TEXT Version of PowerPoint Slide Presentation titled
Network Assessments and Monitoring
Presented by
Sarah C. Brooks and Nathan Nau
California Department of Health Care Services
Medi-Cal Managed Care Division
Program Monitoring and medical Policy Branch
and
Nancy Pheng Street
California Department of Managed Health Care
Office of Plan Licensing
on September 11, 2014
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Presentation Overview
1.	Overview of Network Review Components
-	DHCS Medical Audits
-	DMHC Routine Medical Surveys
-	DHCS and DMHC Interagency Agreements (IA)
-	DHCS and DMHC Audit and Survey Coordination
-	Non-Routine Audits and Surveys
-	Corrective Action Plans
-	Other Monitoring Indicators
2.	Network Adequacy Standards
3.	Plan Monitoring and Evaluation
4.	Work in Progress and Future Endeavors
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Component 1: DHCS Medical Audits
-	Performed by the Audits and Investigations Division, Medical Review Branch
-	Welfare and Institutions Code Section 14456
-	Audits will be annual beginning in 2015
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DHCS Medical Audit Categories:
Administrative and Organizational Capacity
Utilization Management
Case Management and Coordination of Care
Access and Availability of Care
Members Rights Quality Management
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Component 2: DMHC Medical Surveys
-	Performed by the Department of Managed Health Care (DMHC)
-	Knox-Keene Health Care Service Plan Act
-	Conducted at least every three years
-	Link to DMHC Medical Survey reports:  http://www.dmhc.ca.gov/LicensingandReporting/MedicalSurveys/SearchViewMedicalSurveyReports.aspx
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DMHC Medical Survey Categories
Overall plan performance in meeting enrollees’ health care needs
Quality Management
Grievances and Appeals (member complaints) 
Access and Availability
Utilization Management (referrals and authorizations)
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Component 3: DHCS/DMHC Interagency Agreements (IA)
Monitors the following transitions: Seniors and Persons with Disabilities (SPDs); Optional Targeted Low Income Children; Rural Expansion; Cal MediConnect
Each IA has three components: Financial Audit; Network Adequacy Assessments; Medical Survey
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Component 4: Audit and Survey Coordination
-	DHCS and DMHC have a joint audit schedule to coordinate DMHC Knox Keene and IA surveys and DHCS medical audits.
-	Both auditing teams are on-site concurrently.
-	Findings for the DMHC IA surveys and DHCS medical audits are consolidated during the Corrective Action Plan (CAP) process.
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Component 5: Non-Routine Audits and Surveys
-	DHCS and DMHC can also audit and/or survey a plan outside of the normal schedule for any reason.
-	Conducted two times in 2014:  CalOptima; Alameda Alliance
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Component 6: Corrective Action Plans (CAPs)
-	DHCS Medi-Cal Managed Care Division, Plan Monitoring Unit, administers CAPs for:
DHCS Medical Audits
Interagency Agreement Surveys
Other non-scheduled audits or surveys
-	A CAP response is required to be submitted to DHCS within 30 days of notification if any findings are present.
-	DMHC also administers CAPs for routine medical surveys.
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Component 7: Other Monitoring Indicators
1.	Quarterly Grievances and Appeals Reports
2.	Quarterly Reports
-	Medi-Cal Office of the Ombudsman Call Statistics
-	State Fair Hearings
-	DMHC Help Center Data
3.	Internal Quarterly Plan Management Meetings
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Component 7: Other Monitoring Indicators (cont’d.)
4.	Transition Data Submission Requirements
-	Population-specific reporting for Seniors and Persons with Disabilities (SPDs), Optional Targeted Low Income Children (OTLIC), Rural Expansion, Low Income Health Plan (LIHP), and Cal MediConnect:
-	Grievance Report
-	Continuity of Care Report
-	Provider Network Additions and Deletions
-	PCP Assignment and Changes (Rural Expansion) 
-	Consumer Satisfaction (Rural Expansion) 
-	Fraud and Abuse (Rural Expansion) 
-	Complaints and Resolution Tracking (Cal MediConnect)
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Component 7: Other Monitoring Indicators (cont’d.)
