1. SNP Surveyor Update Training June 17, 2013

2. 2 SNP: Surveyor Update Training Objectives of SNP SUT Training Review NCQA’s year-to-year approach to the project and reporting requirements for SNPs Describe the changes in the S&P measures for the 2013 SNP Assessment Explain how to assess performance with individual elements in the S&P Measures

3. 3 SNP: Surveyor Update Training Objectives of SNP Assessment Program Develop a robust and comprehensive assessment strategy Evaluate the quality of care SNPs provide Evaluate how SNPs address the special needs of their beneficiaries Provide data to CMS to allow plan-plan and year-year comparisons

4. 4 SNP: Surveyor Update Training SNP Assessment: How did we get here? Existing contract with CMS to develop measures focusing on vulnerable elderly Revised contract to address SNP assessment 2008 - rapid turnaround, adapted existing NCQA measures and processes from Accreditation programs 2009 - focused on SNP-specific measures 2010 - refined existing measures 2011 - clarified requirements in SNP 1 thru 6 2012 - added elements/factors, removed factors, refined measures and documentation requirements

5. 5 SNP: Surveyor Update Training Who Reports HEDIS measures – All SNP plan benefit packages with 1 or more members as of February 2012 Comprehensive Report (CMS website) S&P measures – All SNP plan benefit packages – Plans with zero enrollment as of April 2013 Comprehensive Report are exempt for certain elements

6. 6 SNP: Surveyor Update Training SNP Reporting Returning SNPs— all SNPs that were operational as of January 1, 2012 AND renewed for 2013 AND have previously submitted. – SNP 1 A-F, SNP 2A-C, SNP 3-6 New SNPs — all SNPs operational as of January 1, 2012 AND renewed for 2013 AND are reporting for the first time. – SNP 1 A-D, SNP 2A-C, SNP 4-6

7. 7 SNP: Surveyor Update Training Project Time Line – 2013-2014 June 2013 through September 2013- Training for SNPs June & July 2013 - Release S&P Measures in hardcopy and ISS Data Collection Tool October 15, 2013 - S&P Measure submissions due to NCQA October 15, 2013 to April 30, 2014 – S&P reviews conducted by NCQA and surveyors June 2014 - NCQA delivers SNP Assessment Report to CMS

8. Structure and Process Measures

9. SNP 1: Care Management and Coordination

10. 10 SNP: Surveyor Update Training Changes since 2012 Replaced elements of Complex Case Management with new ones for Care Management that assess whether SNPs have appropriate programs to coordinate services and help all members access needed resources Better align with CMS MOC requirements for assessment and care plans SNP 1- Care Mgmt. and Coordination

11. 11 SNP: Surveyor Update Training Changes continued Care Mgmt. and Coordination consists of Elements A: Care Management Program Description B: Population Description C: Care Management Process D: Individualized Care Plan E: Satisfaction with Care Management F: Analyzing Effectiveness/Identifying Opportunities G: Implementing Interventions and Follow-up Evaluation SNP 1- Care Mgmt. and Coordination

12. 12 SNP: Surveyor Update Training Definition - Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing coordination of care, eliminating duplication of services and reducing the need for expensive medical services. SNP 1- Care Mgmt. and Coordination

13. 13 SNP: Surveyor Update Training Element A - Program Description The SNP has a description for its Care Mgmt. program that includes: 1.Evidence used to develop the program 2.Criteria for identifying members who are eligible for the program 3.Services offered to eligible members 4.Defined program goals Data source: documented process SNP 1- Care Mgmt. and Coordination

14. 14 SNP: Surveyor Update Training Care Mgmt. program focuses on member- specific activities and the coordination of services; it involves: Comprehensive assessment of member’s condition Determining benefits/resources Developing and implementing a care plan that includes performance goals, monitoring and follow-up SNP 1- Care Mgmt. and Coordination

15. 15 SNP: Surveyor Update Training A SNP must have a Care Mgmt. Program Based on the subpopulations within its membership SNPs may have the following within a larger Care Mgmt. Program: – Complex case mgmt – Transitional case mgmt – High-risk/high utilization programs – Hospital case mgmt SNP 1- Care Mgmt. and Coordination

16. 16 SNP: Surveyor Update Training Factor 1 requires the SNP to describe the evidence it used to develop the program. – E.g., clinical practice guidelines; scientific evidence from clinical or technical literature or government research; or literature reviews for nonclinical aspects of the program like dealing with or promoting behavioral change. Program description must also detail the criteria SNP uses to identify eligible members for factor 2 SNP 1- Care Mgmt. and Coordination

