Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix K. New York Medicaid Advantage Plus

09/01/2013

  Element     Description/Notes  
State and Lead Agency New York State Department of Health (SDOH), Division of Long-Term Care
Program Medicaid Advantage Plus (MAP)
Inception 2006
Year LTSS Added N/A
Medicaid Authority 1915(a)
# Enrolled 1,875 (April 2012)
Group Enrolled Elderly and physically disabled.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

The MCO must designate a compliance officer and establish a compliance committee to:

  • Monitor the plan reporting obligations and ensure that the required reports are accurate and submitted in a timely manner.
  • Develop written policies, procedures and standards of conduct that articulate the plan commitment to adhere to all applicable federal and state standards.
  • Conduct appropriate staff training activities in an atmosphere of open communication.
  • Establish provisions for internal monitoring and auditing.
  • Have provisions for prompt responses to detected offenses with provisions for corrective action initiatives where appropriate.

The MCO must establish a review committee(s) to:

  • Evaluate data collected pertaining to quality indicators, performance standards, and client satisfaction.
  • Make recommendations to the board regarding the process and outcomes of the QA and performance improvement program.
  • Provide input related to processes to evaluate ethical decision-making including end-of-life issues.

Policies and procedures of the review committee should:

  • Define qualifications of individuals participating on the committee(s).
  • Include a method for identifying, selecting and reviewing data and information to be used in the QA and performance improvement program.
  • Integrate the findings of the grievance and appeals process.
  • Define a process for recommending appropriate action to resolve problems identified as part of QA and improvement activities including:
    • Providing feedback to appropriate staff and subcontractors for monitoring effectiveness of corrective actions taken, for reporting QA/PI findings to the board on at least an annual basis.
    • Incorporating review of the care delivery process to include appropriate clinical professionals and paraprofessionals as well as non-clinical staff as appropriate.
b. Staffing and processes for provider monitoring and associated reporting requirements.

All Provider Agreements entered into by the MCO to provide services shall contain provisions specifying:

  • That the credentials of affiliated professionals or other health care providers will be reviewed directly by the MCO or the credentialing process of the provider will be reviewed and approved by the MCO and the MCO must audit the credentialing process on an ongoing basis.
  • How the provider shall participate in the MCO's QA, service authorization and grievance and appeals processes, and the monitoring and evaluation of the MCO's plan.
c. Staffing and processes for care coordinator monitoring and associated reporting requirements.

None specified.

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

The MCO must maintain a health information system that collects, analyzes, integrates and reports data. The system must be sufficient to provide the data necessary to comply with the requirements of the contract. The MCO must take steps to ensure that data entered into the system, particularly that received from providers is accurate and complete. The MCO must make information available to CMS and the state.

e. CI investigation processes and associated reporting requirements.

None specified.

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

The MCO is required to meet the following standards related to access, availability and continuity of service including, but not limited to:

  • Timeliness of receipt of covered services.
  • Quality indicators that are objective, measurable and related to the entire range of services provided by the MCO and which focus on potential clinical problem areas (high volume service, high risk diagnoses or adverse outcomes).

The methodology should assure that all care settings (e.g., day center, nursing home and in-home settings) will be included in the scope of the QA and performance improvement program.

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

The MCO must have a comprehensive grievance system in place that includes a grievance process, access to a fair hearing when the MCO makes a final adverse determination about an action it has taken, an external appeal process, an action appeal process and an expedited action appeals process. The MCO must also have a complaint process and complaint appeals process. The overall system must:

  • Establish, maintain and comply with written procedures and a comprehensive grievance system for:
    • Services that are a Medicare only benefit;
    • Services that are covered under both Medicare and Medicaid.
  • 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.

The MCO must report the following with regard to its grievance system:

  • Quarterly summary of all complaints and action appeals.
  • Quarterly report on the total number of complaints and action appeals that have been unresolved for more than 45 days.
  • Quarterly summary of all grievance and appeals received.
  • Quarterly report on the total number of grievance or appeals that have been unresolved for more than 30 days.
h. Other.

None specified.

  1. LTSS Performance Measures Requirements
Standards for access, availability and continuity of service including but not limited to:
  • Length of time to respond to requests for referrals.
  • Timeliness of receipt of covered services.
  • Timeliness of implementation of care plan.
  • Telephone consultation to assist enrollees in obtaining health information and urgent care on a 24 hour basis.

Quality indicators that are objective, measurable and related to the entire range of services provided by the MCO and focus on potential clinical problem areas (high volume service, high risk diagnoses or adverse outcomes). The methodology should assure that all care settings (e.g., day center, nursing home and in-home settings) will be included in the scope of the QA and performance improvement program.

  1. PIP Requirements
MCOs are required to conduct PIPs that focus on clinical and non-clinical areas to promote QI within the managed long-term care plan. At least 1 PIP each year will be selected as a priority and approved by the state. MCOs must conduct PIPs using standard measures required by CMS and to report results to CMS (if required) and the state. Standard measures may include HEDIS and HOS. MCOs are also required to conduct a CCIP relevant to its membership as directed by CMS and to submit the annual report on CCIP to CMS and the state.
  1. EQRO Requirements
MCOs are required to cooperate with any external quality review conducted by or at the direction of the state.
  1. Care Coordination Requirements
a. Assessment tool requirements.

The MCO, using the patient assessment instrument specified by state, is required to evaluate all applicants to assess:

  • Eligibility for nursing home LOC at the time of enrollment.
  • At the time of enrollment, ability of returning to or remaining in their home and/or community without jeopardy to their health and/or safety, based upon criteria provided by the state.
  • Expectation that applicant requires at least service and care management for at least 120 days from the effective date of enrollment.
b. Care coordinator to LTSS member ratio requirement.

None specified.

c. Frequency and nature of LTSS member monitoring.

None specified.

d. LTSS/acute care coordination requirements.

Care management includes referral to and coordination of other necessary medical, and social, educational, psychosocial, financial and other services of the care plan irrespective of whether such services are covered by the plan.

e. Risk assessment and mitigation requirements.

None specified.

  1. Ombudsman (Function) Requirements
None specified.
  1. Quality-Related Financial Incentives
None specified.
  1. Experience of Care/ Satisfaction Feedback Requirements
None specified.
  1. LTSS Quality Review
The MCO will submit reports to the state on all QAPIPs directed by CMS for the Medicare Advantage Program, including the annual report on the contractor's CCIP. Reports should be duplicative of reports submitted to CMS and separate reports for the dual eligible population are not required.

The MCO shall submit enrollee health and functional status data for each of their enrollees in the format and according to the timeframes specified by the state. The data shall consist of SAAM or any other such instrument the SDOH may request. The data shall be submitted at least semi-annually or on a more frequent basis if requested by the state.

CCIP = Chronic Care Improvement Program
CI = critical incident
CMS = Centers for Medicare and Medicaid Services
EQRO = external quality review organization
HEDIS = Health Effectiveness Data and Information Set

HOS = Health Outcomes Survey
IT = information technology
LOC = level of care
LTSS = long-term services and supports
MAP = New York Medicaid Advantage Plus

MCO = managed care organization
PIP = performance improvement project
QA = quality assurance
QAPIP = Quality Assessment and Performance Improvement Plan
QI = quality improvement

SAAM = semi-annual assessment of member
SDOH = New York State Department of Health

View full report

Preview
Download

"MCOcontr.pdf" (pdf, 1.27Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®