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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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2.2.26 Provision of Health Homes (HH)
The CONTRACTOR is expected to describe how it will provide HH for Members with two or more identified chronic conditions (including mental illness, SUD, asthma, diabetes, heart disease, and obesity); one chronic condition and at risk for a second; or SPMI.
2.2.26.1

The HH must provide:

2.2.26.1.1

Comprehensive care management;

2.2.26.1.2

Care coordination;

2.2.26.1.3

Health promotion;

2.2.26.1.4

Comprehensive transitional care and follow-up;

2.2.26.1.5

Patient and family support; and

2.2.26.1.6

Referral to community and social support services.


2.2.26.2

The preferred model for a HH is a team of health professionals, including physicians and other professionals such as nurses, nutritionists, social workers, behavioral health professionals, and any others necessary to provide the appropriate HH. Attachment I illustrates how the State expects the CONTRACTOR to interact with various providers in the provision of a health home. The CONTRACTOR must describe how it will establish health homes within that framework, so that the State can apply to CMS for enhanced funding for provision of HH. It is expected that provision of HH will begin within twelve (12) months of the awarding of the CONTRACT for at least those Members who have a mental illness or diabetes, or both. By year two (2) all Members with complex needs shall have a HH.


The CONTRACTOR’s plan for HH must include a description of the population(s) covered and of the payment methodology that fits within the parameters described in the CMS State Medicaid Directors Letter # 10-024. HHs may be phased in, beginning with Members who have a mental illness and/or diabetes. CONTRACTOR(S) shall propose a timeline for all relevant populations to have a health home.
The State intends for HHs to incorporate a Member’s current community-based provider wherever possible. As part of the plan for HH, the CONTRACTOR must indicate how it will incorporate existing service structures Members currently access into HH. The CONTRACTOR must also propose a case management and care coordination system that is an integral component of HH.
2.2.26.3

Regardless of HH assignment, the CONTRACTOR(S) shall ensure that all Members have an ongoing source of primary care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the Member.


2.2.27 Encounter Data and Other Data Requirements
The CONTRACTOR shall collect service information in standardized formats approved by the state and must make all collected data available to the State after it is tested for accuracy, completeness, logic and consistency in accordance with 42 CFR §438.242.
CONTRACTOR shall certify data including, but not limited to, all documents specified by the State, enrollment information, encounter data, and other information contained in contracts, proposals. The certification must attest, based on best knowledge, information, and belief as to the accuracy, completeness and truthfulness of the documents and data. The CONTRACTOR must submit the certification concurrently with the certified data and document. Data must be certified by one of the following:

The MCO's or PIHP's Chief Executive Officer

The MCO's or PIHP's Chief Financial Officer

An individual who has delegated authority to sign for, and who reports directly to, the CONTRACTOR's Chief Executive Officer or Chief Financial Officer.


For additional information see Attachment K – Encounter Data and Other Data Requirements.
2.2.28 Disclosure of Financial Records
2.2.28.1

The CONTRACTOR shall establish and maintain an accounting system in accordance with generally accepted accounting principles, and the costs properly applicable to this CONTRACT shall be readily ascertainable. The accounting system shall maintain records pertaining to the services and any other costs and expenditures made under this CONTRACT.


2.2.28.2

The CONTRACTOR and any subcontractors shall make available to the State, the State’s authorized agents, and appropriate representatives of the U.S. Department of Health and Human Services (HHS), any financial records of the CONTRACTOR or subcontractors which relate to the CONTRACTOR’S capacity to bear the risk of potential financial losses, or to the services performed and amounts paid or payable under this CONTRACT. Accounting procedures, policies and records shall be completely open to state and federal audit at any time during the CONTRACT period and for six (6) years thereafter.


