non-compliance with training by the Care Coordinators. The Care Coordinator must: Act as the single point of contact for an Enrollee to the Contractor and the ICT; Be a provider-based clinician or other trained professional; or Be an individual employed or contracted by the Contractor or the Enrollee’s Primary Care Provider who is trained in providing care coordination to persons with disabilities; As a member of the ICT, execute the following responsibilities: Participating in Comprehensive Assessments for care planning; Ensuring that ICT meetings and conference calls are held periodically; Monitoring the provision of services, including outcomes, assessing appropriate changes or additions to services, and making necessary referrals, as needed, for the Enrollee; and Ensuring that appropriate mechanisms are in place to receive Enrollee input, Complaints, and Grievances, and secure communication among relevant parties. 3. Clinical Care Manager For Enrollees with Complex Care Needs, as determined by the Contractor or a Provider under agreement with the Contractor to assume Clinical Care Management responsibilities, the Care Coordinator will be a Clinical Care Manager. In addition to executing the care coordination responsibilities in Section 2.5.C.2 the Clinical Care Manager will provide or as appropriate coordinate Clinical Care Management for medical and Behavioral Health Services. The Clinical Care Manager must be a licensed registered nurse or other individual licensed and/or certified to provide Clinical Care Management, employed by the Enrollee’s Contractor or Primary Care Provider, or patient-centered medical home or health home provider.
5. Maintain a protocol that shall facilitate communication to and from providers and the Contractor, and which shall include, but not be limited to, a provider newsletter and periodic provider meetings; 6. Except as otherwise required or authorized by CMS, EOHHS or by operation of law, ensure that providers receive 30 days advance notice in writing of policy and procedure changes, and maintain a process to provide education and training for providers regarding any changes that may be implemented, prior to the policy and procedure changes taking effect; and 7. Work in collaboration with providers to actively improve the quality of care provided to Enrollees, consistent with the Quality Improvement Goals and all other requirements of this Contract. B. Proximity Access Requirements The Contractor must demonstrate annually that its Provider Network meets the stricter of the following standards: For Medicare medical providers and facilities, time, distance and minimum number standards updated annually on the CMS website ()); For Medicare pharmacy providers, time, distance and minimum number as required in Appendix F, Article II, Section I and 42 C.F.R. §423.120; or Within a 15-mile or 30 minute radius from the Enrollee’s ZIP code of residence: At least two PCPs; b. Two hospitals (when feasible); and
ICOs must provide information, choice and needed supports to promote self-direction of PAS by Enrollees. ICOs must inform Enrollees that they may identify a surrogate to help them if they choose Self-directed PCA Services. ICOs must pay for services rendered by the PCA hired by the Enrollee if the PCA meets MassHealth requirements in 130 CMR 422.411 (A)(1) and has completed the required FI paperwork. The ICO must pay the FI the PCA rate as set by the Division of Health Care and Finance Policy under 114.3 CMR 9.00, which includes both the PCA collective bargaining wage, payment for employer required taxes, and workers’ compensation insurance. ICOs must contract with FIs under contract with EOHHS to support Enrollees in fulfilling their employer required obligations related to the payment of PCAs. PAS Services for Enrollees who do not choose Self-directed PCA: The Contractor must provide Enrollees who do not choose Self-directed PCA, or who are not able to find a surrogate to assist them to self-direct, with the option of having their PAS provided by an agency. ICOs must contract with such agencies, and provide Enrollees with the choice of at least two PAS agency providers, except that with EOHHS prior approval, Contractor may offer Enrollee only one PAS agency provider. Services provided by PAS agency providers must be person-centered and the Enrollee must have a choice of the schedule for PCAs and of who provides PAS. 2.9 Enrollee Access to Services A. General 1. The Contractor must provide services to Enrollees as follows:
