COMPREHENSIVE TECHNICAL REPORT FOR ......Medicare & Medicaid Services (CMS) Protocol, “External Quality Review Protocol for Accessing Compliance with Medicaid Managed Care Regulation,”

South Carolina External

Quality Review

COMPREHENSIVE TECHNICAL REPORT FOR CONTRACT YEAR ’19–20

Submitted: August 26, 2020

Prepared on behalf of the South Carolina Department

of Health and Human Services

Table of Contents

Comprehensive Technical Report for Contract Year ’19–20 | August 26, 2020

EXECUTIVE SUMMARY ........................................................................................................ 3 Overall Findings .................................................................................................................... 3 Overall Scoring ................................................................................................................... 20

Coordinated and Integrated Care Organizations Annual Review ......................................... 21 BACKGROUND ..................................................................................................................... 24 METHODOLOGY .................................................................................................................. 24 FINDINGS ............................................................................................................................. 25

A. Administration ............................................................................................................... 25 Information Systems Capabilities Assessment ............................................................... 26 Strengths .......................................................................................................... 31

B. Provider Services............................................................................................................. 31 Provider Access and Availability Study ....................................................................... 34 Strengths .......................................................................................................... 48 Weaknesses ....................................................................................................... 48 Recommendations................................................................................................ 49

C. Member Services ............................................................................................................ 49 Strengths .......................................................................................................... 57 Weaknesses ....................................................................................................... 57 Recommendations................................................................................................ 57

D. Quality Improvement ..................................................................................................... 58 Performance Measure Validation .............................................................................. 58 Performance Improvement Project Validation .............................................................. 74 Strengths .......................................................................................................... 78 Weaknesses ....................................................................................................... 78 Recommendations................................................................................................ 78

E. Utilization Management ................................................................................................ 78 Strengths .......................................................................................................... 87 Weaknesses ....................................................................................................... 87 Recommendations................................................................................................ 87

F. Delegation ...................................................................................................................... 88 Strengths .......................................................................................................... 89 Weaknesses ....................................................................................................... 89

G. State-Mandated Services ............................................................................................... 89 Weaknesses ....................................................................................................... 91 Recommendations................................................................................................ 91

H. South Carolina Solutions ................................................................................................ 91 Strengths .......................................................................................................... 98 Weaknesses ....................................................................................................... 99 Recommendations................................................................................................ 99

I. Coordinated and Integrated Care Organizations Annual Review ............................... 100 Strengths ........................................................................................................ 105 Weaknesses ..................................................................................................... 105 Recommendations.............................................................................................. 106

FINDINGS SUMMARY ....................................................................................................... 106

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2019–2020 External Quality Review


EXECUTIVE SUMMARY The Balanced Budget Act of 1997 (BBA) requires each State Medicaid Agency that contracts with Managed Care Organizations (MCOs) to evaluate compliance with state and federal regulations in accordance with 42 Code of Federal Regulations (CFR) 438.358. To meet this requirement, the South Carolina Department of Health and Human Services (SCDHHS) executed a contract with The Carolinas Center for Medical Excellence (CCME), an External Quality Review Organization (EQRO), to conduct an External Quality Review (EQR) for all MCOs participating in the Healthy Connections Choices and Healthy Connections Prime Programs.

The EQR ensures that Medicaid members receive quality health care through a system that promotes timeliness, accessibility, and coordination of all services. CCME conducted three mandatory activities: validation of performance improvement projects (PIPs), validation of performance measures (PMs), and evaluation of compliance with state and federal regulations for each health plan. This report is a compilation of the 2019-2020 individual annual review findings for:

• Select Health of South Carolina (Select Health)

• Absolute Total Care (ATC)

• Healthy Blue

• Molina Healthcare of South Carolina (Molina)

• WellCare of South Carolina (WellCare)

• SC Solutions (Solutions)

Overall Findings

An overview of the findings for each section follows. Additional information regarding the reviews, including strengths, weaknesses, and recommendations, are included in the narrative of this report.

Administration All key leadership positions are filled, and each of the MCOs has adequate staffing in place to conduct activities required by their contracts with SCDHHS. Although there were a few vacant positions, the MCOs reported recruiting activities were underway to fill the positions.

Appropriate policy management processes are in place. The MCOs review policies at least annually and revise when needed. Staff can access policies on shared drives or in policy management platforms, and they are advised of new or revised policies.

Comprehensive Compliance and Program Integrity programs have been established and are overseen by the MCO Compliance Officers and Compliance Committees. CCME noted some inconsistencies in documentation of Compliance Committee membership and unclear documentation of Compliance Committee quorums.

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Program documentation includes expectations for employee conduct and processes to guard against fraud, waste, and abuse (FWA), and all employees must complete compliance training at employment and annually thereafter. Staff receive compliance information via publications such as employee handbooks, policies, and office posters. The MCOs maintain an “open-door” culture and employ policies prohibiting retaliation against those who report actual or suspected Compliance or FWA violations.

Each of the MCOs has policies specifying requirements and processes for the contractually required Pharmacy Lock-in Program.

The review of each of the MCOs included an assessment of their Information Management Systems. These reviews confirmed the MCOs are able to perform the required Medicaid information and data processing activities. The MCOs have focused on managing data and resources in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and to mitigate business interruptions and reestablish operations in case of disruption. All of the MCOs met or exceed the contractual requirements for claims payments at 30 days and 90 days.

Provider Services CCME noted issues in MCO policies and other documentation related to provider credentialing and recredentialing. Healthy Blue’s process for ensuring all network providers are enrolled with SCDHHS as Qualified Medicaid Providers was not documented. Healthy Blue and Molina had errors in and/or a lack of documentation of the timeframe for processing credentialing and recredentialing applications. WellCare policy omits performing federal and state database checks for persons identified on Ownership Disclosure forms with an ownership or controlling interest.

MCO credentialing committees include members that are both clinical and nonclinical applicant peers, meet at routine intervals, and ensure establishment of a quorum before decisions are made. CCME noted significant issues in credentialing and recredentialing files, including lack of evidence of required queries, incomplete credentialing applications, failure to collect copies of some required documents, outdated documentation, and failure to complete primary source verification within the required timeframes.

Health plan policies define standards for network availability/provider access and processes for evaluating and monitoring the networks. Issues noted included incorrect or omitted appointment timeframes, particularly related to specialist care and behavioral health care.

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The MCOs monitor network adequacy using a variety of methods. Documentation revealed some Status 1 providers are not included in monitoring activities and/or identified network gaps are not included in network adequacy work plans.

Provider education is conducted for all newly contracted providers, and each plan maintains provider educational resources and reference materials on its website. The MCOs have adopted preventive health and clinical practice guidelines. Information about the guidelines is available to network providers on the plans’ websites, in provider manuals, and via other sources.

As a part of the annual review process for all the plans, CCME performed a Telephonic Provider Access Study focusing on primary care providers (PCPs). Each of the MCOs received a score of “Met” for the standard requiring an improvement in the results of the Telephonic Provider Access Study, with statistically significant improvement in successfully answered calls occurring for all five plans.

Member Services The health plans have policies and other documents that define and describe Member Services requirements. Member handbooks, educational materials, newsletters, and health plan websites are primary modes of communicating information about member benefits, services, rights and responsibilities, health education, and grievance processes and requirements. Additionally, members can speak with Member Services staff at the call centers and the 24-hour nurse advice lines to receive information, address concerns, or make requests.

Processes are in place to educate new and established members about the health plans, available services, and accessing those services. CCME identified an overall shift from mass mailings of member materials, such as Member Handbooks and newsletters, to electronic documents posted on the plans’ websites.

CCME noted issues related to documentation and handling of member grievances, as well as minor issues with documentation of member benefits and services. MCOs conduct the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys annually via a third-party vendor and survey response rates continue to fall below the National Committee for Quality Assurance target response rate of 40%. CCME provided recommendations to address identified issues.

Quality Improvement Quality Improvement (QI) program descriptions adequately described the programs the health plans have implemented to monitor, evaluate, and improve the quality of clinical care and services provided to their members. The MCOs review and update program descriptions at least annually.

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The work plans help guide and monitor activities planned for the year. The health plans provided their QI work plans for review, and each work plan identified specific activities, responsible parties, and dates for completion. Some of the issues identified in the work plans submitted by Healthy Blue, Molina, Select Health, and WellCare included incorrect dates, omission of ongoing monitoring activities, and errors or missing benchmarks and goals.

All health plans have established committees responsible for implementing, monitoring, and directing QI activities. Membership includes a variety of network providers, senior executives, directors, and other health plan staff. Most of the committees met at least quarterly. Minutes document committee discussion points and decisions and are recorded for each meeting.

The health plans conducted an evaluation of the effectiveness of the QI programs and provided copies of their program evaluations. Program evaluations included the QI activities conducted in the previous year, results of those activities, any barriers identified, interventions, and recommendations. Molina’s program evaluation did not include results of all quality improvement activities.

Performance Measure and Performance Improvement Project Validation Health plans are required to have an ongoing program of performance improvement projects and to report plan performance using Healthcare Effectiveness Data and Information Set (HEDIS®) measures applicable to the Medicaid population.

All plans are using a HEDIS® certified vendor or software to collect and calculate the measures. All five MCOs were found “Fully Compliant.” Plan rates for the most recent review year are reported in Table 1, HEDIS® Performance Measure Data for HEDIS 2019. The statewide average is calculated as the average of the plan rates and shown in the last column in the table.

Table 1: HEDIS® Performance Measure Data for HEDIS 2019

Measure/Data Element ATC Healthy Blue Molina Select

Health WellCare Statewide Average

Effectiveness of Care: Prevention and Screening

Adult BMI Assessment (aba) 87.59% 87.35% 90.27% 87.44% 89.37% 88.40%

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (wcc)

BMI Percentile 84.18% 80.29% 73.24% 79.90% 82.48% 80.02%

Counseling for Nutrition 67.40% 67.15% 62.04% 64.07% 63.75% 64.88%

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Counseling for Physical Activity 64.72% 62.53% 56.20% 59.30% 59.12% 60.37%

Childhood Immunization Status (cis)

DTaP 72.26% 75.91% 74.94% 77.62% 75.18% 75.18%

IPV 90.75% 88.08% 84.18% 92.46% 87.83% 88.66%

MMR 87.59% 88.08% 88.08% 88.56% 88.32% 88.13%

HiB 82.48% 83.45% 83.70% 85.40% 83.21% 83.65%

Hepatitis B 90.27% 89.29% 84.91% 91.97% 89.54% 89.20%

VZV 86.62% 87.83% 87.59% 88.32% 88.56% 87.78%

Pneumococcal Conjugate 78.35% 78.10% 77.13% 82.97% 75.18% 78.35%

Hepatitis A 85.16% 83.70% 82.97% 84.43% 82.00% 83.65%

Rotavirus 73.97% 71.29% 70.07% 78.59% 69.10% 72.60%

Influenza 39.90% 41.85% 37.96% 38.69% 40.15% 39.71%

Combination #2 67.88% 71.53% 70.32% 74.21% 71.78% 71.14%

Combination #3 65.94% 69.59% 68.86% 72.51% 68.37% 69.05%

Combination #4 64.96% 67.88% 66.67% 70.56% 65.69% 67.15%

Combination #5 57.18% 60.10% 58.64% 63.50% 58.39% 59.56%

Combination #6 32.85% 36.50% 32.60% 34.31% 32.85% 33.82%

Combination #7 56.69% 59.12% 57.18% 62.53% 56.20% 58.34%

Combination #8 32.60% 36.25% 32.60% 34.31% 32.36% 33.62%

Combination #9 28.95% 32.60% 28.71% 31.39% 29.68% 30.27%

Combination #10 28.71% 32.36% 28.71% 31.39% 29.20% 30.07%

Immunizations for Adolescents (ima)

Meningococcal 74.45% 72.02% 77.13% 76.40% 69.34% 73.87%

Tdap/Td 84.91% 83.21% 87.10% 89.54% 82.48% 85.45%

HPV 73.72% 29.68% 32.12% 34.06% 68.37% 47.59%

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Combination #1 30.66% 71.29% 76.40% 75.43% 28.95% 56.55%

Combination #2 32.36% 28.71% 31.87% 33.3% 29.93% 31.23%

Lead Screening in Children (lsc) 69.13% 70.32% 69.34% 76.32% 71.53% 71.33%

Breast Cancer Screening (bcs) 64.56% 50.95% 58.83% 60.56% 53.89% 57.76%

Cervical Cancer Screening (ccs) 65.94% 57.61% 58.15% 68.71% 55.53% 61.19%

Chlamydia Screening in Women (chl)

16-20 Years 57.14% 51.96% 57.16% 57.09% 57.84% 56.24%

21-24 Years 66.24% 66.23% 68.35% 64.76% 68.86% 66.89%

Total 59.65% 56.88% 60.04% 59.05% 60.55% 59.23%

Effectiveness of Care: Respiratory Conditions Appropriate Testing for Children with Pharyngitis (cwp)

79.47% 84.67% 81.59% 84.10% 81.97% 82.36%

Use of Spirometry Testing in the Assessment and Diagnosis of COPD (spr)

21.86% 30.25% 26.46% 30.92% 23.26% 26.55%

Pharmacotherapy Management of COPD Exacerbation (pce)

Systemic Corticosteroid 66.50% 61.46% 68.76% 62.92% 63.93% 64.71%

Bronchodilator 78.33% 79.05% 78.10% 79.50% 74.24% 77.84%

Medication Management for People With Asthma (mma)

5-11 Years - Medication Compliance 50% 50.70% 56.88% 57.39% 61.29% 52.99% 55.85%








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Total - Medication Compliance 50% 50.44% 57.61% 57.61% 61.03% 52.43% 55.82%


Asthma Medication Ratio (amr)

5-11 Years 83.04% 80.04% 79.71% 75.76% 76.76% 79.06%

12-18 Years 72.66% 71.34% 72.03% 66.96% 70.17% 70.63%

19-50 Years 54.43% 54.73% 54.37% 56.27% 56.94% 55.35%

51-64 Years 60.71% 48.39% 48.78% 59.77% 56.36% 54.80%

Total 73.84% 70.58% 71.49% 69.72% 70.33% 71.19%

Effectiveness of Care: Cardiovascular Conditions Controlling High Blood Pressure (cbp) 46.47% 52.80% 50.12% 60.10% 48.66% 51.63%

Persistence of Beta-Blocker Treatment After a Heart Attack (pbh)

80.43% 54.17* 76.92% 78.31% 70.83%* 76.62%

Statin Therapy for Patients With Cardiovascular Disease (spc)

Received Statin Therapy - 21-75 years (Male) 77.49% 77.29% 79.08% 77.28% 79.77% 78.18%

Statin Adherence 80% - 21-75 years (Male) 50.84% 61.25% 52.26% 58.78% 49.28% 54.48%

Received Statin Therapy - 40-75 years (Female) 72.73% 72.13% 71.43% 75.12% 75.00% 73.28%

Statin Adherence 80% - 40-75 years (Female) 50.66% 57.58% 53.08% 51.13% 34.34% 49.36%

Received Statin Therapy – Total 75.23% 74.87% 75.40% 76.16% 77.70% 75.87%

Statin Adherence 80% - Total 50.76% 59.59% 52.63% 54.86% 43.04% 52.18%

Effectiveness of Care: Diabetes

Comprehensive Diabetes Care (cdc) Hemoglobin A1c (HbA1c)

Testing 89.29% 85.16% 89.77% 89.35% 88.77% 88.47%

HbA1c Poor Control (>9.0%) 42.34% 49.64% 47.49% 46.03% 41.85% 45.47%

HbA1c Control (<8.0%) 48.91% 42.58% 44.19% 43.50% 48.31% 45.50%

HbA1c Control (<7.0%) NR NR NR 29.20% 40.63% 34.92%

Eye Exam (Retinal) Performed 57.91% 36.74% 61.87% 55.42% 52.62% 52.91%

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Medical Attention for Nephropathy 90.79% 88.81% 93.41% 91.16% 91.23% 91.08%

Blood Pressure Control (<140/90 mm Hg) 44.04% 59.61% 55.46% 60.29% 55.38% 54.96%

Statin Therapy for Patients With Diabetes (spd)

Received Statin Therapy 60.74% 61.79% 62.22% 60.58% 59.31% 60.93%

Statin Adherence 80% 45.55% 51.57% 45.24% 50.94% 46.72% 48.00%

Effectiveness of Care: Musculoskeletal Conditions Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis (art)

67.23% 64.29% 71.19% 70.42% 68.13% 68.25%

Effectiveness of Care: Behavioral Health

Antidepressant Medication Management (amm)

Effective Acute Phase Treatment 41.32% 46.90% 39.50% 44.86% 41.40% 42.80%

Effective Continuation Phase Treatment 25.10% 32.17% 25.16% 29.55% 25.54% 27.50%

Follow-Up Care for Children Prescribed ADHD Medication (add)

Initiation Phase 53.06% 38.31% 60.05% 39.38% 36.58% 45.48%

Continuation and Maintenance (C&M) Phase 63.59% 55.75% 76.74% 52.65% 54.42% 60.63%

Follow-Up After Hospitalization for Mental Illness (fuh)

6-17 years -30-Day Follow-Up 79.17% 66.67% 72.15% 72.92% 76.25% 73.43%

6-17 years - 7-Day Follow-Up 40.63% 35.83% 50.00% 43.73% 46.25% 43.29%

18-64 years -30-Day Follow-Up 50.53% 52.42% 54.46% 54.53% 47.44% 51.88%


65+ years - 30-Day Follow-Up* NA NA NA NA NA NA


Total - 30-Day Follow-Up 55.40% 56.22% 59.43% 63.38% 53.32% 57.55%


Follow-Up After Emergency Department Visit for Mental Illness (fum)


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Total - 7-Day Follow-Up 35.54%% 34.46% 39.60% 44.46% 41.86% 40.10%

Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence (fua)

