department of managed health care …€¦ · 16/12/2016 · department of managed health care ....

DEPARTMENT OF MANAGED HEALTH CARE OFFICE OF PLAN MONITORING DIVISION OF PLAN SURVEYS

CAL MEDICONNECT

MEDICAL SURVEY REPORT OF

SANTA CLARA COUNTY HEALTH AUTHORITY DBA SANTA CLARA FAMILY HEALTH PLAN

DATE ISSUED TO DHCS: DECEMBER 16, 2016

Cal MediConnect Medical Survey Report Santa Clara County Health Authority dba Santa Clara Family Health Plan

A Full Service Health Plan December 16, 2016

TABLE OF CONTENTS

EXECUTIVE SUMMARY ................................................................................................. 1

DISCUSSION OF POTENTIAL DEFICIENCIES ............................................................. 6

UTILIZATION MANAGEMENT ................................................................................. 6 CONTINUITY OF CARE ........................................................................................ 11 AVAILABILITY AND ACCESSIBILITY ................................................................... 16 MEMBER RIGHTS ................................................................................................. 24 QUALITY MANAGEMENT ..................................................................................... 31

APPENDIX A. MEDICAL SURVEY TEAM MEMBERS ................................................ 35

APPENDIX B. PLAN STAFF INTERVIEWED .............................................................. 36

APPENDIX C. LIST OF FILES REVIEWED ................................................................. 37

Santa Clara County Health Authority dba Santa Clara Family Health Plan Cal MediConnect Medical Survey Report December 16, 2016

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EXECUTIVE SUMMARY

The Department of Health Care Services (DHCS) received authorization (“CMS APPROVAL”) from the federal government to conduct a Duals Demonstration Project (“Cal MediConnect”) to coordinate the delivery of health and long term care services to beneficiaries within California who are eligible for benefits under both Medicare and Medicaid. Starting in April 2014, DHCS began phase in enrollment of Cal MediConnect beneficiaries in Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara counties. The Department of Managed Health Care (DMHC) and the DHCS then entered into an interagency agreement1 whereby the DMHC will be responsible for conducting medical survey audits related to the provision of Medicaid-based services provided to Cal MediConnect enrollees. Medical Surveys pursuant to this Agreement are conducted once every three years.

On February 17, 2016, the Department notified Santa Clara Health Authority dba Santa Clara Family Health Plan (the “Plan”) that its medical survey had commenced and requested the Plan to provide all necessary pre-onsite data and documentation. The Department’s medical survey team conducted the onsite portion of the medical survey from April 18, 2016 through April 22, 2016.2

SCOPE OF MEDICAL SURVEY

As required by the Inter-Agency Agreement, the Department provides the Cal MediConnect Medical Survey Report to the DHCS. The Report identifies potential deficiencies in Plan operations supporting the provision of Medicaid-based services for the Cal MediConnect population. This medical survey evaluated the following elements specifically related to the Plan’s delivery of care to the Cal MediConnect population as delineated by the Plan’s applicable three-way contract with DHCS and CMS (the Cal MediConnect Three-Way Contract), the Knox-Keene Health Care Service Plan Act of 1975 (Knox Keene Act), and Title 28 of the California Code of Regulations:

I. Utilization ManagementThe Department evaluated Plan operations related to utilization management asit relates to the provision of Medicaid-based services, including implementation ofthe Utilization Management Program and policies, processes for effectivelyhandling prior authorization of services, mechanisms for detecting over- andunder-utilization of services, and the methods for evaluating utilizationmanagement activities of delegated entities.

1 The Inter-Agency Agreement (Agreement Number 13-90167) was approved on October 21, 2013. 2 Pursuant to the Knox-Keene Health Care Service Plan Act of 1975, codified at Health and Safety Code

section 1340, et seq., Title 28 of the California Code of Regulations section 1000, et seq. and the Department of Health Care Services (DHCS) and Centers for Medicare and Medicaid Services (CMS) Cal MediConnect Three-Way Contract and amendments. All references to “Cal MediConnect Three-Way Contract” or “Three-Way Contract” are to the Cal MediConnect Three-Way Contract between CMS, DHCS, and the Plan, and amendments thereto. All references to “Section” are to the Health and Safety Code unless otherwise indicated. All references to the “Act” are to the Knox-Keene Act. All references to “Rule” are to Title 28 of the California Code of Regulations unless otherwise indicated.


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II. Continuity of Care The Department evaluated Plan operations to determine whether Medicaid-based services are effectively coordinated both inside and outside the network. The Department also verified that the Plan takes steps to facilitate coordination of Medicaid-based services with other services delivered under Cal MediConnect, through the enrollees’ primary care physician and/or interdisciplinary team.

III. Availability and Accessibility

The Department evaluated Plan operations to ensure that its Medicaid-based services are accessible and available to enrollees throughout its service areas within reasonable timeframes, and that the Plan addresses reasonable patient requests for disability accommodations.

IV. Member Rights

The Department evaluated Plan operations to assess compliance with internal and external complaint and grievance system requirements related to the provision of Medicaid-based services. The Department also evaluated the Plan’s ability to provide interpreter services and communication materials in both threshold languages and alternative formats.

V. Quality Management

The Department evaluated Plan operations to verify that the Plan monitors, evaluates, takes effective action, and maintains a system of accountability to ensure quality of care as it relates to the provision of Medicaid-based services.

The scope of the medical survey incorporated review of health plan documentation and files from the period of April 1, 2015 through March 31, 2016.


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SUMMARY OF FINDINGS The Department identified 14 potential deficiencies during the current medical survey.

2016 MEDICAL SURVEY POTENTIAL DEFICIENCIES UTILIZATION MANAGEMENT 1 For decisions to deny service authorization requests, notices to enrollees are not produced in a manner, format, and language that can be easily understood. Santa Clara Cal MediConnect Three-Way Contract, Section§ 2.11.4.5-2.11.4.5.1. 2 The Plan does not have an established system to track and monitor specialty referrals requiring prior authorization. Santa Clara Cal MediConnect Three-Way Contract §2.11.5.1. and §2.11.5.1.6. 3 The Plan does not include in its annual Quality Improvement (QI) report an evaluation of aggregate data on utilization. Santa Clara Cal MediConnect Three-Way Contract §2.16.3.3.5., §2.16.3.3.5.1., and §2.16.3.3.5.1.1. 4 The Plan was unable to provide evidence that nursing facility and Community Based Adult Services (CBAS) authorization or re-authorization requests included a primary care provider or case manager signature. Santa Clara Cal MediConnect Three-Way Contract §2.11.6.7.1. and §2.11.6.7.2. CONTINUITY OF CARE 5 In conducting Health Risk Assessments (HRAs), the Plan does not consistently offer each enrollee the opportunity to complete the HRA in-person and notify the enrollee’s PCP of any new enrollee who has not completed an HRA within required timeframes. Santa Clara Cal MediConnect Three-Way Contract §2.8.2.; Duals Plan Letter 15-005.


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6 In developing Individualized Care Plans (ICPs), the Plan does not consistently: • Identify all member’ medical, behavioral health, and long term support needs, and • Create measureable objectives and timetables to address members’ needs. Santa Clara Cal MediConnect Three-Way Contract §2.8.3; Duals Plan Letter 15-001. AVAILABILITY & ACCESSIBILITY 7 The Plan has not adopted policies and procedures to ensure adequate access to Medicaid-based services for Cal MediConnect Enrollees. Santa Clara Cal MediConnect Three-Way Contract § 2.9 – 2.9.2; Santa Clara Cal MediConnect Three-Way Contract §2.10 – 2.10.1.1.5; Santa Clara Cal MediConnect Three-Way Contract §2.10.2.3 – 2.10.2.3.3; Santa Clara Cal MediConnect Three-Way Contract §2.11.1 – 2.11.1.1; Santa Clara Cal MediConnect Three-Way Contract §2.11.2.1; Santa Clara Cal MediConnect Three-Way Contract §2.11.2.1.3 – 2.11.2.1.5. 8 The Plan does not evaluate access to all Medicaid-based services at least annually to demonstrate that its provider network offers adequate access to members for all services and providers. Santa Clara Cal MediConnect Three-Way Contract §2.9.1. 9 The Plan has not identified, by name and job title, the individual who is responsible for Americans with Disabilities Act (ADA) compliance relative to Cal MediConnect, nor has it demonstrated ADA compliance. Santa Clara Cal MediConnect Three-Way Contract §2.11.1.3. 10 The Plan lacks sufficient policies and procedures to reasonably ensure that members with disabilities have the same access, including communication, access, to Plan programs and services as members without disabilities. Santa Clara Cal MediConnect Three-Way Contract §2.11. MEMBER RIGHTS 11 The Plan does not have policies or procedures addressing members’ grievances and appeals regarding Cal-MediConnect services.


