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

The CONTRACTOR(S) shall provide health education such as, but not limited to, toll-free phone numbers, videos, and Member handbooks to the extent that the Member is advised of the appropriate use of health care and is instructed in ways to assist in the maintenance of his or her own health. All such materials shall be provided in language that is easily understood by Members, and as outlined in Sections 2.2.17.1.1-2.2.17.1.4.

The CONTRACTOR(S) shall use its best efforts to provide and arrange for a complete physical examination or age/sex specific health risk assessment for all Members within the first six (6) months of enrollment and continue to provide health education and/or physical exams on an annual basis thereafter.

The CONTRACTOR(S) shall develop programs and participate in activities to enhance the general health and well-being of Members. A plan listing the programs and activities to be developed by the CONTRACTOR shall be included with the vendor’s proposal and approved by the State prior to implementation. Any additions or modifications to such plan shall be approved by the State.

The CONTRACTOR shall ensure that all health education and outreach activities are prior approved in writing by the State.

2.2.16.5

The CONTRACTOR(S) shall provide preventive services which include, but are not limited to, initial and periodic evaluations, family planning services, prenatal care, laboratory services and immunizations in accordance with the State rules and regulations. These services shall be exempt from the State cost sharing responsibilities.

The following information shall be provided in the Member handbook or in separate State approved written materials. The CONTRACTOR(S) must secure approval on all content from the State and provide the information of this section annually to each Member:

2.2.17.1.1

Written information in Spanish, which is Kansas’ designated prevalent non-English language

2.2.17.1.2

Oral interpretation services available free of charge to each Member and potential enrollee. This applies to all non-English languages, not just prevalent non-English languages. The CONTRACTOR shall notify its Members that oral interpretation is available for any language and written information is available in prevalent languages and how to access those services.

2.2.17.1.3

A means available to communicate with the Member in his/her spoken language, and/or access to a phone-based translation service so that someone is readily available to communicate orally with the Member in his/her spoken language

2.2.17.1.4

Written material in an easily understood language and format. Written material must be available in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency. All Members must be informed that information is available in alternative formats and how to access those formats.

2.2.17.1.5

A written notice of termination of a contracted provider, within 15 days after receipt or issuance of the termination notice, to each Member who received his or her primary care from, or was seen on a regular basis by, the terminated provider

2.2.17.1.6

Annual notification to all Members of their disenrollment rights

2.2.17.1.7

Notification to all Members, at the time of enrollment, of the Member’s rights to change providers or disenroll for cause

2.2.17.1.8

Notification to all Members of their right to request and obtain the information listed in this section at least once a year

2.2.17.1.9

Provision of written notice of any change (that the State defines as ‘‘significant’’) in the information specified in this section, at least 30 days before the intended effective date of the change.

The written information provided by the CONTRACTOR must reflect changes in State law regarding Advance Directives as soon as possible, but no later than 90 days after the effective date of the change.

Detailed Description of Behavioral Health Member Services: The CONTRACTOR must have staff available by a toll-free phone number 24 hours a day/365 days a year to respond to Member calls. Interpreter services must be available for the hearing impaired and for non-English speakers. Calls range from non-urgent requests for referral to crises. The 800 number is published in the Member Handbook and associated materials. The help/hot-lines provide 24 hour access to Kansas callers requiring crisis intervention services or seeking assistance with behavioral health issues. The Help Line services include: telephone crisis intervention, risk assessment, and consultation to callers which may include family members and other community agencies seeking assistance with behavioral health issues. Community resources such as contact information to their local RADAC, Social Detoxification unit, Certified Gambling Counselor or MH Center is provided.

The CONTRACTOR, through Member Services, shall facilitate the development of warm transfers from Help Lines when the caller’s crisis cannot be addressed by the Help Lines. The State will consider options other than use of warm transfers for coordination of Help Line services that are proposed by the CONTRACTOR, as long as the other requirements of this section are met.

