For Public Comment
February 24–March 23, 2016
Comments due 5:00 p.m. ET
March 23, 2016
Accreditation Products Updates
Overview
Case Management for Individuals Receiving Long-Term Services &
Supports Accreditation (CM-LTSS) 2016
Case Management-Clinical Accreditation (CM-C) 2017
Health Plan Accreditation (HPA) 2017
Managed Behavioral Healthcare Organization Accreditation (MBHO)
2017
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Table of Contents
Table of Contents
Accreditation Products Overview ...................................................................................................3
Our Mission: Improve the Quality of Health Care........................................................................3
A Guide to Accreditation Product Updates.................................................................................3
Why Is NCQA Addressing Long-Term Services and Supports for Vulnerable Populations?...............3
LTSS Background .................................................................................................................4
The Way Forward .......................................................................................................................4
LTSS Accreditation Product Crosswalk.....................................................................................7
Global Questions for Stakeholders Participating in Public Comment..............................................9
The NCQA Advantage ...........................................................................................................9
CM-LTSS Accreditation Early Adopters ....................................................................................9
New Case Management for Individuals Receiving Long-Term Services & Supports (CM-LTSS)
Accreditation .......................................................................................................................... 10
Program Eligibility ............................................................................................................... 10
Program Development to Date .............................................................................................. 10
NCQA LTSS Advisory Council............................................................................................... 11
CM-LTSS Accreditation Public Comment Feedback Instructions ................................................ 11
Summary of Program Requirements ...................................................................................... 11
Case Management-Clinical Accreditation (CM-C) 2017................................................................... 15
Proposed Updates .............................................................................................................. 15
Health Plan Accreditation (HPA) 2017.......................................................................................... 17
General Complex Case Management Updates (QI 5) ............................................................... 17
Requirements Specific to Comprehensive Medicaid MLTSS Plans (QI 5)..................................... 18
Additional HPA 2017 Updates ............................................................................................... 19
Managed Behavioral Healthcare Organization (MBHO) 2017........................................................... 24
General Complex Case Management Updates (QI 9) ............................................................... 24
Requirements Specific to Medicaid MLTSS MBHOs (QI 9) ........................................................ 24
Additional MBHO 2017 Updates ............................................................................................ 24
Public Comment Instructions ...................................................................................................... 27
Public Comment Questions................................................................................................... 27
Documents......................................................................................................................... 27
Submitting Comments.......................................................................................................... 27
Next Steps ......................................................................................................................... 28
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Accreditation Product Updates Overview
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Accreditation Products Updates Overview
Our Mission: Improve the Quality of Health Care
NCQA is dedicated to improving health care quality.
For over 25 years, NCQA has been driving improvement throughout the health care system, helping to
advance the issue of health care quality to the top of the national agenda. NCQA’s programs and services
reflect a straightforward formula for improvement: measurement, transparency, accountability.
This approach works, as evidenced by the dramatic improvements in clinical quality demonstrated by
NCQA-Accredited health plans—health maintenance organizations (HMO), point-of-service (POS)
organizations, preferred provider organizations (PPO)—using both standards and performance results.
Today, more than 172 million Americans (54 percent) are enrolled in a plan that collects and/or reports
HEDIS data to NCQA. 1
A Guide to the Accreditation Product Updates
NCQA has developed requirements designed to evaluate organizations responsible for delivering and
coordinating long-term services and supports (LTSS). The proposed LTSS standards will apply to the
following accreditation programs:
• NEW! Case Management for Individuals Receiving Long-Term Services and Supports
Accreditation (CM-LTSS).
• Health Plan Accreditation (HPA).
• Managed Behavioral Healthcare Organization Accreditation (MBHO).
NCQA also proposes other product updates, which focus on retiring and evolving standards in HPA,
MBHO and Case Management-Clinical Accreditation (formerly titled Case Management Accreditation).
Detailed information about the proposed accreditation product updates is provided in the sections below.
Why Is NCQA Developing Long-Term Services & Supports Requirements?
Long-term services and supports (LTSS) are vital in helping millions of Americans live more independent
lives by allowing them to remain in their homes and communities. Effectively coordinating LTSS for
individuals may reduce the need for acute medical care and prevent or delay nursing home placement,
thereby reducing total costs.2
The fragmented nature of the delivery system is especially problematic for individuals who need LTSS
because many require both clinical care and LTSS. Effectively serving these individuals involves the
coordinated efforts of clinicians in the medical delivery system, family/friend caregivers and service
providers in the community.
A variety of organizations are responsible for arranging for LTSS, including traditional health plans,
managed LTSS plans and community-based organizations (CBOs). With different organizations
assuming responsibility for managing LTSS it is important that both health plans and CBOs implement
best practices for person-centered care planning, effective care transitions and quality care delivery.
Effective coordination will result in better experience, greater efficiency and improved outcomes that
reflect what matters most to individuals. NCQA developed the proposed LTSS requirements to meet this
challenging need with the goal of improving quality for this growing population.
1
http://w w w.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality.aspx
2http://w w w.n4a.org/files/n4a_policybrief_July2012_Web.pdf
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Accreditation Product Updates Overview
LTSS Background
LTSS consists of a broad range of paid and unpaid supportive services that people may need—for
several weeks, months, or years—when they experience difficulty completing self-care tasks as a result of
aging, chronic illness, or disability. Over the last 20 years, state Medicaid agencies—the largest
purchasers of LTSS 3—have been shifting the provision of this type of care out of institutions into homeand community-based settings. Institutional services are provided in nursing facilities, mental institutions
and intermediate care facilities for the developmentally disabled, while home and community-based
services (HCBS) are provided in the community to help delay or avoid institutional care. The goal of this
transition is to improve individuals’ quality of life by allowing them to stay in their home as long as
possible. The HCBS model is strongly supported by states and the Centers for Medicare & Medicaid
Services (CMS), as indicated by the steady increases in annual expenditure since 1995 for HCBS and
parallel decreases in spending for institutional care. 4
Individuals needing LTSS are some of the most vulnerable and include elderly and non-elderly with
intellectual and developmental disabilities, physical disabilities, severe mental illness and other chronic
conditions. This population generally experiences poorer health, has inadequate access to health care,
and experiences worse health outcomes than other groups. 5 Demographic trends indicate that the
number of Americans who will need LTSS will continue to grow. Among persons age 65 and over, an
estimated 70 percent will use LTSS and persons age 85 and over are four times more likely to need
LTSS compared to persons 65 to 84. 6
About MLTSS
Historically, LTSS has been delivered through the fee-for-service delivery system. However, in recent
years under new federal waivers, states have begun to contract with managed care organizations (MCO)
to finance and manage these services. The delivery of LTSS through capitated managed care programs
is referred to as managed long-term services and supports (MLTSS). 7 As of October 2015, 18 states had
MLTSS programs and at least nine were planning to implement or expand their MLTSS programs. 8 Some
MLTSS plans are responsible solely for LTSS, while medical care is delivered through separate MCOs or
other arrangements. Other MLTSS plans are comprehensive MCOs, with responsibility for both medical
care and LTSS. Both types of MLTSS plans as well as states may use CBOs, such as Area Agencies on
Aging (AAA), to manage and coordinate and arrange care for individuals needing LTSS.
The Way Forward
To support this effort and to better address the changing system in which MCOs and CBOs responsible
for LTSS operate, NCQA has developed requirements across several of its Accreditation programs with
the goal of addressing the unique needs of individuals receiving LTSS in the home and community and
creating a more comprehensive and coordinated system of care for this population.