17. 17 SNP: Surveyor Update Training SNP’s description includes the services it provides to members. Org that stratifies members based on risk or level of need must include eligibility criteria, services to be provided and goals for each tier. Program description also needs to include goals that reflect specific objectives and targets. SNP 1- Care Mgmt. and Coordination

18. 18 SNP: Surveyor Update Training Element B – Population Assessment Annually SNP must: 1.Assess the characteristics and needs of member population and pertinent subpopulations 2.Review and update Care Mgmt. processes to address member needs 3.Review and update Care Mgmt. resources to address member needs Data source: Documented process SNP 1- Care Mgmt. and Coordination

19. 19 SNP: Surveyor Update Training Population assessment includes SNP’s covered population not just members in specific programs like CCM Documentation must show how: – SNP considers specific member characteristics when designing and revising program e.g., Medicaid eligibility categories Nature and extent of carved out benefits Type of SNP Race/ethnicity and language preferences SNP 1- Care Mgmt. and Coordination

20. 20 SNP: Surveyor Update Training Population assessment procedures also need to include consideration of program characteristics and resources e.g., staffing ratios, clinical qualifications, job training, external resources and cultural competency SNP’s documentation needs to be dated after 10/15/12 SNP 1- Care Mgmt. and Coordination

21. 21 SNP: Surveyor Update Training Element C - Care Mgmt. Assessment Process Includes all info for SNP to assess members’ needs and develop interventions for them A SNP’s documentation must address all 8 factors It may submit assessment tools or screenshots as evidence, if these documents demonstrate the system has all required functionality SNP 1- Care Mgmt. and Coordination Data sources: Documented process and reports or materials

22. 22 SNP: Surveyor Update Training SNP’s evidence must include: Documentation of clinical history and meds – e.g., disease onset, inpatient stays, treatment history Initial assessment of: – health status & comorbidities – activities of daily living – mental health status and cognitive function both aspects are required SNP 1- Care Mgmt. and Coordination

23. 23 SNP: Surveyor Update Training Evaluation of: – cultural and linguistic needs review of language needs meets factor 5 – visual & hearing needs, preferences/limitations – caregiver resources e.g., family involvement in decision making – available benefits covered by SNP, carved out for supplemental services such as community behavioral health or national and community resources SNP 1- Care Mgmt. and Coordination

24. 24 SNP: Surveyor Update Training Element D - Individualized Care Plan SNP uses info from assessment e.g., HRAs and other sources to develop a comprehensive care plan Care plan includes info on actions or interventions and their duration a SNP’s Interdisciplinary Care Team (ICT) takes to address members’ medical, BH, functional and support needs. SNP 1- Care Mgmt. and Coordination Data sources: Documented process and reports or materials

25. 25 SNP: Surveyor Update Training A SNP’s documentation shows that the ICT develops a care plan for each member that includes: – prioritized goals that reflect member’s or caregiver’s preferences and involvement – self-management plan – schedule for follow-up/identify barriers – process to assess member progress SNP 1- Care Mgmt. and Coordination

26. 26 SNP: Surveyor Update Training Based on the member’s specific needs the care plan also identifies: – resources to be utilized and appropriate level of care CMs as members of the ICT often facilitate referrals to other providers as part of member’s benefits – planning for coordination of care including transitions and transfers identifying how and when ICTs follow up with a member after referral to a health resource – collaborative approaches to be used SNP 1- Care Mgmt. and Coordination

27. 27 SNP: Surveyor Update Training Element E - Satisfaction with Care Mgmt Intent is for SNP to obtain feedback on its Care Mgmt. program from a broad sample of members, not just those that contacted it SNP must submit a report showing it performed an evaluation of satisfaction by: 1)Obtaining feedback from members 2)Analyzing member complaints and inquiries SNP 1- Care Mgmt. and Coordination Data source: Reports

28. 28 SNP: Surveyor Update Training Factors 1 and 2 require SNPs to use: focus groups or satisfaction surveys that are specific to Care Mgmt program – e.g., assess satisfaction with--program staff, the usefulness of info received, member’s ability to adhere to recommendations. analysis of complaint and inquiry data after 10/15/12 to identify patterns or trends – quantitative and qualitative SNP 1- Care Mgmt. and Coordination

29. 29 SNP: Surveyor Update Training Factors 1 and 2 focus on satisfaction with the Care Mgmt. Program not satisfaction with the SNP’s overall operations Reports with data obtained from CAHPS or general surveys will not meet the intent Results from satisfaction surveys administered across multiple SNPs must be stratified at individual plan level for analysis SNP 1- Care Mgmt. and Coordination

