Quality in Managed Long-Term Services and Supports Programs. Appendix B. Michigan's Managed Specialty Supports and Services


  Element     Description  
MLTSS Program Medicaid Managed Specialty Supports and Services Concurrent 1915(b)/(c) Waiver Program
Lead Agency Michigan Department of Community Health (MDCH)
Medicaid Authority 1915(b) Specialty Services Waiver
1915(c) Habilitation Supports Waiver
Inception 1998 for 1915(b)--serving persons with mental illness and DD.
2002 for 1915(c)--provides additional services (private duty nursing and goods/services), for subgroup of DD population.
Year LTSS Added From inception.
Groups Enrolled Persons with Mental Illness, DD and Dually Diagnosed.
# Enrolled 172,527
Data Source: Section 404(1): Community Mental Health Services Support Programs Report, May 31, 2013.
  1. State Quality Oversight Infrastructure
The Division of Quality Management and Planning (within the Behavioral Health and Developmental Disabilities Administration, Bureau of Community Mental Health Services, MDCH) is the entity responsible for quality oversight of the program.

This Division is comprised of 3 sections:

  • Data Section: Responsible for receiving and analyzing Performance Indicator data from the 18 PIHPs27, 28--the MCO entities with which Michigan contracts and oversees the EQRO contract. Three staff is assigned to this section.
  • Service Innovation Section: Responsible for providing technical assistance to the PIHPs. Eight Program Specialists comprise this section.
  • Federal Compliance Section: Responsible for overall management of the MLTSS program, for PIHP site reviews, and for analysis of quality data. Once fully staffed, this section will have 8 staff members.

The PIHPs are certified by the MDCH. If a PIHP (or subcontractor) is accredited by the Joint Commission, CARF, the Council on Accreditation, certification may be granted for up to 3 years but the MDCH also conducts a limited review of the agency.

All must be licensed or accredited. Licensing is conducted by the Department of Licensing and Regulatory Affairs which shares licensing findings with the Behavioral Health and Developmental Disabilities Administration.

Residential providers are certified by the MDHS. Problems identified by MDHS are forwarded to the MDCH for follow-up.

A Behavior Treatment Review Committee is charged with reviewing and approving/disapproving any plans that propose to use restrictive or intrusive interventions with individuals served by the public MH system (including beneficiaries in this program) who exhibit seriously aggressive, self-injurious or other challenging behaviors that place the individual or others at imminent risk of physical harm.

  1. State IT Infrastructure for Supporting Quality Oversight
PIHPs transmit limited quality-related data to the state via the state's Data Exchange Gateway and much of it is stored in MDCH's data warehouse.

State staffed voiced frustration that the ability to share electronic health records between/among providers, PIHPs and the state does not yet exist. However, there is an ongoing pilot where a handful of PIHPs and Health Plans (MCOs for medical services) are sharing data. By sharing the data, they are able to examine high utilizes of hospital emergency departments for SA users. As of May 2013, only demographic, diagnostic and utilization information had been included as part of the data exchange, but the plan is to also populate the system with care plan information. This system is envisioned as the back-bone of "Care Bridge" for the Duals Demonstration.

  1. MCO Quality Oversight Responsibilities
PIHP contracts with the state require them to develop and implement a QAPIP. A designated senior official of the PIHP must assume responsibility for the QAPIP implementation. PIHPS are accountable to a Community Mental Health Services Program Board of Directors for oversight of their QAPIP.

Contracts entered into by the PIHPs with providers must address how quality will be monitored. Also, it is incumbent upon the PIHP to monitor providers and care coordinators on site annually; the state does not dictate the format or scope of the review, but delegates this to the PIHP.

PIHPs' contract requires them to have a MIS that has capability to track grievances and complaints, quality indicator reporting and information on program participant access and satisfaction.

PIHPs are required to verify that services reimbursed by Medicaid were actually furnished to enrollees by a provider. The PIHP's verification methodology must be approved by the state. The PIHP must annually submit its findings from this process and include in its report any follow-up actions that were taken as a result of the findings.

  1. State Audits of MLTSS Program
The state conducts biennial on-site reviews of each PIHP. On alternate years, the site visits the PIHP to validate implementation of corrective action plans from the previous year's review. If, during a site visit, the state discovers a problem that requires immediate action then the PIHP must develop and implement and plan of correction in a shorter timeframe (specified by the state). In these instances the state will conduct validation in a shorter timeframe as well. In addition, if a problem is discovered on the 1915(c) habilitation waiver, then the PIHP must remediate the problem, within 90 days following the state's issuance of a findings report.

