COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL …

1 COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES COMMONWEALTH COORDINATED CARE PLUS MCO CONTRACT FOR MANAGED LONG TERM SERVICES AND SUPPORTS July 1, 2021 - June 30, 2022 1 SECTION SCOPE OF CONTRACT .. 9 APPLICABLE laws , REGULATIONS, AND INTERPRETATIONS .. 9 COMMITMENT TO DEPARTMENT GOALS FOR DELIVERY SYSTEM REFORM AND PAYMENT TRANSFORMATION .. 10 DEPARTMENTAL MEETINGS .. 10 SECTION REQUIREMENTS PRIOR TO OPERATIONS .. 11 ORGANIZATIONAL STRUCTURE .. 11 READINESS REVIEW .. 13 LICENSURE .. 14 CERTIFICATION OF QUALITY .. 14 NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) ACCREDITATION .. 15 DUAL ELIGIBLE SPECIAL NEEDS PLAN (D-SNP) .. 15 BUSINESS ASSOCIATE AGREEMENT (BAA).

2 17 AUTHORIZATION TO CONDUCT BUSINESS IN THE COMMONWEALTH .. 17 CONFIDENTIALITY STATUTORY REQUIREMENTS .. 17 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST .. 18 PROHIBITED AFFILIATIONS WITH ENTITIES DEBARRED BY FEDERAL AGENCIES .. 20 EXCLUDED ENTITIES .. 21 CONTRACTOR COMPLIANCE PROGRAM .. 21 SECTION ENROLLMENT AND ASSIGNMENT PROCESS .. 23 ELIGIBILITY AND ENROLLMENT RESPONSIBILITIES .. 23 CCC PLUS ENROLLMENT PROCESS .. 26 SECTION BENEFITS AND SERVICE REQUIREMENTS .. 37 GENERAL BENEFITS PROVISIONS .. 37 BEHAVIORAL HEALTH SERVICES .. 37 DENTAL AND RELATED SERVICES .. 52 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) .. 54 EARLY INTERVENTION (EI) .. 56 EMERGENCY AND POST-STABILIZATION SERVICES.

3 59 LONG TERM SERVICES AND SUPPORTS .. 61 PHARMACY SERVICES .. 94 TELEMEDICINE AND TELEHEALTH SERVICES .. 102 NON-EMERGENCY MEDICAL TRANSPORTATION SERVICES .. 104 CARVED OUT SERVICES .. 121 STATE PLAN SUBSTITUTED (IN LIEU OF) SERVICES .. 121 CCC Plus Contract Table of Contents 2 ENHANCED BENEFITS .. 122 SERVICES RELATED TO FEDERAL MORAL/RELIGIOUS OBJECTIONS .. 123 TRANSLATION & INTERPRETER SERVICES .. 123 MEDICAID WORKS .. 124 ACA MINIMUM ESSENTIAL BENEFITS FOR MEDICAID EXPANSION POPULATION .. 124 FOSTER CARE AND ADOPTION ASSISTANCE CHILDREN .. 125 MATERNITY SERVICES .. 126 SECTION CCC PLUS MODEL OF CARE .. 127 GENERAL REQUIREMENTS AND COVERED POPULATIONS .. 127 MEDICALLY COMPLEX DETERMINATION.

4 129 HEALTH RISK ASSESSMENTS (HRA) .. 133 PERSON-CENTERED INDIVIDUALIZED CARE PLAN (ICP) .. 142 INTERDISCIPLINARY CARE TEAM (ICT) .. 146 REASSESSMENTS .. 148 CARE COORDINATION STAFFING .. 149 CARE COORDINATION PARTNERSHIPS .. 151 CARE COORDINATOR STAFFING RATIOS .. 151 CARE COORDINATION REQUIREMENTS .. 154 CARE COORDINATION WITH TRANSITIONS OF CARE .. 156 VIRGINIA EMERGENCY DEPARTMENT CARE COORDINATION PROGRAM .. 158 COORDINATION WITH THE MEMBER S MEDICARE OR OTHER MCO PLAN .. 159 CLINICAL WORKGROUP 162 CONTINUITY OF CARE .. 162 CARE DELIVERY MODEL POLICY AND PROCEDURES .. 166 SECTION UTILIZATION MANAGEMENT REQUIREMENTS .. 172 GENERAL UTILIZATION MANAGEMENT REQUIREMENTS.

5 172 SERVICE AUTHORIZATION .. 172 PATIENT UTILIZATION MANAGEMENT & SAFETY (PUMS) PROGRAM .. 180 ELECTRONIC VISIT VERIFICATION (EVV) SYSTEM .. 183 NOTIFICATION TO THE DEPARTMENT OF SENTINEL EVENTS .. 184 SECTION SUBCONTRACTOR DELEGATION AND MONITORING REQUIREMENTS .. 185 GENERAL REQUIREMENTS FOR SUBCONTRACTORS .. 185 DELEGATION REQUIREMENTS .. 186 MONITORING REQUIREMENTS .. 187 DATA SHARING CAPABILITIES .. 187 BEHAVIORAL HEALTH SERVICES ADMINISTRATOR .. 187 3 SECTION PROVIDER NETWORK MANAGEMENT .. 189 GENERAL NETWORK PROVISIONS .. 189 SPECIALIZED NETWORK PROVISIONS .. 190 CERTIFICATION OF NETWORK ADEQUACY .. 194 PROVIDER CREDENTIALING STANDARDS .. 195 PROVIDER AGREEMENTS.

