CalPACE Member Meeting

CalPACE Member Meeting

June 5, 2018 | 12:00 pm – 3:00 pm California Endowment, 1414 K Street, Suite 100, Sacramento, CA 95814 – Adelante Room, First Floor

Conference Line (267) 930-4000 | Participant Code 759-479-640

A G E N D A

12:00 – 12:30 Check–In; Lunch

12:30 – 1:15 PACE Program Updates

1:15 – 1:45 Rate Setting Update

1:45 – 2:45 Other Issues for Meetings with DHCS and CMS • PACE application process and licensing issues• Managed care enrollment materials• PACE audit updates and issues• Status of PACE regulation and PACE pilots• Overview of CMS implementation of Chronic Care Act provisions for MA

plans to offer supplemental benefits• Overview of CMS policy on use of brokers by MA and duals plans

2:45 -- 3:00 Other Business

3:00 Adjourn

Attachments: 1. List of attendees2. CalPACE comments on managed care enrollment materials and PACE insert3. DHCS PACE clinic audit tool4. CMS 2018 PACE Audit Updates5. HPMS Agenda for Plans6. Chronic Care Act summary – SCAN Foundation – 3-187. Cal MediConnect Broker Pilot slides – DHCS – 5-18-18

CalPACE Member Meeting June 05, 2018 Attachment 1

Attendee List Member Meeting | Tuesday, June 05, 2018 | Sacramento, CA

Name Organization Ann Morrison Sutter SeniorCare PACE Arif Shaikh CalOptima Barbara LaHaie Redwood Coast PACE Bev Dahan InnovAge Bing Isenberg Center for Elders' Independence Brian Wallace San Diego PACE Carol Hubbard St. Paul's PACE Cheryl Wilson St. Paul's PACE Christie Brown O'Hanlon Sutter SeniorCare PACE Claudia Estrada InnovAge Elizabeth Carty Welbe Health Elizabeth Lee CalOptima Fred Main Clear Advocacy Gary Campanella On Lok Lifeways Gilbert Fimbres San Diego PACE Gisela Gomez* CalOptima Grace Li On Lok Lifeways Jennifer Blankenship CalPACE Jillian Simon Welbe Health Joyce Hayes Redwood Coast PACE Katherine Kelly On Lok Lifeways Kevin Mattson San Diego PACE Kristy Weise Capitol Advocacy Linda Trowbridge Center for Elders' Independence Maria Lozzano InnovAge Maria Zamora AltaMed Melina Lewis* Fresno PACE Molly Forrest* Brandman Patricia Sandoval Fresno PACE Peter Hansel CalPACE Peter Kellison The Kellison Company Phil Chuang Sutter SeniorCare PACE Robin Jensen St. Paul's PACE Rosana Scolari San Diego PACE Susie Fishenfeld Brandman Tom Reiter Gary & Mary West PACE

*Participating via conference call

Managed Care Enrollment Materials CalPACE & PACE Organizations

May 18, 2018

Department of Health Care Services | Health Care Delivery Systems Page 1 of 3

# Name Affiliation

Page and Paragraph

Comment is Referencing

Feedback/Comments DHCS Response

A.

A.1 CalPACE Overall booklet

1. We appreciate the opportunity to comment on the proposed PACE insertsin the managed care Health Care Options booklet. In order for theinformation about PACE to be meaningful to beneficiaries and to assist themin considering it as a managed care enrollment option, we recommend thatseveral changes be made in both the content of the information about PACEand its placement in the Health Care Options booklet. We are willing to workwith DHCS on these changes.

2. We request clarification from DHCS on which beneficiaries in whichcounties the booklet is being sent to. We believe this guide is intended to besent to new beneficiaries who are not eligible for Cal MediConnect becausethey live in non-CCI counties or live in CCI counties and are not eligible for it.We believe that new eligibles who are eligible for Cal MediConnect and wholive in CCI counties currently receive the separate Cal MediConnect choicebook and materials.

