EXHIBIT 10.2
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
Page 1 of 1 with Attachment
1. AMENDMENT NO.: 2. CONTRACT NO.: 3. EFFECTIVE DATE OF MODIFICATION: 4. PROGRAM::
- ---------------------------------------------------------------------------------------------------------------
01 YH04-0001-03 MAY 1, 2003 OMC
- ---------------------------------------------------------------------------------------------------------------
5. CONTRACTOR/PROVIDER NAME AND ADDRESS:
HEALTH CHOICE ARIZONA
1600 WEST BROADWAY, SUITE 260
TEMPE, ARIZONA 85282-1136
- ---------------------------------------------------------------------------------------------------------------
6. PURPOSE:
To incorporate GSAs and Special Provisions
- ---------------------------------------------------------------------------------------------------------------
7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
1. The following GSAs are hereby incorporated into Contract Number
YH04-0001-03:
GSA #4 - Mohave, Coconino, Navajo and Apache Counties
GSA#8 - Pinal/Gifa Countries
GSA#10 - Pima county (only)
GSA#12 - Maricopa County
2. The attached Special Provisions are also hereby incorporated into
Contract Number YH04-0001-03.
Note: Please sign, date and return one original to: AHCCCS Contracts and
Purchasing
701 E, Jefferson, MD5700
Phoenix, Arizona 85034
8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL
CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL
EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT.
9. NAME OF CONTRACTOR:
Health Choice Arizona
SIGNATURE OF AUTHORIZED INDIVIDUAL:
/s/ Carolyn Rose
TYPED NAME: Carolyn Rose
TITLE: Chief Executive Officer
DATE: MAY 7, 2003
10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
SIGNATURE: /s/ MICHAEL VEIT
TYPED NAME: MICHAEL VEIT
TITLE: Contracts and Purchasing Administrator.
DATE: May 1, 2003
SPECIAL PROVISIONS (CONTRACT #YH04-0001)
HEALTH CHOICE OF ARIZONA
1. MINIMUM NETWORK STANDARDS
Contractor must have made significant progress toward signed subcontracts with
the entire provider network by June 15, 2003, in order to participate in "Open
Enrollment". Contractors must have their entire provider network contracted,
with providers, that meet or exceed the applicable Geographic Service Area (GSA)
Minimum Network Standards, as outlined in Attachment B of this contract, by
August 15, 2003. Furthermore, the Contractor must have in place a sufficient
number of contracts with providers to ensure that all covered services, as
described in Section D, Paragraph 10 (Scope of Services) of this contract, will
be provided in accordance with Section D, Paragraph 33 (Appointment Standards)
of this contract. Contractor must have a provider network that will be capable
of serving the greater of your existing membership in a GSA or up to one half of
the members in a rural area, one sixth of the members in Maricopa County and one
fourth of the members in Pima County. Provider contracts must include, verbatim,
the minimum sub-contract provisions located in Attachment A of this contract.
Failure to meet this provision may result in contract termination or the
selection of an alternative contractor, financial sanctions, an enrollment cap,
or other penalties in accordance with R9-22-606 and R9 31-606.
2. COMPLIANCE WITH MARKETING POLICY
Marketing materials can only list contracted providers. If Contractor is found
to be in violation of the AHCCCS Health Plan Marketing Policy, Contractor may be
subject to an enrollment cap or other section, in the applicable GSA(s)
affected by the violation. Further detail about Open Enrollment will be sent
under separate cover within the next few days.
3. READINESS ASSESSMENT
As discussed in Section D, Paragraph 70 of the contract, AHCCCS may conduct
Operational and Financial Readiness Reviews on all successful offerors. A
contractor will be permitted to commence operations only if the Readiness Review
establishes the ability to comply with contractual requirements. AHCCCS may
enforce provisions of R9-22-606 and R9-31-606 if contractor does not satisfy
Readiness Review requirements.
4. REVISED FINANCIAL FORECASTS
The Contractor is required to supply AHCCCS with revised financial forecasts by
6/15/03 based on awarded rates and contract terms, excluding prior period
coverage revenues and expenses. On a statewide basis, provide financial
forecasts including income statement and balance sheet for each year of the next
three years. Any loses budgeted will require additional equity and
performance bond coverage.
5. PERFORMANCE BONDS
Contractor must submit a detailed plan to meet the AHCCCS performance bond
requirements to the Office of Managed Care by June 30, 2003. All performance
bond account activity requires the advanced approval of AHCCCS. The performance
bond must be posted within 15 days following notification by AHCCCSA of the
amount required.
6. MINIMUM CAPITALIZATION REQUIREMENT AND EQUITY PER MEMBER
The capitalization requirement must be met by June 30, 2003. Please refer to
Section D, Paragraph 45 of the CYE '04 Contract for the minimum capitalization
requirements by GSA. Refer also to the Performance Bond/Equity Per Member Policy
for more details about the equity requirements. Failure to meet this standard
may result in an enrollment cap being imposed in any or all contracted GSAs.
7. MANAGEMENT SERVICES SUBCONTRACTORS
All proposed management services subcontracts and/or corporate cost allocation
plans must be submitted to the Office of Managed Care for prior approval. Cost
allocation plans must be submitted with the proposed management fee agreement.
AHCCCSA reserves the right to perform a thorough review of actual management
fees changed and/or corporate allocations made. If the fees or allocations
actually paid out are determined to be unjustified or excessive, amounts may be
subject to repayment to the Contractor, the Contractor may be placed on monthly
financial reporting, and/or financial sections may be imposed. Further, no
changes can be made to the management agreements without AHCCCS' prior approval.
Finally, all administrative costs, including management fees, allocated fees,
cannot exceed 10% annually.
8. ADDITIONAL FINANCIAL REPORTING
Contractor is a wholly owned subsidiary of IASIS. Consequently, contractor must
submit quarterly unaudited financial information of the parent or sponsoring
organization (balance sheet and income statement only) within 60 days of quarter
end, and audited financial statements of the parent or sponsoring organization
no later than 120 days after fiscal year end.
9. TITLE XIX WALVER GROUP RATES
AHCCCS acknowledges that the final offered Title XIX Waiver Group rates have not
been provided and will provide the Contractor with these rate as soon as
possible.
10. GSA #10 CAPITATION RATES
AHCCCS acknowledges that the final offered capitation rates for GSA #10 have
not been provided as the previously offered rates assumed an award in Santa Cruz
County. AHCCCS will provide that final GSA #10 rates for Pima County only as
soon as possible.
12. EXTRA CREDIT PROGRAMS/INITIATIVES
Contractor shall implement/maintain the following programs/initiatives as
described in Submission 52 of the Contractor's RFP response:
52A. Care Coordination Department.
52B. Medicity Managed Care Web Portal/Newbridge Information Systems
Contractor shall submit to the Office of Managed Care a detailed description of
the program goals, work plan with timelines and the methodology for assessment
of results within 45 days from the beginning of the contract year. An interim
update report shall be submitted to the Office of Managed Care by April 1, 2004.
A report which covers progress made, an assessment of the success of the
initiative/program, changes made as a result of the project and work plans
covering the future of the project shall be submitted within 45 days of the
beginning of Contract Year Ending 2005.
CONTRACT/RFP NO. YH04-0001
Contract Number YH04-0001-03
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
SOLICITATION, OFFER AND AWARD
REQUEST FOR PROPOSAL NUMBER YH04-0001
DATE ISSUED: FEBRUARY 3, 2003 ISSUED BY : AHCCCSA
SUBJECT OF SOLICITATION: CONTRACTS AND PURCHASING
ACUTE CARE SERVICES 701 E JEFFERSON AVE.
TERM OF CONTRACT: 10/1/03 -9/30/06 PHOENIX, AZ 85034
QUESTIONS CONCERNING THIS SOLICITATION SHALL BE SUBMITTED TO MICHAEL VEIT,
(602) 417-4762 OR
E-mail of MJVeit@ahcccs.state.az.us
I. SOLICITATION
In accordance with A.R.S. Section 36-2901, which is incorporated herein by
reference, competitive sealed proposals will be received at the address above,
until, 3:00 p.m. local time, March 31, 2003. Proposals must be in the actual
possession of AHCCCSA on or prior to the time and date and at the location
indicated above. Late proposals will not be considered. Proposals must be
submitted in a sealed envelops or package (original and 7 copies) with the
Solicitation Number and the offeror's name and address clearly indicated on the
envelope or package. All proposals must be completed in ink or typewritten.
Additional instructions for preparing a proposal are included in this
solicitation document.
TABLE OF CONTENTS
A. SOLICITATION, OFFER AND AWARD ......................................... 1
B. RATES ................................................................. 6
C. DEFINITIONS ........................................................... 7
D. PROGRAM REQUIREMENTS .................................................. 15
E. CONTRACT CLAUSES ...................................................... 73
F. INDEX ................................................................. 81
G. REPRESENTATION & CERTIFICATIONS ....................................... 84
H. EVALUATION FACTORS .................................................... 93
I. INSTRUCTIONS TO OFFERORS .............................................. 96
J. ATTACHMENTS ........................................................... 110
II. OFFER (Must be fully completed by Offeror)
The undersigned Offeror hereby agrees, if this offer is accepted within 120 days
of receipt of proposals, to provide all services in accordance with the term and
requirements stated herein, including all attachments, amendments, and
Best-and-Final Offers (if any).
Name of Offeror: Health Choice Arizona Phone: 480-968-6866
Address: 1600 W Broadway, Suite 260 Fax: 480-784-2933
City/State/Zip: Tempe, AZ 85282 Email: crose@iasishealthcare.com
Printed name of Person Authorized to Sign Offer: Carolyn Rose
Offeror's Signature: /s/ Carolyn Rose Date: March 31, 2003
III. AWARD (To be completed by AHCCCSA)
The offer, including all attachments, amendments and Best-and-Final Offer (if
any), contained herein, is accepted. Awarded this 1st day of May, 2003.
/s/ Michael Veit
- ----------------
Michael Veit, as AHCCCS Contracting Officer
- 1 -
Acute Care RFP
February 3, 2003
2
Page 1 of *
SOLICITATION AMENDMENT
- -----------------------------------------------------------------------------------------------------------------
Arizona Health Care Cost
Containment System Administration
Solicitation Number: RFP YH04-0001 (AHCCCSA)
[AHCCCS LOGO] ACUTE CARE SERVICES - CYE 04 701 East Jefferson, MD 5700
Amendment Number Four Phoenix, Arizona 85034
Solicitation Due Date: March 31, 2003, 3:00 PM (MST) Michael Veit, (602) 417-4762
A signed copy of this amendment shall be included with the proposal, which must
be received by AHCCCSA no later than the Solicitation due date and time. This
solicitation is amended as follows:
The questions and answers document has been updated for the round two questions.
The new questions are shaded for easy identification.
*. All other terms and conditions remains the same, including the proposal due
date and time.
- ----------------------------------------------------------------------------------------------------------------------------
Offeror hereby acknowledges receipt and This Solicitation Amendment is hereby executed this 14th day
understanding of this Solicitation Amendment. of March, 2003, in Phoenix, Arizona.
- ----------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------
Signature Date
- ----------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------
Typed Name and Title Michael Veit
- ----------------------------------------------------------------------------------------------------------------------------
Contracts and Purchasing Administrator
- ----------------------------------------------------------------------------------------------------------------------------
Name of Company
- ----------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
1 6 Sect B What format is required for the actuarially sound A basic actuarial certification letter with a
certification? signature. A member of the American Academy of
Actuaries must attest that the rates they bid are
actuarially sound for that plan.
- ------------------------------------------------------------------------------------------------------------------------------------
2 6 Sect B What is the definition of "actuarially sound" The definition on page 99 of the RFP is adequate
for the purposes of the actuarial certification? at this time.
Is it the general definition as described on
page 99 of the RFP or is it the CMS definition
of "actuarially sound" or should the certifying
actuary refer to the applicable actuarial
standards as issued by the Actuarial Standards
Board?
- ------------------------------------------------------------------------------------------------------------------------------------
3 6 Sect B How will the Offeror know that the bid Yes AHCCCSA agrees that the hard copy print out
submission in the AHCCCSA Web application is will prevail if there is a difference in what is
correct? Not that we don't trust the AHCCCSA entered into the web site and what is on the hard
systems, but wouldn't it be better if the rate copy print out. This statement corrects the
submitted via print out (that the actuary is direction in Attachment E of the RFP as issued on
certifying and can see) is the prevailing bid February 3, 2003.
rather than the bid submitted via Web
application? The actuary can't certify to the If there is a difference, the web site will be
accuracy of the AHCCCSA systems. adjusted to match the hard copy print out. All
reports that will be used in the scoring are
generated from the web site bids; therefore, it
is necessary that the web site bids are correct.
Please note that because the bids will be scored
using the web site, the Offeror must submit one
set of bids only. Barring AHCCCS system issues,
the hard copy and the web bid submissions must be
identical.
- ------------------------------------------------------------------------------------------------------------------------------------
4 6 Sect B Please define more specifically what the Please refer to the answer in question #2 above
definition of "Actuarially Sound" means FROM THE for a description of actuarial soundness. Because
OFFEROR'S PERSPECTIVE. If a health plan has a of concerns regarding adverse selection that an
sicker than average population for a given rate AHCCCCS Contractor had, AHCCCS engaged Mercer to
cell, how should an Offeror reconcile its run AHCCCS health plan encounter data through
"actuarially sound" bid when this rate will be the Chronic Disability Payment System (CDPS) in
above the rate range? 2002. Each of the health plans was scored from a
risk standpoint. Total reimbursement [capitation,
regular reinsurance, catastrophic reinsurance,
AIDS/HIV $, maternity payments, etc.] paid to
health plans were also tabulated for comparison
purposes. Because this analysis showed almost
perfect alignment in the ranking of risk versus
payment, AHCCCS felt the actuarial soundness of
its current payment methodologies had been
confirmed.
- ------------------------------------------------------------------------------------------------------------------------------------
5 6 Sect B In the response to this question in the last The results of running the CDPS model will not be
round, AHCCCSA indicated that a CDPS analysis used in developing capitation rate ranges.
had been performed on all current contractors.
The analysis showed that plans with higher acuity
tended to collect proportionately more in
Supplementary revenue sources such as supplementary revenue. The
- ------------------------------------------------------------------------------------------------------------------------------------
1
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
reinsurance should be correlated to risk purpose of rebasing the capitation rates and the
selection. However rank does not ensure rate supplementary revenue sources is to ensure that
adequacy. A plan may have 6% higher acuity but reimbursement and risk adjusters are adequate.
only 3% more from supplementary revenue
sources. Will AHCCCS use the CDPS risk factors
developed last year to appropriately move the
rate range up or down for each existing plan?
New plans can be assumed to attract an average
"1.00" population.
- ------------------------------------------------------------------------------------------------------------------------------------
6 6 Sect B Given the BBA's requirement for the rate ranges CMS has issued an extensive rate-setting
to be "Actuarially Sound" FROM THE PERSPECTIVE checklist that defines in great detail exactly
OF THE STATE'S ACTUARIES , please define more what is meant by actuarially sound rates. Mercer
specifically what this means. was consulted extensively by CMS in the
development of the tool, and supplied much of the
material that found its way into the checklist.
We do not foresee significant changes in the way
rate ranges are established in Arizona. There may
be significant changes in the way they are
documented and filed with CMS.
Mercer brought the issue of actuarial soundness
to the attention of the American Academy of
Actuaries. As a result, the Actuarial Standards
Board has just begun its own analysis of what it
means to make an assertion that capitation rates
are actuarially sound. Mercer is also represented
on this task force and will take its
recommendations into account as they become
available.
- ------------------------------------------------------------------------------------------------------------------------------------
7 6 Sect B Will AHCCCSA accept a "qualified" certification Yes, we would accept a certification based on the
of actuarial soundness? For example, if a best data and information available at the time
current contractor is expanding into a new GSA that the certification is made. Presumably the
and letters of intent are included for the actuary has satisfied himself or herself that the
network, the actuary will be required to qualify letters of intent will evolve into signed
the opinion with an assumption as to what the contracts at the assumed reimbursement levels.
final reimbursement might be. Is this acceptable The actuary for each offeror will need to certify
to AHCCCSA? Also, will AHCCCSA require a that the rates submitted for initial bids are
certification of actuarial soundness after a actuarially sound for that offeror. Subsequent
BFO? What happens if the actuary can't certify certifications are required after the BFOs (if
to actuarial soundness if the bidder is asked to applicable). If at any time an actuary does not
accept lower rates during the BFO process? feel the proposed rates are actuarially sound for
his or her client, the bidder should not sign a
contract with AHCCCSA
- ------------------------------------------------------------------------------------------------------------------------------------
8 9 Sect C Definition, Is the word inpatient referring to admission to The definition of emergency medical services
Emergency the emergency room? includes services provided in both inpatient and
Medical outpatient settings. This definition did not
Service Can we assume that if it refers to admission to change with BBA. The notification standards have
the hospital that it would only be related to changed. Emergency service providers have up to
emergency surgery or ICU status and once the 10 days to notify the health plan. Notice
patient is stabilized in the ICU that requirements are still being analyzed, and
notification applies? further clarification will be forthcoming.
- ------------------------------------------------------------------------------------------------------------------------------------
2
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
9 18 Sect D #3-Enrollment The RFP states that contractors are responsible The prior period coverage (PPC) time period is
and for payments during prior period coverage and may already defined and limited depending upon the
Disenrollment include services provided prior to the contract eligibility category. Please refer to AHCCCS rule
year. Does AHCCCSA anticipate setting a limit as for those limitations.
to how far back the prior period can go?
- ------------------------------------------------------------------------------------------------------------------------------------
10 18 Sect D #3-Enrollment Health Plan Choice - Members having fewer than The eligibility source informs AHCCCS that the
and 30 days continuous eligibility remaining will not approved eligibility period will extend into the
Disenrollment be placed with a health plan but enrolled in future less than 30 days (example: member is
AHCCCS FFS. Please explain when this may occur. determined they will be ineligible the following
month although they are eligible this month).
However, it is possible to enroll a member with a
health plan (member had been anticipated to
remain eligible) and then have the member become
ineligible before the end of the month (example:
the member is incarcerated, dies, or moves out of
state).
- ------------------------------------------------------------------------------------------------------------------------------------
11 18 Sect D #3-Enrollment Health Plan Choice - What are the "few There are unusual situations, usually
and exceptions" in which the effective date of administrative mistakes, when a TXXI member may
Disenrollment enrollment for a Title XXI member will not be the be enrolled during the month. These are rare, and
first day of the month? will not affect reimbursement.
- ------------------------------------------------------------------------------------------------------------------------------------
12 18-19 Sect D #3-Enrollment Health Plan Choice - How long do newly eligible Members are encouraged to choose a health plan
and persons have to select a health plan? How long prior to the eligibility approval date. If not,
Disenrollment does a mother have to select a health plan for they are auto-assigned through the algorithm. For
her newborn child? For FES babies? newborns, the members have 16 days to choose a
plan for their baby.
- ------------------------------------------------------------------------------------------------------------------------------------
13 19 Sect D #5-Enrollment When will open enrollment dates be finalized and It is anticipated that Open Enrollment will take
and shared with contractors? place in August, 2003 for enrollment October 1,
Disenrollment 2003. The finalized dates will be shared with the
Contractors as soon as they are known.
- ------------------------------------------------------------------------------------------------------------------------------------
14 19 Sect D #3- When does the capitation payment start: When As stated in the RFP, "The Contractor is
Enrollment the hospital calls with notification or when the responsible for notifying AHCCCSA of a child's
and plan calls AHCCCS? birth...." However, a hospital may notify AHCCCSA
Disenrollment in lieu of the contractor when the mother is
enrolled in AHCCCS FFS. The plan is required
to notify AHCCCS of a birth when the mother is
enrolled with the health plan. Capitation begins
the day AHCCCSA is initially notified of the
birth by either the Contractor or the hospital.
For babies born to FES mothers, the eligibility
is retro to the date of birth and PPC capitation
is paid for the date of birth to the date of
notification. For babies of enrolled mothers,
there is no PPC capitation and the plan is
prospectively capitated from the date of
notification forward.
- ------------------------------------------------------------------------------------------------------------------------------------
15 20 Sect D #5--Open How will AHCCCSA handle enrollment in rural Members of the exiting health plan will have an
Enrollment GSAs if a contract is awarded to an incumbent opportunity to choose a new health plan through
and a new Contractor? If members have not an open enrollment process. Per Attachment G,
selected a health plan through the open AHCCCSA reserves the right to adjust the
enrollment process, would AHCCCSA weight the auto algorithm for a Contractor who is awarded
assignment process to ensure that the non- contracts in only rural GSA's. This will be
decided at a later date based on awards. That
adjustment per Attachment G is only applicable to
- ------------------------------------------------------------------------------------------------------------------------------------
3
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
incumbent health plan has a sound membership contractors in Maricopa and Pima counties.
base to allow a viable operating base?
- ------------------------------------------------------------------------------------------------------------------------------------
16 20 Sect D # 5--Open Section notes that the algorithm will be adjusted 1. The exiting contractor's enrollment is
Enrollment to exclude auto assignments to an exiting anticipated to be capped on July 1, 2003.
contractor:
2. New contractor names will be added to AEC
1. On what date would the algorithm be adjusted? materials for mailing in mid-June.
2. When will new contractor names be added to
AEC materials?
- ------------------------------------------------------------------------------------------------------------------------------------
17 20 Sect D # 5-Open For successful Offerors, please describe the open 1. Open enrollment will only be offered to
Enrollment enrollment process for incumbent contractors members of exiting Contractors. Those
awarded a contract under this procurement. Will members will be able to select from all
members of a health plan that is being replaced contractors in the GSA for enrollment on
in a given GSA be the only members participating October 1.
in open enrollment activities, or will all health
plans' members participate? When an additional
health plan is added to a GSA, will members of
all existing health plans within that GSA
participate in open enrollment activities?
- ------------------------------------------------------------------------------------------------------------------------------------
18 20 Sect D # 5-- Open If a contractor is purchased by another The answer will depend upon details and the
Enrollment organization, will AHCCCS hold an open timing of the sale and whether an award is
enrollment for those members? received by the continuing plan.
- ------------------------------------------------------------------------------------------------------------------------------------
19 20 Sect D #6--Auto- Are there specific reasons why AHCCCSA made It is believed that members who are auto assigned
Assignment the statement in the RFP, "Capitation rates may through the algorithm have a lower risk that
Algorithm be adjusted to reflect changes to a contractor's those who choose a health plan. Those who choose
risk due to changes in the algorithm"? Could are believed to be already accessing services, or
AHCCCSA describe the kinds of scenarios that are in the need of services, which is why they
would require a change to the algorithm? How are more concerned about the health plan with
would and what type of notification timeline whom they are enrolled. Therefore, if a plan is
would future changes to the algorithm methodology receiving more members though the algorithm
be communicated to the health plans? through an adjustment, then it is believed by
AHCCCSA's actuaries that the plan's risk is lower
than the other plans. Therefore, an adjustment is
made to all Contractors' rate to ensure actuarial
soundness.
Another scenario is the adjustment that may be
made if there is a Contractor in Pima or Maricopa
County who has total statewide enrollment of less
than 25,000 members. Another scenario is when a
Contractor's enrollment is capped due to
financial performance or sanctions.
- ------------------------------------------------------------------------------------------------------------------------------------
4
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
The health plans would have at least 30 days
notice. This notification would occur through a
contract amendment.
- ------------------------------------------------------------------------------------------------------------------------------------
20 20 Sect D #6--Auto- In the first Q & A, AHCCCS indicated that This determination was based on comparing the
Assignment members who are auto assigned through the financial experience of two AHCCCS contractors
Algorithm algorithm have a lower risk than those who choose before and after one plan's enrollment was
a health plan....if a plan is receiving more capped. AHCCCS also pulled a small sample of data
members through the algorithm through an that supports this contention. AHCCCS is working
adjustment, then it is believed by AHCCCSA's on pulling a larger more statistically sound data
actuaries that the plan's risk is lower than sample to continue to verify this belief.
the other plans. Can AHCCCS provide the data on
why this is believed to be true? It is also a widely held belief that those who
choose a health plan are already receiving
medical services, or have an investment in their
health due to untreated health problems. Those
who do not choose are therefore not believed to
have the same level of health issues.
- ------------------------------------------------------------------------------------------------------------------------------------
21 20 Sect D # 7-- Membership cards: The Offerors should budget 75 cents per card. New
AHCCCS How much will cards cost? cards are issued for the following reasons: new
Member What will the health plans be charged? member, change in RBHA, change in Contractor,
Identificat- What is the frequency of card issuance (one time lost/stolen cards, significant name change,
ion Cards per member, when the member changes rate change in program eligibility, and upon member
codes, when the member changes contractors, request. AHCCCSA issued approximately 40,000
etc.)? cards per month in the recent months.
Will the invoice provided by AHCCCS be at the AHCCCSA has not yet determined how the invoicing
member detail level? will be handled.
If AHCCCS is unsure about any of the above, The bidder should use the information provided
please provide direction as to how the health here in their capitation rate bid submissions.
plan should account for this new cost in its bid.
- ------------------------------------------------------------------------------------------------------------------------------------
22 20 Sect D # 7- Request on question 18: The information AHCCCS has regarding the number
AHCCCS Please provide the number of ID cards distributed of ID cards distributed was included in an
Member by GSA. amendment to the data supplement. The information
Identifica- was not available by GSA, but by health plan.
tion Cards
- ------------------------------------------------------------------------------------------------------------------------------------
23 20 Sect D # 7- What is the average cost per AHCCCS ID card? See the answer to #21 above.
AHCCCS
Member
Identificat-
ion Cards
- ------------------------------------------------------------------------------------------------------------------------------------
24 20 Sect D a. What are the costs to the health plans on a a-c, e, f. See the answer to #21 above.
per card basis?
d. AHCCCSA will contract with the vendor. The
b. For each GSA, how many ID cards (new and content of the card is not the discretion of
the Contractor.
- ------------------------------------------------------------------------------------------------------------------------------------
5
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
reissued) were issued last year? g. The Contractor will be billed for postage
included in the 75 cents.
c. How many replacement cards were issued last
year?
d. For cost control purposes, will the health
plans have input regarding the vendor and content
of the card?
e. How will AHCCCSA monitor and ensure that
health plans are not inadvertently billed for ID
cards for other health plans or FFS members?
f. How will ID card costs be handled for members
who are retroactively disenrolled (i.e.
refunded)?
g. Will postage be charged to the health plan for
the mailing of ID cards?
- ------------------------------------------------------------------------------------------------------------------------------------
25 20 Sect D #8-- Please define "available facility" This is a facility that would normally be
Mainstreaming available for use by your members i.e.,
of AHCCCS in-network or when medically necessary. The
members intent of the statement is that use of such a
facility cannot be denied based on one of the
criteria in the previous paragraph in the RFP,
payor source, race, color etc.
- ------------------------------------------------------------------------------------------------------------------------------------
26 20 Sect D #8-- What does AHCCCSA consider to be "reasonable The phrase is used in the context that
Mainstreaming steps" to be taken with subcontractors to "Contractors must take into account a member's
of AHCCCS encourage mainstreaming of members? culture when addressing members and their
members concerns, and must take reasonable steps to
encourage subcontractors to do the same." The
overall paragraph discusses prohibited
discriminatory practices with respect to a
member's rights to receive services in a manner
that does not discriminate based on payor
source, race, color, gender, etc. The Offeror
should use its own judgment to identify
reasonable steps.
- ------------------------------------------------------------------------------------------------------------------------------------
27 21 Sect D #9-- Transition of Members-Acute Care-If we are When a member is enrolled in CRS, the health plan
Transition of notified from CRS that a patient is coming in or still has the responsibility of providing all
Members out, what is the plan's responsibility of covered services for the member that are not
transition and to whom? included as CRS covered services for the CRS
enrolled diagnosis (refer to CRS covered
diagnosis list). CRS and the health plan are
expected to coordinate applicable services such
as DME, prescriptions, etc as they pertain in the
transition.
- ------------------------------------------------------------------------------------------------------------------------------------
28 21 Sect D #9-- Are PCP's still required to have dental service No, dental treatment records are not required in
Transition of reports in the medical record? the PCP chart. However, record of any verbal
Members referrals/recommendations by the PCP for dental
services should be documented in the patient
record maintained by the PCP.
- ------------------------------------------------------------------------------------------------------------------------------------
29 21 Sect D #10--Scope CRS is currently under procurement for a new If an award is made to a new CRS contractor, the
of Services contractor. How will that new contract's AHCCCS contractors would be responsible for
(CRS-last operations impact coordination of services with coordinating care with and referring potentially
eligible members to the new contractor. It is
- ------------------------------------------------------------------------------------------------------------------------------------
6
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
paragraph AHCCCSA health plans and what will be the not anticipated that this will have any financial
financial impacts of any contract changes to a impact to AHCCCS contractors.
health plan?
- ------------------------------------------------------------------------------------------------------------------------------------
30 22 Sect D #10--Scope Transition of Members-If a member transitions Yes, CRS must notify contractors of enrollments
of Services "enrolls or discharges" from CRS, is CRS and disenrollments in accordance with the
(CRS-last responsible for sending timely notice to the transition policy. Your concern regarding
paragraph health plan? CRS provides a monthly list of transition time frames is noted.
members accepted and discharged from CRS. This
time frame of "Notification" to a plan doesn't
coincide with transition policy 520 in the AMPM.
- ------------------------------------------------------------------------------------------------------------------------------------
31 22 Sect D #10--Scope Who is financially responsible for services if In this instance the member (family or guardian)
of Services the CRS eligible and enrolled member does not is responsible for payment. The member is
(CRS-last utilize CRS services? The AMPM Section 400 choosing to go out of network for services.
paragraph) references medical care paid by the plan to an However, it is AHCCCSA's expectation that Health
eligible, enrolled member when CRS fails to Plans assist members in understanding the
provide timely services. It does not address services delivery system and that plans
which entity pays for the medical expenses if the facilitate the members use of CRS.
member is an eligible, enrolled CRS patient, but
refuses to use their services. Under these
circumstances, does the health plan continue to
pay for medical services or are we not obligated
to pay for the CRS covered services because of
CRS eligibility and enrollment?
- ------------------------------------------------------------------------------------------------------------------------------------
32 23 Sect D #10-Scope Please clarify: how does this apply to out of Providers must register with AHCCCS to be
of Services state providers who are not contracted with the eligible for payment. A contract with the health
(Emergency plan or AHCCCS? What if a provider refuses to plan is not required. Registered providers may
Services, register with AHCCCS? Can they bill the member? not bill members for medically necessary covered
last Is there a statute to protect the member from services. AHCCCS is not aware of a statute that
sentence) billing/collections/by out of state providers? Is protects members from billing/collections by
there a quick registration process for out-of unregistered, out of state providers. State rule
state providers? prohibits billing of Medicaid members for
medically necessary covered services. AHCCCS does
have a simplified registration form for single
use providers.
- ------------------------------------------------------------------------------------------------------------------------------------
33 23 Sect D #10-Scope EPSDT - What are the health plans' specific When this information has not already been
of Services responsibilities in terms of "follow-up" with a received from the member or the RBHA, the
RBHA to monitor whether members have received Contractor is expected to contact the RBHA to
behavioral health services? ensure that the member has either been scheduled
or seen for an appointment or that the member has
refused behavioral health services from the RBHA.
- ------------------------------------------------------------------------------------------------------------------------------------
34 23-24 Sect D #10-Scope Emergency Services - Please confirm that the 10 Analysis re BBA Emergency notification
of Services calendar day requirement applies only to the requirements is ongoing and further clarification
(Emergency notification of emergency services and not to any will be forthcoming.
Services, inpatient stay admission resulting from an
last
- ------------------------------------------------------------------------------------------------------------------------------------
7
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
sentence) emergency department visit. Please confirm that
the 10 calendar day requirement is unrelated to
the 1 hour response time required.
- ------------------------------------------------------------------------------------------------------------------------------------
35 23-24 Sect D #10- Scope When will further clarification be forthcoming on Further clarification for bidding purposes is not
of Services the BBA Emergency Notification requirements? forthcoming; however, AHCCCS is pursuing a waiver
(Emergency with CMS from this provision.
Services,
last BBA states that a health plan may not deny
sentence) payment to a provider of an emergency service for
failure to notify the health plan of the service
within 10 calendar days. This does not preclude a
contractor from conducting retro review or
working with hospitals to maintain current
notification time frames. AHCCCS does not expect
contractors to experience an increase in
utilization due to this change.
- ------------------------------------------------------------------------------------------------------------------------------------
36 24 Sect D #10, Scope of In bullet point #2, clarification is needed Analysis re BBA Emergency notification
Services regarding notification. Does this mean the requirements is ongoing and further clarification
(Emergency EMERGENCY ROOM services must have notification will be forthcoming.
Services, to the health plan within 10 days?
paragraph 2, The Offerors should assume that there will be no
#2) By screening and treatment are you including changes to program costs for this provision when
admissions to the hospital and work up and developing capitation rate bids.
treatment? If so does the facility have 10 days
to notify the health plan of admission?
Does this mean there will be no concurrent
review process for any member admitted through
the Emergency Room?
- ------------------------------------------------------------------------------------------------------------------------------------
37 24 Sect D #10, Scope of "A member who has an emergency medical The issue of authorization is different from that
Services condition may not be held liable for payment of of patient financial responsibility.
(Emergency subsequent screening and treatment needed to Authorization may still be required for follow-up
Services, diagnose the specific condition or stabilize the done after the patient is stabilized. Prior
paragraph 3) patient". Does this statement mean that Authorization is not a guarantee of payment.
authorization would not be needed for follow up
visits resulting from the ER visits?
- ------------------------------------------------------------------------------------------------------------------------------------
38 24 Sect D #10-Scope Emergency services- How long does a provider of The new notification requirements per BBA are
of Services emergency services now have to notify the plan to within 10 calendar days for emergency services.
(Emergency ensure payment, or is there no time limit? Analysis regarding BBA Emergency notification
Services) requirements is ongoing and further clarification
will be forthcoming.
- ------------------------------------------------------------------------------------------------------------------------------------
39 25 Sect D #10--Scope Regarding observation - no specific time frame in Observation services are defined in the AMPM
of Services RFP versus 24 hours in the contracts. Are you Policy 310. There is no anticipated change to
(Hospital) changing the AMPM policy to something other this policy.
- ------------------------------------------------------------------------------------------------------------------------------------
8
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
than the 24 hour or do we presume it will stay as
per policy?
- ------------------------------------------------------------------------------------------------------------------------------------
40 25 Sect D #10--Scope Observation services may be provided on Please see the AMPM Policy 310, Observation
of Services outpatient basis if determined reasonable...when Services for clarification.
(Hospital) deciding if member should be admitted for
inpatient care. There is no specification of the
time frame (prior contracts have indicated up to
24 hours).
1. Is the absence of a time designation meant
that AHCCCS will be following the 48-hour
Medicare standard?
2. If the time frame is expanded from 24 to 48
hours, what criteria are going to be used
to determine that the extended stay to 48
hours was appropriate as observation versus
inpatient?
- ------------------------------------------------------------------------------------------------------------------------------------
41 25 Sect D # 10--Scope What is meaning/financial impact of removing 24- Please see the AMPM Policy 310, Observation
of Services hour limit from observation services? Services for clarification. The financial impact
(Hospital) is unknown at this time.
- ------------------------------------------------------------------------------------------------------------------------------------
42 25 Sect D # 10--Scope What are the adult immunization performance AHCCCS has not established adult immunization
of Services standards? performance indicators for the acute care
(Immunization population.
s)
- ------------------------------------------------------------------------------------------------------------------------------------
43 26 Sect D #10--Scope What would occur when a member no longer The Health Plan is responsible for providing
of Services requires the skilled services of a convalescent medically necessary covered services. Facility
(Nursing care stay, but a discharge from the facility is coverage is not limited to the skilled level of
Facility) deemed inappropriate for a specific reason? For care.
example, Mr. Smith is admitted to a skilled
nursing facility for Rehab Services (OT and PT),
after a hip replacement. A week into his stay, he
is discharged from therapies because he is unable
or unwilling to participate. Mr. Smith no longer
meets the criteria for a convalescent care stay,
but he is still not able to care for himself in
his previous living arrangement, and a discharge
from the skilled nursing facility is not
appropriate because of safely issues.
- ------------------------------------------------------------------------------------------------------------------------------------
44 26 Sect D #10--Scope Can this member (see above question) be kept in There is no prohibition against health plans
of Services the facility at a lower level (e.g. a custodial negotiating rates at a lower level of care.
(Nursing care level) until the discharge is appropriate? AHCCCS does not require notification. Days at a
If this is lower level of care do count toward the 90-day
contract year
- ------------------------------------------------------------------------------------------------------------------------------------
9
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
Facility) possible, how would AHCCCSA like to be notified, maximum benefit.
and would the custodial care days still need to
be counted toward the 90 day contract year
maximum benefit?
- ------------------------------------------------------------------------------------------------------------------------------------
45 27 Sect D #10, Scope of In bullet #2, is 1 hour the correct time for One hour is the correct time for approval of
Services approval of post-stabilization care services at post-stabilization care services approval
(Post- non-contracted facilities? requests for all provide both contracted and
stabilization non-contracted.
Care Services Who will determine the 1-hour time frame? Will
Coverage and telephone logs be used to verify? Both hospitals and plans will likely document the
Payment, one-hour timeframe and telephone logs may be one
paragraph 2, method to accomplish this.
#2.)
Further clarification regarding BBA requirements
will be forthcoming.
- ------------------------------------------------------------------------------------------------------------------------------------
46 27 Sect D #10, Scope of In bullet #3 A Contractor's physician with AHCCCS expects treating physicians to act in the
Services privileges at the treating hospital ASSUMES best interests of the member. Issues such as this
(Post- responsibility for the member's care. What should be brought to the plan Medical Director
stabilization happens when the Contractor's physician with for resolution.
Care Services privileges at the treating hospital is ready and
Coverage and willing to assume the care but the non-contracted
Payment, Attending physician will not relinquish care?
paragraph 3,
#3.)
- ------------------------------------------------------------------------------------------------------------------------------------
47 27 Sect D # 10, Scope Is there any information on expected financial Based upon 18 months of experience with this
of Services, impact of policy change? policy, AHCCCSA believes that the financial
(Pregnancy impact is not material, and capitation rates will
Terminations) not be adjusted for this policy change.
- ------------------------------------------------------------------------------------------------------------------------------------
48 27 Sect D #10, Scope of Post Stabilization - The RFP implies a contractor If authorization is not provided within one hour,
Services must respond to authorization requests within one services are deemed authorized. Methods to
(Post- hour. If not, are services deemed approved? How monitor this performance requirement will be
stabilization will AHCCCSA evaluate health plans' performance developed. Further analysis of BBA will be
Care Services of this requirement? completed and additional information will be
Coverage and forthcoming.
Payment,
paragraph 2,
#2.)
- ------------------------------------------------------------------------------------------------------------------------------------
49 28 Sect D # 10-Scope Omitted...not used as a maintenance regimen...Is Please clarify and resubmit the question.
of Services this changing or does the phrase "potential for
improvement" cover this?
- ------------------------------------------------------------------------------------------------------------------------------------
10
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
50 28 Sect D # 10--Scope Will pharmacy carve-out include OTC items The pharmacy carve out will include those OTC
of Services currently being provided by health plans, for items that require a prescription.
(Prescription example, condoms and nutritional supplements?
Drugs)
- ------------------------------------------------------------------------------------------------------------------------------------
51 28 Sect D #10- Scope of Give examples of medically necessary Includes but is not limited to transportation for
Services transportation. well child care, prenatal appointments, urgent
(Transportat- medical appointments, prescription pick-up at
ion, first pharmacy, ambulance transportation and other
sentence) services that are medically necessary.
- ------------------------------------------------------------------------------------------------------------------------------------
52 28 Sect D # 10- Scope In previous contracts, physical therapy for all There is no change in the coverage due to the
of Services members and occupational and speech therapies deletion of the phrase "if not used as a
for members under the age of 21 are covered on maintenance regimen". Rehabilitation Therapies
both an inpatient and outpatient basis if not are covered when there is an expectation of
used as a maintenance regimen. The underlined improvement in the member's condition.
words are omitted in the RFP. Is there a change
in coverage?
- ------------------------------------------------------------------------------------------------------------------------------------
53 29 Sect D #10--Scope What is the timeline for new or revised policies The deadline is October 1, 2003. As clarification
of Services in AMPM regarding Special Health Care Needs? is available it will be published.
- ------------------------------------------------------------------------------------------------------------------------------------
54 29 Sect D #12- "AHCCCS members are eligible for comprehensive No, SFP members are not eligible for behavioral
Behavioral behavioral health services" - This indicates that health services. This will be clarified in the
Health Family Planning members would also have this RFP document at a future date.
Services, benefit, is this correct?
paragraph 1
- ------------------------------------------------------------------------------------------------------------------------------------
55 30 Sect D #12- In previous publications the PCP was allowed to Since the inception of the psychiatric medication
Behavioral provide medication management for members with initiative in October of 1999, which allows
Health diagnoses of MILD TO MODERATE depression, MILD health plan PCPs to prescribe for certain
Services, TO MODERATE anxiety and attention deficit behavioral health disorders within the scope of
Medication hyperactivity disorder. Were the words mild to their practice, the contract language has
Management moderate intentionally left out? remained the same. The words "mild", "minor", or
Services, "moderate" have not been in contract and there is
paragraph 1 no change in the expectation. AHCCCS policy (AMPM
310) and the guiding principles published in
September 1999 refer to ADD/ADHD, mild
depression, and anxiety disorders as those which
may be managed by the health plan PCP.
