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SNP Surveyor Update Training

June 19, 2012. SNP Surveyor Update Training. Objectives of SNP SUT Training. Review NCQA’s year-to-year approach to the project and reporting requirements for SNPs Describe the changes in the S&P measures for the 2012 SNP Assessment

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SNP Surveyor Update Training

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  1. June 19, 2012

    SNP Surveyor Update Training

  2. Objectives of SNP SUT Training Review NCQA’s year-to-year approach to the project and reporting requirements for SNPs Describe the changes in the S&P measures for the 2012 SNP Assessment Explain how to assess performance with individual elements in the S&P Measures
  3. 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
  4. SNP Assessment: How did we get here? Existing contract with CMS to develop measures focusing on vulnerable elderly Revised contract to address SNP assessment 2008 - rapid turnaround, adapted existing NCQA measures and processes from Accreditation programs 2009 - focused on SNP-specific measures 2010 - refined existing measures 2011 - clarified requirements in SNP 1 thru 6 2012 - added elements/factors, removed factors, refined measures and documentation requirements
  5. Who Reports HEDIS measures All SNP plan benefit packages with 30+ members as of February 2011 Comprehensive Report (CMS website) S&P measures All SNP plan benefit packages Plans with zero enrollment as of April 2012 Comprehensive Report are exempt for certain elements
  6. SNP Reporting Returning SNPs— all SNPs that were operational as of January 1, 2011 AND renewed for 2012 AND have previously submitted. SNP 1 A-B and I-K, SNP 2C, SNP 3-6 New SNPs — all SNPs operational as of January 1, 2011 AND renewed for 2012 AND are reporting for the first time. SNP 1 A-H, SNP 2, SNP 4-6
  7. Project Time Line – 2012-2013 June 2012 through September 2012- Training for SNPs June 2012 - Release ISS Data Collection Tool for S&P Measures October 15, 2012 - S&P Measure submissions due to NCQA October 15, 2012 to April 30, 2013 – S&P reviews conducted by NCQA and surveyors September 28, 2013 - NCQA delivers SNP Assessment Report to CMS

  8. Structure and Process Measures

  9. SNP 1: Complex Case Management
  10. SNP 1- Complex Case Mgmt. Changes since 2011 Look-back period–6 months (all Elements) Added 2 new factors (Element A) Clarified requirements and language for auto enrolling all members in CM (Elements A, B, D & E factor 2) Revised factor 5 (Element B) Deleted language excluding frail members or those near the end of life from guideline application (Element C)
  11. SNP 1- Complex Case Mgmt. Changes continued Removed: factor 1 – right to decline CM participation factor 6 – life planning activities (Element F) Split existing element into 2 separate elements (Elements F and G) Added three new elements for reporting by returning SNPs (Elements I, J and K) See Surveyor Resource Guide for additional changes in data sources
  12. SNP 1 Element A Definition of Complex case mgmt (CM): the coordination of care and services provided to members who have experienced a critical event or diagnosis requiring the extensive use of resources and who need help navigating the system to facilitate appropriate delivery of care and services. Goal of the CM program: to help members regain their health & help them improve their functional capability
  13. SNP 1 Element A SNP must provide actual reports (documented process no longer acceptable) showing it uses 6-7 types of data (not referrals) to identify members for CM claims or encounter data hospital discharge data pharmacy data laboratory results UM data (if it conducts UM activities)
  14. SNP 1 Element A data provided by member or caregiver may include self-reported data provided in risk assessments Caregivers consist of family members or other individuals who support members and on whom the member depends for help coping with a serious condition or disability data provided by practitioners e.g., through electronic health records
  15. SNP 1 Element A Auto enrollment in CM – A SNP can also meet this element (and Elements B, D, factor 2 of E) by showing that it enrolls and maintains all members in CCM and as part of the program does the following: comprehensive assessment of member’s condition determination of available benefits/resources development/implementation of individualized CM plan with performance goals CM plan monitoring and follow-up
  16. SNP 1 Element B A SNP’s documentation must show it uses 5 to 7 types of referrals to consider members for CM Health information line referral Disease Management program referral Discharge planner referral UM referral, if applicable Member or caregiver referral Practitioner referral Other (documentation defines source)
  17. SNP 1 Element B A SNP that has a Health Information Line must accept referrals from it to receive credit for factor 1. If the documentation does not mention health information lines, enter the issue on the OIF requesting evidence or clarification Alternatively, score factor 1 “NA” for a SNP that shows it does not have a Health Information Line.