3. We are unclear on what information and materials are sent to neweligibles who are not eligible for Cal MediConnect but who are subject tomandatory enrollment in managed care for receipt of LTSS. If this bookletrepresents what is sent to these beneficiaries we would comment that thatdoes not comply with Welfare and Institutions Code Section 14186.2 (d),which requires beneficiaries who are required to receive long-term careservices and supports from a managed care plan to be informed that theymay alternatively be assessed for eligibility for PACE and, if eligible, enroll inPACE. If DHCS intends for this booklet to be sent to these beneficiaries, wewould request that DHCS develop an alternative set of choice materials for

Attachment 2

CCS Redesign - Comments Log on Draft Evaluation Design


# Name Affiliation

Page and Paragraph



these beneficiaries that is more consistent with the Cal MediConnect materials.

B.

B.1 CalPACE

Special Services insert

– followingPage 6 of the Choose the

Best Medi-Cal Health Plan

section

1. The current placement of the insert provides little or no value tobeneficiaries in terms of informing them about PACE because it is placed afterthe choice form, Medi-Cal managed care comparison chart, and section onChoose the Best Medi-Cal Health Plan. We would urge that it be placed afterthe Medi-Cal Choice Form (pg. 6 of packet) in order for beneficiaries to reviewit in the context of the other managed care choices.

2. The heading on the insert, “Special Services; County Projects”, is bothmisleading and inaccurate and would request that it be changed to “OtherPlan Choices”. Related, we would recommend that the subheading “SpecialServices” be deleted.

3. The insert does not provide any information to help beneficiariesunderstand the purpose of the insert. We recommend that a sentence beadded at the beginning to say “You may, if you are eligible, enroll in a PACEplan, a specialized plan for beneficiaries who are age 55 and over and havehigher needs. Information about PACE plans in your area is provided below”.

4. The language in the insert is outdated. We would request an opportunityto provide updated language that is more consistent with the language in theCal MediConnect materials. We would also recommend that the insert besupplemented to provide a high level overview of the PACE program or thatan additional insert page with that information be included in the packet.Finally we would note that the current insert includes typos that should becorrected.

Attachment 2

CCS Redesign - Comments Log on Draft Evaluation Design


# Name Affiliation

Page and Paragraph



5. Given the high likelihood of confusion for beneficiaries created by theinsert, we would request the opportunity to provide training on PACE forHealth Care Options staff.

C.

C.1 CalPACE Medi-Cal Choice Form

1. There is no place on the form to indicate that the beneficiary chooses toenroll in PACE. We recommend that the form contain a box that a beneficiarycan check if they wish to consider enrolling in PACE, if it is available, and thatDHCS provide a way for them to be referred to the applicable local PACE plan.

D.

D.1 CalPACE Table of Contents

1. A bullet or bullets should be added to the table of contents to refer to“Other Plan Choices, if Available”

E.

E.1 CalPACE

Medi-Cal Managed Care

Comparison Chart

1. There is no chart listing benefits provided by PACE. We would request theopportunity to develop a chart listing benefits provided by PACE that wouldbe included as an additional insert.

Attachment 2

As of 5/31/2018 Pag e 1 of 4

PACE Organization:Date:Lead:

MET NOT MET COMMENTSMedical Record Review1. IDT Team conducts annual, semi-annualassessment in-person as required (42 CFR460: 460.102, 460.104, 460.106)

2. All 11 members of IDT may collaborate anddevelop the orders for each care plan withservices ordered being provided by PO.(labwork, medications, DME etc)(42 CFR 460:460.106 and 460.104)

3. Medical records are complete and availableto all staff. (42 CFR 460: 460.104, 460.106,and 460.210)

4. Any incidents of infection/falls wereidentified and corrective action taken to reducefuture incidents. (42 CFR 460: 460.74)

MET NOT MET COMMENTS

Attachment 3

As of 5/31/2018 Page 2 of 4

5. PACE organization provides immediateaccess to emergency care. (42 CFR 460:460.84 and 460.100)

6. On call provider is available 24 hours/day.(42 CFR 460: 460.98)

7. Clinical staff are licensed to perform care.

8. All personnel who have direct patient careare free from communicable diseases.

9. Emergency equipment is on site andimmediately available.

10. PACE organization will correct or identifyproblems that threaten the health/safety ofPACE participants.

11. All PACE personnel are competent inproviding patient care.

12. Care Plans included appropriate content.(42 CFR 460: 460.102)


Attachment 3

As of 5/31/2018 Page 3 of 4

13. Medical director is involved in oversight ofquality assessment and performanceimprovement programs related to participantcare and clinical outcomes.

