Att K SOW.docx

Indiana External Quality Review Organization (EQRO) Statement of Work Table of Contents

Executive Summary The Office of Medicaid Policy and Planning is required by the Center for Medicare & Medicaid Services (CMS) to contract with a qualified External Quality Review Organization (EQRO) to conduct all CMS required External Quality Review (EQR) activities and supporting items as described in this Statement of Work.

Background and Current State Introduction/Intent The Family and Social Services Administration (FSSA) is required by federal law to perform annual performance reviews of its health care programs Hoosier Healthwise (HHW), Healthy Indiana Plan (HIP), Hoosier Care Connect (HCC), and Indiana PathWays for Aging Program (PathWays). One such performance review is an External Quality Review (EQR) of contracted Managed Care Organizations (MCOs) for HHW, HIP, HCC, and PathWays.

The Contractor must perform the EQR activities as outlined in 42 CFR § 438.358 and 42 CFR § 438.360 for the Indiana Medicaid managed care programs. Specifically, the Contractor will be required to:

· Develop evaluation methodologies for the EQR activities;

· Perform data collection and analysis;

· Prepare reports presenting evaluation findings and recommendations; and

· Provide technical assistance to FSSA and its contracted MCOs.

The Contractor must complete the deliverables and requirements in accordance with the frequencies and specifications in this Contract so that the State maintains compliance with federal requirements and assures adequate oversight of Indiana’s Medicaid managed care delivery system.

The services to be provided include multiple tasks and deliverables that are consistent with applicable federal EQR regulations and protocols for MCOs.

The Contractor must have the designation as, or subcontract with, a qualified organization that is a National Committee for Quality Assurance (NCQA) certified Healthcare Effectiveness Data and Information Set (HEDIS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Vendor.

The Contractor must have assigned staff who are, or subcontract with a qualified organization that has, NCQA-certified HEDIS Compliance Auditor(s).

Services Provided by the Agency FSSA may review EQR Activity work plans and deliverables, as the State determines is necessary. FSSA will collaborate with the Contractor to provide any reasonable support that is necessary for the execution of this Contract.

Technical Requirements The State has robust and comprehensive security standards that permeate all levels of the organization. The Indiana Office of Technology (IOT) has been tasked with establishing and maintaining these security standards. The security standards include assessing security risks, developing and implementing effective security procedures, and monitoring the effectiveness of those procedures.

The following link introduces the IOT Information Security Framework: https://www.in.gov/iot/iot-vendor-engagement/. Everyone intending to access ISF policies will need to create an Access Indiana account first. Respondents will be required to sign a Non-Disclosure Agreement (NDA) to access the IOT Information Security Framework.

The Contractor must ensure the security and confidentiality of all information and operate in compliance with Indiana IT Policies, Procedures, and Standards. Please seewww.in.gov/iot/policies-procedures-and-standards) for more information. The Contractor must adhere to the State’s standards and establish, maintain, implement and manage the data ownership standards, data security standards, and arbitration protocol. In addition, the Contractor must implement and maintain standards for confirming that only lawfully authorized users are granted access to any systems maintained by the Contractor on behalf of the State and prevent unauthorized access, use, abuse, disclosure, disruption, modification, or destruction of data. All Contractor systems processing State data shall enforce RBAC, MFA, least‑privilege, 1‑day access changes, and 1‑year audit log retention per IOT Identity and Access Management Policy.

In addition to the State standards outlined above, the State requires that the Contractor support all current and future HIPAA Security rules, as well as any applicable federal automated data processing requirements.

The Contractor must ensure security safeguards are in place to assure the integrity of system hardware, software, records, and files. To maintain privacy and security standards, the Contractor must perform the roles and responsibilities listed below, including but not limited to:

· Establishing, maintaining, implementing and managing privacy standards in accordance with State and Federal standards;

· Adhering to FSSA’s Privacy and Security Compliance Policies https://www.in.gov/fssa/security-policies/;

· Mitigating, to the extent practicable, any harmful effect that is known to the Contractor of Protected Health Information (PHI) obtained under this contract in a manner not provided for by this contract or by applicable law of which the Contractor becomes aware;

· Training all staff on the privacy and security requirements;

· Testing security compliance quarterly;

· Applying required changes to security methods that security compliance testing identifies;

· Adhering to role-based access requirements as provided by the State;

· Complying with all confidentiality, security, infrastructure, application, and service solution standards established by the State in this SOW

· Orienting new employees to security policies and procedures;

· Conducting periodic review sessions on security procedures;

· Developing lists of personnel to be contacted in the event of a potential or suspected security breach;

· Maintaining entry logs for limited access areas;

· Maintaining an inventory of Agency assets, not including any financial assets;

· Limiting physical access to systems hardware, software, and libraries; and

· Maintaining confidential and critical materials in limited access, secured areas.

