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


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CONTRACTOR Proposals for Additional P4P Indicators

CONTRACTOR(S) who believe they can exceed the acceptable benchmark standard will be provided an opportunity to create and present additional performance targets and appropriate incentives. The State desires to add P4P measures which focus on patient outcomes, health and functional status. The State is particularly interested in P4P measures which address smoking cessation and obesity rates. Any plan for additional P4P incentives must be submitted by the CONTRACTOR at the same time as the QAPI plan.  The State reserves the right to accept, reject, or modify any additional incentive plan proposed by a CONTRACTOR. 

2.2.21.1.5.9

The State recognizes that improvements in quality will require enhanced coordination of care and consumer engagement, and will entail cooperation and improved systems of care among providers. The State acknowledges the central role that providers will play in achieving improved outcomes and encourages CONTRACTOR(S) to enable providers to share in the modest financial rewards available under this program for high-performing CONTRACTORS. The State also encourages the adoption of innovative, evidence-based provider payment mechanisms that incorporate performance and quality initiatives. Additional performance measures proposed by any CONTRACTOR should strive to decrease the level of reporting and administrative burden on providers.

2.2.21.1.5.10

Dually-Eligible Individuals - The State recognizes that data for individuals who are dually eligible for Medicare and Medicaid can be difficult to obtain and could impact the rates for certain P4P indicators.  If a CONTRACTOR foresees that it will be unable to obtain an accurate measurement for any P4P measure because of data issues in the dual population, that CONTRACTOR shall propose a replacement indicator(s) that shall be used for the dual population only and must be externally validated by an EQRO.  The replacement indicator shall be proposed as soon as the plan deems the data for dually-eligible individuals will not be available.  In the event that a replacement indicator is proposed by a CONTRACTOR, the State will work with the CONTRACTOR to establish acceptable performance benchmarks. The non-dual rate for each P4P indicator must still be calculated in addition to the dual-specific indicator(s).  The State expects CONTRACTOR(S) to assist in preparing recommendations to CMS for shared savings relative to serving Medicare-Medicaid dually eligible Members.

2.2.21.1.6

See Attachment J – State Quality Strategy for additional information regarding these quality strategies and requirements of CONTRACTOR(S).
2.2.22 External Quality Review Organization (EQRO)
Federal law (Section 1902(a) (30) (C) of Title XIX of the Social Security Act) requires entities which are external to and independent of the State and its CONTRACTOR(S) and subcontractors to perform, on an annual basis, a review of the quality of Medicaid MCS furnished by each such CONTRACTOR. Requirements relating to the External Quality Review (EQR) are further defined and described under 42 CFR 433 and 438. The CONTRACTOR(S) shall cooperate and participate in EQR activities in accordance with protocols identified under 42 CFR 438, Subpart E.
2.2.22.1

The EQRO will conduct annual, external, independent reviews of the quality outcomes, timeliness of, and access to the services covered in this CONTRACT. The CONTRACTOR(S) shall collaborate with the EQRO to develop studies, surveys and other analytic activities to access the quality of care and services provided to Members and to identify opportunities for CONTRACTOR improvement. The CONTRACTOR(S) must also work collaboratively with the State and the EQRO to annually measure identified performance measures. The CONTRACTOR shall respond to recommendations made by the EQRO within the timeframe established by the EQRO. For the purposes of this CONTRACT, these requirements shall apply to all Medicaid and CHIP MCS.


2.2.22.2

The purpose of the external review function shall be threefold:



  • To provide the State and Federal government with an independent assessment of the quality of care delivered to Members enrolled with the CONTRACTOR;

  • To resolve identified problems in health care or contribute to improving the care of all T-XIX and T-XXI Members enrolled with the CONTRACTOR;

  • To measure CONTRACTOR(S) compliance with CONTRACT requirements.

2.2.22.3


The State will select an EQRO to assure quality and accessibility of health care in the appropriate setting to Title XIX and Title XXI Members.
2.2.22.4

The CONTRACTOR(S) shall provide full cooperation with the EQRO to assure quality and accessibility of health care in the appropriate setting to Members including the validation of PIPs and performance measures.



