Key Process Enhancements

1. HUMAN SERVICESDEPARTMENT • 1 • 2 • 3 • 4 • PROCESS PHASE • Life Event - Fee for Service (FFS)/Alternative Benefit Plan (ABP/COE 100) Exempt • Coordination of Treatment and Discharge Plans • pt-In to MCO and Assessments Completed • Coordination of Community Benefits • Coordination of Presumptive Community Benefits • Process Step • Life Event: Traumatic Brain Injury (TBI) • Automatic ABP Exemption • ABP Exempt Confirmation by Client • Discharge to Skilled Nursing Facility (SNF) • Client Discharged to SNF • Additional Benefit Information • Opts-Into MCO/Completes HRA • Client Approved for Community Benefits • Comprehensive Care Plan (CCP) is Completed • Coordination of Community Benefits • Treatment Plan • Intake at SNF • Client Discharged Home • Transportation Home • CNA Conducted • Process Steps & Description • Life event: Client hospitalized • Social worker discusses treatment plan options with client or Authorized Representative • Based on medical criteria from the client's provider records, client is approved for FFS ABP exemption • Client or authorized representative confirms ABP exemption via unified portal or text alert • Hospitalist or Discharge Planner coordinates with SNF to trigger automated prior-authorization • Client treatment plan is completed and services are coordinated. • Administrator at SNF reviews plan and processes intake as necessary. • Discharge Planner at SNF lays out client's treatment plan for discharge to home and assists with transportation to home. • Transportation provider picks up client and transports to home. • Notifications are populated by Unified Portal and sent via preferred method(s), communicating additional benefit options. • Client opts into MCO and completes HRA via preferred method. CNA may be triggered. • "Treat-First" Comprehensive Needs Assessment is conducted with client in her home • Care Coordinator assists client with coordinating urgent Community Benefits • Care Coordinator submits the Allocation Tool to MCO's Utilization Management (UM); UM approves Agency Based Community Benefits (ABCB); MCO sends ABCB approval notification to client • Client is contacted by Care Coordinator to schedule and complete the remainder of the CNA and Comprehensive Care Plan (CCP) • Care Coordinator advises and assists client with coordination of the remainder of their Community Benefits • Responsible • Accountable • Consulted • Informed R A C I • Key Process Enhancements • Unified Portal available for FFS benefit review, comparison charts, provider lists, training videos, and access to any additional FFS communication materials.*Client receives real-time prior authorization approval via unified portal or text alert. • Client receives treatment plan via e-mail or text alert from Benefit Management System( BMS) capabilities. • MCO enrollment and benefit options. Automated pre determination for all benefits options based on medical diagnosis." • Real-time data from the benefit management system in the unified portal, the system can proactively flag FFS ABP exemption based on medical criteria from the client's provider records. • Client receives and responds to alert (text, email, verbal by provider, snail mail or preferred method of communication) to confirm ABP exemption. • Client receives real-time prior authorization approval via unified portal or text alert. • Hospitalist or Discharge Planner enters client treat-ment plan into Benefit Management System (BMS), accessible to all authorized parties via preferred method. • Using the unified portal, the Community Health Representative (CHR) coordinates transportation to SNF. • Client receives real-time alerts when plan is completed and status of trans-portation (similar to Uber). MCO enroll-ment and benefit options. Automated pre determination for all benefits options based on medical diagnosis. " • SNF administrator reviews treatment plan with client through the Benefit Management System (BMS) and begins coordination of services at the SNF. • "SNF Administrator enters client treatment plan for home into Benefit Management System (BMS) the information is accessible to all authorized parties via preferred method. • Client receives real-time alerts when plan is completed and status of transportation (similar to Uber).  • CHR begins coordination of services. • Using the unified portal, SNF Administrator coordinates transportation to home. " • Unified Portal available for client and provider review of Value Added Benefits (VAB), comparison charts (showing benfits from all 3 MCOs), provider listing and training videos on "How To" access benefits. • "Client receives alert via preferred method of communication giving opportunity to opt into MCO. • Upon opting in to MCO, client is prompted to complete HRA using preferred method, triggering appropriate next steps. If CNA is needed, automatic scheduling and assignment of care coordinator is completed utilizing automatic pre-fills from HRA and Electronic Health Record (EHR)." • "Care Coordinator (CC) completes ""Treat First"" (""mini CNA""), addressing client's immediate needs only. • Client is in need of Personal Care Services (PCS), so CC approves ""Presumptive Community Benefit Eligibility"" for 90 days until MCO's Utilization Management (UM) gives final approval. " • "Care Coordinator (CC) assists member with contacting Personal Care Services (PCS) providers to schedule services based