Chartered Health Plan

2016Utilization Management Program Description for Individuals Dually Eligible for Medicare and Medicaid

Corporate Location:

Virginia Premier Health Plan, Inc.

600 East Broad Street – Suite 400

Richmond, Virginia 23220

Office: (800) 727-7536

Fax: (804) 819-5187

Central/Western/Fredericksburg VA Hampton Roads/ Tidewater VA Southwestern VA

P.O. Box 5307 P.O. Box 62347 P.O. Box 1751

Richmond, Virginia 23220-0307 Chesapeake, Virginia23320 Roanoke, Virginia 24008-1751

Office: (804) 819-5151 Office: (757) 461-0064 Office: (540) 344-8838

Executive Summary

2016 Utilization Management Program for Dually Eligible Individuals

Program Description

The philosophy, purpose, scope, structure, and tools of the Virginia Premier Health Plan, Inc. (VPHP) Utilization Management (UM) Program are outlined in a proprietary UM Program Description. The following summary highlights some of the primary functions of the UM Program for dually eligible individuals that ensures member’s easy access to the most appropriate and efficient services in the least restrictive, most cost-effective setting to promote person-centered care and improved medical, behavioral, psychosocial and long term care outcomes.

The Health, Quality and Utilization (HQUM) Committee oversees the VPHP UM Program. The Committee is comprised of the Chief Medical Officer (CMO), VPHP Medical Directors and network Practitioners across the full scope of services required by dually eligible individuals. Another role of this committee is to review, develop, and implement best practices/clinical protocols and procedures that ensure compliance with the highest clinical standards and highest standards to meet psychosocial and long term care needs.

VPHP’s Medical Management department is comprised of the CMO, Medical Directors, Vice President (VP)of Pharmacy, and other clinical and non-clinical staff including individuals who are knowledgeable about Long-Term Services and Supports (LTSS), nursing home care, transitions of care and all services that VPHP delivers to dually eligible individuals. This team facilitates the delivery of services rendered in ambulatory, inpatient, community-based and transitional settings including physical, behavioral and social support services. The HQUM Committee further oversees the utilization of care management and disease management services.

The Medical Management department responsibilities include the following:

• Ensuring appropriate member access
• Providing adequate clinical reviews through consistently applied systematic criteria and individual considerations of the uniqueness of the member
• Compliance with applicable regulatory, accreditation and company requirements
• Implementing and monitoring programs for improved member health, mental health, psychosocialand long term care outcomes
• Ensuring appropriate response and follow up of member and provider requests
• Facilitating transitions in care including discharge planning
• Ensuring the clinical accuracy of all Part D coverage determinations and redeterminations involving medical necessity, under the Medical Director’s oversight and direction
• Provides utilization indicators to support re-credentialing activities

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2016 Utilization Management Program Description

Table of Contents

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Virginia Premier Health Plan, Inc.

2016 Utilization Management Program Description

VIRGINIA PREMIER HEALTH PLAN, INC.

2016Utilization Management Program Description

I.SCOPE

The UMProgram for dually eligible individuals is designed to ensure that medical, behavioral, long term care and psychosocial support services rendered to members are appropriate, as well as in conformance withCenters for Medicare and Medicaid Services (CMS) and Department of Medical Assistance Services (DMAS) medical necessitydefinitions, Plan benefits and long term care waiver requirements. The program encompasses services rendered in ambulatory, inpatient, community-based and transitional settings.

The Medical Management Department is responsible for determining medical necessity of services in accordance with definitions provided by Medicare and Medicaid respectively as follows:

The MMP defines medically necessary services as services that:

• Include medical, behavioral health, and psychosocial services;
• Are defined as reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member, or otherwise medically necessary under 42 CFR §1395y for Medicare services;
• Are related to the ability to attain, maintain, or regain functional capacity;

• Are defined as an item or service provided for the diagnosis or treatment of a patient’s condition consistent with community standards of medical practice and in accordance with Medicaid policy (12 VAC 30-130-600) for Virginia Medicaid.

Where there is an overlap between Medicare and Medicaid benefits (i.e., durable medical equipment services), VPHP will apply the definition of medical necessity that is the more generous of the applicable Medicare and Virginia Medicaid standards.

Additionally, for individuals dually eligible for both Medicare and Medicaid and are provided necessary long term care services, the services are provided based upon an individual’s functional needs identified during the review of activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

The UM Program is managed in the following manner:

1. VPHP’sCMO, Medical Directors, HQUM, and Vice President (VP)of Health Services are responsible for administering the UM Program.

1. The Program’s policies and procedures are developed by the Medical Management Department and Medical Payment Policy Committee. Polices arereviewed by theHQUM and recommendations for improvement are given to the Medical Management department. Ratification by the Continuous Quality Improvement Committee (CQIC) shall occur after review and approval of the recommendations and policies of the HQUM and CQIC.

