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

RFP Section 2

SCOPE, APPROACH AND OTHER REQUIREMENTS

Statutory Requirements - The CONTRACTOR(S) shall:

2.2.3.1.1

Retain at all times during the period of this CONTRACT a valid Certificate of Authority issued by the Kansas Department of Insurance.

2.2.3.1.2

Certify to the State, in accordance with section 1932(d)(1) of the Social Security Act, that it does not knowingly have a relationship with the following:

An individual who is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No.12549 or under guidelines implementing Executive Order No. 12549.

An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described in paragraph (a)(1).

2.2.3.1.3

The relationship is described as follows:

A director, officer, or partner of the MCO

A person with beneficial ownership of five percent or more of the MCO's, equity.

A person with an employment, consulting or other arrangement with the MCO obligations under its CONTRACT with the State.
Please refer to the Federal Excluded Parties List located at:
https://www.epls.gov/
for a listing of federally debarred and suspended individuals.

2.2.3.1.4

In accordance with CMS Release No. 35, Medicaid Clinical Laboratory Improvement Amendments (CLIA) Implementation, the CONTRACTOR(S) shall obtain copies of the valid CLIA certificates from the laboratories and/or all entities providing laboratory services funded by Title XIX and Title XXI of the Social Security Act. The CONTRACTOR(S) shall provide a listing to the State of all laboratories and/or entities providing laboratory services used by the CONTRACTOR(S) and shall certify to the State that the laboratories and/or entities providing laboratory services are CLIA certified. The CONTRACTOR(S) shall update the listing and certification as laboratories and/or entities providing laboratory services are added to or dropped from the list.

2.2.3.1.5

The CONTRACTOR(S) shall provide assurance that any providers delivering services are licensed as required by applicable State laws. Addictions Counselor Licensure was made law effective July 1, 2011 (HB 2182). The Behavioral Sciences Regulator Board (BSRB) licenses these professionals. Currently State law also requires that any provider of SUD treatment services in a facility setting be licensed by SRS to provide SUD treatment services; that any provider determining the medical necessity of such services according to the Kansas definition must be a BSRB-licensed practitioner practicing within their scope as defined by the BSRB.

2.2.3.1.6

Comply with all other applicable federal and state statutes and regulations governing MCOs and Title XIX and Title XXI of the Security Act.

2.2.3.1.7

The CONTRACTOR must comply with any applicable Federal and State laws that pertain to member rights and ensure that its staff and affiliated providers take those rights into account when furnishing services to members.
2.2.4 Provider Credentialing and Re-credentialing
2.2.4.1

The CONTRACTOR(S) shall:

2.2.4.1.1

demonstrate that its providers are credentialed as prescribed in 42 CFR 438.214 and:

2.2.4.1.2

follow a documented process for credentialing and re-credentialing of providers who have signed contracts or participation agreements with the CONTRACTOR(S) and use the Kansas Standardized Credentialing Application found at:

not discriminate against particular providers that serve high-risk populations or specialized in conditions that require costly treatment; and

2.2.4.1.4

only CONTRACT with NFs certified under Medicaid but will be expected to help NFs move to both Medicare and Medicaid certification to maximize use of Medicare funding.

2.2.4.1.5

not CONTRACT for services with any provider who also provides either case management or functional eligibility assessments, in order to achieve conflict-free case management for LTC and HCBS services.

2.2.4.1.6

ensure that the credentialing process provides for re-credentialing to occur every three years, at a minimum.

2.2.4.1.7

ensure that credentialing of all service providers applying for network provider status shall be completed as follows: 90% within 30 days; 100% within 45 days. The start time begins when all necessary credentialing materials have been received. Completion time ends when written communication is mailed or faxed to the provider notifying them of the CONTRACTOR’S decision.

The CONTRACTOR(S) shall:

2.2.5.1.1

promote the delivery of services in a culturally competent manner to all members, including those with limited English proficiency and diverse cultural and ethnic backgrounds.

2.2.5.1.2

address the special health needs of members who are poor, homeless and/or members of a minority population group. The CONTRACTOR(S) shall incorporate in its policies, administration, and service practice the values of (1) honoring member’s beliefs, (2) sensitivity to cultural diversity, and (3) fostering in staff and providers attitudes and interpersonal communication styles which respect members’ cultural backgrounds. The CONTRACTOR shall have specific policy statements on these topics and communicate them to sub-CONTRACTORs.

