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

2.2.14.2

Kansas Health Information Exchange, Inc. (KHIE) - Governor Mark Parkinson created the KHIE and its Board of Directors by Executive Order 10-06 to assure the statewide provision of HIE services in Kansas. KHIE has the responsibility of approving Health Information Organizations (HIOs) in the state as well as setting policy for the facilitation of HIE in Kansas. KHIE will focus on policy development and governance of HIE in the state.

HIE development is shared by a diverse range of stakeholders across Kansas. To enable statewide interoperability of healthcare data, Kansas has aligned a number of concurrent projects through a coordinated approach. This coordinated approach includes the participation of the KHIE, Regional Extension Center (REC), Medicaid and at least two HIE technology partners in the state.

Currently, there are two Regional HIOs providing technology services in Kansas:

The Kansas Health Information Network (KHIN) is a collaborative, provider-led HIO solution originally formed by the Kansas Medical Society (KMS) and the Kansas Hospital Association (KHA). Currently, KHIN has a number of planned community-based HIOs which provide core HIT functionality. These include the Wichita HIE, eHealth Align in Kansas City and the Rural Health Information Network.

The Lewis and Clark Health Information Exchange (LACIE) initiated by the Heartland Health System and located in St. Joseph, Missouri is the second technology provider. The exchange is currently expanding participation to include a number of Kansas providers.

Two health systems, the University of Kansas Medical Center and KanCare Network, also incorporate Telemedicine, medical consultation and other services beyond baseline EHR or HIE.

2.2.14.3

HIT/HIE Requirements for the MCO - The CONTRACTOR shall submit a plan to the State that details how it will use HIT and HIE to improve coordination and integration of care, promote prevention and wellness, and improve quality through appropriate sharing of clinical and administrative data among providers and to the State. This plan at a minimum will:

Demonstrate how the CONTRACTOR will accept and utilize data from certified EHR technology;

Demonstrate how the CONTRACTOR will promote and measure meaningful use (as defined in the American Recovery and Reinvestment Act of 2009) of EHRs among its participating providers;

Utilize the HIE and EHR Data to for reporting where appropriate.

2.2.14.4.1

In addition to the partners and stakeholders included in the Statewide HIE effort, in August 2010 KDHE-DHCF convened a Kansas HIT Medicaid Stakeholder Group to solicit input on the projects and Medicaid goals related to this effort. With input from the Kansas HIT Medicaid Stakeholder Group, KDHE-DHCF has established the following HIE goals for the Medicaid program in Kansas:

2.2.14.4.1.1

Utilize the HIE to measure meaningful use;

2.2.14.4.1.2

Utilize the HIE to gather data needed to document and measure qualification for Medicaid incentive payments;

2.2.14.4.1.3

Utilize the HIE as needed to gather data and fill gaps in order to compute quality measures and to help manage and coordinate care to ensure meaningful use for Medicaid beneficiaries – regardless of their connection to a primary care medical home; and,

2.2.14.4.1.4

Utilize the HIE to facilitate a Medical Home and patient centered care for each individual.
2.2.14.5

The CONTRACTOR shall submit a preliminary plan as part of its proposal to the State that details how it will use HIT to improve coordination and integration of care, promote prevention and wellness, and improve quality through appropriate sharing of clinical and administrative data among providers and to the State. This plan, at a minimum, will:

2.2.14.5.1

Specify how the CONTRACTOR will work within the framework outlined by the KHIE Board to facilitate electronic exchange of health information between providers and the CONTRACTOR, and between the CONTRACTOR and the State;

2.2.14.5.2

Demonstrate how the CONTRACTOR will work with providers to assist in their acquisition and use of certified EHR technology in accordance with the Kansas Medicaid HIT Plan State Medicaid HIT Plan (SMHP) .

2.2.14.5.3

Demonstrate how the CONTRACTOR will accept and use data from certified EHR technology.

