Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix O. Texas Star+plus


  Element     Description/Notes  
State and Lead Agency Texas Health and Human Services Commission (HHSC)
Inception 1998
Year LTSS Added 1998
Medicaid Authority 1915(b)/(c) waivers--now 1115
# Enrolled 400,790 (June 2012)
Subset using LTSS is 71,239
Group Enrolled Medicaid beneficiaries who receive SSI and/or qualify for certain waiver services.
Includes dual eligibles.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

The MCO must designate key executive staff with responsibility for QI. If there is any change in this key position the MCO must notify the state within 15 business days. Additionally, the MCO must designate a senior executive responsible for the QI program and the MCO Medical Director must have substantial involvement in program activities.

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

Provider Credentialing--MCOs must review, approve, and periodically recertify the credentials of all participating licensed providers who participate in the MCO's provider network. Credentialing may be subcontracted if the delegated credentialing is maintained in accordance with the NCQA delegated credentialing requirements and any comparable requirements defined by the state. Credentialing and re-credentialing processes must be consistent with recognized MCO industry standards, including NCQA standards and federal regulations. The initial credentialing process, including application and verification of information must be completed before the effective date of the initial contract with the provider. The re-credentialing process must occur at least every 3 years.

Provider Profiling--MCOs must conduct PCP and other provider profiling activities at least annually. As part of its quality program, the MCO must describe the methodology it uses to identify which and how many providers to profile and to identify measures to use for profiling such providers. Provider profiling activities must include, but not be limited to:

  • Developing PCP and provider-specific reports that include a multi-dimensional assessment of a PCP or provider's performance using clinical, administrative, and member satisfaction indicators of care that are accurate, measurable, and relevant to the enrolled population.
  • Establishing PCP, provider, group, service area or regional benchmarks for areas profiled, where applicable.
  • Providing feedback to individual PCPs and providers regarding the results of their performance and the overall performance of the provider network.

Network Adequacy--MCOs are required to systematically and regularly verify that covered services furnished by providers are available and accessible to members in compliance with established appointment wait time standards and within established geographical standard for covered services furnished by PCPs. The MCO must enforce access and other network standards required by the contract and take appropriate action with providers whose performance is determined by the MCO to be out-of-compliance.

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

MCOs are required to monitor the Service Coordinator's workload and performance to ensure that he or she is able to perform all necessary service coordination functions for the members in a timely manner.

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

MCOs must maintain a MIS that supports all functions of the MCO's processes and procedures for the flow and use of MCO data. This also extends to MIS subcontractors. The MCO must have hardware, software, and a network and communications system with the capability and capacity to handle and operate all MIS subsystems for the various operational and administrative areas, including QI.

e. CI investigation processes and associated reporting requirements.

None specified.

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.

The MCO must develop, implement and maintain a system for tracking, resolving, and reporting member complaints and appeals. The MCO must ensure that member complaints and appeals are resolved within 30 calendar days after receipt. If 98% are not resolved in a timely manner, the MCO can be subject to financial penalties. The MCO appeals process must comply with federal regulations.

The MCO must also provide designated Member Advocates to assist members in understanding and using the appeal process. The MCO's Member Advocates must assist members in writing or filing an appeal and monitoring the appeal through the MCO's appeal process until the issue is resolved.

h. Other.

The state may conduct performance profiling of MCOs and recognize MCOs that attain superior performance and/or improvement by publicizing their achievements. Conversely, the state may publicize poor MCO performance. This can include posting reports on the Internet.

  1. LTSS Performance Measures Requirements
Annual performance measures include:
  • Percent members with good access to service coordination.
  • Percent increase in members that receive personal attendant and/or respite services through the consumer-directed services delivery model.
  • Number of members entering NF.
  • Number of waiver clients returning to community services.
  1. PIP Requirements
Each year, the state establishes 2 overarching goals and negotiates a third goal suggested by the MCO for the following calendar year. The MCO must identify and propose 3 annual PIPs relating to the overarching goals for the following calendar year. At least 1 PIP must be related to an overarching goal established by the state. Once finalized, the overarching goals and PIPs are incorporated into the contract. If the state and the MCO cannot agree on the overarching goal or PIPs, the state will unilaterally select them. PIPs will follow CMS protocol. The purpose of health care quality PIPs is to assess and improve processes, and thereby outcomes, of care. In order for such projects to achieve real improvements in care and for interested parties to have confidence in the reported improvements, PIPs must be designed, conducted, and reported in a methodologically sound manner.
  1. EQRO Requirements
MCOs are required to collaborate with state's EQRO to develop studies, surveys, or other analytical approaches that will be carried out by the EQRO. The purpose of the studies, surveys, or other analytical approaches is to assess the quality of care and service provided to members and to identify opportunities for MCO improvement. To facilitate this process, MCOs are required to supply claims data to the EQRO in a format identified by the state in consultation with MCOs, and will supply medical records for focused clinical reviews conducted by the EQRO.