  18. SNP 1 Element C CM Systems The SNP’s documentation for member assessment and management in the CM system must show it: incorporates evidence-based clinical guidelines or other clinical evidence into decision trees/algorithms; automatically documents staff member identification and the date/time of action on the case or interaction with the member; receives automatic prompts for follow-up as CM plan requires
  19. SNP 1 Element C For factor 1 a SNP’s documented process or training manual must: reference the specific clinical guidelines and describe how it uses them for assessment and mgmt of members show guidelines are embedded in system logic Factors 2 and 3 require SNP’s screenshots (rpts) to: show automation of user actions, dates/times and prompts or reminders for follow-up
  20. SNP 1 Element D Frequency of Member Identification A SNP must submit reports for Element D showing it systematically identifies members who qualify for CM services monthly. Since clinical data may be dynamic, the intent is for the SNP to demonstrate it reviews these data frequently to pinpoint members that would benefit from enrollment in CM.
  21. SNP 1 Element E Providing Members With Information A SNP must submit materials that show it supplies written and verbal information to members eligible for CM on how: to use the services members become eligible to participate to opt in opt out
  22. SNP 1 Element E Factors 1 thru 3 require the SNP to submit: call scripts or detailed outlines for in-person or telephone contact materials such as letters, member handbook excerpts for written communication materials to show how members informed about how to opt in/out Factor 3: Score NA if state/others require SNP to provide all members w/CM
  23. SNP 1 Element F CM Assessment Process Includes all info for SNP to assess members’ needs and develop interventions for them A SNP’s written procedures must address all 8 factors It may submit assessment tools or screenshots as evidence, if these documents demonstrate the system has all required functionality
  24. SNP 1 Element F SNP’s evidence must include: Documentation of clinical history and meds e.g., disease onset, inpatient stays, treatment history Initial assessment of: health status & comorbidities activities of daily living mental health status and cognitive function both aspects are required
  25. SNP 1 Element F Evaluation of: cultural and linguistic needs review of language needs meets factor 5 visual & hearing needs, preferences/limitations caregiver resources e.g., family involvement in decision making available benefits covered by SNP, carved out, for supplemental services such community behavioral health or national and community resources
  26. SNP 1 Element G Individualized Care Plan SNP uses info from assessment process to develop a comprehensive care plan CM plan includes descriptions of actions and their duration to address members’ medical, BH, functional and support needs, along with: prioritized goals that reflect member’s or caregiver’s preferences and involvement self-management plan schedule for follow-up/identify barriers process to assess member progress
  27. SNP 1 Element G Based on the member’s specific needs the care plan also identifies: resources to be utilized and appropriate level of care CMs often facilitate referrals to other providers as part of member’s benefits planning for coordination of care including transitions and transfers identifying how and when CMs follow up with a member after referral to a health resource collaborative approaches to be used
  28. SNP 1 Element H Informing and Educating Practitioners Element H requires the SNP to supply materials that show: Instructions on CCM and how to use services Information on how the organization works with a practitioner’s patients in the program
  29. SNP 1 Element H A SNP’s documentation for each factor: Must include the actual materials it uses e.g., a provider manual, website, newsletter or brochure to inform practitioners about CCM services, explaining how the services would benefit members and how to refer them
  30. SNP 1 Element I Satisfaction with Case Mgmt Intent is for SNP to obtain feedback on its CM program from a broad sample of members, not just those that contacted it SNP must submit a report showing it performed an evaluation of satisfaction by: Obtaining feedback from members Analyzing member complaints and inquiries
  31. SNP 1 Element I Factors 1 and 2 require SNPs to use: focus groups or satisfaction surveys that are specific to CM programs e.g., assess satisfaction with--program staff, the usefulness of info received, member’s ability to adhere to recommendations. analysis of complaint and inquiry data to identify patterns or trends quantitative and qualitative
  32. SNP 1 Element I Reports with data obtained from CAHPS or general surveys will not meet the intent Results from satisfaction surveys administered across multiple SNPs must be stratified at individual plan level for analysis Score factors 1 and 2 NA for SNPs that did not have any members at the start of the look-back period. Use the CMS April 2012 Comprehensive Report to confirm this.