The CONTRACTOR shall provide, in writing, a toll-free telephone number for Members to call who have inquiries, questions, grievances, and etc. This line shall also be used to monitor:

2.2.17.5.1

Information provided to beneficiaries;

2.2.17.5.2

Grievances;

2.2.17.5.3

Timely access;

2.2.17.5.4

Coordination/continuity; and

2.2.17.5.5

Quality of care

The data are used to monitor the above topics by obtaining information from the beneficiaries, resolving issues, identifying and addressing trends. If deficiencies are noted the CONTRACTOR must perform corrective action until compliance is met.

CONTRACTOR(S) must provide the following information to all enrollees within ten days:

2.2.17.7.1

Names, locations, telephone numbers of, and non-English languages spoken by current contracted providers in the Member’s service area, including identification of providers that are not accepting new patients. For CONTRACTOR(S) this includes, at a minimum, information on primary care physicians, specialists, and hospitals, and all other included community based/CONTRACT negotiated services/providers

2.2.17.7.2

Any restrictions on the Member’s freedom of choice among network providers. The CONTRACTOR shall not impose any limitation on the Member’s freedom to change SUD providers

2.2.17.7.3

Member rights and protections, as specified in 42 CFR § 438.100.

2.2.17.7.4

Information on grievance and fair hearing procedures, and for MCO Members, the information specified in 42 CFR § 438.10(g)(1).

2.2.17.7.5

The amount, duration, and scope of benefits available under the CONTRACT in sufficient detail to ensure that Members understand the benefits to which they are entitled

2.2.17.7.6

Procedures for obtaining benefits, including authorization requirements

2.2.17.7.7

The extent to which, and how, Members may obtain benefits, including family planning services, from out-of-network providers

2.2.17.7.8

The extent to which, and how, after-hours and emergency coverage are provided, including:

2.2.17.7.8.1

What constitutes emergency medical condition, emergency services, and post-stabilization services, with reference to the definitions in 42 CFR § 438.114(a).

2.2.17.7.8.2

The fact that PA is not required for emergency services and that the CONTRACTOR is responsible for coverage and payment of emergency services and post stabilization care services.

2.2.17.7.8.3

The process and procedures for obtaining emergency services, including use of the 911-telephone system or its local equivalent.

2.2.17.7.8.4

The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization services covered under the CONTRACT

2.2.17.7.8.5

The fact that, subject to the provisions of this section, the Member has a right to use any hospital or other setting for emergency care

2.2.17.7.8.6

The CONTRACTOR may not deny payment for treatment obtained when a representative of the entity instructs the enrollee to seek emergency services.

2.2.17.7.8.7

The CONTRACTOR may not limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms.

2.2.17.7.8.8

The CONTRACTOR may not refuse to cover emergency services based on the emergency room provider, hospital, or fiscal agent not notifying the enrollee's primary care provider, MCO, PIHP, PAHP or applicable State entity of the enrollee's screening and treatment within 10 calendar days of presentation for emergency services.

2.2.17.7.8.9

An enrollee who has an emergency medical condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition.

2.2.17.7.8.10

The attending emergency physician, or the provider actually treating the enrollee, is responsible for determining when the enrollee is sufficiently stabilized for transfer or discharge, and that determination is binding on the CONTRACTOR as responsible for coverage and payment.

2.2.17.7.9

That post stabilization services means covered services, related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition, or, under the circumstances described in 42 CFR 438.114(e) to improve or resolve the enrollee's condition. The post-stabilization care services rules set forth at 42 CFR § 422.113(c)

2.2.17.7.9.1

That post stabilization care services are covered and paid for in accordance with provisions set forth at 42 CFR 422.113(c): Financial responsibility--pre-approved. CONTRACTOR is financially responsible for post-stabilization services obtained within or outside the entity that are pre-approved by a plan provider or other entity representative

2.2.17.7.9.2

That CONTRACTOR is financially responsible for post-stabilization care services obtained within or outside the entity that are not pre-approved by a plan provider or other entity representative, but administered to maintain the enrollee's stabilized condition within 1 hour of a request to the entity for pre-approval of further post-stabilization care services.

