Quality in Managed Long-Term Services and Supports Programs. Appendix F. Tennessee's Choices in Long-term CARE


  Element     Description  
MLTSS Program CHOICES in Long-Term Services and Supports
Lead Agency Bureau of TennCare
Medicaid Authority 1115 Demonstration Waiver
Inception TennCare initiated in 1994.
Year LTSS Added 2010
Groups Enrolled Persons of all ages residing in nursing homes.
Adults 21+ with a PD/LTSS needs.
Seniors 65+ with LTSS needs.
# Enrolled 31,890 (as of September 1, 2013 in CHOICES.
1.2 million enrolled in the broader TennCare managed care program.
  1. State Quality Oversight Infrastructure
For quality oversight, CHOICES relies on both TennCare's Quality Oversight Division (which also monitors the acute and behavioral health components of TennCare), as well as on 2 units in the Division of LTSS (the Audit and Compliance unit and the Quality and Administration unit).

TennCare's Quality Oversight Division assumes responsibility for oversight of each MCO's Care Coordination activities through comprehensive reviews of member records from receipt of referral to implementation of services. This review includes determining if all timelines for contacts were met as well as assessing whether the member was involved in the service planning process, whether the POC accurately addressed needs and risks, and whether the POC was appropriate based on information in the required CNA and risk assessment/risk agreement.

LTSS Division's Audit and Compliance Unit processes routine reports from the MCOs and conducts contract compliance audits. This unit receives reports from the MCOs and conducts on-site LTSS audits of MCOs, assembles the reports and audits into aggregate regional and statewide data sets, analyzes the data and produces actionable information for other LTSS units.

LTSS Division's Quality and Administration Unit works in collaboration with the TennCare Contract Compliance and Performance Division and the Quality Oversight Division to monitor LTSS contract compliance and the quality of LTSS provided. In that role, this unit provides technical assistance, training and support to the MCOs and is typically in daily contact with the MCOs regarding operation of the LTSS program. This division is responsible for leading quarterly joint meetings with the MCOs to discuss quality concerns and opportunities for improvement. The unit fields member inquiries and is responsible for monitoring changes needed in the MCO contracts, or policies/protocols and rules related to LTSS. This unit is also responsible for the oversight of the MCOs' management of the EVV which tracks members' timely receipt of LTSS in real-time. This unit also monitors referrals between the single point of entry (AAAD) and the MCOs. It also monitors MCO customer service and provider service telephone lines as well as AAAD intake and referral lines.

  1. State IT Infrastructure for Supporting Quality Oversight
TennCare utilizes a commercially available web-based tracking tool that has been customized by TennCare's Project Management unit for tracking contract compliance. Management of this tracking system is led by the OCCP. MCOs submit all required reports, member materials and corrective action plans, as well as associated communications through the OCCP tracking tool. All submissions by the MCO requires an action in the automated report/communication by a TennCare business owner who must accept or reject the report/corrective action plan and indicate the reason for the action. This tool documents all communications between TennCare and each MCO, and actions regarding any MCO deliverable.
  1. MCO Quality Oversight Responsibilities
MCOs are required to have a QM/QI program that is accountable to the MCO's board of directors and executive management team, have a QM/QI committee that oversees the QM/QI functions and a staff person responsible for all QM/QI activities. The QM/QI committees are required to include medical, behavioral health, and LTSS staff and contract providers (including medical, behavioral health, and LTSS providers). The QM/QI committee is required to notify the CMO of TennCare of meetings in a timely fashion and to the extent allowed by law, the CMO of TennCare, or his/her designee, may attend the QM/QI committee meetings at his/her option.

MCOs are required to monitor providers' performance on an ongoing basis and subject it to formal review, on at least an annual basis, consistent with NCQA standards and state MCO laws and regulations. A staff person must be responsible for all UM activities, including overseeing prior authorizations. MCOs must have a senior executive responsible for overseeing all subcontractor activities. MCOs are responsible for confirming the provider's capacity and commitment to initiate LTSS, and for monitoring the provider's delivery of services to ensure members' timely receipt of LTSS specified in the POC.

