Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix N. Tennessee Tenncare Choices

09/01/2013

  Element     Description/Notes  
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
Inception 1993
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.
  1. MCO Quality Management Infrastructure
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.

Process:

  • MCOs develop and implement an abuse/neglect plan that includes protocols for preventing, identifying, and reporting suspected abuse, neglect, and exploitation of members; a plan for educating and training providers, subcontractors, care coordinators, and other MCO staff regarding the protocols; and a plan for training members, representatives, and caregivers regarding identification and reporting of suspected abuse and/or neglect.
  • MCOs are required to develop and implement a CI reporting and management system for incidents that occur in a home and community-based long-term care service delivery settings.
  • MCOs are required to identify and track CIs and will review and analyze CIs to identify and address potential and actual quality of care and/or health and safety issues. The MCO will regularly review the number and types of incidents and findings from investigations; identify trends and patterns; identify opportunities for improvement; and develop and implement strategies to reduce the occurrence of incidents and improve the quality of CHOICES HCBS.
  • MCOs require its staff and contract CHOICES HCBS providers to report, respond to, and document CIs as specified by the state.

Reports: MCOs submit:

  • Quarterly CHOICES HCBS CIs Report (MFP participants will be identified).
  • Quarterly Behavioral Health Adverse Occurrences Report that provides information, by month regarding specified measures, which will include the number of adverse occurrences, date of occurrence, type of adverse occurrence, location, provider name; and action taken by facility/provider.
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.

h. Other.

State Annual Monitoring

  • State/designee (or CMS) annually monitors the operation of MCO for compliance with the provisions of contract and applicable federal and state laws and regulations.
  • Monitoring activities will include inspection of MCO's facilities, auditing and/or review of all records developed under the Agreement including periodic medical audits, appeals, enrollments, disenrollments, termination of providers, utilization and financial records, reviewing management systems and procedures developed under this Agreement and review of any other areas or materials relevant to or pertaining to this Agreement.
  • State emphasizes case record validation because of the importance of having accurate service utilization data for program management, utilization review and evaluation purpose.
  • State prepares a report of its findings and recommendations and will require MCOs to develop corrective action plans as appropriate.
i. Other.

Staffing and Background Checks

  • MCO is required to have sufficient full-time clinical and support staff to conduct daily business including administration, accounting and finance, fraud and abuse, UM including prior authorizations, MCO case management, DM, care coordination, QM/QI, member education and outreach, appeal system resolution, member services, provider services, provider relations, claims processing, and reporting.
  • MCO is responsible for ensuring that all employees, agents, subcontractors, providers or anyone acting for or on behalf of MCO, are legally authorized to render services under applicable state law.
  • Fiscal Intermediary is responsible for ensuring that consumer-directed workers are qualified to provide services in accordance with state requirements.
  • MCO is responsible for conducting background checks in accordance with state law and policy and ensuring that all employees, agents, subcontractors, providers or anyone acting for or on behalf of the MCO conducts background checks in accordance with state law and policy. Background checks will include a check of the state's Abuse Registry, Felony Offender Registry, National and State Sexual Offender Registry, and LEIE. The FI will be responsible for conducting background checks on its staff, its subcontractors, and consumer-directed workers.
  1. LTSS Performance Measures Requirements
Not specified in contract. However, contract specifies multiple reports related to quality. See Element #9 below.
  1. PIP Requirements
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.
  1. EQRO Requirements
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.

  1. Care Coordination Requirements
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:

  • Assessing a member's physical, behavioral, functional, and psychosocial needs.
  • Identifying the physical health, behavioral health and long-term care services and other social support services and assistance (e.g., housing or income assistance) that are necessary to meet identified needs.
  • Ensuring timely access to and provision, coordination and monitoring of physical health, behavioral health, and long-term care services needed to help the member maintain or improve his or her physical or behavioral health status or functional abilities and maximize independence.
  • Facilitating access to other social support services and assistance needed in order to ensure the member's health, safety and welfare, and as applicable, to delay or prevent the need for more expensive institutional placement.
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.

