Introduction to NCQA & SNP Assessment June 25 and 27, 2013

1. Introduction to NCQA & SNP AssessmentJune 25 and 27, 2013

2. Purpose of Training Provide brief overview of NCQA Describe the SNP assessment program NCQA is executing on behalf of CMS Give a general understanding of main components of SNP assessment HEDIS® measures Structure & Process measures

3. A Brief Introduction to NCQA • Private, independent non-profit health care quality oversight organization • Founded in 1990 - Celebrating 23 years • Committed to measurement, transparency and accountability • Unites diverse groups around common goal: improving health care quality

4. NCQA: Mission and Vision • Mission • To improve the quality of health care • Vision • To transform health care through measurement, transparency and accountability

5. NCQA: COMMITTED TO MEASUREMENT, TRANSPARENCY, ACCOUNTABILITY • NCQA’s quality programs include: • Accreditation of health plans using performance data • HEDIS clinical measures • CAHPS consumer survey • Measurement of quality in provider groups • Physician Recognition • ACOs • Quality measurement means: • Use of objective measures based on evidence • Results that are comparable across organizations • Impartial third-party evaluation and audit • Public Reporting

6. Achieving the Mission • Over 70 percent of all Americans enrolled in health plans that are accredited by NCQA • More than 90 percent of managed care organizations report HEDIS® quality data • 41 states and the federal government rely on NCQA Accreditation and HEDIS • More than 42,846 clinicians and 5,804 practices* have earned NCQA Recognition; 6 programs form the basis of quality improvement programs and P4P nationwide *As of 5/31/13

7. Objectives of SNP Assessment Program • Develop a robust and comprehensive assessment strategy • Evaluate the quality of care SNPs provide • Evaluate how SNPs address the special needs of their beneficiaries • Provide data to CMS to allow plan-plan and year-year comparisons

8. SNP Assessment Process • Year-to-Year Approach • Defining and assessing desirable structural characteristics • Assessing processes • Assessing outcomes • Two main components • HEDIS Measures-focus on clinical performance • Structure & Process measures-focus on structural characteristics and systems

9. Year-to-Year Strategy

10. Year-to-Year Strategy

11. Year-to-Year Strategy

12. Project Time Line 2013 • June 17 – HEDIS submissions due to NCQA • June & July – NCQA Releases 2013 Structure and Process measures in hardcopy and in ISS • June through September– S&P Training for SNPs • October 15, 2013 – S&P Measure submissions due to NCQA • October 15, 2013 to April 30, 2014 - S&P reviews conducted by NCQA and Surveyors • June 2014– NCQA Delivers Final Report to CMS

13. HEDIS 101

14. What Is HEDIS? Healthcare Effectiveness Data & Information Set HEDIS is an evolving set of standard specifications for measuring health plan performance

15. Where Did HEDIS Come From? • Originally developed by employers and the HMO group in 1991; NCQA took charge of HEDIS in 1992 • Expanded in 1996 to cover all three product lines: commercial, Medicare and Medicaid • Addresses the leading causesof death and morbidity • Includes information on quality, utilization and cost

16. How Are HEDIS Data Used? • Federal, state and other regulatory requirements • Performance-based accreditation • Health plans use for RFP/RFI preparation • Quality improvement activities and health plan operations

17. Data Reporting • Data are reported to NCQA in June of the reporting year • Data reflect events that occurred during the measurement year(calendar year)

18. Data Reporting • Example: • HEDIS 2013 data are reported in June 2013 • Data reflects events that occurred January–December 2012 (per specs) • HEDIS 2013 = 2012 data

19. Effectiveness of Care Measures • Clinical quality of care Focus • Preventive care • Up-to-date treatments for acute episodes of illness • Chronic disease care • Appropriate medication treatment

20. Collecting HEDIS Data

21. Three HEDIS Data Sources Administrative Claims Encounter Eligibility Provider Surveys Medical Records

22. Selecting an Eligible Population • Member ID • Age (DOB) • Enrollment date and type • Dates of service • Diagnosis and procedure codes • Provider specialty • Pharmacy

23. Clinical Measures Data Collection • Defining the denominator is critical • Administrative: Claims and encounter data • Denominator: Based on all eligible members of the population

24. Structure & Process Measures

25. What is a S&P Measure? • A statement about acceptable performance or results • Assesses a plan’s ability to comply with specific requirements • Focus on systems necessary for quality care • Policies & procedures, reports, materials

26. How are S&P Measures Developed Similar to HEDIS measure development Initial literature review and evidence Geriatric Measurement Advisory Panel (GMAP) Diverse set of expert stakeholders Technical expert panels also formed, if necessary Pilot Tests/Public Comment Determine feasibility/burden Input from stakeholders Final approval from GMAP and CMS