MCOs are required to review all reports submitted to the state to identify instances and/or patterns of non-compliance, determine and analyze the reasons for non-compliance, identify and implement actions to correct instances of non-compliance and to address patterns of non-compliance, and identify and implement QI activities to improve performance and ensure future compliance.

  1. State Audits of MLTSS Program
The LTSS Audit and Compliance Unit currently conducts 7 types of audits:
  • New Member Audit (quarterly). This audit is usually conducted at the same time as the Referral Audit. For members who are new to Medicaid and CHOICES ("new" members), it addresses:
    • Whether CNA and person-centered POC were completed timely.
    • Whether MCO authorized all HCBS identified in member's POC.
    • Whether HCBS delivered timely.
  • Referral Audits (quarterly). This audit is usually conducted in conjunction with the New Member Audit. For existing Medicaid enrollees who are referred for CHOICES (referrals), this audit addresses:
    • Whether MCO conducted telephonic screening.
    • Whether MCO conducted face-to-face visit to complete LOC eligibility application (PAE).
    • Whether PAE submitted to TennCare timely.
    • Whether CNA and person-centered POC were completely timely.
    • Whether MCO authorized all HCBS identified in member's POC.
    • Whether HCBS were delivered timely.
  • CI Audit (semi-annually). This audit addresses:
    • Whether the MCO accurately identified and categorized CIs, received CI reports within maximum timeframe (from its staff, HCBS providers and/or FEA), and reported CIs timely to TennCare.
    • Whether the MCO ensured appropriate and timely care of CHOICES members after the occurrence of CIs, gathered evidence regarding CIs and obtained investigative reports and/or corrective action information timely from HCBS providers and/or the FEA.
    • Whether the MCO ensured that appropriate investigations were conducted and corrective actions plan were implemented by staff, contract HCBS providers and FEA within established timeframes.
  • FEA Audit (annually). This audit addresses:
    • Whether the FEA assigned the member a supports broker and notified the care coordinator within 2 business days of MCO referral date.
    • Whether the contractor notified the member of their assigned supports broker, along with contact information, within 5 business days of the MCO referral date.
    • Whether services began within 60 days of MCO referral date. If services did not begin timely, was there documentation showing why.
    • Whether the contractor conducted at least semi-annual face-to-face visits in the member's residence after the CD starts date and if each member had a back-up plan.
    • Whether the contractor ensured all specified member and worker requirements were complete before service initiation.
  • AAAD Audit (annually). This audit addresses:
    • Whether the agency documented and responded to I&R requests within the specified timeframe; and appropriately categorized and documented inquiries in which the potential member was unable to be contacted.
    • Whether the agency demonstrated attempts to contact such members or potential members in accordance with the grant contract.
    • Whether the agency contacted individuals referred through the MDS process within the specified timeframe; conducted a face-to-face screening with eligible MDS referrals within the specified timeframe; demonstrated confirmation of receipt of referrals faxed to MCOs, and maintained referral intake records.
    • Whether the agency ensured face-to-face assessment occurred within prescribed guidelines of initial screening, or in the absence of a screening, within specified timeframe of CHOICES referral; facilitated the applicant's Medicaid application; completed the PAE; submitted the completed PAE to the Bureau with all information necessary for a LOC determination; if applicable, and provided documentation of members' decision to terminate the enrollment process.
  • MFP Audit (annually). This audit addresses:
    • Whether the contractor verified the member's eligibility to participate in the MFP program, including properly qualifying the residence.
    • Whether the contractor provided a written notice to member of MFP enrollment and/or disenrollment. Whether contractor recorded MFP enrollment and/or disenrollment in member's POC.
    • Whether the contractor reported inpatient admissions and discharges to TennCare properly and timely.
    • Whether the contractor conducted face-to-face visit(s) with member after transition and following an inpatient admission according to prescribed guidelines.
  • Provider Qualifications Audit (annually). This audit addresses the MCO processes for examining provider qualifications before including them in the network:
    • Observation of provider licensure and notification of acceptance into the provider network.
    • Whether the contracted provider is actively licensed by the appropriate licensing organization.

