Environmental Scan of MLTSS Quality Requirements in MCO Contracts. III. Scan Highlights


Below we highlight what the scan revealed about the quality requirements MLTSS states choose to include in contracts with MCOs. In some instances there is wide diversity in what the contracts require and in others more convergence. Also, contracts may require the same quality element but one may be very prescriptive and specific about how the requirement is to be carried out and yet another may leave the details of implementation to the MCO discretion. The highlights below provide the reader with a flavor for these similarities and differences.

Presumably, the quality requirements imbedded in the contracts are those that the state deems critical for the delivery of high quality services and for maximizing the health and well-being of members served by these entities. However, we caution that the state summaries do not necessarily present a full description of the QM requirements in each program. The summaries and our review of them present only what appears in the contracts. State practices may vary to the extent to which contract quality requirements wholly represent quality practices in each state.

The matrix represented in Exhibit 1 provides a high-level overview of the types of quality requirements found in each state's MCO MLTSS contract.

  1. Quality Management Infrastructure Requirements

    1. Staffing Requirements for Quality Oversight and Reporting. Although 16 of the 17 contracts reviewed include language related to staffing requirements for quality oversight and monitoring, there is a wide variety of requirements.

      • In Arizona, MCOs must ensure that the QM/Quality Improvement (QI) Unit within the organizational structure is separate and distinct from any other units or departments.
      • In Hawaii and Illinois, the MCO Medical Directors are responsible for overseeing MCO quality programs.
      • Tennessee MCOs are required to have a quality committee that oversees the quality functions and a staff person responsible for all quality activities. The quality committee is required to notify the state of meetings in a timely fashion and to the extent allowed by law; the state may attend the QM/QI committee meetings.
      • Wisconsin MCOs are required to have a governing board accountable for the QM program and a manager responsible for implementation of the QM plan with authority to deploy the resources committed to it.
      • Texas MCOs must designate key executive staff with responsibility for QI and must notify the state if there is any change in this key position.
    2. Staffing and Processes for Provider Monitoring and Reporting Requirements. All 17 states include language in their contracts related to provider monitoring. Most require that MCOs engage in credentialing and re-credentialing of providers.

      • MCOs in Minnesota must submit annual reports to the state that include a complete list of participating providers with name, specialty, and address.
      • New Mexico requires MCOs to have a credentialing committee to make recommendations regarding credentialing decisions.
      • North Carolina requires MCOs to measure the performance of providers and conduct peer review activities such as identification of practices that do not meet plan standards, recommendation of appropriate action to correct deficiencies, and monitoring of corrective action by providers.
    3. Staffing Requirements and Processes for Care Coordinator Monitoring and Reporting. Eleven of the 17 states include language in their contracts related to care coordinator staffing and/or processes for oversight of care coordinators.

      • Wisconsin MCOs are required to conduct ongoing program reviews and collect evidence to demonstrate that appropriate risk assessments are performed on a timely basis, member-centered plans address all participants' assessed needs, assessments are updated and revised accordingly, and services are delivered in accordance with the service plan.
      • In Arizona, MCOs are required to provide an annual case management plan which outlines how all case management and administrative standards will be implemented and monitored by the MCO.
      • In Massachusetts, the MCO (called the Senior Care Organization [SCO]) is required to monitor care coordination agencies to ensure that their performance and qualification requirements are met.
    4. Information Technology Requirements in Support of Quality Monitoring and Reporting. All 17 states include language in their contracts related to information technology requirements. However, several contracts are generic with regard to information technology and the functions it must support. Examples of contracts that call out information technology support for quality activities include:

      • Delaware, Florida, Michigan, New Mexico and Wisconsin require MCOs to maintain a health information system that provides information on quality areas including service utilization, grievances and appeals.
      • North Carolina MCOs are required to maintain an information system that collects, analyzes, integrates, and reports data for recipients with behavioral health, developmental disability, and substance abuse treatment needs.
      • Texas requires MCOs to maintain an information system that supports all quality functions of the MCOs as well as their subcontractors.
    5. Critical Incidents Reporting/Investigation Requirements. Fourteen states include language in their contracts that require MCOs to have critical incident reporting processes and many of these states enumerate the actual critical incidents that they must incorporate into their systems. In addition, some states require the MCO to contact the state in the event of certain critical incidents (e.g., deaths, abuse, neglect, exploitation).

