Texas External Quality Review Administrative Interview 2018 PHYSICAL HEALTH FOR MEASUREMENT PERIOD 1/1/ /31/2017

Transcription

1 Texas External Quality Review Administrative Interview 2018 PHYSICAL HEALTH FOR MEASUREMENT PERIOD 1/1/ /31/2017 The infrmatin cntained in the Administrative Interview supprts the Texas External Quality Review Organizatin (EQRO) evaluatin f the managed care rganizatins participating in Texas Medicaid and the Children's Health Insurance Prgram (CHIP), including the Texas Dual Eligible Integrated Care Prject (the Demnstratin). This tl will dcument health plan respnses and additinal cmments regarding structure and prcesses in place t prvide quality care and service t members. These respnses will be clarified by the EQRO thrugh fllw-up questins and the final dcumentatin will be reviewed by the health plan prir t submissin t the Texas Health and Human Services Cmmissin (HHSC). (Please nte: All questins are applicable t all prgrams, including the Demnstratin, unless nted therwise.) Sectin 1. Organizatinal Structure... 1 Sectin 2. Member Enrllment and Disenrllment... 4 Sectin 3. Children's Prgrams and Preventive Care... 7 Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs Sectin 5. Member Services Sectin 6. Member Cmplaints and Appeals Sectin 7. Prvider Netwrk and Reimbursement Sectin 8. Authrizatin and Utilizatin Management Sectin 9. Infrmatin Systems Sectin 10. Data Acquisitin... 93

2 Sectin 1. Organizatinal Structure 1.1. Which prgram(s) des yur health plan cver? Check all that apply. STAR STAR+PLUS STAR Kids STAR Health CHIP CHIP RSA CHIP Perinate Demnstratin 1.2. Health Plan Mdel Type: Which f the fllwing best describes yur health plan s rganizatinal relatinship with prviders in Medicaid and CHIP prgrams? Check all that apply. Staff Mdel Grup Mdel Netwrk Mdel Independent Practice Assciatin 1.3. Is yur health plan affiliated with a hspital system? N If yes, name f affiliated rganizatin: Date affiliatin began: M M / D D / Y Y Y Y 1.4. Des yur health plan have a cmmercial prduct line? Sectin 1. Organizatinal Structure 1

3 N 1.5. When did yur health plan begin cverage in Texas? Please prvide the date fr each prgram separately. Leave blank if nt applicable. STAR STAR+PLUS STAR Kids STAR Health CHIP CHIP RSA CHIP Perinate Demnstratin [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] 1.6. Des yur health plan ffer Medicaid r CHIP cverage in states ther than Texas? (Nte: Nt applicable t the Demnstratin see the Demnstratin supplement) N If yes, please prvide the number f states in which yur health plan perates. [NUMBER] 1.7. Please prvide the level f experience yur QI Directr has in health plan Quality Imprvement (if there has been a change in the persn wh acted as the QI Directr during the measurement perid, please prvide the level f experience fr the persn wh was the QI Directr fr a majrity f the year, > 26 weeks in the psitin). < 5 years experience 5-10 years experience years experience > 15 years experience 1.8. Please prvide the highest level f educatin f yur QI Directr as f December 31 st f the measurement year (if there has been a change in the persn wh acted as the QI Directr during the measurement perid, please prvide the level f educatin fr the persn wh was the QI Directr fr a majrity f the year, > 26 weeks in the psitin). High Schl Diplma Sme Cllege Bachelr s degree Master s degree Dctral degree 1.9. Fr each service/management categry listed belw, please indicate: (1) which accrediting agency yur health plan is accredited with as f December 31 st f the measurement year; (2) which accrediting agency yur health plan will be seeking accreditatin with during the next Sectin 1. Organizatinal Structure 2

4 measurement year; and (3) which accrediting agency yur health plan s accreditatin will be renewed with during the next measurement year. If yu are neither accredited nr seeking accreditatin in a particular categry, leave that prtin blank. If yur health plan is cntracted with a vendr fr any f the categries belw, please d nt include these accreditatins in yur respnses. Check all that apply. Categry Health plan Credentialing Disease management Case management Utilizatin management / review Accredited as f December 31 st f current measurement year NCQA URAC Other: NCQA URAC Other: NCQA URAC Other: ] NCQA URAC Other: [TEXT NCQA URAC Other: Seeking Accreditatin during next measurement year NCQA URAC Other: NCQA URAC Other: NCQA URAC Other: NCQA URAC Other NCQA URAC Other: Accreditatin up fr Renewal during next measurement year NCQA URAC Other: ] NCQA URAC Other: NCQA URAC Other: NCQA URAC Other: [TEXT NCQA URAC Other: Behaviral health services NCQA URAC Other: NCQA URAC Other: NCQA URAC Other: Other: Please describe. NCQA URAC Other: NCQA URAC Other: NCQA URAC Other: Other: Please describe. NCQA URAC Other: NCQA URAC Other: NCQA URAC Other: Sectin 1. Organizatinal Structure 3