  1. Ombudsman (Function) Requirements
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.

  1. Quality-Related Financial Incentives
Financial incentives will be paid to the MCO based on activities performed as part of the MFP Rebalancing Demonstration in accordance with the following:
  • Upon successful transition to the community of each MFP demonstration participant up to and including the MCO's established benchmark for the calendar year--a one-time payment of $1,000.
  • If a member has been enrolled in more than 1 MCO during the 90-day minimum stay in a Qualified Institution established under ADA, the incentive payment shall be awarded to the MCO in which the person is enrolled at transition to the community and enrollment into MFP. Upon successful transition to the community of each MFP demonstration participant that exceeds the MCO's established benchmark for the calendar year--a one-time payment of $2,000.
  • If a member has been enrolled in more than 1 MCO during the 90-day minimum stay in a Qualified Institution established under ADA, the incentive payment shall be awarded to the MCO in which the person is enrolled at transition to the community and enrollment into MFP.
  • Upon each MFP demonstration participant's completion of community living for the full 365-day demonstration participation period without readmission to a NF (excluding short-term SNF stays solely for purposes of receiving post-hospital short-term rehabilitative services covered by Medicare), a one-time payment of $5,000.
  • If a member has been enrolled in more than 1 MCO during the 365-day participation period in MFP, a pro-rated portion of the incentive payment shall be awarded to each MCO based on the number of days the member was enrolled in each plan. Only days included in the 365-day participation period shall be counted and not any days during which MFP participation was suspended during an inpatient facility stay.
  • Additionally, payments are provided dependent upon the MCOs ability to achieve MFP Program Benchmarks, which address:
    • Number of individuals in each target group in successfully transitioning from an inpatient facility to a qualified residence.
    • Percentage of Medicaid spending for qualified home and community-based long-term care services.
    • Number and percentage of individuals who are elderly and adults with PD receiving Medicaid-reimbursed long-term care services in home and community-based (versus institutional) settings.
    • Number of unduplicated licensed CBRAs contracted with MCOs statewide to provide HCBS in the CHOICES program during each year of the demonstration. Number of persons receiving Medicaid-reimbursed HCBS participating in consumer direction for some or all services.
  1. Experience of Care/ Satisfaction Feedback Requirements
None specified.
  1. LTSS Quality Review
MCOs are required to review all reports submitted to the state to:
  • Identify instances and/or patterns of non-compliance.
  • Determine and analyze the reasons for non-compliance.
  • Identify and implement actions to correct instances of non-compliance.
  • Address patterns of non-compliance.
  • Identify and implement QI activities to improve performance and ensure compliance going forward.

The MCO will submit additional reports as follows:

  • 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.
  • Quarterly 24/7 Nurse Triage Line Report that lists the total calls received by the 24/7 nurse triage line, including the number of calls from CHOICES members, including the ultimate disposition of the call.
  • Quarterly CHOICES Care Coordination Report, in a format specified by TennCare that includes, information on care coordination staffing, enrollment and care coordination contacts, ongoing assessment, care planning and service initiation, and self-directed health care task.
  • MCO will identify and immediately respond to problems and issues, service gaps, and complaints or concerns regarding the quality of care rendered by providers, workers, or care coordination staff.
  • Member services and provider services phone line reports.

MCOS are also required to submit the following LTSS-related reports including:

  • Status of transitioning CHOICES member report.
  • CHOICES NF diversion activities report.
  • CHOICES NF-to-community transition report.
  • CHOICES HCBS late and missed visits report.
  • CHOICES consumer direction of eligible CHOICES HCBS report.
  • CHOICES care coordination report.
  • Monthly CHOICES caseload and staffing ratio report.
  • Quarterly MFP participants report.
  1. Other
Program Evaluation (Satisfaction and Effectiveness) which will include the following:
  • Rate of in-patient admissions and re-admissions of CM members.
  • Rate of ER utilization by CM members.
  • Percent of member satisfaction specific to CM.
  • Contact providers and workers on a periodic basis and coordinate with providers and workers to collaboratively address issues regarding member service delivery and to maximize community placement strategies.
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
ER = emergency room
EVV = electronic visit verification
HCBS = home and community-based services
HIPAA = Health Insurance Portability and Accountability Act

IT = information technology
LEIE = List of Excluded Individuals/Entities
LOC = level of care
LTSS = long-term services and supports
MCO = managed care organization

MFP = Money-Follows-the-Person
NCQA = National Committee on Quality Assurance
NF = nursing facility
PD = physical disability
PIP = performance improvement project

POC = plan of care
QI = quality improvement
QM = quality management
RN = registered nurse
SNF = skilled nursing facility

TCAD = Tennessee Commission on Aging and Disability
UM = utilization management

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