2.2.28.3

The CONTRACTOR and any non-provider subcontractors shall submit to the State an Annual Financial Report in the form prescribed by the Kansas Insurance Department in the attachment to Kansas Administrative Regulation (K.A.R.) 40-1-37, Titled “Policy and Procedure Requiring Audited Financial Reports,” dated November 22, 2010, for health maintenance organizations doing business in Kansas and shall be submitted to the State at the same time it is submitted to the Kansas Insurance Department each year (shall file an Audited financial report with the commissioner on or before June 1 for the year ended December 31 immediately preceding. The commissioner may require an insurer to file an audited financial report earlier than June 1, with ninety (90) days advance notice to the insurer). The report shall contain an income statement detailing the CONTRACTOR’S fourth quarter and year-to-date revenues earned and expenses incurred as a result of the CONTRACTOR’S managed care activities in the State of Kansas. This Annual Report shall also be accompanied by the Medical Loss Ratio report completed for the same period. The CONTRACTOR shall submit a reconciliation of the Medical Loss Ratio report to the annual NAIC filing using an accrual basis that includes an actuarial certification of the claims payable (reported and unreported).


2.2.28.4

The CONTRACTOR shall file with the State, a Quarterly Financial Report. These reports shall be on the form prescribed by the NAIC for health maintenance organizations and shall be submitted to the State on or before November 15 (covering first quarter of current year), February 15 (covering second quarter of current year) and May 15 (covering third quarter of current year). Each quarterly report shall also contain an income statement detailing the CONTRACTOR’S quarterly and year-to-date revenues earned and expenses incurred as a result of the CONTRACTOR’S participation in the KanCare program. The second quarterly report (submitted on August 15) shall include the Medical Loss Ratio report completed on an accrual basis that includes an actuarial certification of the claims payable (reported and unreported) and, if any, other actuarial liabilities reported. The actuarial certification shall be prepared in accordance with NAIC guidelines. The CONTRACTOR shall also submit a reconciliation of the Medical Loss Ratio report to the second quarterly NAIC report.


2.2.28.5

Other Financial Reports

2.2.28.5.1

Fiscal Year Budget - By no later than June 30 of each year, the CONTRACTOR shall submit to the State an annual Financial Plan and Projection of Operating Results Report. This submission shall include the CONTRACTOR’S budget projecting revenues earned and expenses incurred on a State fiscal year basis through the term of this Agreement. This budget shall include narratives explaining the assumptions and calculations utilized in the projections of operating results. The budget shall be accompanied by an Administrative Cost Allocation Plan detailing the funding of administrative expenses.

2.2.28.5.2

Mid Year Comparison - By no later than January 31 of each year, the CONTRACTOR shall submit to the State a mid-year Comparison of Actual Revenues and Expenses to Budgeted Amounts Report. If necessary, the CONTRACTOR shall revise the fiscal year budget based on its actual results of operations. Any revisions to the budget shall include narratives explaining the assumptions and calculations utilized in making the revisions. If applicable, an updated Administrative Cost Allocation Plan will be included.

2.2.28.5.3

Payment Integrity Report - The CONTRACTOR shall submit monthly an updated Payment Integrity Report (Exhibit 1-2) that includes any cost avoidance and cost recoveries for third party resources as well savings for which the CONTRACTOR does not pay a claim due to TPL coverage or Medicare coverage.

2.2.28.5.4

Other Insurance Report - The CONTRACTOR shall submit monthly an updated Other Insurance Report that provides information on any members who have other insurance, including long-term care insurance.

2.2.28.5.5

Medical Loss Ratio Report - The CONTRACTOR shall submit a Medical Loss Ratio Report in the NAIC format monthly with cumulative year-to-date calculations. The CONTRACTOR shall report all medical expenses and complete the supporting claims lag tables. This report shall be accompanied by a letter from an actuary, who may be an employee of the CONTRACTOR, indicating that the reports, including the estimate for incurred but not reported expenses, have been reviewed for accuracy. The CONTRACTOR shall also file this report with its NAIC filings due in March and August of each year using an accrual basis that includes incurred but not reported amounts by calendar service period that have been certified by an actuary. This report shall reconcile to NAIC filings including the income statement. The CONTRACTOR shall also reconcile the amount paid reported on the supporting claims lag tables to the amount paid for the corresponding period as reported on the CONTRACTOR’S encounter file submission.