30-Day Follow-Up: 13-17 Years* 12.90% 5.88% 26.92% 10.68% 17.65% 14.81%


30-Day Follow-Up: 18+ Years 13.48% 16.85% 17.77% 19.80% 15.58% 16.70%


30-Day Follow-Up: Total 13.43% 16.46% 18.33% 18.76% 15.68% 16.53%


Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medication (ssd)

75.19% 75.25% 79.82% 78.67% 70.79% 75.94%

Diabetes Monitoring for People With Diabetes and Schizophrenia (smd)

61.93% 70.15% 74.21% 69.23% 68.53% 68.81%

Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (smc)

47.83% NA* NA 75.00%* 60.00%* 47.83%

Adherence to Antipsychotic Medications for Individuals With Schizophrenia (saa)

62.93% 64.68% 72.34% 67.47% 65.46% 66.58%

Metabolic Monitoring for Children and Adolescents on Antipsychotics (apm)

1-5 Years 0.00%* 0.00%* 0.00%* 19.44% NA* NA

6-11 Years 25.69% 17.39% 20.00% 30.49% 30.00% 24.71%

12-17 Years 35.79% 22.88% 27.67% 41.23% 21.65% 29.84%

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Total 32.00% 20.53% 25.42% 37.27% 24.49% 27.94%

Effectiveness of Care: Medication Management

Annual Monitoring for Patients on Persistent Medications (mpm)

ACE Inhibitors or ARBs 88.29% 88.75% 91.62% 89.70% 89.15% 89.50%

Diuretics 88.89% 87.87% 91.83% 89.85% 89.61% 89.61%

Total 88.57% 88.34% 91.72% 89.77% 89.35% 89.55%

Effectiveness of Care: Overuse/Appropriateness Non-Recommended Cervical Cancer Screening in Adolescent Females (ncs)

2.22% 0.65% 0.92% 0.81% 1.04% 1.13%

Appropriate Treatment for Children With URI (uri) 89.11% 87.75% 87.58% 86.37% 88.66% 87.89%

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (aab)

30.38% 27.59% 26.68% 26.03% 30.38% 28.21%

Use of Imaging Studies for Low Back Pain (lbp) 65.52% 67.00% 63.34% 73.17% 65.48% 66.90%

Use of Multiple Concurrent Antipsychotics in Children and Adolescents (apc)

1-5 Years* 0.00 0.00% NA 0.00% NA NA

6-11 Years 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

12-17 Years 1.53% 1.10% 0.00% 1.44% 1.39% 1.09%

Total .94% 0.68% 0.00% 0.95% 0.89% 0.69%

Use of Opioids at High Dosage (uod) 4.65% 5.23% 2.44% 3.62% 4.10% 4.01%

Use of Opioids From Multiple Providers (uop)

Multiple Prescribers 17.64% 23.56% 25.40% 25.58% 25.44% 23.52%

Multiple Pharmacies 7.78% 4.72% 9.35% 14.92% 8.46% 9.05%

Multiple Prescribers and Multiple Pharmacies 2.91% 1.89% 4.46% 6.51% 4.21% 4.00%

Risk of Continued Opioid Use (cou)

18-64 years - >=15 Days covered 2.59% 1.99% 5.51% 4.00% 6.71% 4.16%


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65+ years - >=15 Days covered* NA NA NA NA NA NA


Total - >=15 Days covered 2.59% 1.99% 5.51% 4.00% 6.71% 4.16%


Access/Availability of Care

Adults' Access to Preventive/Ambulatory Health Services (aap)

20-44 Years 76.47% 75.57% 79.69% 79.79% 73.07% 76.92%

45-64 Years 85.16% 85.50% 89.17% 89.03% 84.20% 86.61%

65+ Years* 100% 66.67% 80.00% 80.00% 100.00% 85.33%

Total 79.17% 78.51% 82.97% 81.99% 77.01% 79.93%

Children and Adolescents' Access to Primary Care Practitioners (cap)

12-24 Months 96.55% 97.19% 96.73% 97.55% 95.53% 96.71%

25 Months - 6 Years 85.33% 86.31% 86.11% 88.74% 83.29% 85.96%

7-11 Years 88.13% 88.40% 89.88% 91.66% 85.98% 88.81%

12-19 Years 86.86% 85.56% 89.48% 90.21% 84.46% 87.31%

Initiation and Engagement of AOD Dependence Treatment (iet)

Alcohol abuse or dependence: Initiation of AOD Treatment:

13-17 Years* 35.71% 25.00% 42.11% 38.10% 36.36% 35.46%

Alcohol abuse or dependence: Engagement of AOD

Treatment: 13-17 Years* 21.43% 25.00% 21.05% 26.67% 9.09% 20.65%

Opioid abuse or dependence: Initiation of AOD Treatment:

13-17 Years* 33.33% 25.00% 0.00% 30.43% 0.00% 17.75%

Opioid abuse or dependence: Engagement of AOD

Treatment: 13-17 Years* 16.67% 25.00% 0.00% 21.74% 0.00% 12.68%

Other drug abuse or dependence: Initiation of AOD

Treatment: 13-17 Years 35.34% 34.41% 40.54% 35.45% 33.70% 35.89%

Other drug abuse or dependence: Engagement of AOD Treatment: 13-17 Years

23.31% 22.58% 25.23% 24.55% 22.83% 23.70%

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Initiation of AOD Treatment: 13-17 Years 34.69% 32.00% 39.67% 35.05% 33.33% 34.95%

Engagement of AOD Treatment: 13-17 Years 21.77% 21.00% 23.97% 24.02% 21.21% 22.39%


18+ Years 44.78% 39.57% 40.92% 39.76% 45.77% 42.16%


Treatment: 18+ Years 9.20% 9.27% 7.38% 9.68% 8.45% 8.80%


18+ Years 39.50% 42.15% 50.59% 46.04% 47.48% 45.15%


Treatment: 18+ Years 14.25% 22.46% 22.78% 25.06% 17.65% 20.44%


Treatment: 18+ Years 42.77% 40.65% 37.96% 34.65% 41.36% 39.48%

Other drug abuse or dependence: Engagement of

AOD Treatment: 18+ Years 11.21% 10.36% 9.41% 10.97% 9.84% 10.36%

Initiation of AOD Treatment: 18+ Years 41.30% 38.89% 39.74% 37.54% 42.88% 40.07%

Engagement of AOD Treatment: 18+ Years 10.55% 10.95% 10.70% 12.92% 9.77% 10.98%


Total 44.44% 39.27% 40.96% 39.63% 45.60% 41.98%


Treatment: Total 9.66% 9.60% 7.77% 10.99% 8.46% 9.30%


Total 39.41% 41.95% 50.29% 45.63% 47.08% 44.87%


Treatment: Total 14.29% 22.49% 22.65% 24.97% 17.50% 20.38%


Treatment: Total 41.91% 40.06% 38.22% 34.82% 40.52% 39.11%


AOD Treatment: Total 12.61% 11.52% 11.01% 13.91% 11.26% 12.06%

Initiation of AOD Treatment: Total 40.82% 38.48% 39.74% 37.17% 42.22% 39.69%

Engagement of AOD Treatment: Total 11.38% 11.55% 11.57% 14.57% 10.56% 11.93%

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Prenatal and Postpartum Care (ppc)

Timeliness of Prenatal Care 91.48% 90.98% 86.37% 88.19% 88.16% 89.04%

Postpartum Care 67.40% 70.22% 69.83% 70.83% 61.05% 67.87%

Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (app)

1-5 Years* 0.00%* NA* 0.00%* 45.16% 0.00%* NA

6-11 Years 52.36% 72.00%* 52.63% 68.31% 60.87%* 57.77%

12-17 Years 52.58% 61.29% 61.63% 57.83% 45.65% 55.80%

Total 52.52% 66.07% 58.40% 61.28% 49.30% 57.51%

Utilization

Well-Child Visits in the First 15 Months of Life (w15)

0 Visits 2.19% 0.97% 0.73% 1.83% 2.66% 1.68%

1 Visit 0.49% 1.46% 0.49% 0.91% 2.39% 1.15%

2 Visits 2.68% 1.22% 2.19% 3.35% 3.19% 2.53%

3 Visits 3.41% 2.68% 4.14% 2.44% 3.46% 3.23%

4 Visits 8.52% 7.54% 8.52% 4.27% 9.84% 7.74%

5 Visits 14.36% 10.71% 14.84% 8.23% 15.16% 12.66%

6+ Visits 68.37% 75.43% 69.10% 78.96% 63.30% 71.03%

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (w34)

63.75% 63.75% 60.83% 76.72% 63.28% 65.67%

Adolescent Well-Care Visits (awc) 55.96% 51.58% 51.58% 65.84% 51.95% 55.38%

NR = Not Reported; NA = Not Applicable due to missing data; * = small denominator

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CCME validated 12 projects for the 2019–2020 EQR period. Table 2, Results of the Validation of PIPs, provides an overview of the PIP validation results for the five health plans.

Table 2: Results of the Validation of PIPs

Project Validation Score

ATC

Postpartum Care 111/111=100%

High Confidence in Reported Results

Provider Satisfaction 104/105=99%


Healthy Blue

Access and Availability of Care- Non-Clinical 130/131= 99%


Comprehensive Diabetes Care- Clinical 120/126=95%


Molina

Breast Cancer Screening (Clinical) 91/91=100%


Well Care Visits (Clinical) 111/111=100%


Improving Claims Accuracy and Provider Satisfaction (Non-Clinical)

90/90=100% High Confidence in Reported Results

Select Health

Diabetes Outcomes Measures: Clinical 105/111=95%


Follow-up After Hospitalization for Mental Health Within 7 and 30 Calendar Days After Discharge: Non-Clinical


WellCare

Improving Dilated Retinal Exam (DRE) Screening


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Access to Care 91/91=100%


Improving Hemoglobin A1C Testing 96/96=100%


Utilization Management CCME’s assessment of Utilization Management (UM) included reviews of program descriptions, program evaluations, policies, committee minutes, corresponding reports, and websites. CCME also reviewed approval, denial, appeal, and case management files. The health plans have individual UM program descriptions, policies, and procedures that define how UM and case management services are operationalized. The purpose, goals, objectives, and staff roles for physical, pharmaceutical, and behavioral health are clearly described. Medical Directors provide oversight of UM activities.

Appropriately licensed reviewers conduct service authorization requests using Milliman Care Guidelines (MCG), InterQual Criteria, and other established criteria. Review of UM approval and denial files revealed staff regularly follow established processes, apply appropriate medical necessity criteria, and request relevant clinical information when necessary.

Health plans have established policies defining processes for handling appeals of adverse benefit determinations. Review of information related to appeals processes and requirements revealed issues with documentation such as incorrect definitions of appeal terminology, errors in forms and letter templates, and incorrect resolution timeframes.

The Case Management (CM) Program Descriptions and policies appropriately document care management processes and services provided. The health plans have well-developed Case Management Programs. Each MCO has established a Population Health Management approach toward reducing health disparities, addressing social determinants of health, and enhancing the overall CM program. CCME’s case management file review for all plans confirmed the health plans follow appropriate processes and conduct appropriate functions. All plans have processes to measure member satisfaction with case management.

Delegation Health plan policies define requirements for delegation of health plan functions and processes for oversight of delegated entities. The MCOs require written agreements with the delegated entity that outline delegated activities, delegate responsibilities,

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performance expectations, reporting responsibilities, and other relevant items. The MCOs have developed tools for delegation monitoring and oversight.

CCME noted some MCO policies regarding delegation of credentialing and recredentialing activities did not include all credentialing requirements. CCME’s review of the delegate oversight documentation revealed issues such as:

• Failure to conduct timely follow-up of issues identified during oversight monitoring

• Oversight documentation lacking evidence that credentialing delegates are monitored for all credentialing/recredentialing queries and website checks

• Delegation oversight tools that did not specify the requirements to which a delegate is held

State Mandated Services Individual health plan documents and file review findings indicate all core benefits specified by the SCDHHS Contract are provided to eligible members. The plans ensure Early and Periodic Screening, Diagnosis, and Treatment and provide immunization services to members from birth through the month of their 21st birthday. The plans monitor provider compliance through member medical record documentation reviews as well as HEDIS® reports of well-child visits and claims analysis. During the previous EQRs, each plan submitted a quality improvement plan to address identified deficiencies; however, Molina and Healthy Blue had uncorrected deficiencies.

SC Solutions South Carolina Solutions (Solutions) is a subsidiary organization of Community Health Solutions of America (CHS). The CHS Corporate Board of Directors governs the organization and adopts rules, policies, procedures, and other directives for the operation of the organization. Solutions’ Executive Director ensures the goals and objectives of SCDHHS, CHS, and Solutions are aligned, and the Program Operations Manager oversees day–to–day operations. Staffing appears to be sufficient to conduct required activities, with no vacancies noted.

Solutions reviews policies annually and as needed for regulatory and process changes. The organization informs staff about new and revised policies, and staff must attest that they have read the relevant policy. Solutions has developed policies to address requirements as well as processes for screening and verifying the qualifications of clinical staff. However, the review did not identify a formal policy defining the requirements for non-clinical staff. CCME recommended revision to the Clinical Staff Credentialing and Re-Credentialing policy to clarify the staff to whom the policy applies. CCME also recommended a revision to clearly describe how Solutions meets the requirement for background checks in states other than South Carolina in which an employee has resided within the last 10 years. Personnel files reflect appropriate processes are followed to

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verify employee information, conduct required screenings, and document initial and ongoing training.

The Compliance Program is applicable to all CHS lines of business and complements the established policies and procedures detailing Compliance requirements, appropriate business conduct, and processes to prevent and detect FWA. Employees receive compliance and FWA training at the time of hire and annually thereafter.

The review of the Provider Services section included the policies, the Provider Manual, and program materials that address provider education. Solutions’ Program Operations Coordinator conducts initial provider orientation and education within 30 days of a provider contracting into the network. Policy CHS.PM.MCCW.01.01, Provider Orientation/Training, discusses the process for onboarding new providers to Solutions’ network. Solutions’ website includes links to download the Provider Manual and to access the list of SCDHHS provider manuals, as well as information about credentialing, reporting FWA, and language services.

Overall, Solutions performed well in the Quality Improvement section of the EQR. During this review period, Solutions met all the requirements. Their program continues to operate under a plan of continuous improvement. The Strategic Quality Plan 2020 describes the program’s structure, scope, goals, and functions.

During this review, Solutions has two Quality Improvement projects underway—Care Plan Streamlining and Care Advocate Outreach. Both projects have since been closed and replaced with the Emergency/Disaster Preparedness and URAC Re-Accreditation projects.

Solutions evaluated the QI Program and summarized the results of this evaluation in “Annual Report: Quality and Performance Improvement Calendar Year 2019.”

CCME’s assessment of Care Coordination/Case Management includes a review of the program description, policies, Provider Manual, case management files, and website. The Waiver Program Description outlines the purpose, goals, objectives, and staff roles. The Program Manager oversees the day-to-day operations of the program, and the Medical Director works closely with the Care Coordinator Team Leads and is responsible for clinical oversight and decision-making. Case Management files indicate Care Coordinators and Care Advocates follow policies to conduct care coordination activities.

As identified in previous EQRs, CCME’s review noted issues with documentation of team conferences and the Waiver Administrator’s phone number. The number provided for the Waiver Administrator on the MCCW Rights and Responsibilities document is incorrect. Documents such as the Provider Manual, Waiver Program Description, and member materials do not accurately describe team conferences as optional activities conducted upon request.

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Overall Scoring

The following figure illustrates the percentage of “Met” standards achieved by each health plan during the 2019-2020 EQRs.

Figure 1: Percentage of Met Standards

CCME applied a numerical score (points) to each standard’s rating within a section to be able to derive the overall score (percentage) for each plan. Using the Centers for Medicare & Medicaid Services (CMS) Protocol, “External Quality Review Protocol for Accessing Compliance with Medicaid Managed Care Regulation,” the overall score was calculated based on the following method: 1. Points were assigned to each rating

("Met" = 2 points, "Partially Met" = 1 point, “Not Met” = 0 points), excluding "Not Evaluated" and "Not Applicable" ratings from the calculation.

2. The total points achieved for each section was calculated by adding the earned points together.

3. An average score for each section was derived by dividing the section’s total points (total points achieved) by the total possible points for that

88%

90%

92%

94%

96%

98%

100%

ATC Healthy Blue Molina Select Health Solutions WellCare

96%97%

98%99%

100%

93%

% M

et S

tand

ards

21



section (total number of ratings in that section x 2 points).

4. The overall score (percentage) was then calculated by averaging the seven section scores (see Table 3: Scoring Matrix).

Table 3: Scoring Matrix

Health Plan Score

ATC 98.1%

Healthy Blue 98.2%

Molina 98.4%

Select Health 99.5%

*Solutions 100%

WellCare 95.4%

*Note. Solutions is reviewed based on a different set of standards. The overall score is calculated using the same methodology as described above.

Coordinated and Integrated Care Organizations Annual Review

CCME conducted an EQR of the Coordinated and Integrated Care Organizations (CICOs) that provide services for the dual eligible Medicare/Medicaid population. This review focused on network adequacy for Home and Community Based Services and behavioral health providers, over/under utilization, and care transitions.

Provider Network Adequacy Contracts require the CICOs to maintain a network of Home and Community Based Service (HCBS) providers that is sufficient to provide all enrollees with access to a full range of covered services in each geographic area. Each CICO submitted an HCBS provider file that was evaluated by CCME to assess the provider adequacy for the following services:

• Adult Day Health

• Case Management

• Home Delivered Meals

• Personal Care

• Personal Emergency Response System (PERS)

• Respite

• Telemonitoring

CCME calculated ATC’s minimum number of required providers for each county and compared that value to the number of current providers for seven services in the 37-

22



county network. Of the 259 services across 37 counties, there were 259 (100%) that met the minimum requirement. This review year showed sustainment, with a rate of 100%.

Molina reported 43 counties with enrollment. Of the 301 services across 43 counties, there were 298 that met the minimum requirement, resulting in a validation score of 99%. The counties and services with fewer than the required minimums were Beaufort, Hampton, and Jasper for Adult Day Health.

Select Health reported members in 46 counties. Of the 322 services across 46 counties, there were 322 (100%) that met the minimum requirement.

