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KYLE L. JANEK, M.D. EXECUTIVE COMMISSIONER VENDOR CONFERENCE PowerPoint Presentation
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KYLE L. JANEK, M.D. EXECUTIVE COMMISSIONER VENDOR CONFERENCE

KYLE L. JANEK, M.D. EXECUTIVE COMMISSIONER VENDOR CONFERENCE

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KYLE L. JANEK, M.D. EXECUTIVE COMMISSIONER VENDOR CONFERENCE

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  1. KYLE L. JANEK, M.D. EXECUTIVE COMMISSIONER VENDOR CONFERENCE STAR+PLUS, Medicaid Rural Service Area Services Request for Proposal No. 529-13-0042 February 15, 2013 (1:00 PM – 4:00 PM)

  2. Welcome • Introductions • Rick Blincoe, Enterprise Contract & Procurement Services (ECPS) • Paula Swenson, Program Operations, Medicaid/CHIP Division • Sherice Williams, HHSC HUB Administrator • Meghan Frkuska, Assistant General Counsel, Office of General Counsel • Housekeeping Items

  3. Vendor Conference Overview • Procurement Activities • RFP Overview • HUB Overview • Question Submittal ========================== • Break ========================== • Preliminary Responses to Questions • Closing

  4. HHSC Procurement Roles • ECPS - Responsible for procurement activity • Program - Responsible for project scope, requirements, performance, results, contract management/monitoring • HUB - Responsible for monitoring HUB activity • Legal – Questions/answers regarding legal issues

  5. ECPS Procurement Activities • Sole Point of Contact • Questions & Answers • Procurement Schedule • Solicitation Access http://www.hhsc.state.tx.us/contract/529130042/announcements.shtml • Submission Requirements • Solicitation Updates • Screening & Evaluation • Award Information

  6. Procurement Schedule • Draft RFP Release Date October 11, 2012 • Draft RFP Respondent Comments Due November 1, 2012 • RFP Release Date December 12, 2012 • Vendor Conference February 15, 2013 • Respondent Questions Due March 1, 2013 • Letters Claiming Mandatory Contract Status Due March 29, 2013 • HHSC Posts Responses to Respondent Questions April 1, 2013 • Proposals Due May 1, 2013 • Deadline for Proposal Withdrawal May 1, 2013 • Respondent Demonstrations/Oral Presentations (HHSC option) To be Announced • Tentative Award Announcement To be Announced • Anticipated Contract Effective Date September 1, 2013 • Operational Start Date September 1, 2014

  7. RFP Overview

  8. Request for Proposals No. 529-13-0042 RFP Overview • Mission • Project Objectives • Scope of Work • Performance Measures

  9. STAR+PLUS Expansion • HHSC is expanding the scope of services and expanding the STAR+PLUS program to the Medicaid Rural Service Area, making STAR+PLUS available statewide. • HHSC will select no less than 2 managed care organizations per Service Area to provide the STAR+PLUS covered services in the Medicaid Rural Service Area (MRSA).

  10. Mission Statement HHSC’s mission is to improve the quality of, and access to care provided to Members, ensure continuity of care; increase utilization of Member benefits; and generate opportunities to contain program costs. HHSC seeks to accomplish its mission by contracting for measurable results that : • Integrate acute care and community-based long-term services and supports. • Provide continuity of care ; and • Ensure timely access to quality care.

  11. Mission Objectives HHSC will prioritize desired outcomes and benefits for the managed care programs, and will focus its monitoring efforts on the Managed Care Organization’s (MCO) ability to provide satisfactory results in the following areas. • Continuity of Care • Network adequacy and access to care • Service Coordination • Increase Utilization of Member Benefits with an Emphasis on Medical Check-ups – especially for the children that volunteer into the STAR+PLUS program. • Quality • Timeliness of claim payment • Timely access to Medically Necessary Behavioral Health Services • Delivery of health care to diverse populations • Provision of a comprehensive disease management program.