- ------------------------------------------------------------------------------------------------------------------------------------
56 30 Sect D #12-- "The Contractor shall allow PCPs to provide Please refer to the answer for question 55.
Behavioral medication management services (prescription,
Health medication monitoring visits, laboratory, and
Services other diagnostic test necessary for diagnosis and
treatment of behavioral disorders) to members
with diagnoses of depression, anxiety and
attention deficit hyperactivity disorder."
- ------------------------------------------------------------------------------------------------------------------------------------
11
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
As this statement does not specify that the PCP
may treat "mild" or "minor" depression, please
clarify whether the expectation has changed from
the original guiding principles published Sept
1999.
- ------------------------------------------------------------------------------------------------------------------------------------
57 30 Sect D #12-- Does AHCCCSA have any guidelines for the No, AHCCCS does not have guidelines specific to
Behavioral monitoring of PCP management of behavioral the monitoring of PCPs' management of behavioral
Health health disorders? health disorders.
Services
- ------------------------------------------------------------------------------------------------------------------------------------
58 30 Sect D #12-- The RFP states," For Prior Period Coverage, the No, the contractor is not responsible the payment
Behavioral Contractor is responsible for payment of all of behavioral health services during a PPC time
Health claims for medically necessary covered behavioral period for non TXIX RBHA enrolled members.
Services health services to members who are not ADHS
behavioral health recipients." Does this mean Yes, the contractor is responsible all behavioral
that if someone is Non-TXIX RBHA enrolled, the health services if the member was not RBHA
RBHA is responsible for Behavior Health emergency enrolled.
services during prior period coverage? Is the
Contractor responsible for outpatient
stabilization services during PPC until the
member is RBHA enrolled?
- ------------------------------------------------------------------------------------------------------------------------------------
59 31 Sect D #14- Regarding transfer of medical information between The MIPS program provides reimbursement for
Medicaid in the Contractor and the member's school or school school districts that are registered providers.
the Public district....Isn't that a violation of the HIPAA The relationship between a health plan and a
Schools, last privacy standard? Would the Health Plan have to provider does not constitute a business associate
paragraph have a Business Associate Contract with the relationship. See 65 Fed. Reg. 82476 (Dec. 28,
schools or school districts? 2000).
Disclosure for purposes of treatment,
payment and certain health care operations are
permitted by the rules and do not necessarily
require a business associate agreement. 45 CFR
164.506. "Payment" activities include
coordination of benefits. "Treatment" includes
activities by a provider to coordinate care with
a third party. 45 CFR 164.501
- ------------------------------------------------------------------------------------------------------------------------------------
60 31 Sect D #14-(MIPS)- The RFP states, "Contractors and their providers The intent of the policy is to prevent
last must coordinate with schools and school districts duplication of service. Contractors can be
paragraph that provide MIPS services to the Contractor's notified via a DDD support coordinator, a parent,
enrolled members." Is the intent of this new a school provider or the school. AHCCCS will not
requirement simply to ensure that services are be providing this information on the FYI file.
not duplicative? How are contractors notified Plans are required to coordinate care with the
when a school or school district is working with most appropriate entity to best meet the needs of
a special needs child? Is AHCCCSA going to the members. Please see HIPAA response given
provide this information on the monthly FYI file? previously. Yes, the school districts have
Are we coordinating with the school or school expressed a desire to coordinate with the health
district or the providers that actually provide plans.
the services?
- ------------------------------------------------------------------------------------------------------------------------------------
12
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
Has consideration been given to the HIPAA
implications? Have the schools/school districts
indicated that they are willing to work with the
health plans?
- ------------------------------------------------------------------------------------------------------------------------------------
61 31 Sect D #14-(MIPS)- Please clarify responsibilities of both the Please refer to the answers for questions #59 and
last health plan and a school in sharing/generating #60.
paragraph appropriate medical record requirements? (i.e.
transfers of member medical information)
- ------------------------------------------------------------------------------------------------------------------------------------
62 32 Section #16- Staff Define difference between Compliance Officer, The staffing requirement for a Compliance Officer
D Requirements contract YH04 vs. Fraud and Abuse Coordinator, is in the current contract. The difference
and Support and contract YH03? between the two positions is the Compliance
Services, Officer is considered a key position and must be
item n. a senior on-site employee. The function is
similar to that of the Fraud and Abuse
Coordinator, with the additional responsibility
to oversee the implementation of a compliance
program as outlined in Paragraph 62 of the RFP.
The Compliance Officer should continue to attend
the AHCCCS Fraud and Abuse Workgroup.
- ------------------------------------------------------------------------------------------------------------------------------------
63 32 Section #16- Staff From the first Q & A, it appears that AHCCCS The requirement for a fraud and abuse coordinator
D Requirements sees the Compliance Officer and the Fraud and does not appear in the RFP. The corporate
and Support Abuse Coordinator to be two different compliance officer must be a senior, on-site
Services, individuals. If a health plan has a Compliance official. The Offeror is responsible for
item n. Officer with its parent organization that is off- designing a system in which its employees do feel
site, can this person be a part of the health comfortable reporting internal issues to the C.C.
plan's compliance program, in cooperation with officer. This, however, does not preclude
the on-site compliance/fraud and abuse program? cooperation and coordination with a compliance
AHCCCS used our compliance program as an example officer in the parent organization.
of what is expected from health plans during a
recent Fraud and Abuse meeting, but it appears
that these two similar, but separate programs
have become one under the RFP. The purpose of an
off-site Compliance Officer is to allow freedom
for the employee to report any individual
including fellow employees, supervisors, or
managers if they believe there is unethical
behavior within the health plan. The fraud and
abuse program is more likely to look for and
report suspected fraud outside the company, such
as with members or providers. This program with
both of its separate components works well.
However, if we are required to merge them, the
employees may feel uncomfortable reporting
internal issues. Is it possible to maintain both
programs without co-mingling?
- ------------------------------------------------------------------------------------------------------------------------------------
13
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
64 32 Sect D #16- Staff This section states that a Grievance Manager is a The 2 position titles are not interchangeable. As
Requirements required position, this is also restated on page part of the staff requirements in paragraph 16,
and Support 33, however, on page 92, Section G, Offeror's Key AHCCCS requires a Grievance Manager who is
Services, Personnel, and the position is listed as responsible for the oversight of the contractor's
item m. Grievance Coordinator. Is it the intent of Grievance System. The reference to Grievance
AHCCCSA to require a Grievance Manager or Coordinator on p. 92 is incorrect and should be
Coordinator? Are these two titles changed to Grievance Manager.
interchangeable?
- ------------------------------------------------------------------------------------------------------------------------------------
65 33-34 Sect D #18- Member According to the revised Member Information No. This information can be in summary form.
Information Policy, it appears that the content requirements Space constraints may result in fewer pictures
for the informational brochure to prospective and other text being used in the brochures.
members has changed, i.e., adding specialists,
telephone numbers and languages spoken. Are
there plans to change the format to allow for the
required content changes?
- ------------------------------------------------------------------------------------------------------------------------------------
66 34 Sect D #18- Member The RFP states affected members must be Other changes include, but are not limited to
Information, informed of any other changes in the network 30 turnover in DME providers and provider address
last days prior to the implementation date of the changes.
paragraph change. Please define "other" changes in the
network and provide examples.
- ------------------------------------------------------------------------------------------------------------------------------------
67 34 Sect D #18- Member Termination of a contracted provider: Yes, for members who were seeing the specialist
Information, Does this include specialty providers? on a regular basis.
last
paragraph
- ------------------------------------------------------------------------------------------------------------------------------------
68 34 Sect D #18- Member What does AHCCCSA consider to be "program Changes in cost sharing or covered services would
Information, changes" that require notification be provided be examples of program changes.
last to "affected members"?
paragraph
- ------------------------------------------------------------------------------------------------------------------------------------
69 36 Sect D #22. Advance In referring to written information to adult The sentence should read, "(4) Changes to State
Directives, enrollees, what is meant by (4): "Changes to law as soon as possible..."
last State as soon as possible, but no later than 90
paragraph days after the effective date of the change?" Does
this requirement conflict with other disseminated
information to member approval requirements?
- ------------------------------------------------------------------------------------------------------------------------------------
70 37 Sect D # 24- What is the responsibility of the Health Plan The Health Plans are responsible for continuing
Performance when a response is not received from AHCCCS in a to improve Performance Indicator rates, and it is
Standards, timely manner as it states that a corrective expected that health plans will develop and
last action plan "must be approved by AHCCCS prior to implement interventions that will assist them in
paragraph implementation"? achieving, at a minimum, the AHCCCS Minimum
Performance Standard. The amount of time a health
Will the health plan be given sufficient time plan will be given to implement a corrective
i.e. (6-9 months) after the date of AHCCCS action plans depends upon the severity of the
approval to demonstrate improvement? issue needing correction and the proposed plan.
- ------------------------------------------------------------------------------------------------------------------------------------
71 37 Sect D # 24- On what are the minimum performance standards The AHCCCS Minimum Performance Standards are
derived from a
- ------------------------------------------------------------------------------------------------------------------------------------
14
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
Performance based? formula that includes, but is not limited to
Standards previous Performance Indicator rates and
statewide averages.
- ----------------------------------------------------------------------------------------------------------------------------------
72 37 Sect D # 24-- As it relates to levels of performance, Demonstrable is statistically significant and
Performance please define "demonstrable and sustained sustained is for more than 1 year.
Standards improvement."
- ----------------------------------------------------------------------------------------------------------------------------------
73 39 Sect D # 24-- In the current contract, health plans are The current contract states "AHCCCSA will
Performance required to report the results of Provider continue to measure and report results for the
Standards Turnovers and Interpreter Services. Will this Performance Measures..." This measurement and
still be required under the new contract? reporting will continue, but because these are
not considered Performance Standards, the
information was removed from the RFP.
- ----------------------------------------------------------------------------------------------------------------------------------
74 40 Sect D #27--Network "For Maricopa and Pima Counties only, this To clarify, the adjective "metropolitan" is
Development includes a network such that 95% of its describing Phoenix only. Metropolitan Phoenix
members residing within the boundary area of includes other cities as shown on the GSA
metropolitan Phoenix and Tucson do not have map for Maricopa County. In Pima County, this
to travel more than 5 miles to see a PCP, standard applies only to the city of Tucson.
dentist or pharmacy."
Attachment B, page 115--"In Tucson (GSA 10) Attachment B, Page 115. Last paragraph should
and Metropolitan Phoenix (GSA 12), read, "In Tucson (GSA 10) and Metropolitan
the Contractor must demonstrate its Phoenix (GSA 12), the Contractor must
ability to provide PCP dental and pharmacy demonstrate its ability to provide PCP, dental
services so that the member so not have to and Pharmacy services to that 95% of members do
travel more than 5 miles from their not have to travel more than 5 miles from their
residence. residence."
There seems to be an apparent conflict
between the wording in the Network
Development in paragraph 27, and Attachment
B, page 115. Can you please clarify which
applies and define metropolitan Tucson?
- ----------------------------------------------------------------------------------------------------------------------------------
75 40 Sect D # 27 Network "Contractors must provide a comprehensive The Contractor is asked to identify network
Development provider network that ensures its membership gaps in its own annual Provider Network
has access at least equal to, or better than, Development and Management plan. In addition,
community norms." How will AHCCCS determine AHCCCSA will utilize information from
community norms? licensing boards, commercial insurers and
other publicly available materials to
determine provider availability.
- ----------------------------------------------------------------------------------------------------------------------------------
76 40 Sect D # 27 Network "Access is supposed to be equal or better The Agency will not advise Offerors about
Development than community norm." How will a potential improving their submission.
Offeror best demonstrate such access
measures/benchmarks in a successful proposal?
- ----------------------------------------------------------------------------------------------------------------------------------
77 40 Sect D # 27 Network Provider Network Development and Management The Agency will not advise Offerors about
Development Plan - The plan is to consider access of improving their submission.
members to specialty care compared to the
general population in the community. How
will a potential
- ----------------------------------------------------------------------------------------------------------------------------------
15
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
Offeror best demonstrate such access in a
successful proposal? How will this criterion
be measured (i.e. what is the benchmark(s)
that will be used?)?
- ----------------------------------------------------------------------------------------------------------------------------------
78 40 Sect D # 27 Network Provider Network Development and Management The Bidder should use its best judgment in
Development Plan - deciding how far in the future projected needs
should be assessed in order to maintain an
What is the time period the health plans accessible network, capable of delivering
should use for "projecting future needs", covered services for the contract period.
e.g., one year?
- ----------------------------------------------------------------------------------------------------------------------------------
79 40 Sect D # 27 Network How does the requirement to consider Providers whose service address is outside of
Development providers in neighboring states in terms of Arizona must be licensed in the state in which
network development reconcile with the they provide services.
requirement that health plan providers must
be licensed in Arizona? Also, how does this
apply to out-of-state hospitals?
- ----------------------------------------------------------------------------------------------------------------------------------
80 41 Sect D # 27 Network Provider Network Development and Management The Offeror should use its expertise and
Development Plan - judgment to identify those populations with
network needs different than the majority of
How is AHCCCSA defining "specialty members in the GSA, who would need special
populations" for the purpose of this plan, consideration in the design of the network.
and what type of information does AHCCCSA
want addressed regarding specialty
populations as it relates to the plan?
- ----------------------------------------------------------------------------------------------------------------------------------
81 41 Sect D # 29-- Re: notifications of significant network The turnaround time will be dependent upon the
Network changes. In the past, AHCCCSA stated that circumstances, such as complexity of the
Management it would respond within 14 days. What will be corrective action plan. As stated in the
AHCCCSA's turnaround time(s) for approvals paragraph, AHCCCSA will expedite the process
of corrective actions arising from such in an emergency.
notifications?
- ----------------------------------------------------------------------------------------------------------------------------------
82 41 Sect D # 29-- For contractor policies, what does "subject "Subject to approval" means the Agency has
Network to approval" by AHCCCSA mean? Is AHCCCSA approval authority over the policies during an
Management approval limited only to network management operational audit. It is not limited to
policies or all contractor policies? Will network policies only. Contractors will be
existing plans have to submit their policies notified of pending operational audits.
for approval?
- ----------------------------------------------------------------------------------------------------------------------------------
83 42 Sect D #30--Primary Once the contractor had determined that No. The Contractor, however, is expected to
Care Provider appointment availability has not been ensure that quality of care standards continue
Standards compromised will action still be required to be met by such providers. The information
should the panel size exceed 1800? may also suggest that the Contractor should
recruit additional providers to serve members
in that area.
- ----------------------------------------------------------------------------------------------------------------------------------
84 43 Sect D #32--"Referral Referral to Medicare HMO including payment of The Contractor must have written policies on
Procedures co-payments". Please explain this their Medicare Cost Sharing responsibilities
and requirement. that should include copayment responsibilities
Standards, when a member is referred to a Medicare HMO.
paragraph 1,
item g.
- ----------------------------------------------------------------------------------------------------------------------------------
16
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
85 45 Sect D #35--Provider The RFP states, "The contractor remains There are a number of "applicable" requirements
Manual liable for ensuring that all providers, that the health plan is responsible for,
WHETHER CONTRACTED OR NOT, meet the regardless of the providers' contract status.
applicable AHCCCSA requirements." What are a Examples include, but are not limited to,
health plan's obligations to non-contracted ensure non-contracted providers do not bill
providers? Please define or further clarify members for covered services, that claims/
"applicable requirements." encounter data is submitted if a financial
liability is incurred by the Contractor, and
that the health plan coordinates benefits.
- ----------------------------------------------------------------------------------------------------------------------------------
86 47 Sect D # 37-- Would the "use of provider more than 25 Yes, the Contractor would be responsible for
Subcontracts, times" include hospitals where members are contracting with physicians who have admitting
paragraph 5 admitted through the Emergency Department? privileges. The Contractor would be encouraged
to contract with the hospital.
- ----------------------------------------------------------------------------------------------------------------------------------
87 47 Sect D # 37-- "The Contractor must enter into a written AHCCCSA is requiring a contract for providers
Subcontracts agreement with any provider (including used more than 25 times a year, regardless of
out-of-state providers) the Contractor the number of services provided or members seen.
reasonably anticipates will be providing
services on its behalf more than 25 times
during the contract year." Can this be
applied to one individual receiving 25
services form one provider, or is it for 25
unique members?
- ----------------------------------------------------------------------------------------------------------------------------------
88 48 Sect D #39-- With the high potential for AHCCCSA to This section refers to contracts that AHCCCSA
Specialty develop specialty contracts going forward, negotiates on behalf of its Contractors.
Contracts (i.e. pharmacy) can AHCCCSA provide Currently, the only specialty contract AHCCCS
additional details on how the process might is negotiating is for transplant services.
work (i.e. health plan involvement, These specialty contracts are for services
adjustments to capitation rates, reporting provided through the health plans and should
requirements (both to and form AHCCCSA), not be confused with a carve out of services.
claims payment, recovery/reinsurance, TPL
related issues)? In the event AHCCCSA carves out the
responsibility for certain medical services
from its Contractors, AHCCCSA will solicit
feedback from its Contractors, capitation
rates will be adjusted and other operating
issues will be addressed. Because AHCCCSA is
not currently in the process of developing a
carve out, it is unknown what impact a carve
out would have on health plan reporting and
involvement. That would need to be addressed
on a case by case basis depending upon the
type of service that is carved out.
- ----------------------------------------------------------------------------------------------------------------------------------
89 49 Sect D #40--Hospital For Maricopa and Pima counties, the RFP The Office of Managed Care will accept
Subcontractin states that, "The Contractor shall submit all hospital subcontracts and amendments for
g and hospital subcontracts and any amendments to review and approval after contract awards are
Reimburseme AHCCCSA, Office of Managed Care". For all made. It is suggested that they be submitted
nt counties EXCEPT Maricopa and Pima it states, as soon after the award that the contracts and
"The Contractor is encouraged to obtain amendments are complete to allow time for the
subcontracts with hospitals in all GSA's and process, prior to implementation.
must submit copies of these subcontracts,
including amendments, to
- ----------------------------------------------------------------------------------------------------------------------------------
17
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
AHCCCSA, Office of Managed Care, at least
seven days prior to the effective dates
thereof". What requirements exist (for
incumbents bidding on new GSA's and new
contractors) to have the Maricopa and Pima
hospital contracts (or any other contract as
required by the RFP) reviewed by AHCCCSA
prior to implementation?
- ----------------------------------------------------------------------------------------------------------------------------------
90 49 Sect D #40--Hospital Hospital Recoupments - Does AHCCCSA have a AHCCCSA is developing an informal policy
Subcontractin policy regarding recoupment of capitation related to this issue. Essentially, medical
g and from one health plan and paid to another when expenditures incurred in these situations
Reimburseme retroactive enrollment occurs, and the should be treated like expenditures incurred
nt initial health plan has paid claims to a during the PPC time period. That means, claims
provider who was not aware of the enrollment should not be denied for lack of prior
change until notified of recoupment (which authorization, but may be denied if reviewed
often occurs after claims submission for medical necessity, and the second health
timeframes)? plan determines that the services were not
medically necessary.
- ----------------------------------------------------------------------------------------------------------------------------------
91 49 Sect D #40--Hospital In the Data Supplement, Offerors are Instructions given in the data supplement
71 Subcontractin instructed to consider the Maricopa/Pima should be considered a valid RFP instruction.
116 g and counties contracting pilot project to be
Reimburseme extended beyond September 30, 2003. This is
nt also reiterated in Amendment #1 dated
February 10, 2003. Is the Data Supplement to
be considered a part of the contract and RFP,
and a valid RFP instruction?
- ----------------------------------------------------------------------------------------------------------------------------------
92 49 Sect D #40--Hospital Out of State Hospitals - Given that Although, Contractors are encouraged to
119 Subcontractin Attachment B represents AHCCCSA's minimum contract with hospitals, they are required to
120 g and network requirements, how would a potential have contracts with physicians with admitting
Reimburseme Offeror successfully address any potential privileges to hospitals considered to be a
nt network deficiencies if Offeror is only part of the network. This is true whether the
"strongly encouraged" but not required to hospital is in-state or out of state.
contract with these out of state providers?
(e.g. regarding out of state providers listed
for GSAs 2 and 4)
- ----------------------------------------------------------------------------------------------------------------------------------
93 50 Sect D #42-- "The Contractor shall disclose to AHCCCSA the This question needs to be clarified. Refer to
Physician information on physician incentive plans the Physician Incentive Plan regulations for
Incentives listed in 42 CFR 417.479(h)(I) through AHCCCSA's responsibility in monitoring
417.479(i) upon contract renewal, prior to compliance with those regulations. The annual
initiation of a new contract, or upon request disclosure reporting requirement is on hold
from AHCCCSA or CMS." until CMS develops a new disclosure form. All
Question: Is CMS providing the state other provisions will continue to be enforced.
oversight in respect to physician incentives?
AHCCCS is required to report to CMS on its
Contractor's compliance with those
regulations.
- ----------------------------------------------------------------------------------------------------------------------------------
18
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
94 50 Sect D #43-- Is a provider that is capitated for No.
Management ophthalmology services and performs the prior
Service authorization function for ophthalmology
Subcontract services (when there is a denial, the health
plan issues the denial) considered a
Management Services Subcontractor?
- ----------------------------------------------------------------------------------------------------------------------------------
95 50 Sect D #43-- Is an organization, such as a Nurse Line This is not considered a management services
Management that provides a 24 hour service to respond subcontractor.
Service to member's health care questions,
Subcontract considered a Management Services The answer is still no.
Subcontractor? Would the answer change if
the same service also receives and refers
all operational issues which arise outside
of normal business hours to the health plan's
staff member on call?
- ----------------------------------------------------------------------------------------------------------------------------------
96 51 Sect D #45-- "Continuing Offerors that are bidding a new A current Contractor is considered an existing
Minimum GSA must provide the additional offeror in all counties to be bid.
Capitalization capitalization for the new GSA they are
Requirements bidding."
Question: Is the capitalization requirement
for UFC going into Cochise/Graham/Greenlee,
the amount for New Contractors or for
Existing Contractors?
- ----------------------------------------------------------------------------------------------------------------------------------
97 51 Sect D #45-- Please clarify what the minimum The minimum capitalization requirement for
Minimum capitalization requirements are for bidders is what is listed in the table.
Capitalization continuing offerors bidding a new GSA. Is it However, a Contractor must also meet it's
Requirements the equity per member standard or the equity per member standard after the contract
capitalization requirements for new is awarded. If the bidder meets its minimum
contractors presented in the table? capitalization, but doesn't meet its equity per
member standard, then the bidder must develop
a plan to meet that standard should they be
awarded a contract.
- ----------------------------------------------------------------------------------------------------------------------------------
98 51 Sect D #45-- Since the current RFP realigns some counties A current Contract is always considered an
Minimum in new GSA's, is a contractor that is existing contractor for capitalization
Capitalization currently an incumbent in one of the county purposes. Refer to the Performance Bond/Equity
Requirements (s) in the GSA but not the other county (s) Per Member Policy for questions regarding
considered to be an existing contractor for encumbrances on equity. The maximum
purposes of the minimum capitalization capitalization that a bidder must have to
requirements? If a contractor uses an secure an award is $10,000,000. However, the
irrevocable letter of credit (LOC) to meet Contractor must also meet the equity per
its performance bond requirement as member requirement. If the $10,000,000 does
described in the RFP, is it correct to say not meet the requirement, then additional
that AHCCCSA will not consider the LOC an capital must be provided.
encumbrance or a loan subject to repayment
(since the LOC is truly an off balance sheet
item and has no outstanding balance owed) as
described in the minimum capitalization
requirements? Regardless of the number of
GSA's a contractor is awarded, is it
- ----------------------------------------------------------------------------------------------------------------------------------
19
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
correct to say that the maximum amount of
capitalization or equity a contractor is
required to meet is $10,000,000?
- ----------------------------------------------------------------------------------------------------------------------------------
99 51 Sect D #45-- Please explain the rationale for the Yavapai The methodology that was used to determine
Minimum County minimum capitalization requirements the amount of the "existing offerors"
Capitalization being the same for both new and incumbent minimum capitalization requirement resulted
Requirements contractors. in an amount in excess of what the equity
per member amount would be. Therefore, the
existing offeror's minimum was limited to
the equity per member amount.
- ----------------------------------------------------------------------------------------------------------------------------------
100 51 SD #45-- If an Offeror is currently an incumbent Incumbent.
Minimum health plan in a county that is included in
Capitalization a "new" GSA (e.g. for GSA 4, in one county
Requirements and not all), then will that incumbent
health plan be considered an incumbent
health plan or a "new" Offeror in that "new"
GSA for proposal submission requirement
purposes?
- ----------------------------------------------------------------------------------------------------------------------------------
101 52 Sect D #47--Amount For the Performance Bond specifications it This does mean termination date, and that
of indicates that it must be effective for 15 clarification will be made in the document
Performance months following the effective date of the at a future date.
Bond contract...should this be 15 months from the
termination date of the contract?
- ----------------------------------------------------------------------------------------------------------------------------------
102 52 Sect D #47 Amount Will you allow one performance bond from Yes.
of Yavapai County listing both Yavapai County
Performance Long Term Care and the acute care program?
Bond
- ----------------------------------------------------------------------------------------------------------------------------------
103 53 Sect D #49-- When does AHCCCSA anticipate making changes OMC anticipates that the revised guide will
Advances, to the "AHCCCSA Reporting Guide for Acute be available by May 2003. Please note that
Distribution, Care Contractors"? reporting requirements will not change.
Loans and
Investments
- ----------------------------------------------------------------------------------------------------------------------------------
103 53 Sect D #50-- The RFP indicates that AHCCCS will monitor Yes, the language will be changed to address
Financial RBUC's Days Outstanding. The standard is set subcontracts that have provisions that are
Viability at no more than 30 days. Plans may have different than the BBA requirement prior to
Standards/ contracts with providers allowing 45 days to the contract effective date.
Performance pay a claim. The Plan may also decide to pay
Guidelines as close to the 45th day deadline as
possible. This may put a Plan out of the
30th day standard. Although there are no
sanctions if a Plan falls outside of the
standard, is there some way to restructure
the RBUC standard to take this into account?
Otherwise a Plan may appear to be out of
compliance while still paying providers
according
- ----------------------------------------------------------------------------------------------------------------------------------
20
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
to contract.
- ----------------------------------------------------------------------------------------------------------------------------------
105 53 Sect D #50-- What is the AHCCCSA definition of "liquid Cash or investments that can be converted to
Financial assets"? cash within 3 business days.
Viability
Standards/Pe
rformance
Guidelines
- ----------------------------------------------------------------------------------------------------------------------------------
106 53-54 Sect D #50-- How can AHCCCSA be assured that the positive AHCCCSA monitors several areas of health
Financial financial performance of a health plan is plan operations to ensure that members are
Viability not the result of not providing all receiving appropriate services including,
Standards/Pe necessary covered services, or limiting types of member grievances for denied
rformance access to sub-specialists, thereby causing services.
Guidelines the more expensive members to select another
health plan?
- ----------------------------------------------------------------------------------------------------------------------------------
107 54 Sect D #50-- How many incumbent health plans in each of Because this ratio varies from quarter to
Financial the past three (3) years have had Medical quarter, several plans have had Medical
Viability Expense Ratios of less than 85%? Expense Ratios of less than 85% at various
Standards/Pe times.
rformance
Guidelines
- ----------------------------------------------------------------------------------------------------------------------------------
108 54 Section #50-- Provide clarification on what is meant by Assets that are set aside on the balance sheet
D Financial "on balance sheet" performance bond. for the stated purpose of a performance bond,
Viability
Standards/Pe
rformance
- ----------------------------------------------------------------------------------------------------------------------------------
109 54 Sect D #51-- Is it the intent of the separate All lines of AHCCCS business must be
Separate incorporation requirement that a separate included in one separate corporation--not
Incorporation corporation be established for various lines separately incorporated. Separate reporting
of AHCCCSA business (i.e. Acute Care, ALTCS to AHCCCS for these lines of business will
and Health Care Group) or may these lines of continue to be required.
AHCCCSA business be part of one corporate
entity as long as separate mandated
reporting can be done for each line of
AHCCCSA business?
- ----------------------------------------------------------------------------------------------------------------------------------
110 54 Sect D #50-- What is AHCCCSA's intent in lowering the Because successful medical management and
150 Financial Medical Expense Ratio requirement to 80%? the implementation of disease management
Viability Please explain the potential impacts on programs can contribute to lower Medical
Standards/Pe capitation rates. Expense Ratios, AHCCCSA felt that its
rformance Contractors should not be discouraged from
Guidelines pursuing these managed care avenues by
potential failure to be in compliance with a
financial standard. This does not impact
capitation rate development.
- ----------------------------------------------------------------------------------------------------------------------------------
112 54-55 Sect D #53-- Given that the "set" rates for PPC and the There was different experience for each
Compensation Title XIX Waiver group have never yielded a plan. This statement is a broad generalization
result above the based on one plan's experience. The "bid"
- ----------------------------------------------------------------------------------------------------------------------------------
21
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
lower bound of the risk corridor, and given rates should be based on expected costs and
that these rates will not be released until utilization for that population. Rate ranges
April 1, 2003, how should the "bid" rates be will not assume any subsidy, therefore, the
adjusted to subsidize these unknown rates? bidder should not build in "subsidy" into
the "bid" rates.
- ----------------------------------------------------------------------------------------------------------------------------------
113 54-55 Sect D #53-- Given the uncertainty in the Title XIX The TWG rates were adjusted due to excessive
Compensation Waiver population historical data, will profits that contractors were making prior
AHCCCSA implement another mid-year rate to April 1, 2002. It is not anticipated that
reduction (as they did in April 2002, by the rates will be adjusted mid year unless
42%) if it appears that most contractors AHCCCS see either excessive profits or
will be profitable in this program? excessive losses.
Offerors' Conference.
- ----------------------------------------------------------------------------------------------------------------------------------
114 55 Sect D #53-- Related to the reconciliation process for AHCCCSA will use the administrative
Compensation PPC costs, what administration percentage percentage that is built into the capitation
does AHCCCSA intend to use in the rates. The policy will be updated to reflect
reconciliation calculation? In the PPC the elimination of PPC reinsurance in the
Reconciliation Policy, the calculation future.
includes a reduction for reinsurance. Should
this not be deleted from the policy as
explained in paragraph 58 on page 58 of the
RFP "Effective October 1, 2003, AHCCCSA will
no longer cover PPC inpatient expenses under
the reinsurance program..." Or are there
medical expenditures related to PPC members
that still qualify for the reinsurance
program?
- ----------------------------------------------------------------------------------------------------------------------------------
115 55 Sect D #53-- Would "programmatic changes that affect Yes, programmatic changes include all
Compensation reimbursement" include the anticipated service categories impacted due a
increase in in-patient stays or other prescription drug In the event that
associated medical expenditures associated prescription drugs are carved out,
with carve out of pharmacy benefit?
Will AHCCCS be making adjustments in cap for AHCCCS will factor in the increases to
increase in malpractice insurance that is provider payments due to malpractice
being passed on through increases in insurance premium increases.
contract rates with providers?
- ----------------------------------------------------------------------------------------------------------------------------------
116 55 Sect D #53-- In determining the various components of
Compensation health plan reimbursement, how will The encounter utilization reports have six
AHCCCSA take into account the significant months of CYE '02 data and financial data as
trends that have occurred since January reported by health plans have the full CYE '02
1, 2002? For example, population changes data. This data is used in thedevelopment of
have increased medical costs. capitation rates. The information contained in
this data plus adjustments for trend and program
changes should account for increased
utilization.
- ----------------------------------------------------------------------------------------------------------------------------------
117 55 Sect D #53-- Given that C-section rates have increased to The rate development will be based upon recent
Compensation almost 30% in the past 6 months, and are actual delivery experience. Information
provided by current Contractors will also
- ----------------------------------------------------------------------------------------------------------------------------------
22
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
expected to continue increasing due to be utilized in developing future c-section /
malpractice concerns and changing provider vaginal delivery percentages. It is
practices (caused, among other things, by anticipated that there will be an increase
VBACs being limited), how will AHCCCSA take to the assumed percentage of babies
into account these factors in health plan delivered by C-section.
capitation rate range development?
- ----------------------------------------------------------------------------------------------------------------------------------
118 55 Sect D #53-- Given that AHCCCSA's historical rate The first statement is subjective, and
Compensation increases have been well below actual health conflicts with the audited financial
plan and market trends, how will future information OMC collects from its contractors.
capitation rate increases be developed? Will [We also note with interest that the example
AHCCCSA adjust its capitation rate increases chosen seems to conflict with the first part
to a targeted Medical Expense Ratio? For of the question.] While health plan
example, if the average of all health profitability is an important input to
plans' profitability is 5%, and expense rate-setting development, other factors must
trends are increasing at 8% annually, then also be considered before reaching the
will AHCCCSA pass along to the health plans conclusion rates are actuarially sound.
8% or 3%?
- ----------------------------------------------------------------------------------------------------------------------------------
119 55 Sect D #53-- When will all reimbursement rates that AHCCCSA anticipates that the "set rates"
Compensation Offerors are not bidding on (by RFP will be available by April 1, 2003.
instruction) be made available to potential
Offerors? (e.g. prior period coverage,
hospital supplemental payments, HIV/AIDS
supplemental payments, Title XIX Waiver
Group capitation, Title XIX Waiver Group
hospital supplemental payment etc.)
- ----------------------------------------------------------------------------------------------------------------------------------
120 55 Sect D #53-- Prior Period Coverage - Please explain With the transition of the MNMI population
Compensation AHCCCSA's rationale for discontinuing to the Title XIX Waiver Group, very little
reinsurance for the PPC population. Will reinsurance is paid through PPC. Therefore,
AHCCCSA be taking this circumstance into it did not seem cost effective to maintain
account when developing the PPC capitation the large administrative burden that it puts
rates being developed (that the Health plans on the agency. The small amount of reinsurance
are not bidding on)? paid for PPC claims will be factored into the
capitation rates.
- ----------------------------------------------------------------------------------------------------------------------------------
121 55 Sect D #53-- Prior Period Coverage - What is the AHCCCSA believes that putting the PPC time
Compensation rationale for putting a retrospective period period at risk will encourage health plans
at risk, and on what basis are AHCCCSA's to review claims for medical necessity.
actuaries developing rates for this program?
AHCCCSA's actuaries will use actual claims
paid data from the reconciliations to
develop the capitation rates. Furthermore,
the rates are reconciled.
- ----------------------------------------------------------------------------------------------------------------------------------
122 55 Sect D #53-- Prior Period Coverage - What assumptions The assumptions will be released with the
Compensation regarding length of enrollment, enrollee capitation rates.
choice, and utilization and cost trends have
been made regarding this population?
- ----------------------------------------------------------------------------------------------------------------------------------
23
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
123 55 Sect D #53-- Prior Period Coverage Reconciliation - Why AHCCCSA believes that putting the PPC time
Compensation is AHCCCSA putting the health plans at 2% period at risk will encourage health plans
risk when the health plans have no ability to review claims for medical necessity.
to manage this utilization and related
costs? Please explain how this will be AHCCCSA has no evidence that the current PPC
accomplished when current PPC capitation rate is not adequate.
rates may not be adequate.
- ----------------------------------------------------------------------------------------------------------------------------------
124 56 Sect D #53-- "Risk sharing for PPC reimbursement" - is Yes.
Compensation the elimination of reinsurance also factored
into the rates?
- ----------------------------------------------------------------------------------------------------------------------------------
125 55 Sect D #53-- Since PPC rates are done by AHCCCS actuaries Profit/loss is not build into capitation
Compensation and not by the plans, what profit/loss did rates. Mercer builds a 2.0% risk contingency
AHCCCS build in to the rate structure? into the PPC rates.
- ----------------------------------------------------------------------------------------------------------------------------------
126 56 Sect D #53-- Please provide a detail definition of the Additional data will be distributed at the
Compensation services included in the delivery Offeror's Conference. Please refer to the
supplemental payment. Please provide service matrix for coding and service
detailed information on the DRGs, revenue category.
codes, and CPT/HCPCS codes included in the
definition
- ----------------------------------------------------------------------------------------------------------------------------------
127 56 Sect D #53-- Please provide details on how the The hospital supplemental payment will be
Compensation hospitalized supplemental payment is calculated based on the costs of the first
calculated. hospitalization for members who were
hospitalized on the date of application.
Encounter data will be used to determine
these costs.
- ----------------------------------------------------------------------------------------------------------------------------------
128 56 Sect D #53-- Title XIX Waiver Group Rates - Will the AHCCCSA anticipates that it will continue
Compensation existing member choice selection adjustment with the choice adjustment.
percentages remain in effect for Title XIX
Waiver Group members, and will those ranges The TWG rates, including the hospitalized
apply to both the AHCCCSA Care and MED supplemental payment, will be set by Mercer.
groups? What assumptions underlie the ranges Rate ranges will not be developed for this
assigned for capitation rate adjustments group. A risk corridor will be built around
under this methodology? these rates.
- ----------------------------------------------------------------------------------------------------------------------------------
129 56 Sect D #53-- Title XIX Waiver Group Rates - Will AHCCCSA AHCCCS will provide the assumptions
Compensation share its assumptions regarding development regarding the development of the hospital
of the hospital supplemental payment? Will supplemental payment at the time they are
AHCCCSA provide application dates to the released.
health plans in order to allow them to track
the receivables for these payments? No, AHCCCSA does not have the application
dates to provide.
- ----------------------------------------------------------------------------------------------------------------------------------
130 56 Sect D #53-- The RFP indicates that AHCCCSA may evaluate The analysis has not been completed. AHCCCS
will continue to
- ----------------------------------------------------------------------------------------------------------------------------------
24
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
Compensation the cost experience of choice members versus pursue this analysis.
those who are auto-assigned. Has AHCCCSA
completed any such analysis, and will that
analysis be shared with Offerors prior to
the proposal due date?
- ----------------------------------------------------------------------------------------------------------------------------------
131 56 Sect D #53-- Delivery Supplement - What specific cost An ad-hoc delivery report will be
Compensation components comprise the delivery supplement distributed to all potential contractors at
payment? What period of time preceding and the bidders' conference to be held on Friday
subsequent to the birth event should be February 21, 2003. The delivery supplemental
included? payment covers costs from six months prior
to the delivery date, the actual delivery,
and two months post delivery. The offset in
the CRCS should be eight months of
capitation for the member.
- ----------------------------------------------------------------------------------------------------------------------------------
132 57 Sect D #55-- If a member is hospitalized with a police If the member meets any of the following
Capitation guard, are they considered incarcerated? If criteria, they will be considered
Adjustments, not, please provide the definition that is incarcerated.
paragraph 2, used by AHCCCS to qualify a member as
item b. "incarcerated." The following are considered inmates:
1. an inmate in a DOC prisoner
2. an inmate of a county, city
or tribal jail
3. an inmate of a prison or jail
prior to conviction
4. an inmate of a prison or jail
prior to sentencing
5. an inmate of a prison or jail
who can leave prison or jail on
work release or work furlough
and must return at specific
intervals
6. an inmate of a prison or jail
who can leave prison or jail on
work release or work furlough and
must return at specific intervals
7. an inmate who receives outpatient
medical services outside of the
prison or jail setting.
- ----------------------------------------------------------------------------------------------------------------------------------
133 57 Sect D #56-- As an incentive, "AHCCCSA will adjust the No, AHCCCS will not accept a plans audited
Incentives auto assignment algorithm methodology to HEDIS results. AHCCCS will generate the
incorporate contractor's clinical performance indicators to ensure consistency
performance indicator results in the in data collection and analysis methodology
calculation of target percentages." AHCCCSA across contractors. However, contractors
will use pre-natal care in the first will be involved in this process and should
trimester as a performance indicator. Will agree with the indicator results based on
AHCCCSA accept the Health Plan's audited data submitted to AHCCCS.
HEDIS results when reporting this indicator?
- ----------------------------------------------------------------------------------------------------------------------------------
134 57 Sect D #56-- As contractors will be required to post Contractors must post AHCCCS generated
Incentives, clinical performance indicators on the performance indicators. These will not be
Use of Health Plan web site, are these indicators posted prior to receiving Contractor
Website, last AHCCCS generated numbers or health plan feedback.
paragraph internal data?
- ----------------------------------------------------------------------------------------------------------------------------------
135 57 Sect D #56-- Use of Web Site - Please confirm when this AHCCCS will inform the plans when this
data information is required to
- ----------------------------------------------------------------------------------------------------------------------------------
25
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
Incentives, must be posted to a health plan's web site. be posted. Available information will be
Use of posted in CYE '04.
Website, last
paragraph
- ----------------------------------------------------------------------------------------------------------------------------------
136 57 Sect D #56-- On what contract year will the clinical As soon as reported by AHCCCS in 2005, for
Incentives, performance indicator results be based to Contract Year 10/1/03 through 9/30/04.
Use of adjust the auto- assignment algorithm? When
Website, last will these clinical performance indicator
paragraph results be made available to the health
plans?
- ----------------------------------------------------------------------------------------------------------------------------------
137 57 Sect D #56-- 49. For prenatal care in the first AHCCCS uses the HEDIS specifications for
Incentives, trimester, what definition of "trimester" definition of trimester. Healthy People 2010
Use of will be used in calculating the performance is the benchmark. Further clarification will
Website, last measures that will impact the be forthcoming.
paragraph auto-assignment algorithm, and how will it
be benchmarked? Examples to consider for
clarification include: first time seen for
this pregnancy, whether or not on AHCCCS;
first time seen on AHCCCS, whether or not by
current health plan or provider, and first
time seen by current health plan or
provider.
- ----------------------------------------------------------------------------------------------------------------------------------
138 58 Sect D #56-- Related to the incentive fund (it is AHCCCSA is not considering a financial
Incentives understood that the incentives would not incentive program at this time--but may in
take place until after the CYE 9/30/04), the future. Contractor input into the
however, what type and or amount of process will be solicited.
capitation is AHCCCSA considering retaining?