2.2.17.7.9.3

That CONTRACTOR is financially responsible for post-stabilization care services obtained within or outside the entity that are not pre-approved by a plan provider or other entity representative, but administered to maintain, improve or resolve the enrollee's stabilized condition if-- The CONTRACTOR does not respond to a request for pre-approval within 1 hour; The CONTRACTOR cannot be contacted; or the CONTRACTOR representative and the treating physician cannot reach an agreement concerning the enrollee's care and a plan physician is not available for consultation. In this situation, the CONTRACTOR must give the treating physician the opportunity to consult with a plan physician and the treating physician may continue with care of the patient until a plan physician is reached or one of the criteria of 422.133(c)(3) is met.

2.2.17.7.9.4

CONTRACTOR must limit charges to enrollees for post-stabilization care services to an amount no greater than what the organization would charge the enrollee if he or she had obtained the services through the CONTRACTOR organization.

2.2.17.7.9.5.

CONTRACTOR’s financial responsibility for post-stabilization care services it has not pre-approved ends when:

2.2.17.7.9.5.1

a plan physician with privileges at the treating hospital assumes responsibility for the enrollee's care;

2.2.17.7.9.5.2

a plan physician assumes responsibility for the enrollee's care through transfer;

an M+C organization representative and the treating physician reach an agreement concerning the enrollee's care; or

2.2.17.7.9.5.4

the enrollee is discharged.

2.2.17.7.10

How and where to access any benefits that are available under the State plan but are not covered under the CONTRACT, including any cost sharing, and how transportation is provided. For a counseling or referral service that the CONTRACTOR(S) does not cover because of moral or religious objections, the CONTRACTOR(S) need not furnish information on how and where to obtain the service. The State must provide information on how and where to obtain the service. For a list of services not covered by the CONTRACTOR(S) but covered by the State, see Attachment F—Services, Section 6.

2.2.17.7.11

Advance Directives, as set forth in 42 CFR §438.6(i)(1).

2.2.17.7.12

Additional information that is available upon request, including the following:

Information on the structure and operation of the MCO or CONTRACTOR(S); and

Physician incentive plans as set forth in 438.6(h) of this chapter.

Additionally, at a minimum, the Member handbook shall include:

2.2.17.8.1

A Table of Contents

2.2.17.8.2

A Glossary

2.2.17.8.3

Information about choosing and changing providers

2.2.17.8.4

Toll free telephone number, permanent for the duration of the contract, to call with questions

2.2.17.8.5

Appointment procedures

2.2.17.8.6

A description of all available health plan and other covered services and an explanation of any service limitations or exclusions from coverage and a notice stating that the health plan will be liable only for those services authorized by the health plan

2.2.17.8.7

How to contact member services and a description of its function

2.2.17.8.8

What to do in case of an emergency and instructions for receiving advice on getting care in case of any emergency, including how to access the CONTRACTOR’S 24-hour toll-free number. Information should also distinguish between an emergency using the prudent layperson standard, emergent care and urgent care. In a life-threatening situation, the Member handbook should instruct Members to use the emergency medical services available or to activate emergency medical services by dialing 911. The fact that the CONTRACTOR shall not require the Member to call the CONTRACTOR or PCP prior to going to the emergency room. According to the Prudent Layperson Law (Section 1932(b)(2) of the Social Security Act) the CONTRACTOR must cover emergency services without PA.

2.2.17.8.9

How to obtain emergency transportation and medically necessary transportation

2.2.17.8.10

How to obtain behavioral health services

2.2.17.8.11

How to obtain all covered services

2.2.17.8.12

Information regarding out-of-county and out-of-state moves

2.2.17.8.13

Informing the Member that if he or she has a worker’s compensation claim, or a pending personal injury or medical malpractice law suit, or has been involved in an auto accident, to immediately contact the KHPA-DHCF Medicaid Unit, Third Party Liability (TPL) Manager.