5 Sectin 2. Member Enrllment and Disenrllment Definitins fr this sectin New member A Medicaid member wh: 1. Enrlled with the MCO during this measurement perid; 2. Had nt previusly been enrlled in the MCO fr 90 r mre cntinuus days at any time during the 730 calendar days prir t the date f enrllment; and 3. Was enrlled fr 90 r mre cntinuus days during the measurement perid. (Nte: Definitin adapted frm Chapter 12.4 f the HHSC Unifrm Managed Care Manual Versin 2.2 (2017). Sme MCOs define new enrllee differently fr members wh were previusly enrlled in the MCO. Questin 2.6 f this sectin permits these MCOs t qualify their definitin f new enrllee. ) 2.1. Hw much time d new members have t select a PCP befre they are assigned a PCP by yur health plan? A new member must select a PCP at the time f enrllment Within 5 days after enrllment Within 10 days after enrllment Within 30 days after enrllment Other: Please describe D yur Medicaid and CHIP plans receive the medical histries f new members wh transfer frm ther plans in the market? (g t A) N If yes, please describe what infrmatin is available, t whm (prviders and/r health plan) is it available, and hw it is made available fr care f the new member. Sectin 2. Member Enrllment and Disenrllment 4

6 2.3. Des yur health plan cnduct a health risk assessment upn intake f new members? N If yes, hw is the infrmatin cllected in the health risk assessment used? Check all that apply. T assign members t disease management T assign members t case management T review with the member's PCP 2.4. Please attach a cpy f the instrument used t cnduct health risk assessments What appraches des yur health plan use t encurage parents f new members t facilitate a first encunter with their assigned PCP? Check all that apply. (Nte: Nt applicable t the Demnstratin) N specific appraches used t facilitate first encunter New member welcme telephne calls Materials in new member enrllment package Additinal Dcumentatin: If yur health plan mails new member materials that encurage scheduling an initial PCP/preventive visit, please attach sample materials used during this measurement perid Hw lng must a previusly enrlled member have been withut cverage (disenrlled) t be cnsidered a "new member" in yur health plan? Select ne. 1 mnth (r 30 days) 3 mnths (r 90 days) 6 mnths (r 180 days) Other time perid: Please Specify Sectin 2. Member Enrllment and Disenrllment 5

7 2.7. What strategies des yur health plan use t encurage ptential members t enrll in Medicaid/CHIP in Texas? Check all that apply. Nne Cmmunity utreach (e.g., churches, nn-prfits, families) Enrllment assistance frm cmmunity-based rganizatins Cllabratin with ther cmmunity rganizatins Advertising (e.g., billbards, radi, TV, buses) Public health fairs 2.8. What strategies des yur health plan use t maintain r imprve Medicaid/CHIP re-enrllment in Texas? Check all that apply. Nne Reminder pstcards t members Phne calls t members Educatinal newsletters t members (g t A) Client representatives Regular updates f member cntact infrmatin Cmmunity-based events Please attach sample materials used during this measurement perid. Sectin 2. Member Enrllment and Disenrllment 6

8 Sectin 3. Children's Prgrams and Preventive Care This sectin fcuses n appraches that yu use with yur pediatric members, as well as yur general appraches t preventive care Des yur health plan attempt t identify children f migrant farmwrkers during the applicatin/enrllment prcess? N If yes, please prvide the ttal number f members under the age f 21 wh were designated as children f "migrant wrkers" as f December 31 st f the measurement year. [NUMBER] Which in-huse methds des yur health plan use t identify children f migrant wrkers? Check all that apply. Nt applicable Enrllment file received frm the State New member surveys New member welcme/utreach calls Screening by Member Services staff Screening during case management assessment Lists prvided by the Texas Educatin Agency Hw des yur health plan cllabrate with cmmunity and migrant farmwrker rganizatins t identify migrant farmwrker families? Check all that apply. N specific strategy Receive training n migrant farmwrker families frm migrant farmwrker rganizatins Participate with migrant farmwrker rganizatins in health fairs/events Cnduct presentatins abut migrant farmwrker children with migrant farmwrker rganizatins Invlve migrant farmwrker rganizatins in netwrk prvider training Sectin 3. Children's Prgrams and Preventive Care 7

9 Describe the actins yur health plan is taking t address barriers t care fr children f migrant wrkers What appraches des yur health plan use t encurage parents f newly enrlled members 0-21 years ld t make an appintment fr a well-child visit within 90 days f jining the health plan? Check all that apply. Nne New member welcme telephne calls Mailing new members educatinal materials (g t A). Assistance with scheduling appintments Cmmunity utreach events Health fairs. Please attach sample materials used during this measurement perid What appraches des yur health plan use t encurage parents f existing members 1-21 years ld t make their annual appintment fr a well-child exam? Check all that apply. Nne Reminder phne calls t members/families Reminder mailings/pstcards/birthday cards Assistance with scheduling appintments Cmmunity utreach events Health fairs 3.4. What strategies des yur health plan use t encurage prviders t be in cmpliance with prviding timely well-child visits? Check all that apply. Nne Mnthly reprts t prviders identifying specific members due fr check-ups Reminders t prviders encuraging fllw-up n members wh are verdue fr check-ups Sectin 3. Children's Prgrams and Preventive Care 8

