Environmental Scan of MLTSS Quality Requirements in MCO Contracts. I. Introduction

09/01/2013

A growing number of states have now decided to expand their managed care programs to encompass Long-Term Services and Supports (LTSS). From 2004 to 2012, the number of states with Medicaid managed LTSS (MLTSS) programs doubled from eight to 16, and ten more states are projected to implement MLTSS programs by 2014.1 With this move comes a major change in roles for quality oversight with states placing substantial responsibility for monitoring and quality reporting on the managed care organizations (MCO) with which they contract. One avenue for understanding how states are delegating these responsibilities is through an environmental scan of the contracts that states have negotiated with MCOs.

Between June and August 2013, Truven Health Analytics conducted an environmental scan of 17 state contracts with MCOs for Medicaid MLTSS programs. The focus of this scan is on the quality requirements specified in these contracts. The scan explores required components of quality in these contracts spanning:

  • MCO quality management (QM) infrastructure (including staffing);
  • Provider monitoring;
  • Mechanisms for tracking receipt of services;
  • Critical incident reporting;
  • Risk assessment and mitigation;
  • Performance measure reporting;
  • Performance improvement projects (PIPs);
  • MCO involvement in External Quality Review Organization (EQRO) activities;
  • Care coordination requirements related to maximizing the health and welfare of members;
  • Ombudsman-like functions that the MCO is required to provide to members;
  • Quality-related financial incentives;
  • Member feedback mechanisms (Experience of Care, satisfaction surveys, focus groups);
  • Quality reports.

In the body of this report, we describe how frequently the various quality elements appear in the contracts, as well as some similarities and differences in quality requirements.

The Appendices at the end of the report provides individual summaries for each contract reviewed. In developing these summaries, we imported language from the contracts when practical. As such, much of the text in these entries has a legalistic flavor. In some instances, the contract language might be interpreted to invoke the quality requirement of interest, but unless it was clearly articulated as required, we did not represent it as required. In many instances (as practical) we have maintained fidelity to the contract language so that the reader may make his/her own determination.

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