The state's on-site reviews include clinical record review (random sample)--some with notice to the state which records will be pulled. However the state review team also selects a portion of the records while on site with no advance notice to the PIHP. The review team oversamples persons deemed "at risk" (i.e., in 24-hour supervised settings and those recently leaving such settings).

The record review during site reviews include focus on whether the sampled individual received services in amount, scope and duration specified in SP. The state requires the PIHP to address (remediate) any problems in beneficiaries not receiving services as delineated in their services plans, but remediation is only tracked and reported for persons served under the 1915(c) habilitation waiver.

A random proportionate sample of 367 records across 2 years (169 one year, 200 the next.) is drawn for persons served by the 1915(c) habilitation waiver. The sample is proportionate to the distribution of persons in the waiver in each PIHP.) The sample for individuals served under the 1915(b) authority is much smaller; the state reports that it reviews enough records to know if there is a systems-level problem and the PIHP concurs; additional records are pulled and added to the sample if the state believes there is a systems-level problem and has not achieved acknowledgement from the PIHP that a problem exists.

The team also conducts interviews with a sample of persons (4-5 beneficiaries) included into the record review sample; they interview protocol focuses on person-centered planning, self-determination arrangements and individual budgets, access to transportation, satisfaction with services, among other topics.

During the site review the state also reviews how the PIHP is monitoring their provider network. During the certification process for Community Mental Health Centers the PIHPs provider monitoring is also reviewed (certification review occurs every 3 years).

PIHPs are required to submit a plan of correction within 30 days that addresses each review dimension for which there was a finding of partial or non-compliance. The state conducts an on-site follow-up the following year to verify corrective actions were implemented. If a PIHP receives a repeat citation on a site review dimension, the state site review team may increase the size of the clinical record review sample for that dimension for the next site review and/or require the program to re-undergo state approval to operate.

Reports are shared with Bureau's management team and QIC. Information is used to take contract action or for making recommendations for system improvements.

The state also conducts administrative reviews using multiple sources of information in tandem to identify potential quality issues (e.g., performance indicators, encounter data, grievance and appeal tracking, sentinel events reports, complaints, etc.).

  1. Performance Measures and Quality-Related Reports
This program requires PIHPs to submit multiple performance indicators in the areas of access, adequacy, appropriateness, effectiveness, outcomes, prevention and structure/plan management. These performance indicators comprise the Michigan Mission-Based Performance Indicator System. The vast majority of the indicators are reported by the PIHPS in the aggregate. The state is moving toward generating the indicators themselves from data in the Department's data warehouse.

Bulk of PI reported in aggregate from PIHPs. State would like to generate the PIs themselves since PIHPs. Use data warehouse for this.

Standards that the PIHP is expected to achieve are associated with several of these indicators. If the PIHP does not meet a performance indicator standard it will be required to implement a plan of correction which the EQRO will review the following year for compliance. The state is considering building a financial withhold into future contracts for below-standard performance EQRO will look at this, validate it, EQRO does plan of correction, and EQRO follows up a year later on the PIHPs compliance with plan of correction.

Performance Indicator results rare reviewed by both the Bureau of Mental Health Services' management team and the QIC.29 Negative outliers in more than 2 consecutive periods are the focus of investigation.

Michigan Mission-Based Performance Indicator System Measures are represented immediately below, organized by domain:


  • The percent of all Medicaid adult and children beneficiaries receiving a pre-admissions screening for psychiatric inpatient care for whom the disposition was completed within 3 hours. Standard = 95% in 3 hours.
  • The percent of new Medicaid beneficiaries receiving a face-to-face meeting with a professional within 14 calendar days of a non-emergency request for service--MI adults, MI children, DD adults, DD children, and Medicaid SA. Standard = 95% in 14 days.
  • The percent of new persons starting any needed ongoing service within 14 days of a non-emergent assessment with a professional--MI adults, MI children, DD adults, DD children, and Medicaid SA. Standard = 95% in 14 days.
  • The percent of discharges from a psychiatric inpatient unit who are seen for follow-up care within 7 days--All children and all adults (MI, DD) and all Medicaid SA (sub-acute detox discharges).
  • The percent of Medicaid recipients having received PIHP managed services--MI adults, MI children, DD adults, DD children, and SA.