1. The Medical Management Department is responsible for determining medical necessity of services in accordance with CMS Guidelines, DMAS requirements and VPHP policies and procedures. If services are determined by the Medical Management Department to be either not medically necessary or not covered under the VPHP benefit’s contract, payment for services will be denied. The member is to be held harmless for payment in cases of lack of prior authorization or medical necessity determinations for covered benefits. VPHP does not prohibit or restrict a health care practitioner to act within their lawful scope of practice, from advising or advocating on behalf of a member that is their patient regarding the following:

• Health status
• Medical care or treatment options
• Any alternative treatments that may be self-administered

D. UM needed for LTSS services

1. Care plan created by trained Care Manager (CM) with background in LTSS (social worker or nurse).

1. Services are driven by functional needs – ADLs and IADLs.

1. Important to note that when care plans are developed that the services need to be cost effective in terms of delivery (i.e. if care plan includes a need to assist someone with bathing, eating, dressing and toileting – the amount of time necessary for each task is accounted for).

1. Providers of service need to be just enough to maintain someone in the community (3 days of Adult day, 4 days a week of PCA services, 2 days a week of home health nursing, etc.).

1. Providers of LTSS include and are not limited to Adult Day, Skilled Nursing Facility, Home Health Agency, residential care, home care, personal care services.

E. For dually eligible individuals, the VPHP UM Program is responsible for:

1. Defining review criteria, information sources and processes used to review and approve the provision of services and prescription drugs.

1. Using its policies and systems to monitor and address both under- and over- utilization of services and prescription drugs.

1. Reviewing and amending the UM review criteria periodically, including the criteria established for prescription drug coverage.

1. Implementing and management of policies and procedures to authorize out-of-network services and specialty care which is not available within the network.

1. Communicating with its complete provider network regarding requirements for prior authorization of services such that contracted providers are aware of the procedures and required time frames for prior authorization.

1. The PCP is responsible for providing and/or managing all health care services for the member. This responsibility includes understanding the Plan requirements for prior authorization of services.
2. Providers are directed to the Provider Manual and Prior Authorization Listlocated on our website for information and instructions on prior authorization requirements, timeframes and procedures that require prior authorization.
3. Information regarding changes and updates throughout the year to the Provider Manual or prior authorization list are sent to providers via regular mail.
4. The Provider Newsletters are mailed to providers throughout the year and contain information about changes or updates to the prior authorization process, including the prior authorization list. This is subsequently posted on the website for reference.
5. Provider Education Meetings are offered quarterly in each region during which changes and updates are discussed.
6. An inservice for providers about plan requirements is available upon request.
7. Provider Services Representatives perform monthly site visits to answer questions, receive and provide feedback, and review changes or updates to the plan.

1. Disseminating practice guidelines that are:
2. Based on valid and reliable evidence and/or consensus of health care professionals;
3. Considers the person-centered needs of members;
4. Can be adopted in consultation with contracted providers;
5. Can be reviewed and periodically updated;
6. Provide a basis for UM related decisions.

1. Informing enrollees of coverage decisions including tailored strategies for individuals with communication barriers.

1. Processing requests for both initial and continuing authorizations to ensure the consistent application of review criteria for authorization decisions; and,

1. Consulting with appropriate providers regarding UM decisions when appropriate.

1. Ensuring that prior authorization requirements are not applied to:
2. Emergency services, including emergency; behavioral health care;
3. Urgent care;
4. Crisis stabilization, including mental health;
5. Family planning services;
6. Preventive services;
7. Communicable disease services, including STI and HIV testing;
8. Out-of-area renal dialysis services.

1. Following the rules for the timing of authorization decisions for Medicaid services in 42 CFR §438.210(d) and for Medicare services in 42 CFR §422.568, 422.570 and 422.572. (See Section VIII.A.2.a.ii).

1. For overlaping services the MMP follows the three-way contract.

1. Making decisions regarding UM to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has appropriate clinical expertise in treating the enrollee’s medical condition, performing the procedure, or providing the treatment.

1. Making sure that a physician and a behavioral health provider are available 24 hours a day for timely authorization of medically necessary services and to coordinate transfer of stabilized enrollees out of the emergency department, if necessary.

1. Covered benefits under the three-way contract between CMS, DMAS and VPHP are listed in Attachment A.

F. Determinations of lack of medical necessity may be made prospectively, concurrently, or retrospectively based on notification to VPHP.

G. Determinations of lack of need based on a functional status review of ADLs and IADLS can be reviewed at any time based upon Medicaid waiver requirements.

H. VPHP’s Physician Advisors, who are board certified physicians in their specialty, assist the UM staff and Medical Directors in the determination of medical necessity in accordance with program policies and procedures when a second opinion is warranted or upon appeal of a denial decision.

I. VPHP’s CMO, Medical Directors, VP ofPharmacy and the HQUM routinely evaluate coverage decisions of new technology in medical and behavioral healthcare procedures, devices and pharmaceuticals based on evidence based guidelines and final approval by the appropriate governing federal agency.