10 Prvider training n peridicity requirements Pst an updated list f members wh are due r verdue fr check-ups n the Prvider Web Prtal Cnduct ffice visits t prvide updated infrmatin n members due/verdue fr check-ups Cnduct ffice visits t prvide educatin n THSteps requirements Prvider incentives (g t A) Please describe the incentives ffered t encurage prviders t cmply with timely well-child visits Des yur health plan have special prgrams t encurage new parents t bring their infant (birth t 15 mnths) in fr well-child visits accrding t the peridicity schedule? (g t A) N If yes, what prgrams des yur health plan have in place t encurage new parents t bring their infant (birth t 15 mnths) in fr well-child visits accrding t the peridicity schedule? Check all that apply. Reminder phne calls t members/families Reminder mailings/pstcards/birthday cards Assistance with scheduling appintments Cmmunity utreach events Health fairs Hspital visits prir t discharge with mthers f newbrns t educate n THSteps and schedule first appintment 3.6. Des yur health plan have special prgrams in place t encurage parents f children 2 t 11 years f age t bring their child in fr their annual well-child visits? (g t A) N Sectin 3. Children's Prgrams and Preventive Care 9

11 If yes, what prgrams des yur health plan have in place t encurage parents f children 2 t 11 years f age t bring their child in fr their annual well-child visits? Check all that apply. Reminder phne calls t members/families Reminder mailings/pstcards/birthday cards Assistance with scheduling appintments Cmmunity utreach events Health fairs 3.7. Des yur health plan have prgrams in place t encurage adlescent members 12 t 21 years f age t receive their annual adlescent wellcare visits? (g t A) N If yes, what prgrams des yur health plan have in place t encurage adlescent members 12 t 21 years f age t receive their annual adlescent well-care visits? Check all that apply. Reminder phne calls t members/families Reminder mailings/pstcards/birthday cards Assistance with scheduling appintments Cmmunity utreach events Health fairs 3.8. Hw des yur health plan ensure that prviders address all required well-child cmpnents during check-ups? Check all that apply. N specific strategy Internal medical recrd review (MCO-initiated) External medical recrd review (Auditr) Review f claims data Sectin 3. Children's Prgrams and Preventive Care 10

12 3.9. Whm des yur health plan require PCPs screen fr behaviral health prblems? Check all that apply. Children Adlescents Adults N requirement fr BH screening Please describe the screening requirements: What type f supprt is prvided t PCPs wh are treating members with behaviral health prblems? Nt applicable Orientatin fr PCPs regarding referrals t behaviral health services Educatin fr PCPs n behaviral health issues Case management services t supprt PCPs treating members with BH prblems Whm des yur health plan require PCPs screen fr substance abuse prblems? Check all that apply. Children Adlescents Adults N requirement Please describe the screening requirements: What type f supprt is prvided t PCPs wh are treating members with substance abuse prblems? Nt applicable Orientatin fr PCPs regarding referrals t behaviral health services Educatin fr PCPs n behaviral health issues Case management services t supprt PCPs treating members with BH prblems Sectin 3. Children's Prgrams and Preventive Care 11

13 3.11. Which f the fllwing services des yur health plan prvide t wmen f reprductive age? Check all that apply. Nne Family planning (cntraceptin use, etc.) Prenatal health prmtin and educatin Prenatal risk assessment Pst-partum health prmtin and educatin Case Management Child birth classes HPV vaccinatin Sexually Transmitted Infectin (STI) screening Des yur health plan have prcedures fr cntacting and assisting pregnant/delivering members in selecting a primary care prvider fr their baby? (g t A) N If yes, please describe these prcedures: Des yur health plan have a prgram t encurage new mthers t attend pstpartum visits? (g t A) N If yes, please describe the prgram: Please indicate whether yur health plan mnitrs prvider cmpliance with any f the fllwing screenings fr wmen. Check all that apply. Cervical cancer screening Breast cancer screening Sectin 3. Children's Prgrams and Preventive Care 12

14 Clrectal screening Heart disease screening Chlamydia screening Nne f the abve Sectin 3. Children's Prgrams and Preventive Care 13