  12. Scope of Work • The MCO must comply with all Contract provisions including all applicable state and federal laws, rules, regulations, and waivers • Covered Services • The MCO must provide full coverage of Medically Necessary Covered Acute Services to all Medicaid only Members in accordance with the requirements of the Contract • The MCO must also provide Functionally Necessary Community-based Long-Term Care Services • The MCO may propose Value-added Services

  13. Scope of Work • Covered Community-based Long-Term Care Services • Day Activity and Health Services (DAHS) • All members may receive medically and functionally necessary Day Activity and Health Services • Personal Assistance Services (PAS) • All members may receive medically and functionally necessary Personal Assistance Services

  14. Scope of Work • HCBS STAR+PLUS Waiver • STAR+PLUS provides access to an enriched array of services for who would otherwise qualify for nursing facility care. SSI members have access without an interest list • STAR+PLUS Services Areas still maintain an interest list for 217-Like Group Non-Member applicants • The MCO is responsible for tracking end dates of the Individual Service Plans and initiating the annual review

  15. Scope of Work • Service Coordination • Service Coordinators are responsible for assessing member needs, formulating an individualized plan of care, coordinating and authorizing acute and long-term care, and making referrals to community organizations • The Service Coordinator must actively work with the Member’s primary and specialty care Providers in order to integrate care • Minimum requirements are set for categories of members, based upon acuity, functional needs, and/or other needs. These requirements include a minimum number of contacts, types of contacts, and credentials of Service Coordination staff.

  16. Scope of Work • Improvements! • 8.1.4.8.3 Advanced Payments • MCOs are required to develop a process by which providers may request advanced payments for authorized services that have not yet been delivered. • 8.1.4.10 Provider Advisory Groups • The MCO must establish and conduct quarterly meetings with Network Providers in each service area in which it operates.  Membership in the Provider Advisory Group(s) must include, at a minimum, acute care, community-based LTSS, and pharmacy providers.  • 8.1.5.10 Member Advisory Groups • The MCO must establish and conduct quarterly meetings with Members in each service area in which it operates.  Membership in the Member Advisory Group(s) must include, at least three Members attending each meeting and allow for member advocates to participate.

  17. Scope of Work • Assessment Instruments • The MCO must use functional instruments to assess Members including: • The DADS Consumer Needs Assessment Questionnaire and Task/Hour Guide, Form 2060 • The Texas Medicaid Personal Care Assessment Form (PCAF) for assessment of children under the age of 21 • The Community Medical Necessity and Level of Care (MN/LOC) Assessment Instrument • The HMO must also complete the Individual Service Plan (ISP), Form 3671, for each Member receiving HCBS STAR+PLUS Waiver services.

  18. Scope of Work • Access to Care • The MCO must have network PCPs and Specialty Providers in sufficient numbers and capacity • Appointments for Covered Services must be provided within the specified timeframes • The MCO is required to regularly verify that Covered Services are available and accessible to Members in compliance of required standards

  19. Scope of Work • Provider Network • The MCO must enter into written contracts with properly credentialed Providers • The MCO must maintain a Provider Network sufficient to provide all Members with access to the full range of Covered Services required under the Contract • Providers must be furnished with a Provider Manual, materials, training, and a toll-free Provider Hotline

  20. Scope of Work • Member Services • The MCO must have a Member Services Department to assist Members in obtaining Covered Services • Member Services must include Member Hotline, Nurseline, Member Education, and a Member Complaints and Appeals process • Member Materials must include a Member Identification Card, Member Handbook, Provider Directory, and Internet Website

  21. Scope of Work • Marketing and Prohibited Practices • MCOs must adhere to the Marketing Policies and Procedures in the Contract and the HHSC Uniform Managed Care Manual • All Marketing Policies and Procedures are applicable to the MCO, its Agents, Subcontractors and Providers • Marketing representatives are required to complete orientation and training

  22. Scope of Work • Management Information System (MIS) Requirements • The MCO must maintain a MIS to handle the following operational and administrative areas: • Enrollment/Eligibility Subsystem • Provider Subsystem • Encounter/Claims Processing Subsystem • Financial Subsystem • Utilization/Quality Improvement Subsystem • Reporting Subsystem • Interface Subsystem • Third Party Recovery (TPR) Subsystem

  23. Scope of Work • Fraud and Abuse • The MCO is subject to all state and federal laws and regulations relating to Fraud, Abuse, and Waste • The MCO must cooperate with HHSC and any state or federal agency charged with the duty of identifying, investigating, sanctioning, or prosecuting suspected Fraud, Abuse, and Waste • The MCO must submit a written Fraud and Abuse compliance plan to the Office of Inspector General (OIG) for approval each year

  24. Scope of Work • Reporting Requirements • The MCO must provide all information as required under the Contract and the Uniform Managed Care Manual (UMCM) • Required reports with a description of the format, content, file layout, and submission deadlines are included in the UMCM • HHSC may require additional reports as necessary

  25. Scope of Work • Continuity of Care and Out-of-Network Providers • The MCO must ensure that the care of newly enrolled Members is not disrupted • Members must be provided access to Out-of-Network services if necessary and covered benefits are not available within the Network • The MCO is required to ensure continued authorization of Community-based Long Term Care Services at the time of implementation

  26. Scope of Work • Medicaid Significant Traditional Providers • The MCO must seek participation in its Network from all Medicaid Significant Traditional Providers (STPs) defined by HHSC • The HHSC website includes a list of Medicaid STPs by Service Area (see addendum 2 dated January 30, 2013)

  27. Points of Interest • 2013 Legislative session includes many bills that may affect this RFP and current MCO contracts. • 8.1.45 Nursing Facility Services • HHSC reserves the right to amend the scope of the Contract to include Nursing Facility (NF) services for Medicaid Members. If NF services are added to the scope of the Contract, HHSC will provide advance written notice and conduct appropriate Readiness Review.