J. VPHP’s CMO,Medical Directors and VP ofPharmacy review the health plan’s prescription drug and covered over the counter medication utilization trends for appropriateness and cost effectiveness with feedback to providers and the VPHP’s pharmacy benefits manager (PBM) for improvements. VPHP utilizes VPHP Pharmacy and Therapeutics’ committee for recommendations of formulary changes.

K. Participating providers are responsible for complying with program policies and procedures prior to rendering services.

L. When reimbursement is reduced or denied, the member cannot be held financially responsible for denied service costs unless the member has agreed to bear such costs prior to receiving non-covered services by signing in advance a waiver permitting billing for service.

M. Determinations of lack of compliance with the program by participating providers are reviewed by the UM staff and directed to the Medical Director. VPHP’s Medical Director gives individual feedback to providers if they are not in compliance with the program’s policies and procedures.

N. Determinations of lack of medical necessity or lack of compliance with the program may be appealed according to established VPHP Appeal and Grievance policies and procedures.

O. Findings of repeated occurrences of lack of medical necessity or lack of compliance with the program will be referred to VPHP’s HQUM and subsequently to the CQIC.

P. VPHP’s CMO and VP of Health Servicesprovide oversight of all delegated UM activities.

Q. Dissemination and storage of patient information shall comply with Federal, State, HIPAA and any other applicable statutes and regulations pertaining to confidentiality.

R. The program accommodates the contractual requirements of the DMAS, the Balanced Budget Act (BBA),the CMS regulations, and accreditation standards for the National Committee for Quality Assurance (NCQA).

S. Practitioners, providers, members and staff are notified in writing annually that UM review decisions are not based on financial incentives that encourage underutilization. All decisions are based on appropriateness of care and service and reviewers are not rewarded for issuing denials.

II.OBJECTIVE

This section outlines VPHP’s UM Program. The objective of the program is to ensure that services rendered to members enrolled in VPHP are necessary, based on Medicare and Medicaid benefits and definitions for dually eligible individuals as stated herein. Medicare and some Medicaid services must be medically necessary while appropriateness of LTSS services should be evaluated based on functional need. The program functions on consistently applied systematic evaluation of appropriateness criteria and by considering person-centered circumstances unique to the member. UM decisions are made in a collaborative manner with a member’s individually assigned CM and UM. In addition to making medical necessity determinations, VPHP’s UR nurse sends a review with the information to the CM to make contact with the member and facilitate any needed referrals by conferring with the PCP and member.

III.GOALS

1. The goals of the UM Program are to ensure:

1. Services rendered are medically necessary, timely and provided in the least restrictive, most cost-effective setting.

1. Services are rendered at the appropriate level of care, and at the appropriate duration and intensity.

1. Available resources are utilized in an efficient manner in the delivery of services in a person-centered manner that considers medical, behavioral and social support needs.

1. Services are rendered in accordance with the benefits of VPHP’s program for dually eligible individuals.

1. In support of these goals, the program incorporates the following objectives:

1. To implement prospective, concurrent, and retrospective review procedures.

1. To provide guidance, feedback, and education to participating providers in the person-centered, culturally and linguistically appropriate and efficient delivery and utilization of resources.

1. To convey identified relevant information to the HQUM and the CQIC committee for examination at the person-specific level and at the plan level.

1. The Medical Management Department shall evaluate and update the UM Program on an annual basis with data as well as review and feedback from the HQUMand staff.

1. The Medical Management Department and others may submit recommendations for program improvements to the HQUM.

1. All recommended changes to the UM program will be presented to the CQIC for approval.

1. VPHP will review utilization measures under the direction of the HQUM consistent with the requirements stated in the three-way contract between VPHP, CMS and DMAS.

IV.ORGANIZATION

A. Program Participants:

The following individuals and organizations play key roles in VPHP’s UM Program:

1. HQUM Committee
2. CMO, Medical Directors, VP of Pharmacy and VPof Health Services
3. Medical Payment Policy Committee

1. Care Management, Utilization Review Nurses and Support Staff

1. Physician Advisors (Consultants)

1. Participating Providers/Contracted Facilities including LTSS and nursing home providers among others.

B. Responsibilities and Limits of Authority

The responsibilities and limits of authority for each of the individuals and organizations which play key roles in the UM Program is delineated in the following subsections:

1. VPHP’s Principals:

The Principals of VPHP are the CQIC, and HQUM Committee and Medical Management.

2.Continuous Quality Improvement Committee

1. The CQIC is composed of the senior management team of VPHPand includes representation regarding medical, behavioral and LTSS services.
2. The committee meets at least four (4) times a year. The CQIC is responsible for reviewing the decisions of the Medical Management Department and HQUM.

3. CMO, Medical Directors and HQUM

The HQUM Committee is composed of board certified participating providers within VPHP’s network. The provider specialties represented on the committee include: Internal Medicine, Family Practice, Pediatrics, OB/GYN, Endocrinology/Metabolism, Gastroenterology, General Surgery, Psychiatry and Gerontology. This committee meets on a quarterly basis.