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Serving Children and Youth with Special Health Care Needs in Medicaid Managed Care: Targeted Contract Language

Introduction

Since 2014, states have used the National Standards of Care for Children and Youth with Special Health Care Needs (CYSHCN) as a basis for improving their Medicaid managed care programs to provide more effective systems of care for their CYSHCN. This tool shows how five states (GA, MD, MI, TX, and VA) incorporated aspects of the National Standards into their Medicaid managed care contracts. The National Academy for State Health Policy (NASHP) has organized these contract provisions by aligning them with National Standards’ identification/assessment, access to care, medical home/care coordination, and quality domains so state leaders and stakeholders can better meet the needs of CYSHCN within a managed care environment.

Background

States have long used managed care delivery systems in their Medicaid programs to improve the quality of care provided to enrollees, achieve better health outcomes, and control health care costs. As of June 2017, 47 states and Washington, DC used some form of managed care to provide services to all or some children and adults enrolled in Medicaid. Historically, many children and youth with special health care needs (CYSHCN) were exempt from enrollment in Medicaid managed care (MMC) programs because of the complexity and number of specialty services they required. These included community-based supports, such as in-home and respite care, care coordination, and long-term services and supports that state health policymakers deemed were best delivered by a fee-for-service model.

As states have become more adept at designing and implementing managed care programs for Medicaid beneficiaries, they are increasingly enrolling individuals with complex needs into managed care to better coordinate care, control costs, and improve health care quality and outcomes. All 47 states cited in the report now enroll some or all of their CYSHCN into some type of Medicaid managed care. States rely on several types of managed care delivery systems to provide services to Medicaid enrollees, including:

  • Risk-based managed care organizations (MCOs);
  • Primary care case management (PCCM); and
  • Prepaid ambulatory health plan (PAHP) systems.

Contracting with risk-based MCOs is the most common managed care delivery system used to serve Medicaid beneficiaries, including CYSHCN.

The contracting process and contract language play an important role in defining MCOs scope of services and requirements. A 2016 study by the Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) underscored the significance and role of MMC contracts in ensuring access to quality care for CYSHCN. It found that a majority of states use general managed care contract provisions for all enrollees and lacked requirements specific to CYSHCN.[1] For example, network adequacy provisions and wait times for appointments typically applied to all enrollees without separate requirements for CYSHCN.[2] CYSHCN can require more frequent access to providers (particularly specialty providers), increased hospitalization or emergency room visits, and the need for multiple medications.[3] Their unique needs demonstrate that managed care plans have to specifically address certain aspects of CYSHCN’s care, such as identification and assessment of needs, access to providers, and coordination of care to ensure quality. This tool provides examples of states’ contract language that specifically addresses CYSHCN. It is designed to help states find ways to strengthen their contract language with MCOs and improve care for this vulnerable population.

In 2014, the release of the National Standards of Care for Children and Youth with Special Health Care Needs raised interest in Medicaid managed care contract language. Designed to “address the core components of the structure and process of an effective system of care for CYSHCN,”[4] the National Standards include specific system standards that address population identification, scope of benefits, a process for determining medical necessity, sufficient specialist provider networks, establishment of a medical home model, and specific quality measures.[5] Many states, including Virginia and Michigan, have used the standards as a basis for amending Medicaid managed care contracts to better serve CYSHCN.[6,7] Virginia’s and Michigan’s efforts are indicative of a larger trend of states revisiting their MMC contract language to provide more effective systems of care for CYSHCN.  This tool shows how five states (GA, MD, MI, TX, and VA) are incorporating specific provisions and requirements into their MCOs to better serve CYSHCN. The contract language is taken verbatim from Medicaid managed care contracts. The National Academy for State Health Policy (NASHP) organized contract provisions by aligning them with several core domains from the National Standards. These domains are identification/assessment, access to care, medical home/care coordination, and quality.

As more states serve populations with complex health needs through managed care, there will be increased interest in ensuring that these populations receive the care that they need. This tool provides state leaders and stakeholders with examples of how specific contract language provisions can be useful in ensuring high-quality care to meet the needs of CYSHCN within a managed care environment.

State Use of Managed Care to Serve CYSHCN

The five states highlighted have actively worked to provide Medicaid services and supports to CYSHCN through managed care delivery systems. The states represent a variety of models and approaches to specific populations, contracting models (procurement vs. regulatory), and types of managed care plans (standard vs. specialized for CYSHCN).

Georgia

Georgia Medicaid beneficiaries receive services primarily through Georgia’s Medicaid managed care programs. As of 2016, nearly 70 percent of the Medicaid population was enrolled in a managed care program.[8,9]  In 2014, Georgia created Georgia Families 360, a MMC program that specifically serves vulnerable children, defined in the Medicaid managed care contract as children in state custody, children receiving adoption assistance, and certain youth in the custody of the Department of Juvenile Justice. During 2017, Georgia Families 360 served about 47,000 members. [10] In addition to physical health services, Georgia Families 360 provides behavioral health services, comprehensive care coordination services, and dental services.[11]

Georgia sample contract language

Identification and Assessment

Early and Periodic Screening, Diagnostic and Treatment (EPSDT):

Primary care providers (PCPs) within the contractor’s network are responsible for providing, at the time of the member’s preventive visit, all of the EPSDT-required components along with those identified in the state’s periodicity schedule. The required EPSDT components include:

  1. A comprehensive health and developmental history (including assessment of both physical and mental health development);
  2. A comprehensive unclothed physical examination (unclothed means to the extent necessary to conduct a full, age-appropriate exam);
  3. Appropriate immunizations (according to the schedule established by the Advisory Committee on Immunization Practices (ACIP) for individuals 18 and younger and individuals 19 and older;
  4. Certain laboratory tests (including the federally required blood lead level assessment appropriate to age and risk screening);
  5. Health education (including anticipatory guidance);
  6. Measurements (including head circumference for infants and body mass index);
  7. Sensory screening (vision and hearing);
  8. Oral health assessment; and
  9. Sexually transmitted infection/HIV screening.

The contractor’s contracts with its network hospitals/birthing centers shall ensure the EPSDT initial newborn preventive visit occurs in the hospital/birthing center. The newborn preventive visit should be completed within 24 hours after birth and prior to discharge of the infant.

The contractor shall provide for a blood lead screening test for all EPSDT-eligible children at 12 and 24 months of age. Children between 36 months and 72 months of age should receive a blood lead screening test if there is no record of a previous test.

The contractor shall provide inter-periodic screens, which are screens that occur between the complete periodic screens and are medically necessary to determine the existence of suspected physical or mental illnesses or conditions. This includes, at a minimum, vision and hearing services. An inter-periodic visit may be performed only for vision or hearing services.

The contractor shall ensure an initial health and screening visit is performed, as appropriate, for all newly enrolled GF 360º EPSD-eligible children within 90 calendar days and within 24 hours of birth for all newborns. If the member’s PCP provides medical record evidence to the contractor that the initial health and screening visit have already taken place, this evidence will meet this contract requirement. The contractor should incorporate this evidence for this member in its tracking system. The contractor shall share EPSDT health check screening results with PCPs.

Minimum contractor compliance with the health check screening requirements is an 80 percent screening ratio for the periodic preventive health visits, using the methodology prescribed by the US Centers for Medicaid & Medicare Services (CMS) to determine the screening ratio. This requirement and screening percentage is related to the CMS-416 Report requirements.

A critical component of the success of the contractor depends upon the contractor’s ability to conduct and report required assessments and screenings upon member enrollment. These tools are used to identify immediate needs of members transitioning into and out of GF 360º. Required assessments and screening vary by population type and include:

The Comprehensive Child & Family Assessment (CCFA) is used by Division of Family and Children services (DFCS) to assist in developing case plans, making placement decisions, expediting permanency and planning for effective service intervention. The contractor shall be responsible for ensuring that the Medical and Trauma Assessments required for the Foster Care (FC) members as part of the CCFA are conducted and reported in a timely manner as set forth herein. Each instance of failure to meet a timeframe specified in this section shall constitute a Category 4 event as set forth in Section 25.5.

Includes all EPSDT periodicity schedule requirements relevant to the member’s age. The contractor shall ensure providers conducting the medical assessment provide outcomes of the assessment to the contractor within 20 calendar days of the contractor’s receipt of the eligibility file from Department of Community Health (DCH) or electronic notification from DFCS or DCH. The contractor must provide outcomes of the medical assessments to the DFCS-contracted CCFA provider within 20 calendar days of the contractor’s receipt of the eligibility file from DCH or electronic notification from DFCS or DCH.

The Trauma Assessment Screening, at a minimum, shall include:

  • A trauma history with information about any trauma that the child may have experienced or been exposed to as well as how they have coped with that trauma in the past and present.
  • Completion of the age appropriate assessment tool.
  • A summary of assessment results and recommendations for treatment (if needed).

Health Risk Screening:

The contractor shall provide a health risk screening within 30 days of receipt of the eligibility file from DCH. The health risk screening is used to develop a comprehensive understanding of the member’s health status and will be used by the contractor to develop the health care service plan and used by the care coordination team to determine the member’s care coordination needs.

The health risk screening is independent of the assessments conducted for the CCFA; however, the contractor may utilize the information from the CCFA assessments it coordinates to further inform the comprehensive understanding of the member’s health.

The contractor must assess the need to complete a new health risk screening each time a member moves to a new placement or based on a change in the member’s medical or behavioral health as identified by providers.

The contractor shall submit policies and procedures for conducting the health risk screening and the tools that will be used to conduct the screenings to DCH for review and approval within one 120 calendar days of the operational start date.

Children 1st and Babies Can’t Wait (BCW):

The contractor shall educate network providers about the federal laws on child find (e.g., 20 U.S.C. §1435 (a)(5); 34 C.F.R. §303.321(d)) and require network providers to identify and refer any FCAAP member birth through 35 months of age suspected of having a developmental delay or disability, or who is at risk of delay, to the designated Children 1st program for assessment and evaluation.

Access to Care

The Georgia Families 360° Supplier must expand upon its Georgia Families provider network to meet the unique needs of Georgia Families 360° members. The Georgia Families 360° Supplier shall employ innovative solutions for providing access in underserved areas. For example, the Georgia Families 360° supplier may consider the provision of physical health and behavioral health telemedicine services in local schools. The Georgia Families 360° provider network must, at a minimum, include the following:

  1. Primary care and specialist providers who are trained or experienced in trauma informed care and in treating individuals with complex special needs, including the population which comprises the Georgia Families 360° members;
  2. providers who have knowledge and experience in identifying child abuse and neglect;
  3. providers who render Core services and Intensive Family Intervention (IFI) services. The Georgia Families 360° Supplier is encouraged to contract with the community service boards to provide comprehensive community providers;

The contractor must provide a 24-hour call center staffed with experienced personnel familiar with GF 360º, Georgia child-serving agencies and the Georgia provider community.

For members up to and including age two, the contractor shall be responsible for medically necessary Individuals with Disabilities Education Act (IDEA) Part C services provided pursuant to an Individualized Family service Plan (IFSP) or Individualized Education Program (IEP).

For Medicaid children under 21 years of age, the contractor is required to provide medically necessary services to correct or ameliorate physical and behavioral health disorders, a defect, or a condition identified during an EPSDT screening or preventive visit, regardless of whether those services are included in the state plan, but are otherwise allowed pursuant to 1905(a) of the Social Security Act.

The contractor must ensure that Medicaid and PeachCare for Kids® children younger than 21 years of age receive the services available under the federal EPSDT benefit.

Care Coordination

Case management functions include, but are not limited to:

  • Early identification of members who have or may potentially have special needs by receiving referrals, reviewing medical records, claims and/or administrative data, or by conducting interviews, while gaining consent when appropriate. An initial assessment of pregnant women may be performed by a local public health agency at the time of the presumptive eligibility determination. This completed assessment will be forwarded to the woman’s selected care management organizations (CMO);
  • Assessment of a member’s risk factors such as an over- or under-utilization of services, inappropriate use of services, non-adherence to established plan of care or lack thereof, lack of education or understanding of current condition, lack of support system, financial barriers that impede adherence to plan of care, compromised patient safety, cultural or linguistic challenges, and physical, mental, or cognitive disabilities;

The contractor shall enroll members in the GF 360º program and immediately begin care coordination upon the receipt of an electronic notification from Department of Community Health (DCH), Division of Family and Children Services (DFCS) or Department of Juvenile Justice (DJJ) stating that the member is eligible for the GF 360º program.

