Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix L. North Carolina Mental HEALTH/DEVELOPMENTAL DISABILITIES/SUBSTANCE Abuse Services Health Plan Waiver


  Element     Description/Notes  
State and Lead Agency North Carolina Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA)
Program North Carolina MH/DD/SAS Health Plan Waiver
Inception 2005
Year LTSS Added Since inception.
Medicaid Authority 1915(b)/(c)
# Enrolled 1,426,398: Total number enrolled.
84,861: Using MH, DD or SAS (breakout by disability group currently not available).
Group Enrolled IDD
Contract Date(s) April 2012
Covers 2 years with the option to extend an additional year.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

The LME-MCO is required to employ a full-time QM Director with at least 5 years recent QM experience and 2 years managed care experience or experience in MH, DD and SA care. The QM Director shall have a Bachelor's Degree in a Human Services Field or a Master's Degree in a human services field.

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

The LME-MCO shall adopt and implement written policies and procedures governing the qualification, credentialing, re-credentialing, accreditation, and re-accreditation of its network providers, maintain records of its qualification, credentialing, and accreditation activities and make it records available to the state upon request. LME-MCO credentialing and accreditation criteria shall be consistent with state and federal rules and regulations and shall routinely monitor the licensure, certification, registration, and accreditation status of its network providers.

LME-MCOs are required to:

  • Establish mechanisms to ensure that providers comply with the timely access requirements appointment availability and appointment wait times.
  • Monitor providers regularly to determine compliance.
  • Take corrective action if a provider fails to comply.

LME-MCOs shall measure the performance of providers and conduct peer review activities such as identification of practices that do not meet plan standards, recommendation of appropriate action to correct deficiencies and monitoring of corrective action by providers.

LME-MCOs shall also measure provider performance through medical record audits, provide performance feedback to providers, including detailed discussions of clinical standards and the expectations of LME-MCO; develop and adopt clinically appropriate practice parameters and protocols/guidelines and provide LME-MCO's providers enough information about the protocols/guidelines to enable them to meet the established standards.

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

LME-MCOs shall use Quality Monitoring and the CQI process to ensure that individual treatment plans are developed consistent with federal regulations and to ensure enrollee participation in the treatment planning process. LME-MCO shall manage enrollee care by performing, at a minimum, the following Care Management functions:

  • Be available 24 hours per day, 7 days per week, to perform telephone assessments and crisis intervention.
  • Determine which behavioral health services are medically necessary.
  • Perform quality monitoring of the behavioral health services provided to enrollees.
  • Coordinate and monitor behavioral health hospital and institutional admissions and discharges including discharge planning.
  • Ensure the coordination of care with each enrollee's primary care and behavioral health providers.
d. IT requirements in support of quality monitoring and reporting.

LME-MCO shall maintain a health information system that collects, analyzes, integrates, and reports data for recipients with behavioral health, DD, and SA treatment needs. One of the stated purposes of the system is for quality. Also, the LME-MCO shall collect service utilization data for trend analysis and benchmarking to establish long-term validity and accuracy.

e. CI investigation processes and associated reporting requirements.

The LME-MCO must submit CI reports as part of ongoing statistical reporting.

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.

LME-MCO shall have a grievance and appeal system in place that is compliant with federal regulations. The grievance and appeal procedures must:

  • Be approved in writing by the state.
  • Provide for prompt resolution of enrollee grievances and appeals.
  • Assure the participation of individuals with the authority to require LME-MCO to take corrective action when appropriate.

In addition LME-MCOs shall:

  • Use grievance and appeal data for QI and shall report enrollee grievances and appeals to the state by number, type, and outcome by no later than 45 calendar days after the end of each quarter of the state fiscal year.
  • Attend state training on the enrollee appeal process.
  • Use state standardized letters to notify recipients of their rights to appeal.
  • Provide quarterly report on grievance and appeals.
h. Other.

