Bid Event id number: evt0001028 KanCare Medicaid and chip capitated Managed Care Services Preface: High Priority Events and Items

CONTRACTOR(S) shall comply with the requirements set forth in 42 CFR 438.6(i)(2) and 42 CFR 422.128 for maintaining written policies and procedures for advance directives.

2.2.34.1.1

The CONTRACTOR(S) shall maintain written policies and procedures respecting advance directives with respect to all adult individuals receiving medical care by or through CONTRACTOR as set forth in 42 CFR subpart I of 489.

2.2.34.1.2

Advance Directives shall have the following meaning in accordance with the provisions of 42 CFR 489.100:

Advance directive means a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated.
2.2.34.2

CONTRACTOR(S) shall provide written information to each Member with respect to the following:

2.2.34.2.1

Their rights under the law of Kansas to make decisions concerning their medical care, including the right to accept or refuse medical or surgical treatment and the right to formulation of advance directives. Providers may contract with other entities to furnish this information but remain legally responsible for ensuring that the requirements of this section are met. Changes in State law must be provided as soon as possible, but no later than 90 days after the effective date of the change in State law. Applicable State law of Kansas may be found in Kansas Statutes Annotated (KSA) 65-28,101; Withholding or withdrawal of life-sustaining procedures; legislative finding and declaration and KSA 58-625; The Kansas Durable Power of Attorney for Health Care Decisions.

2.2.34.2.2

The organizations' policies respecting the implementation of those rights, including a statement of any limitation regarding the implementation of advance directives as a matter of conscience.

2.2.34.2.3

The Member’s right to file complaints concerning noncompliance with the advance directive requirements with the State survey and certification agency

2.2.34.2.4

The CONTRACTOR’s written policies respecting the implementation of those rights, including a clear and precise statement of limitation if the CONTRACTOR cannot implement an advance directive as a matter of conscience. At a minimum, this statement must do the following:

2.2.34.2.4.1

Clarify any differences between institution-wide conscientious objections and those that may be raised by individual physicians;

2.2.34.2.4.2

Identify the state legal authority (KSA 65-28,107 or KSA 58-625) permitting such objection; and

2.2.34.2.4.3

Describe the range of medical conditions or procedures affected by the conscientious objection.

Provide the information specified incSection 2.2.17 and its subsections and Section 2.2.35, to each Member at the time of initial enrollment. If a Member is incapacitated at the time of initial enrollment and is unable to receive information (due to the incapacitating condition or a mental disorder) or articulate whether or not he or she has executed an advance directive, the CONTRACTOR may give advance directive information to the Member’s family or surrogate in the same manner that it issues other materials about policies and procedures to the family of the incapacitated Member or to a surrogate or other concerned persons in accordance with State law. The CONTRACTOR is not relieved of its obligation to provide this information to the Member once he or she is no longer incapacitated or unable to receive such information. Follow-up procedures must be in place to ensure that the information is given to the Member directly at the appropriate time.

The CONTRACTOR shall document in a prominent part of the Member’s current medical record whether or not the Member has executed an advance directive.

The CONTRACTOR shall not condition the provision of care or otherwise discriminate against a Member based on whether or not the Member has executed an advance directive.

The CONTRACTOR shall ensure compliance with requirements of State law (whether statutory or recognized by the courts of the State) regarding advance directives.

The CONTRACTOR shall provide for education of staff concerning its policies and procedures on advance directives.

The CONTRACTOR shall provide for community education regarding advance directives that may include material required herein, either directly or in concert with other providers or entities. Separate community education materials may be developed and used, at the discretion of the CONTRACTOR. The same written materials are not required for all settings, but the material should define what constitutes an advance directive, emphasizing that an advance directive is designed to enhance an incapacitated individual’s control over medical treatment, and describe applicable State law concerning advance directives. The CONTRACTOR must be able to document its community education efforts upon request by the State or applicable agents of the Federal government.

The CONTRACTOR:

Is not required to provide care that conflicts with an advance directive; and

2.2.34.9.2

Is not required to implement an advance directive if, as a matter of conscience, the CONTRACTOR cannot implement an advance directive and State law allows any health care provider or any agent of the provider to conscientiously object.

2.2.35.2

2.2.35.3

2.2.35.4

2.2.35.5

2.2.35.6

2.2.35.7

2.2.35.8

All Medically approved services prescribed by physician/ARNP/nurse midwife and physician’s assistant including diagnosis, treatment, counseling, drug, supply, or device to individuals of childbearing age shall be covered.

For family planning purposes, sterilization shall only be those elective sterilization procedures performed for the purpose of rendering an individual permanently incapable of reproducing and must always be reported as family planning services, in accordance with mandated federal regulations 42 CFR 441.250-441.259.