15 Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs Definitins fr this sectin Care Crdinatin Disease Management The deliberate rganizatin f patient care activities between tw r mre participants (including the patient) invlved in a patient's care t facilitate the apprpriate delivery f health care services. Organizing care invlves the marshalling f persnnel and ther resurces needed t carry ut all required patient care activities, and is ften managed by the exchange f infrmatin amng participants respnsible fr different aspects f care. (Nte: Agency fr Healthcare Research and Quality (AHRQ) Clsing the Quality Gap: A Critical Analysis f Quality Imprvement Strategies: Vlume 7 Care Crdinatin.) A grup f cherent interventins designed t prevent r manage ne r mre chrnic cnditins using a systematic, multidisciplinary apprach and ptentially emplying multiple treatment mdalities. The gal f disease management is t identify persns at risk fr ne r mre chrnic cnditins, t prmte selfmanagement by patients, and t address the illnesses r cnditins with maximum clinical utcme, effectiveness, and efficiency regardless f treatment setting(s) r typical reimbursement patterns. (Nte: Schrijvers, G "Disease Management: A Prpsal fr a New Definitin." Internatinal Jurnal f Integrated Care 9(12): 1-3.) Individual Service Plan An individualized and persn-centered plan in which a Member enrlled in the STAR+PLUS Hme and Cmmunity Based Services prgram perated by the MCO, with assistance as needed, identifies and dcuments his r her preferences, strengths, and health and wellness needs in rder t develp shrt-term bjectives and actin steps t ensure persnal utcmes are achieved within the mst integrated setting by using identified supprts and services. The ISP is supprted by the results f the Member's prgram-specific assessment and must meet the requirements f 42 CFR Fr the Demnstratin ppulatin, an Individual Service Plan (ISP) is a persn-centered plan develped fr Enrllees eligible fr HCBS STAR+PLUS Waiver services by the Service Crdinatr and incrprated int the Enrllee s Plan f Care. Service planning includes: 1) determining the Enrllee needs; 2) determining service levels; 3) maintaining csts and cst ceilings; 4) regularly reviewing services; and 5) btaining apprval fr planned services frm the Enrllee and the Service Crdinatr. Fr Enrllees seeking r needing the HCBS STAR+PLUS Waiver services, the STAR+PLUS MMP must use the medical necessity/level f care (MN/LOC) assessment instrument, as amended r mdified, t assess Enrllees and t supply current medical infrmatin fr Medical Necessity determinatins. Fr each Enrllee receiving HCBS STAR+PLUS Waiver services, the STAR+PLUS MMP must als cmplete the ISP frm. The ISP is established fr a ne year perid. After the initial ISP is established, the ISP must be cmpleted n an annual basis and the end date r expiratin date des nt Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 14

16 change, regardless f mid-year updates. Bth f these frms (MN/LOC assessment instrument and ISP frm) must be cmpleted annually at reassessment. (Nte: Texas Health and Human Services Cmmissin (HHSC). Unifrm Managed Care Cntract Terms and Cnditins. Versin 2.24 and Medicare-Medicaid Dual Demnstratin (MMDD) Cntract.) Member with Special Health Care Needs (MSHCN) Service Management Service Plan Includes CSHCN, and any adult member wh: (1) has a serius nging illness, a chrnic r cmplex cnditin, r a disability that has lasted r is anticipated t last fr a significant perid f time; and (2) requires regular, nging therapeutic interventin and evaluatin by apprpriate trained health care persnnel. (Nte: Texas Health and Human Services Cmmissin (HHSC). Unifrm Managed Care Cntract Terms and Cnditins. Versin 2.24) An administrative service perfrmed by the MCO t facilitate develpment f a Service Plan and crdinatin f services amng a member's PCP, specialty prviders, and nn-medical prviders t ensure Members with Special Health Care Needs have access t, and apprpriately utilize, medically necessary cvered services, nn-capitated services, and ther services and supprts. (Nte: Texas Health and Human Services Cmmissin (HHSC). Unifrm Managed Care Cntract Terms and Cnditins. Versin 2.24). An individualized and persn-centered plan develped with and fr members with special health care needs, including persns with disabilities r chrnic r cmplex cnditins. The plans are develped by the individual, with assistance as needed, and identify and dcument his r her preferences, strengths, and needs in rder t develp shrt-term bjectives and actin steps t ensure persnal utcmes are achieved within the mst integrated setting by using identified supprts and services. The Service Plan is supprted by the results f the member s prgram-specific assessment. (Nte: Texas Health and Human Services Cmmissin (HHSC). Unifrm Managed Care Cntract Terms and Cnditins. Versin 2.19; Texas Health and Human Services Cmmissin (HHSC). Unifrm Managed Care Cntract Terms and Cnditins. Versin 2.24) Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 15

17 4.1. What strategies des yur health plan use t identify Members with Special Health Care Needs? Fr each prgram, select fr all that apply. Identificatin strategy STAR STAR+PLUS STAR Kids STAR Health CHIP Demnstratin Phne calls t members pre-screened as MSHCN by HHSC Member surveys Phne calls t all new members Rutine review f medical recrds New member health risk assessments (g t A) Other: Please describe N specific strategy N N N N N N N N N N N N N N Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 16 N N N N N N N If yur health plan uses new member Health Risk Assessments t identify MSHCN, wh perfrms these assessments? Check all that apply. Licensed Clinical Scial Wrker (CSW) Licensed Registered Nurse (RN) Licensed Vcatinal Nurse (LVN) Cmmunity Health Wrker Case Manager, Care Crdinatr, r Service Manager Call Center staff Member with RN review N N N N N N N N N N N N N N N N N N N N N