AHCCCSA has previously discussed Any amounts withheld from capitation would
incorporating incentives and performance be small enough so as to not impact the
outcomes into the reimbursement to actuarial soundness of the capitation rates.
contractors but has not previously
implemented a process. How much input will
AHCCCSA solicit from the contractors in
developing incentives and/or the performance
measured outcomes? If contractors are
required to develop/submit actuarially sound
capitation rates how can AHCCCSA retain a
portion of the capitation for an incentive
fund? Would this action cause the capitation
rates to not be actuarially sound?
- ----------------------------------------------------------------------------------------------------------------------------------
139 58 Sect D #57-- Related to inpatient reinsurance and nursing Please refer to the Reinsurance Claims
Reinsurance facility service expenditures in lieu of Processing Manual, Chapter 2, Section 2,
hospitalization, can AHCCCSA be more Chapter 3, Section 2, and Chapter 6,
specific on what expenditures would qualify Section 4.
for reinsurance reimbursement as described
in the RFP? The definition of what qualifies
as "...provided in lieu of
- ----------------------------------------------------------------------------------------------------------------------------------
26
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
hospitalization..." has been an issue in the
past.
- ----------------------------------------------------------------------------------------------------------------------------------
140 58 Sect D #57-- What are the reinsurance premiums in regards This will be published by the end of February.
Reinsurance to the reinsurance table on page 58?
- ----------------------------------------------------------------------------------------------------------------------------------
141 58 Sect D #65 Incentive Fund - What performance measures AHCCCSA has not developed a methodology for
Incentives does AHCCCSA intend to use in administering the incentive fund at this time.
the Incentive Fund? Will such incentive fund
measurements be linked to the accessibility
and quality of covered services coordinated
by the health plan, or to the Medical
Expense Ratio?
- ----------------------------------------------------------------------------------------------------------------------------------
142 60 Sect D #57-- What does "certify" mean as it references Per the BBA all encounter submissions must
Reinsurance "verify and certify" encounters? be certified as accurate by the submitter.
OMC EPARS unit has issued a format for that
certification.
- ----------------------------------------------------------------------------------------------------------------------------------
143 61 Sect D # 57-- Please give a clearer explanation of AHCCCS will not reimburse for penalties
Reinsurance, "Pre-hearing and/or hearing penalties assessed to Contractors through reinsurance.
Reinsurance discoverable during the review process will Contractors have sole financial
Audits, Audit not be reimbursed under reinsurance." responsibility for penalties that are
Consideration awarded through the grievance process.
s, first
paragraph
- ----------------------------------------------------------------------------------------------------------------------------------
144 61 Sect D # 58-- Is CRS considered a third party? CRS meets the definition as a third party.
Coordination However, this does not mean that this entire
of Benefits, section applies appropriately to CRS
paragraph 2, coverage. Contractors are required to
Cost coordinate service with CRS per Paragraph
Avoidance 10, page 22.
- ----------------------------------------------------------------------------------------------------------------------------------
145 61 Sect D # 58-- AHCCCSA is currently under procurement for a The new contractor will perform the same
Coordination new TPL contractor. How will that new functions as the current contractor.
of Benefits, contract's operations impact coordination of Therefore, there are no financial impacts
paragraph 2, services with AHCCCS health plans and what anticipated.
Cost will be the financial impacts of any
Avoidance contract changes to a health plan?
- ----------------------------------------------------------------------------------------------------------------------------------
146 61 Sect D # 58-- Third Party Liability: The TPL amount reported by health plans is
Coordination Where is historical information for TPL? approximately $3.5M per year. This is the
of Benefits, If the amounts reported with plans' amount recovered through pay and chase
paragraph 2, financial PMPM's are net of TPL, what is the recoveries. This amounts to less than 50
Cost TPL offset? Also, how would a new bidder pmpm. We do not have additional detailed
know what is in the plans' information.
- ----------------------------------------------------------------------------------------------------------------------------------
27
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
Avoidance financials?
- ----------------------------------------------------------------------------------------------------------------------------------
147 64 Sect D #62-- This health plan is a part of a larger Please refer to the answers for questions
Corporate corporation; this larger corporation has a #62 and #64.
Compliance defined Corporate Compliance Program and
Officer. This Officer is located in
Washington D.C.; This health plan
additionally has a Fraud and Abuse Officer
on site. This section appears to mingle the
two together. Are we meeting the guideline
if we have an Off-site Compliance Officer
and Committee, if we have a local on site
Fraud and Abuse officer?
- ----------------------------------------------------------------------------------------------------------------------------------
148 65 Sect D #63--Records "The Contractor shall preserve and make All member records, regardless of the age of
Retention available all records for a period of five the member must be maintained and available
years from the date of final payment under as delineated in this paragraph.
this contract."
As the statement does not differentiate for
age, does the same limit apply to pediatric
patient (<21) records?
- ----------------------------------------------------------------------------------------------------------------------------------
149 66 Sect D Page 66, Upon request, the Contractor shall provide We do not anticipate that this information
Section 64, updated, date-sensitive PCP assignments: will be required in the upcoming contract
Data Does AHCCCS anticipate requiring this during year.
Exchange the upcoming contract year? If so, when will
Requirements the file layout be provided?
, first
paragraph
- ----------------------------------------------------------------------------------------------------------------------------------
150 66 Sect D # 64, Data Are security code/data transmissions already The security code/data transmissions have
Exchange in effect with the AHCCCS VPN and PMMIS been in effect with the AHCCCS VPN and PMMIS
Requirements systems or is this something new? systems since October of 2002.
- ----------------------------------------------------------------------------------------------------------------------------------
151 66 Sect D # 64, Data Does the Health Plan have to obtain a The AHCCCS Administration is not aware of
Exchange business associate contract with AHCCCS for any covered functions that it performs on
Requirements the release of member information to AHCCCS behalf of Health Plans under this RFP that
under the HIPAA privacy standards? would require the Health Plans to consider
the Administration to be a business
associate of the Health Plan. Furthermore,
it is the AHCCCS Administration's position
that neither will Health Plans, under this
RFP, be required to perform covered
functions on behalf of the AHCCCS
Administration that would require the AHCCCS
Administration to consider the Health Plans
to be business associates of the AHCCCS
- ----------------------------------------------------------------------------------------------------------------------------------
28
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
Administration. Neither does the AHCCCS
Administration consider a business associate
agreement to be a prerequisite for the
exchange of protected health information
between health plans and the AHCCCS
Administration. For example, covered
entities may disclose protected health
information to another covered entity for
purposes of treatment, payment or certain
health care operations. See 45 CFR 164.506.
There are also a number of disclosures
permitted by 45 CFR 164.512 that pertain to
the relationship between the health plans
and the AHCCCS Administration. Neither of
these rules mandates that a business
associate agreement be executed as a
precondition for disclosures pursuant to
these rules.
- ----------------------------------------------------------------------------------------------------------------------------------
152 66 Sect D # 64, Data Do we need to state specifically in our It is the position of the AHCCCS
Exchange notice of privacy practices that information Administration that it falls within the
Requirements can and will be released to AHCCCS for the regulatory definition of a health oversight
purposes of oversight? agency as set forth at 45 CFR 164.501. The
Privacy Rule, at 45 CFR 164.520(b)(ii)(B),
requires that the notice of privacy
practices include a description of the
purposes for which a covered entity is
permitted to disclose protected health
information. Disclosures for health
oversight activities are permitted by the
rule. See 45 CFR 164.512(d). Determining the
precise contents of the contractor's notice
of privacy practices is the contractor's
responsibility. Any advice or direction
provided by the Administration is not
binding on the federal agency responsible
for enforcement of the HIPAA Privacy
requirements.
- ----------------------------------------------------------------------------------------------------------------------------------
153 66 Sect D # 64, Data Will AHCCCS have a notice of privacy Yes.
Exchange practices that addresses sending information
Requirements to the Health Plans?
- ----------------------------------------------------------------------------------------------------------------------------------
154 70 Sect D # 72-- When will the Sanctions policy be available? The policy will be available prior to
Sanctions October 1, 2003 in order to be in compliance
with the BBA. OMC will make every effort to
finalize it well in advance of that date.
- ----------------------------------------------------------------------------------------------------------------------------------
155 70 Sect D # 73-- When will the Business Continuity Plan A draft of the Business Continuity Plan
Business policy be available? Policy is in the bidder's library and on the
Continuity AHCCCS web site.
Plan
- ----------------------------------------------------------------------------------------------------------------------------------
156 70 Sect D # 73-- When will draft AHCCCSA policies or AHCCCSA These policies will all be posted on the web
70 Business policies in revision as referenced in RFP be site when completed. Most of these are
ready currently posted there. It is the bidder's
- ----------------------------------------------------------------------------------------------------------------------------------
29
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
72-73 Continuity and how will they be distributed? If not by responsibility to regularly review the web
Plan website, how will potential Offerors be site or physical bidder's library for
notified? (e.g. Sanctions policy; Current updates.
Health plan Change policy; Member Transition
for Annual Enrollment Choice policy, Open
Enrollment and Other Plan Changes, and
Business Continuity Plan policy.)
- ----------------------------------------------------------------------------------------------------------------------------------
157 71 Sect D #75--Pending Relating to the inpatient pilot program, if Yes.
Legislative legislation is not enacted to extend the
/Other pilot program in Maricopa and Pima counties
Issues beyond 9/30/03, will AHCCCSA adjust the
capitation rates it pays to contractors?
- ----------------------------------------------------------------------------------------------------------------------------------
158 71 Sect D #75--Pending When will all of the pending issues listed AHCCCSA is unable to determine the exact
Legislative on page 71 of the RFP (e.g., transplants) be date the pending issues will be resolved. It
/Other Issues resolved and will those issues be resolved is unlikely that they will be resolved prior
before the bid due date? to the bid submission due date.
- ----------------------------------------------------------------------------------------------------------------------------------
159 71 Sect D #76-- Please confirm that the increased costs These are program changes and should be
Balanced associated with the BBA, particularly those considered when developing the capitation
Budget Act of related to the 10-day window for ER bid proposal. Please note, the direction
1997 (BBA) notification, post-stablization changes, that was provided in answer #
etc. are considered program changes and
that the health plan should bid as if those
changes were not in effect.
- ----------------------------------------------------------------------------------------------------------------------------------
160 71 Sect D #76-- What is the timeline for new or revised October 1, 2003
Balanced policies in AMPM regarding Balanced budget
Budget Act of Act of 1997 (BBA)?
1997 (BBA)
- ----------------------------------------------------------------------------------------------------------------------------------
161 71 Sect D #76-- When will policies be completed regarding October 1, 2003
Balanced Special Health care needs and Emergency
Budget Act of Services according to BBA?
1997 (BBA)
- ----------------------------------------------------------------------------------------------------------------------------------
162 71 Sect D #75--Pending Prescription Drugs - Has AHCCCSA or the AHCCCSA is in the process of hiring a
Legislative Governor's Office prepared a position or consultant to determine if cost savings can
/Other Issues policy paper that outlines the pros and cons be achieved with carving out prescription
of carving out pharmacy services from the drugs from the Contractors. The result of
AHCCCS program? If yes, when will this be that study is anticipated to be finalized in
made available to potential Offerors? the Summer of 2003. The report should
include both pros and cons of a prescription
drug carve out.
- ----------------------------------------------------------------------------------------------------------------------------------
163 71 Sect D #75--Pending Prescription Drugs - Given the complexity of If implemented, AHCCCSA anticipates that the
Legislative a pharmacy services carve out, is the prescription drug carve out would be
/Other Issues October 1, 2003 implementation date effective October 1, 2004.
feasible?
- ----------------------------------------------------------------------------------------------------------------------------------
164 71 Sect D #75--Pending Prescription Drugs - How much in PMPM dollar AHCCCSA is in the process of hiring a
consultant to determine
- ----------------------------------------------------------------------------------------------------------------------------------
30
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
Legislative savings does AHCCCSA anticipate to realize the potential cost savings of carving out
/Other if pharmacy services are carved out from the prescription drug costs from the
Issues health plans? Contractors. The result of that study is
anticipated to be finalized in the Summer of
2003. The report should include both pros
and cons of a prescription drug carve out.
- ----------------------------------------------------------------------------------------------------------------------------------
165 71 Sect D #75--Pending Prescription Drugs - Will AHCCCSA implement AHCCCSA does not anticipate implementing any
Legislative/ quantity limits per month and per additional type of quantity limit at this
Other Issues prescription, prescriptions per period of time. Please refer to the AMPM, Chapter 300
time and dosage limits to manage utilization for current limits.
problems that could affect medical costs?
(Over-utilization of antibiotics causing
resistance - a CDC effort is underway to
address this problem as well as
under-utilization of statins in diabetics
and CAD, and asthma as mentioned above.
Higher than recommended or safe doses result
in adverse effects).
- ----------------------------------------------------------------------------------------------------------------------------------
166 71 Sect D #75--Pending Prescription Drugs - Will AHCCCSA identify PBM's have these types of edits and AHCCCSA
Legislative/ and work with health plan case management to expects that this information will be made
Other Issues restrict members to prevent drug-seeking available to the Contractors.
behavior and help them get proper treatment
of their condition?
- ----------------------------------------------------------------------------------------------------------------------------------
167 71 Sect D #75--Pending Prescription Drugs - Will AHCCCSA provide Yes, AHCCCSA anticipates that real time data
Legislative/ the health plans concurrent access to the will be made available to its Contractors.
Other Issues pharmacy database for their respective
membership to allow them to do reviews that
impact care plans, disease management, and
health outcomes?
- ----------------------------------------------------------------------------------------------------------------------------------
168 71 Sect D #75--Pending Prescription Drugs - Will AHCCCSA assign The responsibility will be shared by the PBM
Legislative/ responsibility to the PBM to perform all of and the Contractors, not unlike the current
Other Issues the management of these pharmacy issues? system. Yes there will be staff to
Will AHCCCSA or the PBM hire staff to coordinate the administration of the
address health plan interests and data program.
integration requirements?
- ----------------------------------------------------------------------------------------------------------------------------------
169 71 Sect D #75--Pending Prescription Drugs - In the event that The bidder should assume that all outpatient
Legislative/ pharmacy services are carved out of the pharmacy services will be carved out. Any of
Other Issues AHCCCSA program, please delineate which the listed drugs when administered in an
drugs will be carved out. Examples include: outpatient setting will be carved out. If
- Injectables any of the listed drugs are administered in
an inpatient setting, then they are covered
- Enterals under the AHCCCS tier per diem
reimbursement.
- Infusion drugs / Hemo factor Prescriptions administered in a Skilled
Nursing Facility will be carved out.
- Chemotherapy
- Family Planning drugs
- Pharmacy dispensed in a physician or
hospital setting
- Psychotropic drugs currently being
provided by RBHAs
- ----------------------------------------------------------------------------------------------------------------------------------
31
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
170 71 Sect D #75--Pending Prescription Drugs - If injectables are not Injectables will be carved out.
Legislative/ carved out, will there be compensation to
Other Issues the plans for the increased costs associated
with obtaining them on the medical side? The
discount obtained running them through the
retail pharmacy benefit will be lost if they
are not. (MC)
- ----------------------------------------------------------------------------------------------------------------------------------
171 71 Sect D #75--Pending Prescription Drugs - Will AHCCCSA carve out Yes, prescription drugs associated with
Legislative/ all transplant related therapy and manage transplants will be carved out, and the PBM
Other Issues the coordination of benefits with Medicare? will be responsible for coordinating
benefits with Medicare.
- ----------------------------------------------------------------------------------------------------------------------------------
172 71 Sect D #75--Pending Prescription Drugs - Given certain members' One prior authorization policy will be
Legislative/ complex pharmacy regimens designed to developed by AHCCCSA with input from its
Other Issues control or improve chronic and costly Contractors.
medical conditions, how will AHCCCSA adjust
capitation rates for such identified The plans should factor the impact of the
members' increased non-pharmacy utilization prescription drug carve out to other service
costs if pharmacy services are carved out of categories.
the AHCCCS program? For example, what may be
the pharmacy prior authorization
requirements that will need to be
coordinated among the "statewide" pharmacy
benefits manager and the health plans to
achieve cost savings and consistency in
application of clinical criteria?
- ----------------------------------------------------------------------------------------------------------------------------------
173 71 Sect D #75--Pending Prescription Drugs - If pharmacy management The Contractors will continue to receive
Legislative/ is carved out, what does AHCCCSA intend to real time information that will permit
Other Issues do with over-prescribing physicians? How provider profiling. This will be the
will such issues be coordinated with health responsibility of the Contractor to monitor.
plans? Will this data be made available by
health plan?
- ----------------------------------------------------------------------------------------------------------------------------------
174 71 Sect D #75--Pending Prescription Drugs - If pharmacy management All prescriptions will most likely be filled
Legislative/ services are carved out, how will AHCCCSA unless the pharmacy is not in the PBM's
Other Issues deal with prescriptions for health plan network.
members that are written by physicians who
are not contracted with the member's health
plan?
- ----------------------------------------------------------------------------------------------------------------------------------
175 71 Sect D #75--Pending Prescription Drugs - Who will be responsible Both the Contractor and the PBM will be
Legislative/ for reporting and monitoring pharmacy fraud responsible for monitoring fraud and abuse
Other Issues and abuse issues? issues.
- ----------------------------------------------------------------------------------------------------------------------------------
176 71 Sect D #75--Pending Prescription Drugs - Given federal Medicaid CMS has recently interpreted the Medicaid
Legislative/ drug rebate requirements and recent lawsuits Drug Rebate Program as permitting the use of
Other Issues limiting the use of a formulary, how will a formulary that encourages management of
AHCCCSA restrict the usage of high cost and the pharmacy benefit. States with
inappropriate pharmaceuticals? formularies have recently prevailed in the
courts.
- ----------------------------------------------------------------------------------------------------------------------------------
177 71 Sect D #75--Pending Prescription Drugs - Rebates are based on Noted. The study will address this question.
Legislative/ increased utilization of brand name
medications,
- ----------------------------------------------------------------------------------------------------------------------------------
32
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
Other Issues not cost-effective management, thus
resulting in higher cost of the pharmacy
benefit. The logic of doing this, to get
back a greater percentage of rebate dollars,
is flawed. If one is spending $100 to get
back $4 (4%), and keeping generic
utilization in the 60%-plus range, how would
it benefit to treat the same condition for
$200 to get back $36 (18%) and drive up the
average cost per prescription, since the use
of generics would most likely decline 15-25
percentage points?
- ----------------------------------------------------------------------------------------------------------------------------------
178 71 Sect D #75--Pending Prescription Drugs - If AHCCCSA decides to The study will address the question.
Legislative/ carve out the pharmacy benefit, any gain Additionally, the Contractors will continue
Other Issues from increased rebates will be to receive data as the currently do from the
offset by increased health plan costs (PMPM PBM to perform the "back end" utilization
and $/Rx). The current requirements management. Each plan must make its own
to obtain Federal Rebates are contradictory determination of the impact that the
to the ability to manage over-, under- and prescription drug carve out will have to
mis-utilization of the pharmacy benefit and other service categories. AHCCCS' actuaries
ultimately affect patient care in a have not made final determinations of the
positive manner. The carve out of pharmacy impact to other service categories.
services from the health plans could result
in misinformed decisions, increased
hospitalizations, emergency room visits and
physician visits. What are the assumptions
of AHCCCSA's actuaries regarding the impact
on other health care costs if pharmacy
management is carved out of the program?
- ----------------------------------------------------------------------------------------------------------------------------------
179 71 Sect D #75--Pending Prescription Drugs - If pharmacy management AHCCCS will work with its Contractors to
Legislative/ is carved out, how will AHCCCSA handle develop a prior authorization process for
Other Issues requests for non-formulary drugs? non-formulary drugs.
- ----------------------------------------------------------------------------------------------------------------------------------
180 71 Sect D #75--Pending Prescription Drugs - Managing the pharmacy There will not be an open formulary. CMS is
Legislative/ benefit at the health plan level with closed flexible with the states in establishing
Other Issues formularies allows for more effective case formularies that have effective management
management, concurrent review and disease procedures.
management, to name a few activities that
positively impact member health outcomes and There will be no impact to the capitation
reduce overall program costs. An open rates for open or closed formularies.
formulary focused on obtaining rebates will
ultimately result in increased medical
service and pharmacy costs, and hinder
health plans' abilities to implement
effective medical management programs that
readily influence member behaviors and
health outcomes. Will AHCCCSA be
establishing an
- ----------------------------------------------------------------------------------------------------------------------------------
33
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
open or closed formulary? Will it be a
uniform statewide formulary? What will be
AHCCCSA's assumptions in developing health
plan capitation rates for open and closed
formularies?
- ----------------------------------------------------------------------------------------------------------------------------------
181 71 Sect D #75--Pending Prescription Drugs - One of the most As mentioned previously, the Contractors
Legislative/ effective ways to control pharmacy costs is will receive data that will permit them to
Other Issues to conduct academic detailing and profiling continue their provider profiling.
of physicians' prescribing behaviors. Who
from AHCCCSA will be responsible for these
initiatives? How will this information be
conveyed to providers? How often?
- ----------------------------------------------------------------------------------------------------------------------------------
182 71 Sect D #75--Pending Prescription Drugs - With pharmacy services These will continue to be included in the
Legislative/ carved out of the AHCCCSA program, how does tier per diems. The rates will be adjusted
Other Issues AHCCCSA intend to address the issuance and as provided for in Arizona statute.
payment of prescriptions written in an
inpatient setting that are reimbursed on a
per diem basis? Will AHCCCS adjust facility
tiered per diem rates?
- ----------------------------------------------------------------------------------------------------------------------------------
183 71 Sect D #75--Pending Prescription Drugs - With pharmacy services This detail has not been worked out yet.
Legislative/ carved out of the AHCCCS program, how does
Other Issues AHCCCSA intend to handle prescriptions
written in an emergency room? Will only
short-term prescriptions be issued, with
written instructions for the member to
follow up with his/her PCP? How will the
information about such prescriptions written
in the emergency room be
communicated/transmitted to the member's
PCP? Which provider will be responsible for
effecting such information transfers?
- ----------------------------------------------------------------------------------------------------------------------------------
184 71 Sect D #75--Pending Hospital Pilot Program - Even though AHCCCSA Yes, AHCCCSA anticipates that the pilot will
Legislative/ instructs Offerors to bid as if this program be extended.
Other Issues is extended beyond September 30, 2003, does
AHCCCSA anticipate that such extension will
actually occur? And what will be the impacts
if the pilot program is not extended?
- ----------------------------------------------------------------------------------------------------------------------------------
185 71 Sect D #76-- BBA When is it anticipated that AHCCCSA's final AHCCCSA will have that decision as soon as
decision regarding the BBA requirement to possible. When a final decision is made.
have an expedited hearing process through Offerors will be informed immediately
the State Medicaid agency be made available through the web site and in written form.
to potential Offerors?
- ----------------------------------------------------------------------------------------------------------------------------------
186 72 Sect D #77-- Does agreement to participate in the HCG In the case of negligible differences
Healthcare program provide any weight in award between two or more competing proposals for
Group of decisions for the acute care program? a particular GSA, in the best interest of
the State, AHCCCSA may consider an Offeror,
who participates
- ----------------------------------------------------------------------------------------------------------------------------------
34
- ----------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ----------------------------------------------------------------------------------------------------------------------------------
Arizona satisfactorily in other lines of AHCCCS
business, as a factor in awarding the
contract..
- ----------------------------------------------------------------------------------------------------------------------------------
187 89 Sect G Related Party Are questions 1 & 2 specific to the health These questions are specific to the
Transactions plans board and staff or do these questions Offeror's board and staff.
relate to the health plan's parent company?
- ----------------------------------------------------------------------------------------------------------------------------------
188 90 Sect G Related Party Furnishing of goods or services - does this Yes, this applies to payments made to
Transactions include payments made to brother/sister related party organizations in the normal
organizations made in the normal course of course of business.
business, i.e., payment to a hospital for
inpatient services when the plan and
hospital are owned by the same organization?
- ----------------------------------------------------------------------------------------------------------------------------------
189 92 Sect G Please define "AHCCCSA program" as to be The AHCCCS acute care line of business.
used in the final column of this table? Is
this meant to include responsibilities
pertaining to other AHCCCSA programs as
well, such as the ALTCS and Premium Sharing
programs?
- ----------------------------------------------------------------------------------------------------------------------------------
190 93 Sect H What percentages/values will be assigned to This information is not being shared with
each of the five scoring categories? Offerors.
- ----------------------------------------------------------------------------------------------------------------------------------
191 93 Sect H Can AHCCCSA define "negligible differences" The definition is not being shared with
in the contents of the sentence, "In the Offerors.
case of negligible differences between two
or more competing proposals for a particular
GSA..."
- ----------------------------------------------------------------------------------------------------------------------------------
192 93 Sect H If a Letter of Intent (AHCCCSA mandated LOI Capitation rates will not be based on LOI's,
format for CYE 9/30/04 approved version) but rather on historical cost and
does not include language to address the utilization data provided by health plans.
amount of reimbursement to be paid a
provider for services rendered, how can the Historical experiences with appropriate
determination of a capitation rate based on trends that are applied to the historical
such LOI's be considered to be actuarially data are sufficient to develop actuarially
sound? If CMS has mandated that all sound capitation rates.
capitation rates be actuarially sound, how
can AHCCCSA consider an LOI with no
negotiated fee schedule to have the same
weight as fully executed contract?
- ----------------------------------------------------------------------------------------------------------------------------------
193 94 Sect H The RFP addresses the situation when an If the Offeror's bid is above the top of the
offeror submits a capitation bid below the rate range, AHCCCSA may elect to initiate a
actuarial rate range, what will AHCCCSA do BFO process to guide the bidder into the
if the offeror's capitation bid is above the rate range, or may set the rate at some
actuarial rate range? Will AHCCCSA place the point below the mid point of the rate range.
offeror within the range and if so, at point The exact placement is confidential.
within the range?
- ----------------------------------------------------------------------------------------------------------------------------------
35
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
194 94 Sect H What are the maximum and minimum The scoring methodology for capitation bids is
number of points possible for the proprietary and confidential.
capitation bids by GSA and risk group?
If a bid is between the minimum and
maximum rate within the actuarial rate
range, will points be awarded on a
linear basis or some other method?
- ------------------------------------------------------------------------------------------------------------------------------------
195 97 Sect H Is AHCCCSA anticipating that No.
Offerors will submit policies with
their proposals? If yes, what policies
are to be submitted in Offerors'
proposals?
- ------------------------------------------------------------------------------------------------------------------------------------
196a 97 Sect H In responding to questions presented It is anticipated that the narrative will
in this section of the RFP, may fully address the submission requirement.
potential Offerors provide attachments Only specified attachments may be included
that further illustrate their per the submission instructions. The
narrative responses? Will such narrative may include a description of
attachments be counted toward (i.e. policies, handbooks, manuals, newsletters or
included as part of) the three (3) or other documents, but the documents should
five (5) page limit instructions? not be included in the submission unless
specifically requested.
- ------------------------------------------------------------------------------------------------------------------------------------
196b Sect H Please clarify the award of points for The first full paragraph on page 95 of the RFP
the extra credit submissions. which begins, "The Offeror may submit up to
three programs/initiatives, ..." should be
changed to read, "There are a specific number
of points available for each category. In order
to receive the full number of points available,
an initiative/program must be submitted for
each category. If multiple submissions in a
single category are received, they will be
considered one initiative/program. Offerors
should be aware that the points earned through
extra credit responses may be significant
enough to determine the outcome of contract
awards."
- ------------------------------------------------------------------------------------------------------------------------------------
197 98 Sect I May the bidders submit the provider Yes.
network on a CD as opposed to a 3.5"
floppy disk?
- ------------------------------------------------------------------------------------------------------------------------------------
198 98 Sect I What is the intent of "network Each hospital the bidder considers to be a part
hospital?" Does this include the of the network, whether there is a contract,
hospitals that are listed in LOI or not. Please note that in Maricopa and
Attachment B, or the hospitals for Pima Counties where the Pilot Program exists,
whom the contractor has obtained a Offerors are required to have contracts or
LOI? LOI's with hospitals.
- ------------------------------------------------------------------------------------------------------------------------------------
199 Sect I We have a group of physician's that The file to which you refer is not public and
we have gotten an LOI from and a will not be shared with potential contractors.
great number of them are not If for some reason the providers do not know
currently serving AHCCCS members, but their own AHCCS ID numbers, the submission may
we know it does not mean they don't be submitted with 0s filling the field for the
have an AHCCCS ID number. I know you AHCCCS ID number.
mentioned that the file is extremely
large, but is there a way we could
either get access to this file or
come to the bidder's library and look
these providers up?
- ------------------------------------------------------------------------------------------------------------------------------------
200 98 Sect I If the provider is currently contracted A contract covering the participation of a
with our long provider in the LTC
- ------------------------------------------------------------------------------------------------------------------------------------
36
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
term care program, is he considered a program solely does not constitute a contract
provider currently contracted for for the Acute Care program. The LOI should be
purposes of this database? If we have reflected in the submission.
both a contract for LTC and a LOI for
acute care, how do we indicate it?
- ------------------------------------------------------------------------------------------------------------------------------------
201 98 Sect I How would you like multiple addresses of AHCCCS has successfully entered multiple
providers entered in the database? If a entries with the same ID number and had them
provider has multiple service addresses accepted by Access 2000. Perhaps the Offeror is
how do you wish us to list them by line using the primary key on the ID number. If this
item - the Access 2000 database will not is the problem, removal should allow
accept multiple entries of the same ID acceptance. Or they may be indexing and set
number, and we would need to modify the their index to not accept duplicates.
number somehow.
- ------------------------------------------------------------------------------------------------------------------------------------
202 98 Sect I Question 1 Should a printed copy of the Provider It is not necessary to submit a printed copy.
Network File be submitted with the 3.5' The file may be submitted on a CD. Three copies
disk? Due to size of the file can the of the disk (CD) should be submitted. Sorting
Provider network File be submitted on of the data will be done after receipt of the
CD? How many copies of the disk (or CD) file by AHCCCS.
should be submitted with the response?
Should the Provider Network File be
sorted by GSA and Provider Type? Please
Clarify.
- ------------------------------------------------------------------------------------------------------------------------------------
203 98 Sect I Question 2 What format is required for the This information should be submitted on hard
contracted physicians who have admitting copy. There is no page limit. Please sort by
privileges to the network hospitals? Is hospital with provider ID and name.
the response limited to three pages? Are
there preferred column formats and/or
length limit on data fields?
- ------------------------------------------------------------------------------------------------------------------------------------
204 98 Sect I Question 3 Is the response limited to three pages? No.
- ------------------------------------------------------------------------------------------------------------------------------------
205 98 Sect I If the Plan does a group contract, do No. Proof of authority of signatory must be
you need to have a letter of Intent for available if requested.
each provider/location for a group
practice?
- ------------------------------------------------------------------------------------------------------------------------------------
206 98 Sect I If the Plan has evergreen contracts with No.
an existing provider in a GSA they
already occupy, do you have to have a
Letter of Intent for those providers?
- ------------------------------------------------------------------------------------------------------------------------------------
207 98 Sect I If the Plan currently contracts with a There must be a contract or LOI that covers the
provider in a specific county in which pertinent GSA and time period.
the Plan currently has membership and
that provider also services other
counties, does the Plan need a LOI for
counties in which the Plan is bidding
but does not currently have membership?
Or is the current contract for the
county sufficient?
- ------------------------------------------------------------------------------------------------------------------------------------
37
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
208 98 Sect I Can potential Offerors submit their Yes.
responses to this question on a CD-ROM
instead of floppy disks?
- ------------------------------------------------------------------------------------------------------------------------------------
209 98I Sect I In the first Q & A, AHCCCS indicated No.
that for each network hospital, we
should provide a list of contracted
physicians who have admitting privileges
to that facility on hard copy, sorted by
hospital with provider ID and name. Does
AHCCCS require any additional information
such as the provider's specialty or
address, etc.?
- ------------------------------------------------------------------------------------------------------------------------------------
210 98- Sect I 2,3,4,8, For each of the four requirements, should The Agency is interested in a response that
99I the response only pertain to the current includes submissions describing the GSAs for
GSAs in which the health plan operates or which the Offeror is bidding, GSAs in which the
should the response also include Offeror is an incumbent and those in which they
the potential GSAs on which the health are a new bidder.
plan will be bidding?
- ------------------------------------------------------------------------------------------------------------------------------------
211 99 Sect I When will the rates being calculated by AHCCCSA anticipates that the capitation rates
AHCCCS for PPC, HIV, T19, and HIFA be in question will be available April 1,
available? Are the bidders to include 2003. Because the PPC and TWG rates are
these rates in the projections they reconciled, the Offeror should estimate what
prepare or should they be carved out? their profitability will be for the TWG and PPC
experience and build that into their financial
projections. For the HIFA parents, assume a
rate that is 10% greater than the applicable
TANF rates.
- ------------------------------------------------------------------------------------------------------------------------------------
212 100 Sect I How can AHCCCSA deem that the rate AHCCCSA will adjust the capitation rates after
proposal includes the cost of the pending items are resolved, if necessary.
administrative adjustments required Contractor feedback will be solicited.
during the term of the contract when of
the financial impact of several major
issues is unknown and contingent on
pending legislation? Is AHCCCSA prepared
to adjust capitation rates and or the
administrative component due the
resolution of pending legislation?
- ------------------------------------------------------------------------------------------------------------------------------------
213 100 Sect I Capitation "The offeror's rate proposal will be Examples of administrative adjustments include
Last deemed by AHCCCSA to include the costs BBA costs, HIPAA costs, member ID card costs,
paragraph of administrative adjustments required and the impact to administrative costs due to
on page during the term of this contract. the carve out of pharmacy (pharmacy bid only).
100
Please define what is meant by
"administrative adjustments."
- ------------------------------------------------------------------------------------------------------------------------------------
214 101 Sect I What does benchmarking Family Planning The submission requirement regarding Family
Services mean? Planning has been modified. Benchmarking is
deleted as a submission requirement.
- ------------------------------------------------------------------------------------------------------------------------------------
215 101 Sect I Will AHCCCS have goals and benchmarks None are planned at this time.
set as in the performance standards as
relates to Family
- ------------------------------------------------------------------------------------------------------------------------------------
38
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
Planning services?
- ------------------------------------------------------------------------------------------------------------------------------------
216 101 Sect I Please define "other hard to reach The health plan should define this based upon
populations." the geographic areas served.
- ------------------------------------------------------------------------------------------------------------------------------------
217 101 Sect I What is meant by, "Comprehensive Case Comprehensive Case Management is the process
Management"? What benchmarks are used of identifying members who require special
for case manager to member ratios for assistance in accessing health care
the health plan? services, evaluating their needs, and
assisting the member in meeting those needs.
Not all members with Special Health Care
Needs require case management, and not all
members who would benefit from Case
Management are members with Special Health
Care Needs. There are no AHCCCS defined case
manager to member ratio in the Acute Care
Program.
- ------------------------------------------------------------------------------------------------------------------------------------
218 102 Sect I How far back should I go to indicate an Please use the last complete contract year.
average speed for resolution? (the last
quarter, last contract year, calendar
year)
- ------------------------------------------------------------------------------------------------------------------------------------
219 103 Sect I In the first Q&A, AHCCCS responded in Page 1 of the Solicitation Amendment states,
question #199 that this bid submission "This solicitation is amended as follows:
requirement had been eliminated. However, 1. Finalized version of the Questions and
this was not listed as eliminated in Answers distributed at the Bidder's Conference
solicitation Amendment 2 (unless AHCCCS on February 21, 2003..." As stated in the
considers inclusion of the question and answer to Question 199, the requirement has
related answer). Please clarify whether been eliminated. This information will not be
this has been eliminated or not, and if repeated in another amendment.
it has, whether the health plan can
expect to see it specifically identified
on a subsequent amendment.
- ------------------------------------------------------------------------------------------------------------------------------------
220 103 Sect I Grievance This item asks for both a flowchart and The narrative should be three pages; the flow
and Appeals a written description of the grievance chart should not be included in the 3 page
and appeals process. Due to the many limit.
contingencies of the grievance and
appeal process, may responses include
the requested flowchart as an attachment
to the three-page response? Or is the
flowchart to be included within the
three-page response?
- ------------------------------------------------------------------------------------------------------------------------------------
221 103 Sect I Question 36 Requests a description of the grievance No. With the new Balanced Budget Act
and appeal process, including "both the regulations, there is no mandated informal
informal and formal processes."--is process. We are amending the submission
there a mandated informal process and if requirement to: Provide a flow chart and
so what are the parameters given the written description of the grievance and
administrative code and the process set appeals processes; include general timeframes.
forth in Attachment H? Identify the staff that will be involved at
each phase and provide their qualifications.
(Limit 3 pages plus a flowchart)
- ------------------------------------------------------------------------------------------------------------------------------------
222 103 Sect I Is this "informal" process the expedited Please refer to the answer in question # 221.
appeal process in response to the Notice
of Action described in Attachment H, or
some part of that process?
- ------------------------------------------------------------------------------------------------------------------------------------
223 103 Sect I Question 40. How must this requirement be met for a A new Offeror, currently acting as an MCO, must
new submit their
- ------------------------------------------------------------------------------------------------------------------------------------
39
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
offeror? As a current LTC PC, must we claims aging for the current line of business
submit claims aging data from our LTC used throughout the submission.
program?
- ------------------------------------------------------------------------------------------------------------------------------------
224 103 Sect I Question 40 What format is required for the claims This bid submission requirement is eliminated.
aging report - detail or summary?
- ------------------------------------------------------------------------------------------------------------------------------------
225 103 Sect I In response to first-round question 199, The answers to the questions in Amendment #2
AHCCCS stated that the bid requirement to were incorporated by reference into the RFP.
submit claims aging reports was The submission requirement is eliminated.
eliminated (i.e., RFP Question 40).
However, Solicitation Amendment #2 did
not amend the RFP to reflect this change.
Please confirm that Question 40 has been
eliminated and that the Bidder is not
expected to respond to this question.
- ------------------------------------------------------------------------------------------------------------------------------------
226 103 Sect I What format is required for the claims This submission has been eliminated for all
aging report-detail or summary? This bid Offerors.
submission requirement is eliminated.
Is this bid requirement eliminated for
only New Offeror's or has it been
eliminated for all Offeror's?
- ------------------------------------------------------------------------------------------------------------------------------------
227 104 Sect I The health plan compiles quarterly Yes. Please provide the Balance Sheet and
financial information for AHCCCS. Will Income Statement, and notes to financial
a copy of the quarterly financial statements.
statements submitted to AHCCCS meet this
requirement? If yes, which schedules
should be submitted? If no, please
provide more details as to what specific
financial schedules are required.
- ------------------------------------------------------------------------------------------------------------------------------------
228 104 Sect I In answering the questions in Section I Only submit financial statements assuming the
of the bid, specifically financial prescription drug benefit remains the
forecasts (items #48) and financial responsibility of the Contractor.
viability calculations (item #49), how
should the offeror incorporate the fact AHCCCSA anticipates that the capitation rates
that; capitation rates have to be in question will be available April 1, 2003.
submitted with and without (carved out) Because the PPC and TWG rates are reconciled,
the pharmacy component, and capitation the Offeror should estimate what their
rates for several risk groups are profitability will be for the TWG and PPC
unknown and will be set by AHCCCSA? These experience and build that into their financial
items will have a direct impact on an projections. For the HIFA parents, assume a
offeror's forecasted financial results. rate that is 10% greater than the applicable
TANF rates.
- ------------------------------------------------------------------------------------------------------------------------------------
229 104 Sect I Question 52 Can programs initiated prior to 10/1/2003 Yes, programs initiated and expected to
be used for extra credit? Is the total continue in the new contract period may be
page limit for the response 9 pages submitted for extra credit. The total page
(limit of three programs/initiatives/ limit is 9 pages, a limit of 3 per program/
limit of three pages each) plus the initiative. The timelines are in addition to
timeline for each program/initiative? the 9 pages.
Please clarify.
- ------------------------------------------------------------------------------------------------------------------------------------
40
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
230 104 Sect I The RFP calls for financial forecasts in No--just the Balance Sheet and Income Statement
"at least the level of detail specified and notes to the financial statements. This
for annual audited financial statements". information should be statewide rather than by
Does this mean that we need to submit the county or GSA.
income statement at the risk code
category level as well as a combined
income statement for the entire county?
- ------------------------------------------------------------------------------------------------------------------------------------
231 104 Sect I We are preparing two sets of capitation No--just one assuming that the prescription
rates, one with and one without drug benefit remains the responsibility of the
prescriptions. Do we need to prepare two Contractors.
sets of financial projections also?
- ------------------------------------------------------------------------------------------------------------------------------------
232 104 Sect I Will AHCCCS determine which set of The Offeror should use the capitation rates
capitation rates we should use in our that assume prescription drug will continue to
projections? be the responsibility of the health plans in
their projections.
- ------------------------------------------------------------------------------------------------------------------------------------
233 104 Sect I Who is considered to be within The entities mentioned could be considered a
"community involvement"? Members, part of the community, but community is not
Agencies, Community Providers, Hospitals, limited to these entities.
etc.
- ------------------------------------------------------------------------------------------------------------------------------------
234 104 Sect I Please clarify whether the entire Please refer to the answer to question #229.
response to this section is three (3)
pages maximum or three (3) pages maximum
per each initiative selected?
