907 KAR 17:025.
Managed care organization requirements and policies related to utilization
management and quality.
RELATES TO: 194A.025(3), 42 U.S.C.
1396n(c), 42 C.F.R. 438
STATUTORY AUTHORITY: KRS 194A.010(1), 194A.025(3),
194A.030(2), 194A.050(1), 205.520(3), 205.560, 42 U.S.C. 1396n(b), 42 C.F.R. Part
438
NECESSITY, FUNCTION, AND CONFORMITY: The
Cabinet for Health and Family Services, Department for Medicaid Services, has
responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the
cabinet, by administrative regulation, to comply with a requirement that may be
imposed or opportunity presented by federal law to qualify for federal Medicaid
funds. 42 U.S.C. 1396n(b) and 42 C.F.R. Part 438 establish requirements
relating to managed care. This administrative regulation establishes the Medicaid
managed care organization requirements and policies relating to utilization
management and quality.
Section 1. Utilization Management or UM.
(1) An MCO shall:
(a) Have a utilization management program
that shall:
1. Meet the requirements established in
42 C.F.R. Parts 431, 438, and 456, and the
private review agent requirements of KRS
304.17A, as applicable;
2. Identify, define, and specify the
amount, duration, and scope of each service that the MCO is required to offer;
3. Review, monitor, and evaluate the
appropriateness and medical necessity of care and services;
4. Identify and describe the UM mechanisms
used to:
a. Detect the under or over utilization
of services; and
b. Act after identifying under
utilization or over utilization of services;
5. Have a written UM program description
in accordance with subsection (2) of this section; and
6. Be evaluated annually by the:
a. MCO, including an evaluation of
clinical and service outcomes; and
b. Department;
(b) Adopt nationally-recognized standards
of care and written criteria that shall be:
1. Based upon sound clinical evidence, if
available, for making utilization decisions; and
2. Approved by the department;
(c) Include physicians and other health
care professionals in the MCO network in reviewing and adopting medical
necessity criteria;
(d) Have:
1. A process to review, evaluate, and
ensure the consistency with which physicians and other health care
professionals involved in UM apply review criteria for authorization decisions;
2. A medical director who:
a. Is licensed to practice medicine or
osteopathy in Kentucky;
b. Is responsible for treatment policies,
protocols, and decisions; and
c. Supervises the UM program; and
3. Written policies and procedures that
explain how prior authorization data will be incorporated into the MCO’s
quality improvement plan;
(e) Submit a request for a change in
review criteria for authorization decisions to the department for approval
prior to implementation;
(f) Administer or use a CAHPS survey to
evaluate and report enrollee satisfaction with the quality of, and access to,
care and services in accordance with 907 KAR 17:010;
(g) Provide written confirmation of an approval
of a request for a service within two (2) business days of providing notification
of a decision if:
1. The initial decision was not in
writing; and
2. Requested by an enrollee or provider;
(h) If the MCO uses a subcontractor to
perform UM, require the subcontractor to have
written policies, procedures, and a process to
review, evaluate, and ensure consistency with which physicians and other health
care professionals involved in UM apply review criteria for authorization decisions;
and
(i) Not provide a financial or other type
of incentive to an individual or entity that conducts UM activities to deny,
limit, or discontinue a medically necessary service to an enrollee pursuant to
42 C.F.R. 422.208, 42 C.F.R. 438.6(h), and 42 C.F.R. 438.210(e).
(2) A UM program description referenced
in subsection (1)(a)5. of this section shall:
(a) Outline the UM program’s structure;
(b) Define the authority and
accountability for UM activities, including activities delegated to another
party; and
(c) Include the:
1. Scope of the program;
2. Processes and information sources used
to determine service coverage, clinical necessity, and appropriateness and effectiveness;
3. Policies and procedures to evaluate:
a. Care coordination;
b. Discharge criteria;
c. Site of services;
d. Levels of care;
e. Triage decisions; and
f. Cultural competence of care delivery;
and
4. Processes to review, approve, and deny
services as needed.