Nurse Case Manager (NCM): The contractor staff is responsible for assisting members, identified through the health assessment as members with special health care needs, with obtaining medically necessary services, health-related services and coordinating their clinical care needs with holistic consideration.

Members identified as needing complex care coordination services due to behavioral health needs must receive care coordination services provided by coordinators who have been certified and trained in the delivery of high fidelity wrap around care. The contractor shall include a NCM to assist members identified through the health assessment as members with special health care needs. The NCM will help members with special health care needs obtain care, health related services and coordinate clinical care needs with holistic consideration. The contractor’s NCM must coordinate across a member’s providers and health systems. The contractor must have a process to facilitate, maintain and coordinate both care and communication with State agency staff, providers, Caregivers, Foster or Adoptive Parents, service providers, and members.

The contractor will build individual care coordination teams for members based on their specific needs and will assign the care coordination team within one business day of enrollment. The care coordination team will be updated as necessary as determined by the member’s health care service plan. The contractor staff available to participate in care coordination teams shall include at a minimum:

  1. Masters level licensed social worker or counselor;
  2. NCM to assist members identified through the health assessments;
  3. Members with special health care needs;
  4. Behavioral health Specialist with at least five years of behavioral health experience;
  5. Family peer support specialist;
  6. Youth peer support specialist; and
  7. Care coordinator.

The care coordination team shall involve and include the preferences of the member and the family (adoptive parent(s), foster care parent(s), caregiver and/or biological family members as indicated by DFCS or DJJ) in care coordination processes, care planning, and care plan implementation in adherence to system of care youth- and family-driven principles.

The contractor shall develop transition policies and procedures, including the guidelines it will use to identify members with special health care needs requiring priority coordination and care, within 90 Calendar days of the operational start date.

Quality Assurance and Improvement

The Department of Community Health (DCH) will have a written strategy for assessing and improving the quality of services provided by the contractor. In accordance with 42 CFR 438.204, this strategy will, at a minimum, monitor:

  1. The availability of services;
  2. The adequacy of the contractor’s capacity and services;
  3. The contractor’s coordination and continuity of care for members;
  4. The coverage and authorization of services;
  5. The contractor’s policies and procedures for selection and retention of providers;
  6. The contractor’s compliance with member information requirements in accordance with 42 CFR §438.10;
  7. The contractor’s compliance with State and federal privacy laws and regulations relative to member’s confidentiality;
  8. The contractor’s compliance with member enrollment and disenrollment requirements and limitations;
  9. The contractor’s grievance system;
  10. The contractor’s oversight of all subcontractor relationships and delegations;
  11. The contractor’s adoption of practice guidelines, including the dissemination of the guidelines to providers and providers’ application of them;
  12. The contractor’s quality assessment and performance improvement program; and
  13. The contractor’s health information systems.
  14. DCH will have a written strategy for assessing and improving the quality of services provided by the contractor

Consumer Assessment of Healthcare Providers and Systems (CAHPS): CAHPS surveys ask Medicaid and PeachCare for Kids® members or their parents/guardians to report on and evaluate their experiences with their health care. The surveys cover topics that are important to members and focus on aspects of quality that members and parents/guardians are best qualified to assess, such as the communication skills of providers and ease of access to health care services. The acronym CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). DCH uses the Adult and Child CAHPS surveys.

Performance Measures

The contractor shall comply with the GF 360º DCH Quality Strategic Plan requirements to improve the health outcomes for all members. Improved health outcomes will be documented using established performance measures. DCH uses the Centers for Medicaid Services (CMS) issued the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Core Set and the Adult Core Set of Quality Measures technical specifications along with the Healthcare Effectiveness Data and Information Set (HEDIS®) and the Agency for Healthcare Research and Quality (AHRQ) technical specifications for the quality and health improvement performance measures. DCH will monitor Performance Measures and incent contractor improvement through the value-based purchasing program.

Several of the Adult and Child Core Set measures along with certain other HEDIS® measures utilize hybrid methodology, that is, they require a medical record review in addition to the administrative data requirements for measurement reporting. The number of required record reviews is determined by the specifications for each hybrid measure.

Maryland

Maryland mandatorily enrolls all CYSHCN into their MMC program, HealthChoice.[12]  HealthChoice is a comprehensive MCO that provides managed care services to 75 percent of Maryland’s Medicaid population, including CYSHCN, foster care youth, individuals with physical and mental disabilities, and the homeless. HealthChoice provides a wide variety of services to these beneficiaries, however, certain services such as behavioral health and personal care services are delivered through a combination of a separate managed care program and fee-for-service. Under current law, Maryland does not use a procurement process to select MCOs to provide services to Medicaid beneficiaries, as is typical for many other states. Instead, state regulations outline a defined set of standards and requirements for provision of services. An MCO that applies to participate in the Medicaid program and meets the standards is entitled to participate in the program.

Maryland contract  language: Maryland State Code 10.09.62

Identification and Assessment

Definition of CYSHCN

“Child with a special health care need” means an individual younger than 21 years old, regardless of marital status, suffering from a moderate to severe chronic health condition:

  1. With significant potential or actual impact on health and ability to function;
  2. Which requires special health care services; and
  3. Which is expected to last longer than 6 months.”

Assessment

  1. The Department or its agent shall attempt to complete the health service needs information at the time of enrollment.
  2. The Department shall transmit any information obtained from health service needs information to the recipient’s MCO within five business days.

Upon its receipt and review of the health service needs information, an MCO shall take appropriate action to ensure that a new enrollee, who needs special or immediate health care services, as identified by the health service needs information, receives them in a timely manner.

Access to Care

    1. A managed care organization (MCO) shall demonstrate that its pediatric and adult primary care providers (PCPs) and specialists are clinically qualified based upon generally accepted community standards to provide or arrange for the provision of appropriate health care services to individuals who are members of a special needs population. The MCO shall submit to the department referral protocols that demonstrate the conditions under which PCPs will make the arrangements for referrals to specialty care networks.
    2. Clinical qualifications are to be determined through the MCO’s credentialing and recredentialing processes, including a review of the provider’s medical education, special training, and work history and experience.
    3. Specialty and subspecialty providers shall:
      • Have experience in treating individuals within a special needs population;
      • Have experience in interdisciplinary medical management; and
      • Understand the relationship between somatic and behavioral health care issues and interventions.

    An MCO shall demonstrate that its therapies provider network is adequate by demonstrating its:

    1. Providers’ pediatric specialties;
    2. Collaboration with schools that provide IEP or IFSP services to its enrollees, where available; and
    3. Provision of family-focused services and development of family-focused plans of care.

    When a child, who is an MCO enrollee, is diagnosed with a special health care need requiring a plan of care which includes specialty services, and that health care need was undiagnosed at the time of enrollment, the parent or guardian of that child may request approval from the MCO for a specific out-of-network specialty provider to provide those services when the MCO does not have a local in-network specialty provider with the same professional training and expertise who is reasonably available and provides the same service and modality, subject to the following provisions:

    1. If the MCO denies the request for an out-of-network provider referral, the child’s parent or guardian may initiate the complaint and appeal process set forth at code of Maryland regulations (COMAR)10.09.72;
    2. If at any time the MCO decides to terminate or reduce services provided by the approved out-of-network provider, the child’s parent or guardian may initiate the complaint and appeal process set forth at COMAR 10.09.72;

    The MCO shall continue to cover the services of the out-of-network provider during the course of the appeal until such time as the Office of Administrative Hearings issues its decision.

Care Coordination

The managed care organization (MCO) shall demonstrate the use of a primary care system of care delivery which includes a comprehensive plan of care for an enrollee who is a member of a special needs population and which uses a coordinated and continuous case management approach, involving the enrollee and, as appropriate, the enrollee’s family, guardian, or caregiver, in all aspects of care, including primary, acute, tertiary, and home care.

To meet the commitment outlined in §C(4) of this regulation, an MCO shall:

  1. Provide case management services to adult and pediatric enrollees as appropriate;
  2. Have the capacity to perform home visits as part of the ongoing case management program and have the ability to respond to urgent care needs while in the enrollee’s home;
  3. Ensure that, if warranted, a case manager is assigned to an enrollee at the time of the initial health screen by the MCO;
  4. Ensure that the primary care provider (PCP), who may also be the specialist, shall be the admitting or referring provider for all hospital admissions;
  5. Ensure that it will:
    • Collaborate with inpatient facilities in facilitating preadmission and discharge planning, and
    • Communicate all post-discharge home and community arrangements to the enrollee, the PCP, and, as appropriate, the enrollee’s family, guardian, and caregiver;
  6. Document the plan of care and treatment modalities provided to enrollees in special populations, assuring that the plan of care:
    • Is updated annually, and
    • Involves the enrollee and, as appropriate, the enrollee’s family, guardian, and caregiver in care decisions; and
  7. Be familiar with community-based resources available for the special populations.

An MCO shall establish protocols for effecting medically necessary service referrals to specialty care providers for children with special health care needs.

  1. The service referrals referenced in §H of this regulation shall:
    • Include services intended to improve or preserve the continuing health and quality of life for children with special health care needs, regardless of the ability of the services to effect permanent cure; and
    • Be made when the child is:
      1. Identified as being at risk of a developmental delay by the developmental screen required by Early and Periodic Screening, Diagnostic and Treatment (EPSDT);
      2. Experiencing a delay of 25 percent or more in any developmental area as measured by appropriate diagnostic instruments and procedures;
      3. Manifesting atypical development or behavior; or

Diagnosed with a physical or mental condition that has a high probability of resulting in developmental delay.

Quality Assurance & Improvement

The department shall maintain a record of the complaints received through the department’s enrollee and provider hotlines which involve the denial of care for children and review these complaint logs as part of its quality assurance system.

  1. A managed care organization (MCO) shall establish a consumer advisory board to facilitate the receipt of input from enrollees.
  2. The consumer advisory board membership shall:
    • Consist of enrollees and enrollees’ family members, guardians, or caregivers; and
    • Be comprised of no less than one third representation from the managed care organizations (MCO’s) special needs populations, or their representatives and the MCO’s special needs coordinator.
  3. The consumer advisory board shall meet at least six times a year.

Pursuant to Regulation .15E(2) of this chapter, the consumer advisory board shall annually report its activities and recommendations to the Secretary.

Michigan

In Michigan, services for CYSHCN enrolled in the state’s Medicaid managed care program are closely integrated with the state Title V CYSHCN program, Children’s Special Health Care services (CSHCS).[13] Children who are eligible for both CSHCS and Medicaid are mandatorily enrolled into a managed care program. Because of this mandatory enrollment, the state Medicaid agency requires coordination between managed care plans and CSHCS. The Michigan CSHCS program and the state’s managed care programs are both administered by the state Medicaid agency. This administrative structure allows for coordination between these programs and provides an opportunity for CSHCS staff to be closely involved with the development of managed care contracts to ensure consideration of the unique needs of CYSHCN.