Scope of Work Objectives of Engagement Minimum Requirements The Contractor must meet the federal criteria and qualifications for EQR organizations, including the competence and independence requirements set forth in 42 CFR § 438.354. The Contractor must conduct an annual EQR of the contracted MCOs, in accordance with the Centers for Medicare and Medicaid Services (CMS) EQR protocols for the activities described in Section III.a.ii.

The Contractor must have, at a minimum, the following:

· Demonstrated experience, knowledge and/or skills of:

· Serving Medicaid beneficiaries, handling Medicaid policies, data systems and processes;

· Managed care delivery systems, organizations, and financing;

· Quality assessment and improvement methods;

· Research design and methodology, including statistical analysis;

· Practical or clinical health care experience; and

· Other clinical and non‐clinical skills necessary to carry out EQR or EQR‐related activities and to oversee the work of any Subcontractors.

· The Contractor and its Subcontractors must be independent from the State Medicaid agency and from the MCOs’ entities (described in 42 CFR § 438.310(c)(2)) that they review.

Technical Assistance The Contractor must provide technical assistance to FSSA and all MCOs upon request and approval of FSSA. Any technical assistance provided to an MCO must include an FSSA point of contact; this point of contact must be approved by FSSA. The specific nature of the technical assistance will be defined on a case‐by‐case basis, and must include, but not be limited to, the following items:

· Performance improvement project development and implementation;

· Performance measure support;

· Educational sessions to enhance the use of EQR results;

· Identification of healthcare trends or “best practices” in performance measures or quality improvement activities;

· Providing clinical consultation and/or expertise; and

· Conducting evaluations of healthcare initiatives.

EQR Activity Protocols Overview FSSA requires that the Contractor complete all EQR activities as set forth in 42 CFR § 438.358 for Medicaid and incorporated into separate CHIP regulations through a cross-reference at 42 CFR § 457.1250, which must be conducted on each managed care plan.

The four mandatory EQR activities are as follows:

1. Performance Measurement Validation;

2. Performance Improvement Project (PIP) Validation;

3. A review, conducted within the previous 3-year period, to determine the MCO's compliance with the standards set forth in subpart D; and

4. Network Adequacy Validation (NAV).

The State may also require the Contractor to complete additional EQR activities per 42 CFR § 438.358 and 42 CFR § 457.1250. The seven additional EQR activities are as follows:

1. Encounter data validation;

2. Administration or validation of consumer or provider surveys of quality of care;

3. Calculation of performance measures;

4. Implementation of performance improvement projects;

5. Focus studies on quality of care;

6. Rating of managed care plans (CMS must develop a protocol before this activity can be used by states.); and

7. Assistance with evaluation activities related to quality strategies, state directed payments, and In Lieu of Services or Settings (ILOSs). (CMS must first develop a protocol before this activity can be used by states.).

For every EQR activity required by this Contract, the Contractor must perform all of the following requirements:

· Adhere to the published CMS protocol for the performance of an EQR activity. The State expects the Contractor to build upon past EQRO efforts and use existing EQR resources and data to the maximum extent possible and as requested by FSSA. The Contractor should actively identify and propose improvement opportunities for FSSA’s approval as part of the implementation of an EQR activity. Any modifications to the published CMS protocol must be consistent with the Final Rule (42 CFR § 438.358) and approved by FSSA. The Final Rule states that EQR Mandatory and Optional (referred to as “Additional” in this Contract) Activities are to be conducted in a manner consistent with (as opposed to identical to) published CMS EQR Protocols. This approach is intended to ensure that protocols do not prevent states and their EQRO contractors from using more refined approaches to these activities as they develop. Protocols used by the Contractor must be the most current version published by CMS. The Contractor is expected to operationalize EQR activities on a continuous, year‑round cycle, rather than executing them as a single, annual deliverable. The Contractor must proactively collect, maintain, and refresh all related documents, materials, and data throughout the contract period, and ensure that these artifacts, along with activity status updates, are accessible to the State on at least a quarterly cadence. FSSA reserves the right to request the following items from the Contractor:

· The data the Contractor plans to gather in performance of the EQR Activity;

· The sources of the data the Contractor plans to gather in performance of the EQR Activity;

· The templates and forms the Contractor plans to use to collect the data;

· The activities and steps the Contractor plans to follow to collect the data and how those activities and steps help promote the accuracy, validity and reliability of that data;

· The Contractor’s planned method(s) for validating, analyzing, and interpreting the data once it is obtained;

· A description of the assistance and materials the Contractor anticipates it will need from FSSA to perform the EQR Activity, and when that assistance will be needed;

· A description of the assistance and materials the Contractor anticipates it will need from each MCO to perform the EQR Activity, including, but not limited to, the staff who the Contractor intends to contact or interview, whether the Contractor believes a site visit(s) is required, and the activities that would occur on site; and

· Draft instructions, guidelines, worksheets, and questions for MCOs and other documents or tools that it proposes to use to implement the protocol.