(3) Only a physician with clinical
expertise in treating an enrollee’s medical condition or disease shall be
authorized to make a decision to deny a service authorization request or authorize
a service in an amount, duration, or scope that is less than requested by the
enrollee or the enrollee’s treating physician.
(4) A medical necessity review process
shall be in accordance with Section 2 of this administrative regulation.
Section 2. Service Authorization and
Notice. (1) For the processing of a request for initial or continuing
authorization of a service, an MCO shall identify what constitutes medical
necessity and establish a written policy and procedure, which includes a timeframe
for:
(a) Making an authorization decision; and
(b) If the service is denied or
authorized in an amount, duration, or scope which is less than requested,
providing a notice to an enrollee and provider acting on behalf of and with the
consent of an enrollee.
(2) For an authorization of a service, an
MCO shall make a decision:
(a) As expeditiously as the enrollee’s
health condition requires; and
(b) Within two (2) business days following
receipt of a request for service.
(3) The timeframe for making an
authorization decision referenced in subsection (2) of this section may be
extended:
(a) By the:
1. Enrollee, or the provider acting on
behalf of and with consent of an enrollee, if the enrollee requests an extension;
or
2. MCO, if the MCO:
a. Justifies to the department, upon
request, a need for additional information and how the extension is in the
enrollee’s interest;
b. Gives the enrollee written notice of
the extension, including the reason for extending the authorization decision
timeframe and the right of the enrollee to file a grievance if the enrollee
disagrees with that decision; and
c. Makes and carries out the
authorization decision as expeditiously as the enrollee’s health condition
requires and no later than the date the extension expires; and
(b) Up to fourteen (14) additional
calendar days.
(4) If an MCO denies a service
authorization or authorizes a service in an amount, duration, or scope which is
less than requested, the MCO shall provide a notice:
(a) To the:
1. Enrollee, in writing, as expeditiously
as the enrollee’s condition requires and within two (2) business days of
receipt of the request for service; and
2. Requesting provider, if applicable;
(b) Which shall:
1. Meet the language and formatting
requirements established in 42 C.F.R. 438.404;
2. Include the:
a. Action the MCO or its subcontractor,
if applicable, has taken or intends to take;
b. Reason for the action;
c. Right of the enrollee or provider who
is acting on behalf of the enrollee to file an MCO appeal;
d. Right of the enrollee to request a
state fair hearing;
e. Procedure for filing an appeal and
requesting a state fair hearing;
f. Circumstance under which an expedited
resolution is available and how to request it; and
g. Right to have benefits continue
pending resolution of the appeal, how to request that benefits be continued,
and the circumstance under which the enrollee may be required to pay the costs
of these services; and
3. Be provided:
a. At least ten (10) days before the date
of action if the action is a termination, suspension, or reduction of a covered
service authorized by the department, department designee, or enrollee’s MCO,
except the department may shorten the period of advance notice to five (5) days
before the date of action because of probable fraud by the enrollee;
b. By the date of action for the
following:
(i) The death of a member;
(ii) A signed written enrollee statement
requesting service termination or giving information requiring termination or
reduction of services in which the enrollee understands this will be the result
of supplying the information;
(iii) The enrollee’s address is unknown
and mail directed to the enrollee has no forwarding address;
(iv) The enrollee has been accepted for
Medicaid services by another local jurisdiction;
(v) The enrollee’s admission to an
institution results in the enrollee’s ineligibility for more services;
(vi) The enrollee’s physician prescribes
a change in the level of medical care;
(vii) An adverse decision has been made
regarding the preadmission screening requirements for a nursing facility
admission, pursuant to 907 KAR 1:755 and 42 U.S.C. 1396r(b)(3)(F), on or after
January 1, 1989; or
(viii) The safety or health of
individuals in a facility would be endangered, if the enrollee’s health
improves sufficiently to allow a more immediate transfer or discharge, an
immediate transfer or discharge is required by the enrollee’s urgent medical
needs, or an enrollee has not resided in the nursing facility for thirty (30)
days;
c. On the date of action, if the action
is a denial of payment and the service has not been provided to the member;
d. As expeditiously as the enrollee’s
health condition requires and within two (2) business days following receipt of
a request;
e. When the MCO carries out its
authorization decision, as expeditiously as the enrollee’s health condition
requires and no later than the date the extension as identified in subsection
(3) of this section expires;
f. If a provider indicates or the MCO determines
that following the standard timeframe could seriously jeopardize the enrollee’s
life or health, or ability to attain, maintain, or regain maximum function, as
expeditiously as the enrollee’s health condition requires and no later than two
(2) business days after receipt of the request for service; and
g. For an authorization decision not made
within the timeframe identified in subsection (2) of this section, on the date
the timeframe expires as this shall constitute a denial.