Medical Records consist of: (42 CFR 460.210)Care Plan

TreatmentsProgress Notes

Medical EligibilityER/Hospital Visit

Discharge SummaryPOA/Advance Directives

MedicationsDietary

Height and WeightPsycho-Social

Mental Exam as requiredDental needs

Home environmentBehavioral needs

Cultural needs

Participant ObservationsOff Site

Home VisitSNF


Attachment 3

As of 5/31/2018 Page 4 of 4

On SiteClinical observations

Clinical Observation (42 CFR 460: 460.84)Oxygen

Suction MachineGlucometer

Crash Cart/Airways/Emergency Medications

Dietary Observation (Title 22, CCR, Section 54331)Nutritional/dietary services

Transportation (Title 22, CCR, Section 51151))Interview driver

Ride along (more than hour to and from)

Subcontract Agreements (Title 22, CCR, Section 53250)(DHCS Contract, Exhibit A, Attachment 6, Provider Network. Section 11. Subcontract Requirements)

Review a random sample of 10 subcontractors with direct participant contact.

Attachment 3

PACE Updates

Caroline Zeman

Division of Analysis, Policy and Strategy, Medicare Parts C and D Oversight and Enforcement Group, Center for Medicare, CMS

Attachment 4

Agenda

• PACE Overview• 2017 PACE Audits

General Overview of AuditsAudit ScoresCommon Conditions

• 2018 Process Improvements

PACE Overview

• The Programs of All-Inclusive Care For the Elderly (PACE) is a unique program designed to provide comprehensive care to the frail elderly.

• PACE is a 3-way agreement between PACE Organizations (POs), CMS, and the State.

• Participants are nursing home eligible.• PACE provides comprehensive care 24 hours a day with the goal

of keeping participants living in the community.

PACE Overview (continued)

• PACE is centered around an Interdisciplinary Team (IDT) which meets to manage the health of participants.

• PACE provides all the care and services covered by Medicare and Medicaid, as well as additional care and services authorized by the IDT.

• Services may include, but are not limited to, physical therapy, occupational therapy, primary care services, and dental services.

PACE Enrollment

Oversight of the PACE Program

• CMS Oversight: Medicare Drug & Health Plan Contract Administration Group

(MCAG)– Functions as the coordinator of the PACE program across all CMS

components– Is responsible for the PACE regulation, manual guidance, and

responding to questions on PACE policy Medicare Parts C and D Oversight and Enforcement Group (MOEG)

– Develops and implements the PACE Audit strategy, protocols, and operational processes

Center for Medicaid and CHIP Services (CMCS)– Oversees the Medicaid portion of the PACE benefit, including state

coordination

Oversight of the PACE Program(continued)

• CMS Oversight (continued): CMS Regional Offices

– Account Managers provide day-to-day oversight of PACE Organizations

– Staff audit teams• State Involvement Each State has a State Administering Agency (SAA)

responsible for coordinating and overseeing PACE Organizations within that State

PACE Audit Authority

• PACE Organizations must be audited annually during the trial period.

• PACE Organizations must be audited every two years following the trial period.

• Audits must be comprehensive reviews and include an onsite visit.

• CMS conducted 74 PACE audits in 2017.

2017 Audit Overview

2017 PACE Audit Overview

• New audit protocol implemented for 2017• Focused on outcome measures and participant data/

experiences• Audited 5 specific elements: Service Delivery Requests, Appeals, and Grievances (SDAG) Clinical Appropriateness and Care Planning (CACP) Personnel An Onsite Element Quality Assessment

2017 PACE Audit Overview(continued)

• PACE Organizations were cited findings at the

“condition” level and not the element level.• Conditions were classified by a PACE Audit

Consistency Team (PACT) as ICARs, CARs, or Observations.

• Audits were scored based on condition classification.• Audit data have been analyzed and will be included in

the first PACE Annual Report due for release later in 2018.