2.2.5.1.3

encourage and foster cultural competency among providers. The CONTRACTOR(S) shall permit members to choose providers from among the CONTRACTOR’S network based on cultural preference. The CONTRACTOR shall permit members to change primary providers based on cultural preference. Members may submit grievances to the CONTRACTOR(S) and/or the State related to inability to obtain culturally appropriate care. The member may request to be assigned to another provider with their current CONTRACTOR(S) or the State will permit the member to disenroll and enroll with another CONTRACTOR(S). Culturally appropriate care is care by a provider who can relate to the member and provide care with sensitivity, understanding, and respect for the member’s culture.

2.2.5.1.4

ensure access to treatment services for all cultural, ethnic, age, and gender groups.

2.2.5.1.5

participate in the State’s efforts to promote the delivery of services in a culturally competent manner to all Members and potential enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds.

2.2.5.1.6

identify people with high needs and to initiate ongoing treatment coordination and ensure provider treatment planning and service coordination with the Member and others working with the Member.

In order to identify Members with special SUD treatment needs, the CONTRACTOR(S) is required to identify Members who meet the criteria for intravenous (IV) drug user, pregnant substance abuse user, or dual diagnosis (concurrent substance abuse and mental illness diagnosis).

The CONTRACTOR(S) shall implement mechanisms, using appropriate health care professionals, to assess each Member to identify any ongoing special conditions that require a course of treatment or regular care monitoring

For Members with special health care needs who need a course of treatment or regular care monitoring, the CONTRACTOR is required to ensure that the Member has a treatment plan that meets the requirements in this RFP and Kansas Statute and/or Regulation.

The CONTRACTOR(S) is required to coordinate the services provided to the Member with special health care needs.

The CONTRACTOR(S) shall require, as allowed by confidentiality laws, that providers of treatment for individuals with special needs shall agree to develop treatment plans that:

2.2.5.6.1

ensure that in the process of coordinating care, each enrollee's privacy is protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR Part 164 specifically describes the requirements regarding the privacy of individually identifiable health information. Health plans must comply with these requirements if they meet the definition of health plan found at 160.103: group health plan; health insurance issuer; HMO; Medicaid programs; SCHIP program, any other individual or group plan, or combination of individual or group plans, that provides or pays for the cost of medical care. CMS recommends that Medicaid Managed care contracts include a provision that states that the MCO/PIHP/PAHP, as applicable, is in compliance with the requirements in 45 CFR Parts 160 and 164.

2.2.5.6.2

Are developed with the Member’s primary care provider (PCP), Member’s participation, and in consultation with any specialists caring for the Member (the member may choose to involve another physician other than their PCP in the development of their treatment plan. If the PCP chooses not to participate in the development of the mental health treatment plan, on-going communication with the PCP is required to be documented by the CONTRACTOR(S) and/or its sub-CONTRACTOR.);

2.2.5.6.3

Are approved by the CONTRACTOR(S) in a timely manner, if prior authorization of any service in the treatment plan is required;

2.2.5.6.4

Are in accord with any applicable State quality assurance and utilization review (UR) standards;

2.2.5.6.5

Permit direct access to specialists, as appropriate; and

2.2.5.6.6

Require focused coordination of treatment programs.

The CONTRACTOR(S) will work in conjunction with the member, family members and others to develop the plan of care, and to support the member’s treatment team in their review of the plan of care.

The CONTRACTOR will ensure that 100% of Mental Health treatment plans are developed with consumer/family involvement. Reports from Corporate Compliance will be provided annually summarizing the efforts of the reviews for this requirement. The report will indicate the statewide average, and report out by provider type (CMHC, Child Welfare or Private Provider). The report will include an analysis and improvement plan should any identified provider groups fall below the standard.

The CONTRACTOR(S) shall provide the services of interpreters or those with other special training as necessary free of charge to each potential enrollee or enrollee.

The CONTRACTOR(S) shall have procedures in place to ensure medically necessary services are available to Members on a 24 hours-per-day, seven (7) days per week basis.