Section 3. Health Risk Assessment. An MCO
shall:
(1) After the initial implementation of
the MCO program, conduct an initial health risk assessment of each enrollee
within ninety (90) days of enrolling the individual if the individual has not
been enrolled with the MCO in a prior twelve (12) month period;
(2) Use health care professionals in the
health risk assessment process;
(3) Screen an enrollee who it believes to
be pregnant within thirty (30) days of enrollment;
(4) If an enrollee is pregnant, refer the
enrollee for prenatal care;
(5) Use a health risk assessment to
determine an enrollee’s need for:
(a) Care management;
(b) Disease management;
(c) A behavioral health service;
(d) A physical health service or
procedure; or
(e) A community service.
Section 4. Care Coordination and Management. An MCO shall:
(1) Have a care coordinator and a case
manager who shall:
(a) Arrange, assure delivery of, monitor,
and evaluate care, treatment, and services for an enrollee; and
(b) Not duplicate or supplant services
provided by a targeted case manager to:
1. Adults with a chronic mental illness
pursuant to 907 KAR 1:515; or
2. Children with a severe emotional disability
pursuant to 907 KAR 1:525;
(2) Have guidelines for care coordination
that shall be approved by the department prior to implementation;
(3) Develop a plan of care for an
enrollee in accordance with 42 C.F.R. 438.208;
(4) Have policies and procedures to
ensure access to care coordination for a DCBS client or a DAIL client;
(5) Provide information on and coordinate
services with the Women, Infants and Children program; and
(6) Provide information to an enrollee
and a provider regarding:
(a) An available care management service;
and
(b) How to obtain a care management service.
Section 5. Quality Assessment and
Performance Improvement (QAPI) Program. An MCO shall:
(1) Have a quality assessment and
performance improvement (QAPI) program that shall:
(a) Conform to the requirements of 42
C.F.R. 438 Subpart D, 438.200 to 438.242;
(b) Assess, monitor, evaluate, and
improve the quality of care provided to an enrollee;
(c) Provide for the evaluation of:
1. Access to care;
2. Continuity of care;
3. Health care outcomes; and
4. Services provided or arranged for by
the MCO;
(d) Demonstrate the linkage of quality improvement
(QI) activities to findings from a quality evaluation; and
(e) Be developed in collaboration with input
from enrollees;
(2) Submit annually to the department a
description of its QAPI program;
(3) Conduct and submit to the department
an annual review of the program;
(4) Maintain documentation of:
(a) Enrollee input;
(b) The MCO’s response to the enrollee
input;
(c) A performance improvement activity;
and
(d) MCO feedback to an enrollee;
(5) Have or obtain within four (4) years
of initial implementation National Committee for Quality Assurance (NCQA)
accreditation for its Medicaid product line;
(6) If the MCO has obtained NCQA accreditation:
(a) Submit to the department a copy of
its current certificate of accreditation with a copy of the complete
accreditation survey report; and
(b) Maintain the accreditation;
(7) Integrate behavioral health service indicators
into its QAPI program;
(8) Include a systematic, on-going process
for monitoring, evaluating, and improving the quality and appropriateness of a
behavioral health service provided to an enrollee;
(9) Collect data, monitor, and evaluate
for evidence of improvement to a physical health outcome resulting from integration
of behavioral health into an enrollee’s care; and
(10) Annually review and evaluate the effectiveness
of the QAPI program.