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Santa Clara Cal MediConnect Three-Way Contract §2.14.2.; Santa Clara Cal MediConnect Three-Way Contract §2.15.3.3.; Rule 1300.68 (a). 12 The Plan’s grievance acknowledgement and resolution letters do not display the Department’s telephone number, TDD line, and Internet address, as well as the Plan’s telephone number in the format required by Health and Safety Code, section 1368.02(b). Santa Clara Cal MediConnect Three-Way Contract §2.14.3.1; Section 1368.02(b). 13 The Plan does not provide a written acknowledgement within five calendar days of receipt of a grievance. Santa Clara Cal MediConnect Three-Way Contract §2.14.2.1.1.; Section 1368 (a)(4)(A); Rule 1300.68(d)(1). QUALITY MANAGEMENT 14 The Plan does not consistently document that the quality of care provided is being reviewed, that problems are being identified, that effective action is taken to improve care where deficiencies are identified, and that follow-up is planned where indicated. Santa Clara Cal MediConnect Three-Way Contract §2.16.2.; Santa Clara Cal MediConnect Three-Way Contract §2.16.3.1.; Rule 1300.70(a)(1); Rule 1300.70(b)(1)(A)(B). OVERVIEW OF THE PLAN’S EFFORTS TO SUPPORT CAL MEDICONNECT ENROLLEES

• The Plan provides Care Plan Options services that are an addition to the required services for Cal MediConnect enrollees. Some of the services provided include:

o Vision services o Meals brought to the member’s home o Training to help members get paid or unpaid jobs o Respite Care


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DISCUSSION OF POTENTIAL DEFICIENCIES

UTILIZATION MANAGEMENT

Potential Deficiency 1: For decisions to deny service authorization requests, notices to enrollees are not produced in a manner, format, and language that can be easily understood.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract, Section 2.11.4.5-2.11.4.5.1. Santa Clara Cal MediConnect Three-Way Contract 2.11.4.5. The Contractor must notify the requesting Network Provider, either orally or in writing, and give the Enrollee written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements of 42 C.F.R. § 438.404 and Title 22 CCR § 53261, and must: 2.11.4.5.1. Be produced in a manner, format, and language that can be easily understood; Documents Reviewed:

• Plan’s 2016 UM Program Description • 5 Utilization Management (UM) Standard Denial Files (04/01/15 – 03/30/15)

Assessment: The Plan’s 2016 UM Program Description states:

Communication to members for denial, delay, or modification of all or part of the requested service shall include the following: • Be written in a language that is easily understandable by a layperson • Specify the specific health care service approved • Provide a clear and concise explanation of the reasons for the Plan’s

decision to deny, delay, or modify health care services • Specify a description of the criteria or guidelines used for the Plan’s

decision to deny, delay, or modify health care services • Specify the clinical reasons for the Plan’s decision to deny, delay, or

modify health care services • Include information as to how he / she may file a grievance to the Plan • Include information as to how he / she may request an independent

medical review (p.21) However, the Department found that in practice, the Plan is not meeting its own internal requirements or contractual requirements. In a review of standard denial files, the Department found that the Plan’s responses to providers and enrollees are not complete, do not provide the clinical reason(s) why the health care service is not


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medically necessary, and do not describe the criteria or guidelines used to make the denial decision, thus rendering the notices difficult to understand. File Review The Department reviewed five standard UM denial files, which represents the universe of denials for the review period. The Department determined that in four files3 (80%), the denial letters did not include clear and concise explanations of the rationale for the decision. In the same four letters (80%), the Plan failed to provide a description of the criteria or guidelines used to make the decisions and in two letters4 (40%), the Plan failed to provide the clinical reason for the denials. The following files exemplify these problems:

• File 1 (ID): The Plan denied this request for hearing aids. The denial letter states:

Your request was denied. We’ve denied the medical services/items listed below requested by you or your doctor UNKNOWN PROVIDER. Why did we deny your request? We denied the medical services/items listed above because: [The paragraph stops here.]

The letter included no information about why the request was denied.

• File 3 (ID): The Plan denied a request for Ensure, a dietary supplement. The letter stated:

We denied the medical services/items listed above because: Deny Ensure request as it does not meet Medicare or MediCal criteria. No nutritional or absorptive abnormality, absence of G tube, normal BMI.

While the letter attempted to explain the clinical reason for the denial (e.g., absence of G tube, assuming the patient did not have a gastrointestinal tube), the letter did not describe the criteria, stating only that the “medical services/items” did not “meet Medicare or Medical criteria.” As well, the letter used medical terminology (“No nutritional or absorptive abnormality, absence of G tube, normal BMI.) that would be difficult for a layperson to comprehend, resulting in an unclear explanation. As a result of these deficiencies, the letter provides an unclear explanation of the decision.

• File 4 (ID): The Plan denied a request for Glucerna, a dietary supplement. The

letter stated: We denied the medical services/items listed above because: Does not meet Medicare Criteria for coverage, National Coverage Determination (NCD) for ENTERAL NUTRITIONAL THERAPY (180.2) Less than 50% of nutritional needs.

3 File 1 (ID); File 2 (ID); File 3 (ID); File 4 (ID). 4 File 1 (ID); File 2 (ID).


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The letter did not describe the criteria used for the denial, simply stating that it “[d]oes not meet Medicare Criteria.” As well, the letter did not clearly explain the clinical reason for the denial: A lay person would not know that “less than 50% of nutritional needs” means the requested dietary supplement is medically necessary only when it provides more than 50% of the enrollee’s/patient’s nutritional needs, and the enrollee did not meet this criteria.

TABLE 1 Denial Letters Meet Required Elements

NUMBER FILE TYPE OF ELEMENT COMPLIANT DEFICIENT

FILES Reason for denial easily 1 (20%) 4 (80%) understood Denial letter includes

Utilization description of the criteria 1 (20%) 4 (80%) Management 5 or guidelines used for the Denials decision

Denial letter specifies the clinical / medical reasons 2 (40%) 3 (60%) for the denial

The Plan’s medical director indicated that missing denial reasons in two files was the result of a systems error, which had been corrected. Conclusion: For utilization management denials, the Santa Clara Cal MediConnect Three-Way Contract Sections 2.11.4.5. and 2.11.4.5.1. require the Plan to provide notices produced in a manner, format, and language that can be easily understood; The Department found through file review that the Plan’s letters do not consistently contain these elements. Therefore, the Plan finds the Plan in violation of these contractual requirements.

Potential Deficiency 2: The Plan does not have an established system to track and monitor specialty referrals requiring prior authorization.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.11.5.1. and §2.11.5.1.6. Santa Clara Cal MediConnect Three-Way Contract 2.11.5.1. Utilization management program ... Contractor is responsible to ensure that the utilization management program includes:


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2.11.5.1.6. An established specialty referral system to track and monitor referrals requiring prior authorization through the Contractor. The system shall include authorized, denied, deferred, or modified referrals, and the timeliness of the referrals. Contractor shall ensure that all contracted Network Providers and non-contracting specialty providers are informed of the prior authorization and referral process at the time of referral. Documents Reviewed:

• 2016 Utilization Management Program Description • Utilization Management Committee (UMC) Minutes, January 2015, May 2015,

July 2015, October 2015, February 2015

Assessment: The Plan was unable to provide evidence of “an established specialty referral system to track and monitor referrals requiring prior authorization” as required by §2.11.5.1. and §2.11.5.1.6. of the Santa Clara Cal MediConnect Three-Way Contract. As a result of the lack of a tracking system, no reports detailing the Plan’s determinations on referrals (i.e., authorized, denied, deferred or modified) and timeliness of those determinations were produced to facilitate monitoring of referral activities by Plan staff and committees. The Plan was unable to produce policies or procedures related to the establishment or maintenance of a specialty referral tracking system. The Plan’s 2014 Utilization Management Program Description includes a limited discussion of data analysis and reporting and does not detail the required content of those reports, stating:

The UMC [Utilization Management Committee] is responsible for reviewing all utilization management issues and related information and making recommendations to the Plan’s QIC [Quality Improvement Committee], which reports to the BOD [Board of Directors]. The UMC monitors and analyzes relevant data to detect and correct patterns of potential or actual inappropriate under- or over-utilization, which may impact health care services, coordination of care and appropriate use of services and resources as well as member and practitioner satisfaction with the UM process. Analysis of the above tracking and monitoring processes, as well as status of corrective action plans, as applicable, are reported to the Plan’s QIC.