2.2.14.5.4

Demonstrate how the CONTRACTOR will assist providers in developing registries of patients with chronic conditions to help improve care management.

2.2.14.5.5

Demonstrate of the CONTRACTOR will use its HIT system to provide information on areas including, but not limited to, utilization, grievances and appeals, and disenrollments for any reason other than a loss of Medicaid eligibility.

2.2.14.5.6

Collect data on enrollee and provider characteristics, as specified by the State and on services furnished to Members through an encounter data system or other methods as may be specified by the State.

Upon CONTRACT implementation, the CONTRACTOR shall work with the State and other relevant CONTRACTOR(S) to develop a joint plan to move HIT and EHR forward in Kansas.

One example of HIT/HIE required by this CONTRACT is that the State requires CONTRACTOR(S) to provide the following service:

2.2.14.7.1

Operate and maintain a fully-functional Prior Authorization (PA) system to support both automated and manual PA determinations and responses, at minimum, capable of:

2.2.14.7.1.1

Examining up to 24 months of administrative data; for example, patient-specific pharmacy, medical and encounter claims from both FFS and MCOs and applying evidence-based guidelines to determine prescribing appropriateness (administrative data includes but is not limited to pharmacy, hospitalizations, length of stay, emergency department utilization, eligibility, paid/denied clams, provider, etc).

2.2.14.7.1.2

Gathering and applying appropriate decision criteria needed to make an automated authorization or precertification decision.

2.2.14.7.1.3

Integrating with the Point of Service (POS) claims processor and all corresponding processing applications and providing an automated decision during the POS transaction with the vendor’s POS system in accordance with National Council for Prescription Drug Programs (NCPDP) mandated response times with 95% of electronic PA system transactions completing in less than one second.

2.2.14.7.1.4

Submitting PA requests electronically in Health Insurance Portability and Accountability Ace (HIPAA)-compliant transaction formats and in the NCPDP v5.1 format by the operational start date, and accept the NCPDP D.0 format by the HIPAA required compliance date at no additional charge to the plan.

2.2.14.7.1.5

Providing a detailed reporting package.

2.2.14.7.1.6

Generating and distributing PA Denial letters to plan participants and applicable healthcare providers.

2.2.14.7.1.7

Communicating the decision clearly and quickly to the healthcare provider.

2.2.14.7.1.8

Updating internal records in adjudication/claims systems and call tracking systems in conjunction with claims adjudication.

2.2.14.7.1.9

Provide continuity care contingencies upon the implementation of new Prescription Drug List (PDL) and PA programs.

2.2.14.7.1.10

Provide capability of exempting all medications prescribed for a beneficiary with a specific disease state.

2.2.14.7.1.11

Provide capability to utilize a prescriber’s specialty code in rendering an automated prior authorization determination.

2.2.14.7.2

Allow for low impact and quick turnaround maintenance of PDL and PA criteria through table-driven criteria as opposed to hard coded criteria;

2.2.14.7.3

Possesses documented experience in the Medicaid arena (10 or more Medicaid Clients) with a comprehensive library of effective criteria to leverage and expand the PA portfolio;

2.2.14.7.4

Provide documented administrative and drug savings through previous experience;

2.2.14.7.5

Provide measurable outcomes for quality improvement reports;

2.2.14.7.6

Offer back-up system redundancy to provide for business continuity with uninterrupted 24 hours a day, seven (7) days a week production support and service 365 days a year;

2.2.14.7.7

Provide the provider community with the ability to automate the prior authorization process through a HIPAA-compliant, Web-based provider portal which must, at minimum, must be capable of:

2.2.14.7.7.1

Minimizing the burden on the provider community while driving appropriate utilization;

2.2.14.7.7.2

Supplying access to electronic health records to healthcare providers via a secure login process;

2.2.14.7.7.3

Electronically and securely submit pharmacy and non-pharmacy PA requests for automated and manual review by examining up to 24 months of administrative data; for example, patient-specific pharmacy, medical and encounter claims and applying evidence-based guidelines to determine prescribing appropriateness (administrative data includes but is not limited to pharmacy, hospitalizations, length of stay, emergency department utilization, eligibility, paid/denied claims, provider, etc.).