2.2.28.5.6

MCO Reporting Template - The CONTRACTOR(S) shall submit to the State the MCO Reporting Template (MRT) (Exhibit 1-1) for two calendar years of activity. The MRT for the preceding year shall be submitted by no later than March 1st with an update for claims runout by May 1st. The final MRT for the two years preceding shall be submitted by January 1st.

2.2.28.5.7

The CONTRACTOR shall provide policy impact analyses and support. Review and analyze policy options, develop documents for review, analyze fiscal and programmatic impacts, conduct federal regulatory review, make presentations to senior officials and interested parties, and assist with implementation of adopted strategies. Implementation tasks may include, but are not limited to, preparation of work plans, facilitation of stakeholder working groups, development of contractor specifications, detailed actuarial and related analyses, initial and ongoing program monitoring, and necessary evaluations for state or federal reporting. Respond to requests for policy impact and analyses within 30-days of request.

2.2.28.5.8

The CONTRACTOR shall submit to the State any additional financial information or reports on a schedule and in a format determined by the State.

2.2.28.5.9

The CONTRACTOR shall submit to the State annual Audited Financial Statements as they become available.

2.2.28.5.10

The CONTRACTOR(S) shall provide a written assurance stating a copy of your signed reinsurance policy will be submitted not later than 30 days after contract signing.


2.2.28.6

The CONTRACTOR(S) shall provide a written assurance stating the required performance bond and restricted reserve account will be submitted not later than 45 days after contract signing.


2.2.28.7

The CONTRACTOR(S) shall provide an insolvency plan documenting arrangements made which protect your subscribers in the event of insolvency. The plan must include provisions for dividing the cash reserves, capital and surplus requirements among plan providers in the event of insolvency. CONTRACTOR(S) shall hold harmless your members in the event of insolvency and your providers shall not charge members any portion of the costs associated with the provision of services under this contract.


2.2.28.8

The CONTRACTOR(S) shall provide a copy of each Letter of Credit held.


2.2.28.9

The CONTRACTOR(S) shall notify the State in writing of any person or corporation that has 5% or more ownership or controlling interest in the entity. The CONTRACTOR(S) shall submit financial statements for all owners with interest of 5% or greater.


2.2.29 Appeals to the State for CONTRACTOR Non-payment of Non-participating Providers
The CONTRACTOR shall accept the State’s determinations regarding provider appeals. In cases where there is a dispute between the CONTRACTOR and a non-participating provider about whether a service is medically necessary, is an emergency, or is an appropriate diagnostic test to determine whether an emergency condition exists, the State will hear appeals and make final determinations. The State will accept written comments from all parties involved in the dispute prior to making a final decision. After reviewing the pertinent facts the State shall make determination whether or not payment is ordered as appropriate.
Any CONTRACTOR(S) which has a pattern of inappropriately denying payments for emergency related services may be subject to suspension of new enrollments, withholding of capitation payments, CONTRACT termination or refusal to CONTRACT in a future time period. This applies to cases where the State has ordered payment after appeal and also to cases where no appeal has been made (i.e., the State is knowledgeable about abuse from other sources).
2.2.30 Program Integrity and Disclosure Requirements 
2.2.30.1

The CONTRACTOR shall have administrative and management arrangements or procedures, and a mandatory compliance plan, that are designed to guard against fraud and abuse. The CONTRACTOR arrangements or procedures must include the following:

2.2.30.1.1

Written policies, procedures, and standards of conduct that articulates the organization's commitment to comply with all applicable Federal and State standards.

2.2.30.1.2

The designation of a compliance officer and a compliance committee that are accountable to senior management.

2.2.30.1.3

Effective training and education for the compliance officer and the organization's employees.

2.2.30.1.4

Effective lines of communication between the compliance officer and the organization's employees.

2.2.30.1.5

Enforcement of standards through well-publicized disciplinary guidelines.

2.2.30.1.6

Provision for internal monitoring and auditing.

