Request for Proposal (RFP) Organization
This RFP is organized in the following manner:
RFP Section 1: RFP Purpose, Background, and General and Administrative Information: Contains an explanation of the RFP purpose, the program backgrounds, information concerning existing the Kansas Department of Health and Environment – Division of Health Care Finance (KDHE-DHCF); The Kansas Department of Social and Rehabilitation Services (SRS); The Kansas Department on Aging (KDOA); managed care services (MCS) to be procured; background and history of the various programs; mandatory VENDOR qualifications, the Procurement Schedule, various VENDOR instructions, and other items of interest to the VENDOR.
RFP Section 2: MCS Procurement Scope and Approach: Contains information about the procurement goal, key stakeholders, CONTRACT and term information, and a summary of the solution scope, including core functional scope, implementation and integration services scope, ongoing operations scope, organizational scope, and other scope considerations. Resources, facilities, and equipment to be provided by the State are also discussed.
RFP Section 3: Proposal Response: Contains proposal submission information, and instructions concerning how VENDORs are to structure and format their proposals. Detailed preparation instructions are given for each section of both the Technical Proposal and the Cost Proposal.
RFP Section 4: CONTRACT Terms and Conditions: Contains several terms and conditions under which the CONTRACTOR shall perform the CONTRACT.
RFP Section 5: Forms: Contains the various forms that support the procurement process and the submission of a proposal.
RFP Attachments, Exhibits, and Universal/Uniform Resource Locator (URL) Links:
Attachments:
The instructions, information, deliverables and other provisions as applicable found in Attachments A through L attached hereto, are hereby incorporated in this CONTRACT and made a part hereof.
Exhibits:
Information provided in Exhibits 1-1 through 6-17 is provided for informational purposes only. Such information is typically historical or illustrative in nature and is provided for your information. These documents are not incorporated in this CONTRACT and are not made a part hereof.
URL Links:
The Instructions, information, deliverables and other provisions as applicable found in forms; instructions; manuals; standards; orders; Medicaid and Children’s Health Insurance Plan (CHIP) State Plans and State Plan Amendment documents; waivers; state and federal regulations; state and federal laws; and other documents provided in the various URLs (a character string that specifies where a known resource is available on the Internet and the mechanism for retrieving it) provided herein are not incorporated in this CONTRACT and are not made a part hereof. However, CONTRACTOR(S) providing services under a CONTRACT awarded through this RFP shall monitor the information provided in the various URLs on a regular basis for any changes, amendments or addenda and will be required, through the term of CONTRACT, to comply with all applicable forms; instructions; manuals; standards; orders; Medicaid and CHIP State Plans and State Plan Amendment documents; waivers; regulations; state and federal laws; and other documents provided in the various URLs affecting the performance of their duties in accordance with the terms and provisions of their CONTRACT.
Federal and State Laws and Regulations:
The State has elected to NOT PROVIDE copies of Federal and State Laws and Regulations. Certain legal or regulatory citations have been provided either as required by law or regulation or in the interest of facilitating the CONTRACTOR(S) awareness of the citations. It is the CONTRACTOR(S) responsibility to remain aware of applicable laws and regulations and to remain compliant with them as required by the Terms and Conditions of this RFP.
Kansas Statutes and Regulations can be found at:
http://www.kslegislature.org/li/statute/
and,
http://www.kssos.org/Pubs/pubs_kar.aspx
RFP Section 1
RFP PURPOSE, CONTRACTOR(S) DUTIES, BACKGROUND, IMPLEMENTATION AND GENERAL AND ADMINISTRATIVE INFORMATION
1.1 PURPOSE
The State of Kansas is issuing this RFP to obtain competitive responses from VENDORs to provide managed care for the Kansas Medicaid and CHIP programs. Services included in this RFP are physical health services, behavioral health services, and long term care (LTC), including nursing facility (NF) care and home and community based services (HCBS). These services will be provided statewide and include Medicaid funded inpatient and outpatient mental health and substance use disorder (SUD) services including existing 1915 c HCBS Waiver programs for children with a Serious Emotional Disturbance (SED). Three statewide contracts will be awarded to winning VENDORs.
Almost all Medicaid members and 100 percent of CHIP members will be required to enroll in a managed care plan. Certain Medicaid eligibles including dual eligibles (Medicare and Medicaid), foster care children and disabled children may be voluntarily enrolled, but may not be enrolled on a mandatory basis without a waiver from Centers for Medicare and Medicaid (CMS). Kansas is applying for a waiver to allow for mandatory enrollment of these eligible groups in managed care. Section 1.3.6 and Exhibit 1 describe who will be required to enroll and which populations are excluded.