2.2.14.7.7.4

Provide authorized users with access to participants’:

2.2.14.7.7.4.1

Patient profile information;

2.2.14.7.7.4.2

Prescriber information;

2.2.14.7.7.4.3

PA history;

2.2.14.7.7.4.4

PA questions;

2.2.14.7.7.4.5

Automated criteria check;

2.2.14.7.7.4.6

Approval and Denial outcomes;

2.2.14.7.7.4.7

Ability to attach applicable medical record data to PA submissions;

2.2.14.7.7.4.8

Ability to request reconsideration of denial outcomes electronically.

Electronic Visit Verification (EVV) System.

2.2.14.8.1.

The CONTRACTOR shall utilize and comply with all terms of the State’s Contract procuring an EVV system. The EVV system will be used to monitor the receipt and utilization of HCBS services, including at least, but not limited to the following: Personal services, attendant care, adult day care, personal emergency response installation, wellness monitoring, nurse evaluation visit, sleep cycle support, comprehensive support, overnight respite, LPN specialized medical care, RN specialized Medical care, personal service attendant.

2.2.14.8.2

The CONTRACTOR shall work with the current State procured EVV system which has the following functionality:

2.2.14.8.2.1

The ability to log the arrival and departure of an individual provider staff person or worker;

2.2.14.8.2.2

The ability to verify in accordance with business rules that services are being delivered in the correct location (e.g., the Member’s home);

2.2.14.8.2.3

The ability to verify the identity of the individual provider staff person or worker providing the service to the Member; The ability to match services provided to a Member with services authorized in the plan of care;

2.2.14.8.2.4

The ability to ensure that the provider/worker delivering the service is authorized to deliver such services;

2.2.14.8.2.5

The ability to establish a schedule of services for each Member which identifies the time at which each service is needed, and the amount, frequency, duration and scope of each service, and to ensure adherence to the established schedule;

2.2.14.8.2..6

The ability to provide immediate (i.e., “real time”) notification to care coordinators if a provider or worker does not arrive as scheduled or otherwise deviates from the authorized schedule so that service gaps and the reason the service was not provided as scheduled, are immediately identified and addressed, including through the implementation of back-up plans, as appropriate; and

2.2.14.8.2.7

The ability for a provider, to log in and enter attendance for the day.

2.2.14.8.3

The CONTRACTOR shall ensure that the EVV system creates and makes available on at least a daily basis an electronic claims submission file in the 837 format, including exceptions which have been resolved, which may be submitted to the CONTRACTOR for claims processing at the appropriate frequency.

2.2.14.8.4

The CONTRACTOR shall monitor and use information from the EVV system to verify that services are provided as specified in the plan of care, and in accordance with the established schedule, including the amount, frequency, duration, and scope of each service, and that services are provided by the authorized provider/worker; and to identify and immediately address service gaps, including late and missed visits. The CONTRACTOR shall monitor services anytime a member is receiving services, including after the CONTRACTOR’s regular business hours.

In general, the CONTRACTOR shall provide available, accessible, and adequate numbers of institutional facilities, service locations, service sites, professional, allied, and paramedical personnel for the provision of covered services, including all emergency services, on a 24-hour-a-day, 7-day-a-week basis. At a minimum, this shall include:

2.2.15.1.1

Primary Care Physician or Extender (most commonly a nurse practitioner or physician assistant):

2.2.15.1.1.1

Distance/Time Rural: 30 miles or 30 minutes

2.2.15.1.1.2

Distance/Time Urban: 20 miles or 30 minutes

2.2.15.1.1.3

Patient Load: 2,500 or less for physician; one-half this for a physician extender.