For young persons with disabilities or diseases which require specialty care and who qualify for services under Special Health Services (SHS), Title V, through the KDHE and are enrolled in the MCO, the CONTRACTOR(S) must contact the Bureau of Children and Families within KDHE. KDHE shall be responsible for the assessment and plan of treatment for CSHCN. The CONTRACTOR shall follow SHS advice on referrals and coordination of care and shall have a mechanism in place to allow members to directly access a specialist or specialists as appropriate for the member’s condition and identified needs. The CONTRACTOR(S) shall implement and have in place, using appropriate health care professionals, mechanisms to assess each Medicaid and CHIP member identified as having special health care needs in order to identify any ongoing special conditions of the member that require a course of treatment or regular care monitoring. The CONTRACTOR(S) shall have in place mechanisms to assess the quality and appropriateness of care furnished to members with special health care needs and shall report the results of their assessment to SHS and the State.

2.2.6.2

The CONTRACTOR’S obligation to pay for services for CSHCN that are received from providers other than the CONTRACTOR(S) or its subcontractor is limited to covered services provided by a specialist or specialists as appropriate for the member’s condition and identified needs.

The CONTRACTOR(S) shall establish procedures to ensure that network providers comply with all timely access requirements and be able to provide documentation demonstrating monitoring. CONTRACTOR(S) shall regularly monitor providers to ensure compliance, and shall take corrective actions if a provider is found to be noncompliant.

The CONTRACTOR(S) shall maintain a network of appropriate providers that is supported by written agreements and sufficient to provide adequate access to all services covered under the CONTRACT. In establishing and maintaining the network, the CONTRACTOR(S) must consider the following:

2.2.8.2.1

The anticipated Medicaid enrollment,

2.2.8.2.2

The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented in the particular CONTRACTOR,

2.2.8.2.3

The numbers and types (in terms of training, experience, and specialization) of providers required to furnish the contracted Medicaid services,

2.2.8.2.4

The numbers of network providers who are not accepting new Medicaid patients, and

2.2.8.2.5

The geographic location of providers and Members, considering distance, travel time, the means of transportation ordinarily used by Members, and whether the location provides physical access for Members with disabilities.

The CONTRACTOR(S) must submit documentation to the State, in an approved format, that demonstrates the provider network offers an appropriate range of preventive, primary and specialty services that is adequate for the anticipated number of Members.

If a CONTRACTOR’S provider network is unable to provide medically necessary services covered under the CONTRACT to a particular T-XIX Member, the CONTRACTOR shall adequately and timely cover these services out of network for the T-XIX Member, for as long as the CONTRACTOR is unable to provide them. The CONTRACTOR(S) shall negotiate and execute written single-case agreements or arrangements with non-network providers, when necessary, to ensure access to covered services. Out-of-network providers shall coordinate with the CONTRACTOR(S) with respect to payment. The CONTRACTOR(S) shall ensure that no provider bills a Member for all or any part of the cost of a treatment service, except as allowed for Title XIX cost sharing, spenddown and client obligations, and non-T-XIX sliding fee scale payments by Members. The CONTRACTOR shall ensure that cost to the Member is no greater than it would be if services were provided within the network.

As permitted by Federal and State laws and regulations, for the first three (3) years of this CONTRACT, the CONTRACTOR(S) will give all Kansas CMHCs the opportunity to be part of its provider network. CONTRACTORS shall tender at least three (3) reasonable contract offers at a rate of reimbursement at or above the FFS rate described in the Medicaid SP. During this three-year time period, the CONTRACTOR may recommend disenrollment of providers not meeting defined performance measures. The State will retain final approval of the performance measures and any disenrollment recommendations. Any recommendation related to CMHCs must specifically demonstrate how defined performance measures can be achieved within the context of the requirements at 1.2.1.3.5.

2.2.8.5.1

The CONTRACTOR(S) will provide a complete description of how it will ensure Members the right to select the providers of their choice without regard to variations in reimbursement.

The CONTRACTOR(S) shall maintain a network of providers that is sufficient in number, mix, and geographic distribution to meet the needs of the number of anticipated Members and shall document adequate capacity:

2.2.8.6.1

at the time it enters into a CONTRACT with the State;

2.2.8.6.2

at any time there is a significant change (as defined by the State) in the CONTRACTOR’S operation that would affect

adequate capacity and services;

2.2.8.6.3

if there are changes in services, benefits, geographic service areas; or

2.2.8.6.4

if a new population is enrolled.

