Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix Q. Wisconsin Family CARE


  Element     Description/Notes  
State and Lead Agency Wisconsin Department of Health Care Services, Division of Long-Term Care
Program Family Care
Inception 1999
Year LTSS Added 1999
Medicaid Authority 1915(b)/(c)
# Enrolled 33,141
Group Enrolled IDD, aged and physically disabled.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

MCO's are required to have a governing board accountable for the MCO's QM program, a manager responsible for implementation of the QM plan with authority to deploy the resources committed to it, and a QM committee or other coordinating structure. The QM committee includes both administrative and clinical personnel to facilitate communication and coordination among all aspects of the QM program and between other functional areas of the organization that affect the quality of service delivery and clinical care.

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

MCOs are required to create a means for MCO staff and providers, including attendants, informal caregivers, and long-term care and health care providers with appropriate professional expertise to participate in the QM program. MCO are required to monitor the performance of subcontracted providers and collect evidence that both licensed/certified providers and non-licensed/non-certified providers continuously meet required licensure, certification, or other standards and expectations, including caregiver background checks, education or skills training, and reporting of CIs to the MCO. If the MCO identifies deficiencies or areas for improvement, the MCO and the provider(s) shall take corrective action.

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

The MCO will conduct an ongoing program of reviews that collects evidence that:

  • Appropriate risk assessments are performed on a timely basis.
  • Members participate in the preparation of the care plan and are provided opportunities to review and accept it.
  • MCPs address all participants' assessed needs (including health and safety risk factors) and outcomes.
  • MCPs are updated and revised in accordance with the applicable standards for timeliness and when warranted by changes in the members' needs and outcomes.
  • Services are delivered in accordance with the type, scope, amount, and frequency specified in the MCP.
  • Members are afforded choice among covered services and providers.
d. IT requirements in support of quality monitoring and reporting.

MCOs are required to maintain an information system that collects, analyzes, integrates, and reports data to support the objectives of the QM program. The system must provide information on areas including grievances, appeals, and disenrollments. It also includes systematic data related to:

  • Achievement of member outcomes.
  • Performance indicators for internal use that are relevant and timely for QM purposes.
  • Interpretation of the indicators to care managers and providers.
e. CI investigation processes and associated reporting requirements.

The state defines a CI as a circumstance, event or condition resulting from action or inaction that is either associated with suspected abuse, neglect, financial exploitation, other crime, a violation of member rights, or any unplanned, unapproved use of restrictive measures; or that resulted in serious harm to the health, safety or well-being of a member, substantial loss in the value of the personal or real property of a member; resulted in the unexpected death of a member; or posed an immediate and serious risk to the health, safety, or well-being.

The MCO is required to adopt and carry out policies governing the processes used for identification, review and analysis of each CI to ensure that CIs are reported to designated MCO staff by providers or by MCO staff within 1 business day after the incident or death was discovered. MCOs are required to take steps immediately to prevent further harm. Incidents where there is a potential violation of criminal law are reported to local law enforcement authorities. Incidents meeting protective service criteria are reported in accordance with the applicable statute to the appropriate authority.

This investigation shall be completed within 30 calendar days unless information or findings necessary for completion of the investigation cannot be obtained within that time for reasons outside of the MCO's control, in which case the investigation should be completed as promptly as possible.

The MCO is required to have designated staff to conduct CI investigations to determine:

  • Whether the reported incident occurred and the facts of the reported incident.
  • The type and extent of harm experienced by the member.
  • Any actions that were taken to protect the member and to halt or ameliorate the harm.
  • Whether reasonable actions by the provider or others with responsibility for the well-being of the member would have prevented the incident.
  • Whether any changes in the MCO's or provider's policies or practices might prevent occurrence of similar incidents in the future.

MCOs are required to have an ongoing program of collecting information about adverse events, monitoring for patterns or trends, and using that information in the QM program. MCOs are required to compile and submit quarterly report to the state on information related to its identification of and response to CIs, the date the MCO incident analysis was completed and a brief description of any policies or standard practices that have been or will be changed or adopted to prevent similar incidents in the future.

