Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix J. New Mexico Coordination of Long-term Services


  Element     Description/Notes  
State and Lead Agency New Mexico Human Services Department (HSD)
New Mexico Aging and Long-Term Services Department (ALTSD)
Program Coordination of Long-Term Services (CoLTS)
Inception 2008
Year LTSS Added N/A
Medicaid Authority Enrollment: 1915(b)
LTSS: State Plan Personal Care Option and 1915(c)
# Enrolled 39,607 (March 2012)
Group Enrolled Elderly, physically disabled and children with LTSS needs.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

The MCO must designate an individual within the company responsible for compliance with all the QM/QI requirements.

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

MCOs are required to have written policies and procedures for the credentialing process for individual practitioners including the MCO's initial credentialing of practitioners and subsequent re-credentialing, recertifying and/or re-appointment of practitioners as required by the state. MCOs must designate a credentialing committee or other peer review body to make recommendations regarding credentialing decisions. The MCO shall formally re-credential network providers at least every 3 years.

The MCO must also have written policies and procedures for the initial and ongoing assessment of all providers. The MCO must confirm that the provider:

  • Is in good standing with state and federal regulatory bodies.
  • Has been reviewed and approved by an accrediting body.

The MCO must also develop and implement standards of participation that demonstrate the provider is in compliance with provider participation requirements under federal law and regulations if the provider has not been approved by an accrediting body.

The state and the MCO shall mutually agree to a single primary source verification entity to be used by the MCO and its subcontractors in its provider credentialing process. All MCOs shall use 1 standardized credentialing form. The state shall have the right to mandate a standard credentialing application.

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

None specified.

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

MCOs are required to maintain system hardware, software, and information systems resources sufficient to provide the capacity to accept, process, maintain, and report specific information necessary to the state program administration and other contracted service arrangements, including but not limited to, data pertaining to providers, members, claims, encounters, grievance and appeals, disenrollment for other than loss of Medicaid eligibility and HEDIS and other quality measures and comply with the most current federal standards for encryption of any data that is transmitted via the Internet.

e. CI investigation processes and associated reporting requirements.

The MCO shall develop and implement policies and procedures for CI reporting to include the ability to track, analyze, and report to the state as required, those reporting indicators identified by the state, specific to physical health and/or behavioral health visits handled by the PCPs that shall enable the state to determine potential problem areas, including but not limited to, quality of care, access to care, provider payment timeliness, or service delivery issues.

The MCO must:

  • Utilize the report formats provided by the state and provide monthly analysis report findings.
  • Utilize critical indicator monitoring for early identification and interventions of quality of care and/or health and safety issues.
  • Analyze the data including the identification of any significant trends.
  • Address negative trends in the analysis and develop appropriate CQI initiatives.
  • Conduct annual provider reviews of all network providers on data collected on medication management to identify harmful practices.
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 is required to have a grievance, appeal system, fair hearing and an expedited resolution of appeals process that is responsive to concerns raised by members and meets all the state requirements in regards to notices to providers on the grievance policies to providers; reasonable accommodations to assist members in submitting a grievance; timeframes confirming receipt of a grievance, conducting the investigation and completing the resolution process; and, notice to parties affected by the decision.

The MCO must name a specific individual designated as the Medicaid Member Grievance Coordinator with the authority to administer the policies and procedures for resolution of a grievance and/or appeal, to review patterns/trends in grievances and/or appeals, and to initiate corrective action. Under certain state-specified circumstances, the MCO must continue covered services and other benefits while the appeal and fair hearing process is pending.

The MCO must maintain all grievance and appeals files in a secure, designated area and be accessible to the state upon request. The MCO must provide the state with monthly reporting of all provider and member Grievances, Appeals, and Fair Hearing using the state-specified reporting template and a monthly report of the analysis of all grievances to include the identification of any indications of trends as well as any interventions taken to address those trends.

h. Other.

None specified.

  1. LTSS Performance Measures Requirements
In collaboration with the state, the MCO implements performance measures and tracking measures of HCBS delivery and activities designed to improve coordination of services.
  1. PIP Requirements
LTSS PIPs not specified.

As part of the MCO's annual QM work plan which must be approved by the state, the MCO must specify PIPs, plans and activities consistent with federal and state laws and regulations.

  1. EQRO Requirements
The state retains the services of an EQRO and the MCO must cooperate fully with the EQRO. The EQRO will audit a statistically valid sample of the MCO's physical health and long-term care services, and decisions including authorizations, reductions, terminations and denials to determine if authorized service levels are appropriate with respect to accepted standards of clinical care. The EQRO will also audit the MCO's QM/QI program and review performance measures and PIPs, based on federal criteria.
  1. Care Coordination Requirements
a. Assessment tool requirements.

None specified.

b. Care coordinator to LTSS member ratio requirement.

None specified.

c. Frequency and nature of LTSS member monitoring.

MCOs are required to have Service Coordinators to meet face-to-face or telephonically with those individuals receiving long-term support services as frequently as appropriate to support the member's goals and to foster independence and in accordance with the service or treatment plan developed by the Service Coordinator consistent with professional standards or care and agreed to by the member. At a minimum, Service Coordinators meet face-to-face with members at least once quarterly and a telephone contact shall occur at least once monthly.

d. LTSS/acute care coordination requirements.

