NCQA Comments on HCBS Access Rule

July 3, 2023

Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Ave. SW
Washington, DC 20201

Attention: CMS-2442-P

Dear Administrator Brooks-LaSure:

The National Committee for Quality Assurance (NCQA) appreciates the opportunity to provide feedback on the proposed rule for “Ensuring Access to Medicaid Services.”

NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation and measurement programs. We are a national leader in quality oversight and a pioneer in digital quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate the challenges associated with transitioning to a digital future. Our mission is to improve the quality of health for all Americans, with an intentional focus on health equity and support for meaningful value-based payment models.

We applaud CMS’s efforts to improve access to care, quality and health outcomes while addressing Medicaid’s health equity issues across FFS, managed care delivery and HCBS programs. We support CMS’s proposal to standardize requirements across these programs, which will allow better comparison of care rendered.

NCQA recognizes that the population receiving HCBS frequently comprises the most vulnerable, high-need, high-cost individuals served by state Medicaid programs. NCQA’s suite of LTSS programs and measures are a tool for states to create standardization, reduce the burden of oversight on state staff and keep individuals in their preferred setting of care. Our standards not only set a quality bar for organizations, they also go beyond some proposed federal requirements.

Summary of NCQA Comments

• State partners managing HCBS programs should leverage NCQA’s LTSS programs and measures to meet federal requirements.
• CMS should continue to incorporate NCQA HEDIS measures in the HCBS Quality Measure Set and drive states to develop benchmarks and improvement plans to assess quality of care.

Leveraging NCQA’s LTSS Programs and Measures to Meet Federal Requirements

Enhancing Medical Care Advisory Committees. We support CMS’s proposed updates to provide specificity for Medical Care Advisory Committees. Including the member’s voice in policymaking is vital to a health coverage program that meets member needs. It is especially important to recognize and ensure that diverse voices are accurately represented on committees. This aligns with NCQA’s commitment to internal evaluation of culture to address issues of diversity, equity and inclusion.

Comprehensive approach to HCBS. We acknowledge CMS’s work to develop broader support of HCBS and advance person-centered care. NCQA’s programs reinforce expectations for plans and community providers to use an integrated model for providing services to members. NCQA continues to work with states on adoption of programs that align with many proposed changes in the rule.

Elevating the importance of person-centered service plans. The proposed rule introduces crucial enhancements to the assessment process, which will help safeguard keeping people in their preferred setting and will reduce unplanned care transitions. Core criteria in NCQA’s LTSS programs implement rigorous standards to ensure that comprehensive assessments are performed to improve the quality of whole-person centered care. Our standards require health plans and community organizations to conduct person-centered care planning and goal development, which includes the following assessments:

1. Health status, including condition-specific issues.
2. Clinical history, including medications.
3. Activities of daily living, including use of supports.
4. Instrumental activities of daily living, including use of supports.
5. Behavioral health status.
6. Cognitive functioning.
7. Social needs.
8. Social functioning.
9. Health beliefs and behaviors.
10.    Cultural and linguistic needs, preferences or limitations.
11.    Visual and hearing needs, preferences or limitations.
12.    Physical environment for risk.

NCQA recognizes the value of reassessing accuracy of the service plan to validate that individuals receive the appropriate level of care and does so through multiple avenues in our LTSS programs:

• Reducing unplanned transitions: NCQA requires MCOs to monitor their members, to identify individuals who might be susceptible to unplanned care transitions. MCOs are required to take measures to minimize risks, which may entail reassessing the service plan (LTSS 3, Element B: Reducing Unplanned Transitions for Members).
• Service authorizations: Beginning in July 2024, MCOs achieving LTSS Distinction will be required to describe their process for authorizing and denying initial/additional service requests. This information will inform the service plan and incorporate a reassessment process (LTSS 1, Element B: Service Authorizations). MCOs will also be required to notify members about service denials in language that is easy to understand, and to reference the criterion on which the denial was based and how the care plan informed the decision.
• Performance measurement: These HEDIS LTSS measures validate that health plans conduct reassessments promptly and comprehensively, facilitating creation of an appropriate service plan:
  • LTSS Comprehensive Assessment and Update (LTSS-CAU) looks for assessment of new members in 90 days and assessment of established members within the measurement year.
  • LTSS Reassessment/Care Plan Update After Discharge (LTSS-RAC) determines whether an entity reassesses and updates the care plan following discharge from a facility.