2.2.17.8.14

Contributions the Member can make toward his or her own health, Member responsibilities, appropriate and inappropriate behavior, and any other information deemed essential by the CONTRACTOR or the State

2.2.17.8.15

Rights and responsibilities of the Member

2.2.17.8.16

The CONTRACTOR’S policy on referrals for specialty care

2.2.17.8.17

The CONTRACTOR’S policy regarding copayments and charges to Members. Any cost sharing imposed on Medicaid and CHIP Members is in accordance with 42 CFR 447.50 through 42 CFR 447.60

2.2.17.8.18

The CONTRACTOR’S procedures for appeals

2.2.17.8.19

The CONTRACTOR’S procedures for notifying Members about terminations and/or changes in benefits, services or delivery dates

2.2.17.8.20

The State’s procedures for fair hearings

2.2.17.8.21

Information regarding advance directives in accordance with 42 CFR 489 Subpart 1, including a description of State law as found in Kansas Statutes Annotated (KSA) 65-28,101. Withholding or withdrawal of life-sustaining procedures; legislative finding and declaration.

The CONTRACTOR(S) will cover the following:

2.2.20.1.1

Emergency ambulance transportation;

2.2.20.1.2

Non-emergency ambulance transportation from the member’s home to the nearest medical facility, or transportation from one facility to another if the first facility is inadequate for treatment;

2.2.20.1.3

Non-ambulance transportation to all medically necessary services;

2.2.20.1.4

Transportation to family planning services even if these services are obtained from a provider not participating in the CONTRACTOR’S network; and

2.2.20.1.5

Lodging and meals will be provided for the Member and one attendant (if the Member is 20 years of age or younger) when the receipt of medical services necessitates an overnight stay.

Improving the quality and coordination of care provided to Members is a key goal of Medicaid Reform Initiative. Successful CONTRACTOR(S) will be required to report quality data and measures to the State, and must meet specific performance benchmarks that ensure high-quality care. The following strategies shall be utilized by the State to accomplish high-quality care in this CONTRACT:

2.2.21.1.1

A written Quality Assessment and Performance Improvement (QAPI) program;

2.2.21.1.2

Performance Improvement Projects (PIP);

2.2.21.1.3

MCO Accreditation;

2.2.21.1.4

Performance Measures; and

2.2.21.1.5

Pay for Performance Incentives (P4P)

2.2.21.1.5.1

As discussed in previous sections of this quality strategy, the CONTRACTOR(S) will be required to report on all HEDIS, CAHPS, and other performance measures for specific populations as required in Appendices 1-12 of Attachment J. 

2.2.21.1.5.1.1

The year one operational measures are listed in the table below, with the contractual requirements in the middle column, and the P4P incentive requirements in the right column.

Performance Measure	Required Contractual Standard	Standard Required to Receive Incentive Payment (Benchmark)
Timely claims processing	Section 2.2.39.2.1- 100% of clean claims are processed within 30 days 2.2.39.2.2-99 % of all no clean claims are processed within 60 days 2.2.39.2.3-100% of all claims are processed within 90 days	100% of all clean claims are processed within 20 days 99% of all non clean claims are processed within 45 days 100% of all claims are processed within 60 days
Encounter data submission	See Attachment K	Contractor meets all of the performance standards within 60 days from implementation date.
Credentialing process	Section 2.2.4.1.7- credentialing of providers shall be completed as follows: 90% in 30 days 100% in 45 days	90% are completed in 20 days 100% are completed in 30 days
Grievances	(See Attachment D) 98 % of grievances are resolved within 30 days 100% of grievances are resolved within 60 days	98 % of grievances are resolved within 20 days 100% of grievances are resolved within 40 days
Appeals	(See Attachment D) The CONTRACTOR must send a letter to the member within five (5) business days acknowledging receipt of the appeal request.	Contractor sends an acknowledgement letter within 3 business days of receipt of the appeal request
Customer Service	Section 2.2.42.7 95% of all inquiries shall be resolved within two (2) business days of receipt 98% of all inquiries shall be resolved within five (5) business days 100% of all inquiries shall be resolved within 15 business days .	98% of all inquiries are resolved within 2 business days from receipt date 100% of all inquiries are resolved within 8 business days from receipt date

Each of the six (6) areas identified above (timely claims processing, encounter data submission, credentialing process, grievances, appeals, and customer service) will be weighted at .5% of the 3% capitation withhold. A CONTRACTOR failing to meet all the required standards for an incentive payment in a given area will not receive .5% of their capitation payments back for each area in which it fails to meet the benchmark standard in full or in part. For example, if a CONTRACTOR fails to meet all of the required benchmarks in grievances, appeals, and customer services will not receive back 1.5% of their capitation payments back.

