Environmental Scan of MLTSS Quality Requirements in MCO Contracts

Executive Summary

Pat Rivard, Beth Jackson, Jason Rachel, Julie Seibert and Taylor Whitworth

Truven Health Analytics

September 2013

Contracts with managed care organizations (MCOs) in 17 states were reviewed. The scan of managed long-term services and supports (MLTSS) quality requirements revealed wide diversity in some instances and in others more convergence. Also, whereas contracts may require the same quality elements, in one state the requirement may be very specific and prescriptive whereas in another state the details of implementing the requirement may be left to MCO discretion. Finally, quality elements that are not contractually required may, in some states, nevertheless be standard practice.

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.

   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.

   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.

   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.

   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).

   6. Required Mechanisms for Monitoring Receipt of Long-Term Services and Supports (LTSS). Ten states include contract language related to mechanisms for monitoring receipt of community LTSS and associated reporting requirements. There is a fair amount of variability in these monitoring mechanisms from the real-time Electronic Verification System (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.

   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. However, there is variability in how this requirement is delegated to the MCOs.

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.

   Several contracts also specify outcomes related to community retention rate, rate of preventable hospital admissions, rates of nursing facility and chronic hospital admission.

   When a contract does not enumerate performance measures, it cannot be assumed that the MCO has no responsibility for reporting measures and using them as barometers for performance and improvement. While no performance measures may be specifically articulated in the contract, the quality reports that the MCO is required to produce may require inclusion of information that measures 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. Much of the PIP language in many contracts is taken verbatim from Code of Federal Regulations (CFR) 438. Accordingly, the contractual language is often vague enough that it is difficult to tell whether there are any LTSS-related PIP requirements. Out of the 17 contracts, only two clearly articulated LTSS-specific PIP requirements.

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. Often states have used 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.

   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.

   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. Nearly all the contracts (16) include clauses requiring such coordination.

   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.

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.

7. Financial Incentives for Performance

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

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 it should not be assumed that if such a requirement is not included in the MCOs contract that the state does not have a LTSS feedback mechanism in place.

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.