2017 Audit Scores (1 of 3)



2017 PACE Audit Overview (1 of 3)

Element TotalConditions

ICARs CARs Observations

CACP 118 55 (46.6%) 44 (37.3%) 19 (16.1%)

SDAG 498 171 (34.3%) 251 (50.4%) 76 (15.3%)

Onsite 17 15 (88.2%) 1 (5.9%) 1 (5.9%)

Personnel 72 20 (27.8%) 36 (50.0%) 16 (22.2%)

Quality 36 2 (5.6%) 33 (91.7%) 1 (2.8%)

Totals 741 263 365 113



2017 Common Conditions (1 of 3)

Clinical Appropriateness and Care Planning:• The PO failed to maintain a medical record that was complete, accurate,

and available to all staff.• The PO failed to provide services that were accessible and/or adequate to

meet the needs of its participants.

Onsite Element:• The PO failed to have emergency equipment onsite and immediately

available.• The PO failed to provide care and services in accordance with

participants’ approved care plans.


Personnel:• The PO failed to evaluate the competency of all personnel and

contractors prior to those individuals performing participant care.• The PO failed to provide emergency training as required. Quality Assessment:• The PO did not ensure that all IDT members, PACE staff, and contract

providers were involved in the development and implementation of quality assessment and performance improvement activities.

• The PO failed to develop and/or implement an effective, data driven quality assessment and performance improvement program.


SDAG:• The PO failed to conduct in-person

assessments and/or reassessments asoften as required.*

• The PO’s denial notifications failed to include thespecific reason(s) for the denial in a clear andunderstandable manner.

*This condition was cited for any missing in-person assessment includingannual, semi-annual, and change in condition. Therefore, it was cited in bothCACP and SDAG.

2017 Common Causes

• Lack of documentation or the inability to show compliance with the requirement Example: No evidence or documentation that medications

were provided as scheduled/ordered• Misunderstanding the CMS requirement or regulation Example: Most POs were not aware that they should be

auto-processing untimely service delivery requests as appeals

• Lack of oversight or training to ensure staff or personnel adhered to internal procedures

2018 Process Improvements

• Developing Core Audit Leads that will be responsible for conducting all PACE Audits in 2018.

• Account Managers will no longer participate as an audit lead or team member for any account/organization they oversee.

• Audit fieldwork will be split into two weeks. The first week will be done via desk review, and the second week will be onsite.

• CMS will be piloting a survey to several POs to gather feedback on the 2018 audit process.

2018 Process Improvements(continued)

• Enhancements to the Health Plan Management System (HPMS) to streamline the audit process, such as:Entering draft audit report comments and

responses directly in the system Issuing ICAR notifications through the systemAllowing for multiple file uploads/downloads at one

time

Questions?

• If a PO has questions or concerns regarding howan audit is being conducted, please reach out tothe email address below.

• For questions on this presentation orPACEAudits, please email:[email protected]

mailto:[email protected]

PACE HPMS Call –Site Data Report / Narrative Descriptions Report / Quality Indicator Report

Review Period: Q 201

Attendance:CMS:

PO:

SAA:

Introductions: CMS Staff / PACE Staff / SAA Staff

CMS

Administrative

Agenda Staffing Issues:

Topics Organization has all IDT members (Yes/NO)?:

Identify staff (positions) hired since last conference call:

Has orientation & competency been completed? (Yes/No):

Have any key personnel left the organization since the last call? (Is new organization chart needed?)

Have there been any changes to the Board of Directors?

Corrective Action Plan:

Review any issues related to latest audit CAP(s):

Marketing Issues:

Any new marketing material or marketing plans for the upcoming year?:

Current Enrollment (broken down by center):

As of the date of the Conference call:

Enrollment Withdrawals/Denials:

Denials (Level of Care (LOC) and Health and Safety) Totals:

Withdrawals (Due to relocation, preference for physician, or other in home support services pffered by the state that would

make a potential participant ineligble for PACE) Total:Withdrawal/Denial Trends this quarter:

Attachment 5

Disenrollment’s:

Voluntary (# and Trends):

Involuntary (# and type):

Grievances (#):

Trends for the quarter:

Service Requests (for the quarter):

#Approved: #Denied:

Appeals (#):Trends for the quarter:

Service Area Expansion or Alternative Care Setting Plans/Issues:

Transaction Reply Report (TRR):

Name of staff responsible for checking TRR:How Often are TRRs checked?:# Retro enrollment issues this month:

ClinicalElectronic Medical Record Data Issues:

QAPI:

Current issues under review/study (Please include evidence of tracking and trending Quality Initiatives):Observed outcomes/results of quality initiatives from previous quarters:Observed outcomes/results of internal monitoring of systems:

PAC:

Date of last PAC?Concerns identified as a result of most recent PAC meetings?Date of next PAC?

