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

CONTRACTOR Responsibilities

The CONTRACTOR is responsible for handling and responding to calls concerning the KanCare programs. The CONTRACTOR will use trained staff to respond courteously, accurately, and concisely to inquiries. Whenever possible, questions will be answered at the time of the call. The CONTRACTOR must provide interpreter service, bilingual service, TDD, etc. The CONTRACTOR must provide language assistance and translation services necessary to ensure meaningful access at no cost to the Limited English Proficiency (LEP) beneficiaries. The CONTRACTOR must record all calls for future retrieval. The CONTRACTOR must provide other services as directed by the State. The CONTRACTOR must provide a detailed description of its proposed solutions in its response and describe how it will operate the customer service center.
2.2.42.2

Toll-Free Telephone Service

The CONTRACTOR must provide toll-free telephone service, for use by Members, potential Members, community based service organizations, and other public or private agencies. The CONTRACTOR is responsible for providing sufficient in-bound toll-free lines to meet the performance standards outlined in Section 2.2.42.7 below. Automated Voice Response System (AVRS) may be incorporated into the customer service plan. If an AVRS is used, separate queues must be available for English and Spanish calls. The AVRS must be capable of providing specific information such as the fax number, hours of operation, etc, as well as allowing the caller to access a call center representative

Toll Free Fax Line

The CONTRACTOR must provide a toll free fax system with sufficient capacity to handle the incoming volume.
2.2.42.4

Voicemail

The CONTRACTOR must provide a voicemail system that allows messages to be left during and after business hours.

The CONTRACTOR must ensure that messages are retrieved and responded to voice mail messages within two business day of receipt.
2.2.42.5

Website:

The CONTRACTOR is responsible for developing, hosting and maintaining a website. The website shall include the following:

2.2.42.5.1.

Communication in both English and Spanish;

2.2.42.5.2

Easy navigation;

2.2.42.5.3

CONTRACTOR contact information;

2.2.42.5.4

Frequently Asked Questions (FAQs);

2.2.42.5.5

Benefit information;

2.2.42.5.6

Timely updates when there are significant policy and program changes; and

2.2.42.5.7

Links to other related websites, including the KDHE-DHCF Medicaid website.

Call tracking system

The CONTRACTOR must provide a system to track and document all phone contacts, including incoming calls, outgoing calls and voice messages. The call tracking system shall have the capability to generate statistical reports regarding, for example, call volumes, length of time to answer, abandonment rates, length of the calls, nature of the calls and who answered the call.
2.2.42.7

Customer Service Performance Standards

The CONTRACTOR(S) shall meet the following requirements for Customer Service:

2.2.42.7.1

100% of incoming and outgoing calls must be documented

2.2.42.7.2

99% of calls will be answered by an individual or an electronic device without receiving a busy signal

2.2.42.7.3

95% of all calls, whether incoming or outgoing, will be placed on hold for no more than one minute

2.2.42.7.4

90% of calls answered will be resolved by the CONTRACTOR during the initial contact

2.2.42.7.5

100% of received phone calls are recorded and the recordings maintained

2.2.42.7.6

100% of calls left on voice mail during or after working hours will be retrieved and returned within one (1) business day
2.2.42.7.7

98% of the time, facsimile (FAX) lines shall meet customer demand.

2.2.42.7.8

For all inquiries either received over the phone or in writing the following performance standards apply:

2.2.42.7.8.1

95% of all inquiries shall be resolved within two (2) business days of receipt

2.2.42.7.8.2

98% of all inquiries shall be resolved within five (5) business days

2.2.42.7.8.3

100% of all inquiries shall be resolved within 15 business days.

The State shall be responsible for the management of this CONTRACT. Management shall be conducted in good faith within the resources of the State with the best interest of the Medicaid and CHIP Members being the prime consideration. The State shall retain full authority and responsibility for the administration of Medicaid and CHIP in accordance with the requirements of federal and state laws and regulations.

Medicaid Title XIX and CHIP Title XXI Eligibility - The State shall be responsible for determining the eligibility of an individual for Medicaid or CHIP funded services. See Exhibit 1 for eligibility criteria.

Approval of Materials Developed by CONTRACTOR - The State shall have the right to approve, disapprove or require modification of procedures and materials developed by the CONTRACTOR under this CONTRACT. Material requiring State approval shall include but is not limited to:

2.3.1.2.1

Marketing plans and all related materials,

2.3.1.2.2

Complaint/Grievance Appeal procedures,

2.3.1.2.3

Insolvency protection,

2.3.1.2.4

Member Handbook,

2.3.1.2.5

PCP enrollment procedures,

2.3.1.2.6

QM procedures,

2.3.1.2.7

Insurance and bonding plans,

2.3.1.2.8

Fraud and abuse plan, and

2.3.1.2.9

Physician Incentive Plans.

Interpreting Federal and State Law – The State shall be responsible for the interpretation of all Federal and State laws and regulations governing or in any way affecting this CONTRACT. When interpretations are required, the CONTRACTOR shall submit written requests to the State. The State will contact the appropriate agencies in responding to the request.

Provide Assistance - The State shall assist, cooperate, and provide information to the CONTRACTOR as may be necessary for the performance of obligations and duties under the terms of this CONTRACT. The State shall reserve the right to determine what is necessary for performance.

External Quality Review (EQR) - The State shall establish a system of annual EQR in accordance with Section 1902(a) (30) (C) of the Social Security Act. This system of EQR shall provide for the identification and collection of management data for use by the external quality review group.

Disenrollment During Termination Hearing Process - After the State notifies CONTRACTOR that it intends to terminate the CONTRACT, the State shall:

2.3.1.6.1

Give the CONTRACTOR’S Members written notice of the State’s intent to terminate the CONTRACT, and

2.3.1.6.2

Allow Members to disenroll immediately.

Local Health Departments - KDHE provides funding to local health departments for the provision of health care services to low income individuals. The CONTRACTOR shall make a reasonable effort to subcontract with any local health care provider receiving funds from Titles V and X of the Social Security Act. Close cooperation with these entities is strongly encouraged.

