NCQA Accreditation for LTSS is in High Demand

By Nancy Ross Bell, RN

Estimated time to read:  4 minutes

As the US population over age 65 grows, the need to provide care in the home, community-based settings, or in facilities such as nursing homes also grows. Assisting individuals to live more independently also supports health equity.

However, these services are not only for the older population. In some States, people with disabilities, including intellectual/developmental and serious mental illness, among other populations, are moving into the State’s managed programs. Some States recognize NCQA Accreditation for LTSS as meeting their regulatory requirements for their managed programs, and more are requiring Distinction every year.

NCQA has long-recognized long-term services and supports (LTSS). NCQA standards on LTSS (Long-term Services and Supports) are included in three NCQA-accredited programs: Health Plans (HP), Managed Behavioral Health Organizations (MBHO), and Case Management (CM).

• NCQA-Accredited HPs and MBHOs can earn LTSS Distinction for coordinating LTSS services.
• NCQA-Accredited CM organizations can earn Accreditation for LTSS (CM-LTSS Accredited) or Distinction for LTSS (CM Accredited-LTSS Distinction)

In this blog, we highlight some of NCQA’s recent updates pertaining to LTSS.

Who are the organizations that are NCQA-Accredited for LTSS?

What is evident is that the needs of individuals receiving LTSS services and supports are complex, expensive, and require intense coordination. Becoming NCQA-Accredited promotes healthcare quality and adds value to organizations. 

At the time of this writing and according to NCQA’s Report Cards, which are updated on the 15^th of each month, there are:

• 51 Accredited Health Plans with LTSS Distinction spanning 15 states. All are Medicaid HMOs, and one Medicaid plan also includes the Medicare line of business.
• 104 CM-LTSS Accredited
• 1 CM-Accredited with LTSS Distinction

Updates

Take Note! These updates may differ slightly between the three different standard sets (CM-LTSS, HP, and MBHO) and are not all-inclusive of changes by NCQA. Due to the length of updates, specific standards are not called out in this blog. So always read the latest standards as applicable and regularly access NCQA’s Policy Changes and FAQs! Or, you can ask your MHR Consultant.

Promoting Health Equity (New Factor)

Health Equity has been at the top of the list in many standards and is added as a new factor for case management program descriptions in LTSS-1 CM and HP documented processes.

When referring to documented processes, NCQA clarified that their review includes policies and procedures, which are formal documents approved by the organization and must include an effective date.  (Caution!  Job aids are not considered formal policies and procedures.)

Collecting Demographic Data (New Element)

Race/ethnicity and language must be collected at the population and individual levels. Documented processes and reports or materials are required prior to the survey date. Health plans may already be meeting this requirement for their population health assessment.

Always look to the scope of review for the type of documentation that must be submitted.

Privacy Protections for Data (New Element)

In addition to collecting data on race/ethnicity and language, organizations must have policies and procedures for protecting its access and use.

Social Needs (Critical Factor), Social Connection (New Term) and Social Functioning (Separate Factor)

Social needs, the non-clinical needs individuals identify as essential to their well-being, must be assessed and are evaluated by file review. CM-LTSS requires three areas of social needs assessment. Policies must be updated with current terminology (formerly social determinants of health) and a new term, social connection, which includes, in part, social isolation, loneliness, or inadequate social support.

However, don’t forget about social functioning, a separate factor that refers to an individual’s ability to interact with others successfully.

When reviewing an organization’s comprehensive assessments, the scope of review explains a 60-day rule:    

Files are selected from active or closed member cases that were identified during the look-back period and remained open for at least 60 calendar days during the look-back period, from the date when the individual was identified for case management.

Documentation to meet all factors includes evidence that assessments were completed and results were documented.

Clinical Integration (New Element)

Sending and receiving information between providers and LTSS organizations must be completed within 60 days of completion of the assessment.

Prioritized-Person Centered Goals (New Emphasis-Critical Factors - Clarifications)

Organizations must have a documented process for conducting Person-Centered Assessments. This includes prioritizing individuals’ goals and preferences and then demonstrating by file review how they planned and implemented actions toward the prioritized goals.

Goals must be prioritized or ranked in a SMART (Specific, Measurable, Attainable, Relevant, and Time-bound) format.

Complaints (Clarification)

While complaints may be viewed as feedback, feedback is not always a complaint! NCQA clarified that organizations must collect data on complaints. This change could mean changing your documented process for identifying and reporting complaints.