Waivers:

Please list current CMS waivers (both approved and pending)?

Please list pending waivers if any:

Compliance Notices Issued in the Quarter:

Falls Without Injury: (Refers to falls that requires only first aid treatment, or minimal treatment (i.e. ace bandaged for a sprain) and do not require a hospitalization greater than 24 hours. (e.g., falls that cause scrapes, cuts and or bruises).

Total (break-down by Center):Trends related to place (specific Nursing Facilities, Assisted Living Facilities etc.):Repeat Falls Data (can include graphs):

Infectious Disease Outbreak:

Current Pharmacy Issues:

Attachment 5

Burns: (1st degree or less. An injury to tissue by heat, friction, electricity, radiation, or chemicals)

Other Unusual Occurrences: (e.g., Issues that do not meet the Level II Threshold)

Medication Errors (#):Pressure Ulcers (#):

Level II Reports Filed this quarter?: (Please list totals by month. Level II issues should be discussed on a separate call using Level II guidance)

Influenza Immunizations: (Total for all PO)

Total eligible to receive the immunization:Number of vaccines administered to eligible participants:Total number eligible participants who did not receive the Influenza Vaccine:

Immunization rate: (Goal at a minimum 80%):

Emergency Room Care: (Includes with & without PO approval, and within or outside service area)

ER visits only (Less than 24 hours and not admitted):Please list top three reasons for ER visits only?123Trends in Setting? (Participant home, assisted living, SNF, etc.):ER to admits and Direct AdmitsTop three diagnosis for Admits12

3Trends in Setting? (Participant home, assisted living, SNF, etc.):Readmission Number or Rate for the quarter:

State SpecificUpdates:

Action Items:MeetingAdjourned

Next Meeting:

Attachment 5

March 2018

www.TheSCANFoundation.org 3

Major Sections of the CHRONIC Care ActBelow is a brief summary of key sections of the new law that advance the goals of integrated, person-centered care.8

Updates Medicare Advantage

• Expands supplemental benefits to meet the needs of chronically ill Medicare Advantage enrollees:Allows MA plans to offer an expanded set of supplemental benefits to chronically ill enrolleesbeginning in 2020. Rather than requiring that the benefits be primarily health-related, the lawloosens this requirement to allow for supplemental benefits that have a “reasonable expectationof improving or maintaining the health or overall function of the chronically ill enrollee.” Further,the law allows an MA plan the flexibility to target supplemental benefits to specific chronically illenrollees. (Section 50322)

• Adapts benefits to meet the needs of chronically ill Medicare Advantage enrollees: Expands testingof the Value-Based Insurance Design (VBID) model, which allows MA plans to experiment withdifferent types of benefit packages to meet the needs of chronically ill beneficiaries. MA plans in anystate can participate starting in 2020. (Section 50321)

Continues Access to SNPs with Key Changes

• Permanently authorizes three types of SNPs: D-SNP (dual eligibles), C-SNP (those with severe ordisabling chronic conditions), and I-SNP (those in institutions). (Section 50311)

• Promotes integrated care in D-SNPs:

• Formalizes the Medicare-Medicaid Coordination Office as the dedicated point of contact forstates to assist with integration efforts.

• Establishes a unified grievance and appeals process across Medicare and Medicaid for D-SNPsby 2021.

• Provides D-SNPs three options for integrating Medicare and Medicaid long-term services andsupports and/or behavioral health services by 2021.

• Requires the Medicare Payment Advisory Commission (MedPAC), in consultation with theMedicaid and CHIP Payment and Access Commission (MACPAC), to conduct a study and report toCongress on the quality of D-SNPs.

