Special Needs Plans Structure & Process Measures. Policy Clarifications and Frequently Asked Questions (FAQs)

Transcription

1 Effective June 4, 2010 Special Needs Plans Structure & Process Measures Policy Clarifications and Frequently Asked Questions (FAQs) CMS Contract No. HHSM C

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3 Contents General Questions Q1: Difference between HEDIS and S&P measures Q2: Level of HEDIS Reporting Q3: Level of S&P Reporting Q4: How SNPs Report S&P Measures Q5: Submission Dates Q6: Submission of Separate Survey Tools for Each SNP Q7: Phase 3 Reporting Requirements - New! Q8: Look-Back-Period Q9: Public Reporting Q10: Reporting Fees Q11: SNP Survey Team Assignment Q12: Policies for MA Product Line and SNP Benefit Packages Q13: Documenting Functions Performed by Contracted Entities SNP 1: Complex Case Management Q14: Case Management Program Conditions Q15: Case Management Services Within Disease Management Program Q16: Members of an Institutional SNP Cannot Opt Out of Case Management- New! Q17: Case Manager Licensure Requirements SNP 2: Improving Member Satisfaction Q18: Satisfaction Assessment Applies to SNP Operations Q19: Analyzing Data for Entire SNP Population Q20: Lack of Improvement Opportunities Q21: Showing Improvement Based on Actions Taken SNP 3: Clinical Quality Improvements Q22: Showing Improvement for Clinical Measures Q23: Documenting Clinical Measurement Q24: Use of Behavioral and Medical Care Coordination Measures - New! SNP 4: Care Transitions Q25: Using Job Descriptions as Documentation Q26: Use of Patient Data in Reports Q27: Differences Between Two Types of Analyses Q28: Definition of Long-Term Care Facilities Q29: Preauthorization for SNF Admissions - New! SNP 5: Institutional SNP Relationship With Facility Q30: Different Timeframes for Different Issues Q31: Start of Notification Timeframe Q32: SNP Does Not Contract With Nursing Facilities - New! SNP 6: Coordination of Medicare and Medicaid Coverage Q33: SNP is Not Involved With Administering Medicaid Benefits Q34: Required Data Sources for SNPs That Have a Relationship With State - New! Q35: Examples List Job Descriptions as Documented Processes - New! Q36: Determining the Percentage of Dual-Eligible Members Q37: Documenting an Assessment of Network Adequacy

4 General Questions (back to contents) Q1 Difference between HEDIS and S&P measures Question: What is the difference between the HEDIS measures and the Structure & Process measures? Response: HEDIS measures focus on performance for specific clinical issues and require the use of administrative claims data and for some measures, review of the medical records as well. HEDIS measure specifications are used to calculate rates based on a defined numerator and denominator. Structure & Process measures are designed to assess the systems SNPs have in place to perform specific functions related to quality care such as case management. Structure & Process measures rely on review of plan policies and procedures, data reports, prepared materials and other data sources plans use to implement their programs, analyze internal data, document processes and convey information to members and practitioners. Q2 Level of HEDIS Reporting Question: Which SNPs must report HEDIS measures and what is the level of reporting? Response: Every SNP benefit package (identified by the CMS H-number and Plan ID) that had 30 or more members enrolled, as reported in the February 2009 SNP Comprehensive Report, must submit HEDIS results for the SNP subset of 15 HEDIS measures. The February 2009 SNP Comprehensive Report is available on the CMS Website at: If a SNP benefit package is listed in the February 2009 SNP Comprehensive Report, but had 29 or fewer members, a HEDIS report is not required. Q3 Level of Structure and Process (S&P) Measure Reporting Question: Which SNPs must report S&P measures and what is the level of reporting? Response: Please note that the reporting requirements for the Structure & Process measures are different from the reporting requirements for HEDIS results. CMS requires all SNPs that were operational in 2009 and renewed for 2010 to report the Structure & Process measures regardless of enrollment size Structure & Process Measures FAQs Effective June 4, 2010

