Version: August 18, 2016 MEDICARE-MEDICAID CAPITATED FINANCIAL ALIGNMENT MODEL REPORTING REQUIREMENTS: MICHIGAN-SPECIFIC REPORTING REQUIREMENTS Effective as of January 1, 2016, Issued August 18, 2016 MI-1 Version: August 18, 2016 Table of Contents Michigan-Specific Reporting Requirements Appendix ........................................... MI-3 Introduction ................................................................................................................ MI-3 Definitions ................................................................................................................... MI-3 Quality Withhold Measures ....................................................................................... MI-4 Reporting on Disenrolled and Retro-disenrolled Members .................................... MI-4 Reporting on Assessments and IICSPs Completed Prior to First Effective Enrollment Date .......................................................................................................... MI-5 Guidance on Adopted Level II Assessments ........................................................... MI-6 Guidance on Assessments and IICSPs for Members with a Break in Coverage .. MI-6 Hybrid Sampling ......................................................................................................... MI-8 Value Sets ................................................................................................................. MI-10 Michigan’s Implementation, Ongoing, and Continuous Reporting Periods ....... MI-11 Data Submission ...................................................................................................... MI-11 Resubmission of Data .............................................................................................. MI-12 Section MI I. Assessment ........................................................................................ MI-13 Section MI II. Care Coordination ............................................................................. MI-26 Section MI III. Enrollee Protections ........................................................................ MI-41 Section MI IV. Organizational Structure and Staffing ........................................... MI-43 Section MI V. Performance and Quality Improvement .......................................... MI-47 Section MI VI. Systems ............................................................................................ MI-60 Section MI VII. Utilization ........................................................................................ MI-63 MI-2 Version: August 18, 2016 Michigan-Specific Reporting Requirements Appendix Introduction The measures in this appendix are required reporting for all MMPs in the Michigan MI Health Link Demonstration. CMS and the state reserve the right to update the measures in this document for subsequent demonstration years. These state-specific measures directly supplement the Medicare-Medicaid Capitated Financial Alignment: Core Reporting Requirements, which can be found at the following web address: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid- Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/InformationandGuidanceforPlans.html MMPs should refer to the core document for additional details regarding Demonstration- wide definitions, reporting phases and timelines, and sampling methodology, except as otherwise specified in this document. The core and state-specific measures supplement existing Part C and Part D reporting requirements, as well as measures that MMPs report via other vehicles or venues, such as HEDIS®1 and HOS. CMS and the state will also track key utilization measures, which are not included in this document, using encounter and claims data. The quantitative measures are part of broader oversight, monitoring, and performance improvement processes that include several other components and data sources not described in this document. MMPs should refer to the three-way contract and subsequent amendments for other reporting submissions to the Michigan Department of Health and Human Services. Additionally, revisions to the Reporting Requirements may periodically follow. MMPs should contact the MI HelpDesk at [email protected] with any questions about the Michigan state-specific appendix or the data submission process. Definitions Calendar Quarter: All quarterly measures are reported on calendar quarters. The four calendar quarters of each calendar year will be as follows: 1/1 – 3/31, 4/1 – 6/30, 7/1 – 9/30, and 10/1 – 12/31. Calendar Year: All annual measures are reported on a calendar year basis. Implementation Period: The initial months of the demonstration during which MMPs will report to CMS and the state on a more intensive reporting schedule. The Implementation period is as follows: For the three MMPs that implement during Phase I on March 1, 2015, the implementation period begins on March 1, 2015 and continues until September 30, 2015. 1 HEDIS® is a registered trademark of the National Committee of Quality Assurance (NCQA). MI-3 Version: August 18, 2016 For the remaining MMPs that implement during Phase II on May 1, 2015, the implementation period begins on May 1, 2015 and continues until December 31, 2015. For any MMP in both Phase I and Phase II, the implementation period begins on March 1, 2015 and continues until September 30, 2015. Long Term Supports and Services (LTSS): A variety of supports and services that help elderly individuals and/or individuals with disabilities meet their daily needs for assistance and improve the quality of their lives. Examples include assistance with bathing, dressing, and other basic activities of daily life and self-care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over an extended period, predominantly in homes and communities, but also in facility-based settings such as nursing facilities. Please refer to the rules and regulations that further define specialty populations (mental illness, intellectual and developmental disabilities, and substance use disorders). Primary Care Provider (PCP): Practitioner of primary care selected by the Enrollee or assigned to the Enrollee by the ICO and responsible for providing and coordinating the Enrollee’s health care needs, including the initiation and monitoring of referrals for specialty services when required. Primary Care Providers may be nurse practitioners, physician assistants or physicians who are board certified, or a specialist selected by an Enrollee. Quality Withhold Measures CMS and the state will establish a set of quality withhold measures, and MMPs will be required to meet established thresholds. Throughout this document, state-specific quality withhold measures for Demonstration Year 1 (DY 1) are marked with the following symbol: (i). CMS and the state will update the quality withhold measures for subsequent demonstration years closer to the start of Demonstration Year 2. For more information about DY 1 quality withhold requirements, refer to the Quality Withhold Technical Notes (DY 1): Michigan Specific Measures at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid- Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/InformationandGuidanceforPlans.html. Reporting on Disenrolled and Retro-disenrolled Members Unless otherwise indicated in the reporting requirements, MMPs should report on all members enrolled in the demonstration who meet the definition of the data elements, regardless of whether that member was subsequently disenrolled from the MMP. Measure-specific guidance on how to report on disenrolled members is provided under the Notes section of each state-specific measure. Due to retro-disenrollment of members, there may be instances where there is a lag between a member’s effective disenrollment date and the date on which the MMP is MI-4 Version: August 18, 2016 informed about that disenrollment. This time lag might create occasional data inaccuracies if an MMP includes members in reports who had in fact disenrolled before the start of the reporting period. If MMPs are aware at the time of reporting that a member has been retro-disenrolled with a disenrollment effective date prior to the reporting period (and therefore was not enrolled during the reporting period in question), then MMPs may exclude that member from reporting. Please note that MMPs are not required to re-submit corrected data should you be informed of a retro-disenrollment subsequent to a reporting deadline. MMPs should act upon their best and most current knowledge at the time of reporting regarding each member’s enrollment status. Reporting on Assessments and IICSPs Completed Prior to First Effective Enrollment Date For MMPs that have requested and obtained CMS approval to do so, Level I and Level II Assessments may be completed up to 20 days prior to the individual’s coverage effective date for individuals who are passively enrolled. Early Level I and Level II Assessment outreach for opt-in members is permitted for all participating MMPs. For purposes of reporting data on Level I Assessments (Core 2.1, Core 2.2 and state- specific measures MI1.1 and MI1.2), MMPs should report any Level I Assessments completed prior to the first effective enrollment date as if they were completed on the first effective enrollment date. For example, if a member’s first effective enrollment date was June 1 and the Level I Assessment for that member