In any case where the Contractor believes a protocol cannot reasonably rely on existing documents, data, reports or other materials, the Contractor must inform FSSA why such materials are inadequate and provide a description of the materials, data, reports or other written documents that it believes are necessary to perform the EQR Activity. If FSSA determines that the protocol cannot reasonably be completed, FSSA will support the Contractor in acquiring the necessary materials, at the sole discretion of FSSA. For all activities under this Contract, the terms “Managed Care Organization” and “MCO” refer to the company providing managed care services and also includes any Indiana Medicaid programs it provides services for (i.e. PathWays, Hoosier Care Connect, Healthy Indiana Plan, and Hoosier Healthwise) unless otherwise stated.

EQR Activity Deliverables The Contractor must complete the following deliverables listed below on a timeline determined by the State:

· For each MCO, develop one (1) MCO-Specific Report Card that breaks out each completed EQR activity and one (1) Summary Report Card that includes all MCOs and EQR activities Statewide. Each time a new EQR activity is complete, the results must be added to the MCO’s report card and summary report card;

· For each MCO, develop one (1) Findings Report that details findings from each completed EQR activity, and includes an executive summary, introduction, summary of findings (which includes, but is not limited to, a minimum of three (3) previous years and an MCO-to-MCO comparison), conclusion, and recommendations for improvement. This report must include both MCO-level and Statewide findings;

· Develop one (1) Summary Report (approximately two‐five (2‐5) pages in length) that summarizes how all MCOs performed in the compliance audit submitted to FSSA and contains narrative summary findings and graphical displays. This report must cover all EQR activities and be submitted annually; and

· Develop one (1) Data Workbook that contains all data utilized by the Contractor for each EQR activity and any associated items. This must be updated on an ongoing basis and shared with FSSA at the end of each EQR year. FSSA reserves the right to request the Data Workbook at any time. The Data Workbook must be in a format approved by FSSA.

FSSA may require additional deliverables for a specific activity which are included in the activity-specific sections in this Contract. The Contractor must work with the State to ensure that all formatting and content meets the State’s needs.

Mandatory EQR Activities Validation of Performance Measures FSSA currently uses MCO self‐reported, State-specified performance measures and audited HEDIS performance measures as components of the Quality Strategy to evaluate MCO performance, monitor MCO compliance with FSSA’s performance standards, meet federal requirements for the mandatory activity of validation of performance measures as specified in 42 CFR § 438.358, and complete a comparative review of quality process and outcome measures based on HEDIS. MCOs employ their own certified HEDIS auditor to complete the data collection and submission of the measures to NCQA and as required in the Medicaid managed care program. The measures must have received a “report” designation from the HEDIS‐certified auditor and must be specific to the Medicaid population under evaluation.

For each MCO, the Contractor must complete the following:

· Review the health plans’ final audit reports to identify any potential data collection or reporting issues that may impact the final audited rates;

· Evaluate the reason any self‐reported measures received an audit designation of “Not Reported” (NR);

· Based on the review of the final audit reports and any NR designations for reported measures, provide a report summarizing the final audit reports. This report must include documentation of any findings that impact FSSA’s evaluation of managed care delivery system performance, determination of the managed care delivery system’s compliance with minimum performance standards, evaluation of performance related to the award of performance incentives, and recommendations to FSSA related to potential corrective actions or quality improvement;

· Develop, maintain, and update FSSA’s specifications documents for health plans’ self‐reported, audited results;

· Validate that the State-specified and HEDIS measures reported by the health plans are consistent with the protocols established by the State and CMS for performance measure validation; and use the results for the evaluation of each MCO’s performance, by line of business, in serving its respective population, as compared to the previous year.

Validation of PIPS FSSA defines quality management as the evaluation and assessment of member care and services to ensure adherence to standards of care and appropriateness of services that can be assessed at a member, provider, or population level. FSSA leadership has directed that continuous quality management be an ongoing, organization‐wide activity aimed at achieving the goals within Indiana’s Quality Strategy and improving member outcomes.

During each Contract Year, each MCO will be required to conduct performance improvement projects (PIP) as outlined in their contract. A PIP is a data-driven initiative focusing on clinical or non-clinical areas designed to achieve significant, sustainable improvement in health outcomes, service delivery, or member satisfaction. Each PIP must include:

· A design to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction;

· Measurement of performance using objective quality indicators;

· Implementation of interventions to achieve improvement in the access to and quality of care;

· An evaluation of the effectiveness of the interventions based on the performance measures collected as part of the PIP; and

· Planning and initiation of activities for increasing or sustaining improvement.

Each PIP will be validated by the Contractor. MCOs must adhere to FSSA improvement project content and format specifications. All FSSA‐specified improvement projects span a minimum of thirty-six (36) months, unless otherwise indicated by FSSA, which includes planning and implementation activities, as well as putting processes in place for sustainability, further testing, and refinement of interventions during the project period.