Michigan contract language source: Michigan Medicaid Sample Health Plan Contract, 2016

Access to Care

Network Requirements

  1. The contractor must maintain a network of qualified providers in sufficient numbers, mix, and geographic locations throughout their respective service area, including counties contiguous to contractor’s service area, for the provision of all covered services.
  2. The contractor’s provider network must be sufficient to serve the maximum number of enrollees specified under this contract including children with special health care needs (CSHCS) enrollees and persons with special health care needs and submit documentation to MDHHS to that effect.
  3. The contractor must ensure contracted primary care providers (PCP) have a system to provide or arrange for coverage of services 24 hours per day, seven days per week when medically necessary.
  4. The contractor must consider anticipated enrollment and expected utilization of services with respect to the specific Medicaid populations (e.g., disabled, CSHCS, duals).
  5. The contractor must ensure enrollees have an ongoing source of primary care appropriate to the enrollees needs and covered services are administered or arranged for by a formally designated PCP.
  6. The contractor must ensure contracted providers offer an appropriate range of preventive care, primary care, and specialty services to meet the needs of all enrollees including CSHCS enrollees and persons with special health care needs and submit documentation to Michigan Department of Health and Human Services (MDHHS) to that effect.
  7. The contractor must maintain a PCP-to-enrollee ratio of at least one full-time (minimum of 20 hours per week per practice location) PCP per 750 members, except when this standard cannot be met because a geographic area (rural county) does not have sufficient PCPs to meet this standard; MDHHS has the sole authority to determine whether an exception will be granted.
  8. The contractor must provide access to specialists, including specialists in contiguous counties to the contractor’s service area, if those specialists are more accessible or appropriate for the enrollee.
  9. The contractor must maintain a network of pediatric subspecialists, children’s hospitals, pediatric regional centers, and ancillary providers to provide care for CSHCS enrollees.
  10. The contractor must consider the geographic location of providers and enrollees, including distance, travel time and available means of transportation and whether the provider location provides access for enrollees with physical or developmental disabilities.
  11. The contractor must ensure PCP services, and hospital services are available within 30 miles or 30 minutes travel time from the enrollee’s home unless MDHHS grants an exception.

Primary Care Provider (PCP) Selection and Requirements

The contractor must provide all enrollees the opportunity to select their PCP at the time of enrollment.

The contractor must allow CSHCS enrollees to remain with their established PCP at the time of enrollment with the contractor not limited to in network providers; upon consultation with the family and care team, CSHCS enrollees may be transitioned to an in-network PCP.

CSHCS enrollees who do not choose a PCP must be assigned a CSHCS-attested PCP

CSHCS PCP Requirements

  1. The contractors must assign CSHCS enrollees to CSHCS-attested PCP practices that provide family-centered care.
  2. The contractors must obtain a written attestation from PCPs willing to serve CSHCS enrollees that specifies the PCP/practice meets the following qualifications:
    • Is willing to accept new CSHCS enrollees with potentially complex health conditions.
    • Regularly serves children or youth with complex chronic health conditions.
    • Has a mechanism to identify children/youth with chronic health conditions.
    • Provides expanded appointments when children have complex needs and require more time.
    • Has experience coordinating care for children who see multiple professionals (pediatric subspecialists, physical therapists, behavioral health professionals, etc.).
    • Has a designated professional responsible for care coordination for children who see multiple professionals.
    • Provides services appropriate for youth transitioning into adulthood.
  3. The contractors must maintain a roster of providers who meet the criteria listed above and able to serve CSHCS enrollees.

The contractor must take the availability of handicap accessible public transportation into consideration when making PCP assignments.

The contractor must allow a CSHCS enrollee to choose a non-network PCP if:

  1. The CSHCS enrollee has an established relationship with the PCP at the time of enrollment with the contractor.

Upon consultation with the family, the selected PCP is the most appropriate for the CSHCS enrollee.

Care Coordination

Care Management Requirements

For children with special health care services (CSHCS) enrollees:

  • The contractor must assess the need for a care manager and a family-centered care plan developed in conjunction with the family and care team
  • The contractors must collaborate with the family and established primary and specialty care providers to assure access to the most appropriate provider for the enrollee.
  • The contractor must have separate, specific prior authorizations (PA) procedures for CSHCS enrollees.
    1. In order to preserve continuity of care for ancillary services, such as therapies and medical supplies, contractors must accept prior authorizations in place when the CSHCS enrollee is enrolled with the contractor’s plan. If the prior authorization is with a non-network ancillary provider, contractors must reimburse the ancillary provider at the Medicaid rate through the duration of the prior authorization.
    2. Upon expiration of the prior authorization, the contractor may utilize the contractor’s prior authorization procedures and network ancillary services.
  • The contractors must accept prior authorizations in place at the time of transition for non-custom fitted durable medical equipment and medical supplies but may utilize the contractor’s review criteria after the expiration of the prior authorization. In accordance with Medicaid policy, the payer who authorizes the custom-fitted durable medical equipment is responsible for payment of such equipment.

For Persons with Special Health Care Needs:

contractor is required to do the following for members identified by Michigan Department of Health and Human Services (MDHHS) as persons with special health care needs:

  • Conduct an assessment in order to identify any special conditions that require ongoing case management services for the enrollee.
  • Allow direct access to specialists (for example, through a standing referral or an approved number of visits) as appropriate for the enrollee’s condition and identified needs.
  • For individuals determined to require case management services, maintain documentation that demonstrates the outcome of the assessment and services provided based on the special conditions of the enrollee

Local Health Departments and CSHCS Coordination

contractor must enter into an agreement with all local health departments (LHDs) to coordinate care for CSHCS enrollees in contractor’s service area; the agreement must address the following topics:

  1. Data sharing
  2. Communication on development of care coordination plans
  3. Reporting requirements
  4. Quality assurance coordination
  5. Grievance and appeal resolution
  6. Dispute resolution and
  7. Care planning for enrollees transitioning into adulthood

contractor must utilize an electronic data system by which providers and other entities can send and receive client-level information for the purpose of care management and coordination (VIII-C).

The contractor must assess the need for a care manager and family-centered care plan, and if established, updated annually.

The contractor may share enrollee information with LHD to facilitate coordination of care without specific agreements.

Quality Assurance & Improvement

Data Analysis to Support Population Health Management

The contractor must utilize information such as claims data, pharmacy data, and laboratory results, supplemented by University of Michigan data, health risk assessment results and eligibility status, such as children in foster care, persons receiving Medicaid for the blind or disabled and children with special health care services (CSHCS), to address health disparities, improve community collaboration, and enhance care coordination, care management, targeted interventions, and complex care management services for targeted populations including:

  • Enrollees who are eligible for Medicaid based on an eligibility designation of disability.
  • Persons with high prevalence chronic conditions, such as diabetes, obesity and cardiovascular disease.
  • Enrollees in need of complex care management, including high risk enrollees with dual behavioral health and medical health diagnoses who are high utilizers of services.
  • Women with a high-risk pregnancy.
  • Children eligible for the CSHCS program.
  • People with special health care needs (PSHCN).
  • Other populations with unique needs as identified by Michigan Department of Health and Human Services (MDHHS) such as foster children or homeless members

Grievance and Appeal Process for Enrollees

The contractor’s internal grievance and appeal procedure must include the following components:

  1. Allow enrollees 90 days from the date of the adverse action notice within which to file an appeal under the contractor’s internal grievance and appeal procedure.
  2. Give enrollees assistance in completing forms and taking other procedural steps. The contractor must provide interpreter services and TeleTYpewriter / Telecommunication Device for the Deaf toll-free numbers.
  3. Acknowledge receipt of each grievance and appeal
  4. Ensure that the individuals who make decisions on grievances and appeals are individuals who:
  5. Are not involved in any previous level of review or decision-making, and
  6. Are health care professionals who have the appropriate clinical expertise in treating the enrollee’s condition or disease when the grievance or appeal involves a clinical issue.

In reviewing appeals for CSHCS enrollees, the contractor should utilize an appropriate pediatric subspecialist provider to review decisions to deny, suspend, terminate or limit pediatric subspecialist provider services.

Texas

Texas has spent the past several years designing a specialty Medicaid managed care program, STAR Kids, which exclusively serves children with complex health care needs.[14] As of November 2016, Texas children who are enrolled in Supplemental Security Income (SSI) Medicaid or the Medically Dependent Children Program (MDCP) are enrolled in STAR Kids. The state Medicaid managed care contract with STAR Kids’ MCOs is specific to children with complex health care needs and therefore, it outlines specific requirements for this population, including detailed requirements for assessing child health needs and providing comprehensive care coordination to all enrollees.

Texas sample contract language

Identification and Assessment

STAR Kids Screening and Assessment Process:

In addition to the initial telephonic member screening, all STAR Kids Medicaid managed care organizations (MCOs) are responsible for conducting a comprehensive, holistic, and evidence-based service needs assessment for all members. This process will be known as the “STAR Kids Screening and Assessment Process” and must help to inform or identify:

  1. Service coordination level;
  2. Service preferences and goals for the member and the member’s LAR;
  3. Natural strengths and supports such as member abilities or helpful family members;
  4. Non-capitated services and community supports that the member already receives or that would be beneficial to the member;
  5. Members requiring immediate attention;
  6. Members who need long-term services and supports (LTSS);
  7. Members with behavioral health needs;
  8. Members who need physical, occupational, speech, or other specialized therapy services;
  9. Members who require durable medical equipment and medical supplies;
  10. Members who currently receive and those who meet functional criteria to receive medically dependent children program (MDCP) STAR Kids or Home and Community Based services (HCBS) Waiver services;
  11. Members who need personal care services;
  12. Members who need nursing services, including home health skilled nursing, private duty nursing, and nursing services offered through a prescribed pediatric extended care center.

The MCO must conduct an initial telephonic member screening for all new members.  The telephonic screening must be used to help the MCO prioritize which members require the most immediate attention. The MCO must also review claims data to prioritize members who may need the most immediate assistance. For all members who are new to the STAR Kids MCO on the operational start date of the STAR Kids program, the STAR Kids MCO may take up to 15 business days for the initial telephonic member screening unless notified by the member, legally authorized representative (LAR), or member’s primary care provider (PCP) by phone or in writing of a more urgent need. Members who enroll in STAR Kids six months after the operational start date or later must receive the initial telephonic member screening within ten business days from the day the member is enrolled with the MCO.

The MCO must make at least three efforts to contact new members telephonically. If an MCO is unable to reach a member or a member’s LAR by telephone, the MCO must mail written correspondence to the member and member’s LAR explaining the need to contact the MCO and requesting that the member or member’s LAR contact the MCO as soon as possible.

As a part of the telephonic communication with the member or member’s LAR, or through written materials provided by the MCO to the member, the MCO must inform the member about the STAR Kids screening and assessment process and include the following details:

  1. Information on the purpose and goals of the STAR Kids screening and assessment process;
  2. The estimated timeframe it will take to complete the STAR Kids Screening and Assessment Instrument (SAI);
  3. Information the family should be prepared to discuss as a part of STAR Kids screening and assessment process including medication information, diagnoses, current services, and general questions and concerns.

The MCO must prioritize how quickly individual members receive the STAR Kids SAI based on urgency identified through the initial telephonic screening and claims data. The initial telephonic screening must include Health and Human services Commission-approved screening questions to determine if the member has historical or potential nursing needs that would necessitate the STAR Kids SAI to be conducted by an registered nurse (RN). If the member or the member’s LAR declines the SAI process, the MCO must document this in the member’s case file. The MCO must explain that member refusal to participate in the SAI process may impair the MCO’s ability to identify and provide covered services that the member does not currently access for which the member has a need. The MCO will not be required to meet timelines outlined below for members who have refused the SAI if the member refusal is documented or if the MCO is unable to reach the member

The MCO must assess all priority one members within seven business days of requesting services. The MCO must assess all priority two, priority three, and priority four members within six months of the operational start date. Within that six-month period, the MCO must schedule assessments according to priority level, assessing priority two members first and Priority four members last.

Priority One: Members who become STAR Kids members after the operational start date and request immediate services.

Priority Two: Members with the most urgent or unmet needs for services or service.

Priority Three: Members with few unmet needs who are currently receiving the services they require to remain.

Priority Four: Members receiving MDCP services, other LTSS, or non-capitated waiver services (including community living assistance and support services, deaf blind with multiple disabilities, HCS, Texas home living, and youth empowerment services).

Notwithstanding the member’s assigned priority level, the MCO must assess any member who has experienced a significant change in condition and contacts the MCO to request assessment within 15 business days. A change in condition is defined as any physical or mental change that results in either an improvement or decline in the member’s overall health status or level of function. Examples include: inpatient hospitalization; increase or decrease in need of services (nursing, therapies, personal care services (PCS), etc.); changes in enteral feeding (change from continuous to bolus; bolus to continuous, becomes oral feeding only); change in need for ventilator; new or removal of tracheostomy; need for intravenous therapy; or change in member’s ability to complete activities of daily living at age and condition appropriate level.