• Instructs the Government Accountability Office (GAO) to report on state-level integrationbetween D-SNPs and Medicaid within two years of enactment. (Section 50311)

Attachment 6

http://www.thescanfoundation.org/

March 2018


• Updates C-SNPs: C-SNPs must meet additional care management requirements starting in 2020. By2022, and every five years thereafter, the Health and Human Services (HHS) Secretary must updatethe list of chronic conditions eligible for participation. The list must include HIV/AIDS, end stagerenal disease, and chronic/disabling mental illness. (Section 50311)

• Authorizes quality reporting at the plan level: The HHS Secretary may require quality measurereporting for SNPs at the plan level (rather than the contract level), and consider this change for allMedicare Advantage plans. (Section 50311)

Enhances ACOs

• Provides flexibility for beneficiaries to be part of an ACO: It gives ACOs the choice to prospectivelyidentify populations they will be managing, and allows beneficiaries who might not otherwise beassigned to an ACO to “align with” one in which their primary care provider participates.(Section 50331)

• Eliminates barriers to care coordination in ACOs: It establishes the new ACO Beneficiary IncentiveProgram whereby eligible ACOs can make incentive payments to beneficiaries for receiving primarycare services (up to $20 per service). HHS will evaluate the program, including its impact onspending and health outcomes. (Section 50341)

Authorizes Other Delivery System Enhancements

• Extends the Independence at Home Demonstration Program: An “Independence at Home” practicecan now participate in the demonstration for up to seven years (previously five years). It expandsthe total number of beneficiaries from 10,000 to 15,000, and gives practices an extra year to provecost savings. (Section 50301)

• Expands access to home dialysis therapy: This section expands the ability of Medicare beneficiarieson home dialysis to receive ongoing monthly assessments through telehealth, rather than face-to-face visits. (Section 50302)

• Expands access to telehealth services in MA, Next Generation ACOs, and for people with strokesymptoms: Recognizing how telehealth could replace face-to-face office visits, reduce emergencyroom visits, and prevent hospitalizations, the law expands the types of telehealth benefits providedby both MA plans and Next Generation ACOs. It further allows Medicare reimbursement tophysicians using telehealth for patients presenting with stroke symptoms regardless of geographicarea. (Sections 50323, 50324, and 50325)

Attachment 6


March 2018


New Federal Studies

• GAO will issue three new studies on the following topics:

• Feasibility of developing a payment code for longitudinal, comprehensive care planning servicesfor Medicare beneficiaries diagnosed with serious or life-threatening illness. (Section 50342)

• Prevalence and effectiveness of Medicare and other payer medication synchronization programs.(Section 50351)

• Impact of obesity drugs on patient health and spending. (Section 50352)

• HHS study on long-term Medicare cost drivers: This new study will identify long-term risk factorsfor chronic conditions among Medicare beneficiaries, including obesity, tobacco use, mental healthconditions, and other factors. (Section 50353)

Next StepsThe CHRONIC Care Act creates substantial new opportunities to transform the Medicare and Medicaid payment and delivery systems to advance the goals of integrated, person-centered care. Now is the time for federal officials – in concert with state leaders, delivery system champions, and consumer advocates – to bring this new law to life. The Administration should maximize stakeholder feedback when craftingguidance and regulation to deliver on the promise of a high-quality system of care for adults with complexneeds and their family caregivers.

Attachment 6


Cal MediConnectBroker Pilot

Sarah BrooksDeputy Director, Health Care Delivery Systems

Department of Health Care Services

Attachment 7

• Passive Enrollment:– Objective Enrollment Broker – Health Care Options

• Enrollment Policy Updates:– Streamlined Enrollment with Beneficiary Protections– Some Flexibility to Remove Broker Disincentives

6/1/2018 2

BackgroundAttachment 7

• Eligible Plans– Can only offer Cal MediConnect Medicare products in the county– Must seek approval to participate

• Process & Beneficiary Protections– Streamlined Enrollment process: enrollments processed by HCO,

including outbound calls to confirm beneficiary choice– Broker payments from plan funds – no additional dollars– Will allow beneficiaries to choose a CMC plan that is not their

existing Medi-Cal plan (change from existing Streamlined process)• Effective for plan year 2019

6/1/2018 3

Broker PilotAttachment 7

Documents

CalPACE Member Meeting