MCOs must submit the status and results of each improvement project and its individual phases to FSSA and the Contractor on a schedule determined by FSSA. FSSA will work with the Contractor to identify which phases of the PIP must be included in each year’s validation process.

For the validation of each PIP, the Contractor must:

· Provide technical assistance to MCOs in development, implementation, and administration of the FSSA approved PIP(s), following CMS guidance on a Model for Improvement, and focused on an FSSA population stream;

· Develop a standardized tool that incorporates CMS’ PIP protocol with the Model for Improvement and rapid cycle improvement tools, such as process mapping, Pareto charts, run charts, key driver diagrams, the Plan Do Study Act (PDSA), and statistical process control methods. The standard tool should establish objective criteria that will be used to document the design, implementation, and outcomes of the PIP;

· Perform an evaluation of any intervention(s) during the project period, specifically on the impact of these interventions and their sustainability long-term. The Contractor must evaluate that the intervention is still sustaining while the intervention is on the MCO workplan for a minimum of three (3) years after the PIP project is completed;

· Using the standardized tool, referenced above, develop a scoring methodology that will be used to determine if the PIPs are valid and to rate the percentage of compliance with CMS’ PIP protocols. The scoring methodology must be in compliance with the External Quality Review Protocols determined by CMS;

· Calculate percentage scores in accordance with the scoring methodology developed;

· Assign a validation status of ‘Met’, ‘Partially Met’, or ‘Not Met’ based on the calculation of an overall percentage score;

· Provide a written assessment and/or technical report of what must be changed for the health plan to achieve a status of ‘Met’;

· The Annual Technical Report should include an assessment of the overall validity and reliability of study results and include any threats to accuracy and/or confidence in reporting; and

· Ensure that the Annual Technical Report includes a description of PIP interventions and outcomes information associated with each State‐required PIP topic for the current EQR review cycle.

Ongoing MCO Compliance Reviews MCOs are required to comply with federal and State program requirements specified in the Code of Federal Regulations, the Indiana Code, the Indiana Administrative Code, FSSA policies and procedures, requirements for each Indiana Medicaid program, future program manuals, guidance and policies and procedures, as well as any amendments thereto.

The Contractor must conduct an assessment, at a frequency and on a cycle determined by the State, of each plan’s compliance with the requirements that are in effect during the time period under review. The Contractor must conduct each of the following:

· A comprehensive review of each MCO’s compliance with federal regulations described in 42 CFR § 438, submitted every three (3) years. The Contractor may be required to conduct partial reviews annually, as determined by FSSA; and

· Targeted reviews must be conducted, as follows:

· Case Management desk reviews, conducted quarterly. All MCOs are included in this review; and

· Select additional operational topics (e.g., claims adjudication, non‐emergency transportation, grievances and appeals) at intervals to be determined by FSSA. The number of MCOs subject to a review will vary depending on the topic selected.

Any assessment that the Contractor conducts must include, but is not limited to, a review of the following areas:

· Availability of services;

· Assurance of adequate capacity and services;

· Coordination and continuity of care;

· Coverage and authorization of services;

· Credentialing and recredentialing of services;

· Subcontracted relationships and delegation;

· Enrollee information and enrollee rights;

· Confidentiality of health information;

· Enrollment and disenrollment;

· The grievance and complaint process;

· Practice guidelines;

· Quality assessment and performance improvement program;

· Health information systems; and

· Fraud and abuse.

As part of each assessment, the Contractor must conduct each of the following tasks:

· Identify the topic areas and administrative standards that will be reviewed, in consultation with FSSA;

· Develop an evaluation methodology and standardized data collection tool, in consultation with FSSA, that will be used for each MCO review. This will include, but is not limited to, a review of policies and procedures, staff interviews, and file reviews;

· Conduct desk and on‐site reviews. On-site reviews may be conducted virtually with the approval of FSSA;

· Aggregate and analyze the data and information collected in order to communicate findings of compliance with the administrative standards;

· Prepare MCO‐specific reports of findings, as described in Section III.a.ii.1, that include the completed data collection tool with cited references, as appropriate; and

· Prepare program‐specific reports if needed, as requested by FSSA.

The State recognizes that while this EQR Activity is to be finalized every three years per CMS requirements, the Contractor is required to complete portions of this activity each year and include findings in the Annual Technical Report and deliverables described in Section III.a.ii.1, at the State’s direction.

Network Adequacy and Availability Validation MCOs must ensure access to medically necessary Medicaid covered services and must meet network adequacy requirements as set forth by 42 CFR § 438.68, 42 CFR § 438.206, 42 CFR § 438.207, and 405 IAC 1-1-2. The Contractor will validate these MCO requirements according to CMS protocols, when applicable. Additional requirements may be added related to Network Adequacy Standards when CMS releases new protocols related to 42 CFR § 438.358(b)(1)(iv) and/or there are updates to NCQA or State guidance.