For all members enrolled six months after the operational start date, the MCO must attempt to schedule the STAR Kids SAI within 15 business days of a new members’ enrollment for level one members, and within 30 business days of a new member’s enrollment for level two and level three members.

The MCO must ensure:

  1. The member and the member’s LAR are involved in the STAR Kids screening and assessment process;
  2. The member and the member’s LAR are included in the development of the individual service plan (ISP);
  3. The member and the member’s LAR understand and, to the greatest extent possible, are in agreement with the completed ISP; and
  4. The member and the member’s LAR receives a completed copy of the STAR Kids SAI.

As a critical component of the STAR Kids screening and assessment process, the MCO or the MCO’s subcontractor must administer the Health and Human services Commission (HHSC) designated STAR Kids SAI in an electronic format that will be determined by HHSC. The STAR Kids SAI includes four modules:

  1. The core module
  2. The personal care assessment module (PCAM)
  3. The nursing care assessment module (NCAM)
  4. The MDCP module

The MCO must provide the core module to all STAR Kids members. The core module will be used to:

  1. Determine member preferences;
  2. Trigger for the personal care assessment module, nursing care assessment module, or both;
  3. Identify follow-up assessment needs;
  4. Help determine service coordination level; and
  5. Inform the development of the member’s ISP.

The STAR Kids SAI must be provided in the member’s place of residence, unless otherwise requested by the member or the member’s LAR. The member and member’s LAR must be present when the STAR Kids SAI is administered. The STAR Kids SAI will include certain information that must be relayed to the member and member’s LAR. This information will include information concerning member rights and responsibilities and covered services. More information about the SAI Modules is included in the Procurement Library.

Needs identified through the STAR Kids SAI must inform the types of follow-up assessments that must be administered. If determined through the STAR Kids core module that PCS or nursing services may be appropriate, the MCO must administer the STAR Kids SAI’s PCAM module, NCAM module or both the PCAM and the NCAM module.

A RN, advance practice nurse (APRN), physician assistant (PA) social worker (master of social work, licensed clinical social worker, or licensed baccalaureate social worker), licensed professional counselor if the member’s service needs are primarily for behavioral health, or licensed vocational nurse (LVN) (with a minimum of one year previous service coordination or case management experience and experience with pediatric clients), must administer the STAR Kids SAI core module and PCAM, if needed, and these modules may not be administered by any contracted entity that is or will be providing direct services to the member. An RN or advanced practice registered nurse (APRN) must administer the STAR Kids SAI NCAM and MDCP module, if needed. Any MCO staff, or MCO contracted staff, administering the SK SAI must take the SK SAI training module required by HHSC before administering the SAI. All MCO staff, or MCO-contracted staff administering the MDCP portion of the SKSAI must have completed the HHSC-approved Star Kids SAI training, and must be certified through the state-approved RUG training found at the Texas State website under “Continuing Education.” For quality monitoring purposes, the MCO must submit data collected through the SAI to the HHSC administrative services contractor in the format prescribed by HHSC. The MCO must provide any requested data to HHSC or its administrative services subcontractor in accordance with the terms of this Contract.

The personal care assessment module (PCAM) must be used to assess member’s need for functionally necessary personal care services. MCOs may adapt the PCAM to reflect the MCO’s name or distribution instructions, but all other elements must be the same. Instructions for completion must be followed exactly as stated. MCOs will not complete the PCAM for members enrolled in intellectual or developmental disabilities waiver programs.

The nursing care assessment module (NCAM) is a module included in the STAR Kids SAI that collects clinical information on a member’s physical condition in order to inform potential nursing service needs. MCOs may adapt the NCAM to reflect the MCO’s name or distribution instructions, but all other elements must be the same. Instructions for completion must be followed exactly as stated.

If the PCP of a STAR Kids member submits an order for services to the STAR Kids MCO before the member has been assessed in-person by the MCO, the MCO must initiate a short-term plan of care for services until the STAR Kids screening and assessment process is complete.

If a current STAR Kids member is considered by HHSC for entry into the MDCP STAR Kids program, the MCO must use the STAR Kids SAI, including the MDCP Module, for the purposes of gathering and submitting medical information to HHSC or its designee for medical necessity determinations.

The STAR Kids SAI will indicate if further screening or evaluation is needed for behavioral health services, physical therapy, occupational therapy, and speech therapy. The MCO may use additional evidence-based assessments or promising practices to further inform these specific behavioral health and therapy services, as well as durable medical equipment, medical supplies, or any other need identified during the STAR Kids screening and assessment process. The MCO, a Subcontractor, a local intellectual or developmental disabilities authority, or a provider may complete additional assessment instruments, but the MCO remains responsible for the data recorded. To the extent appropriate, MCOs must ensure additional assessment tools administered are either evidence or research based.

The MCO must coordinate the assessment and gathering of any required documentation in a manner that ensures that the authorization and initiation of a member’s services are in no way delayed and that the member’s access to care is in no way delayed or limited. Failure of the MCO to obtain information required by HHSC or to obtain any additional information that may be requested by the MCO in a particular case, shall not result in any lapse in service, service authorization, or delay in the initiation of any services. The MCO must not require any additional information or documentation that has the effect of creating a delay in, or barrier to, the member receiving timely and appropriate care or has the effect of depriving any member of access to such care.

For members with a physical disability seeking or needing Community First Choice services, the MCO must use the STAR Kids Screening and Assessment Instrument and supply current medical information for Medical Necessity determinations. After the initial service plan is established, it must be completed on an annual basis. The STAR Kids Screening and Assessment Instrument must be completed annually at reassessment. The MCO is responsible for tracking the renewal dates to ensure all member reassessment activities have been completed and submitted to the HHSC Administrative services contractor 30 days prior to the expiration date of the STAR Kids Screening and Assessment Instrument for members who are physically disabled. The MCO cannot submit a renewal of the STAR Kids Screening and Assessment Instrument earlier than 90 days prior to the expiration date of the ISP.

For all members who receive behavioral health services, the MCO must encourage participation of both the member’s PCP and behavioral health providers in the assessment and treatment planning process.

If the member or the member’s LAR indicates an immediate need for covered services the MCO must provide appropriate authorizations prior to administering the face-to-face STAR Kids Screening and Assessment Instrument. If at any time prior to conducting the STAR Kids SAI the MCO is notified or becomes aware of an increase in the member’s needs, the MCO must initiate the change based on the urgency of the member’s condition, but no longer than ten days of becoming aware of the increase in the member’s needs.

Following completion of the STAR Kids SAI, the MCO must review the information populated in the assessment with the member or member’s LAR for verification and make edits, as appropriate, prior to submitting to the HHSC administrative service contactor. The service coordinator must notify the member or member’s LAR that the STAR Kids SAI will be available on the member’s portal and that they may also request and receive a copy of the SAI. Upon request, the MCO must provide the member or member’s LAR with a printed or electronic copy of the SAI within seven days of the request. The MCO must post the results of the STAR Kids SAI to the member’s portal within seven days of submitting the assessment to the HHSC administrative services contractor. The MCO must provide a summary document on significant findings from the STAR Kids SAI and STAR Kids screening and assessment process to the member’s PCP, if requested. For all members receiving community first choice (CFC) services, the MCO must provide the CFC provider with a copy of the SAI and ISP in order to comply with person-centered planning requirements.

Based on the functional assessment of a member’s needs, appropriate community-based LTSS must be authorized no later than three business days from the date of the assessment. The date on an authorization for community-based LTSS must be no earlier than the date the authorization is sent to a provider, unless the provider gives the MCO written consent for an earlier authorization date. The provider’s written consent must be maintained in the member’s case file. Community-based LTSS must be initiated within the timeframes specified in Section 8.1.3.1, appointment accessibility.

Access to Care

All covered services must be available to members on a timely basis in accordance with the contract’s requirements and medically appropriate guidelines generally accepted practice parameters. The managed care organization (MCO) must comply with the access requirements as established by the Texas Department of Insurance (TDI) for all MCOs doing business in Texas, except as otherwise required by this contract.

The MCO must provide coverage for emergency services in compliance with 42 C.F.R. § 438.114, and as described in more detail in Section 8.1.24.1. The MCO must provide coverage for emergency services to members 24 hours a day and seven days a week, without regard to prior authorization or the emergency service provider’s contractual relationship with the MCO. The MCO’s policy and procedures, covered services, claims adjudication methodology, and reimbursement performance for emergency services must comply with all applicable state and federal laws and regulations, whether the provider is in the MCO’s network or out-of-network.

A Medicaid MCO is not responsible for payment for unauthorized non-emergency services provided to a member by out-of-network providers, except when that provider is an Indian health care provider (IHCP) enrolled as a federally qualified health center (FQHC), as provided in Section 8.1.26.

The MCO must also have an emergency and crisis behavioral health services hotline available 24 hours a day, seven days a week, toll-free throughout the service area(s). The behavioral health services hotline must meet the requirements described in Section 8.1.16.2. The MCO may arrange emergency services and crisis behavioral health services through mobile crisis teams.

The MCO must require, and make best efforts to ensure, that primary care providers (PCPs) are accessible to members 24 hours a day, seven days a week and that network primary care providers have after-hours telephone availability consistent with Section 8.1.5.6.2. The MCO must ensure that network providers offer office hours to members that are at least equal to those offered to the MCO’s commercial lines of business or Medicaid fee-for service participants, if the provider accepts only Medicaid members.

If medically necessary covered services are not available through network physicians or other providers, the MCO must allow referral to an Out-of-network physician or provider upon request of a network provider. The referral must occur within the time appropriate to the circumstances relating to the delivery of the services and the condition of the member, but in no event to exceed five business days after receipt of reasonably requested documentation. The MCO must fully reimburse the out-of-network provider in accordance with the out-of-network methodology for Medicaid as defined by HHSC in 1 Tex. Admin. Code § 353.4. The MCO must provide these services within the timeframes specified in Section 8.1.4.6 and within the time appropriate to the circumstances and member’s need.

The MCO must ensure the provision of covered services meet the specific preventive, acute care, community-based services, long-term services and supports, and specialty healthcare needs appropriate for treatment of the individual member’s condition(s).

The MCO must provide access to PCPs and specialist physicians with experience serving children and adolescents with special healthcare needs, including behavioral health needs. The MCO must make best efforts to recruit and contract with PCPs and specialist physicians who are board-certified in their specialty. As described in Section 8.1.38.2, the MCO is responsible for working with members, their LAR, and their providers to develop a seamless package of care in which primary care, community based care, behavioral health, and specialty care needs are met through an Individual service Plan (ISP) that is culturally competent and understandable to the member.

The MCO may not require the member to pay for any medically necessary or functionally necessary covered services other than Health and Human services Commission (HHSC)-specified copayments and applied income for Medicaid members, where applicable, if HHSC implements Medicaid cost sharing after the effective date of the contract.

Appointment Accessibility:

Through its provider network composition and management, the MCO must ensure that the following standards for appointment accessibility are met. The standards are measured from the date of presentation or request, whichever occurs first.

