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EXHIBIT A-4-cLTC SUBMISSION REQUIREMENTS

AND EVALUATION CRITERIA (10-2-17)RESPONDENT NAME:

A. RESPONDENT BACKGROUND / EXPERIENCE

LTC SRC# 1 – Participant Direction of Services (Statewide):

The respondent shall describe its experience with participant direction of services (also referred to as self-directed or consumer-directed) by specifying the model(s) of participant direction used in the states in which the respondent currently operates and previously operated (e.g., agency with choice or fiscal employer agent). The respondent shall include a flowchart depicting how services are authorized and delivered through the participant direction programs referenced in the response. The description shall include:

Whether the model(s) includes the use of employer authority, budget authority, or both; The target population (ABD, DD, general aging population, etc.); The number of participants in each participant direction program; The services provided through its participant direction programs; The monitoring approach used to prevent and detect waste and abuse, specifically over-

utilization of services; The lessons learned from implementing participant direction programs; and The innovations it has deployed to enhance the delivery of services through the

participant direction program.

Response:

Evaluation Criteria:

1. The extent to which the respondent’s description includes experience with managing a participant direction of service delivery model.

2. The extent to which the respondent’s flowchart provides a description that addresses the following components:

(a) Care planning; (b) Service authorization; (c) Involvement of the Fiscal Employer Agent;(d) Electronic Visit Verification;(e) Claims processing;(f) Claims payment; and(g) Encounter data submission.

3. The extent to which lessons learned have been utilized to improve the respondent’s participant direction of service delivery model.

4. The extent to which the described experience demonstrates past innovations or planned innovations in participant direction of services (e.g., mobile telephone applications,

AHCA ITN 002-17/18, Attachment A, Exhibit A-4-c (10-2-2017), of 17


AND EVALUATION CRITERIA (10-2-17)implementation of electronic access/training to complete required forms, and electronic visit verification).

5. The extent to which the respondent’s monitoring approach ensures that fraud, waste and abuse is monitored and prevented, including over utilization of services.

Score: This section is worth a maximum of 55 raw points with each of the above components being worth a maximum of 5 points each.

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AND EVALUATION CRITERIA (10-2-17)

LTC SRC# 2 – Performance Measures (Statewide):

a. The respondent shall describe its experience in measuring performance and achieving quality standards with populations similar to the target population for the long-term care (LTC) component of the SMMC program. Describe experience with and performance on measures of the following elements of LTC:

(1) Comprehensive LTC assessment and update (the percentage of LTC plan enrollees who have documentation of a comprehensive assessment within the appropriate time frame);

(2) Comprehensive LTC Care Plan (the percentage of LTC enrollees who have documentation of a Comprehensive LTC Care Plan within the appropriate time frame);

(3) Shared Care Plan (the percentage of LTC plan enrollees with a care plan for whom all or part of the care plan was transmitted to key LTC providers and the primary care provider within the appropriate time frame);

(4) Re-Assessment and Care Plan Update after Discharge (the percentage of discharges from inpatient facilities in the measurement year for LTC plan enrollees resulting in a re-assessment and care plan update within 30 days of discharge);

(5) Admission to an Institution from the Community among LTC enrollees (the percentage of LTC enrollee admissions to an institution (nursing facility or intermediate care facility for individuals with intellectual disabilities (ICF/IID)) from the community that result in a short-term or long-term stay during the measurement year);

(6) Successful Transition after Short-Term Institutional Stay among LTC enrollees (the percentage of LTC enrollee institutional admissions that result in successful discharge to the community (community residence for 30 or more days) within 100 days of admission); and

(7) Successful Transition after Long-Term Institutional Stay among LTC enrollees (the percentage of LTC enrollees who are long-term residents (101 days or more) of institutions who are successfully discharged to the community (community residence for 30 or more days)).

b. The respondent shall describe any instances of failure to meet Contract-required quality standards for these types of measures, actions taken to improve performance, and how improvement was measured. (See Section 409.966(3)(a)2., Florida Statutes)

c. The respondent shall describe its experience with and performance on other LTC performance measures, any instances of failure to meet Contract-required quality standards for these measures, actions taken to improve performance, and how improvement was measured.

d. The respondent shall describe the data sources used for collecting and reporting LTC performance measures.

e. The respondent shall describe how the respondent has obtained data needed to track measures related to care plan updates after hospital admissions and discharges, and emergency department visits.