The CICOs are also required to have a network of behavioral health (BH) providers to ensure a choice of at least two providers located within no more than 50 miles from any enrollee unless the plan has a SCDHHS-approved alternative standard. All three plans met these requirements.

Evaluation of Over/Under Utilization The CICOs are required to monitor and analyze utilization data to look for trends or issues that may provide opportunities for quality improvement. ATC monitors use of the five required services, as well as other services. The utilization data monitoring showed some of the reported rates were below the goal; however, ATC had adopted interventions and recommendations to address these issues.

Molina reported on 30-day readmissions, ER utilization, mental health service utilization rate, and length of stay. The data showed that ER visits were trending higher, and one causative factor was a lack of PCPs. Molina reported the Community Connectors program was continued to engage members with their PCPs and eliminate social barriers to accessing PCP appointments. Molina conducts member-specific analyses to determine which members are not engaged with PCPs.

Select Health reported on utilization for four of the five required services, along with other services. Select Health monitors the rates, and there was adequate evidence that trends are analyzed and that issues are addressed to improve utilization rates.

All CICOs met the requirements for evaluating over/under utilization.

Care Transitions CCME reviewed Transition of Care files for members readmitted to the hospital fewer than 30 days after discharge. The files revealed insufficient documentation to indicate care transitions activities are conducted. Similar issues identified in previous EQRs are repeated in Care Transition files in the current review. Some of the common issues identified in the files include:

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• Failure to identify a facility-based Care Manager

• Inconsistent outreach and collaboration with PCPs

• Failure to document clinical follow-up within 72 hours after transition

Other deficiencies noted in the file review included lack of, or insufficient, documentation of:

• Timely notifications of admission and discharge

• Barriers to aftercare and strategies to address those barriers

• Medication monitoring

• Reassessments

• Clinical and non-clinical supports needed by members

• Transition and aftercare appointments

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BACKGROUND As detailed in the Executive Summary, CCME as the EQRO conducts an EQR of each MCO participating in the Medicaid Managed Care Program on behalf of SCDHHS. CCME’s contract with SCDHHS require an annual review that include three activities: validation of PIPs, validation of PMs, and evaluation of compliance with state and federal regulations for each health plan.

After completing the annual EQR activities, CCME submits a detailed technical report to SCDHHS and the health plan. This report describes the data aggregation and analysis, as well as the manner in which conclusions were drawn about the quality, timeliness, and access to care furnished by the plan. The report also contains the plan’s strengths and weaknesses, recommendations for improvement, and the degree to which the plan addressed quality improvement recommendations made during the prior year’s review. Annually, CCME prepares a comprehensive technical report for the State which is a compilation of the individual annual review findings. The comprehensive technical report for contract year 2019 through 2020 contains data for: ATC, Healthy Blue, Molina, Select Health, Solutions, and WellCare. The report also includes EQR findings for the plans participating in the Healthy Connections Prime Program under review during this reporting period.

METHODOLOGY CCME used a process for the EQR activities that is based on CMS protocols and includes a desk review of documents submitted by each health plan and an onsite visit to each plan’s office. After completing the annual review, CCME submits a detailed technical report to SCDHHS and the health plan (covered in the preceding section titled Background). For a health plan not meeting requirements, CCME requires the plan to submit a quality improvement plan for each standard not fully met. CCME provides technical assistance to each health plan until all deficiencies are corrected.

The following table displays the dates of the EQRs conducted for each health plan.

Table 4: External Quality Review Dates

Health Plan EQR Initiated Onsite Dates Report Submitted

ATC 12/2/19 2/26/19 – 2/27/19 3/26/20

Healthy Blue 3/16/20 5/13/20 – 5/14/20 6/11/20

Molina 2/3/20 4/22/20 – 4/23/20 5/21/20

Solutions 6/8/20 7/14/20 8/7/20

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Health Plan EQR Initiated Onsite Dates Report Submitted

Select Health 9/30/19 11/13/19 – 11/14/19 12/12/19

WellCare 10/21/19 12/17/19 – 12/18/19 1/16/20

FINDINGS The plans were evaluated using the standards developed by CCME and summarized in the tables for each of the sections that follow. CCME scored each standard as fully meeting a standard (“Met”), acceptable but needing improvement (“Partially Met”), failing a standard (“Not Met”), “Not Applicable,” or “Not Evaluated.” The tables reflect the scores for each standard evaluated in the EQR. The arrows indicate a change in the score from the previous review. For example, an arrow pointing up (↑) would indicate the score for that standard improved from the previous review and a down arrow (↓) indicates the standard scored lower than the previous review. Scores without arrows indicate that there was no change in the score from the previous review.

A. Administration

CCME’s review of the Administration section for each MCO focused on the processes and requirements for policy and procedure management, review, and revision; key leadership and adequacy of staffing; information systems; and processes and requirements related to compliance, program integrity, and confidentiality.

The reviews found that each of the MCOs had adequate staffing in place to ensure health care products and services required by the State of South Carolina are provided to members. ATC had several vacancies on its Organizational Chart but reported the positions had either been filled or were in a “hold” or “closed” status. Also, ATC successfully filled its Vice President of Medical Management position previously filled by the Senior Vice President of Quality Improvement. CCME noted several staffing vacancies for Select Health, and one WellCare position was vacant. Both MCOs reported recruiting activities were underway to fill the vacant positions.

The MCOs ensure policies and procedures are reviewed annually. Most use a policy management and storage platform, such as Compliance 360 or RSA Archer®; however, each MCO has established processes to manage policies and procedures and to routinely review and revise policies. Policies are accessible to staff, and staff are informed of new or revised policies through various avenues, such as email, staff meetings, and newsletters.

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The MCOs have established comprehensive Compliance and Program Integrity programs. The MCO Compliance Officers and Compliance Committees oversee these programs. Healthy Blue’s documentation of Compliance Committee membership was inconsistent when comparing the BlueChoice HealthPlan Medicaid and Amerigroup Partnership Plan Compliance Committee Charter and the 2020 Committee Membership List. Healthy Blue’s 2019 EQR also noted inconsistent documentation of Compliance Committee membership. The quorums for Molina’s and WellCare’s Compliance Committees were not clearly documented.

Program documentation includes expectations for employee conduct and processes to guard against fraud, waste, and abuse (FWA). The MCOs require employees to complete compliance training at the time of employment and annually thereafter. Training topics include FWA, the code of conduct, and processes for reporting suspected compliance or FWA issues. In addition to formal training, staff receives compliance information through various publications, such as the MCOs’ employee handbooks, policies, and office posters. Orientation for newly-contracted providers includes information about FWA prevention and reporting. CCME noted ATC’s Compliance Plan states training on identifying and reporting FWA is provided to contracted providers as necessary or upon request; however, the MCO confirmed these topics are included in the orientation for all new providers. CCME recommended ATC revise its Compliance Plan to reflect this. The MCOs maintain an “open-door” culture as well as policies prohibiting retaliation against those who report actual or suspected Compliance or FWA violations.

Each of the MCOs has policies specifying requirements and processes for the contractually required Pharmacy Lock-in Program. WellCare’s policy, however, did not describe the process for locking members into a specific provider. Additionally, CCME noted the version of the Pharmacy Lock-in Policy (SC22-RX-005) found in an appendix of the Compliance Plan was outdated.

Information Systems Capabilities Assessment

The review of each of the MCOs included an assessment of their Information Management Systems. These reviews confirmed the MCOs are able to perform the Medicaid information and data processing activities required by the SCDHHS Contract. The MCOs focus on managing data and resources in compliance with the Health Insurance Portability and Accountability Act (HIPAA). The health plans have comprehensive processes in place to mitigate business interruptions and reestablish operations if there is an event that causes a disruption. All of the MCOs meet or exceed the contractual requirements for claims payments at 30 days and 90 days.

As noted in Figure 2: Administration, each of the MCOs achieved scores of “Met” for 100% of the standards in the Administration section.

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Figure 2: Administration

An overview of the scores for the Administration section is illustrated in Table 5: Administration Comparative Data.

Table 5: Administration Comparative Data

Standard ATC Healthy Blue Molina Select Health WellCare

General Approach to Policies and Procedures The MCO has in place policies and procedures that impact the quality of care provided to members, both directly and indirectly

Met Met Met Met Met

Organizational Chart / Staffing The MCO’s resources are sufficient to ensure that all health care products and services required by the State of South Carolina are provided to members. At a minimum, this includes designated staff performing in the following roles: *Administrator (CEO, COO, Executive Director)

Met Met Met Met Met

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ATC Healtly Blue Molina Select Health WellCare

100% 100% 100% 100% 100%

% M

et S

tand

ards

28




Chief Financial Officer (CFO)

Met Met Met Met Met

*Contract Account Manager

Met Met Met Met Met

Information Systems personnel Claims and Encounter Manager/ Administrator

Met Met Met Met Met

Network Management Claims and Encounter Processing Staff

Met Met Met Met Met

Utilization Management (Coordinator, Manager, Director)

Met Met Met Met Met

Pharmacy Director Met Met Met Met Met

Utilization Review Staff Met Met Met Met Met

*Case Management Staff Met Met Met Met Met

*Quality Improvement (Coordinator, Manager, Director)

Met Met Met Met Met

Quality Assessment and Performance Improvement Staff

Met Met Met Met Met

*Provider Services Manager Met Met Met Met Met

*Provider Services Staff Met Met Met Met Met

*Member Services Manager Met Met Met Met Met

Member Services Staff Met Met Met Met Met

*Medical Director Met Met Met Met Met

*Compliance Officer Met Met Met Met Met

Program Integrity Coordinator

Met Met Met Met Met

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Compliance /Program Integrity Staff

Met Met Met Met Met

*Interagency Liaison Met Met Met Met Met

Legal Staff Met Met Met Met Met

Board Certified Psychiatrist or Psychologist

Met Met Met Met Met

Post-payment Review Staff Met Met Met Met Met

Operational relationships of MCO staff are clearly delineated

Met Met Met Met Met

Management Information Systems The MCO processes provider claims in an accurate and timely fashion

Met Met Met Met Met

The MCO is capable of accepting and generating HIPAA compliant electronic transactions

Met Met Met Met Met

The MCO tracks enrollment and demographic data and links it to the provider base

Met Met Met Met Met

The MCO’s management information system is sufficient to support data reporting to the State and internally for MCO quality improvement and utilization monitoring activities

Met Met Met Met Met

The MCO has policies, procedures and/or processes in place for addressing data security as required by the contract

Met Met Met Met Met

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The MCO has policies, procedures and/or processes in place for addressing system and information security and access management

Met Met Met Met Met

The MCO has a disaster recovery and/or business continuity plan that has been tested, and the testing has been documented

Met Met Met Met Met

Compliance/Program Integrity

The MCO has a Compliance Plan to guard against fraud and abuse

Met Met Met Met Met

The Compliance Plan and/or policies and procedures address all requirements

Met ↑ Met ↑ Met ↑ Met Met ↑

The MCO has an established committee responsible for oversight of the Compliance Program

Met Met Met Met Met

The MCO’s policies and procedures define processes to prevent and detect potential or suspected fraud, waste, and abuse

Met Met Met Met Met

The MCO’s policies and procedures define how investigations of all reported incidents are conducted

Met Met Met Met Met

The MCO has processes in place for provider payment suspensions and recoupments of overpayments

Met Met Met Met Met

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The MCO implements and maintains a statewide Pharmacy Lock-In Program (SPLIP)

Met Met Met Met Met ↑

Confidentiality The MCO formulates and acts within written confidentiality policies and procedures that are consistent with state and federal regulations regarding health information privacy

Met Met Met Met Met

Strengths

• The MCOs have established processes to ensure policies and procedures are reviewed annually and revised as needed.

• No vacancies were noted in key personnel positions, and each of the MCOs has adequate staffing to conduct all functions required by the SCDHHS Contract.

• The MCOs’ health information systems are adequate to fulfill obligations of the SCDHHS Contract. The MCOs test disaster recovery plans routinely, and policies and procedures are in place to ensure the privacy and security of protected information.

• Compliance Program documentation, including FWA plans and associated policies and procedures, detail the MCOs’ activities and processes to prevent, detect, and respond to violations of ethical conduct standards and suspected or actual FWA.

B. Provider Services

CCME’s review of Provider Services included policies and procedures, credentialing and recredentialing, provider network adequacy and accessibility, provider education and medical record documentation, and preventive health and clinical practice guidelines (CPGs).

The MCOs have policies and other documentation that describe requirements and processes for credentialing and recredentialing providers in their networks. For Healthy Blue, CCME could not identify the process for ensuring all individuals and entities in the network are enrolled with SCDHHS as Qualified Medicaid Providers, as required by the

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SCDHHS Contract, Section 2.8.1.1. For Healthy Blue and Molina, CCME noted errors in and/or lack of documentation of the timeframe for processing credentialing and recredentialing applications in various documents. A WellCare policy omits performing federal and state database checks for persons identified on Ownership Disclosure forms with an ownership or controlling interest as required in the SCDHHS Contract, Section 11.2.10 and the Policy and Procedure Guide for Managed Care Organizations, Section 11.2.

Each of the MCOs has a committee that renders decisions regarding credentialing and recredentialing of providers. The committees meet at routine intervals and as needed, and membership includes peers of the applicants.

Review of credentialing and recredentialing files revealed issues such as:

• Lack of evidence that the SCDHHS Terminated for Cause List was queried at credentialing (ATC and WellCare) and recredentialing (WellCare) — CCME noted this was a repeat finding for WellCare.

• Lack of evidence that the SCDHHS Excluded Provider List was queried at recredentialing (ATC)

• Lack of evidence that the Social Security Death Master File was queried at initial credentialing and recredentialing (Healthy Blue)

• Initial credentialing applications with incomplete information regarding providers’ hospital admitting privileges (Molina)

• Missing Clinical Laboratory Improvement Amendments (CLIA) Certificates in ATC’s and WellCare’s initial credentialing files and in ATC’s recredentialing files

• Outdated Ownership Disclosure forms at initial credentialing and recredentialing (WellCare)

• Primary source verification for initial credentialing and recredentialing outside of the required timeframe specified in MCO policy (Select Health)

• An outdated collaborative agreement listing an incorrect supervising physician for a Nurse Practitioner at recredentialing (WellCare)

• Organizational provider credentialing files with missing, outdated, or incorrect certification documents, licenses, Ownership Disclosure forms, lack of evidence of all required queries, and/or outdated queries (ATC and WellCare) — CCME noted this was a repeat finding for WellCare.

Each health plan has policies that define standards for network availability and provider access as well as network evaluation and monitoring processes. Issues noted in documentation included:

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• Molina’s Provider Manual listed an incorrect appointment timeframe for routine specialist care appointments and omitted the requirements for emergent visits and urgent medical condition care appointments. Molina’s Provider Availability Standards policy omitted the specialty requirements for emergent visits, urgent medical condition care appointments, and routine care appointments.

• Select Health’s Accessibility of Services / After Hours Survey and High Volume High Impact Survey policy contained incorrect appointment timeframes for routine visits. The Accessibility of Behavioral Healthcare Services policy and the 2019 Behavioral Health Access Survey Report listed a different appointment access standard than that reported in the Quality Assessment and Performance Improvement: 2018 Program Evaluation.

• WellCare’s Provider Appointment Accessibility and After-Hours Coverage policy contained an incorrect timeframe for routine PCP visits.

The MCOs monitor network adequacy using a variety of methods, including Geo Access reports, gap analyses, Member Satisfaction Survey results, and grievances about provider access and availability. ATC provided Geo Access reports reflecting evaluation of network provider access for most Status 1 providers, but there was no evidence that ATC measures geographic access for rehabilitative behavioral health providers and audiology therapy providers. Molina’s policy did not define the required time/distance parameters for hospitals. WellCare’s documentation indicated access requirements were not met for pulmonary medicine, neurology, and urology. Although WellCare staff reported continuing efforts to recruit providers in these categories and described barriers affecting the recruiting efforts, CCME noted the 2019 SC Medicaid Q2 Work Plan for Network Adequacy did not include all Status 1 Providers for monitoring (e.g., neurology and urology). WellCare staff did, however, report that relationships have been established with out-of-network providers to provide services to WellCare members as needed.

Each plan conducts provider education for all newly contracted providers and maintains educational resources and reference materials on its website. The MCOs have processes to provide ongoing provider education when there are changes to programs, member benefits, standards, and policies and procedures. Provider education about medical record documentation standards is accomplished through provider orientation, education sessions, the provider manuals, and MCO websites. The MCOs evaluate provider compliance to those standards through medical record audits. Healthy Blue’s Medical Record Compliance Audit for Documentation Standards policy incorrectly defined the expected passing score for the Medical Record Compliance Audits. The Medical Record Documentation Standards document found on ATC’s website was not consistent with the Medical Record Documentation Audit Tool used to evaluate providers.

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The MCOs have adopted preventive health and clinical practice guidelines. Information about the guidelines is available to network providers on the plans’ websites, in provider manuals, and through other sources.

Provider Access and Availability Study

As a part of the annual review process for all the plans, CCME performed a Telephonic Provider Access Study focusing on PCPs. CCME requested and received a list of network providers and contact information from each of the health plans. From each plan’s list, CCME defined a population of PCPs and selected a statistically relevant sample of providers for the study. CCME attempted to contact these providers to ask a series of questions about the access plan members have to their PCPs.

All five plans received a score of “Met” for the standard requiring an improvement in the results of the Telephonic Provider Access Study with statistically significant improvement in successfully answered calls occurring for all five plans. The following charts summarize CCME’s Provider Access and Availability Study findings and compare the five plans surveyed.

Population and Sample Size From the five MCOs reviewed, CCME identified a total population of 13,018 PCPs. From each plan’s population, CCME drew a random sample and selected a total of 1,183 providers, as shown in Figure 3: Population and Sample Sizes for Each Plan.