2.2.30.1.7

Provision for prompt response to detected offenses, and for development of corrective action initiatives relating to this contract.

2.2.30.2

The CONTRACTOR shall diligently safeguard against the potential for, and promptly investigate reports of, suspected fraud and abuse by employees, subcontractors, providers, and others with whom the CONTRACTOR does business. The CONTRACTOR shall provide the State with its policies and procedures on handling issues of suspected fraud and abuse.


2.2.30.3

The CONTRACTOR shall comply with all Federal and State Laws and Regulations related to Program Integrity and Disclosure Requirements. This includes any future Laws and Regulations that may be required as well as current Laws and Regulations.


2.2.30.4

CONTRACTOR(S) shall notify the State, on a monthly basis, as to any adverse action that has been taken against a provider’s participation in the program, including when it denies credentialing for fraud-related concerns. The CONTRACTOR must follow all requirements in Attachment L – Program Integrity and Disclosure Requirements.


2.2.31 Consumer Fraud and Abuse
The CONTRACTOR shall notify the State of Members who have been identified as participating in fraudulent or abusive activities. Notification must be in written format with supporting documentation attached. The Members may be identified through utilization management, chart review, or by referral from network providers. The CONTRACTOR shall notify the State of suspected fraudulent activities within 24 hours of identification.
2.2.31.1

The CONTRACTOR is expected to provide Member education in an attempt to correct abusive behavior. Abusive behavior may include, but is not limited to:

2.2.31.1.1

Concurrently obtaining services from two or more providers of the same specialty, not in the same group practice, with no referrals;


2.2.31.1.2

Using two or more emergency facilities for non-emergent diagnosis;

2.2.31.1.3

Concurrently using two or more prescribing physicians to obtain drugs from the same therapeutic class of medication;

2.2.31.1.4

Two or more occurrences of having prescriptions for the same therapeutic class of medication filled two or more times on the same or subsequent day by the same or different providers;

2.2.31.1.5

Concurrently using two or more pharmacies to obtain quantity of drugs from the same therapeutic class of medication which exceed the manufacturer’s maximum recommended dosage as approved by the Food and Drug Administration (FDA);

2.2.31.1.6

Report of Member using the medical card to purchase drugs on a forged prescription;

2.2.31.1.7

Report of Member loaning a card to another individual to obtain Medicaid reimbursed services;

2.2.31.1.8

On request or recommendation of State Legal or KDHE-DHCF for cause; or

2.2.31.1.9

Consistently seeking/obtaining medical services which are not supported by diagnosis or medical records/documentation.


2.2.32 Administrative Lock-In
The CONTRACTOR shall have in place an Administrative Lock-In system for the situations described below. The CONTRACTOR’s Lock-In system shall be consistent with State and Federal regulations. The CONTRACTOR must notify the State immediately when a Member has been placed in Administrative Lock-In and if a Member in Lock-In transfers to FFS or another plan.

2.2.32.1


Situations in which CONTRACTOR may place a Member in Administrative Lock-in:

2.2.32.1.1

Persistent non-compliance: Member persistently refuses to follow prescribed treatments or comply with the MCO’s requirements.

2.2.32.1.2

Abusive or threatening conduct: Member engages in abusive or threatening conduct.

2.2.32.1.3

Fraud/Abuse: Member is found to be committing fraud or abuse of medical benefits.

2.2.32.1.4

Overutilization: Member utilizes Medicaid services at a frequency or amount that is not medically necessary.
2.2.32.2

The CONTRACTOR shall provide education to the Member regarding their behavior prior to placing a Member in Administrative Lock-In. If the Member has an SUD, MH or disability diagnosis related to the persistent non-compliant behavior, the CONTRACTOR will work with behavioral health and disability providers to help the Member change behavior prior to placing the Member in administrative lock-in. The CONTRACTOR’s attempts to educate and change the Member’s behavior shall be documented. During the Lock-In period, the Member may be required to use one pharmacy, one hospital, and/or one service provider. The Member has the right to appeal their placement into Administrative Lock-In. The Member must be given notice and opportunity for a fair hearing before placement into Administrative Lock-In. The CONTRACTOR must ensure that the Member has reasonable access (taking into account geographic location and reasonable travel time) to Medicaid services of adequate quality. Restrictions must not apply to emergency services furnished to the Member.