3
https://w ww.medicaid.gov/medicaid-chip-program-infor mation/by-topics/long-ter m-services-andsupports/dow nloads/ltss-expenditures-fy2013.pdf
4
https://w ww.medicaid.gov/medicaid-chip-program-infor mation/by-topics/long-ter m-services-andsupports/dow nloads/ltss-presentation-jul-31.pdf
5
http://w w w.commonw ealthfund.org/publications/fund-reports/2011/oct/ensuring-equity
6
https://kaiserfamilyfoundation.files.w ordpress.com/2015/12/8617-02- medicaid-and-long-ter m-services-and-supportsa-primer.pdf
7
https://w ww.medicaid.gov/Medicaid-CHIP- Program- Infor mation/By-Topics/Delivery-Systems/Medicaid- ManagedLong-Term-Services-and-Supports-MLTSS.html
8
https://w ww.openminds.com/dow nloads/w hich-states-provide-medicaid-long-ter m-services-supports-throughmanaged-care-an-open-minds-market- intelligence-report/
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Accreditation Product Updates Overview
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NEW! Case Management for Individuals Receiving LTSS (CM-LTSS) 2016
NCQA has developed a new accreditation product specific to organizations that provide case
management for LTSS (e.g., CBOs, MLTSS-only health plans). This product consists of standards
adapted from NCQA’s Case Management-Clinical Accreditation (formerly Case Management
Accreditation) program. Revisions enhance the standards applicability to non-clinical programs and
include new LTSS-specific requirements. Refer to New Case Management for Individuals Receiving
Long-Term Services & Supports (CM-LTSS) Accreditation
Case Management-Clinical Accreditation (CM-C)9 2017
Formerly referred to as “Standards for the Accreditation of Case Management Programs,” these
standards are appropriate for clinically-based case management programs. NCQA is proposing updates
to put greater emphasis on person-centered care and integration with non-clinical services. Refer to Case
Management-Clinical Accreditation (CM-C) 2017 for additional information.
Health Plan Accreditation (HPA) 2017
Includes new standards for comprehensive Medicaid MLTSS plans and updated complex case
management standards for all product lines that focus on effective management of care transitions and
person-centered care planning. Refer to General Complex Case Management Updates (QI 5)
and Requirements Specific to Comprehensive Medicaid MLTSS Plans (QI 5)
Updates also include a proposal to retire several standards due to shifting member needs or changes in
how care is being delivered. Refer to Additional HPA 2017 Updates
Managed Behavioral Healthcare Organization Accreditation (MBHO) 2017
The LTSS, complex case management and other standards updates will be aligned where appropriate
with proposed updates for Health Plan Accreditation 2017. Refer to Managed Behavioral Healthcare
Organization (MBHO) 2017
Key LTSS Updates Aligned Across Accreditation Programs
NCQA is proposing several updates aligned across its accreditation programs that are central to
improving the coordination of services for individuals receiving LTSS. Where appropriate, NCQA is also
recommending these requirements be applied for all individuals receiving case management services.
Care Transitions. CMS defines care transitions as “the movement of a patient from one setting of care
(hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home
health, rehabilitation facility) to another.” 10 Unnecessary and poorly managed care transitions can result in
adverse outcomes, especially among older adults and people with multiple chronic conditions,11 who are
often the recipients of case management services. Research indicates that inadequate care coordination,
including poor management of care transitions, contributed to $25–$45 billion in wasteful spending in
2011 through avoidable complications and unnecessary hospital readmissions. 12 Managing transitions
effectively can reduce errors. Case managers need to manage care transitions so that a change in care
setting does not disrupt the flow of care, but leads to the delivery of safe and effective health care. 13
9Formerly
titled Case Management Accreditation (CM)
https://w ww.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/dow nloads/8_Trans ition_of_Care_Summary.pdf
11http://w w w.longtermscorecard.org/~/media/Microsite/Files/2015/AARP987_EffectiveCareTransitions_June2015.pdf
12 http://w w w.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76
13 Case Managers Optimize Patient Safety by Facilitating Effective Care Transitions, Dana Deravin Carr RNC, CCM,
MPH, MS, Professional Case Management; March/April 2007, Volume 12 Number 2, Pages 70–80.
10
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Accreditation Product Updates Overview
The need for effective care transitions is emphasized in the most recent Medicaid Managed Care Notice
of Proposed Rule Making (NPRM), which calls for coordination of care across settings and with services
delivered inside and outside health plans. The NPRM describes the benefit of enhanced care
coordination to “enable people with disabilities and LTSS enrollees to live, work, and participate in the
setting of their choice more safely, effectively, and with fewer lapses in care.” 14
The 2014 Case Management Accreditation standards currently include care transition requirements.
NCQA is proposing updates to these requirements for inclusion in CM-C 2017 and CM-LTSS 2016.
NCQA also proposes to add these requirements to HPA 2017 and MBHO 2017 for all product lines.
Qualifications for LTSS Providers. LTSS are frequently delivered in the individual’s home by unlicensed
providers for whom traditional credentialing procedures do not apply. The lack of standardized oversight
raises concerns about the safety and potential risk of exploitation of individuals receiving LTSS. Currently,
40 states require the use of background checks on home care workers employed through home health
agencies with another four states moving towards this requirement. AARP suggests using an additional
screening tool in combination with a background check to best vet possible LTSS providers. 15
NCQA is proposing to include requirements for establishing qualifications for LTSS providers for CMLTSS and for comprehensive Medicaid-MLTSS plans.
Critical Incident Management System. Critical incidents are events or occurrences that cause harm to
an individual or serve as indicators of risk to a member’s health or welfare such as abuse, neglect and
exploitation by providers. Critical incident management systems can be used to facilitate immediate and
appropriate response to critical incidents such as complaints of abuse, neglect or exploitation. During
NCQA’s informational interviews, states with MLTSS programs discussed the need for organizations
providing LTSS to develop and implement policies and procedures to address training, tracking and
following-up on critical incidents. Critical incidents are a particularly salient concern for people who are
dependent on highly intimate, in-home services.
NCQA is proposing to include requirements for establishing critical incident management systems for CMLTSS and comprehensive Medicaid-MLTSS plans.
Person-Centered Care Planning. Person-centered care refers to the practice of basing decisions (both
clinical and social) on the individual’s preferences and goals. In the final HCBS rule for Medicaid
programs, CMS has strengthened its commitment to person-centered care by requiring that service
planning for participants served through 1915(c) and (i) waivers be developed through a person-centered
planning process that address health and long-term service and support needs in a manner that reflects
individual preferences and goals. 16 CMS further requires that the person-centered planning process be
directed by the individual with LTSS needs, who may choose to include a representative and others to
contribute to the process. Per the rule, the planning process and the person-centered service plan will
help people achieve personally defined outcomes in an integrated community setting, ensure delivery of
services in a manner that reflects personal preferences and choices and contribute to the assurance of
health and welfare. Person-centered principles are embedded throughout NCQA’s case management
requirements. These principles are specifically addressed in standards for assessment and care planning.
NCQA is proposing updates that increase the focus on person-centered planning for CM-C, CM-LTSS, as
well as HPA 2017 and MBHO 2017 for all product lines.
14
https://w ww.federalregister.gov/articles/2015/06/01/2015-12965/medicaid-and-childrens-health-insurance-programchip-programs-medicaid- managed-care-chip-delivered#h-220
15 Safe at Home? Developing Effective Criminal Background Checks and Other Screening Policies f or Home Care
Workers.
16 https://w ww.medicaid.gov/Medicaid-CHIP- Program- Infor mation/By-Topics/Long-Ter m-Services-andSupports/Home-and- Community-Based-Services/Dow nloads/final-rule-fact-sheet.pdf
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Accreditation Product Updates Overview
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LTSS Accreditation Product Crosswalk
The table below provides a crosswalk of the case management requirements across the four accreditation products available for public comment.