Response:


1. The extent of experience (e.g., number of Contracts, enrollees or years) in achieving quality standards with similar target populations, for measures related to the elements of LTC identified as number a.(1) through a.(7).

2. The extent of experience (e.g., number of Contracts, enrollees, or years) in achieving quality standards with similar target populations for other LTC performance measures.

3. The extent to which the described experience demonstrates the ability to effectively measure quality improvement.

4. The extent to which the described experience demonstrates the ability to improve quality in a meaningful way.

5. The extent to which the respondent met all quality measures or successfully remediated all failures.

6. The extent to which the respondent has used multiple data sources and has obtained data needed to collect and report on LTC performance measures, including those that require information related to care plan updates after hospital admissions and discharges, and emergency department visits.






B. AGENCY GOALS

LTC SRC# 3 – Transitions of Care (Statewide):

The respondent shall describe how it will address transition and discharge planning for an enrollee going from a hospital or nursing facility rehabilitation setting and returning to a community setting. The respondent should identify specific strategies for ensuring that transition and discharge planning incorporates assessment of appropriate supports in the home, provision of supplies and home care/nursing services. The respondent shall include an example of an effective transition plan with appropriate timeframes for each step of the process.

Response:


1. The extent to which the respondent’s process and example address the following components of transition and discharge planning:

(a) Assessment criteria for ensuring the enrollee can be served safely in the community;

(b) Collaboration with providers’ discharge planning staff (e.g., hospitals, institutional settings, assisted living facilities, ancillary providers);

(c) Referral and scheduling assistance; (d) Coordination with home and community-based providers, including DME and

home health providers as appropriate to meet the enrollee’s needs; and(e) Processes to prevent unnecessary hospital or nursing facility readmissions.

2. The extent to which the respondent’s process and example ensure the protection of the enrollee’s privacy consistent with confidentiality requirements.

3. The extent to which the respondent’s example provides appropriate timeframes for each step of the transition and discharge planning process.






LTC SRC# 4 – Provider Network Agreements/Contracts (Regional):

The Agency has identified some the key network provider types that will be critical in order for the respondent to promote the Agency’s goals.

The respondent shall demonstrate its progress with executing agreements or contracts it had with providers in the region by submitting Exhibit A-4-c-1, Provider Network Agreements/Contracts (Regional) (10-2-2017):

Response:

Evaluation Criteria: For each service type the respondent may receive up to 60 points as described below. There are four (4) service types available in a region.

Percentage of agreements/contracts for each service type

Points

0.0% 01.0% - 25% 1525.1% - 50% 3050.1% - 75% 4575.1% or greater 60

Score: This section is worth a maximum of 240 raw points based on the above point scale.





C. RECIPIENT EXPERIENCE

LTC SRC# 5 – Transition from Nursing Facility to Community (Statewide):

The respondent shall describe its experience with transitioning individuals from institutional to community settings and strategies to ensure individuals maintain successful community placement including:

a. Experience and strategies pertaining to deploying transitional care teams and using evidence-based practices with support from other clinical resources and community-based organizations.

b. Experience and strategies pertaining to individuals who reside in an institutional setting for rehabilitation, or have otherwise resided in a facility for less than one year.

c. Experience and strategies pertaining to individuals who have resided in an institutional setting for more than one year.

Response:


1. The extent to which the respondent identifies how it will coordinate care with all individuals and/or entities necessary.

2. The extent to which the respondent assesses potential caregiver willingness and availability in supporting the transition.

3. The extent to which the respondent’s description addresses transitioning enrollees with special circumstances or medical conditions (e.g., complex needs); enrollees with ongoing needs; and enrollees who at the time of their transition have existing prior authorization or approval for ancillary services.

4. The extent to which the respondent demonstrates through data its success rate at transitioning individuals from institutional to community settings.

5. The extent to which the respondent demonstrates through data its success rate at maintaining individuals who have transitioned from an institutional placement to community placements.





LTC SRC# 6 – Care Planning (Statewide):

The respondent shall provide a flowchart depicting how it will use the information contained in the State of Florida approved assessment (Florida Department of Elder Affairs 701B Comprehensive Assessment), the respondent’s supplemental assessment (if applicable), and any additional information collected in its utilization and case management processes for LTC services, in order to properly complete the initial care planning process for a recipient in a facility-based setting and in a community-based setting.