2.2.33 Use of and Safeguarding Data
In addition to the provisions of Attachment K – Encounter and Other Data, CONTRACTOR agrees to comply with the following:
2.2.33.1

Data Files - Data files and data contained therein shall be and remain the property of the State and shall be returned to the State by the CONTRACTOR upon the termination of this Agreement. State data shall not be utilized by the CONTRACTOR for any purpose other than that of rendering services to the State under this CONTRACT, nor shall State data or any part thereof be disclosed, sold, assigned, leased or otherwise disposed of to third parties by the CONTRACTOR unless there has been prior written State approval. The State shall have the right of access and use of any data files retained or created by the CONTRACTOR for systems operation under this CONTRACT.


2.2.33.2

Safeguarding Data: The CONTRACTOR shall establish and maintain at all times, reasonable safeguards against the destruction, loss or alteration of the program data and any other data in the possession of the CONTRACTOR necessary to the performance of operations under this CONTRACT.


2.2.33.3

Confidentiality of Data and Records:

2.2.33.3.1

The CONTRACTOR shall comply with 45 CFR 205.50, and 42 CFR Part 2, Safeguarding Information for the Financial Assistance and Social Service Program, 42 CFR 431 Subpart F, as well as 41 USC 423 27. The CONTRACTOR must comply with any other applicable Federal and State laws (such as Title VI of the Civil Rights Act of 1964, 42 CFR Part 2, etc.) and other laws regarding privacy and confidentiality. As deemed necessary, the State or its designated agent, and the Federal government shall be allowed access to this data. All information, except as noted above, as to personal facts and circumstances obtained by the CONTRACTOR shall be treated as privileged communications, shall be held confidential, and shall not be divulged without the written consent of the State and the written consent of the Member, or his/her attorney, or his/her responsible parent or guardian.

2.2.33.3.2

Data and information received by the CONTRACTOR and maintained in the CONTRACTOR’s database shall be used only for health policy decisions and research. Persons or agencies making requests for data or information from the CONTRACTOR’s database shall be directed to the State.

2.2.33.3.3

Appropriate administrative, technical, procedural and physical safeguards shall be established by the CONTRACTOR to protect the confidentiality of the data and to prevent unauthorized access to it. The State reserves the right to approve or disapprove of the CONTRACTOR’s security procedures.


2.2.33.4

Security of Facilities: The CONTRACTOR shall provide all reasonable security procedures at any place where services are performed by the CONTRACTOR under this CONTRACT. CONTRACTOR personnel shall comply with the rules of the State with respect to access to State offices, data files and data.


2.2.33.5

Rights in Data and Disclosure of Information

2.2.33.5.1

The State of Kansas operates under the Open Records Act. The State may duplicate, use or disclose in any manner and for any purpose whatsoever, all data, reports and documentation delivered to the State under this CONTRACT. This obligation is not subject to any limitation in any respect except as provided under State or Federal laws. The CONTRACTOR hereby grants to the State, a royalty-free, non-exclusive, and irrevocable license to publish, reproduce, deliver and to authorize others to do so, all such data, reports and documentation.

2.2.33.5.2

It is recognized by the parties that certain information or financial data pertaining to the CONTRACTOR may be exempted from public disclosure under both State and Federal law. Such data, which the CONTRACTOR does not want disclosed, will be prominently identified by the CONTRACTOR.

2.2.33.5.3

If the State receives a request for disclosure of such information which the CONTRACTOR has marked as proprietary, the State as an accommodation to the CONTRACTOR, before releasing the same will give the CONTRACTOR notice orally or in writing at least 48 hours before the release, in order that the CONTRACTOR may immediately seek any relief available to it under State or Federal law. Failure to give timely notice shall not be a basis for a cause of action against the State of Kansas, their employees, agents and representatives.

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