The Department’s review of UMC meeting minutes following the start of the Plan’s Cal MediConnect program in January 2015 show that some UM reports were generated, but they are limited to authorizations and turn-around times. Data on referrals was not yet available for reporting at the 2015 UMC meetings and was not evident in the minutes of the February 2016 UMC meeting. Conclusion: The Santa Clara Cal MediConnect Three-Way Contract §2.11.5.1. and §2.11.5.1.6. require the Plan to establish a system to track and monitor specialty referrals requiring prior authorization. The Plan was unable to furnish policies or other documentation detailing the operation of such a system, and Plan staff acknowledged


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that the Plan has not yet developed such a system. Therefore, the Department finds the Plan in violation of this contractual requirement. Potential Deficiency 3: The Plan does not include in its annual Quality

Improvement (QI) report an evaluation of aggregate data on utilization.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.16.3.3.5., §2.16.3.3.5.1., and §2.16.3.3.5.1.1. Santa Clara Cal MediConnect Three-Way Contract 2.16.3.3.5. Contractor shall develop an [sic] QI report for submission to DHCS and CMS on an annual basis. The annual report shall include … 2.16.3.3.5.1. An Assessment of the QI activities undertaken and an evaluation of areas of success and needed improvements in services rendered within the QI program, including but not limited to … 2.16.3.3.5.1.1. The collection of aggregate data on utilization … Documents Reviewed:

• Utilization Management Committee (UMC) Minutes, January 2015, May 2015, July 2015, October 2015, February 2015

• QI [Quality Improvement] Committee Meeting Minutes, February 2015, May 2015, August 2015, November 2015

• Cal MediConnect HEDIS Graph spreadsheets 11 16 15_V1

Assessment: The Plan did not include in its annual QI report a “collection of aggregate data on utilization” as required by the Santa Clara Cal MediConnect Three-Way Contract. In response to the Department’s request, the Plan was unable to provide documentation that the Plan’s annual QI report includes a collection of aggregate data on utilization. During interviews, the Chief Medical Officer reported that the Plan was finalizing Cal MediConnect data for 2015. Further, he stated that the 2015 QI Annual Report was also in process and would be presented in the second quarter of 2016. The Department was referred to the Cal MediConnect HEDIS Graph spreadsheet dated 11/16/15, which contains several performance measures (e.g., readmissions, A1c testing and control), as examples of Plan data. Conclusion: The Santa Clara Cal MediConnect Three-Way Contract §2.16.3.3.5., §2.16.3.3.5.1., and §2.16.3.3.5.1.1. require the Plan to analyze and report aggregate data on utilization. The Plan was unable to provide the Department with documentation of such reporting and analysis with the exception of a few HEDIS measures. Therefore, the Department finds the Plan in violation of this contractual requirement. Potential Deficiency 4: The Plan was unable to provide evidence that nursing

facility and Community Based Adult Services (CBAS)


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authorization or re-authorization requests included a primary care provider or case manager signature.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.11.6.7.1. and §2.11.6.7.2. Santa Clara Cal MediConnect Three-Way Contract Section 2.11.6.7 2.11.6.7 LTSS Authorization as follows: 2.11.6.7.1. Must include the PCP or case manager signature on any nursing facility authorization or reauthorization request. 2.11.6.7.2. Must include the PCP or case manager signature on any CBAS authorization or reauthorization request. Documents Reviewed:

• Plan Policy CM116_01: Community Based Adult Services: Initial Assessment (Standard) and Reassessment of Eligibility (02.01.13)

• CBAS desktop procedure Assessment: The Santa Clara Cal MediConnect Three-Way Contract requires that the Plan must “include the PCP or case manager signature on any nursing facility authorization or reauthorization request … [and] … any CBAS authorization or reauthorization request.” Plan Policy CM116_01, Community Based Adult Services: Initial Assessment (Standard) and Reassessment of Eligibility, does not specifically address the signature requirement, stating simply that the nurse (RN) conducts the assessment, and the decision is submitted in writing. When asked, the Plan could not produce documentation to show that a PCP or case manager does, in fact, sign such authorization and reauthorization requests. Conclusion: The Santa Clara Cal MediConnect Three-Way Contract §2.11.6.7.1. and §2.11.6.7.2. require the Plan to include a PCP or case manager signature on authorization/re-authorization requests for nursing and CBAS facilities. The Plan could not produce documentation to show that a PCP or case manager does, in fact, sign such authorization and reauthorization requests. Therefore, the Department finds the Plan in violation of this contractual requirement. CONTINUITY OF CARE Potential Deficiency 5: In conducting Health Risk Assessments (HRAs), the Plan

does not consistently offer each enrollee the opportunity to complete the HRA in-person and notify the enrollee’s PCP of any new enrollee who has not completed an HRA within required timeframes.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.8.2.; Duals Plan Letter 15-005.


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Santa Clara Cal MediConnect Three-Way Contract 2.8.2. Health Risk Assessment (HRA). In accordance with all applicable federal and state laws WIC Section 14182.17(d)(2), the CMS Model of Care requirements, Dual Plan Letter 13-002, Contractor will complete HRAs for all Enrollees. 2.8.2.5. Contractor shall notify PCPs of enrollment of any new Enrollee who has not completed a HRA within the time period set forth above and whom Contractor has been unable to contact. Contractor shall encourage PCPs to conduct outreach to their Enrollees and to schedule visits. Duals Plan Letter 15-005 In-Person HRAs MMPs are required to first offer an in-person HRA to all enrollees at an agreed upon location. This in-person HRA is particularly important for enrollees who are stratified as higher risk. Furthermore, enrollees always have the option to request to complete the HRA in-person. MMPs are required to document and report their outreach efforts to enrollees related to HRAs including: telephone attempts, mailing dates of the HRA, enrollee refusals to participate in the HRA process, requests for in-person HRAs, and other outreach efforts, as determined by DHCS. However, the provision of medically necessary services in no contingent on the completion of the HRA. Documents Reviewed:

• 52 Health Risk Assessment (HRA) files (04/01/15 – 03/30/15)

Assessment: The Plan was unable to demonstrate that it consistently offers each enrollee the opportunity to complete the HRA in person and notifies the enrollee’s PCP if an enrollee has not completed an HRA within required timeframes. The Santa Clara Cal MediConnect Three-Way Contract §2.8.2 requires the Plan to complete an HRA for each Enrollee to “serve as the starting point for the development of the ICP [Interdisciplinary Care Plan].” The HRA includes a series of questions that assists the Plan in identifying the need for various referrals and services (e.g., referrals to home and community based services; assistance with access to primary care; specialty care; durable medical equipment (DME); medications; assistance with self-management skills or techniques; health education; and case management services). Duals Plan Letter 15-005 specifies that the Plan is “required to first offer an in-person HRA to all enrollees at an agreed upon location. This in-person HRA is particularly important for enrollees who are stratified as higher risk.” The Letter directs Plan staff to “document and report their outreach efforts to enrollees related to HRAs including: telephone attempts, mailing dates of the HRA, enrollee refusals to participate in the HRA process, requests for in-person HRAs, and other outreach efforts …” If the Plan is unable to complete the HRA within specified timeframes, §2.8.2.5. requires the Plan to “notify PCPs of enrollment of any new Enrollee who has not completed a HRA within the time period …”


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The Department reviewed 52 HRA files for the review period. One file5 contained no copy of the HRA; therefore, it was counted as deficient in all measures. In the remaining 51 files, 486 showed no evidence that the Plan offered the enrollee the option of completing the HRA in-person as required by Duals Plan Letter 15-005, resulting in a total of 49 (94%) deficient files. In six7 cases the Plan was unable to complete the HRA within required timeframes. In four8 of those cases the Plan failed to notify the enrollee’s PCP that the HRA had not been completed. Conclusion: The Santa Clara Cal MediConnect Three-Way Contract requires that the each enrollee be offered the opportunity to complete the HRA in-person. File review demonstrated that the Plan did not consistently offer an in-person HRA to all enrollees at an agreed upon location as required by Duals Plan Letter 15-005. Additionally, the Plan did not consistently notify PCPs when the HRA could not be completed within timeframes, as required by Section 2.8.2.5. Therefore, the Department finds the Plan in violation of this contractual requirement.

TABLE 2 HRA File Review Results

NUMBER FILE TYPE ELEMENT COMPLIANT DEFICIENT OF FILES Enrollee offered the

52 opportunity to complete 3 (6%) 49 (94%) Health Risk the HRA in-person Assessment

PCP notified when HRA (HRA) 6 not completed within 2 (33%) 4 (67%)

timeframes

Potential Deficiency #6: In developing Individualized Care Plans (ICPs), the Plan does not consistently: • Identify all member’s medical, behavioral health, and

long term support needs, and • Create measureable objectives and timetables to

address members’ needs.

5 File 37 (ID). 6 File1 (ID), File2 (ID), File3 (ID), File 4 (ID), File 5 (ID), File 6 (ID), File 7 (ID), File 8 (ID), File 9 (ID), File 10 (ID), File 11 (ID), File 12 (ID), File 13 (ID), File 14 (ID), File 15 (ID), File 16 (ID, File17 (ID), File 18 (ID), File 19 (ID), File 20 (ID), File 21 (ID), File 23 (ID), File 24 (ID), File 25 (ID), File 26 (ID), File 27 (ID), File28 (ID), File 29 (ID), File 30 (ID), File 31 (ID), File 32 (ID), File 33 (ID), File 34 (ID), File 35 (ID), File 36 (ID), File 38 (ID), File 39 (ID), File 40 (ID), File 41 (ID), File 42 (ID), File 43 (ID), File 44 (ID), File 45 (ID), File 47 (ID 5), File 49 (ID), File 50 (ID), File 51 (ID), File 52 (ID). 7 File 7 (ID), File10 (ID), File 27 (ID), File 28 (ID), File 37 (ID), File 39 (ID). 8 File 10 (ID), File 28 (ID), File 37 (ID), File 39 (ID).


