                                 CODE OF VIRGINIA

REPORTS RELATED TO LONG-TERM SERVICES AND SUPPORTS (§ 32.1-330.01)

A. The Department shall (i) develop a program for the training and certification
of individuals who perform long-term services and supports screenings for
community and institutional long-term services and supports provided in
accordance with the state plan for medical assistance services and ensure that
all screeners are trained on and certified in the use of the long-term services
and supports screening tool for long-term services and supports screening, (ii)
develop guidelines for a standardized long-term services and supports screening
process for community and institutional long-term services and supports provided
in accordance with the state plan for medical assistance services and ensure
that all long-term services and supports screenings are performed in accordance
with such guidelines, (iii) establish and monitor performance according to
established standards, and (iv) strengthen oversight of the long-term services
and supports screening process for community and institutional long-term
services and supports to ensure that problems are identified and addressed
promptly.

B. The Department shall require managed care organizations that provide managed
long-term services and supports in the Commonwealth to develop the portion of
the plan of care addressing the type and amount of long-term services and
supports for each recipient. For recipients of long-term services and supports,
the managed care organization shall participate in and collaborate with the
existing interdisciplinary care team planning process already established
pursuant to federal law and regulations in the development of the care plan.

C. The Department shall work with its actuary to (i) ensure that trends are
consistent with Actuarial Standards of Practice, including consideration of
negative historical trends in medical spending by managed care organizations to
be carried forward when setting capitation rates paid to managed care
organizations through the managed care program where appropriate, and (ii)
annually rebase administrative expenses per member per month for projected
enrollment changes and future program changes impacting administrative costs
beginning in Fiscal Year 2019.

D. The Department shall include additional financial and utilization reporting
requirements in contracts with managed care organizations and the Managed Care
Technical Manual, including requirements for submission of (i) income statements
that show medical services expenditures by service category, (ii) statements of
revenues and expenses, (iii) information about related party transactions, and
(iv) information about service utilization metrics, and shall monitor data
submitted by managed care organizations to identify undesirable trends in
spending and service utilization and work with managed care organizations to
address such trends.

E. The Department shall (i) establish a compliance enforcement review process
and apply consistent and uniform compliance standards in accordance with the
Managed Care Technical Manual, managed care contracts, and federal standards;
(ii) return all compliance feedback to managed care organizations within the
same reporting or auditing period in which such reports were generated; (iii)
review the reasons for which the Commonwealth will mitigate or waive sanctions
imposed on managed care organizations that fail to fulfill contract requirements
and review and consider infractions due to unforeseen circumstances beyond the
managed care organization&#8217;s control, infractions occurring during the
first year of the managed care organization&#8217;s operation, infractions
occurring for the first time, and infractions that are self-reported by the
managed care organization; (iv) when applicable, include guidance in the Managed
Care Technical Manual for managed care organizations that state the reasons for
which sanctions may be mitigated or waived; (v) include information about the
number of sanctions mitigated or waived and the reasons for such mitigation or
waiver in its monthly compliance reports; and (vi) annually review the results
of its contract compliance enforcement action process and include information
about the process and results, including the percentage of points and fines
mitigated or waived and the reasons for mitigating them for each managed care
organization, in its annual report.

F. The Department shall (i) incrementally increase the amount of performance
incentive awards granted to managed care organizations that meet certain
performance goals to create a stronger incentive for managed care organizations
to improve performance and (ii) retain at least one metric related to chronic
conditions in the performance incentive award program.

G. The Department shall work collaboratively with managed care organizations and
relevant stakeholders, where appropriate, to annually publish a uniform and
agreed-upon managed care organization report card for the Department for the
managed care program and shall make such information available to new enrollees
as part of the enrollment process.

H. Upon the inclusion of behavioral health services in the managed care program
and implementation of managed long-term services and supports, the Department
shall require all managed care organizations participating in the managed care
program to provide to the Department information about (i) the managed care
organization&#8217;s policies and processes for identifying behavioral health
providers who provide services deemed to be inappropriate to meet the behavioral
health needs of the individual receiving services and (ii) the number of such
providers that are disenrolled from the managed care provider&#8217;s provider
network.

I. The Department shall develop a process that allows managed care organizations
providing services through the managed care program to determine utilization
control measures for services provided but includes monitoring of the impact of
utilization controls on utilization rates and spending to assess the
effectiveness of each managed care organization&#8217;s utilization control
measures.

J. The Department shall include language in contracts for managed care long-term
services and supports requiring managed care organizations providing services
through the managed care program to develop a plan that includes (i) a
standardized process to determine the capacity of individuals receiving services
to self-direct services received, (ii) criteria for determining when a person
receiving services is no longer able to self-direct services received, and (iii)
the roles and responsibilities of service facilitators, including requirements
to regularly verify that appropriate services are provided.

K. Following inclusion of managed long-term services and supports in the managed
care program, the Department shall (i) review information about utilization and
spending on long-term services and supports provided by managed care
organizations and work with managed care organizations to make necessary changes
to managed care organizations&#8217; prior authorization and quality management
review processes when undesirable trends are identified; (ii) include revenue
and expense reports, information about related party transactions, and
information about service utilization metrics in contracts for managed long-term
services and supports and the Managed Care Technical Manual and utilize data and
information received from managed long-term services and supports providers to
monitor spending and utilization trends for managed long-term services and
supports and address problems related to spending and utilization of services
through managed long-term services and supports program contracts or the
rate-setting process; (iii) include additional requirements for information
about metrics related to behavioral health services in the managed long-term
services and supports contract and the Managed Care Technical Manual to
facilitate identification of undesirable trends in service utilization and
enable the Department to address problems identified with managed care
organizations participating in the program; and (iv) include additional metrics
related to the long-term services and supports in the managed long-term services
and supports contract and the Managed Care Technical Manual to facilitate
identification of differences between models of care, assessment of progress in
and challenges related to keeping service recipients in community-based rather
than institutional care, and cooperation with managed care organizations in
resolving problems identified.

HISTORY: 2017, c. 749; 2020, cc. 304, 365.