DCS Comprehensive Health Plan

Health Plan Function Oversight

Statement/Purpose

This policy details DCS CHP’s oversight of its health plan functions and those of its contracted managed care organization (MCO) to improve healthcare outcomes for children and youth.

Definitions

Administrative Services Subcontract/Subcontractor: An agreement that delegates any of the requirements of the Contract with AHCCCS, including, but not limited to the following:

• Claims processing, including pharmacy claims,

• Pharmacy Benefit Manager (PBM),

• Dental Benefit Manager,

• Credentialing, including those for only primary source verification (i.e., Credential Verification Organization [CVO]),

• Medicaid Accountable Care Organization (ACO),

• Service Level Agreements with any Division or Subsidiary of a corporate parent owner, and

• CHP and DES/DDD Subcontracted Health Plan.

Centers for Medicaid and Medicare Services (CMS): The Federal agency within the United States Department of Health and Human Services (HHS), which administers the Medicare (Title XVIII) and Medicaid (Title XIX) programs and the State Children’s Health Insurance Program (Title XXI).

Corrective Action Plan (CAP): A written work plan that identifies the root cause(s) of a deficiency, includes goals and objectives, actions/tasks to be taken to facilitate an expedient return to compliance, methodologies to be bused to accomplish CAP goals and objectives, and staff responsible to carry out the CAP within established timelines.

Department of Child Safety (DCS): The Department of Child Safety is an Arizona state agency charged with child protection. DCS serves as a leader in primary prevention, partnering with other family-serving agencies and community organization to improve community health and strengthen families.

DCS CHP: Health plan for children and youth in out of home care as outlined in statute. It is also the regulatory oversight body of the Managed Care Organization (MCO).

Managed Care Organization (MCO): A health plan which is focused on quality care while maximizing fiscal efficiencies to reduce healthcare costs.

Policy

DCS CHP uses various oversight mechanisms to ensure children and youth have timely, quality care and caregivers are supported. Mechanisms include, but are not limited to, the following:

• DCS CHP Business Review: DCS CHP conducts a Business Review with its contracted partner on a monthly business. These meetings offer a forum to review key metrics ranging from member enrollment and provider visits to discussion of clinical performance measures. It provides a more frequent cadence to identify, document and problem solve issues related to the healthcare for DCS CHP’s population.

• Policies and Process Workflows: To document contract expectations, DCS CHP and its contracted MCO develop and adhere to written policies and process flows designed to ensure consistency and maximize efficiencies in all facets of health plan operations. Policies, process flows and protocols align with annual plans and related deliverables and support DCS CHP’s oversight of its contracted MCO.

• Oversight Workbooks: DCS CHP uses functional area oversight workbooks designed to outline general principles, expectations and methodology for review of compliance and documentation of compliance and/or non-compliance of its contracted MCO performance as follow up, as appropriate.

• Review of Deliverables: DCS CHP functional areas are responsible to review deliverables submitted by its contracted MCO for both AHCCCS required deliverables and DCS CHP required deliverables outside AHCCCS’ purview.

• Annual Plans: DCS CHP outlines health plan benefits through Annual Plans specific to areas of health plan functions. Implementation of health plan functions and goals are outlined in the Annual Workplans, and Annual Evaluations report on the performance of the health plan in achieving the implementation goals.

• Member Information: DCS CHP educates members about the availability and accessibility of covered services as specified in DCS policy and ACOM 404. Member materials are disseminated by the contracted MCO as approved by DCS CHP. DCS CHP functional areas are responsible to review member materials for compliance with both AHCCCS and DCS requirements.

• Committee Participation: DCS CHP leads and/or participates in various committees that are designed to oversee the activities of the health plan and its contracted health plan. Committees include, but are not limited, to the following:

  • Regulatory Compliance Meeting

  • Medical Management Committee

  • Pharmacy & Therapeutics

  • Quality Management Process Improvement (QMPI)

  • Peer Review

  • Cultural Competency Committee

  • Policy Committee

  • Delegation Oversight Meeting

  • Community-based Integrated Health & Clinical Services (CBIHCS); and

  • Credentialing/Re-credentialing Committee

Function Area Specific Oversight Activities

Key function areas of the health plan oversight mechanisms are designed to meet the following goals:

• Network Administration: ensure children and youth have timely access to quality providers;

• Health Services: ensure children receive appropriate, medically necessary services in a timely manner;

• Quality Management: improve health outcomes for children and youth in care using quality management mechanism and tools to review service delivery, measure clinical performance and conduct oversight activities of DCS CHP’s contracted health plan;

• Finance: ensure sound business practices; internal controls; and

• Compliance: guard against fraud, waste and abuse.