2.2.8.6.5

The documentation of network adequacy shall be signed by the Chief Executive Officer (CEO) and submitted at least annually to the State.

2.2.8.6.5.1

Network adequacy is addressed through different Kansas performance indicators that focus on specific time measures and the provider number, mix and geographic distribution. This measure is outlined in Attachment J- State Quality Strategy.

2.2.8.6.5.2

The data are used to: 1) develop a quantitative, regional understanding of the health care or service delivery system, including the subsystems and their relation; 2) identify needs for further data collection; and 3) identify processes and areas for detailed study. In addition, this information aids in the assessment of the effectiveness of the quality improvement processes. The data from all sources are analyzed for compliance. If indicated, the CONTRACTOR is required to implement corrective action.
2.2.8.7

The CONTRACTOR(S) shall maintain a network sufficient to offer Members a choice of providers to the extent possible and appropriate.

If an individual joins the CONTRACTOR(S) and is already established with a provider who is not a part of the network, the CONTRACTOR(S) shall make every effort to arrange for the Member to continue with the same provider if the Member so desires. In this case, the provider would be requested to meet the same qualifications as other providers in the network.

If a Member needs a specialized service that is not available through the network, the CONTRACTOR(S) shall arrange for the service to be provided outside the network if a qualified provider is available.

Periodic Comparison of Number and Types of Providers

2.2.8.10.1

The CONTRACTOR shall annually report the number and types of providers in their network.

Additional considerations for determining network adequacy include:

2.2.8.11.1

CONTRACTOR(S) shall respond to every contact or request for services in a place and manner that address the needs of the member.

2.2.8.11.2

If the initial or unplanned request is determined to be an emergency, all services shall be provided immediately as necessary to resolve the emergency. After the emergency has been resolved, if the Member is not detained for inpatient care and treatment, that Member shall be scheduled for a follow-up appointment and provided any necessary and appropriate services consistent with the requirements of the CONTRACT.

2.2.8.11.3
If the initial or unplanned request is determined to be an urgent matter or a routine matter, the Member shall be scheduled for an appointment with the appropriate staff within a timely period after that initial contact.

2.2.8.11.4

After a Member's first appointment, CONTRACTOR(S) shall begin providing any necessary and appropriate services to that Member within a timely period.
2.2.8.12

Some specific crisis responsiveness considerations relevant to mental health services include:

2.2.8.12.1

Crisis responsiveness which includes 24-hours a day, seven (7) days a week 365 days a year emergency treatment and first response for Members experiencing a MH crisis, including, when appropriate, staff going out of the office and to the individual for personal intervention, for any person found within the service area of the center who is thought to be experiencing a crisis or other emergency;

2.2.8.12.2

prevision of or referral to psychiatric and other community services, when appropriate;

2.2.8.12.3

emergency consultation and education when requested by law enforcement officers, other professionals or agencies, or the public for the purposes of facilitating emergency services;

2.2.8.12.4

assessment of any person found within the service area of the center to determine the need for inpatient, treatment, crisis services, or other community treatment services. This evaluation shall meet the following criteria:

2.2.8.12.5

follow-up with any Member seen for or provided with any emergency service and not detained for inpatient care and treatment, to determine the need for any further services or referral to any services.

2.2.8.12.6

In cases of discharge from institutional care, the CONTRACTOR will monitor and report provider contact to member following inpatient discharge with goals of offering and encouraging member’s attendance at follow-up appointments. The timeframe begins with the day of the member’s discharge. The CONTRACTOR will ensure 85% of Contacts will occur between 24 to 72 hours of discharge, 90% of Contacts will occur within 1-7 days and 95% of Contacts will occur within 1-10 days.   The Corporate Compliance Department of the CONTRACTOR will have protocols in place to review for compliance with this CONTRACT requirement and will report to SRS Quarterly by statewide average and by established catchment areas.

Behavioral Health, Disabilities and LTC Provider Contracts

2.2.8.13.1

The CONTRACTOR shall establish written provider subcontracts. The State shall approve all standard subcontract provisions required of network providers prior to the CONTRACTOR’s offering subcontract terms to the provider network.

2.2.8.13.2

The CONTRACTOR shall follow an open panel approach to SUD provider recruitment; that is, the CONTRACTOR shall subcontract with all providers of SUD services who are appropriately licensed, certified or accredited, who meet the credentialing criteria, who agree to the standard subcontract provisions and who wish to participate. The CONTRACTOR may limit the number of providers in the open panel to those needed to provide adequate provider network coverage and services. The State shall make a determination of provider network adequacy, based on substantiation by the CONTRACTOR.