  • The percent of HSW enrollees during the quarter with encounters in data warehouse who are receiving at least 1 HSW service per month that is not supports coordination.


  • The percent of total expenditures spent on managed care administrative functions for PIHPs.


  • The percent of adult Medicaid beneficiaries with mental illness and the percent of adult Medicaid beneficiaries with DD served by PIHPs who are in competitive employment.
  • The percent of adult Medicaid beneficiaries with mental illness and the percent of adult Medicaid beneficiaries with DD served by PIHPs who earn state minimum wage or more from employment activities (competitive, self-employment, or sheltered workshop).
  • The percent of MI and DD children and adults readmitted to an inpatient psychiatric unit within 30 days of discharge. Standard = 15% or less within 30 days.
  • The annual number of substantiated recipient rights complaints per thousand Medicaid beneficiaries with MI and with DD served, in the categories of Abuse I and II, and Neglect I and II.
  • The percent of adults with DD served, who live in a private residence alone, or with spouse or non-relative.
  • The percent of adults with serious mental illness served, who live in a private residence alone, or with spouse or non-relative.
  • The percent of children with DD (not including children in the Children's Waiver Program) in the quarter who receive at least 1 service each month other than case management and respite.

In addition to the Michigan Mission-Based Performance Indicators, the state also requires the PIHP to submit additional measures:

  • PIHPs must meet a standard of 100% whereby people who meet the OBRA Level II Assessment criteria for specialized MH services for people residing in nursing homes, as determined by MDCH shall receive PIHP managed MH services.
  • An increased number of Medicaid children (birth through age 17 years) with SUD per 1,000 in the PIHP service area who are provided Medicaid SA specialty services and supports.
  • An increased number of Medicaid adults (age 18 and older) with SUD per 1,000 in the PIHP service area who are provided Medicaid SA specialty services and supports.
  • An increased percentage in FY 2011 Medicaid expenditures over the base year of FY 2006 Medicaid expenditures for children and adults with SUD.

For the following measures each PIHP must negotiate its individual performance targets. A baseline for FY 2006 will be established. For FY 2008 no sanctions will be imposed for failure to reach target. In future years, P4P will be imposed, with the details of the P4P arrangement negotiated between MDCH and the PIHP and included in subsequent contract amendments.

  • An increased number of Medicaid children per 1,000 Medicaid-eligible children in the PIHP service area who are provided Medicaid MH specialty services and supports.
  • For children with: (a) SED; and (b) DD/SED co-occurring conditions, an increased number of Medicaid children per 1,000 Medicaid-eligible children in the PIHP service area who are provided Medicaid MH specialty services and supports.
  • For children with DD, an increased number of Medicaid children per 1,000 Medicaid-eligible children in the PIHP service area who receive MH specialty services and supports.

In addition to these measures, the state also develops and reports to CMS performance measures as agreed upon in its approved waiver for the 1915(c) habilitation waiver. These measures are responsive to the 1915(c) assurances and sub-assurances.

  1. LTSS-Focused PIPs
Because the population in the program is, by definition, the LTSS population, all PIPs focus on the LTSS population.

The state identifies PIPs for each waiver based on analyses of quality data, EQRO findings and stakeholder concerns.

All PIHPs must conduct a minimum of 2 PIPS during a waiver cycle. All PIHPs conduct 1 mandatory 2-year PIP assigned by the state. PIHPs are allowed to choose the second PIP, unless a PIHP is having difficulty in a given area, then the state may assign the second PIP relevant to the area of concern.

Semi-annually PIHPs report to the state on their PIP's progress, which is reviewed by the state and the QIC.

In FY 2012-2013, the state-mandated PIP is targeted to Increasing the proportion of Medicaid-eligible adults with mental illness who receive at least 1 peer-delivered service or support.

  1. Care Coordination
Supports Coordination is a service that most members choose. Targeted case management is also available for persons experiencing acute MH episodes.

Care coordinators may be employed by the PIHP/CMH or a provider agency within the PIHP network; and there are independent supports coordinators as well.

For the DD clients care coordination tends to typically include assessment, service planning, and monitoring service provision. However for members receiving behavioral health services care coordination for persons with chronic mental illness is less constant and tends to focus on assistance with housing and linkages to community services. Rather than the care coordinator being the person with whom the member has the primary relationship, behavioral health members tend to have that primary relationship with their counselor or a peer support specialist.