upon Allocation Tool (to be submitted to Utilization Management (UM)). • CC notifies client that service hours may change upon fianl UM review." • The process will remain as it currently is in the Contract/Policy Manual. Time frames can remain the same as the PE is in place for client. • Care Coordinator (CC) contacts client to complete in-home visit. CC and client discuss any changes in Community Benefits (based on UM findings). Comprehensive Care Plan (CCP) is completed to fill in any items not addressed during Treat First Comprehensive Needs Assessment (CNA). • Care Coordinator (CC) assists member with contacting providers to schedule services based upon Utilization Management's approval of Community Benefits. • MCO • CI • CI • CI • RA • RA • RA • RA • RA • RA • BHSD • CI • CI • CI • CI • CI • CI • CI • CI • CI • CI • ISD • MAD • CI • CI • CI • CI • CI • CI • CI • CI • CI • CI • CI • CI • Medical Provider • RA • RA • RA • RA • RA • RA • RA • CCSC • CI • CI • CI • RA • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Unified Public Interface (UPI) Data Services (DS) Benefit Management Services (BMS) • Systems Involved • From 2 to 0 as the information is automated to be sent to client • Change in Number of Handoffs • Automatic HRA completed by client at the time of opting into MCO decreases handoffs and time spent by the MCO and makes this more efficient for the client to receive services 30-60 days sooner • Reduced by 50% • 1-4 with automation makes these handoff's more efficient for the client • From 2 to 0 as the information is automated to be sent to client • Touch points may increase from 0 to 3 to make communication of available benefits efficient to the client and establish clear contacts and address the gap areas of communication identified • Automatic HRA completed by client at the time of opting into MCO decreases handoffs and time spent by the MCO and makes this more efficient for the client to receive services 30-60 days sooner • Change in Number of Touchpoints • Reduced by 50% • From 2 to 0 as the information is automated to be sent to client • Change in Number of Staff Hours • From 0 staff hours to staff hours being used to anlyze the FFS population with the automation of information and create program improvements where gaps were identified • Reduced to 1% • Decrease in staff hours attempting to coordinate untilmey reviews and monitor MCO's as issues or concerns are received by HSD • 2-4 handoffs (~90% reduction) • Pain Points addressed • The Unified Portal for providers will include a comprehensive list of ABP benefits providers can refer to and clients can access. The Unified Portal will also include a live chat bot, and will list resources to contact if questions or issues arise utilizing benefits. • Client receives automatic response for "Prior Authorization" via text message or preferred method of communication. Client receives communication via e-mail or text message to include care plan for the client. • By automating the ABP Exception approval process the client no longer has to collect and submit all their medical records to a third party assessor. • The provider and client are notified in real time of the approval, this eliminates any confusion and assures transparency between the client and the provider. • Automated prior authorization process interfaces in real time into the BMS system to eliminate third party assessor workflow and to notify the provider and the client in real time that the prior authorization is approved. • Client can view their treatment plan on the Unified Portal in real time eliminating confusion, questions, misunderstanding and creates transparency between all involved with the client's case. Client benefit app will alert the client when their transportation will arrive and transport to destination. • Unified portal will have instructions for Community Health Worker (CHW) on how to help with transportation • Combination of services client wants are not available from one MCO, has to decide which is best for her needs • 30-day wait time • 5-day wait time; client doesn't understand letter; client is unhappy with number of PCS hours • Scheduling issues; client has trouble understanding CCP after CC leaves • Providers don't return calls timely; scheduling issues

2. Note: Review the full list of ideas generated from the workshop. Combine ideas that are similar and make the verbiage succinct. Put the final list into this format and identify which ideas are MMISR impacted. • Benefit Mgmt & CC The journey redesign workshop generated solution ideas that could be implemented to improve Fee-For-Service clients’ ABP Exempt andCommunity Benefit experience Client • Communication Plan for FFS/ABP/ABP Exempt • Simplify ABP Exempt • Approval Process • Develop process for expedited Community Benefit determination 3 5 4 2 • Communication and Education: Fact sheet, brochure, video describing temp/expedited NFLOC • Rule change: create temporary/expedited NFLOC contract language • Training: • Provide correct contact info to ISD, • Conduent for LOC and Community Benefits • Workflow Automation • Visual app tracker • Claims trigger review for combined HRA, CNA • MCO receives client information from MMIS • MCO/provider interface: provider can enter Presumptive Eligibility (PE) for Community Benefits 1 • Expedite Prior Authorization • Expedited, shorter or temporary NFLOC • HRA within 5 business days vs. 30 • HRA and CNA performed concurrently • "Treat first (mini-CNA)", virtual CNA • Reduce allocation tool timelines • ABP Exempt triggers expedited NFLOC assessment process MMISR NOT impacted MMISR impacted 1 • MCO/FFS contractors create benefit comparison chart for ABP and ABP exempt Create videos with Native Americans’ client experiences and “how-to” (including how-to "Opt-in/out of MCO or for providers) - YouTube, Facebook, HSD website, portal 2 3 4 5 • Unified Portal • User-friendly, simple search process, filters • YES-NM buildout with apps, links • automatically sends blasts tailored to client • Chat feature • Filter information to sister agencies