2.3.2.1.1

The CONTRACTOR shall coordinate all cases of Sexually Transmitted Diseases (STD) and tuberculosis (TB) with the local health departments to ensure prevention and to limit the spread of disease. The CONTRACTOR shall cooperate with the treatment plan developed by the local health department. The State requires the CONTRACTOR(S) to provide language, in their subcontracts with any local health departments, regarding the coordination of care and reporting on STDs and TB to the State health department.

2.3.2.1.2

The CONTRACTOR shall coordinate with the Special Supplemental Food Program for Women, Infants and Children (WIC). The State shall assure that coordination exists between the WIC and CONTRACTOR. This coordination should include the referral of potentially eligible women, infants, and children to the WIC Program and the provision of medical information by providers working within managed care plans to the WIC Program.

2.3.2.1.2.1

To be eligible for WIC benefits, a competent professional authority must diagnose a pregnant woman, a breast feeding woman, a non-breast feeding postpartum woman, an infant or a child under age five (5) as being at nutritional risk. Suggested medical information for a WIC referral includes: Nutrition related metabolic disease; diabetes; low birth weight; failure to thrive; premature birth; infants of alcoholic mothers, developmentally disabled infants, drug addicted or HIV positive mothers; AIDS; allergy or intolerance that effects nutritional status; and anemia.

2.3.2.1.2.2

The WIC Program in the State of Kansas is coordinated through the local health departments. CONTRACTOR(S) is expected to subcontract or coordinate with the local health departments in their areas.

2.3.2.1.3

The CONTRACTOR(S) shall also coordinate with other Title V programs such as the IDEA, the Healthy Start Home Visiting Program, the Maternal and Infant (M & I) and Family Planning Clinics as well as any other programs operated by the local health departments.

2.3.2.1.4

The CONTRACTOR shall also cooperate with the justice systems in Kansas, to include but not limited to: Kansas Department of Corrections and the Juvenile Justice Authority.

Local Education Agencies - The CONTRACTOR is encouraged to cooperate with these agencies on the provision of services. The State will be monitoring this cooperation in order to assess possible future CONTRACT requirements.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) - The CONTRACTOR shall make a reasonable effort to subcontract with any RHC and/or FQHC located within its service area. Close cooperation with these entities is strongly encouraged.

2.3.2.4

Indian Health Services - The CONTRACTOR shall coordinate with any Indian Health Service Clinics or tribally operated facilities in their service area. Documentation of such coordination is required.

Enrollment

2.3.3.1.1

Member Enrollment/Assignment - Enrollment for the new CONTRACT period will begin prior to November 1, 2012 and continue on an ongoing basis. Medicaid Members aged less than 21 and CHIP Members aged less than 19 will have a continuous 12-month period of eligibility. Assignment for Medicaid Members is effective the first day of the eligibility start month, pending waiver approval to eliminate the choice period. Assignment for CHIP Members shall begin the day eligibility is received by the MMIS and is forwarded to the CONTRACTOR. Neither Medicaid nor CHIP Members are subject to waiting periods or pre-existing condition clauses excluding coverage for conditions as of the effective date of their coverage. Enrollment in the Medicaid and CHIP managed care programs is the responsibility of the State and its enrollment broker. Managed physical and behavioral health care services, as well as dental services for those currently eligible for them, must be available to Members beginning November 1, 2012.

2.3.3.1.1.1

Persons eligible for enrollment with CONTRACTORs are those encompassed by the categories listed in Exhibit 1. The State shall have the exclusive right to determine an individual’s eligibility for Medicaid. The State, through its eligibility broker, shall have the exclusive right to determine an individual’s eligibility for CHIP. Such determinations are not subject to review or appeal by the CONTRACTOR. Nothing in this section prevents the CONTRACTOR from providing the State with information the CONTRACTOR believes indicates that the Member’s eligibility has changed.

2.3.3.1.1.2

If and when the State receives a waiver from CMS, dual eligibles (Medicare-Medicaid), disabled children, and foster care children will be included in the eligible Member categories. These eligibility groups may be voluntarily enrolled prior to waiver approval.

2.3.3.1.1.3

All eligible beneficiaries will be automatically assigned to a CONTRACTOR based on an algorithm applied by the State’s fiscal agent that is designed to achieve parity in numbers and population mix within in the first year of implementation. The State will notify the new Member that they have 90 days to choose another CONTRACTOR if they wish. Along with this notification, the State, through its fiscal agent, will send information on all available CONTRACTORS to allow beneficiaries the opportunity to make an informed choice of plans. Kansas is seeking a waiver of 42 CFR 438.56(c)(2)(i) to reduce the allowable disenrollment time and to eliminate the upfront enrollment choice period.

2.3.3.1.1.4

Beneficiaries with enrollment questions may contact the fiscal agent. When the beneficiary chooses or is assigned a managed care program, the fiscal agent will send the Member a letter informing them of the assigned managed care program.

2.3.3.1.1.5

The CONTRACTOR will send the Member a welcome packet including the information in Sections 2.2.17.8 and 2.2.17.9 and allow the Member 10 business days to choose a PCP. If the Member does not choose a PCP within 10 business days, the CONTRACTOR shall the auto-assign the Member to a PCP. Members will be informed that they may request, and be assigned a new PCP at any time. The welcome packet will include: PCP enrollment materials, Member ID card, a Member handbook, a provider listing and Member’s rights and responsibilities.

2.3.3.1.1.6

At the beginning of the first month of enrollment, the CONTRACTOR shall send the Member an identification card containing the benefit plan (Medicaid or CHIP), effective date, PCP, CONTRACTOR organization name, how to access dental and MH services and other relevant enrollment information. The CONTRACTOR and the State will jointly design this card.

2.3.3.1.1.7

The CONTRACTOR will maintain a permanent Member service hotline, with specially trained operators to handle calls from new enrollees and from Members needing assistance in obtaining services.

2.3.3.1.1.8

Members eligible to enroll in a managed care plan may be eligible beginning the first day of the application month with the exception of newborns who are eligible beginning with their date of birth. The CONTRACTOR shall be responsible for coverage of newborn children born to a mother assigned to the CONTRACTOR during the month of birth.