  33. SNP 1 Element J Analyzing Effectiveness/Identifying Opportunities The SNP measures the effectiveness of its case management program using three measures. For each measure, it: Identifies a relevant process or outcome Uses valid methods that provide quantitative results Sets a performance goal Clearly identifies measure specifications Analyzes results Identifies opportunities for improvement, if applicable
  34. SNP 1 Element J SNP’s report must contain appropriate measures Likely to have significant and demonstrable bearing on all or a subset of CM members Outcomes based Relevant to target population Valid methodology Contains info on sampling (if used) and sample size calculation Measurement periods reflect the effects of seasonality Denominator specific to CM population
  35. SNP 1 Element J Report shows appropriate analysis – goes beyond simple reporting or data display Comparison to goal or benchmark Quantitative and qualitative Opportunities for improvement SNP can use 3 patient experience measures e.g., improved quality of life, pain management and health status May only use 1 satisfaction measure with CM program operations Scoring is based on an average for all 3 measures
  36. SNP 1 Element J Score factor 6 NA if your assessment of the SNP’s documentation confirms it does not have any opportunities for improvement Score factors 1 thru 6 NA for SNPs that did not have any members at the start of the look-back period. Use the CMS April 2012 Comprehensive Report to confirm this.
  37. SNP 1 Element J Examples of measures HEDIS measures of effectiveness for chronic conditions e.g., controlling high blood pressure, persistence of beta blocker treatment after a heart attack SF-36 or SF-12 results Use of service measures for which consensus indicates improvement – e.g., ED visits Readmission rates Ambulatory-care sensitive admissions
  38. SNP 1 Element K Implementing Interventions and Follow-up Evaluation Based on the results of its measurement and analysis of case management effectiveness, the organization: Implements at least one intervention for the three opportunities identified in Element J to improve performance Develops a plan for evaluation of the intervention and re-measurement
  39. SNP 1 Element K Scoring is based on an average for all 3 measures A SNP’s documentation must show that it developed a plan to evaluate the effectiveness of its interventions; this evaluation includes re-measurement using methods consistent with initial measurement.
  40. SNP 1 Element K Factor 1 may be NA if no opportunities Factor 2, re-measurement, must be completed whether there are opportunities or not. Score factors 1 and 2 NA for SNPs that did not have any members at the start of the look-back period. Use the CMS April 2012 Comprehensive Report to confirm this.
  41. SNP 2: Improving Member Satisfaction
  42. Summary of Changes for 2012 Look-back period – all elements – 6 months SNP 2 Element A Modified factors 1-3 to make it clear that plans must provide both a qualitative and quantitative analysis Added documented processes as a required data source SNP 2 Element B Added documented processes as a required data source SNP 2 Element C (New!) SNP must show implementation of interventions based on results from 2A and 2B
  43. SNP 2: Overview Who reports? Initial SNPs are responsible for reporting all of SNP 2. This includes Elements A, B and C. Returning plans are required to report the new Element C must use results from 2A and 2B; may use new data/opportunities from analysis, if appropriate.
  44. SNP 2 Element A Assessment of Member Satisfaction a SNP must supply a documented process and a report explaining how it performs the assessment and an analysis of member satisfaction data that shows it: identified the appropriate population selected appropriate samples from the affected population, (if used) conducted an quantitative and qualitativeanalysis annually Score factor 2 “yes” if the SNP collected data on its entire SNP population
  45. SNP 2 Element A A SNP’s complaint and appeal data must relate to at least the four major categories Quality of Care Access Attitude and Service Billing and Financial It must submit a report that shows the data collected, sampling methodology, quantitative and qualitative analyses. Complaint, grievance and appeal data or satisfaction survey data collected 12 months prior to the start of the look-back period--(4/15/11) will not meet the intent
  46. SNP 2 Element A All SNP complaint/appeal data must be at the PBP level. If not, Score 50% for data only identified as “Medicare” Score 0% if data source is not specified at all Score 100% for SNP that performed its own analysis (did not just attach vendor’s report) of CAHPS data, which may be at contract level
  47. SNP 2 Element A If the SNP has no complaints, appeals or grievances, it must still show a table, spreadsheet or other documentation that demonstrates it collected appropriate data for an analysis
  48. SNP 2 Element A The analysis must be SNP-specific; plans must break out the data at the PBP level for an aggregate analysis of complaints and appeals across multiple benefit plans If a SNP has no members as of the start of look-back period, score the factors 1-3 “NA”. Confirm with CMS April 2012 SNP Comprehensive Report.
  49. SNP 2 Element B Opportunities for Improvement Element B requires a SNP to show: How it identifies opportunities for improvement of member satisfaction (documented processes) At least 2 opportunities for improvements based on its data and analysis for SNP 2A (reports). Analysis should indicate reasons for opportunities identified May be lesser priorities
  50. SNP 2 Element B Score Element B NA if: a SNP does not identify any opportunities for improvement analysis does not result in the identification of one or more opportunities for improvement. Reasons for no improvement opportunities may include: no or very low enrollment; no trendable data available very low number of complaints/appeals.
  51. SNP 2 Element B If a SNP has no members as of the start of look-back period, score the element “NA”. Confirm with CMS April 2012 SNP Comprehensive Report.