5 Q4 General Questions continued How SNPs Report S&P Measures Question: How will SNPs report the Structure & Process measures? Response: All SNPs that meet the requirements stated above (see Question 2) will submit the Structure & Process measures via NCQA s Interactive Survey System (ISS). The ISS is a Web-based data collection tool that allows SNPs to self-evaluate against the Structure & Process measures and submit supporting documentation to verify their answers for each of the elements of each measure. The SNP ISS Tool was sent to all eligible SNPs on March 31, 2010 and it is due back to NCQA NO LATER THAN JUNE 30, If your organization has not received this tool or has discontinued its SNP program for 2010, please contact NCQA at SNP@NCQA.ORG. Q5 Submission Dates Question: Can SNPs request an extension to submit their Structure & Process measures after the June 30, 2010 deadline? Response: No. All SNPs that meet the above-stated requirements for submission for the SNP Evaluation program must submit their completed ISS Tool no later than June 30, Q6 Submission of Separate Survey Tools for Each SNP Question: My organization has several SNP benefit packages; do we need to submit a different tool for each SNP? Response: Yes, your organization must submit a separate ISS Tool for each SNP benefit package. Each ISS license contains the name of the SNP, H-number and Plan ID to assist you with identifying the appropriate tool for each SNP.

6 General Questions (back to contents) Q7 Phase 3 Reporting Requirements Question: What measures does NCQA require an organization to report based on its survey type? Response: The column labeled Returning Surveys includes the reporting requirements for SNPs that were assessed in The Initial Surveys column contains the reporting requirements for new SNPs that have not reported before. Only SNP benefit packages that were operational in 2009 and renewed in 2010 are required to report. SNP Returning Surveys Operational 1/1/09; renewed in 2010; submitted in 2008 or 2009 Initial Surveys Operational 1/1/09; renewed in 2010; no previous submission SNP 1 X SNP 2 X SNP 3 X SNP 4 X X SNP 5 X SNP 6 X X New! 2010 Structure & Process Measures FAQs Effective June 4, 2010

7 Q8 General Questions continued Look-Back-Period Question: What is the look-back-period and must all of our policies and procedures have been in place from March 31 st to June 30 th to meet the look-back period? Response: The look-back-period is the three month period prior to the date the ISS Tool is due to NCQA (i.e., March 31, 2010 to June 30, 2010). The look-back period is the same for all SNP surveys. SNPs may submit their ISS Tool(s) any time prior to June 30, 2010 and the look-back-period will not be affected. If an organization did not have a policy in place when NCQA released the Structure & Process measures, surveyors will look for evidence which shows the organization developed the policy and incorporated it into its operations within the look-back period. All documentation (e.g., policies and procedures) must be current as of the look-back-period, but could have been developed prior to that time. Q9 Public Reporting Question: Will NCQA publicly report the results of each SNPs evaluation? Response: NCQA does not publicly report any of the data from the SNP evaluations (Structure & Process and HEDIS measures). NCQA will provide the data to the Centers for Medicare and Medicaid Services (CMS) and CMS will determine how it will use the results of the SNP evaluation. Q10 Reporting Fees Question: Are there any direct fees associated with the assessment against the Structure & Process measures or the submission of HEDIS data to NCQA by SNPs? Response: No. There are no fees for SNPs to undergo the assessment against the Structure & Process measures. CMS has contracted with NCQA to perform this evaluation. SNPs will have other costs associated with the requirements, including the cost of a HEDIS audit.

8 Q11 General Questions continued SNP Survey Team Assignment Question: Does NCQA anticipate assigning an Accreditation Survey Coordinator (ASC) to each organization for its assessment against the Structure & Process measures? Response: While NCQA is not assigning an ASC to each organization, we are providing a variety of resources available to assist SNPs throughout the assessment process (e.g., training sessions and Q&A forums). There is a dedicated SNP assessment team at NCQA that will be actively working with the SNPs to provide information and assistance throughout the SNP assessment process. If SNPs have questions related to the Structure & Process measures, HEDIS measures or the use of the ISS or IDSS data collection tools, they should submit those questions through NCQA s Policy Clarification Support System ( SNPs may also direct general inquiries about the SNP assessment program to SNP@NCQA.ORG. Q12 Policies for MA Product Line and SNP Benefit Packages Question: My organization has a Medicare Advantage product line, a Medicaid product line and two SNP benefit packages and case management services are included as part of the entire memberships benefits. If we attach policies as evidence of performance for a particular element must they be specifically for the SNP population or could they reference the SNP population along with the other product lines? Response: Your organization can choose to do this either way. Please keep in mind that an over-arching policy would need to indicate whether all of the provisions are applicable to all SNP members or just certain subpopulations. Q13 Documenting Functions Performed by Contracted Entities Question: We contract with other entities (medical groups) to perform a number of the functions assessed by the Structure & Process measures. How should we demonstrate performance with these requirements? Response: Your organization needs to provide the appropriate evidence from these contracted entities to document your performance. In addition you should discuss the details of this documentation with a member of the NCQA SNP team by sending an to SNP@NCQA.org Structure & Process Measures FAQs Effective June 4, 2010