TennCare's Quality Oversight Division conducts audits semi-annually on each MCO to evaluate care coordination contractual responsibilities, including:

  • Whether members who meet NF LOC are offered freedom of choice between HCBS and NF services (semi-annual review).
  • Whether POC is reviewed/updated at least annually (annual review).
  • Whether education of member/family occurred on how to identify and report Abuse, Neglect and Exploitation (reviewed annually).
  • Whether member was informed of their right to a fair hearing (semi-annual review) upon initiation of any adverse action.
  • Whether CIs are reported within specified timeframes (semi-annual review).
  • Whether members meet LTSS LOC criteria (reviewed quarterly).

If deficiencies are discovered, a Plan of Correction is required.

The Oversight Division has multiple approaches to monitoring the delivery of care coordination by the MCOs, including:

  • Visits with the care coordinator--also called "ride-alongs" where state staff accompany the care coordinator on member visits and assess the care coordinator's ability to meet all contractual care coordination requirements. Quality Oversight conducts 6 visits per quarter per MCO. The visits are typically "ride-alongs" with care coordinators to both HCBS and NF members. Members who are visited may be chosen randomly or by care coordinator or geographic area (county). Following the ride-alongs Quality Oversight staff holds a debriefing with MCO CHOICES management staff to identify strengths and opportunities for improvement.
  • POC Review. The state also conducts a review of care plans from all care coordinator visits as well as a random sample of 30 per MCO per quarter. The care plans are reviewed to insure they meet all contractual requirements. An inter-rater reliability study is also conducted. If any problems are detected, the MCO is required to remediate all deficiencies.
  • In order to assess ongoing care coordination, each year the state follows 1 enrollee per MCO to assure that all care coordination processes are completed and service coordination is timely. (This is in addition to LTSS Audit and Compliance Audits which review a much larger sample of members.)
  • The state conducts quarterly visits with each MCO to review any issues identified in monitoring of care coordination contractual requirements.

The state also conducts Provider Network Adequacy Monitoring. It uses a GeoAccess software application to identify potential deficiencies in each MCO's provider network. Reports are prepared for each MCO on a monthly basis using this software. Reports help identify trends regionally and by provider type/specialty. The software calculates distance/driving times between providers and members. There are different standards for different services. The standards for Adult Day Care specify that members from urban areas must not have to travel more than 20 miles to adult day care services; for members living in suburban locations, not more than 30 miles, and those from rural areas not more than 60 miles. For other LTSS HCBS the MCO must contract with at least 2 providers per service type (e.g., assistive technology; attendant care, home-delivered meals, etc.) in each county of the state's 3 regions to ensure freedom of choice. Timely access to services is also monitored through ongoing review of member appeals for CHOICES LTSS.

  1. Performance Measures and Quality-Related Reports
The state develops quality-related performance measures responsive to some assurances/sub assurances associated with the Medicaid 1915(c) program--related to LOC, service planning, provider qualifications, and health and welfare (education of member/representative regarding identification about abuse, neglect, exploitation; and timely reporting of CIs).

MCOs must submit the following LTSS quality reports:

  • Late/Missed Visit Reports (by MCO by HCBS type, including reason for missed/late visit).
  • Quarterly reports from AAADs (single point of entry) on timeliness of I&R requests, CHOICES screenings/assessments.
  • Nursing Facility-To-Community Transitions Report by MCO including community tenure.
  • Consumer Direction Reports including timeliness from FEA referral to receipt of consumer-directed services.
  • CIs Reports (quarterly) by residential setting and provider type (agency vs. consumer direction).
  • Quarterly Complaints Report including resolution.
  • CHOICES Advisory Group Report--(required to meet quarterly; reports are submitted semi-annually), including meeting dates and topics the group addressed.
  • Annual Qualified Workforce Strategies Report by MCO.
  • Care Coordination Reports, including timeliness of face-to-face and telephonic contacts as well as timely completion of the annual reassessment.
  • Monthly Caseload and Staffing Ratio Report.
  • Quarterly MFP Participants Report.
  • Quarterly Cost-Effective Alternative Report.
  • Quarterly Behavioral Health Adverse Occurrences Report details the number of adverse occurrences, date of occurrence, type of adverse occurrence, location, provider name; and action taken by facility/provider.
  1. LTSS-Focused PIPs
MCOs (with assistance from the EQRO) are required to conduct PIPs--2 clinical and 3 non-clinical. The 2 clinical PIPS must include 1 in the area of behavioral health that is relevant to 1 of the Population Health (DM) programs and 1 in the area of either child health or prenatal health. Two of the 3 non-clinical PIPs must be in the area of long-term care.