  1. Emergency services must be provided upon member presentation at the service delivery site, including at non-network and out-of-area facilities;
  2. An urgent condition, including urgent specialty care and behavioral health services, must be provided within 24 hours; treatment for behavioral health services may be provided by a licensed behavioral health clinician;
  3. Primary routine care must be provided within 14 days;
  4. Specialty routine care must be provided within 21 days;
  5. Specialty therapy evaluations must be provided within 21 days of submission of a signed referral. If an additional evaluation or assessment is required as a condition for authorization of therapy evaluation, the additional required evaluation or assessment should be scheduled to allow the specialty therapy services to occur within 21 days from date of submission of a signed referral;
  6. Initial outpatient behavioral health visits must be provided within 14 days;
  7. Initial outpatient behavioral health visits must be provided within seven days upon discharge from an inpatient psychiatric setting;
  8. Community-based services for members must be initiated within seven days from the authorization;
  9. For members receiving medically dependent children program (MDCP) services, services must be initiated by the start date of the individual service plan (ISP) tracker;
  10. Prenatal care must be provided within 14 days of request for initial appointments, except for high-risk pregnancies or new members in the third trimester, for whom an initial appointment must be offered within five days, or immediately, if an emergency exists. Appointments for ongoing care must be available in accordance to the treatment plan as developed by the provider;
  11. Preventive health services for members less than six months of age must be provided within 14 days. Preventive health services for members six months through age 20 must be provided within 60 days. Members should receive preventive care in accordance with the Texas health steps periodicity schedule. MCOs must encourage new members 20 years of age or younger to receive a Texas health steps checkup within 90 days of enrollment. For purposes of this requirement, the term “New member” is defined in Uniform Managed Care Manual Chapter 12.4.

Access to Network Providers

The MCO’s network must include all of the provider types described in this section in sufficient numbers, and with sufficient capacity, to provide timely access to all covered services in accordance with the waiting times for appointments in RFP Section 8.1.3.1. To the extent possible, providers must have experience working with children or young adult populations. The MCO’s primary care provider network must provide timely access to regular and preventive care to all members, and Texas health steps services to all child members. The MCO must allow each member to choose his or her network provider to the extent possible and appropriate, in accordance with federal and state law and policy, including 42 C.F.R. § 438.3(l) and § 457.1201(j).

This section includes access standards for each provider type. For each provider type, the MCO must provide access to at least 90 percent of members in each service area within the prescribed distance or travel time standard. This 90 percent benchmark does not apply to pharmacy providers (refer to the “pharmacy Access” heading for applicable benchmarks). For the purposes of this section, counties will be designated as metro, micro, or rural. The county designation is based on population and density parameters. A map of counties by designation and parameters is available in Attachment B-5. Members’ residence in eligibility files with HHSC will be used to assess distance and travel times.

HHSC will track MCO performance. HHSC will use the MCO provider Files to run the quarterly geo-mapping report which will measure distance and travel time. HHSC will compile the reports related to distance and travel time based on each MCOs network. HHSC will share identified deficiencies with the MCO on a quarterly basis. This report is based on the provider data on file at HHSC for the first month of the quarter. The MCO may be subject to liquidated damages as specified in Attachment B-3. For the purposes of quarterly geo-mapping reporting, MCOs meeting either the distance or travel time standards specified below will be considered in compliance.

Primary Care Provider (PCP) Access: At a minimum, the MCO must ensure that all adult and child members have access to a choice of age-appropriate network PCPs with an open panel within the following number of miles or travel time of the member’s residence. Members residing in a Metro County: 10 miles or 15 minutes; members residing in a Micro County: 20 miles or 30 minutes: Members residing in a rural county: 30 miles or 40 minutes. The MCO must request and be granted an exception by HHSC if the MCO is unable to meet this standard. For the purposes of assessing compliance with this requirement, an internist who provides primary care to adults only is not considered an age-appropriate PCP choice STAR Kids members.

OB/GYN Access: STAR Kids program networks must ensure that all female members have access to an OB/GYN in the provider network within the following number of miles or travel time of the member’s residence. Members residing in a Metro County: 30 miles or 45 minutes; members residing in a Micro County: 60 miles or 80 minutes: Members residing in a Rural County: 75 miles or 90 minutes. If the OB/GYN is acting as the member’s PCP, the MCO must follow the access requirements for the PCP.

Prenatal Care: Members who are pregnant must have access to a network provider for prenatal care within the following number of miles or travel time of the member’s residence. Members residing in a Metro County: 10 miles or 15 minutes; members residing in a Micro County: 20 miles or 30 minutes: Members residing in a Rural County: 30 miles or 40 minutes. The MCO must allow a pregnant member past the 24th week of pregnancy to remain under the member’s current OB/GYN’s care through the member’s post-partum checkup, even if the OB/GYN provider is, or becomes, Out-of-Network.

Outpatient Behavioral Health Service Provider Access: At a minimum, the MCO must ensure that all members have access to an outpatient behavioral health service provider in the network within the following number of miles or travel time of the member’s residence. Members residing in a Metro and Micro County: 30 miles or 45 minutes; members residing in a Rural County: 75 miles or 90 minutes. The behavioral health service provider should be the appropriate provider type to meet each individual member’s needs.

Outpatient behavioral health service providers must include psychiatrists including those that treat children; masters and doctorate-level trained practitioners practicing independently or at clinics/group practices, or at outpatient Hospital departments; licensed clinical social workers (LCSWs); licensed marriage and family therapists (LMFTs); licensed professional counselors (LPCs); licensed psychologists, licensed Chemical Dependency Treatment facilities, including those that treat adolescents; and Local Mental Health Authorities.

Mental Health Rehabilitative Services and Mental Health Targeted Case Management: Members must have access to a network provider of mental health rehabilitation and mental health targeted case management within the following number of miles or travel time of the member’s residence. Members residing in Metro County and Micro Counties: 30 miles or 45 minutes; members residing in a Rural County: 75 miles or 90 minutes.

Specialist Physician Access: At a minimum, the MCO must ensure that all members have access to a choice of network specialist provider within the following number of miles and travel time of the member’s residence. PCPs must make referrals for specialty care on a timely basis, based on the urgency of the member’s medical condition, but no later than five days.

Cardiology/cardiovascular disease, general surgery, ophthalmology, and orthopedics/orthopedic surgery for members residing in a Metro County: 20 miles or 30 minutes; members residing in a Micro County: 35 miles or 50 minutes: Members residing in a Rural County: 60 miles or 75 minutes.

Psychiatry, and urology for members residing in a Metro County: 30 miles or 45 minutes; members residing in a Micro County: 45 miles or 60 minutes: Members residing in a Rural County: 60 miles or 75 minutes.

Access to a choice of pediatricians must be available to child members within the following number of miles and travel time of the member’s residence. Members residing in a Metro County: 20 miles or 30 minutes; members residing in a Micro County: 35 miles or 50 minutes: Members residing in a Rural County: 60 miles or 75 minutes.

Audiology, otolaryngology and all other specialties not listed above for members residing in a Metro County: 30 miles or 45 minutes; members residing in a Micro County: 60 miles or 80 minutes: Members residing in a Rural County: 75 miles or 90 minutes. In addition, all members must be allowed to: 1) select a network ophthalmologist or therapeutic optometrist to provide eye health care services, other than surgery, and 2) have access, without a PCP referral, to eye health care services from a network specialist who is an ophthalmologist or therapeutic optometrist for non-surgical services.

The MCO must request and be granted an exception by HHSC if the MCO is unable to meet this standard.

Occupational, Physical, and Speech Therapy Provided in an Outpatient Clinic or Facility: Members must have access to at least one network provider for occupational therapy, physical therapy, and speech therapy within the following number of miles or travel time of the member’s residence. Members residing in a Metro County: 30 miles or 45 minutes; members residing in a Micro County: 60 miles or 80 minutes: Members residing in a Rural County: 60 miles or 75 minutes.

In accordance with UMCM Chapter 5.0, MCOs shall report on therapy provider terminations, provider inability to accept new members, and complaints resulting from therapy rate reductions. MCOs shall submit a report detailing members’ inability to access a therapy provider due to provider availability.

Hospital Access: The MCO must ensure that all members have access to an acute care hospital with a staff or on-call pediatrician in the provider network within 30 miles or 45 minutes of the member’s residence. MCOs may request exceptions on a case-by-case basis. The MCO also must ensure that members have access by transfer to an appropriate network or out-of-network hospital providing the needed level of care.

Pharmacy Access: Members must have access to a network pharmacy provider within the following number of miles or travel time of the member’s residence co residing in a Metro County: 10 miles or 15 minutes; members residing in a Micro County: 20 miles or 30 minutes; members residing in a Rural County: 30 miles or 40 minutes.

The following standards apply to the Medicaid rural service area:

  1. In a Metro county, at least 75 percent of members must have access to a network pharmacy within 2 miles or 5 minutes of the members’ residence;
  2. In a Micro County, at least 55 percent of members must have access to a network pharmacy within 5 miles, or 10 minutes of the member’s residence; and
  3. In a Rural County, at least 90 percent of members must have access to a network pharmacy within 15 miles, or 20 minutes of the member’s residence.
  4. At least 90 percent of members must have access to a 24-hour pharmacy within 75 miles, or 90 minutes of the member’s residence.

For all other counties:

  1. In a Metro County, at least 80 percent of members must have access to a network pharmacy within 2 miles, or 5 minutes of the member’s residence;
  2. In a Micro County, at least 75 percent of members must have access to a network pharmacy within 5 miles or 10 minutes of the member’s residence;
  3. In a Rural County, at least 90 percent of members must have access to a network pharmacy within 15 miles, or 25 minutes of the member’s residence; and
  4. At least 90 percent of members must have access to a 24-hour pharmacy within 75 miles, or 90 minutes of the member’s residence.

Mail order pharmacies, including specialty pharmacies that only mail prescriptions, will not be included when calculating these percentages. However, MCOs will be required to report on the number of prescriptions filled and number of members served through mail order/specialty pharmacies by MCO program and service area.

Private Duty Nursing: STAR Kids MCOs must ensure that members have access to a choice of at least two home and community support services agencies able to provide authorized private duty nursing services to members in each county.

In-home Occupational, Physical, and Speech Therapies: STAR Kids MCOs must ensure that members have access to a choice of at least two providers able to provide authorized in-home occupational, physical, and speech therapy services to members in each county in each service area for which the MCO provides services under the contract.

Attendant Care to include attendant care provided through CFC and state plan PCS: STAR Kids MCOs must ensure that members have access to a choice (at least two) of home and community support services agencies or providers who are contracted with HHSC to provide services under the home and community-based services (HCS) or Texas home living (TxHmL) waiver programs that are able to provide authorized personal care services to members in each county in each service area for which the MCO provides services under the contract. 

CFC Habilitation Services: STAR Kids MCOs must ensure that members have access to a choice of at least two home and community support services agencies or providers who are contracted with HHSC to provide services under the home and HCS or TxHmL waiver programs that are able to provide authorized CFC Habilitation services to members in each county in each service area for which the MCO provides services under the contract.

Consumer Directed Services (CDS): STAR Kids MCOs must ensure that members have access to a choice of at least two financial management service agencies able to provide authorized administrative services for members that elect to receive CDS.

All other Covered services, except for services provided in the member’s residence: At a minimum, the MCO must ensure that all members have access to at least one network provider for each of the remaining covered services within 75 miles of the member’s residence. This access requirement includes: specialists not previously referenced in this section, oncology including surgical and radiation, hospitals with specialist children’s services, children’s hospitals and special hospitals, psychiatric hospitals, diagnostic services, and single or limited service healthcare physicians or providers. MCOs may request exceptions on a case-by-case basis.

The MCO may make arrangements with physicians or providers outside the state for members to receive a higher level of skill or specialty than the level available within the state, including treatment of cancer, burns, and cardiac diseases.

The MCO must make arrangements with physicians or providers outside the MCO’s service area if necessary for a member to receive a higher level of skill or specialty than the level available within the service area.

Exception Process: HHSC will consider requests for exceptions to the access standards for all provider types under limited circumstances (e,g. if no appropriate provider types are located within the mileage standards). Each exception request must be supported by information and documentation as specified in HHSC’s exception request template. Exceptions may be granted when an MCO has established, through utilization data, that a normal pattern for securing healthcare services within an area does not meet these standards, or when an MCO is providing care of a higher skill level or specialty than the level which is available within the service area.

Monitoring Access

The MCO must verify that covered services are available and accessible to members in compliance with the standards described in Sections 8.1.3 and 8.1.3.2. For covered services furnished by PCPs, the MCO must also comply with the standards described in Section 8.1.2.

The MCO must develop and implement a provider directory verification survey to verify that the provider information maintained by the MCO is correct and in alignment with the provider information maintained by the HHSC Administrative services contractor.