18 If new member Health Risk Assessments are nt cnducted, please describe hw MSHCNs are assessed Des yur health plan require a written Service Plan fr members wh are identified with chrnic cnditins r special health care needs? (g t A) N Wh participates in the develpment f a member's written Service Plan? Check all that apply. Member's PCP Member's specialist prviders Member Member's family Case Manager Service Manager Service Crdinatr Individual meeting LTSS service crdinatin requirements Is the Service Plan develped by an individual trained in persn-centered planning using a persn-centered prcess and plan? N (Please explain) Which f the fllwing cmpnents are included in a member's written Service Plan? Check all that apply. Identificatin f care needs Shrt-term gals Lng-term gals Actin plan/interventin Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 17

19 Hw frequently d health plan staff review and update a member's written Service Plan? Check all that apply. Mnthly Quarterly Semi-annually Annually At member s request Hw des yur health plan ensure that prviders adhere t implementatin and mnitring requirements f written Service Plans? Check all that apply. Calling prviders as needed t discuss/review the treatment plan Prvider ffice visits Medical recrds review Analysis f claims data Hw des yur health plan ensure that members cmply with prescribed treatment in their written Service Plans? Check all that apply. Telephne cntact and fllw-up Hme visits Medical recrd review Analysis f claims data Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 18

20 D members receive their care crdinatr s cntact infrmatin? N If yur health plan requires written Service Plans t be apprved prir t implementatin, hw lng des the apprval prcess take? 4.3. Des yur health plan have an algrithm t identify members wh are at risk fr having frequent utilizatin f services? (g t A) N If yes, please select the services fr which yur health plan has an algrithm fr identifying frequent utilizatin. Check all that apply. Nt applicable Inpatient Admissins Readmissins ED Visits High Pharmacy Use Please attach a cpy f yur health plan s algrithm t identify members wh are at risk fr frequent utilizatin f services Des yur health plan have an algrithm t identify members wh already have frequent utilizatin f services? (g t A) N If yes, please select the services fr which yur health plan has an algrithm fr identifying frequent utilizatin. Check all that apply. Nt applicable Inpatient Admissins Readmissins Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 19

21 ED Visits High Pharmacy Use Please attach a cpy f yur health plan s algrithm t identify members wh already have frequent utilizatin f services Once these members are identified, which f the fllwing measures des yur health plan take t intervene t reduce their health care use? Nt Applicable N algrithm in place t identify members at risk f r wh already have frequent utilizatin f services. N interventin, cntinue t mnitr Enrll Member in a Disease Management Prgram Prvide enhanced Care Crdinatin Prvide Scial Wrk Services Cnduct Hme Visits and/r Face-t-face visits (g t A) Utilize Telehealth Optins Send mbile alerts and reminders If yur health plan cnducts hme visits and/r face-t-face visits with members at risk f and/r wh already have frequent utilizatin f services, please describe what the visits entail. Fr the members wh were identified as at risk f r already frequent utilizers f services, please indicate n the grid belw the number and percentage f members eligible fr hme visits and/r face-t-face visits, the percentage f members wh received a hme visit and/r face-t-face visit, and the number and percentage f members wh received mre than ne hme/face-t-face visit during this measurement year. Number f Members Eligible fr a Visit Percentage f Members wh Percentage f Eligible Members Number f Members wh Percentage f Members wh Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 20

22 were Eligible fr a Visit wh Received a Visit Received Mre than ne Visit Received Mre than ne Visit Hme Visits Face-t-Face Visits Ttal 4.6. Hw effective d yu think yur interventins are in reducing high health care use? Nt Applicable N interventins in place t reduce high health care use and/r d nt mnitr high health care use Very Effective Smewhat Effective Nt Sure Smewhat Ineffective Ineffective If yur health plan has interventins in place, please describe hw yu measure the effectiveness f the interventins t determine whether r nt effrts were successful in reducing high health care use Des yur health plan have a prgram in place t identify high health care users? (g t A) N (g t B) If yes, please describe the prgram yur health plan has in place. Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 21

23 If n, des yur health plan intend t implement a prgram t identify high health care users? (g t C) N (g t D) If yes, when des yur health plan intend t implement this prgram? If n, please describe why yur health plan will nt implement a prgram t identify high health care users. Care Crdinatin 4.8. Please indicate n the grid belw hw care crdinatin is ffered t yur health plan s members with chrnic cnditins and special health care needs. Care Crdinatin Type Health plan ffers Care Crdinatin prgram General chrnic care N Dual-eligible members (Medicaid/Medicare) N Lng-term care N Cmmunity-based resurces Children with Special Health Care Needs (CSHCN) N N Health plan ffers prvider training Health Plan ffers Telehealth Care Crdinatin Prgram Health Plan Sends Alerts t Members Mbile Devices t Remind Members f Needed and Scheduled Services N N N N N High-risk OB Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 22 N N N N N N N N N N