NEW CM-LTSS
Accreditation
CM-LTSS 1: Program Description
A: Program Description
B: Systematic Review of Evidence
and Professional Standards
C: Program Content Consistent
With Evidence and Professional
Standards
CM-LTSS 2: Assessment Process
Identification
and Assessment A: Population Assessment
B: Comprehensive Assessment
Process
C: Comprehensive Assessment
Implementation
Program Area
Program
Description
Care Planning
Care Monitoring
Care Transitions
CM-C Accreditation
CM-C 1: Program Description
A: Program Description
HPA QI 5
QI 5B: Program Description
MBHO QI 9
QI 9B: Program Description
CM-C 2: Patient Identification and
Assessment
B: Comprehensive Assessment
Process
C: Comprehensive Assessment
Implementation
QI 5C:Identifying Members for Case
Management
QI 5F: Comprehensive Assessment
Process*
QI 5G:Comprehensive Assessment
Implementation*
*LTSS specific factors
CM-LTSS 3: Person-Centered
Care Planning
A: Person-Centered Case
Management Plan
B: Person-Centered Care Planning
Process
CM-LTSS 4: Care Monitoring
A: Case Management Systems
B: Ongoing Case Management
Implementation
CM-C 3: Person-Centered Care
Planning
A: Person-Centered Care Planning
Process
QI 5H:Person-Centered Care
Planning Process
*LTSS specific factors
QI 9C: Identifying Members for
Case Management
QI 9F: Comprehensive
Assessment Process*
QI 9G: Comprehensive
Assessment
Implementation*
*LTSS specific factors
QI 9H: Person-Centered Care
Planning Process
*LTSS specific factors
CM-C 4: Care Monitoring
B: Ongoing Case Management
Implementation
QI 5E: Case Management Systems
QI 5I: Ongoing Case Management
Implementation*
*LTSS specific factors
CM-LTSS 5: Care Transitions
A: Process for Transitions from the
Community
B: Process for Transitions Back to
the Community
C: Support for Individuals During
Transitions
CM-C 5: Care Transitions
A: Process for Transitions Between
Settings
B: Process for Follow-up After
Discharge
C: Support for Patients During
Transitions
NEW Requirements
QI 5M:Process for Transitions from
the Community (LTSS Only)
QI 5N:Process for Transitions Back
to the Community
(LTSS Only)
QI 5O:Process for Transitions
Between Settings
© 2016 National Committee for Quality Assurance
QI 9E: Case Management
Systems
QI 9I: Ongoing Case Management
Implementation*
*LTSS specific factors
NEW Requirements
QI 9M: Process for Transitions from
the Community (LTSS Only)
QI 9N: Process for Transitions
Back to the Community
(LTSS Only)
QI 9O: Process for Transitions
Between Settings
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Accreditation Product Updates Overview
Program Area
Measurement
and Quality
Improvement
Staffing,
Training &
Verification
Rights &
Responsibilities
NEW CM-LTSS
Accreditation
D: Reducing Unplanned
Transitions for Individuals
E: Reducing Unplanned
Transitions for the Population
CM-LTSS 6: Measurement and
Quality Improvement
A: Experience with Case
Management
B: Measuring Effectiveness
C: Action and Remeasurement
CM-LTSS 7: Staffing, Training and
Verification
B: Qualifications and Assistance
for LTSS Providers
CM-LTSS 8: Rights and
Responsibilities
A: Critical Incident Management
System
Privacy, Security CM-LTSS 9: Privacy Security and
& Confidentiality Confidentiality Procedures
CM-C Accreditation
D: Reducing Unplanned Transitions
for Patients
E: Reducing Unplanned Transitions
for the Population
HPA QI 5
QI 5P: Process for Follow-up After
Discharge
QI 5Q:Support for Members During
Transitions
QI 5R:Reducing Unplanned
Transitions for Members
QI 5S: Reducing Unplanned
Transitions for the Population
QI 5J: Experience with Case
Management
QI 5K: Measuring Effectiveness
QI 5L: Action and Remeasurement
MBHO QI 9
QI 9P: Process for Follow-up After
Discharge
QI 9Q: Support for Members During
Transitions
QI 9R: Reducing Unplanned
Transitions for Members
QI 9S: Reducing Unplanned
Transitions for the Population
QI 9J: Experience with Case
Management
QI 9K: Measuring Effectiveness
QI 9L: Action and Remeasurement
CM-C 7: Staffing, Training and
Verification
QI 5T: Qualifications and Assistance
for LTSS Providers (LTSS
Only)
QI 9T: Qualifications and
Assistance for LTSS
Providers (LTSS Only)
CM-C 8: Rights and Responsibilities
QI 5U:Critical Incident Management
System (LTSS Only)
QI 9U: Critical Incident Management
System (LTSS Only)
CM-C 9: Privacy Security and
Confidentiality Procedures
RR 4: Privacy & Confidentiality
RR 5: Privacy & Confidentiality
CM-C 6: Measurement and Quality
Improvement
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Summary of Proposed Changes to
9
Global Questions for Stakeholders Participating in Public Comment
NCQA shares draft standards to generate thoughtful commentary and constructive criticism from
interested parties. Many comments lead to changes in our standards and policies, and the review process
makes our standards stronger and more worthwhile for all stakeholders. When providing feedback, NCQA
asks respondents to consider whether the requirements are feasible as written, are they clearly
articulated and what areas might need clarification.
NCQA encourages reviewers to provide insights on global issues related to the proposed LTSS and case
management updates across all of the accreditation products, including:
1. Will the proposed LTSS updates across NCQA’s accreditation programs assist your organization
in meeting its objectives? If so, how? If not, why not?
2. Are there key expectations not addressed in the proposed LTSS requirements?
3. Do the proposed requirements align with your state’s LTSS managed care efforts?
4. Will the proposed requirements assist you in identifying quality partner organizations to contract
with?
5. Consumers: Do these requirements adequately address what individuals receiving LTSS need
from organizations that are arranging their care?
Stakeholders may respond to these questions and element-specific questions for each product on
NCQA’s public comment Web site: https://ncqa.secure.force.com/publiccomments/PCLogin
The NCQA Advantage
Over the last five years, NCQA has conducted extensive research, including case studies on personcentered and integrated care practices. With the support from The SCAN Foundation and the John A.
Hartford Foundation, NCQA has engaged ten health plans and CBOs that coordinate LTSS in a learning
collaborative to pilot the draft standards. NCQA convened an expert Advisory Committee composed of a
diverse group of stakeholders representing states, consumers, CBOs, Medicaid MLTSS plans, and
research organizations to guide the development of new requirements. Throughout this process, NCQA
sought feedback from key stakeholders such as the Administration for Community Living and the National
Association of Area Agencies on Aging.
CM-LTSS Accreditation Early Adopters
Early adopters are market leaders who seek to distinguish themselves by being among the first to be
evaluated under a case management product specific for individuals needing LTSS. Early adopters are
promoted in NCQA press releases and on the NCQA Web site as part of the program launch in addition
to receiving other benefits.
Typically, early adopters undergo a survey within a specified period after launch and receive discounted
survey fees. Interested organizations must sign up before the program is launched. Information on the
launch date, pricing and discounts will be provided at a later date.
If you are interested being an early adopter, contact: CE@ncqa.org.
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Summary of Proposed Standards to CM-LTSS 2016
New Case Management for Individuals Receiving Long-Term Services
& Supports (CM-LTSS) Accreditation
Case management is a collaborative process of assessment, planning, facilitation, care coordination,
evaluation and advocacy for options and services to meet the comprehensive clinical, behavioral health
and psychosocial needs of an individual and the individual’s family, while promoting quality, cost-effective
outcomes. Although the specific definition varies among organizations, common to all definitions is the
focus on assessment, planning, monitoring and care coordination. Typically, case management programs
concentrate on patients who are at high risk of experiencing costly hospitalizations or adverse health
outcomes as a result of complex social, behavioral or clinical needs.