2.2.15.1.1.4

Appointment/Waiting Times: Usual and customary practice (see definition below), not to exceed 3 weeks from date of a patient’s request for regular appointments and 48 hours for urgent care. Waiting times shall not exceed 45 minutes.

Documentation/Tracking requirements:

LTC: All Licensed and Medicaid – Certified NFs will be offered inclusion in the CONTRACTOR(S) provider network for three years consistent with the timing provisions of this CONTRACT. Following the minimum period, the CONTRACTOR(S) can evaluate each provider’s continued network enrollment based on assessment of quality and performance outcomes and consistent with CONTRACTOR requirements for coordination of care, approved by the State.

SUD Access to Care Standards:

Note: These are the minimum standards. All calls for all members are clinically triaged to ascertain if a more urgent level of care is appropriate.

2.2.15.3.1

Standard: Members are seen immediately.

2.2.15.3.2

Urgent: Means a service need that is not emergent and can be met by providing an assessment within 24 hours of the initial contact, and services delivered within 48 hours from initial contact without resultant deterioration in the individual's functioning or worsening of his or her condition. If the Member is pregnant they are to be placed in the urgent category.

Standard: Members are assessed within 24 hours of initial contact; services delivered within 48 hours of initial contact.

2.2.15.3.3

IV Drug Users: If a Member has used IV drugs within the last six months, and they do not fall into the Emergent or Urgent categories because of clinical need, they will need to be placed in this category. Members who have utilized IV drugs within the last six months need to be seen for treatment within 14 (calendar) days of initial contact. There is not a time standard requirement for the assessment, nor is there an IV Drug User category in the KCPC. These Members are categorized as routine but are to receive treatment within 14 days of their initial contact – not within 14 days of their assessment.

Standard: Members receive treatment within 14 days of initial contact.

2.2.15.3.4

Routine: Means a service need that is not urgent and can be met by a receiving an assessment within 14 (calendar) days of the initial contact, and treatment within 14 calendar days of the assessment, without resultant deterioration in the individual's functioning or worsening of his or her condition.

Standard: Members assessed within 14 days of initial contact and treatment services are delivered within 14 days of assessment.

MH Access Standards

2.2.15.4.1

Access: Post-stabilization services

Referral: 1 hour

Assessment and/or Treatment: within 1 hour from referral for post-stabilization services (both inpatient and outpatient) in an emergency room

2.2.15.4.2

Access: Emergent

Referral: Immediate

Assessment and/or Treatment: Within 3 hours for an outpatient MH services, and; within 1 hour from referral for an emergent concurrent utilization review screen

2.2.15.4.3

Access: Urgent

Referral: 24 hours

Assessment and/or Treatment: 48 hours from referral for outpatient MH services, and; within 24 hours from referral for an urgent concurrent utilization review screen

2.2.15.4.4

Access: Planned inpatient psychiatric

Referral: 48 hours

Assessment and/or Treatment: 5 working days from referral.

2.2.15.4.5

Access: Routine Outpatient

Referral: 5 days

Assessment and/or Treatment: 9 working days from referral; 10 working days from previous treatment

2.2.15.4.6

Documentation – the CONTRACTOR(S) must have a system in place to document appointment scheduling times.

2.2.15.4.7

Tracking – the CONTRACTOR(S) must have a system in place to document the exchange of Member information if a provider, other than the PCP (i.e., school-based clinic or health department clinic), provides health care.

Specialty Care and Urgent Care: Referral appointments to specialists (e.g., specialty physician services, hospice care, home health care, SUD treatment, rehabilitation services, etc.) shall not exceed 30 days for routine care or 48 hours for urgent care. Waiting times shall not exceed 45 minutes.

Emergency Care: All emergency care is immediate, at the nearest facility available, regardless of CONTRACT.

Hospitals: Transport time will be the usual and customary, not to exceed 30 minutes, except in rural areas where access time may be greater. If greater, the standard needs to be the community standard for accessing care, and exceptions must be justified and documented to the State on the basis of community standards.