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Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.8.3; Duals Plan Letter 15-001. Santa Clara Cal MediConnect Three-Way Contract 2.8.3. Individualized Care Plan (ICP). An ICP will be developed for each Enrollee that includes Enrollee goals and preferences, measurable objectives and timetables to meet medical needs, Behavioral Health and LTSS needs. It must include timeframes for reassessment. Duals Plan Letter 15-001 Interdisciplinary Care Team and Individual Care Plan Requirements for Medicare-Medicaid Plans

A. Care Plans 1. Should a dual-eligible beneficiary demonstrate the need for a Care Plan,

MMPs are required to develop a plan and engage the dual-eligible beneficiary and/or his or her representative(s) in its design. The Care Plan is the responsibility of the MMP and is separate and distinct from the medical care plan the primary care provider creates, establishes, and maintains.

a. The need for a Care Plan may be identified by MMPs through interactions with dual-eligible beneficiaries (e.g. when conducting Health Risk Assessments [HRAs]), stratifying beneficiaries into lower and higher-risk categories (e.g. through the HRA risk-stratification process), and any other appropriate interactions.

2. Dual-eligible beneficiaries or their authorized representative must have the opportunity to review and sign the Care Plan and any of its amendments. MMPs must provide dual-eligible beneficiaries with copies of the Care Plan and any of its amendments. The Care Plan must be made available in alternative formats and in a beneficiary’s preferred written or spoken language.

3. A Care Plan must include: a. The dual-eligible beneficiary’s goals, preferences, choices,

and abilities; b. Measurable objectives and timetables to meet medical, behavioral

health, and long term support needs as determined through the HRA, In-Home Supportive Services (IHSS) assessment results, Multipurpose Senior Services Program (MSSP), and Community-Based Adult Services (CBAS) records, behavioral health utilization, other data, self and provider referrals, and input from members of the ICT, as appropriate; and

c. Coordination of carved-out and linked services, and referral to appropriate community resources and other agencies, when appropriate.

MMPs must reassess and update Care Plans at least annually or if a significant change in a beneficiary’s condition occurs.


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Documents Reviewed: • 30 Individualized Care Plan (ICP) Files (04/01/15 – 03/30/15)

Assessment: Through a review of 30 ICP files, the Department found that the Plan did not consistently identify all medical, behavioral health, and long term support needs of members, and create measureable objectives and timetables to address those needs. The Santa Clara Cal MediConnect Three-Way Contract §2.8.3., requires than an ICP “be developed for each Enrollee that includes Enrollee goals and preferences, measurable objectives and timetables to meet medical needs, Behavioral Health and LTSS needs.” Duals Plan Letter 15-001 supports this contractual requirement and details procedures and components to be included in developing ICPs, including “engag[ing] the dual-eligible beneficiary and/or his or her representative(s) in its design.” File Review The Department’s review of 30 HRA files showed that ICPs were indicated and completed for 29 cases. Of these 29 cases, the Plan failed to identify and address significant medical, behavioral health, and long-term support needs required by Duals Plan Letter 15-001 in 79 cases (24%) as exemplified below:

• File 5 (ID): File notes indicate that the Plan contacted the member several times to elicit input into the ICP without success. Although the member did not participate in development of the ICP, the Plan had information from the HRA available for use in care planning (as per Santa Clara Cal MediConnect Three-Way Contract 2.8.2.1). This information (e.g., financial factors, pain that could not be relieved) was not addressed in the ICP.

• File 8 (ID): The ICP did not include objectives and timetables to address the

member’s diabetes, hypertension, high cholesterol, and expressed interest in CBAS.

• File 10 (ID): Issues related to the member’s reported diagnoses of anxiety and

depression were not included in the ICP. The HRA states that the member was being treated by a behavioral health provider; however, this information was not adequately addressed in the ICP. (There was no attestation that the behavioral health provider and PCP had both reviewed and approved the ICP; there was no record of at least one case review meeting that included the behavioral health provider with evidence of creation or adjustment of care goals).

Conclusion: The Santa Clara Cal MediConnect Three-Way Contract §2.8.3. and Duals Plan Letter 15-001 require the Plan develop ICPs to meet members’ medical, behavioral health, and LTSS needs and create measurable objectives and timetables to meet those needs. When developing ICPs, the Plan does not consistently address all of

9 File 2 (ID); File 4 (ID); File 5 (ID); File 6 (ID); File 8 (ID); File 9 (ID); File 10 (ID).


16

these elements. Therefore, the Department finds the Plan in violation of these contractual requirements.

TABLE 3 ICP File Review Results

FILE TYPE NUMBER OF FILES ELEMENT COMPLIANT DEFICIENT

Individualized Care Plan (ICP)

29

Identify and address all medical, behavioral health, and long term support needs

22 (76%) 7 (24%)

AVAILABILITY AND ACCESSIBILITY Potential Deficiency 7: The Plan has not adopted policies and procedures to

ensure adequate access to Medicaid-based services for Cal MediConnect Enrollees.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.9 – 2.9.2; Santa Clara Cal MediConnect Three-Way Contract § 2.10 – 2.10.1.1.5; Santa Clara Cal MediConnect Three-Way Contract §2.10.2.3 – 2.10.2.3.3; Santa Clara Cal MediConnect Three-Way Contract §2.11.1 – 2.11.1.1; Santa Clara Cal MediConnect Three-Way Contract §2.11.2.1; Santa Clara Cal MediConnect Three-Way Contract §2.11.2.1.3 – 2.11.2.1.5. Santa Clara Cal MediConnect Three-Way Contract 2.9. Provider Network 2.9.1. The Contractor must demonstrate annually that it has an adequate network as approved by CMS and the state to ensure adequate access to medical, Behavioral Health, pharmacy, and LTSS, excluding IHSS, providers that are appropriate for and proficient in addressing the needs of the enrolled population, including physical, communication, and geographic access. 2.9.2. The Contractor must maintain a Provider Network sufficient to provide all Enrollees with access to the full range of Covered Services, including Behavioral Health services, other specialty services, and all other services required in 42 C.F.R. §§ 422.112, 423.120, and 438.206 and under this Contract (see Covered Services in Appendix A).

Santa Clara Cal MediConnect Three-Way Contract 2.10. Network Management 2.10.1. General requirements. The Contractor shall establish, maintain, and monitor a network that is sufficient to provide adequate access to all Covered Services in the Contract. Section 2.9.1 discusses the annual network review and approval requirement. 2.10.1.1. Taking into consideration:


17

2.10.1.1.1. The anticipated number of Enrollees; 2.10.1.1.2. The expected utilization of services, in light of the characteristics and health care needs of Contractor’s Enrollees; 2.10.1.1.3. The number and types of providers required to furnish the Covered Services; 2.10.1.1.4. The number of Network Providers who are not accepting new patients; and 2.10.1.1.5. The geographic location of Network Providers and Enrollees, taking into account distance, travel time, the means of transportation and whether the location provides physical access for Enrollees with disabilities.

Santa Clara Cal MediConnect Three-Way Contract 2.10.2.3. For Medi-Cal providers and facilities, the Contractor contract with a sufficient number of LTSS providers, including but not limited to SNFs (distinct part and freestanding), MSSP, CBAS and County Social Services Agencies located in the Contractor’s Service Area. 2.10.2.3.1. If the LTSS provider within the Service Area cannot meet the Enrollee’s medical needs, the Contractor must contract with the nearest LTSS provider outside of the covered Service Area. Contractor is responsible for all Covered Services, pursuant to WIC section 14186.3(c). 2.10.2.3.2. Contractor shall ensure the provision of acceptable accessibility standards in accordance with Title 28 CCR Section 1300.67.2.2 and as specified below. 2.10.2.3.3. Ensure that Network Providers offer hours of operation that are no less than the hours of operation offered to commercial Enrollees or comparable to Medi-Cal fee-for-service, if the provider serves only Medi-Cal Enrollees.

Santa Clara Cal MediConnect Three-Way Contract 2.11.1. General. The Contractor must provide services to Enrollees as follows: 2.11.1.1. Authorize, arrange, coordinate and provide to Enrollees all Covered Services that are Medically Necessary. Santa Clara Cal MediConnect Three-Way Contract 2.11.2.1. Contractor shall establish acceptable accessibility requirements in accordance with Title 28 CCR Section 1300.67.2.1 and as specified below. DHCS will review and approve requirements for reasonableness. Contractor shall communicate, enforce, and monitor Network Providers’ compliance with these requirements. 2.11.2.1.3. Waiting Times: Contractor shall develop, implement, and maintain a procedure to monitor waiting times in the Network Providers' offices, telephone calls (to answer and return), and time to obtain various types of appointments indicated in 2.9.2.6.1.1. above. 2.11.2.1.4. Telephone Procedures: Contractor shall require Network Providers to maintain a procedure for triaging Enrollees' telephone calls, providing telephone medical advice (if it is made available) and accessing telephone interpreters. 2.11.2.1.5. After Hours Calls: At a minimum, Contractor shall ensure that all Enrollees have access to appropriate licensed professional for after-hours calls. Documents Reviewed:

• Network Reports(04/15, 05/15, 06/15, 07/15, 08/15, 09/15,10/15, 11/15, 12/15, 1/16, 2/16)


