|State and Lead Agency||Tennessee Department of Finance and Administration, Bureau of TennCare, Division of Long-term Services and Supports|
|Program||TennCare CHOICES in Long-Term Services and Supports|
|Year LTSS Added||2010|
|Medicaid Authority||1115 Demonstration Waiver|
|# Enrolled||31,890 (September 1, 2013)
Subset of members using LTSS: All CHOICES members use LTSS; 1.2 million enrolled in the broader TennCare managed care program.
|Group Enrolled||Persons of all ages residing in nursing homes.
Adults 21+ with a PD/LTSS needs.
Seniors 65+ with LTSS needs.
||a. Staffing requirements for quality oversight/reporting.
MCOs are required to have a QM/QI program that is accountable to the MCO's board of directors and executive management team, have a QM/QI committee that oversees the QM/QI functions and a staff person responsible for all QI/QM activities. The QM/QI committees are required to include medical, behavioral health, and long-term care staff and contract providers (including medical, behavioral health, and long-term care providers). The QI/QM committee is required to notify the CMO of TennCare of meetings in a timely fashion and to the extent allowed by law, the CMO of TennCare, or his/her designee, may attend the QM/QI committee meetings at his/her option.
|b. Staffing and processes for provider monitoring and associated reporting requirements.
MCOs are required to monitor the subcontractor's performance on an ongoing basis and subject it to formal review, on at least an annual basis, consistent with NCQA standards and state MCO laws and regulations. MCO must have a senior executive responsible for overseeing all subcontractor activities and a staff person responsible for all UM activities, including overseeing prior authorizations. MCOs are to be responsible for confirming the provider's capacity and commitment to initiate services.
|c. Staffing and processes for care coordinator monitoring and associated reporting requirements.
The MCO will have a full-time staff person dedicated to the TennCare CHOICES program who is a RN and has at least 3 years' experience providing care coordination to persons receiving long-term care services and an additional 2 years' work experience in managed and/or long-term care. This person will oversee and be responsible for all care coordination activities.
Quality of care activities will be monitored through information obtained in a quarterly CHOICES Care Coordination Report and through activities performed by the Quality Oversight Division of TennCare.
|d. IT requirements in support of quality monitoring and reporting.
MCOs are required to have Information management processes and Information Systems that enable it to meet TennCare and federal reporting requirements and other Agreement requirements and that are in compliance with this Agreement and all applicable state and federal laws, rules and regulations including HIPAA. The MCO's Systems is required to possess capacity sufficient to handle the workload projected for the start date of operations and will be scalable and flexible so they can be adapted as-needed, within negotiated timeframes, in response to changes in agreement requirements, increases in enrollment estimates, etc. MCOs and TennCare are required to establish an information systems workgroup/committee to coordinate activities and develop cohesive systems strategies.
|e. CI investigation processes and associated reporting requirements.
Reports: MCOs submit:
|f. Mechanisms for monitoring receipt of community LTSS and associated reporting requirements.
When MCOs begin initiation of the member's POC, the member's care coordinator/care coordination team is required to monitor to ensure that services have been initiated and continue to be provided as authorized. This includes ongoing monitoring via EVV to ensure that services are provided in accordance with the member's POC, including the amount, frequency, duration and scope of each service, in accordance with the member's service schedule; and that services continue to meet the member's needs.
MCOs are required to conduct monthly monitoring regarding missed and late visits. State reviews Late and Missed Visits reports submitted by the MCO to determine the MCO's performance. The state may validate the report and may conduct a more in-depth review and/or request additional information and may require a corrective action plan and/or impose sanctions to address non-compliance issues and to improve MCO performance.
|g. Mechanisms for handling complaints/grievances/appeals, and associated reporting requirements.
Members have the right to file appeals regarding adverse actions taken by the MCO to deny, reduce, terminate, delay or suspend a covered service as well as any other acts or omissions of the MCO which impair the quality, timeliness, or availability of such benefits.
Complaint means a written or verbal expression of dissatisfaction about an action taken by the MCO or service provider other than those that meet the definition of an adverse action such as quality of care or services provided and aspects of interpersonal relationships such as rudeness of a provider or employee.
MCOs will devote a portion of its regularly scheduled QM/QI committee meetings to the review of member complaints and appeals that have been received.
MCOs will ensure that punitive action is not taken against a provider or worker who files an appeal on behalf of a member.