LTC Services: Transport distance to licensed ADC providers will be the usual and customary not to exceed 20 miles for Members in urban areas, not to exceed 30 miles for Members in suburban areas and not to exceed 60 miles for Members in rural areas except where community standards and documentation shall apply.

General Optometry Services:

Transport time will be the usual and customary, not to exceed 30 minutes, except in rural areas where community standards and documentation shall apply.

Appointment/Waiting Times: Usual and customary not to exceed three (3) weeks for regular appointments and 48 hours for urgent care. Waiting times shall not exceed 45 minutes.

Lab and X-Ray Services:

Transport time will be the usual and customary, not to exceed 30 minutes, except in rural areas where community access standards and documentation will apply.

Appointment/Waiting Times: Usual and customary not to exceed three (3) weeks for regular appointments and 48 hours for urgent care. Waiting times shall not exceed 45 minutes.

All other services not specified here shall meet the usual and customary standards for the community.

The CONTRACTOR(S) shall ensure access to specialty providers (specialists) for the provision of covered services. At a minimum, this means that:

2.2.15.12.1

The CONTRACTOR(S) shall have provider agreements with providers practicing the following specialties: Allergy, Cardiology, Dermatology, Endocrinology, Otolaryngology, Gastroenterology, General Surgery, Neonatology, Nephrology, Neurology, Neurosurgery, Oncology/Hematology, Ophthalmology, Orthopedics, Plastic and Reconstructive Surgery, Psychiatry (adult), Psychiatry (child and adolescent), and Urology (See Behavioral Health Provider Network Section for behavioral health specialties).

Specific Requirements of the behavioral health, disabilities and LTC provider network access shall be measured by:

2.2.15.13.1

Acuity of Need — For Members presenting for SUD services with emergency needs shall be referred to services immediately. Members with urgent, non-emergency needs shall be assessed within twenty-four hours of a request for services. Members with non-urgent needs shall be assessed within 14 calendar days of the date the services are requested. IV Drug users must receive assessment and treatment within 14 days.

2.2.15.13.2

Acuity of Need—For Members presenting for MH services Members with emergency needs shall be referred to services immediately. Members with urgent, non-emergency needs shall be assessed within 72 hours of a request for services. Members with non-urgent needs shall be assessed within 14 working days of the date the services are requested.

2.2.15.13.3

Urgent, non-emergency services for members shall be delivered within 24 hours of the date/time of assessment. Treatment services for non-urgent needs shall be delivered within 14 calendar days of the date of assessment. The CONTRACTOR shall document waiting lists and funding shortages preventing admission to treatment in the prescribed time frames.

2.2.15.13.4

Special Service Needs — Members who are pregnant women, regardless of T-XIX status, shall be provided treatment within 24 hours of an assessment. Members who are IV drug users shall be admitted no later than 14 calendar days after an assessment, or 120 calendar days after the date of such request if no program has the capacity to admit the individual on the date of such request and if interim services are made available to the individual not later than 48 hours after such request.

2.2.15.13.5

Geographical Standards — The availability of types of SUD programs will vary from area to area, but access problems may be especially acute in rural and frontier areas. The CONTRACTOR shall establish a program of assertive outreach and telemedicine programming capabilities to all areas but especially to rural and frontier areas where SUD services may be less available than in more urban areas. The CONTRACTOR shall monitor utilization in regions across the State to ensure access and availability in all regions.

2.2.15.13.6

Timeliness of MH Appointments-- Access standards are the standard for the timeliness of response for the assessment of consumer need and the provision of services necessary to resolve the situation. The assessment of consumer need must be done in a manner that is consistent with applicable clinical practices and meets the needs of the consumer. The timeliness of response will meet the requirements as defined in the emergent, urgent, or routine criteria for individuals already in service as well as individuals not currently in services. The CONTRACTOR(S) is expected to meet the Network Access Requirement provisions specified in Attachment G – Liquidated Damages.