The state Medicaid, MH, IDD, SAS agencies shall jointly conduct an Annual Monitoring Review on-site at the LME-MCO. The frequency of on-site reviews may be decreased to every 2 years at the discretion of the state if it is determined that other on-site review activities required by CMS are sufficient to assure the effective operation of LME-MCO and compliance with state and federal requirements. The Review includes the LME-MCO's compliance the requirements of this contract and with state and federal Medicaid requirements.

An IMT meets at least quarterly to review Performance Indicators, reports and data, and timeliness of submission of reports. The Medicaid Agency leads the IMT, in collaboration with DMH/DD/SAS. At a minimum, the IMT shall include representatives from the following sections and offices:

  • Medicaid:
    • Finance Management;
    • Behavioral Health, Clinical Policies and Programs;
    • QEHO;
    • Waiver Development;
    • Budget Management;
    • Program integrity;
    • IT.
    • Best Practice;
    • Financial Operations;
    • LME System Performance Team;
    • QM;
    • Accountability;
    • Advocacy and Customer Service;
    • IT.
  • LME-MCO:
    • Management;
    • Finance;
    • Information System;
    • Operations (Access, Network, Waiver Implementation);
    • Quality.
  • State:
    • Office of the Controller;
    • Office of Budget and Analysis.
  1. LTSS Performance Measures Requirements
Performance measures for LTSS recipients include the following measures specific to individuals with a primary diagnosis of IDD:
  • Health and safety.
  • Choice.
  • Quality of the SP.
  • Provider remediation, compliance, standards, enrollment and capacity.
  • LOC process and instrument.
  • Slot transfer and tracking.

The following measures are specific to individuals with a primary diagnosis of MI or SA.

Effectiveness of care measures:

  • Follow-up after hospitalization for mental illness (HEDIS).
  • 30 day readmission rates for MH hospitalization.
  • 30 day readmission rates for SA hospitalization.
  • Ambulatory follow-up within 7 and 30 calendar days of hospital discharge for SA therapy.
  • Ambulatory follow-up within 7 and 30 calendar days of discharge for MH.

Access and Availability:

  • Initiation and engagement of alcohol and other drug dependence treatment (HEDIS).
  • Call answer timeliness (HEDIS).
  • Call abandonment (HEDIS).
  • Number and percent of requests for authorization that were denied by LME-MCO.
  • Number and percent of services rendered by an out of network provider.

Use of Services:

  • MH Utilization--Inpatient discharges and average length of stay (HEDIS).
  • MH Utilization--Percentage of members receiving inpatient, day/night care, ambulatory and other support services (HEDIS).
  • Chemical Dependence Utilization--Inpatient discharges and average length of stay (HEDIS).
  • Chemical Dependency Utilization--Percentage of members of receiving inpatient, day/night care, ambulatory and other support services.
  • Integrated Care--For adults, reports the percentage of enrollees who had an ambulatory or preventative care visit during the measurement year. For children and adolescents, reports the percentage that had a visit with a PCP.

LME-MCOs are required to implement a total of 3 PIPs over the 2 years of the contract. During year 1, the LME-MCO shall implement 2 PIPS, 1 clinical and 1 non-clinical.

Appropriate topics for PIPs include:

  • Primary, secondary and/or tertiary prevention of acute mental illness conditions.
  • Primary, secondary and/or tertiary prevention of chronic mental illness conditions.
  • Care of acute mental illness conditions.
  • Recovery/outcome measures.
  • Care of chronic mental illness conditions.
  • High volume services.
  • High risk services.
  • Continuity and coordination of care.
  • Availability, accessibility, and cultural competency of services.
  • Quality of provider/patient encounters.
  • Appeals and grievances.
  1. PIP Requirements
The state will contract with an EQRO to conduct an annual independent external quality review that includes the following:
  • Determining LME-MCO compliance with federal Medicaid managed care regulations.
  • Validation of performance measures produced by LME-MCOs.
  • Validation of PIPs undertaken by LME-MCOs.