MCOs must also work collaboratively with the state and the EQRO to annually measure selected HEDIS measures that require chart reviews. During the first year of operations, the state anticipates that the selected measures will include, at a minimum, well-child visits and immunizations, appropriate use of asthma medications, measures related to members with diabetes, and control of high blood pressure. Additionally, the state or the EQRO will evaluate the MCO's DM program. The state may also request that the MCO submit encounter data file to the EQRO in the format provided in the Uniform Managed Care Manual. The EQRO has an additional role in collection and calculation of HEDIS, CAHPS, and other performance measures.

  1. Care Coordination Requirements
a. Assessment tool requirements.

MCOs are required to use the state's Task/Hour Guide to assess a member's need for Personal Assistance Service. For members and applicants seeking or needing HCBS Waiver services, the MCO must use the state's Community Medical Necessity and LOC Assessment Instrument. The MCOs will be expected to complete the same activities for each annual reassessment as required for the initial eligibility determination.

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.

The MCO must ensure that each member has a qualified PCP who is responsible for overall clinical direction and, in conjunction with the Service Coordinator, serves as a central point of integration and coordination of Covered Services, including Acute Care, long-term care and Behavioral Health Services. The Service Coordinator must work with the member's PCP to coordinate all Covered Services and any applicable non-capitated services.

e. Risk assessment and mitigation requirements.

None specified.

  1. Ombudsman (Function) Requirements
The MCO is required to provide Member Advocates to assist members. Member Advocates must be physically located within the service area and must inform members of their rights and responsibilities, the complaints and appeals process and the array of services that are available to them. Member Advocates must also assist members in writing complaints and are responsible for monitoring the complaint. Member Advocates are responsible for making recommendations to MCO management on any changes needed to improve either the care provided or the way care is delivered. Member Advocates are also responsible for helping or referring members to community resources available to meet member needs that are not available from the MCO as covered services.
  1. Quality-Related Financial Incentives
The state has established the following quality-related financial incentives:
  • 5% risk--The state will place each MCO at risk for 5% of the Capitation Payment(s). If the MCO meets the performance expectations they will receive up to 100% of the risk reserve.
  • Quality Challenge Award--If 1 or more MCOs are unable to earn the full amount of the performance-based at risk portion of the Capitation Rate, the state will reallocate all or part of the funds through the MCOs Program's Quality Challenge Award. The state will use these funds to reward MCOs that demonstrate superior clinical quality, service delivery, access to care, and/or member satisfaction. The state will determine the number of MCOs that will receive these funds annually based on the amount of the funds to be reallocated.
  • Additionally, there are programs based on inpatient and nursing home utilization. These MCOs must achieve a 22% reduction in projected FFS Hospital Inpatient Stay costs, for the Medicaid-only population, through the implementation of the STAR+PLUS model. MCOs achieving savings beyond 22% will be eligible for the STAR+PLUS Shared Savings Award and will be at risk for savings less than 22%.
  • NF Utilization Dis-incentive--The state will compare the annual rate of nursing home admissions for enrollees to determine if there is a statistically significant increase in admissions. Those admitted and discharged within 120 days are excluded.
  • Additional Incentives and Dis-incentives--The state will evaluate all performance-based incentives and dis-incentive methodologies annually and in consultation with the MCOs. The state may then modify the methodologies as-needed in an effort to motivate, recognize, and reward MCO for performance.
  1. Experience of Care/ Satisfaction Feedback Requirements
None specified.
  1. LTSS Quality Review
The MCO must file quarterly LTSS utilization reports.
CAHPS = Consumer Assessment Health Care Providers and Systems
CI = critical incident
DM = disease management
EQRO = external quality review organization
FFS = fee-for-service

HCBS = home and community-based services
HEDIS = Health Effectiveness Data and Information Set
HHSC = Texas Health and Human Services Commission
IT = information technology
LOC = level of care

LTSS = long-term services and supports
MCO = managed care organization
MIS = Management Information System
NCQA = National Committee on Quality Assurance
NF = nursing facility

PCP = primary care provider/physician
PIP = performance improvement project
QI = quality improvement
SSI = Supplemental Security Income

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