- ------------------------------------------------------------------------------------------------------------------------------------
235 105 Sect I What would cause AHCCCSA to not have a BFOs can be time consuming and resource
Best and Final Offer (BFO) process? intensive for both the state, as well as the
bidders. If the initial bids for a given GSA
fall generally within the established rate
ranges, the state has reserved the right to
finish scoring the proposals and to make
tentative awards. Rate offers to the successful
bidders would then be made to the extent
necessary to ensure all rates fall within the
established rate ranges.
- ------------------------------------------------------------------------------------------------------------------------------------
236 106 Sect I Capitation Rates Offered after BFOs - Yes.
Please further clarify the following, "At
this point, should the Offeror have a
rate code(s) without an accepted
capitation rate, AHCCCSA shall offer a
capitation rate to the Offeror. Note that
all rates offered in this manner shall
be identical for all Offerors in the same
GSA and rate code." Please further
clarify the meaning of "all Offerors"
in this context. Is this only to be
applied to those Offerors not having
acceptable rates?
- ------------------------------------------------------------------------------------------------------------------------------------
237 107 Sect I In the RFP amendments about Pima/Santa The Offeror must submit a bid for the entire
Cruz, 5 contracts will be awarded in GSA. Capitation scoring will be based upon the
Pima but only 2 will blended capitation rate. After all
- ------------------------------------------------------------------------------------------------------------------------------------
41
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
get Santa Cruz County. When bidding in RFP scoring is completed, the two bidders with
Santa Cruz Co., should we bid as blended the highest overall scores will receive an
rates or separate per county? award for both Pima and Santa Cruz counties.
The next highest scorers will receive an
award in Pima County only. The Pima County
only Contractors will be offered a rate that
is their bidded rate for both counties as
adjusted based upon a percentage difference
between the risk of the two counties
combined and Pima County only as determined
by Mercer. If the Pima County awardee does
not accept the offered rate, then the next
highest scorer will be offered a rate until
all available Contractor slots are awarded.
- ------------------------------------------------------------------------------------------------------------------------------------
238 109 Sect I Will all Bidders Library items be posted It is AHCCCSA's intention to have virtually all
on AHCCCSA's web site? If not, how will bidders' items posted on the web site.
potential Offerors be notified that new Potential Offerors should review the web site
materials are available in the Bidders on a regular basis to receive updates.
Library?
- ------------------------------------------------------------------------------------------------------------------------------------
239 115 + Attach Geographic As part of the Minimum Network If a contractor can demonstrate to AHCCCS that
B Service Area- Requirements for a particular GSA, a there is only one provider who would meet the
Minimum specialty OB provider is required in a minimum standard, and that provider cannot be
Network specific municipality. If the health plan credentialed by the contractor due to quality
Requirements has specific and direct knowledge that issues, AHCCCS will not require the contractor
the only provider in this municipality to contract with the provider. A contractor in
providing specialty OB services has this situation would be considered in
serious quality issues, does AHCCCS compliance with the minimum network standard.
expect the health plan to contract with
this provider? If no, will the health
plan be considered out of compliance with
the Minimum Network Requirements?
- ------------------------------------------------------------------------------------------------------------------------------------
240 115 Attach Minimum If an Offeror attempts to contract with a If the Contractor can show a good faith effort,
ment B: Network Provider (particularly a hospital in an the Agency will consider waiving the
Standards urban GSA) and the provider is unwilling contracting requirement. Yes per state statute,
to contract with the Offeror even at the health plans default to the AHCCCS tier per
AHCCCS FFS rates (Pilot I/P rates in this diems if they do not have a contract with a
case) and the Offeror can demonstrate it hospital for different reimbursement.
tried to contract in good faith, would
AHCCCS consider the Provider (facility)
as a contracted facility for purposes of
meeting the minimum network requirements?
Is there not, already a contract between
the Health Plan (through AHCCCS) and the
Provider (I/P facility) that if an
AHCCCCS member presents at the Providers
facility, the Provider must treat the
member and accept the AHCCCS FFS rate
(Pilot I/P rates) as full reimbursement
if no other arrangements exist between
the Provider and the Health Plan?
- ------------------------------------------------------------------------------------------------------------------------------------
42
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
241 115 Attach In terms of assessing and evaluating a This information is not being shared with
B health plan's network of providers, are bidders.
PCPs, dentists, pharmacies, hospitals
and specialty care providers all assessed
equally? If not, how are they assessed
or evaluated in the scoring process? How
are ancillary providers assessed or
evaluated in the scoring process?
- ------------------------------------------------------------------------------------------------------------------------------------
242 Attach Please clarify this statement - "if Contracted providers able to deliver these
B outpatient specialty services (OB, family specialty services, should be available in the
planning, internal medicine and service sites specified. If the services are
pediatrics) are not included in the not available, this information should be
primary care provider contract, at included in the Network Development and
least one subcontract is required for Management plan, along with the steps to be
each of these specialties in the service taken to provide the services to members.
sites specified."
- ------------------------------------------------------------------------------------------------------------------------------------
243 115 Attach Instructions May a prospective bidder include in their We do not believe that a provider is a member
B floppy disk containing their provider of an Offeror's network, when they are unaware
network, an existing network developed of this fact. In order for a contract to be
for a line of business other than AHCCCS? considered for a submitted provider it must
Would the prospective bidder be required contain all required components.
to notify the providers that make up that
network of the intent to include them in
their proposal to meet the minimum
network standards for that GSA? If so, if
they're current contracts do not contain
the AHCCCSA minimum subcontract provisions
can they be considered "contracted" for
the AHCCCS line of business?
- ------------------------------------------------------------------------------------------------------------------------------------
244 119 Attach Will AHCCCSA waive pharmacy minimum Please be aware that a slash mark (/) between
120 B network standard requirements for the two geographic service sites, indicates that
124 following communities that currently do the service must be available in at least one
not have a pharmacy: Ash Fork (GSA 4), of the sites. The GSA 2 service site list for
Carefree (GSA 12), Seligman (GSA 4) and pharmacies should read San Luis/Somerton. With
San Luis (GSA 2)? this correction there are pharmacies in these
sites.
- ------------------------------------------------------------------------------------------------------------------------------------
245 125 Attach Map For GSA 14, the map indicates that PCP, Please refer to the answer to question #244.
B Dentists and Pharmacies are a minimum
requirement for both Morenci and Clifton.
However, the list on the left side of
the page indicates that Morenci and
Clifton are together. Are Clifton and
Morenci considered one in the same for
this requirement, or do you need these
services in both cities?
- ------------------------------------------------------------------------------------------------------------------------------------
246 Attach Page 49 states, "all counties except It is required that the Offeror have either
B Maricopa and Pima contractor is contracts or LOIs with physicians with
encouraged to obtain admitting privileges to hospitals in the
Offerors
- ------------------------------------------------------------------------------------------------------------------------------------
43
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
subcontracts with hospital" network. Offerors are encouraged to contract
and Attachment B lists with hospitals.
hospitals a minimum network requirement
in all counties. Is it required or
encourages to obtain and LOI in counties
other than Maricopa and Pima in order to
meet minimum network requirements?
- ------------------------------------------------------------------------------------------------------------------------------------
247 126 Attach Instructions Could AHCCCSA further define or add A Management Services Subcontractor is defined
C additional clarity to what it considers in the opening paragraph of Attachment C. For
"any administrative function or service purposes of responding to the RFP, the
for the Contractor" as it relates to the subcontractor is an individual or firm who is
term "Management Services Subcontractor"? responsible for day today operations of the
For example, would our PBM and GACCP health plan.
(Credentialing Primary Source
Verification) be considered Management
Services Subcontractors?
- ------------------------------------------------------------------------------------------------------------------------------------
248 126 Attach Instructions Page 126, Attachment C, Management For purposes of Attachment C, the opening
C Services Subcontractor Statements. Based definition is applicable. Therefore, data
upon the answers to the Bidders' questions information systems, PBM, etc. are not
released at the Bidders' Conference and included. However, clarification for which sub
the feedback from the past two years' contractors require and audit submission will
Operational and Financial Reviews, there be clarified in the revised acute care
seems to be conflicting definitions and reporting guide.
interpretations around management services
subcontractors. Based on OFR feedback, we
believe that subcontractors for services
such as data information systems, pharmacy
benefit managers (PBM), management
services and any other organization to
which day-to-day operations are delegated
(such as recoveries and clinical
evaluations) are required to complete a
management services subcontractor
statement. Please clarify.
- ------------------------------------------------------------------------------------------------------------------------------------
249 126 Attach Attachment C is not included on the Yes.
C Offeror's Checklist. For submission
purposes, should Attachment C be
submitted following completion of
Section G in General Matters?
- ------------------------------------------------------------------------------------------------------------------------------------
250 126 Attach Please provide additional examples of what See answer to #247 above.
C Constitutes a "Management Services
Subcontractor".
- ------------------------------------------------------------------------------------------------------------------------------------
251 126 Attach Please identify whether the following None of these listed meet the requirement.
C meets the requirement for a management
services subcontract:
- ------------------------------------------------------------------------------------------------------------------------------------
44
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
1. Organization which coordinates
purchasing of health insurance for
health plan employees
2. Organization which coordinates
purchasing of other insurance (such
as liability) for the health plan
3. organization which manages the
health plan's data center
operations but does not have
decision making authority in areas
such as methodology for claims
processing, authorization
processing, etc.; it would,
however, be involved in implementing
changes to the health plan's
information systems based on
direction by health plan employees
4. provides legal services to the
health plan
5. acts as the Human Resources/Payroll
department for the health plan to
assist with hiring, addressing
employee questions regarding
benefits, processing payroll, etc.
Would any of the answers to the above be
different if the services were provided
by a related party? If yes, which ones
and why?
- ------------------------------------------------------------------------------------------------------------------------------------
252 126 Attach Most of the current AHCCCS plans are These would not qualify.
C owned by larger organizations which
provide some administrative services to
the health plans, but are not actively
involved in the normal operations of
the plan. In this case, would a management
services subcontract be required between
the health plan and its parent company?
- ------------------------------------------------------------------------------------------------------------------------------------
253 126 Attach Does AHCCCS consider a Pharmacy Benefit No.
C Manager contract, which has as one of the
contractual responsibilities, the
processing of retail pharmacy claims, a
Management Service Subcontractor?
- ------------------------------------------------------------------------------------------------------------------------------------
254 126 Attach Does a specialty provider delegated for More information is needed.
C limited prior auth, i.e. approvals only,
qualify as a management services
contract?
- ------------------------------------------------------------------------------------------------------------------------------------
255 126 Attach Is Medifax EDI considered a Management No.
- ------------------------------------------------------------------------------------------------------------------------------------
45
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
C Services Subcontractor? They provide
electronic claims clearinghouse and
member eligibility verification services.
- ------------------------------------------------------------------------------------------------------------------------------------
256 126 Attach Please clarify that Data Information They are excluded.
C Systems are excluded from the Attachment
C Statement requirements.
- ------------------------------------------------------------------------------------------------------------------------------------
257 126 Attach Management Services Subcontractor Any organization that is hired by a parent
C Statement - Please clarify which company to run the operations of the health
subcontractors AHCCCSA anticipates to be plan. A subcontractor that provides all of the
included with an Offeror's proposal? operations of a medical service, i.e. family
planning services.
- ------------------------------------------------------------------------------------------------------------------------------------
258 127 Attach Management Services Subcontractor No.
C Statement-- Is this required on an LOI
provider?
- ------------------------------------------------------------------------------------------------------------------------------------
259 129 Attach Will a copy of the organization's most The two most recent audited financial
C recent Form 10-K be acceptable in lieu statements must be included. If the 2002 has
of a copy of the audited financial not been completed, then please submit the most
statements? recent 10-K for 2002.
- ------------------------------------------------------------------------------------------------------------------------------------
260 132 Attach In a group practice - does each Please refer to the answer to question # 205.
D(1) physician need a separate LOI or can a
group administrator sign for all
physicians within group?
- ------------------------------------------------------------------------------------------------------------------------------------
261a 138 Attach If a provider is in the process of The provider ID field should be filled with
D(2) obtaining an AHCCCS ID number, how should zeros.
they be reported on the LOI file?
- ------------------------------------------------------------------------------------------------------------------------------------
261b 138 Attach Page 138, Attachment D(2), Service Q1. The plan should give AHCCCS the hyphenated
D(2) Provider Name - If an individual provider name without spaces (Smith-Jones).
has a last name which is hyphenated, how Q2. For this submission, it is not necessary to
should the name be listed? Example: match the name with the AHCCCS Provider File.
Smith-Jones/John A. (hyphen without However, the health plan may do so if they
spaces); Smith - Jones/John A. (hyphen wish.
with spaces); SmithJones/John A. (without
hyphen or spaces). Please clarify.
Page 138, Attachment D(2), Service
Provider Name - Should the Plan try to
match first names to the AHCCCS Provider
File registered name even though the
provider may utilize a different name?
Example: AHCCCS Provider File list the
provider's name as Charles G. Jones; the
physician actually goes by his middle
name and APIPA has him registered as C.
George Jones, or should the name be
listed as Charles George
- ------------------------------------------------------------------------------------------------------------------------------------
46
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
Jones? Please clarify.
- ------------------------------------------------------------------------------------------------------------------------------------
262 145 - The Specialty Code Table seems to be The field should be populated with 99.
147 missing many of the Provider Specialty
values that appear in the PMMIS Menu,
Screen RF613. If we use a code that
does not appear in the Provider Specialty
Table on pages 145 - 147, do we use the
codes in the PMMIS Menu, Screen RF613?
Or, do we populate the Provider Specialty
fields with 999?
- ------------------------------------------------------------------------------------------------------------------------------------
263 136 Attach N/A Page 136 asks the offer to submit the Please refer to the answer to question 262.
and E entire provider network. If the provider
144 network contains provider type codes
which are valid in the state PMMIS
system, but are not included on the
provider type codes listed on page 144,
should the providers be reported as 99
"Other" or should the table include
all AHCCCS valid provider types?
- ------------------------------------------------------------------------------------------------------------------------------------
264 136 Attach N/A Page 136 asks the offer to submit the Please refer to the answer to question 262.
and E entire provider network. If the provider
145- network contains specialty codes which
147 are valid in the state PMMIS system, but
are not included on the specialty codes
table listed on pages 145 - 147, should
the specialists be reported as 999
"Other" or should the table include all
AHCCCS valid specialty codes?
- ------------------------------------------------------------------------------------------------------------------------------------
265 150 Attach For Pima and Santa Cruz - in that not all The Offeror must submit a bid for the entire
E contractors who receive an award for the GSA. Capitation scoring will be based upon the
GSA will be active in Santa Cruz County, blended capitation rate. After all RFP
should the rates be bid as a blended rate scoring is completed, the two bidders with the
or as stand-alone rates for each county? highest overall scores will receive an award
for both Pima and Santa Cruz counties. The next
highest scorers will receive an award in Pima
County only. The Pima County only Contractors
will be offered a rate that is their bidded
rate for both counties as adjusted based upon a
percentage difference between the risk of the
two counties combined and Pima County only as
determined by Mercer. If the Pima County
awardee does not accept the offered rate, then
the next highest scorer will be offered a rate
until all available Contractor slots are
awarded.
- ------------------------------------------------------------------------------------------------------------------------------------
266 150 Attach Is AHCCCS providing any alternatives to OMC has received many assurances from ISD that
the Web the web traffic
- ------------------------------------------------------------------------------------------------------------------------------------
47
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
E Based Capitation Rate Proposal should the will not prevent bidders from completing their
web site being down? What assurances is bids via the web application. Offerer's are
AHCCCS providing that its web site will required to submit a hard copy of their bids
be up and accessible and that the that will be used as back up should the web
response time will not be compromised application fail.
when a significant number of Contractors
might be attempting to access it at the
same time?
- ------------------------------------------------------------------------------------------------------------------------------------
267 150 Attach What will be the recourse for material Material errors and omissions would be
E errors and omissions in the development disclosed and corrected. To the extent rate
of rate ranges by AHCCCSA? Errors or ranges were modified, awarded rates would be
omissions may be identified by the health adjusted by the same percentage(s). Beyond
plans, AHCCCSA or AHCCCSA's actuary. that, it would depend on the nature of CMS'
Furthermore, what is the recourse if the concerns. As long as the covered services and
development of the rate ranges does not populations in the contracts have not changed,
meet with CMS' approval subsequent or the rates would probably stand. The bidder's
concurrently to the bid process? actuary would have already certified that the
rates were actuarially sound for the bidder,
and AHCCCS' actuaries will have done the same
for the rate ranges. Issues related to federal
match or CMS requirements for documentation
should not affect the acute care contracts.
- ------------------------------------------------------------------------------------------------------------------------------------
268 150 Attach Please explain AHCCCSA's decision to not Refer to question 1. The rate setting
E use a diagnostic-based risk adjuster, methodology is in compliance with CMS
given that CMS lists it as a requirement regulations.
to actuarially sound rates, and explain
why it is not applicable if omitted.
- ------------------------------------------------------------------------------------------------------------------------------------
269 150 Attach Please explain the methodology that will a. The state's reimbursement schedules,
E be used to develop the upper and lower and the health plan paid amounts.
bounds of the capitation rate ranges. b. The inpatient component of the
- a. What fee schedule assumptions capitation rate is based upon cost and
will be used to price encounter data utilization information from health plan
for the upper and lower bounds of the reported encounters and financials. AHCCCS
rate range? will inflate the component by the
- b. What percentage of the Medicaid inflation used for the tier per diems for
Fee schedule will be used for inpatient 10/1/03.
given that AHCCCSA states that the c. The PMPM assumptions will closely match
average reimbursement is 97% in their the blended experience of the current
most recently submitted budget to the contractors, adjusted for trends and
JLBC? changes in approved drugs.
- c. What are the assumptions related d. Rate ranges will be established for 3
to the average dispensing fees, AWP, different zones, or groupings of counties,
and rebate assumptions for retail based on the encounters priced out by the
pharmacy? health plan paid amounts. This should
- d. What percentage of the fee reflect health plans' contracting issues
schedule will be assumed in rural as closely as possible. This pricing of
counties where contracting requires encounters by health plan paid amounts has
payments that exceed the AHCCCSA fee been cross- walked against their audited
schedules? financial experience for 3 years.
- e. How will outpatient encounters e. For clarification, health plans are not
be priced required to contract at a percentage of
billed charges. Health plan paid amount
is used for pricing.
- ------------------------------------------------------------------------------------------------------------------------------------
48
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
given that plans must contract at a f. As discussed in the data supplement,
percentage of billed charges at subcapitated encounters, if no value is
multiple facilities? assigned by the health plan, will be
- f. What assumptions were made for priced at the AHCCCS FFS schedule.
pricing encounters for typically g. The Offerors should bid what they
sub-capitated costs such as PCP, expect their administration component to
laboratory and DME, regarding under be.
-submission of encounter data by the h. !0/1/99-3/31/02
providers?
- g. What administrative component
will be priced into the upper and
lower bound of the rate range?
- h. What time periods are the State's
actuary using as their base rate
assumptions? What time period(s) will
AHCCCSA use as its base for developing
the rate ranges? If this varies by GSA
or rate cell, please provide to
potential Offerors.
- ------------------------------------------------------------------------------------------------------------------------------------
270 150 Attach Will AHCCCSA share its trend assumptions Trends assumptions used to develop the State
E with Offerors? How do the 5% trend Legislative budget were their own best
assumptions in the State Legislative estimates. AHCCCSA's actuaries will make their
budget for the AHCCCS program relate own trend estimates.
to this process?
- ------------------------------------------------------------------------------------------------------------------------------------
271 150 Attach When will AHCCCSA make available Information is provided in Section B of the
E information regarding program changes? data supplement. Potential contractors will be
made aware of any additional program changes,
as they become available.
- ------------------------------------------------------------------------------------------------------------------------------------
272 150 Attach How will financial data be used given Financial statements are revised and
E changes in reserves for other prior restated for adjustments, and are audited
period adjustments that skew actual on a periodic basis. Financials represent
results? For instance, if a health plan one supplemental data source used in the
releases reserves or recognizes revenue development of actuarially sound rates.
from older periods, the health plan's These revised financial statements are not
experience will look more favorable than provided in the data supplement.
their "run rate" for that period.
- ------------------------------------------------------------------------------------------------------------------------------------
273 150 Attach If the Legislature eliminates eligibility Any material change within a rate cell, such
E groups (e.g., KidsCare, HIFA parents), as the elimination of one subset of a category
will AHCCCSA adjust the capitation rates, of aid will be adjusted for in the capitation
given that the prospective bidders are rates.
bidding rates assuming continued coverage
of all groups? And if so, how will the The Offeror should assume that all current
adjustment be made? If adjustments are eligibility groups will continue to exist
made in the rates, how will this impact in CYE '04.
the algorithm?
- ------------------------------------------------------------------------------------------------------------------------------------
274 151 Attach Since the Web application for submitting Yes. A presentation of the web site will be
E capitation rates has not been issued yet, forthcoming at the bidder's conference.
will offerors have the opportunity to
formally ask questions and receive A second set of technical questions will be
responses after the February 14, 2003 issued by AHCCCSA by due March 7, 2003.
deadline to submit questions?
- ------------------------------------------------------------------------------------------------------------------------------------
49
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
275 153 Attach Please describe what the health plans Contractor submitted pharmacy encounters are
F will be required to report on the newly still the "official" documentation for AHCCCS.
required "Prescription Drug Utilization However, contractors will be asked to provide
Report"? standard monthly production reports of
aggregate pharmacy cost and utilization data
in a mutually agreeable format
- ------------------------------------------------------------------------------------------------------------------------------------
276 84-92 Attach Are any of these forms available for Electronic version of section G has been
G electronic fillin? Or are we to print out placed on the web page.
the PDF version and fill in by hand?
AHCCCS Website
- ------------------------------------------------------------------------------------------------------------------------------------
277 157 Attach. In you previous response to question 250 Yes, prevalent refers to the 5%/ 1000 standard
H (1) regarding LEP, is your intent with the for purposes of vital documents, and there is
use of the word prevalent to mean 1,000 no requirement to provide written translation
or 5% as per RFP? If the health plan to a member who speaks a language not meeting
becomes aware of 1 member LEP, is the the 5%/1000. However, the BBA requires the MCO
health plan required to translate all to provide oral translations of any
member information to that non-prevalent language-regardless of whether prevalent or not
LEP, i.e. Farsi? when requested by a member.
- ------------------------------------------------------------------------------------------------------------------------------------
278 Page Attach. When asked for clarification of See answer to question #305.
157, H (1) definitions, the offerors are told to
100, refer to the CFR 438 subpart F for
102 definitions. However, AHCCCS continues to
use the term complaint in requirements
13 and 28, yet refers to CFR 438. CFR
438 does not recognize the term
"complaint". Are we to assume that AHCCCS
is talking about "grievances" and the
term complaint will be eliminated?
- ------------------------------------------------------------------------------------------------------------------------------------
279 157 Attach Is the "Notice of Action" considered the 42 CFR 438.404 delineates Notice of Action
H same as an initial organization requirements. State statute ARS Section
determination? Also, normally, a member 36-2903.01 specifies a 60-day timeframe for
has 60 days following an adverse action filing non claim related grievances. However,
to file an appeal. The timeframe listed the BBA provisions have will have a major
in this section of the RFP is different. impact on the existing AHCCCS/Contractor
Has this timeframe changed and, if so, grievance process. These changes shall be
when? communicated through regulation and/or formal
policy.
- ------------------------------------------------------------------------------------------------------------------------------------
280 157 Attach It refers to the Notice of Action and the The BBA regulations require that notice be
H situations in which that must be given enrollees for denial of payment, in whole
generated, including notice to members or in part. Expedited resolution of an appeal
when a claim is denied--does this applies to situations when taking the time for
mandate and EOB to be sent to a standard resolution could seriously jeopardize
member? If it does, can the member ask the enrollee's life or health or ability to
for an expedited appeal in that attain, maintain, or regain maximum function.
situation? It does not appear that appeals of this nature
would satisfy the criteria for expedited
resolution. Moreover, it is anticipated that
most of these appeals will be withdrawn once
the MCO explains to the enrollee, as part of
its resolution process, that the enrollee will
- ------------------------------------------------------------------------------------------------------------------------------------
50
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
not be not financially responsible for payment.
- ------------------------------------------------------------------------------------------------------------------------------------
281 157 Attach It refers to a "standard appeal"--what is 42 CFR 438.408 delineates requirements for
H this? A non-expedited appeal as described standard and expedited resolution of appeals.
in previous paragraphs? A grievance as The existing AHCCCS/Contractor grievance
set forth in the current administrative process will be amended to ensure compliance
code? If it is the latter, are the with the BBA provisions. These changes will be
timeframes for response changed from 30 communicated through regulation, contract,
days to 45 days with extension of 2 weeks and/or formal policy.
without member agreement, but only notice?
- ------------------------------------------------------------------------------------------------------------------------------------
282 157 Attach Are there member grievances as previously Attachments H(1) and H(2) have been written to
H provided for in the administrative code? incorporate all required changes due to the
If so, under what circumstances, and what BBA. This attachment prevails over rule and
rules, etc applies? statute effective October 1, 2003.
- ------------------------------------------------------------------------------------------------------------------------------------
283 157 Attach Is the process of requesting a "fair Attachments H(1) and H(2) have been written to
H hearing" the same as the current process incorporate all required changes due to the
of appealing a decision from a member BBA. This attachment prevails over rule and
grievance? Does this still exist in its statute effective October 1, 2003.
current form, and if so, under what
circumstances?
- ------------------------------------------------------------------------------------------------------------------------------------
284 157 Attach Can a member appeal from the process set As in the current scheme, a member may file a
H forth in Attachment H (either standard or Petition for Judicial Review in Superior Court.
expedited), beyond the fair hearing
process or is that the full and final
process?
- ------------------------------------------------------------------------------------------------------------------------------------
285 157 Attach Attachment H provides that the enrollee The 20/90 day requirement for appealing a
H is to be given no less than 20 days and Contractor Notice of Action is delineated in
no more than 90 days from date of Notice 42 CFR 438.402 and applies to both expedited
of Action to file an appeal--does this and standard appeals.
apply to expedited grievances (appeals)
under Article 13 or to "standard"
grievance which currently have 60 days
limit?
- ------------------------------------------------------------------------------------------------------------------------------------
286 157 Attach Entire This section uses the terms grievance, Attachments H(1) and H(2) have been written to
H Attachment H appeal, expedited appeal, State fair incorporate all required changes due to the
(1) (1) hearing and expedited hearing. BBA. This attachment prevails over rule and
Contractors currently utilize the AHCCCSA statute effective October 1, 2003. The BBA
definitions of the terms grievance and has defined specific terms which pertain to the
expedited hearing. May Contractors Grievance System;any current terms which do not
assume that the definitions and conform to the BBA must be amended to insure
requirements will stay the same for compliance. As an example, refer to the
these two terms? Please provide more definition of "action," "appeal", and
information, definitions and processes "grievance" as defined in 438.400.
for appeal, expedited appeal and State
fair hearing.
- ------------------------------------------------------------------------------------------------------------------------------------
287 157 Attach Paragraph 3 Currently, we rely on the language in the If the Contractor is aware that the enrollee
H Member Information section of the has a limited English proficiency in a
(1) contract. Therefore, vital materials, prevalent non English language, the Contractor
including Notices for Denials, must translate the written material , e.g. the
Reductions, Suspensions or Terminations Contractor resolution notice, in the prevalent
of non English language-rather than simply
- ------------------------------------------------------------------------------------------------------------------------------------
51
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
Services are translated when we are aware including language in the document advising the
that a language is spoken by 1,000 or, 5% enrollee that the information is available in
of our members. We also inform our the prevalent non English language.
members of their right to interpretation
and translation services when we are
aware that 1,000 or 5% of the members
speak a specific language and have LEP.
Attachment H of the RFP states, "Written
documents, including but not limited to
the Contractor's Notice of Action, the
Notice of Contractor's Appeal/Grievance
Resolution, ... shall be translated in
the enrollee's language if information is
received by the Contractor, orally or in
writing, indicating that the enrollee has
Limited English Proficiency." We are
interpreting this to say that we must
print the stated documents in a member's
chosen language if the member tells us
that he/she has LEP. Is this correct?
- ------------------------------------------------------------------------------------------------------------------------------------
288 157 Attach Bullet 2 This bullet requires a contractor to "Appeal" is defined in 42 CFR 438.400.
H define appeal. Please provide a
(1) definition and the context that AHCCCSA
is using the term appeal.
- ------------------------------------------------------------------------------------------------------------------------------------
289 157 Attach Bullet 4 This bullet allows for an enrollee to 42 CFR 438.402 delineates requirements for oral
H file both a grievance and an appeal and written appeals. The BBA does not mandate a
(1) orally. Currently, enrollees that dispute hearing process for grievances as defined in
a grievance decision must submit a 438.400.
request for hearing in writing. Does this
oral request include the appeal of a
grievance decision?
- ------------------------------------------------------------------------------------------------------------------------------------
290 157 Attach Bullet 5 The RFP states that an enrollee shall be AHCCCS anticipates establishing a specific
H given no less than 20 days (and no more timeframe for appealing through regulation
(1) than 90 days) to file an appeal. Is it and/or formal policy.
the intent of AHCCCSA to allow individual
health plans choose the time frame for
filing grievances and appeals, or is
AHCCCSA going to define the timeline?
- ------------------------------------------------------------------------------------------------------------------------------------
291 157 Attach Bullet 6 Item This bullet indicates that a contractor Please refer to the answer to question # 280.
H 2 shall notify enrollees at the time of any
(1) action affecting the claim when there has
been a denial of payments. Is it the
intent of AHCCCSA to require Contractors
to notify enrollees when provider claims
have been denied? Is it the intent of
AHCCCSA to allow enrollees to appeal
provider claim denials? If so what level
of appeal is meant by this section?
- ------------------------------------------------------------------------------------------------------------------------------------
292 157 Attach Bullet 6 As this statement does not specify Please refer to Subpart F. Notice of Action
working or mailing requirements
- ------------------------------------------------------------------------------------------------------------------------------------
52
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
H calendar days, can we assume it is are found in 438.404. The timeframes generally
(1) calendar days? This statement would imply refer to calendar days although he expedited
that the Notice of Action is sent out 10 timeframe is stated in terms of working days.
days before the date of the action. Is
this to mean the "effective" date of the
action?
- ------------------------------------------------------------------------------------------------------------------------------------
293 157 Attach Are there set definitions of the terms Yes, please refer to 438.400.
H Appeal, grievance and complaint?
(1)
- ------------------------------------------------------------------------------------------------------------------------------------
294 157 Attach Are the terms appeals and grievances Please refer to the definitions found in
H being used interchangeably OR Are you Subpart F. These terms are not used
(1) allowing the Health Plan to define these interchangeably and must conform to the BBA
terms OR Do we use CFR 438 subpart F to definitions.
define the terms? Note - CFR 438 does not
recognize the term "complaint".
- ------------------------------------------------------------------------------------------------------------------------------------
295 157 Attach Where it states "inquiries appealing an Please refer to 42 CFR 438.406(b).
H action are treated as appeals and are
(1) confirmed in writing...." Please clarify
who is "confirming in writing" -the
Health Plan or the enrollee?
- ------------------------------------------------------------------------------------------------------------------------------------
296 158 Attach Bullet 7 This item refers to the enrollee's right No, the terms "grievances" and "appeals" have
H Item 3 to file an appeal with the contractor. distinct meanings as defined in Subpart F.
(1) Does this mean the enrollee's right to
file a grievance?
- ------------------------------------------------------------------------------------------------------------------------------------
297 158 Attach Bullet 7 This bullet refers to the enrollee's The BBA permits enrollees to file requests for
H Item 4 right to file a request for State fair hearing with the State concerning "actions"
(1) hearing. May we take this to mean the which are not resolved solely in favor of the
enrollees right to file a request for enrollee by the Contractor. Some of these
expedited hearing? If not, from whom does actions may qualify as "expedited" matters.
the enrollee request a State fair
hearing?
- ------------------------------------------------------------------------------------------------------------------------------------
298 158 Attach Bullet 7 In this item it refers to the enrollee's Expedited resolution is discussed in 438.408
H Item 6 right to file an expedited resolution. and 438.410.
(1) Please provide a definition of expedited
resolution in this context and the
circumstances in which an enrollee can
utilize or request the expedited
resolution. With whom does the enrollee
request an expedited resolution?
- ------------------------------------------------------------------------------------------------------------------------------------
299 158 Attach Bullet 10 This bullet uses the term standard Attachments H(1) and H(2) have been written to
H appeal. Does this terminology refer to incorporate all required changes due to the
(1) what is currently called a grievance? Or BBA. This attachment prevails over rule and
is this a new appeal process? This bullet statute effective October 1, 2003.
allows the contractor to respond to
standard appeals within 45 days, if this
is referring to the current grievance
process, is the AHCCCSA eliminating the
30 day time frame currently used for
processing grievances?
- ------------------------------------------------------------------------------------------------------------------------------------
53
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
300 158 Attach Bullet 14 Item This bullet indicates that an enrollee Subpart F delineates MCO requirements for
H 3 can appeal the denial in whole or in part appeals of "actions" which include the denial
(1) of payment for service. Is this to mean of payment for a service, in whole or in part.
the enrollees can appeal provider claim Also refer to response number 280.
denials? If so, what level of appeal is
meant by this section?
- ------------------------------------------------------------------------------------------------------------------------------------
301 158 Attach Bullet 21 Item This bullet indicates that a health plan 42 CFR438.408 delineates the content
H 2 b has to provide written notice of the requirements which must be included in the
(1) enrollee's right to receive benefits Contractor's written notice of resolution. The
pending the hearing and how to request right to receive continued benefits must be
continuation of benefits. Bullet 15, on included.
page 158, indicates that benefits shall
continue if the enrollee meets all five
criteria. Should the health plan include
this information only if all of the
criteria in Bullet 15 had been previously
met? Or is it the intent of AHCCCSA to
have the health plans include this
language in every letter?
- ------------------------------------------------------------------------------------------------------------------------------------
302 158 Attach Attachment H provides that the Contractor Please refer to the answer to question #298.
H shall permit both oral and written
appeals and grievances and those oral
inquiries appealing an action are treated
as appeals and are confirmed in writing
unless expedited resolution is requested.
Please clarify what an "expedited
resolution" is? Is this is referring to
an Article 13 request for expedited
appeal?
- ------------------------------------------------------------------------------------------------------------------------------------
303 158 Attach Attachment H refers to the Contractor Attachments H(1) and H(2) have been written to
H resolving all expedited appeal within 3 incorporate all required changes due to the
working days and making reasonable BBA. This attachment prevails over rule and
efforts to provide oral notice to an statute effective October 1, 2003.
enrollee regarding an expedited appeal
resolution--is this effort to provide
notice regarding an appeal of the
expedited appeal? Is that same as Article
13? Does this mean after the Contractor
makes decision on expedited that the
member then can access the expedited, or
non-expedited, appeal process in either
Article 13 or 8?
- ------------------------------------------------------------------------------------------------------------------------------------
304 158 Attach Attachment H1 refers to right of enrollee Attachments H(1) and H(2) have been written to
H to file appeal of "failure to provide incorporate all required changes due to the
services in timely manner"--is this a BBA. This attachment prevails over rule and
grievance filed with Contractor about statute effective October 1, 2003.
provider's car, e.g., quality of care
complaint, that is a "standard appeal"
(with 45? Days to resolve and right of
appeal?) or a
- ------------------------------------------------------------------------------------------------------------------------------------
54
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
"traditional" grievance under Article 8?
- ------------------------------------------------------------------------------------------------------------------------------------
305 Attach AHCCCS has changed most of the The BBA does not address the provider dispute
H terminology in the member grievance resolution process. Therefore, AHCCCCS intends
system section to reflect new BBA to retain the existing process, with some minor
language. For example: modifications. AHCCCCS will communicate any
changes through a formal policy.
Previous Language New Language
----------------- ------------ Submission #28, under Member Services, is
Complaints Grievances amended to read, "Describe the member
Grievances Appeals grievances and resolution process, including
Appeals State Fair communications with other departments,
Hearings benchmarks used and the average speed for
resolution of grievances (or complaints using
AHCCCS has not changed this terminology previous terminology)". #36 is amended to read,
in the provider grievance section to "Provide a flowchart and written description
reflect these changes. Nor has AHCCCS of the appeals and State fair hearing processes
updated the language in questions #13 and and general timelines.
#28 of this RFP. Should Offeror answer
provider grievance questions and other 438.400 defines "grievance" as an expression of
questions (13 and 28) based on previous dissatisfaction about a matter other than an
language definitions or new language "action." This regulation states, "possible
definitions? subjects for grievances include, but are not
limited to, the quality of care or services
provided, and aspects of interpersonal
relationships such as rudeness of a provider or
employee, or failure to respect the enrollee's
rights." Generally speaking, "grievances" under
the BBA are similar to "complaints" under the
previous nomenclature. The BBA does not provide
hearing rights regarding grievance disposition.
Although quality of care complaints may be
communicated to the Contractor in a variety of
ways, those which are reported by members are
to be treated as grievances. Quality of care
complaints not communicated to the Contractor
by members are not assumed to be grievances and
are therefore treated independently of the
grievance system.
In general, "appeals" (BBA terminology) refer
to what previously were known as grievances,
when filed by members regarding an action taken
by the contractor. as defined in Attachment H1,
page 158, eighth bullet of the RFP.
- ------------------------------------------------------------------------------------------------------------------------------------
306 Attach We have interpreted an expedited appeal The BBA defines "actions" and "grievances." For
H to be what was formerly known as an purposes of the Enrollee Grievance System
expedited grievance, which would be delineated in Attachment H(1), an "action"
submitted directly to AHCCCS. Please confers hearing rights whereas a "grievance"
clarify the process as it relates to does not. The BBA sets forth requirements for
the Offeror. expedited resolution of "actions" which are
found in 438.408 and 410. "Grievances" are
- ------------------------------------------------------------------------------------------------------------------------------------
55
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
not subject to expedited resolution. When the
Contractor determines or the provider indicates
that taking the time for standard resolution
could seriously jeopardize the enrollee's life
or health or ability to attain, maintain, or
regain maximum function, then the appeal must
be resolved no longer than 3 working days after
the MCO receives the appeal - unless the
timeframe is extended in accordance with the
requirements in 438.408(C). This applies to
denials, reductions, and terminations.
Currently, AHCCCS Policy and Rule permit
appeals of denials, reductions and terminations
of services to be scheduled directly to
hearing, by passing the Contractor review
process. It is likely that AHCCCS will amend
the current Member Rights and Responsibility
Policy and Article 13 of AHCCCS Regulations,
"Members' Rights and Responsibilities for
Expedited Hearings" to require the Contractor
to initially address all enrollee actions and
grievances through the Contractor Grievance
System. These changes will be communicated to
Contractors through formal policy and/or rule.
- ------------------------------------------------------------------------------------------------------------------------------------
307 Attach Does b) only apply if an expedited appeal See response to number 306 above.
H was filed directly with AHCCCS, within
10 days of service and only to original
services requested? Please clarify the
process as it relates to the Offeror.
- ------------------------------------------------------------------------------------------------------------------------------------
308 Attach If a State fair hearing results in Please refer to 438.420 and 424 for
H reversal of a decision, can Offerors continuation of benefits and reversal of
limit only to medically necessary decisions. In order for services to continue
covered services in the scope of the during an appeal, the requirements in 438.420
original request? Does this only apply must be met. Additionally, Contractors must
if services were received under an ensure the timely provision of services which
approved request for continuation of were originally denied by the Contractor if the
services? Can we require out-of-state AHCCCS Hearing Decision subsequently reverses
providers to comply with policies, such the Contractor's denial. All services must be
as obtaining an AHCCCS provider ID number medically necessary. These requirements are
and to accept the AHCCCS fee schedule? discussed in several areas in Attachment H(1).
Federal regulations require that all Medicaid
providers sign a provider agreement. In
addition, State Law ARS Section 36-2904L,
authorizes payment of non-hospital services at
the AHCCCS capped fee for service schedule - in
the absence of an agreement to the contrary.
- ------------------------------------------------------------------------------------------------------------------------------------
309 Attach It states that Offerors are to continue The Director's Decision, issued on behalf of
H benefits under certain conditions, such the AHCCCS Director, shall be considered the
as until "3) State hearing office Decision by the State Hearing Office for
issues decision adverse to enrollee." purposes of duration of continued benefits in
Currently, the Administrative Law Judge 438.4200 or effectuation of reversed a
at the Office of Administrative resolutions in 438.424. Please note that the
Hearings hears the case duration of continued benefits is determined by
the
- ------------------------------------------------------------------------------------------------------------------------------------
56
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
and issues a Recommended Order & Decision. occurrence of any of the four conditions
The Director of AHCCCS then reviews that in 438.420(C)-only one of which pertains
decision and issues the Director's to a hearing decision. For example, if the
Decision, accepting, rejecting or time period or service limits of a
modifying the Administrative Law Judge's previously authorized service have been
decision. Please clarify decision is met, the continued benefits must cease
applicable for the timeframe of coverage. even if a Hearing Decision has not yet
been issued.
- ------------------------------------------------------------------------------------------------------------------------------------
310 Attach Other bidders raised some questions Please refer to responses to questions 306
H regarding definition and processes were and 307.
referred back to CFR. How will this affect
the current "expedited appeal" process in
Arizona? We are uncertain how to
coordinate the "expedited appeal" and
denial of an "expedited resolution."
- ------------------------------------------------------------------------------------------------------------------------------------
311 Attach The change in definitions would indicate Please refer to response to question 305.
H that what is currently called the member
complaint process (as reflected in
questions 28 and 13) is now the member
grievance process. If this is true, should
the current member complaint process be
included in the flowchart? Please clarify.