2.3.3.1.1.9

The CONTRACTOR shall also be responsible to provide retroactive Medicaid coverage to Members determined eligible by the State. Retroactive Medicaid coverage is defined as a period of time up to three (3) months prior to the application month. (There is no retroactive coverage for CHIP Members.) When a retroactive assignment is made to the health plan the CONTRACTOR is responsible for paying the historical FFS claims even if the FFS claims are past the CONTRACTOR’s timely filing policies.

2.3.3.1.1.10

The Assignment Adjustment Process is used when a change to the existing managed care assignment occurs. The adjustment is approved and submitted by the State at its discretion.

2.3.3.1.1.11

When an assignment is removed from the CONTRACTOR, a recoupment of the capitation payment will occur for the appropriate months. When an assignment is added to the CONTRACTOR, a capitation payment will be made for the appropriate months.

2.3.3.1.1.12

The Assignment Adjustment information is forwarded to the following entities:

The State’s Fiscal Agent’s Managed Care Team

CONTRACTOR Assignment and Eligibility Team

KDHE-DHCF Staff

2.3.3.1.2

Enrollment Responsibilities

2.3.3.1.2.1

CONTRACTOR Responsibilities

2.3.3.1.2.1.1

The CONTRACTOR shall accept, on a monthly basis, any eligible program Member who selects or is assigned to the CONTRACTOR in the order in which they apply or are assigned without restriction, (unless authorized by the Regional Administrator), up to the limits set under the contract. regardless of the Member’s age, sex, ethnicity, language needs, or health status up to the limits set under the contract.. These Members must also appear on the CONTRACTOR Enrollment Information. Enrollment in the CONTRACTOR will occur starting with the first month of eligibility for Medicaid eligibles and the day eligibility is forwarded to the CONTRACTOR for CHIP eligibles. (Kansas is seeking a waiver from choice enrollment to mandatory enrollment.) The CONTRACTOR is responsible for obtaining any necessary signatures of medical releases.

2.3.3.1.2.1.2

Coverage of services including inpatient hospital care will be the responsibility of the CONTRACTOR as of the beginning of the month enrollment becomes effective. All other (ancillary) charges, not reimbursed by the inpatient hospital payments, are the responsibility of the CONTRACTOR. CHIP inpatient hospital claims will be the responsibility of the Member. Non-inpatient (ancillary) charges are the responsibility of the CONTRACTOR if the admission date occurs before assignment. If an admission date occurs during the assignment to the CONTRACTOR, that CONTRACTOR is responsible for the cost of the entire admission regardless of assignment or eligibility.

2.3.3.1.2.1.3

The CONTRACTOR must have written policies and procedures for providing all medically necessary services required under the benefit package to newborn children of program Members effective at the time of birth. Newborns of eligible mothers who were enrolled at the time of the child’s birth shall be covered under the mother’s health plan. The CONTRACTOR shall receive capitation payment for the month of birth and for all subsequent months the child remains enrolled with the CONTRACTOR if the CONTRACTOR provided the newborn information to the State within 60 days of the date of birth. If there is an administrative lag that is not the fault of the Member in enrolling the newborn and costs are incurred during that period, the Member shall be held harmless for those costs.
2.3.3.1.2.1.4

The CONTRACTOR must agree to make available the full scope of benefits to which a Member is entitled immediately upon the effective date of enrollment.

2.3.3.1.2.1.5

The CONTRACTOR must have written policies and procedures for orienting new Members and potential enrollees to their benefits, the role of the PCP, how to utilize services, what to do in an emergent or urgent medical situation, how to register a complaint or file a grievance and their right to disenroll. The CONTRACTOR may propose alternative methods for orienting new Members and potential enrollees, but must be prepared to demonstrate their effectiveness. Also refer to Section 2.2.17 regarding the Member handbook.

2.3.3.1.2.1.6

The CONTRACTOR must have written policies and procedures for assigning each of its Members to a PCP/health home. The process must include at least the following features:

The CONTRACTOR must contact the Member within 10 business days of his or her enrollment and provide information on the options for selecting a PCP.

If a Member does not select a PCP within 10 business days of enrollment the health plan must make an automatic assignment, taking into consideration such factors, if known, as current provider relationships, language need and area of residence. The CONTRACTOR may choose to assign new Members to a PCP immediately, notify the Member of that assignment in writing and allow the Member no less than 10 business days to change this assignment if it is not acceptable. The CONTRACTOR must notify the Member in writing of his or her PCP’s name, specialty, hospital affiliation, and office telephone number.

If a Member requests a change to his or her PCP following the initial visit, the CONTRACTOR must agree to grant the request to the extent possible and practical and in accordance with its policies for other enrolled groups or product lines.

2.3.3.1.2.1.7

The CONTRACTOR shall provide separate, monthly reports for Medicaid and CHIP populations. These electronic reports shall be in Excel and shall list each PCP, hospital and pharmacy per county. The PCPs shall have an indicator for open/closed panels and include the number of Members assigned to each provider and that provider’s maximum caseload.

2.3.3.1.2.1.8

If a PCP is terminated from the managed care plan, the CONTRACTOR shall have written policies and procedures for Members to select or be assigned to a new PCP within 15 days of the termination effective date.

2.3.3.1.2.2

State Responsibilities

2.3.3.1.2.2.1

The State will conduct education and enrollment activities for program eligibles.

2.3.3.1.2.2.2

The State will make available to the CONTRACTOR on a monthly basis, an electronic roster of Members enrolled in the health plan for the entire benefit month. The roster will include information consistent with the HIPAA compliant 834 transaction.

2.3.3.1.2.2.3

The State will make available to the CONTRACTOR on a daily basis, an electronic roster (HIPAA 834) of Members enrolled in the health plan. This roster will contain Medicaid newborn children and CHIP daily assignments.

2.3.3.1.2.2.4

Following the original assignment to a CONTRACTOR, the Member will have a 90 day choice period to change plans, if desired. (Kansas is seeking a waiver of 42 CFR 438.56(c)(2)(i) to reduce the allowable disenrollment time.) Member choice of a managed care plan shall be voluntary and neither the State nor its agents shall do anything to influence the Member’s exercise of free choice. Members shall be provided assurances that a decision not to enroll in the CONTRACTOR’s plan shall not affect their eligibility for benefits.