30. 30 SNP: Surveyor Update Training Score factor 2 NA if SNP provides evidence (e.g., tracking mechanism) showing it did not receive any Care Mgmt. complaints and inquiries after 10/15/12 Score factors 1 and 2 NA for SNPs that did not have any members at the start of the look-back period. Confirm this with CMS April 2013 Comprehensive Report. SNP 1- Care Mgmt. and Coordination

31. 31 SNP: Surveyor Update Training Element F - Analyzing Effectiveness/ Identifying Opportunities The SNP measures the effectiveness of its Care Mgmt. program using three measures. For each measure, it: 1)Identifies a relevant process or outcome 2)Uses valid methods that provide quantitative results 3)Sets a performance goal 4)Clearly identifies measure specifications 5)Analyzes results 6)Identifies opportunities for improvement, if applicable SNP 1- Care Mgmt. and Coordination Data source: Reports

32. 32 SNP: Surveyor Update Training SNP’s report must contain appropriate measures likely to have significant and demonstrable bearing on all or a subset of Care Mgmt. members –Outcomes based –Relevant to target population –Valid methodology Contains info on sampling (if used) and sample size calculation Measurement periods reflect the effects of seasonality –Denominator specific to Care Mgmt. population SNP 1- Care Mgmt. and Coordination

33. 33 SNP: Surveyor Update Training Report shows appropriate analysis – goes beyond simple reporting or data display –Comparison to goal or benchmark Measure must not have exceeded goal from outset –Quantitative and qualitative –Opportunities for improvement SNP can use 3 patient experience measures e.g., improved quality of life, pain management and health status May only use 1 satisfaction measure with Care Mgmt. program operations SNP 1- Care Mgmt. and Coordination

34. 34 SNP: Surveyor Update Training Scoring is based on an average for all 3 measures Analysis of measures must be SNP- specific. Org can present aggregate analysis if it breaks out data and results for individual SNPs SNP must have performed analyses of measures after 10/15/12 SNPs that submit Care Mgmt. worksheets also need to provide actual reports SNP 1- Care Mgmt. and Coordination

35. 35 SNP: Surveyor Update Training Score factor 6 NA if your assessment of the SNP’s documentation confirms it does not have any opportunities for improvement Score factors 1 thru 6 NA for SNPs that did not have any members at the start of the look-back period. Confirm this with CMS April 2013 Comprehensive Report. SNP 1- Care Mgmt. and Coordination

36. 36 SNP: Surveyor Update Training Examples of measures – HEDIS measures of effectiveness for chronic conditions e.g., controlling high blood pressure, persistence of beta blocker treatment after a heart attack – SF-36 or SF-12 results – Use of service measures for which consensus indicates improvement – e.g., reduced ED visits – Readmission rates – Ambulatory-care sensitive admissions SNP 1- Care Mgmt. and Coordination

37. 37 SNP: Surveyor Update Training Element G - Implementing Interventions and Follow-up Evaluation Based on the results of its measurement and analysis of Care Mgmt. effectiveness, the organization: 1)Implements at least one intervention for each of the three opportunities identified in Element F to improve performance 2)Develops a plan for evaluation of the intervention and re-measurement SNP 1- Care Mgmt. and Coordination Data source: Documented process and Reports

38. 38 SNP: Surveyor Update Training Scoring is based on an average for all 3 measures Interventions must have been implemented after 10/15/12 A SNP’s documentation needs to show that it developed a plan to evaluate the effectiveness of its interventions; this evaluation includes re-measurement using methods consistent with initial measurement. SNP 1- Care Mgmt. and Coordination

39. 39 SNP: Surveyor Update Training Factor 1 may be NA if no opportunities Factor 2, re-measurement, must be completed whether there are opportunities or not. Score factors 1 and 2 NA for SNPs that did not have any members at the start of the look-back period. Use the CMS April 2013 Comprehensive Report to confirm this. SNP 1- Care Mgmt. and Coordination

40. 40 SNP: Surveyor Update Training Questions?

41. SNP 2: Improving Member Satisfaction

42. 42 SNP: Surveyor Update Training SNP 2 Element A and B – Now applicable to both initial and returning SNPs SNP 2 Element C – Added new example for factor 2 that emphasizes continuing the intervention and then re-measuring when an organization does not meet its initial goal Summary of Changes for 2013

43. 43 SNP: Surveyor Update Training Who reports? – Initial and returning SNPs are responsible for reporting all of SNP 2. This includes Elements A, B and C – SNPs with no members at the start of the look- back period are exempt from SNP 2 Surveyors will need to confirm with CMS April 2013 SNP Comprehensive Report. SNP 2: Overview