Section 6. Quality Assessment and
Performance Improvement Plan. (1) An MCO shall:
(a) Have a written QAPI work plan that:
1. Outlines the scope of activities;
2. Is submitted quarterly to the department;
and
3. Sets goals, objectives, and timelines
for the QAPI program;
(b) Set new goals and objectives:
1. At least annually; and
2. Based on a finding from:
a. A quality improvement activity or
study;
b. A survey result;
c. A grievance or appeal;
d. A performance measure; or
e. The external quality review organization;
(c) Be accountable to the department for
the quality of care provided to an enrollee;
(d) Obtain approval from the department
for its QAPI program and annual QAPI work plan;
(e) Have an accountable entity within the
MCO:
1. To provide direct oversight of its
QAPI program; and
2. To review reports from the quality
improvement committee referenced in paragraph (h) of this subsection;
(f) Review its QAPI program annually;
(g) Modify its QAPI program to
accommodate a review finding or concern of the MCO if a review finding or
concern occurs;
(h) Have a quality improvement committee
that shall:
1. Be responsible for the QAPI program;
2. Be interdisciplinary;
3. Include:
a. Providers and administrative staff;
and
b. Health professionals with knowledge of
and experience with individuals with special health care needs;
4. Meet on a regular basis;
5. Document activities of the committee;
6. Make committee minutes and a committee
report available to the department upon request; and
7. Submit a report to the accountable
entity referenced in paragraph (e) of this subsection that shall include:
a. A description of the QAPI activities;
b. Progress on objectives; and
c. Improvements made;
(i) Require a provider to participate in
QAPI activities in the provider agreement or subcontract; and
(j) Provide feedback to a provider or a
subcontractor regarding integration of or operation of a corrective action
necessary in a QAPI activity if a corrective action is necessary.
(2) If a QAPI activity of a provider or a
subcontractor is separate from an MCO’s QAPI program, the activity shall be integrated
into the MCO’s QAPI program.
Section 7. QAPI Monitoring and
Evaluation. (1) Through its QAPI program, an MCO shall:
(a) Monitor and evaluate the quality of
health care provided to an enrollee;
(b) Study and prioritize health care
needs for performance measurement, performance improvement, and development of
practice guidelines;
(c) Use a standardized quality indicator:
1. To assess improvement, assure
achievement of at least a minimum performance level, monitor adherence to a
guideline, and identify a pattern of over and under utilization of a service;
and
2. Which shall be:
a. Supported by a valid data collection
and analysis method; and
b. Used to improve clinical care and services;
(d) Measure a provider performance
against a practice guideline and a standard adopted by the quality improvement
committee;
(e) Use a multidisciplinary team to
analyze and address data and systems issues; and
(f) Have practice guidelines that shall:
1. Be:
a. Disseminated to a provider, or upon
request, to an enrollee;
b. Based on valid and reliable medical
evidence or consensus of health professionals;
c. Reviewed and updated; and
d. Used by the MCO in making a decision
regarding utilization management, a covered service, or enrollee education;
2. Consider the needs of enrollees; and
3. Include consultation with network providers.
(2) If an area needing improvement is
identified by the QAPI program, the MCO shall take a corrective action and
monitor the corrective action for improvement.
Section 8. Quality and Member Access
Committee. (1) An MCO shall:
(a) Have a quality and member access committee
(QMAC) composed of:
1. Enrollees who shall be representative
of the enrollee population; and
2. Individuals from consumer advocacy
groups or the community who represent the interests of enrollees in the MCO;
and
(b) Submit to the department annually a
list of enrollee representatives participating in the QMAC.