CONTRACTOR(S) shall include CDDOs in their provider networks and shall comply with the provisions of Kansas Administrative Regulation (K.A.R.) 30-64-27.

2.2.8.14.1

Excerpt from K.A.R. 30-64-27. “Powers and duties of community developmental disability organizations. In addition to any other power and duty prescribed by law, and subject to appropriations, a CDDO shall have the power and duty to:

2.2.8.14.1.1

Directly or by subcontract, serve as a single point of application or referral for services, and assist all persons with a DD to have access to and an opportunity to participate in community services, except in those circumstances in which the secretary determines, subject to an immediate hearing before the district court located in the county in which the person with a DD resides, participation in community services is not the appropriate placement for such person because such person is presently likely to cause harm to self or others;

2.2.8.14.1.2

provide either directly or by subcontract, services to persons with a DD, including, but not limited to, eligibility determination; explanation of available services and service providers; case management services, if requested; assistance in establishing new providers, if requested; and advocacy for participation in community services;

2.2.8.14.1.3

organize a council of community members, consumers or their family members or guardians, and community service providers, composed of a majority of consumers or their family members or guardians who shall meet not less than quarterly to address systems issues, including, but not limited to, planning and implementation of services; and develop and implement a method by which consumer complaints, interagency and other intra-system disputes are resolved;

2.2.8.14.1.4

provide, directly or by subcontract, information about affiliate and referral services to persons with a DD whose particular needs can be met in the community or through government; and

2.2.8.14.1.5

ensure that affiliates have the option to review referrals and waiting lists on a periodic basis to contact potential consumers with information concerning their services.”

In-State and Out-of-State Providers: CONTRACTOR(S) shall establish a preference for in-state providers when available at competitive rates and levels of quality.

The CONTRACTOR(S) shall provide a detailed proposal to utilize physician extenders to better coordinate care and lower the cost of providing services under this RFP.

The CONTRACTOR(S) shall utilize the state’s Financial Management Services (FMS) providers.

Persons self directing their services use a payroll agent to assist in processing claims and payments to their direct support workers. These payroll agents use a portion of the funds drawn down through the claims they file to cover their administrative costs. CMS has mandated that the State separate the costs for administration and the payments for direct service workers. This separation has been done with the implementation of FMS.
All training courses and materials, approved SRS providers and additional information can be found at:
www.selfdirect.ks.gov
2.2.9 Relationship between CONTRACTOR and Network Providers
2.2.9.1

Any CONTRACTOR that engages or proposes to engage in a relationship(s) with any parties that have any legal, financial, contractual or related party interests with a provider or group of providers to be reimbursed through the State shall demonstrate both (a) an organizational structure and (b) policies and procedures that would prevent the opportunity for, or an actual practice which allows, a situation in which the CONTRACTOR gains any financial benefit from any policy or practice related to network recruitment, referral, reimbursement, service authorization, monitoring and oversight, or any other practice which might bring financial gain.

Situations that might indicate an attempt to assure financial gain include, but are not limited to:

a change of the distribution of referrals or reimbursement among providers within a level of care;

2.2.9.2.2

referral by the CONTRACTOR to only those providers with whom the CONTRACTOR shares an organizational relationship;

2.2.9.2.3

preferential financial arrangements by the CONTRACTOR with those providers with whom the CONTRACTOR shares an organizational relationship;

2.2.9.2.4

different requirements for credentialing, privileging, profiling or other network management strategies for those providers with whom the CONTRACTOR shares an organizational relationship; and

2.2.9.2.5

substantiated complaints by Members of limitations on their access to participating providers of their choice within an appropriate level of care.

Should a CONTRACTOR be selected who has an organizational relationship with a direct service provider(s), and should preferential treatment be determined by the State at any time during the CONTRACT Period, the State reserves the right to sanction the CONTRACTOR including, but not limited to:

2.2.9.3.1

requiring an independent audit to be done at the expense of the CONTRACTOR;

2.2.9.3.2

paying any costs incurred by the State to eliminate the preferential treatment, including costs associated with any legal or equitable remedy;

2.2.9.3.3

imposing limits on the amount of reimbursement allowable to the direct service providers represented by the organizational relationship; and

2.2.9.3.4

removing the direct service providers from the network by terminating the subcontract.