- ------------------------------------------------------------------------------------------------------------------------------------
Page Attach Question 262 states that questions about Attachment H(2) will be retained. Subpart
161 H Attachments H(1) and H (2) "have been F of Part 438 does not address the
written to incorporate all required provider dispute resolution process.
changes due to the BBA". The BBA does not Therefore, AHCCCS intends to retain the
recognize the providers' right to file a existing provider grievance system process
grievance or an appeal except on behalf of with some minor modifications, and will
the member, with the member's permission. advise contractors of changes to the
See 438.402 section c (1) ii "A provider, provider process through a formal policy.
acting on behalf of the enrollee and with
the enrollee's written consent, may file The statement means that providers may not
an appeal. A provider may not file a file a grievance or request a state fair
grievance or request a state fair hearing for a member.
hearing." Are we to follow the CFR 438
subpart F, as we have been told in answer
to the bidders question to "refer to 42
CFR 438"? If so, will H2 be revised to
comply with the BBA?
- ------------------------------------------------------------------------------------------------------------------------------------
312 161 Attach Item J "If the contractor's decision is appealed The terms "appeal and request for hearing"
H(2) and a request for hearing is filed......". in this context represent one action and
Is that 1 step or 2 steps? Can the provider refers to appealing the Contractor
appeal the Health Plan grievance decision decision to the State.
to be relooked at and if not satisfied,
request a hearing or is "appeal and request
for hearing" saying the same thing which
would be an appeal to AHCCCS?
- ------------------------------------------------------------------------------------------------------------------------------------
57
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
313 Data General Upon reviewing the data supplement, it AHCCCSA is unaware of any pertinent issues
Supp Question appears that in general the medical that contributed to a decrease in medical
expenses for the TANF/KidsCare under 1 age expenses. This information is based upon
category show a decrease in medical health plan self-reported data.
expenses from 2001 to 2002. Please explain
any pertinent issues that may cause a
decrease in medical expenses during these
time periods.
- ------------------------------------------------------------------------------------------------------------------------------------
314 Data Section A Please provide additional details on how This information will be presented at the
Supp Overview Mercer will develop the mid-point and rate Bidder's Conference
ranges for the contract period?
- ------------------------------------------------------------------------------------------------------------------------------------
315 Data Section A Please provide information on any medical The information in the data supplement is
Supp Overview trend analysis that was completed using not directly used in the development of
the data in the data supplement. medical trends. The encounter utilization
reports are used to aid in the development
of utilization trends.
- ------------------------------------------------------------------------------------------------------------------------------------
316 Data Section A Please provide additional details on Health plans receive monthly capitation
Supp Overview capitation offset on the CRCS form for for the pregnant women enrolled in their
Delivery Supplement. plan. Currently, the assumed duration of a
pregnant woman in the program is 8 months
including the post partum time period.
Therefore, in order to avoid double paying
the plans, the maternity payment is
reduced for the eight months of capitation
dollars that the plans will received.
- ------------------------------------------------------------------------------------------------------------------------------------
317 Data Section D How do the Provider Type and Category of The Provider type and Category of Service
Supp and F Service drive the rate setting? Please make up the criteria for developing
clarify the relationship of the service general service categories that are the
matrix which includes Provider Type and basis of the capitation rates. The
Category of Service to the Capitation Rate crosswalk between the service matrix to
Setting worksheets. the CRCS is provided so you can use the
encounter utilization reports for
developing your capitation bids by those
service categories.
- ------------------------------------------------------------------------------------------------------------------------------------
318 Data When evaluating utilization for rate Both the professional component and
Supp setting, how do codes with global rates technical component for lab and radiology
billed with TC, 26 modifier get handled? services are included in the lab and
Are the professional (26) component in radiology services category. See the
physician services and the technical (TC) service matrix in Section D of the Data
portion in lab, radiology, etc.? If they Supplement for further information.
are split, what are the percentages of
splits that will apply?
- ------------------------------------------------------------------------------------------------------------------------------------
319 Data What is the 4/1/03 AHCCCS fee schedule AHCCCS will increase the hospital tier per
Supp status? How will adjustments to that fee diems based on the 3rd quarter DRI. An
schedule be factored into the rate estimate of this will be used in
setting? developing the capitation rates. AHCCCS
will continue to freeze its fee schedule
for all other rates. This will be factored
into the capitation rate development.
- ------------------------------------------------------------------------------------------------------------------------------------
320 Data Capitation Can you give an example of a This is a service that does not fit any of
Supp Rate "Miscellaneous" service? There are no the categories that are contained in the
Calculation AHCCCSA Service Matrix Categories that service matrix.
Sheet (CRCS) crosswalk to this line in the CRCS.
- ------------------------------------------------------------------------------------------------------------------------------------
321 Data Service In the Service Matrix of the data set, It should be the number of units that is
Supp Matrix non-emergency transportation is counted as defined as a trip for transportation
number of services.
- ------------------------------------------------------------------------------------------------------------------------------------
58
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
encounters. Should this not be number of
units?
- ------------------------------------------------------------------------------------------------------------------------------------
322 Data Maternity Is the "Encounter Data" for the SOBRA The data handed out was for all Maternity
Supp Costs Supplement available in electronic form? costs irrespective of their eligibility
This data includes utilization per 1,000 category. This information is available
and costs per unit by type of service for electronically through the AHCCCS web
the three contract years ending 2000, site's bidder's library.
2001, and 2002 (six months) for each
county and GSA. It is comparable to what
the AHCCCSA provided in electronic format
on their CD earlier for acute care aid
categories. AHCCCSA handed out hard copy
printouts of the SOBRA Supplement data at
the bidder's conference.
- ------------------------------------------------------------------------------------------------------------------------------------
323 Gen How many disease management programs need AHCCCS has not established a standard for
quest to be in place and are there specific the number of disease management programs
diseases that are mandated? a plan must offer. The development and
implementation of disease management
programs should be based on the needs of
the health plan's members.
- ------------------------------------------------------------------------------------------------------------------------------------
324 Gen What is meant by "disease management Disease Management Programs are disease
quest programs"? Do they include management of specific programs designed to assist
diseases within the realm of case persons with chronic illnesses improve
management, or are they looking for their self-management skills. Case
"disease-specific" programs? management can be one tool of disease
management.
- ------------------------------------------------------------------------------------------------------------------------------------
325 Gen Will they accept referrals to current HIHS Disease management programs can be
quest programs as disease management, i.e. provided in many different methods. It is
MMC's/CHC CHF Program, Diabetes Education up to the Contractor to determine what is
& Coagulation Clinic, informal asthma effective for their population.
education, etc?
- ------------------------------------------------------------------------------------------------------------------------------------
326 Gen If they truly mean specific "disease AHCCCS will monitor the implementation of
quest management programs", with tracking of Disease Management programs at the first
CLINICAL Indicator, (in addition to round of Operational and Financial Reviews
Utilization Monitoring which can be easily conducted under the new contract.
done by the HP), is there a date by which
these programs must be in place?
- ------------------------------------------------------------------------------------------------------------------------------------
327 Gen Does AHCCCSA intend to now, or at any time In lieu of specific standards by
quest during the contract term, install geographic area, AHCCCS is utilizing the
geographic access standards for community access standard as the guideline
specialists? for network development. Essentially, this
means that services that are generally
available to the population of a given
community, should be equally available to
the AHCCCS members residing in that same
community. Additional specific
requirements are not currently
anticipated.
- ------------------------------------------------------------------------------------------------------------------------------------
59
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
328 Gen Will the performance bond and The Offeror should assume that they will
quest capitalization levels remain consistent remain constant.
during the period of the financial
statement forecast?
- ------------------------------------------------------------------------------------------------------------------------------------
329 Gen What years' growth assumptions should be AHCCCSA will provide the estimates used by
quest used of the overall AHCCCS population the AHCCCS budget office at the bidder's
growth in the financial statement conference.
forecast?
- ------------------------------------------------------------------------------------------------------------------------------------
330 Gen Should we assume our same mixture of This is a decision that the Offeror will
quest membership by rate group as of now as our need to make based upon its estimates.
mixture in the financial statement
forecast?
- ------------------------------------------------------------------------------------------------------------------------------------
331 Gen Should the margin on Financial Statement The contractor should not factor the
quest Forecast rates set by AHCCCS' actuaries be "margin" (risk/contingency) that is
included in the financial statement included in the capitation rate
forecast? development. They should report their
actual expected margin.
- ------------------------------------------------------------------------------------------------------------------------------------
332 Gen When setting the rates without pharmacy, Yes, some portion of the administrative
quest will all administrative costs related to costs will be borne by another entity. It
the pharmacy benefit be borne by another is unknown at this point the amount.
entity?
- ------------------------------------------------------------------------------------------------------------------------------------
333 Gen For the capitation rates set by AHCCCS' AHCCCSA anticipates that the capitation
quest actuaries (PPC, HIV/AIDS, Title XIX rates in question will be available April
Waiver, HIFA Parents, etc.) when will that 1, 2003. Because the PPC and TWG rates are
data be available? What are the reconciled, the Offeror should estimate
inflationary assumptions used for the what their profitability will be for the
contract period? TWG and PPC experience and build that into
their financial projections. For the HIFA
parents, assume a rate that is 10% greater
than the applicable TANF rates.
- ------------------------------------------------------------------------------------------------------------------------------------
334 Gen When will the reinsurance adjustment table The reinsurance offsets will be available
quest for plans with a deductible greater than by the end of February. Those offsets will
$20,000 be available? Will this be be adjusted annually when additional date
consistent through out the contract is analyzed including inpatient rate
period? adjustments, program changes, and actual
reinsurance claims paid.
- ------------------------------------------------------------------------------------------------------------------------------------
335 Gen Will the bidder be able to modify the The bidder can modify their capitation
quest capitation rates after they are input into rate bids until 3:00 pm, March 31, 2003.
the web site? If so, when will they no
longer be available for modification?
- ------------------------------------------------------------------------------------------------------------------------------------
336 Gen Does AHCCCSA have any enrollment AHCCCSA will provide the estimates used by
quest projections for the acute care program the AHCCCS budget office at the bidder's
over the next 1-5 years split by GSA conference.
and/or eligibility category? If so, please
provide copies of what is available.
- ------------------------------------------------------------------------------------------------------------------------------------
337 Gen Upon bidding for GSA 10, will separate The Offeror must submit a bid for the
quest capitation rates be quoted for Pima County entire GSA. Capitation scoring will be
and Santa Cruz County? based upon the blended capitation rate.
After all RFP scoring is completed, the
two bidders with the highest overall
scores will receive an award for both Pima
and Santa Cruz counties. The next highest
scorers will receive an award in Pima
County only. The Pima County only
Contractors will be offered a rate that is
their bidded rate for both counties as
adjusted based upon a percentage
difference between the risk of the two
counties
- ------------------------------------------------------------------------------------------------------------------------------------
60
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
combined and Pima County only as
determined by Mercer. If the Pima County
awardee does not accept the offered rate,
then the next highest scorer will be
offered a rate until all available
Contractor slots are awarded.
- ------------------------------------------------------------------------------------------------------------------------------------
338 Gen Will AHCCCSA make available experience The TPL experience is included in the
quest information regarding Third Party current health plan financial statements.
Recoveries?
- ------------------------------------------------------------------------------------------------------------------------------------
339 Gen Will AHCCCSA make available experience The amount of the copayments will be hard
quest information regarding member co pays? coded into the CRCS.
- ------------------------------------------------------------------------------------------------------------------------------------
340 Gen Is there a preferred form for the Please refer to the answer to question #1.
quest actuarial certification?
- ------------------------------------------------------------------------------------------------------------------------------------
341 Gen Can AHCCCSA provide guidance as to how CYE AHCCCS will increase the hospital tier per
quest '04 reimbursement rates will vary from CYE diems based on the 3rd quarter DRI. An
'03, specifically identifying percentage estimate of this will be used in
changes to inpatient hospital tiered per developing the capitation rates. AHCCCS
diems, outpatient hospital reimbursement, will continue to freeze its fee schedule
and other fee-for-service reimbursement? for all other rates. This will be factored
into the capitation rate development.
- ------------------------------------------------------------------------------------------------------------------------------------
342 Gen How many hospital supplement payments per AHCCCS will provide total hospital
quest 1,000 non-MED members occurred in supplemental payments for CYE '02 when the
historical contract years? rates are provided.
- ------------------------------------------------------------------------------------------------------------------------------------
343 Gen What aid code groups do the $15,000 and The $15,000 applies to Title XIX Waiver
quest $20,000 deductibles correspond to in Group rates categories. The $20,000
Exhibit U of the data supplement? applies to all other rate categories. See
further definitions of risk groups in the
data supplement and paragraph 2 of the
RFP.
- ------------------------------------------------------------------------------------------------------------------------------------
344 Gen Will elements of the Capitation Rate AHCCCS will set the following items in the
quest Calculation sheet be set by AHCCCS? If so, CRCS:
please describe them. 1. reinsurance offsets
2. copayment amounts
- ------------------------------------------------------------------------------------------------------------------------------------
345 Gen Per instruction, all responses should be Please refer to the answer to question
quest limited to three pages unless indicated #196a.
otherwise. Does this three page limitation
include attachments, i.e. manual, sample
reports, handbooks, etc?
- ------------------------------------------------------------------------------------------------------------------------------------
346 Gen Can attachments be marked as such in the Where attachments are permitted, yes.
quest 1/2 inch margin around the page?
- ------------------------------------------------------------------------------------------------------------------------------------
347 Gen Is the response page limit to narrative Page limits apply to the narrative.
quest only? Do you want response attachments to Attachments which are specifically
be included? requested do not count toward the limit.
- ------------------------------------------------------------------------------------------------------------------------------------
348 Gen How do you want attachments that are not Attachments, which are specifically
quest within the 81/2x 11 requirements to be requested, may be submitted in hard copy
displayed? I.e. electronic file (if form in a sleeve, following the applicable
available), Xerox copy of material, in narrative.
sleeves, in separate binder?
- ------------------------------------------------------------------------------------------------------------------------------------
349 Gen May we have a BID Rating Tool? No.
- ------------------------------------------------------------------------------------------------------------------------------------
61
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
quest
- ------------------------------------------------------------------------------------------------------------------------------------
350 Gen Does AHCCCS intend to adjust its FFS No. AHCCCS will freeze its rate schedule.
quest schedule to reflect the Medicare Fee
schedule in 2003/2004
- ------------------------------------------------------------------------------------------------------------------------------------
351 Gen When using the rate worksheets on the web, Yes. After that, the bidder will be locked
quest are bidder's able to change them up until out.
3/31/03, 3pm?
- ------------------------------------------------------------------------------------------------------------------------------------
352 Gen When using the rate worksheets on the web, Yes. More information will be provided at
quest are these secured and confidential from the bidder's conference.
other bidders?
- ------------------------------------------------------------------------------------------------------------------------------------
353 Gen Freedom-To-Work a) Based on March 2003
quest
a) Can AHCCCSA provide enrollment in COCHISE 4
Freedom-to-Work aid codes by county? COCONINO 5
GILA 1
b) What data can be made available to MARICOPA 66
assess the cost of these members as MOHAVE 5
compared to SSI members without Medicare? NAVAJO 1
PIMA 23
PINAL 4
YAVAPAI 6
b) AHCCCS has no data because this
population became eligible January 1,
2003. The capitation rates were not
changed for the population as it is not
expected that their risk will be greater
than the general SSI population, and
because there are so few members
potentially eligible.
- ------------------------------------------------------------------------------------------------------------------------------------
354 Offeror's Does AHCCCSA intend to truncate any Some of the rate cells will no doubt be
Conference encounter data when developing standard too small to give them full statistical
deviations for their rate range credibility. Mercer will be looking more
development? closely at the statistical relationships
between the rating regions (county
groupings), rather than taking a literal
interpretation of the statistical
analysis.
- ------------------------------------------------------------------------------------------------------------------------------------
355 Offeror's Given the large increases in hospital AHCCCS is developing a methodology that
Conference charge masters, has AHCCCS made a will limit the outpatient facility trend.
determination as to whether they will AHCCCSA does not anticipate the trend to
trend unit costs for outpatient services exceed 5%.
- ------------------------------------------------------------------------------------------------------------------------------------
356 Offeror's What additional data / information is the AHCCCS provided Mercer with encounter data
Conference state making available to its actuaries to develop reinsurance offsets. AHCCCSA
that the plans have not been given? also provides health plan specific data to
Mercer. All other data has been provided
to bidders.
Are the actuaries receiving encounter data
by quarter? No.
The data that was provided in the data
supplement--October 1,
- ------------------------------------------------------------------------------------------------------------------------------------
62
- ------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------
What is the most recent time period 2001 through March 31, 2002.
they have received?
The additional data provided to Mercer will
If additional data has been not aid the Offerors in their capitation
provided to the state's actuaries, rate bid development. Also, AHCCCS does not
what is the rationale for not release health plan specific data.
providing the additional data to
potential offerors, in particular,
new offerors?
- ------------------------------------------------------------------------------------------------------------------
357 AHCCCS http://www.ahcccs.state.az.us/ These are forms with specific purposes that
Website Contracting/OpenR FPs/YH04-0001/ are referenced in the RFP document in a
YH04-0001.asp has three forms at similar manner as policies. Therefore
the bottom of the page: Marketing AHCCCS included them in their bidder's
Attestation Statement (PDF), AHCCCS library. There is no submission requirement
Medicare Research Request Form for these forms.
(PDF), and Third Party Liability
(TPL) Change Form (PDF). Are we
expected to do anything with these
forms for this RFP? Specifically,
are they to be submitted with the
bid? If so, where should they be
placed in the response?
- ------------------------------------------------------------------------------------------------------------------
358 Gen If a continuing offeror currently Yes, such as a county resolution.
quest holds a Bond Substitute, should
the offeror assume that the
substitute will continue to be
acceptable in response to this
question?
- ------------------------------------------------------------------------------------------------------------------
359 Gen If the offeror is part of a larger This is not required.
quest governmental organization (e.g. an
enterprise fund), should it submit
a copy of the CAFR for the entire
governmental entity?
- ------------------------------------------------------------------------------------------------------------------
360 Gen How does AHCCCS intend that bidders The HIV-AIDS supplemental payment will be
quest account for the HIV-AIDS set. The benefits covered by this
supplemental payments in the bids supplemental payment should not be included
and in the CRCS sheets? in any of the CRCS sheets.
- ------------------------------------------------------------------------------------------------------------------
361 Gen At the Bidders' conference, the The bidder should develop their own trends
quest Mercer actuary shared some of their for pharmacy. For outpatient, AHCCCS is
trend assumptions (0% for developing a methodology for reimbursement
physician, 4% for hospital for October 1, 2003 that should minimize
inpatient). What trends will Mercer trends. As discussed, AHCCCS is freezing
use for hospital outpatient? For its free for service fee schedule for a
prescription drugs? For other second year. That should be factored into
services? trend assumptions. Each bidder should
consider their own expected trends based on
historical experience expected future
payments to providers.
- ------------------------------------------------------------------------------------------------------------------
362 Gen Is the plan required to notice AHCCCS is getting clarification from CMS on
quest members on every denied claim? this issue.
- ------------------------------------------------------------------------------------------------------------------
363 Gen For the Utilization Data provided Yes. Refer to the data supplement section J.
by the State for
- ------------------------------------------------------------------------------------------------------------------
63
- -----------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- -----------------------------------------------------------------------------------------------------------------
quest Yrs 18, 19 and 20, do the numbers
for the various TANF risk pools
include KidsCare? (KidsCare groups
were streamlined to TANF effective
10/01/02; however, health plans
are still required to report them
separately from TANF.)
- -----------------------------------------------------------------------------------------------------------------
364 Gen Health plans are to bid for two Yes. Please note no financial
quest sets of rates to be effective forecasts are required for bids
10/01/03; one with a pharmacy without the pharmacy benefit.
benefit and one without pharmacy
benefit. For the three-year
financial forecasts, do health
plans need to consider
inflation/adjustments for the
second and third year forecasts?
- -----------------------------------------------------------------------------------------------------------------
365 Gen (paraphrased) Are all medical costs Yes.
quest for pregnant women included in the
development of the delivery
supplemental payment, and is
that why there is 8 months of
capitation subtracted from the
gross rate to get to a net
delivery supplement rate?
- -----------------------------------------------------------------------------------------------------------------
366 Gen The amounts for deliveries and 1. Births and delivery numbers are
quest births are different. However, the different - ANSWER = the reason the
difference is small and may be numbers do not exactly match is due to
easily explained in accounting for two things: 1) mom may not have been
twins and stillborns. AHCCCS eligible and therefore we do
not have the delivery information; 2)
More perplexing, however, is that multiple births will have more than
the member months for TANF 14-44 one birth but only one delivery.
Females and SOBRA moms should
theoretically be the same from one 2. MM different from databook to
report to the next. In the "Birth to member month analysis" - the
membership data file, reason that the member months do not
"MemberMonths_Detail.txt" exactly match is because the databook
membership is different from that groups member months based upon
reported in section R of the updated eligibility information that
Revised Data Supplement, "Birth to many times comes after the payment of
Member Month Analysis - Summary by member months. This allows the
County". utilization in the databook to be
classified into the most precise risk
grouping. The birth report gathered member
months based upon "paid" member months.
- -----------------------------------------------------------------------------------------------------------------
367 Gen The Mercer actuary said that the
quest width of the rate ranges was
calculated based on a 95%
confidence interval.
a. The expectation is that plan
a. Are we correct to interpret experience will fall within the rate
this to mean that the range range for the specific rate being
is set in such a way that considered 95% of the time.
the rates have a 95% chance b. A 1 year period.
of being correct for a given c. A 1 year period. By eligibility
population over a given time group, county groupings, or rating
period? levels, as explained at the bidders'
conference. These are then used to
develop rate ranges for the GSAs.
- -----------------------------------------------------------------------------------------------------------------
64
- ------------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------
b. For what time period is this
calculated? A month, a year?
5 years? The range would be
wider for a short time period
due to random statistical
fluctuation.
c. For what time period is this
calculated? Statewide? By GSA?
By plan? A 95% confidence
interval will be wider, the
fewer the members it is based
on. A confidence interval based
on statewide data would be much
narrower than the confidence
interval which is appropriate
for any given plan.
- ------------------------------------------------------------------------------------------------------------------
368 Gen The AHCCCS encounter data supplied SOBRA mom utilization does not include
quest includes a SOBRA category. Do these SOBRA Family Planning as it is not a
costs include Family Planning? If covered service under that eligibility
so, how can we split out the SOBRA category. Please refer to the data
Family Planning costs from the rest supplement which details what is included
of the medical costs for the SOBRA in the encounter data, and the supplemental
Moms? If they don't include Family SOBRA Family Planning data.
Planning costs, what data is used
to calculate these numbers? (Note Family planning services (such as pharmacy
that the health plan financial data costs) are included in the encounter data
included in the Data Supplement for the TANF rate categories and not broken
does not split out Family Planning out separately as a service category.
costs by age and so cannot be used
to allocate the SFP costs between
TANF Female 14-44 and TANF 45+).
- ------------------------------------------------------------------------------------------------------------------
369 Gen The TANF Rate Calculation Sheets The offset is removed in the web site CRCS'.
quest have a line for "Family Planning
Svc Offset" The rate categories
allow the health plan data to
completely split out the SOBRA
Family Planning. What is the
purpose of the offset? Are the
health plans to put the SOBRA
Family Planning costs in the
calculations for the Gross
Capitation Rate and then offset it
below, rather than just exclude it
from the Gross Capitation Rate?
- ------------------------------------------------------------------------------------------------------------------
370 Gen The Delivery Supplement is a) A delivery has to be a live birth. In
quest described to cover the costs for 6 the event of a stillbirth, if the criteria
months prior to delivery, the outlined in the OMM policy manual is met,
actual delivery and 2 months past then a delivery supplemental payment can
actual delivery. still be generated.
a. What is considered a delivery? b)The CRCS for the delivery supplement does
Does the delivery have to be include an "other" category for all non
a live birth? If not, what are maternity related services. The supplemental
the criteria for payment is intended to cover all costs
distinguishing between a associated with a member who delivers a baby.
delivery and a miscarriage? The use of the "capitation offset" will
b. The Capitation Rate reduce the amount of this payment so that
Calculation Sheet for duplicate payments for this
- ------------------------------------------------------------------------------------------------------------------
65
- -----------------------------------------------------------------------------------------------------------------
QUEST
# PAGE SECT PARAGRAPH QUESTION ANSWER
- -----------------------------------------------------------------------------------------------------------------
the Delivery Supplement does population are not made.
not include all types of c) N/A
service. It is our
understanding that the
Supplemental payment is
intended to only include the
maternity-related costs. Is
this correct?
c. If the answer to b. is yes,
then: There is a capitation
offset of 8 months for the
Delivery Supplement. If the
Delivery Supplement is only
meant to cover maternity
related costs, then is it
correct to assume that this
offset should be less than the
full capitation rate?
- -----------------------------------------------------------------------------------------------------------------
371 103 Sect The change in definitions would See answer to question #305.
H indicate that what is currently
called the member complaint process
(as reflected in questions 28 and
13) is now the member grievance
process. If this is true, should
the current member complaint
process be included in the
flowchart? Please clarify.
- -----------------------------------------------------------------------------------------------------------------
66
Page 1 of 2
SOLICITATION AMENDMENT Arizona Health Care Cost
Containment System Administration
Solicitation Number: RFP YH04-0001 (AHCCCSA)
[AHCCCS LOGO] ACUTE CARE SERVICES - CYE 04 701 East Jefferson, MD 5700
Amendment Number Three Phoenix, Arizona 85034
Solicitation Due Date: March 31, 2003, 3:00 PM (MST) Michael Veit, (602) 417-4762
A signed copy of this amendment shall be included with the proposal, which must
be received by AHCCCSA no later than the Solicitation due date and time. This
solicitation is amended as follows:
1. As part of the Data Supplement that was previously issued, an Encounter
Utilization Reports binder and CD was also issued. The information in
the Encounter Utilization Reports did not previously include Per Member
Per Month (PMPM) cost information. That information was being reviewed
internally and also by Mercer and has now been authorized to be
released. As a result, the summary information included in the previous
binder has been updated and the reports and a CD have been generated
with this additional information. This information is attached to this
Amendment.
2. Please refer to Section C of the Data Supplement for information about
the contents and layout of the CD.
3. The PMPM cost information will be used in addition to the health plan
financial information in the development of the capitation rate ranges
for CYE04.
4. All other terms and conditions remains the same, including the proposal
due date and time.
- -----------------------------------------------------------------------------------------------------------------------------------
Offeror hereby acknowledges receipt and This Solicitation Amendment is hereby executed this 7th day of
understanding of this Solicitation Amendment. March, 2003, in Phoenix, Arizona.
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
Signature Date
- -----------------------------------------------------------------------------------------------------------------------------------
Signed Copy in File
- -----------------------------------------------------------------------------------------------------------------------------------
Typed Name and Title Michael Veit
- -----------------------------------------------------------------------------------------------------------------------------------
Contracts and Purchasing Administrator
- -----------------------------------------------------------------------------------------------------------------------------------
Name of Company
- -----------------------------------------------------------------------------------------------------------------------------------
HISTORICAL UTILIZATION DATA FOR CAPITATED MEMBERS
ENCOUNTER UTILIZATION REPORTS
The following reports present historical encounter utilization information for
capitated enrollees for contract year 18 (10/99-9/00), contract year 19
(10/00-9/01) and the first six months of contract year 20 (10/01-3/02
annualized). Utilization is shown for each risk group and age/sex category by
county, GSA, and statewide. All of the column totals, GSA information, and
statewide information have been weighted. These utilization reports are for
prospective enrollment only.
Before utilizing this information, the bidder should review Section D, Service
Matrix/ Selection Criteria. The Service Matrix defines and describes the
selection criteria used for each of the service categories shown in this
section. The bidder should also review Sections F and G providing the CRCS
screen layouts for bidding and the Crosswalk from the Service Matrix to the CRCS
screen layouts.
UNITS PER 1000
The first set of reports in this section present utilization information by
county and GSA. These detailed reports are sorted by contract year and then
service categories within each year. The second set of reports in this section
present statewide utilization. The statewide reports are sorted by service
category first and then contract year under each service category.
The utilization information presented in this section represents historical
annual utilization per 1,000 members. With the exception of the average length
of stay information, the utilization statistics have been calculated by dividing
the total number of the units/encounters counted, by the total number of member
months in the rate code and age/sex categories, and multiplying the result by
12,000 (1,000 members for 12 months). The member months used in the denominator
of the calculation can be found in Section I, Acute Capitated Member Months
Paid.
UNIT COST
The first set of reports in this section present unit cost information by county
and GSA. These detailed reports are sorted by contract year and then service
categories within each year. The second set of reports in this section present
statewide unit costs. The statewide reports are sorted by service category first
and then contract year under each service category.
The unit cost information presented in this section represents historical annual
unit costs for medical services. With the exception of the average length of
stay information, the unit cost statistics have been calculated by dividing the
total price of encounters (health plan paid, or valued at the AHCCCS FFS
schedule if the provider is subcapitated) , by the total number of encounters.
COST PMPM
The first set of reports in this section present cost PMPM information by county
and GSA. These detailed reports are sorted by contract year and then service
categories within each year. The second set of reports in this section present
statewide costs PMPM. The statewide reports are sorted by service category first
and then contract year under each service category.
The cost PMPM information presented in this section represents historical annual
costs PMPM for medical services. The cost PMPM statistics have been calculated
by dividing the total cost of the encounters (health plan paid, or valued at the
AHCCCS FFS schedule if the provider is subcapitated) by the total number of
member months in the rate code and age/sex categories.
Page 1 of 2
SOLICITATION AMENDMENT Arizona Health Care Cost
Containment System Administration
Solicitation Number: RFP YH04-0001 (AHCCCSA)
[AHCCCS LOGO] Amendment Number Two 701 East Jefferson, MD 5700
Solicitation Due Date: March 31, 2003, 3:00 PM (MST) Phoenix, Arizona 85034
Michael Veit, (602) 417-4762
A signed copy of this amendment shall be included with the proposal, which must
be received by AHCCCSA no later than the Solicitation due date and time. This
solicitation is amended as follows:
1. Finalized version of the Question and Answers distributed at the
Bidder's Conference on February 21, 2003. The following questions had
amended answers: 8, 12, 18, 63, 142-163, 179, 218b, 230b
2. Guidance for bidding capitation rates with the prescription drug
benefit excluded in the rates.
3. Revised Attachment H(1) and H(2)
4. Section H, Page 103, Required Submission Claims, #38. Please add "Limit
5 pages" after the submission requirement text.
5. Section H, Page 101, Submission #22. This should be changed to read,
"Describe how utilization of family planning services for all members
is monitored.
6. Attachment B, Page 115. Last paragraph should read, "In Tucson (GSA 10)
and Metropolitan Phoenix (GSA 12), the Contractor must demonstrate its
ability to provide PCP, dental and pharmacy services so that 95% of
members do not have to travel more than 5 miles from their residence."
7. Section D, Paragraph 32, Page 43. subpart c: Add: "PCP referral is not
required for dental service for members under the age of 21." Add prior
to the last sentence in c.
8. Medicaid Eligibility Verification System (MEVS). Names and Addresses of
vendors.
9. Attachment E. Add Instructions for Web Based Capitation Rate Proposal
Application.
10. Data Supplement Section H - Enrollment and Demographic Information
- REPLACEMENT - Enrollment and Demographic Information - Replace
previous summary sheet
- ADDITION - Member Growth Projections - Add this chart to the back
of the information in this section.
- ADDITION - Acute Enrollment Activity - Add this report to the back
of the information in this section.
- ADDITION - Acute Member ID Cards - Add this report to the back of
the information in this section.
11. Data Supplement Section N - SOBRA Family Planning Services Member
Months
- REPLACEMENT - Replace entire section with this new information.
12. Data Supplement Section O - Utilization for SOBRA Family Planning
Services
- REPLACEMENT - Replace entire section with this new information.
13. Data Supplement Section P - SOBRA Family Planning Services Costs - PMPM
- REPLACEMENT - Replace entire section with this new information.
14. Data Supplement Section S - Deliveries - C-Section vs. Vaginal
- REPLACEMENT - Replace entire section with this new information.
*. All other terms and conditions remains the same, including the proposal
due date and time.
- -----------------------------------------------------------------------------------------------------------------------------------
Offeror hereby acknowledges receipt and This Solicitation Amendment is hereby executed this 28th day
understanding of this Solicitation Amendment. of February, 2003, in Phoenix, Arizona.
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
Signature Date
- -----------------------------------------------------------------------------------------------------------------------------------
Signed Copy in File
- -----------------------------------------------------------------------------------------------------------------------------------
Typed Name and Title Michael Veit
- -----------------------------------------------------------------------------------------------------------------------------------
Contracts and Purchasing Administrator
- -----------------------------------------------------------------------------------------------------------------------------------
Name of Company
- -----------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
1 6 Sect N/A What format is required for the actuarially sound A basic actuarial certification letter with
B certification? a signature. A member of the American
Academy of Actuaries must attest that the
rates they bid are actuarially sound for
that plan.
- ------------------------------------------------------------------------------------------------------------------------------------
2 6 Sect N/A What is the definition of "actuarially sound" for The definition on page 99 of the RFP is
B the purposes of the actuarial certification? Is adequate at this time.
it the general definition as described on page 99
of the RFP or is it the CMS definition of
"actuarially sound" or should the certifying
actuary refer to the applicable actuarial
standards as issued by the Actuarial Standards
Board?
- ------------------------------------------------------------------------------------------------------------------------------------
3 6 Sect N/A How will the Offeror know that the bid submission Yes AHCCCSA agrees that the hard copy print
B in the AHCCCSA Web application is correct? Not out will prevail if there is a difference
that we don't trust the AHCCCSA systems, but in what is entered into the web site and
wouldn't it be better if the rate submitted via what is on the hard copy print out. This
print out (that the actuary is certifying and can statement corrects the direction in
see) is the prevailing bid rather than the bid Attachment E of the RFP as issued on
submitted via Web application? The actuary can't February 3,2003.
certify to the accuracy of the AHCCCSA systems.
If there is a difference, the web site will
be adjusted to match the hard copy print
out. All reports that will be used in the
scoring are generated from the web site
bids; therefore, it is necessary that the
web site bids are correct. Please note that
because the bids will be scored using the
web site, the Offeror must submit one set
of bids only. Barring AHCCCS system issues,
the hard copy and the web bid submissions
must be identical.
- ------------------------------------------------------------------------------------------------------------------------------------
4 6 Sect Please define more specifically what the Please refer to the answer in question #2
B definition of "Actuarially Sound" means FROM THE above for a description of actuarial
OFFEROR'S PERSPECTIVE. If a health plan has a soundness. Because of concerns regarding
sicker than average population for a given rate adverse selection that an AHCCCCS
cell, how should an Offeror reconcile its Contractor had, AHCCCS engaged Mercer to
"actuarially sound" bid when this rate will be run AHCCCS health plan encounter data
above the rate range? through the Chronic Disability Payment
System (CDPS) in 2002. Each of the health
plans was scored from a risk standpoint.
Total reimbursement [capitation, regular
reinsurance, catastrophic reinsurance,
AIDS/HIV $, maternity payments, etc.] paid
to health plans was also tabulated for
comparison purposes. Because this analysis
showed almost perfect alignment in the
ranking of risk versus payment, AHCCCS felt
the actuarial soundness of its current
payment methodologies had been confirmed.
- ------------------------------------------------------------------------------------------------------------------------------------
5 6 Sect Given the BBA's requirement for the rate ranges CMS has issued an extensive rate-setting
B to be "Actuarially Sound" FROM THE PERSPECTIVE OF checklist that defines in great detail
THE STATE'S ACTUARIES, please define more exactly what is meant by actuarially sound
specifically rates. Mercer was consulted extensively by
CMS in the development of
- ------------------------------------------------------------------------------------------------------------------------------------
1
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
what this means. the tool, and supplied much of the material
that found its way into the checklist. We
do not foresee significant changes in the
way rate ranges are established in Arizona.
There may be significant changes in the way
they are documented and filed with CMS.
Mercer brought the issue of actuarial
soundness to the attention of the American
Academy of Actuaries. As a result, the
Actuarial Standards Board has just begun
its own analysis of what it means to make
an assertion that capitation rates are
actuarially sound. Mercer is also
represented on this task force and will
take its recommendations into account as
they become available.
- ------------------------------------------------------------------------------------------------------------------------------------
6 9 Sect Definition, Is the word inpatient referring to admission to The definition of emergency medical
C Emergency the emergency room? services includes services provided in both
Medical Can we assume that if it refers to admission to inpatient and outpatient settings. This
Service the hospital that it would only be related to definition did not change with BBA. The
emergency surgery or ICU status and once the notification standards have changed.
patient is stabilized in the ICU that Emergency service providers have up to 10
notification applies? days to notify the health plan. Notice
requirements are still being analyzed, and
further clarification will be forthcoming.
- ------------------------------------------------------------------------------------------------------------------------------------
7 18 Sect #3-Enrollment The RFP states that contractors are responsible The prior period coverage (PPC) time period
D and for payments during prior period coverage and is already defined and limited depending
Disenrollment may include services provided prior to the upon the eligibility category. Please refer
contract year. Does AHCCCSA anticipate setting to AHCCCS rule for those limitations.
a limit as to how far back the prior period can
go?
- ------------------------------------------------------------------------------------------------------------------------------------
8 18 Sect #3-Enrollment Health Plan Choice - Members having fewer than The eligibility source informs AHCCCS that
D and 30 days continuous eligibility remaining will the approved eligibility period will extend
Disenrollment not be placed with a health plan but enrolled into the future less than 30 days (example:
in AHCCCS FFS. Please explain when this may member is determined they will be
occur. ineligible the following month although
they are eligible this month). However, it
is possible to enroll a member with a
health plan (member had been anticipated to
remain eligible) and then have the member
become ineligible before the end of the
month (example: the member is incarcerated,
dies, or moves out of state).
- ------------------------------------------------------------------------------------------------------------------------------------
9 18 Sect #3-Enrollment Health Plan Choice - What are the "few There are unusual situations, usually
D and exceptions" in which the effective date of administrative mistakes, when a TXXI member
Disenrollment enrollment for a Title XXI member will not be may be enrolled during the month. These are
the first day of the month? rare, and will not affect reimbursement.
- ------------------------------------------------------------------------------------------------------------------------------------
10 18-19 Sect #3-Enrollment Health Plan Choice - How long do newly eligible Members are encouraged to choose a health
D and persons have to select a health plan? How long plan prior to the eligibility approval
Disenrollment does a mother have to select a health plan for date. If not, they are auto-assigned
her newborn child? For FES babies? through the algorithm. For newborns, the
members have 16 days to choose a plan for
their baby.
- ------------------------------------------------------------------------------------------------------------------------------------
11 19 Sect #5-Enrollment When will open enrollment dates be finalized It is anticipated that Open Enrollment will
and take place in August,
- ------------------------------------------------------------------------------------------------------------------------------------
2
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
D and shared with contractors? 2003 for enrollment October 1, 2003. The
Disenrollment finalized dates will be shared with the
Contractors as soon as they are known.
- ------------------------------------------------------------------------------------------------------------------------------------
12 19 Sect #3- Enrollment When does the capitation payment start: When As stated in the RFP, "The Contractor is
D and the hospital calls with notification or when responsible for notifying AHCCCSA of a
Disenrollment the plan calls AHCCCS? child's birth...." However, a hospital may
notify AHCCCSA in lieu of the contractor
when the mother is enrolled in AHCCCS FFS.
The plan is required to notify AHCCCS of a
birth when the mother is enrolled with the
health plan. Capitation begins the day
AHCCCSA is initially notified of the birth
by either the Contractor or the hospital.
For babies born to FES mothers, the
eligibility is retro to the date of birth
and PPC capitation is paid for the date of
birth to the date of notification. For
babies of enrolled mothers, there is no PPC
capitation and the plan is prospectively
capitated from the date of notification
forward.
- ------------------------------------------------------------------------------------------------------------------------------------
13 20 Sect #5--Open How will AHCCCSA handle enrollment in rural Members of the exiting health plan will
D Enrollment GSAs if a contract is awarded to an incumbent have an opportunity to choose a new health
and a new Contractor? If members have not plan through an open enrollment process.
selected a health plan through the open Per Attachment G, AHCCCSA reserves the
enrollment process, would AHCCCSA weight the right to adjust the algorithm for a
auto assignment process to ensure that the Contractor who is awarded contracts in only
non-incumbent health plan has a sound rural GSA's. This will be decided at a
membership base to allow a viable operating later date based on awards. That adjustment
base? per Attachment G is only applicable to
contractors in Maricopa and Pima counties.
- ------------------------------------------------------------------------------------------------------------------------------------
14 20 Sect # 5--Open Section notes that the algorithm will be 1. The exiting contractor's enrollment is
D Enrollment adjusted to exclude auto assignments to an anticipated to be capped on July 1,
exiting contractor: 2003.
1. On what date would the algorithm be 2. New contractor names will be added to
adjusted? AEC materials for mailing in mid-June.
2. When will new contractor names be added to
AEC materials?
- ------------------------------------------------------------------------------------------------------------------------------------
15 20 Sect # 5--Open For successful Offerors, please describe the 1. Open enrollment will only be offered to
D Enrollment open enrollment process for incumbent members of exiting Contractors. Those
contractors awarded a contract under this members will be able to select from all
procurement. Will members of a health plan that contractors in the GSA for enrollment on
is being replaced in a given GSA be the only October 1.
members participating in open enrollment
activities, or will all health plans' members
participate? When an additional health plan is
added to a GSA, will members of all existing
health plans within that GSA participate in
open enrollment activities? '
- ------------------------------------------------------------------------------------------------------------------------------------
16 20 Sect # 5-- Open If a contractor is purchased by another The answer will depend upon details and the
D Enrollment organization, will AHCCCS hold an open timing of the sale and whether an award is
enrollment for those received by the continuing plan.