  52. SNP 2 Element C Improving Satisfaction Element C requires a SNP to show that it is actively working on implementing interventions and measuring their effectiveness. Plans must provide BOTH Documented Processes and Reports The interventions must relate to those opportunities identified in SNP 2B, or from other opportunities identified from the analysis of member satisfaction data in SNP 2A Do not have to show improvement on interventions, but do have to show SNP measured the effectiveness of them.
  53. SNP 2 Element C Score factor 2 NA if SNP 2B is scored NA. SNP must still provide a documented process explaining how it implements interventions and monitors them for effectiveness. If a SNP has no members as of the start of look-back period, score the element “NA”. Confirm with CMS April 2012 SNP Comprehensive Report.
  54. SNP 3: Clinical Quality Improvement
  55. SNP 3 Element A (New!) Plan no longer provides 3 relevant clinical measures If a SNP has achieved three statistically significant improvements in its Effectiveness of Care measures, it receives a 100% score for the element. NCQA uses the previous year’s HEDIS results as the baseline and compares them to results for current year i.e., 2012 HEDIS results are compared to 2011 results If previous year’s data is unavailable the plan will receive a score of NA
  56. SNP 3 Element A Which SNPs must demonstrate clinical improvement? Returning SNPs will be scored Initial SNPs and plans with <30 members (as of 2/11 CMS Comp. Report) are exempt Surveyors are not responsible for reviewing SNP 3 Element A. NCQA staff will score it at ER stage.
  57. Activity
  58. Activity Instructions Surveyors are divided up into 4 groups Each table is given documentation to review and an OIF to write as a group After 10 minutes each table will exchange OIFs The groups are given 10 more minutes to act as an Executive Reviewer and determine whether or not they agree with the other table’s OIF. Groups will then come together and we will review the documents as a whole.
  59. SNP 2, Element C - SUT Exercise Deficiencies: Factor 1 New opportunity for improvement identified; however, Documentation demonstrating analysis of member satisfaction data to identify opportunity, as outlined in Element A and B, is missing Documented process lacks a detailed methodology outlining process to implement the intervention and measure effectiveness. Factor 2 Data used for analysis is not appropriate member satisfaction data or CAHPS data. It does not follow data collection requirements Note: Analysis of member satisfaction data in Element C shows a decline in performance, this is not a deficiency.
  60. SNP 4: Care Transitions
  61. What’s Changed? No major content, documentation or scoring changes Look-back period—6 months Clarified explanations of planned and unplanned transitions (Elements A & B) Defined number of examples needed to meet intent (Elements A, B & D) Defines sampling universe (Elements C & E) Member coordination/education must target at-risk members from Element E (Element F)
  62. SNP 4 Element A: Managing Transitions Managing & coordinating planned/unplanned transitions from one care setting to another Factor 1 focuses on planned transitions to and from a hospital Requires SNP to show it is aware that a transition is about to take place—before it happens and provide support throughout the transition process, not just after discharge A preauthorization policy included in documentation must show how it triggers clinical action. Cannot solely pertain to a coverage or payment decision.
  63. SNP 4 Element A Factor 2 specifies requirements for planned and unplanned transitions to and from a hospital Sending setting must share care plan with receiving setting within 1 business day of transition notification Care plan consists of patient info that facilitates communication, collaboration and continuity of care across settings Org determines what info care plan includes Must specify practitioner to receive care plan for planned transitions to hospital—must show evidence SNP shared care plan with practitioner w/in specified timeframe
  64. SNP 4 Element A Factor 3: Notifying member’s usual practitioner of transition planned and unplanned transitions to and from all care settings must specify a timeframe for completion of transition activities, e.g., 24-48 hours prior to member movement to receiving setting within 1 business day of member’s discharge at least 2 calendar days before the scheduled procedure
  65. SNP 4 Element B Supporting Members Through Transitions Communications with members/caregivers within specified timeframes regarding: the transition process and what to expect changes in health status and their care plan who will support them through the process Factors 1 thru 3 pertain to planned andunplanned transitions to and from all care settings
  66. SNP 4 Element B A SNP’s documented process for factors 1 thru 3 must specify a timeframe for completion of required transition activities The following do not qualify as timeframes during the encounter …. upon identification of transition needs …. regular contact and review …. on an ongoing basis …. during discharge ….