Whether or not the Contractor has met the quality withhold requirements in a given year will be made public. Additional details regarding the quality withholds, including the more detailed specifications, required thresholds and other information regarding the methodology will be made available in future technical guidance. 5. Withhold Measures in Demonstration Year 1 Figure 4.1 below identifies core withhold measures for Demonstration Year 1. Together, these will be utilized as the basis for a 1% withhold. Additional details, including technical specifications, withhold methodology and required benchmarks, will be provided in subsequent guidance. Because Demonstration Year 1 crosses calendar and Contract years, the Contractor will be evaluated to determine whether it has met required quality withhold requirements at the end of both CY 2013 and CY 2014. The determination in CY 2013 will be based solely on those measures that can appropriately be calculated based on the actual enrollment volume during CY 2013. Consistent with such evaluations, the withheld amounts will be repaid separately for each calendar year. Figure 4.1: Quality Withhold Measures for Demonstration Year 1 Measure Description Measure Steward/Data Source CMS Core Withhold Measure Withhold Measure Encounter data (for CY 2014 only) Submission of production Prescription Drug Event and Risk Adjustment System files. CMS/State defined process measure X Assessments Percent of Enrollees with an in-person assessment for care planning purposes completed within 90 days of enrollment. CMS/State defined process measure X
Tracking of demographic information Determination that the Contractor can demonstrate that the ICO Centralized Enrollee Record allows recording of specific demographic data including race, ethnicity, primary language, and homelessness, in compliance with contract requirements. CMS/State defined process measure X Documentation of care goals (for CY 2014 only) Percent of Enrollees with documented discussions of care goals. CMS/State defined process measure X Access to an IL-LTSS Coordinator (for CY 2014 only) Percent of Enrollees with LTSS needs who have an IL-LTSS Coordinator. CMS/State defined process measure X Consumer governance board Establishment of Consumer advisory board or inclusion of Consumers on governance board consistent with contract requirements. CMS/State defined process measure X Withhold Measures in Demonstration Years 2 and 3 The quality withhold will be 0% in Demonstration Year 2 and 1% in Demonstration Year 3. Payment will be based on performance on the quality withhold measures listed in Figure 4.2, below. Figure 4.2: Quality Withhold Measures for Demonstration Years 2 and 3 Measure Description Measure Steward/Data Source CMS Core Withhold Measure Withhold Measure
Screening for clinical depression and care Percentage of patients ages 18 years and older screened for clinical depression using an age-appropriate standardized tool AND follow-up plan documented. CMS X Controlling blood pressure Percentage of members 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90) for members 18-59 years of age and 60-85 years of age with diagnosis of diabetes or (150/90) for members 60-85 without a diagnosis of diabetes during the measurement year. NCQA/HEDIS X Part D medication adherence for diabetes medications Percent of plan members with a prescription for diabetes medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication. CMS X Initiation and engagement of alcohol and other drug dependence treatment The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence who received the following: Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit. NCQA/HEDIS X Encounter data (for DY 3 only) Encounter data submitted accurately and completely in compliance with Contract requirements. CMS/State defined process measure X American Recovery and Reinvestment Act of 2009
Loss or Gain ≤ 1% 99.0% to 101.0% 100% 0% 0% 0% Gain >1% and ≤ 10% 90.0% to 98.9% 10% 90% (90%) * (Medicare A/B Percent of Rate) (90%)* (Medicaid Percent of Rate) Gain >10% and ≤ 20% 80.0% to 89.9% 50% 50% (50%) * (Medicare A/B Percent of Rate) (50%)* (Medicaid Percent of Rate) Gain >20% < 80.0% 100% 0% 0% 0% 1 Loss and gain reflected on an incremental basis, rounded to the nearest one tenth of a percent. Loss or gain >20.0% still results in risk sharing reconciliation for the loss or gain between 1.1% and 20.0%. 3 All EOHHS Risk Sharing shall be treated as Medicaid expenditures eligible for FMAP. Demonstration Year 2 Incremental Loss or Gain (as % of Total Adjusted Capitation Rate Revenue)1 Corresponding Risk Corridor Percentage % Contractor Risk Sharing % EOHHS & CMS Risk Sharing % CMS Risk Sharing % EOHHS Risk Sharing2 Loss >10% >110.0% 100% 0% 0% 0% Loss >3% and ≤ 10% 103.1% to 110.0% 50% 50% (50%) * (Medicare A/B Percent of Rate) (50%)* (Medicaid Percent of Rate)