• Resource Coordination: ensure caregivers who identify children new to their homes as having a chronic or acute condition receive timely care management support;

Network Administration

The DCS CHP Network Administration Team maintains a documentation system for collection, analysis and dissemination of data as part of its network management and performance oversight. Oversight activities include but are not limited to, the following:

• Conduct statewide site visits of healthcare facilities and physician offices to ensure compliance with applicable federal and state laws;

• Provide education to healthcare entities related to the special needs of DCS CHP enrolled children and youth; and serve as an escalation point of contact to address provider concerns;

• Review the contracted MCO’s provider training activities and records indicating compliance with federal requirements and state regulations, including training on EPSDT program requirements;

• Review provider education and outreach material for compliance with federal requirements and state regulations;

• Assist DCS internal stakeholders in resolving member access to care issues, investigate and report on member and DCS field experience feedback and complaints;

• Monitor and track the contracted MCO’s performance related to provider oversight (including training) and network adequacy;

• Document DCS CHP’s contracted MCO’s adherence to Medicaid and other contractual requirements related to network adequacy; and

• Document in-field encounters to identify trends, provide a historical record and to inform process improvement activities.

Quality Management

The DCS CHP Quality Management Team uses various mechanism and tools to review service delivery, measure clinical performance and conduct oversight activities. Oversight activities include, but are not limited to, the following:

• Oversee the contracted MCO’s network capacity to accommodate the diverse needs of the member population including sub populations, such as CRS and special healthcare needs as well as those with specific language or cultural needs and preferences;

• Oversee the contracted MCO’s compliance with federal and state regulatory requirements related to health;

• Incorporate awareness of member safety in quality activities and conduct oversight of the contracted MCO’s quality and activities to do so;

• Develop and monitor performance improvement projects (PIPs);

• Monitor outpatient and inpatient services to identify deviations from standard of care and/or services; and

• Measure clinical performance and assess outcomes against established standards and benchmarks, including AHCCCS performance measures.

Health Services

The DCS CHP Health Services Team oversees activities related to concurrent review, pharmacy, medical (including behavioral health) and oral health utilization management. Oversight activities include, but are not limited to, the following:

• EPSDT Within 30 Days of Entering Care: DCS and DCS CHP policy requires children and youth in DCS care receive a comprehensive well visit within 30 days of entering care. DCS CHP monitors enrollees’ receipt of EPSDT services within 30 days of entering care through the use of claims data (regardless of payment status).

• Dental Visits Within 30 Days of Entering Care: Using similar methodology to comprehensive well visits, DCS CHP monitors enrollees’ receipt of dental visits using dental procedure (CDT) codes. Children entering care often need restorative dental care upon entry. As such, DCS CHP and its contracted MCO measure preventative dental visits and any other dental visits children and youth receive.

• EPSDT Specialty Referrals: DCS CHP monitors the receipt of specialty services noted on the EPSDT tracking form, as appropriate, for its members. Members should receive these services within 60 days. Administrative (claims) methodology is the primary source for reporting. As such, data is restated on a routine basis to account for data lag in provider claims submittal.

• EPSDT Participation Ratio: To ensure children and youth are receiving healthcare services in accordance with the EPSDT Periodicity Schedule, DCS CHP monitors the EPSDT Participation ratio as using CMS-416 methodology. This metric is discussed at the DCS CHP Business Review with its contracted partner with quarterly updates.

• Higher Level of Care: For children and youth in DCS care, a robust network which includes higher levels of care (HLOC) including Therapeutic Foster Care (TFC), Behavioral Health Residential Facilities (BHRF) and Behavioral Health Inpatient Facilities (BHIF) is vital. To monitor requests for HLOC, DCS CHP and its contracted MCO review approvals, denial and denial reasons to recognize and address trends more readily. Regarding special populations, Transition Aged Youth residing in HLOC are monitored on a monthly basis and coordination and planning is discussed between DCS CHP and its subcontractor.

• CFT Practice: DCS CHP System of Care Coordinators conduct CFT Practice Evaluations to better monitor fidelity to the Child and Family Team protocols. These evaluations are conducted monthly using a methodology by which a random sample of members are selected and assigned to a DCS CHP SOC Coordinator (CFT Practice Evaluator). CFT Practice Evaluators escalate any observable concern with CFT practice to the regional System of Care Coordinator to support the Child and Family Team and ensure member needs are being met.

• Discharge Planning and Coordination: DCS CHP Health Services staff provide monitoring and oversight of members in acute hospital settings and Emergency Departments. Staff participate in weekly Utilization Management meetings with the subcontractor to discuss escalated needs for members who are hospitalized for both physical and behavioral health needs. Health Services leadership receive a daily census of youth holding in the Emergency Department and escalate for further coordination when needs are identified.

• Maternal Care: DCS CHP Health Services Team coordinates with Maternal Care Coordinators to review the maternity services for pregnant youth in DCS care. These coordination efforts involve ongoing exchange of information on the youth and quarterly summary meetings to review progress and evaluate appropriate maternity service delivery.

• Children’s Rehabilitation Services (CRS): The DCS CHP Health Services Team coordinates with Care Coordinators to review the specialty and preventive services for children who qualify for CRS designation. These coordination efforts involve ongoing exchange of information on the youth and quarterly summary meetings to review progress and evaluate service delivery and adherence to the CRS program requirements. Services for children who qualify for CRS are reviewed at a minimum on an annual basis.

