Welcome to TIM TALK’s: Business Acumen

“The Role of Accreditation as a CBO Business 

Strategy Option”

November 15th , 2017
The Role of 

Accreditation as a 

CBO Business 

Strategy Option

Timothy P. McNeill, RN, MPH

Consultant
Managed Medicaid Key Issues

• Increasingly States are adopting Managed Medicaid 

waivers

• Managed Medicaid and Managed Long-Term Services 

and Supports (MLTSS) impacts some of the most 

vulnerable residents

• Medicaid benefits managed by a third party MCO

– Personal Care

– Home-delivered meals

– Transportation

– Nursing home care
Benefit to the State and MCO

• States

– Medicaid is the nation’s largest payer of long-term services and 

supports

– States seek to leverage capitated financing arrangements to 

achieve key objectives

• Improve coordination of care

• Promote HCBS over institutional care

• Provide person-centered, high-quality care

• MCO

– Financial incentive to manage a high-risk population 

– Rewarded with shifting from institution to community
MLTSS in 2016
NASUAD MLTSS Tracker
What’s happening in your State?

• http://www.nasuad.org/initiatives/tracking-stateactivity/state-medicaid-integration-tracker
Business Opportunities for the CBO

• The MLTSS population poses the most risk for cost 

increases and lower quality

• Support the movement from Institutional care to HCBS

• Person-centered care

• Reducing unnecessary admissions and readmissions

• Addressing Social Determinants of Health

• Coordination of community resources to achieve Healthy 

Aging in Place
Factors Impacting MCO success

• Dual-Eligible and the MLTSS plan

– *Limited ability to manage Medicare funded utilization that 

impacts Medicaid spending

– *Limited capacity to coordinate Medicare/Medicaid & 

community-based social services

• Impact of Poverty

– Healthy Lifestyles

– Medication Adherence (Co-pays, coverage limits)

– Access to care

• Limited disease self-management capacity

– Health Literacy

– Access and utilization of preventive health services
ACCREDITATION & HEALTH 

PLAN QUALITY 

REQUIREMENTS
Health Plan Quality Requirements

• Medicare Advantage plans must have an internal quality 

assurance program

– Many States have similar requirements for Medicaid plans

• Medicare Advantage plans are deemed to have satisfied 

the Medicare quality assurance requirements by receiving 

accreditation and having a periodic review and reaccreditation, from a private organization approved by 

CMS

– NCQA

– URAC

– Joint Commission
Select List of Accreditation Options that CBOs Can 

Consider

• NCQA

– http://www.ncqa.org

• URAC

– https://www.urac.org

• Joint Commission

– https://www.jointcommission.org

• CARF

– http://www.carf.org/Accreditation
The Alabama Experience

• As the State of Alabama prepares for MLTSS 

implementation, the State Unit on Aging Director and the 

AAA Directors began working together to develop a 

strategy to support ALL of the AAA’s prepare for the 

change.

• Today, we are highlighting the experience of the AL 

AAAs as they are one of the first States that developed a 

Statewide strategy that focuses on supporting all AAAs in 

the State in seeking accreditation.
Do I Need Accreditation for Contracting?

• We know of AAAs and other CBOs that have secured 

contracts with and without accreditation

– If your business development strategy is limited to working 

directly with physicians and hospitals, and doesn’t include 

managed care contracting, their may be limited benefit in 

accreditation

– If you plan to contract with MCOs, now or in the future, you 

may want to consider accreditation

• Accreditation, is only one of many things that should be 

considered as part of an overall business development 

strategy

– There are no single magic bullets in this business 
What should be part of the consideration for 

choosing an accreditation model?

• Do the plans in your area maintain NCQA accreditation?

– http://healthinsuranceratings.ncqa.org

• For NCQA accredited health plans, an accredited MLTSS 

plan is required to provide all core services of LTSS case 

management

• For NCQA accredited heath plans, if any element is 

delegated to another entity, the accredited entity is 

responsible for providing oversight of the services 

provided by the third-party

– Failure of third-party delegated organization, to adhere to NCQA 

standards, can negatively impact the accreditation status of the 

accredited entity
When Could I Consider NCQA Accreditation?

• Do I wish to seek contracts, with an NCQA accredited 

MCO, to provide any service that is part of the required 

core care accreditation standards?

– If Yes, then you should consider obtaining accreditation

• How does accreditation improve my ability to secure 

contracts?