Figure 3: Population and Sample Sizes for Each Plan

0

500

1,000

1,500

2,000

2,500

3,000

ATC HealthyBlue

Molina SelectHealth

WellCare

2,862 2,816 2,812

2,216 2,312

289 209 207 238 240

Population Sample

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Successfully Answered Calls Using the telephone contact information provided by the plans, CCME called each provider to ask a series of questions. CCME calculated the success rate as follows:

• Success Rate: number of calls answered / (total number of calls - calls answered by a general or personal voicemail service)

In aggregate, the providers answered 77% of the calls successfully (see Figure 4: Percentage of Successfully Answered Calls), a 19% increase from the previous review cycle rate of 58%. All plans had a statistically significant (p<.05) increase in successful calls when rates were examined using Fisher’s exact test.

Figure 4: Percentage of Successfully Answered Calls

Currently Accepting the Plan Of the calls successfully answered, 92% responded that the provider accepts the respective health plan, representing a 1 percentage point increase from the previous year’s rate of 91%. Figure 5: Percentage of Providers Accepting the Plan, displays the percentage of providers that indicated they accept the plan.

0%

10%

20%

30%

40%

50%

60%

70%

ATC HealthyBlue

Molina SelectHealth

WellCare Aggregate

60%57% 57%

50%

68%

58%

71% 77% 74% 81% 80% 77%

Previous Year Current Year

36



Figure 5: Percentage of Providers Accepting the Plan

Accepting Medicaid Patients In aggregate, 66% of the providers accepting the plan responded that they are accepting new Medicaid patients, which is an 11 percentage point decrease from last year’s rate of 77% (see Figure 6: Percentage of Providers Accepting Medicaid Patients). Individual plan results range from 63% to 75%.

Figure 6: Percentage of Providers Accepting Medicaid Patients

0%10%20%30%40%50%60%70%80%90%

100%

ATC HealthyBlue

Molina SelectHealth

WellCare Aggregate

91% 95% 96%89% 88%

92%

0%10%20%30%40%50%60%70%80%90%

100%

ATC HealthyBlue

Molina SelectHealth

WellCare Aggregate

75%63% 64% 63% 67% 66%

37



Summary of Study Findings For the five plans, overall access to providers improved from the previous cycle, as indicated by the increase in the percentage of successfully answered calls in the Telephonic Provider Access Study. The percentage of providers that are currently accepting the plan (92%) is an increase from last year’s rate of 91%. The study revealed an 11 percentage point decrease in providers accepting new Medicaid patients when compared to last year’s rate. All five met the standard for improvement from the previous Telephonic Provider Access Study results.

The percentages of “Met” scores achieved by each plan for the Provider Services section of the review are illustrated in Figure 7: Provider Services.

Figure 7: Provider Services

An overview of the scores for the Provider Services section is illustrated in Table 6: Provider Services Comparative Data.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ATC Healthy Blue Molina Select Health WellCare

92%96% 100% 99%

94%

% M

et S

tand

ards

38



Table 6: Provider Services Comparative Data


Credentialing and Recredentialing The MCO formulates and acts within policies and procedures related to the credentialing and recredentialing of health care providers in a manner consistent with contractual requirements

Met ↑ Partially Met Met ↑ Met Partially Met

Decisions regarding credentialing and recredentialing are made by a committee meeting at specified intervals and including peers of the applicant. Such decisions, if delegated, may be overridden by the MCO

Met Met Met Met Met

The credentialing process includes all elements required by the contract and by the MCO’s internal policies.

Met Met Met Met Met

Verification of information on the applicant, including: Current valid license to practice in each state where the practitioner will treat members

Met Met Met Met Met

Valid DEA certificate and/or CDS certificate

Met Met Met Met Met

Professional education and training, or board certification if claimed by the applicant

Met Met Met Met Met

Work history Met Met Met Met Met

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Malpractice claims history

Met Met Met Met Met

Formal application with attestation statement delineating any physical or mental health problem affecting ability to provide health care, any history of chemical dependency/ substance abuse, prior loss of license, prior felony convictions, loss or limitation of practice privileges or disciplinary action, the accuracy and completeness of the application

Met Met Met Met Met

Query of the National Practitioner Data Bank (NPDB)

Met Met Met Met Met

No debarred, suspended, or excluded from Federal procurement activities: Query of System for Award Management (SAM)

Met Met Met Met Met

Query for state sanctions and/or license or DEA limitations (State Board of Examiners for the specific discipline)

Met Met Met Met Met

Query of the State Excluded Provider's Report and the SC Providers Terminated for Cause list

Partially Met Met ↑ Met ↑ Met Not Met ↓

40




Query for Medicare and/or Medicaid sanctions (5 years); OIG List of Excluded Individuals and Entities (LEIE)

Met Met Met Met Met

Query of Social Security Administration’s Death Master File (SSDMF)

Met Partially Met ↓ Met Met Met

Query of the National Plan and Provider Enumeration System (NPPES)

Met Met Met Met Met

In good standing at the hospital designated by the provider as the primary admitting facility

Met Met Met Met Met

Clinical Laboratory Improvement Amendment (CLIA) Certificate (or certificate of waiver) for providers billing laboratory procedures

Partially Met ↓ Met Met Met Partially Met ↓

Ownership Disclosure form

Met Met Met Met Met

Receipt of all elements prior to the credentialing decision, with no element older than 180 days

Met Met Met Met Met

The recredentialing process includes all elements required by the contract and by the MCO’s internal policies

Met Met Met Met Met

Recredentialing conducted at least every 36 months

Met Met Met Met Met

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Verification of information on the applicant, including: Current valid license to practice in each state where the practitioner will treat members

Met Met Met Met Met

Valid DEA certificate and/or CDS certificate

Met Met Met Met Met

Board certification if claimed by the applicant

Met Met Met Met Met

Malpractice claims since the previous credentialing event

Met Met Met Met Met

Practitioner attestation statement

Met Met Met Met Met

Requery the National Practitioner Data Bank (NPDB)

Met Met Met Met Met

Requery of System for Award Management (SAM)

Met Met Met Met Met

Requery for state sanctions and/or license or DEA limitations (State Board of Examiners for the specific discipline)

Met Met Met Met Met

Requery of the State Excluded Provider's Report, the SC Providers Terminated for Cause list

Partially Met Met ↑ Met ↑ Met Not Met

Requery for Medicare and/or Medicaid sanctions since the previous credentialing event; OIG List of Excluded Individuals and Entities (LEIE)

Met Met Met Met Met

Query of the Social Security Administration’s Death Master File (SSDMF)

Met Partially Met ↓ Met Met Met

42




Query of the National Plan and Provider Enumeration System (NPPES)

Met Met Met Met Met

In good standing at the hospitals designated by the provider as the primary admitting facility

Met Met Met Met Met

Clinical Laboratory Improvement Amendment (CLIA) Certificate for providers billing laboratory procedures

Partially Met ↓ Met Met Met Met

Ownership Disclosure form

Met Met Met Met ↑ Met

Review of practitioner profiling activities


The MCO formulates and acts within written policies and procedures for suspending or terminating a practitioner’s affiliation with the MCO for serious quality of care or service issues

Met Met Met Met Met

Organizational providers with which the MCO contracts are accredited and/or licensed by appropriate authorities

Partially Met Met ↑ Met ↑ Met Not Met

Monthly provider monitoring is conducted by the MCO to ensure providers are not prohibited from receiving Federal funds

Met ↑ Met ↑ Met ↑ Met Met

Adequacy of the Provider Network

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The MCO maintains a network of providers that is sufficient to meet the health care needs of members and is consistent with contract requirements. Members have a primary care physician located within a 30-mile radius of their residence

Met Met Met Met Met↑

Members have access to specialty consultation from a network provider located within reasonable traveling distance of their homes. If a network specialist is not available, the member may utilize an out-of-network specialist with no benefit penalty


The sufficiency of the provider network in meeting membership demand is formally assessed at least bi-annually

Met Met Met Met Met

Providers are available who can serve members with special needs such as hearing or vision impairment, foreign language/cultural requirements, and complex medical needs

Met Met Met Met Met

The MCO demonstrates significant efforts to increase the provider network when it is identified as not meeting membership demand

Met Met Met Met Met

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The MCO maintains a provider directory that includes all requirements outlined in the contract

Met Met Met Met Met

The MCO formulates and ensures that practitioners act within written policies and procedures that define acceptable access to practitioners and that are consistent with contract requirements

Met Met Met Partially Met Met ↑

The Telephonic Provider Access Study conducted by CCME shows improvement from the previous study’s results

Met Met ↑ Met Met ↑ Met

Provider Education The MCO formulates and acts within policies and procedures related to initial education of providers


Initial provider education includes: MCO structure and health care programs

Met Met Met Met Met

Billing and reimbursement practices

Met Met Met Met Met

Member benefits, including covered services, excluded services, and services provided under fee-for-service payment by SCDHHS

Met Met Met Met Met

Procedure for referral to a specialist

Met Met Met Met Met

Accessibility standards, including 24/7 access

Met Met Met Met Met

45




Recommended standards of care

Met Met Met Met Met

Medical record handling, availability, retention and confidentiality

Met Met Met Met Met

Provider and member grievance and appeal procedures

Met Met Met Met Met

Pharmacy policies and procedures necessary for making informed prescription choices

Met Met Met Met Met

Reassignment of a member to another PCP

Met Met Met Met Met

Medical record documentation requirement.

Met Met Met Met Met

The MCO provides ongoing education to providers regarding changes and/or additions to its programs, practices, member benefits, standards, policies and procedures

Met Met Met Met Met

Primary and Secondary Preventive Health Guidelines The MCO develops preventive health guidelines for the care of its members that are consistent with national standards and covered benefits and that are periodically reviewed and/or updated

Met Met Met Met Met

The MCO communicates the preventive health guidelines and the expectation that they will be followed for MCO members to providers

Met Met Met Met Met

46




The preventive health guidelines include, at a minimum, the following if relevant to member demographics: Well child care at specified intervals, including EPSDTs at State-mandated intervals

Met Met Met Met Met

Recommended childhood immunizations

Met Met Met Met Met

Pregnancy care Met Met Met Met Met

Adult screening recommendations at specified intervals

Met Met Met Met Met

Elderly screening recommendations at specified intervals

Met Met Met Met Met

Recommendations specific to member high-risk groups

Met Met Met Met Met

Behavioral Health Services

Met Met Met Met Met

Clinical Practice Guidelines for Disease and Chronic Illness Management The MCO develops clinical practice guidelines for disease, chronic illness management, and behavioral health services of its members that are consistent with national or professional standards and covered benefits, are periodically reviewed and/or updated and are developed in conjunction with pertinent network specialists


47




The MCO communicates the clinical practice guidelines for disease, chronic illness management, and behavioral health services and the expectation that they will be followed for MCO members to providers

Met ↑ Met Met Met Met

Continuity of Care The MCO monitors continuity and coordination of care between the PCPs and other providers

Met Met Met Met Met

Practitioner Medical Records The MCO formulates policies and procedures outlining standards for acceptable documentation in the member medical records maintained by primary care physicians

Met Met Met Met Met

Standards for acceptable documentation in member medical records are consistent with contract requirements

Met Met Met Met Met

The MCO monitors compliance with medical record documentation standards through periodic medical record audit and addresses any deficiencies with the providers

Met Met Met Met Met

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Accessibility to member medical records by the MCO for the purposes of quality improvement, utilization management, and/or other studies is contractually assured for a period of 5 years following expiration of the contract

Met Met Met Met Met

Strengths

• Preventive health and clinical practice guidelines that are pertinent to the member populations are adopted, reviewed routinely, and communicated to providers using a variety of methods.

• Adequate processes have been developed for initial and ongoing provider education, and MCO websites contain provider educational materials, links to relevant resources, and additional information to assist providers in understanding health plan operations and requirements.

• Results of Provider Access Studies conducted by CCME confirmed improvement from previous study results for all of the MCOs. There was improvement in the percentage of providers indicating acceptance of the health plans.

Weaknesses

• Credentialing and recredentialing policies and procedures contain errors and omissions that could impact the successful conduction of these activities.

• Credentialing and recredentialing files do not contain evidence of all required components.

• Appointment timeframe requirements are incorrectly documented in policies, provider manuals, monitoring reports, etc.

• Network adequacy monitoring does not include all Status 1 providers and identified deficiencies in provider networks are not included as an action item in network adequacy work plans.

• Results of the Provider Access and Availability Studies demonstrated a decrease in the rate of providers accepting new Medicaid patients.

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Recommendations

• Ensure credentialing and recredentialing policies and procedures are revised to correct errors and to include all credentialing and recredentialing requirements.

• Ensure credentialing and recredentialing files contain evidence of all required components.

• Revise policies and other documents to correctly reflect appointment timeframe requirements.

• Ensure network adequacy monitoring includes all Status 1 providers and identified deficiencies in provider networks are included as an action item in any work plans for network adequacy monitoring and assessment.

• Implement internal monitoring of new patient acceptance rate to determine if interventions are needed to improve access to PCPs for members that are considered new patients.

C. Member Services

CCME reviewed the MCOs’ policies and procedures, program descriptions, member handbooks, and websites to determine how the MCOs were meeting SCDHHS Contract requirements. The Member Services review included member rights and responsibilities, member program education including preventive/chronic disease management education, processes for member disenrollment, processes for receiving and responding to member grievances, and Member Satisfaction Surveys.

All members have access to information and resources in the member handbooks, provider directories, on plan websites, and in member newsletters that document available services and instructions for accessing and utilizing benefits. All the health plans direct members to the plans’ public websites to access resources, such as the member handbooks, the online provider directories, preferred drug lists, newsletters, forms, and grievance and appeal information. The plans also encourage members to register for member portals, where they can access ID Cards, review individual benefit information, and communicate via email with Member Services Representatives.

The health plans have policies defining members’ rights and responsibilities, including the right to be treated with due consideration for dignity and privacy, the right to participate in decision-making regarding their health care, and the right to refuse treatment. The plans inform members of their rights in newsletters, on websites, and in member handbooks. However, CCME identified instances where members are not clearly notified of their right to request a copy of the member handbook and provider directory annually (ATC, WellCare).

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In general, member handbooks included the information members need to make decisions about their care. Each plan’s member handbook informs members about their rights and responsibilities, preventive health guidelines, and appointment guidelines, and it provides instructions on how to access benefits. Additionally, the member handbooks provide information on obtaining Advance Directives, requesting disenrollment, and accessing the Fraud and Abuse Hotlines. The handbooks are available in Spanish and alternate formats including large font, audio, and Braille. Except for ATC, plans have discontinued mailing member handbooks to new members. Instead, a new member receives a mailed Welcome Packet and an orientation phone call from the health plan. Welcome Packets include instructions for contacting Member Services, selecting a PCP, initiating services, and accessing additional information on the plans’ websites. However, CCME found that not all required information is available or easily accessible on the plans’ websites. Areas of concern included member rights and responsibilities (Healthy Blue), and member grievances and preventive health guidelines (ATC).

The MCOs use methods such as member handbooks, mailings, website content, and community events to encourage members to obtain recommended preventive services, including age-appropriate care. The plans instruct members to contact Member Services staff with questions about health topics, benefit information, eligible programs, and copayments. Each MCO has a member newsletter that provides supplemental information about the individual health plan, services offered, and topics of interest to members. The plans have processes in place to verify member materials are written in appropriate language and meet the sixth-grade reading comprehension level as required by SCDHHS. However, WellCare did not have documentation of minimum required font sizes.

CCME noted that MCOs have transitioned from the traditional method of mass mailing member materials, such as member handbooks and newsletters, towards the electronic method of posting member materials on the website. The plans notify members via mailed postcards that information is posted and available to be accessed from the website. To ensure members are accessing the necessary information required by the SCDHHS Contract, CCME recommended that MCOs monitor website traffic to ensure this online strategy is effective.

Member Services call centers are staffed and available per contract requirements. Each plan’s toll-free Member Services telephone number routes calls to Interactive Voice Response (IVR) menus that allow callers to reach appropriate staff during the hours of 8:00 a.m. to 6:00 p.m. Eastern Time, Monday through Friday. The toll-free number, fax number, and mailing address are in each plan’s member handbook and website. Outside of normal business hours, members can speak with staff at a 24-hour nurse advice line or leave a confidential voicemail message for Member Services staff. Additionally, in 2019, Select Health implemented enhanced communication features with a mobile application

51



and texting capabilities that allow members to access their ID Card, Member Handbook, and online resources, and to communicate with their case manager if applicable.

Each plan conducts an annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey via a third-party vendor. Despite oversampling, there were instances where actual sample sizes were not adequate and did not meet the National Committee for Quality Assurance (NCQA) minimum sample size and requirement of at least 411 valid surveys (Healthy Blue, Molina, WellCare). Although most of the plans’ surveys earned response rates above the national average, the rates were below NCQA target of 40%.

Policies, member handbooks, provider manuals, and websites document grievance requirements and processes. Each of the health plans tracks and analyzes grievance data to identify outstanding issues and adverse trends, and the results are routinely reported to health plan management teams and committees. CCME reviewed grievance files to determine the health plans’ compliance with grievance processes, guidelines, and contractual requirements. CCME identified the following issues with grievance documentation and files:

• Grievance information on websites was not easily accessible and lacked complete information and instructions

• Failure to require written consent for a representative to file a grievance on a member’s behalf (Healthy Blue)

• Incorrect information in ATC’s Member Handbook and Provider Manual that members can request their grievance to be processed expeditiously

• Failure to meet grievance acknowledgement and resolution timeframes (Healthy Blue, WellCare)

• Molina’s grievance files reflected grievances referred to Provider Services were closed with no documentation of investigation or resolution of the issues included in the grievance, and members were provided with a generic resolution that did not specifically address the grievance. This is a repeat finding from the previous EQR.

Figure 8: Member Services provides an overview of the plans’ performance in the Member Services section.

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Figure 8: Member Services

A comparison of the plans’ scores for the standards in the Member Services section is illustrated in Table 7: Member Services Comparative Data.