For each Contract Year, the Contractor must validate all Network Adequacy Standards that were in place during the preceding twelve (12) months for each MCO by completing the items listed below. The Contractor may be required to only validate a subset of MCOs or Standards based on direction from FSSA.

· Collaborate with FSSA to obtain the Network Adequacy Standards for each MCO;

· On a timeline determined by FSSA, meet with FSSA to address any preliminary questions about the Network Adequacy Standards;

· Conduct GeoAccess validation and reporting on a quarterly basis and share with the State when requested;

· Validate each MCO meets the defined network adequacy standards for availability and accessibility outlined in terms of the MCO contract and/or the MCO Reporting Manual;

· Determine compliance with federal and State network and access requirements;

· Upon completion of the review, analyze the results and identify areas of compliance and non-compliance. For each MCO, the Contractor must include the MCO findings and results in the Annual Technical Report; and

· Collaborate as needed with the State to develop a provider survey including, survey design, sampling methodologies, and analysis methodologies.

In order to maintain compliance with CMS, the Contractor must conduct Secret Shopper surveys as described in CFR 42 § 438.68. Through these surveys, the Contractor must determine each MCO’s compliance with the provider directory requirements in CFR 42 § 438.10(h) and appointment wait time requirements as specified in 42 CFR § 438.68(f). The Contract must utilize appropriate methodological standards as described in 42 CFR § 438.68(f)(4) and ensure results are reported in compliance with 42 CFR § 438.68(f)(5). Secret Shopper surveys must be conducted on a quarterly basis unless otherwise determined by FSSA.

a. Evaluation of Provider Directory Accuracy MCOs are required to submit provider directory information, in a manner specified by FSSA, to ensure the accuracy of the provider information listed in directories that are used by Medicaid recipients. In accordance with 42 CFR § 438.68(f)(1), the Contractor will evaluate the accuracy of provider directory information submitted by MCOs through secret shopper surveys. This evaluation must include, but is not limited to, the following:

· An audit of online provider directories to validate that the data elements are correct and in compliance with the provider directory requirements in 42 CFR § 438.10(h);

· For the audits described above, the Contractor must assess the accuracy of the information in each MCO's most current electronic provider directories, as described in 42 CFR § 438.68(f)(1); and

· For the audits described above, the Contractor must do the following as approved by FSSA:

· Develop a study methodology that describes the evaluation approach;

· Develop a standardized data collection tool;

· Develop a sampling methodology;

· Collect and analyze data; and

· Prepare a report containing MCO‐specific findings and deliver all raw data to FSSA, as described in Section III.a.ii.1.

Evaluations will be conducted by the Contractor on a quarterly basis, unless otherwise indicated by FSSA.

b. Provider Access Surveys To ensure MCOs’ enrollees are able to appropriately access providers, the Contractor must conduct quarterly telephone surveys among a sample of providers to determine appointment availability information for new and existing enrollees, as described in 42 CFR § 438.68(f)(2).

The Contractor must conduct the following:

· Develop and/or update a study methodology describing the evaluation approach;

· Develop a standardized data collection tool;

· Develop a sampling methodology;

· Collect and analyze data; and

· Prepare a report containing MCO‐specific findings and deliver all raw data to FSSA, as described in Section III.a.ii.1.

Surveys will be conducted by the Contractor on a quarterly basis, unless otherwise indicated by FSSA.

c. Performance Measure Calculation and Reporting The Contractor will be required to calculate, for each MCO, a performance measure that uses results from the secret shopper and telephone surveys, as described in Sections III.a.iii.4.a and III.a.iii.4.b. This must include:

· Developing and updating a measure methodology document with FSSA’s input;

· Recommending a strategy for setting and adjusting a performance standard;

· Producing an annual report of MCO‐specific rates in a format specified by FSSA; and

· Providing technical assistance to each plan in each line of business and FSSA related to the measure.

Additional Required EQR Activities Encounter Data Validation Indiana requires that all MCOs are compliant with the rules and requirements of 42 CFR § 438.242. Specifically, the Contractor must support FSSA in ensuring that each of its MCOs maintain a health information system that collects, analyzes, integrates, and reports data on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollment. The Contractor must review and validate encounter data collected, maintained, and submitted by the MCOs, including encounter data submitted via their subcontracted vendors, to ensure that it is a complete and accurate representation of the services provided to its Medicaid members and report all findings to FSSA. On an annual basis, the Contractor must develop a plan and conduct an encounter data validation (EDV) study in alignment with the most recently published CMS EQR Protocol 5 Validation of Encounter Data Reported by the Medicaid and CHIP managed care plan. The EDV study must utilize a sample of Medicaid encounter data which must include medical and clinical record reviews and may include a review of NCQA’s Baseline Assessment Tool (BAT) findings and/or other sources of data that may be required by Federal CMS rules and guidelines.