6 198 SECTION ACCESS TO CARE STANDARDS .. 205 GENERAL STANDARDS .. 205 CHOICE OF PROVIDER STANDARDS .. 205 MEMBER TRAVEL TIME AND DISTANCE STANDARDS .. 206 EXCEPTIONS TO ACCESS STANDARDS .. 207 TWENTY-FOUR HOUR COVERAGE .. 207 URGENT CARE ACCESS .. 207 EMERGENCY SERVICES COVERAGE .. 208 INPATIENT HOSPITAL ACCESS .. 208 MEMBER PRIMARY CARE ACCESS (ADULT AND PEDIATRIC) .. 208 TIMELINESS ACCESS STANDARDS .. 210 SECOND OPINIONS .. 211 OUT-OF-NETWORK SERVICES .. 211 OUT-OF-STATE SERVICES .. 211 PROVIDER TRAVEL CONSIDERATIONS .. 212 POLICY OF NONDISCRIMINATION .. 212 ACCOMMODATING PERSONS WITH DISABILITIES .. 212 ASSURANCES THAT ACCESS STANDARDS ARE BEING MET .. 213 NATIVE AMERICAN HEALTH CARE PROVIDERS.

7 213 SECTION QUALITY MANAGEMENT AND IMPROVEMENT .. 214 QUALITY DEFINITION AND DOMAINS .. 214 CONTINUOUS QUALITY IMPROVEMENT PRINCIPLES AND EXPECTATIONS .. 214 QUALITY INFRASTRUCTURE .. 214 ANNUAL EVALUATION OF THE QAPI/QI PROGRAM .. 216 QI STAFFING .. 216 PERFORMANCE MEASUREMENT .. 217 PERFORMANCE IMPROVEMENT PROJECTS (PIPs) .. 220 EXTERNAL QUALITY REVIEW (EQR) ACTIVITIES .. 221 WAIVER ASSURANCES .. 223 QI FOR UTILIZATION MANAGEMENT ACTIVITIES .. 223 4 CLINICAL PRACTICE GUIDELINES .. 223 QUALITY COLLABORATIVE AND OTHER WORKGROUPS .. 224 MEMBER INCENTIVES .. 225 SOCIAL DETERMINANTS OF HEALTH .. 225 BEHAVIORAL HEALTH SERVICES OUTCOMES .. 227 ARTS SPECIFIC MEASUREMENT AND REPORTING.

8 227 MEDICAID EXPANSION POPULATION SPECIFIC MEASUREMENT AND REPORTING .. 227 QUALITY SYSTEM .. 228 NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) ACCREDITATION .. 228 SECTION MEMBER SERVICES AND COMMUNICATIONS .. 230 MEMBER CALL CENTERS .. 230 MEMBER INQUIRIES .. 233 MEMBER RIGHTS AND PROTECTIONS .. 233 ADVANCED DIRECTIVES .. 234 CULTURAL COMPETENCY .. 234 234 PROTECTING MEMBER FROM LIABILITY FOR PAYMENT .. 235 MEMBER ADVISORY COMMITTEE .. 235 PROTECTION OF CHILDREN AND AGED OR INCAPACITATED ADULTS .. 236 PROTECTION OF MEMBER-PROVIDER COMMUNICATIONS .. 236 MEMBER COMMUNICATIONS AND ENROLLMENT MATERIALS .. 237 MARKETING REQUIREMENTS .. 242 PROHIBITED MARKETING AND OUTREACH ACTIVITIES.

9 246 SECTION PROVIDER SERVICES AND CLAIMS PAYMENT .. 248 PROVIDER CALL CENTER .. 248 PROVIDER TECHNICAL ASSISTANCE .. 250 PROVIDER EDUCATION .. 250 PROVIDER PAYMENT SYSTEM .. 252 INCREASED PAYMENTS TO ENSURE ACCESS .. 262 SECTION VALUE BASED PAYMENTS .. 264 264 CONTRACTOR VBP PLAN .. 264 VBP STATUS 265 CONTRACTOR HCP-LAN APM DATA COLLECTION SUBMISSION .. 265 DMAS APPROVAL OF VBP FOR CERTAIN SERVICES .. 266 SECTION PROGRAM INTEGRITY (PI) AND OVERSIGHT .. 267 5 GENERAL PRINCIPLES .. 267 PROGRAM INTEGRITY PLAN, POLICIES, & PROCEDURES .. 267 COMPLIANCE OFFICER .. 272 PROGRAM INTEGRITY LEAD .. 272 TRAINING AND EDUCATION .. 272 EFFECTIVE LINES OF COMMUNICATION BETWEEN CONTRACTOR STAFF.

10 272 ENFORCEMENT OF STANDARDS THROUGH WELL-PUBLICIZED DISCIPLINARY GUIDELINES .. 273 DEVELOPMENT OF CORRECTIVE ACTION INITIATIVES .. 273 REPORTING AND INVESTIGATING SUSPECTED FRAUD AND ABUSE TO THE DEPARTMENT .. 273 QUARTERLY FRAUD/WASTE/ABUSE REPORT .. 274 COOPERATION WITH STATE AND FEDERAL INVESTIGATIONS .. 275 MEDICAID FRAUD CONTROL UNIT (MFCU) .. 275 MINIMUM AUDIT REQUIREMENTS .. 275 PROVIDER AUDITS, OVERPAYMENTS, AND RECOVERIES .. 275 SECTION MEMBER AND PROVIDER GRIEVANCES AND APPEALS .. 278 GENERAL REQUIREMENTS .. 278 GRIEVANCES .. 279 GENERAL APPEALS REQUIREMENTS .. 280 MEMBER APPEALS .. 280 PROVIDER APPEALS .. 286 EVALUATION OF GRIEVANCES AND APPEALS .. 291 GRIEVANCE AND APPEAL REPORTING.