associated with the MCO and not consistently eliminate any particular subset of enrollees or topics when viewed over multiple years. The MCO is encouraged to continue participation in PIP collaborative initiatives that coordinate PIP topics and designs between MCOs. The MCO may use its Medicare QIP to meet the PIP requirements including using Medicare's measurement standards and reporting timelines. The MCO will consult with the state on the topic and interventions prior to submission to CMS. The MCO will provide the state with copies of the final QIP proposal within 15 days of submission.

The MCO shall provide the state an annual written work plan that details the MCO's proposed QA and PIPs for the year.

  1. EQRO Requirements
The MCO is required to cooperate with the EQRO in an annual independent, external review of the quality of services furnished by the MCO. Such co-operation includes:
  • Meeting with the EQRO and responding to questions.
  • Providing requested medical records and other data in the requested format.
  • Providing copies of MCO policies and procedures, and other records, reports and/or data necessary for the external review.

To avoid duplication, the state may use information collected from Medicare or private accreditation reviews in place of a Medicaid review by the state, its agent, or EQRO. The MCO may request an exemption to the EQRO requirements from the state if the MCO meets federal requirements and is approved by the state and CMS.

The state shall allow the MCO to review a final draft copy of the EQRO Annual Technical Report prior to the date of publication. The MCO shall provide the state any written comments about the report, including comments on its scientific soundness or statistical validity, within 30 days of receipt of the final draft report. The state will include a summary of the MCO's written comments in the final publication of the report and may limit the MCO's comments to the report's scientific soundness and/or statistical validity. The MCO is required to effectively address recommendations for improving the quality of health care services made by EQRO in the Annual Technical Report for obligations under the contract.

  1. Care Coordination Requirements
a. Assessment tool requirements.

Within 30 calendar days of enrollment and annually thereafter, the MCO shall make a best effort to conduct a health risk assessment of each enrollee's health needs. All assessments shall be kept in the individual enrollee health record at the MCO care system or county care coordination system. The assessment should address medical, social and environmental and MH factors including the physical, psychosocial, and functional needs of the enrollee. MCOs must integrate required Medicare assessments, LTCC assessments and any additional comprehensive assessments being conducted for enrollees to the extent possible.

b. Care coordinator to LTSS member ratio requirement.

MCOs shall establish policies and criteria for caseload ratios for care coordinators serving all enrollees. The MCO will submit these policies and procedures to the state for review. Criteria used to develop ratios will include but not be limited to:

  • Non-English speaking or need for translation.
  • Case-mix.
  • Need for high intensity acute Care Coordination.
  • MH status.
  • Travel time.
  • Lack of family or informal supports.
c. Frequency and nature of LTSS member monitoring.

For each enrollee, a care plan is implemented based on the needs assessment, the establishment of goals and objectives, the monitoring of outcomes through regular follow-up, and a process to ensure that care plans are revised as necessary. These plans must be designed to accommodate the specific cultural and linguistic needs of enrollees.

For NF residents, care coordination communication with facility staff and primary care as part of an IDT must be established to address risk areas and manage services as-needed. Routine care plan evaluations shall be conducted to support a proactive, preventive approach. More extensive evaluations may be required based on clinical needs or changes in condition.

For community enrollees, services shall be coordinated with providers based on the results of the assessment and with input from the enrollee, family members as appropriate, primary care and the care system team. Primary care for enrollees who have not had access to these services in the past must be arranged. A comprehensive reassessment shall be conducted annually or upon change of condition. Risk assessments shall be conducted annually or upon change in condition followed by a comprehensive assessment as-needed based on identified risk. A schedule for regular contact with the enrollees by the care coordinator shall be established in order to identify and monitor changes in condition.

d. LTSS/acute care coordination requirements.