2.2.23               Grievances and Appeals
See Attachment D – “Grievances and Appeals” for additional information.
2.2.23.1         

Definition: A grievance is an expression of dissatisfaction about any matter. A grievance shall be filed on behalf of a Member who expresses dissatisfaction, regardless of a specific request to file a grievance.  Grievances may include:  denial of service, partial denial of service, not given clear and accurate information from staff, lack of action being taken on a case, quality of care, aspects of the business relationships such as rudeness of an employee or failure to respect the Member’s rights. A grievance may be received by telephone, voice mail, e-mail, written communication or by a person. The CONTRACTOR(S) is responsible for documenting, investigating and resolving all grievances in a courteous and prompt manner.  The CONTRACTOR(S) shall establish an internal grievance and appeal process to identify, record, investigate, resolve and report grievances that shall be in compliance with Attachment D – Grievance and Appeals, and approved, in advance, by the State. The grievance process must be in full compliance with all applicable State and Federal laws and shall not supplant, delay, or hinder the fair hearing/appeal process.

2.2.23.2

Grievance Tracking

The CONTRACTOR(S) must provide a system to track and document all grievances.   The grievance tracking and log will provide staff a tool to respond to grievances timely and effectively

2.2.23.2.1            

Functionality

2.2.23.2.1.1

The grievance tracking system shall provide operational and management information at various levels.   

2.2.23.2.1.2

Examples of functions the grievance tracking and log solution will support include, but are not limited to the following:

2.2.23.2.1.2.1

allow staff to identify all cases with open or outstanding grievances at any point;  

2.2.23.2.1.2.2

identify priority grievances requiring resolution;

2.2.23.2.1.2.3

allow staff to track and view grievance history by client; and

2.2.23.2.1.2.4

provide reports, including management reports, to track compliance.               

2.2.23.2.2            

Requirements 

2.2.23.2.2.1

The system will capture all elements to meet State grievance reporting requirements. 

2.2.23.2.2.2

The system must allow elements to easily be added or removed. 

2.2.23.2.2.3

The system must track grievances by type, status or other element as required by the State.

2.2.23.2.2.4

The system must show the resolution.

2.2.23.2.2.5

The system must measure and track time frames.

2.2.23.2.2.6

Must allow and track referrals to other entities.

2.2.23.2.2.7

Must coordinate and allow input regarding fair hearings.

2.2.23.2.2.8

Must allow inquiry through multiple fields.

2.2.23.2.3 CONTRACTOR(S) shall also develop a database extract file that can be imported into the State fiscal agent’s grievance database.


2.2.24 Clinical and Medical Records
The CONTRACTOR shall maintain, and shall require CONTRACT providers and subcontractors to maintain clinical and medical records in a manner that is current, detailed and organized; and, which permits effective and confidential patient care and quality review, administrative, civil and/or criminal investigations and/or prosecutions.
2.2.24.1

The CONTRACTOR(S) shall have clinical and medical record keeping policies and practices which are consistent with 42 CFR §456 and current National Committee for Quality Assurance (NCQA) standards as well as all other related State and Federal laws for medical record documentation. The CONTRACTOR shall distribute these policies to practice sites. At a minimum, the policies and procedures shall address:

2.2.24.1.1

Confidentiality of clinical medical records - CONTRACTOR(S) and subcontractors must maintain the confidentiality of clinical and medical record information and release the information only in the following manner:

2.2.24.1.1.1

All clinical and medical records of enrolled Members shall be confidential and shall not be released without the written consent of the Member or responsible party except as required above.

2.2.24.1.1.2

Written consent of the Member is required for the transmission of the clinical and medical record information of a former enrolled Member to any physician not connected with the CONTRACTOR.

2.2.24.1.1.3

The extent of clinical or medical record information to be released in each instance shall be based upon tests of medical necessity and a “need to know” on the part of the practitioner or a facility requesting the information.

2.2.24.1.1.4

All release of information for SUD specific clinical or medical records must meet Federal guidelines at 42 CFR Part 2.