9 SNP 1: Complex Case Management (back to contents) Q14 Case Management Program Conditions Question: What conditions qualify for entry into a case management program? Response: It is up to the SNP to design a program appropriate for its population and to specify what conditions qualify for entry into its case management program. Q15 Case Management Services Within Disease Management Program Question: What if Case Management (CM) is part of a larger Disease Management (DM) program? How would NCQA score the elements of SNP 1 if an organization s documentation is from its DM program? Response: SNPs must have a CM program. This program may be part of a broader DM program, but the SNP must demonstrate that it meets the requirements for CM as stated in SNP 1. The DM program documentation must clearly indicate that CM is part of the DM program. Q16 Members of an Institutional SNP Cannot Opt Out of Case Management Question: My organization has an Institutional SNP that not only enrolls and maintains all members in case management but it operates under a model that requires members remain enrolled in case management. If a member wants to opt out of case management then he or she must disenroll from the SNP. Could NCQA clarify what we need to submit to meet the intent of factor 3 of SNP 1 Element E? Response: If your organization can provide evidence (in the form of documented processes and materials) which shows that Institutional SNP members must disenroll from the plan if they want to opt out of its case management program, then NCQA surveyors will score factor 3 of SNP 1 Element E not applicable (NA). New!

10 Q17 SNP 1: Complex Case Management continued Case Manager Licensure Requirements Question: Do the Structure & Process measures stipulate specific education or licensure requirements for case managers? Response: No. The organization may determine the appropriate level of education and the type of licensure necessary for case managers Structure & Process Measures FAQs Effective June 4, 2010

11 SNP 2: Improving Member Satisfaction (back to contents) Q18 Satisfaction Assessment Applies to SNP Operations Question: Does the member satisfaction assessment for Element A apply only to the SNP s case management program? Response: A SNP must assess member satisfaction across its entire operations, not just its CM program. Q19 Analyzing Data for Entire SNP Population Question: If we analyze member satisfaction data for our entire SNP population and do not pull a sample, will NCQA score SNP 2 Factor 2 NA? Response: NCQA scores Factor 2 Yes when an organization analyzes member satisfaction data for its entire SNP population. Q20 Lack of Improvement Opportunities Question: What if a SNP does not have any opportunities for improvement for SNP 2 Element B? Response: NCQA surveyors review the rationale a SNP provides on why it did not identify any opportunities for improvement and the SNP s analysis of its member satisfaction data. If the surveyor agrees with the conclusion that the analysis does not result in the identification of one or more opportunities for improvement, the SNP receives a NA score for this element.

12 Q21 SNP 2: Improving Member Satisfaction continued Showing Improvement Based on Actions Taken Question: Do SNPs have to show improvement based on the actions they have taken to address opportunities identified? Response: No. SNPs undergoing the SNP Evaluation for the first time in 2010 (Initial Surveys) are required to demonstrate that they have identified opportunities for SNP 2 Element B based on their analysis for SNP 2 Element A. They are not required to show improvement on the opportunities identified or the interventions based on those opportunities. Returning SNPs are not required to submit SNP 2 Elements A and B in Structure & Process Measures FAQs Effective June 4, 2010

13 SNP 3: Clinical Quality Improvements (back to contents) Q22 Showing Improvement for Clinical Measures Question: Do SNPs have to show actual clinical improvements for this phase? Response: No. SNPs do not have to demonstrate actual clinical improvements. SNP 3 Element A does not require plans undergoing the SNP Evaluation for the first time in 2010 (initial Surveys) to identify opportunities or demonstrate they have taken action to show improvement. Q23 Documenting Clinical Measurement Question: Should a SNP use a particular format for its documentation? Response: SNP 3 Element A in the ISS Survey tool contains a supplemental worksheet that plans can use to demonstrate performance. The worksheet is not required but NCQA recommends that SNPs use it. Q24 Use of Behavioral and Medical Care Coordination Measures Question: Can a SNP submit any service oriented performance measures to meet the intent for SNP 3 Element A? Response: No, measures for this element must involve improvements in the quality of clinical care. However, if the performance measures are related to improvements in the quality of clinical care it may meet the intent. For example, If a SNP provides a measure of care coordination or continuity of care such as sharing information from behavioral health practitioners with PCPs, the activity in effect involves improving communication between practitioners and care coordination. This type of information sharing can ultimately have a positive impact on the quality of members clinical care; therefore, this type of measure can be used to meet the intent of SNP 3 Element A. New!