In 2012, NCQA launched its Case Management Accreditation program with the goal of improving how
organizations carry out care management and coordination activities. Although this program was
designed for a wide variety of organizations, the primary focus of the requirements are on clinical case
management. For case management organizations responsible for delivering LTSS, it is important to
address both clinical and non-clinical needs such as assessment of instrumental activities of daily living
and caregiver capabilities, connecting to community resources and managing care transitions. Therefore,
the proposed standards for the CM-LTSS Accreditation program will consist of existing Case
Management-Clinical Accreditation standards along with new requirements as described in the section
below.
Program Eligibility
NCQA is in the process of determining the eligible entities for this program. The following entities are
currently being considered:
Community based organizations (CBOs) that provide comprehensive case management services
and/or coordinate LTSS for eligible individuals, including:
• Area Agencies on Aging (AAA): Provide or arrange for home and community-based services to
older adults as well as people with disabilities who live independently in their local planning and
service area.
• Centers for Independent Living (CIL): Provide services and advocacy to promote leadership,
independence and productivity of people with disabilities in a non-residential setting.
• Aging and Disability Resource Centers (ADRC): Provide a single, more coordinated system of
information and access for all persons seeking long-term support to minimize confusion, enhance
individual choice and support informed decision-making.
MLTSS health plans that are only responsible for the provision of LTSS and do not coordinate
medical/behavioral health benefits.
Case Management organizations that coordinate LTSS.
Program Development to Date
NCQA convened an LTSS Advisory Committee to gain insight into the current LTSS field and to
determine the best way NCQA standards could meet the needs of individuals receiving LTSS.
In November, NCQA held a two day in-person learning collaborative meeting with the pilot organizations
to discuss the sites’ baseline assessment results, identify areas for improvement and facilitate
connections between the sites to collaborate on improvement activities. Sites used the information at the
meeting to develop improvement plans for implementation over the next year. Since the November
learning collaborative meeting, the sites have been participating in monthly calls with NCQA navigators to
discuss their process for improving their performance on select elements. Additionally, a learning
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Summary of Proposed Standards to CM-LTSS 2016
11
collaborative curriculum has been developed based on topics most requested by the pilot sites and their
choices in element improvement.
In addition, NCQA staff conducted extensive literature reviews and obtained input from the Standards
Committee, the Review Oversight Committee, the Health Plan Advisory Council and informational
interviews with key stakeholders (e.g., health plans, consumer representatives, employer
representatives).
NCQA LTSS Advisory Council
Chair: Alice Lind, RN, MHP, Washington State
Healthcare Authority
Lauren Murray, National Partnership for Women
and Families
Camille Dobson, MPA, National Association of
States United for Aging and Disabilities
Cheryl Phillips, MD, LeadingAge
Jason Rachel, PhD, Department of Medical
Patricia Kirkpatrick, MJ, RN, CPHQ, Amerigroup Assistance Services Commonwealth of Virginia
Community Care
Susan Reinhard, RN, PhD, FAAN, AARP, Public
Kristen LaEace, MBA, CAE, Indiana Association Policy Institute
of Area Agencies on Aging
Lisa Roth, MS, SCAN Health Plan
Bruce Leff, MD, Johns Hopkins University School
June Simmons, MSW, Partners in Care
of Medicine
Foundation
Rebecca May-Cole, MPA, Pennsylvania
Allicyn Wilde, JD, SEIU
Association of Area Agencies on Aging
CM-LTSS Accreditation Public Comment Feedback Instructions
NCQA seeks public comment feedback on the proposed requirements for the CM-LTSS program.
Stakeholders have the opportunity to provide varying levels of feedback, including:
• General feedback for each of the proposed program areas (e.g., Program Description).
• Element-specific feedback for each of the elements within a program area. For example,
stakeholders can provide feedback on each of the elements in Program Description.
• Targeted feedback for certain elements as noted in the “Targeted Questions” text in the sections
below.
To access the full set of questions go to NCQA’s public comment Web page:
https://ncqa.secure.force.com/publiccomments.
Select “CM-LTSS 2016” from the Products drop-down menu.
Select a Program Area (e.g., Care Transitions) from the Topic drop-down menu.
Select a specific question or element under Element.
Select a support type (e.g., support with modifications) and provide additional comments (optional).
Summary of Program Requirements
Refer to Appendix 1: Proposed Standards for CM-LTSS 2016 for the full set of proposed standards and
explanations for each of the program areas described below.
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Summary of Proposed Standards to CM-LTSS 2016
Program Description
The Program Description standard for clinical case management programs requires organizations to use
current and emerging evidence in development, ongoing review and updating of their programs. Clinically
focused programs usually use clinical practice guidelines to meet this requirement.
NCQA proposes to broaden the requirement for organizations that provide LTSS to include professional
standards (e.g., contract or state waiver requirements, standardized techniques, specialized models) as a
source used to operate their program. CBOs and plans participating in the learning collaborative indicated
that their programs and services offered are guided by state requirements rather than clinical practice
guidelines.
TARGETED QUESTION
• For the program description requirements, we have included the use of professional standards in
addition to evidence for program operations. What are examples of professional standards used for
program operations?
Assessment Process
The Comprehensive Assessment Process standards require organizations to have systematic population
and individual level assessment processes.
Comprehensive social assessments are key to optimizing the delivery of LTSS. A study on the benefit of
comprehensive geriatric assessments in hospitalized individuals found individuals who received the
assessment were more likely to be living in their homes and to have experienced improved cognition,
compared to individuals who did not receive the assessment. The individuals who received the
assessment were also less likely to have experienced death, decline or a move to a nursing home,
relative to the control group. 17
NCQA proposes to expand the existing set of social assessment areas to include initial assessment of
instrumental activities of daily living, behavioral health status, and lifestyle preferences and goals.
TARGETED QUESTION
• Does your organization’s assessment processes differ between the initial assessment and
subsequent contacts? For example, are there particular assessments that MUST take place at the
initial visit?
Person-Centered Care Planning
Person-Centered Care Planning requires organizations to coordinate services for individuals through the
development of individualized care plans.
Refer to the Person-Centered Care Planning section for additional information on the importance of this
activity.
In addition to the person-centered planning requirements incorporated in all products, NCQA proposes to
include LTSS-specific requirements for:
17http://w w w.bmj.com/content/343/bmj.d6553.long
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Development of a plan for follow-up and communication with LTSS providers. LTSS providers are
often responsible for the provision of services and supports identified in the care plan. Organizations
should work closely with these providers to facilitate seamless care delivery.
NCQA defines LTSS providers as individuals and organizations that provide paid LTSS in home-and
community-based settings.
Development of emergency back-up plans: Emergency back-up plans are used to ensure that the
individual’s care needs are met when unforeseen events occur. Emergency back-up plans should be
customized to an individual’s specific needs and services they are receiving. For example, if an individual
is dependent on a personal care attendant to get out of bed and the caregiver calls in sick or does not
show up, the emergency back-up plan should be implemented. Care plans and emergency back-up plans
should be reviewed following any critical incidents to determine their effectiveness or to remedy gaps in
care.
TARGETED QUESTION
• Are there key pieces of person-centered care planning missing from these requirements? If so, what
should NCQA consider adding?
Care Monitoring
The Care Monitoring standards require organizations to coordinate case management services for
individuals and help them access needed resources. The care monitoring requirements evaluate
adherence (via file review) to the assessment processes in the Person-Centered Care Planning Process
elements.