In 2012, all MCOs were required to conduct a PIP on LTSS rebalancing, and were allowed to choose the topic of the other PIP. Other LTSS PIPs conducted included 1 on utilization of Adult Day Care by CHOICES members; 1 on the culture of integration between physical and behavioral health for CHOICES members; and a third on depression screenings for a CHOICES members receiving HCBS and who are NF-eligible.

  1. Care Coordination
Comprehensive Care Coordination is provided by the MCOs. Each CHOICES member has an assigned Care Coordinator (nurses and social workers). Care coordinators are responsible for coordination of the physical, behavioral, functional and social support needs of the member as well as management of chronic conditions and care transitions.

Care coordinators are responsible for completing the PAE form utilized by the state to make LOC determinations. Care coordinators are also responsible for completion of the CNA, the risk assessment and risk agreement, and developing the POC and updating the POC as needed.

MCOs develop and utilize their own CNA instruments and care planning formats which must include minimum elements specified by TennCare and be approved by TennCare.

Members have a right to request an objective review by the state of their needs assessment and/or care planning process.

Care coordinators conduct a risk assessment using a state-approved tool, following protocol developed by the state, and develop a state-specified risk agreement to be signed by the applicant or his/her representative which will 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. MCO care coordinators review, and revise as necessary, the member's risk assessment and risk agreement and have the member or his/her representative sign and date any revised risk agreement.

MCOs have DM (recently changed to "Population Health") contractual requirements that specify that the MCO must have methods for integrating CHOICES care coordination into its DM program and methods within its DM and Care Coordination programs for supporting the continuity and coordination of covered physical and behavioral health, and LTSS benefits as well as coordination with the providers of such services. Predictive modeling methods are used to identify TennCare individuals for a given DM program. If a CHOICES member is identified in a DM program, DM staff must contact the CHOICES care coordinator to ensure the required continuity and coordination of applicable benefits. DM staff will also take referrals from CHOICES care coordinators. Care coordinators, not DM staff, are the conduit to the member. Care coordinators are responsible for reviewing educational materials with the member and caregiver, and for integrating aspects of DM that would help to better manage the member's condition into the POC. The care coordinator is also the conduit to the member's physician regarding DM.

Care coordination ratios are recommended but not mandated by the state. However, the MCO is required to submit a monthly caseload and staffing ratio report. If the state finds the MCO out-of-compliance on any care coordinator contractual requirements and the MCO has care coordination ratios that are in excess of the state's recommended ratios, the state will double the amount of liquidated damages that may be assessed against the MCO.

  1. 24-Hour Back-Up
A written back-up plan is required as a component of the POC for all members receiving companion care or non-residential HCBS. The plan must identify individuals and/or providers who are willing to be available as needed when a regularly scheduled worker or provider is not able to provide services. The care coordinator must ensure the adequacy of the back-up plan.

Using the EVV system, MCO's are required to monitor member receipt and utilization of scheduled personal care visits, attendant care, in-home respite, companion care, home-delivered meals, and adult day services. The EVV system is programmed with the day and time a service provider is expected based on the member's needs and preference (member-preferred scheduling). MCOs and contracted providers receive real-time alerts when a worker does not log in at the designated time. This allows the MCOs to resolve any potential gaps in service immediately. When a member's back-up plan must be implemented, the care coordinator is responsible for ensuring the plan was implemented and appropriate back-up workers or services are in place. Both the MCO and the state use reports from the EVV system to identify and track areas for QI (late/missed visits).

