Quality in Managed Long-Term Services and Supports Programs. Appendix C. Minnesota Senior CARE Plus and Minnesota Senior Health Options


  Element     Description  
MLTSS Program Minnesota Senior Care Plus (MSC+)
Minnesota Senior Health Options (MSHO)
Lead Agency Minnesota Department of Human Services
Medicaid Authority MSC+: 1915(b)/(c)
MSHO: 1915(a)/(c)
Inception MSC+: 2005
MSHO: 1997
Year LTSS Added From inception.
Groups Enrolled MSC+: Elderly.
MSHO: Elderly eligible for both Medicaid and Medicare Parts A & B.
# Enrolled MSC+: 13,120 (August 2013).
MSHO: 35,739 (August 2013).
  1. State Quality Oversight Infrastructure
The state utilizes the single state Medicaid agency (Department of Human Services) and the Department of Health to oversee 8 MCO plans for the MCS+ and MSHO programs. Within Medicaid, there are several entities that play a quality oversight role including monitoring of MCO contracts and program oversight, with 5 quality oversight staff dedicated to the project. The Department of Health licenses providers and conducts quality monitoring utilizing 4 staff.
  1. State IT Infrastructure for Supporting Quality Oversight
The state relies on its MMIS for generating information on encounter data, claims data, diagnosis of members, MLTSS enrollment, eligibility information and screening data.
  1. MCO Quality Oversight Responsibilities
The state requires MCOs to maintain and report annually on 2 quality oversight activities, adhering to NCQA's sampling standards, which are as follows:
  • Care Plan Audit--This protocol covers all the aspects of care plan development to ensure all policies and procedures are adequately followed.
  • Care System Audit--This protocol is broader and encompasses all aspects of the service delivery system.

The audit reports generated from these protocols also include corrective actions taken by the MCO when issues of non-compliance are discovered. The annual reports are submitted to the state for review. These reports are then used as part of the state's evidence-based report for fulfilling the 1915(c) HCBS quality requirements.

The State's Department of Health conducts "look-back" reviews of the audits 18 months after the MCO audits are completed to monitor remediation activities on any issues/deficiencies identified during the review.

  1. State Audits of MLTSS Program
The state conducts a TCA, which is a validation of contract compliance done for each MCO. It involves a review of 16 elements that are used to evaluate the care given to members. This information is collected during its QA Examination, which is done every 3 years.

During the on-site exam the state collects, validates and reports MCO compliance information. The state then develops a summary of the information gathered for the 16 elements of the TCA, including:

  • Coverage of services;
  • Accessibility of providers;
  • QI program structure;
  • UM;
  • Special health care needs;
  • Practice guidelines;
  • Credentialing/Re-credentialing;
  • Annual QAPIP evaluation;
  • PIPs;
  • DM;
  • MCO grievances process requirements;
  • DTR notice of action to enrollees;
  • MCO appeals process requirements;
  • Advance directives compliance;
  • MCO care plans for MSHO and MSC+;
  • Information system.

Between the TCA, the state conducts follow-up visits approximately 1.5 years from the TCA to monitor the MCO's progress on resolving any issues discovered during the tri-annual audit.

The state holds a group meeting with the MCOs monthly to discuss operations and monitoring.

  1. Performance Measures and Quality-Related Reports
The state utilizes the Care Plan Audit protocol which contains approximately 30 performance measures (mostly process-oriented measures). The sampling methodology used for the Care Plan Audit is the NCQA-approved 8 and 30 process. In addition to the Care Plan Audit, the state also compares NF versus community placement to monitor NF admissions. This is monitored at both the system-wide level and the MCO level.
  1. LTSS-Focused PIPs
The state does not require MCOs to conduct LTSS-focused PIPs.
  1. Care Coordination
The state utilizes a multi-entry system for individuals to receive an initial LOC (i.e., the initial LOC evaluation can be conducted by the MCO, a subcontractor or the county). The LOC is re-determined annually. The initial assessment and the ongoing assessments are conducted by the Care Coordinator. MCOs use a state-defined assessment tool, however they are permitted to add additional questions. Care Coordinators also develop the SPs using a holistic, person-centered approach.

The state does not require a specific care coordinator-member ratio, however each MCO is required to develop a methodology for how they determine their care coordinator-member ratio and submit to the state for approval.

The MCO must provide Care Coordination services that are designed to ensure access to, and coordinate the delivery of preventive, primary, acute, post-acute and rehabilitation services.

The MCO's Care Coordination system must be designed to ensure communication and coordination of an enrollee's care across the Medicare and Medicaid provider network and settings, to accomplish smooth transitions for enrollees who move among various settings, as well as to facilitate and maximize the level of enrollee self- determination and enrollee choice of services, providers and living arrangements. The MCO must provide each enrollee with a primary contact person who will assist in access to services and information.