44. 44 SNP: Surveyor Update Training Assessment of Member Satisfaction a SNP must supply BOTH a documented process and a report explaining how it performed the assessment and an analysis of member satisfaction data that shows it: – identified the appropriate population – selected appropriate samples from the affected population, (if used) – conducted an quantitative and qualitative analysis annually The SNP will receive credit for factor 2 if it collects data for its entire population SNP 2 Element A

45. 45 SNP: Surveyor Update Training A SNP’s complaint and appeal data must relate to at least the four major categories – Quality of Care – Access – Attitude and Service – Billing and Financial It must submit a report that shows the quantitative and qualitative analyses was performed after 10/1/12. Complaint, grievance and appeal data or satisfaction survey data collected 12 months prior to the start of the look-back period--(4/15/12) will not meet the intent SNP 2 Element A

46. 46 SNP: Surveyor Update Training All SNP complaint/appeal data must be at the PBP level. The SNP should receive a score of: – 50% for data only identified as “Medicare” – 0% if data source is not specified at all SNPs must perform their own analysis of CAHPS results, not just attach a vendor’s report to meet the intent of Element A. SNP 2 Element A

47. 47 SNP: Surveyor Update Training If the SNP has no complaints, appeals or grievances, it must still show a table, spreadsheet or other documentation that demonstrates it collected appropriate data for an analysis and found no complaints or appeals for its members SNP 2 Element A

48. 48 SNP: Surveyor Update Training The analysis must be SNP-specific; plans must break out the data at the PBP level for an aggregate analysis of complaints and appeals across multiple benefit plans SNP 2 Element A

49. 49 SNP: Surveyor Update Training Opportunities for Improvement Element B requires a SNP to show: – How it identifies opportunities for improvement of member satisfaction (documented processes) – At least 2 opportunities for improvements based on its data and analysis for SNP 2A (reports) – It identified opportunities after 10/1/12. Analysis should indicate reasons for opportunities identified – May be lesser priorities SNP 2 Element B

50. 50 SNP: Surveyor Update Training Element B is NA if: – a SNP’s analysis does not result in the identification of one or more opportunities for improvement. Reasons for no improvement opportunities may include: – no or very low enrollment – no trendable data available – very low number of complaints/appeals SNP 2 Element B

51. 51 SNP: Surveyor Update Training Improving Satisfaction Element C requires a SNP to show that it is actively working on implementing interventions and measuring their effectiveness. – Plans must provide BOTH documented processes and reports The interventions must relate to those opportunities identified in SNP 2B, or from other opportunities identified from the analysis of member satisfaction data in SNP 2A Do not have to show improvement on interventions, but a SNP must show it measured intervention effectiveness. SNP 2 Element C

52. 52 SNP: Surveyor Update Training Timeframes – Interventions must be implemented within one year of the submission date (October 15, 2012 – October 15, 2013) – Analysis of intervention effectiveness or remeasurement for those that do not have opportunities must be performed within the look-back period (April 15, 2013 – October 15, 2013) SNP 2 Element C

53. 53 SNP: Surveyor Update Training When evaluating intervention effectiveness for factor 2 - SNPs must perform remeasurement against an original goal, or a targeted intermediate measurement of specific interventions SNP 2 Element C

54. 54 SNP: Surveyor Update Training If a SNP has no members as of the start of look-back period, score the element “NA”. – Confirm with CMS April 2013 SNP Comprehensive Report. Initial SNPs with no opportunities for improvement get an “NA” for factors 1-2 Returning SNPs with no opportunities for improvement get an “NA” for factor 1 only SNP 2 Element C

55. SNP 3: Clinical Quality Improvement

56. 56 SNP: Surveyor Update Training Methodology has been revised to calculate statistically significant improvement. The new methodology better addresses the “small numbers” issues related to low enrollments and denominators for many of the HEDIS measures and more accurately reflects year-to-year improvement without penalizing plans SNPs that do not have at least one member as of the CMS February 2012 SNP Comprehensive Report are exempt from reporting this measure and receive a score of “NA”. Surveyors do not score this measure SNP 3 Element A

57. 57 SNP: Surveyor Update Training What is statistical significance? – 0-59: At least a 6 percentage point change – 60-74: At least a 5 percentage point change – 75-84: At least a 4 percentage point change – 85-92: At least a 3 percentage point change – 93-96: At least a 2 percentage point change – 97-99: At least a 1 percentage point change This applies to measures where both higher and lower percentages are better SNP 3 Element A

58. 58 SNP: Surveyor Update Training Which SNPs must demonstrate clinical improvement? – Only returning SNPs will be scored – Initial SNPs and plans with no members (as of Feb 2012 CMS Comp. Report) are exempt Plans are not required to submit anything in ISS. NCQA will score this element internally. SNP 3 Element A

59. 59 SNP: Surveyor Update Training Questions?