Similar to the LTSS-specific updates in the Person-Centered Care Planning Process, NCQA proposes to
include LTSS-specific requirements for:
• Development of a plan for follow-up and communication with LTSS providers.
• Development of emergency back-up plans.
Care Transitions
The Care Transitions standards require organizations to have a process to manage care transitions,
identify problems that could cause care transitions and prevent unplanned transitions, when possible.
NCQA proposed LTSS-specific requirements for care transitions to include:
• Process for transitions from the community that seeks to facilitate safe transitions to other
settings (e.g., nursing homes, hospitals) by communicating with the individual’s usual provider and
the receiving setting and tracking the status of the transition.
• Process for transitions back to the community that seeks to facilitate safe transitions back to
the community by communicating with the individual’s usual provider, collaborating with the
discharge team and reassessing the care plan to make necessary modifications.
For additional information on the importance of care transitions, refer to the Care Transitions.
TARGETED QUESTION
• After identifying an individual is at elevated risk for a transition, what steps would organizations
eligible for CM-LTSS take to mitigate risk?
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Summary of Proposed Standards to CM-LTSS 2016
Measurement and Quality Improvement
The Measurement and Quality Improvement standards require organizations to at least annually:
• Measure individual experience with the program through surveys and analysis of complaints.
• Measure the effectiveness of the program by using at least three process or outcome measures.
• Implement interventions to improve individual experience and program performance.
Staffing, Training and Verification
The Staffing, Training and Verification standards require organizations to define staffing needs, provide
staff with ongoing training and oversight and verify health care staff credentials.
NCQA proposes to include LTSS-specific requirements for qualifications and assistance for LTSS
providers in addition to the set of requirements currently applied to clinical case management programs.
The requirement calls for organizations to define qualifications necessary for LTSS providers, to conduct
background checks along with using an additional screening tool (e.g., reference check) and to provide
training assistance (e.g., training on how to handle difficult behaviors).
For additional information on the importance of setting qualifications for non-licensed providers, refer to
the Qualifications for LTSS Providers.
TARGETED QUESTIONS
• Should NCQA require periodic reassessment of background checks on LTSS providers? If so, at
what frequency?
• What other assistance does your organization provide to LTSS providers to support them in
delivering care?
Rights and Responsibilities
The Rights and Responsibilities standards require organizations to communicate their commitment to the
rights of individuals and their expectations of individuals’ responsibilities.
NCQA proposes to include LTSS-specific requirements for critical incident management systems in
addition to the current set of standards for clinical case management programs. The element requires
organizations to have a critical incident management system to track critical incidents, prompt
investigations and implement appropriate interventions.
For additional information on the importance of critical incident management systems, refer to the Critical
Incident Management System.
Privacy, Security and Confidentiality Procedures
The Privacy, Security and Confidentiality Procedures standards require organizations to protect the
privacy of individuals’ health information by keeping information safe from inappropriate release or
disclosure by having:
• A process to annually review and update its confidentiality policies and procedures.
• A process to train employees about how to safely access protected health information (PHI).
• Providing information to individuals receiving case management services about how their health
information will be used.
NCQA recommends aligning these requirements with those for clinical case management programs.
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Case Management-Clinical Accreditation (CM-C) 2017
NCQA is proposing updates to its existing Case Management-Clinical Accreditation (CM-C) program to
put even greater emphasis on care coordination and patient-centeredness. These updates will apply to all
organizations seeking CM-C Accreditation or those that will renew their existing accreditation starting July
2017.
Program Eligibility
Many different types of organizations perform case management functions. NCQA considers entities that
perform relevant functions to be eligible for NCQA CM-C Accreditation, including, but not limited to:
• CM organizations.
• Population health management organizations.
• Health plans.
• Managed behavioral healthcare organizations (MBHO)
• Provider-based organizations, including medical groups, hospitals, integrated delivery systems,
patient-centered medical homes (PCMH) and accountable care organizations (ACO).
• Community care teams.
Proposed Updates
Refer to Appendix 2: Proposed Standards Updates to CM-C 2017 for the full list of updated standards
and explanations
CM 1A: Program Description
Requires organizations to describe their case management program, including its evidence base, and
reviews and adopts new findings that are relevant to its program as they become available.
Update:
• Updated factor 3 to include “professional standards” along with evidence for program operations. In
some situations, states determine what services the program will provide, which limits the
organizations’ control over program development. However, organizations can use evidence and
professional standards to support the structure of program operations.
• Added a new factor 5 to require organizations to identify how they coordinate case management
services with the services provided by others involved in the patient’s care. Documenting a policy for
coordinating care and disseminating it to staff is critically important for patients in case management
programs who often receive services through multiple programs.
CM 2C: Frequency of Patient Identification
Requires organizations to systematically identify patients who qualify for case management.
Update:
• Retire element. This requirement was retired from NCQA’s Special Needs Structure and Process
measures for individuals eligible for Medicare and Medicaid and was removed because of the high
performance on this element.
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Summary of Proposed Changes to CM-C 2017
CM 2C/D: Comprehensive Assessment Process & Implementation
Requires organizations to have a process for performing an assessment of patients’ key indicators of
health status and care needs (Element C) and to demonstrate adherence to the process via file review
(Element D).
Update:
• Added factors to require initial assessment of instrumental activities of daily living, behavioral health
status, and lifestyle preferences and goals. Comprehensive social assessments, inclusive of social
aspects of care, are critical to optimizing overall care and services to patients receiving case
management services.
CM 3A: Person-Centered Care Planning Process
Requires the organization’s care planning process to address certain areas such as development of
individualized care management plan, identification of barriers and development of a follow-up schedule
and communication of patient self-management goals among other activities.
Update:
• Revised the title of the element to reflect the importance of embedding person-centered principles into
the care planning process.
• Revised factors 1 and 2 to emphasize the importance and integration of the patient’s goals in the care
planning process.
CM 5: Care Transitions
Requires organizations to have a process to manage care transitions, identify problems that could cause
transitions and prevent unplanned transitions, when possible.
Update:
• Reorganized the existing care transition elements to more clearly distinguish and outline activities
related to discharge planning, which is instrumental to avoiding readmissions. The proposed set of
requirements for discharge planning apply to discharges from any setting, not just hospitals.
CM 9: Privacy, Security and Confidentiality Procedures
Requires organizations to have processes to protect the privacy of patients’ health information.
Update:
• Retire the following elements:
– Element A: Written Process.
– Element B: Physical and Electronic Access.
– Element C: Accountability and Responsibility.
The elements proposed for retirement are generally duplicative of the minimum requirements of HIPAA
and their assessment is not necessary as part of the Case Management Accreditation evaluation. NCQA
recommends retiring the equivalent elements in Health Plan Accreditation. Refer to RR 4: Privacy &
Confidentiality
QUESTION FOR CONSIDERATION
• Should NCQA have a separate accreditation program for organizations providing LTSS?
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Health Plan Accreditation (HPA) 2017
General Complex Case Management Updates (QI 5)
The proposed updates are aligned with the general updates proposed for the Case Management
Accreditation Clinical (CM-C) program. The intent of these updates is to put greater emphasis on care
coordination and patient-centeredness. The proposed updates will apply to all product lines brought
forward for Accreditation.
Element 5C: Identifying Members for Case Management
Requires organizations to use multiple data sources to identify members for complex case management.
Update:
• Added a factor to require the use of lab data to identify members for complex case management.
• Collapsed the use of data from practitioners into a new requirement for using electronic clinical systems
data. Collapsed the use of data from members and caregivers into data from health appraisals or risk
appraisal/scoring tool.
– These data sources provide important and useful information to help identify members who may
need complex case management services.
– These updates align with the current requirements in Case Management-Clinical Accreditation.