      • Wisconsin requires MCOs to have designated staff to conduct critical incident investigations and to determine whether any changes in the MCO or provider policies or practices might prevent occurrence of similar incidents in the future.
      • Michigan requires that the Pre-paid Inpatient Health Plans (PIHPs) (MCO entities in Michigan) notify the state immediately of any deaths.
      • Florida requires that MCOs contact the state within 48 hours when there is any incident that may jeopardize the health, safety and welfare of an enrollee or impair continued service delivery.
      • Massachusetts requires SCOs to inform the state the next business day when there is an incident related to abuse, neglect or exploitation.
      • Hawaii does not require the MCO to have a critical incident system but does require the MCO to report instances of abuse, neglect, and exploitation to the appropriate state agency.
    6. Required Mechanisms for Monitoring Receipt of LTSS Services. Ten states include contract language related to mechanisms for monitoring receipt of community LTSS services and associated reporting requirements. There is a fair amount of variability in these monitoring mechanisms from the real-time Electronic Visit Verification (EVV) System in Tennessee (where the MCO is alerted to late receipt of services in a member's service plan) to retrospective verification of service receipt for which a provider has billed.

      • Kansas and Tennessee MCOs are required to use an EVV System to monitor the receipt and utilization of LTSS services. The EVV System logs the arrival and departure of a provider staff person, verifies the identity of the individual provider staff person, and provides immediate notification to care coordinators if a provider does not arrive as scheduled.
      • The MCOs in Pennsylvania and Wisconsin must have a mechanism to detect both under utilization and over utilization of services.
      • MCOs in Michigan and Delaware must verify that services reimbursed by Medicaid were actually furnished to enrollees by a provider (although this does not necessarily guarantee that the services/supports in the member's service plan were delivered).
    7. Required Mechanisms for Handling Complaints, Grievances, Appeals, and Associated Reporting. Sixteen states include language in their contracts related to MCO mechanisms for handling complaints, grievances, and appeals. This is not surprising given that grievances and appeals are a fundamental Medicaid requirement and spelled out in detail in the federal Medicaid managed care regulations.5 What is interesting is the variability in how this requirement is delegated to the MCOs.

      • Delaware MCOs are required to maintain records of grievances and appeals and must review and analyze the information as part of the state quality strategy and take any corrective action as a result of this analysis.
      • In Kansas, MCOs must provide a system to track and document all grievances and must develop a database extract file that can be imported into the state fiscal agent's grievance database.
      • Massachusetts SCOs must report the number and types of complaints filed by enrollees and must cooperate with the state to implement improvements based on the findings of these reports.
      • The MCOs in New Mexico must designate a member grievance coordinator with the authority to administer policies and procedures for resolution of a grievance or appeal and review patterns and trends to initiate corrective actions as-needed.
      • In Tennessee, each MCO is required to devote a portion of its regularly scheduled quality committee meeting to review member complaints and appeals.
  2. Required LTSS Performance Measures

    Thirteen states include language related to LTSS performance measures in their MCO contracts. Some measures focus on the processes for response time to respond to referrals, timeliness of receipt of covered services, timeliness of care plan implementation, process for handling critical incidents, and process for coordination of services. Examples of these process measures include:

    • Percent of members offered an initial appointment within ten days of initial contact.
    • Percent of appeals resolved as expeditiously as the enrollees' health condition requires.
    • Percent of beneficiaries receiving a pre-admissions screening for psychiatric inpatient care for whom the disposition was completed within three hours.
    • Percent of new beneficiaries receiving a face-to-face meeting with a professional within 14 calendar days of a non-emergency request for service.
    • Percent of complaints received and resolved.
    • Percent of grievances received and resolved.
    • Percent of discharges from a psychiatric inpatient unit seen for follow-up care within seven days.
    • Percent of re-admissions at 30 days, 90 days and one year from last discharge from state mental health hospital, psychiatric inpatient program, or Psychiatric Residential Treatment Facility.
    • Percent of new enrollees who have met with their service coordinator.
    • Percent of enrollees diagnosed with dementia who are receiving geriatric support services.
    • Percent increase in enrollees that receive participant-directed personal care.
    • Percent of depression screens conducted on a quarterly basis.