2.3.3.1.2.2.5

An application for enrollment in the program and selection of a plan, which includes a list of plans, will be provided to the Members. Fiscal Agent managed care enrollment staff will be available, by calling a toll-free number or in person; to assist program eligibles that request a change in managed care plans.

2.3.3.1.2.2.6

A brochure explaining the managed care program and CONTRACTOR services (such as different languages, interpreting services for the deaf, etc.) will be provided to Members. Members will be advised as to which providers offer special services that the Member may need. In addition, these materials will be offered in alternate formats to address physical and language barriers.

2.3.3.1.2.2.7

The State’s responsibilities at the time of the eligibility determination will include the following:

2.3.3.1.2.2.7.1

Educating Members about the basic features of managed care; which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; and MCO, PIHP, PAHP, and PCCM responsibilities for coordination of enrollee care; Information specific to each MCO, PIHP, PAHP, or PCCM program operating in potential enrollee’s service area.

2.3.3.1.2.2.7.2

Providing a summary of the following information and the State shall provide more detailed information upon request: Benefits covered; Cost sharing, if any; Service area; Names, locations, telephone numbers of, and non-English language spoken by current contracted providers, and including identification of providers that are not accepting new patients. For MCOs, PIHPs, and PAHPs, this includes at a minimum information on primary care physicians, specialists, and hospitals; Benefits that are available under the State plan but are not covered under the contract, including how and where the enrollee may obtain those benefits, any cost sharing, and how transportation is provided. For a counseling or referral service that the MCO, PIHP, PAHP, or PCCM does not cover because of moral or religious objections, the State shall provide information about where and how to obtain the service.

2.3.3.1.2.2.7.3

Educating Members about the responsibilities of the Member, their rights to file grievances and appeals, as well as the benefits available in and out of the plan

2.3.3.1.2.2.7.2

Informing Members of available managed care plans and outlining criteria that might be important when making a choice (e.g., presence or absence of the Member’s existing health care provider in a plan’s network)

2.3.3.1.2.2.7.3

The State will employ an assignment method that will ensure parity in initial numbers and case mix among plans for the first year during implementation of the CONTRACT. No plan will be permitted enrollment numbers that constitute more than 50% of the total eligible Medicaid and CHIP population. Should any plan in the first (implementation) year fall below enrollment of 20% of the total Medicaid and CHIP population, the assignment algorithm will be re-assessed.

2.3.3.1.2.2.7.4

Members who are disenrolled from a managed care plan due to loss of eligibility will automatically be re-enrolled, or assigned, to the same plan should they regain eligibility within 60 calendar days. The CONTRACTOR must agree to re-enroll these Members. If more than 60 days have elapsed, the Member will be auto-assigned to a plan through the assignment method described in 2.3.3.1.2.2.7.3 and permitted 45 days to choose a different plan, if desired.

2.3.3.1.2.2.7.5

The effective date of enrollment with the CONTRACTOR for Medicaid Members shall be the first day of the month in which the individual is assigned to the CONTRACTOR. The only exceptions to this are Medicaid newborn Members. These children are to be considered the responsibility of the CONTRACTOR upon birth. The effective date of enrollment with the CONTRACTOR for CHIP Members shall be the first day eligibility is established and forwarded to the CONTRACTOR. Individuals are entitled to be covered by the CONTRACTOR when the State notifies the CONTRACTOR that the Member is enrolled in their plan. A newborn’s enrollment is effective immediately in CHIP if the mother is enrolled in CHIP during the month of birth.

2.3.3.1.2.2.7.6

Members who lose eligibility due to failure to provide eligibility information to the State on a timely basis but whose eligibility is subsequently re-established prior to the end of the month, will be reported to the CONTRACTOR on a second Member roster sent to the CONTRACTOR on or around the fifth of each month. Capitation payments for those Members reported on this second roster will be made with the regular capitation payment for the following month.
2.3.3.2

Marketing - Marketing means any communication, from an MCO, PIHP, PAHP, or PCCM to a Medicaid recipient who is not enrolled in that entity, that can reasonably be interpreted as intended to influence the recipient to enroll in that particular MCO's, PIHP's, PAHP's, or PCCM's Medicaid product, or either to not enroll in, or to disenroll from, another MCO's, PIHP's, PAHP or PCCM's Medicaid product. The State is responsible for all marketing to Members during the enrollment process. The CONTRACTOR shall not influence Member enrollment in the CONTRACTOR’s plan through the offer of any compensation, reward or benefit to the Member except for additional health-related services or informational or educational services that have been approved by the State. Direct solicitation of Members is not allowed. The CONTRACTOR must comply with the following marketing restrictions:

2.3.3.2.1

The CONTRACTOR shall not conduct directly or indirectly, door-to-door, telephonic, or other forms of “cold-call” marketing. Cold Call Marketing means any unsolicited personal contact by the CONTRACTOR with a potential enrollee for the purpose of marketing as defined in 2.3.3.2.2, below.

2.3.3.2.2

The CONTRACTOR may not make any communication to a person, who is not enrolled in the CONTRACTOR’S MCO, which can reasonably be interpreted as intended to influence the person to enroll in the CONTRACTOR’s MCO, or to influence any enrollment or disenrollment decisions the person might make

2.3.3.2.3

Marketing materials cannot contain any assertion or statement (whether written or oral) that:

The recipient must enroll in the MCO in order to obtain benefits or in order not to lose benefits.

That the MCO is endorsed by CMS, the Federal or State government or similar entity.

2.3.3.2.4

Marketing material means any materials that are produced in any medium, by or on behalf of the CONTRACTOR that can reasonably be interpreted as intended to market to potential enrollees.

2.3.3.2.5

The CONTRACTOR shall not distribute any marketing materials without first obtaining the State’s approval.

2.3.3.2.6

CONTRACTOR shall distribute marketing materials to its entire membership, unless otherwise approved by the State.

2.3.3.2.7

CONTRACTOR shall not offer the sale of any other type of insurance product as an enticement to enrollment.

2.3.3.2.8

CONTRACTOR marketing, including plans and materials, must be accurate, shall not contain false or misleading information, and does not mislead, confuse, or defraud the recipients or the State.