24 Care Crdinatin Type Health plan ffers Care Crdinatin prgram Health plan ffers prvider training Health Plan ffers Telehealth Care Crdinatin Prgram Health Plan Sends Alerts t Members Mbile Devices t Remind Members f Needed and Scheduled Services N N N N Behaviral health N N N N Chemical dependency N N N N Obesity N N N N Other: Please describe N N N N Hw des yur health plan ensure that all female members have direct access t a wmen s health specialist? Hw des yur health plan ensure that all members with special health care needs have direct access t a specialist, such as with a standing referral r apprved number f visits? Des yur health plan have any specific care crdinatin appraches in place t address issues f transitin t adult care fr children with special health care needs (CSHCN)? (g t A) N Nt applicable If yes, please describe. Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 23

25 4.12. Des yur health plan have any specific care crdinatin appraches in place fr members with behaviral health cnditins wh transitin frm inpatient t utpatient care? (g t A) N Nt applicable If yes, please describe. Disease Management Please indicate n the grid belw whether yur health plan ffers disease management (DM) prgrams fr yur plan s members with any f the fllwing chrnic cnditins r special health care needs. Fr each DM prgram, please indicate whether yur plan administers the prgram in-huse ("internal") r thrugh an externally cntracted vendr, such as a DMO ("external"). DM Prgram Administratin If an external DMO is used, please name the DMO belw: Asthma Internal External N DM prgram Diabetes Internal External N DM prgram High-Risk OB Internal External Behaviral Health (BH)/Mental Health (MH) N DM prgram Internal External N DM prgram Depressin Internal External N DM prgram Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 24

26 DM Prgram Administratin If an external DMO is used, please name the DMO belw: CAD Internal External N DM prgram CHF Internal External N DM prgram COPD Internal External N DM prgram HIV/AIDS Internal External N DM prgram Onclgy Internal External N DM prgram Adult Obesity Internal External N DM prgram Childhd Obesity Internal External N DM prgram ADHD Internal External General Disease Management Other: Please describe. N DM prgram Internal External N DM prgram Internal External N DM prgram Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 25

27 4.14. Des yur health plan administer any disease management prgrams fr cnditins that are nt listed abve? (g t A) N If yes, please describe belw. Include the type f DM prgrams and indicate whether they are administered internally r externally. If the DM prgram is administered thrugh a cntracted DMO, please specify the name f the DMO Please indicate n the grid belw whether yur health plan ffers DM prgrams fr yur plan s members with any f the fllwing chrnic cnditins r special health care needs. Fr each DM prgram, please indicate which activities r cmpnents are frmal parts f yur health plan s DM prgram. DM Prgram Health Plan Has DM Prgram? Asthma N Activities/Cmpnents f Frmal DM Prgram Check all that apply Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 26

28 Diabetes N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency High-risk OB N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency Behaviral Health (BH)/Mental Health (MH) N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 27

29 Depressin N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency CAD N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency CHF N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 28

30 COPD N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency HIV/AIDS N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency Onclgy N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 29

31 Adult Obesity N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency Childhd Obesity N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency ADHD N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 30

32 General Disease Management. Other: Please describe. N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency N Patient self-management educatin Patient self-management tls Use f evidence-based clinical practice guidelines Rutine mnitring f patient prgress Training/educatin f prviders n patient safety Use f decisin supprt tls and technlgy Linking patient care t cmmunity resurces Training/educatin f prviders n cultural cmpetency Fr each f the fllwing DM prgrams, please indicate n the grid belw whether yur health plan calculates perfrmance measures that specifically address the care prvided t members enrlled in the DM prgram. If yur health plan calculates perfrmance measures fr ne r mre f these DM prgrams, please specify these measures and their frequency f calculatin. DM Prgram Perfrmance Measures Asthma N N/A Diabetes N N/A Specify perfrmance measures used t assess DM prgram impact Frequency f calculatin Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 31 Mnthly Quarterly Semi-annually Annually Mnthly Quarterly Semi-annually Annually

33 DM Prgram Perfrmance Measures Specify perfrmance measures used t assess DM prgram impact Frequency f calculatin High-Risk OB Mnthly N Quarterly N/A Semi-annually Annually Behaviral Health (BH)/Mental Health Mnthly (MH) N Quarterly N/A Semi-annually Annually Depressin Mnthly N Quarterly N/A Semi-annually Annually CAD Mnthly N Quarterly N/A Semi-annually Annually CHF Mnthly N Quarterly N/A Semi-annually Annually COPD Mnthly N Quarterly N/A Semi-annually Annually HIV/AIDS Mnthly N Quarterly N/A Semi-annually Annually Onclgy Mnthly N Quarterly N/A Semi-annually Annually Adult Obesity Mnthly N Quarterly N/A Semi-annually Annually Childhd Obesity Mnthly N Quarterly N/A Semi-annually Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 32