  1. CI Reporting and Investigation
The state requires that MCOs have plans and protocols in place for the prevention, reporting and investigation of CIs.
  • MCOs must develop and implement an abuse/neglect plan that includes protocols for preventing, identifying, and reporting suspected abuse, neglect, and exploitation of members; a plan for educating and training providers, subcontractors, care coordinators, and other MCO staff regarding these protocols; and a plan for training members, representatives, and caregivers regarding identification and reporting of suspected abuse and/or neglect.
  • MCOs are required to develop and implement a CI reporting and management system for incidents that occur in a HCBS delivery settings. CIs include: suspected physical, sexual, mental or emotional abuse, neglect, unexpected death, theft, financial exploitation, medication error, severe injury, other (e.g., falls, damage to member's property). CIs must be reported to the MCO within 24 hours, and investigated within 30 days.
  • MCOs are required to identify and track CIs and must review and analyze CIs to identify and address potential and actual quality of care and/or health and safety issues. The MCO must regularly review the number and types of incidents and findings from investigations; identify trends and patterns; identify opportunities for improvement; and develop and implement strategies to reduce the occurrence of incidents and improve the quality of CHOICES HCBS.
  • MCOs must require its staff and contract CHOICES HCBS providers to report, respond to, and document CIs as specified by the contractor.

MCOs must report to TennCare any death and any incident that could significantly impact the health or safety of a member (e.g., physical or sexual abuse) within 24 hours of detection or notification. In addition, the state requires MCOs to submit quarterly reports on the number and type of CIs experienced by its HCBS member population. If an incident is reported to APS, the MCO is required to submit a copy of that CI report to the state. In addition, the state conducts semi-annual audits of the MCOs handling of CI reports and investigations (see #4 State Audits).

  1. Mortality Review
A member's death must be reported to TennCare within 24 hours of notification to the MCO. Any unexpected death of a member that is receiving HCBS must be reported as a CI. The MCO is required to conduct the appropriate investigation or report the death to Adult Protective Services if the unexpected death is suspected to be a result of abuse or neglect of the member.
  1. EQRO Responsibilities
In addition to the federally-required Annual Quality Survey of each MCO, the performance measure validation, and the PIP validation, TennCare requires the EQRO to assist MCO's with PIPs, HEDIS/CAHPS reports, and training MCO and TennCare quality staff. If any deficiencies are uncovered in the compliance review, the EQRO reviews (with the state Quality Oversight staff) all corrective action plans; if the state deems the corrective action plans unacceptable, the states' Quality Oversight division works with the EQRO to develop an acceptable plan. The EQRO also is responsible for a legislatively-mandated annual network adequacy review and for training MCO and TennCare quality staff.
  1. Ombudsman/ Function
The state has a Long-Term Care Ombudsman Program, a statewide program for the benefit of individuals residing in long-term care facilities, which may include nursing homes, residential homes for the aged, assisted care living facilities, and community-based residential alternatives developed by the state. The Ombudsman is available to assist CHOICES member and their families (as well as private pay and Medicare nursing home residents) resolve questions or problems. The program is authorized by the federal Older Americans Act and administered by the TCAD.

TennCare also requires MCOs to employ a consumer advocate responsible for internal representation of members' interests including input into planning and delivery of long-term care services, QM/QI activities, program monitoring and evaluation, as well as member, family, and provider education.

The state is currently exploring options for expanding the Long-Term Care Ombudsman Program to include all (and not just residential) HCBS.

  1. Experience of Care/ Satisfaction Surveys
The state contracts with the AAADs to conduct an annual CHOICES member survey; items for the survey are derived from the PES and the MFP Quality of Life Survey. The survey's primary focus is on the member's experience of care. Upon completion of the surveys, the AAADs submit the responses to the EQRO who is contracted to analyze the data and compile the survey result report.

In addition, TennCare requires the FEA to conduct an annual consumer satisfaction survey specific to the participant's experience in consumer direction. All (100%) consumer-directed members are asked to participate in the survey.