  67. SNP 4 Element C An aggregate analysis of transitions should contain: Measures that directly assess the frequency a SNP performs the functions assessed in factors 1-3 of Elements A & B A description of: how the SNP collects the data who performs the functions assessed the timeframe for the analysis Universe of planned & unplanned transitions included and care settings involved
  68. SNP 4 Element C The intent of the aggregate analysis for this element is for plans to assess how well they are managing transition activities. Factors 1 and 3 need to show: data collected; a quantitative and qualitative analysis; and the opportunities for improvement Factors 2 and 4 must describe: the universe of members in the sample sampling methodology how the SNP drew at least 3 months of data
  69. SNP 4 Element C What is an Analysis? An evaluation of aggregate performance that includes: quantitative data – number of transitions in the denominator for a factor and the number of transitions where the SNP performed the activity specified by the factor within any pertinent timeframes qualitative data – notations on results, trends, anomalies, assessment of causes/reasons for findings identification of opportunities and recommendations for further action
  70. SNP 4 Element D Identifying Unplanned Transitions A SNP must show that it: has a documented process and reviews reports of hospital admissions within 1 business day of the admission Must show at least 3 admissions reviews reports of long-term care facility admissions within 1 business day of the admission Must show at least 3 admissions
  71. SNP 4 Element E Focus of element is on minimizing unplanned transitions and keeping patients in least restrictive setting Factor 1 requires an analysis of patient-specific data to identify those at risk E.g., claims, UM or provider reports, predictive modeling A SNP can also analyze the same data for factor 1 that it uses to identify members eligible for case management (SNP 1:A, B and D)
  72. SNP 4 Element E A SNP’s documentation for factor 1 needs to show: data collected—must monitor all members members targeted areas where it acts to minimize the risk of unplanned transitions and keep members in the least restrictive setting
  73. SNP 4 Element E Factor 2 requires SNPs to analyze data and identify areas where avoidable, unplanned transitions can be reduced Analyze member admissions to all hospitals and ED visits Population focus (aggregate data) Actual analysis to identify areas for improvement
  74. SNP 4 Element E SNP’s documentation for factor 2 must show: data collected quantitative and qualitative analysis opportunities for improvement. SNP must include in-network and out of network facilities and EDs in this analysis for factor 2. If it only includes in-network facilities, it does not receive full credit for this factor (cannot score >50%).
  75. SNP 4 Element E SNP must provide evidence of 1 analysis performed w/in the look-back period (April 1-October 15, 2012). Data for analysis can go back to April 2011. Analyses must be SNP-specific; organizations that perform an aggregate analysis of multiple benefit plans must break out the data for each individual plan
  76. SNP 4 Element F Reducing Transitions Factors 1 and 2 require a SNP’s documentation to show that it: Coordinates services for at-risk members Educates these members or their caregivers on how to prevent unplanned transitions Actions must relate to findings from monthly analyses in SNP 4:E, factor 1
  77. SNP 4 Element F Factor 1—Care Coordination may be done through Case Mgmt; SNP must maintain special procedures if all members are not in CM A SNP can assign functions for factors 1 and 2 to providers and practitioners but it is responsible for meeting these factors
  78. SNP 5: Institutional SNP Relationship with Facility
  79. Summary of Changes for 2012 All Elements Added language to explicitly extend SNP 5 requirements to Assisted Living Facilities (ALFs) Look back period- 6 months SNP 5 Element A Changed the time frame for monitoring health status changes from quarterly to monthly SNP 5 Element B Revised the scoring to better reflect the intent that the SNPs must address all 4 factors to receive a score of 100% Specified which 3 of the 4 factors must be met to receive a score of 50% SNP 5 Element C No change
  80. SNP 5 Element A Monitoring Members’ Health Status Institutional SNPs only Focus is on communications with facilities to monitor member needs and services provided Facilities include contracted nursing facilities and assisted living facilities The SNP must show that it monitors information on members’ health status at least monthly Communication should include information that may indicate a change in health status or no change
  81. SNP 5 Element A Scoring changes from 2011 to 2012 Element is no longer all or nothing 100% or full credit Institutional SNPs who monitor at least monthly 50% or partial credit Institutional SNPs who monitor at least quarterly 0% or no credit Institutional SNPs who monitor less often than quarterly
  82. SNP 5 Element A Monitoring methods a SNP can use: data derived from MDS or other reports on member health status it requires from the institutional facility reports from its staff who visit members in facilities data on members’ health status it collects through case management on a monthly basis Status reports may include: Functional status assessments Medication regimen Self-reported health status Reports on falls, socialization and depression
  83. SNP 5 Element A Documentation a SNP must provide evidence in the required data source (documented processes) and one additional data source or it does not receive full credit for this element Element is NA for: An Institutional SNP that shows it does not have contracts with nursing facilities or assisted living facilities all members reside in the community Dual Eligible and Chronic Care SNPs are exempt Score all elements in this measure “NA”