(2) A QMAC shall be responsible for reviewing:
(a) Quality and access standards;
(b) The grievance and appeals process;
(c) Policy modifications needed based on
reviewing aggregate grievance and appeals data;
(d) The member handbook;
(e) Enrollee education materials;
(f) Community outreach activities; and
(g) MCO and department policies that affect
enrollees.
(3) The QMAC shall provide the results of
its reviews to the MCO.
Section 9. External Quality Review. (1)
In accordance with 42 U.S.C. 1396a(a)(30), the department shall have an
independent external quality review organization (EQRO) annually review the
quality of services provided by an MCO.
(2) An MCO shall:
(a) Provide information to the EQRO as
requested to fulfill the requirements of the mandatory and optional activities
required in 42 C.F.R. Parts 433 and 438; and
(b) Cooperate and participate in external
quality review activities in accordance with the protocol established in 42
C.F.R. 438 Subpart E, 438.310 to 438.370.
(3) The department shall have the option
of using information from a Medicare or private accreditation review of an MCO
in accordance with 42 C.F.R. 438.360.
(4) If an adverse finding or deficiency
is identified by an EQRO conducting an external quality review, an MCO shall
correct the finding or deficiency.
Section 10. Health Care Outcomes. An MCO
shall:
(1) Comply with the requirements
established in 42 C.F.R. 438.240 relating to quality assessment and performance
improvement;
(2) Collaborate with the department to establish
a set of unique Kentucky Medicaid managed care performance measures which
shall:
(a) Be aligned with national and state preventive
initiatives; and
(b) Focus on improving health;
(3) In collaboration with the department
and the EQRO, develop a performance measure specific to individuals with special
health care needs;
(4) Report activities on performance
measures in the QAPI work plan established in Section 6 of this administrative
regulation;
(5) Submit an annual report to the
department after collecting performance data which shall be stratified by:
(a) Medicaid eligibility category;
(b) Race;
(c) Ethnicity;
(d) Gender; and
(e) Age;
(6) Collect and report HEDIS data annually;
and
(7) Submit to the department:
(a) The final auditor’s report issued by
the NCQA certified audit organization; and
(b) A copy of the interactive data submission
system tool used by the MCO.
Section 11. Performance Improvement
Projects (PIPs). (1) An MCO shall:
(a) Implement PIPs to address aspects of
clinical care and nonclinical services;
(b) Collaborate with local health departments,
behavioral health agencies, and other community-based health or social service
agencies to achieve improvements in priority areas;
(c) Initiate a minimum of two (2) PIPs
each year with at least one (1) PIP relating to physical health and at least
one (1) PIP relating to behavioral health;
(d) Report on a PIP using standardized indicators;
(e) Specify a minimum performance level
for a PIP; and
(f) Include the following for a PIP:
1. The topic and its importance to
enrolled members;
2. Methodology for topic selection;
3. Goals of the PIP;
4. Data sources and collection methods;
5. An intervention; and
6. Results and interpretations.
(2) A clinical PIP shall address
preventive and chronic healthcare needs of enrollees including:
(a) The enrollee population;
(b) A subpopulation of the enrollee population;
and
(c) A specific clinical need of enrollees
with conditions and illnesses that have a higher prevalence in the enrolled
population.
(3) A nonclinical PIP shall address
improving the quality, availability, and accessibility of services provided by
an MCO to enrollees and providers.
(4) The department may require an MCO to
implement a PIP specific to the MCO if:
(a) A finding from an EQRO review
referenced in Section 9 of this administrative regulation or an audit indicates
a need for a PIP; or
(b) Directed by CMS.
(5) The department shall be authorized to
require an MCO to assist in a statewide PIP which shall be limited to providing
the department with data from the MCO’s service area.
Section 12. Centers for Medicare and
Medicaid Services Approval and Federal Financial Participation. A policy established in
this administrative regulation shall be null and void if the Centers for
Medicare and Medicaid Services:
(1) Denies or does not provide federal
financial participation for the policy; or
(2) Disapproves the policy. (39 Ky.R.
1841; 2356; eff. 6-27-2013.)