The Contractor must complete the following items as part of the annual EDV study:

· Collaborate with FSSA to determine the focus of the study and the specific claim type(s) that the evaluation will target;

· Develop data submission requirements to collect data from MCOs and share with FSSA for approval;

· Conduct preliminary and final file reviews of submitted encounter and claims data from both the State and the MCOs to ensure compliance;

· Produce individual reports for each MCO outlining the findings from the preliminary review;

· Develop and submit to FSSA an aggregate final report that includes Statewide results and the variation in performance across all MCOs, as well as the key findings and recommendations. The report will also include MCO-specific results in an appendix to allow for a more granular analysis. All data must be submitted in a format approved by FSSA;

· Conduct a technical assistance webinar with the MCOs to introduce the EDV study, review the data submission requirements document, and address questions related to data preparation and extraction, at the direction of FSSA;

· Conduct a targeted information systems review to assess ability to promote and maintain high-quality encounter data; and

· Conduct a comparative analysis by comparing FSSA’s professional encounter data against the claims data from the MCOs to assess completeness and accuracy.

Focused Studies on Quality of Care At the request of FSSA, the Contractor must conduct specific focus studies on areas determined by the State. These areas may include, but are not limited to, studies on quality of clinical or non-clinical services, evaluation of peer support services, or other services and programs from a member and/or provider perspective. For any focus study conducted, the Contractor must submit the data spreadsheets utilized, including all sources of data, denominators, numerators and methods of calculation for both the aggregate as well as subsections of each work product (e.g., charts, graphs, tables, etc.). The data and findings from any focus studies must be documented in a report, as described in Section III.a.ii.1, that meets the specifications set forth by the State, but must include, at a minimum, introduction, methodology, findings, conclusions, and recommendations.

Rating of Managed Care Plans Pending final guidance from CMS, the Contractor will assist FSSA with adopting a Medicaid managed care Quality Rating System (QRS) developed by CMS to evaluate and apply a rating to measure the quality of care provided by Indiana Medicaid MCOs. FSSA will utilize the CMS framework, methodology and identified performance measures in accordance with 42 CFR § 438.334 that align with the summary indicators of the qualified health plan QRS developed per 45 CFR § 156.1120. The State reserves the right to add additional performance measures to the QRS to ensure alignment with Indiana’s quality strategy.

Following the issuance of final CMS guidance, technical specifications and protocols determined by the CMS and FSSA, and on a timeline determined by FSSA, the Contractor must:

· Establish a work plan for producing validated data that will be used in the Indiana Medicaid Quality Rating System, considering applicable national requirements from CMS including compliance with new CMS guidelines and innovative approaches used by other state Medicaid programs and/or the health care industry;

· Support as necessary any data collection from MCOs and data submission to CMS as required for QRS performance measures;

· Produce any associated reference materials (e.g., score calculation and data source documentation), as specified and approved by FSSA, on a frequency determined by FSSA;

· Develop and maintain the Indiana Medicaid QRS data compliance technical specifications, which may include methodology documents, and revise annually to ensure alignment with CMS in collaboration with FSSA;

· Integrate new measures as CMS and industry measurement sets evolve with approval from FSSA;

· Modify and enhance the MCO Quality Rating System as specified by FSSA in response to and in alignment with the with the State’s changing business requirements (e.g., State branding, changes in federal regulations, revisions to the Contracts between the State and the MCOs) and/or changes to report card measure specifications;

· Modify and/or enhance the QRS tools (e.g., analytics, reporting, and/or reference materials) as needed, to align with FSSA’s changing business requirements;

· Provide assistance to the MCOs on how to read, interpret, and use the system as part of a performance improvement strategy; and

· Produce and evaluate the electronic QRS scores and produce both individual MCO and summary results, as described in Section III.a.ii.1.

Assistance with Evaluation Activities Related to Quality Strategies The Contractor must assist FSSA in evaluating the effectiveness of the Indiana Medicaid Quality Strategy. The Contractor must, in consultation with FSSA, develop an evaluation methodology and tools required to evaluate the effectiveness of the Medicaid managed care Quality Strategy as required by 42 CFR § 438 Subpart E, that may be refined on an annual basis to reflect lessons learned from the prior year’s evaluation.

The Contractor will conduct the evaluation and prepare a written report of review findings to be submitted to FSSA within thirty (30) calendar days after completion of the evaluation.

Other Scope Requirements In addition to the mandatory and additional EQR activities set forth in 42 CFR § 438.358 and 42 CFR § 457.1250, there are other requirements for this Statement of Work that must also be conducted on each MCO, as directed by the State.