2.2.9.3.5

financial penalties to be determined by the State.

The CONTRACTOR(S) shall conduct ongoing network management activities. The activities shall include, but not be limited to:

2.2.10.1.1

developing, and submitting to the State for approval, a provider manual that:

2.2.10.1.2

contains dated CONTRACTOR policy and procedure information, including, in part, credentialing criteria, UM policies and procedures, billing and payment procedures, provider and Member grievance and appeal processes, and network management requirements;

2.2.10.1.3

is distributed to all network providers following approval of the State no later than 30 calendar days following the CONTRACT effective date, and then to network and non-network providers upon request thereafter;

2.2.10.1.4

is updated regularly, and distributed in whole or in part to network providers at least 30 calendar days in advance of any policy or procedure change;

2.2.10.1.5

developing a process and timeline for provider-specific profile reports. Profile reports shall include a multi-dimensional assessment of each provider’s performance using indicators for performance that address, at a minimum, clinical quality, access, utilization management, and Member satisfaction. The indicators selected shall be clinically relevant, quantitatively measurable, and appropriate to the population. The CONTRACTOR(S) shall submit the proposed profile report contents and formats to the State for review and approval prior to implementing them.

EPSDT Background and Definition: The CONTRACTOR(S) shall comply with Federal law and regulations governing the administration of the Medicaid services which require that a state provide health screening and necessary diagnostic and treatment services for all children under age 21 who are eligible for Medicaid. EPSDT is sometimes referred to as KAN Be Healthy (KBH) in Kansas. All references and provisions relating to EPSDT coverage shall also include all children enrolled under this CONTRACT under the age of 19 who are eligible for CHIP benefits. The federal law requires the State to have 80% of all Medicaid members under 21 years of age EPSDT screened in accordance with Attachment B – American Academy of Pediatrics Periodicity Schedule. The State expects the CONTRACTOR to work with providers to ensure completeness of all screenings done for each age range. The State is committed to assuring that as many eligible children as possible have a source of regular ongoing health care. A child should be able to receive examination, treatment, and when necessary, referral services from one provider to another provider. This program allows members under the age of 21 years (under the age of 19 years for CHIP) to receive any services which are medically necessary (Attachment C - Definitions and Acronyms).

Screening, Diagnosis And Treatment: The CONTRACTOR(S) shall ensure the completion of health screens within six months of entrance to the program, and at specific intervals, which consist of a health history, developmental assessment, complete physical exam, vision screening, hearing test, urinalysis, blood test, immunizations, nutrition screen, anticipatory guidance and other tests as needed and referrals for treatment. Vision and hearing tests shall be completed at the specified intervals for these tests.

Current State policy requires the following additional screenings and services:

2.2.11.3.1

Participants may have a dental screening at the age of 12 months but must have a dental screening annually if three (3) years of age or older. Some services require prior authorization.

2.2.11.3.2

Participants must have a vision screening at the age of three (3) years. Examinations every year and treatment for medical conditions of the eye are covered.

2.2.11.3.3

Participants must have a hearing screening at the age of three (3) years. Examinations every three (3) years and treatment for medical conditions of the ear are covered.

2.2.11.3.4

If a service is determined to be medically necessary by a physician for plan participants, the MCO is responsible for the provision of and reimbursement for that service.

Reports and Records: The State has the obligation of assuring the Federal government that EPSDT services are being provided as required. All requested records, including medical and peer review records, must be available for inspection by State or Federal personnel or their representatives. The CONTRACTOR(S) must record their health screenings and examination related activities and must report those findings quarterly, in a State approved format.

2.2.11.4.1

All reports shall be stratified by Medicaid, CHIP and CSHCN. The CONTRACTOR shall use the State’s approved Current Procedural Terminology (CPT) codes for EPSDT. These can be found in the KBH manual found at:

Updates to these codes can be found in provider manuals and provider bulletins. In addition to the State’s periodic onsite record inspection, the following information shall be reported by the CONTRACTOR(S) to the State in the encounter data that is submitted during a month.

• 
  The child’s name, Medicaid or CHIP ID Number, and date of birth.
  
• 
  The date and type of the EPSDT screening.
  