The MCO must provide case management services that are designed to ensure access to, and coordinate the delivery of preventive, primary, acute, post-acute and rehabilitation services. The care coordination system must be designed to ensure communication and coordination of an enrollee's care across the Medicare and Medicaid network provider types and settings to ensure smooth transitions for enrollees who move among various settings. The system should strive to facilitate and maximize the level of enrollee self-determination and enrollee choice of services, providers and living arrangements. The care coordination system should provide each enrollee with a primary contact person who will assist the enrollee in simplifying access to services and information. The system must be designed to promote and assure service accessibility, attention to individual needs, continuity of care, comprehensive and coordinated service delivery, culturally appropriate care and fiscal and professional accountability.

e. Risk assessment and mitigation requirements.

Within 60 calendar days of enrollment and annually for all enrollees, the MCO shall conduct a risk screening or assessment of each enrollee's health needs. The screening may be conducted by phone, mail or face-to-face. The screening should address medical, social, environmental, and MH factors. A risk assessment tool may be used with follow-up assessments conducted based on level of risk. ADLs should be included in the assessment.

  1. Ombudsman (Function) Requirements
The state has established a State Office of the Ombudsman for managed care enrollees. The MCO is required to inform the enrollee of options for further assistance through Office of the Ombudsman.
  1. Quality-Related Financial Incentives
The state withholds a portion of the rates of the MCO's payments and these funds are returned to the MCO only if, in the judgment of the state performance targets are achieved. The withheld funds will be returned to the MCO for the based on the scoring system for each of the performance targets including:
  • Specific provider measures.
  • Completion of and submission to state of the Care Plan audit.
  • Timely completion of initial health risk screening or assessments.

In addition, the MCO is required to cooperate with the state to develop and implement a P4P model for chronic disease care.

The state pays the incentive payments to the MCO based on criteria established by the state. The MCOs pay the state's program administrator (private vendor) the same incentive reward payment. The program administrator then distributes the appropriate payment to the eligible MCOs based on their performance. In order to receive the annual reward, the MCO contracted clinic or medical group must have achieved optimal chronic disease care for a designated percentage of its patients, as determined by the Program Administrator. The P4P projects are limited to diabetes care and coronary/vascular disease care.

  1. Experience of Care/ Satisfaction Feedback Requirements
The state conducts an annual enrollee satisfaction survey, and if necessary, the MCO shall cooperate with the entity arranged by the state to conduct the survey. The state will consult with the MCOs on the survey tool. If the MCO or any of its contracted care systems conduct an enrollee satisfaction survey, including the Medicare CAHPS, the MCO must provide the state with a copy of the survey results in a timely manner.
  1. LTSS Quality Review
The MCO must conduct an annual QAPIP evaluation consistent with state and federal regulations, including the CMS "Quality Framework for the Elderly Waiver" and current NCQA "Standards and Guidelines for the Accreditation of Health Plans." This evaluation must review the impact and effectiveness of the MCO's QAPIP including performance standard measures and MCO's PIPs. The evaluation must also include an analysis on the impact and effectiveness of MSHO Care Coordination activities. This evaluation may be combined with the required Medicare evaluation, provided it is conducted at the Dual Eligible SNP plan level.

Any substantive changes in the Service Delivery Plan previously submitted shall be provided by the MCO to the state within 30 days of the effective date of the contract and prior to any subsequent changes made by the MCO. The state must approve all changes to the MCO's Service Delivery Plan. Each Contract Year, the MCO must provide an updated description of the Case Management System.

ADL = activity of daily living
CAHPS = Consumer Assessment Health Care Providers and Systems
CI = critical incident
CMS = Centers for Medicare and Medicaid Services
DTR = denial, termination, and reduction

EQRO = external quality review organization
IDT = interdisciplinary team
IT = information technology
LTSS = long-term services and supports
MCO = managed care organization

MH = mental health
MSC+ = Minnesota Senior Care Plus
MSHO = Minnesota Senior Health Option
NCQA = National Committee on Quality Assurance
NF = nursing facility

P4P = pay-for-performance
PIP = performance improvement project
QA = quality assurance
QAPIP = Quality Assessment and Performance Improvement Plan
QIP = Quality Improvement Project

SNP = special needs plan

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