2.3.3.2.9

CONTRACTOR shall not discriminate against individuals eligible to be covered under the CONTRACT on the basis of health status or need of health services and accept individuals in the order in which they apply without restriction, (unless authorized by the Regional Administrator), up to the limits set under the contract. CONTRACTOR(S) shall not seek to influence enrollment in conjunction with the sale or offering of any private insurance.
2.3.3.3

Disenrollment: Disenrollment provisions apply to all managed care arrangements whether enrollment is mandatory or voluntary and regardless of entity type.

2.3.3.3.1

CONTRACTOR Responsibilities

2.3.3.3.1.1

The CONTRACTOR’s responsibility for Member-initiated disenrollments shall include referring the Member to the Fiscal Agent’s Managed Care Enrollment Center to process the disenrollment. The CONTRACTOR is also required to track the reason for the disenrollments for the CONTRACTOR’s QAPI process.

2.3.3.3.1.2

It may be necessary to transfer a Member between plans. As an example, the transfer may be necessary if the change is ordered as part of a grievance resolution. The CONTRACTOR must have written policies and procedures for transferring relevant patient information, including medical records and other pertinent materials, when a Member is transferred to or from another plan.

2.3.3.3.1.3

When a Member changes plans while hospitalized, the relinquishing plan shall notify the hospital of the change prior to the transition. The relinquishing plan shall be responsible for payment of inpatient charges for the entire hospitalization through discharge. All other non-inpatient (ancillary) charges are the responsibility of the new plan at the beginning of the first month of enrollment.

2.3.3.1.4

The CONTRACTOR may not request disenrollment because of a change in the member's health status, or because of the member's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment seriously impairs the CONTRACTOR'’S ability to furnish services to either this particular member or other members).

2.3.3.3.1.5

The CONTRACOR must specify how it will assure the State that it does not request disenrollment for reasons other than those permitted under the contract.

2.3.3.3.2

State Responsibilities

2.3.3.3.2.1

The State has an annual open enrollment. Members may disenroll as outlined in 42 CFR 438.56 with cause at any time and with or without cause during the 90-day choice period following the initial enrollment (pending waiver approval of reducing the choice period from 90 days to 45 days) and during the annual open enrollment period thereafter. Members who wish to disenroll must submit an oral or written request to the State or its fiscal agent (these disenrollments will be effective on the first day of the second month following the month in which the Member or CONTRACTOR filed the request for disenrollment, whenever possible).

2.3.3.3.2.2

The State, through its fiscal agent, shall be responsible for any Member enrollments and disenrollments with the managed care plans. The State has sole authority and discretion for disenrolling program Members from managed care plans subject to the conditions specified below:

2.3.3.3.2.3

The Member moves out of state

2.3.3.3.2.4

The plan does not, because of moral or religious objections, cover the service the enrollee seeks

2.3.3.3.2.5

Loss of eligibility.

2.3.3.3.2.6

Placement in an adult or juvenile correctional facility

2.3.3.3.2.7

Selection by the Member, of another managed care plan

2.3.3.3.2.8

Death of the Member

2.3.3.3.2.9

Transfer to a Medicaid eligibility category not included in this CONTRACT

2.3.3.3.2.10

To implement the decision of a hearing officer in a formal grievance procedure by the Member against the CONTRACTOR or by the CONTRACTOR against the Member

2.3.3.3.2.11

The Member needs related services (for example a caesarean section and a tubal ligation) to be performed at the same time; not all related services are available with the network; and the Member’s PCP or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk

2.3.3.3.2.12

Other reasons, including but not limited to, poor quality of care, lack of access to services covered under the CONTRACT, or lack of access to providers experienced in dealing with the Member’s health care needs

2.3.3.3.2.13

The effective date of an approved disenrollment must be no later than the first day of the second month following the month in which the Member or CONTRACTOR files the request for disenrollment. If the State or its fiscal agent fails to make the determination within the timeframes specified herein, the disenrollment is considered approved.

2.3.3.3.2.14

Members who are disenrolled from a managed care plan due to loss of eligibility will automatically be re-enrolled, or assigned, to the same plan should they regain eligibility within 60 calendar days. The CONTRACTOR must agree to re-enroll these Members. If more than 60 days have elapsed, the Member will be auto-assigned to a plan through the assignment process as described in Section 2.3.3.1.2.2.7.3 and permitted 90 days to choose a different plan, if desired.

General Reporting Procedures

2.3.4.1.1

Time Frames for Audit & Report Submissions - The CONTRACTOR(S) shall submit all reports to the State, unless indicated otherwise in this Agreement, according to the schedule below:

2.3.4.1.2

Reporting Requirements - The CONTRACTOR shall provide reports to the State in the frequency specified by the State, following the format(s) developed by the CONTRACTOR in collaboration with the State, and approved by the State.  Initial reporting formats must be developed and approved prior to the implementation of the program covered by this contract, must meet all contract and legal reporting requirements, and must include uniform and standardized elements so that the information reported is comparable across all CONTRACTORS/subcontractors.  Ongoing and additional reporting issues and formats are subject to development and revision as necessary across the time span of this contract, and each such report must be consistent with the criteria described above and presented to/approved by the State prior to use.  The CONTRACTOR agrees to furnish information, as required, from its records to the State and the State’s authorized agents and to provide an assessment of identified deficiencies and CONTRACTOR’s proposed CAP which the State will use to correct any identified deficiencies, including but not limited to the following:

2.3.4.1.3

Additional Reports: Upon request by the State, the CONTRACTOR shall prepare and submit other operational data reports. Such requests will be limited to situation in which the desired data is considered essential and cannot be obtained through existing CONTRACTOR reports. Whenever possible, the CONTRACTOR will be provided with ninety (90) days notice and the opportunity to discuss and comment on the proposed requirements before work is begun. However, the State reserves the right to give 30 days notice in circumstances where time is of the essence.

2.3.4.1.3.1

Access to Care Reports: The CONTRACTOR(S) shall submit to the State access to care reports pursuant to Section 2.2.15 General Access Standards.