14 SNP 4: Care Transitions (back to contents) Q25 Using Job Descriptions as Documentation Question: Can SNPs provide job descriptions of staff responsible for managing transitions to demonstrate performance for SNP 4 Element B? Answer: Yes. A SNP may provide job descriptions as an example of materials which detail how it performs transition coordination activities. SNPs must also provide documented processes (e.g., policies and procedures) to satisfy the documentation requirements for all elements in SNP 4. Q26 Use of Patient Data in Reports Question: Should a SNP provide actual patient data in its admissions reports? Response: Yes, but a plan should NOT submit any reports that contain protected health information (PHI). Therefore, please blind or redact all patient identifiable data from reports before attaching them to ISS as evidence of performance. Q27 Differences Between Two Types of Analyses Question: Can you please describe the differences between the two analyses required for SNP 4 Factor 1 and Factor 4 of Element D? Response: Factor 1 requires the organization to analyze data from claims, the UM process or reports from providers to identify individual patients who are at-risk for a transition. Factor 4 requires the organization to analyze aggregate data for its entire SNP population to identify areas where it can act to reduce unplanned transitions. Plans must submit an actual analysis for both factors. Please note, SNPs should NOT submit any reports that contain protected health information (PHI). Be sure to blind or redact all patient identifiable data from reports before attaching them to ISS as evidence of performance. Q 28 Definition of Long-Term Care Facilities Question: Could NCQA define long-term care facilities referenced in SNP 4 Element C Factor 2 and indicate whether the requirements of this factor encompass skilled nursing facilities and custodial nursing facilities? Response: NCQA s definition for long-term care facilities aligns with CMS definition of nursing facilities; it includes facilities that primarily provide skilled nursing care to residents and relates to services for the rehabilitation of injured, disabled, or sick members. These facilities cover health care and related services for more than 90 days and the services are above the level of custodial care. It does not include facilities that provide custodial care or nonskilled, personal care such as help with activities of daily living and care most individuals perform themselves Structure & Process Measures FAQs Effective June 4, 2010

15 Q 29 Preauthorization for SNF Admissions Question: My organization requires preauthorization for all SNF admissions for long-term care. As a result, all of our admissions to long-term facilities involve planned transitions not unplanned transitions. What type of evidence should we submit to demonstrate that we meet the intent of SNP 4 Element C Factor 2? Response: In this instance your organization would need to submit a copy of its policies or a contract or agreement with a nursing facility which shows the prior authorization requirements for all long-term care admissions. You would also need to submit a report which identifies the nursing facility, lists the date of the authorization request and the subsequent date of admission. These two types of evidence would show that your SNP meets and exceeds the requirements specified in SNP 4 Element C factor 2. New!

16 SNP 5: Institutional SNP Relationship With Facility (back to contents) Q30 Different Timeframes for Different Issues Question: For SNP 5, Element B, can a SNP require different timeframes for notification for different issues such as falls, weight loss, etc? Response: Yes. The SNP may set its own notification parameters; however, they cannot exceed 48 hours to receive a 100 percent score for SNP 5 Element B. Q31 Start of Notification Timeframe Question: For SNP 5, Element B, when does the timeframe for notification start, at the time of the health status change or the identification of that change? Response: The notification timeframe for SNP 5 Element B begins once someone (facility or SNP staff) identifies that an eligible health status change or triggering event has occurred. For example, a member gets a fever at 3:00 am, but it is not observed or recorded until 6:00 am. The timeframe for notification to the SNP/practitioner starts at 6:00 am. Q32 SNP Does Not Contract with Nursing Facilities Question: We have an Institutional SNP but we do not have any contracts with nursing facilities. All of our members reside in the community and we provide the support necessary for them to do so. Could you supply some examples of types of evidence we must submit meet the intent of elements in SNP 5? Response: If your organization does not own or contract with any nursing facilities and all the members in the Institutional SNP reside in the community then NCQA surveyors will score the elements of SNP 5 not applicable during the review; your organization must however provide documentation which demonstrates this. Examples of such documentation may include the Model of Care, and home and community based waiver from a state or federal regulatory agency (e.g., CMS), policies or a statement of benefits or other materials that show the SNP maintains all of its members in the community. New! 2010 Structure & Process Measures FAQs Effective June 4, 2010