• 
  Whether the child was referred for diagnosis and/or treatment for dental, hearing, vision or other.
  

2.2.11.5

The CONTRACTOR(S) shall propose a plan to conduct initial health risk assessments:

2.2.12.1.1

For all new Members

2.2.12.1.2

To assess Members who have not been enrolled in the prior 12 months

2.2.12.1.3

For the purpose of assessing Members’ need for any special health care services within 90 days of enrollment

2.2.12.1.4

For Members for whom there is a reasonable belief they are pregnant.

The CONTRACTOR(S) shall make reasonable efforts to contact Members in person, by phone, or by mail to complete health risk assessments.

The health risk assessment shall consist of the following minimum components:

2.2.12.3.1

Total cholesterol level

2.2.12.3.2

HDL cholesterol level

2.2.12.3.3

LDL cholesterol level

2.2.12.3.4

TC/HDL ratio

2.2.12.3.5

Triglycerides

2.2.12.3.6

Glucose level

2.2.12.3.7

Blood pressure check

2.2.12.3.8

Waist circumference measurement

2.2.12.3.9

Height measurement

2.2.12.3.10

Body mass index (BMI) calculation

2.2.12.3.11

Depression screening

2.2.12.3.12

Identification of allergy history

2.2.12.3.13

Medication use discussion

2.2.12.3.14

Complete age-appropriate EPSDT screenings as specified in Section 2.2.11

2.2.12.3.15

Information collected shall also include demographic information and current health and behavioral health status to determine the need for care management, behavioral health services, or any other health or community services.

The CONTRACTOR(S) shall use appropriate health care professionals in the assessment process. Members shall be offered assistance in arranging an initial visit with their PCP for a baseline medical assessment and other preventive services, including an assessment or screening of the Member’s potential risk, if any, for specific diseases or conditions.

The CONTRACTOR(S) shall provide quarterly reports to the State on the number of health risk assessments completed, as well as a summary and analysis of the information collected as it pertains to the prevalence of chronic conditions, need for preventive care, referrals to prenatal care (including the month a pregnant member was identified and screened), and relevant demographic and regional information.

The CONTRACTOR(S) must make health risk assessment information available to Members’ PCPs and other relevant providers and shall include health risk assessment information in any electronic exchange of data it develops or maintains between the CONTRACTOR(S) and providers so that providers may have access to relevant data about Members they treat or serve. The CONTRACTOR(S) shall also make such data available to the State and the External Quality Review Organization (EQRO) upon request as well as when a Member transfers from one contractor to another in accordance with all State and Federal regulations.

Successful CONTRACTOR(S) will not be responsible for conducting assessments of functional eligibility for Medicaid programs.

CONTRACTOR(S) may propose additional services for coverage. These are referred to as “Value-added Services.” Value-added Services may be actual health care services, benefits, or positive incentives that Kansas determines will promote healthy lifestyles and improved health outcomes among Members. Value-added Services that promote healthy lifestyles should target specific weight loss, smoking cessation, or other programs approved by Kansas. Temporary phones, cell phones, additional transportation benefits, and extra home health services may be Value-added Services, if approved by the State. Best practice approaches to delivering covered services are not considered Value-added Services.

The CONTRACTOR(S) generally must offer Value-added Services to all MCO Program Members. For Medicaid acute care services, the CONTRACTOR(S) may distinguish between the Dual Eligible and non-Dual Eligible populations. Value-added Services do not need to be consistent across more than one (1) CONTRACTOR Program. Value-added Services that are approved by Kansas during the contracting process will be included in the CONTRACT’s scope of services.

Any Value-added Services that a CONTRACTOR elects to provide must be provided at no additional cost to Kansas. The costs of Value-added Services are not reportable as allowable medical or administrative expenses, and therefore are not factored into the rate setting process. In addition, the CONTRACTOR(S) must not pass on the cost of the Value-added Services to Providers. The CONTRACTOR(S) must specify the conditions and parameters regarding the delivery of the Value-Added Services in the CONTRACTOR(S)’s marketing materials and Member Handbook, and must clearly describe any limitations or conditions specific to the Value-added Services, including:

2.2.13.4

Note any limits or restrictions that apply to the Value-added Service;

Identify the providers responsible for providing the Value-added Service;

Describe how the CONTRACTOR will identify the Value-added Service in administrative (encounter) data;

Propose how and when the CONTRACTOR will notify providers and Members about the availability of such Value-added Service while still meeting the federal requirements prohibiting marketing, which means any communication from an MCO to a Medicaid recipient who is not enrolled in that MCO, that can reasonably be interpreted as intended to influence the recipient to enroll in that particular MCO’s Medicaid product, or either to not enroll in, or to disenroll from, another MCO’s Medicaid product ;

Describe how a Member may obtain or access the Value-added Service; and

Include a statement that the CONTRACTOR will provide such Value-added Service for at least 12 months from the effective date.