  28. HUB Subcontracting Plan(HSP) Requirements

  29. Agenda Topics • RFP Section 4.0 Historically Underutilized Business Participation Requirement • HUB Subcontracting Plan Development and Submission • HSP Quick Checklist • HSP Methods • HSP Prime Contractor Progress Assessment Report

  30. RFP Section 4.0 Historically Underutilized Business Participation Requirements • HUB Participation Goals • Potential Subcontracting Opportunities • Vendor Intends to Subcontract • Centralized Master Bidders List and HUB Directory

  31. RFP Section 4.0 Historically Underutilized Business Participation Requirements • Minority or Women Trade Organizations • Self Performance • HSP Changes After Contract Award • Reporting and Compliance with the HSP

  32. HUB Participation Requirements HUB Subcontracting Plan (HSP) Development and Submission

  33. If HSP is inadequate, response will be rejected HUB GOALS Special reminders and instructions HSP Information Page

  34. HUB Participation Requirements HSP Quick Checklist

  35. HUB Participation Requirements HSP Methods

  36. METHOD I If all (100%) of your subcontracting opportunities will be performed using only HUB vendors, complete: • Section 1 - Respondent and Requisition Information; • Section 2 a. – Yes, I will be subcontracting portions of the contract; • Section 2 b. – List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB vendors; • Section 2 c. – Yes; • Section 4 – Affirmation; and, • HSP GFE Method A (Attachment A) – Complete this attachment for each subcontracting opportunity.

  37. HSP Information Page Respondent and Requisition Information

  38. Company Name and Requisition # Subcontracting Intentions: Complete Section 2-a; Yes, I will be subcontracting portions of the contract.

  39. Complete Section 2-b;List all the portions of work you will subcontract, and indicate the % of the contract you expect to award to all HUBs. Complete Section 2-c; Yes if you will be using only HUBs to perform all SubcontractingOpportunities in 2-b.

  40. Section 4; Affirmation Signature Affirms that Information Provided is True and Correct.

  41. HSP GFE Method A (Attachment A) Complete this attachment (Sections A-1 and A-2) and List Line # and Subcontracting Opportunity. HUB Subcontractor Selection for this Subcontracting Opportunity Reminders: Notice to subcontractors and HHSC.

  42. METHOD II If any of your subcontracting opportunities will be performed using HUB protégés, complete: • Section 1 - Respondent and Requisition Information; • Section 2 a. – Yes, I will be subcontracting portions of the contract; • Section 2 b. – List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB vendors; • Section 4 – Affirmation; and, • HSP GFE Method B (Attachment B) – Complete Section B-1 and Section B-2 only for each subcontracting opportunity as applicable.

  43. HSP Information Page Respondent and Requisition Information

  44. Company Name and Requisition # Subcontracting Intentions: Complete Section 2-a; Yes, I will be subcontracting portions of the contract.

  45. Complete Section 2-b;List all the portions of work you will subcontract, and indicate the % of the contract you expect to award to HUB Protégés. Skip Sections 2-c and 2-d.

  46. Section 4; Affirmation Signature Affirms that Information Provided is True and Correct.

  47. HSP GFE Method B (Attachment B) Complete Sections B-1; and B-2 only for each HUB Protégé subcontracting opportunity.

  48. HSP GFE Method B (Attachment B) List the HUB Protégé(s)

  49. METHOD III If you are subcontracting with HUBs and Non-HUBs, and the aggregate percentage of subcontracting with HUBs, holding an existing contract with HUBs for 5 years or less, which meets or exceeds the HUB Goal identified in the solicitation, complete: • Section 1 - Respondent and Requisition Information; • Section 2 a. – Yes, I will be subcontracting portions of the contract; • Section 2 b. – List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB vendors and Non HUB vendors; • Section 2 c. – No; • Section 2 d. – Yes; • Section 4 – Affirmation; and, • HSP GFE Method A (Attachment A) – Complete this attachment for each subcontracting opportunity.

  50. HSP Information Page Respondent and Requisition Information