    Several contracts also specify outcomes related to community retention rate, rate of preventable hospital admissions, rates of nursing facility (NF) and chronic hospital admission. Examples of outcome performance measures in the reviewed contracts include:

    • Percent of enrollees reporting their physical health as good.
    • Percent of enrollees reporting they are connected to the people who support them the most.
    • Percent of enrollees reporting they are doing what they want for their work.
    • Percent of enrollees who report having a place to live that is comfortable for them.
    • Percent mentally ill/developmentally disabled beneficiaries who are in competitive employment.
    • Percent of mentally ill/developmentally disabled beneficiaries readmitted to an inpatient psychiatric unit within 30 days of discharge.
    • Percent of mentally ill/developmentally disabled beneficiaries who live in a private residence alone, or with spouse or non-relative.
    • Reduction in law enforcement involvement.
    • Reduction in psychiatric inpatient and emergency room hospitalizations.
    • Reduction in law enforcement involvement.
    • Reduction in mental health crisis interventions.
    • Reduction in falls.
    • Increase in percentages of participants with jobs or volunteer opportunities.

    One cannot assume that because a contract does not enumerate performance measures that the MCO has no responsibility for reporting measures and using them as barometers for performance and improvement. Tennessee's contract is a good example. While no performance measures are specifically articulated in that contract, the quality reports that the MCO is required to produce clearly include information that measure the MCO's performance in multiple domains.

  3. Required Performance Improvement Projects (PIPs)

    All 17 states require that MCOs carry out 2-3 PIPs that focus on clinical and non-clinical areas. This is not surprising given that CFR 438 requires "an ongoing program of PIPs that focus on clinical and non-clinical areas."6 Indeed much of the PIP language in many of these contracts is taken verbatim from CFR 438 and the reader will observe this in the contract summaries in the Appendices.

    What we were most interested in learning from the scan was whether contracts specified PIPs related specifically to the LTSS nature of the program (i.e., PIPs focusing on clinical conditions/outcomes or non-clinical services/providers/ outcomes for the LTSS population(s) served). The language in the contracts is often vague enough that it is difficult to tell whether there are any LTSS-related PIP requirements. Out of the seventeen contracts, only two clearly articulated LTSS-specific PIP requirements.

    • In Washington, MCOs must collaborate with peers to conduct one non-clinical statewide PIP focused on enrollees with special health care needs or who are at risk for re-institutionalization, re-hospitalization, or substance use.
    • Tennessee requires MCOs to perform at least one PIP relevant to one of the behavioral health disease management programs for bipolar disorder, major depression, or schizophrenia.
  4. Required Involvement with the External Quality Review Organization (EQRO)

    All 17 states include language regarding the role of an EQRO which includes validation of performance measure data and PIP--also expected given the CFR 438 requirement for an external quality review.7 Again, the reader will observe in the Appendices contract summaries, states have dropped into the documents verbatim language from CFR 438. Most include language that requires MCOs to cooperate with the EQRO.

  5. Care Coordination Requirements

    1. Assessment Requirements. Fourteen states require that MCOs use either a state assessment form or a form approved by the state to determine member needs and/or level of care eligibility for the LTSS program.

    2. Care Coordinator/Member Ratio Requirements. Only six states include language in their MCO contracts that establish caseload ratios.

      • Caseload maximums in Arizona are calculated based on a weighting scheme that takes into account the care coordinators' mix of members (HCBS, NF, Assisted Living, etc.).
      • Tennessee MCOs are not held to a specified caseload ratio but are required to provide monthly reports to the state on staffing ratios.
      • MCOs in Delaware must maintain varying case manager staffing ratios for members in NFs, those receiving HCBS, and Money-Follows-the-Person participants.
      • Illinois' ratios are based on level of case management need (intensive versus supportive) of enrollees.
      • In Hawaii, service coordinator caseloads cannot exceed 1,880 hours annually. Hawaii also has limits on the number of members a service coordinator is allowed to serve.
      • Minnesota requires MCOs to submit policies and criteria for caseload ratios to the state for review.
    3. Frequency and Nature of Member Monitoring Requirements. One of the major functions of most care coordination is to monitor the service delivery to and well-being of members. Ten state contracts specify expectations about how these functions will be carried out.