18

• SCFHP Policy No. CO2014 Long Term Care Facility, Skilled Nursing Facility and Sub-acute Facility Contract Terms (6/1/14)

• MOU between the Plan and the Santa Clara County Public Authority Coordinated Care Initiative.(1/20/14)

• SCFHP Policy No.: MS 007-03 Plan Notification to Members of Provider or Hospital Contract Termination (6/25/12)

• SCFP Policy No.: PS 009_10 Notification to Members of Provider Termination. (4/1/11)

• Transportation contracts V&B Transportation (4/1/14) and Yellow Checker Cab Company (1/1/15)

Assessment: Following a Plan document review and interviews with Plan officers, the Department determined that the Plan has not established policies and procedures to ensure adequate access to Medicaid-based services for Cal MediConnect Enrollees. Plan Document Review and Interview Results The Department noted during its review of Plan documents that the Plan had established some policies and procedures relative to Cal MediConnect operations.10 However, the Department did not find policies and procedures that addressed several key elements of access and availability of services. During interviews, the Plan’s Compliance Officer and the Director of Provider Operations confirmed that the Plan does not have Cal MediConnect specific policies and procedures that address/specify the following aspects of access for Cal MediConnect members:

• A detailed description of how the Plan will evaluate adequacy of access to all Medicaid-based services (e.g., measurement methodology, requirements/standards against which adequacy will be measured, frequency of measurements), taking into consideration at a minimum:

o the anticipated number of Cal MediConnect members when evaluating adequate access to Medicaid-based services.

o the expected utilization of services, accounting for the clinical characteristics and health care needs of Cal MediConnect members when evaluating adequate access to Medicaid-based services.

o the number of providers who are not accepting new customers or patients when evaluating adequate access to Medicaid-based services.

o the geographic location of providers and Cal MediConnect members accounting for distance, travel time, and mode of transportation when evaluating adequate access to covered services.

10 SCFHP Policy No. CO2014 Long Term Care Facility, Skilled Nursing Facility and Sub-acute Facility Contract Terms establishes the Plans procedures for moving residents who reside in a Nursing Facility undergoing Medicaid decertification to other licensed facilities. SCFHP Policy No.: MS 007-03 Plan Notification to Members of Provider or Hospital Contract Termination and SCFHP Policy No.: PS 009_10 Notification to Members of Provider Termination detail Plan activities in the event of provider terminations. Transportation contracts with V&B Transportation and Yellow Checker Cab Company address the Plan requirement to provide non-medical/non-emergency transportation.


19

o whether the location of a provider is physically accessible to Cal MediConnect members with disabilities when evaluating adequate access to Medicaid-based services.

• A requirement that Medicaid-based services providers and facilities offer hours of operation for Cal MediConnect members that are no fewer than the hours of operation offered to commercial members or fee-for-service Medi-Cal members.

• A policy to how the Plan ensures that a sufficient number of Medicaid-based Behavioral Health services providers are available via the County based Behavioral Health program to meet the needs of Cal MediConnect members.

Plan Staff Interviews Upon confirming that the Plan has not established policies and procedures addressing the aspects of adequate access to Medicaid-based services, the Plan’s Compliance Officer and the Director of Provider Operations also stated that newly developed, but not yet approved or implemented, policies and procedures will address these requirements. The Plan had no such policies and procedures in place during the survey review period and could not provide draft documents to the Department. Conclusion: The Santa Clara Cal MediConnect Three-Way Contract requires the Plan to have an adequate provider network sufficient to provide all Enrollees with access to the full range of Covered Services, establish, maintain, and monitor a network that is sufficient to provide adequate access to all Covered Services in the Contract. The Santa Clara Cal MediConnect Three-Way Contract and the Care Initiative Memorandum of Understanding require the Plan to adopt policies and procedures to “ensure adequate access to Medicaid-based services” for Cal MediConnect Enrollees. The Plan has not created, implemented, or adopted policies and procedures to ensure adequate access to Medicaid-based services for Cal MediConnect Enrollees. Therefore, the Department finds the Plan in violation of this requirement. Potential Deficiency 8: The Plan does not evaluate access to all Medicaid-based

services at least annually to demonstrate that its provider network offers adequate access to members for all services and providers.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.9.1. Santa Clara Cal MediConnect Three-Way Contract 2.9.1 The Contractor must demonstrate annually that it has an adequate network as approved by CMS and the state to ensure adequate access to medical, Behavioral Health, pharmacy, and LTSS, excluding IHSS, providers that are appropriate for and proficient in addressing the needs of the enrolled population, including physical, communication, and geographic access. Documents Reviewed:


20

The Department reviewed the below listed Plan Access and Availability documents. Documents reviewed however were mostly specific to Medi-Cal, with three policies also including Healthy Kids and Healthy Families lines of business. No Plan policies reviewed for Access and Availability were applicable to, and did not specify, application to the CMC line of business.

• Monthly Summary Reconciliation which detailed number of providers by line of business and type (04/15-02/16)

• Plan Policy MS007_03 Notification to Members of Provider or Hospital Contract Termination

• Plan Policy PS029_04 Provider Satisfaction Survey • Plan Policies MS004_02 Plan Assignment of Provider and MS002_03 Member

Request to Change Primary Provider • Plan Policy PS023_04 Quarterly Provider Network Analysis-Medi-Cal • Plan Policies PS007_After Hours Survey and PS0742 Non-Discriminatory

Provider Hours of Operation • SCFHP Active Specialists 031416 The Plan was unable to furnish any documents specific to CMC to support this requirement.

Assessment: The Plan does not have policies or procedures in place to demonstrate, on an annual basis, that its members have adequate and appropriate access to all required services and providers, including physical, communication, and geographic access. In interviews during the onsite survey, the Plan’s Compliance Officer and the Director of Provider Operations, acknowledged this failure. The Plan has not established and implemented policies and procedures to ensure that access to LTSS (excluding IHSS) for its Cal MediConnect members is evaluated at least annually. Similarly, the Plan has not established policies and procedures to ensure that access to county-based behavioral health services, non-emergent medical transportation services and non-medical transportation services is evaluated annually. Given the absence of a formal evaluation of access to these services, the Plan was unable to demonstrate that it meets the requirement of Section 2.9.1 of the Santa Clara Cal MediConnect Three-Way Contract to ensure adequate access to these services Conclusion: The Plan has failed to develop and implement policies and procedures to annually assess its network to ensure and demonstrate adequate access to medical, behavioral health, pharmacy, and LTSS, excluding IHSS, providers as required by Section 2.9.1. of the Santa Clara Cal MediConnect Three-Way Contract. Therefore, the Department finds the Plan in violation of this contractual requirement. Potential Deficiency 9: The Plan has not identified, by name and job title, the

individual who is responsible for Americans with


21

Disabilities Act (ADA) compliance relative to Cal MediConnect, nor has it demonstrated ADA compliance.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.11.1.3. Santa Clara Cal MediConnect Three-Way Contract 2.11.1.3 The Contractor must identify to DHCS the individual in its organization who is responsible for ADA compliance related to this Demonstration and his/her job title. The Contractor must also establish and execute a work plan to achieve and maintain ADA compliance. Documents Reviewed: The Department reviewed the Plan Access and Availability documents. Documents reviewed did not reveal by name and job title, the individual who is responsible for Americans with Disabilities Act (ADA) compliance relative to Cal MediConnect, nor did they demonstrate compliance to ADA. The reviewed documents were mostly specific to Medi-Cal. No Plan policies reviewed for Access and Availability were applicable to, and did not specify, application to the CMC line of business.

• Executive Organization Chart, QI Organization Chart, UM Organization Chart, and Member Services Organization Chart

• QI Committee Minutes (2/15-11/15) • UM Committee Minutes (1/15-10/15) • JOC Minutes (5/15-11/15) • 2015 SCFHP Policy Log • 2016 MediConnect Pharmacy Readiness Training • BF18007 Privacy & Security Overview V8 Non Audio • CMC Quick Reference Card • SCFHP MLTSS Training Summary • Member Evidence of Coverage • SCFHP Provider Manual

The Plan was unable to furnish any documents to support this requirement.