CMS-published protocols shall be utilized by the EQRO. In addition, based on the availability of encounter data, the EQRO shall conduct encounter data validation per the CMS protocols. The LME-MCO is required to address the EQRO findings.

  1. EQRO Requirements
The state contracts with an EQRO to conduct an annual independent external quality review. The EQRO conducts 3 mandatory activities during these reviews: (1) determining PIHP compliance with federal Medicaid managed care regulations; (2) validation of performance measures produced by the PIHP; and (3) validation of PIPs undertaken by the PIHP. In addition, the EQRO conducts encounter data validation based on the availability of encounter data.
  1. Care Coordination Requirements
a. Assessment tool requirements.

The LME-MCO is required to use the LOC tool for the 1915(c) waiver.

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 coordination shall be coordinated with the physical health Medicaid providers (Community Care--CCNC network). The LME-MCO is to use the 4 quadrant method to determine if behavioral health or physical health needs are predominant.

  • If behavioral health needs are predominant, the LME-MCO is responsible for care coordination.
  • If physical health needs are more pressing then CCNC is to provide care coordination.

The LME-MCO shall ensure the coordination of care with each enrollee's PCP/Health Home. The LME-MCO shall encourage, support and facilitate communication between PCPs and behavioral health providers regarding medical management, shared roles in the care and crisis plan, exchange of clinically relevant information, annual exams, coordination of services, case consultation and problem solving as well as identification of medical home for persons determined to have need. (The LME-MCO shall conduct at least 1 coordination meeting per month).

The LME-MCO shall also ensure acute care coordination through the following mechanisms:

  • LME-MCOs have the responsibility to provide feedback to the referring source on all referrals.
  • LME-MCOs shall conduct at least 1 meeting per month to facilitate communication.
  • LME-MCOs shall provide follow-up activities to:
    • High risk enrollees who do not appear for scheduled appointments;
    • Enrollees for whom a crisis service has been provided as the first service to facilitate engagement with ongoing care;
    • Individuals discharged from 24 hour care.

LME-MCOs shall ensure that each enrollee's privacy is protected in accordance with state and federal law.

e. Risk assessment and mitigation requirements.

None specified.*

*Supports Intensity Scale and Supports Needs are referenced in the contract.

  1. Ombudsman (Function) Requirements
None specified.
  1. Quality-Related Financial Incentives
The LME-MCO shall conduct a patient satisfaction survey annually using a survey instrument approved by the state. The LME-MCO shall be required to use some statewide standardized questions on each survey. The LME-MCO must have the patient satisfaction survey created and administered by an outside vendor. The survey shall utilize the sampling and format defined by the NCQA. The results of the survey must be submitted to the state.
  1. Experience of Care/ Satisfaction Feedback Requirements
LME-MCOs are required to report Medicaid 1915(c) HCBS waiver performance measures.
  1. LTSS Quality Review
LME-MCOs are required to report Medicaid 1915(c) HCBS waiver performance measures.
CCNC = Community Care of North Carolina
CI = critical incident
CMS = Centers for Medicare and Medicaid Services
CQI = continuous quality improvement
DD = developmental disability

DHHS = North Carolina Department of Health and Human Services
DMA = North Carolina Division of Medical Assistance
DMH/DD/SAS = North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services
EQRO = external quality review organization
HCBS = home and community-based services

HEDIS = Health Effectiveness Data and Information Set
IDD = intellectual and developmental disabilities
IMT = intra-departmental monitoring team
IT = information technology
LME = local management entity

LTSS = long-term services and supports
MCO = managed care organization
MH = mental health
MI = mentally ill
NCQA = National Committee on Quality Assurance

PCP = primary care provider/physician
PIHP = Pre-paid Inpatient Health Plan
PIP = performance improvement project
QEHO = quality, evaluation, and health outcomes
QI = quality improvement

QM = quality management
SA = substance abuse
SAS = substance abuse services
SP = service plan

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