2.2.24.1.2

Clinical and Medical record documentation standards

2.2.24.1.2.1

Standards for the availability of clinical and medical records - The CONTRACTOR(S) shall maintain a system of access to clinical and medical records. The CONTRACTOR(S) must have in effect arrangements which provide for access to the clinical and medical records and clinical and medical record-keeping systems which include a complete record for each enrolled Member in accordance with provisions set forth in the CONTRACT. CONTRACTOR(S) shall include sufficient information to comply with the provisions of 42 CFR 456.111 and 456.211 regarding UR. The State, or its designated agent, and the Federal government shall be allowed access to this system.

2.2.24.1.2.2

Records Retention - The CONTRACTOR(S) shall retain, preserve and make available upon request all records relating to the performance of its obligations under the CONTRACT, including clinical and medical records and claim forms, for a period of not less than six (6) years from the date of termination of the CONTRACT. Records involving matters which are the subject of litigation shall be retained for a period of not less than six (6) years following the termination of such litigation, if the litigation is not terminated within the normal retention period. Electronic copies of documents contemplated herein may be substituted for the originals with the prior written consent of the State, provided that the microfilming procedures are approved by the State as reliable and are supported by an effective retrieval system. Upon expiration of the six (6) year retention period, unless the subject of the records is under litigation, the subject records may be destroyed or otherwise disposed of without the prior written consent of the State.


2.2.25 Coordination and Continuation of Care
The CONTRACTOR(S) shall be responsible for care coordination and establish a set of Member-centered, goal-oriented, culturally relevant and logical steps to ensure that a Member receives needed services in a supportive, effective, efficient, timely and cost-effective manner. Case management, disease management, discharge and transition planning are elements of care coordination for Members across all providers and settings.
During the implementation phase of this agreement, the CONTRACTOR(S) shall ensure that each Member receiving existing authorized services is transitioned with minimal service disruption and continuance of current provider.  Each CONTRACTOR shall submit a plan to the State detailing how this requirement will be accomplished for all affected Members.
2.2.25.1

General Requirements: The CONTRACTOR shall be responsible for the management, coordination, and continuity of care for all its Members and shall develop and maintain policies and procedures to address this responsibility. For Members, these policies and procedures shall specify the role of the health home in conducting these functions.

2.2.25.1.1

The CONTRACTOR shall have systems in place to ensure well-managed care, including at a minimum:

2.2.25.1.1.1

Management and integration of health care through primary provider/other means;

2.2.25.1.1.2

Provision of systems to assure referrals for medically necessary, specialty, secondary and tertiary care and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the enrollee;

2.2.25.1.1.3

Provision of systems to assure provision of care in emergency situations, including an educational process to help assure that Members know where and how to obtain medically necessary care in emergency situations;

2.2.25.1.2

Refer to Section 2.2.15 General Access Standards for additional requirements;

2.2.25.1.3

Monitoring coordination of care among PCPs, specialists, behavioral health providers, and LTC providers;

2.2.25.1.4

Maintaining performance-based outcomes in NFs for care coordination including case management;

2.2.25.1.5

Maximizing Medicare benefits-- Medicaid should be the payer of last resort (e.g. The CONTRACTOR should ensure that Medicare skilled NF benefits have been exhausted prior to utilizing Medicaid);

2.2.25.1.6

Performing age and gender specific preventive health care management services in accordance with current best practices; having mechanisms to assess the quality and appropriateness of services furnished, and provide appropriate referral and scheduling assistance;

2.2.25.1.7

Monitoring Members with ongoing medical or behavioral health conditions;

2.2.25.1.8

Identifying Members using emergency department services inappropriately to assist in scheduling follow-up care with PCPs and/or appropriate specialists to improve continuity of care and establish a medical home;

2.2.25.1.9

Maintaining and operating a formalized hospital and/or institutional discharge planning program;

2.2.25.1.10

Coordinating hospital and/or institutional discharge planning that includes post-discharge care, as appropriate;

2.2.25.1.11

Maintaining an internal tracking system that identifies the current preventive services screening status and pending preventive services screening due dates for each Member;

2.2.25.1.12

Authorizing services provided by non-CONTRACT providers, as required in this Agreement.


2.2.25.2

School Based and Early Childhood Intervention Services - The CONTRACTOR shall establish procedures to coordinate care for children receiving school-based services and early intervention services in a manner that prevents duplication of services provided and/or managed by the CONTRACTOR. The CONTRACTOR shall monitor the continuity and coordination of care for these children as part of its QAPI program.