Table 7: Member Services Comparative Data


Member Rights and Responsibilities

The MCO formulates and implements policies guaranteeing each member’s rights and responsibilities and processes for informing members of their rights and responsibilities

Met Met Met Met Met

All Member rights included Met Met Met Met Met

Member MCO Program Education

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


97% 94% 97% 100%

88%

% M

et S

tand

ards

53




Members are informed in writing within 14 calendar days from the MCO’s receipt of enrollment data of all benefits and MCO information

Met Met Met Met ↑ Partially Met

Members are notified at least once per year of their right to request a Member Handbook or Provider Directory

Met Met Met Met Met

Members are informed in writing of changes in benefits and changes to the provider network


Member program education materials are written in a clear and understandable manner and meet contractual requirements

Met Met Met Met Partially Met ↓

The MCO maintains, and informs members how to access, a toll-free vehicle for 24-hour member access to coverage information from the MCO

Met Met Met Met Met

Member Enrollment and Disenrollment

The MCO enables each member to choose a PCP upon enrollment and provides assistance if needed

Met Met Met Met Met

MCO-initiated member disenrollment requests are compliant with contractual requirements

Met Met Met Met Met

Preventive Health and Chronic Disease Management Education

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The MCO informs members of available preventive health and disease management services and encourages members to utilize these services

Met Met Met Met Met

The MCO tracks children eligible for recommended EPSDT services/immunizations and encourages members to utilize these benefits

Met Met Met Met Met

The MCO provides education to members regarding health risk factors and wellness promotion

Met Met Met Met Met

The MCO identifies pregnant members; provides educational information related to pregnancy, prepared childbirth, and parenting; and tracks the participation of pregnant members in recommended care

Met Met Met Met Met

Member Satisfaction Survey

The MCO conducts a formal annual assessment of member satisfaction with MCO benefits and services. This assessment includes, but is not limited to

Met Met Met Met Met

55




Statistically sound methodology, including probability sampling to ensure it is representative of the total membership

Met Met Met Met Met

The availability and accessibility of health care practitioners and services

Met Met Met Met Met

The quality of health care received from MCO providers

Met Met Met Met Met

The scope of benefits and services Met Met Met Met Met

Claim processing procedures Met Met Met Met Met

Adverse MCO claim decisions Met Met Met Met Met

The MCO analyzes data obtained from the member satisfaction survey to identify quality issues

Met Met Met Met Met

The MCO implements significant measures to address quality issues identified through the member satisfaction survey

Met Met Met Met Met

The MCO reports the results of the member satisfaction survey to providers

Met Met Met Met Met

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The MCO reports results of the member satisfaction survey and the impact of measures taken to address identified quality issues to the Quality Improvement Committee

Met Met Met Met Met

Grievances

The MCO formulates reasonable policies and procedures for registering and responding to member grievances in a manner consistent with contract requirements, including, but not limited to

Met Met Met Met Met

The definition of a grievance and who may file a grievance

Met Partially Met ↓ Met Met Met ↑

Procedures for filing and handling a grievance Partially Met ↓ Met Met Met ↑ Met

Timeliness guidelines for resolution of a grievance Met Partially Met Met Met ↑ Partially Met ↓

Review of grievances related to clinical issues or denial of expedited appeal resolution by a Medical Director or a physician designee

Met Met Met Met Met

Maintenance and retention of a grievance log and grievance records for the period specified in the contract

Met Met ↑ Met Met Met

The MCO applies grievance policies and procedures as formulated

Met ↑ Met Not Met ↓ Met ↑ Partially Met ↓

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Grievances are tallied, categorized, analyzed for patterns and potential quality improvement opportunities, and reported to the Quality Improvement Committee


Grievances are managed in accordance with the MCO confidentiality policies and procedures

Met Met Met Met Met

Strengths

• Member newsletters include preventive health information and resources that are universally geared toward all members, as well as information for specific populations such as teenagers, women, and those with chronic illnesses.

Weaknesses

• Plans do not consistently notify members of their right to request copies of the Member Handbook and Provider Directory annually.

• The documentation of the minimum font sizes required for member materials was not consistently noted in policies.

• Member satisfaction survey response rates continue to fall below the NCQA target response rate of 40%. Low CAHPS survey response rates affect generalizability of results.

• The plans did not consistently meet requirements for grievance acknowledgement and resolution timeframes, processing grievance requests and for capturing grievance requirements in policies and other documents.

Recommendations

• Ensure members are clearly informed of their rights to request copies of the Member Handbook and Provider Directory at least once each calendar year, as required in the SCDHHS Contract, Section 3.13.2.18.

• Ensure policies include the requirement to use 12-point font size for regular print and 18-point font size for large printed member materials as per the SCDHHS Contract, Sections 3.15.1.3 and 3.15.2.8.

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• Continue working with survey vendors to increase response rates for Adult and Child surveys.

• Ensure staff adhere to timeframes for processing grievance requests and documenting grievance requirements.

D. Quality Improvement

For the Quality Improvement (QI) section, CCME reviewed program descriptions, committee structures and minutes, performance measures, PIPs, and the QI program evaluations.

QI program descriptions adequately described the programs the health plans have implemented to monitor, evaluate, and improve the quality of clinical care and services provided to their members. The plans review and update program descriptions at least annually.

The work plans help guide and monitor activities planned for the year. The health plans provided their QI work plans for review. Each work plan identified specific activities, responsible parties, and specific dates for completion. Some of the issues identified in the work plans submitted by Healthy Blue, Molina, Select Health, and WellCare included incorrect dates, errors, or missing benchmarks and goals. In addition, the work plans did not always include ongoing monitoring activities.

All health plans established committees responsible for implementing, monitoring, and directing QI activities. Committee membership includes a variety of network providers, senior executives, directors, and other health plan staff. Most of the committees met at least quarterly. Minutes were recorded for each meeting and documented committee discussion points and decisions.

The health plans conducted an evaluation of the effectiveness of the QI programs and provided copies of their program evaluation. Program evaluations included the QI activities conducted in the previous year, results of those activities, any barriers identified, interventions, and recommendations. Molina provided the “2018 Molina of South Carolina QI Program Evaluation/Executive Summary.” This summary did not include all quality improvement activities. Practitioner Availability and Accessibility of Services, patient safety initiatives, medical record review activities, delegation monitoring, and performance improvement project results were not included.

Performance Measure Validation

Health plans are required to report plan performance using HEDIS® measures applicable to the Medicaid population. To evaluate the accuracy of the PMs reported, CCME uses the

59



CMS Protocol, Validation of Performance Measures. This validation protocol balances the subjective and objective parts of the review, supports a review that is fair to the plans, and provides the State with information about how each plan is operating.

All plans are using a HEDIS® certified vendor or software to collect and calculate the measures, and all were found “Fully Compliant.” Plan rates for the most recent review year are reported in Table 8, HEDIS® Performance Measure Data for HEDIS 2019. The statewide average is calculated as the average of the plan rates and shown in the last column in the table.

Table 8 : HEDIS® Performance Measure Data for HEDIS 2019



Effectiveness of Care: Prevention and Screening

Adult BMI Assessment (aba) 87.59% 87.35% 90.27% 87.44% 89.37% 88.40%

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (wcc)

BMI Percentile 84.18% 80.29% 73.24% 79.90% 82.48% 80.02%

Counseling for Nutrition 67.40% 67.15% 62.04% 64.07% 63.75% 64.88%

Counseling for Physical Activity 64.72% 62.53% 56.20% 59.30% 59.12% 60.37%

Childhood Immunization Status (cis)

DTaP 72.26% 75.91% 74.94% 77.62% 75.18% 75.18%

IPV 90.75% 88.08% 84.18% 92.46% 87.83% 88.66%

MMR 87.59% 88.08% 88.08% 88.56% 88.32% 88.13%

HiB 82.48% 83.45% 83.70% 85.40% 83.21% 83.65%

Hepatitis B 90.27% 89.29% 84.91% 91.97% 89.54% 89.20%

VZV 86.62% 87.83% 87.59% 88.32% 88.56% 87.78%

Pneumococcal Conjugate 78.35% 78.10% 77.13% 82.97% 75.18% 78.35%

Hepatitis A 85.16% 83.70% 82.97% 84.43% 82.00% 83.65%

Rotavirus 73.97% 71.29% 70.07% 78.59% 69.10% 72.60%

Influenza 39.90% 41.85% 37.96% 38.69% 40.15% 39.71%

Combination #2 67.88% 71.53% 70.32% 74.21% 71.78% 71.14%

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Combination #3 65.94% 69.59% 68.86% 72.51% 68.37% 69.05%

Combination #4 64.96% 67.88% 66.67% 70.56% 65.69% 67.15%

Combination #5 57.18% 60.10% 58.64% 63.50% 58.39% 59.56%

Combination #6 32.85% 36.50% 32.60% 34.31% 32.85% 33.82%

Combination #7 56.69% 59.12% 57.18% 62.53% 56.20% 58.34%

Combination #8 32.60% 36.25% 32.60% 34.31% 32.36% 33.62%

Combination #9 28.95% 32.60% 28.71% 31.39% 29.68% 30.27%

Combination #10 28.71% 32.36% 28.71% 31.39% 29.20% 30.07%

Immunizations for Adolescents (ima)

Meningococcal 74.45% 72.02% 77.13% 76.40% 69.34% 73.87%

Tdap/Td 84.91% 83.21% 87.10% 89.54% 82.48% 85.45%

HPV 73.72% 29.68% 32.12% 34.06% 68.37% 47.59%

Combination #1 30.66% 71.29% 76.40% 75.43% 28.95% 56.55%

Combination #2 32.36% 28.71% 31.87% 33.3% 29.93% 31.23%

Lead Screening in Children (lsc) 69.13% 70.32% 69.34% 76.32% 71.53% 71.33%

Breast Cancer Screening (bcs) 64.56% 50.95% 58.83% 60.56% 53.89% 57.76%

Cervical Cancer Screening (ccs) 65.94% 57.61% 58.15% 68.71% 55.53% 61.19%

Chlamydia Screening in Women (chl)

16-20 Years 57.14% 51.96% 57.16% 57.09% 57.84% 56.24%

21-24 Years 66.24% 66.23% 68.35% 64.76% 68.86% 66.89%

Total 59.65% 56.88% 60.04% 59.05% 60.55% 59.23%

Effectiveness of Care: Respiratory Conditions Appropriate Testing for Children with Pharyngitis (cwp)

79.47% 84.67% 81.59% 84.10% 81.97% 82.36%

Use of Spirometry Testing in the Assessment and Diagnosis of COPD (spr)

21.86% 30.25% 26.46% 30.92% 23.26% 26.55%

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Pharmacotherapy Management of COPD Exacerbation (pce)

Systemic Corticosteroid 66.50% 61.46% 68.76% 62.92% 63.93% 64.71%

Bronchodilator 78.33% 79.05% 78.10% 79.50% 74.24% 77.84%

Medication Management for People With Asthma (mma)











Asthma Medication Ratio (amr)

5-11 Years 83.04% 80.04% 79.71% 75.76% 76.76% 79.06%

12-18 Years 72.66% 71.34% 72.03% 66.96% 70.17% 70.63%

19-50 Years 54.43% 54.73% 54.37% 56.27% 56.94% 55.35%

51-64 Years 60.71% 48.39% 48.78% 59.77% 56.36% 54.80%

Total 73.84% 70.58% 71.49% 69.72% 70.33% 71.19%

Effectiveness of Care: Cardiovascular Conditions Controlling High Blood Pressure (cbp) 46.47% 52.80% 50.12% 60.10% 48.66% 51.63%

Persistence of Beta-Blocker Treatment After a Heart Attack (pbh)

80.43% 54.17* 76.92% 78.31% 70.83%* 76.62%

Statin Therapy for Patients With Cardiovascular Disease (spc)

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Received Statin Therapy - 21-75 years (Male) 77.49% 77.29% 79.08% 77.28% 79.77% 78.18%

Statin Adherence 80% - 21-75 years (Male) 50.84% 61.25% 52.26% 58.78% 49.28% 54.48%

Received Statin Therapy - 40-75 years (Female) 72.73% 72.13% 71.43% 75.12% 75.00% 73.28%

Statin Adherence 80% - 40-75 years (Female) 50.66% 57.58% 53.08% 51.13% 34.34% 49.36%

Received Statin Therapy – Total 75.23% 74.87% 75.40% 76.16% 77.70% 75.87%

Statin Adherence 80% - Total 50.76% 59.59% 52.63% 54.86% 43.04% 52.18%

Effectiveness of Care: Diabetes

Comprehensive Diabetes Care (cdc)

Hemoglobin A1c (HbA1c) Testing 89.29% 85.16% 89.77% 89.35% 88.77% 88.47%

HbA1c Poor Control (>9.0%) 42.34% 49.64% 47.49% 46.03% 41.85% 45.47%

HbA1c Control (<8.0%) 48.91% 42.58% 44.19% 43.50% 48.31% 45.50%

HbA1c Control (<7.0%) NR NR NR 29.20% 40.63% 34.92%

Eye Exam (Retinal) Performed 57.91% 36.74% 61.87% 55.42% 52.62% 52.91%

Medical Attention for Nephropathy 90.79% 88.81% 93.41% 91.16% 91.23% 91.08%

Blood Pressure Control (<140/90 mm Hg) 44.04% 59.61% 55.46% 60.29% 55.38% 54.96%

Statin Therapy for Patients With Diabetes (spd)

Received Statin Therapy 60.74% 61.79% 62.22% 60.58% 59.31% 60.93%

Statin Adherence 80% 45.55% 51.57% 45.24% 50.94% 46.72% 48.00%

Effectiveness of Care: Musculoskeletal Conditions Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis (art)

67.23% 64.29% 71.19% 70.42% 68.13% 68.25%

Effectiveness of Care: Behavioral Health

Antidepressant Medication Management (amm)

Effective Acute Phase Treatment 41.32% 46.90% 39.50% 44.86% 41.40% 42.80%

Effective Continuation Phase Treatment 25.10% 32.17% 25.16% 29.55% 25.54% 27.50%

Follow-Up Care for Children Prescribed ADHD Medication (add)

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Initiation Phase 53.06% 38.31% 60.05% 39.38% 36.58% 45.48%

Continuation and Maintenance (C&M) Phase 63.59% 55.75% 76.74% 52.65% 54.42% 60.63%

Follow-Up After Hospitalization for Mental Illness (fuh)









Follow-Up After Emergency Department Visit for Mental Illness (fum)








Total - 7-Day Follow-Up 35.54%% 34.46% 39.60% 44.46% 41.86% 40.10%

Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence (fua)





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Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medication (ssd)

75.19% 75.25% 79.82% 78.67% 70.79% 75.94%

Diabetes Monitoring for People With Diabetes and Schizophrenia (smd)

61.93% 70.15% 74.21% 69.23% 68.53% 68.81%

Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (smc)

47.83% NA* NA 75.00%* 60.00%* 47.83%

Adherence to Antipsychotic Medications for Individuals With Schizophrenia (saa)

62.93% 64.68% 72.34% 67.47% 65.46% 66.58%

Metabolic Monitoring for Children and Adolescents on Antipsychotics (apm)

1-5 Years 0.00%* 0.00%* 0.00%* 19.44% NA* NA

6-11 Years 25.69% 17.39% 20.00% 30.49% 30.00% 24.71%

12-17 Years 35.79% 22.88% 27.67% 41.23% 21.65% 29.84%

Total 32.00% 20.53% 25.42% 37.27% 24.49% 27.94%

Effectiveness of Care: Medication Management

Annual Monitoring for Patients on Persistent Medications (mpm)

ACE Inhibitors or ARBs 88.29% 88.75% 91.62% 89.70% 89.15% 89.50%

Diuretics 88.89% 87.87% 91.83% 89.85% 89.61% 89.61%

Total 88.57% 88.34% 91.72% 89.77% 89.35% 89.55%

Effectiveness of Care: Overuse/Appropriateness Non-Recommended Cervical Cancer Screening in Adolescent Females (ncs)

2.22% 0.65% 0.92% 0.81% 1.04% 1.13%

Appropriate Treatment for Children With URI (uri) 89.11% 87.75% 87.58% 86.37% 88.66% 87.89%

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (aab)

30.38% 27.59% 26.68% 26.03% 30.38% 28.21%

Use of Imaging Studies for Low Back Pain (lbp) 65.52% 67.00% 63.34% 73.17% 65.48% 66.90%

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Use of Multiple Concurrent Antipsychotics in Children and Adolescents (apc)

1-5 Years* 0.00 0.00% NA 0.00% NA NA

6-11 Years 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

12-17 Years 1.53% 1.10% 0.00% 1.44% 1.39% 1.09%

Total .94% 0.68% 0.00% 0.95% 0.89% 0.69%

Use of Opioids at High Dosage (uod) 4.65% 5.23% 2.44% 3.62% 4.10% 4.01%

Use of Opioids From Multiple Providers (uop)

Multiple Prescribers 17.64% 23.56% 25.40% 25.58% 25.44% 23.52%

Multiple Pharmacies 7.78% 4.72% 9.35% 14.92% 8.46% 9.05%

Multiple Prescribers and Multiple Pharmacies 2.91% 1.89% 4.46% 6.51% 4.21% 4.00%

Risk of Continued Opioid Use (cou)







Access/Availability of Care

Adults' Access to Preventive/Ambulatory Health Services (aap)

20-44 Years 76.47% 75.57% 79.69% 79.79% 73.07% 76.92%

45-64 Years 85.16% 85.50% 89.17% 89.03% 84.20% 86.61%

65+ Years* 100% 66.67% 80.00% 80.00% 100.00% 85.33%

Total 79.17% 78.51% 82.97% 81.99% 77.01% 79.93%

Children and Adolescents' Access to Primary Care Practitioners (cap)

12-24 Months 96.55% 97.19% 96.73% 97.55% 95.53% 96.71%

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25 Months - 6 Years 85.33% 86.31% 86.11% 88.74% 83.29% 85.96%

7-11 Years 88.13% 88.40% 89.88% 91.66% 85.98% 88.81%

12-19 Years 86.86% 85.56% 89.48% 90.21% 84.46% 87.31%

Initiation and Engagement of AOD Dependence Treatment (iet)