60. SNP 4: Care Transitions

61. 61 SNP: Surveyor Update Training No major content, documentation or scoring changes Element E—Added a new factor that requires plans to take actions or interventions related to the opportunities identified in factor 2. Element E—clarified that plans may use their existing CMS QIP related to reducing hospital admissions to satisfy factor 3 requirements What’s Changed?

62. 62 SNP: Surveyor Update Training SNP 4 Element A: Managing Transitions Managing & coordinating planned/unplanned transitions from one care setting to another – Factor 1 focuses on planned transitions to and from a hospital Requires SNP to show it is aware that a transition is about to take place—before it happens and provide support throughout the transition process, not just after discharge A preauthorization policy included in documentation must show how it triggers clinical action. Cannot solely pertain to a coverage or payment decision.

63. 63 SNP: Surveyor Update Training SNP 4 Element A Factor 2 specifies requirements for planned and unplanned transitions to and from a hospital Sending setting must share care plan with receiving setting within 1 business day of transition notification – Care plan consists of patient info that facilitates communication, collaboration and continuity of care across settings – Org determines what info care plan includes – Must specify practitioner to receive care plan for planned transitions to hospital—must show evidence SNP shared care plan with practitioner w/in specified timeframe

64. 64 SNP: Surveyor Update Training SNP 4 Element A Factor 3: Notifying member’s usual practitioner of transition – planned and unplanned transitions to and from all care settings – must specify a timeframe for completion of transition activities, e.g., 24-48 hours prior to member movement to receiving setting within 1 business day of member’s discharge at least 2 calendar days before the scheduled procedure

65. 65 SNP: Surveyor Update Training SNP 4 Element B Supporting Members Through Transitions Communications with members/ caregivers within specified timeframes regarding: – the transition process and what to expect – changes in health status and their care plan – who will support them through the process Factors 1 thru 3 pertain to planned and unplanned transitions to and from all care settings

66. 66 SNP: Surveyor Update Training SNP 4 Element B A SNP’s documented process for factors 1 thru 3 must specify a timeframe for completion of required transition activities – The following do not qualify as timeframes during the encounter …. upon identification of transition needs …. regular contact and review …. on an ongoing basis …. during discharge ….

67. 67 SNP: Surveyor Update Training An aggregate analysis of transitions should contain: – Measures that directly assess the frequency a SNP performs the functions assessed in factors 1-3 of Elements A & B – A description of: how the SNP collects the data who performs the functions assessed the timeframe for the analysis Universe of planned & unplanned transitions included and care settings involved SNP 4 Element C

68. 68 SNP: Surveyor Update Training SNP 4 Element C The intent of the aggregate analysis for this element is for plans to assess how well they are managing transition activities. Factors 1 and 3 need to show: – data collected; – a quantitative and qualitative analysis; and – the opportunities for improvement Factors 2 and 4 must describe: – the universe of members in the sample – sampling methodology – how the SNP drew at least 3 months of data

69. 69 SNP: Surveyor Update Training What is an Analysis? An evaluation of aggregate performance that includes: – quantitative data – number of transitions in the denominator for a factor and the number of transitions where the SNP performed the activity specified by the factor within any pertinent timeframes – qualitative data – notations on results, trends, anomalies, assessment of causes/reasons for findings » identification of opportunities and recommendations for further action SNP 4 Element C

70. 70 SNP: Surveyor Update Training Identifying Unplanned Transitions A SNP must show that it: – has a documented process and reviews reports of hospital admissions within 1 business day of the admission Must show at least 3 admissions – reviews reports of long-term care facility admissions within 1 business day of the admission Must show at least 3 admissions SNP 4 Element D

71. 71 SNP: Surveyor Update Training SNP 4 Element E Focus of element is on minimizing unplanned transitions and keeping patients in least restrictive setting Factor 1 requires an analysis of patient-specific data to identify those at risk − E.g., claims, UM or provider reports, predictive modeling

72. 72 SNP: Surveyor Update Training SNP 4 Element E A SNP’s documentation for factor 1 needs to show: – data collected—must monitor all members – members targeted – areas where it acts to minimize the risk of unplanned transitions and keep members in the least restrictive setting

73. 73 SNP: Surveyor Update Training SNP 4 Element E Factor 2 requires SNPs to analyze data and identify areas where avoidable, unplanned transitions can be reduced Analyze member admissions to all hospitals and ED visits – Population focus (aggregate data) – Actual analysis to identify areas for improvement

74. 74 SNP: Surveyor Update Training SNP 4 Element E SNP’s documentation for factor 2 must show: 1)data collected 2)quantitative and qualitative analysis 3)opportunities for improvement. SNP must include in-network and out of network facilities and EDs in this analysis for factor 2. If it only includes in-network facilities, it does not receive full credit for this factor (cannot score >50%).