The State intends to develop an innovative managed care program. Requirements in this RFP are extensive, reflecting the ambitious nature of this program. The State recognizes that VENDORS will bring a variety of strengths, experience, innovation, and added value to the KanCare program, all of which will be considered in the selection. The State encourages and solicits the widest-possible range of responses to this RFP. The State is interested in developing a vibrant business relationship with its CONTRACTORS to help identify, define, and implement a continuing series of market reforms which lead to optimal integration of care.
1.2 CONTRACTOR RESPONSIBILITIES:
1.2.1
The selected CONTRACTOR(S) shall be responsible for duties and activities that include but are not limited to:
1.2.1.1
Federal and State Laws and Regulations: The CONTRACTOR(S) shall observe and comply at all times with all, then current, Federal and State Laws and Regulations related to or affecting this CONTRACT during the term of this CONTRACT. This includes existing laws and regulations as well as any laws and regulations that may be enacted during the term of this CONTRACT. It is the CONTRACTOR(S)’ responsibility to remain aware of changes in existing Federal and State Laws and Regulations as well as the enactment of new Laws and Regulations as they affect the CONTRACTOR(S)’ duties and responsibilities under this CONTRACT.
The remaining terms and conditions of the CONTRACT shall remain unchanged.
1.2.1.2
The CONTRACTOR(S) will demonstrate an eight (8) to 10 percent increase in savings to the State for these programs, and a significant improvement in core outcomes for the people served in these programs over the initial three (3) years of this Agreement. These savings should be achieved by increased care coordination and better outcomes (e.g. National Outcome Measures (NOMS), Healthcare Effectiveness Data and Information Set (HEDIS) and others) rather than by significant or widespread reduction in rates to providers, by withholding required services, or by decreasing quality of or access to any services.
1.2.1.3
The CONTRACTOR(S) selected for this work will need to demonstrate:
1.2.1.3.1
How they will work with existing Community Mental Health Centers (CMHCs) and the Community Developmental Disability Organizations (CDDOs) across Kansas, and how they will incorporate the functions of the CMHCs and CDDOs to the extent required by law
1.2.1.3.2
How they will minimize potential conflict of interest between assessment of need for services and service delivery
1.2.1.3.3
How they will work with existing and additional provider networks and stakeholders to successfully meet the needs of people with mental health (MH), SUD, physical disability (PD), developmental disability (DD), traumatic brain injury (TBI), TA, autism and frail elderly (FE) waiver service needs
1.2.1.3.4
How they will implement a health home model that ensures a maximum number of people have the option of using as their medical home, a qualified health home that also has specialized or non-traditional provider with particular knowledge about/experience with the person’s treatment needs and/or a relationship with the person
1.2.1.3.5
Unless and until the State makes a specific finding of provider panel inadequacy, communicated in writing with a specific explanation of the inadequacy and the expected resolution of such a finding, the CONTRACTOR(S) selected for this work are required to utilize Community Mental Health Centers to provide specialized mental health services, including rehabilitation, SED waiver, attendant care and related services. The CONTRACTOR(S) will retain the right to directly provide targeted case management (TCM) or utilize CMHCs or other providers to provide TCM.