The survey must be conducted each fiscal year. At a minimum, the survey must include verification of provider directory critical elements in accordance with UMCM Chapter 5.4.1.10 Provider Directory Verification Report.

The MCO may conduct the survey through its online provider portal, telephone calls, onsite visits, email, or other method that collects and verifies information. For each service area, the MCO must conduct a statistically-valid random sample (95 percent confidence level with a margin of error +/- 5 percent) of network PCPs and specialists. The MCO must collect, analyze, and submit survey results and supporting documentation as specified in UMCM Chapter 5.4.1.10, provider Directory Verification Report.

The MCO must enforce access and other network standards required by the contract and take appropriate action with providers whose performance is determined by the MCO to be out of compliance.

Telemedicine, Telehealth, and Telemonitoring Access:

Telemedicine, telehealth, and telemonitoring are covered services and are benefits of Texas Medicaid as provided in the Texas Medicaid provider Procedures Manual. MCOs are encouraged to contract with providers offering these services to provide better access to healthcare for its members. In addition, a Medicaid MCO must be able to accept and process provider claims for these services in conformity with the Texas Medicaid benefit. The MCO must contract with providers with Telemedicine, Telehealth, and Telemonitoring capabilities to increase access to specialty and behavioral healthcare.  The MCO must include information in its provider Directory on providers with Telemedicine, Telehealth, and Telemonitoring capabilities. Section 8.1.16, behavioral health (BH) services and Network, provides additional information regarding Telemedicine, Telehealth, and Telemonitoring.

The MCO must determine the exact number and locations of all Telemedicine, Telehealth, and Telemonitoring end points and the number of providers who will commit to working with the MCO’s Telemedicine, Telehealth, and Telemonitoring contractors. The MCO must outreach to its Telemedicine, Telehealth, and Telemonitoring providers to encourage the increase and availability of end points in rural and medically underserved areas. The MCO must also outreach to pediatric specialty and behavioral health providers to assure engagement of qualified Telemedicine, Telehealth, and Telemonitoring contractors. In the outreach process the MCO must offer trainings and supports to help establish Telemedicine, Telehealth, and Telemonitoring literacy and capabilities. In addition, the MCO must actively recruit additional rural providers in order to increase member access to the services that Telemedicine, Telehealth, and Telemonitoring can provide.

School-based Telemedicine Services

As required by Texas Government Code § 531.0217, school-based telemedicine medical services are a covered service for members. MCOs must reimburse the distant site physician providing treatment even if the physician is not the member’s primary care physician or provider, or is an out-of-network physician. To be eligible for reimbursement, distant site physicians providing treatment must meet the service requirements outlined in Texas Government Code § 531.0217 (c-4).

MCOs may not request prior authorization for school-based telemedicine medical services.

Care Coordination

Service Coordination Description

Service coordination provides the member with initial and ongoing assistance identifying, selecting, obtaining, coordinating, and using covered services and other supports to enhance the member’s well-being, independence, integration in the community, and potential for productivity. Managed care organizations (MCO) must ensure that service coordination is used to:

  1. Provide a holistic evaluation of the member’s individual dynamics, needs and preferences.
  2. Educate and help provide health-related information to the member, the member’s legally authorized representative (LAR), and others in the member’s support network;
  3. Help identify the member’s physical, behavioral, functional, and psychosocial needs;
  4. Engage the member and the member’s LAR and other caretakers in the design of the member’s individual service plan (ISP);
  5. Connect the member to covered and non-covered services necessary to meet the member’s identified needs;
  6. Monitor to ensure the member’s access to covered services is timely and appropriate;
  7. Coordinate covered and non-covered services; and
  8. Intervene on behalf of the member if approved by the member.

Service Coordination Structure

Through service coordination and other methods determined appropriate by the MCO, the MCO must implement a systematic process to coordinate non-capitated services and, if determined advantageous to the member, enlist the involvement of community organizations providing non-covered services that are important to the health and wellbeing of members. The MCO also must also seek to establish relationships with state and local programs and community organizations, such as the following, to make referrals for members who need community services.

  1. Peer supports and family partners for behavioral health conditions;
  2. Community resource coordination groups (CRCGs);
  3. Early childhood intervention (ECI) program;
  4. Local school districts (special education);
  5. Health and Human Services Commission (HHSC) medical transportation program
  6. Department of assistive and rehabilitative services (DARS) blind children’s vocational discovery and development program;
  7. Department of State Health (DSHS) services, including community mental health programs, the Title V Maternal and Child Health, case management for children and pregnant women, children with special health care needs (CSHCN) programs, and youth empowerment services (YES) Home and Community-Based Services (HCBS) waiver;
  8. Supplemental nutrition assistance program (SNAP), the women, infants, and children’s (WIC) program, and head start;
  9. Department of Aging and Disability services (DADS) HCBS Waivers, including community living assistance and support services (CLASS), deaf blind with multiple disabilities (DBMD), Texas home living (TxHmL), and home and community-based services (HCS); and
  10. Civic and religious organizations and consumer and advocacy groups, such as easter seals and the arc, that also work on behalf of specific member populations; and
  11. Texas Department of Family and Protective services (DFPS) nurse family partnership (NFP).

To assure coordination between programs for all STAR Kids members who are enrolled in DADS or DSHS HCBS Waivers, the named STAR Kids service coordinator must communicate regularly with the DADS or DSHS staff members or contractors responsible for overseeing the member’s HCBS waiver services.

All STAR Kids MCOs must provide dedicated toll-free service coordination phone numbers. These numbers, if not regional, must have the capabilities of warm transferring to the MCO’s regional office. These numbers must have the capability for a member, their family, or a provider to leave a message between five p.m. and eight a.m. central time on weekdays and on weekends. Any messages must be returned within two business days. If the number transfers to another MCO hotline after normal business hours, the caller must be able to leave a message for the service coordination team and the message must be returned within two business days.

As described in Attachment A, Section 4.04.1, an integrated health home may perform service coordination functions, and serve as an identified service coordinator.

Individual Service Plan (ISP) Description

Each STAR Kids MCO must create and regularly update a comprehensive Person-centered ISP for each STAR Kids member, unless the member or member’s LAR declines the STAR Kids screening and assessment process as described in Section 8.1.39. The purpose of the ISP is to articulate assessment findings, short and long-term goals, service needs, and member preferences. The MCO must use the ISP to communicate and help align expectations between the member, their LAR, the MCO and key service providers. The MCO must use the ISP to measure member outcomes over time.

The MCO must ensure that all ISPs must contain the following information:

  1. A summary document describing the recommended service needs identified through the STAR Kids screening and assessment process;
  2. Covered services currently received;
  3. Covered services not currently received, but that the member might benefit from;
  4. A description of non-covered services that could benefit the member;
  5. Member and family goals and service preferences;
  6. Natural strengths and supports of the member including helpful family members, community supports, or special capabilities of the member;
  7. With respect to maintaining and maximizing the health and well-being of the member, a description of roles and responsibilities for the member, their LAR, others in the member’s support network, key service providers, the member’s Health Home, the MCO, and the member’s school, if applicable;
  8. A plan for coordinating and integrating care between providers and covered and non-covered services;
  9. Short and long-term goals for the member’s health and well-being;
  10. If applicable, services provided to the member through YES, TxHmL, DBMD, HCS, CLASS, or third-party resources, and the sources or providers of those services;
  11. Plans specifically related to transitioning to adulthood for members age 15 and older; and
  12. Any additional information to describe strategies to meet service objectives and member goals.

ISP Requirements

The MCO must ensure that the ISP is informed by findings from the STAR Kids screening and assessment process, in addition to input from the member; their family and caretakers; providers; and any other individual with knowledge and understanding of the member’s strengths and service needs who is identified by the member, the member’s LAR, or the MCO. To the extent possible and applicable, the MCO must ensure that the ISP accounts for school-based service plans and service plans provided outside of the MCO. The MCO is encouraged to request, but may not require the member to provide a copy of the member’s Individualized Education Plan (IEP).

The MCO must update each member’s ISP:

  1. At least annually;
  2. following a significant change in health condition that impacts service needs;
  3. upon request from the member or the member’s LAR;
  4. at the recommendation of the member’s PCP;
  5. following a change in life circumstance; and
  6. following the STAR Kids Screening and Assessment Process or re-assessment process.

Service Coordination Teams

Service coordination teams are member-centered support networks designed to enhance services provided by the service coordinator. Service coordination team members must be individually selected based on the needs and preferences of the member. The MCO will provide a service coordination team when the MCO or a provider determines the member could benefit from a multidisciplinary approach to service coordination or determines specific expertise is necessary to address needs identified in the member’s ISP. Service coordination teams must be led by at least one service coordinator employed by the MCO, or appropriate health home employee, if the member receives service coordination through their health home. If a member has a named service coordinator, the named service coordinator must lead the service coordination team. Service coordination teams must have access to individuals with expertise or access to identified subject matter experts in the following areas:

  1. Behavioral health
  2. Co-occurring behavioral health conditions and intellectual or developmental disability (IDD)
  3. Medically complex conditions
  4. Substance abuse disorder
  5. Local resources (e.g., basic needs like housing, food, utility assistance)—MCOs are encouraged to use certified community health workers to support individuals in local areas
  6. Pediatrics
  7. Long-term services and supports (LTSS), including HCBS Waiver programs
  8. Durable medical equipment (DME)
  9. End of life/advanced illness
  10. Curative treatment or palliative care
  11. Acute care
  12. Preventive care
  13. Cultural competency based on national standards for culturally and linguistically appropriate services (CLAS)
  14. Pharmacology
  15. Nutrition
  16. Consumer Directed services
  17. Texas Promoting Independence strategies such as diversion and relocation
  18. Person-Centered Planning
  19. Family Partners
  20. Peer Supports
  21. Positive behavior support
  22. Assistive technology including augmentative communication and seating and positioning
  23. Supported employment
  24. Permanency planning
  25. School transition

A member’s interaction with a service coordination team must be tied to the level and frequency of coordination desired by the member and the member’s LAR and appropriate to the member’s needs. The named service coordinator responsible for leading the service coordination team must work with the team to ensure the team addresses objectives identified in the member’s ISP.

All members who receive LTSS through a nursing facility, the Intermediate Care Facilities for Individuals with an Intellectual Disability (ICF/IID) program, or through non-capitated HCBS waiver programs must be offered access to a service coordination team that includes representatives from the member’s STAR Kids MCO, and at least one coordinator representing the member’s non-capitated LTSS. All STAR Kids MCO representatives on a service coordination team must work in collaboration with other members of the service coordination team to ensure the member receives adequate and appropriate covered and non-covered services.

Health Homes

The managed care organization (MCO) must provide access to a health home to any member the MCO determines would most benefit from a health home or for any member who requests a health home. A health home must provide an array of services and supports, outlined below, that extend beyond what is required of a primary care provider (PCP). STAR Kids health homes must operate through either a primary care practice or, if appropriate, a specialty care practice and must provide a team-based approach to care that is designed to enhance ease of access, coordination between providers, and quality of care.

Health home services must be part of a person-based approach and holistically address the needs of persons with multiple chronic conditions or a single serious and persistent mental or health condition.

Health Home services must include:

  1. Patient self-management education;
  2. Provider education;
  3. Patient-centered and family-centered care;
  4. Evidence-based models and minimum standards of care; and
  5. Patient and family support (including authorized representatives).

Health home services may also include:

  1. A mechanism to incentivize providers for provision of timely and quality care;
  2. Implementation of interventions that address the continuum of care;
  3. Mechanisms to modify or change interventions that are not proven effective;
  4. Mechanisms to monitor the impact of the health home services over time, including both the clinical and the financial impact;
  5. Comprehensive care coordination and health promotion;
  6. Palliative care options in the event of a life-limiting diagnosis;
  7. Comprehensive traditional care, including appropriate follow-up, from inpatient to other settings;
  8. Data management focused on improving outcome-based quality of care and improved patient and provider satisfaction;
  9. Referral to community and social support services, if relevant; and
  10. Use of health information technology to link services, as feasible and appropriate.