- ------------------------------------------------------------------------------------------------------------------------------------
3
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
members?
- ------------------------------------------------------------------------------------------------------------------------------------
17 20 Sect #6--Auto- Are there specific reasons why AHCCCSA made the It is believed that members who are auto
D Assignment statement in the RFP, "Capitation rates may be assigned through the algorithm have a lower
Algorithm adjusted to reflect changes to a contractor's risk that those who choose a health plan.
risk due to changes in the algorithm"? Could Those who choose are believed to be already
AHCCCSA describe the kinds of scenarios that accessing services, or are in the need of
would require a change to the algorithm? How services, which is why they are more
would and what type of notification timeline concerned about the health plan with whom
would future changes to the algorithm they are enrolled. Therefore, if a plan is
methodology be communicated to the health receiving more members though the algorithm
plans? through an adjustment, then it is believed
by AHCCCSA's actuaries that the plan's risk
is lower than the other plans. Therefore,
an adjustment is made to all Contractors'
rate to ensure actuarial soundness.
Another scenario is the adjustment that may
be made if there is a Contractor in Pima or
Maricopa County who has total statewide
enrollment of less than 25,000 members.
Another scenario is when a Contractor's
enrollment is capped due to financial
performance or sanctions.
The health plans would have at least 30
days notice. This notification would occur
through a contract amendment.
- ------------------------------------------------------------------------------------------------------------------------------------
18 20 Sect # 7-- AHCCCS Membership cards: The Offerors should budget 75 cents per
D Member How much will cards cost? card. New cards are issued for the
Identification What will the health plans be charged? following reasons: new member, change in
Cards What is the frequency of card issuance (one RBHA, change in Contractor, lost/stolen
time per member, when the member changes rate cards, significant name change, change in
codes, when the member changes contractors, program eligibility, and upon member
etc.)? request. AHCCCSA issued approximately
Will the invoice provided by AHCCCS be at the 40,000 cards per month in the recent
member detail level? months.
If AHCCCS is unsure about any of the above,
please provide direction as to how the health AHCCCSA has not yet determined how the
plan should account for this new cost in its invoicing will be handled.
bid.
The bidder should use the information
provided here in their capitation rate bid
submissions.
- ------------------------------------------------------------------------------------------------------------------------------------
19 20 Sect # 7-- AHCCCS What is the average cost per AHCCCS ID card? See the answer to #18 above.
D Member
Identification
Cards
- ------------------------------------------------------------------------------------------------------------------------------------
20 20 Sect a. What are the costs to the health plans on a a-c, e, f. See the answer to #18 above.
per
- ------------------------------------------------------------------------------------------------------------------------------------
4
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
D card basis? d. AHCCCSA will contract with the vendor.
b. For each GSA, how many ID cards (new and The content of the card is not the
reissued) were issued last year? discretion of the Contractor.
c. How many replacement cards were issued last g. The Contractor will be billed for
year? postage included in the 75 cents.
d. For cost control purposes, will the health
plans have input regarding the vendor and
content of the card?
e. How will AHCCCSA monitor and ensure that
health plans are not inadvertently billed for
ID cards for other health plans or FFS members?
f. How will ID card costs be handled for
members who are retroactively disenrolled (i.e.
refunded)?
g. Will postage be charged to the health plan
for the mailing of ID cards?
- ------------------------------------------------------------------------------------------------------------------------------------
21 20 Sect #8-- Please define "available facility" This is a facility that would normally be
D Mainstreaming available for use by your members i.e.,
of AHCCCS in-network or when medically necessary. The
members intent of the statement is that use of such
a facility cannot be denied based on one of
the criteria in the previous paragraph in
the RFP, payor source, race, color etc.
- ------------------------------------------------------------------------------------------------------------------------------------
22 20 Sect #8-- What does AHCCCSA consider to be "reasonable The phrase is used in the context that
D Mainstreaming steps" to be taken with subcontractors to "Contractors must take into account a
of AHCCCS encourage mainstreaming of members? member's culture when addressing members
members and their concerns, and must take
reasonable steps to encourage
subcontractors to do the same." The overall
paragraph discusses prohibited
discriminatory practices with respect to a
member's rights to receive services in a
manner that does not discriminate based on
payor source, race, color, gender, etc. The
Offeror should use its own judgment to
identify reasonable steps.
- ------------------------------------------------------------------------------------------------------------------------------------
23 21 Sect #9--Transition Transition of Members-Acute Care-If we are When a member is enrolled in CRS, the
D of Members notified from CRS that a patient is coming in health plan still has the responsibility of
or out, what is the plan's responsibility of providing all covered services for the
transition and to whom? member that are not included as CRS covered
services for the CRS enrolled diagnosis
(refer to CRS covered diagnosis list). CRS
and the health plan are expected to
coordinate applicable services such as DME,
prescriptions, etc as they pertain in the
transition.
- ------------------------------------------------------------------------------------------------------------------------------------
24 21 Sect #9--Transition Are PCP's still required to have dental service No, dental treatment records are not
D of Members reports in the medical record? required in the PCP chart. However, record
of any verbal referrals/recommendations by
the PCP for dental services should be
documented in the patient
- ------------------------------------------------------------------------------------------------------------------------------------
5
- -----------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- -----------------------------------------------------------------------------------------------------------------------------------
record maintained by the PCP.
- ------------------------------------------------------------------------------------------------------------------------------------
25 21 Sect #10--Scope of CRS is currently under procurement for a new If an award is made to a new CRS
D Services (CRS- contractor. How will that new contract's contractor, the AHCCCS contractors would be
last paragraph operations impact coordination of services with responsible for coordinating care with and
AHCCCSA health plans and what will be the referring potentially eligible members to
financial impacts of any contract changes to a the new contractor. It is not anticipated
health plan? that this will have any financial impact to
AHCCCS contractors.
- ------------------------------------------------------------------------------------------------------------------------------------
26 22 Sect #10--Scope of Who is financially responsible for services if In this instance the member (family or
D Services (CRS- the CRS eligible and enrolled member does not guardian) is responsible for payment. The
last paragraph) utilize CRS services? The AMPM Section 400 member is choosing to go out of network for
references medical care paid by the plan to an services. However, it is AHCCCSA's
eligible, enrolled member when CRS fails to expectation that Health Plans assist
provide timely services. It does not address members in understanding the services
which entity pays for the medical expenses if delivery system and that plans facilitate
the member is an eligible, enrolled CRS the members use of CRS.
patient, but refuses to use their services.
Under these circumstances, does the health plan
continue to pay for medical services or are we
not obligated to pay for the CRS covered
services because of CRS eligibility and
enrollment?
- ------------------------------------------------------------------------------------------------------------------------------------
27 23 Sect #10-- Scope of Please clarify: how does this apply to out of Providers must register with AHCCCS to be
D Services state providers who are not contracted with the eligible for payment. A contract with the
(Emergency plan or AHCCCS? What if a provider refuses to health plan is not required. Registered
Services, last register with AHCCCS? Can they bill the member? providers may not bill members for
sentence) Is there a statute to protect the member from medically necessary covered services.
billing/collections/by out of state providers? AHCCCS is not aware of a statute that
Is there a quick registration process for protects members from billing/collections
out-of state providers? by unregistered, out of state providers.
State rule prohibits billing of Medicaid
members for medically necessary covered
services. AHCCCS does have a simplified
registration form for single use providers.
- ------------------------------------------------------------------------------------------------------------------------------------
28 23 Sect #10-- Scope of EPSDT - What are the health plans' specific When this information has not already been
D Services responsibilities in terms of "follow-up" with a received from the member or the RBHA, the
RBHA to monitor whether members have received Contractor is expected to contact the RBHA
behavioral health services? to ensure that the member has either been
scheduled or seen for an appointment or
that the member has refused behavioral
health services from the RBHA.
- ------------------------------------------------------------------------------------------------------------------------------------
29 23-24 Sect #10-- Scope of Emergency Services - Please confirm that the 10 Analysis re BBA Emergency notification
D Services calendar day requirement applies only to the requirements is ongoing and further
(Emergency notification of emergency services and not to clarification will be forthcoming.
Services, last any inpatient stay admission resulting from an
sentence) emergency department visit. Please confirm that
the 10 calendar day requirement is unrelated to
the 1 hour response time required.
- ------------------------------------------------------------------------------------------------------------------------------------
6
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
30 24 Sect #10, Scope of In bullet point #2, clarification is needed Analysis re BBA Emergency notification
D Services regarding notification. Does this mean the requirements is ongoing and further
(Emergency EMERGENCY ROOM services must have notification clarification will be forthcoming.
Services, to the health plan within 10 days?
paragraph 2, By screening and treatment are you including The Offerors should assume that there will
#2) admissions to the hospital and work up and be no changes to program costs for this
treatment? If so does the facility have 10 days provision when developing capitation rate
to notify the health plan of admission? bids.
Does this mean there will be no concurrent
review process for any member admitted through
the Emergency Room?
- ------------------------------------------------------------------------------------------------------------------------------------
31 24 Sect #10, Scope of "A member who has an emergency medical The issue of authorization is different
D Services condition may not be held liable for payment of from that of patient financial
(Emergency subsequent screening and treatment needed to responsibility. Authorization may still be
Services, diagnose the specific condition or stabilize required for follow-up done after the
paragraph 3) the patient". Does this statement mean that patient is stabilized. Prior Authorization
authorization would not be needed for follow up is not a guarantee of payment.
visits resulting from the ER visits?
- ------------------------------------------------------------------------------------------------------------------------------------
32 24 Sect #10-- Scope of Emergency services-- How long does a provider The new notification requirements per BBA
D Services of emergency services now have to notify the are within 10 calendar days for emergency
(Emergency plan to ensure payment, or is there no time services. Analysis regarding BBA Emergency
Services) limit? notification requirements is ongoing and
further clarification will be forthcoming.
- ------------------------------------------------------------------------------------------------------------------------------------
33 25 Sect #10--Scope of Observation services may be provided on Please see the AMPM Policy 310, Observation
D Services outpatient basis if determined Services for clarification.
(Hospital) reasonable...when deciding if member should be
admitted for inpatient care. There is no
specification of the time frame (prior
contracts have indicated up to 24 hours).
1. Is the absence of a time designation meant
that AHCCCS will be following the 48-hour
Medicare standard?
2. If the time frame is expanded from 24 to 48
hours, what criteria are going to be used to
determine that the extended stay to 48 hours
was appropriate as observation versus
inpatient?
- ------------------------------------------------------------------------------------------------------------------------------------
34 25 Sect # 10--Scope What is meaning/financial impact of removing Please see the AMPM Policy 310, Observation
D of Services 24-hour limit from observation services? Services for clarification. The financial
impact is unknown at this time.
- ------------------------------------------------------------------------------------------------------------------------------------
7
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
(Hospital)
- ------------------------------------------------------------------------------------------------------------------------------------
35 25 Sect # 10--Scope of What are the adult immunization performance AHCCCS has not established adult
D Services standards? immunization performance indicators for the
(Immunizations) acute care population.
- ------------------------------------------------------------------------------------------------------------------------------------
36 26 Sect #10--Scope of What would occur when a member no longer The Health Plan is responsible for
D Services requires the skilled services of a convalescent providing medically necessary covered
(Nursing care stay, but a discharge from the facility is services. Facility coverage is not limited
Facility) deemed inappropriate for a specific reason? For to the skilled level of care.
example, Mr. Smith is admitted to a skilled
nursing facility for Rehab Services (OT and
PT), after a hip replacement. A week into his
stay, he is discharged from therapies because
he is unable or unwilling to participate. Mr.
Smith no longer meets the criteria for a
convalescent care stay, but he is still not
able to care for himself in his previous living
arrangement, and a discharge from the skilled
nursing facility is not appropriate because of
safely issues.
- ------------------------------------------------------------------------------------------------------------------------------------
37 26 Sect #10--Scope of Can this member (see above question) be kept in There is no prohibition against health
D Services the facility at a lower level (e.g. a custodial plans negotiating rates at a lower level of
(Nursing care level) until the discharge is appropriate? care. AHCCCS does not require notification.
Facility) If this is possible, how would AHCCCSA like to Days at a lower level of care do count
be notified, and would the custodial care days toward the 90-day contract year maximum
still need to be counted toward the 90 day benefit.
contract year maximum benefit?
- ------------------------------------------------------------------------------------------------------------------------------------
38 27 Sect #10, Scope of In bullet #2, is 1 hour the correct time for One hour is the correct time for approval
D Services approval of post-stabilization care services at of post-stabilization care services
(Post- non-contracted facilities? approval requests for all providers both
stabilization Who will determine the 1-hour time frame? Will contracted and non-contracted.
Care Services telephone logs be used to verify? Both hospitals and plans will likely
Coverage and document the one-hour timeframe and
Payment, telephone logs may be one method to
paragraph 2, accomplish this.
#2.) Further clarification regarding BBA
requirements will be forthcoming.
- ------------------------------------------------------------------------------------------------------------------------------------
39 27 Sect #10, Scope of In bullet #3 A Contractor's physician with AHCCCS expects treating physicians to act
D Services (Post- privileges at the treating hospital ASSUMES in the best interests of the member. Issues
stabilization responsibility for the member's care. What such as this should be brought to the plan
Care Services happens when the Contractor's physician with Medical Director for resolution.
Coverage and privileges at the treating hospital is ready
and willing to assume the care but
- ------------------------------------------------------------------------------------------------------------------------------------
8
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
Payment, the non-contracted Attending physician will not
paragraph 3, relinquish care?
#3.)
- ------------------------------------------------------------------------------------------------------------------------------------
40 27 Sect # 10, Scope of Is there any information on expected financial Based upon 18 months of experience with
D Services, impact of policy change? this policy, AHCCCSA believes that the
(Pregnancy financial impact is not material, and
Terminations) capitation rates will not be adjusted for
this policy change.
- ------------------------------------------------------------------------------------------------------------------------------------
41 27 Sect #10, Scope of Post Stabilization - The RFP implies a If authorization is not provided within one
D Services contractor must respond to authorization hour, services are deemed authorized.
(Post- requests within one hour. If not, are services Methods to monitor this performance
stabilization deemed approved? How will AHCCCSA evaluate requirement will be developed. Further
Care Services health plans' performance of this requirement? analysis of BBA will be completed and
Coverage and additional information will be forthcoming.
Payment,
paragraph 2,
#2.)
- ------------------------------------------------------------------------------------------------------------------------------------
42 28 Sect # 10-- Scope of Omitted...not used as a maintenance regimen... Please clarify and resubmit the question.
D Services Is this changing or does the phrase "potential
for improvement" cover this?
- ------------------------------------------------------------------------------------------------------------------------------------
43 28 Sect # 10--Scope Will pharmacy carve-out include OTC items The pharmacy carve out will include those
D of Services currently being provided by health plans, for OTC items that require a prescription.
(Prescription example, condoms and nutritional supplements?
Drugs)
- ------------------------------------------------------------------------------------------------------------------------------------
44 28 Sect #10--Scope of Give examples of medically necessary Includes but is not limited to
D Services transportation. transportation for well child care,
(Transportation, prenatal appointments, urgent medical
first sentence) appointments, prescription pick-up at
pharmacy, ambulance transportation and
other services that are medically
necessary.
- ------------------------------------------------------------------------------------------------------------------------------------
45 29 Sect #10--Scope What is the timeline for new or revised The deadline is October 1, 2003. As
D of Services policies in AMPM regarding Special Health Care clarification is available it will be
Needs? published.
- ------------------------------------------------------------------------------------------------------------------------------------
46 29 Sect #12-- "AHCCCS members are eligible for comprehensive No, SFP members are not eligible for
D Behavioral behavioral health services" - This indicates behavioral health services. This will be
Health that Family Planning members would also have clarified in the RFP document at a future
Services, this benefit, is this correct? date.
paragraph 1
- ------------------------------------------------------------------------------------------------------------------------------------
47 30 Sect #12-- In previous publications the PCP was allowed to Since the inception of the psychiatric
D Behavioral provide medication management for members with medication initiative in October of 1999,
Health diagnoses of MILD TO MODERATE depression, MILD which allows health plan PCPs to prescribe
Services, TO MODERATE anxiety and attention deficit for certain behavioral health disorders
within the scope of their practice, the
contract language has remained the same.
The
- ------------------------------------------------------------------------------------------------------------------------------------
9
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
Medication hyperactivity disorder. Were the words mild to words "mild", "minor", or "moderate" have
Management moderate intentionally left out? not been in contract and there is no change
Services, in the expectation. AHCCCS policy (AMPM
paragraph 1 310) and the guiding principles published
in September 1999 refer to ADD/ADHD, mild
depression, and anxiety disorders as those
which may be managed by the health plan
PCP.
- ------------------------------------------------------------------------------------------------------------------------------------
48 30 Sect #12-- "The Contractor shall allow PCPs to provide Please refer to the answer for question 47.
D Behavioral medication management services (prescription,
Health medication monitoring visits, laboratory, and
Services other diagnostic test necessary for diagnosis
and treatment of behavioral disorders) to
members with diagnoses of depression, anxiety
and attention deficit hyperactivity disorder."
As this statement does not specify that the PCP
may treat "mild" or "minor" depression, please
clarify whether the expectation has changed
from the original guiding principles published
Sept 1999.
- ------------------------------------------------------------------------------------------------------------------------------------
49 30 Sect #12-- Does AHCCCSA have any guidelines for the No, AHCCCS does not have guidelines
D Behavioral monitoring of PCP management of behavioral specific to the monitoring of PCPs'
Health health disorders? management of behavioral health disorders.
Services
- ------------------------------------------------------------------------------------------------------------------------------------
50 31 Sect #14-- Medicaid Regarding transfer of medical information The MIPS program provides reimbursement for
D in the Public between the Contractor and the member's school school districts that are registered
Schools, last or school district. ...Isn't that a violation providers. The relationship between a
paragraph of the HIPAA privacy standard? Would the Health health plan and a provider does not
Plan have to have a Business Associate Contract constitute a business associate
with the schools or school districts? relationship. See 65 Fed. Reg. 82476 (Dec.
28, 2000). Disclosure for purposes of
treatment, payment and certain health care
operations are permitted by the rules and
do not necessarily require a business
associate agreement. 45 CFR 164.506.
"Payment" activities include coordination
of benefits. "Treatment" includes
activities by a provider to coordinate care
with a third party. 45 CFR 164.501
- ------------------------------------------------------------------------------------------------------------------------------------
51 31 Sect #14-(MIPS)- The RFP states, "Contractors and their The intent of the policy is to prevent
D last paragraph providers must coordinate with schools and duplication of service. Contractors can be
school districts that provide MIPS services to notified via a DDD support coordinator, a
the Contractor's enrolled members." Is the parent, a school provider or the school.
intent of this new requirement simply to ensure AHCCCS will not be providing this
that services are not duplicative? How are information on the FYI file. Plans are
contractors notified when a school or school required to coordinate care with the most
district is working with a special needs child? appropriate entity to best meet the needs
Is AHCCCSA going to provide this of the members. Please see HIPAA response
given previously. Yes, the school districts
have expressed a desire to coordinate with
the health plans.
- ------------------------------------------------------------------------------------------------------------------------------------
10
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
information on the monthly FYI file? Are we
coordinating with the school or school district
or the providers that actually provide the
services? Has consideration been given to the
HIPAA implications? Have the schools/school
districts indicated that they are willing to
work with the health plans?
- ------------------------------------------------------------------------------------------------------------------------------------
52 31 Sect #14-(MIPS)- Please clarify responsibilities of both the Please refer to the answers for questions
D last paragraph health plan and a school in sharing/generating #50 and #51.
appropriate medical record requirements? (i.e.
transfers of member medical information)
- ------------------------------------------------------------------------------------------------------------------------------------
53 32 Secti #16-- Staff Define difference between Compliance Officer, The staffing requirement for a Compliance
on D Requirements contract YH04 vs. Fraud and Abuse Coordinator, Officer is in the current contract. The
and Support and contract YH03? difference between the two positions is the
Services, item Compliance Officer is considered a key
n. position and must be a senior on-site
employee. The function is similar to that
of the Fraud and Abuse Coordinator, with
the additional responsibility to oversee
the implementation of a compliance program
as outlined in Paragraph 62 of the RFP. The
Compliance Officer should continue to
attend the AHCCCS Fraud and Abuse
Workgroup.
- ------------------------------------------------------------------------------------------------------------------------------------
54 32 Sect #16-- Staff This section states that a Grievance Manager is The 2 position titles are not
D Requirements a required position, this is also restated on interchangeable. As part of the staff
and Support page 33, however, on page 92, Section G, requirements in paragraph 16, AHCCCS
Services, item Offeror's Key Personnel, and the position is requires a Grievance Manager who is
m. listed as Grievance Coordinator. Is it the responsible for the oversight of the
intent of AHCCCSA to require a Grievance contractor's Grievance System. The
Manager or Coordinator? Are these two titles reference to Grievance Coordinator on p. 92
interchangeable? is incorrect and should be changed to
Grievance Manager.
- ------------------------------------------------------------------------------------------------------------------------------------
55 34 Sect #18-- Member The RFP states affected members must be Other changes include, but are not limited
D Information, informed of any other changes in the network 30 to turnover in DME providers and provider
last paragraph days prior to the implementation date of the address changes.
change. Please define "other" changes in the
network and provide examples.
- ------------------------------------------------------------------------------------------------------------------------------------
56 34 Sect #18-- Member Termination of a contracted provider: Does this Yes, for members who were seeing the
D Information, include specialty providers? specialist on a regular basis.
last paragraph
- ------------------------------------------------------------------------------------------------------------------------------------
57 34 Sect #18-- Member What does AHCCCSA consider to be "program Changes in cost sharing or covered services
D Information, changes" that require notification be provided would be examples of program changes.
last paragraph to "affected members"?
- ------------------------------------------------------------------------------------------------------------------------------------
58 36 Sect #22. Advance In referring to written information to adult The sentence should read, "(4) Changes to
D Directives, enrollees, what is meant by (4): "Changes to State law as soon as possible..."
last State as soon as
- ------------------------------------------------------------------------------------------------------------------------------------
11
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
paragraph possible, but no later than 90 days after the
effective date of the change?" Does this
requirement conflict with other disseminated
information to member approval requirements?
- ------------------------------------------------------------------------------------------------------------------------------------
59 37 Sect # 24-- What is the responsibility of the Health Plan The Health Plans are responsible for
D Performance when a response is not received from AHCCCS in continuing to improve Performance Indicator
Standards, a timely manner as it states that a corrective rates, and it is expected that health plans
last paragraph action plan "must be approved by AHCCCS prior will develop and implement interventions
to implementation"? that will assist them in achieving, at a
Will the health plan be given sufficient time minimum, the AHCCCS Minimum Performance
i.e. (6-9 months) after the date of AHCCCS Standard. The amount of time a health plan
approval to demonstrate improvement? will be given to implement a corrective
action plans depends upon the severity of
the issue needing correction and the
proposed plan.
- ------------------------------------------------------------------------------------------------------------------------------------
60 37 Sect # 24-- On what are the minimum performance standards The AHCCCS Minimum Performance Standards
D Performance based? are derived from a formula that includes,
Standards but is not limited to previous Performance
Indicator rates and statewide averages.
- ------------------------------------------------------------------------------------------------------------------------------------
61 37 Sect # 24-- As it relates to levels of performance, please Demonstrable is statistically significant
D Performance define "demonstrable and sustained and sustained is for more than 1 year.
Standards improvement."
- ------------------------------------------------------------------------------------------------------------------------------------
62 39 Sect # 24-- In the current contract, health plans are The current contract states "AHCCCSA will
D Performance required to report the results of Provider continue to measure and report results for
Standards Turnovers and Interpreter Services. Will this the Performance Measures..." This
still be required under the new contract? measurement and reporting will continue,
but because these are not considered
Performance Standards, the information was
removed from the RFP.
- ------------------------------------------------------------------------------------------------------------------------------------
63 40 Sect #27--Network "For Maricopa and Pima Counties only, this To clarify, the adjective "metropolitan" is
D Development includes a network such that 95% of its members describing Phoenix only. Metropolitan
residing within the boundary area of Phoenix includes other cities as shown on
metropolitan Phoenix and Tucson do not have to the GSA map for Maricopa County. In Pima
travel more than 5 miles to see a PCP, dentist County, this standard applies only to the
or pharmacy." city of Tucson.
Attachment B, page 115--"In Tucson (GSA 10) and Attachment B, Page 115. Last paragraph
Metropolitan Phoenix (GSA 12), the Contractor should read, "In Tucson (GSA 10) and
must demonstrate its ability to provide PCP Metropolitan Phoenix (GSA 12), the
dental and Pharmacy services so that the member Contractor must demonstrate its ability to
so not have to travel more than 5 miles from provide PCP, dental and pharmacy services
their residence. to that 95% of members do not have to
travel more than 5 miles from their
There seems to be an apparent conflict between residence."
the wording in the Network Development in
paragraph 27, and Attachment B, page 115. Can
you please
- ------------------------------------------------------------------------------------------------------------------------------------
12
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
clarify which applies and define metropolitan
Tucson?
- ------------------------------------------------------------------------------------------------------------------------------------
64 40 Sect # 27 Network "Contractors must provide a comprehensive The Contractor is asked to identify network
D Development provider network that ensures its membership gaps in its own annual Provider Network
has access at least equal to, or better than, Development and Management plan. In
community norms." How will AHCCCS determine addition, AHCCCSA will utilize information
community norms? from licensing boards, commercial insurers
and other publicly available materials to
determine provider availability.
- ------------------------------------------------------------------------------------------------------------------------------------
65 40 Sect # 27 Network "Access is supposed to be equal or better than The Agency will not advise Offerors about
D Development community norm." How will a potential Offeror improving their submission.
best demonstrate such access measures/
benchmarks in a successful proposal?
- ------------------------------------------------------------------------------------------------------------------------------------
66 40 Sect # 27 Network Provider Network Development and Management The Agency will not advise Offerors about
D Development Plan - The plan is to consider access of improving their submission.
members to specialty care compared to the
general population in the community. How will a
potential Offeror best demonstrate such access
in a successful proposal? How will this
criterion be measured (i.e. what is the
benchmark(s) that will be used?)?
- ------------------------------------------------------------------------------------------------------------------------------------
67 40 Sect # 27 Network Provider Network Development and Management The Bidder should use its best judgment in
D Development Plan - deciding how far in the future projected
What is the time period the health plans should needs should be assessed in order to
use for "projecting future needs", e.g., one maintain an accessible network, capable of
year? delivering covered services for the
contract period.
- ------------------------------------------------------------------------------------------------------------------------------------
68 40 Sect # 27 Network How does the requirement to consider providers Providers whose service address is outside
D Development in neighboring states in terms of network of Arizona must be licensed in the state in
development reconcile with the requirement that which they provide services.
health plan providers must be licensed in
Arizona? Also, how does this apply to
out-of-state hospitals?
- ------------------------------------------------------------------------------------------------------------------------------------
69 41 Sect # 27 Network Provider Network Development and Management The Offeror should use its expertise and
D Development Plan - judgment to identify those populations with
How is AHCCCSA defining "specialty populations" network needs different than the majority
for the purpose of this plan, and what type of of members in the GSA, who would need
information does AHCCCSA want addressed special consideration in the design of the
regarding specialty populations as it relates network.
to the plan?
- ------------------------------------------------------------------------------------------------------------------------------------
70 41 Sect # 29--Network Re: notifications of significant network The turnaround time will be dependent upon
D Management changes. In the past, AHCCCSA stated that it the circumstances, such as complexity of
would respond within 14 days. What will be the corrective action plan. As stated in
AHCCCSA's turnaround time(s) for approvals of the paragraph, AHCCCSA will expedite the
corrective actions process in an emergency.
- ------------------------------------------------------------------------------------------------------------------------------------
13
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
arising from such notifications?
- ------------------------------------------------------------------------------------------------------------------------------------
71 41 Sect # 29--Network For contractor policies, what does "subject to "Subject to approval" means the Agency has
D Management approval" by AHCCCSA mean? Is AHCCCSA approval approval authority over the policies during
limited only to network management policies or an operational audit. It is not limited to
all contractor policies? Will existing plans network policies only. Contractors will be
have to submit their policies for approval? notified of pending operational audits.
- ------------------------------------------------------------------------------------------------------------------------------------
72 42 Sect #30--Primary Once the contractor had determined that No. The Contractor, however, is expected to
D Care Provider appointment availability has not been ensure that quality of care standards
Standards compromised will action still be required continue to be met by such providers. The
should the panel size exceed 1800? information may also suggest that the
Contractor should recruit additional
providers to serve members in that area.
- ------------------------------------------------------------------------------------------------------------------------------------
73 43 Sect #32-- Referral "Referral to Medicare HMO including payment of The Contractor must have written policies
D Procedures co-payments". Please explain this requirement. on their Medicare Cost Sharing
and Standards, responsibilities that should include
paragraph 1, copayment responsibilities when a member is
item g. referred to a Medicare HMO.
- ------------------------------------------------------------------------------------------------------------------------------------
74 45 Sect #35--Provider The RFP states, "The contractor remains liable There are a number of "applicable"
D Manual for ensuring that all providers, WHETHER requirements that the health plan is
CONTRACTED OR NOT, meet the applicable AHCCCSA responsible for, regardless of the
requirements." What are a health plan's providers' contract status. Examples
obligations to non-contracted providers? Please include, but are not limited to, ensure
define or further clarify "applicable non-contracted providers do not bill
requirements." members for covered services, that
claims/encounter data is submitted if a
financial liability is incurred by the
Contractor, and that the health plan
coordinates benefits.
- ------------------------------------------------------------------------------------------------------------------------------------
75 47 Sect # 37-- Would the "use of provider more than 25 times" Yes, the Contractor would be responsible
D Subcontracts, include hospitals where members are admitted for contracting with physicians who have
paragraph 5 through the Emergency Department? admitting privileges. The Contractor would
be encouraged to contract with the
hospital.
- ------------------------------------------------------------------------------------------------------------------------------------
76 47 Sect # 37-- "The Contractor must enter into a written AHCCCSA is requiring a contract for
D Subcontracts agreement with any provider (including providers used more than 25 times a year,
out-of-state providers) the Contractor regardless of the number of services
reasonably anticipates will be providing provided or members seen.
services on its behalf more than 25 times
during the contract year." Can this be applied
to one individual receiving 25 services form
one provider, or is it for 25 unique members?
- -----------------------------------------------------------------------------------------------------------------------------------
77 48 Sect #39--Specialty With the high potential for AHCCCSA to develop This section refers to contracts that
D Contracts specialty contracts going forward, (i.e. AHCCCSA negotiates on behalf of its
pharmacy) can AHCCCSA provide additional Contractors. Currently, the only specialty
details on how the process might work (i.e. contract AHCCCS is negotiating is for
health plan involvement, adjustments to transplant services. These specialty
capitation rates, reporting contracts are for services provided through
the health plans and should not be confused
with a carve out of services.
- ------------------------------------------------------------------------------------------------------------------------------------
14
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
requirements (both to and form AHCCCSA), claims In the event AHCCCSA carves out the
payment, recovery/reinsurance, TPL related responsibility for certain medical services
issues)? from its Contractors, AHCCCSA will solicit
feedback from its Contractors, capitation
rates will be adjusted and other operating
issues will be addressed. Because AHCCCSA
is not currently in the process of
developing a carve out, it is unknown what
impact a carve out would have on health
plan reporting and involvement. That would
need to be addressed on a case by case
basis depending upon the type of service
that is carved out.
- ------------------------------------------------------------------------------------------------------------------------------------
78 49 Sect #40--Hospital For Maricopa and Pima counties, the RFP states The Office of Managed Care will accept
D Subcontracting that, "The Contractor shall submit all hospital hospital subcontracts and amendments for
and subcontracts and any amendments to AHCCCSA, review and approval after contract awards
Reimbursement Office of Managed Care". For all counties are made. It is suggested that they be
EXCEPT Maricopa and Pima it states, "The submitted as soon after the award that the
Contractor is encouraged to obtain subcontracts contracts and amendments are complete to
with hospitals in all GSA's and must submit allow time for the process, prior to
copies of these subcontracts, including implementation.
amendments, to AHCCCSA, Office of Managed Care,
at least seven days prior to the effective
dates thereof". What requirements exist (for
incumbents bidding on new GSA's and new
contractors) to have the Maricopa and Pima
hospital contracts (or any other contract as
required by the RFP) reviewed by AHCCCSA prior
to implementation?
- ------------------------------------------------------------------------------------------------------------------------------------
79 49 Sect #40--Hospital Hospital Recoupments - Does AHCCCSA have a AHCCCSA is developing an informal policy
D Subcontracting policy regarding recoupment of capitation from related to this issue. Essentially, medical
and one health plan and paid to another when expenditures incurred in these situations
Reimbursement retroactive enrollment occurs, and the initial should be treated like expenditures
health plan has paid claims to a provider who incurred during the PPC time period. That
was not aware of the enrollment change until means, claims should not be denied for lack
notified of recoupment (which often occurs of prior authorization, but may be denied
after claims submission timeframes)? if reviewed for medical necessity, and the
second health plan determines that the
services were not medically necessary.
- ------------------------------------------------------------------------------------------------------------------------------------
80 49 Sect #40--Hospital In the Data Supplement, Offerors are instructed Instructions given in the data supplement
71 D Subcontracting to consider the Maricopa/Pima counties should be considered a valid RFP
116 and contracting pilot project to be extended beyond instruction.
Reimbursement September 30, 2003. This is also reiterated in
Amendment #1 dated February 10, 2003. Is the
Data Supplement to be considered a part of the
contract and RFP, and a
- ------------------------------------------------------------------------------------------------------------------------------------
15
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
valid RFP instruction?
- ------------------------------------------------------------------------------------------------------------------------------------
81 49 Sect #40--Hospital Out of State Hospitals - Given that Attachment Although, Contractors are encouraged to
119 D Subcontracting B represents AHCCCSA's minimum network contract with hospitals, they are required
120 and requirements, how would a potential Offeror to have contracts with physicians with
Reimbursement successfully address any potential network admitting privileges to hospitals
deficiencies if Offeror is only "strongly considered to be a part of the network.
encouraged" but not required to contract with This is true whether the hospital is
these out of state providers? (e.g. regarding in-state or out of state.
out of state providers listed for GSAs 2 and 4)
- ------------------------------------------------------------------------------------------------------------------------------------
82 50 Sect #42-- "The Contractor shall disclose to AHCCCSA the This question needs to be clarified. Refer
D Physician information on physician incentive plans listed to the Physician Incentive Plan regulations
Incentives in 42 CFR 417.479(h)(I) through 417.479(i) upon for AHCCCS's responsibility in monitoring
contract renewal, prior to initiation of a new compliance with those regulations. The
contract, or upon request from AHCCCSA or CMS." annual disclosure reporting requirement is
Question: Is CMS providing the state oversight on hold until CMS develops a new disclosure
in respect to physician incentives? form. All other provisions will continue to
be enforced.
AHCCCS is required to report to CMS on its
Contractor's compliance with those
regulations.
- ------------------------------------------------------------------------------------------------------------------------------------
83 51 Sect #45--Minimum "Continuing Offerors that are bidding a new GSA A current Contractor is considered an
D Capitalization must provide the additional capitalization for existing offeror in all counties to be bid.
Requirements the new GSA they are bidding."
Question: Is the capitalization requirement for
UFC going into Cochise/Graham/Greenlee, the
amount for New Contractors or for Existing
Contractors?
- ------------------------------------------------------------------------------------------------------------------------------------
84 51 Sect #45-- Minimum Please clarify what the minimum capitalization The minimum capitalization requirement for
D Capitalization requirements are for continuing offerors bidders is what is listed in the table.
Requirements bidding a new GSA. Is it the equity per member However, a Contractor must also meet it's
standard or the capitalization requirements for equity per member standard after the
new contractors presented in the table? contract is awarded. If the bidder meets
its minimum capitalization, but doesn't
meet its equity per member standard, then
the bidder must develop a plan to meet that
standard should they be awarded a contract.
- ------------------------------------------------------------------------------------------------------------------------------------
85 51 Sect #45--Minimum Since the current RFP realigns some counties in A current Contract is always considered an
D Capitalization new GSA's, is a contractor that is currently an existing contractor for capitalization
Requirements incumbent in one of the county (s) in the GSA purposes. Refer to the Performance
but not the other county (s) considered to be Bond/Equity Per Member Policy for questions
an existing contractor for purposes of the regarding encumbrances on equity. The
minimum capitalization requirements? If a maximum capitalization that a bidder must
contractor uses an irrevocable letter of credit have to secure an award is $10,000,000.
(LOC) to meet its performance bond requirement However, the Contractor must also meet the
as described in the RFP, is it correct to say equity per member requirement. If the
that AHCCCSA will not $10,000,000 does not meet the requirement,
then additional capital must be provided.
- ------------------------------------------------------------------------------------------------------------------------------------
16
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
consider the LOC an encumbrance or a loan
subject to repayment (since the LOC is truly
an off balance sheet item and has no
outstanding balance owed) as described in the
minimum capitalization requirements?
Regardless of the number of GSA's a
contractor is awarded, is it correct to say
that the maximum amount of capitalization or
equity a contractor is required to meet is
$10,000,000?
51 Sect #45--Minimum Please explain the rationale for the Yavapai The methodology that was used to determine
D Capitalization County minimum capitalization requirements the amount of the "existing offerors" minimum
Requirements being the same for both new and incumbent capitalization requirement resulted in an
contractors. amount in excess of what the equity per
member amount would be. Therefore, the
existing offeror's minimum was limited to the
equity per member amount.
86 51 SD #45--Minimum If an Offeror is currently an incumbent Incumbent.
Capitalization health plan in a county that is included in a
Requirements "new" GSA (e.g. for GSA 4, in one county and
not all), then will that incumbent health
plan be considered an incumbent health plan
or a "new" Offeror in that "new" GSA for
proposal submission requirement purposes?
87 52 Sect #47--Amount For the Performance Bond specifications it This does mean termination date, and that
D of Performance indicates that it must be effective for 15 clarification will be made in the document
Bond months following the effective date of the at a future date.
contract...should this be 15 months from the
termination date of the contract?
88 52 Sect #47--Amount of Will you allow one performance bond from Yes.
D Performance Yavapai County listing both Yavapai County
Bond Long Term Care and the acute care program?
89 53 Sect #49-- When does AHCCCSA anticipate making changes OMC anticipates that the revised guide will
D Advances, to the "AHCCCSA Reporting Guide for Acute be available by May 2003. Please note that
Distribution, Care Contractors"? reporting requirements will not change.
Loans and
Investments
90 53 Sect #50--Financial What is the AHCCCSA definition of Cash or investments that can be converted to
D Viability "liquid assets"? cash within 3 business days.
Standards/Perf
ormance
Guidelines
91 53-54 Sect #50--Financial How can AHCCCSA be assured that the positive AHCCCSA monitors several areas of health plan
D Viability financial performance of a health plan is not operations to ensure that members are
Standards/Perf the result of not providing all necessary receiving appropriate services including,
covered types of member grievances for denied
services.
17
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
ormance services, or limiting access to
Guidelines sub-specialists, thereby causing the more
expensive members to select another health
plan?
92 54 Sect #50--Financial How many incumbent health plans in each of Because this ratio varies from quarter to
D Viability the past three (3) years have had Medical quarter, several plans have had Medical
Standards/Perf Expense Ratios of less than 85%? Expense Ratios of less than 85% at various
ormance times.
Guidelines
93 54 Secti #50--Financial Provide clarification on what is meant by Assets that are set aside on the balance
on D Viability "on balance sheet" performance bond. sheet for the stated purpose of a performance
Standards/Perf bond,
ormance
94 54 Sect #51--Separate Is it the intent of the separate All lines of AHCCCS business must be included
D Incorporation incorporation requirement that a separate in one separate corporation--not separately
corporation be established for various lines incorporated. Separate reporting to AHCCCS
of AHCCCSA business (i.e. Acute Care, ALTCS for these lines of business will continue to
and Health Care Group) or may these lines of be required.
AHCCCSA business be part of one corporate
entity as long as separate mandated reporting
can be done for each line of AHCCCSA business?
95 54 Sect #50--Financial What is AHCCCSA's intent in lowering the Because successful medical management and the
150 D Viability Medical Expense Ratio requirement to 80%? implementation of disease management programs
Standards/Perf Please explain the potential impacts on can contribute to lower Medical Expense
ormance capitation rates. Ratios, AHCCCSA felt that its Contractors
Guidelines should not be discouraged from pursuing these
managed care avenues by potential failure to
be in compliance with a financial standard.
This does not impact capitation rate
development.
96 55 Sect #53-- Related to the reconciliation process for PPC AHCCCSA will use the administrative
D Compensation costs, what administration percentage does percentage that is built into the capitation
AHCCCSA intend to use in the reconciliation rates. The policy will be updated to reflect
calculation? In the PPC Reconciliation the elimination of PPC reinsurance in the
Policy, the calculation includes a reduction future.
for reinsurance. Should this not be deleted
from the policy as explained in paragraph 58
on page 58 of the RFP "Effective October 1,
2003, AHCCCSA will no longer cover PPC
inpatient expenses under the reinsurance
program..." Or are there medical expenditures
related to PPC members that still qualify for
the reinsurance program?
97 55 Sect #53-- Would "programmatic changes that affect Yes, programmatic changes include all
service categories
18
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
D Compensation reimbursement" include the anticipated impacted due a prescription drug In the
increase in in-patient stays or other event that prescription drugs are carved
associated medical expenditures associated out,
with carve out of pharmacy benefit?