1.2.1.3.5
How they will manage nearly all statewide physical, behavioral health services, LTC and HCBS services for Kansas residents who meet the eligibility requirements defined in this RFP
1.2.1.3.6
How they will apply managed care practices in a manner that results in eligible individuals receiving services that are timely, culturally relevant, and effective in reducing problems and symptoms stemming from physical or behavioral health issues, maximizing functioning, and improving the recipient’s quality of life
1.2.1.3.7
How they will operate in partnership with the State and the community to ensure that managed care operations and services result in the delivery of effective services that sustain individual functional gains. The CONTRACTOR(S) shall routinely solicit input from stakeholders, including individuals and family members receiving services that inform the CONTRACTOR(S) about needed system improvements (See Attachment J – State Quality Strategy)
1.2.1.3.8
How they will establish a comprehensive, accessible provider network that offers a choice of provider to the extent possible and appropriate and a coordinated array of services to eligible individuals
1.2.1.3.9
Pro-activity and innovation in organizing and administering a service delivery system that meets the needs of eligible individuals, while complying with all federal and state laws, regulatory and contractual requirements
1.2.1.3.10
How they will ensure the delivery of services to eligible individuals that are readily accessible and provided in the least restrictive, safe environment likely to result in desired outcomes
1.2.1.3.11
How they will ensure the delivery of services to all areas of the state, ensuring access in rural and remote areas as well as urban areas
1.2.1.3.12
How they will conduct managed care activities including, but not limited to, provider network development and management, access to care, customer service, care management, utilization management (UM), quality management (QM), and effective resolution of complaints, and grievances and appeals
1.2.1.3.13
How they will make data-based decisions that positively impact the delivery system
1.2.1.3.14
How they will operate in a manner that promotes efficiency in the service delivery system while offering the highest quality services
1.2.1.4
CONTRACTOR(S) shall provide a managed care process that does not add to the administrative burden for providers, and,
1.2.1.4.1
Provide their recommendations to reduce administrative burdens on beneficiaries and providers. The State will consider administrative simplification recommendations even if they might require waiver or special consideration/approval from CMS. Such recommendations could include proposals to:
1.2.1.4.1.1
Reduce or simplify provider credentialing requirements;
1.2.1.4.1.2
Simplify or streamline claims processing for providers; or
1.2.1.4.1.3
Simplify or streamline prior authorization (PA) processes.
1.2.1.5
Innovative Ideas: The State intends to include future initiatives, following the first year of implementation that can be incorporated into a comprehensive managed care delivery system, with or without additional federal waivers. Future initiatives will include the following.
1.2.1.5.1
The State intends to allow families and individuals who obtain jobs with income that makes them ineligible for the KanCare program to buy into health plans selected in this procurement. This program will include a second, basic coverage plan that transitioning Members could select and expects to consider a plan that incorporates the use of a health savings account. The State seeks recommendations for the design of this program.
1.2.1.5.2
The State intends to create Health Opportunity Accounts (HOAs) to allow Members to purchase health care directly up to allowable amounts and seeks options for such a program.
1.2.1.5.3
The State seeks options to allow the creation of individualized budgets in conjunction with HOAs to allow eligible Members to purchase HCBS.
1.2.1.5.4
The State encourages the development of shared savings programs for providers who participate in health homes, substantially improve health outcomes, or otherwise demonstrate specific value-added service.
1.3 BACKGROUND
The State of Kansas has determined that contracting with multiple MCOs will result in the provision of efficient and effective health care services to the populations currently covered by Medicaid and CHIP in Kansas, as well as ensure coordination of care and integration of physical and behavioral health services with each other and with HCBS.
The Kansas Medicaid population is divided into three distinct populations – parents, pregnant women and children, various disability groups (e.g., those with intellectual or PD, or both, and persons with SPMI), and the aged (65 and older). Parents, pregnant women and children (low-income populations) are currently in a capitated, risk-based managed care program called HealthWave which serves both Medicaid and CHIP members. Roughly 238,000 are in this population. HealthWave services are provided through two MCOs. Another 75,000 individuals are in the disabled group and about 30,000 are in the aged group.
Presently, Kansas Medicaid services are managed across three different State agencies. KDHE is the single state Medicaid agency (SSMA) and its DHCF is responsible for the Medicaid State Plan (SP), interactions with CMS, drawing down federal financial participation (FFP) funds, and managing physical health care for all Medicaid beneficiaries and behavioral health for children enrolled in CHIP. KDHE-DHCF also formulates eligibility policy and manages the Eligibility Clearinghouse, where the majority of the HealthWave eligibility determinations are made. KDHE also manages a capitated non-emergency medical transportation (NEMT) CONTRACT to provide transportation to individuals in the fee for service (FFS) portion of physical health Medicaid.
KDOA provides policy decisions and day-to-day management of targeted case management (TCM) and HCBS for FE, NF, and the Program for All-Inclusive Care for the Elderly (PACE).
SRS manages behavioral health care for the non-CHIP populations and also manages six of the seven HCBS waivers the State has been granted. In addition, SRS field workers make eligibility determinations for the aged and disabled populations.
Behavioral health services are currently provided to the Medicaid populations through a pre-paid ambulatory health plan (PAHP) including the 1915 (c) HCBS Waiver for SED and the Psychiatric Residential Treatment Facility (PRTF) Community Based Alternatives (CBA) Demonstration Grant. The non-Medicaid populations access mental health supports through a State grant to 27 CMHCs. SRS field staff members oversee the regulatory compliance of the CMHCs for the non-Medicaid population.