– Measure of quality of services

– Assurance that the service provided meets established standards

– MCO will receive credits towards their accreditation, when they 

contract with another accredited entity
Resources to Help Prepare for NCQA 

Accreditation

• http://pages.ncqa.org/ltssroadmap/
NCQA Accreditation Programs

• Health Plan Accreditation

• Disease Management

• Case Management

• Case Management for LTSS

• Wellness & Health Promotion

• Accountable Care Organizations

• Managed Behavioral Healthcare Organizations
NCQA Case Management for LTSS Standards

1. Program Description

2. Assessment Process

3. Person-Centered Care Planning and Monitoring

4. Care Transitions 

5. Measurement and Quality Improvement 

6. Staffing, Training and Verification

7. Rights and Responsibilities 

8. Delegations of LTSS
States Use of Accreditation
NCQA Quality Measures

21

• HEDIS

– Health Effectiveness Data and Information Set

– HEDIS is the Registered trademark of the National Committee for 

Quality Assurance (NCQA)

• Tool Used to measure performance of health plans

• 90% of all health insurance plans use HEDIS to measure 

performance

• LTSS Quality Measures

– NCQA is working with Mathematica to develop LTSS standards

– MLTSS Quality Measures will closely align with NCQA 

accreditation requirements
Guest Panelist

Torshira Moffett, 

MPH

Director, Product 

Development

NCQA

Dana G Eidson, 

CPA

Executive Director

SARCOA, Area 

Agency on Aging

Neal Morrison

Former 

Commissioner,

Alabama

Department of 

Senior Services
TORSHIRA MOFFETT, NCQA, 

MPH

PANEL GUEST QUESTIONS
DANA EIDSON, SARCOA, CPA

PANEL GUEST QUESTIONS
NEAL MORRISON

PANEL GUEST QUESTIONS
CONTRACTING IMPLICATIONS
Expressing Your Value Proposition

27

• Improving quality and reducing costs

– Capturing clinical quality measures

– Drive member engagement

• ROI greater than 1 (>1): greater than expected savings

• ROI less than 0 (<0): less than expected savings

• Track and continually reinforce your ROI to the customer
Leading MCOs in the MLTSS Market 

• Centene

• United Healthcare

• Amerigroup

• Molina

• Cigna Healthspring

• AmeriHealth
Risks DRIVE the MCO

• It is CRITICAL that you determine the risks to the MCO

• Risks will drive the decision making for the MCO

– What their risks are

– What population presents the most risk

– Their ability to manage these risks

– Your access to the population that presents the most risk

– Your ability to mitigate risks for the MCO
MLTSS Risks

• Changing utilization patterns

– Overall reduction in Long-term care facility admissions over 

time

– Shift towards HCBS expansion

• Many States are requiring that Medicaid MCOs adopt 

Value-Based Payment Models that align with Medicare 

VBP models

– ACOs

– Bundled Payment
Skilled Nursing Facility coverage

31

• Medicare covers the cost of care for SNF care as 

follows

– *Avg length of stay in a SNF is 20 days

– SNF Readmissions likely occur between day 20 - 39

For Days Medicare Pays for 

Covered Services

Beneficiary is 

responsible for the 

following

1 – 20 Full Cost Nothing

21 – 100 All but a daily 

copayment

Daily copayment

(2014 = $152/day)

Beyond 100 Nothing Full Cost
How Payment Alignment is impacted by MLTSS

• Alignment of MLTSS and Medicare VBP models

– Some States are now requiring MCOs to establish Medicaid and 

MLTSS Value-Based Payment models that align with Medicare 

VBP

– This will require greater adoption of the following contract 

types:

• Bundled Payment

• ACOs

• The possibility exists for LTSS ACO Networks that align 

with Medicare ACOs and Bundled Payment Programs
Alignment of Payment Incentives

• Incentives to reduce Medicare and Medicaid directly 

impacts providers that serve duals

• Reductions in Medicare costs and Medicaid costs can 

have a dramatic impact on the overall cost of care 

• Medicare

• Medicaid (Medicare Supplemental Coverage)

• Managed Long-Term Services and Supports 

– Medicaid Waiver
Challenge for CBOs

• Understanding how your business brings value to the 

system

• Determine if Accreditation aligns with your contracting 

strategy

• Define your value proposition and outline the return on 

investment (ROI)

• Implement the required culture change to realize the 

opportunity

• Implement systems to drive change and document your 

impact
Guest Panelist

• Neal Morrison

– Former Commissioner

– Alabama Department of Senior Services

– Nealgmorrison@gmail.com

• Dana Eidson, CPA

– Executive Director

– SARCOA, Area Agency on Aging

– Dana.Eidson@sarcoa.org

• Torshira Moffet, MPH

– Director, Product Development

– NCQA

– Moffett@ncqa.org