13-17 Years* 35.71% 25.00% 42.11% 38.10% 36.36% 35.46%


Treatment: 13-17 Years* 21.43% 25.00% 21.05% 26.67% 9.09% 20.65%


13-17 Years* 33.33% 25.00% 0.00% 30.43% 0.00% 17.75%


Treatment: 13-17 Years* 16.67% 25.00% 0.00% 21.74% 0.00% 12.68%


Treatment: 13-17 Years 35.34% 34.41% 40.54% 35.45% 33.70% 35.89%

Other drug abuse or dependence: Engagement of AOD Treatment: 13-17 Years

23.31% 22.58% 25.23% 24.55% 22.83% 23.70%

Initiation of AOD Treatment: 13-17 Years 34.69% 32.00% 39.67% 35.05% 33.33% 34.95%

Engagement of AOD Treatment: 13-17 Years 21.77% 21.00% 23.97% 24.02% 21.21% 22.39%


18+ Years 44.78% 39.57% 40.92% 39.76% 45.77% 42.16%


Treatment: 18+ Years 9.20% 9.27% 7.38% 9.68% 8.45% 8.80%


18+ Years 39.50% 42.15% 50.59% 46.04% 47.48% 45.15%


Treatment: 18+ Years 14.25% 22.46% 22.78% 25.06% 17.65% 20.44%


Treatment: 18+ Years 42.77% 40.65% 37.96% 34.65% 41.36% 39.48%


AOD Treatment: 18+ Years 11.21% 10.36% 9.41% 10.97% 9.84% 10.36%

Initiation of AOD Treatment: 18+ Years 41.30% 38.89% 39.74% 37.54% 42.88% 40.07%

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Engagement of AOD Treatment: 18+ Years 10.55% 10.95% 10.70% 12.92% 9.77% 10.98%


Total 44.44% 39.27% 40.96% 39.63% 45.60% 41.98%


Treatment: Total 9.66% 9.60% 7.77% 10.99% 8.46% 9.30%


Total 39.41% 41.95% 50.29% 45.63% 47.08% 44.87%


Treatment: Total 14.29% 22.49% 22.65% 24.97% 17.50% 20.38%


Treatment: Total 41.91% 40.06% 38.22% 34.82% 40.52% 39.11%


AOD Treatment: Total 12.61% 11.52% 11.01% 13.91% 11.26% 12.06%

Initiation of AOD Treatment: Total 40.82% 38.48% 39.74% 37.17% 42.22% 39.69%

Engagement of AOD Treatment: Total 11.38% 11.55% 11.57% 14.57% 10.56% 11.93%

Prenatal and Postpartum Care (ppc)

Timeliness of Prenatal Care 91.48% 90.98% 86.37% 88.19% 88.16% 89.04%

Postpartum Care 67.40% 70.22% 69.83% 70.83% 61.05% 67.87%

Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (app)

1-5 Years* 0.00%* NA* 0.00%* 45.16% 0.00%* NA

6-11 Years 52.36% 72.00%* 52.63% 68.31% 60.87%* 57.77%

12-17 Years 52.58% 61.29% 61.63% 57.83% 45.65% 55.80%

Total 52.52% 66.07% 58.40% 61.28% 49.30% 57.51%

Utilization

Well-Child Visits in the First 15 Months of Life (w15)

0 Visits 2.19% 0.97% 0.73% 1.83% 2.66% 1.68%

1 Visit 0.49% 1.46% 0.49% 0.91% 2.39% 1.15%

2 Visits 2.68% 1.22% 2.19% 3.35% 3.19% 2.53%

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3 Visits 3.41% 2.68% 4.14% 2.44% 3.46% 3.23%

4 Visits 8.52% 7.54% 8.52% 4.27% 9.84% 7.74%

5 Visits 14.36% 10.71% 14.84% 8.23% 15.16% 12.66%

6+ Visits 68.37% 75.43% 69.10% 78.96% 63.30% 71.03%

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (w34)

63.75% 63.75% 60.83% 76.72% 63.28% 65.67%

Adolescent Well-Care Visits (awc) 55.96% 51.58% 51.58% 65.84% 51.95% 55.38%

NR = Not Reported; NA = Not Applicable due to missing data; * = small denominator

SCDHHS Withhold Measures The plans were required to report 12 quality clinical withhold measures. Per the SCDHHS Medicaid Playbook and Policy and Procedure Guide for Managed Care Organizations, individual measures within the quality index are weighted differently. A point value is assigned for each measure based on percentile (<10 Percentile = 1 point; 10-24% = 2 points; 25-49% = 3 points; 50-74% = 4 points; 75-90% = 5 points; >90% = 6 points). Points attained for each measure are multiplied by individual measure weights, then summed to obtain the quality index score. The 2018 rate, percentile, point value, and index score are shown in the tables that follow.

Table 9: ATC Quality Withhold Measures

Measure ATC 2018 Rate

ATC 2018 Percentile

Point Value Index Score

DIABETES

Hemoglobin A1c (HbA1c) Testing 89.29% 90 6

4.45 HbA1c Control (< =9) 42.34% 25 3

Eye Exam (Retinal) Performed 57.91% 75 5

Medical Attention for Nephropathy 90.79% 25 3

WOMEN'S HEALTH

Timeliness of Prenatal Care 91.48% 90 6 5.10

Breast Cancer Screen 64.09% 75 5

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Measure ATC 2018 Rate

ATC 2018 Percentile


Cervical Cancer Screen 65.94% 75 5

Chlamydia Screen in Women (Total) 59.65% 50 4

PEDIATRIC PREVENTIVE CARE

6+ Well-Child Visits in First 15 months of Life 68.37% 50 4

3.25

Well Child Visits in 3rd,4th,5th & 6th Years of Life 63.75% 10 2

Adolescent Well-Care Visits 55.96% 50 4

Weight Assessment/Adolescents: BMI % Total 84.18% 75 5

BEHAVIORAL HEALTH

Follow-Up After Hospitalization for Mental Illness - 7 Days 27.43% 10 2

3.25

Initiation & Engagement of Alcohol & Other Drug Dependence Treatment - Initiation – Total

40.82% 25 3

Follow Up for Children Prescribed ADHD Medication – Initiation 53.06% 75 5

Continuation Phase-Antidepressant Medication Management - 180 Days (6 Months)

25.1% <10 1

Metabolic Monitoring for Children & Adolescents on Antipsychotics - Total 32.00% 50 4

Use of First-Line Psychosocial Care for Children & Adolescents on Antipsychotics - Total

52.52% 10 2

Table 10: Healthy Blue Quality Withhold Measures

Measure Healthy Blue 2018 Rate

Healthy Blue 2018

Percentile


DIABETES


2.40 HbA1c Control (< =9) 49.64% 25 3

Eye Exam (Retinal) Performed 36.74% <10 1


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Measure Healthy Blue 2018 Rate

Healthy Blue 2018

Percentile


WOMEN'S HEALTH

Timeliness of Prenatal Care 90.08% 90 6

4.10 Breast Cancer Screen 50.95% 25 3





3.45




BEHAVIORAL HEALTH

Follow Up Care for Children Prescribed ADHD Medication- Initiation

38.31% 10 2

2.25

Antidepressant Medication Management Effective Continuation Phase Treatment

32.17% 25 3

Use of First Line Psychosocial Care for children and Adolescents on Antipsychotics- Total

66.07% 75 5

Metabolic Monitoring for Children and Adolescents on Antipsychotics- Total

20.53% <10 1

Follow Up After Hospitalization for mental Illness- 7 Day Follow Up Total 31.78% 25 3

Initiation and Engagement of AOD use or Dependence Treatment: Initiation Total

38.48% 25 3

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Table 11: Molina Quality Withhold Measures

Measure Molina 2018 Rate

Molina 2018

Percentile


DIABETES


5.05 HbA1c Control (< =9) 47.49% 25 3

Eye Exam (Retinal) Performed 61.87% 90 6


WOMEN'S HEALTH

Timeliness of Prenatal Care 86.37% 75 5

4.05 Breast Cancer Screen 58.83% 50 4





2.85




BEHAVIORAL HEALTH

Follow Up Care for Children Prescribed ADHD Medication- Initiation 60.05% 90 6

3.25

Antidepressant Medication Management Effective Continuation Phase Treatment 25.16 <10 1

Use of First Line Psychosocial Care for children and Adolescents on Antipsychotics- Total

58.4 25 3

Metabolic Monitoring for Children and Adolescents on Antipsychotics- Total 25.42 25 3

Follow Up After Hospitalization for mental Illness- 7 Day Follow Up Total 33.45 25 3

Initiation and Engagement of AOD use or Dependence Treatment: Initiation Total 39.74 25 3

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Table 12: Select Health Quality Withhold Measures

Measure Select Health

2018 Rate

Select Health 2018

Percentile


DIABETES

Hemoglobin A1c (HbA1c) Testing 89.35 90 6

4.25 HbA1c Control (< =9) 46.03 25 3

Eye Exam (Retinal) Performed 55.42 50 4

Medical Attention for Nephropathy 91.16 25 3

WOMEN'S HEALTH

Timeliness of Prenatal Care 88.19 75 5

4.80 Breast Cancer Screen 60.56 50 4

Cervical Cancer Screen 68.71 90 6

Chlamydia Screen in Women (Total) 59.05 50 4


6+ Well-Child Visits in First 15 months of Life 78.96 90 6

5.00

Well Child Visits in 3rd,4th,5th & 6th Years of Life 76.72 50 4

Adolescent Well-Care Visits 65.84 90 6

Weight Assessment/Adolescents: BMI % Total 79.90 50 4

BEHAVIORAL HEALTH

Follow-Up Care for Children Prescribed ADHD Medication- Initiation Phase 39.38 10 2

3.00

Antidepressant Medication Management- Continuation Phase Treatment 29.55 25 3

Metabolic Monitoring for Children and Adolescents on Antipsychotics-Total 37.27 75 5

Initiation and Engagement of AOD Abuse or Dependence Treatment- Initiation Total 37.17 10 2

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Table 13: WellCare Quality Withhold Measures

Measure WellCare 2018 Rate

WellCare 2018

Percentile


DIABETES

Hemoglobin A1c (HbA1c) Testing 85.00% 25 3.00

3.60 HbA1c Control (< =9) 51.83% 25 3.00

Eye Exam (Retinal) Performed 50.83% 25 3.00

Medical Attention for Nephropathy 94.00% 90 6.00

WOMEN'S HEALTH

Timeliness of Prenatal Care 93.03% 90 6.00

4.10 Breast Cancer Screen 54.42% 25 3.00

Cervical Cancer Screen 59.04% 25 3.00

Chlamydia Screen in Women (Total) 57.43% 50 4.00


6+ Well-Child Visits in First 15 months of Life 66.00% 25 3.00

2.40

Well Child Visits in 3rd,4th,5th & 6th Years of Life 59.50% <10 1.00

Adolescent Well-Care Visits 54.00% 25 3.00

Weight Assessment/Adolescents: BMI % Total 87.39% 75 5.00

BEHAVIORAL HEALTH

Follow-Up Care for Children Prescribed ADHD Medication- Initiation Phase 26.84% 10 2.0

Not Reported

Antidepressant Medication Management- Continuation Phase Treatment 51.02% 50 4.0

Metabolic Monitoring for Children and Adolescents on Antipsychotics-Total 21.58% <10 1.0

Initiation and Engagement of AOD Abuse or Dependence Treatment- Initiation Total

45.00% 50 4.0

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Performance Improvement Project Validation

Each health plan is required to submit its Performance Improvement Projects (PIPs) to CCME annually for review. CCME validates and scores the submitted projects using a CMS-designed protocol that evaluates the validity and confidence in the results of each project. The 12 projects reviewed in 2019-2020 for the five plans are displayed in Table 14, Results of the Validation of PIPs.

Table 14: Results of the Validation of PIPs


ATC

Postpartum Care 111/111=100%


Provider Satisfaction 104/105=99%


Healthy Blue

Access and Availability of Care- Non-Clinical 130/131= 99%


Comprehensive Diabetes Care- Clinical 120/126=95%


Molina

Breast Cancer Screening (Clinical) 91/91=100%


Well Care Visits (Clinical) 111/111=100%


Improving Claims Accuracy and Provider Satisfaction (Non-Clinical)


Select Health

Diabetes Outcomes Measures: Clinical 105/111=95%


Follow-up After Hospitalization for Mental Health Within 7 and 30 Calendar Days After Discharge: Non-Clinical


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WellCare

Improving Dilated Retinal Exam (DRE) Screening 91/91=100%


Access to Care 91/91=100%


Improving Hemoglobin A1C Testing 96/96=100%


All 12 PIPs (100%) received a score in the High Confidence Range.

Issues for PIPs Most plans received strong validation scores for their PIPs. However, the validation identified some issues. The rates and rate components (numerator/denominator) were not accurately documented in some PIP reports. CCME recommends initiating new interventions or revising current intervention to improve rates, as indicator rates declined for some PIPs.

Overall, the plans performed well in the QI section. Figure 9: Quality Improvement and Table 15: Quality Improvement Comparative Data provide an overview of the plans’ performance in the QI section.

Figure 9: Quality Improvement

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


100% 100%

86%

100% 100%

% M

et S

tand

ards

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Table 15: Quality Improvement Comparative Data


The Quality Improvement (QI) Program

The MCO formulates and implements a formal quality improvement program with clearly defined goals, structure, scope and methodology directed at improving the quality of health care delivered to members

Met Met Met Met Met

The scope of the QI program includes investigation of trends noted through utilization data collection and analysis that demonstrate potential health care delivery problems

Met Met Met Met Met

An annual plan of QI activities is in place which includes areas to be studied, follow up of previous projects where appropriate, timeframe for implementation and completion, and the person(s) responsible for the project(s)

Met Met Partially Met ↓ Met Met

Quality Improvement Committee

The MCO has established a committee charged with oversight of the QI program, with clearly delineated responsibilities

Met Met Met Met Met

The composition of the QI Committee reflects the membership required by the contract

Met Met Met Met Met

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The QI Committee meets at regular quarterly intervals

Met Met Met Met Met

Minutes are maintained that document proceedings of the QI Committee

Met Met Met Met Met

Performance Measures

Performance measures required by the contract are consistent with the requirements of the CMS protocol “Validation of Performance Measures”

Met Met Met Met Met

Quality Improvement Projects

Topics selected for study under the QI program are chosen from problems and/or needs pertinent to the member population

Met Met Met Met Met

The study design for QI projects meets the requirements of the CMS protocol “Validating Performance Improvement Projects”

Met Met Met ↑ Met Met

Provider Participation in QI Activities

The MCO requires its providers to actively participate in QI activities

Met Met Met Met Met

Providers receive interpretation of their QI performance data and feedback regarding QI activities

Met Met Met Met Met

Annual Evaluation of the QI Program

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A written summary and assessment of the effectiveness of the QI program for the year is prepared annually

Met Met Partially Met ↓ Met Met

The annual report of the QI program is submitted to the QI Committee and to the MCO Board of Directors

Met Met Met Met Met

Strengths

• All the plans have quality improvement programs designed to monitor, evaluate, and improve the quality of clinical care and services provided to members.

• Qualitative narrative analyses were clearly documented for PIPs.

• All health plans provided evidence for PIP rationale and alignment of interventions according to barrier analysis.

Weaknesses

• Results were not reported accurately for some PIPs.

• Indicator rates declined, suggesting interventions were not yet effective.

Recommendations

• Confirm accuracy for indicator rates, including numerator and denominator reporting.

• Initiate new interventions or revise current intervention to improve rates.

E. Utilization Management

Each of the MCOs has a Utilization Management (UM) program description specific to the Medicaid line of business. The program descriptions define program structures, lines of authority, goals, objectives, and staff roles. Policies and procedures define how medical necessity determinations, appeals, and Case Management services are operationalized to provide services to members. UM processes and requirements are also included in the MCOs’ member handbooks, provider manuals, and on websites. CCME identified various issues that were discussed during the in-person or teleconference onsite visits and provided recommendations to correct them.

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UM activities occur with oversight by a Medical Director whose responsibilities include, but are not limited to, supervising medical necessity decisions, conducting UM reviews, and participating in plan committees. Roles for the Behavioral Health (BH) Medical Directors and Pharmacy Directors are also outlined.

Service authorization requests are conducted by appropriately licensed reviewers using Milliman Care Guidelines (MCG), InterQual Criteria, and other established criteria. Standards such as annual inter-rater reliability studies are conducted to assess applications of medical necessity criteria and decision-making. Even though CCME identified minor errors and deviations across all plans, UM files revealed staff consistently follow established procedures and requirements for processing authorization requests, and review of approval and denial files reflect timely acknowledgement and determinations. Additionally, the list of UM Physician reviewers reflects a diversity of clinical specialties.

Each MCO either directly provides the pharmacy benefit or has a pharmacy benefit manager in place to process and determine medication authorization requests by a licensed pharmacist within 24 hours. The only exception is that Molina’s pharmacy authorizations are acknowledged by fax within 24 hours, and standard determinations are made within 14 days of receipt. The Preferred Drug List (PDL) provides formulary restrictions indicating medications that require prior authorization, limitations, or step therapy. For ATC, a review of pharmacy documents revealed issues such as: inconsistent timeframes required for PDL changes, PDL changes not prominently displayed on the website, and discrepancies in timeframes for new members to fill prescriptions needing prior authorization.

The MCOs have established policies and procedures for handling appeals of adverse benefit determinations. Additionally, information and resources for filing appeals are in member handbooks, provider manuals, on plan websites, and in other member materials. However, Healthy Blue did not have any appeals information on its website. CCME identified instances where website information was not visibly located or easily accessible.

CCME found minor documentation issues related to appeals repeated across the health plans, such as documenting incorrect or inconsistent timelines for when the appeal process begins, use of incorrect terminology, and incomplete information when defining appeals and related terms. Other issues included omitted or incorrect timeframes, missing documentation of member rights related to appeal processes and State Fair Hearings.