Elements 5F/G: Comprehensive Assessment Process and Implementation
Requires organizations to have a process for performing an assessment of members’ k ey indicators of
health status and care needs (Element F) and to demonstrate adherence to the process via a file review
(Element G).
Note: The factors included derived from the element previously called “Case Management Process” and
“Initial Assessment.” Some factors from “Case Management Process” have been moved into a new
element: “Person-Centered Care Planning Process.”
Update:
• Added factors to require initial assessment of instrumental activities of daily living, cognitive functions,
behavioral health status, and lifestyle preferences and goals. These updates emphasize social aspects
of care important to members receiving case management services.
NEW Care Transitions Requirements
•
•
•
•
•
•
•
Element M: Process for Transitions from the Community.
Element N: Process for Transitions Back to the Community.
Element O: Process for Transitions Between Settings
Element P: Process for Follow-Up After Discharge
Element Q: Support for Members During Transitions
Element R: Reducing Unplanned Transitions for Members
Element S: Reducing Unplanned Transitions for the Population
Similarly to the care transitions requirements in Case Management Clinical Accreditation, NCQA
recommends requiring health plans to establish a process for care transitions between settings and
following-up with members after discharge. Plans will also be expected to support members during
transitions and to implement activities aimed at reducing unplanned transitions.
For additional information on the importance of care transitions, refer to Care Transitions.
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Summary of Proposed Changes to HPA 2017
Requirements Specific to Comprehensive Medicaid MLTSS Plans (QI 5)
As of October 2015, 18 states had MLTSS programs and at least nine were planning to implement or
expand their MLTSS programs. 18 Some MLTSS plans are responsible solely for LTSS, while clinical care
is delivered through separate MCOs or other arrangements. Other MLTSS plans are comprehensive
MCOs, with responsibility for both clinical care and LTSS. NCQA is proposing updates to the existing
requirements in QI 5: Complex Case Management to evaluate the non-clinical components of care
management provided by comprehensive MLTSS plans. The updated standards will provide health
plans with a roadmap for integrating LTSS functions into their operations. In turn, this may increase
states’ comfort level with contracting with these plans. Many of the proposed updates are similar to the
non-clinical requirements in the CM-LTSS program.
Refer to Appendix 3: Proposed Standards Updates to HPA 2017 for full set of updated standards and
explanations.
Elements F/G: Comprehensive Assessment Process and Implementation
Requires organizations to have a process for performing an assessment of members’ k ey indicators of
health status and care needs (Element F) and to demonstrate adherence to the process via a file review
(Element G).
Update:
• Added factor 16 (initial assessment of the member’s physical environment for risk), which applies only
to comprehensive MLTSS plans.
– Because organizations that provide LTSS have direct contact with members in their home, they can
play a key role in assessing physical environmental risks, which can prevent avoidable harm and
hospitalizations.
Element H/I: Person-Centered Care Planning Process/Ongoing Case Management
Implementation
Requires organizations to have procedures to address development of case management plans,
identification of barriers, and ways to measure progress against goals set in in the care plan among other
activities (Element H). Adherence is assessed via a file review (Element I).
Update:
• Added factor 5 (development of a plan for follow-up and communication with usual providers), which
applies only to comprehensive MLTSS plans.
• Added factor 6 (development of emergency back-up plans), which applies only to comprehensive
MLTSS plans.
Care Transitions
Elements applicable only to comprehensive Medicaid MLTSS plans
• Element M: Process for Transitions From the Community
• Element N: Process for Transitions Back to the Community
Elements applicable to all product lines, including comprehensive Medicaid MLTSS plans
• Element O: Process for Transitions Between Settings
• Element P: Process for Follow-Up After Discharge
18
https://w ww.openminds.com/dow nloads/w hich-states-provide-medicaid-long-ter m-services-supports-throughmanaged-care-an-open-minds-market- intelligence-report/
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• Element Q: Support for Members During Transitions
• Element R: Reducing Unplanned Transitions for Members
• Element S: Reducing Unplanned Transitions for the Population
Similar to the care transition requirements proposed for all product lines in the section above, NCQA
recommends requiring comprehensive MLTSS plans to also manage care transitions. Element M:
Process for Transitions From the Community and Element N: Process for Transitions Back to the
Community apply only to comprehensive MLTSS plans to put emphasis on developing processes that
focus specifically on transitions from and back to the community. The direction of the transition calls for
different set of activates, therefore, it is important to make these activities transparent so that
organizations can focus their improvement activities in the areas where they might be facing challenges.
For additional information on the importance of care transitions, refer to Care Transitions.
Element T: Qualifications and Assistance for LTSS Providers
NCQA proposes adding an element to require comprehensive MLTSS plans to verify LTSS providers’
qualifications via background checks and at least one other screening tool.
For additional information on the importance of vetting LTSS providers, refer to Qualifications for LTSS
Providers.
Element U: Critical Incident Management System
NCQA recommends adding an element to require comprehensive MLTSS plans to use a critical incident
management system to facilitate timely response to critical incidents and to protect members receiving
LTSS when an adverse event takes place.
For additional information on the importance of critical incident management systems, refer to Critical
Incident Management System.
Additional HPA 2017 Updates
Proposed Requirements for Retirement
In addition to changes related to complex case management and MLTSS for HPA 2017, NCQA is
proposing to retire several standards due to shift in member needs or changes in how care is being
delivered. Overall, retiring the standards/elements/factors proposed would free plans to redeploy their
resources to other value-added activities and allow NCQA to put more weight (i.e., points) on
requirements that remain. Retiring all recommended requirements would free up approximately 3.45 (out
of 50) Renewal points. 19
To develop the proposed recommendations, NCQA conducted literature reviews to identify best practices
and evidence to support the proposed updates; analyzed health plan submission data to understand how
plans are currently meeting the intent of the requirements; sought feedback from Standards Committee,
the Review Oversight Committee, the Health Plan Advisory Council and the Accreditation and
Certification Users Group (ACUG).
Refer to Appendix 3: Proposed Standards Updates to HPA 2017 for full set of updated standards and
explanations.
19
Elements are assigned different point values depending on the Evaluation Option (i.e., Interim, First and Renew al)
a plan is being surveyed. Point values differ because not all elements apply to each of the Evaluation Options. The
Renew al Evaluation Option has the greatest number of applicable elements.
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Summary of Proposed Changes to HPA 2017
QI 2: Program Operations
Element B: Informing Members and Practitioners, factor 2
Requires plans to make information about the QI program processes, goals and outcomes annually
available to members (factor 1) and practitioners (factor 2).
• Plans have indicated that this activity is not necessary because physicians know where to locate the
information.
QI 7: Practice Guidelines
Element A: Adoption and Distribution of Guidelines, factor 3 and Element B: Adoption and
Distribution of PH Guidelines, factor 3
Requires plans to distribute evidence-based preventive health guidelines to the appropriate practitioners.
• The distribution of guidelines is an interim step in the process of using guidelines to reduce practice
pattern variation.
• For First Surveys, NCQA assesses adherence to the guidelines in Element D: Performance
Measurement and via HEDIS for Renewal Surveys.
• Health plans have indicated that there is a lack of evidence demonstrating that the distributing of
practice guidelines from plans to practitioners reduces practice variation and improves outcomes.
UM 11: Emergency Services
Requires plans to cover emergency services when emergency medical condition exists as determined by
prudent layperson or when authorized by organization representative.
• This requirement overlaps with state laws for health plans to cover emergency care when an
emergency medical condition exist.
CR 5: Practitioner Office Site Quality
Requires plans to set physician office site performance standards and thresholds, monitor complaints and
conduct office site visits when complaint threshold is met then take corrective action to address concerns,
if needed.