Response:


1. The extent to which the flowchart outlines specific data components it will use from the State of Florida approved assessment in the development of the plan of care for enrollees.

2. The extent to which the flowchart outlines specific data components it will use from the respondent’s supplemental assessment, and/or any additional informational sources, in the development of the plan of care for enrollees.

3. The extent to which the flowchart incorporates specific data components it will use to ensure a person-centered approach is achieved in the care planning process, including documenting personal goals.

4. The extent to which the respondent uses the caregiver assessment to determine the availability of family/informal support systems, and the amount of assistance the existing support systems are able to provide the enrollee, in making authorization decisions.






LTC SRC# 7 – Freedom of Choice & Residential Settings (Statewide):

The respondent shall describe how it will address the enrollee’s preference in residential settings (i.e., home, adult family care home, assisted living, or nursing facility). The respondent shall describe the safeguards it will have in place during the implementation of the re-procurement of the SMMC program to ensure enrollees do not have to move out of their current residence, by residential setting.

Response:


1. The extent to which the respondent’s description addresses the process it will use to ensure enrollees are educated about their choice in residential setting, including freedom of choice.

2. The extent to which the respondent describes initial or ongoing case manager training to confirm enrollee preference in residential setting.

3. The extent to which the respondent’s description addresses how all residential settings are considered for enrollee placement.

4. The extent to which the respondent’s description includes safeguards the respondent has in place to ensure enrollees will not have to move out of their current residence, by residential setting.






D. PROVIDER EXPERIENCE

LTC SRC# 8 Home and Community-Based Services (HCBS) Performance and Credentialing (Statewide):

The respondent shall describe how its staff will create, collect, report and use internal provider performance measures and/or criteria for home and community-based, residential, and participant direction provider types. The respondent shall include how the performance measures will improve network quality and be utilized in recredentialing activities, and if/how the respondent will use the internally-developed performance measures to limit its provider networks pursuant to Section 409.982(1)(c), Florida Statutes.

Response:


1. The extent to which the respondent’s description includes a plan to create, collect, report and use provider performance measures.

2. The extent to which the respondent describes how performance measures are reported and trended for each participating provider type and incorporates utilization data, quality of care concerns, performance measure scoring, and provider and enrollee satisfaction in recredentialing activities.

3. The extent to which the respondent’s description includes a plan to communicate the performance measure results to providers, including any provider incentives or alternative payment methodology opportunities available.

4. The extent to which the respondent’s description includes the establishment of data-based targets to determine the completion of provider corrective action plans and utilization of these targets pursuant to Section 409.982(1), Florida Statutes, including the ability for providers to be notified of performance issues prior to termination.






LTC SRC# 9 – Claims Submission and Payment (Statewide):

The respondent shall describe how it will educate and train LTC providers about claims submission and payment processes.

Note: Pursuant to Section 409.966(3)(c)6., Florida Statutes, response to this submission requirement will be considered for negotiations.

Response:


1. The extent to which the respondent describes the initial and ongoing training targeted to LTC providers, including the type, location, and frequency of training.

2. The extent to which the respondent’s initial and ongoing training addresses characteristics unique to facility-based vs. community-based providers’ claims submission and payment (e.g., rate changes, patient responsibility, Medicare coordination and crossover).

3. The extent to which the respondent will provide ongoing education and training, including problem resolution, responding to provider requests for training and how the respondent will evaluate the effectiveness of its education and training activities, including provider satisfaction.

4. The extent to which the respondent ensures training materials and tools are transparent and easily accessible.

5. The extent to which the training materials provided to LTC providers include information on how to access the Agency’s third party claims dispute resolution contract (Maximus).

6. The extent to which the respondent will provide training to providers on medical necessity criteria, as defined in the Contract pursuant to 42 Code of Federal Regulations 447.45 and in 59G-1.010(166), Florida Administrative Code.

7. The adequacy of the respondent’s notification process when system issues are identified/resolved by the respondent and/or its subcontractor(s), including notification to all impacted parties of estimated time for resolution, and updates and notification to providers prior to launching system changes that may impact billing and payment.