75. 75 SNP: Surveyor Update Training SNP 4 Element E SNP must provide evidence of 1 analysis performed w/in the look-back period (April 1-October 15, 2013). – Data for analysis can go back to April 2012 Analyses must be SNP-specific; organizations that perform an aggregate analysis of multiple benefit plans must break out the data for each individual plan

76. 76 SNP: Surveyor Update Training Factor 3—implementing interventions New for 2013 – The SNP must implement at least one intervention from the opportunities identified in factor 2. – Do not have to show improvement or effectiveness of the intervention – SNPs can use their existing CMS QIP related to reducing hospital readmissions SNP 4: Element E

77. 77 SNP: Surveyor Update Training SNP 4 Element F Reducing Transitions Factors 1 and 2 require a SNP’s documentation to show that it: Coordinates services for at-risk members Educates these members or their caregivers on how to prevent unplanned transitions Actions must relate to findings from monthly analyses in SNP 4:E, factor 1

78. 78 SNP: Surveyor Update Training SNP 4 Element F Factor 1—Care Coordination may be done through Case Mgmt or other programs; SNP must maintain special procedures if all members are not in CM Factor 2—Educational opportunities must be related to specific, targeted populations, not just general health education

79. 79 SNP: Surveyor Update Training

80. SNP 5: Institutional SNP Relationship with Facility

81. 81 SNP: Surveyor Update Training SNP 5 Element A Monitoring Members’ Health Status Institutional SNPs only –Focus is on communications with facilities to monitor member needs and services provided –Facilities include contracted nursing facilities and assisted living facilities The SNP must show that it monitors information on members’ health status at least monthly –Communication should include information that may indicate a change in health status or no change

82. 82 SNP: Surveyor Update Training Scoring 100% or full credit –Institutional SNPs who monitor at least monthly 50% or partial credit –Institutional SNPs who monitor at least quarterly 0% or no credit –Institutional SNPs who monitor less often than quarterly SNP 5 Element A

83. 83 SNP: Surveyor Update Training SNP 5 Element A Monitoring methods a SNP can use : –data derived from MDS or other reports on member health status it requires from the institutional facility –reports from its staff who visit members in facilities –data on members’ health status it collects through care management if collected on a monthly basis Status reports may include: –Functional status assessments –Medication regimen –Self-reported health status –Reports on falls, socialization and depression

84. 84 SNP: Surveyor Update Training Documentation – a SNP must provide a documented process and one additional data source or it does not receive full credit for this element Element is NA for: –An Institutional SNP that shows it does not have contracts with nursing facilities or assisted living facilities  all members reside in the community Dual Eligible and Chronic Care SNPs are exempt –Score all elements in this measure “NA” SNP 5 Element A

85. 85 SNP: Surveyor Update Training Monitoring Changes in Members’ Health Status Organization monitors and responds to triggering events and changes by: 1.Setting parameters for the types of changes and triggering events contracted facilities must report within 48 hours, 3 calendar days and 4 to 7 calendar days 2.Identifying who will act on that information and should be contacted 3.Identifying how the member’s care will be coordinated with appropriate clinicians or the clinical care plan 4.Identifying one monitoring or data collection method it uses to assess changes in all members’ health status SNP 5 Element B

86. 86 SNP: Surveyor Update Training An organization must submit evidence that shows it has identified specific conditions or early warning signs and symptoms that facilities must report within a minimum of:  48 hours  3 calendar days  4-7 days The SNP must submit a documented process and reports or materials showing how and when facility staff must report a list of triggers such as:  changes in vital signs  changes in the member’s behavior  changes in their functional status  complaints of pain Factor 1 Details

87. 87 SNP: Surveyor Update Training Explanation of scoring 100% or full credit –The organization meets all 4 factors 50% or partial credit –The organization meets 3 factors including factors 1 through 3 (critical factors) 0% or no credit –The organization meets 0-2 factors or does not meet factors 1, 2 or 3 SNP 5 Element B

88. 88 SNP: Surveyor Update Training SNP 5 Element B The SNP must demonstrate it monitors members through one of the following methods: –Reports from facilities to the organization such as Minimum Data Set (MDS) –Reports from organization staff who visit the members –Oversight of facility monitoring and reporting changes to treating practitioners rather than to the organization –A combination of the processes above

89. 89 SNP: Surveyor Update Training SNP 5 Element C Maintaining Members’ Health Status Organizations use the information from SNP 5 Elements A&B to identify at-risk members and work with facilities/practitioners to arrange for necessary care and adjust care plans as needed to prevent declines in member health status Scoring is 100% or 0% (all or nothing element)

