Network Assessments and Monitoring
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1 Network Assessments and Monitoring Sarah C. Brooks, Chief Managed Care Quality and Monitoring Division California Department of Health Care Services Medi-Cal Children s Health Advisory Panel March 18,
2 Presentation Overview 1. Network Adequacy Standards 2. Network Review Components DHCS Medical Audits DMHC Routine Medical Surveys DHCS and DMHC Interagency Agreements (IA) DHCS and DMHC Audit and Survey Coordination Non-Routine Audits and Surveys Corrective Action Plans Other Monitoring Indicators 3. Plan Monitoring and Evaluation 4. Work in Progress and Future Endeavors 2
3 Network Access Requirements (1) Have sufficient providers to serve the enrollees In order to have sufficient networks, health plans must: (2) Meet service area needs with the geographic distribution of primary care providers (PCP) and specialists (3) Provide timely access to care 3
4 Primary Care Physician (PCP) Capacity Standard: Authority: Plan Monitoring and Evaluation: 1 PCP per 2,000 Enrollees Title 28, (d)(g)(2)(h) Title 22 CCR Section DHCS Contract, Exhibit A, Attachment 6 Provider Network Readiness Full network certification submission to DHCS Material Modification filing with DMHC Deliverables submission per DHCS Contract, Exhibit A, Attachment 18 Implementation Plan and Deliverables Contract Submission Quarterly Provider Network report DMHC Medical Survey 4 Other Monitoring Indicators
5 Physician Extenders Capacity Standard: Authority: Plan Monitoring and Evaluation: 1 Physician Extender per 1,200 Enrollees Title 28, (d)(g)(2)(h) Title 22 CCR Section 53853(a) Welfare & Institutions Code Section 14182(c)(2) DHCS Contract, Exhibit A, Attachment 6 Provider Network Readiness Full network certification submission to DHCS Material Modification filing with DMHC Deliverables submission per DHCS contract, Exhibit A, Attachment 18 Implementation Plan and Deliverables Contract Submission Quarterly Provider Network report DHCS Medical Audit DMHC Medical Survey 5 Other Monitoring Indicators
6 Time and Distance Access Standard: 15 miles/30 minutes (Title 28) 10 miles/30 minutes (DHCS Contract) Authority: Plan Monitoring and Evaluation: Title 28 CCR Rule (d)(H) DHCS Contract, Exhibit A, Attachment 6 Provider Network Readiness Geo Access maps evaluation Contract Submission Quarterly Provider Network report DHCS Medical Audit DMHC Medical Survey Other Monitoring Indicators 6
7 Timely Access Appointment Type Urgent care appointments that do not require prior authorization Urgent care appointment that do require prior authorization Non-urgent primary care appointments Non-urgent Specialist Non-urgent Mental health provider (non-physician) Non-urgent appointment for ancillary services for the diagnosis or treatment of injury, illness, or other health condition Telephone Wait Times Normal business hours Triage 24/7 services Standards 48 hours 96 hours 10 business days 15 business days 10 business days 15 business days Standards No more than 10 minutes 24/7 services; Call back time of no more 7 than 30 minutes
8 Timely Access (continued) Authority: Title 28 CCR Section DHCS Contract, Exhibit A, Attachment 9 Access and Availability Plan Monitoring and Evaluation: DHCS Medical Audit Other Monitoring Indicators Grievances data Call Center Reports data CAHPS Survey results 8
9 Component 1: DHCS Medical Audits Performed by the Audits and Investigations Division, Medical Review Branch Welfare and Institutions Code Audits will be annual beginning in
10 DHCS Medical Audit Categories Utilization Management Administrative and Organizationa l Capacity Medical Audit Categories Case Management and Coordination of Care Members Rights Quality Management Access and Availability of Care 10
11 Component 2: DMHC Medical Surveys Performed by the Department of Managed Health Care (DMHC) Knox-Keene Health Care Service Plan Act Conducted at least every three years Link to DMHC Medical Survey reports: chviewmedicalsurveyreports.aspx 11