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

The MCO is required to have a QM program that include processes to:

  • Monitor and detect under utilization and over utilization of services.
  • Assess the quality and appropriateness of care furnished to members.
  • Have appropriate health professionals reviewing the provision of health services.
  • Provide for systematic data collection of performance and results.
  • Provide for making needed changes.
g. Mechanisms for handling complaints/grievances/appeals, and associated reporting requirements.

MCOs are required to have a grievance and appeal system that is responsive to concerns raised by members. The MCO must dispose of each grievance and resolve each appeal, and provide notice of a final decision, as expeditiously as the member's health condition requires, within timeframes that may not exceed the state established timeframes.

h. Other.

Use of Isolation, Seclusion and Restrictive Measures--MCOs and its subcontracted providers are required to follow the states' written guidelines and procedures on the use of isolation, seclusion and restrictive measures in community settings, and follow the required process for approval of such measures.

24-Hour Coverage--The MCO is responsible 24/7 for providing members with services necessary to support outcomes including immediate access to urgent and emergency services to protect health and safety, access to services in the benefit package and linkages to protective services.

  1. LTSS Performance Measures Requirements
The contract states that the state may specify MCO performance measures. The MCO is required to specify 1 or more quality indicators specified for each PIP.
  1. PIP Requirements
MCOs are required to work with the state and EQRO to complete PIPs using a performance improvement model or method based on the state's defined process. While the PIP is in the planning stage, the MCO must submit the study questions and the project aims or goals to be reviewed by the state or the EQRO. PIPs must be approved by the state. MCOs are required to submit interim reports and document ongoing progress.

Each PIP must clearly define a focus area that relates to the demographic characteristics and to the prevalence and potential consequences of the desirable or undesirable conditions among the MCO's membership. The planned improvements should affect either a significant portion of the members or a clearly specified sub-portion. The focus area should be selected on the basis of data collection and analysis of members' needs, care, and services, or on the basis of member input. MCO's PIPs address a broad spectrum of key aspects for member care and services in both clinical and non-clinical focus areas.

Each year, the MCO shall make active progress on at least 1 PIP relevant to long-term care, and for those MCOs that include primary and acute care in the benefit package, 1 additional PIP relevant tor primary and acute care. The MCO may satisfy this requirement by actively participating in a collaborative PIP in conjunction with 1 or more MCOs. Each PIP must be completed in a reasonable time period so as to generally allow information on the success of the PIP in aggregate to produce new information on quality of care every year. The state may require specific topics for PIPs and specify performance measures.

The MCO are required to report annually to the state on the status and results of each PIP.

  1. EQRO Requirements
The MCO is subject to an annual external independent review of quality outcomes, timeliness, and access to the services covered in the benefit package. The MCO must assist EQRO in identifying and collecting information required to carry out on-site or off-site reviews and interviews with MCO staff, providers, and members.

In the event that a review by the EQRO results in findings that concern the state, the MCO will cooperate in further investigation or remediation, which may include:

  • Revision of a care plan or any of its elements for correction, if found to be incomplete or unsatisfactory.
  • Corrective action within a timeframe to be specified in the notice, if the effect on the member is determined to be serious.
  • Additional review to determine the extent and causes of the noted problems.
  • Action to correct systemic problems that are found to be affecting additional members.
  1. Care Coordination Requirements
a. Assessment tool requirements.

Each MCO is required to use an assessment tool developed or approved by the state to document the information collected to assess the availability and stability of the participant's informal and supports and community supports, the member's preferred living situation and a risk for the stability of housing and finances. MCOs are required to document the member's outcomes, clinical and functional concerns.

b. Care coordinator to LTSS member ratio requirement.

None specified.

c. Frequency and nature of LTSS member monitoring.

MCOs are required to conduct a face-to-face visit with a member during each quarter of the calendar year. After the first 6 months of enrollment, if MCO staff has established a relationship with the member staff can waive the minimum standard but a member must receive at least 1 face-to-face visit each year.

d. LTSS/acute care coordination requirements.