• Federal and state regulations provide better oversight and are a better enforcement mechanism for
practitioner office issues consumers might face. For example, the Americans with Disabilities Act
(ADA) 20 defines health care provider’s offices as public accommodations that need to be accessible to
individuals with disabilities.
• The U.S. Equal Employment Opportunity Commission enforces the ADA. The Department of Justice
may file lawsuits in federal court to enforce the ADA.
• The Medicare Managed Care Manual, Chapter 6: Relationship with Providers 21 requires MA plans to
conduct a practitioner office site visit and identify corrective actions when they are made aware that
there are safety and access issues.
• Complaints related to office site quality will continued to be captured and evaluated via QI 4: Member
Experience, Element C: Annual Assessment.
• Element D: Opportunity for Improvement requires plans to identify opportunities for improvement, which
could include office site quality.
20http://w w w.ada.gov/pubs/adastatute08.htm
21https://w ww.cms.gov/Regulations-and-Guidance/Guidance/Manuals/dow nloads/mc86c06.pdf
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CR 7: Notification to Authorities and Practitioner Appeal Rights
Element B: Reporting to Appropriate Authorities
Requires plans to notify authority if action is taken against a practitioner.
Element C: Practitioner Appeal Process
Requires plans to have a well-defined and communicated appeal process for the practitioners.
• Both elements overlap with existing regulations.
– For Element B, the Healthcare Quality Improvement Act (HCQIA) and the National Practitioner Data
Bank (NPDB) regulation requires health plans to notify the authorities if an action is taken against a
practitioner. In addition to these regulations, states may have their own regulations regarding
reporting to licensing authorities. These regulations better cover and enforce the requirement.
– Element C tracks the notice and fair hearing process under HCQIA for professional review actions
against physicians.
NCQA recommends maintaining Element A: Actions Against Practitioners to allow the ability to contact
organizations in the event that a practitioner has a complaint about not being notified of their rights.
RR 4: Privacy & Confidentiality
Element A: Adopting Written Policies
Requires plans to adopt policies and procedures address privacy and personal health information.
This requirement duplicates the minimum requirements of HIPAA and communication to members is
better assessed in Element E, which will be retained.
Element B: Physical and Electronic Access
Requires plans to have a process for managing access to sensitive information.
This requirement is better assessed under HIPAA, which allows health plans to implement appropriate
measures based on risk assessment for their organization.
The HIPAA requirements allow the health plan to determine the appropriate actions for their organization
structure and result in more robust enforcement of compliance.
Element C: Protections for PHI Sent to Plan Sponsors
Requires plans to prohibit sharing of member PHI with plan sponsor or other entities without member
consent.
This requirement is more completely covered and enforced under HIPAA Section 164.504(f), which
includes specific rules for health plans sharing PHI with plan sponsors and has specific requirements that
go beyond Element C.
Element D: Authorization
Requires plans to have a policy for member authorization for use of PHI.
This requirement is a mandated aspect of HIPAA under Section 164.508 and there is a model
Authorization form under HIPAA that must organization will follow to satisfy the elements of authorization.
Element F: Accountability and Responsibility
Requires plans to define impermissible use of sensitive information and report use.
This requirement is a mandated aspect of HIPAA under Section 164.308(a)(5), which requires a covered
entity to implement a security awareness and training program for all members of its workforce (including
management).
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Summary of Proposed Changes to HPA 2017
MEM 7: Health Information Line
Requires plans to have a 24/7 health information telephone line staffed by appropriate professionals and
to monitor and evaluate use of the line.
The health information line requirement 22 was implemented in HPA a decade ago with the intent of
reducing emergency department and urgent care visits, especially for members needing after-hours
medical care. Changes in delivery of care and alternative payment models—particularly the emergence of
patient centered medical homes and accountable care organizations—as well as technological advances
such as telemedicine, offer more effective ways to support members in this area. Retiring the health
information line requirement will allow organizations to invest their resources in other types of solutions
that better serve their members’ needs.
Health plans have expressed mixed feedback regarding benefits and return on investment of their health
information lines. The primary concern many plans share is low member utilization rate coupled with high
cost to maintain the service. Integrated care systems, such as Kaiser Permanente, indicated that their
health information line is an integral part of their care delivery model and has significant benefits to
members.
There are a number of requirements in HPA that offer member protections related to after-hours care,
including:
• RR 2: Subscriber Information, which requires organizations to provide members information about
how to obtain primary care services, case after normal hours and emergency care.
• NET 2A: Access to Primary Care, which requires organizations to set standards, collect data and
perform an annual analysis of access to after-hours primary care.
Overall, retiring the requirement from HPA will not prevent and should not discourage plans from
continuing to offer a health information line to their members.
MEM 8: Support for Healthy Living, Element C: Encouraging Member Health
Requires organizations to offer incentives to members for completing comprehensive health
assessments, accessing guideline-specific appropriate care and using disease-specific, web-based tools.
Plans are not required to provide incentives and may report NA; many plans do report NA. Evidence
around effectiveness of plan incentive is mixed. Removing this requirement allows plans to determine
best practices for their members regarding incentives.
Other HPA Standard Updates
NCQA also proposes updates to NET 4, Element C: Marketplace Member Experience.
Member Experience with Behavioral Health
NCQA recommends evaluating member experience with behavioral health for the Marketplace product
line in NET 4. This update will streamline the analysis of member experience with the Marketplace
product line in the same element and improves the surveyability of the requirement.
Currently, the assessment of member experience with the Marketplace product line is split across two
standards: QI 4 and NET 4.
• Experience with medical services is included in NET 4C, Marketplace Member Experience.
• Member experience with behavioral health care services is included in QI 4, Element E: Annual
Assessment of Behavioral Healthcare and Services and QI 4, Element F: Behavioral Healthcare
Opportunities for Improvement.
22
Also referred to as “nurse advice line.”
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QHP Enrollee Experience Survey
NCQA proposes to update NET 4, Element C: Mark etplace Member Experience to include analysis of
QHP Enrollee Experience Survey results. This update would require splitting the element into two
separate elements: Element C: Marketplace Member Experience and Element D: Marketplace Member
Experience Opportunities for Improvement. This update will align expectations for all product lines.
Analysis of CAHPS results are required in the assessment of member experience for the commercial,
Medicare and Medicaid product lines. Marketplace plans are required to conduct a QHP Enrollee
Experience Survey in order to be offered as a qualified healthcare plan and to maintain their NCQA
Accreditation.
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Summary of Proposed Changes to MBHO 2017
Managed Behavioral Healthcare Organization (MBHO) 2017
General Complex Case Management Updates (QI 9)
NCQA proposes to carry over the proposed updates to the general complex case management
requirements in HPA to MBHOs, including:
• Element B: Program Description
• Element C: Identifying Members for Case Management
• Element F/G: Comprehensive Assessment Process & Implementation
• Element H/I: Person-Centered Care Planning Process & Ongoing Case Management
Implementation
• Care Transitions related elements
• Element T: Qualification and Assistance for LTSS Providers
• Element U: Critical Incident Management System
For a summary of updates, reference General Complex Case Management Updates (QI 5)
Refer to Appendix 4: Proposed Standards Updates to MBHO 2017 for full set of updated standards and
explanations.
Requirements Specific to Medicaid MLTSS MBHOs (QI 9)
Similar to the proposed updates for comprehensive Medicaid MLTSS plans in HPA, NCQA recommends
implementing the same requirements for MBHOs responsible for administering both behavioral health
and LTSS benefits. For summary of updates, reference Requirements Specific to Comprehensive
Medicaid MLTSS Plans (QI 5)
Additional MBHO 2017 Updates
In addition to changes related to complex case management and MLTSS for MBHO 2017, NCQA is
proposing to retire several standards due to shift in member needs or changes in how care is being
delivered. These updates are aligned with the proposed elements for retirement from HPA.