5.	Ongoing Data Submission Requirements
-	Rural Expansion and Optional Targeted Low Income Children (OTLIC):
-	All Member Grievance Report
-	Detailed Provider Network Report
-	Continuity of Care Report
-	Grievance Log
-	Geo Access Report
-	Out of Network Report
-	Network Adequacy Report
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Component 7: Other Monitoring Indicators (Cont’d.)
5.	Ongoing Data Submission Requirements
	-	Seniors and Persons with Disabilities (SPDs):
-	Continuity of Care Report
	-	Risk Stratification and Risk Assessment Data Report
	-	SPD Grievance Report
	-	Detailed Provider Network Report
	-	Grievance Log
	-	Geo Access Report
	-	Out of Network Report
	-	Network Adequacy Report
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Network Access Requirements
In order to have sufficient networks, health plans must:
	1.	Have sufficient providers to serve the enrollees;
	2.	Meet service area needs with the geographic distribution of primary care providers (PCP) and specialists;
	3.	Provide timely access to care.
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Primary Care Physician (PCP) Capacity
Standard:	1 PCP per 2,000 Enrollees
Authority:	Title 28 CCR Rule 1300.51(d)(H)
		Title 22 CCR Section 53853
		DHCS Contract, Exhibit A, Attachment 6 – Provider Network
Plan Monitoring and Evaluation:
Readiness
-	Full network certification submission to DHCS
-	Material Modification filing with DMHC
-	Deliverables submission per DHCS Contract, Exhibit A, Attachment 18 – Implementation Plan and Deliverables
Contract Submission
-	Quarterly Provider Network report
DMHC Medical Survey
Other Monitoring Indicators
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Specialists Capacity
Standard:	1 Specialist per 1,200 Enrollees
Authority:	Title 28 CCR Rule 1300.51(b)(2)(H)
Title 22 CCR Section 53853(a)
Welfare & Institutions Code Section 14182(c)(2)
DHCS Contract, Exhibit A, Attachment 6 – Provider Network
Plan Monitoring and Evaluation:
Readiness
-	Full network certification submission to DHCS
-	Material Modification filing with DMHC
-	Deliverables submission per DHCS contract, Exhibit A, Attachment 18 – Implementation Plan and Deliverables
Contract Submission
-	Quarterly Provider Network report
DHCS Medical Audit
DMHC Medical Survey
Other Monitoring Indicators
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Time and Distance Access
Standard:	15 miles/30 minutes (Title 28)
		10 miles/30 minutes (DHCS Contract)
Authority:	Title 28 CCR Rule 1300.51(d)(H)
		DHCS Contract, Exhibit A, Attachment 6 – Provider Network
Plan Monitoring and Evaluation:
		Readiness
-	Geo Access maps evaluation
Contract Submission
-	Quarterly Provider Network report
DHCS Medical Audit
DMHC Medical Survey
Other Monitoring Indicators
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Timely Access
Appointment Type
Urgent care appointments that do not require prior authorization: Standard 48 hours
Urgent care appointment that do require prior authorization: Standard 96 hours
Non-urgent primary care appointments: Standard 10 business days
Non-urgent Specialist: Standard 15 business days
Non-urgent Mental health provider (non-physician): Standard 10 business days
Non-urgent appointment for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: Standard 15 business days
Telephone Wait Times During Normal Business Hours: No more than 10 minutes
Telephone Wait Times for Triage – 24/7 services: 24/7 services; Call back time of no more than 30 minutes
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Timely Access (cont’d.)
Authority:	Title 28 CCR Section 1300.67.2.2
		DHCS Contract, Exhibit A, Attachment 9 – Access and Availability
Plan Monitoring and Evaluation:
		DHCS Medical Audit
Other Monitoring Indicators
-	Grievances data
-	Call Center Reports data
CAHPS Survey results
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Work in Progress and Future Endeavors
September 2014:
-	DHCS/DMHC joint response for network findings
-	Revised reporting requirement for Grievances & Appeals and Call Center reports that will track data at the beneficiary level
-	DHCS Timely Access Verification Studies – Cal Optima pilot
December 2014:
-	New Network Adequacy/Monitoring Unit in the Medi-Cal Managed Care Division
Ongoing:
-	Provide technical assistance
-	Continue stakeholders/workgroup engagement
-	Enhance Medi-Cal Managed Care Performance Dashboard
-	Use encounter data to monitor networks and utilization
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Closing Slide-Logo of Department of Health Care Services
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