Health Home Services and Participating Providers:

The MCO must provide information and other resources to PCPs and other health home providers regarding federal incentive programs and nationally recognized accreditation, recognition, and certification programs addressing medical and health home models. At a minimum, the MCO must consider offering financial incentives to health homes that achieve nationally recognized levels of accreditation, recognition, and certification for the development of a medical or health home model.

The MCO must develop provider incentive programs for designated providers who meet the requirements for patient-centered medical homes found in Texas Government Code § 533.0029.

At a minimum, the MCO must:

  1. Maintain a system to track and monitor all health home services participants for clinical, utilization, and cost measures;
  2. Implement a system for providers to request specific health home interventions;
  3. Inform providers about differences between recommended prevention and treatment and actual care received by members enrolled in a health home services program and members’ adherence to a service plan; and
  4. Provide reports on changes in a member’s health status to his or her PCP for members enrolled in a health home services program.

Virginia

Virginia has a long history of serving enrollees in Medicaid managed care. In 2017, they launched Commonwealth Coordinated Care Plus, a specialized managed care program that serves Medicaid-enrolled adults over the age of 65, children or adults with complex health care needs, nursing facility residents, and those receiving services and supports through a home- and community-based waiver.[15]  Commonwealth Coordinated Care Plus is now the mandatory Medicaid managed care program for children and adults with special health care needs statewide, providing coverage for approximately 207,722 individuals as of mid-2018.[16]

Virginia sample contract language

Identification and Assessment

Identification:

The contractor shall use data from multiple sources (including utilization data, health risk assessments, state agency aid categories, demographic information, and Health Department epidemiology reports) to identify members with complex health needs, including members who need help navigating the health system to receive appropriate delivery of care and services. When clinically indicated, the contractor will assign each member to a care coordinator to provide care coordination support throughout the course of treatment, ensuring that all relevant information is shared with the treating providers through care transitions.

Health Risk Assessment (HRA):

The contractor shall use a health risk assessment (HRA) as a tool to develop the member’s person-centered individualized care plan (ICP) (see section person centered individualized care plan and reassessments for more information). The department reserves the right, providing the contractor with at least 60 calendar days advance notice, to require the contractor to add additional elements to its HRA. The contractor shall participate in an HRA workgroup in the Summer of 2018 that includes representation from all plans, DMAS, and relevant stakeholders. The goal of the HRA workgroup is to create a universal HRA that is portable and that can follow the member from one MCO to another.

At a minimum, the contractor’s HRA shall effectively identify the member’s unmet needs, and shall encompass social factors (such as housing, informal supports, and employment), functional, medical, behavioral, cognitive, long-term services and support (LTSS), wellness and preventive domains, the member’s strengths and goals, the need for any specialists, community resources used or available for the member, the member’s desires related to their health care needs (as appropriate), and the person-centered ICP maintenance. The contractor should use appropriate documentation (e.g., medical transition report (MTR) data, early intervention individualized family service plan, minimum data set (MDS), uniform assessment instrument (UAI) when current/relevant) to complete HRA elements in order to avoid unnecessary burden to the member, caregiver or provider.

The contractor’s HRA shall also:

  1. Document that during the initial health risk assessment, the member was informed of the program name, covered benefits, and the role of the care coordinator.
  2. Document the source of information for the HRA i.e. the member, providers, facility staff, family/caregivers, etc. to include name and title) and location of completion (face to face or telephone and physical location).

For CCC Plus Waiver members, in addition to the required elements above, the contractor’s assessment shall also include the following elements:

  1. Pertinent information from the UAI, when available.
  2. Discussion with member/caregiver regarding satisfaction with services received;
  3. Evaluate the environment for appropriateness, safety, and member comfort;
  4. Confirmation of the member’s needs;
  5. Clarification with member/caregiver program services, limits, and rights and responsibilities of everyone involved in providing care;
  6. Confirmation that the waiver provider(s) is working to meet member’s care plan as written; and,
  7. Confirmation that all appropriate documentation is available in the home (i.e. plan of care).

For CCC Plus waiver members who are technology dependent, in addition to the required elements above, the contractor’s assessment shall also include the following elements:

  1. Determination that appropriate medical equipment is available;
  2. Confirmation that medical needs are as described on the DMAS 108/109;
  3. Confirmation that the private duty nursing provider is working to meet member’s care plan as written; and,
  4. Confirmation that all appropriate documentation is available in the home (i.e. physicians’ orders, home health certification and plan of are (CMS-485), nursing care and medication administration documentation, etc.).

For CCC Plus members who reside in a nursing facility, in addition to the required elements above, the contractor’s assessment shall also include the following elements:

  1. All pertinent information from the MDS;
  2. Information from the MDS Section Q, in addition to separate documentation of the member’s interest and desire for transition to the community and available resources and barriers to doing so;
  3. The transition process including any identified health, safety or welfare needs which may result in the member’s inability to transition by to the community; and,
  4. Pertinent information from the UAI, when available.

Timelines for HRAs:

Care coordinators shall complete an initial face to face HRA for newly enrolled members as expeditiously as the member’s condition requires and within the timeframes set forth below.

CCC Plus Waivers and EPSDT Populations

  1. For CCC Plus members who receive private duty nursing services, the contractor shall ensure that HRAs are completed face to face within 14 calendar days of plan enrollment,
  2. For CCC Plus waiver members who do not receive private duty nursing services, the contractor shall ensure that HRAs are completed face to face within 30 calendar days of plan enrollment.

Nursing Facility CCC Plus Populations

For CCC Plus members who reside in a nursing facility, the contractor shall ensure that HRAs are completed face to face within 120 calendar days of plan enrollment. The contractor shall contact the nursing facility and member within 30 calendar days of enrollment and provide the contact name and number of the care coordinator.

Other High-Risk Populations

The contractor shall ensure that HRAs are completed for remaining CCC Plus high-risk subpopulations, within 60 calendar days of plan enrollment. Populations include: individuals with serious mental illness, and individuals (duals and non-duals) with complex or multiple conditions who are identified by the plan or self-identified as having conditions that are not well managed, e.g. multiple emergency department visits, multiple inpatient admits, or have a lack of medication adherence, etc. The contractor shall conduct HRAs for serious mental illness (SMI) populations face-to-face, as described in Section 5.2.3. Otherwise, the contractor is not required to conduct HRAS face to face except in circumstances where appropriate based upon the member’s needs and preferences. The contractor shall use risk stratification and predictive modeling protocols to identify and prioritize completion of assessments for its CCC subpopulations in an efficient manner that considers the acuity of need for its members.

CCC Plus Populations with Emerging High Risks

The contractor shall complete HRAs for emerging high risk subpopulations within 120 calendar days of enrollment. The completion timeframe for this population is extended to within 180 days during Medallion aged, blind, and disabled (ABD) Transition. The contractor shall contact the member within 30 calendar days of enrollment and provide the contact name and number of the care coordinator. DMAS reserves the right to revise this completion standard in future Contracts. Assessments are not required to be conducted face-to face except in circumstances where appropriate based upon the member’s needs and preferences. Refer to model of care (MOC), assessment (HRA) And individualized care plan (ICP) requirements, attachment 11 of this Contract.

The contractor’s model of care shall include all of the required elements:

  1. Provide the full scope of care coordination and related services for the CCC Plus populations (listed below) as required in this Contract.
  2. Operate using person-centered care coordination for all members
  3. Include methods to identify, assess, and stratify vulnerable CCC Plus Populations and populations with emerging high risks.
  4. Include comprehensive health risk assessments, individualized care planning, and interdisciplinary care team involvement
  5. Integrate primary, acute, behavioral health, and LTSS,
  6. Be responsive to the member’s needs and preferences, and shall take into account the health, safety, and welfare of its members.
  7. Include staff and provider training on the CCC Plus model of care to ensure members receive person-centered, culturally competent care through trained care coordinators and through a network of high-quality, credentialed providers who have attested to or demonstrated the required competencies required by the contractor.
  8. Include processes and systems of care that engage members and family members in person centered, culturally competent care and ensures seamless transitions between levels of care and care settings.

HRA Requirements

  1. The contractor shall ensure that its HRAs conducted by telephone interview, if recorded, shall have the member’s consent to be audio recorded. The contractor shall provide the audio recording including the member’s consent to the department of medical assistance services (DMAS) upon request.
  2. The contractor shall conduct HRAs for members in the CCC Plus waiver, for members residing in nursing facilities, and for members with serious mental illness, via face-to-face communication. DMAS may recognize HRAs conducted via telehealth as an accepted means of face to face communications. The contractor shall ensure that any telehealth communication processes are an effective and appropriate option based upon the member’s condition, communication abilities, and preferences. The contractor shall submit any telehealth HRA protocols to DMAS for approval prior to implementation.
  3. The contractor’s care coordinators shall make accommodations available at no charge to the member that address the needs of members with communication impairments (e.g., hearing and vision limitations) and members with limited English proficiency, in a culturally and developmentally appropriate manner and shall consider a member’s physical and cognitive abilities and level of literacy in the assessment process.
  4. The contractor’s care coordinators shall document efforts made to outreach and conduct HRAs for members the contractor has difficulty locating.
  5. The contractor shall conduct HRAs in a location that meets the needs of the member.
  6. The contractor’s care coordinator shall have the demonstrated ability to communicate with members who have complex medical needs and may have communication barriers.
  7. Relevant and comprehensive data sources (including the member, providers, family/caregivers, etc.) shall be used by the contractor. Results of the HRA shall be used to confirm the appropriate stratification level for the member and as the basis for developing the ICP.
  8. The contractor shall ensure that each element of the HRA, including a description of the CCC Plus Waiver and other covered services to be provided until the next person-centered ICP review, is reflected in the ICP. In addition, the contractor shall ensure that its intensive community treatment (ICT) process ensures that all relevant aspects of the member’s care is addressed in a fully integrated manner on an ongoing basis.
  9. During assessments and reassessments, the contractor’s care coordinator shall gather advance directive information. This includes educating the member about advance directives, obtaining any advance directives documentation, and complying with all Federal and State requirements for advance directives, including maintaining a copy of all related documents in the member’s file.
  10. The contractor shall report specific data elements from the HRAs in a format and frequency as specified by DMAS in the CCC Plus technical manual.

The contractor shall use care coordinators who shall complete an initial face to face HRA for newly enrolled members as expeditiously as the member’s condition requires and according to the guidelines set forth in the HRA section of this Contract.

Access to Care

The contractor shall be solely responsible for arranging and administering covered services to enrolled members and shall ensure that its delivery system provides available, accessible, and adequate numbers of facilities, locations and personnel for the provision of covered services, including all emergency services on a 24 hour-a-day, seven day-a-week basis. Emergency services shall be provided per Section 4.6 of this contract.

The contractor’s network shall meet or exceed Federal network adequacy standards at 42 CFR §438.68 and shall have sufficient types and numbers of traditional and long-term services and supports (LTSS) providers in their networks to meet historical need and must be able to add providers to meet increased member needs in specific geographic areas. Adequacy will be assessed along a number of dimensions, including: number of providers, mix of providers, hours of operation, providers not accepting new patients, accommodations for individuals with physical disabilities (wheelchair access) and barriers to communication (translation services); and geographic proximity to beneficiaries (provider to members or members to provider). See provider network Management section of this Contract.

The contractor shall provide members with a choice of at least two providers for each type of service listed below in accordance with time and distance standards specified in Section 9.3 or where an exception is granted by the Department as described in Section 9.4.

  • Primary Care provider (PCP)
  • Pediatrician
  • Specialist
  • Outpatient behavioral health
  • CMHRS – Psychosocial Rehabilitation, day Treatment/Intensive Outpatient, Therapeutic day Treatment
  • Nursing Facility – Skilled
  • Nursing Facility – Custodial
  • Pharmacy
  • OB/GYN

Individuals with Special Health Care Needs:

When a member with special health care needs has been identified through an assessment to need a course of treatment or regular care monitoring, and in compliance with 42 CFR § 438.208(c)(4), the contractor shall have a mechanism in place to allow the member to directly access a specialist, as appropriate for the member’s condition and identified needs.