90. 90 SNP: Surveyor Update Training SNP 5 Element C Methods of providing care: SNPs may have differing models of relationships with facilities to address these monitoring functions –Facility oversight: relies on facilities to modify/carry out care plans –Staff practitioners: SNP staff practitioners visit facilities and order care plan modifications –Other models of care: SNPs may use a combination of above models or different one

91. 91 SNP: Surveyor Update Training SNP 5 Element C Documentation A SNP must submit: – Documented Processes; AND Policies describing increases in frequency of visits to member by the organization’s nurse managers to assess, revise the care plan and monitor his or her condition after a health status decline and resulting inpatient stay – Reports Screenshots from the organization’s care management system documenting monitoring visits, assessments and care plan changes the nurse managers discussed with the member’s treating practitioner and notes confirming the practitioner’s agreement

92. 92 SNP: Surveyor Update Training

93. SNP 6: Coordination of Medicare and Medicaid Coverage

94. 94 SNP: Surveyor Update Training No Major Changes for 2013 !!! What’s Changed?

95. 95 SNP: Surveyor Update Training SNP 6 Element A Coordination of Benefits for Dual-Eligible Members Dual-eligible SNPs coordinate Medicare & Medicaid benefits/services for their members by: Giving members access to staff knowledgeable about both programs Providing clear explanations of rights to pursue grievances/appeals under both programs Providing clear explanations of benefits and any communications they receive re: claims, cost sharing Not Applicable for C-SNPs & I-SNPs

96. 96 SNP: Surveyor Update Training For all factors — SNP must provide information to members for Medicare AND Medicaid per the requirements of the factors. SNP 6 Element A

97. 97 SNP: Surveyor Update Training Documentation must show: – SNP’s reports cover the details of members’ specific benefit plans – It gives members information on staff who can answer questions regarding both programs in lieu of written documents – SNP staff can answer questions about Medicare benefits and the state’s payment cost-sharing as well as Medicaid eligibility and cost-sharing for services where the member is liable. SNP 6 Element A

98. 98 SNP: Surveyor Update Training Documentation - SNPs must provide reports and may provide documented processes or materials – Reports: Evidence of Coverage (EOC) documentation – Documented processes: Evidence of Coverage (EOC) documentation Processes describing how coordination occurs – Materials: Scripts or guidelines for staff who help members with eligibility SNP 6 Element A

99. 99 SNP: Surveyor Update Training SNP 6 Element B Administrative Coordination of Dual-Eligible Benefit Packages The organization coordinates services by: Identifying changes in members’ Medicaid eligibility Coordinating adjudication of Medicare/ Medicaid claims for which it is contractually responsible Not Applicable for C-SNPs & I-SNPs

100. 100 SNP: Surveyor Update Training SNP 6 Element B SNPs must demonstrate that they monitor instances where members are losing and regaining Medicaid eligibility for factor 1 SNPs without a contract for Medicaid adjudication can meet the intent of factor two if they show they help members understand the state’s adjudication of claims submitted by providers for factor 2

101. 101 SNP: Surveyor Update Training SNP 6 Element B Documentation SNPs must provide (1) documented processes and (2) reports OR materials – Documented processes: Procedures used to determine changes in Medicaid eligibility Procedures used to coordinate adjudication of Medicare and Medicaid claims – Materials: Scripts or guidelines for staff who help members eligibility, benefits, and claims for both programs – Reports: Redacted reports on Medicaid eligibility used by organization

102. 102 SNP: Surveyor Update Training SNP 6 Element C Administrative Coordination for Chronic and Institutional Benefit Packages SNP shows it coordinates Medicare/Medicaid benefits for C-SNP& I-SNP members by: –Using a process to identify changes in members’ Medicaid eligibility –Informing members about maintaining Medicaid eligibility –Giving members information about benefits they are eligible to receive under both programs –Giving members access to staff who can advise them on using both programs Not Applicable for D-SNPs

103. 103 SNP: Surveyor Update Training Factors 1, 3 and 4—SNP must supply documentation that shows it provides information to members for Medicare AND Medicaid. The SNP cannot receive credit for factors 1, 3 and 4 if it provides the required information only for Medicare. SNP 6 Element C

104. 104 SNP: Surveyor Update Training To receive credit for factor 2: – I-SNPs’ documentation must address changes where members gain Medicaid eligibility; – C-SNPs’ documentation must show that they monitor instances where members are gaining and losing Medicaid eligibility. SNP 6 Element C