2.2.13.10

The CONTRACTOR may submit proposals to provide Value-added Services to Members for:

2.2.13.10.1

Completion of health assessments,

2.2.13.10.2

Participation in chronic condition management programs,

2.2.13.10.3

Participation in prevention and smoking cessation and weight loss/obesity programs,

2.2.13.10.4

Participation in other health and wellness initiatives,

2.2.13.10.5

Demonstration of personal responsibility for health outcomes,

2.2.13.10.6

Completion of health literacy activities, or

2.2.13.10.7

Creation of a bridge to independence and private health coverage, incentivizing employment without putting health care benefits at risk.

Such value-added services may include anything permissible under applicable Federal Medicaid and CHIP regulations and may include, but will not be limited to:

2.2.13.11.1

Gift cards and vouchers

2.2.13.11.2

Medical equipment or devices not already covered by the health plan to assist in prevention, wellness, or management of chronic conditions

2.2.13.11.3

Additional transportation services beyond what is required by the CONTRACTOR(S)

2.2.13.11.4

Health Opportunity Accounts (HOA) in which funds earned as incentives by the member are deposited into an account to be used for purchasing health care services or products not covered by the health plan or other out of pocket medical expenses. This account will follow the member after enrollment.

2.2.13.11.5

CONTRACTORs are specifically encouraged to propose additional value-added services programs, beyond those currently allowed by Federal regulations, for which Federal approval would be required.

2.2.13.12

All such value-added services proposals must be submitted to the State for approval and, in implementing such services, the CONTRACTOR must:

2.2.13.12.1

Track participation in the program and validate changes in health risk and outcomes with clinical data, including the adoption and maintenance of healthy behaviors by Members;

2.2.13.12.2

Establish standards and health status targets for Members’ participating in the program and measure the degree to which such standards and targets are met;

2.2.13.12.3

Evaluate the effectiveness of the program, including an estimation of cost savings, and provide the State with such evaluations;

2.2.13.12.4

Report to the State on processes that have been developed and lessons learned from the program; and

2.2.13.12.5

Report on preventive services as part of reporting on quality measures as described in the State Quality Strategy (Attachment J).

For any value-added services proposal the CONTRACTOR submits, the following conditions must also be met:

2.2.13.13.1

Create Member awareness of the high cost of care;

2.2.13.13.2

Provide incentives to Members to seek preventive care services;

2.2.13.13.3

Reduce inappropriate use of services;

2.2.13.13.4

Enable Members to take responsibility for outcomes;

2.2.13.13.5

Provide incentive enrollment counselors and ongoing education activities;

2.2.13.13.6

Allow transactions involving HOAs to be conducted electronically and without cash; and

2.2.13.13.7

Increase Member awareness of benefits of employment in overall health.

The CONTRACTOR may not apply any disincentives or punitive measures to Members.

HIT and HIE are two of the cornerstones of efforts in Kansas to improve the coordination and delivery of health care services. They are also central to Federal efforts under the Affordable Care Act to improve the quality and effectiveness of health care services.

2.2.14.1.1

HIT refers to electronic systems that make it possible for health care providers to better manage patient care through secure use and sharing of health information. HIT includes the use of electronic health records (EHRs) instead of paper medical records to maintain people's health information.

2.2.14.1.2

HIE refers to the electronic movement of health-related data and information among organizations according to agreed standards, protocols, and other criteria.

2.2.14.1.3

KDHE’s vision and strategy for implementing HIT initiatives is to pursue initiatives that encourage the adoption of certified EHR technology, promote health care quality and advance HIE capacity in Kansas. KDHE’s mission for HIT in Kansas is:

Transform health care in Kansas through the deployment, coordination, and use of
Health Information Technology and Health Information Exchange.