2.3.4.1.3.2

Annual Financial Statements: The CONTRACTOR(S) shall submit to Kansas Insurance Department (KID) the results of an annual audit performed by an independent certified public account and to authorize the KID to share this information with other State agencies as required. The CONTRACTOR(S) shall authorize the independent accountant to allow representatives of the State, including the KID, upon written request, to verify the audit report (see Section 2.2.29 Disclosure of Financial Records).

2.3.4.1.3.3

Quarterly Financial Statements: For providers licensed as MCOs by the KID: Copies of financial reports and financial solvency reports as outlined in Section 2.2.28.5.7 to be submitted to the KID pursuant to the T-XIX Managed Care Interagency Agreement as well as any additional reports or information required by KDHE-DHCF or its sister agency, the KID. For non-MCO-licensed providers and for those providing services for T-XXI Members, income and expense statements specific to the contracted program(s) will be required semi-annually, for the six (6)-month period of January to June, and July to December of each CONTRACT period.

2.3.4.1.3.4

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Reports: The CONTRACTOR(S) will submit a CAHPS report annually. The CONTRACTOR(S) are responsible to analyze this data and provide an analysis summary with this report and track and trend all aspects of the survey and take corrective action as needed to improve performance.

2.3.4.1.3.5

Claims Processing/Payment Reports: Quarterly report to the State enumerating the total number of claims processed during the preceding quarter; percentages of claims paid within 30 days, 60 days and 90 days; and average number of days to pay claims. This report shall be submitted within 15 working days from the end of each calendar year quarter.

2.3.4.1.3..6

Encounter Data: The CONTRACTOR shall prepare and submit encounter data as prescribed in Attachment K to the State through the State’s designated Fiscal Agent. Each CONTRACTOR is required to have a valid MMIS Provider Identification Number including a unique identifier. Submissions shall be comprised of encounter records or adjustments to previously submitted records, which the CONTRACTOR has received and processed from provider encounter or claim records of all contracted services rendered to the Member in the current or any preceding months. Submissions must be received by the Fiscal Agent in accordance with Attachment K. CONTRACTOR(S) will submit attestation concurrently with each encounter data submission which states all of the data submitted are, to the best of the CONTRACTOR’S information, knowledge and belief, accurate and complete. Failure to submit data of expected quality will result in immediate suspension of all payments and accrual of liquidated damages outlined in Attachment G.

2.3.4.1.3.7

EPSDT Reports: EPSDT information as required. This information is included in the encounter data submitted monthly. EPSDT services and reporting shall comply with 42 CFR 411 Subpart B.

2.3.4.1.3.8

Fraud and Abuse Reports : The CONTRACTOR must submit to the State a quarterly fraud and abuse report. The report shall be submitted in the format provided by the State. (See Attachment L) On an annual basis the CONTRACTOR shall submit its policies for employees, CONTRACTORs and agents that comply with Section 1902(a)(68) of the Social Security Act.

2.3.4.1.3.9

Grievance and Appeal Reports: The CONTRACTOR shall submit a quarterly report to the State summarizing formal grievance, appeals, administrative law hearing requests and informal inquiries and resolutions. The call center report should also contain the original contact resulting in a formal grievance or appeal with a resolution of “sent to grievances and appeals process”. The report shall summarize formal grievances and appeals and informal inquiries and resolutions (call center report). The report shall be submitted in the format provided by the State. Report is to list all complaints and report from escalation to grievance (see Attachment D).

2.3.4.1.3.10

Hysterectomies and Sterilizations Reports (42 CFR 441 Subpart F-Sterilizations): Hysterectomies and sterilizations shall comply with 42 CFR 441 Subpart F. This includes completion of the consent forms. Completion of the consent forms must be verified prior to the CONTRACTOR reimbursement.

2.3.4.1.3.11

Licenses Verification: The CONTRACTOR will provide information on an annual basis, as requested by the State or the EQRO for verification of Licenses (CONTRACTOR & subcontractors).

2.3.4.1.3.12

Member Assignment Reports: The CONTRACTOR will submit Member assignment to PCP at least one (1) time per month, or as assigned by the State and the fiscal agent.

2.3.4.1.3.13

Other Financial Reports:

2.3.4.1.3.13.1

Participating Provider Network Reports: The CONTRACTOR shall submit a quarterly updated provider network report that includes information on all providers of health services, including physical, behavioral health and long-term care providers as outlined in Section 2.2.8. This includes but is not limited to, PCP’s, physician specialists, hospitals, home health agencies, CMHC, nursing facilities, PRTF’s, Community based SUD providers, HCBS providers, and emergency and non-emergency transportation providers. Networks must be reported separately for each county in which the CONTRACTOR operates. Any changes in a provider’s CONTRACT status from the previous submission shall be indicated in the file generated in the quarter the change became effective. In addition to the quarterly submission, provider rosters must be submitted:

At the time the CONTRACTOR(S) enters into a CONTRACT with the State

At any time there has been a significant change (as defined by the State) in the entity’s operations that would affect adequate capacity and services.

2.3.4.1.3.13.2

Pharmacy Reports: Pursuant to requirements of the federal Patient Protection and Affordable Care Act (PPACA), P.L. 111-148 and Health Care and Education Reconciliation Act of 2010 (HCERA), P.L. 111-152, together called the Affordable Care Act, MCOs must provide information on drugs administered to individuals enrolled in the MCO if the MCO is responsible for coverage of such drugs. Specifically, Section 1927(b) of the Social Security Act, as amended by Section 2501(c) of PPACA, requires the State to provide utilization information for MCO covered drugs in the quarterly rebate invoices to drug manufacturers and in quarterly utilization reports to the Centers for Medicare and Medicaid Services. The CONTRACTOR shall provide data to the State for dates of services beginning with implementation of services as follows:

Submit drug utilization information on a monthly basis.

Report information on: total number of units of each dosage form; strength and package size by National Drug Code (NDC) of each covered outpatient drug administered to MCO Members; and such other data as the State determines necessary.

2.3.4.1.3.13.3

Quality Assessment and Performance Improvement Reports: At a minimum, the QAPI Report as outlined in Attachment J.