Will AHCCCS be making adjustments in cap for AHCCCS will factor in the increases to
increase in malpractice insurance that is being provider payments due to malpractice
passed on through increases in contract rates with insurance premium increases.
providers?
- ------------------------------------------------------------------------------------------------------------------------------------
98 55 Sect #53-- In determining the various components of health The encounter utilization reports have
D Compensation plan reimbursement, how will AHCCCSA take into six months of CYE '02 data and financial
account the significant trends that have occurred data as reported by health plans have the
since January 1, 2002? For example, population full CYE '02 data. This data is used in the
changes have increased medical costs. development of capitation rates. The
information contained in this data plus
adjustments for trend and program changes
should account for increased utilization.
- ------------------------------------------------------------------------------------------------------------------------------------
99 55 Sect #53-- Given that C-section rates have increased to almost The rate development will be based upon
D Compensation 30% in the past 6 months, and are expected to recent actual delivery experience.
continue increasing due to malpractice Information provided by current Contractors
concerns and changing provider practices will also be utilized in developing future
(caused, among other things, by VBACs being c-section/vaginal delivery percentages. It
limited), how will AHCCCSA take into account is anticipated that there will be an
these factors in health plan capitation rate increase to the assumed percentage of
range development? babies delivered by C-section.
- ------------------------------------------------------------------------------------------------------------------------------------
101 55 Sect #53-- Given that AHCCCSA's historical rate increases The first statement is subjective, and
D Compensation have been well below actual health plan and market conflicts with the audited financial
trends, how will future capitation rate information OMC collects from its
increases be developed? Will AHCCCSA adjust contractors. [We also note with interest
its capitation rate increases to a targeted that the example chosen seems to conflict
Medical Expense Ratio? For example, if the with the first part of the question.] While
average of all health plans' profitability is 5%, health plan profitability is an important
and expense trends are increasing at 8% annually, input to rate-setting development, other
then will AHCCCSA pass along to the health plans factors must also be considered before
8% or 3%? reaching the conclusion rates are
actuarially sound.
- ------------------------------------------------------------------------------------------------------------------------------------
102 55 Sect #53-- When will all reimbursement rates that Offerors are AHCCCSA anticipates that the "set rates"
D Compensation not bidding on (by RFP instruction) be made will be available by April 1, 2003.
available to potential Offerors? (e.g. prior period
coverage, hospital supplemental payments,
HIV/AIDS supplemental payments, Title XIX Waiver
Group capitation, Title XIX Waiver Group hospital
supplemental payment etc.)
- ------------------------------------------------------------------------------------------------------------------------------------
19
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
103 55 Sect #53-- Prior Period Coverage - Please explain AHCCCSA's With the transition of the MNMI population
D Compensation rationale for discontinuing reinsurance for the PPC to the Title XIX Waiver Group, very little
population. Will AHCCCSA be taking this reinsurance is paid through PPC. Therefore,
circumstance into account when developing the PPC it did not seem cost effective to maintain
capitation rates being developed (that the Health the large administrative burden that it
plans are not bidding on)? puts on the agency. The small amount of
reinsurance paid for PPC claims will be
factored into the capitation rates.
- ------------------------------------------------------------------------------------------------------------------------------------
104 55 Sect #53-- Prior Period Coverage - What is the rationale for AHCCCSA believes that putting the PPC
D Compensation putting a retrospective period at risk, and on what time period at risk will encourage health
basis are AHCCCSA's actuaries developing rates for plans to review claims for medical
this program? necessity.
AHCCCSA's actuaries will use actual claims
paid data from the reconciliations to
develop the capitation rates. Furthermore,
the rates are reconciled.
- ------------------------------------------------------------------------------------------------------------------------------------
105a 55 Sect #53-- Prior Period Coverage - What assumptions regarding The assumptions will be released with the
D Compensation length of enrollment, enrollee choice, and capitation rates.
utilization and cost trends have been made
regarding this population?
- ------------------------------------------------------------------------------------------------------------------------------------
105b 55 Sect #53-- Prior Period Coverage Reconciliation - Why is AHCCCSA believes that putting the PPC time
D Compensation AHCCCSA putting the health plans at 2% risk when period at risk will encourage health plans
the health plans have no ability to manage this to review claims for medical necessity.
utilization and related costs? Please explain how
this will be accomplished when current PPC AHCCCSA has no evidence that the current
capitation rates may not be adequate. PPC rate is not adequate.
- ------------------------------------------------------------------------------------------------------------------------------------
107 56 Sect #53-- "Risk sharing for PPC reimbursement" - is the Yes.
D Compensation elimination of reinsurance also factored into the
rates?
- ------------------------------------------------------------------------------------------------------------------------------------
108 55 Sect #53-- Since PPC rates are done by AHCCCS actuaries Profit/loss is not build into capitation
D Compensation and not by the plans, what profit/loss did AHCCCS rates. Mercer builds a 2.0% risk
build in to the rate structure? contingency into the PPC rates.
- ------------------------------------------------------------------------------------------------------------------------------------
109 56 Sect #53-- Please provide a detail definition of the services Additional data will be distributed at the
D Compensation included in the delivery supplemental payment. Offeror's Conference. Please refer to the
Please provide detailed information on the DRGs, service matrix for coding and service
revenue codes, and CPT/HCPCS codes included in category.
the definition
- ------------------------------------------------------------------------------------------------------------------------------------
110 56 Sect #53-- Please provide details on how the hospitalized The hospital supplemental payment will be
D Compensation supplemental payment is calculated. calculated based on the costs of the first
hospitalization for members who were
hospitalized on the date of application.
Encounter data will be
- ------------------------------------------------------------------------------------------------------------------------------------
20
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
used to determine these costs.
- ------------------------------------------------------------------------------------------------------------------------------------
111 56 Sect #53-- Title XIX Waiver Group Rates - Will the existing AHCCCSA anticipates that it will continue
D Compensation member choice selection adjustment percentages with the choice adjustment.
remain in effect for Title XIX Waiver Group
members, and will those ranges apply to both the The TWG rates, including the hospitalized
AHCCCSA Care and MED groups? What assumptions supplemental payment, will be set by
underlie the ranges assigned for capitation rate Mercer. Rate ranges will not be developed
adjustments. under this methodology? for this group. A risk corridor will be
built around these rates.
- ------------------------------------------------------------------------------------------------------------------------------------
112 56 Sect #53-- Title XIX Waiver Group Rates - Will AHCCCSA AHCCCS will provide the assumptions
D Compensation share its assumptions regarding development of the regarding the development of the hospital
hospital supplemental payment? Will AHCCCSA supplemental payment at the time they are
provide application dates to the health plans in released.
order to allow them to track the receivables for
these payments? No, AHCCCSA does not have the application
dates to provide.
- ------------------------------------------------------------------------------------------------------------------------------------
113 56 Sect #53-- The RFP indicates that AHCCCSA may evaluate the The analysis has not been completed. AHCCCS
D Compensation cost experience of choice members versus those will continue to pursue this analysis.
who are auto-assigned. Has AHCCCSA
completed any such analysis, and will that
analysis be shared with Offerors prior to
the proposal due date?
- ------------------------------------------------------------------------------------------------------------------------------------
114 56 Sect #53-- Delivery Supplement - What specific cost An ad-hoc delivery report will be
D Compensation components comprise the delivery supplement distributed to all potential contractors at
payment? What period of time preceding and the bidders' conference to be held on
subsequent to the birth event should be included? Friday February 21, 2003. The delivery
supplemental payment covers costs from six
months prior to the delivery date, the
actual delivery, and two months post
delivery. The offset in the CRCS should be
eight months of capitation for the member.
- ------------------------------------------------------------------------------------------------------------------------------------
115 57 Sect #55-- If a member is hospitalized with a police guard, If the member meets any of the following
D Capitation are they considered incarcerated? If not, please criteria, they will be considered
Adjustments, provide the definition that is used by AHCCCS to incarcerated.
paragraph 2, qualify a member as "incarcerated."
item b The following are considered inmates:
1. an inmate in a DOC prisoner
2. an inmate of a county, city or
tribal jail
3. an inmate of a prison or jail prior
to conviction
4. an inmate of a prison or jail prior
to sentencing
5. an inmate of a prison or jail who
can leave prison or jail on work
release or work furlough and must
return at specific intervals
6. an inmate of a prison or jail who
can leave prison or jail on work
release or work furlough and must
return at specific intervals
- ------------------------------------------------------------------------------------------------------------------------------------
21
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
7. an inmate who receives outpatient
medical services outside of the
prison or jail setting.
- ------------------------------------------------------------------------------------------------------------------------------------
116 57 Sect #56-- As contractors will be required to post Contractors must post AHCCCS generated
D Incentives, Use clinical performance indicators on the Health performance indicators. These will not be
of Website, Plan web site, are these indicators AHCCCS posted prior to receiving Contractor
last paragraph generated numbers or health plan internal data? feedback.
- ------------------------------------------------------------------------------------------------------------------------------------
117 57 Sect #56-- Use of Web Site - Please confirm when this data AHCCCS will inform the plans when this
D Incentives, Use must be posted to a health plan's web site. information is required to be posted.
of Website, Available information will be posted in
last paragraph CYE '04.
- ------------------------------------------------------------------------------------------------------------------------------------
118 57 Sect #56-- On what contract year will the clinical As soon as reported by AHCCCS in 2005, for
D Incentives, Use performance indicator results be based to Contract Year 10/1/03 through 9/30/04.
of Website, adjust the auto-assignment algorithm? When
last paragraph will these clinical performance indicator
results be made available to the health plans?
- ------------------------------------------------------------------------------------------------------------------------------------
119 57 Sect #56-- 49. For prenatal care in the first trimester, AHCCCS uses the HEDIS specifications for
D Incentives, Use what definition of "trimester" will be used in definition of trimester. Healthy People
of Website, calculating the performance measures that will 2010 is the benchmark. Further
last paragraph impact the auto-assignment algorithm, and how clarification will be forthcoming.
will it be benchmarked? Examples to consider
for clarification include: first time seen
for this pregnancy, whether or not on
AHCCCS; first time seen on AHCCCS, whether or
not by current health plan or provider, and
first time seen by current health plan or
provider.
- ------------------------------------------------------------------------------------------------------------------------------------
120 58 Sect #56-- Related to the incentive fund (it is understood AHCCCSA is not considering a financial
D Incentives that the incentives would not take place until incentive program at this time--but may
after the CYE 9/30/04), however, what type and in the future. Contractor input into the
or amount of capitation is AHCCCSA considering process will be solicited.
retaining?
AHCCCSA has previously discussed incorporating Any amounts withheld from capitation would
incentives and performance outcomes into the be small enough so as to not impact the
reimbursement to contractors but has not actuarial soundness of the capitation
previously implemented a process. How much rates.
input will AHCCCSA solicit from the contractors
in developing incentives and/or the performance
measured outcomes? If contractors are required
to develop/submit actuarially sound capitation
rates how can AHCCCSA retain a portion of the
capitation
- ------------------------------------------------------------------------------------------------------------------------------------
22
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
for an incentive fund? Would this action cause
the capitation rates to not be actuarially
sound?
- ------------------------------------------------------------------------------------------------------------------------------------
121 58 Sect #57-- Related to inpatient reinsurance and nursing Please refer to the Reinsurance Claims
D Reinsurance facility service expenditures in lieu of Processing Manual, Chapter 2, Section 2,
hospitalization, can AHCCCSA be more specific Chapter 3, Section 2, and Chapter 6,
on what expenditures would qualify for Section 4.
reinsurance reimbursement as described in
the RFP? The definition of what qualifies
as "...provided in lieu of
hospitalization..." has been an issue in
the past.
- ------------------------------------------------------------------------------------------------------------------------------------
122 58 Sect #57-- What are the reinsurance premiums in regards to This will be published by the end of
D Reinsurance the reinsurance table on page 58? February.
- ------------------------------------------------------------------------------------------------------------------------------------
123 58 Sect #65 Incentives Incentive Fund - What performance measures does AHCCCSA has not developed a methodology for
D AHCCCSA intend to use in administering the the incentive fund at this time.
Incentive Fund? Will such incentive fund
measurements be linked to the
accessibility and quality of covered
services coordinated by the health plan,
or to the Medical Expense Ratio?
- ------------------------------------------------------------------------------------------------------------------------------------
124 60 Sect #57-- What does "certify" mean as it references Per the BBA all encounter submissions must
D Reinsurance "verify and certify" encounters? be certified as accurate by the submitter.
OMC EPARS unit has issued a format for that
certification.
- ------------------------------------------------------------------------------------------------------------------------------------
125 61 Sect # 57-- Please give a clearer explanation of AHCCCS will not reimburse for penalties
D Reinsurance, "Pre-hearing and/or hearing penalties assessed to Contractors through
Reinsurance discoverable during the review process reinsurance. Contractors have sole
Audits, Audit will not be reimbursed under financial responsibility for penalties that
Considerations reinsurance." are awarded through the grievance process.
, first
paragraph
- ------------------------------------------------------------------------------------------------------------------------------------
126 61 Sect # 58-- Is CRS considered a third party? CRS meets the definition as a third party.
D Coordination of However, this does not mean that this
Benefits, entire section applies appropriately to CRS
paragraph 2, coverage. Contractors are required to
Cost coordinate service with CRS per Paragraph
Avoidance 10, page 22.
- ------------------------------------------------------------------------------------------------------------------------------------
127 61 Sect # 58-- AHCCCSA is currently under procurement for The new contractor will perform the same
D Coordination of a new TPL contractor. How will that new functions as the current contractor.
Benefits, contract's operations impact coordination of Therefore, there are no financial impacts
paragraph 2, services with AHCCCS health plans and what anticipated.
will be the financial
- ------------------------------------------------------------------------------------------------------------------------------------
23
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
Cost impacts of any contract changes to a health plan?
Avoidance
- ------------------------------------------------------------------------------------------------------------------------------------
128 64 Sect # 62-- This health plan is a part of a larger corporation; Please refer to the answers for questions
D Corporate this larger corporation has a defined Corporate #53 and #54.
Compliance Compliance Program and Officer. This Officer is
located in Washington D.C.; This health plan
additionally has a Fraud and Abuse Officer on site.
This section appears to mingle the two together.
Are we meeting the guideline if we have an Off-site
Compliance Officer and Committee, if we have a
local on site Fraud and Abuse officer?
- ------------------------------------------------------------------------------------------------------------------------------------
129 65 Sect #63--Records "The Contractor shall preserve and make available All member records, regardless of the age
D Retention all records for a period of five years from the of the member must be maintained and
date of final payment under this contract." available as delineated in this paragraph.
As the statement does not differentiate for age,
does the same limit apply to pediatric patient
(< 21) records?
- ------------------------------------------------------------------------------------------------------------------------------------
130 66 Sect Page 66, Upon request, the Contractor shall provide updated, We do not anticipate that this information
D Section 64, date-sensitive PCP assignments: Does AHCCCS will be required in the upcoming contract
Data anticipate requiring this during the upcoming year.
Exchange contract year? If so, when will the file layout be
Requirements, provided?
first
paragraph
- ------------------------------------------------------------------------------------------------------------------------------------
131 66 Sect # 64, Data Are security code/data transmissions already in The security code/data transmissions have
D Exchange effect with the AHCCCS VPN and PMMIS systems or is been in effect with the AHCCCS VPN and
Requirements this something new? PMMIS systems since October of 2002.
- ------------------------------------------------------------------------------------------------------------------------------------
132 66 Sect # 64, Data Does the Health Plan have to obtain a business The AHCCCS Administration is not aware of
D Exchange associate contract with AHCCCS for the release of any covered functions that it performs on
Requirements member information to AHCCCS under the HIPAA behalf of Health Plans under this RFP that
privacy standards? would require the Health Plans to
consider the Administration to be a
business associate of the Health Plan.
Furthermore, it is the AHCCCS
Administration's position that neither
will Health Plans, under this RFP, be
required to perform covered functions on
behalf of the AHCCCS Administration that
would require the AHCCCS Administration to
consider the Health Plans to be business
associates of the AHCCCS
- ------------------------------------------------------------------------------------------------------------------------------------
24
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
Administration. Neither does the AHCCCS
Administration consider a business
associate agreement to be a prerequisite
for the exchange of protected health
information between health plans and the
AHCCCS Administration. For example,
covered entities may disclose protected
health information to another covered
entity for purposes of treatment, payment
or certain health care operations. See 45
CFR 164.506. There are also a number of
disclosures permitted by 45 CFR 164.512
that pertain to the relationship between
the health plans and the AHCCCS
Administration. Neither of these rules
mandates that a business associate
agreement be executed as a precondition
for disclosures pursuant to these rules.
- ------------------------------------------------------------------------------------------------------------------------------------
133 66 Sect # 64, Data Do we need to state specifically in our notice of It is the position of the AHCCCS
D Exchange privacy practices that information can and will be Administration that it falls within the
Requirements released to AHCCCS for the purposes of oversight? regulatory definition of a health
oversight agency as set forth at 45 CFR
164.501. The Privacy Rule, at 45 CFR
164.520(b)(ii)(B), requires that the
notice of privacy practices include a
description of the purposes for which a
covered entity is permitted to disclose
protected health information. Disclosures
for health oversight activities are
permitted by the rule. See 45 CFR
164.512(d). Determining the precise
contents of the contractor's notice of
privacy practices is the contractor's
responsibility. Any advice or direction
provided by the Administration is not
binding on the federal agency responsible
for enforcement of the HIPAA Privacy
requirements.
- ------------------------------------------------------------------------------------------------------------------------------------
134 66 Sect # 64, Data Will AHCCCS have a notice of privacy practices that Yes.
D Exchange addresses sending information to the Health Plans?
Requirements
- ------------------------------------------------------------------------------------------------------------------------------------
135 70 Sect # 72-- When will the Sanctions policy be available? The policy will be available prior to
D Sanctions October 1, 2003 in order to be in
compliance with the BBA. OMC will make
every effort to finalize it well in
advance of that date.
- ------------------------------------------------------------------------------------------------------------------------------------
136 70 Sect # 73-- When will the Business Continuity Plan policy be A draft of the Business Continuity Plan
D Business available? Policy is in the bidder's library and on
Continuity the AHCCCS web site.
Plan
- ------------------------------------------------------------------------------------------------------------------------------------
137 70 Sect # 73-- When will draft AHCCCSA policies or AHCCCSA These policies will all be posted on the
70 D Business policies in revision as referenced in RFP be ready web site when completed. Most of these are
currently posted there. It is the bidder's
- ------------------------------------------------------------------------------------------------------------------------------------
25
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
72-73 Continuity and how will they be distributed? If not by responsibility to regularly review the web
Plan website, how will potential Offerors be notified? site or physical bidder's library for
(e.g. Sanctions policy; Current Health plan Change updates.
policy; Member Transition for Annual Enrollment
Choice policy, Open Enrollment and Other Plan
Changes, and Business Continuity Plan policy.)
- ------------------------------------------------------------------------------------------------------------------------------------
138 71 Sect #75--Pending Relating to the inpatient pilot program, if Yes.
D Legislative/ legislation is not enacted to extend the pilot
Other Issues program in Maricopa and Pima counties beyond
9/30/03, will AHCCCSA adjust the capitation rates
it pays to contractors?
- ------------------------------------------------------------------------------------------------------------------------------------
139 71 Sect #75--Pending When will all of the pending issues listed on page AHCCCSA is unable to determine the exact
D Legislative/ 71 of the RFP (e.g., transplants) be resolved and date the pending issues will be resolved.
Other Issues will those issues be resolved before the bid due It is unlikely that they will be resolved
date? prior to the bid submission due date.
- ------------------------------------------------------------------------------------------------------------------------------------
140 71 Sect #76--Balanced What is the timeline for new or revised policies in October 1, 2003
D Budget Act of AMPM regarding Balanced budget Act of 1997
1997 (BBA) (BBA)?
- ------------------------------------------------------------------------------------------------------------------------------------
141 71 Sect #76--Balanced When will policies be completed regarding Special October 1, 2003
D Budget Act of Health care needs and Emergency Services
1997 (BBA) according to BBA?
- ------------------------------------------------------------------------------------------------------------------------------------
142 71 Sect #75--Pending Prescription Drugs - Has AHCCCSA or the AHCCCSA is in the process of hiring a
D Legislative/ Governor's Office prepared a position or policy consultant to determine if cost savings
Other Issues paper that outlines the pros and cons of carving can be achieved with carving out
out pharmacy services from the AHCCCS program? If prescription drugs from the Contractors.
yes, when will this be made available to potential The result of that study is anticipated to
Offerors? be finalized in the Summer of 2003. The
report should include both pros and cons
of a prescription drug carve out.
- ------------------------------------------------------------------------------------------------------------------------------------
143 71 Sect #75--Pending Prescription Drugs - Given the complexity of a If implemented, AHCCCSA anticipates that
D Legislative/ pharmacy services carve out, is the October 1, 2003 the prescription drug carve out would be
Other Issues implementation date feasible? effective October 1, 2004.
- ------------------------------------------------------------------------------------------------------------------------------------
144 71 Sect #75--Pending Prescription Drugs - How much in PMPM dollar AHCCCSA is in the process of hiring a
D Legislative/ savings does AHCCCSA anticipate to realize if consultant to determine the potential cost
Other Issues pharmacy services are carved out from the health savings of carving out prescription drug
plans? costs from the Contractors. The result of
that study is anticipated to be finalized
in the Summer of 2003. The report should
include both pros and cons of a
prescription drug carve out.
- ------------------------------------------------------------------------------------------------------------------------------------
145 71 Sect #75--Pending Prescription Drugs - Will AHCCCSA implement AHCCCSA does not anticipate implementing
D Legislative/ quantity limits per month and per prescription, any additional type of quantity limit at
Other Issues prescriptions per period of time and dosage limits this time. Please refer to the AMPM,
to Chapter 300 for current limits.
- ------------------------------------------------------------------------------------------------------------------------------------
26
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
manage utilization problems that could affect
medical costs? (Over-utilization of antibiotics
causing resistance - a CDC effort is underway to
address this problem as well as under-utilization
of statins in diabetics and CAD, and asthma as
mentioned above. Higher than recommended or safe
doses result in adverse effects).
- ------------------------------------------------------------------------------------------------------------------------------------
146 71 Sect #75--Pending Prescription Drugs - Will AHCCCSA identify and PBM's have these types of edits and
D Legislative/ work with health plan case management to restrict AHCCCSA expects that this information will
Other Issues members to prevent drug-seeking behavior and help be made available to the Contractors.
them get proper treatment of their condition?
- ------------------------------------------------------------------------------------------------------------------------------------
147 71 Sect #75--Pending Prescription Drugs - Will AHCCCSA provide the Yes, AHCCCSA anticipates that real time
D Legislative/ health plans concurrent access to the pharmacy data will be made available to its
Other Issues database for their respective membership to Contractors.
allow them to do reviews that impact care plans,
disease management, and health outcomes?
- ------------------------------------------------------------------------------------------------------------------------------------
148 71 Sect #75--Pending Prescription Drugs - Will AHCCCSA assign The responsibility will be shared by the
D Legislative/ responsibility to the PBM to perform all of the PBM and the Contractors, not unlike the
Other Issues management of these pharmacy issues? Will current system. Yes there will be staff to
AHCCCSA or the PBM hire staff to address health coordinate the administration of the
plan interests and data integration requirements? program.
- ------------------------------------------------------------------------------------------------------------------------------------
149 71 Sect - #75-- Prescription Drugs - In the event that pharmacy The bidder should assume that all
D Pending services are carved out of the AHCCCSA program, outpatient pharmacy services will be
Legisl- please delineate which drugs will be carved out. carved out. Any of the listed drugs when
ative/ Examples include: administered in an outpatient setting will
Other be carved out. If any of the listed drugs
Issues - Injectables are administered in an inpatient setting,
- Enterals then they are covered under the AHCCCS
- Infusion drugs / Hemo factor tier per diem reimbursement. Prescriptions
- Chemotherapy administered in a Skilled Nursing Facility
- Family Planning drugs will be carved out.
- Pharmacy dispensed in a physician or
hospital setting
- Psychotropic drugs currently being provided
by RBHAs
- ------------------------------------------------------------------------------------------------------------------------------------
150 71 Sect #75--Pending Prescription Drugs - If injectables are not carved Injectables will be carved out.
D Legislative/ out, will there be compensation to the plans for
Other Issues the increased costs associated with obtaining them
on the medical side? The discount obtained running
them through the retail pharmacy benefit will be
lost
- ------------------------------------------------------------------------------------------------------------------------------------
27
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
if they are not. (MC)
- ------------------------------------------------------------------------------------------------------------------------------------
151 71 Sect #75--Pending Prescription Drugs - Will AHCCCSA carve out all Yes, prescription drugs associated with
D Legislative/ transplant related therapy and manage the transplants will be carved out, and the
Other Issues coordination of benefits with Medicare? PBM will be responsible for coordinating
benefits with Medicare.
- ------------------------------------------------------------------------------------------------------------------------------------
152 71 Sect #75--Pending Prescription Drugs - Given certain members' One prior authorization policy will be
D Legislative/ complex pharmacy regimens designed to control or developed by AHCCCSA with input from its
Other Issues improve chronic and costly medical conditions, how Contractors.
will AHCCCSA adjust capitation rates for such
identified members' increased non-pharmacy The plans should factor the impact of the
utilization costs if pharmacy services are carved prescription drug carve out to other
out of the AHCCCS program? For example, what may be service categories.
the pharmacy prior authorization requirements that
will need to be coordinated among the "statewide"
pharmacy benefits manager and the health plans to
achieve cost savings and consistency in application
of clinical criteria?
- ------------------------------------------------------------------------------------------------------------------------------------
153 71 Sect #75--Pending Prescription Drugs - If pharmacy management is The Contractors will continue to receive
D Legislative/ carved out, what does AHCCCSA intend to do with real time information that will permit
Other Issues over-prescribing physicians? How will such issues provider profiling. This will be the
be coordinated with health plans? Will this data be responsibility of the Contractor to
made available by health plan? monitor.
- ------------------------------------------------------------------------------------------------------------------------------------
154 71 Sect #75--Pending Prescription Drugs - If pharmacy management All prescriptions will most likely be
D Legislative/ services are carved out, how will AHCCCSA deal filled unless the pharmacy is not in the
Other Issues with prescriptions for health plan members that PBM's network.
are written by physicians who are not contracted
with the member's health plan?
- ------------------------------------------------------------------------------------------------------------------------------------
155 71 Sect #75--Pending Prescription Drugs - Who will be responsible for Both the Contractor and the PBM will be
D Legislative/ reporting and monitoring pharmacy fraud and abuse responsible for monitoring fraud and abuse
Other Issues issues? issues.
- ------------------------------------------------------------------------------------------------------------------------------------
156 71 Sect #75--Pending Prescription Drugs - Given federal Medicaid drug CMS has recently interpreted the Medicaid
D Legislative/ rebate requirements and recent lawsuits limiting Drug Rebate Prgram as permitting the use
Other Issues the use of a formulary, how will AHCCCSA restrict of a formulary that encourages management
the usage of high cost and inappropriate of the pharmacy benefit. States with
pharmaceuticals? formularies have recently prevailed in the
courts.
- ------------------------------------------------------------------------------------------------------------------------------------
157 71 Sect #75--Pending Prescription Drugs - Rebates are based on Noted. The study will address this
D Legislative/ increased utilization of brand name medications, question.
Other Issues not cost-effective management, thus resulting in
higher cost of the pharmacy benefit. The logic of
doing
- ------------------------------------------------------------------------------------------------------------------------------------
28
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
this, to get back a greater percentage of rebate
dollars, is flawed. If one is spending $100 to get
back $4 (4%), and keeping generic utilization in
the 60%-plus range, how would it benefit to treat
the same condition for $200 to get back $36 (18%)
and drive up the average cost per prescription,
since the use of generics would most likely decline
15-25 percentage points?
- ------------------------------------------------------------------------------------------------------------------------------------
158 71 Sect #75--Pending Prescription Drugs - If AHCCCSA decides to carve The study will address the question.
D Legislative/ out the pharmacy benefit, any gain from increased Additionally, the Contractors will
Other Issues rebates will be offset by increased health plan continue to receive data as the currently
costs (PMPM and $/Rx). The current requirements to do from the PBM to perform the "back end"
obtain Federal Rebates are contradictory to the utilization management. Each plan must
ability to manage over-, under- and mis-utilization make its own determination of the impact
of the pharmacy benefit and ultimately affect that the prescription drug carve out will
patient care in a positive manner. The carve out of have to other service categories. AHCCCS'
pharmacy services from the health plans could actuaries have not made final
result in misinformed decisions, increased determinations of the impact to other
hospitalizations, emergency room visits and service categories.
physician visits. What are the assumptions of
AHCCCSA's actuaries regarding the impact on other
health care costs if pharmacy management is carved
out of the program?
- ------------------------------------------------------------------------------------------------------------------------------------
159 71 Sect #75--Pending Prescription Drugs - If pharmacy management is AHCCCS will work with its Contractors to
D Legislative/ carved out, how will AHCCCSA handle requests for develop a prior authorization process for
Other Issues non-formulary drugs? non-formulary drugs.
- ------------------------------------------------------------------------------------------------------------------------------------
160 71 Sect #75--Pending Prescription Drugs - Managing the pharmacy benefit There will not be an open formulary. CMS
D Legislative/ at the health plan level with closed formularies is flexible with the states in
Other Issues allows for more effective case management, establishing formularies that have
concurrent review and disease management, to effective management procedures.
name a few activities that positively impact member
health outcomes and reduce overall program costs. There will be no impact to the capitation
An open formulary focused on obtaining rebates will rates for open or closed formularies.
ultimately result in increased medical service and
pharmacy costs, and hinder health plans' abilities
to implement effective medical management programs
that readily influence member behaviors and health
outcomes. Will AHCCCSA be establishing an open or
closed formulary? Will it be a uniform statewide
- ------------------------------------------------------------------------------------------------------------------------------------
29
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
formulary? What will be AHCCCSA's assumptions in
developing health plan capitation rates for open
and closed formularies?
- ------------------------------------------------------------------------------------------------------------------------------------
161 71 Sect #75--Pending Prescription Drugs - One of the most effective ways As mentioned previously, the Contractors
D Legislative/ to control pharmacy costs is to conduct academic will receive data that will permit them to
Other Issues detailing and profiling of physicians' prescribing continue their provider profiling.
behaviors. Who from AHCCCSA will be responsible for
these initiatives? How will this information be
conveyed to providers? How often?
- ------------------------------------------------------------------------------------------------------------------------------------
162 71 Sect #75--Pending Prescription Drugs - With pharmacy services carved These will continue to be included in the
D Legislative/ out of the AHCCCSA program, how does AHCCCSA intend tier per diems. The rates will be adjusted
Other Issues to address the issuance and payment of as provided for in Arizona statute.
prescriptions written in an inpatient setting that
are reimbursed on a per diem basis? Will AHCCCS
adjust facility tiered per diem rates?
- ------------------------------------------------------------------------------------------------------------------------------------
163 71 Sect #75--Pending Prescription Drugs - With pharmacy services carved This detail has not been worked out yet.
D Legislative/ out of the AHCCCS program, how does AHCCCSA
Other Issues intend to handle prescriptions written in an
emergency room? Will only short-term prescriptions
be issued, with written instructions for the member
to follow up with his/her PCP? How will the
information about such prescriptions written in the
emergency room be communicated/transmitted to the
member's PCP? Which provider will be responsible
for effecting such information transfers?
- ------------------------------------------------------------------------------------------------------------------------------------
164 71 Sect #75--Pending Hospital Pilot Program - Even though AHCCCSA Yes, AHCCCSA anticipates that the pilot
D Legislative/ instructs Offerors to bid as if this program is will be extended.
Other Issues extended beyond September 30, 2003, does
AHCCCSA anticipate that such extension will
actually occur? And what will be the impacts if the
pilot program is not extended?
- ------------------------------------------------------------------------------------------------------------------------------------
165 71 Sect #76-- BBA When is it anticipated that AHCCCSA's final AHCCCSA will have that decision as soon as
D decision regarding the BBA requirement to have an possible. When a final decision is made.
expedited hearing process through the State Offerors will be informed immediately
Medicaid agency be made available to potential through the web site and in written form.
Offerors?
- ------------------------------------------------------------------------------------------------------------------------------------
166 72 Sect #77-- Does agreement to participate in the HCG program In the case of negligible differences
D Healthcare provide any weight in award decisions for the acute between two or more competing proposals
Group of care program? for a particular GSA, in the best interest
of the State, AHCCCSA may consider an
Offeror, who participates
- ------------------------------------------------------------------------------------------------------------------------------------
30
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
Arizona satisfactorily in other lines of AHCCCS
business, as a factor in awarding the
contract.
- ------------------------------------------------------------------------------------------------------------------------------------
167 89 Sect Related Party Are questions 1 & 2 specific to the health plans These questions are specific to the
G Transactions board and staff or do these questions relate to the Offeror's board and staff.
health plan's parent company?
- ------------------------------------------------------------------------------------------------------------------------------------
168 90 Sect Related Party Furnishing of goods or services - does this include Yes, this applies to payments made to
G Transactions payments made to brother/sister organizations related party organizations in the normal
made in the normal course of business, i.e., course of business.
payment to a hospital for inpatient services when
the plan and hospital are owned by the same
organization?
- ------------------------------------------------------------------------------------------------------------------------------------
169 92 Sect Please define "AHCCCSA program" as to be used in The AHCCCS acute care line of business.
G the final column of this table? Is this meant to
include responsibilities pertaining to other
AHCCCSA programs as well, such as the ALTCS and
Premium Sharing programs?
- ------------------------------------------------------------------------------------------------------------------------------------
170 93 Sect What percentages/values will be assigned to each of This information is not being shared with
H the five scoring categories? Offerors.
- ------------------------------------------------------------------------------------------------------------------------------------
171 93 Sect Can AHCCCSA define "negligible differences" in the The definition is not being shared with
H contents of the sentence, "In the case of Offerors.
negligible differences between two or more
competing proposals for a particular GSA..."
- ------------------------------------------------------------------------------------------------------------------------------------
172 93 Sect If a Letter of Intent (AHCCCSA mandated LOI format Capitation rates will not be based on
H for CYE 9/30/04 approved version) does not include LOI's, but rather on historical cost and
language to address the amount of reimbursement utilization data provided by health plans.
to be paid a provider for services rendered, how
can the determination of a capitation rate based on Historical experience with appropriate
such LOI's be considered to be actuarially sound? trends that are applied to the historical
If CMS has mandated that all capitation rates be data are sufficient to develop actuarially
actuarially sound, how can AHCCCSA consider an LOI sound capitation rates.
with no negotiated fee schedule to have the same
weight as fully executed contract?
- ------------------------------------------------------------------------------------------------------------------------------------
173 94 Sect The RFP addresses the situation when an offeror If the Offeror's bid is above the top of
H submits a capitation bid below the actuarial rate the rate range, AHCCCSA may elect to
range, what will AHCCCSA do if the offeror's initiate a BFO process to guide the bidder
capitation bid is above the actuarial rate range? into the rate range, or may set the rate
Will at some point below the mid point of the
rate range. The exact placement is
confidential.
- ------------------------------------------------------------------------------------------------------------------------------------
31
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
AHCCCSA place the offeror within the range and if
so, at point within the range?
- ------------------------------------------------------------------------------------------------------------------------------------
174 94 Sect What are the maximum and minimum number of The scoring methodology for capitation
H points possible for the capitation bids by GSA and bids is proprietary and confidential.
risk group? If a bid is between the minimum and
maximum rate within the actuarial rate range, will
points be awarded on a linear basis or some other
method?
- ------------------------------------------------------------------------------------------------------------------------------------
175 97 Sect Is AHCCCSA anticipating that Offerors will submit No.
H policies with their proposals? If yes, what
policies are to be submitted in Offerors'
proposals?
- ------------------------------------------------------------------------------------------------------------------------------------
176a 97 Sect In responding to questions presented in this It is anticipated that the narrative will
H section of the RFP, may potential Offerors provide fully address the submission requirement.
attachments that further illustrate their narrative Only specified attachments may be included
responses? Will such attachments be counted per the submission instructions. The
toward (i.e. included as part of) the three (3) or narrative may include a description of
five (5) page limit instructions? policies, handbooks, manuals, newsletters
or other documents, but the documents
should not be included in the submission
unless specifically requested.
- ------------------------------------------------------------------------------------------------------------------------------------
176b Sect Please clarify the award of points for the The first full paragraph on page 95 of the
H extra credit submissions. RFP which begins, "The Offeror may submit
up to three programs/initiatives, ..."
should be changed to read, "There are a
specific number of points available for
each category. In order to receive the
full number of points available, an
initiative/program must be submitted for
each category. If multiple submissions in
a single category are received, they will
be considered one initiative/program.
Offerors should be aware that the points
earned through extra credit responses may
be significant enough to determine the
outcome of contract awards."
- ------------------------------------------------------------------------------------------------------------------------------------
177 98 Sect I May the bidders submit the provider network on a Yes.
CD as opposed to a 3.5" floppy disk?
- ------------------------------------------------------------------------------------------------------------------------------------
178 98 Sect I What is the intent of "network hospital?" Does this Each hospital the bidder considers to be a
include the hospitals that are listed in Attachment part of the network, whether there is a
B, or the hospitals for whom the contractor has contract, LOI or not. Please note that in
obtained a LOI? Maricopa and Pima Counties where the Pilot
Program exists, Offerors are required to
have contracts or LOI's with hospitals.
- ------------------------------------------------------------------------------------------------------------------------------------
179 98 Sect I If the provider is currently contracted with our A contract covering the participation of a
long term care program, is he considered a provider provider in the LTC program solely does
currently contracted for purposes of this database? not constitute a contract for the Acute
If we have both a contract for LTC and a LOI for Care program. The LOI should be reflected
acute in the submission.
- ------------------------------------------------------------------------------------------------------------------------------------
32
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
care, how do we indicate it?
- ------------------------------------------------------------------------------------------------------------------------------------
180 98 Sect I How would you like multiple addresses of providers AHCCCS has successfully entered multiple
entered in the database? If a provider has multiple entries with the same ID number and had
service addresses how do you wish us to list them them accepted by Access 2000. Perhaps the
by line item - the Access 2000 database will not Offeror is using the primary key on the ID
accept multiple entries of the same ID number, and number. If this is the problem, removal
we would need to modify the number somehow. should allow acceptance. Or they may be
indexing and set their index to not accept
duplicates.
- ------------------------------------------------------------------------------------------------------------------------------------
181 98 Sect I Question 1 Should a printed copy of the Provider Network File It is not necessary to submit a printed
be submitted with the 3.5' disk? Due to size of the copy. The file may be submitted on a CD.
file can the Provider network File be submitted on Three copies of the disk (CD) should be
CD? How many copies of the disk (or CD) should be submitted. Sorting of the data will be
submitted with the response? Should the Provider done after receipt of the file by AHCCCS.
Network File be sorted by GSA and Provider Type?
Please Clarify.
- ------------------------------------------------------------------------------------------------------------------------------------
182 98 Sect I Question 2 What format is required for the contracted This information should be submitted on
physicians who have admitting privileges to the hard copy. There is no page limit. Please
network hospitals? Is the response limited to three sort by hospital with provider ID and
pages? Are there preferred column formats and/or name.
length limit on data fields?
- ------------------------------------------------------------------------------------------------------------------------------------
183 98 Sect I Question 3 Is the response limited to three pages? No.
- ------------------------------------------------------------------------------------------------------------------------------------
184 98 Sect I If the Plan does a group contract, do you need to No. Proof of authority of signatory must
have a letter of Intent for each provider/location be available if requested.
for a group practice?
- ------------------------------------------------------------------------------------------------------------------------------------
185 98 Sect I If the Plan has evergreen contracts with an existing No.
provider in a GSA they already occupy, do you have
to have a Letter of Intent for those providers?
- ------------------------------------------------------------------------------------------------------------------------------------
186 98 Sect I If the Plan currently contracts with a provider in There must be a contract or LOI that
a specific county in which the Plan currently has covers the pertinent GSA and time period.
membership and that provider also services other
counties, does the Plan need a LOI for counties in
which the Plan is bidding but does not currently
have membership? Or is the current contract for the
county sufficient?
- ------------------------------------------------------------------------------------------------------------------------------------
187 98 Sect I Can potential Offerors submit their responses to Yes.
this question on a CD-ROM instead of floppy disks?
- ------------------------------------------------------------------------------------------------------------------------------------
188 99 Sect I When will the rates being calculated by AHCCCS for AHCCCSA anticipates that the capitation
rates in question will be
- ------------------------------------------------------------------------------------------------------------------------------------
33
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
PPC, HIV, T19, and HIFA be available? Are the available April 1, 2003. Because the PPC
bidders to include these rates in the projections and TWG rates are reconciled, the Offeror
they prepare or should they be carved out? should estimate what their profitability
will be for the TWG and PPC experience
and build that into their financial
projections. For the HIFA parents, assume
a rate that is 10% greater than the
applicable TANF rates.
- ------------------------------------------------------------------------------------------------------------------------------------
189 100 Sect I How can AHCCCSA deem that the rate proposal AHCCCSA will adjust the capitation rates
includes the cost of administrative adjustments after the pending items are resolved, if
required during the term of the contract when of necessary. Contractor feedback will be
the financial impact of several major issues is solicited.
unknown and contingent on pending legislation? Is
AHCCCSA prepared to adjust capitation rates and or
the administrative component due the resolution of
pending legislation?
- ------------------------------------------------------------------------------------------------------------------------------------
190 100 Sect I Capitation "The offeror's rate proposal will be deemed by Examples of administrative adjustments
Last AHCCCSA to include the costs of administrative include BBA costs, HIPAA costs, member ID
paragraph adjustments required during the term of this card costs, and the impact to
on page 100 contract. administrative costs due to the carve out
of pharmacy (pharmacy bid only).