Supports coordinator cannot make utilization determinations--amount/scope/duration.

Supports coordinator help develop SPs, but cannot approve amount/scope/ duration of services. A utilization manager at PIHP is responsible for authorizing services; in some instances the utilization review function may be delegated to a "super-provider" or the Community Mental Health Center.

The care coordinator is responsible for updating SPs on annual basis for person enrolled in the 1915(c) waiver, as well as when the person's needs change. In the 1915(b) waiver, the SP must only be revised when the person's needs change.

Care coordinator contacts with members vary depending on need. For more intense need monthly contacts are recommended, but not required. Amount, scope and duration of care coordination are specified in the SP.

There are no caseload requirements.

  1. 24-Hour Back-Up
PIHPs are required to provide emergency and after-hours access to services for persons experiencing a MH emergency.
  1. CI Reporting and Investigation
CI Reporting System. PIHPs must report 5 CIs to the state via the state's CI reporting site on the state's website:
  • Suicide;
  • Non-suicide death;
  • Emergency Medical treatment due to Injury or Medication Error;
  • Hospitalization due to Injury or Medication Error;
  • Arrest of Consumer.

CIs must be reported within 60 days after the end of the month in which the event occurred, except for suicide. If 90 calendar days have elapsed without a determination of cause of death, the PIHP must submit a "best judgment" determination of whether the death was a suicide.

PIHPs must notify the state immediately of deaths that occur as a result of a suspected staff member action or inaction, or any death that is the subject of a recipient rights, licensing, or police investigation. Reports must be submitted electronically within 48 hours of either the death, or the PIHP's receipt of notification of the death, or the PIHP's receipt of notification that a rights, licensing, and/or police investigation has commenced.

The PIHP or its delegate is responsible for implementing the process of the review and follow-up of sentinel events. And other CIs and events that put people at risk of harm. The PIHP or its delegate has 3 business days after a CI occurs to determine if it is a sentinel event. If the CI is classified as a sentinel event, the PIHP or its delegate has 2 business days to commence a root cause analysis of the event. Persons involved in the review of sentinel events must have the appropriate credentials.

The state reviews CI data on a monthly basis then rolls it up into quarterly reports for trend analysis.

Abuse, Neglect and Exploitation. Two other entities within the state receive reports on abuse, neglect and exploitation--the Office of Recipient Rights (within the MH system) and Adult Protective Services (MDHS). Multiple entities could be involved in investigations, including law enforcement.

Risk Event Management. The PIHP must have a process for analyzing additional critical events that put individuals at risk of harm. This analysis is used to determine what action needs to be taken to remediate the problem or situation and to prevent the occurrence of additional events and incidents. The state will request documentation of this process when performing site visits. These events include:

  • Actions taken by individuals who receive services that cause harm to themselves.
  • Actions taken by individuals who receive services that cause harm to others.
  • Two or more unscheduled admissions to a medical hospital within a 12-month period.

Restrictive Interventions. On a quarterly basis, the PIHP is required to review data from a Behavior Treatment Review Committee (which is part of the local MH agency) where intrusive or restrictive techniques have been approved for use with beneficiaries and where physical management or 911 calls to law enforcement has been used in an emergency behavioral crisis. Only the techniques permitted by the Technical Requirement for Behavior Treatment Plan Review Committees and that have been approved during person-centered planning by the beneficiary or his/her guardian, may be used with beneficiaries. Data must include:

  • Dates and numbers of interventions used.
  • The settings (e.g., individual's home or work) where behaviors and interventions occurred.
  • Observations about any events, settings, or factors that may have triggered the behavior.
  • Behaviors that initiated the techniques.
  • Documentation of the analysis performed to determine the cause of the behaviors that precipitated the intervention.
  • Description of positive behavioral supports used.
  • Behaviors that resulted in termination of the interventions.
  • Length of time of each intervention.
  • Staff development and training and supervisory guidance to reduce the use of these interventions.
  • Review and modification or development, if needed, of the individual's behavior plan.
  1. Mortality Review
PIHPs are required to conduct mortality reviews as part of their QAPIP. According to the PIHP's contract, they are required to review all unexpected deaths (suicides, homicides, deaths experienced by person having an undiagnosed condition, accidental deaths, deaths where there is suspicion of abuse or neglect). Reviews must include:
  • Screens of individual deaths with standard information (e.g., coroner's report, death certificate).
  • Involvement of medical personnel in the mortality reviews.
  • Documentation of the mortality review process, findings, and recommendations.
  • Use of mortality information to address quality of care.
  • Aggregation of mortality data over time to identify possible trends.
  1. EQRO Responsibilities
EQRO monitors the PIHP's implementation of its QAPIP during an on-site review. The EQRO reviews. If any deficiencies are found, the EQRO works with the PIHP to develop and implement performance improvement activities, and is responsible for validating they have been implemented.
  1. Ombudsman/ Function
PIHPs must have Customer Services unit to:
  • Welcome and orient individuals to services and benefits available, and the provider network.
  • Provide information about how to access MH, primary health, and other community services.
  • Provide information about how to access the various rights processes.
  • Help individuals with problems and inquiries regarding benefits.
  • Assist people with and oversee local complaint and grievance processes.
  • Track and report patterns of problem areas for the organization.
  1. Experience of Care/ Satisfaction Surveys
PIHPs are required to conduct an annual survey of adults with mental illness using the MHSIP. This is a mail survey using a convenience sample of individuals who receive services during 1 month of the year.

The state is collecting data using the National Core Indicators to survey DD members. This effort is funded under a 1-year grant by the federal Administration for Community Living. The state would like to sustain this effort but finding state funds to continue may be problematic. The state is drawing a random sample across its DD system and using local ARC chapters and CMHC staff for data collection.

  1. Membership Oversight
The QIC comprised of consumers, advocates, provider organizations, PIHPs and Community Mental Health Service Programs meets regularly to review quality reports.

During the state's biennial PIHP on-site reviews focus groups are conducted with consumers, advocates, providers and other community stakeholders to elicit evaluation of the PIHP's progress implementing initiatives such as person-centered planning, self-determination, employment, recovery, rights, etc. as well as involvement of beneficiaries and stakeholders in the QAPIP.

  1. State Technical Assistance to MCOs
Program Specialists in the state's MDCH provide technical assistance to the PIHPs on quality.
  1. MCO Report Cards on LTSS
None specified.
  1. Financial Incentives, Penalties and Withholds
The state offered a financial incentive to the PIHPs for increasing self-determination arrangements. Self-report data was submitted by the PIHPs for consideration of the award. However; the state had no mechanism for independently confirming the data from PIHPS. This incentive was only offered for 1 year.

Currently, the PIHPs are eligible for first and second place monetary award who has shown a relative improvement over the last fiscal year in the following areas:

  • Overall number of consumers engaged in meaningful employment.
  • Overall number of consumers served that are living in a private residence not owned by the PIHP or the contracted provider, either alone or with spouse or non-relative.
  • Overall numbers of enrollees discharged from a SA detox unit and seen for follow-up within 7 days.

In order to be eligible for the award, a PIHP must not have received a non-compliance score for any site review dimension in their site review report.

The state characterized these as modest financial incentives: $30,000 for first place and $25,000 for second place. The incentives are so modest some PIHPs said it was not worth their while to participate.

The PIHP contract specifies that financial sanctions may be imposed to address repeated or substantial breaches, or reflect a pattern of non-compliance or substantial poor performance on performance indicator standard, repeated site review non-compliance, substantial inappropriate denial of services, or substantial or repeated health and/or safety violations.

In the next contract (January 2014), the state intends to include withholds for poor performance.

  1. Other Quality Management/ Improvement Activities
"Creating a Culture of Gentleness" is training efforts to improve the skills of direct care workers and supervisors in the support of people with DD who have behaviors that put themselves or others at risk of harm. Over 2,700 staff has been trained. MDCH was looking to expand the program to increase training statewide.
CI = critical incident
DD = developmental disability/developmentally disabled
EQRO = external quality review organization
HSW = Habilitation Supports Waiver
IT = information technology

LTSS = long-term services and supports
MCO = managed care organization
MDCH = Michigan Department of Community Health
MDHS = Michigan Department of Human Services
MH = mental health

MHSIP = Mental Health Statistics Improvement Program
MI = mentally ill
MIS = Management Information System
MLTSS = managed long-term services and supports
P4P = pay-for-performance

PIHP = Pre-paid Inpatient Health Plan
PIP = performance improvement project
QAPIP = Quality Assessment and Performance Improvement Plan
QIC = Quality Improvement Council
SA = substance abuse

SP = service plan
SUD = substance use disorder

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