NEW YORK STATE DEPARTMENT OF H

NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS OFFICE OF QUALITY AND PATIENT SAFETY

EXTERNAL QUALITY REVIEW TECHNICAL REPORT FOR:

FIDELIS CARE NEW YORK [NEW YORK QUALITY HEALTHCARE CORPORATION]

Reporting Year 2018

FINAL REPORT

Published April 2020

Table of Contents

I. About This Report.......................................................................................................................... 1 Purpose of This Report.................................................................................................................... 1 Structure of This Report.................................................................................................................. 1

II. MCO Corporate Profile ................................................................................................................... 2 III. Enrollment and Provider Network ................................................................................................... 4

Enrollment .................................................................................................................................... 4 Provider Network........................................................................................................................... 7 Primary Care and OB/GYN Access and Availability Survey?2018 ............................................................ 9 IV. Utilization................................................................................................................................... 11 Encounter Data............................................................................................................................ 11 Health Screenings......................................................................................................................... 11 QARR Use of Services Measures ..................................................................................................... 12 V. Performance Indicators ................................................................................................................ 13 HEDIS?/QARR Performance Measures............................................................................................. 13 Quality Indicators......................................................................................................................... 13 Access to/Timeliness Indicators...................................................................................................... 17 NYSDOH-Calculated Prenatal Care Measures.................................................................................... 19 Member Satisfaction..................................................................................................................... 20 Quality Performance Matrix--Measurement Year 2018..................................................................... 21 Performance Improvement Project................................................................................................. 24 Health Disparities......................................................................................................................... 26 VI. Health Information Technology..................................................................................................... 28 VII. Structure and Operation Standards................................................................................................ 31 Compliance with NYS Structure and Operation Standards .................................................................. 31 External Appeals .......................................................................................................................... 33 VIII. Strengths and Opportunities for Improvement................................................................................ 34 IX. Appendix.................................................................................................................................... 40 References .................................................................................................................................. 40

Fidelis Care New York | Reporting Year 2018 Technical Report i

List of Tables

Table 1: Medicaid Enrollment--2016-2018 ............................................................................................... 4 Table 2: Enrollment in Other Product Lines--2016-2018 ............................................................................. 4 Table 3: Medicaid Membership Age and Gender Distribution--December 2018 ............................................. 5 Table 4 HEDIS?/QARR Board Certification Rates--2016-2018....................................................................... 7 Table 5: Medicaid Providers by Specialty--2018 (4th Quarter)...................................................................... 7 Table 6: Ratio of Enrollees to Medicaid Providers--2018 (4th Quarter) .......................................................... 8 Table 7: Medicaid PCPs with an Open Panel--2016-2018 (4th Quarter).......................................................... 8 Table 8: MCO Provider Participation Rate ................................................................................................. 9 Table 9: Appointment Availability and After-Hours Access Rates --2018 ..................................................... 10 Table 10: Medicaid Encounter Data--2016-2018 ..................................................................................... 11 Table 11: Health Screenings--2016-2018................................................................................................ 11 Table 12: QARR Use of Services Rates--2016-2018................................................................................... 12 Table 13a: HEDIS?/QARR MCO Performance Rates 2016-2018--Prevention and Screening1........................... 14 Table 13b: HEDIS?/QARR MCO Performance Rates 2016-2018--Acute and Chronic Care1.............................. 15 Table 13c: HEDIS?/QARR MCO Performance Rates 2016-2018--Behavioral Health1 ...................................... 16 Table 14a: HEDIS?/QARR MCO Performance Rates 2016-2018--Utilization1 ................................................ 17 Table 14b: HEDIS?/QARR MCO Performance Rates 2016-2018--Access to Care1 .......................................... 18 Table 15: QARR Prenatal Care Rates ? 2015-2017..................................................................................... 19 Table 16: CAHPS?--2014, 2016, 2018..................................................................................................... 20 Table 17: Quality Performance Matrix--Measurement Year 2018 .............................................................. 22 Table 18: Performance Improvement Project Results--2017-2018 ............................................................. 25 Table 19: MCO Use of Health Information Technology--2018 Survey of NYS MCOs....................................... 28 Table 20: Focused Review Types............................................................................................................ 32 Table 21: Summary of Citations ............................................................................................................. 33 Table 22: External Appeals--2016-2018.................................................................................................. 33

Fidelis Care New York | Reporting Year 2018 Technical Report ii

List of Figures

Figure 1: Fidelis Map of Participating Counties........................................................................................... 3 Figure 2: Fidelis Enrollment Trends--All Product Lines................................................................................ 4 Figure 3: Medicaid Enrollees by Age--December 2018................................................................................ 5 Figure 4: Medicaid Enrollees by Aid Category--December 2018................................................................... 6

Fidelis Care New York | Reporting Year 2018 Technical Report iii

Acronyms Used in This Report

ALOS: AO:

Average Length of Stay Area Office

CFR: CHP: CMS:

COM:

Code of Federal Regulations Child Health Plus Centers for Medicare and Medicaid Services Commercial

DBA:

Doing Business As

EQR: EQRO:

External Quality Review External Quality Review Organization

F/A: FAR: FFS: FIDA: FTE:

Failed Audit Final Audit Report Fee-For-Service Fully Integrated Duals Advantage Full Time Equivalent

HARP: HCS: HEDIS:

HIE: HIT: HMO: HPN:

Health and Recovery Plan Health Commerce System Healthcare Effectiveness Data and Information Set Health Information Exchange Health Information Technology Health Maintenance Organization Health Provider Network

MAP: MCD: MCO: MLTC: MMC: MMCOR:

MRT: MY:

Medicaid Advantage Plus Medicaid Managed Care Organization Managed Long-Term Care Medicaid Managed Care Medicaid Managed Care Operating Report Medicaid Redesign Team Measurement Year

N: N/A: NCQA:

NP: NR:

Denominator Not Available National Committee for Quality Assurance Not Provided Not Reported

NV: NYC: NYCRR: NYS: NYSDOH:

Not Valid New York City New York Code of Rules and Regulations New York State New York State Department of Health

OB/GYN: OHIP: OPMC: OP: OQPS:

Obstetrician/Gynecologist Office of Health Insurance Programs Office of Professional Medical Conduct Optimal Practitioner Contact Office of Quality and Patient Safety

PCP: PHSP: PIP: PIHP: PNDS: POC: PMPY: PTMY: PQI:

Primary Care Practitioner/Provider Prepaid Health Services Plan Performance Improvement Project Prepaid Inpatient Health Plan Provider Network Data System Plan of Corrective Action Per Member Per Year Per Thousand Member Years Prevention Quality Indicator

Q1: Q2: Q3: Q4: QARR:

First Quarter (Jan.--March) Second Quarter (Apr.--June) Third Quarter (July--Sept.) Fourth Quarter (Oct.--Dec.) Quality Assurance Reporting Requirements

ROS:

Rest of State

RY:

Reporting Year

SN: SOD: SS: SSI: SWA:

Safety Net Statement of Deficiency Small Sample (less than 30) Supplemental Security Income Statewide Average

TANF: TR:

Temporary Aid to Needy Families Technical Report

UR:

Utilization Review

Fidelis Care New York | Reporting Year 2018 Technical Report iv

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