      • Delaware MCOs must conduct on-site member reviews at least every 180 days for members in an institutional setting and every 90 days for a member receiving HCBS.
      • Service coordinators in New Mexico are required to meet face-to-face with members at least once quarterly and by telephone contact at least once monthly.
      • In Massachusetts, SCOs must perform needs assessments at least every six months or whenever an enrollee experiences a major change. A quarterly assessment is required for enrollees who require complex care.
      • In Pennsylvania, the MCO must review the plan at least every three months and after each episode that triggers implementation of crisis intervention or the use of a restraint.
      • In Wisconsin MCOS are required to conduct face-to-face visits with a member every three months. After the first six months of enrollment, if the MCO staff has established a relationship with the member, the minimum standard can be waived but a member must receive at least one face-to-face visit each year.
    4. LTSS-Acute Care Coordination Requirements. Regardless of whether a program offers both managed medical care and LTSS or just MLTSS, coordination of medical and LTSS is in the member's best interest. Indeed coordination is one of the hallmarks of managed care. It is interesting to observe that nearly all the contracts (16) include clauses requiring such coordination.

      • Illinois requires MCOs to establish a community-based Integrated Care Team that consists of a care coordinator, community liaison, and service provider representative. The team is supported by the MCO's medical staff. If an enrollee is receiving medical care or treatment in an acute care hospital, the MCO is required to assume responsibility for the management of such care.
      • Florida MCOs must ensure that all subcontractors delivering services covered by the contract agree to cooperate with the goal of an integrated and coordinated service delivery system for the enrollee.
      • In Hawaii, MCOs are required to have a patient-centered, holistic, service delivery approach to coordinating member benefits across all providers and settings.
      • Minnesota requires MCOs to provide case management services that are designed to ensure access to, and coordinate the delivery of preventive, primary, acute, post-acute and rehabilitation services by providing each enrollee with a primary contact person who will assist the enrollee in simplifying access to services and information. The contract also requires MCOs to develop and implement written policies and procedures that ensure that health and social service delivery is coordinated across providers and service systems.
      • Washington requires MCOs to have written operational agreements with the state, community physical and behavioral health hospitals, long-term care facilities, and drug and alcohol treatment programs for the purpose of facilitating transitions of care for enrollees.
    5. Risk Assessment and Mitigation Requirements. Nine states include requirements related to risk assessment and mitigation in their MCO contracts but they vary in the type of risk focused upon and whether mitigation requirements are specified.

      • Illinois requires MCOs to indentify categories of risk for enrollees (no risk, moderate risk or high risk) using a health risk questionnaire.
      • In Massachusetts, SCOs must have protocols to monitor risk assessment mechanisms to identify enrollees at risk of institutionalization or hospitalization for pneumonia, dehydration, injuries from falls, skin breakdown, loss of informal caregiver, and non-compliance with treatment programs.
      • Aiming at risk mitigation, MCOs in Tennessee must conduct a risk assessment using a state-specified tool and protocol and develop, as applicable, a risk agreement to be signed by the applicant or his/her representative. The agreement must 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.
      • In Wisconsin MCOs are required to have a mechanism to monitor, evaluate and improve their performance in the area of safety and risk issues.
  6. Ombudsman--Like Functions Requirements

    Eight states address either the availability of an Ombudsman program or require the MCO to fulfill some ombudsman-like functions (e.g., member advocacy) in their contracts.

    • Wisconsin, Tennessee, Massachusetts and Hawaii include language that references an external or state Ombudsman program/service to which the MCO can refer members.
    • Minnesota has established a state Ombudsman office for managed care enrollees and MCOs are required to inform the enrollee of assistance available through this office.
    • Texas and Delaware require MCOs to employ member advocates to work with members and providers to facilitate the provision of benefits.
    • Tennessee requires MCOs to have a consumer advocate for members responsible for internal representation of members' interests and member, family, and provider education.
    • In Texas, MCOs must provide advocates to assist members in writing or filing an appeal and monitoring the appeal through the MCO's appeal process until the issue is resolved.
  7. Financial Incentives for Performance

    Nine states include financial incentives for performance in their contracts with MCOs.

