Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix M. Pennsylvania Adult Community Autism Program


  Element     Description/Notes  
State and Lead Agency Pennsylvania Office of Developmental Programs, Bureau of Autism Services
Program Adult Community Autism Program (ACAP)
Inception 2009
Year LTSS Added 2009
Medicaid Authority 1915(a)
# Enrolled 110
Group Enrolled Adults with autism.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

The MCO is required to establish a Plan Advisory Committee that includes the Medical Director, a Behavioral Health Practitioner, a parent of an adult with autism, providers representing the scope of services provided under the Plan, and representatives from the religious, law, and ethics communities. The Plan Advisory Committee will report to and advise the governing body on matters related to the complaint and grievance processes, QM, utilization review processes, and ethics.

The MCO shall establish, maintain, and provide support to a QM and Utilization Review Committee. The Committee shall provide guidance and assistance to support the MCO in carrying out the following responsibilities:

  • Developing mechanisms for collecting and evaluating information, identifying problems, formulating recommendations, disseminating information.
  • Implementing corrective actions and evaluating the effectiveness of action taken.
  • Reviewing annually and making recommendations concerning the formulation, revision or implementation of the policies governing the scope of services offered, practice guidelines, medical supervision, ISPs, crisis intervention care, clinical records, personnel qualifications and program evaluation.
  • Providing technical advice regarding professional questions and individual service problems.
  • Participating in program evaluation including annual evaluation of the MCO's performance.
  • Assisting in maintaining liaison with professional groups and health providers in the community.
  • Participating in the development and ongoing review of written policies, procedures, and standards of patient care and QM.
  • Reviewing the adequacy and effectiveness of QM and utilization activities on a quarterly basis.
  • Developing mechanisms for evaluating responsiveness of the complaint and grievance processes and for collecting and analyzing information about voluntary disenrollments.
b. Staffing and processes for provider monitoring and associated reporting requirements.

When the MCO or the state identifies deficiencies or areas for improvement in a provider's performance, the MCO and provider must take corrective action to ensure that the provider removes the deficiencies and improves performance.

The MCO is required to:

  • Establish ongoing mechanisms to monitor provider compliance with the state's standard for timely access to care and services as specified.
  • Monitor the performance of its providers on an ongoing basis, conducting formal review of each provider at least annually and if any deficiencies or areas of improvement are identified, take corrective action or require the provider to take corrective action to detect both under utilization and over utilization of services and to assess the quality and appropriateness of care furnished to all participants.
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 is required to purchase all compatible computer software and required licenses for the MCO's and the state's use as may be necessary to allow for electronic communication and transfer of information between the MCO and the state. The software must allow the MCO to collect, analyze, integrate, and report data.

e. CI investigation processes and associated reporting requirements.

The MCO must ensure that the MCO and each provider responds, reports, and follows up on CIs as specified by the state.

The MCO is required to develop Seclusion and Restraint policies and procedures and ensure that staff and providers receive training on these policies and the appropriate use of these restraints identified in the approved behavioral support plan. MCOs are required to file an incident report any time a Restraint is used.

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

The MCO is required to ensure that authorized services are delivered timely and consistent with the needs of the participant. The MCO must have a mechanism to detect both under utilization and over utilization of services and to assess the quality and appropriateness of care furnished to all participants.

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

The MCO shall develop complaint, grievance, and state fair hearing procedures that must be approved by the state before implementation. The MCO must inform each participant verbally and in the Participant Handbook of the Participant's right to file a complaint or grievance, the requirements and timeframes for filing a complaint or grievance, the availability of assistance in the filing process, the toll-free numbers that the participant can use to file a complaint or grievance, and the participant's right to request the state's fair hearing. The MCO must inform the provider of the right of each participant to file a complaint or grievance.

h. Other.

None specified.