2.2.36.2.1

At least 30 calendar days, but not more than 180 calendar days, must have passed between the date of informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery.

2.2.36.2.2

A Member may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery if at least 72 hours have passed since the Member gave informed consent for the sterilization.

In the case of premature delivery, the informed consent must have been given at least 30 calendar days before the expected date of delivery.

2.2.36.2.4

The Member must be at least 21 years old at the time consent is obtained.

2.2.36.2.5

The Member must be mentally competent.

2.2.36.2.6

The Member must not be institutionalized (i.e., not involuntarily confined or detained under a civil or criminal status in a correctional or rehabilitative facility or confined in a mental hospital or other facility for the care and treatment of mental illness, whether voluntarily or involuntarily committed).

2.2.36.2.7

The Member must have voluntarily given informed consent on the approved “Sterilization Consent Form” which is available on the KMAP web site at:

2.2.36.2.8

The CONTRACTOR must assure that the Federal Sterilization Consent form required by CMS in 42.CFR 441.250 - 441.259 is properly completed as described in the instructions and a copy of the Sterilization Consent form is obtained from the performing provider before paying the service claim. The CONTRACTOR must maintain a copy of the form in the event of audit. In the event of an audit the CONTRACTOR will provide additional supporting documentation to ascertain compliance with Federal and State regulations. Such documentation may include admission history and physical, pre and post procedure notes, discharge summary, court records or orders.
2.2.37 Information Requirements
If the CONTRACTOR elects not to provide, reimburse for, or provide coverage of, a counseling or referral service because of an objection on moral or religious grounds, then consistent with 42 CFR 438.10 CONTRACTOR must furnish information about the services it does not cover as follows:

2.2.37.1

2.2.37.2

2.2.37.3

A claim is defined below:

2.2.38.1.1

Claim means 1) a bill for services 2) a line item of service or 3) all services for one recipient within a bill.

2.2.38.1.2

Clean claim means one that can be processed without obtaining additional information from the provider of the service or from a third party.  It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.

The CONTRACTOR shall meet the following payment requirements:

100% of all clean claims including adjustments must be processed and paid or processed and denied within 30 days of receipt.

2.2.38.2.2

99% of all non clean claims including adjustments must be processed and paid or processed and denied within 60 days of receipt.

2.2.38.2.3

100% of all claims including adjustments must be processed and paid or processed and denied within 90 days of receipt.

2.2.38.2.4

Abide by the specifications of the following:

2.2.38.2.4.1

The date of receipt is the date the CONTRACTOR receives the claim, as indicated by its date stamp on the claim.

2.2.38.2.4.2

The CONTRACTOR(S) shall identify each claim and adjustment with a unique Internal Control Number that includes date of receipt, batch number and sequence of the claim within the batch (as appropriate).

2.2.38.2.4.3

The date of payment is the date of the check or other form of payment.

2.2.38.2.5

The CONTRACTOR(S) shall provide technical assistance to providers for claims submission.

2.2.38.2.6

The CONTRACTOR(S) must track and report separately the number of submitted, paid and denied claims each month.

Nursing Facilities (NF)

2.2.38.3.1

The CONTRACTOR shall:

2.2.38.3.1.1

pay the full contracted rate to nursing facilities; and

2.2.38.3.1.2

collect the Member’s portion of the rate.

2.2.38.3.1.3

pay 90 percent of clean claims within 14 days and 99.5 percent of clean claims within 21 days. The contractor will also provide technical assistance to nursing home providers for claims submission.

Exception:  The CONTRACTOR and its providers may, by mutual agreement, establish an alternative payment schedule.  Any alternative schedule must be stipulated in the subcontract.

Reports:  The CONTRACTOR shall report on claims payments as required in Section 2.3.4.1.3.5

Successful CONTRACTOR(S) shall collaborate to provide consistent practices, such as on-line billing, for claims submission to simplify claims submission and ease administrative burdens for providers in working with multiple CONTRACTORS. 

CONTRACTOR agrees that no Member will be liable for CONTRACTOR’s debts, in the event of CONTRACTOR’s insolvency.

Each subcontract must provide that compensation to individuals or entities that conduct UM activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any Member.

The UM program shall identify and describe the mechanisms to detect under-utilization as well as over-utilization of services. The written program description shall address the procedures used to evaluate medical necessity, the criteria used, information sources, timeframes and the process used to review and approve the provision of medical services.

Members shall have access to emergency services without PA, even if the emergency services provider does not have a subcontract with the CONTRACTOR.