The contractor shall maintain adequate provider network coverage to serve its enrolled members 24 hours per day, seven days a week. The contractor shall make arrangements to refer members seeking care after regular business hours to a covering physician or shall direct the member to go to an urgent care or emergency room when a covering physician is not available. Such referrals may be made via a recorded message. Refer to Warm Transfer to a Clinical Professional Staff for more information.

Member Primary Care Access (Adult and Pediatric)

The contractor shall offer each member covered under this contract the opportunity to choose a primary care provider (PCP) affiliated with the contractor to the extent that open panel slots are available pursuant to travel time and distance standards described in this Contract. Except for dual eligible members, the contractor shall ensure that each member has an assigned PCP at the date of enrollment. Members shall be allowed to select or be assigned a new PCP when requested by the individual, when the contractor has terminated a PCP, or when a PCP change is ordered as part of the resolution to a formal grievance proceeding.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT):

The contractor is responsible for all EPSDT services for their members under age 21. The contractor shall comply with EPSDT requirements, including providing coverage for all medically necessary services for children needed to correct, ameliorate, or maintain health status. Refer to the Commonwealth Coordinated Care Plus (CCC Plus) coverage chart attached to this contract for more information.

The contractor shall provide coverage through EPSDT for medically necessary benefits for children outside the basic Medicaid benefit package including, but not limited to, extended behavioral health benefits, nursing care (including private duty), personal care, pharmacy services, treatment of obesity, neurobehavioral treatment, durable medical equipment, nutritional supplements, and other individualized treatments specific to developmental issues where it is determined that otherwise excluded services/benefits for a child is a medically necessary service that will correct, improve, or is needed to maintain (ameliorate) the child’s medical condition. The contractor shall cover medical services (even if experimental or investigational) for children per EPSDT guidelines if it is determined that the treatment or item would be effective to address the child’s condition. The determination whether a service is experimental must be reasonable and based on the latest scientific information available.

The contractor’s EPSDT review process for medical necessity shall consider the EPSDT correct, maintain or ameliorate criteria. The determination of whether a service is medically necessary for an individual child must be made on a case-by-case basis, taking into account the particular needs of the child. The contractor shall consider the child’s long-term needs, not just what is required to address the immediate presenting problem. The contractor shall consider all aspects of a child’s needs, including nutritional, social development, and mental health and substance use disorders. services for Medicaid children that do not meet the plan’s general coverage criteria shall receive an individualized review by a physician with experience in treating the member’s condition or disease and that ensures that the EPSDT provision has been considered. The contractor shall not use a definition of medical necessity that is more restrictive than the state’s definition. The contractor shall not issue a denial for children services until an individualized medical necessity review has been completed. The policies and procedures must allow providers to contact care coordinators to explore alternative services, therapies, and resources for members when necessary. No service provided to a child under EPSDT can be denied as “out-of-network” and/or “experimental” or “noncovered,” unless specifically noted as non-covered or carved out of this contract.

The department must review and approve the policies and procedures for the contractor’s EPSDT review process prior to implementation, at revision or upon request.

The contractor shall inform members about EPSDT services and how to access care. The contractor shall assure that a participating child is periodically screened following the American Academy of Pediatrics (AAP) and Bright Future recommendations, and treated in conformity with the AAP periodicity schedule. To comply with this requirement, the contractor shall design and employ policies and methods to assure that children receive prescreening and treatment when due.

The contractor must educate and inform members identified as not complying with the EPSDT periodicity and immunization schedules, as appropriate. The contractor shall provide copies of any such notices to the department and provide documentation as to the frequency and timing of these notices, as well as further outreach if notices are not successful.

Private Duty Nursing (PDN) Services for Children

The contractor shall cover medically necessary private duty nursing (PDN) services for children under age 21, in accordance with the department’s criteria described in the Department of Medical Assistance Services (DMAS) EPSDT Manual, and as required in accordance with EPSDT regulations described in 42 CFR §§ 441.50, 440.80, and the Social Security Act §§1905(a) and 1905(r) I. Individuals who require continuous nursing that cannot be met through home health may qualify for PDN. EPSDT PDN differs from home health nursing which provides for short-term, intermittent care where the emphasis is on member or caregiver teaching. Under EPSDT PDN, the individual’s condition must warrant continuous nursing care, including but not limited to, nursing level assessment, monitoring, and skilled interventions.

Transportation:

An escort or personal assistant is a parent, caretaker, relative or friend who is authorized by the contractor to accompany a member or group of members who have special needs or who are minor children (defined as under age 18). No charge shall be made for escorts or personal assistants. The contractor shall authorize transportation services for children under the age of 18. The contractor shall have guidelines that include transporting children by themselves to after school Medicaid programs with an attendant or escort. If an escort cannot be found, then the contractor will work with the member/designated representative to identify and secure an attendant to ensure timeliness and reduce behavioral problems while in route.

Care Coordination

Assignment of the care coordinator shall be based on the assessment of the member’s needs and condition, as well as the qualifications of the care coordinator. All care coordinators shall complete a comprehensive training curriculum that includes Commonwealth Coordinated Care Plus (CCC Plus) members’ various medical/behavioral health needs, including training in specialized areas (e.g., dementia, substance use disorders); person-centered, culturally competent care; and, standards of care. The contractor’s care coordinators shall also be trained and knowledgeable about the CCC Plus program and services described in the CCC Plus covered services chart. Care coordinators shall also be knowledgeable of involuntary psychiatric admissions related to emergency custody orders and temporary detention orders. Care coordination staff shall also be trained in providing assistance to members in crisis. Care coordination staff shall have demonstrated ability to communicate with members who have complex medical needs and who may have communication barriers. For members receiving private duty nursing (PDN) services, the care coordinator shall be a registered nurse who is licensed in Virginia or holds a multi-state license recognized by Virginia and has at least one year of related clinical nursing experience with medically complex members dependent on life sustaining equipment. For all other members with long-term services and supports (LTSS) needs (institutional and community-based), the care coordinator shall meet the qualifications in 5.6.1.

All members identified as a “Vulnerable Subpopulation” shall receive the minimum care coordination activities as specified above; additionally, they must receive enhanced care coordination services as identified during the health risk assessment (HRA), individual care plan (ICP) and interdisciplinary care team (ICT) processes. Enhanced care coordination for these members includes:

  1. Setting up appointments and in-person contacts as appropriate;
  2. Building strong working relationships between care coordinators, individuals, caregivers, and physicians;
  3. Setting up evidence-based patient education programs;
  4. Arranging transportation as needed
  5. For dual-eligible members, assisting with referrals and access to Medicare-covered services as requested by the member when the need is identified and included in the ICP;
  6. Providing enhanced monitoring of functional and health status;
  7. Providing coordination of seamless transitions of care across specialties and settings;
  8. For members with disabilities, providing effective communication with health care providers and participate in assistance with decision making with respect to treatment options;
  9. Coordination with early intervention providers, including for children who “age-out” of the early intervention program and need to continue receiving services. The care coordinator shall ensure that services are transitioned to non- early intervention providers (PT, OT, speech, etc.);
  10. Connecting members to services that promote community living and help avoid premature or unnecessary nursing facility or other residential placements or inpatient hospitalizations (medical or psychiatric);
  11. Coordinating with social service agencies (e.g.; local departments of health) and referring members to state, local, and other community resources; and,
  12. Working with nursing facilities and community-based LTSS providers to include management of chronic conditions, medication optimization, prevention of falls and pressure ulcers, and coordination of services beyond the scope of the LTSS benefit.

The contractor shall have formalized systems and operational processes in place that assist the care coordinator with performing enhanced care coordination activities for this member subpopulation. These processes shall include methods for identifying these members and for securing the identified add-on services and benefits available as necessary for these members.

Quality Assurance & Improvement

The contractor shall incorporate Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements such as lead testing and developmental screenings, according to American Academy of Pediatrics (AAP) and Bright Futures, in its quality assurance activities. The contractor must implement interventions/strategies to meet the following criteria:

  1. Childhood immunization rates;
  2. Well-child rates in all age groups;
  3. Lead testing rates;
  4. Increase percentage of lead testing of one – five year olds each contract year; and,
  5. Improve the current tracking system for monitoring EPSDT corrective action referrals (referrals based on the correction or amelioration of the diagnosis).

Notes

[1] Silow-Carroll S, Brodsky K, Rodin D, et al. “Access to Care for Children with Special Health Care Needs: The Role of Medicaid Managed Care Contracts, Final Report to the Medicaid and CHIP Payment and Access Commission”, Health Management Associates and The Urban Institute, February 2016.

[2] Ibid.

[3] Edmunds M, Coye MJ, editors. “America’s Children: Health Insurance and Access to Care,” National Research Council and Institute of Medicine Committee on Children, Health Insurance, and Access to Care. 1998.

[4] Ibid.

[5] Association of Maternal and Child Health Programs. “Developing Structure and Process Standards for Systems of Care Serving Children and Youth with Special Health Care Needs, A White Paper from the National Consensus Framework for Systems of Care for Children and Youth with Special Health Care Needs Project” Accessed April 11, 2017. http://www.amchp.org/AboutAMCHP/Newsletters/member-briefs/Documents/Standards%20White%20Paper%20FINAL.pdf

[6] 2019 NASHP survey of state Medicaid officials’ use of the National Standards.

[7] “How States Use the National Standards for CYSHCN in Their Health Care Systems.” The National Academy for State Health Policy, October 29, 2019. https://www.nashp.org/how-states-use-the-national-standards-for-cyshcn-in-their-health-care-systems/.

[8] Mathematica Policy Research , and Centers for Medicare and Medicaid Services . “Medicaid Managed Care Enrollment and Program Characteristics,” 2016. https://www.medicaid.gov/medicaid/managed-care/downloads/enrollment/2016-medicaid-managed-care-enrollment-report.pdf.

[9] “Georgia Medicaid Managed Care Organizations Received Capitation Payments After Beneficiaries’ Deaths.” Georgia Medicaid Managed Care Organizations Received Capitation Payments After Beneficiaries’ Deaths Audit (A-04-15-06183) 08-09-2019, August 9, 2019. https://oig.hhs.gov/oas/reports/region4/41506183.asp.

[10] State of Georgia Department of Community Health. “2018 External Quality Review Annual Report,” April 2018. https://dch.georgia.gov/document/document/annual-report-april-2018/download.

[11] State of Georgia Medicaid. Contract Between the Georgia Department Of Community Health And [contractor] For Provision Of Services To Georgia Families 360˚. http://www.bidnet.com/bneattachments?/353533613.pdf

[12] Maryland Department of Health and Mental Hygiene. “HealthChoice”, Accessed April 26, 2017. https://mmcp.dhmh.maryland.gov/healthchoice/pages/home.aspx

[13] Michigan Department of Health and Human Services. “General Information For Families About “Children’s Special Health Care Services(CSHCS)”,  Accessed April 26, 2017. http://www.michigan.gov/mdhhs/0,5885,7-339-71547_35698-15087–,00.html

[14] Texas Health and Human Services. STAR Kids Information Website. Accessed April 24, 2017. https://hhs.texas.gov/services/health/medicaid-chip/programs/star-kids

[15] The Virginia Department of Medical Assistance Services. “Commonwealth Coordinated Care Plus (a managed long term services and supports program)”, Accessed April 26, 2017. http://www.dmas.virginia.gov/Content_pgs/mltss-home.aspx

[16] “Commonwealth Coordinated Care Plus Stakeholder Report 2018.” Commonwealth Coordinated Care Plus Stakeholder Report 2018, n.d. http://www.dmas.virginia.gov/files/links/1984/Stakeholder%20Update%20October%202018.pdf

Acknowledgements: Support for this work was provided by the Lucile Packard Foundation for Children’s Health, Palo Alto, CA. The views presented here are those of the authors’ and not necessarily those of the foundation, its directors, officers, or staff.

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