34 DM Prgram Perfrmance Measures ADHD N N/A General Disease Management N N/A Other Please describe. N N/A Specify perfrmance measures used t assess DM prgram impact Frequency f calculatin Annually Mnthly Quarterly Semi-annually Annually Mnthly Quarterly Semi-annually Annually Mnthly Quarterly Semi-annually Annually Des yur health plan use a predictive mdeling lgic t identify members fr care management and/r disease management? N If yes, please prvide the predictr variables used (e.g., health status) and the utcmes n which yur health plan is fcusing (e.g., inpatient admissins, ED visits, etc.) Is yur health plan s DM prgram an pt-in r pt-ut prgram? Opt-in Opt-ut Please elabrate if special cnditins apply. Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 33

35 4.19. Cmplete the fllwing table fr each f the DM prgrams checked abve. Leave blank where inapplicable. Please nte that Active Participatin is defined as 1 encunter (either by phne r face-t-face) between DM staff and member r member s representative. DM Prgram STAR # Eligible as f 12/31 f the measurement perid STAR # Actively Participating as f 12/31 f the measurement perid STAR+PLUS # Eligible as f 12/31 f the measurement perid STAR+PLUS # Actively Participating as f 12/31 f the measurement perid STAR Kids # Eligible as f 12/31 f the measurement perid STAR Kids # Actively Participating as f 12/31 f the measurement perid STAR Health # Eligible as f 12/31 f the measurement perid STAR Health # Actively Participating as f 12/31 f the measurement perid CHIP # Eligible as f 12/31 f the measurement perid CHIP # Actively Participating as f 12/31 f the measurement perid Demnstratin # Eligible as f 12/31 f the measurement perid Demnstratin # Actively Participating as f 12/31 f the measurement perid Asthma [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] Diabetes [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] High Risk OB [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] Behaviral Health (BH)/Mental Health (MH) [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] Depressin [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] CHF [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] Onclgy [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] Obesity-Adults [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] Obesity-Children [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] CAD [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] ADHD [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] COPD [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] HIV/AIDS [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] GENERAL DISEASE MANAGEMENT [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] [NUMBER] Des yur health plan measure the participatin rates by race and ethnicity in yur plan s DM prgram(s) cmpared t yur verall health plan enrllment? (g t A) Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 34

36 N Please cmplete the table and prvide the participatin rates by race and ethnicity fr yur health plan s DM prgrams cmpared t yur verall health plan enrllment. Percent f health plan enrllment Percent f disease management enrllment African American [number]% [number]% Hispanic [number]% [number]% White, nn-hispanic [number]% [number]% Other: Please describe [number]% [number]% TOTAL (shuld be 100%) [number]% [number]% Des yur health plan assess reasns why members drp ut f DM prgram(s)? (g t A) N If yes, select the reasns why members have drpped ut f yur health plan's DM prgram(s). Check all that apply. Lss f eligibility, member relcated, r member changed health plan Member declines participatin Unable t cntact member Member met gals/graduated frm prgram Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 35

37 4.22. Des yur health plan use Health Infrmatin Technlgy (HIT) in its DM prgram? (g t A) N If yes, please select all types f technlgy yur health plan uses. Check all that apply. Electrnic Health Recrds (EHR) Persnal Health Recrds (PHR) EHR fr persnal use by member where the member updates the recrd and can include ntes n dayt-day activities and health status Persnal Health Tls (i.e., phne apps, technlgy t mnitr bld pressure, technlgy t mnitr glucse levels, etc.) Online cmmunities where the members can cmmunicate with ther members with the same cnditin Skype with members as a methd f cmmunicatin Text messaging as a methd f cmmunicatin : Sectin 4. Care Crdinatin and Disease Management Prgrams fr Members with Chrnic Cnditins r Special Health Care Needs 36

38 Sectin 5. Member Services 5.1. Please submit a cpy f yur health plan's Member Handbk in all languages in which it is prduced, fr each Medicaid/CHIP prgram in which yur plan participates as f December 31 st f the measurement perid Please prvide yur health plan s website address (URL) that members can access fr infrmatin abut yur Medicaid/CHIP prgram(s). If yur health plan ffers multiple prgrams and each prgram has a separate link, please prvide each link per prgram Des yur health plan have written plicies and prcedures fr written and electrnic member cmmunicatin, e.g., plicies that specify fnt size, tag lines, accessibility, etc.? This includes, but is nt limited t, member handbks, ntices f adverse benefit determinatin, and ntices f cmplaint r appeal reslutin. (g t A) N If yes, please submit a cpy f yur health plan s plicies and prcedures fr written and electrnic member cmmunicatin Hw des yur health plan ensure new members receive a cpy f their member handbk within the State-established time frame? Mail a printed cpy f the member handbk t all new members a cpy f the member handbk t the member after btaining the member s cnsent Pst a cpy f the member handbk n yur health plan s website and infrm the member in print r electrnically that the member handbk is available n the internet using the included internet address 5.5. Hw d members access written health plan materials in languages ther than English and Spanish? Written materials are nt available in ther languages at this time By calling the member htline r member services By visiting the health plan's website By submitting an request t the health plan Sectin 5. Member Services 37