The CONTRACTOR shall disseminate the Kansas medical necessity definition, ASAM criteria as contained in the KCPC system (for SUD), authorization policies, procedures, and any applicable practice guidelines to all affected providers and, upon request, to Members and potential Members.

The CONTRACTOR shall ensure that decisions for UM, Member education, coverage of services, and other areas to which the guidelines apply are consistent with the guidelines.

2.2.40.6

The CONTRACTOR shall have in effect mechanisms to ensure consistent application of review criteria for authorization decisions and consult with requesting providers when appropriate.

The CONTRACTOR shall provide appropriate and timely written notice to the requesting provider and the Member of the authorization or decision to deny a service authorization request or to authorize a service in the amount, duration, or scope that is less than the request. The decision or request shall be made by a health care professional who has appropriate clinical expertise in treating the Member’s condition or disease. The notice must meet the requirements of 42 CFR 438.404, except that the notice to the provider need not be in writing

2.2.40.9

Timeframe for Decisions: Authorization decisions and related notices must be delivered within the timeframes outlined in 42 CFR Subpart F.

The CONTRACTOR shall submit the policies, procedures, and any applicable practice guidelines to State for approval.

The CONTRACTOR shall conduct sample reviews. The CONTRACTOR shall perform ongoing monitoring of UM data, on-site review results, and claims data review. The designated State staff will review the CONTRACTOR's UR process. 2.2.40.11.1

Frequency of use: URs occur at intervals, first within the initial treatment period and then regularly thereafter. Data related to utilization review are reported in the State Quality Report and are reviewed by the State on a quarterly basis. Providers shall have over and under-URs through the use of outlier reports and regular utilization reports and analyses.

2.2.40.11.2

UM data can be used to monitor program integrity and/or coverage/authorization accuracy.
2.2.40.12

The data are utilized to indicate opportunities for improvement and to assess compliance with utilization policies and procedures at the provider and CONTRACTOR level. This information is primarily used for provider and Member monitoring and is part of the QM. If areas for improvement are noted, the CONTRACTOR works with the specific provider noted or incorporates the identified aspects into the implementation of performance measures. If the UR process identifies issues with program integrity, the CONTRACTOR shall follow up with providers, recoup overpayments or report abusive or fraudulent claiming to the Medicaid Fraud Control Unit (MFCU) via the State Medicaid Agency.

The CONTRACTOR must disclose all criteria it uses for UM as part of this proposal.

SUD Specific UM - The CONTRACTOR shall have in place and follow, written policies, procedures, and practice guidelines for processing requests for PA and authorization for requests for continuing services. The policies, procedures, and practice guidelines shall include requirements for use of the Kansas medical necessity definition and the ASAM criteria as contained in the KCPC system.

2.2.40.14.1

The policies, procedures and practice guidelines shall be:

2.2.40.14.1.1

consistent with the Kansas medical necessity definition and the ASAM criteria as contained in the KCPC system;

2.2.40.14.1.2

based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field;

2.2.40.14.1.3

consider the needs of the Members; and

adopted in consultation with contracting health care professionals, and reviewed and updated periodically as appropriate.

The CONTRACTOR shall have a single point of contact and similar method of PA.

The CONTRACTOR shall ensure that subcontracted providers use the required Kansas medical necessity definition, ASAM criteria as contained in the KCPC system for determination of level of service, even when PA from the CONTRACTOR is not required.

The CONTRACTOR shall permit Members to self-refer (i.e. access services without PA) under the following circumstances or to the following subset of services in this RFP and resultant CONTRACT: Members shall be able to access all outpatient services without a referral up to a pre-specified initial authorization service limit. In addition, and any service for any woman who is pregnant or has dependent children, can be accessed without a referral up to a pre-specified initial authorization service limit. For services above that limit, Members shall obtain PA.

Staffing Plan - The CONTRACTOR shall describe its staffing plan for the managed care CONTRACT. The proposal shall outline how the staffing plan will achieve consistent, dependable service regardless of changes that may directly influence work volume. The proposal shall also provide a general description of its proposed staff with number of years of experience in their fields and number of years of experience in the managed care field. In addition the CONTRACTOR shall:

2.2.41.1.1

report staff departures to State staff no later than five (5) business days prior to the last date the employee is employed, to the extent possible;

2.2.41.1.2

report staff role changes to the State in advance of the change;

2.2.41.1.3

notify the State at least 30 calendar days in advance of any plans to change, hire, or re assign designated Key Personnel;

2.2.41.1.4

ensure that knowledge is transferred from an employee leaving a position to a new employee to the extent possible;

2.2.41.1.5

fill key positions within 60 calendar days of departure, unless a different timeframe is approved by the State. The replacement must be a qualified individual approved by the State; and,

2.2.41.1.6

identify a minimum staffing level defined over time and maintain that defined minimum staffing level at all times during designated business hours.