105. 105 SNP: Surveyor Update Training C-SNPs and I-SNPs are exempt from this element if less than 5% of the members in their SNP population are dual eligibles as of the start of the look-back period Score each factor “NA” if they meet this criterion. – This can be confirmed using the surveyor resource guide. SNP 6 Element C

106. 106 SNP: Surveyor Update Training Documentation - SNPs must provide Documented processes AND; Procedures used to verify changes in Medicaid eligibility – Reports or Materials: Sample benefit summaries provided to members SNP 6 Element C

107. 107 SNP: Surveyor Update Training SNP 6 Element D Service Coordination Organization coordinates delivery of services covered by Medicare/Medicaid through the following: –Helping members access network providers that participate in both programs or accept Medicaid patients –Educating providers about coordinating benefits for which members are eligible and about members’ special needs –Helping members obtain services funded by either program when needed * C-SNPs and I-SNPs are exempt from this element if less than 5% of the members in their SNP population are dual Applicable for all SNPs*

108. 108 SNP: Surveyor Update Training For factor 1 SNP must publish a directory that shows: – providers that participate in both programs or – providers that accept Medicare for services covered by Medicare and – providers that accept Medicaid for dual- eligible members SNP 6 Element D

109. 109 SNP: Surveyor Update Training SNP 6 Element D Factor 2 requires SNPs to educate network practitioners and providers about their role coordinating Medicare/Medicaid benefits and members’ special needs. –Alert their providers to the range of benefits or services for which members are eligible, as well as responsibility for cost-sharing, if any, and the members right to reimbursement –Inform providers who is responsible for coordinating services for both programs

110. 110 SNP: Surveyor Update Training SNP 6 Element D Factor 3 requires SNPs to help members obtain services funded by either program when assistance is needed. –Referring members to non-contracted facilities –Assisting members in scheduling services or directly providing the services

111. 111 SNP: Surveyor Update Training SNP 6 Element D Documentation - SNPs must provide: – Documented processes; AND Policies and procedures for arranging services for members – Reports or Materials Reports detailing how members were assisted in obtaining services from Medicaid when needed. Materials such as the provider directory or provider manuals.

112. 112 SNP: Surveyor Update Training SNP 6 Element E Network Adequacy Assessment Organization assesses the adequacy of the network of practitioners and providers by: -Establishing standards of the number and geographic distribution of each type of practitioner and provider -Conducting an annual analysis of performance against numeric and geographic standards * Element is NA for C-SNPs and I-SNPs w/less than 5% dual eligible members and D-SNPs with no enrollment at the start of the look-back period. Applicable for all SNPs*

113. 113 SNP: Surveyor Update Training Review the organization’s documented process for factors 1 and 2 and reviews reports for factors 3 and 4. The SNP’s documentation must include the geographic and numeric standards for practitioners and providers and a description of its methodology used to perform the analysis. SNP 6 Element E

114. 114 SNP: Surveyor Update Training A SNP’s analysis must include a network access indicator (ratio of member to practitioner availability based a number of miles/minutes). A plan that uses: 1)Access data (appointment availability) 2)Data on members’ cultural or linguistic needs or 3)Satisfaction data (surveys, complaints and appeals) must supplement its assessment with another network access indicator SNP 6 Element E

115. 115 SNP: Surveyor Update Training Organization must determine adequate access for members for the following types of providers – Primary care practitioners (e.g. general practitioners, internal medicine specialist) – High volume specialist (e.g. cardiologist, neurologist, gynecologists, psychiatrists) – Providers (e.g. hospitals, skilled nursing facilities) SNP 6 Element E

116. 116 SNP: Surveyor Update Training GEO Access analysis for a SNP’s Medicare practitioner network only is insufficient to meet this element. The GEO Access or other analysis must include practitioners and providers that accept coverage for services paid for by Medicare and Medicaid. GEO Access maps must be accompanied by an assessment of quantitative data If the plan can show all of its providers accept Medicaid and Medicare then GEO Access or other access reports are sufficient SNP 6 Element E

117. 117 SNP: Surveyor Update Training SNP 6 Element E The SNP’s methodology must include: direct measurement of results against standards, info about sampling (if used), and analysis of causes of any deficiencies Analysis can be aggregate if org breaks out data and results for the individual SNP PBP

118. 118 SNP: Surveyor Update Training SNP 6 Element E SNPs must provide the following documentation: – Documented processes; AND P&Ps for assessing network adequacy – Reports Reports on availability of Medicare and Medicaid practitioners and providers Reports on access indicators such as percentage of in-network and out-of-network use; rate of ED use compared to norms in area; or member surveys of satisfaction with access

119. 119 SNP: Surveyor Update Training Questions?