MCOs submit a quarterly Member Complaints Report that includes information regarding the number of complaints received by type, and by member group, and the number and percent of complaints for which the MCO met/did not meet the specified timeframe for resolution. The report also includes identification of any trends regarding complaints (e.g., the type or number of complaints) and any action steps to address these trends, including QI activities.
MCOs submit a quarterly Provider Complaints Report that provides information on the number and type of provider complaints received, either in writing or by phone, by type of provider, and the disposition/resolution of those complaints.
State Annual Monitoring
Staffing and Background Checks
||Not specified in contract. However, contract specifies multiple reports related to quality. See Element #9 below.|
||MCOs are required to perform at least 2 clinical PIPs with at least 1 PIP in the area of behavioral health. The behavioral health PIP is required to be relevant to 1 of the behavioral health DM programs for bipolar disorder, major depression, or schizophrenia. MCOs are required to submit an annual report on PIPs.|
||MCOs are required to cooperate with EQRO which will conduct a periodic and/or an annual independent review of the MCO.
MCO QI/QM committee meeting minutes are to be available for review upon request and during the annual on-site EQRO review and/or NCQA accreditation review.
||a. Assessment tool requirements.
MCOs may employ a screening process, using state-specified tools and protocols.
MCO care coordinators conduct any needs assessment deemed necessary by the MCO using a state-approved tool.
|b. Care coordinator to LTSS member ratio requirement.
Although care coordinator ratios requirements are not stipulated, MCOs submit a monthly caseload and staffing ratio report that reflects the weighted care coordinator-to-member staffing ratios and care coordinator caseloads.
|c. Frequency and nature of LTSS member monitoring.
Requirements for frequency of monitoring are dependent upon the level or group the member is in.
Members in CHOICES Group 1 (who are residents of a NF) and who are 21 years of age and older are to receive a face-to-face visit from their care coordinator at least twice a year. Members in CHOICES Group 1 (who are residents of a NF) who are under the age of 21 are to receive a face-to-face visit from their care coordinator at least quarterly.
Members in CHOICES Group 2 (age 65+ or 21+ with disability meeting NF LOC) are to be contacted by their care coordinator at least monthly either in person or by telephone. These members are to be visited in their residence face-to-face by their care coordinator at least quarterly.
Members in CHOICES Group 3 (age 65+ or 21+ with disability who do not meet NF LOC and in the absence of HCBS are at risk for NF care) are to be contacted by their care coordinator at least quarterly either in-person or by telephone. These members are to be visited in their residence face-to-face by their care coordinator at least semi-annually.
|d. LTSS/acute care coordination requirements.
MCOs are required to use care coordination as the continuous process of:
|e. Risk assessment and mitigation requirements.
MCOs conduct a risk assessment using state-specified tool and protocol and develop, as applicable, a risk agreement to be signed by the applicant or his/her representative which will include identified risks to the applicant, the consequences of such risks, strategies to mitigate the identified risks, and the applicant's decision regarding his/her acceptance of risk. MCO care coordinators review, and revise as necessary, the member's risk assessment and risk agreement and have the member or his/her representative sign and date any revised risk agreement.
||Long-Term Care Ombudsman Program--A statewide program for the benefit of individuals residing in long-term care facilities, which may include nursing homes, residential homes for the aged, assisted care living facilities, and community-based residential alternatives developed by the state. The Ombudsman is available to help these individuals and their families resolve questions or problems. The program is authorized by the federal Older Americans Act and administered by the TCAD.
A consumer advocate for members will be responsible for internal representation of members' interests including input into planning and delivery of long-term care services, QM/QI activities, program monitoring and evaluation, and member, family, and provider education.
||Financial incentives will be paid to the MCO based on activities performed as part of the MFP Rebalancing Demonstration in accordance with the following:
|MCOs are required to review all reports submitted to the state to:
The MCO will submit additional reports as follows:
MCOS are also required to submit the following LTSS-related reports including:
||Program Evaluation (Satisfaction and Effectiveness) which will include the following:
|ADA = Americans with Disabilities Act
CI = critical incident
CMO = Chief Medical Officer
CMS = Centers for Medicare and Medicaid Services
DM = disease management
EQRO = external quality review organization
IT = information technology
MFP = Money-Follows-the-Person
POC = plan of care
TCAD = Tennessee Commission on Aging and Disability