  84. Question
  85. SNP 5 Element A An Institutional SNP that shows it does not have contracts with nursing facilities or assisted living facilities is exempt from reporting True False
  86. SNP 5 Element B Monitoring Changes in Members’ Health Status Organization monitors and responds to triggering events and changes by: Setting parameters for the types of changes and triggering events contracted facilities must report within 48 hours, 3 calendar days and 4 to 7 calendar days Identifying who will act on that information and should be contacted Identifying how the member’s care will be coordinated with appropriate clinicians or the clinical care plan Identifying one monitoring or data collection method it uses to assess changes in all members’ health status
  87. Factor 1 Details An organization must submit evidence that shows it has identified specific conditions or early warning signs and symptoms that facilities must report within a minimum of: 48 hours 3 calendar days 4-7 days The SNP must submit a policy and reports or materials showing how and when facility staff must report a list of triggers such as: changes in vital signs changes in the member’s behavior changes in their functional status complaints of pain
  88. SNP 5 Element B Scoring changes from 2011 to 2012 100% or full credit The organization meets all 4 factors 50% or partial credit The organization meets 3 factors including factors 1 through 3 (critical factors) 0% or no credit The organization meets 0-2 factors or does not meet factors 1, 2 or 3
  89. SNP 5 Element B The SNP must demonstrate it monitors members through one of the following methods: Reports from facilities to the organization such as Minimum Data Set (MDS) Reports from organization staff who visit the members Oversight of facility monitoring and reporting changes to treating practitioners rather than to the organization A combination of the processes above
  90. SNP 5 Element C Maintaining Members’ Health Status Organizations use the information from SNP 5 Elements A&B to identify at-risk members and work with facilities/practitioners to arrange for necessary care and adjust care plans as needed to prevent declines in member health status Scoring is 100% or 0% (all or nothing element)
  91. SNP 5 Element C Methods of providing care: SNPs may have differing models of relationships with facilities to address these monitoring functions Facility oversight: relies on facilities to modify/carry out care plans Staff practitioners: SNP staff practitioners visit facilities and order care plan modifications Other models of care: SNPs may use a combination of above models or different one
  92. SNP 5 Element C Documentation A SNP must submit: Documented Processes; AND Policies describing increases in frequency of visits to member by the organization’s nurse managers to assess, revise the care plan and monitor his or her condition after a health status decline and resulting inpatient stay Reports Screenshots from the organization’s care management system documenting monitoring visits, assessments and care plan changes the nurse managers discussed with the member’s treating practitioner and notes confirming the practitioner’s agreement

  93. SNP 6: Coordination of Medicare and Medicaid Coverage

  94. What’s Changed? Look-back period – 6 months Element A: Eliminated previous factors 1-3 Elements A & B: Added reports/materials to the required data sources. Eliminated Element C: Relationship with State Medicaid Agency for Dual-Eligible SNPs
  95. What’s Changed? Old Element D: Coordination for Chronic and Institutional Benefit Packages: Now Element C Added reports/materials to the required data sources. Revised the language regarding billing and co-payments for dual-eligible members. Element E: Service CoordinationNow Element D Element F: Network Adequacy Assessment: Now Element E Added requirements for a SNP to establish geographic and numeric standards for practitioners and providers and analyze its performance against those standards
  96. SNP 6 Element A Not Applicable for C-SNPs & I-SNPs Coordination of Benefits for Dual-Eligible Members Dual-eligible SNPs coordinate Medicare & Medicaid benefits/services for their members by: Giving members access to staff knowledgeable about both programs Providing clear explanations of rights to pursue grievances/appeals under both programs Providing clear explanations of benefits and any communications they receive re: claims, cost sharing
  97. SNP 6 Element A Documentation - SNPs must provide reports and may include documented processes or materials to supplement them Reports: Evidence of Coverage (EOC) documentation Documented processes: Job descriptions for staff who help members with coordination of both sets of benefits Materials: Job descriptions, scripts or guidelines for staff who help members with eligibility, benefits and claims for both Medicare and Medicaid (Factors 1 & 2)
  98. SNP 6 Element A For all factors — SNP must provide information to members for Medicare AND Medicaid per the requirements of the element. The SNP cannot receive credit for any factor where itprovides the required information for only Medicare without a report demonstrating resources for information on Medicaid.Evidence of implementation is required.
  99. SNP 6 Element A Documentation must show: SNP’s materials cover the details of members’ specific benefit plans It gives members information on staff who can answer questions regarding both programs in lieu of written documents SNP’s staff can answer questions about Medicare benefits and the state’s payment cost-sharing as well as Medicaid eligibility and cost-sharing for services where the member is liable.