2.3.4.1.3.13.4

Telephone and Internet Activity Reports: The CONTRACTOR shall submit a summary report monthly, in a format provided by the State, and make available upon request any and all supporting documentation. Each telephone and internet activity report shall include but not be limited to the following; call volume, e-mail volume, average call length, average hold time, abandoned call rate, content of call or email and resolution and blocked call rate.

2.3.4.1.3.13.5

TPL Notification Reports: The CONTRACTOR shall provide TPL notification reports as outlined in Section 2.3.5, as specified by the State and the Fiscal Agent.

2.3.4.1.3.13.6

UM Reports: UM reports must include an analysis of data and identification of opportunities for improvement and follow up of the effectiveness of the intervention. Utilization data is to be reported based on claim data. The reports shall include specific data elements that are defined in section 2.2.40 such that all CONTRACTORS are reporting on common data set. The CONTRACTOR(S) shall submit UM report on utilization patterns and aggregate trend analysis. The CONTRACTOR(S) shall also submit individual physician and other provider profiles to the State, as requested. These reports should provide to the State analysis and interpretation of utilization patterns, including but not limited to, high volume services, high risk services, services driving cost increases, including prescription drug utilization; fraud and abuse trends; and quality and disease management. The CONTRACTOR(S) shall submit a proposed reporting mechanism, including but not limited to focus of study and data sources to the State for approval.
2.3.4.2

Corrective Action Plans (CAP) - The State may require corrective action in the event that any report, filing, examination, audit, survey, inspection, or investigation should indicate that a CONTRACTOR, or any subcontractor is not in substantial compliance with any material provision of this CONTRACT, or in the event that the State receives a substantiated Grievance or Appeal respecting the standard of care rendered by the CONTRACTOR or any subcontractor. The State may also require the modification of any policies or procedures of a CONTRACTOR relating to the fulfillment of its obligations pursuant to this CONTRACT. Should the State desire to take any such corrective action it must issue a written deficiency notice and require a CAP to be filed by the CONTRACTOR within 15 days following the date of the notice. A CAP shall delineate the time and manner in which each deficiency is to be corrected. The plan shall be subject to approval by the State, which may accept the plan as submitted, accept the plan with specified modifications, or reject the plan. The State may extend or reduce the time allowed for corrective action depending upon the nature of the deficiency.

2.3.4.2.1

Notice of Contractor Breach - If a Contractor fails to cure a default in accordance with a plan of correction under Section 2.3.4.2 the State shall issue a written notice to the CONTRACTOR indicating the violation(s) and advising the CONTRACTOR that failure to cure the violation(s) within a defined time period to the satisfaction of the State, may lead to the imposition of any sanction or combination of sanctions provided by the terms of this Contract, or otherwise provided by law, including but not limited to the following:

2.3.4.2.1.1

Suspension of further Enrollment for a Defined Time Period: When the State determines the CONTRACTOR is out of compliance with the CONTRACT, the State may suspend the CONTRACTOR’s right to new enrollment under this CONTRACT. The suspension will take effect if the non-compliance remains uncorrected at the end of the notice period. The State may suspend enrollment sooner than the time period specified in this paragraph if the State finds that Members’ health or welfare is jeopardized. The suspension period may be for any length of time specified by the State, or may be indefinite. The suspension period may extend to the expiration of this Contract.

2.3.4.2.1.2

Suspension of Capitation Payments;

2.3.4.2.1.3

Suspension or recoupment of the Capitation Rate paid for any month for any Member who was denied the full extent of Covered Services meeting the standards set by this Contract, or who received or is receiving substandard services;

2.3.4.2.1.4

Liquidated damages; or

2.3.4.2.1.5

Termination of this Contract.

All reports must be stratified as directed by the State.

General Audit Procedures - The CONTRACTOR, all subcontractors and parent companies agree to provide the results of an annual audit performed by an independent certified public accountant and to authorize the KID to share this information with the State. The CONTRACTOR shall authorize the independent accountant to allow representatives of the State, including the KID, upon written request, to verify the audit report.

2.3.4.4.1

Throughout the duration of the CONTRACT, and for a period of six (6) years after termination of the CONTRACT, the CONTRACTOR or its subcontractors shall provide duly authorized representatives of the State or Federal government, access to all records and material, including financial records, relating to the CONTRACTOR’S provision of and reimbursement for activities contemplated under the CONTRACT. Such access shall include the right to inspect, audit and reproduce all such records and material and to verify reports furnished in compliance with the provisions of the CONTRACT.

2.3.4.4.2

Allow duly authorized agents or representatives of the State and Federal government, during normal business hours, access to the CONTRACTOR’s premises or the CONTRACTOR’s subcontractor’s premises to inspect, audit, monitor or otherwise evaluate the performance of the CONTRACTOR’s or subcontractor’s contractual activities and shall forthwith produce all records requested as part of such review or audit.

2.3.4.4.3

In the event right of access is requested under this section, the CONTRACTOR or subcontractor shall upon request provide and make available staff to assist in the audit or inspection effort, and provide adequate space on the premises to reasonably accommodate the State or Federal representatives conducting the audit or inspection effort. In practice, the State notifies any entity audited well before the actual audit occurs. A pre-entrance conference is scheduled to inform the CONTRACTOR about the process. Audits are generally scheduled at a mutually agreed upon time. However, there may be unusual circumstances which require that the State perform an audit with minimal notice. These circumstances would include alleged failure to comply with the CONTRACT. If the CONTRACTOR complies with the CONTRACT, the timing of any audit is unlikely to be a problem.

2.3.4.4.4

All inspections or audits shall be conducted in a manner as will not unduly interfere with the performance of CONTRACTOR’s or subcontractor’s activities. The CONTRACTOR shall be given 10 business days, or an amount of time agreed upon by the State and the CONTRACTOR, to respond to any findings of an audit before the State shall finalize its findings. All information so obtained will be accorded confidential treatment as provided under applicable law.

Identification of Patients for Purposes of Making DSH Payments

2.3.4.5.1

The CONTRACTOR(S) shall provide to the State information necessary to determine the hospital services provided under the contract (and the identity of hospitals providing such services) for purposes of calculating Disproportionate Share Payments.

