Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix P. Washington Medicaid Integration Partnership

09/01/2013

  Element     Description/Notes  
State and Lead Agency Washington Department of Social and Health Services (DSHS)
Program Washington Medicaid Integration Partnership (WMIP)
Inception 2005
Year LTSS Added 2006
Medicaid Authority 1932(a)
# Enrolled 4,834 (May 2012)
Group Enrolled Adults 21-64 with SSI or SSI-related Medicaid
Adults 65+
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

MCOs are required to have a QI Committee that oversees the quality functions of the MCO. The committee is comprised of:

  • A MH professional with substantial involvement in the implementation of mental health care aspects of the QAPIP.
  • A chemical dependency professional with substantial involvement in the implementation of chemical dependency health care aspects of the QAPIP.
  • A geriatric specialist with substantial involvement in the implementation of the long-term care aspects of the QAPIP.
b. Staffing and processes for provider monitoring and associated reporting requirements.

The MCO's policies and procedures related to the credentialing and re-credentialing of providers must comply with federal regulations and shall ensure compliance with the following requirements:

  • The MCO's medical director or other designated physician's shall have direct responsibility and participation in the credentialing process.
  • The MCO must have a designated Credentialing Committee to oversee credentialing process.
  • Identification of the type of providers that are credentialed and re-credentialed.
  • Verification sources used to make credentialing decisions, including any evidence of provider sanction.
  • Prohibition against employment or contracting with providers excluded from participation in federal health care programs under federal law.

The MCO must also have a process for re-credentialing providers at least every 36 months through information verified from primary sources. The MCO must also have a system for monitoring sanctions or limitations on licensure, complaints and quality issues or information from identified adverse events and provide evidence of action, as appropriate based on state-defined methods or criteria.

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 shall maintain, and shall require subcontractors to maintain, a health information system that complies with federal requirements and provides the information necessary to meet the MCOs contractual obligations.

The MCO must have in place mechanisms to verify the health information received from subcontractors by having the ability to:

  • Collect, analyze, integrate, and report data. The system must provide information on areas including but not limited to, utilization, grievance and appeals, and terminations of enrollment for other than loss of Medicaid eligibility.
  • Ensure data received from providers is accurate and complete by:
    • Verifying the accuracy and timeliness of reported data;
    • Screening the data for completeness, logic, and consistency;
    • Collecting service information on standardized formats to the extent feasible and appropriate.

The MCO shall make all collected data available to the state and CMS upon request.

e. CI investigation processes and associated reporting requirements.

The MCO is required to notify the state of any CI including homicide, attempted homicide, suicide, the unexpected death of a consumer, abuse or neglect of an enrollee by an employee or volunteer. Notification must include a description of the event, any actions taken in response to the incident, the purpose for which any action was taken, and any implications to the service delivery system. The MCO must submit the report during the business day in which the MCO becomes aware of such an event.

The MCO is required to maintain a record of known enrollee deaths, including the enrollee's name, date of birth, age at death, location of death, and cause(s) of death. The MCO is required to assist the state in efforts to evaluate and improve the availability and utility of selected mortality information for QI purposes.

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

The MCO is required to have mechanisms to detect both under utilization and over utilization of services.

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

Members have the right to file appeals regarding 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 benefits. Grievances may be written or verbal expression of dissatisfaction about an action taken by the MCO or service provider. A provider may not file a grievance on behalf of an enrollee.

The MCO is required to provide a report of completed actions, grievances, appeals and independent reviews to the state in accordance with the state's Grievance System Reporting Requirements. All grievances are to be recorded and counted whether the grievance is remedied by the MCO immediately, or through its grievance and quality of care service procedures.

h. Other.

None specified.

  1. LTSS Performance Measures Requirements
LTSS performance measures required by the state focus on:
  • Antidepression medication management.
  • Follow-up after hospitalization for mental Illness.
  • Drugs to be avoided in the elderly.
  • Falls.
  • Number of screens conducted on a quarterly basis.
  • Quality of preparation offered to patients for post-hospital care.
  1. PIP Requirements
The MCO is required to conduct at least 5 PIPs of which at 2 are non-clinical.
  1. EQRO Requirements
The MCO's quality program shall be examined using a series of required validation procedures conducted by the state or the EQRO. This includes PIPs, performance measures, and a review of standards established by the state. The state also reserves the right to include additional optional activities if additional funding becomes available and as mutually negotiated between the state and the MCO.

The MCO is required to submit to annual EQRO monitoring review using data collection tools and methods to assesses the MCO's compliance with regulatory requirements and standards of the quality outcomes and timeliness of, and access to, services provided by the MCO. In addition, the contract monitoring tool shall include specific contract regulations relating to MH, long-term care, and chemical dependency.

The MCO is required to provide evidence of how external quality review findings, agency audits and contract monitoring activities, enrollee grievances, are used to identify and correct problems and to improve care and services to enrollees.

  1. Care Coordination Requirements
a. Assessment tool requirements.

The MCO is required to provide an initial screening and needs assessment but contract does not specify whether a uniform tool must be used. However the MCO is required to conduct a screening for dementia using the state's approved dementia screening tool.

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 is required to ensure continuity of care and if possible and reasonable, shall preserve enrollee provider relationships through transitions.

e. Risk assessment and mitigation requirements.

None specified.

  1. Ombudsman (Function) Requirements
None specified.
  1. Quality-Related Financial Incentives
None specified.
  1. Experience of Care/ Satisfaction Feedback Requirements
None specified.
  1. LTSS Quality Review
The MCO is required to provide an annual report on long-term care service utilization data for enrollees must provide unduplicated counts in the following categories in dollars and the total number of unduplicated clients that received:
  • Personal care;
  • Environmental modification;
  • PERS installation and service;
  • Adult day care;
  • Home-delivered meals;
  • Home health aide;
  • Skilled nursing;
  • Client training;
  • Specialized medical equipment and supplies;
  • Nurse delegation (in-home);
  • Adult family home;
  • Enhanced residential care;
  • Community transition services;
  • Assisted living.

In addition, The MCO must track and report service days paid for all WMIP enrollees to licensed boarding homes that have an Assisted Living contract with the state.

CI = critical incident
CMS = Centers for Medicare and Medicaid Services
DSHS = Washington Department of Social and Health Services
EQRO = external quality review organization
IT = information technology

LTSS = long-term services and supports
MCO = managed care organization
MH = mental health
PERS = Personal Emergency Response System
PIP = performance improvement project

QAPIP = Quality Assessment and Performance Improvement Plan
QI = quality improvement
SSI = Supplemental Security Income
WMIP = Washington Medicaid Integration Partnership

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