  100. SNP 6 Element B Not Applicable for C-SNPs & I-SNPs Administrative Coordination of Dual-Eligible Benefit Packages A dual-eligible SNP coordinates Medicare and Medicaid benefits for its members by: Identifying changes in members’ Medicaid eligibility Coordinating adjudication of Medicare/Medicaid claims for which it is contractually responsible
  101. SNP 6 Element B SNPs must demonstrate that they monitor instances where members are losing Medicaid eligibility and regaining Medicaid eligibility to receive credit for factor 1. Score factor 2 “Yes” if a SNP that is not contractually responsible for the adjudication of Medicaid claims submits documentation showing that it helps members understand the state’s adjudication of claims submitted by providers.
  102. SNP 6 Element B Documentation SNPs must provide (1) documented processes and (2) reports OR materials Documented processes: Procedures used to determine changes in Medicaid eligibility Procedures used to coordinate adjudication of Medicare and Medicaid claims Materials: Instructions on where to reapply for Medicaid Reports: Redacted reports on Medicaid eligibility used by organization
  103. SNP 6 Element C Not Applicable for D-SNPs Administrative Coordination for Chronic and Institutional Benefit Packages SNP shows it coordinates Medicare/Medicaid benefits for C-SNP& I-SNP members by: Using a process to identify changes in members’ Medicaid eligibility Informing members about maintaining Medicaid eligibility Giving members information about benefits they are eligible to receive under both programs Giving members access to staff who can advise them on using both programs
  104. SNP 6 Element C Factors 1, 3 and 4—SNP must supply documentation that shows it provides information to members for Medicare AND Medicaid per the requirements of the element. The SNP cannot receive credit for factors 1, 3 and 4 if the SNP provides the required information only for Medicare without a documented process directing the member to a resource for information on Medicaid.
  105. SNP 6 Element C To receive credit for factor 2: I-SNPs’ documentation must address changes where members gain Medicaid eligibility; C-SNPs’ documentation must show that they monitor instances where members are gaining and losing Medicaid eligibility.
  106. SNP 6 Element C SNP’s materials cover the details of members’ specific benefit plans SNP’s staff can answer questions about Medicare benefits and the state’s payment cost-sharing as well as Medicaid eligibility and cost-sharing for services where the member is liable. Documentation - SNPs must provide Documented processes; AND Procedures used to verify changes in Medicaid eligibility Reports or Materials Sample benefit summaries provided to members
  107. SNP 6 Element C C-SNPs and I-SNPs are exempt from this element if less than 5% of the members in their SNP population are dual eligibles as of the start of the look-back period (April 15, 2012). Score each factor “NA” if they meet this requirement. Surveyors should verify this information using the SNP Plans by Type list provided in the Surveyor Resource Guide.
  108. SNP 6 Element D Applicable for all SNPs* Service Coordination Organization coordinates delivery of services covered by Medicare/Medicaid through the following: Helping members access network providers that participate in both programs or accept Medicaid patients Educating providers about coordinating benefits for which members are eligible and about members’ special needs Helping members obtain services funded by either program when needed
  109. SNP 6 Element D Helping dual-eligible members obtain services covered by Medicare & Medicaid The SNP must require that its network physicians do not bill dual-eligible members for more than the copayment amount which the state pays for individuals in that category of Medicaid eligibility.
  110. SNP 6 Element D For factor 1 SNP must publish a directory that shows: providers that participate in both programs or providers that accept Medicare for services covered by Medicare and providers that accept Medicaid for dual-eligible members
  111. SNP 6 Element D Factor 2 requires SNPs to educate network practitioners and providers about their role coordinatingMedicare/Medicaid benefits and members’ special needs. A SNP can: Alert their providers to the range of benefits or services for which members are eligible, as well as responsibility for cost-sharing, if any, and their right to reimbursement Inform providers who is responsible for coordinating services for both programs
  112. SNP 6 Element D Factor 3 requires SNPs to help members obtain services funded by either program when assistance is needed. The SNP can: Arrange services by contracting with providers, working with facilities, referring members, or by assisting members and providing services directly Help its members obtain services and detail how they can obtain non-emergency transportation
  113. SNP 6 Element D C-SNPs and I-SNPs are exempt from this element if less than 5% of the members in their SNP population are dual eligibles as of the start of the look-back period (April 15, 2012). Score each factor “NA” if they meet this requirement. Surveyors should verify this information using the SNP Plans by Type list provided in the Surveyor Resource Guide.