12 DMHC Medical Survey Categories Quality Management Overall plan performance in meeting enrollees health care needs Medical Survey Categories Grievances and Appeals (member complaints) Utilization Management (referrals and authorizations) Access and Availability 12
13 Component 3: DHCS/DMHC Interagency Agreements (IA) Monitors the following transitions: Seniors and Persons with Disabilities (SPDs) Optional Targeted Low Income Children Rural Expansion Cal MediConnect Each IA has three components: Financial Audit Network Adequacy Assessments Medical Survey 13
14 Component 4: Audit and Survey Coordination DHCS and DMHC have a joint audit schedule to coordinate DMHC Knox Keene and IA surveys and DHCS medical audits. Both auditing teams are on-site concurrently. Findings for the DMHC IA surveys and DHCS medical audits are consolidated during the Corrective Action Plan (CAP) process. 14
15 Component 5: Non-Routine Audits and Surveys DHCS and DMHC can also audit and/or survey a plan outside of the normal schedule for any reason. Conducted two times in 2014: CalOptima Alameda Alliance 15
16 Component 6: Corrective Action Plans (CAPs) DHCS Medi-Cal Managed Care Division, Plan Monitoring Unit, administers CAPs for: DHCS Medical Audits Interagency Agreement Surveys Other non-scheduled audits or surveys A CAP response is required to be submitted to DHCS within 30 days of notification if any findings are present. DMHC also administers CAPs for routine medical surveys. 16
17 Component 7: Other Monitoring Indicators 1. Quarterly Grievances and Appeals Reports 2. Quarterly Reports Medi-Cal Office of the Ombudsman Call Statistics State Fair Hearings DMHC Help Center Data 3. Internal Quarterly Plan Management meetings 17
18 Component 7: Other Monitoring Indicators 4. Transition Data Submission Requirements Population-specific reporting for Seniors and Persons with Disabilities (SPDs), Optional Targeted Low Income Children (OTLIC), Rural Expansion, Low Income Health Plan (LIHP), and Cal MediConnect: Grievance Report Continuity of Care Report Provider Network Additions and Deletions PCP Assignment and Changes (Rural Expansion) Consumer Satisfaction (Rural Expansion) Fraud and Abuse (Rural Expansion) Complaints and Resolution Tracking (Cal MediConnect) 18
19 Component 7: Other Monitoring Indicators 5. Ongoing Data Submission Requirements Rural Expansion and Optional Targeted Low Income Children (OTLIC): All Member Grievance Report Detailed Provider Network Report Continuity of Care Report Grievance Log Geo Access Report Out of Network Report Network Adequacy Report 19
20 Component 7: Other Monitoring Indicators 5. Ongoing Data Submission Requirements Seniors and Persons with Disabilities (SPDs): Continuity of Care Report Risk Stratification and Risk Assessment Data Report SPD Grievance Report Detailed Provider Network Report Grievance Log Geo Access Report Out of Network Report Network Adequacy Report 20
21 Work in Progress and Future Endeavors Late 2014 Finalized DHCS/DMHC joint response process for network findings Standardized Grievances & Appeals and Call Center reporting requirements to track data at the beneficiary level Implemented Timely Access Verification Studies Summer 2015 Onboard new Network Adequacy/Monitoring Unit in the Managed Care Quality and Monitoring Division Implement the Network Adequacy Monitoring Project: Incorporate encounter data into network monitoring More robust data evaluation State access mapping for alternate access standards, watch list, and provider panels 21
22 Work in Progress and Future Endeavors Ongoing Provide technical assistance to ameliorate poor performance Impose Corrective Action Plans (CAPs) for poor performance or not meeting contractual requirements Enforce sanctions when necessary Continue stakeholders/workgroup engagement Enhance Medi-Cal Managed Care Performance Dashboard 22
23
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Stakeholder feedback is requested on the following: 1) metrics 69 through 94; and 2) withhold measures for years 1, 2, and 3. Steward/ 1 Antidepressant medication management Percentage of members 18 years