2.2.25.2.1

Services provided under these programs are authorized under the Federal Individuals with Disabilities Education Act (IDEA) and through an Individual Education Plan (IEP), but typically excluded from coverage by the CONTRACTOR except in situations where a child’s course of treatment is interrupted due to school breaks, after school hours or during summer months. The CONTRACTOR is responsible for providing all medically necessary covered services. IEP services shall not be duplicated by the CONTRACTOR.

2.2.25.2.2

School-based services are excluded from managed care coverage and are reimbursed through FFS Medicaid when provided by a Medicaid-enrolled provider. School-based services provided by local health departments are included in the CONTRACTOR’s coverage. Coordination between the schools and the CONTRACTOR will ensure that Members receive medically necessary services that complement IEP services and promote the highest level of functioning for the child.

2.2.25.2.3

The CONTRACTOR shall coordinate services between the early childhood intervention (ECI) program and CONTRACTOR-managed services. The ECI program is also authorized by IDEA and funded by Federal, State, and local funds. The goal of the program is to provide early intervention services to children from birth to age three who have DDS or delays.

2.2.25.2.4

The CONTRACTOR shall effectively coordinate care for Members who qualify for these services to ensure children are receiving necessary services and that those services are not duplicated, as well as by sharing information with EIC and school-based providers with appropriate parental permissions.


2.2.25.3

Special requirements for care coordination for Members with complex needs:

2.2.25.3.1

The State intends to procure services that promote patient-centered care and improve health outcomes for the entire population, but particularly for high-risk, high-service utilizers and other high-cost individuals with complex needs to provide improved through:


2.2.25.3.1.1

Increased integration among providers of medical and behavioral health care for all Members;

2.2.25.3.1.2

Increased integration of treatment for MH and SUD conditions;

2.2.25.3.1.3

A care management program to assist Members with complex medical and/or behavioral health needs in the coordination of their care; and

2.2.25.3.1.4

Providing incentives for performance based on desired outcomes and based on measures that demonstrate an improvement in the quality of care provided to Members and ensure efficient use of health care services.

2.2.25.3.1.4.1

The State intends this RFP and the resulting CONTRACT to promote its vision of having a managed care plan that features an integrated medical and behavioral health delivery system that focuses on involving the Member in identifying his or her needs, and facilitates collaboration among those individuals and the medical and behavioral health clinicians to make informed health care decisions. According to current literature, the following are some key principles of a well-integrated health care delivery system that produces improved health outcomes:

2.2.25.3.1.4.2

Improving screening and treatment of MH and SUD diagnoses in primary care settings that facilitate appropriate medical care for individuals with SPMI, especially those with other chronic conditions;

2.2.25.3.1.4.3

Treating individuals at the point of care where they are comfortable, and applying a patient-centered, strength-based approach to treatment that incorporates shared decision-making practices;

2.2.25.3.1.4.4

Ensuring that individuals are treated in a holistic manner, using a single treatment plan that addresses both physical and MH needs and taking into account unmet needs such as SUD treatment; and also helping the individual access his/her natural community supports based on his/her strengths and preferences;

2.2.25.3.1.4.5

Improving communication and collaboration between behavioral health and medical clinicians;

2.2.25.3.1.4.6

Operating with a collaborative team approach to deliver care using a standardized protocol. The team includes the individual, key clinicians, and other persons whom the individual may select for support in designing and accessing services, such as a neighbor, relative, friend, or case manager; and

2.2.25.3.1.4.7

Establishing the necessary permissions from the individual to coordinate care among different providers, and establishing the required HIPAA-approved and 42 CFR Part 2 compliant Business Associate Agreements (BAA) to address protected health information (PHI).


2.2.25.4

The State will annually establish clear incentives for the CONTRACTOR to improve health outcomes for Members.