Post-Pay Recovery {Third Party Liability (TPL)}

2.3.5.1.1

TPL refers to any individual, entity or program that may be liable for all or part of a member’s health coverage. Under Section 1902(a)(25) of the Social Security Act, the state is required to take all reasonable measures to identify legally liable third parties and treat verified TPL as a resource of the T-XIX member. The CONTRACTOR shall also follow all federal regulations and all State of Kansas statutes and regulations for TPL, medical subrogation and estate recovery.

2.3.5.1.1.1

The CONTRACTOR must agree to take responsibility for identifying and pursuing TPL for its T-XIX members. The CONTRACTOR must make best efforts to identify and coordinate with all third parties against whom members may have a claim for payment or reimbursement for services. These third parties may include Medicare, any other group insurance, trustee, union, welfare, or employer organization, employee benefit organization including preferred provider organizations or similar type organizations, any coverage under governmental programs, and any coverage required to be provided for by state law.

Coordination of Benefits (COB)

2.3.5.2.1

T-XIX is secondary to all other third parties with the exception of Special Health Services, Vocational Rehabilitation, Indian Health Services and Crime Victim’s Compensation Funds. As capitated payments made to the CONTRACTOR are from T-XIX funds, the CONTRACTOR would be secondary to all other third parties not listed above.

2.3.5.2.2

The State has adjusted the CONTRACTOR capitation payment equal to the State’s TPL recoveries for Medicaid members. In lieu of this offset to capitation, the CONTRACTOR will retain its TPL recoveries.

2.3.5.2.3

The CONTRACTOR shall perform data matches with Medicare and with Private Health Insurance companies to ensure that it maintains a full and accurate list of primary insurance. The CONTRACTOR shall also participate in the DEERS data match and the PARIS data match.

2.3.5.2.4

The CONTRACTOR must track its TPL cost avoidance and recovery for all members and report this recovery amount to the State according to the format and schedule specified by the State in the Payment Integrity Report (Exhibit 1-2).

2.3.5.2.5

Data transfer of TPL information on any member shall occur according to the format and schedule specified by the State.

2.3.5.2.6

The CONTRACTOR shall transfer to the State any new TPL information on any member that comes to their attention.

2.3.5.2.7

The State shall transfer to the CONTRACTOR any new TPL information for any member that comes to their attention.

2.3.5.2.8

The CONTRACTOR will coordinate with the State to comply with any information requests regarding child support birth expenses within 10 business days

2.3.6.1.1.1

REQUIREMENT: Each proposal must include a completed Exhibit 1-3, Low Cost Estimate Discount Form.

Databook, Financial/Rate Development Questions, and Bidder’s Conference - To assist the vendors in developing a competitive bid discount, the State and the State’s actuaries will develop a comprehensive, summary level databook containing information on the populations and services to be included within this procurement by region. The vendors will be allowed to submit questions regarding the financial terms of this RFP and the rate development process and the State will make those questions and the corresponding answers available to all vendors registered for this RFP, consistent with Kansas procurement law. In addition, the State and the State’s actuaries will conduct a Bidder’s Conference to answer questions about the RFP, the financial terms, and the rate development process. Vendors are cautioned that any verbal answers provided during the Bidder’s Conference, per Kansas procurement law, are considered non-binding and only those answers formally provided in writing by the designated procurement officer are binding. Vendors are cautioned that any communication with any State or State’s Actuarial staff other than through the designated procurement officer is grounds for disqualification of their proposal.

2.3.6.1.5

Final Capitation Rates

The LCE shall be used to determine the capitation rates paid using the following formula:

x Vendor’s Discount Factor by Region

x State’s Rate Cell Factors

x State’s Regional Factors by Rate Cell

+ State’s PMPM Non-Medical Load by Rate Cell

=Vendor’s Capitation Rates by Region by Rate Cell

Monthly Capitation Payments calculated in accordance with the Contract will be paid by the State. The State will reduce the capitation for Enrollee Share of Cost Contributions. Capitation rates will be net of third party liability recoveries. In Year 1 of the contract, the State will include a 3% quality improvement withhold that MCOs can earn back based on their performance on the quality improvement targets included in Section 2.2.21.1.5 and Attachment J of the Contract. In Year 2 or 3, the State intends to increase the quality improvement withhold to 5% and link it directly to the risk-sharing program in order to ensure that financial incentives in this contract appropriately reflect the State’s interest in improving the quality of the services. As noted above, in Year 2, the State reserves the right to adapt the auto-assignment algorithm to incorporate differential enrollment percentage targets linked to a plan’s quality improvement scores.

2.3.6.2.1

Contractor’s shall observe a payment floor for all providers at 100% of FFS inclusive of options for quality and outcomes incentive payments.

2.3.6.3

Risk Sharing Agreement

Definitions.

2.3.6.3.1.1

“Adjusted Medical Expenditures” means expenditures submitted by the Contractor that are adjusted to reflect the lesser of the plan’s actual medical expenditures, or 105% of the State’s fee-for-service level, in aggregate, for all medical services (with the exception of Pharmacy and Transportation services which shall be included as Adjusted Medical Expenditures based on Actual Medical Expenditures). Expenditures will exclude any and all case management and administrative costs and amounts equal to any Co-Payments the Contractor imposes or could impose on Enrollees. Any administrative capitation pmpm paid to a provider in addition to medical fee for services reimbursement shall be excluded as a case management cost and not a medical cost for purposes of calculating medical expenditures. Actual medical expenditures must be reduced by any recoveries from other payers including those pursuant to coordination of benefits, third party liability, reinsurance (net of reinsurance premiums), rebates, or adjustments in claims paid, or from providers including adjustments to claims paid. Adjusted Medical Expenditures excludes non-State Plan services.

2.3.6.3.1.2

“Routine Encounter Data” as defined by CMS means, "Detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form.”

2.3.6.3.1.3

“Total Adjusted Expenditures” is defined as the sum of the Adjusted Medical expenditures plus the Administrative amount plus the privilege fee amount.

2.3.6.3.1.4

“Actual Medical Expenditures” is defined as the Contractor’s actual amount paid for medical expenditures.

2.3.6.3.1.5

“Total Capitation Rate(s)” is defined as capitation and delivery payments to Contractor.