17 Q33 SNP 6: Coordination of Medicare and Medicaid Coverage continued SNP is Not Involved With Administering Medicaid Benefits Question: My organization has a SNP that is not required to integrate Medicare and Medicare benefits. We do not have a contract with the state agency to integrate Medicare and Medicaid benefits. Further, we only provide Medicare benefits to SNP members and did not have any involvement with the provision of Medicaid benefits. In view of this, are we still required to demonstrate that we meet the intent of SNP 6 Elements A through E? Response: Yes. This measure does not require that a plan have a contract with the state to integrate the Medicaid program for its SNP members. SNP 6 Elements A, B and D ask whether your SNP provides its members with information about both programs (Medicare/Medicaid) and helps coordinate certain functions so that members can more easily navigate through the differing requirements of both programs. Your organization does not need an integrated contract to perform any of these functions. SNP 6 Element C asks if your organization has a contract with the state or is working toward one to administer some part of the Medicaid benefits. If the state(s) your SNP operates in does not allow Medicare plans to contract with the State Medicaid agency or if the state refuses to do so, you can score this element "NA", but you must provide a letter, legislation/regulations or other documentation that the state does not or will not enter into such an agreement. NCQA is aware of the upcoming Medicare Improvements for Patients and Providers Act of 2008(MIPPA) requirements for all new dual eligible SNPs to have a contract with the state to integrate Medicare and Medicaid. However, the elements of SNP 6 assess the level of coordination and information SNPs currently provide, not what they must do to meet MIPPA requirements in Q34 Required Data Sources for SNPs That Have a Relationship with State Question: Could NCQA clarify whether SNP 6 Element C requires a SNP to submit evidence in all three data sources documented processes, reports and materials? Response: A SNP can demonstrate performance by providing documented processes or reports or materials that meet the intent of the requirements. New! Q35 Examples List Job Descriptions as Documented Processes Question: Documented processes are required data sources for SNP 6 Elements A and D. Can a SNP submit job descriptions as appropriate evidence in this data source? Response: No. Job descriptions were inadvertently listed as examples of documented processes in these two elements. They should only be classified as materials and submitted as evidence in the materials data source for the requirements in these two elements. New!

18 Q36 SNP 6: Coordination of Medicare and Medicaid Coverage continued Determining the Percentage of Dual-Eligible Members Question: SNP 6 Elements C and D are not applicable if an institutional SNP or chronic care SNP s dual-eligible population is less than 5 percent of its membership. What point in time should institutional SNPs and chronic care SNPs use to establish the percentage of membership their dual-eligible population comprises? Response: SNPs should use the CMS' April 2010 Comprehensive Report (on the CMS website) to determine their enrollment information. They can then calculate the percentage of that enrollment for to determine their dual-eligible population. The CMS Comprehensive Report does not contain the actual percentage of dual eligible members, but provides the overall enrollment number that a SNP would need to calculate the percentage. Institutional and Chronic and disabling condition SNPs with dual-eligible populations that comprise less than 5% of their total membership should enter this information in the survey tool. NCQA surveyors will use enrollment data from CMS to determine whether or not the 5% exception applies Structure & Process Measures FAQs Effective June 4, 2010

19 Q37 SNP 6: Coordination of Medicare and Medicaid Coverage continued Documenting an Assessment of Network Adequacy Question: Could an organization demonstrate performance with SNP 6 Element E, Factor 4 by providing a geoaccess analysis of its Medicare practitioner network? Response: No. The analysis of your practitioner network must include practitioners and providers that accept coverage for care and services paid for by both Medicare and Medicaid. Element E requires SNPs to coordinate the delivery of Medicare and Medicaid benefits and help members to obtain services covered by both programs. Therefore, dual-eligible members may not have access to care covered by Medicaid if a SNP only assesses and ensures that its network permits sufficient access to practitioners who accept their Medicare coverage. NCQA does not prescribe the mechanism a SNP should use to assess the adequacy of its provider network so it can choose to perform geoaccess analyses, but that analysis must include an assessment of providers and practitioners that accept Medicare and Medicaid. A SNP can also select another indicator that enables it to monitor and adjust its network based upon members health, cultural and linguistic needs.