  1. LTSS Performance Measures Requirements
Performance Measures include:
  • Fewer episodes of :
    • Law enforcement involvement;
    • Psychiatric inpatient and ER hospitalizations;
    • MH crisis interventions.
  • Increase in percentages of participants with jobs or volunteer opportunities.
  • Participant satisfaction and quality of life indicators.
  • Percentages of:
    • Complaints received and resolved;
    • Grievances received and resolved.
  1. PIP Requirements
If deficiencies are identified by the MCO or the state, the MCO is required to develop a corrective action plan to improve performance.
  1. EQRO Requirements
The MCO is required to comply with requests from the state for submission of data required to complete an annual external independent review of the quality outcomes, timeline and access to authorized services. The MCO is also required to cooperate with the state/authorized representatives in the state's monitoring of the MCO and provider compliance with the contract requirements and the provider's performance as it relates to participant outcomes and consistency of quality indicators.
  1. Care Coordination Requirements
a. Assessment tool requirements.

The MCO is required to complete an assessment annually designated by the state for each participant and shall transmit the results of the assessments to the state in an electronic format.

b. Care coordinator to LTSS member ratio requirement.

None specified.

c. Frequency and nature of LTSS member monitoring.

The MCO is responsible for developing an initial support plan within 14 days of being notified by the state that an applicant is eligible for enrollment. The plan must be reviewed at least every 3 months and after each episode that triggers implementation of the crisis intervention plan or the use of a restraint and must be reassessed and updated at least annually. Monitoring and annual reassessments must address the participant's progress toward more inclusive and less restrictive services than were provided the previous year.

d. LTSS/acute care coordination requirements.

The MCO is required to ensure that every participant has an assigned PCP. The MCO is required to assign a team to each participant, which is responsible for assessment, service planning, care delivery and managing delivery of services, quality of services, and continuity of care. The team shall include the participant, participant's guardian if the participant has a guardian, and his or her family consistent with the participant's or guardian's wishes, a behavioral health specialist, and supports coordinator.

The MCO is required to ensure that the authorized services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are furnished.

The MCO shall establish practice guidelines to govern the authorization and delivery of services which are:

  • Based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field.
  • Adopted in consultation with contracting health care professionals.
  • Reviewed and updated periodically as appropriate.

Practice guidelines must be approved by the state before being implemented. Guidelines must be shared with all affected providers and upon request, with participants and applicants.

e. Risk assessment and mitigation requirements.

The MCO s required to develop a crisis intervention plan to plan for a crisis event to protect the partitioned from hurting himself/herself or others. The MCO will reassess the plan to avoid a crisis event in the future. A description of how the effectiveness of the plan and its implementation in supporting the participant will be monitored and evaluated on a regular basis and after each crisis event.

  1. Ombudsman (Function) Requirements
None specified.
  1. Quality-Related Financial Incentives
None specified.
  1. Experience of Care/ Satisfaction Feedback Requirements
The MCO is required to regularly evaluate participants' satisfaction with services and shall facilitate implementation of such consumer satisfaction surveys as the state determines are necessary in order to evaluate services provided.
  1. LTSS Quality Review
The MCO is required to submit a written report of QM activities including standard measures required by the state on an annual basis which describes topics reviewed, method of review, recommendations for improvement, and evaluation of corrective actions implemented.

The MCO is required to meet with the state on a semi-annual basis to review the MCO's performance, the development of specific quality goals, and establishment of performance measurement criteria. The MCO must submit the reports required by the state 2 weeks before it meets with the state.

The MCO is required to submit quarterly reports that include the following information:

  • Number of participant deaths.
  • Number of complaints received and resolved.
  • Number of grievances received and resolved.
  • Services furnished to participants.
  1. Other
The MCO is required to maintain an after-hours call-in system to provide access, 24 hours per day, 7 days per week to covered services when medically necessary.
ACAP = Adult Community Autism Program
CI = critical incident
EQRO = external quality review organization
ER = emergency room
IT = information technology

LTSS = long-term services and supports
MCO = managed care organization
MH = mental health
PCP = primary care provider/physician
PIP = performance improvement project

QM = quality management

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