As part of an IDT, MCO Care Managers provide individualized assessment and care planning, authorizing, arranging and coordinating services in the MCP and periodic reassessments and updates of the MCP. The comprehensive assessment includes an initial and ongoing member-centered planning process employed by the IDT to identify the member's outcomes and the services and supports needed to help support those outcomes. It includes an ongoing process of using the knowledge and expertise of the member and caregivers to collect information about the member's:

  • Needs, strengths and outcomes.
  • Resources, informal supports and community connections.
  • Close family members and friends.
  • Ongoing conditions or other risk factors that require a course of treatment or regular care monitoring.
  • Preferences for the way in which the services and supports will be delivered.

Care management also includes assistance in filing grievances and appeals, maintaining eligibility, accessing community resources and obtaining advocacy services.

e. Risk assessment and mitigation requirements.

MCOs are required to have policies and procedures in place regarding member safety and risk which shall be submitted to the state for approval. These policies and procedures shall identify how IDT staff will assess and respond to risk factors affecting members' health and safety and guidelines for use by IDT staff in balancing member rights with member safety through a process of ongoing negotiation and joint problem solving.

MCOs are required to develop a MCP to identify clinical and functional needs of the member identified by the MCO IDT which the member may not want to receive assistance with at this time, but for health and safety reasons the IDT staff need to recognize and attempt to mitigate.

MCOs are also required to have a mechanism to monitor, evaluate and improve its performance in the area of safety and risk issues. These mechanisms shall ensure that the MCO offers individualized supports to facilitate a safe environment for each member. The MCO shall assure its performance consistent with the understanding of the desired member outcomes and preferences. The MCO is required to include family members and other informal supports when addressing safety concerns per the member's preference.

  1. Ombudsman (Function) Requirements
MCO must designate a "Member Rights Specialist" who is responsible for assisting members when they are dissatisfied and offering assistance to members in submitting grievances or appeals and may be responsible for scheduling and facilitating meetings. The Member Rights Specialist may not represent the MCO at a hearing of the MCO grievance and appeal committee, in a state review or at a fair hearing. In addition, MCOs are required to provide members with a Member Handbook which includes information about Ombudsman and independent advocacy services available as sources of advice, assistance and advocacy.
  1. Quality-Related Financial Incentives
None specified.
  1. Experience of Care/ Satisfaction Feedback Requirements
MCOs are required to survey members or a representative sample of members to identify their level of satisfaction with the MCO's services. This survey shall include a set of standard questions provided by the state and the MCO shall compile these results and provide them to the state.
  1. LTSS Quality Review
Each year, MCOs must develop a QM work plan that outlines the scope of activity and the goals, objectives, timelines, and responsible person for the QM work plan for the contract period. The work plan will also contain evidence of the MCO's commitment of adequate resources to carry out the program. MCOs are required to submit quarterly reports that includes an analysis and trends of the following components:
  • Copies of newspaper or magazine articles about the MCO that appeared during the quarter.
  • CI response reports.
  • Appeal and grievance summary and logs.
  • Provider appeals log.

MCOs are required to maintain documentation of the following activities:

  • Annual QM work plan and its approval by the governing board.
  • Monitoring the quality of assessments and MCPs.
  • Monitoring the completeness and accuracy of completed functional screens.
  • Member satisfaction surveys.
  • Provider surveys.
  • Response to CIs.
  • Monitoring adverse events, including appeals and grievances that were resolved as requested by the members.
  • Monitoring access to providers and verifying that the services were actually provided.
  • PIPs.
  • Results of the annual evaluation of the QM program.
  1. Other
QM Plan--MCOs are required to develop an annual QM plan based on findings from QA and improvement activities included in the QM program. The MCO shall evaluate the overall effectiveness, including the impact, of its QM program annually to determine whether the program has achieved significant improvement, where needed, in the quality of service provided to its members.
CI = critical incident
EQRO = external quality review organization
IDD = intellectual and developmental disabilities
IDT = interdisciplinary team
IT = information technology

LTSS = long-term services and supports
MCO = managed care organization
MCP = member-centered plan
PIP = performance improvement project
QA = quality assurance

QM = quality management

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