  1. 24-Hour Back-Up
At the individual level, the Care Plan must include identification of any risks to health and safety and plans for addressing these risks, including Informed Choices made by members to manage their own risk, and back-up plans for emergency situations.

At the systems level, each MCO must have a 24/7 nurse hotline for members to access.

  1. CI Reporting and Investigation
The state mandates that the local county social services agencies accept reports of maltreatment, provide emergency protective services and investigate maltreatment allegations.

MCO address incidents of self-neglect.

  1. Mortality Review
The state selectively conducts mortality reviews in its MLTSS programs.
  1. EQRO Responsibilities
EQRO responsibilities include:
  • Assessing each contracted MCO's strengths and weaknesses with respect to quality, timeliness and access to health care services.
  • Providing recommendations for improving quality of services furnished by each MCO.
  • Providing appropriate comparative information about all MCOs.
  • Assessing the degree to which each MCO has addressed problems and effected changes as previously identified by the state. Minnesota Department of Human Services or as recommended by the EQRO.
  • Evaluating the implementation and effectiveness of the Quality Strategy.
  • Advising the state on opportunities for improvement.

Annually, the EQRO conducts the 3 mandatory quality review activities:

  • Validation of PIPs.
  • Validation of performance measures.
  • MCO compliance with Medicaid structure and operational standards.
  1. Ombudsman/ Function
The state has established a state Office of the Ombudsman for managed care enrollees. MCO enrollees are informed by their care coordinator about the state Office of the Ombudsman and its functions at their initial visit and subsequently at annual visits. When a service is denied, terminated, or reduced, the MCO must give the enrollee a notice of action including a description of the enrollees' rights with respect to MCO appeals and state Fair Hearing process. On a quarterly basis, MCOs submit specific information about each notice of action to the state Ombudsman Office. This office reviews this information, and tracks and trends DTRs.
  1. Experience of Care/ Satisfaction Surveys
The state administers a bi-annual consumer survey to persons aged 65 and older who are enrolled in the state's MLTSS and HCBS FFS programs. The survey was designed by the state's aging division and is based on the PES. The state draws a random sample from the entire LTSS population.

Survey results are disseminated to lead agencies and any specific issues revealed as a result of the survey are forward to the responsible county for resolution.

  1. Membership Oversight
Each MCO must have a Member Advisory Committee which must meet regularly. Minutes from each meeting are submitted to the state to demonstrate how the issues discussed during the meeting are addressed.
  1. State Technical Assistance to MCOs
The state engages in technical assistance to the MCOs through a variety of forums including:
  • Workgroups;
  • Monthly meetings with MCOs;
  • Video conferences with MCOs.

The state also provides targeted technical assistance to an individual MCO if the state detects plan-specific issues through the audits, grievances or complaints, or from communication with the managed care ombudsman program.

  1. MCO Report Cards on LTSS
The state does not utilize MCO report cards.
  1. Financial Incentives, Penalties and Withholds
The state withholds a portion of MCO payments which are returned to the MCO only if performance targets are achieved. The withheld funds are returned to the MCO based on a scoring system for each of the performance targets including:
  • Specific provider measures.
  • Completion and submission of the Care Plan audit.
  • Timely completion of initial health risk screening or assessments.

In addition, the MCO is required to cooperate with the state to develop and implement a P4P model for chronic disease care. The state pays the monetary incentives to the MCO based on criteria established by the state. The MCO, in turn, conveys payments to its provider network, based on having achieved optimal chronic disease care for a designated percentage of its patients. The P4P projects are limited to diabetes care, and coronary/vascular disease care.

  1. Other Quality Management/ Improvement Activities
MCOs collaborate on the development and implementation of PIPs.

In the spirit of fostering a partnership with the MCOs, the state has implemented workgroups across MCOs to improve quality. These workgroups consist of state personnel and various staff from the MCOs including care coordinators, supervisors and auditors.

CI = critical incident
DM = disease management
DTR = denial, termination, and reduction
EQRO = external quality review organization
FFS = fee-for-service

HCBS = home and community-based services
IT = information technology
LOC = level of care
LTSS = long-term services and supports
MCO = managed care organization

MLTSS = managed long-term services and supports
MMIS = Medicaid Management Information System
MSC+ = Minnesota Senior Care Plus
MSHO = Minnesota Senior Health Option
NCQA = National Committee on Quality Assurance

NF = nursing facility
P4P = pay-for-performance
PES = Participant Experience Survey
PIP = performance improvement project
QA = quality assurance

QAPIP = Quality Assessment and Performance Improvement Plan
QI = quality improvement
SP = service plan
TCA = Triennial Compliance Assessment
UM = utilization management

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