Slide 1: Implementation Council
Oct 12, 2021
Commonwealth Care Alliance
Slide 2: One Care Rating Categories| Definitions
Data is shown by rating category in this presentation. See rating category definitions below for reference:

F1 - Facility-based Care. Individuals identified as having a long-term facility stay of more than 90 days

C3- Community Tier 3- High Community Need. Individuals who have a daily skilled need; two or more Activities of Daily Living (ADL) limitations AND three days of skilled nursing need; and individuals with 4 or more ADL limitations
-	In CY2014, C3 split into two subsets:
		C3B: for C3 individuals with certain diagnoses (e.g., quadriplegia, ALS, Muscular Dystrophy and Respirator dependence) leading to costs considerably above the average for current C3
		C3A: for remaining C3 individuals

C2 - Community Tier 2 – Community High Behavioral Health. Individuals who have a chronic and ongoing Behavioral Health diagnosis that indicates a high level of service need
- In CY2014, C2 split into two subsets
		C2B: for C2 individuals with co-occurring diagnoses of substance abuse and serious mental illness
		C2A: for remaining C2 individuals

C1 - Community Tier 1 Community Other. Individuals in the community who do not meet F1, C2 or C3 criteria
Footer:  CONFIDENTAIL – For Policy Development Purposes Only
Slide 3: UM Process Slide
Note: the following information was shown in a flowchart with each item in a box with an arrow in between pointing to the next box which illustrates movement from one step to the next.

•	Members’ needs assessed for LTSS services1
•	PCA needed- referral sent to PCM for evaluation
•	PCA evaluation prior auth. request created and sent to UM for approval and fax to PCM agency
•	PCA Assessment is completed by PCM agency then faxed to CCA with supporting documentation
•	UM team reviews PCA assessment and MDS2
•	Member and Care Team notified of decision3
•	Care Team is notified of adverse determination to develop alternate care plan
•	Care Partner works with member to identify and develop care plan to meet needs

CCA ensures all decisions are executed with a holistic understanding of members.

1Commonwealth Care Alliance members’ PCA needs are identified through the onboarding process, all initial and reassessments, LTSC and Care partner touches
2CCA will request additional information from the member’s Care Team or PCM agency through RFI process as needed
3All Home and Community Based Services (HCBS) are flagged in authorization and pulled to the member’s Care Plan in their Electronic Medical Record
Slide 4: 96% of all ICO PCA PA decisions are Approved

Of the 17,869 ICO PCA requests received by CCA since 2018*:
- 93% were Approved
–	93% were approved without modification
–	3.6% were approved with modifications
–	All modifications are downgrades and considered “partial approvals”
–	3% were denied
Note: the following information was shown in a pie chart.

Approved without modification	93%
Approved with modification	3.6%
Denied	3%
Slide 5: 96% of all ICO PCA PA decisions are Approved
Note: the following information was shown in a table.

2018
Approved Without Modification 	530 (92%)
Approved With Modification 	20 (3%)
Denied 	26 (4.5%)
Total Requests 	576

2019
Approved Without Modification 	5,455 (94%)
Approved With Modification 	179 (3%)
Denied 	154(2.6%)
Total Requests 	5,788

2020
Approved Without Modification 	6,953 (93%)
Approved With Modification 	256 (3%)
Denied 	225 (3%)
Total Requests 	7,434

2021 YTD
Approved Without Modification 	3,733 (91%)
Approved With Modification 	193 (4%)
Denied 	145 (3.5%)
Total Requests 	4,071

Grand Total
Approved Without Modification 	16,671 (93%)
Approved With Modification 	648 (3.6%)
Denied 	555 (3%)
Total Requests 	17,869

Volume of PCA Requests by Final Decision and Year

Note: the following information was shown in a bar chart.

2021YTD
Denied	145
Approved w/ Modifications	193
Approval	3733

2020
Denied	225
Approved w/ Modifications	256
Approval	6953

2019
Denied	154
Approved w/ Modifications	179
Approval	5455

2018
Denied	26
Approved w/ Modifications	20
Approval	530
Slide 6: ICO PCA Decisions- Rating Category
The overwhelming majority of ICO PCA requests are for C3A members.
-C1: 1%
-C2: 2% 
–	C2A: 2% 
–	C2B: <1% 
-C3: 96%
–	C3A: 87%
–	C3B: 9%
-F1: <1% 

Note: the following information was shown in a bar chart.

C1
2018	10
2019	92
2020	86
2021YTD	82

C2A
2018	11
2019	107
2020	134
2021YTD	82

C2B
2018	0
2019	9
2020	18
2021YTD	12

C3A
2018	471
2019	4908
2021	6505
2021YTD	3576

C3B
2018	77
2019	618
2021	628
2021YTD	303

F1
2018	2
2019	9
2020	11
2021YTD	1

*Data reflects Oct 2018 –July 2021
Slide 7: PCA Decisions- Rating Category*
Note: the following information was shown in a bar chart.

2018, N: C1 = 10, C2 = 11, C3 = 548
Approved
C1	90%
C2 	91%
C3 	92%
Approved w/ Modifications
C1 	0%
C2 	9%
C3 	3%
Denial
C1	10%
C2 	0%
C3 	5%

2019, N: C1 = 92, C2 = 116, C3 = 5526
Approved
C1 	90%
C2 	84%
C3 	94%
Approved w/ Modifications
C1 	1%
C2 	0%
C3 	3%
Denial
C1 	9%
C2 	16%
C3 	2%

2020, N: C1 = 86, C2 = 152, C3 = 7133
Approved
C1 	79%
C2 	86%
C3 	94%
Approved w/ Modifications
C1 	2%
C2 	3%
C3 	3%
Denial
C1 	19%
C2 	11%
C3 	3%

2021YTD, N: C1 = 24, C2 = 94, C3 = 3879
Approved
C1 	82%
C2 	76%
C3 	92%
Approved w/ Modifications
C1 	4%
C2 	1%
C3 	5%
Denial
C1 	15%
C2 	23%
C3 	3%

*F1 members excluded due to low volume (<1%).
Slide 8: PCA Modification Rates
•	All PCA Approvals with modifications1 since 2018 have been reductions.
•	Majority of reductions are less than 10% from original request.

Magnitude of Service Level Modifications with Decreases

Note: the following information was shown in a bar chart.

2019
0-10%	24.38%
10-20%	20.47%
20-30%	11.41%
30-40%	8.59%
40-50%	8.13%
>50%	27.03%

2020
0-10%	50.41%
10-20%	12.50%
20-30%	8.97%
30-40%	6.93%
40-50%	6.93%
>50%	14.27%

2021YTD
0-10%	71.13%
10-20%	8.16%
20-30%	5.65%
30-40%	4.71%
40-50%	2.93%
>50%	7.43%

1Examples of Common Reasons for PCA Modifications include: 1) Comprehensive assessment not yet completed or overdue 2) Current services already address member needs, 3) Time Requested exceeds allocated time based on member’s level of functioning and internal standards.
*Data reflects Oct 2018 –July 2021.
Slide 9: PCM Agency Modification Rates
•	PCM Modifications constitute ~3% of all UM decisions
•	PCM agencies range in modification rates.
•	No PCM has had more than 5% of PCA decisions as modifications.

Approvals with Modifications as a % of All Decisions by PCM*

Note: the following information was shown in a bar chart.

A = 3%
B = 4%
C = 3%
D = 1%
E = 0%
F = 0%
G = 0%
H = 0%
I = 0%
J = 0%
K = 0%

The letter K represents all other 47 PCMs where data was statistically insignificant.
Data reflects Oct 2018 –July 2021