SUD services are provided through a pre-paid inpatient plan (PIHP); however, behavioral health services for children in the CHIP portion of HealthWave are provided by a separate, risk-based capitated CONTRACT. Multiple state and federal funds for SUD and Problem Gambling services (Substance Abuse Prevention and Treatment Services (SAPT) Block Grant (BG) and associated state funds, driving under the influence (DUI) and Problem Gambling) are also managed through the PIHP.
1.3.1 SUD Program
T-XIX-funded SUD services and SUD services funded by other sources such as the SAPT BG are overseen by SRS. SRS, through its Disability and Behavioral Health Services (DBHS) Division of Addiction and Prevention Services (AAPS) funds a comprehensive SUD treatment infrastructure, guided by evidence-based practices, data-driven processes, and outcomes-based planning and evaluation via the Substance Abuse-Prepaid Inpatient Health Plan (SA-PIHP). The SA-PIHP is managed by ValueOptions-KS (VO-KS) which was awarded this CONTRACT beginning July 1, 2007. VO-KS administers statewide managed care to include authorizing services, paying claims, managing a credentialed network and providing access to SUD services.
Providers are required to use the AAPS integrated data system to request and receive authorization for care from VO-KS. The basis of this system is the Kansas Client Placement Criteria (KCPC) screening/assessment tool which is based on American Society of Addiction Medicine (ASAM) criteria. This system captures the NOMS and Treatment Episode Data Set (TEDS) as required by Substance Abuse and Mental Health Services Administration (SAMHSA), and monitors quality of care. As required by SRS, VO-KS has used the AAPS Integrated Data System and integrated the use of this system with their managed care information systems. The platform for the KCPC is antiquated. Fox-pro will stop being supported in 2014; therefore AAPS is in the process of researching other options. Selected CONTRACTORs will be required to work with this and the replacement system.
Prior to July 1, 2007 AAPS had traditionally funded Regional Alcohol and Drug Assessment Centers (RADACs) to provide statewide on-site assessment and referrals to the SUD treatment service that best meets the member’s needs. The two RADACs currently conduct state-wide assessments, referrals, outreach and care coordination services via their contracts with VO-KS.
The current system provides SUD treatment services to approximately 20,000 people annually. Of those, approximately 30 percent are women and 70 percent are men. The majority of people present with alcohol as their primary drug of choice followed by marijuana, cocaine, methamphetamine and other. Approximately 30% of all Members receiving services were T-XIX eligible. More information about T-XIX enrollment is provided in the Data Book to be provided at a later date.
AAPS provides services through approximately 60 AAPS funded providers, with about 100 facilities providing Medicaid funded treatment services. In addition, about 60 programs provide services under the DUI treatment grants. Twenty-one of the providers offer residential services with 728 beds available. Over 200 of these beds are dedicated to serving pregnant women and women with children. All providers of Medicaid and AAPS funded services are, or may become, eligible to deliver recovery case management and peer support services. Currently, about 100 of the funded facilities can bill for recovery supports such as peer mentoring and case management. SUD treatment services are provided on a FFS basis.
1.3.2 Mental Health (MH)
The SRS DBHS Mental Health Services Community Based Managed Care Team has provided oversight to the contractual monitoring of the non-risk PAHP. SRS Field Staff provide oversight for regulatory compliance of the CMHCs. The State insists that persons with mental illness should receive services that support their MH recovery and to live safe, healthy, productive, successful, self-determined lives in their homes and communities. The focus on community based services and supports, the SED Waiver, PRTF CBA Demonstration Grant and monitoring of the utilization of inpatient care are central to this value. In efforts to expand the MH provider network and meet CMS requirements, the PAHP recruited providers and developed and administered a comprehensive MH provider network assuring access to care for all enrollees. The PAHP was paid a cost-related administrative fee and reimbursement for each service pursuant to 42 CFR 447.362, the approved CMS 1915(b) and 1915(c) waivers, consistent with the terms of the CONTRACT. The PAHP was responsible for authorizing payments for services, processing and paying claims, conducting utilization and QM functions, serving in an administrative capacity for placing into operation the 1915 (c) SED Waiver and PRTF CBA Demonstration Grant to maintain compliance with the approved waiver application and various provider compliance activities that included a robust fraud and abuse prevention plan.