1 Loss and gain reflected on an incremental basis, rounded to the nearest one tenth of a percent. Loss or gain >8.0% still results in risk sharing reconciliation for the loss or gain between 4.1% and 8.0%. 2 All EOHHS Risk Sharing shall be treated as Medicaid expenditures eligible for FMAP. Demonstration Year 1, if the Contract is terminated prior to June 30, 2015 Incremental Loss or Gain (as % of Total Adjusted Capitation Rate Revenue)1 Corresponding Risk Corridor Percentage % Contractor Risk Sharing % EOHHS & CMS Risk Sharing % CMS Risk Sharing % EOHHS Risk Sharing2 Loss >20% >120.0% 100% 0% 0% 0% Loss > 3% and ≤ 20% 103.1% to 120.0% 50% 50% (50%) * (Medicare A/B Percent of Rate) (50%)* (Medicaid Percent of Rate) Loss >1% and ≤ 3% 101.1% to 103.0% 10% 90% (90%) * (Medicare A/B Percent of Rate) (90%)* (Medicaid Percent of Rate) Loss or Gain ≤ 1% 99.0% to 101.0% 100% 0% 0% 0% Gain >1% and ≤ 3% 97.0% to 98.9% 10% 90% (90%) * (Medicare A/B Percent of Rate) (90%)* (Medicaid Percent of Rate) Gain > 3% and ≤ 20% 80.0% to 96.9% 50% 50% (50%) * (Medicare A/B Percent of Rate) (50%)* (Medicaid Percent of Rate) Gain >20% < 80.0% 100% 0% 0% 0%
APPENDIX B – COVERED SERVICES DEFINTIONS Exhibit 4: New Community-based Services Day Services that provide for on-site structured day activity typically for Enrollees with pervasive and extensive support needs who are not ready to join the general workforce. Such day services are individually designed around Consumer choice and preferences with a focus on improvement or maintenance of the person’s skills and their ability to live as independently as possible in the community; Such services often include assistance to learn activities of daily living and functional skills; language and communication training; compensatory, cognitive, and other strategies; interpersonal skills; prevocational skills; and recreational/socialization skills. Home Care Services provided within the Enrollee’s home or in the community. Such services include several types of home supports, including: Providing a worker or support person to perform general household tasks such as preparing meals, doing laundry and routine housekeeping, and/or to provide companionship to the member; Providing a range of personal support and assistance to enable an Enrollee to accomplish tasks that they would normally do for themselves if they could, including such things as help with bathing, dressing, personal hygiene and other activities of daily living. Such assistance may take the form of hands-on assistance or cueing and supervision to prompt the Enrollee to perform a task; Providing a variety of activities to help the Enrollee acquire, retain, or improve his/her skills related to personal finance, health, shopping, use of community resources, community safety, and other social and adaptive skills to live in the community. This may include skills training and education in self-determination and self-advocacy to enable the Enrollee to acquire skills to exercise control and responsibility over the services and supports they receive, and to become more independent, integrated, and productive in their communities; and Requires all such home care services/supports to be appropriate when the Enrollee needs them and/or when the person who is regularly responsible for the activities, such as a family caregiver, is absent or unable to manage the tasks. Respite Care services provided within the Enrollee’s home or in locations such as hospitals, rest homes, nursing facilities, assisted living residences, adult day health or adult foster care. Such services include services provided to an Enrollee to support his/her caregiver (family member, friend); and
The Contractor shall analyze results of the survey in order to understand the underlying causes of ED utilization for their Enrollees, including the use of and/or or failure of LTSS or whether there was a lack of appropriate LTSS to adequately support the Enrollee in his or her environment. The Contractor will identify issues within its system of care that require improvement to promote appropriate utilization of both LTSS and emergency department services and shall implement such improvements. The Contractor will report its results to EOHHS and to CMS. IL-LTSS Coordinator. The goal of this initiative is to better understand the use of IL-LTSS Coordinators by ICO Enrollees. The Contractor shall identify a random sample of a minimum of 20 members each year who will be interviewed about use of an IL-LTSS Coordinator during that year. An independent quality assurance entity shall conduct interviews of each Enrollee in the sample to determine his or her experience with an IL-LTSS Coordinator, using a semi-structured interview tool provided by EOHHS. The Contractor shall analyze results of its survey in order to understand Enrollee experience with an IL-LTSS Coordinator, and to identify best practices as well as to understand the underlying reasons why Enrollees are or are not engaged with IL-LTSS Coordinators. The ICO will identify issues within its enrollment and assessment processes which require change and shall implement such improvements. The Contractor will report its results to EOHHS and to CMS.