Each proposal must describe its back up personnel plan, including a discussion of the staffing contingency plan for:

2.2.41.2.1

The process for replacement of personnel in the event of the loss of key personnel or other personnel before or after signing a CONTRACT;

Allocation of additional resources to this CONTRACT in the event of inability to meet a performance standard;

2.2.41.2.3

Replacement of staff with key qualifications and experience and new staff with similar qualifications and experience;

2.2.41.2.4

The timeframes necessary for obtaining replacements; and

2.2.41.2.5

Method of bringing replacements or additions up-to-date regarding this CONTRACT.

Key Personnel - This section identifies designated key personnel and certain other staff where specific requirements for the position must be met. Individuals filling designated key personnel positions must be approved by the State. Designated key personnel and their general responsibilities are listed below. All designated key personnel must be dedicated to the CONTRACT full time, unless otherwise noted, and may not serve in another position, unless noted. Generally, it is preferred by the State that all key staff assigned to this CONTRACT serve full time, unless otherwise noted.

2.2.41.3.1

A full-time Senior Executive / project director solely dedicated to the KanCare program who has clear authority over the general administration and day-to-day business activities of this Agreement;

2.2.41.3.2

A full-time Senior Executive finance officer solely dedicated to the KanCare program responsible for accounting and finance operations, including all audit activities;

2.2.41.3.3

A full-time Medical Director solely dedicated to the KanCare program who is a licensed physician in the State of Kansas to oversee and be responsible for all clinical activities, including but not limited to the proper provision of covered services to Members, developing clinical practice standards and clinical policies and procedures;

2.2.41.3.4

A full-time QM Director responsible for all QAPI activities. This person shall have relevant experience in QM for physical and or behavioral healthcare quality;

2.2.41.3.5

A full-time staff person dedicated to the KanCare program responsible for Member services, who shall communicate with KanCare regarding Member service activities;

2.2.41.3.6

A staff person responsible for all UM activities, including but not limited to overseeing PAs. This person shall be under the direct supervision of the Medical Director and shall ensure that UM staff have appropriate clinical backgrounds in order to make UM decisions;

2.2.41.3.7

For behavioral health UM activities, a part-time or on-call board certified psychiatrist and addictionologist who has at least five (5) years combined experience in MH and SUD services;

2.2.41.3.8

A full-time staff information systems director/manager dedicated to the KanCare program responsible for all CONTRACTOR information systems supporting this Agreement who is trained and experienced in information systems, data processing and data reporting as required to oversee all information systems functions supporting this Agreement including, but not limited to, establishing and maintaining connectivity with KanCare information systems and providing necessary and timely reports to KanCare;

2.2.41.3.9

Claims/Encounter Manager: The Health Plan shall have a designated person qualified by training and experience to oversee claims and encounter submittal and processing, where applicable, and to ensure the accuracy, timeliness and completeness of processing payment and reporting.

2.2.41.3.10

All key personnel shall be employed by, or committed to join, the vendor's organization by the beginning of the pertinent CONTRACT phase or task.

2.2.41.4

2.2.41.4.1

In keeping with Kansas values of strong work ethic and the understanding that work builds self-esteem and provides financial security and that people who are ready, willing and able to work with disabilities are healthier when they do, it is vitally important that people with disabilities are employed in integrated settings in the work place. Therefore, the CONTRACTOR(S) shall hire people with disabilities and shall be able to demonstrate what percentage of their workforce helps them to meet this requirement.
2.2.41.5

The CONTRACTOR shall conduct training of staff in all departments to ensure appropriate functioning in all areas. This training shall be provided to all new staff members and on an ongoing basis for current staff.

The CONTRACTOR shall ensure that quality of service is not compromised by excessive staff turnover. The CONTRACTOR shall, within 60 days of CONTRACT signing deliver to the State a staffing contingency plan including but not limited to:

2.2.41.6.1

The process for replacement of personnel in the event of loss of key personnel or other personnel before or after signing of the CONTRACT;

Allocation of additional resources to the CONTRACT in the event of inability to meet any performance standard;

2.2.41.6.3

Replacement of staff with key qualifications and experience with new staff with similar qualifications and experience;

2.2.41.6.4

Discussion of time frames necessary for obtaining replacements;

2.2.41.6.5

CONTRACTOR’S capabilities to provide, in a timely manner, replacements/additions with comparable experience; and

2.2.41.6.6

The method of bringing replacements/additions up to date regarding the Kansas CONTRACT must be emphasized.