    • Illinois, Kansas, Minnesota and Texas have established an incentive pool from which MCOs may earn payments based on performance with respect to specific quality metrics. To fund the pool, states withhold a portion of the MCOs capitation rate. In addition, Texas has created a Quality Challenge Award to reward MCOs that demonstrate superior clinical quality, service delivery, access to care, and/or member satisfaction as determined by the state.
    • New Mexico's contract indicates that the state may provide incentives to MCOs that receive exceptional grading for ongoing performance for quality assurance standards, performance indicators, etc.
    • Tennessee and Hawaii have incentives for meeting established performance and quality goals using Health Effectiveness Data and Information Set measures and other benchmarks.
    • Michigan has established monetary awards for PIHPs showing relative improvement over the previous fiscal year without receiving a non-compliance score in the site review.
  8. Experience of Care/Satisfaction Feedback Requirements

    Nine states include language in their contracts related to experience of care/satisfaction surveys or focus groups. That said, language in the contracts was not always specific enough to determine if the required feedback mechanism included a focus on LTSS as most of the examples below exhibit. Some states may assume this responsibility or employ an independent vendor for this purpose rather than delegate this activity to MCOs. Thus the reader should not assume that if such a requirement is not included in the MCOs contract that the state does not have a LTSS feedback mechanism in place.

    • Delaware MCOs must survey their members on an annual basis and must agree to collect and assist the state in gathering annual member satisfaction data through application of a uniform instrument to a randomly selected sample of its members.
    • In Florida, the MCOs are required to conduct an enrollee satisfaction survey for members having received long-term care services.
    • Michigan PIHPs are required to conduct periodic surveys and focus groups to assess member experiences with its services addressing issues of the quality, availability, and accessibility of care.
    • SCOs in Massachusetts must administer an annual survey to all enrollees and report the results to the state. SCOs must conduct one survey or focus group with each of the following groups: non-English speaking enrollees, persons with physical disabilities, enrollees from a minority ethnic group served by the SCO, and family members and significant caregivers of enrollees.
    • In New Mexico, MCOs must conduct at least one annual survey of member satisfaction with input from the Consumer Advisory Board and the state to assess member satisfaction with quality, availability, and accessibility of services.
    • North Carolina MCOs are required to conduct a patient satisfaction survey annually using a survey instrument approved by the state and administered by an outside vendor.
    • In Wisconsin, MCOs are required to survey members or a representative sample to identify member level of satisfaction with the MCO's services using a set of standardized questions provided by the state.
  9. Quality Improvement Reports

    Sixteen states include language in their MCO contacts related to LTSS Quality Reports. Some states require quarterly reports and others require annual reports. Some examples of the information/data that MCOs must report to the state include:

    • Critical incidents such as hospitalizations, falls resulting in hospitalizations, behavior resulting in injury to self or others, medical errors resulting in hospitalizations, deaths, etc.
    • Results of member satisfaction/experience of care surveys.
    • Performance data for specific performance measures.
    • Complaint, grievance and appeal reports.
    • MCO program goals, objectives, work plans, timetables for implementation, accomplishments, and improvements.
    • Reports of preventable hospitalizations and admissions/discharges from nursing homes facilities.
    • Number of members engaged in meaningful employment.
    • Late and missed provider visit reports.
    • Provider recognition and training reports.
EXHIBIT 1. MLTSS MCO Quality Contract Requirements
Requirements   AZ     DE     FL     HI     IL     KS     MA     MI     MN     NM     NY     NC     PA     TN     TX     WA     WI  
Staffing for Quality Oversight * * * * * * * *   * * * * * * * *
Provider Monitoring * * * * * * * * * * * * * * * * *
Care Coordinator Monitoring *   * * * * *   *     *   * *   *
Information Technology * * * * * * * * * * * * * * * * *
Critical Incident Processes * * * * * * * *   *   * * *   * *
Monitoring Receipt of LTSS Services     * *     * * *     *   * *   * *
Complaints, Grievances, Appeals * * * * * * *   * * * * * * * * *
LTSS Performance Measures *     * * * * *   * * * *   * * *
EQRO * * * * * * * * * * * * * * * * *
Assessment Tools *   * * * * *   *   * * * * * * *
Care Coordinator-Member Ratio * *   * *       *         *      
Frequency of Member Monitoring * * *     * *   * *     * *     *
LTSS-Acute Care Coordination * * * * * * *   * * * * * * * * *
Risk Assessment and Mitigation       * * * *   * *     * *     *
Ombudsman * *   *     *   *         * *   *
Quality-Related Financial Incentives   *   * * *   * * *       * *    
Experience of Care   * *       * * * *   * *       *
Quality Improvement Reports * * * * * * *   * * * * * * * * *

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