Information Systems Capability Assessments (ISCA) An Information Systems Capability Assessment (ISCA) is an assessment of the desired capabilities and strength of an MCO’s Information System (IS) through standard questions. An ISCA provides information to an EQRO regarding the extent to which the IS operated by the MCO is capable of producing valid encounter data, Performance Measures (PM), and other data necessary to support quality assessment and improvement, as well as managing care delivered to its members.

An ISCA is a mandatory component of the EQR as part of CMS Protocols 1, 2, 3, 4, and 5. In accordance with 42 CFR § 438.350(e) and 42 CFR § 457.1250(a), the Contractor must obtain information from the MCOs through methods consistent with these EQR protocols. This standard applies to both the mandatory EQR-related activities and to any additional EQR-related activities the State elects to apply to its MCOs.

The Contractor must conduct ISCAs, on a timeline approved by FSSA, to evaluate the desired capabilities and strength of an MCO’s IS. 42 CFR § 438.242 requires the State to ensure each MCO maintains a Health IS that collects, analyzes, integrates, and reports data for areas including, but not limited to, utilization, grievances and appeals, and disenrollment for reasons other than loss of Medicaid eligibility. The IS maintained by MCOs is expected to achieve the following:

· Collect data on members and provider characteristics, and on services furnished to enrollees through an encounter data system;

· Ensure data received from providers is accurate and complete; and

· Make all collected data available to the State and CMS upon request.

As described in Section V.a.i, the Contractor must include an ISCA specific workplan that describes how the Contractor will:

· Develop an understanding of State requirements;

· Prepare MCOs for onsite activities;

· Conduct an assessment or review of results of prior assessments of MCOs’ IS;

· Review and assess MCOs’ procedures for collecting and integrating data;

· Evaluate MCOs’ processes to produce PMs;

· Evaluate MCOs' processes for State reporting;

· Produce required reports for State; and

· Conduct necessary follow-ups with MCOs.

The Contractor must conduct ISCA activities consistent with applicable CMS EQR Protocols and timeframes set forth in 42 CFR § 438.358. ISCA activities must include, at a minimum:

· Collection of standardized information included in the Information Systems Capabilities Assessment Tool (ISCAT) about each MCO’s IS;

· Gather additional information to assess the integrity of information in the ISCA; and

· A review of initial ISCA findings involving interactive sessions with MCO staff to validate information on the MCO’s IS.

The Contractor must prepare an ISCA report that includes, at a minimum:

· Identification of EQR activity scope, purpose, objectives and intended use;

· Data collection methodology and survey instrument(s);

· Sampling plan and strategies to maximize response rate;

· Methodology used in developing scoring criteria;

· Quality assurance plan and process to resolve disputes;

· Communication plan and methodology;

· Methodology used to gather, assess, and validate information;

· Audit findings and recommendations for quality improvement;

· Assessment of the degree to which each MCO has effectively addressed recommendations for quality improvement made by EQRO during previous EQR; and

· Technical assistance provided to MCOs.

FSSA reserves the right to request additions and/or alterations to the report, and the Contractor must address any requests on a timeline determined by the State.

Workshops and Training Classes The Contractor must provide quality improvement education to MCOs and FSSA to support system-wide quality improvement and FSSA quality initiatives. As described in Section III.a.i.1, the Contractor will provide technical assistance at the direction of the State. The Contractor will provide in-person or virtual, as determined by the State, educational quality forums to keep key stakeholders informed and involved in quality initiatives. The in-person quality forums events must be held annually in a location determined by the State. The location and catering must be approved by FSSA and accommodate MCOs, stakeholders and FSSA staff.

The Contractor must complete the following items in advance of the Contractor’s facilitation of quality improvement education:

· Develop a plan to elicit input from MCOs and other stakeholders about their educational needs and how this information will be used to develop the educational meetings;

· Lead agenda preparation, topic selection, and speaker arrangement, with consultation and approval from FSSA to inform this work; and

· Submit written materials intended for MCO communication or education activities to FSSA for approval in advance of distribution to stakeholders.

Case Management Performance Evaluation On an annual basis, the Contractor must compile MCO reporting of data on case management services provided by the MCOs and conduct analysis of the MCOs case management services to determine, at a minimum, the number of individuals, the types of conditions, and the impact that case management services have on members receiving those services. The Contractor must verify the MCO’s case management performance is in compliance with 42 CFR § 438.208, 42 CFR § 441.18, and PHM 5: Complex Case Management.

To complete the case management services analysis, the Contractor must:

· Facilitate the annual collection and validation of data submitted by MCOs regarding case management services;

· Evaluate the MCO’s compliance with the case management provisions of its Contract with FSSA;

· Evaluate the rates of engagement in case management, the specific services offered to enrollees receiving case management, and the effectiveness of case management in terms of increasing the quality of care, increasing the receipt of necessary services, and reducing the receipt of potentially unnecessary services such as acute care;

· Develop a draft report of its results and findings. The Contractor must collaborate with FSSA to determine the strategy, approach, timing, and report format; and

· Participate with FSSA in an annual, formal webinar or in‐person meeting with the MCOs to review results from the case management data, identify opportunities for improvement, and determine efficient application of case management services to positively impact outcomes.