3. Note: Sort ideas into immediate actions and strategic investments (long term investments). • Benefit Mgmt & CC The solution ideas were then synthesized and prioritized to identify a set of immediate actions and strategic investments to consider Client • Process Changes1 • Immediate actions • Strategic investments to consider i • Benefit Comparison Chart MCO/FFS contractors create benefit comparison chart for ABP and ABP exempt • Data analytics capabilities and dedicated reporting review team to centralize report reviews and utilization of findings within MAD and with MCOS • Newsletters FAQs and updates on providers and FF Services and outreach (electronic and hard copy) ii • System changes • Strengthen relationships with MCOs and engage MCOs as partner to share report review insights and jointly identify opportunities to enhance programmatic outcomes • Create review process and refine report data requirements internally and together with MCOs iii • Organizational Changes2 • Set up quarterly meeting with HSD and MCOs to report results, next steps, and potential penalties iv • Develop and automated reporting system to enable automatic report generation based on data interfaces with existing MCO data stores, systematic penalty calculation and a dashboard/port for all stakeholders to view key metrics, reports and historical trends • Collaborate with MCOs to define clear reporting expectations, practices, and methodologies v • Align on contractual thresholds and define clear penalty rules vi vii • Develop standardized criteria for report reviewing • Conduct data analytics training across all bureaus viii ix • Experiment with dashboard prototypes (MCO and Internal) to test usefulness/utilization and help identify priority use cases for MMISR DS module x • Develop and implement SharePoint workflows for use throughout the reporting process and provide necessary training for MAD employees 1 Process changes are improvements that can be implemented within MAD 2 Organizational changes require collaboration across divisions and/or agencies (e.g. DOH, Long-term Aging Services, etc.)

4. Note: For each immediate action, detail the outcomes that the action will enable and which MMISR model it will impact if applicable. • Reporting Ten actions have been identified to enable the near-term changes to measurably improve the client and staff experience MCO • MMISR SOLUTIONS MODULES IMPACTED • IMMEDIATE ACTIONS • OUTCOMES ENABLED • Increased Transparency so the public and providers are informed of the available comprehensive benefit packages offered MCO/FFS contractors create benefit comparison chart for ABP and ABP exempt • Unified Portal i • Increased proactive utilization of report results to drive program improvements • Create quarterly internal meetings to discuss report findings and how to utilize results ii • Data Services • Create review process and refine report data requirements internally and together with MCOs • Clarity for MCOs on report requirements and decreased number of report rejections due to mis-interpretation of reporting requirements iii • Set up quarterly meeting with HSD and MCOs to discuss report results, next steps, and potential penalties iv • Proactively partner with MCOs to identify comprehensive corrective action plans or other improvement opportunities • Data Services • Improved relationships with MCOs and a decreased number of penalties due to misaligned expectations • Collaborate with MCOs to define clear reporting expectations, practices, and methodologies v • Data Services • Financial Services • Align on contractual thresholds and define clear penalty rules • Consistent application of penalties across MCOs and up to 50% decrease in time spent reviewing contractual compliance • Automated processing and recording of penalty payments vi • Consistency of analysis across report reviews and 5-10% reduction of time spent on report reviews due to process clarity • Data Services vii • Develop standardized criteria for report reviewing • Conduct data analytics training across all bureaus • Data Services viii • Increased confidence and more depth in report reviewing • Increased clarity of business needs to inform MMISR requirements • Experiment with dashboard prototypes (MCO and Internal) to test usefulness/utilization and help identify priority use cases for MMISR DS module • Comprehensive list of what dashboard elements should be considered for MMISR • Unified Portal • Data Services ix x • Approximately 40% reduction in the use of email and closed feedback loops due to increased document visibility • Data Services • Develop and implement SharePoint workflows for use throughout the reporting process and provide necessary training for MAD employees SOURCE: Team Analysis