Assessment: The Plan was unable to identify, through documentation or interview, the individual within the Plan who is responsible for ADA compliance, nor was it able to substantiate that it has established and executed a work plan to achieve and maintain ADA compliance. The Santa Clara Cal MediConnect Three-Way Contract §2.11.1.3., requires the Plan to “identify to DHCS the individual in its organization who is responsible for ADA compliance ... [and] establish and execute a work plan to achieve and maintain ADA compliance.” The Plan produced no documentation in response to the Department’s request for a copy of the ADA work plan. During interviews, the Plan Compliance Officer and the Director of Provider Operations confirmed that the Plan had not established or executed a work plan to achieve and maintain ADA compliance. These Plan officers were unable


22

to furnish the name and job title of the individual within the Plan who had been assigned responsibility for ADA compliance for Cal MediConnect and were unsure who in the organization had that responsibility. Conclusion: The Santa Clara Cal MediConnect Three-Way Contract §2.11.1.3., requires the Plan to identify the individual within the Plan who is responsible for ADA compliance and to establish and execute a work plan to achieve and maintain ADA compliance. The Plan was unable to identify the individual in the Plan responsible for ADA compliance nor did it provide evidence of a work plan. Therefore, the Department finds the Plan in violation of this contractual requirement. Potential Deficiency 10: The Plan lacks sufficient policies and procedures to

reasonably ensure that members with disabilities have the same access, including communication access, to Plan programs and services as members without disabilities.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.11. Santa Clara Cal MediConnect Three-Way Contract 2.11.1. The Contractor must provide services to Enrollees as follows: 2.11.1.2. Reasonably accommodate Enrollees and ensure that the programs and services are as accessible (including physical and geographic access) to an Enrollee with disabilities as they are to an Enrollee without disabilities, and shall have written policies and procedures to assure compliance, including ensuring that physical, communication, and programmatic barriers do not inhibit Enrollees with disabilities from obtaining all Covered Services from the Contractor by: 2.11.1.2.1. Providing flexibility in scheduling to accommodate the needs of the Enrollees 2.11.1.2.3. Ensuring that Enrollees with disabilities are provided with reasonable accommodations to ensure effective communication, including auxiliary aids and services. Reasonable accommodations will depend on the particular needs of the Enrollee and include but are not limited to: 2.11.1.2.3.2. Ensuring that all written materials are available in formats compatible with optical recognition software; 2.11.1.2.3.3. Reading notices and other written materials to Enrollees upon request; 2.11.1.2.3.5. Ensuring effective communication to and from Enrollees with disabilities through email, telephone, and other electronic means; 2.11.1.2.3.6. TTY, computer-aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays and qualified interpreters for the deaf; and 2.11.1.2.3.7. Individualized assistance. Documents Reviewed:

• Plan Policy QM 107: Facility Site Review Tool (04/01/11) • Plan Policy CU 003: Language Assistance Policy (04/01/11)


23

• Cultural and Linguistic Program, Section 3 (2015) Assessment: In a review of Plan documents and through interviews with Plan officers, the Department found that the Plan lacks sufficient policies and procedures to ensure that members with disabilities have the same access, especially in terms of communication accommodation, to Plan programs and services as members without disabilities. The Department’s document review found that the Plan has established some policies to address services tailored to the needs of enrollees with disabilities, as follows:

• Plan Policy QM 107, Facility Site Review Tool ensures that the Plan evaluates provider facilities for adequate physical access for enrollees with disabilities (e.g., parking, building, elevator, doctor’s office, exam room and restroom).

• Plan Policy CU 003, Language Assistance Policy, provides for telephonic assistance to members in filling out forms.

• Plan document, Cultural and Linguistic Program, Section 3, addresses a no-cost provision for sign language interpreters for members who are deaf and hard of hearing.

However, in its review of Plan documents, the Department found no policies and procedures or other documentation addressing several key services for members with disabilities. In response to the Department’s queries, Plan staff acknowledged that its policies and procedures do not provide for reading services for notices and other written materials sent to members upon request. Although the Plan provides qualified interpreters for the deaf, Plan documents show no evidence that it offers TTY, computer-aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays and written materials in formats compatible with optical recognition software. The Plan does not provide Cal MediConnect members with disabilities electronic communication methods, such as email and telephone, which reasonably accommodate the disabilities of such members. The Plan has no policies that ensure the Plan provides reasonable accommodation for those needing individualized assistance due to a disability. During interviews, the Plan’s Compliance Officer and the Director of Provider Operations, confirmed with the Department that the Plan does not have policies and procedures that address flexibility in scheduling to accommodate the needs of the enrollees with disabilities or the availability of reasonable accommodations to ensure effective communication, including auxiliary aids and services. The Plan’s Compliance Officer stated that policies were under development that would address these requirements; however, these policies were still in draft form and had not yet been approved by the governing body. Conclusion: The Santa Clara Cal MediConnect Three-Way Contract §2.11.1.2., requires the Plan to have written policies and procedures to ensure that its programs and services are as accessible to members with disabilities as they are to members without disabilities. Provisions of this section specifically identify the ways in which the


24

Plan must accommodate the needs of members with disabilities, especially in the area of communications. While the Plan has in place some policies and documents that outline the Plan’s efforts to address the needs of this membership, it lacks documentation demonstrating that it provides the specific communication devices and services listed, which are critical to the successful provision of health care services. Therefore, the Department finds the Plan in violation of this contractual requirement.

MEMBER RIGHTS

Potential Deficiency 11: The Plan does not have policies or procedures addressing members’ grievances and appeals regarding Cal-MediConnect services.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.14.2.; Santa Clara Cal MediConnect Three-Way Contract § 2.15.3.3.; Rule 1300.68 (a).

Santa Clara Cal MediConnect Three-Way Contract 2.14.2. Internal (plan level) Grievance: An Enrollee may file an Internal Enrollee grievance regarding Medicare and Medi-Cal covered benefits and services at any time with the Contractor or its providers by calling or writing to the Contractor or provider. The Contractor must have a system in place for addressing Enrollee grievances, including grievances regarding reasonable accommodations and access to services under the ADA. 2.14.2.1.1. Internal Grievance: Contractor shall establish and maintain a grievance process under which Enrollees may submit their grievance regarding all covered services and benefits to the Contractor. Contractor shall establish and maintain a grievance process approved by DHCS under which enrollees may submit their grievances regarding all benefits and services, pursuant to the Knox-Keene Health Care Services Plan Act of 1975, WIC Section 14450 and CCR, Title 22, Section 53260.

Santa Clara Cal MediConnect Three-Way Contract 2.15.3.3. Contractor shall implement and maintain an Enrollee internal Appeals system, which includes oversight of any First Tier, Downstream or Related Entity, in accordance with all applicable federal and state laws and regulations, including but not limited to the following: 2.15.3.3.2. Standards for expedited review of grievances involving an imminent and serious threat to the health of the Enrollee: Title 28, CCR, Sections 1300.68 and 1300.68.01; 2.15.3.4. Expedited internal Medi-Cal Appeals. Contractor shall comply with all state law and regulations pertaining to expedited Appeals, as well as the following requirements: 2.15.3.4.1. Contractor shall implement and maintain procedures as described below to resolve expedited internal Appeals for Medi-Cal services. These procedures shall be followed whenever Contractor determines or the provider indicates that taking the time for a standard resolution.


25

Rule 1300.68 (a) Every health care service plan shall establish a grievance system pursuant to the requirements of Section 1368 of the Act. (a) The grievance system shall be established in writing and provide for procedures that will receive, review and resolve grievances within 30 calendar days of receipt by the plan, or any provider or entity with delegated authority to administer and resolve the plan's grievance system. Documents Reviewed:

• Plan Policy GA 001_11: Member Grievance and Appeals Process (09/21/15) • Cal MediConnect Appeals and Grievance Intake Workflow (Undated) • Cal MediConnect Expedited Considerations Workflow (Undated) • Plan Member Handbook (2015 and 2016)

Assessment: The Plan does not identify Cal MediConnect members in its grievances and appeals policy, thereby failing to validate that a grievance system is in place for this membership. The Plan failed to provide written policies and procedures outlining the grievance system as it applies to Cal MediConnect members. During interviews, Plan staff stated that the Plan has developed grievance and appeals policies and procedures for other lines of business, but these did not include the Cal MediConnect line of business. Plan staff explained that several policies were under development, which will address Cal MediConnect members, but they were not yet approved. Plan documents, Cal MediConnect Appeals and Grievance Intake Workflow and Cal MediConnect Expedited Considerations Workflow, display a broad overview of the Plan’s process for addressing member grievances and appeals. Additionally, the Plan outlines for enrollees a process for filing grievances and notes the timeframe for resolution in the 2015 and 2016 editions of the Cal MediConnect Plan Member Handbook. No written policies and procedures to provide detailed instructions for staff on the receipt, review and resolution of Cal MediConnect grievances (including exempt, standard and expedited grievances, standard and expedited appeals, Independent Medical Reviews or the State Fair Hearing Process) were provided to the Department, nor did the Plan provide any additional documents showing development and review of the grievance system. Plan Policy GA 001_11, Member Grievance and Appeals Process establishes and maintains procedures that enable members to submit their grievances and appeals to the Plan for investigation and receive resolutions in a timely manner. However, the policy excludes Cal MediConnect when identifying the lines of business covered under its provisions, citing only Health Kids, Healthy Families, and Medi-Cal enrollees. Conclusion: Section 2.14.2. and Section 2.15.3. of the Santa Clara Cal MediConnect Three-Way Contract require the Plan to develop and maintain written processes to identify, acknowledge, investigate, and resolve members’ grievances and appeals. The Plan does not have policies and procedures in place for grievances and appeals that are submitted by Cal MediConnect members. Therefore, the Department finds the Plan in violation of these contractual, statutory, and regulatory requirements.


26

Potential Deficiency 12: The Plan’s grievance acknowledgement and resolution

letters do not display the Department’s telephone number, TDD line, and Internet address, as well as the Plan’s telephone number in the format required by Section 1368.02(b).

Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.14.3.1; Section 1368.02(b). Santa Clara Cal MediConnect Three-Way Contract 2.14.3.1. Pursuant to Health & Safety Code Section 1368(b), Contractor shall inform Enrollees that they may file an external grievance for Medi-Cal only covered benefits and services (not including IHSS) through the DMHC’s consumer complaint process. Contractor shall inform Enrollees of the DMHC’s toll-free telephone number, the DMHC’s TDD line for the hearing and speech impaired, and the DMHC’s website address pursuant to Health & Safety Code Section 1368.02. Section 1368.02(b) Every health care service plan shall publish the Department’s toll-free telephone number, the Department’s TDD line for the hearing and speech impaired, the plan’s telephone number, and the Department’s Internet address, on every plan contract, on every evidence of coverage, on copies of plan grievance procedures, on plan complaint forms, and on all written notices to enrollees required under the grievance process of the plan, including any written communications to an enrollee that offer the enrollee the opportunity to participate in the grievance process of the plan and on all written responses to grievances. The Department’s telephone number, the Department’s TDD line, the plan’s telephone number, and the Department’s Internet address shall be displayed by the plan in each of these documents in 12-point boldface type in the following regular type statement:

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (insert health plan’s telephone number) and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.


27

The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

Documents Reviewed:

• 29 Standard Grievances and Appeals Files (04/01/15 – 03/31/16)

Assessment: The Department found that the Plan failed to include the prescribed language in the enrollee rights statement as required by Section 1368.02(b) in grievance resolution letters and failed to include the prescribed format in the enrollee rights statements in both grievance acknowledgement and resolution letters. Plan staff acknowledged that a non-compliant template for all resolution letters was in use throughout the survey period and stated that the Plan is implementing corrective action. File Review The Department reviewed 29 standard grievances and appeals files, which represent the universe of grievances received by the Plan during the review period. Four11 of the 29 files were excluded as the appeals pertained to Medicare benefits, and one file12 was excluded as the enrollee withdrew the grievance on the same day it was filed. Of the remaining 24 files eligible for this review, the Department found that the Plan failed to format the required statement correctly in all acknowledgement and resolution letters. In addition, the Plan failed to include the prescribed language in all resolution letters. Acknowledgement letters: Five13 files did not contain acknowledgement letters; these were deemed to be non-compliant. All of the remaining 1914 files failed to follow the required format in the enrollee rights statements in the acknowledgement letters. Resolution letters: One file15 did not contain a resolution letter and was deemed non-compliant. All of the remaining 2316 files failed to follow the format of the required statements and failed to include the prescribed language in the resolution letters.

11 File 8 (ID); File 12 (ID); File 14 (ID); File 15 (ID). 12 File 2 (ID). 13 File 5 (ID), File 6 (ID), File 16 (ID), File 19 (ID), File 25 (ID). 14 File 1 (ID), File 4 (ID), File 7 (ID), File 9 (ID), File 10 (ID), File 11 (ID), File 13 (ID), File 17 (ID), File 18 (ID), File 20 (ID), File 21 (ID), File 22 (ID), File 23 (ID), File 24 (ID), File 26 (ID), File 27 (ID), File 28 (ID), File 29 (ID). 15 File 16 (ID). 16 File 1 (ID), File 3 (ID), File 4 (ID), File 5 (ID), File 6 (ID), File 7 (ID), File 9 (ID), File 10 (ID), File 11(ID), File 13 (ID), File 17 (ID), File 18 (ID), File 19 (ID), File 20 (ID), File 21 (ID), File 22 (ID), File 23 (ID), File 24 (ID), File 25 (ID), File 26 (ID), File 27 (ID), File 28 (ID), File 29 (ID).

http://www.hmohelp.ca.gov/


28

Language deficiency In the Plan’s grievance resolution letters, the first sentence of the enrollee rights statement was replaced with two sentences, which are noncompliant with Section 1368.02(b). In Section 1368.02(b), the first sentence of the enrollee rights statement is as follows:

The California Department of Managed Health Care is responsible for regulating health care service plans.

In the Plan’s grievance resolution letters, the required sentence was replaced with the following two sentences:

You may also contact the California Department of Managed Health Care (DMHC). DMHC is responsible for regulating health care service plans.

Format Deficiency In acknowledgement and resolution letters, the enrollee rights statement was presented in boldface type in its entirety, which is noncompliant with Section 1368.02(b).

TABLE 4 Formatting of Enrollee Rights Statement as Required by Section 1368.02(b)

FILE TYPE NUMBER

OF FILES

ELEMENT COMPLIANT DEFICIENT

Standard Grievance and Appeals

24

Acknowledgement letter includes required statement as specified in Section 1368.02(b)

0 (0%) 24 (100%)

Standard Grievance and Appeals

24

Resolution letter includes grievance statement language as specified in Section 1368.02(b).

0 (0%) 24 (100%)

Conclusion: Santa Clara Cal MediConnect Three-Way Contract § 2.14.3.1 and Section 1368.02(b) require the Plan to publish the Department’s toll-free telephone number, the Department’s TDD line for the hearing and speech impaired, the Plan’s telephone number, and the Department’s Internet website address in a prescribed


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statement of enrollee rights in all written communication to enrollees involving the grievance process. In a file review, the Department found that the Plan failed to use the required language and format in both acknowledgement and resolution letters. Therefore, the Department finds the Plan in violation of these contractual and statutory requirements. Potential Deficiency 13: The Plan does not provide a written acknowledgement

within five calendar days of receipt of a grievance. Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.14.2.1.1.; Section 1368 (a)(4)(A); Rule 1300.68(d)(1). Santa Clara Cal MediConnect Three-Way Contract 2.14.2.1.1. Internal Grievance: Contractor shall establish and maintain a grievance process under which Enrollees may submit their grievance regarding all covered services and benefits to the Contractor. Contractor shall establish and maintain a grievance process approved by DHCS under which enrollees may submit their grievances regarding all benefits and services, pursuant to the Knox-Keene Health Care Services Plan Act of1975, WIC Section 14450 and CCR, Title 22, Section53260. Section 1368 (a)(4)(A) (a) Every plan shall do all of the following: … (4) (A) Provide for a written acknowledgment within five calendar days of the receipt of a grievance, except as noted in subparagraph (B). The acknowledgment shall advise the complainant of the following: (i) That the grievance has been received. (ii) The date of receipt. (iii) The name of the plan representative and the telephone number and address of the plan representative who may be contacted about the grievance. Rule 1300.68(d)(1) (d) The plan shall respond to grievances as follows: (1) A grievance system shall provide for a written acknowledgment within five (5) calendar days of receipt, except as noted in subsection (d)(8). The acknowledgment will advise the complainant that the grievance has been received, the date of receipt, and provide the name of the plan representative, telephone number and address of the plan representative who may be contacted about the grievance. Documents Reviewed:

• Cal MediConnect Plan Member Handbook (2015 and 2016) • 29 Standard Grievance Files (04/01/15 – 03/31/16)

Assessment: In a review of the Plan’s standard grievance files, the Department found that the Plan does not acknowledge enrollee grievances within five calendar days as required and in some cases, it fails to send an acknowledgement letter. In response to the Department request for copies of the missing acknowledgement letters, the Plan


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provided a document after the onsite survey stating that acknowledgement letters were not created for the files identified as missing those letters. While the Plan has not established policies or procedures related to the timeliness of processing members’ grievances and appeals for Cal MediConnect members, the 2015 and 2016 editions of the Cal MediConnect Plan Member Handbook, section 10.1, states: “We will send you a letter within 5 days, letting you know we received your grievance.” File Review The Department reviewed 29 standard grievance files, which constitute the universe of files for the review period. Four17 of the files were excluded from review as they were related to Medicare-based services, and one file18 contained a complaint that was withdrawn on the same day. Of the remaining 24 files eligible for review, five19 files lacked acknowledgment letters, and two files20 contained acknowledgement letters that were one day late, totaling seven noncompliant files. The following files exemplify this failure:

• File 3 (ID): The Plan received the grievance on [date], and sent an acknowledgement letter on [date].

• File 16 (ID): The file did not contain an acknowledgement letter.

TABLE 5 Timeliness of Acknowledgement Letters

FILE TYPE NUMBER

OF FILES

ELEMENT COMPLIANT DEFICIENT

Standard Grievance Files

24 Acknowledgement letters sent within 5 calendar days

17 (71%) 7 (29%)

Conclusion: The Santa Clara Cal MediConnect Three-Way Contract § 2.14.2.1.1., requires the Plan to maintain a grievance system in accordance with Section 1368 (a)(4)(A), which requires the Plan to send acknowledgement letters to members within five day of receipt of the grievances. Rule 1300.68(d)(1) and the Plan’s member handbook support the five-day requirement. In a review of grievance files, the Plan found that the Plan does not consistently send acknowledgement notices to members within five calendar days. Therefore, the Department finds the Plan in violation of these contractual, statutory, and regulatory requirements.

17 File 8 (ID), File12 (ID), File 14 (ID), File 15 (ID). 18 File 2, (ID). 19 File 5 (ID), File 6 (ID), File 16 (ID), File 19 (ID), File 25 (ID). 20 File 3 (ID), File 10 (ID).