QI 2: Program Operations, Element B: Informing Members and Practitioners, factor 2
Requires plans to make information about the QI program processes, goals and outcomes annually
available to members (factor 1) and practitioners (factor 2).
Plans have indicated that this activity is not necessary because physicians know where to locate the
information.
QI 10: Clinical Practice Guidelines
Element A: Adopting Relevant Guidelines, factor 3
Requires plans to distribute evidence-based preventive health guidelines to the appropriate practitioners.
The distribution of guidelines is an interim step in the process of using guidelines to reduce practice
pattern variation. NCQA assesses adherence to the guidelines in Element B: Performance Measurement.
MBHOs have indicated that there is a lack of evidence demonstrating that distribution of practice
guidelines from plans to practitioners reduces practice variation and improves outcomes.
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UM 11: Emergency Services
Requires plans to cover emergency services when emergency medical condition exists as determined by
prudent layperson or when authorized by an organization representative.
This requirement overlaps with state laws regarding coverage of emergency care when an emergency
medical condition exist.
CR 5: Practitioner Office Site Quality
Requires plans to set physician office site performance standards and thresholds, monitor complaints and
conduct office site visits when complaint threshold is met then take corrective action to address concerns,
if needed.
Federal and state regulations provide better oversight and are a better enforcement mechanism for
practitioner office issues consumers might face. For example, the Americans with Disabilities Act (ADA) 23
defines health care provider’s offices as public accommodations that need to be accessible to individuals
with disabilities. The U.S. Equal Employment Opportunity Commission enforces the ADA. The
Department of Justice may file lawsuits in federal court to enforce the ADA. The Medicare Managed Care
Manual, Chapter 6: Relationship with Providers 24 requires MA plans to conduct a practitioner office site
visit and identify corrective actions when they are made aware that there are safety and access issues.
Complaints related to office site quality will continue to be captured and evaluated via QI 6: Member
Experience, Element A: Annual Assessment. Element C: Improvement Activities requires organizations to
identify opportunities for improvement, which could include office site quality.
CR 7: Notification to Authorities and Practitioner Appeal Rights
Element B: Reporting to Appropriate Authorities
Requires MBHOs to notify authorities if action is taken against a practitioner.
Element C: Practitioner Appeal Process
Requires MBHOs to have a well-defined and communicated appeal process for the practitioners.
Both elements overlap with existing regulation. For Element B, the Healthcare Quality Improvement Act
(HCQIA) and the National Practitioner Data Bank (NPDB) regulation requires organizations to notify the
authorities if an action is taken against a practitioner. In addition to these regulations, states may have
their own regulations regarding reporting to licensing authorities. These regulations better cover and
enforce the requirement. Element C tracks the notice and fair hearing process under HCQIA for
professional review actions against physicians.
NCQA recommends maintaining Element A: Actions Against Practitioners to allow the ability to contact
organizations in the event that a practitioner has a complaint about not being notified of their rights.
RR 5: Privacy & Confidentiality
Element A: Adopting Written Policies
Requires plans to adopt policies and procedures address privacy and personal health information.
This requirement is duplicative of the minimum requirements of HIPAA and communication to members is
better assessed in Element E, which will be retained.
23http://w w w.ada.gov/pubs/adastatute08.htm
24https://w ww.cms.gov/Regulations-and-Guidance/Guidance/Manuals/dow nloads/mc86c06.pdf
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Summary of Proposed Changes to MBHO 2017
Element B: Physical and Electronic Access
Requires plans to have a process for managing access to sensitive information.
This requirement is better assessed under HIPAA, which allows MBHOs to implement appropriate
measures based on risk assessment for their organization. The HIPAA requirements allow the
organization to determine the appropriate actions for their organization structure and result in more robust
enforcement of compliance.
Element C: Protections for PHI Sent to Plan Sponsors
Requires plans to prohibit sharing of member PHI with plan sponsor or other entities without member
consent.
This requirement is more completely covered and enforced under HIPAA Section 164.504(f), which
includes specific rules for MBHOs sharing PHI with plan sponsors and has specific requirements that go
beyond Element C.
Element D: Authorization
Requires plans to have a policy for member authorization for use of PHI.
This requirement is a mandated aspect of HIPAA under Section 164.508 and there is a model
Authorization form under HIPAA that organizations must follow to satisfy the elements of authorization.
Element F: Accountability and Responsibility
Requires plans to define impermissible use of sensitive information and report use.
This requirement is a mandated aspect of HIPAA under Section 164.308(a)(5) which requires a covered
entity to implement a security awareness and training program for all members of its workforce (including
management).
© 2016 National Committee for Quality Assurance
Obsolete After March 23, 2016
Public Comment Instructions
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Public Comment Instructions
Public Comment Questions
Public Comment is integral to the development of all NCQA standards and measures. NCQA actively
seeks thoughtful commentary and constructive criticism from interested parties, and considers all
suggestions. Many comments lead to changes in our standards and policies and the review process
makes our standards stronger and more worthwhile for all stakeholders.
Documents
Draft standards and explanations for all product updates can be found in the materials below:
• Appendix 1: Proposed Standards for CM-LTSS 2016 provides the full set of proposed standards
and explanations.
• Appendix 2: Proposed Standards Updates to CM-C 2017 provides only updated standards and
explanations.
• Appendix 3: Proposed Standards Updates to HPA 2017 provides only updated standards and
explanations.
• Appendix 4: Proposed Standards Updates to MBHO 2017 provides only updated standards and
explanations.
Submitting Comments
Submit all comments through NCQA’s Public Comment Web site (http://publiccomments.ncqa.org).
NCQA does not accept comments via mail, e-mail or fax.
All comments are due by 5 p.m. (ET) on Wednesday, March 23.
To enter comments:
1. Go to the Public Comment database.
2. Enter your e-mail address and contact information.
3. Select one of the following:
• Global Accreditation Products Updates Questions
• 2016 Case Management for Individuals Receiving Long-Term Services and Supports
Accreditation (CM-LTSS)
• 2017 Case Management-Clinical Accreditation (CM-C)
• 2017 Health Plan Accreditation (HPA)
• 2017 Managed Behavioral Healthcare Organization Accreditation (MBHO)
4. Click on the Instructions link to the view public comment materials including instructions,
proposed specifications and measures.
5. Select the Topic and Element (i.e., question) on which you would like to comment.
6. Select your support option (i.e., Support, Do not support, Support with modifications).
If you choose Do not support, include your rationale in the text box. If you choose Support with
modifications, enter the suggested modification in the text box.
© 2016 National Committee for Quality Assurance
Obsolete After March 23, 2016
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Public Comment Instructions
7. Enter your comments in the Comments box.
Note: There is a 2,500 character limit for each comment. Be concise in your feedback. We
suggest you develop your comments in Word to check your character limit, and save a copy for
reference. Use the “cut and paste” function to copy your comment into the Comments box.
8. If you are submitting more than one comment use the Submit and Return button. When you have
submitted all comments use the Submit and Logout button to receive an e-mail notification with all
submitted comments.
All comments are due Wednesday, March 23, by 5:00 p.m. ET.
Next Steps
The final Standards and Guidelines for HPA 2017, MBHO 2017, CM-C 2017 and CM-LTSS 2016 will be
released in July 2016, following approval by the NCQA Standards Committee and the Board of Directors.
Requirements for HPA 2017, MBHO 2017 and CM-C 2017 take effect July 1, 2017.
Requirements for CM-LTSS 2016 take effect July 25, 2016.
Organizations coming forward for accreditation after these dates must meet the new requirements.
© 2016 National Committee for Quality Assurance
Obsolete After March 23, 2016