  114. SNP 6 Element D Documentation - SNPs must provide: Documented processes; AND Policies and procedures for arranging services for members Reports or Materials Reports detailing how members were assisted in obtaining services from Medicaid when needed. Materials such as the provider directory orprovider manuals.
  115. SNP 6 Element E Applicable for all SNPs* Network Adequacy Assessment Organization assesses the adequacy of the network for member access to practitioners and provider by: Establishing standards of the number and geographic distribution of each type of practitioner and provider Conducting an annual analysis of performance against said standards * Element is NA for C-SNPs and I-SNPs w/less than 5% dual eligible members and D-SNPs with no enrollment at the start of the look-back period.
  116. SNP 6 Element E The SNP’s documentation must include the geographical and numeric standards for practitioners and providers and a description of its methodology used to perform the analysis. Review the organization’s documented process for factors 1 and 2 and reviews reports for factors 3 and 4.
  117. SNP 6 Element E A SNP’s analysis must include a network access indicator (ratio of member to practitioner availability based a number of miles/minutes). A plan that uses: Access data (appointment availability) Data on members’ cultural or linguistic needs or Satisfaction data (surveys, complaints and appeals) must supplement its assessment with another network access indicator
  118. SNP 6 Element E Organization must determine adequate access for members for the following types of providers Primary care practitioners (e.g. general practitioners, internal medicine specialist) High volume specialist (e.g. cardiologist, neurologist, gynecologists, psychiatrists) Providers (e.g. hospitals, skilled nursing facilities)
  119. SNP 6 Element E GEO Access analysis for a SNP’s Medicare practitioner network only is insufficient to meet this element. The GEO Access or other analysis must include practitioners and providers that accept coverage for services paid for by Medicare and Medicaid. GEO Access maps must be accompanied by an assessment of quantitative data
  120. SNP 6 Element E The SNP’s methodology must include: direct measurement of results against standards, info about sampling (if used), and analysis of causes of any deficiencies, if SNP did not identify any gaps/deficiencies, determine whether this conclusion is reasonable. Analyses must be SNP-specific; organizations that perform an aggregate analysis of multiple benefit plans must break out the data for each individual plan.
  121. SNP 6 Element E SNPs must provide the following documentation: Documented processes; AND P&Ps for assessing network adequacy Reports Reports on accessibility of Medicare and Medicaid practitioners and providers Reports on access indicators such as percentage of in-network and out-of-network use; rate of ED use compared to norms in area; or member surveys of satisfaction with access
  122. Activity
  123. Activity Instructions Surveyors are divided up into 4 groups Each table is given documentation to review and an OIF to write as a group After 10 minutes each table will exchange OIFs The groups are given 10 more minutes to act as an Executive Reviewer and determine whether or not they agree with the other table’s OIF. Groups will then come together and we will review the documents as a whole.
  124. 4C Activity Answer Slide Factor 1: Conducting an analysis of all transitions The SNPs P&Ps indicate that it collects and analyzes planned and unplanned transitions data. The analysis shows data for planned transitions only; did not include an analysis of its unplanned transitions performance. While the SNP stratifies all members into three categories, (low, medium and high-risk) only high-risk members are assigned a case manager. The SNP does not consistently capture transition episodes for low and medium risk members from home to hospital.
  125. 4C Activity Answer Slide Factor 1 The analysis shows data for planned transitions only; did not include an analysis of its unplanned transitions performance. Factors 2 and 4: Drawing an appropriate sample (if sample used) SNP submitted data for the month of June. Does not meet the requirement – if the SNP uses a sampling of its data, it must draw a minimum of three month’s worth of data.
  126. 4C Activity Answer Slide Factor 3: Communicating with member and/or responsible party SNP provided discharge planning and does not following members throughout the care transitions process. This factor requires the SNP to support its members through the entire transition process to include planning for the transition as well as follow-up care needs post-transition.
  127. Questions?
  128. Contacts Brett KayDirector, SNP Assessment202-955-1722kay@ncqa.org Casandra MonroeAssistant Director, SNP Assessment202-955-5136monroe@ncqa.org Sandra Jones Assistant Director, SNP Assessment202-955-5189 jones@ncqa.org
  129. Contacts Nidhi Dalwadi Accreditation Manager, SNP Assessment 202-955-3585 dalwadi@ncqa.org Anthony Davis Accreditation Manager, SNP Assessment 202 –955-1713 ahdavis@ncqa.org Priyanka Oberoi Analyst, SNP Assessment 202-955-5130 oberoi@ncqa.org Delia Ponce Coordinator, SNP Assessment 202-955-1742 ponce@ncqa.org
  130. Please visit theSNP Surveyor Website:www.NCQA.org/SNPSurveyor
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