Increased rigor for grievance systems. NCQA supports CMS’s proposal to establish grievance procedures for members receiving HCBS, regardless of delivery system. We strongly advocate for a “no wrong door” approach for filing grievances, and we recommend CMS take steps to ensure that the burden does not fall solely on Area Agencies on Aging and community organizations, whose resources are already limited. We want to highlight that community organizations Accredited under our Accreditation of Case Management for LTSS (CM-LTSS) program are already required to have a formal complaint structure for timely recording, investigating, triaging and notifying individuals of complaint resolution (CM-LTSS 7, Element D: Handling Complaints from Individuals). States can leverage our program to validate that community organizations have a standardized process for handling complaints. States can also explore aggregating these data to study trends in grievances.

Strengthening incident management systems. NCQA supports CMS’s proposal to strengthen incident management systems as a safeguard for members. The proposal to standardize requirements regarding incidents that may put members at risk closely aligns with NCQA’s standards in our LTSS Distinction program. We require organizations to define critical incidents; identify responsibility, follow–up and action for critical incidents; and track critical incidents, investigations and intervention (LTSS 1, Element L: Critical Incident Management Systems).

Reporting on the HCBS Quality Measure Set

The proposed rule accurately points out inconsistencies across and within services with regard to expectations for quality measurement and reporting. NCQA strives to reduce the burden of quality reporting by ensuring that the measures in our standards-based programs apply to the quality framework of that program. Organizations pursuing LTSS Distinction for Health Plan Accreditation may submit performance results for certain HEDIS LTSS measures, instead of a documented process or file review, streamlining compliance efforts:

• LTSS-CAU Measure: MCOs may submit performance results for the LTSS-CAU measure in place of file review to meet the Comprehensive Assessment Implementation standard in LTSS Distinction (LTSS 1, Element H: Comprehensive Assessment Implementation).
• LTSS-CPU Measure: MCOs may submit performance results for LTSS-CPU in place of file review (LTSS 1, Element G: Implementing the Care Planning Process).
• LTSS-RAC Measure: MCOs may submit performance results for LTSS-RAC in place of policies and procedures (LTSS 3, Element A: Process for Transitions of Care).

NCQA is sensitive to the burden on state Medicaid agencies regarding quality measurement, and we understand the proposal to require biennial reporting on the HCBS Quality Measure Set. We note that MCOs have the capacity to report HEDIS LTSS measures annually, allowing more frequent performance updates. We recommend including our new Person-Centered Outcomes Measures: Goal Identification, Goal Follow-Up, Goal Progress or Achievement. We welcome the opportunity to engage in discussions with CMS on updating the HCBS Quality Measure Set to include measures that call for a person-centered approach to assessment of care quality for this population.

HCBS Quality Measure Set. The HCBS Quality Measure Set proposed in 2022 included three NCQA HEDIS measures, including LTSS-specific measures. NCQA continues to strive to publicly report HEDIS LTSS measure rates and benchmarks, which we know are of interest to states using these measures. We have retired Flu Vaccination measure included in the HCBS Quality Measure Set, and we welcome the opportunity to explore an alternative measure for inclusion.

We support CMS’s drive to improve health equity, and the proposal to stratify reporting of HCBS Quality Measure Set data. NCQA is currently analyzing our first year of stratified data, and we look forward to discussing stratification across a variety of measures. We are closely examining potential challenges associated with stratifying small numbers, focusing on ensuring data usability. Although there are challenges, we support CMS’s phased-in approach on stratification to ensure ongoing movement to support addressing disparities over the long term. NCQA continues to support states and organizations in sharing best practices for collecting and stratifying data:

• Race and Ethnicity Stratification Learning Network Home Page and Data Learning Network Summary Report: The Race and Ethnicity Stratification Learning Network was created to provide insights into health care organizations’ ability to report on five stratified HEDIS measures, and to answer key questions about collection and use of race and ethnicity data for quality improvement purposes.
• Advancing Health Equity: A Recommended Measurement Framework for Accountability in Medicaid: Provides considerations about the importance of equity measurement in HCBS.

Thank you again for the opportunity to comment. We welcome the chance to discuss our experience and findings, and we remain committed to working with CMS to build a more equitable, sustainable and responsible American health care system. If you have any questions, please contact Kristine Toppe, Assistant Vice President of State Affairs, at (202) 955-1744 or at toppe@ncqa.org; Amy Maciejowski, Senior Program Manager of State Affairs, at maciejowski@ncqa.org; or Lindsey Lozoskie, Analyst, State Affairs, at llozoskie@ncqa.org.

Sincerely,

Margaret E. O’Kane
President
National Committee for Quality Assurance

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