The Contractor must produce an annual report on the findings of the case management analysis. The report must include an introduction, methodology, an MCO-to-MCO comparison of outcomes, general findings, conclusions and recommendations in a format approved by FSSA.

MCO Readiness Review At the State’s discretion, the Contractor may be required to participate in Readiness Reviews focused on elements related to EQR. This may include, but is not limited to, evaluating each prospective MCO’s compliance with MCO requirements related to EQR and providing supporting review and development of other Readiness Review material related to EQR.

MCO Corrective Action Plans If the Contractor determines that an MCO has not completed an EQR activity in accordance with the CMS requirements for that activity, the Contractor will apply a Corrective Action Plan (CAP), at FSSA’s discretion, to the MCO. FSSA must approve and audit all CAPs.

If appropriate, the Contractor will provide a CAP for the MCO to address. The CAP must include the following:

· Documentation that shows the failure to meet expectations;

· A description of the impacts of the failure and the measures being taken and/or the recommendations to remedy the deficiency; and

· Timeline for completion of the CAP and responsible parties, including if it is a permanent or temporary solution.

During the CAP process, the Contractor must do the following:

· Work with the MCO to remediate the CAP until all items have been satisfied;

· Provide a status update on the CAP to FSSA for review at the completion of the CAP, during weekly update meetings, and whenever requested; and

· Ensure that CAP items are reviewed, specifically during the annual EQR, and documented in the annual technical report.

Ad-Hoc In addition to the ad-hoc reports as described in Section IV.e.1, FSSA may require that the Contractor conduct additional EQR-related projects that it deems necessary to support EQR activities or EQR processes. FSSA will work with the Contractor to determine the urgency, timeline, and parameters of any ad-hoc items.

External Quality Review Annual Technical Report The Contractor must produce a detailed annual technical report to ensure FSSA’s compliance with 42 CFR § 438.364 and ensure that a finalized annual technical report is submitted to CMS by April 30th of each year. The Contractor must electronically submit annual technical reports to FSSA after the completion of the annual review of each Medicaid MCO and it must be submitted on a timeline determined by the State, but no later than March 1st of each calendar year, prior to the CMS deadline of April 30th. The Contractor must provide all data utilized for the annual technical report to FSSA in an Excel format approved by FSSA.

The most recent report can be viewed on the following website: https://www.in.gov/fssa/ompp/files/OMPP_Technical_Report_2025_PW.pdf The Contractor must produce a detailed annual technical report that includes the following components:

· An Executive Summary that provides a high-level summary that includes key findings and recommendations and includes supporting visuals and/or dashboards;

· A description of the manner in which the data from all EQR activities conducted in accordance with 42 CFR § 438.358 were aggregated and analyzed, and conclusions that were drawn with regard to the quality, timeliness and access to health care services furnished to health plans’ members;

· A description of the objectives, technical methods of data collection and analysis, data obtained (including validated performance data for each activity conducted in accordance with 42 CFR § 438.358(b) and (c)), conclusions that were drawn from the data for each activity included in the report, and problems encountered in performing the review;

· An assessment of each MCO’s strengths and weaknesses for the quality, timeliness and access to health care services furnished to Medicaid managed care members and recommendations for improving the quality of services furnished by each MCO, including how the State can target goals and objects in the quality strategy to better support improvement in the quality, timeliness, and access to health care services furnished to Medicaid managed care members. This assessment must also include a comparison of each MCO against the other MCOs in both narrative and visual formats. The Contractor must include tables, matrices, or other visuals that map the findings for each MCO and summarizes all MCOs;

· Methodologically appropriate, comparative information about all MCOs operating within Indiana, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR § 438.352(e);

· An assessment of the degree to which a MCO has effectively addressed recommendations for quality improvement made by the EQRO during the previous year’s EQR;

· A review of the current MCO market and identification of any MCOs leaving the market. As part of this review, the Contractor must identify how the MCO met/did not meet the goals of the National and State Quality Strategies, the performance of the MCO compared to the other MCOs, process of the MCO leaving the market, and continuity of care for the member during the transition between MCOs, which should include insight on the Quality of Care and provider adequacy. This review must include a detailed narrative description of the required items and graphics and/or visuals to support the findings;

· An assessment of the degree to which Indiana’s quality strategy goals have been achieved and how EQR findings may impact quality strategy goals in the future;

· Recommendations for MCOs and the State must be actionable and measurable and include the Contractor’s suggested prioritization and any supporting data; and

· A legislative summary that can be shared with the legislators and other stakeholders as a standalone document.

FSSA may not…