Overall, reviews of appeals files indicate that staff primarily followed appropriate appeals processes and requirements, that appeal resolutions were timely, and that

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appeal resolution letters contained all contractually required components. However, CCME identified the following plan-specific appeal file issues:

• Lack of signed Appeal Representative Forms, lack of signed medical record releases prior to sending members’ case files, failure to notify members when an expedited appeal request is downgraded to a standard request, and failure to have a medical necessity file reviewed by a physician (Healthy Blue).

• Members not informed they have access to their appeal case file and other documents related to the appeal prior to the resolution timeframe and inconsistencies in the address to submit written appeals (Molina).

The MCOs have Case Management (CM) Programs that follow standards developed by the Case Management Society of America (CMSA) and use case management techniques to ensure comprehensive, coordinated care for all members at various risk levels. Each MCO has established a Population Health Management (PHM) approach towards reducing health disparities, addressing social determinants of health, and enhancing the overall CM program. The plans use various methods to identify members for CM services, including predictive modeling, data mining, and internal and external referrals.

CM files indicate case management activities include a multi-disciplinary team of both clinical and non-clinical staff in physical health, behavioral health, and pharmaceutical areas. Case Managers follow policies and guidelines to conduct appropriate case management, care coordination, and disease management activities. The plans consistently verify HIPAA, identify care-gaps, and address social determinants of health factors during member outreach. Member outreach occurs either telephonically or in-person according to SCDHHS and health plan policy. In early Spring 2020, health plans suspended in-person visits due to COVID-19 restrictions from SCDHHS, and member interactions were only by phone.

Each MCO annually evaluates the UM and CM Programs to assess strengths, effectiveness, and opportunities for improvement. Evaluations include an analysis of UM and CM resources, metrics, and key performance indicators, and the results are reported to the respective UM and Quality committees. Review of committee meeting minutes reflects network practitioners are voting members who participate and provide input on medical necessity determination guidelines and other UM decisions.

Documents, such as program evaluations and committee meeting minutes, indicate the MCOs monitor and analyze under- and over-utilization of medical services as required by the contract.

A comparison of all scores for the UM section is illustrated in Figure 10: Utilization Management and in Table 16: Utilization Management Comparative Data.

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Figure 10: Utilization Management

Table 16: Utilization Management Comparative Data


The Utilization Management (UM) Program

The MCO formulates and acts within policies and procedures that describe its utilization management program, including but not limited to

Met Met Met Met Met

Structure of the program and methodology used to evaluate the medical necessity

Met Met Met Met Met

Lines of responsibility and accountability Met Met Met Met Met

Guidelines / standards to be used in making utilization management decisions

Met Met Met Met Met

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


98% 98% 98% 100%

88%

% M

et S

tand

ards

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Timeliness of UM decisions, initial notification, and written (or electronic) verification

Met ↑ Met ↑ Met ↑ Met Partially Met

Consideration of new technology Met Met Met Met Met

The absence of direct financial incentives or established quotas to provider or UM staff for denials of coverage or services

Met Met Met Met Met

The mechanism to provide for a preferred provider program

Met Met Met ↑ Met Met

Utilization management activities occur within significant oversight by the Medical Director or the Medical Director’s physician designee

Met Met Met Met Met

The UM program design is periodically reevaluated, including practitioner input on medical necessity determination guidelines and grievances and/or appeals related to medical necessity and coverage decisions

Met Met Met Met Met

Medical Necessity Determinations

Utilization management standards/criteria used are in place for determining medical necessity for all covered benefit situations

Met Met Met Met Met

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Utilization management decisions are made using predetermined standards/criteria and all available medical information

Met Met Met Met Met

Coverage of hysterectomies, sterilizations and abortions is consistent with state and federal regulations

Met Met Met Met Met

Utilization management standards/criteria are reasonable and allow for unique individual patient decisions

Met Met Met Met Met

Utilization management standards/criteria are consistently applied to all members across all reviewers

Met Met Met Met Met

Any pharmacy formulary restrictions are reasonable and are made in consultation with pharmaceutical experts


If the MCO uses a closed formulary, there is a mechanism for making exceptions based on medical necessity

Met Met Met Met Met

Emergency and post stabilization care are provided in a manner consistent with the contract and federal regulations

Met Met Met Met Met

Utilization management standards/criteria are available to providers

Met Met Met Met Met

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Utilization management decisions are made by appropriately trained reviewers

Met Met Met Met Met

Initial utilization decisions are made promptly after all necessary information is received

Met Met Met Met Met

A reasonable effort that is not burdensome on the member or the provider is made to obtain all pertinent information prior to making the decision to deny services

Met Met Met Met Met

All decisions to deny services based on medical necessity are reviewed by an appropriate physician specialist

Met Met Met Met Met

Denial decisions are promptly communicated to the provider and member and include the basis for the denial of service and the procedure for appeal

Met Met Met Met Met

Appeals

The MCO formulates and acts within policies and procedures for registering and responding to member and/or provider appeals of an adverse benefit determination by the MCO in a manner consistent with contract requirements, including

Met Met Met Met Met

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The definitions of an adverse benefit determination and an appeal and who may file an appeal

Met Met ↑ Met Met Met

The procedure for filing an appeal Met Met ↑ Partially Met ↓ Met Met

Review of any appeal involving medical necessity or clinical issues, including examination of all original medical information as well as any new information, by a practitioner with the appropriate medical expertise who has not previously reviewed the case

Met Met Met Met Met

A mechanism for expedited appeal where the life or health of the member would be jeopardized by delay

Met Met Met Met Met

Timeliness guidelines for resolution of the appeal as specified in the contract;

Met Met ↑ Met Met Partially Met ↓

Written notice of the appeal resolution as required by the contract

Met Met Met Met Partially Met ↓

Other requirements as specified in the contract Met Met ↑ Met Met Partially Met ↓

The MCO applies the appeal policies and procedures as formulated

Met Not Met ↓ Met Met Partially Met

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Appeals are tallied, categorized, analyzed for patterns and potential quality improvement opportunities, and reported to the Quality Improvement Committee

Met Met Met Met Met

Appeals are managed in accordance with the MCO confidentiality policies and procedures

Met Met Met Met Met

Case Management

The MCO formulates policies and procedures that describe its case management/care coordination programs

Met Met Met Met Met

The MCO has processes to identify members who may benefit from case management

Met Met Met Met Met

The MCO provides care management activities based on the member’s risk stratification

Met Met Met Met Met

The MCO utilizes care management techniques to ensure comprehensive, coordinated care for all members

Met Met Met Met Met

The MCO has developed and implemented policies and procedures that address transition of care

Met Met Met Met Met

The MCO has a designated Transition Coordinator who meets contract requirements

Met ↑ Met Met Met Met

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The MCO measures case management performance and member satisfaction, and has processes to improve performance when necessary

Met Met Met Met Met

Care management and coordination activities are conducted as required

Met Met Met Met Met

Evaluation of Over/Underutilization

The MCO has mechanisms to detect and document under-utilization and over-utilization of medical services as required by the contract

Met Met Met Met Met

The MCO monitors and analyzes utilization data for under and over utilization

Met Met Met Met Met

Strengths

• Appeal resolution letters are written in language that is easily understood.

• Case Managers consistently conduct pre-call reviews and assess for social determinants of health factors and gaps in care.

• Health plans have implemented PHM strategies into their UM Programs.

Weaknesses

• ATC had discrepancies in pharmacy timeframe requirements and failed to display PDL changes prominently on its website.

• All health plans have errors, discrepancies, and omissions in documentation of appeals information, requirements, timeframes, and procedures.

Recommendations

• Ensure that pharmacy timeframe requirements are documented correctly and that PDL changes are located in a prominent and easily accessible location on the website (ATC).

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• Ensure documentation of appeals requirements and procedures are correct.

F. Delegation

Health plan policies define requirements for delegation of health plan functions and processes for oversight of delegated entities. Each MCO requires a written agreement with the delegated entity that outlines the activities to be delegated, the delegate’s responsibilities in conducting those activities, performance expectations, reporting responsibilities, and other relevant information. The MCOs have developed tools for delegation monitoring and oversight.

Several MCOs’ policies regarding delegation of credentialing and recredentialing activities did not include all credentialing requirements for which a delegate is responsible. Issues noted during CCME’s review of the MCOs’ delegate oversight documentation include:

• Not conducting timely follow-up of issues identified during delegation oversight activities

• Oversight documentation lacking evidence that credentialing delegates are monitored for all required queries and website checks that must be conducted at initial credentialing and/or recredentialing

• Delegation oversight tools that did not specify the requirements to which a delegate is held, such as authorization turn-around times

As noted in Figure 11: Delegation, ATC and Molina scored “Met” for 100% of the Delegation standards. The remaining MCOs received “Met” scores for 50% of the Delegation standards.

Figure 11: Delegation

0%10%20%30%40%50%60%70%80%90%

100%


100%

50%

100%

50% 50%

% M

et S

tand

ards

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Table 17: Delegation Comparative Data


The MCO has written agreements with all contractors or agencies performing delegated functions that outline responsibilities of the contractor or agency in performing those delegated functions


The MCO conducts oversight of all delegated functions sufficient to ensure that such functions are performed using those standards that would apply to the MCO if the MCO were directly performing the delegated functions

Met ↑ Partially Met Met ↑ Partially Met Partially Met

Strengths

• All MCOs require written agreements between the health plan and the delegate. The written agreements specify activities to be delegated, the delegate’s responsibilities, performance expectations, reporting responsibilities, and other relevant information.

Weaknesses

• ATC failed to conduct follow-up of identified deficiencies until the delegate’s next annual oversight audit.

• Healthy Blue’s delegation oversight documentation did not indicate whether delegates are monitored for querying the National Practitioner Databank and the National Plan and Provider Enumeration System.

• Select Health and WellCare policies and/or other documentation related to delegation of credentialing activities did not include all credentialing requirements.

G. State-Mandated Services

Review of State-Mandated Services focused on the MCOs’ compliance with tracking provider compliance in administering immunizations, performing Early and Periodic

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Screening, Diagnostic and Treatment (EPSDT) services, providing core benefits specified by the SCDHHS Contract, and addressing deficiencies identified from the previous EQRs.

The MCOs follow the American Academy of Pediatrics periodicity schedule for required screenings and health treatments to ensure EPSDT services and immunizations are provided to members through the month of their 21st birthdays. The plans notify and remind both members and providers of needed EPSDT services through member handbooks, provider manuals, websites, member education materials, newsletters, and EPSDT Tool Kits. The MCOs use medical record reviews conducted by clinical reviewers, HEDIS® reports, and claims analysis to monitor provider compliance with EPSDT services and required immunizations.

Individual plan documents and file review findings indicate all core benefits specified by the SCDHHS Contract are provided to eligible members.

A component of the EQR process is assessing the degree to which each health plan addressed quality improvement recommendations made during the prior year’s review. Molina was noted to have an uncorrected a deficiency from the 2019 EQR related to closing member grievances prior to investigation and for providing inadequate information in grievance resolution notices. WellCare also had an uncorrected deficiency related to the SCDHHS Contract requirement that health plans query the SCDHHS List of Providers Terminated for Cause when credentialing or recredentialing a provider.

Each plan’s percentage of “Met” scores is demonstrated in Figure 12: State-Mandated Services.

Figure 12: State-Mandated Services

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


100% 100%

75%

100%

75%

% M

et S

tand

ards

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Table 18: State-Mandated Services Comparative Data


The MCO tracks provider compliance with administering required immunizations

Met Met Met Met Met

Performing EPSDTs/Well Care Met Met Met Met Met

Core benefits provided by the MCO include all those specified by the contract

Met Met Met Met Met

The MCO addresses deficiencies identified in previous independent external quality reviews

Met Met↑ Not Met ↓ Met Not Met

Weaknesses

• Molina and WellCare did not correct all deficiencies identified during the 2018-2019 EQR.

Recommendations

• Ensure corrections for identified deficiencies are implemented.

H. South Carolina Solutions

SCDHHS contracts with South Carolina Solutions (Solutions) to provide Primary Care Case Management (PCCM) and care coordination for the Medically Complex Children’s Waiver (MCCW) Program. CCME’s review focused on administrative functions, committee minutes, member and provider demographics, member and provider educational materials, and the Quality Improvement (QI) and Care Coordination/Case Management Programs.

Administration Solutions is a subsidiary organization of Community Health Solutions of America (CHS). The CHS Corporate Board of Directors governs the organization and adopts rules, policies, procedures, and other directives for the organization. Solutions’ Executive Director ensures the goals and objectives of SCDHHS, CHS, and Solutions are aligned, and the Program Operations Manager oversees day–to–day operations. Staffing appears to be sufficient to conduct required activities with no vacancies noted.

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Solutions’ policies are reviewed annually and as needed for regulatory and process changes. Solutions informs staff of new and revised policies, and staff members must attest that they have read the policies.

Policies have been developed to address requirements and processes for screening and verifying the qualifications of clinical staff; however, no formal policy defining the requirements for non-clinical staff was identified. CCME recommended a revision to the Clinical Staff Credentialing and Re-Credentialing policy to clarify the staff to whom the policy applies and to clearly describe how Solutions meets the requirement for background checks in states other than South Carolina in which an employee has resided within the last 10 years. Personnel files reflect appropriate processes are followed to verify employee information, conduct required screenings, and document initial and ongoing training.

The Compliance Program is applicable to all CHS lines of business and complements the established policies and procedures detailing Compliance requirements, appropriate business conduct, and processes to prevent and detect FWA. Compliance and FWA training are provided to employees at the time of hire and annually thereafter.

Solutions has an extensive set of policies and procedures detailing methods to secure devices and to protect participant data. System backups are scheduled regularly and routinely tested. The business continuity plan is a thorough, multi-phase plan that guides the workforce through the resources and processes to mitigate interruptions if an incident occurs. A recent weather event tested Solutions’ disaster preparedness, and operations were maintained before and after the event with no loss of data.

Table 19: Administration/Organization Activities displays the scores for all standards in the Administration section of the 2020 EQR.

Table 19: Administration/Organization Activities

Standard Solutions

General Approach to Policies and Procedures

Policies and procedures are organized, reviewed, and available to staff Met

Organizational Chart / Staffing

The organization’s infrastructure complies with contract requirements. At a minimum, this includes designated staff performing the following activities:

Administrative oversight of day-to-day activities of the organization

Met

Pre-assessment Met

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Standard Solutions

Care coordination and enhanced case management Met

Provider services and education Met

Quality assurance Met

Designated compliance officer Met

The organization formulates and acts within policies and procedures which meet contractual requirements for verification of qualifications and screening of employees. At a minimum, the following are included:

Criminal background checks are conducted on all potential employees

Met

Verification of nursing licensure and license status Met

Screening all employees and subcontractors monthly to determine if they have been excluded from participation in state or federal programs Met

Ensuring Care Coordinators and Pre-Admission Screening staff meet all contract requirements Met

Ensuring staff are independent of the service delivery system and are not a provider of other services which could be incorporated into a participant’s Person-Centered Service Plan

Met

Employee personnel files demonstrate compliance with contract and policy requirements Met

Governing Board/Advisory Board

The Organization has established a governing body or Advisory Board Met

The responsibility, authority, and relationships between the governing body, the organization, and network providers are defined Met

Contract Requirements

The organization carries out all activities and responsibilities required by the contract, including but not limited to:

Available by phone during normal business hours 8:30 am to 5:00 pm Monday through Friday

Met

Adherence to contract requirements for holidays and closed days Met

Processes to conduct onsite supervisory visits within 5 days of receiving a request from SCDHHS Met

Organization and participant record retention and availability as required by the contract Met

Participant materials written in a clear and understandable manner, and are available in alternate formats and translations for prevalent non-English languages

Met

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Standard Solutions

Processes are in place to ensure care coordination services are available statewide Met

Confidentiality

The organization formulates and acts within written confidentiality policies and procedures that are consistent with state and federal regulations regarding health and information privacy

Met

Data Systems/Security

Policies, procedures and/or processes are in place for addressing data, system, and information security and access management Met

The organization has a disaster recovery and/or business continuity plan that has been tested and the testing documented Met

Compliance and Program Integrity

The organization has policies/procedures in place designed to guard against fraud, waste, and abuse, and including the following:

Written policies, procedures, and standards of conduct comply with federal and state standards and regulations

Met

A compliance committee that is accountable to senior management Met

Employee education and training that includes education on the False Claims Act, if applicable Met

Effective lines of communication between the compliance officer and the organization employees, subcontractors, and providers Met

Enforcement of standards through well-publicized disciplinary guidelines Met

Provisions for internal monitoring and auditing Met

Provisions for prompt response to detected offenses and development of corrective action initiatives Met

A system for training and education for the Compliance Officer, senior management, and employees Met

Processes for immediate reporting of any suspicion or knowledge of fraud and abuse Met

The organization reports immediately any suspicion or knowledge of fraud or abuse Met

Provider Services Solutions’ Program Operations Coordinator is responsible for conducting initial provider orientation and education within 30 days of a provider contracting into the network. Process for onboarding new providers to Solutions’ network are found in Solutions’ policies. Provider orientation includes an overview of the organization, staff, duties, the

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SCDHHS contractual relationship, the Medically Complex Children’s Waiver (MCCW) program, and contractual requirements.

Solutions’ website includes links to download the Provider Manual and to the list of SCDHHS provider manuals. The website also includes information about credentialing, reporting FWA, and language services. The 2020 Provider Manual and the Complaint and Grievance Process policy provided information regarding the member/participant grievance process; however, the definition of grievance is incorrect. The Provider Manual and the policy indicate a grievance is an expression of dissatisfaction about any matter other than an “action.” Per 42 CFR 438.400 (b), a grievance is defined as an expression of dissatisfaction about any matter other than an adverse benefit determination. Also, the definitions for action and appeal in the policy are incorrect.

Table 20: Provider Services displays the scores for all standards in the Provider Services section of the 2020 EQR.

Table 20: Provider Services

Standard Solutions

The organization formulates and acts within policies and procedures related to initial and ongoing education of providers Met

Initial provider education includes:

Organization structure, operations, and goals Met

Medical record documentation requirements, handling, availability, retention, and confidentiality Met

How to access language interpretation services Met

The organization provides ongoing education to providers regarding changes and/or additions to its programs, practices, standards, policies and procedures

Met

Quality Improvement Solutions’ QI Program operates under a plan of continuous improvement. The Strategic Quality Plan 2020 describes the program’s structure, scope, goals, and functions.