  1. Membership Oversight
Stakeholder meetings are organized by the state, at minimum, semi-annually. Annual reports are provided to all stakeholders.

In addition, each MCO is required to have a CHOICES Advisory Group that must meet quarterly. The advisory group provides input into the development of the MCO's policies and procedures, planning and delivery of LTSS, quality activities, program monitoring/evaluation and member/family/provider education. 51% of the group must be comprised of member and/or their representatives. Membership also includes representatives from the provider and advocacy communities.

  1. State Technical Assistance to MCOs
The state's LTSS Quality and Administration Unit, through required reporting elements, member experience, and provider and stakeholder feedback, identifies areas of needed process, operations or service delivery system improvement. Likewise, the OCCP and Quality Oversight Divisions may identify improvement opportunities. TennCare provides technical assistance through scheduled and routine interactions with each MCO.
  1. MCO Report Cards on LTSS
Using ongoing analysis of data from required reports and on-site audit processes, the LTSS Audit and Compliance Unit is developing an MCO report card for LTSS. Currently the report (which continues to be refined) is utilized primarily by internal LTSS management staff to help monitor LTSS health plan performance. Over time, specified measures will be integrated with the existing MCO report card for TennCare.
  1. Financial Incentives, Penalties and Withholds
The CRA contains provisions for the state to levy financial penalties (i.e., liquidated damages) for failure to meet specified performance standards and benchmarks. Liquidated damages correspond to 3 levels of transgressions/omissions, ranging from those actions/inactions that result in significant threat to the member's care to those that represent threats to the smooth and efficient operation of TennCare. These liquidated damages cover all TennCare services, not just LTSS. The damages range from $250 per day for failure to meet a deliverable timeline to $100,000 per month for failure to meet a threshold for specified care coordination activities, depending on the severity of the issue. Damages assessed for failure to meet specified care coordination requirements can be multiplied by a factor of 2 if the MCO's LTSS care coordination caseload or staffing recommendations are not followed.

In addition, TennCare withholds a percentage of each month's capitation payments that is released to the MCO the following month, so long as there are no serious quality or compliance concerns. If there are serious quality or compliance concerns, the withhold is retained by TennCare until the issue is resolved, and if retained for 6 months, is permanently retained by the state. Any quality or compliance concern resulting in the retention of a withhold triggers a higher monthly withhold amount, which is reduced gradually over time, so long as quality and compliance are maintained.

Through the MFP Rebalancing Demonstration Grant, TennCare offers a financial incentive for MCOs. MCOs receive $1,000 for every member they transition to the community from a nursing home who also enrolls in the MFP program, up to the MCO's assigned target and $2,000 per transition that exceeds the MCO's assigned target. If the member stays in the community for 1 year and remains enrolled in the MFP program, the MCO receives added financial incentives. There are additional statewide benchmarks the MCOs must accomplish together to receive additional incentive payments.

  1. Other Quality Management/ Improvement Activities
None specified.
AAAD = Area Agency on Aging and Disability
CAHPS = Consumer Assessment Health Care Providers and Systems
CI = critical incident
CMO = Chief Medical Officer
CNA = Comprehensive Needs Assessment

CRA = Contractor Risk Agreement
DM = disease management
EQRO = external quality review organization
EVV = electronic visit verification
FEA = Fiscal Employer Agent

HCBS = home and community-based services
HEDIS = Health Effectiveness Data and Information Set
I&R = information and referral
IT = information technology
LOC = level of care

LTSS = long-term services and supports
MCO = managed care organization
MDS = minimum data set
MFP = Money-Follows-the-Person
MLTSS = managed long-term services and supports

NCQA = National Committee on Quality Assurance
NF = nursing facility
OCCP = Tennessee Office of Contract Compliance and Performance
PAE = Pre-Admission Evaluation
PD = physical disability

PES = Participant Experience Survey
PIP = performance improvement project
POC = plan of care
QI = quality improvement
QM = quality management

TCAD = Tennessee Commission on Aging and Disability
UM = utilization management

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