Corporate Compliance

The Corporate Compliance Team guards against fraud, waste and abuse through implementation and oversight of the Compliance Program. Oversight activities include:

• Establish and implement procedures and systems for routine internal monitoring and auditing of compliance risks;

• Investigate potential compliance problems as identified in the course of self-evaluation and audits;

• Monitor and audit subcontractors, including the completion and submission of annual subcontractor monitoring and reporting deliverables;

• Coordinate annual security risk audits with the DCS Chief Information Officer and staff;

• Maintain and participate in a Regulatory Compliance Committee involving DCS CHP senior management charged with overseeing the Contractor’s compliance program and its compliance with the requirements of the Contract;

• Participate in CHP Quality Management committees and sub-contracted, delegated authority oversight meetings;

• Participate in AHCCCS/OIG Compliance Officer Network Group (CONG) meetings;

• Monitor a system for training and education for the Corporate Compliance Program;

• Establish and implement procedures that include provision for the prompt referral of any potential fraud, waste, or abuse to AHCCCS/OIG, including but not limited to:

  • Disclosure of Ownership or Control Interest;

  • Fiscal agents;

  • Business transactions;

  • Persons convicted of crimes.

• Create and submit an External Audit Plan/Schedule, and Audit Report of all individual provider audits to AHCCCS/OIG as specified in the AHCCCS Contractors Operations Manual (ACOM) and the DCS/AHCCCS IGA.

ContractI Compliance

The Contract Compliance Team monitors operations and performance of DCS CHP program compliance and that of DCS CHP administrative services subcontractors including DCS CHP’s contracted MCO. Oversight activities include:

• AHCCCS Deliverable Submission: DCS CHP Contract Compliance coordinates the monitoring, review and submission of Contract deliverables. If a deliverable is rejected, DCS CHP notifies its contracted MCO to gain an explanation and/or rectify and re-submit the deliverable. Upon receipt of resubmission, DCS CHP reviews contents of the deliverable to ensure content has been provided or modified to prevent further rejection.

• CHP Oversight: DCS CHP conducts internal oversight and audits of CHP to ensure compliance with contractual requirements between CHP and AHCCCS. This includes coordination of Operational Review activities between CHP, AHCCCS and the subcontractor and the management of Corrective Action Plans (CAPS).

• Subcontractor Oversight: DCS CHP participates in Bi-Weekly meetings with subcontractor staff to discuss potential concerns and rectify potential risks. Oversight and audits of the health plan subcontractor are conducted to ensure compliance with the contract between the subcontractor and DCS CHP. This includes coordination of Operational Review activities between CHP, AHCCCS and the subcontractor and management of Manage Corrective Action Plans (CAPS).

• Contract Management: DCS CHP coordinates and administers contract amendments with AHCCCS and administrative services subcontractors.

Finance

DCS CHP’s Finance Team conducts the following activities:

• Review and approve as appropriate financial information received from DCS CHP contracted MCO;

• Participate in audits and other oversight activities to ensure compliance with appropriate federal and state regulations; and

• Develop and adhere to internal controls to ensure sound business practices.

Resource Coordination

The DCS CHP Resource Coordination Team contacts caregivers immediately upon health plan enrollment to offer an overview of the health plan and to identify/escalate a need if any for immediate care coordination and/or interventions from other DCS departments. Resource Liaisons escalate acute or chronic health conditions reported by caregivers to the member’s assigned Care Manager. Weekly reports are submitted to the contracted MCO identifying members who do not appear to have an assigned Care Manager. DCS CHP initiates and participates in quarterly meetings with contracted MCO staff to discuss potential concerns with this coordination process and opportunities for improvement.

Additional Oversight Activities

Cultural Competency, Literacy and Social Determinants of Health

DCS CHP and its contracted MCO’s implement Cultural Competency Programs that promote the delivery of services in a culturally competent trauma informed manner to all our members with diverse cultural, racial, ethnic, geographic, social, spiritual, and economic backgrounds, including individuals with Limited English Proficiency (LEP) or reading skills; and medical, developmental, educational, emotional, cultural, environmental, and financial needs, special health care needs/disabilities and regardless of sex, gender, sexual orientation, gender identify, national origin or age. DCS CHP collaborates with its contracted MCO to develop, implement, modify and assess a Cultural Competency Program and provide data/information for the preparation of annual reports for stakeholders.

Contract and/or Deliverable Non-Compliance/Escalation Process

DCS CHP’s contracted MCO is expected to adhere to all AHCCCS and DCS CHP contract requirements and policies. In the event that DCS CHP’s contracted MCO cannot demonstrate compliance in a given area at any time, DCS CHP works with the contracted MCO to correct.

DCS CHP provides the contracted MCO a reasonable amount of time to respond to the request for additional documentation or requested items in order to demonstrate compliance. Non-compliance may result in DCS CHP issuing a written notice and/or a corrective action plan (CAP) to the contracted MCO. DCS CHP monitors the implementation and execution of the CAP until the CAP requirements have been satisfactorily completed.

DCS CHP makes available technical assistance to the contracted MCO in order to support compliance with contract and policy requirements.