2.2.21.1.5.1.2

For CONTRACT years two (2) and three (3), 15 measures have been selected by the State as pay for performance (P4P) indicators (Five (5) for physical health, five (5) for behavioral health, and five (5) for LTC).  To incentivize high performance and quality health outcomes, 5% of each CONTRACTOR’s total per-Member, per-month payments will be held back each year for the purpose of incentive payments in years two (2) and year (3).  If the CONTRACTOR meets quality benchmarks established by the State for each of the 15 selected P4P indicators, the CONTRACTOR will receive the 5% back in full. 

2.2.21.1.5.2

The P4P indicators are listed below.

2.2.21.1.5.2.1

Physical Health:

2.2.21.1.5.2.1.1

Comprehensive Diabetes Care

This measure is actually a composite HEDIS measure composed of 10 rates. To be considered compliant with this measure, the CONTRACTOR must meet or exceed the benchmark rate for HbA1c screening, and meet or exceed the benchmark for seven (7) of the remaining nine (9) Comprehensive Diabetes Care rates following all required HEDIS methodology.

2.2.21.1.5.2.1.2

Well-Child Visits in the First 15 Months of Life

The CONTRACTOR(S) shall meet or exceed the benchmark using HEDIS methodology and specifications.

2.2.21.1.5.2.1.3

Preterm Births

CONTRACTOR(S) shall utilize Joint Commission National Quality Measures methodology and meet or exceed the State-defined benchmark.

2.2.21.1.5.2.1.4

Annual Monitoring for Patients on Persistent Medications

The CONTRACTOR(S) shall meet or exceed the benchmark using HEDIS methodology and specifications.

2.2.21.1.5.2.1.5

• 
  Follow-up after Hospitalization for Mental Illness
  
• 
  The CONTRACTOR(S) shall meet or exceed the benchmark using HEDIS methodology and specifications.
  

Behavioral Health, LTC and HCBS Waivers (for complete description and methodology please see Appendix 12 of Attachment J):

2.2.21.1.5.2.2.1

Increased Competitive Employment: An increased number of people with developmental or physical disabilities, or with significant mental health treatment needs, will gain and maintain competitive employment.

2.2.21.1.5.2.2.2

National Outcome Measures (NOMs):

The NOMs for people receiving Substance Use Disorder services will meet or exceed the benchmark in at least 4 of these 5 areas: Living Arrangements; Number of Arrests; Drug and Alcohol Use; Attendance at Self-Help Meetings; and Employment Status.

The NOMs for people with SPMI or SED receiving mental health services will meet or exceed the benchmark in at least 4 of these 5 areas: Adult Access to Services; Youth Access to Services; Homeless SPMI; Youth School Attendance; and Youth Living in a Family Home.

2.2.21.1.5.2.2.3

Decreased Utilization of Inpatient Services: A decreased number of people with mental health treatment needs will utilize inpatient psychiatric services, including state psychiatric facilities and private inpatient mental health services.

2.2.21.1.5.2.2.4

Improved Life Expectancy: The life expectancy for people with disabilities will improve.

2.2.21.1.5.2.2.5

Increased Integration of Care: The rate of integration of physical, behavioral (both mental health and substance use disorder), long term care and HCBS waiver services will increase.

2.2.21.1.5.2.3

Long-Term Care (for complete description and methodology please see Appendix 12 of Attachment J):

2.2.21.1.5.2.3.1

Nursing Facility Claim Denials: The MCO will meet or exceed the benchmark for denial of nursing facility claims.

2.2.21.1.5.2.3.2

Fall Risk Management: The number of people at risk of falling (i.e., who had a fall, had problems with balance and walking, or were identified as at risk for a fall) will be seen by a practitioner and receive fall risk intervention.

2.2.21.1.5.2.3.3

Decreased Hospital Admission After Nursing Facility Discharge: The percentage of members discharged from a nursing facility who had a hospital admission within 30 days will be decreased.