MCOs are required to develop and implement written policies and procedures that ensure that health and social service delivery is coordinated across providers, service systems, and varied levels of care maximizing the member's ISP goals, as well as outcomes and that ensure that all transitions of care from institutional to community-based services be proactively coordinated with all providers involved in the member's SP.

e. Risk assessment and mitigation requirements.

MCOs are required to identify actual or potential health, behavioral or personal safety risk to members during the initial and ongoing comprehensive assessment process, discuss such risks with the member and interventions to mitigate such risks. The MCO must conduct home safety evaluations for each member annually or more frequent if needed. MCO's must coordinate with the member's PCP, acute and long-term service practitioners. MCOs must also identify special risks to members transitioning from institutional to home and community-based settings.

MCO must also identify system-wide risks and aggregation of risk trends.

  1. Ombudsman (Function) Requirements
None specified.
  1. Quality-Related Financial Incentives
The state may provide incentives to the MCO that receives exceptional grading during the procurement process and for ongoing performance for QA standards, performance indicators, enrollment processing, fiscal solvency, access standards, encounter data submission, reporting requirements, Third Party Liability collections and marketing plan requirements as determined. The state determines whether the MCO has met, exceeded, or fallen below any and all such performance standards.
  1. Experience of Care/ Satisfaction Feedback Requirements
As part of the QM/QI program, the MCO must conduct at least 1 annual survey of member satisfaction with input from the Consumer Advisory Board and the state to assess member satisfaction with quality, availability, and accessibility of services including state-specific topics of at least 1 question each relating to the ability of ISHCN to participate in their SP and goals; the convenience of service locations and appointment times for members; service coordinator helpfulness getting members what they need; level of satisfaction with MCOs; satisfaction with member participation in treatment decisions; and degree to which members feels they can manage day-to-day lives.

The state specifies survey administration criteria and dissemination of the results.

  1. LTSS Quality Review
The MCO must be able to provide QI related reports for various public forums that are easily understandable to the lay person and collect, manage and report to the state, data necessary to support the QI activities.

MCOs must base management and service delivery on principles of CQI/TQM and submit annually a QM/QI work plan that includes the following:

  • Acute and long-term health and social service delivery and coordination.
  • Scope of the objectives, projects, or activities planned, timeframes and data indicators for tracking performance.
  • PIPs, plans and activities consistent with federal and state laws and regulations.
  • At least 1 member safety indicator.
  • Institute QM/QI policies and procedures that emphasize and promote wellness and prevention, DM of chronic illnesses, and complex service coordination.

The MCO must also submit an annual program evaluation of overall effectiveness to demonstrate improvements in the quality of clinical care and service to its members that includes the following:

  • Goals, objectives and structure, and that result in CQI for members.
  • Description of ongoing and completed QI activities.
  • Trending of measures to assess performance in quality of clinical care and service.
  • An analysis of whether or not there have been demonstrable improvements in the quality of clinical care and service.
  • Incorporation of findings of overall effectiveness in the development of the following year's plan.
  • Protocols for working with school age members.
  • Member and network provider satisfaction surveys and other relevant member and family/caregiver surveys.
  • DM protocols.
  • Continuity and coordination of services.
  • Tracking and trending of member and provider grievances for early identification and resolution of systems' issues and potential trends.
  • Service coordination protocols that reflect their comprehensive needs and SP priorities, including coordination and integration of home and community-based waiver services.
  • Provide quality oversight of ALFs.
  1. Other
DM Programs--The state requires MCOs to improve their ability to manage chronic illnesses/diseases through DM protocols in order to meet goals based on jointly established targets. The MCO must provide comprehensive DM for a minimum of 2 chronic diseases using strategies consistent with nationally recognized DM guidelines. The MCO must submit cumulative data-driven measurements from each of its DM programs with written analysis describing the effectiveness of its DM interventions as well as any modifications implemented to improve its DM performance. Annually, the MCO must submit to the state a DM plan, which includes a program description, the overall program goals, measurable objectives, targeted interventions and its methodology used to identify other diseases for potential DM programs. Annually, the MCO must also submit a quantitative evaluation of the efficacy of the prior year's DM program and demonstrate consistent improvement in the overall DM program goals.
  1. Other
Consumer Advisory Board--MCO's are required to have a Consumer Advisory Board according to state requirements and keep a written record of all attempts to invite and include its members in its meetings, a Board roster and minutes. The Consumer Advisory Board shall consist of an equitable representation of the MCO's members in terms of race, gender, special populations, and the state's geographic areas.
ALF = assisted living facility
ALTSD = New Mexico Aging and Long-Term Services Department
CI = critical incident
CoLTS = Coordination of Long-Term Services
CQI = continuous quality improvement

DM = disease management
EQRO = external quality review organization
HCBS = home and community-based services
HEDIS = Health Effectiveness Data and Information Set
HSD = New Mexico Human Services Department

ISHCN = individuals with special health care needs
ISP = individualized service plan
IT = information technology
LTSS = long-term services and supports
MCO = managed care organization

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

SP = service plan
TQM = total quality management

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