39 5.6. Which f the fllwing resurces are available fr health plan members wh may be visually impaired? Check all that apply. Resurces are nt available at this time Health plan materials are available in Braille Health plan materials are available in large print Health plan materials are available in audi frmat 5.7. Which f the fllwing resurces are available fr health plan members wh may be hearing impaired? Check all that apply. Resurces are nt available at this time TDD peratr r TDD phne line Prfessinal sign interpreter fr medical appintments Texas Relay services Natinal 711 TTY service 5.8. Please describe yur health plan s requirements r plicies regarding the prvisin f ral interpretatin services 5.9. Des yur health plan have a member advisry cmmittee (grup)? (g t A) N If yes, please describe the cmpsitin f its membership and the prcess fr selecting members: Fr what rles des yur health plan emply cmmunity health wrkers? Check all that apply. Nt applicable Sectin 5. Member Services 38

40 Member utreach fr multiple health plan services Member utreach services t supprt prviders Marketing, sales, and enrllment Disease Management What steps des yur health plan take t ensure that prviders furnish linguistically accessible services fr members wh have Limited English Prficiency (LEP) r are hearing impaired? Hw des yur health plan ensure members knw what medicatins (brand name and generic) are cvered by the health plan? Member Rights Des yur health plan have written plicies n member rights? (g t A) N If yes, please submit a cpy f yur health plan s plicies n member rights Please describe hw yur staff and netwrk prviders cmply with the federal and state requirements f Title VI f the Civil Rights Act f Please describe hw yur staff and netwrk prviders cmply with the federal and state requirements f the Age Discriminatin Act f Please describe hw yur staff and netwrk prviders cmply with the federal and state requirements the Rehabilitatin Act f Sectin 5. Member Services 39

41 5.17. Please describe hw yur staff and netwrk prviders cmply with the federal and state requirements f Titles II and III f the Americans with Disabilities Act Please describe hw yur staff and netwrk prviders cmply with the federal and state requirements f Sectin 1557 f the Patient Prtectin and Affrdable Care Act that prhibits discriminatin n the basis f race, clr, natinal rigin, sex, age, r disability Which f the fllwing measures des yur health plan have in place t ensure cmpliance with HIPAA regulatins regarding the prtectin f cnfidential member infrmatin? Check all that apply. HIPAA training/certificatin f health plan staff wh handle prtected health infrmatin (g t A) Secure strage f written health infrmatin Secure strage f electrnic health infrmatin Plicies and prcedures fr the secure transfer f prtected health infrmatin (Please attach a cpy) N particular measures If yur health plan requires staff members t receive HIPAA training/certificatin, are they required t renew their HIPAA training/certificatin n an annual basis? N Nt applicable Hw des yur health plan ensure that Member Service representatives treat members with dignity and respect their right t privacy? Hw des yur health plan ensure that members receive written ntificatin f any significant changes t the health plan at least 30 days prir t the intended effective date f the change? Sectin 5. Member Services 40

42 5.22. Hw des yur health plan ensure that members receive written ntificatin within 15 days that their primary care prvider, r a prvider they visit n a regular basis, is n lnger under cntract with yur plan? Hw des yur health plan ensure that prviders share infrmatin with members n available treatment ptins and alternatives? Hw des yur health plan ntify members f their right t request and receive cpies f their medical recrds? Hw des yur health plan ntify members f their right t request that their medical recrds be amended r crrected? Cultural Cmpetency Des yur health plan have a written Cultural Cmpetency Plan? (g t A) N If yes, please attach a cpy f yur Cultural Cmpetency Plan Hw many Member Service representatives were actively emplyed in yur health plan in Texas as f December 31 st f this measurement perid? [NUMBER] Hw many f these Member Service representatives are bilingual in English and Spanish? [NUMBER] Sectin 5. Member Services 41

43 5.29. Please describe yur health plan s effrts t prmte the delivery f services in a culturally cmpetent manner t members, including thse with limited English prficiency and diverse cultural and ethnic backgrunds. Check all that apply. Nt applicable Bilingual staff Language line services fr languages ther than English r Spanish Written materials fr members are prvided in English and Spanish Prvider directries indicate languages spken in the ffice Prvide services fr the hearing impaired Prvide services fr the visually impaired Prvide interpreters New-hire Cultural Cmpetency Training Cultural Cmpetency Training fr emplyees Cmmunity health wrkers emplyed by health plan. Member Educatin What prgrams des yur health plan ffer t imprve the health literacy f yur members? Check all that apply. Nt applicable Member materials are written at a 6 th grade reading level Member materials are multi-lingual and culturally sensitive Educatin materials abut preventing and managing illness are sent t members Case manager training prgrams include health literacy techniques Members in case management r disease management are assessed t identify health literacy needs Members in CM and DM prgrams are assisted with understanding the disease prcess Prvider utreach t educate prviders n health literacy needs f members Des yur health plan cnduct health educatin classes fr yur plan s members? (g t A) N Sectin 5. Member Services 42