Staffing, Training, and Verification (New Element)

CM organizations must have a documented process for recruiting and hiring a workforce that supports diversity, equity, and inclusion, reflecting the population it serves. The Explanation section of the Element calls out the need to address diversity for staff, including LTSS providers, leadership (individuals with managerial authority and executive roles such as managers, directors, vice presidents, and chief officers), committees (individuals internal and external to the organization, appointed for a specific function, if applicable), and governance bodies (including, but not limited to, the organization’s board of directors, if applicable).

Please note this language is “and” and not “or,” meaning that all need to be addressed. The HPs and MBHOs already have a requirement in their respective standards for offering training and addressing diversity for their workforce, but this requirement for LTSS goes beyond those requirements.

Quantitative and Qualitative Analysis (High point standards)

Organizations coordinating and providing LTSS services are required to annually provide three measures of the effectiveness and efficiency of their program, using quantitative and qualitative analysis, and Renewal Surveys require that the organization takes action to improve one experience measure from Element A and one measure of effectiveness from  Elements B – D.

Qualitative and quantitative (Q&Q) analyses on three measures of effectiveness are required. After summarizing your data, conclusions about the results and responsible staff must be documented. Refer to the NCQA Glossary for a full description of Q&Q analysis requirements.  Read more on Q&Q Analyses that Bring Results.

Organizations must also measure the rates of participation compared to eligible individuals.

MHR has found that some clients are confused when identifying eligible individuals and calculating active participation rates.  

In NCQA’s explanation, the Case Management (CM) participation rate is defined.

CM Participation rate=

Number of individuals with completed assessments and at least one additional interactive contact

/ (divided by)

Total number of eligible individuals (Eligible individuals are individuals for whom the organization has been contracted to provide CM services).

Read NCQA’s full explanation for details on state-defined participation rates and client restrictions!

Service Authorizations and Denials  (New Elements)  

Health plans must have a process to authorize new and additional service requests and notify members of service denials, including the reason for denial and how the decision was made. The care plan and reassessment of the care plan must be considered when approving or denying service requests.

CM organizations must distribute information to individuals on receiving assistance with navigating appeals along with other individuals’ rights. We recommend that CM organizations, along with having a documented process for distributing individuals’ rights, also have a documented process for staff handling the appeal process.  

Care Transitions (Clarification)

Organizations must now manage care transitions for all individuals (the entire LTSS population) who need services. Read more on how to Prevent Unplanned Transitions of Care.

How Can MHR Help?

Do any of these scenarios sound like your organization?

• Your staff who are responsible for LTSS services are new to NCQA Accreditation and not familiar with the standards
• Your staff handling Health Plan Accreditation are the same ones responsible for LTSS but are not familiar with the unique standards or the services
• Your state now requires LTSS, and you’re not sure where to start

MHR’s Consultants have worked with health plans, MBHOs, and CM organizations for their LTSS initial survey and resurvey. We can help you make sure you achieve success and plan for your submission to meet your look-back period, train your staff on the LTSS standards and Q&Q analysis, assess your documentation, review your delegation agreements for eligibility of auto-credit, and conduct mock audits of your files. Heavily weighted areas are those with file reviews on evaluating comprehensive assessments and reports requiring Q&Q analysis. 

MHR is currently working on a crosswalk of LTSS requirements among CM, MBHO, and HPs and will notify you of its availability in our newsletter when it is ready. We are also working on a file review auditing document for the Person-Centered Assessments like we have for HP and MBHO CM file audits.

Let us know when you are ready for MHR to help guide you on your successful LTSS NCQA Accreditation or Distinction journey.

Call to Action:    

• Read the November 20, 2023, issue of NCQA’s Corrections, Clarifications, and Policy Changes for the 2024 standards on HPA LTSS Distinction and for CM-LTSS.
• Ensure your formal policies and procedures are updated with new terminology, approved by your organization, and dated when effective.
• Assess if your information systems are set up to collect comprehensive individual data on race, ethnicity, and language.
• Schedule training for the LTSS standards and Q&Q analysis.
• Purchase the 2024 standards at NCQA’s Store to ensure you have the latest information for surveys with a start date of July 1, 2024, and forward.

Managedhealthcareresources.com or email Susan K. Moore 

Tina Morton, BSN, RN, CCM, CPHQ, an MHR Independent Consultant, provided valuable insight into this blog on NCQA LTSS Accreditation. Read more about Tina.

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