2.2.21.1.5.2.3.4

Decreased Nursing Facility Days of Care: The number of nursing facility days used by eligible beneficiaries will be decreased.

2.2.21.1.5.2.3.5

Increased use of PEAK (Promoting Excellent Alternatives in Kansas)-Certified Days of Care: The percentage of nursing facility days paid for services in PEAK-certified person centered care homes will be increased.

2.2.21.1.5.3

CONTRACTOR(S) shall follow the required HEDIS, NOMS, or State-defined methodology when calculating the P4P indicators in years two (2) and three (3).  Each of the above 15 P4P indicators shall be externally validated by the EQRO. Each CONTRACTOR is required to collect performance data for all 15 of the P4P measures in CONTRACT year one (1) to serve as baseline data upon CONTRACTOR(S) will be expected to increase.

2.2.21.1.5.4

CONTRACTORS will be assessed with regard to acceptable performance on the P4P indicators.  For performance to be considered acceptable, the CONTRACTOR must meet the respective performance standards for all 15 P4P measures.  The criteria for performance standards in the second measurement year shall be as follows:

Failure to Meet Performance Standard- Any CONTRACTOR which has performed below the national Medicaid 50^th percentile as defined by the NCQA (when applicable) for the measurement year or five (5) percentiles higher than the CONTRACTOR’s Medicaid benchmark rate for Kansas from the previous measurement year, whichever is higher, shall be considered as failing to meet performance standards. 

Minimum Acceptable Performance- Any CONTRACTOR which has performed at or above the national Medicaid 50^th percentile as defined by the NCQA (when applicable) for the measurement year or five (5) percentiles higher than the CONTRACTOR’s Medicaid benchmark rate for Kansas from the previous measurement year, whichever is higher, shall be considered to have accomplished acceptable performance.  CONTRACTORs performing at or above the higher of these two (2) benchmarks for all of the 15 P4P measures will receive the 5% PMPM withholding back in full at the end of measurement year.

2.2.21.1.5.5

The State expects to achieve continuous improvement in its Medicaid and CHIP programs, and will establish escalating targets for each measure over the three (3) year period of this CONTRACT.  CONTRACTOR(S) will be expected to accomplish a five (5) percentile improvement on each P4P indicator in CONTRACT years two and three. This requirement is designed to ensure that CONTRACTOR(S) work to continually work to improve their performance on all P4P indicators and other performance measures. If any CONTRACTOR fails to meet the five (5) percentile improvement standard in year two or three, 1/15^th of the 5% PMPM withholding will be kept by the State for each P4P indicator for which the CONTRACTOR failed to meet the performance benchmark. Further, in year three, if a CONTRACTOR fails to meet the year two (2) performance benchmark for any one of the 15 performance measures, 2/15^ths of the 5% PMPM withholding will be kept by the State and not returned to the CONTRACTOR for each indicator where performance levels were not met. In the event of additional CONTRACT years, 3/15ths would be kept for failure to meet the year two (2) benchmark in year four (4), or to meet the year three (3) benchmark in year five (5), and 4/15ths would be kept for failure to meet the year two (2) benchmark in year five (5)

2.2.21.1.5.6

The State reserves the right to assess and modify the P4P indicators and benchmarks after the first CONTRACT year.  If optional years are added to the CONTRACT with a CONTRACTOR, the State expects to escalate expected levels of performance on the original levels and/or to add additional performance measures to the process.  For each new indicator the performance target would be set at an initial level in the first year of its inclusion and this target would escalate each year until reaching an exemplary level.  New indicators may replace a corresponding number of previous indicators in the calculation of performance incentives, maintaining a list of 15 for which performance payments are calculated.  Sustained performance at the highest levels would be expected for the growing list of performance targets, including those selected by the State for replacement by new measures.

2.2.21.1.5.7

The State reserves the right to tie PIP requirements to P4P indicators where the CONTRACTOR has failed to meet the benchmark or improvement standard. CAPs may also be instituted by the State for less than acceptable performance by a CONTRACTOR on the P4P indicators.

2.2.21.1.5.8