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QUALITY MANAGEMENT Potential Deficiency 14: The Plan does not consistently document that the quality

of care provided is being reviewed, that problems are being identified, that effective action is taken to improve care where deficiencies are identified, and that follow-up is planned where indicated.

Contractual/Statutory/Regulatory Reference(s): Santa Clara Cal MediConnect Three-Way Contract §2.16.2.; Santa Clara Cal MediConnect Three-Way Contract § 2.16.3.1.; Rule 1300.70(a)(1); Rule 1300.70(b)(1)(A)(B). Santa Clara Cal MediConnect Three-Way Contract 2.16.2. Apply the principles of Continuous Quality Improvement (CQI) to all aspects of the Contractor’s service delivery system through ongoing analysis, evaluation and systematic enhancements. Santa Clara Cal MediConnect Three-Way Contract 2.16.3.1. The Contractor shall maintain a well-defined QI organizational and program structure that supports the application of the principles of CQI to all aspects of the Contractor’s service delivery system. The QI program must be communicated in a manner that is accessible and understandable to internal and external individuals and entities, as appropriate. The Contractor’s QI organizational and program structure shall comply with all applicable provisions of 42 C.F.R. § 438,, including Subpart D, Quality Assessment and Performance Improvement, 42 C.F.R. § 422, Subpart D Quality Improvement, and shall meet the quality management and improvement criteria described in the most current NCQA health plan accreditation requirements in 28 CCR Section 1300.70. Rule 1300.70(a)(1) The QA program must be directed by providers and must document that the quality of care provided is being reviewed, that problems are being identified, that effective action is taken to improve care where deficiencies are identified, and that follow-up is planned where indicated. Rule 1300.70(b)(1)(A)(B) To meet the requirements of the Act which require plans to continuously review the quality of care provided, each plan's quality assurance program shall be designed to ensure that: (A) A level of care which meets professionally recognized standards of practice is being delivered to all enrollees; (B) Quality of care problems are identified and corrected for all provider entities. Documents Reviewed:

• Plan Policy QM002_02: Potential Quality of Care Issues (revised March 2011)


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• Four files for cases identified by the Plan as potential quality issues (PQIs)21 (04/01/15 – 03/30/15)

Assessment: The Plan did not adequately review and investigate the quality of care delivered by its providers. The Plan identified four PQIs during the survey period. In two (50%) of the PQI files the Plan did not adequately investigate all issues, identify and assess the severity of existing quality problems, and determine whether/what corrective actions were needed to ensure correction of those problems. Plan Policy QM002_02, Potential Quality of Care Issues, establishes a process for addressing potential quality issues.

C. Clinical Review Process 1. A Quality Improvement Nurse and/or QI Coordinator will review the referral and make a determination regarding what information is needed to complete the review. 2. A communication is generated to the provider(s) ... within five (5) calendar days ... requesting medical records ... If the QI staff does not receive the requested documentation within fourteen (14) calendar days of the initial request, a second request is made. If no response is received ... a telephone call is made … If after a total of 30 days ... records have not been received ... an action plan for non-responsiveness will then be determined … QI Department/Medical Director has the right to resolve the case without the benefit of medical records or provider recommendation… 8. The QI staff is to complete the PQI Summary Report form and forward, with all pertinent medical records, to the QIC Chairman and/or peer review designee for review and determination. 9. If a quality of care issue is determined, a corrective action plan (CAP) is requested within 30 working days … 10. The QIC Chairman and/or peer review designee will consider professionally recognized standards of care and practice, Plan adopted clinical practice guidelines, thresholds established by the Quality Improvement Committee (QIC), the pertinent medical record documentation, the provider’s input and any other relevant source of information … 11. The QI Department completes the review within 90 days …

D. Assignment of Quality Level of Care Based upon the outcome of the PQI case review, a Quality of Care code and Severity Level [sic] will be assigned to the PQI referral that reflects the outcome: 1. Level I – No quality of care or quality of service issue noted.

21 Cases, providers, processes or concerns identified through enrollee grievances, sentinel events (e.g., mortalities), data analysis, provider site visits and other sources as having potential quality issues that require investigation are often referred to as PQIs.


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2. Level II – Opportunity for improvement in care, service, or system ispresent.3. Level III – Unacceptable care and/or service.

F. Corrective Action Plan (CAP)A CAP will be developed by the QI Department through the

recommendation of the medical director, QIC Chairman and/or designee, and/or the QIC. 1. If, after review, a PQI is confirmed, a CAP will be implementedimmediately ... will also include any planned follow-up activities to ensurethat the problem does not recur.

In two22 (50%) of the four PQI files reviewed by the Department, the Plan did not ensure that it adequately investigated, appropriately assigned a severity level, and implemented corrective actions on all existing problems to ensure correction:

• File 2 (ID): The enrollee’s niece complained about poor care the enrolleereceived at a SNF. The Plan requested medical records from the facility forreview; however, it could not be determined from the Plan’s file whether medicalrecords were ever received; no records were present in the file. There was nodocumentation that the case had been reviewed or investigated by Plan staff, norwas any explanation documented as to why no review occurred. The Plan didnot assign the case a severity level or otherwise document the outcome of aclinical review, nor were any corrective actions documented.

• Case 3 (ID): This PQI was identified by a nurse case manager. The enrolleewas discharged from a SNF, but proper DME was not sent to the enrollee’s homeupon discharge, nor was the enrollee’s granddaughter notified of home healthfollow-up. A Plan nurse reviewed the case; however, it was not assigned aseverity level. The case was not elevated for physician review to assess theseverity of the issues and to determine whether corrective actions (e.g.,education to the SNF regarding its responsibilities for coordinating dischargeplanning with the member’s family/responsible person, improvements to DMEprocess) were indicated.

Conclusion: The Plan did not effectively investigate potential quality issues and take action to improve care as required by the Santa Clara Cal MediConnect Three-Way Contract, §2.16.2. and §2.16.3.1., by Rule 1300.70(a)(1), by Rule 1300.70(b)(1)(A)(B), and by its own policy. Therefore, the Department finds the Plan in violation of these contractual and regulatory requirements.

22 File 2 (ID); File 3 (ID).


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TABLE 6 PQI File Review Results

NUMBER FILE OF ELEMENT COMPLIANT DEFICIENT TYPE FILES Identification and full investigation of all existing 2 (50%) 2 (50%) quality of care problems Assignment of a severity

Potential level or other 2 (50%) 2 (50%) Quality 4 documentation of the Issue outcome of review

Assignment and implementation of 2 (50%) 2 (50%) appropriate corrective actions where indicated


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APPENDIX A. MEDICAL SURVEY TEAM MEMBERS

DEPARTMENT OF MANAGED HEALTH CARE TEAM MEMBERS Joseph Marino Survey Team Lead Victoria Ciganda Plan Surveys Attorney MANAGED HEALTHCARE UNLIMITED, INC. TEAM MEMBERS Peter Leidl, MD Quality Management and Continuity of Care Elizabeth Fuhrman, PhD, RN Utilization Management, Emergency Services and Prescription Drugs Karolyn Rim Stein, RN Utilization Management, Emergency Services and Prescription Drugs Jennifer Luna Member Rights Ed Lowenstein, MD Quality Management Bruce Hoffman Access and Availability and Language Assistance Pat Schano Access and Availability


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APPENDIX B. PLAN STAFF INTERVIEWED

PLAN STAFF INTERVIEWED: Christine Tomcala Chief Executive Officer Chris Turner Chief Operations Officer Dave Cameron Chief Financial Officer Jeff Robertson MD Chief Medical Officer Jonathan Tamayo Chief Information Officer Gary Kaplan Vice President Vendor Relations and Delegation Oversight Andres Aguirre Quality Improvement Manager Angela Sheu-Ma Health Educator Anna Vuong Compliance Coordinator Beth Paige Compliance Officer Dan Johns Appeals & Grievance Manager Daniel Welsh Director, Integration Business Solutions Jennifer Clements Director, Provider Operations Joan McKay Medical Management Consultant RN Johanna Liu, PharmD., MBA Pharmacy & QI Director Jordan Yamashita Compliance and Audit Manager Laura Watkins Director Marketing and Business Development Lily Boris MD Medical Director Lori Anderson Operations Director, Long Term Services and Support Peggy Periandri Director, Delegation Oversight Rebecca Weaver Nurse Case Manager Robert Ostrander Claims Director Robin Bilinski Manager of Contracts and Credentialing Sherry Holm Behavioral Health Program Manager Tami Ogino, PharmD Clinical Pharmacist Tanya Nguyen Member Services Director Tariq Brown Medicare Compliance Coordinator


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APPENDIX C. LIST OF FILES REVIEWED

Type of Case Files Reviewed

Sample Size (Number of

Files Reviewed)

Explanation

Standard Grievances 29

The Plan identified a universe of 29 files during the review period. Based on the Department’s File Review Methodology, a random sample of 29 files were reviewed.

Health Risk Assessment / Individual Care Plan

52

The Plan identified a universe of 1,595 files during the review period. Based on the Department’s File Review Methodology, a random sample of 52 files were reviewed.

Potential Quality Issues 4


UM Medical Necessity Denials 5