The current system for delivering MH services consists of 25 CMHCs that are designated as “participating” MH centers by law, and two “affiliated” MH centers. The two affiliated MH centers are located in Shawnee and Sedgwick County. Each of the participating CMHC operates in either the Osawatomie State Mental Health Hospital (SMHH) catchment area in eastern Kansas or the Larned SMHH catchment area in western Kansas.
The participating CMHC are responsible for making sure that a core array of MH services is available in the areas they serve. These core services include rehabilitative and community based supports such as TCM, Community Psychiatric Support as well as the 1915 (c) Waiver specific services. Under the State’s current approach to MH, these centers are responsible for performing the primary provider function using clinically licensed providers to assess an individual’s risk for inpatient services. The purpose of the assessment is to ensure that clients who need hospitalization get coordinated access to that service, with appropriate aftercare planning and access. Those who do not need hospitalization get connected to services in their communities that are least restrictive and most appropriate for them. Participating centers are entitled to a variety of State and federal funds, including state aid, MH reform grants, and State hospital closure grants. They are also allowed to bill Medicaid for the services they provide eligible beneficiaries.
State regulations require CMHCs to provide necessary MH services to all clients regardless of their ability to pay, but the main emphasis of their services is on a targeted population. The targeted population includes those who are most at risk of being hospitalized–adults with SPMI and children with SED. Many of these in the target populations access services through the SED 1915(c) waiver. During the past twelve years, the number of adults served in the targeted population has nearly doubled from 7,775 to 14,831 in FY 05. The number of children served in the targeted population during that same period has more than tripled from about 6,000 to 20,305. The targeted population represents about one quarter of the clients served by the CMHCs.
The inclusion of the independent practitioners as Medicaid providers in 2007 has expanded the overall MH provider network. The Mental Health Service delivery system outside of the CMHCs is now comprised of more than 1,200 independently credentialed providers. These providers range from Psychiatrists, to Advanced Registered Nurse Practitioners (ARNP) to Licensed Clinical Social Workers.
MH and SUD Prevention services funded under the SA/MH BG are not the responsibility of the CONTRACTOR.
1.3.2.1
Waiver Populations Served -
HCBS is currently provided through seven 1915(c) waivers, targeting these specific populations:
1.3.2.1.1
Children with autism
1.3.2.1.2
Children and adults with DD
1.3.2.1.3
People ages 16 – 64 with PD
1.3.2.1.4
Medically fragile children ages 0 - 22 dependent on intensive medical technology (TA)
1.3.2.1.5
People ages 16 – 64 with TBI
1.3.2.1.6
People 65 and older who are functionally eligible for nursing facilities (FE)
1.3.2.1.7
Children who are SED.
1.3.2.2
A variety of community-based organizations (CBOs) currently provide services to HCBS populations, including, but not limited to:
1.3.2.2.1
Area Agencies on Aging (AAA),
1.3.2.2.2
Centers for Independent Living (CIL),
1.3.2.2.3
Community Developmental Disability Organizations (CDDO),
1.3.2.2.4
Community Mental Health Centers (CMHC), and
1.3.2.2.5
Home Health Agencies (HHA).
1.3.2.3
In addition, most of the populations served through HCBS waivers also receive TCM through the SP. TCM is provided through the CBOs listed above or through other agencies or individuals affiliated with CBOs.
The populations served by HCBS waivers, along with others who are aged or disabled, receive their physical health care services in an unmanaged, FFS environment. One of the primary aims of this RFP is to improve integration and coordination of care for this group which contains individuals who have multiple chronic conditions. While managing several populations and programs allows for administrative efficiencies, Kansas CONTRACTOR(S) are required to report separately on expenditures and utilization for behavioral health, physical health, LTC and HCBS. Additional aims for providing all services in a comprehensive managed care CONTRACT are to:
1.3.2.3.1
Measurably improve health care outcomes for members in the following areas:
1.3.2.3.1.1
Diabetes
1.3.2.3.1.2
Coronary Artery Disease
1.3.2.3.1.3
Chronic Obstructive Pulmonary Disease
1.3.2.3.1.4
Prenatal Care
1.3.2.3.1.5
Behavioral Health
1.3.2.3.1.5.1
Improve coordination and integration of physical health care with behavioral health care
1.3.2.3.1.5.2
Support members successfully in their communities
1.3.2.3.1.5.3
Promote wellness and healthy lifestyles
1.3.2.3.1.5.4
Lower the overall cost of health care
1.3.3 Current Waivers
1.3.3.1
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