LTC SRC# 10 – Claims Submission and Payment (Statewide):

The respondent shall describe how it will ensure that electronically-submitted nursing facility and hospice claims processes will enable claims payment within ten (10) business days after receipt of clean claims. (See Section 409.982 (5), Florida Statutes) The respondent shall provide the specific data metrics it will use to ensure compliance with this provision.

Response:


1. The extent to which the respondent describes the systems that will be used to measure timeliness of claims payment.

2. The extent to which the respondent’s data metrics demonstrate an ability to comply with Section 409.982(5), Florida Statutes.

3. The extent to which the respondent describes how it will work with providers when the timeliness standards are not met.

4. The extent to which the respondent ensures that billing systems platform changes will be limited.






E. DELIVERY SYSTEM COORDINATION

LTC SRC# 11 – Case Vignette (Statewide):

The respondent shall review the below case vignette, which describes potential Florida Medicaid recipients. Note: The vignette included below is fictional.

Alisha is a 35-year old single mother who suffered from a major car accident when she was 27 years old, which resulted in incomplete paraplegia. Until she received Medicaid coverage, Alisha was unable to afford the recommended level of physical and occupational therapy treatments that would have assisted her in maintaining maximum mobility in her upper extremities. As such, Alisha requires assistance with almost all self-care tasks. Alisha has suffered from clinical depression since her accident. She is cognitively intact and since starting individual therapy sessions with a licensed mental health clinician, she has started to express a desire to be more engaged in her community. Alisha has a primary care physician (who specializes in internal medicine) and is also seen by a neurologist. Alisha’s physician has ordered ongoing maintenance physical therapy; she also receives personal care services and durable medical equipment. Alisha gave birth to a son, Noah, one year before the accident. Alisha’s mother assists with Noah’s care as often as she can, but her mother recently accepted a job in a different city, which will mean Alisha will have less supports (both for herself and Noah). Alisha and Noah currently live with her mother. Because her mother is moving, Alisha has been looking for a new place to live, but she is having trouble finding a home that is functional for her needs. Since Alisha is experiencing changes in her support system and living situation, she requests assistance from her case manager.

The respondent shall describe its approach to coordinating care for an enrollee with Alisha’s profile, including a detailed description and workflow demonstrating notable points in the system where the respondent’s processes are implemented:

a. Comprehensive Assessment;b. Caregiver Assessment;c. Person Centered Care Planning;d. Transition Planning;e. Disease Management;f. Utilization Management/Service Authorization; andg. Grievance and Appeals.

Where applicable, the respondent should include specific experiences the respondent has had in addressing these same needs in Florida or other states.

Response:


1. The adequacy of the respondent’s approach in addressing the following:




(a) Description of the sources of data/information that would be utilized in the assessment process, including timeframes for completion;

(b) Application of the respondent’s case management risk stratification protocol, including a rationale for the decision;

(c) Application of a person centered care planning approach;(d) Identification of service needs (covered and non-covered) and a description for

service referral processes that the plan has in place;(e) Description of the interventions and strategies that would be used to facilitate

community integration and transition planning;(f) Application of coordination protocols utilized with other insurers (when

applicable), primary care providers, specialists, other service providers, and community partners particularly when referrals are needed for non-covered services;

(g) Description of the assessment of provider capacity to meet the specific needs of enrollees;

(h) Identification of strategies that promote self-management and compliance with the plan of care;

(i) Application of utilization management protocols (i.e., identification of the criteria that will be utilized, processes to ensure continuity of care, etc.); and

(j) Application of strategies to integrate information across the plan and various subcontractors when the respondent has delegated functions.

2. The extent to which the respondent’s workflows/narrative descriptions include timeframes for completion of each step in the care planning process.

3. The extent to which the respondent demonstrates innovative processes that it has in place to enhance communication among all service providers and subcontractors (for delegated functions).

4. The extent to which the respondent demonstrates experience providing services to enrollees with complex medical needs and provide evidence of strategies utilized that resulted in improved health outcomes.

5. The extent to which the respondent demonstrates a system of coordinated health care interventions designed to achieve cost savings through the organized and timely delivery of high quality services.

6. The extent to which the respondent describes innovative strategies to integrate information across all systems/processes into its workflows.