2.2.25.5

Care Management Program


2.2.25.5.1

In its proposal the CONTRACTOR(S) shall,

Describe its experience operating a care management program or similarly functional program model, including:

2.2.25.5.1.1

How individuals were identified for and engaged in care management including the use of predictive modeling that incorporates medical, pharmacy and behavioral health claims and the successful outreach rate that led to engagement in care management;

2.2.25.5.1.2

The target populations included in the program;

2.2.25.5.1.3

A description of the barriers and opportunities to engaging individuals in care management and how barriers can be overcome;

2.2.25.5.1.4

Key features of the program(s), including:

2.2.25.5.1.4.1

how the program involves and supports individuals in the creation of and adherence to their individual care plan;

2.2.25.5.1.4.2

how the program supports PCPs and ensures that the program’s care plan supports their treatment plan; and

2.2.25.5.1.4.3

how the program supports other providers that interact with the Member, including hospital Emergency departments and other key providers regardless of whether these providers are included in the CONTRACTOR(S)’s network;

2.2.25.5.1.5

A general description of the type(s) of care management needs of the population served and how those were determined;

2.2.25.5.1.6

Outcomes the CONTRACTOR(S)’ model was intended to achieve and whether such outcomes were achieved; if outcomes were not achieved, describe the reasons the goals were not accomplished;

2.2.25.5.1.7

How the model was staffed, including use of nurses and social workers, make-up of multi-disciplinary teams, use of physician consultation, and ratios of staff to care management participants, including how staffing differed across levels of care management; and

2.2.25.5.1.8

How this experience will assist the CONTRACTOR(S) in performing the Care Management Program requirements of this CONTRACT.
2.2.25.6

Describe how it would collaborate with case managers and critical networks, key providers, family members and community supports, and hospitals for individuals in care management.


2.2.25.7

Provide a sample, of an existing or proposed individual care plan developed by the CONTRACTROR(S) and explain how, if at all, it would adapt or modify such individual care plan to conform to the CONTRACT’s definition of an individual care plan.


2.2.25.8

Describe how the CONTRACTROR(S) will engage providers in the care management program regardless of whether or not the provider participates in the behavioral health provider network, and how the CONTRACTOR(S) will build working relationships with PCPs and other key providers of Members’ care.


2.2.25.9

Describe how the CONTRACTOR(S) will engage Members to participate in the care management program, including any incentives it would propose utilizing, and why it believes those incentives will be effective.


2.2.25.10

Describe the tools the CONTRACTOR(S) proposes to utilize to measure the success of the care management program. Identify whether these tools have been utilized by the CONTRACTOR(S) for other contracts, and describe how the CONTRACTOR(S) will utilize the outcomes in order to continually improve its care management program.


2.2.25.11

Improved Integration of Medical and Behavioral Health Care - The CONTRACTOR(S) shall describe:

2.2.25.11.1

Its experience in working with Members’ PCPs and behavioral health providers to facilitate a high degree of coordination and communication of care across disciplines for the benefit of its Members;

2.2.25.11.2.

How it will engage Members, and physical, HCBS, LTC and behavioral health providers under the CONTRACT to ensure optimal coordination and communication, including a description of best practices in this area and how the CONTRACTOR(S) proposes to address any barriers to integration;

2.2.25.11.3

How it will focus its integration efforts to get the most value and what anticipated improved health outcomes for Members or improved compliance with established medical protocols the CONTRACTOR(S) would expect based on its efforts to improve the integration of medical and behavioral health care;

2.2.25.11.4

What other outcomes, in addition to health outcomes, the CONTRACTOR(S) would expect to improve and monitor;

2.2.25.11.5

What type of clinical support it will offer to providers treating behavioral health conditions such as depression in the primary care setting;

2.2.25.11.6

How it would promote and support primary care-based behavioral health in the pediatric and adult populations; what best practices and recommended protocols the CONTRACTOR(S) would use to support the integration of medical and behavioral health care; and, what materials and tools the CONTRACTOR(S) would utilize in order to engage Members and providers to improve integration;

2.2.25.11.7

How it would engage Members in order to obtain consent to share PHI across behavioral health, HCBS, LTC and physical health care providers, when such consent is required, and its previous experience in obtaining Member consent, particularly as it relates to 42 CFR, Part 2 for SUD care; and

2.2.25.11.8

Examples of innovative network designs or structures that the CONTRACTOR(S) has tested or implemented, if any, to facilitate integration of medical and behavioral health care services, and any direct improvements that resulted.

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