27. Components of the S&P Measure Components of the S&P Measure Standard Statement A statement about acceptable performance or results

28. Components of the S&P Measure Intent Statement A sentence that describes the importance of the S&P measure

29. Components of the S&P Measures Components of an S&P Measure ELEMENT FACTORS SCORING DATA SOURCES

30. Components of an S&P Measure The extent of the organization’s services evaluated during an NCQA survey. The period of time for which NCQA evaluates the SNPs documentation to assess performance against an element

31. Components of an S&P Measure Guidance for demonstrating performance against the element Descriptive information illustrating performance against an element’s requirements. Examples are for guidance and are not intended to be all-inclusive

32. Data Source Types Reports Documented Process Materials

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34. Data Source Types--Reports Report

35. Data Source Types—Reports (cont’d)

36. Data Source Types--Materials Materials

37. 2013 Assessment Against S&P Measures

38. SNP Assessment Process • S&P Measures assessment • Data collection through Web-based Interactive Survey System (ISS) survey tool. • Several levels of review: • Off-site Review (Level 1) • Executive Review/Plan Comment (Level 2) • Final Eyes (Level 3) • Final Stage Review (Level 4)

39. S&P Assessment • Plan Comment Period • Plans will have an opportunity to provide additional information to clarify issues from original submission materials • Quick turnaround: Plans will have to respond to NCQA requests for more information rapidly • One-time opportunity: Only chance plans have to provide additional documentation before data is finalized and sent to CMS

40. S&P Assessment • Plan Comment Period (continued) • If you have questions, please contact a SNP team member immediately • Please ensure additional data submitted is within the look-back period or it will not meet the requirements

41. Final Stage Review • Occurs after plans receive preliminary final scores • One last opportunity for review • Only for scoring inconsistencies • Radio buttons and support text language differ • Different scores for similar SNP PBPs • No new documentation will be reviewed

42. Look-Back Period • What is the Look-Back Period & how does it work? • The look-back period is the six-month period prior to survey submission – April 15, 2013 to October 15, 2013. All documentation must be current as of the look-back period but it could have been developed before that time. • Data used for reports can go back up to 1 year prior to submission, unless the explanation indicates otherwise. • For evidence consisting of a policy, an organization that did not have one in place can develop and incorporate it into its operations during the look-back period.

43. Who Reports • HEDIS measures • All SNP plan benefit packages with 30+ members as of February 2012 Comprehensive Report (CMS website) • S&P measures • All SNP plan benefit packages • Plans with zero enrollment are exempt for certain elements

44. SNP Reporting • Returning SNPs— all SNPs that were operational as of January 1, 2012 AND renewed for 2013 AND have previously submitted. • SNP 1-6 • New SNPs — all SNPs operational as of January 1, 2012 AND renewed for 2013 AND are reporting for the first time. • SNP 1 A-D, SNP 2, SNP 4-6

45. 2013 S&P Measures • SNP 1: Care Management – Major changes to measure to align with MOC requirements • All SNP Types • Focus on assessment, individualized care plans, how SNPs coordinate services and manage care for members • SNP 2: Member Satisfaction – Added examples • All SNP Types • Focus on monitoring member satisfaction to identify areas for improvement & take action

46. S&P Measures: What’s New for 2013 • SNP 3: Clinical Quality Improvement – revised methodologyfor calculating significant improvement to address small numbers • All SNP types • Focus on demonstrating quality improvement • SNP 4: Care Transitions – Added new factor in Element E • All SNP Types • Focus on how SNPs manage and support members through planned and unplanned transitions in care

47. S&P Measures: What’s New for 2013 • SNP 5: Institutional SNP Relationship With Facility – No major changes • I-SNPs only • Focus on how SNPs communicate with facilities to monitor services and members’ needs • SNP 6: Coordination of Medicare and Medicaid Coverage – No major changes • Different requirements for Duals and I & C SNPs • Focus on coordination and administration of benefits for Duals

48. SNP Data & Reporting

49. Data Submissions • S&P measures • Submission date: October 15, 2013 • ISS data collection tool • No Fees required to submit • All SNPs that were operational as of January 1, 2012, AND renewed in 2013. • Plans with zero enrollment are exempt for certain elements NCQA will verify enrollment using CMS Comprehensive Report—publicly available enrollment data

50. What happens after submission? • NCQA Analysis of HEDIS and S&P measures • Comparison to MA plans (HEDIS) and to other SNPs • Demographic (size, type, region) • Statistical significance • Deliver report to CMS • CMS will make all decisions regarding the use of the data • NCQA will not publicly report any of the SNP data