LTC SRC# 12 – Case Vignette (Statewide):

The respondent shall review the below case vignette, which describes potential Florida Medicaid recipients. Note: The vignette included below is fictional.

Mr. and Mrs. Smith are a husband and wife, both in their early 70s. They have an adult daughter who lives in State. The Smiths are both enrolled in Medicaid managed care and are dual-eligible for Medicaid and Medicare. The Smiths are enrolled in Medicare FFS. Mr. Smith is enrolled in a Managed Medical Assistance plan, while Mrs. Smith is newly enrolled in your LTC Plus Plan or Comprehensive Plan. Mrs. Smith has moderate to severe dementia that is progressing. She is able to walk with the aid of a walker and she can feed herself. However, she needs assistance with bathing and dressing, and she needs supervision due to wandering. Mrs. Smith was admitted to the hospital three months ago for pneumonia but was discharged to a nursing facility, as her husband was unable to care for her on his own anymore. Mrs. Smith would like to move home. Mr. Smith would like for her to move home, but he is concerned that he cannot meet all of her needs on his own. Mr. Smith has a single, below-the-knee amputation, but is otherwise healthy. Their small home is cluttered, and they have many pets. Mr. Smith says he is overwhelmed because she needs more care than he can provide by himself.

The respondent shall describe its approach to coordinating care for an enrollee with Mrs. Smith’s profile, including a detailed description and workflow demonstrating notable points in the system where the respondent’s processes are implemented:

a. Comprehensive Assessment;b. Caregiver Assessment;c. Person Centered Care Planning;d. Transition Planning;e. Disease Management;f. Utilization Management/Service Authorization; andg. Grievance and Appeals.

Where applicable, the respondent should include specific experiences the respondent has had in addressing these same needs in Florida or other states.

Response:


1. The adequacy of the respondent’s approach in addressing the following:

(a) Description of the sources of data/information that would be utilized in the assessment process, including timeframes for completion;

(b) Application of the respondent’s case management risk stratification protocol, including a rationale for the decision;

(c) Application of a person centered care planning approach;



AND EVALUATION CRITERIA (10-2-17)(d) Identification of service needs (covered and non-covered) and a description for

service referral processes that the plan has in place;(e) Description of the interventions and strategies that would be used to facilitate

community integration and transition planning;(f) Application of coordination protocols utilized with other insurers, (when

applicable) primary care providers, specialists, other service providers, and community partners particularly when referrals are needed for non-covered services;

(g) Description of the assessment of provider capacity to meet the specific needs of enrollees;

(h) Identification of strategies that promote self-management and compliance with the plan of care;

(i) Application of utilization management protocols (i.e., identification of the criteria that will be utilized, processes to ensure continuity of care, etc.); and

(j) Application of strategies to integrate information across the plan and various subcontractors when the respondent has delegated functions.

2. The extent to which the respondents workflows/narrative descriptions include timeframes for completion of each step in the care planning process.

3. The extent to which the respondent demonstrates innovative processes that it has in place to enhance communication among all service providers and subcontractors (for delegated functions).

4. The extent to which the respondent demonstrates experience providing services to enrollees with complex medical needs and provide evidence of strategies utilized that resulted in improved health outcomes.

5. The extent to which the respondent demonstrates a system of coordinated health care interventions designed to achieve cost savings through the organized and timely delivery of high quality services.

6. The extent to which the respondent describes innovative strategies to integrate information across all systems/processes into its workflows.






F. OVERSIGHT AND ACCOUNTABILITY

LTC SRC# 13 – Management Experience and Retention (Statewide):

The respondent shall describe its approach to the hiring and promoting retention, throughout the Contract term, of executive managers (e.g., CEO, COO, CFO, CMO, vice presidents, senior managers) who have expertise and experience in serving elders and adults with disabilities who require LTC, and document such expertise and experience. The respondent shall describe the relevant experience of their current management team. [See Section 409.981(3)(a), Florida Statutes]

Response:


1. The extent to which executive managers have expertise and experience in implementing innovative care delivery systems serving elders and adults with disabilities who require LTC.

2. The extent to which executive managers have expertise and experience for their respective positions.

3. The degree to which the respondent provides evidence, data, or metrics to demonstrate the effectiveness of its approaches to staff retention, including staff tenure, by contract, for the respondent’s two (2) most recent contracts.




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