The Compliance & Quality Management Committee (CQMC) is responsible for the development and implementation of the QI Program. Voting members include the Chief Medical Officer, Executive Vice President of Compliance, Clinical Quality Programs Manager, and Care Coordinator Team Leads. The Chief Medical Officer serves as the chairperson for the meetings.

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Annually, Solutions develops a QI Work Plan to guide and monitor activities for the year. The health plan provided the 2019 and 2020 QI Work Plans. There were two areas noted as needing revisions or updates.

Quality improvement projects are initiated when opportunities to correct or improve are identified. Solutions had two projects underway at the time of the review—Care Plan Streamlining and Care Advocate Outreach. The goal for the Care Plan Streamlining project was to decrease the time spent updating monthly care plans. The analysis of this project showed documentation time decreased for one quarter. Results were presented to the Corporate Compliance and Quality Management Committee (CQMC) for recommendations. The project failed to produce meaningful data, and, therefore, the committee recommended closing the project.

The goal for the Care Advocate Outreach project was to identify customer service gaps. No patterns in gaps in care were identified. The project was closed with the outreach calls added as part of the routine Care Advocate workflow.

Two new quality improvement projects recently initiated are Emergency/Disaster Preparedness and URAC Re-accreditation.

Solutions evaluated the QI Program and summarized the results of this evaluation in “Annual Report: Quality and Performance Improvement Calendar Year 2019.”

For this review period, Solutions achieved “Met” scores for all the standards for the Quality Improvement section, as noted in Table 21: Quality Improvement.

Table 21: Quality Improvement

Standard Solutions

The Quality Improvement (QI) Program

The organization formulates and implements a formal quality improvement program with clearly defined goals, structure, scope and methodology directed at improving the quality of health care delivered to participants

Met

An annual QI work plan is in place which includes activities to be conducted, follow up of any previous activities where appropriate, timeframe for implementation and completion, and the person(s) responsible for the activity

Met

Quality Improvement Committee

The organization has established a committee charged with oversight of the QI program, with clearly delineated responsibilities Met

The QI Committee meets at regular intervals Met

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Standard Solutions

Minutes are maintained that document proceedings of the QI Committee Met

Annual Evaluation of the Quality Improvement Program

A written summary and assessment of the effectiveness of the QI program for the year is prepared annually Met

The annual report of the QI program is submitted to the QI Committee Met

Care Coordination/Case Management CCME’s assessment of Care Coordination/Case Management included review of the program description, policies, Provider Manual, case management files, and website. The MCCW Program Description outlines the framework for the program’s goals, scope, and lines of responsibility. The plan uses enhanced case management techniques to ensure comprehensive, coordinated care for all participants with various chronic health conditions.

Overall, no major issues were identified. CCME noted minor documentation issues of a typing error in the two policies. The Medically Complex Criteria-Assessment policy and the Growth and Development policy incorrectly states, “Medically complex children, as defined by the MCC waiver, are children with a serious illness or condition expected to live at least 12 months”, instead of last at least 12 months.

As in previous EQRs, the following issues with documentation of Team Conferences and the Waiver Coordinator’s telephone number were identified:

• The number on the MCCW Rights and Responsibilities form given to members to contact the MCCW Administrator (1-803-898-0079), rings to a different SCDHHS staff person. Additionally, the correct number is not posted on Solutions’ website.

• Documents such as the Provider Manual 2020, Waiver Program Description, and member materials do not indicate that team conferences are optional, when they are determined, or who can request them.

The review of Case Management (CM) files indicated Care Coordinators and Care Advocates follow policies as outlined. The files also reflect Care Coordinators interact with participants at required intervals by phone and in person. In March 2020, SCDHHS suspended home visits until further notice due to restrictions related to COVID-19. During this time, Care Coordinators completed monthly calls instead.

Solutions met all requirements in the Care Coordination/Case Management section of the EQR.

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Table 22: Care Coordination/Case Management

Standard Solutions

The organization formulates and acts within written policies and procedures and/or a program description that describe its care coordination and case management programs

Met

Policies and procedures and/or the program description address the following:

Structure of the program Met

Lines of responsibility and accountability Met

Goals and objectives of Care Coordination/Case Management Met

Intake and assessment processes for Care Coordination/Case Management Met

Providing required information to participants at the time of enrollment Met

Minimum standards for phone contacts, in-home visits, and physician/nurse plan oversight as applicable

Met

Processes to develop, implement, coordinate, and monitor individual Person-Centered Service Plans with the participant/caregivers and the PCP

Met

Processes to ensure caregiver/parent participation in and understanding of the Person-Centered Service Plans

Met

Process to regularly update and evaluate the Person Centered Service Plans on an ongoing basis Met

Processes for following up with participants admitted to the hospital and actively participate in discharge planning Met ↑

Processes for reporting suspected abuse, neglect, or exploitation of a participant Met

A back-up service provision plan to ensure that the Participant receives the authorized care coordination services and a process to notify SCDHHS if services cannot be provided

Met

The organization provides a written, formal evaluation of the Person Centered Plan to SCDHHS every 6 months or upon request Met

The organization conducts Care Coordination and Case Management functions as required by the contract Met

Strengths

• Strong physical security techniques implemented at the organization’s data centers, including badges and biometric controls, effectively limit access. Extensive information technology security policies are frequently reviewed and revised.

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• Information about FWA is placed prominently on Solutions’ website and includes methods for reporting suspected or actual FWA.

• Provider education resources are available in the Provider Manual and on the Solutions website.

• The file review showed consistent collaboration between Care Coordinators and Care Advocates.

Weaknesses

• The Clinical Staff Credentialing and Re-Credentialing policy title indicates it applies to clinical staff, but the policy “Scope” section states the policy applies to all workforce members. The policy does not address background checks for states other than South Carolina when an employee has resided out of state within the last 10 years.

• A policy addressing the requirement for criminal background checks for non-clinical staff was not identified.

• A discrepancy in the frequency of ride-along audits of staff was identified when comparing the Chart Review Process policy and the Medically Complex Criteria-Onsite Supervisory Visits policy.

• The definition of a grievance in the Provider Manual and in Policy CHS.QM.ALL.01.10, Complaint and Grievance Process, is incorrect.

• The review noted errors noted in policies and the incorrect telephone number for the MCC Waiver Administrator.

• The Provider Manual, Waiver Program Description, and member materials do not indicate that team conferences are optional and can be requested by the PCP or RP, nor indicate how team conferences are determined.

Recommendations

• Ensure each policy’s scope correctly states to which staff the policy applies.

• Ensure that policies or other documents include the process for obtaining criminal background checks for non-clinical staff and background checks for states other than South Carolina in which an employee has resided within the last 10 years.

• Ensure the frequency of Care Coordinator supervision during a home visit is documented correctly in all policies.

• Update the definition of a grievance in the Provider Manual and in Policy CHS.QM.ALL.01.10. Remove the term “action” and replace with “adverse benefit determination.”

• Ensure policies have correct SCDHHS Contract language and ensure member materials have correct telephone numbers.

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• Update applicable documents to reflect Team Conferences are optional services that are available upon request by providers or participants.

I. Coordinated and Integrated Care Organizations Annual Review

For this contract year, CCME conducted an EQR of the CICOs that provide services for the dual eligible Medicare/Medicaid population. This review focused on network adequacy for Home and Community Based Services (HCBS) and behavioral health (BH) providers, over/under utilization, and care transitions.

To conduct the review, CCME requested desk materials from each CICO. These items focused on administrative functions, committee minutes, member and provider demographics, over and under/utilization data, and care transition files.

Findings Standards were scored as meeting all requirements (“Met”), acceptable but needing improvement (“Partially Met”) or failing a standard (“Not Met”). An overview of the findings for each section follows. The tables reflect the scores for each standard evaluated in the EQR. The arrows indicate a change in the score from the previous review. For example, an arrow pointing up (↑) would indicate the score for that standard improved from the previous review and a down arrow (↓) indicates the standard was scored lower than the previous review. Scores without arrows indicate there was no change in the score from the previous review.

Provider Network Adequacy The CICOs are required by contract to maintain a network of HCBS providers that is sufficient to provide all enrollees with access to a full range of covered services in each geographic area. The CICOs are also required to have a network of BH providers to ensure a choice of at least two providers located within no more than 50 miles from any enrollee unless the plan has a SCDHHS-approved alternative standard.

Home and Community-Based Services SCDHHS established minimums of at least two providers for each service in each county except Anderson, Charleston, Florence, Greenville, Richland, and Spartanburg counties. For these larger counties, the minimum was set as three providers for each service. Each CICO submitted an HCBS provider file that was evaluated by CCME to assess provider adequacy. The assessment is summarized in Figure 13: HCBS Network Adequacy Review Results.

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Figure 13: HCBS Network Adequacy Review Results

The minimum number of required providers for each active county was calculated and compared to the number of current providers for seven different services:

• Adult Day Health

• Case Management

• Home Delivered Meals

• Personal Care

• Personal Emergency Response System (PERS)

• Respite

• Telemonitoring

ATC’s minimum number of required providers for each county was calculated and compared to the number of current providers for seven services in the 37-county network. Of the 259 services across 37 counties, there were 259 (100%) that met the minimum requirement. This review year showed sustainment, with a rate of 100%.

For HCBS services, Molina had 43 counties that were documented as having enrollment in the Member Demographics 2019 file in the desk materials. Of the 301 services across 43 counties, there were 298 that met the minimum requirement resulting in a validation score of 99%. The counties and services with fewer than the required minimums were Beaufort, Hampton, and Jasper for Adult Day Health.

Select Health reported members in 46 counties. Of the 322 services across 46 counties, there were 322 (100%) that met the minimum requirement. This resulted in a validation score of 100%, which is a sustained rate from last year’s rate of 100%.

All three plans earned a “Met” score.

0%

20%

40%

60%

80%

100%

ATC Molina Select Health

100% 100% 100%100% 99% 100%

Previous Year Current Year

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Behavioral Health Network Prover Adequacy As directed by SCDHHS, CCME used the following criteria to evaluate the network adequacy of BH providers for each CICO.

• Plans are required to have a network of BH providers to ensure a choice of at least two providers located no more than 50 miles from any enrollee unless the plan has a SCDHHS-approved alternative standard. All network providers must serve the target population (i.e., adults aged 65 and older).

• At least one of the BH providers used to meet the two providers per 50 miles requirement must be a Community Mental Health Center (CMHC). Either of the following combinations would meet the minimum requirements:

o One CMHC and one or more of any other listed provider type(s), or

o Two CMHCs.

• No other BH provider types are required, though any of the provider types listed may be used as the non-CMHC provider used to meet the two providers per 50 miles requirement.

ATC submitted a Geo Access report provided by Quest Analytics that showed 99.8% of members have access to a psychiatrist, psychologist, social worker, and a CMHC (using a requirement of one in 50 miles). All counties have at least one CMHC, according to the report submitted. There were seven members noted for each service as not having access, although the report was unclear on the county in which those members resided. A follow-up email from ATC noted that of those seven members, five reside in Dorchester County and two reside in Berkeley County. ATC met the requirements for network adequacy and received a “Met” score for this standard.

For Molina’s behavioral health services, it was noted that coverage was adequate for having one provider within 50 miles or 75 minutes, except for Opioid Treatment Centers in five counties, where Molina will provide transportation for members requiring treatment. There is also at least one CMHC within 50 miles for the 38 counties in the report.

Select Health’s Geo Access reports demonstrated that at least 90% of members have access to at least one BH provider and one CMHC within the 50-mile radius. The average distance is approximately 20 miles for BH providers and 9 miles for CMHCs.

Table 23: Provider Network Adequacy Comparative Data provides an overview of each plan’s score for the Provider Network Adequacy section.

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Table 23: Provider Network Adequacy Comparative Data

Standard ATC Molina Select Health

The CICO maintains a network of Home and Community Based Services (HCBS) providers in each geographic area that is sufficient to provide all enrollees with access to a full range of covered services

Met Met Met

The CICO maintains a network of behavioral health (BH) providers in each geographic area that is sufficient to provide all enrollees with access to a full range of covered services

Met Met Met

Evaluation of Over/Under Utilization The CICOs are required to monitor and analyze utilization data to look for trends or issues that may provide opportunities for quality improvement.

ATC monitors utilization in the five required services, as well as other services. The 30-day readmission rate was below the expected utilization at 11.6%. Length of Stay was well above the goal rate of 6.5 at 12.8 bed days. Emergency room (ER) utilization was below goal at 814 per 1000; the goal is 870 per 1000. Mental health admissions were at 9.9, but the goal was not documented. Penetration rate for BH services was at .90% for the last measurement. Skilled Nursing Facility (SNF) Length of Stay (LOS) was submitted after the onsite and monthly trends were displayed. The 2018 Medicare QI Evaluation included information on interventions and recommendations based on utilization data monitoring.

Molina files contained reports on utilization for 30-day readmission, ER utilization, mental health service receival rate and LOS. The 2nd and 3rd quarter 2019 reports mentioned ER visits trending higher; additional analyses are needed to identify causative factors in the data evaluation. It seems that one of the causative factors is a lack of PCPs. According to Molina, the Community Connectors program was continued to engage members with their PCPs and eliminate social determinants in getting to PCP appointments. Member-specific analyses are conducted to determine which members are not engaged with PCPs. For readmission, the Transition of Care Coach program arranges face-to-face visits with members and assists with discharge planning, contact information, and educational materials, as well as offering nutrition and medication directions.

Select Health reported on utilization for four of the five required services, along with other services. The rates are monitored, and the desk materials provided adequate evidence that trends are analyzed and that issues are addressed to improve utilization rates. The review found there was a specific deep-dive analysis for ER utilization, as well

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as monthly trend analysis for LOS, admissions, and readmissions. Information on the number and percentage of members receiving mental health services was uploaded after the onsite and contained the required number and rate.

All CICOs met the requirements for evaluating over/under utilization as shown in Table 24: Evaluation of Over/Under Utilization Comparative Data.

Table 24: Evaluation of Over/Under Utilization Comparative Data


The CICO monitors and analyzes utilization data to look for trends or issues that may provide opportunities for quality improvement. Utilization data monitored should include, but not be limited to: 30-day hospital readmission rates for any potentially avoidable hospitalization (enrollees readmitted with a diagnosis of Bacterial Pneumonia, Urinary Tract Infection, CHF, Dehydration, COPD/Asthma, and Skin Ulcers)

Met ↑ Met Met

Length of stay for hospitalizations Met ↑ Met Met

Length of stay in nursing homes Met ↑ Met Met

Emergency room utilization Met ↑ Met Met

Number and percentage of enrollees receiving mental health services Met ↑ Met Met

Care Transitions CCME reviewed Transition of Care (TOC) files for members readmitted fewer than 30 days after discharge. The files revealed insufficient documentation to indicate care transition activities are conducted for ATC, Molina, and Select Health members. Some of the common issues identified included:

• Failure to identify a facility-based Care Manager

• Inconsistent outreach and collaboration with PCPs

• Lack of documentation of clinical follow-up within 72 hours after transition

Other deficiencies noted in the file review included lack of, or insufficient, documentation of:

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• Timely notifications of admission and discharge

• Barriers to aftercare and strategies to address those barriers

• Medication monitoring

• Reassessments

• Clinical and non-clinical supports needed by members

• Transition and aftercare appointments

The CICOs acknowledged these issues and have implemented or are in the process of implementing interventions to address these deficiencies.

Table 25: Care Transitions Comparative Data shows all plans demonstrated they monitor admissions that result in a higher level of care to determine factors that contributed to the change in acuity level.

Table 25: Care Transitions Comparative Data


The CICO conducts appropriate care transition functions, as defined by the CICO 3-Way Contract, Section 2.5 and 2.6, to minimize unnecessary complications related to care setting transitions

Partially Met Partially Met ↓ Partially Met

Transitions that result in a move to a higher level of care are analyzed to determine factors that contributed to the change and actions taken by the CICO to improve outcomes

Met Met Met

Strengths

• All CICOs demonstrated adequate provider networks to meet SCDHHS’ requirements for HCBS and BH providers.

• The evaluation of over/underutilization increased for all health plans, with all three plans achieving 100% of requirements.

Weaknesses

• The files revealed insufficient documentation to indicate care transitions activities are conducted.

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Recommendations

• Ensure all TOC functions required by the SCDHHS Contract, Sections 2.5 and 2.6 are conducted and clearly documented in the members’ files.

FINDINGS SUMMARY Overall, ATC, Healthy Blue and Molina showed the most improvements in four areas. Table 26: Annual Review Comparisons reflects the total percentage of standards scored as “Met” for the 2019 through 2020 EQR. The percentages highlighted in green indicate an improvement over the prior review findings. Those highlighted in yellow represent a reduction in the prior review findings. Areas reviewed for the MCOs that are not applicable for Solutions are noted as Not Applicable (NA).

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Table 26: Annual Review Comparisons

ATC HEALTHY BLUE MOLINA SELECT HEALTH SOLUTIONS WELLCARE

2018 2019 2019 2020 2019 2020 2018 2019 2019 2020 2019 2020

Administration 97.5% 100% 97.5% 100% 98% 100% 100% 100% 100% 100% 95% 100%

Provider Services 92% 92% 92% 96% 94% 100% 94% 99% 100% 100% 90% 94%

Member Services 97% 97% 94% 94% 97% 97% 88% 100% NA NA 88% 88%

Quality Improvement 93% 100% 100% 100% 87% 86% 100% 100% 100% 100% 100% 100%

*Utilization Management 96% 98% 91% 98% 96% 98% 100% 100% 93% 100% 96% 89%

Delegation 50% 100% 50% 50% 50% 100% 50% 50% NA NA 50% 50%

State Mandated Services 100% 100% 75% 100% 100% 75% 100% 100% NA NA 75% 75%

*Care Coordination/Case Management for Solutions