Please define what is meant by "administrative
adjustments."
- ------------------------------------------------------------------------------------------------------------------------------------
191 101 Sect I What does benchmarking Family Planning Services The submission requirement regarding
mean? Family Planning has been modified.
Benchmarking is deleted as a submission
requirement.
- ------------------------------------------------------------------------------------------------------------------------------------
192 101 Sect I Will AHCCCS have goals and benchmarks set as in None are planned at this time.
the performance standards as relates to Family
Planning services?
- ------------------------------------------------------------------------------------------------------------------------------------
193 101 Sect I Please define "other hard to reach populations." The health plan should define this based
upon the geographic areas served.
- ------------------------------------------------------------------------------------------------------------------------------------
194 102 Sect I How far back should I go to indicate an average Please use the last complete contract
speed for resolution? (the last quarter, last year.
contract year, calendar year)
- ------------------------------------------------------------------------------------------------------------------------------------
195 103 Sect I Grievance This item asks for both a flowchart and a written The narrative should be three pages; the
and Appeals description of the grievance and appeals process. flow chart should not be included in the
Due to the many contingencies of the grievance and 3 page limit.
appeal process, may responses include the requested
flowchart as an attachment to the three- page
response? Or is the flowchart to be included within
the three-page response?
- ------------------------------------------------------------------------------------------------------------------------------------
34
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
196 103 Sect I Question 36 Requests a description of the grievance and appeal No. With the new Balanced Budget Act
process, including "both the informal and formal regulations, there is no mandated informal
processes."--is there a mandated informal process process. We are amending the submission
and if so what are the parameters given the requirement to: Provide a flow chart and
administrative code and the process set forth in written description of the grievance and
Attachment H? appeals processes; include general
timeframes. Identify the staff that will
be involved at each phase and provide
their qualifications. (Limit 3 pages plus
a flowchart)
- ------------------------------------------------------------------------------------------------------------------------------------
197 103 Sect I Is this "informal" process the expedited appeal Please refer to the answer in question
process in response to the Notice of Action # 196.
described in Attachment H, or some part of that
process?
- ------------------------------------------------------------------------------------------------------------------------------------
198 103 Sect I Question 40. How must this requirement be met for a new offeror? A new Offeror, currently acting as an MCO,
As a current LTC PC, must we submit claims aging must submit their claims aging for the
data from our LTC program? current line of business used throughout
the submission.
- ------------------------------------------------------------------------------------------------------------------------------------
199 103 Sect I Question 40 What format is required for the claims aging This bid submission requirement is
report - detail or summary? eliminated.
- ------------------------------------------------------------------------------------------------------------------------------------
104 The health plan compiles quarterly financial Yes. Please provide the Balance Sheet and
information for AHCCCS. Will a copy of the Income Statement, and notes to financial
quarterly financial statements submitted to AHCCCS statements.
meet this requirement? If yes, which schedules
should be submitted? If no, please provide more
details as to what specific financial schedules are
required.
- ------------------------------------------------------------------------------------------------------------------------------------
200 104 Sect I In answering the questions in Section I of the bid, Only submit financial statements assuming
specifically financial forecasts (items #48) and the prescription drug benefit remains the
financial viability calculations (item #49), how responsibility of the Contractor.
should the offeror incorporate the fact that;
capitation rates have to be submitted with and AHCCCSA anticipates that the capitation
without (carved out) the pharmacy component, and rates in question will be available April
capitation rates for several risk groups are 1, 2003. Because the PPC and TWG rates are
unknown and will be set by AHCCCSA? These items reconciled, the Offeror should estimate
will have a direct impact on an offeror's what their profitability will be for the
forecasted financial results. TWG and PPC experience and build that into
their financial projections. For the HIFA
parents, assume a rate that is 10% greater
than the applicable TANF rates.
- ------------------------------------------------------------------------------------------------------------------------------------
201 104 Sect I Question 52 Can programs initiated prior to 10/1/2003 be used Yes, programs initiated and expected to
for extra credit? Is the total page limit for the continue in the new contract period may be
response 9 pages (limit of three programs/ submitted for extra credit. The total page
initiatives/limit of three pages each) plus the limit is 9 pages, a limit of 3 per
timeline for each program/initiative? Please program/initiative. The timelines are in
clarify. addition to the 9 pages.
- ------------------------------------------------------------------------------------------------------------------------------------
202 104 Sect I The RFP calls for financial forecasts in "at least No--just the Balance Sheet and Income
the Statement and notes to
- ------------------------------------------------------------------------------------------------------------------------------------
35
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
level of detail specified for annual audited the financial statements. This information
financial statements". Does this mean that should be statewide rather than by county
we need to submit the income statement at the risk or GSA.
code category level as well as a combined income
statement for the entire county?
- ------------------------------------------------------------------------------------------------------------------------------------
203 104 Sect I We are preparing two sets of capitation rates, one No--just one assuming that the
with and one without prescriptions. Do we need to prescription drug benefit remains the
prepare two sets of financial projections also? responsibility of the Contractors.
- ------------------------------------------------------------------------------------------------------------------------------------
205 104 Sect I Will AHCCCS determine which set of capitation The Offeror should use the capitation
rates we should use in our projections? rates that assume prescription drug will
continue to be the responsibility of the
health plans in their projections.
- ------------------------------------------------------------------------------------------------------------------------------------
206 104 Sect I Who is considered to be within "community The entities mentioned could be considered
involvement"? Members, Agencies, Community a part of the community, but community is
Providers, Hospitals, etc. not limited to these entities.
- ------------------------------------------------------------------------------------------------------------------------------------
207 104 Sect I Please clarify whether the entire response to this Please refer to the answer to question
section is three (3) pages maximum or three (3) #104.
pages maximum per each initiative selected?
- ------------------------------------------------------------------------------------------------------------------------------------
208 105 Sect I What would cause AHCCCSA to not have a Best BFOs can be time consuming and resource
and Final Offer (BFO) process? intensive for both the state, as well as
the bidders. If the initial bids for a
given GSA fall generally within the
established rate ranges, the state has
reserved the right to finish scoring the
proposals and to make tentative awards.
Rate offers to the successful bidders
would then be made to the extent necessary
to ensure all rates fall within the
established rate ranges.
- ------------------------------------------------------------------------------------------------------------------------------------
209 106 Sect I Capitation Rates Offered after BFOs - Please Yes.
further clarify the following, "At this point,
should the Offeror have a rate code(s) without an
accepted capitation rate, AHCCCSA shall offer a
capitation rate to the Offeror. Note that all rates
offered in this manner shall be identical for all
Offerors in the same GSA and rate code." Please
further clarify the meaning of "all Offerors" in
this context. Is this only to be applied to those
Offerors not having acceptable rates?
- ------------------------------------------------------------------------------------------------------------------------------------
210 107 Sect I In the RFP amendments about Pima/Santa Cruz, 5 The Offeror must submit a bid for the
contracts will be awarded in Pima but only 2 will entire GSA. Capitation scoring will be
get Santa Cruz County. When bidding in Santa Cruz based upon the blended capitation rate.
Co., should we bid as blended rates or separate per After all RFP scoring is completed, the
two bidders with the highest overall
scores will receive an award for both Pima
and Santa Cruz
- ------------------------------------------------------------------------------------------------------------------------------------
36
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
county? counties. The next highest scorers will
receive an award in Pima County only. The
Pima County only Contractors will be
offered a rate that is their bidded rate
for both counties as adjusted based upon a
percentage difference between the risk of
the two counties combined and Pima County
only as determined by Mercer. If the Pima
County awardee does not accept the offered
rate, then the next highest scorer will be
offered a rate until all available
Contractor slots are awarded.
- ------------------------------------------------------------------------------------------------------------------------------------
211 109 Sect I Will all Bidders Library items be posted on It is AHCCCSA's intention to have
AHCCCSA's web site? If not, how will potential virtually all bidders' items posted on the
Offerors be notified that new materials are web site. Potential Offerors should review
available in the Bidders Library? the web site on a regular basis to
receive updates.
- ------------------------------------------------------------------------------------------------------------------------------------
212 115 Attach In terms of assessing and evaluating a health This information is not being shared with
B plan's network of providers, are PCPs, dentists, bidders.
pharmacies, hospitals and specialty care providers
all assessed equally? If not, how are they assessed
or evaluated in the scoring process? How are
ancillary providers assessed or evaluated in the
scoring process?
- ------------------------------------------------------------------------------------------------------------------------------------
213 Attach Please clarify this statement - "if outpatient Contracted providers able to deliver these
B specialty services (OB, family planning, internal specialty services, should be available in
medicine and pediatrics) are not included in the the service sites specified. If the
primary care provider contract, at least one services are not available, this
subcontract is required for each of these information should be included in the
specialties in the service sites specified." Network Development and Management plan,
along with the steps to be taken to
provide the services to members.
- ------------------------------------------------------------------------------------------------------------------------------------
214 115 Attach Instructions May a prospective bidder include in their floppy We do not believe that a provider is a
B disk containing their provider network, an existing member of an Offeror's network, when they
network developed for a line of business other than are unaware of this fact. In order for a
AHCCCS? Would the prospective bidder be required contract to be considered for a submitted
to notify the providers that make up that network provider it must contain all required
of the intent to include them in their proposal to components.
meet the minimum network standards for that GSA? If
so, if they're current contracts do not contain the
AHCCCSA minimum subcontract provisions can they be
considered "contracted" for the AHCCCS line of
business?
- ------------------------------------------------------------------------------------------------------------------------------------
37
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
215 119 Attach Will AHCCCSA waive pharmacy minimum network Please be aware that a slash mark (/)
120 B standard requirements for the following communities between two geographic service sites,
124 that currently do not have a pharmacy: Ash Fork indicates that the service must be
(GSA 4), Carefree (GSA 12), Seligman (GSA 4) and available in at least one of the sites.
San Luis (GSA 2)? The GSA 2 service site list for pharmacies
should read San Luis/Somerton. With this
correction there are pharmacies in these
sites.
- ------------------------------------------------------------------------------------------------------------------------------------
216 125 Attach Map For GSA 14, the map indicates that PCP, Dentists Please refer to the answer to question
B and Pharmacies are a minimum requirement for both #215.
Morenci and Clifton. However, the list on the left
side of the page indicates that Morenci and Clifton
are together. Are Clifton and Morenci considered
one in the same for this requirement, or do you
need these services in both cities?
- ------------------------------------------------------------------------------------------------------------------------------------
217 Attach Page 49 states, "all counties except Maricopa and It is required that the Offeror have
B Pima contractor is encouraged to obtain either contracts or LOIs with physicians
subcontracts with hospital" and Attachment B lists with admitting privileges to hospitals in
hospitals a minimum network requirement in all the Offerors network. Offerors are
counties. Is it required or encourages to obtain encouraged to contract with hospitals.
and LOI in counties other than Maricopa and Pima in
order to meet minimum network requirements?
- ------------------------------------------------------------------------------------------------------------------------------------
218a 126 Attach Instructions Could AHCCCSA further define or add additional A Management Services Subcontractor is
C clarity to what it considers "any administrative defined in the opening paragraph of
function or service for the Contractor" as it Attachment C. For purposes of responding
relates to the term "Management Services to the RFP, the subcontractor is an
Subcontractor"? For example, would our PBM and individual or firm who is responsible for
GACCP (Credentialing Primary Source Verification) day today operations of the health plan.
be considered Management Services Subcontractors?
- ------------------------------------------------------------------------------------------------------------------------------------
218b 126 Attach Instructions Page 126, Attachment C, Management Services For purposes of Attachment C, the opening
C Subcontractor Statements. Based upon the definition is applicable. Therefore, data
answers to the Bidders' questions released at the information systems, PBM, etc. are not
Bidders' Conference and the feedback from the past included. However, clarification for which
two years' Operational and Financial Reviews, sub contractors require and audit
there seems to be conflicting definitions and submission will be clarified in the
interpretations around management services revised acute care reporting guide.
subcontractors. Based on OFR feedback, we believe
that subcontractors for services such as data
information systems, pharmacy benefit managers
(PBM), management services and any other
organization to which day-to-day operations are
delegated (such as recoveries and clinical
- ------------------------------------------------------------------------------------------------------------------------------------
38
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
evaluations) are required to complete a management
services subcontractor statement. Please clarify.
- ------------------------------------------------------------------------------------------------------------------------------------
219 126 Attach Attachment C is not included on the Offeror's Yes.
C Checklist. For submission purposes, should
Attachment C be submitted following completion of
Section G in General Matters?
- ------------------------------------------------------------------------------------------------------------------------------------
220 126 Attach Please provide additional examples of what See answer to #218 above.
C Constitutes a "Management Services
Subcontractor".
- ------------------------------------------------------------------------------------------------------------------------------------
221 126 Attach Please identify whether the following meets the None of these listed meet the requirement.
C requirement for a management services subcontract:
1. Organization which coordinates purchasing of
health insurance for health plan employees
2. Organization which coordinates purchasing of
other insurance (such as liability) for the
health plan
3. organization which manages the health plan's
data center operations but does not have
decision making authority in areas such as
methodology for claims processing, authorization
processing, etc.; it would, however, be involved
in implementing changes to the health plan's
information systems based on direction by health
plan employees
4. provides legal services to the health plan
5. acts as the Human Resources/Payroll department
for the health plan to assist with hiring,
addressing employee questions regarding
benefits, processing payroll, etc.
Would any of the answers to the above be different
if the services were provided by a related party?
If yes, which ones and why?
- ------------------------------------------------------------------------------------------------------------------------------------
222 126 Attach Most of the current AHCCCS plans are owned by These would not qualify.
C larger organizations which provide some
administrative services to the health plans, but
are not actively involved in the normal operations
of the
- ------------------------------------------------------------------------------------------------------------------------------------
39
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
plan. In this case, would a management services
subcontract be required between the health plan and
its parent company?
- ------------------------------------------------------------------------------------------------------------------------------------
223 126 Attach Does AHCCCS consider a Pharmacy Benefit No.
C Manager contract, which has as one of the
contractual responsibilities, the processing of
retail pharmacy claims, a Management Service
Subcontractor?
- ------------------------------------------------------------------------------------------------------------------------------------
224 126 Attach Does a specialty provider delegated for limited More information is needed.
C prior auth, i.e. approvals only, qualify as a
management services contract?
- ------------------------------------------------------------------------------------------------------------------------------------
225 126 Attach Is Medifax EDI considered a Management Services No.
C Subcontractor? They provide electronic claims
clearinghouse and member eligibility verification
services.
- ------------------------------------------------------------------------------------------------------------------------------------
226 126 Attach Management Services Subcontractor Statement - Any organization that is hired by a parent
C Please clarify which subcontractors AHCCCSA company to run the operations of the
anticipates to be included with an Offeror's health plan. A subcontractor that provides
proposal? all of the operations of a medical
service, i.e. family planning services.
- ------------------------------------------------------------------------------------------------------------------------------------
227 127 Attach Management Services Subcontractor Statement--Is No.
C this required on an LOI provider?
- ------------------------------------------------------------------------------------------------------------------------------------
228 129 Attach Will a copy of the organization's most recent Form The two most recent audited financial
C 10-K be acceptable in lieu of a copy of the audited statements must be included. If the 2002
financial statements? has not been completed, then please submit
the most recent 10-K for 2002.
- ------------------------------------------------------------------------------------------------------------------------------------
229 132 Attach In a group practice - does each physician need a Please refer to the answer to question
D(1) separate LOI or can a group administrator sign for # 184.
all physicians within group?
- ------------------------------------------------------------------------------------------------------------------------------------
230a 138 Attach If a provider is in the process of obtaining an The provider ID field should be filled
D(2) AHCCCS ID number, how should they be reported with zeros.
on the LOI file?
- ------------------------------------------------------------------------------------------------------------------------------------
230b 138 Attach Page 138, Attachment D(2), Service Provider Name - Q1. The plan should give AHCCCS the
D(2) If an individual provider has a last name which is hyphenated name without spaces
(Smith-Jones).
- ------------------------------------------------------------------------------------------------------------------------------------
40
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
hyphenated, how should the name be listed? Q2. For this submission, it is not
Example: Smith-Jones/John A. (hyphen without necessary to match the name with the
spaces); Smith - Jones/John A. (hyphen AHCCCS Provider File. However, the health
with spaces); SmithJones/John A. (without hyphen or plan may do so if they wish.
spaces). Please clarify.
Page 138, Attachment D(2), Service Provider Name -
Should the Plan try to match first names to the
AHCCCS Provider File registered name even though
the provider may utilize a different name? Example:
AHCCCS Provider File list the provider's name as
Charles G. Jones; the physician actually goes by
his middle name and APIPA has him registered as C.
George Jones, or should the name be listed as
Charles George Jones? Please clarify.
- ------------------------------------------------------------------------------------------------------------------------------------
231 150 Attach For Pima and Santa Cruz - in that not all The Offeror must submit a bid for the
E contractors who receive an award for the GSA will entire GSA. Capitation scoring will be
be active in Santa Cruz County, should the rates based upon the blended capitation rate.
be bid as a blended rate or as stand-alone rates After all RFP scoring is completed, the
for each county? two bidders with the highest overall
scores will receive an award for both Pima
and Santa Cruz counties. The next highest
scorers will receive an award in Pima
County only. The Pima County only
Contractors will be offered a rate that
is their bidded rate for both counties
as adjusted based upon a percentage
difference between the risk of the two
counties combined and Pima County only as
determined by Mercer. If the Pima County
awardee does not accept the offered rate,
then the next highest scorer will be
offered a rate until all available
Contractor slots are awarded.
- ------------------------------------------------------------------------------------------------------------------------------------
232 150 Attach Is AHCCCS providing any alternatives to the Web OMC has received many assurances from ISD
E Based Capitation Rate Proposal should the web site that the web traffic will not prevent
being down? What assurances is AHCCCS providing bidders from completing their bids via
that its web site will be up and accessible and the web application. Offerer's are
that the response time will not be compromised when required to submit a hard copy of their
a significant number of Contractors might be bids that will be used as back up should
attempting to access it at the same time? the web application fail.
- ------------------------------------------------------------------------------------------------------------------------------------
233 150 Attach What will be the recourse for material errors and Material errors and omissions would be
E omissions in the development of rate ranges by disclosed and corrected. To the extent
rate ranges were modified, awarded rates
would be
- ------------------------------------------------------------------------------------------------------------------------------------
41
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
AHCCCSA? Errors or omissions may be identified adjusted by the same percentage(s). Beyond
by the health plans, AHCCCSA or AHCCCSA's that, it would depend on the nature of
actuary. Furthermore, what is the recourse if the CMS' concerns. As long as the covered
development of the rate ranges does not meet with services and populations in the contracts
CMS' approval subsequent or concurrently to the bid have not changed, the rates would probably
process? stand. The bidder's actuary would have
already certified that the rates were
actuarially sound for the bidder, and
AHCCCS' actuaries will have done the same
for the rate ranges. Issues related to
federal match or CMS requirements for
documentation should not affect the acute
care contracts.
- ------------------------------------------------------------------------------------------------------------------------------------
234 150 Attach Please explain AHCCCSA's decision to not use a Refer to question 1. The rate setting
E diagnostic-based risk adjuster, given that CMS methodology is in compliance with CMS
lists it as a requirement to actuarially sound regulations.
rates, and explain why it is not applicable if
omitted.
- ------------------------------------------------------------------------------------------------------------------------------------
235 150 Attach Please explain the methodology that will be used to a. The state's reimbursement schedules,
E develop the upper and lower bounds of the and the health plan paid amounts.
capitation rate ranges.
b. The inpatient component of the
- a. What fee schedule assumptions will be capitation rate is based upon cost and
used to price encounter data for the upper and utilization information from health
lower bounds of the rate range? plan reported encounters and
financials. AHCCCS will inflate the
- b. What percentage of the Medicaid Fee component by the inflation used for the
schedule will be used for inpatient given that tier per diems for 10/1/03.
AHCCCSA states that the average reimbursement is
97% in their most recently submitted budget c. The PMPM assumptions will closely
to the JLBC? match the blended experience of the
current contractors, adjusted for
- c. What are the assumptions related to the trends and changes in approved drugs.
average dispensing fees, AWP, and rebate
assumptions for retail pharmacy? d. Rate ranges will be established for
3 different zones, or groupings of
- d. What percentage of the fee schedule will be counties, based on the encounters
assumed in rural counties where contracting priced out by the health plan paid
requires payments that exceed the AHCCCSA amounts. This should reflect health
fee schedules? plans' contracting issues as closely as
possible. This pricing of encounters by
- e. How will outpatient encounters be priced health plan paid amounts has been
given that plans must contract at a percentage cross-walked against their audited
of billed charges at multiple facilities? financial experience for 3 years.
- f. What assumptions were made for pricing e. For clarification, health plans are
encounters for typically sub-capitated costs not required to contract at a
such as PCP, laboratory and DME, regarding percentage of billed charges. Health
under-submission of encounter data by the plan paid amount is used for pricing.
providers?
f. As discussed in the data supplement,
- g. What administrative component will be subcapitated encounters, if no value
is assigned by the health plan, will be
priced at the AHCCCS FFS schedule.
g. The Offerors should bid what they
expect their administration component
to be.
h. !0/1/99-3/31/02
- ------------------------------------------------------------------------------------------------------------------------------------
42
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
priced into the upper and lower bound of the rate
range?
- h. What time periods are the State's actuary
using as their base rate assumptions? What time
period(s) will AHCCCSA use as its base for
developing the rate ranges? If this varies by GSA
or rate cell, please provide to potential
Offerors.
- ------------------------------------------------------------------------------------------------------------------------------------
236 150 Attach Will AHCCCSA share its trend assumptions with Trends assumptions used to develop the
E Offerors? How do the 5% trend assumptions in the State Legislative budget were their own
State Legislative budget for the AHCCCS program best estimates. AHCCCSA's actuaries will
relate to this process? make their own trend estimates.
- ------------------------------------------------------------------------------------------------------------------------------------
237 150 Attach When will AHCCCSA make available information Information is provided in Section B of
E regarding program changes? the data supplement. Potential contractors
will be made aware of any additional
program changes, as they become available.
- ------------------------------------------------------------------------------------------------------------------------------------
238 150 Attach How will financial data be used given changes in Financial statements are revised and
E reserves for other prior period adjustments that restated for adjustments, and are audited
skew actual results? For instance, if a health plan on a periodic basis. Financials represent
releases reserves or recognizes revenue from older one supplemental data source used in the
periods, the health plan's experience will look development of actuarially sound rates.
more favorable than their "run rate" for that These revised financial statements are not
period. provided in the data supplement.
- ------------------------------------------------------------------------------------------------------------------------------------
239 150 Attach If the Legislature eliminates eligibility groups Any material change within a rate cell,
E (e.g., KidsCare, HIFA parents), will AHCCCSA adjust such as the elimination of one subset of
the capitation rates, given that the prospective a category of aid will be adjusted for in
bidders are bidding rates assuming continued the capitation rates.
coverage of all groups? And if so, how will the
adjustment be made? If adjustments are made in the The Offeror should assume that all current
rates, how will this impact the algorithm? eligibility groups will continue to exist
in CYE '04.
- ------------------------------------------------------------------------------------------------------------------------------------
240 151 Attach Since the Web application for submitting capitation Yes. A presentation of the web site will
E rates has not been issued yet, will offerors have be forthcoming at the bidder's conference.
the opportunity to formally ask questions and
receive responses after the February 14, 2003 A second set of technical questions will
deadline to submit questions? be issued by AHCCCSA by due March 7, 2003.
- ------------------------------------------------------------------------------------------------------------------------------------
241 153 Attach Please describe what the health plans will be Contractor submitted pharmacy encounters
F required to report on the newly required are still the "official" documentation for
"Prescription Drug Utilization Report"? AHCCCS. However, contractors will be
asked to provide standard monthly
production reports of aggregate pharmacy
cost and utilization data in a mutually
agreeable format.
- ------------------------------------------------------------------------------------------------------------------------------------
43
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
242 157 Attach Is the "Notice of Action" considered the same as an 42 CFR 438.404 delineates Notice of Action
H initial organization determination? Also, normally, requirements. State statute ARS Section
a member has 60 days following an adverse action to 36-2903.01 specifies a 60-day timeframe
file an appeal. The timeframe listed in this for filing non claim related grievances.
section of the RFP is different. Has this timeframe However, the BBA provisions have will have
changed and, if so, when? a major impact on the existing AHCCCS/
Contractor grievance process. These
changes shall be communicated through
regulation and/or formal policy.
- ------------------------------------------------------------------------------------------------------------------------------------
243 157 Attach It refers to the Notice of Action and the The BBA regulations require that notice be
H situations in which that must be generated, given enrollees for denial of payment, in
including notice to members when a claim is whole or in part. Expedited resolution of
denied--does this mandate and EOB to be sent an appeal applies to situations when
to a member? If it does, can the member ask for taking the time for standard resolution
an expedited appeal in that situation? could seriously jeopardize the enrollee's
life or health or ability to attain,
maintain, or regain maximum function. It
does not appear that appeals of this
nature would satisfy the criteria for
expedited resolution. Moreover, it is
anticipated that most of these appeals
will be withdrawn once the MCO explains to
the enrollee, as part of its resolution
process, that the enrollee will not be not
financially responsible for payment.
- ------------------------------------------------------------------------------------------------------------------------------------
244 157 Attach It refers to a "standard appeal"--what is this? A 42 CFR 438.408 delineates requirements for
H non-expedited appeal as described in previous standard and expedited resolution of
paragraphs? A grievance as set forth in the current appeals. The existing AHCCCS/Contractor
administrative code? If it is the latter, are the grievance process will be amended to
timeframes for response changed from 30 days to 45 ensure compliance with the BBA provisions.
days with extension of 2 weeks without member These changes will be communicated through
agreement, but only notice? regulation, contract, and/or formal
policy.
- ------------------------------------------------------------------------------------------------------------------------------------
245 157 Attach Are there member grievances as previously provided Attachments H(1) and H(2) have been
H for in the administrative code? If so, under what written to incorporate all required
circumstances, and what rules, etc applies? changes due to the BBA. This attachment
prevails over rule and statute effective
October 1, 2003.
- ------------------------------------------------------------------------------------------------------------------------------------
246 157 Attach Is the process of requesting a "fair hearing" the Attachments H(1) and H(2) have been
H same as the current process of appealing a decision written to incorporate all required
from a member grievance? Does this still exist in changes due to the BBA. This attachment
its current form, and if so, under what prevails over rule and statute effective
circumstances? October 1, 2003.
- ------------------------------------------------------------------------------------------------------------------------------------
247 157 Attach Can a member appeal from the process set forth in As in the current scheme, a member may
H Attachment H (either standard or expedited), beyond file a Petition for Judicial Review in
the fair hearing process or is that the full and Superior Court.
final process?
- ------------------------------------------------------------------------------------------------------------------------------------
248 157 Attach Attachment H provides that the enrollee is to be The 20/90 day requirement for appealing a
H given no less than 20 days and no more than 90 Contractor Notice of Action is delineated
in 42 CFR 438.402 and applies to both
- ------------------------------------------------------------------------------------------------------------------------------------
44
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
days from date of Notice of Action to expedited and standard appeals.
file an appeal--does this apply to
expedited grievances (appeals) under
Article 13 or to "standard" grievance
which currently have 60 days limit?
- ------------------------------------------------------------------------------------------------------------------------------------
249 157 Attach Entire This section uses the terms grievance, Attachments H(1) and H(2) have been
H Attachment H appeal, expedited appeal, State fair written to incorporate all
(1) (1) hearing and expedited hearing. required changes due to the BBA.
Contractors currently utilize the This attachment prevails over
AHCCCSA definitions of the terms rule and statute effective October 1,
grievance and expedited hearing. May 2003. The BBA has defined specific
Contractors assume that the terms which pertain to the Grievance
definitions and requirements will stay System; any current terms which do not
the same for these two terms? Please conform to the BBA must be amended to
provide more information, definitions ensure compliance. As an example,
and processes for appeal, expedited refer to the definition of "action,"
appeal and State fair hearing. "appeal", and "grievance" as defined
in 438.400.
- ------------------------------------------------------------------------------------------------------------------------------------
250 157 Attach Paragraph 3 Currently, we rely on the language in If the Contractor is aware that the
H the Member Information section of the enrollee has a limited English
(1) contract. Therefore, vital materials, proficiency in a prevalent non English
including Notices for Denials, language, the Contractor must
Reductions, Suspensions or translate the written material, e.g.
Terminations of Services are the Contractor resolution notice, in
translated when we are aware that a the prevalent non English language-
language is spoken by 1,000 or, 5% of rather than simply including language
our members. We also inform our in the document advising the enrollee
members of their right to that the information is available in
interpretation and translation the prevalent non English language.
services when we are aware that
1,000 or 5% of the members speak a
specific language and have LEP.
Attachment H of the RFP states,
"Written documents, including but not
limited to the Contractor's Notice of
Action, the Notice of Contractor's
Appeal/Grievance Resolution, ... shall
be translated in the enrollee's
language if information is received by
the Contractor, orally or in writing,
indicating that the enrollee has
Limited English Proficiency." We are
interpreting this to say that we must
print the stated documents in a
member's chosen language if the member
tells us that he/she has LEP. Is this
correct?
- ------------------------------------------------------------------------------------------------------------------------------------
251 157 Attach Bullet 2 This bullet requires a contractor to "Appeal" is defined in 42 CFR 438.400.
H define appeal. Please provide a
(1) definition and the context that
AHCCCSA is using the term appeal.
- ------------------------------------------------------------------------------------------------------------------------------------
252 157 Attach Bullet 4 This bullet allows for an enrollee to 42 CFR 438.402 delineates requirements
H file both a grievance and an appeal for oral and written appeals. The BBA
(1) orally. Currently, enrollees that does not mandate a hearing process for
dispute a grievance decision must grievances as defined in 438.400.
submit a
- ------------------------------------------------------------------------------------------------------------------------------------
45
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
request for hearing in writing. Does
this oral request include the appeal
of a grievance decision?
- ------------------------------------------------------------------------------------------------------------------------------------
253 157 Attach Bullet 5 The RFP states that an enrollee shall AHCCCS anticipates establishing a
H be given no less than 20 days (and no specific timeframe for appealing
(1) more than 90 days) to file an appeal. through regulation and/or formal
Is it the intent of AHCCCSA to allow policy.
individual health plans choose the
time frame for filing grievances and
appeals, or is AHCCCSA going to define
the timeline?
- ------------------------------------------------------------------------------------------------------------------------------------
254 157 Attach Bullet 6 Item 2 This bullet indicates that a Please refer to the answer to question
H contractor shall notify enrollees at # 243.
(1) the time of any action affecting the
claim when there has been a denial of
payments. Is it the intent of AHCCCSA
to require Contractors to notify
enrollees when provider claims have
been denied? Is it the intent of
AHCCCSA to allow enrollees to appeal
provider claim denials? If so what
level of appeal is meant by this
section?
- ------------------------------------------------------------------------------------------------------------------------------------
255 157 Attach Bullet 6 As this statement does not specify Please refer to Subpart F. Notice of
H working or calendar days, can we Action mailing requirements are found
(1) assume it is calendar days? This in 438.404. The timeframes generally
statement would imply that the Notice refer to calendar days although he
of Action is sent out 10 days before expedited timeframe is stated in terms
the date of the action. Is this to of working days.
mean the "effective" date of the
action?
- ------------------------------------------------------------------------------------------------------------------------------------
256 157 Attach Are there set definitions of the terms Yes, please refer to 438.400.
H Appeal, grievance and complaint?
(1)
- ------------------------------------------------------------------------------------------------------------------------------------
257 157 Attach Are the terms appeals and grievances Please refer to the definitions found
H being used interchangeably OR Are you in Subpart F. These terms are not used
(1) allowing the Health Plan to define interchangeably and must conform to
these terms OR Do we use CFR 438 the BBA definitions.
subpart F to define the terms? Note -
CFR 438 does not recognize the term
"complaint".
- ------------------------------------------------------------------------------------------------------------------------------------
258 157 Attach Where it states "inquiries appealing Please refer to 42 CFR 438.406(b).
H an action are treated as appeals and
(1) are confirmed in writing...." Please
clarify who is "confirming in writing"
-the Health Plan or the enrollee?
- ------------------------------------------------------------------------------------------------------------------------------------
259 158 Attach Bullet 7 This item refers to the enrollee's No, the terms "grievances" and
H Item 3 right to file an appeal with the "appeals" have distinct meanings as
(1) contractor. Does this mean the defined in Subpart F.
enrollee's right to file a grievance?
- ------------------------------------------------------------------------------------------------------------------------------------
46
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
260 158 Attach Bullet 7 This bullet refers to the enrollee's The BBA permits enrollees to file
H Item 4 right to file a request for State fair requests for hearing with the State
(1) hearing. May we take this to mean the concerning "actions" which are not
enrollees right to file a request for resolved solely in favor of the
expedited hearing? If not, from whom enrollee by the Contractor. Some of
does the enrollee request a State fair these actions may qualify as
hearing? "expedited" matters.
- ------------------------------------------------------------------------------------------------------------------------------------
261 158 Attach Bullet 7 In this item it refers to the Expedited resolution is discussed in
H Item 6 enrollee's right to file an expedited 438.408 and 438.410.
(1) resolution. Please provide a
definition of expedited resolution in
this context and the circumstances in
which an enrollee can utilize or
request the expedited resolution. With
whom does the enrollee request an
expedited resolution?
- ------------------------------------------------------------------------------------------------------------------------------------
262 158 Attach Bullet 10 This bullet uses the term standard Attachments H(1) and H(2) have been
H appeal. Does this terminology refer to written to incorporate all required
(1) what is currently called a grievance? changes due to the BBA. This
Or is this a new appeal process? This attachment prevails over rule and
bullet allows the contractor to statute effective October 1, 2003.
respond to standard appeals within 45
days, if this is referring to the
current grievance process, is the
AHCCCSA eliminating the 30 day time
frame currently used for processing
grievances?
- ------------------------------------------------------------------------------------------------------------------------------------
263 158 Attach Bullet 14 Item This bullet indicates that an enrollee Subpart F delineates MCO requirements
H 3 can appeal the denial in whole or in for appeals of "actions" which include
(1) part of payment for service. Is this the denial of payment for a service,
to mean the enrollees can appeal in whole or in part. Also refer to
provider claim denials? If so, what response number 243.
level of appeal is meant by this
section?
- ------------------------------------------------------------------------------------------------------------------------------------
264 158 Attach Bullet 21 Item This bullet indicates that a health 42 CFR438.408 delineates the content
H 2 b plan has to provide written notice of requirements which must be included in
(1) the enrollee's right to receive the Contractor's written notice of
benefits pending the hearing and how resolution. The right to receive
to request continuation of benefits. continued benefits must be included.
Bullet 15, on page 158, indicates that
benefits shall continue if the
enrollee meets all five criteria.
Should the health plan include this
information only if all of the
criteria in Bullet 15 had been
previously met? Or is it the intent of
AHCCCSA to have the health plans
include this language in every letter?
- ------------------------------------------------------------------------------------------------------------------------------------
265 158 Attach Attachment H provides that the Please refer to the answer to question
H Contractor shall permit both oral and #261.
written appeals and grievances and
those oral inquiries appealing an
action are treated as appeals and are
confirmed in writing
- ------------------------------------------------------------------------------------------------------------------------------------
47
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
unless expedited resolution is
requested. Please clarify what an
"expedited resolution" is? Is this is
referring to an Article 13 request for
expedited appeal?
- ------------------------------------------------------------------------------------------------------------------------------------
266 158 Attach Attachment H refers to the Contractor Attachments H(1) and H(2) have been
H resolving all expedited appeal within written to incorporate all required
3 working days and making reasonable changes due to the BBA. This
efforts to provide oral notice to an attachment prevails over rule and
enrollee regarding an expedited appeal statute effective October 1, 2003.
resolution--is this effort to provide
notice regarding an appeal of the
expedited appeal? Is that same as
Article 13? Does this mean after the
Contractor makes decision on expedited
that the member then can access the
expedited, or non-expedited, appeal
process in either Article 13 or 8?
- ------------------------------------------------------------------------------------------------------------------------------------
267 158 Attach Attachment H1 refers to right of Attachments H(1) and H(2) have been
H enrollee to file appeal of "failure to written to incorporate all required
provide services in timely manner"--is changes due to the BBA. This
this a grievance filed with Contractor attachment prevails over rule and
about provider's car, e.g., quality of statute effective October 1, 2003.
care complaint, that is a "standard
appeal" (with 45? Days to resolve and
right of appeal?) or a "traditional"
grievance under Article 8?
- ------------------------------------------------------------------------------------------------------------------------------------
268 161 Attach Item J "If the contractor's decision is The terms "appeal and request for
H(2) appealed and a request for hearing is hearing" in this context represent one
filed..........". Is that 1 step or 2 action and refers to appealing the
steps? Can the provider appeal the Contractor decision to the State.
Health Plan grievance decision to be
relooked at and if not satisfied,
request a hearing or is "appeal and
request for hearing" saying the same
thing which would be an appeal to
AHCCCS?
- ------------------------------------------------------------------------------------------------------------------------------------
269 Data General Upon reviewing the data supplement, it AHCCCSA is unaware of any pertinent
Supp Question appears that in general the medical issues that contributed to a decrease
expenses for the TANF/KidsCare under 1 in medical expenses. This information
age category show a decrease in is based upon health plan self-
medical expenses from 2001 to 2002. reported data.
Please explain any pertinent issues
that may cause a decrease in medical
expenses during these time periods.
-----------------------------------------------------------------------------------------------------------------------------------
270 Data Section A Please provide additional details on This information will be presented at
Supp Overview how Mercer will develop the mid-point the Bidder's Conference
and rate ranges for the contract
period?
- ------------------------------------------------------------------------------------------------------------------------------------
48
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
271 Data Section A Please provide information on any The information in the data supplement
Supp Overview medical trend analysis that was is not directly used in the
completed using the data in the data development of medical trends. The
supplement. encounter utilization reports are used
to aid in the development of
utilization trends.
- ------------------------------------------------------------------------------------------------------------------------------------
272 Data Section A Please provide additional details on Health plans receive monthly
Supp Overview capitation offset on the CRCS form for capitation for the pregnant women
Delivery Supplement. enrolled in their plan. Currently, the
assumed duration of a pregnant woman
in the program is 8 months including
the post partum time period.
Therefore, in order to avoid double
paying the plans, the maternity
payment is reduced for the eight
months of capitation dollars that the
plans will received.
- ------------------------------------------------------------------------------------------------------------------------------------
273 Data Section D and How do the Provider Type and Category The Provider type and Category of
Supp F of Service drive the rate setting? Service make up the criteria for
Please clarify the relationship of the developing general service categories
service matrix which includes Provider that are the basis of the capitation
Type and Category of Service to the rates. The crosswalk between the
Capitation Rate Setting worksheets. service matrix to the CRCS is provided
so you can use the encounter
utilization reports for developing
your capitation bids by those service
categories.
- ------------------------------------------------------------------------------------------------------------------------------------
274 Data When evaluating utilization for rate Both the professional component and
Supp setting, how do codes with global technical component for lab and
rates billed with TC, 26 modifier get radiology services are included in the
handled? Are the professional (26) lab and radiology services category.
component in physician services and See the service matrix in Section D of
the technical (TC) portion in lab, the Data Supplement for further
radiology, etc.? If they are split, information.
what are the percentages of splits
that will apply?
- ------------------------------------------------------------------------------------------------------------------------------------
275 Data What is the 4/1/03 AHCCCS fee schedule AHCCCS will increase the hospital tier
Supp status? How will adjustments to that per diems based on the 3rd quarter
fee schedule be factored into the rate DRI. An estimate of this will be used
setting? in developing the capitation rates.
AHCCCS will continue to freeze its fee
schedule for all other rates. This
will be factored into the capitation
rate development.
- ------------------------------------------------------------------------------------------------------------------------------------
276 Data Capitation Can you give an example of a This is a service that does not fit
Supp Rate "Miscellaneous" service? There are no any of the categories that are
Calculation AHCCCSA Service Matrix Categories that contained in the service matrix.
Sheet (CRCS) crosswalk to this line in the CRCS.
- ------------------------------------------------------------------------------------------------------------------------------------
277 Data Service Matrix In the Service Matrix of the data set, It should be the number of units that
Supp non-emergency transportation is is defined as a trip for
counted as number of encounters. transportation services.
Should this not be number of units?
- ------------------------------------------------------------------------------------------------------------------------------------
278 Gen How many disease management programs AHCCCS has not established a standard
quest need to be in place and are there for the number of disease management
specific diseases that are mandated? programs a plan must offer. The
development and implementation of
disease management programs should be
based on the needs of the health
plan's members.
- ------------------------------------------------------------------------------------------------------------------------------------
279 Gen What is meant by "disease management Disease Management Programs are
programs"? disease specific programs
- ------------------------------------------------------------------------------------------------------------------------------------
49
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
quest Do they include management of diseases designed to assist persons with
within the realm of case management, chronic illnesses improve their self-
or are they looking for "disease- management skills. Case management can
specific" programs? be one tool of disease management.
- ------------------------------------------------------------------------------------------------------------------------------------
280 Gen Will they accept referrals to current Disease management programs can be
quest HIHS programs as disease management, provided in many different methods. It
i.e. MMC's/CHC CHF Program, Diabetes is up to the Contractor to determine
Education & Coagulation Clinic, what is effective for their
informal asthma education, etc? population.
- ------------------------------------------------------------------------------------------------------------------------------------
281 Gen If they truly mean specific "disease AHCCCS will monitor the implementation
quest management programs", with tracking of of Disease Management programs at the
CLINICAL Indicator, (in addition to first round of Operational and
Utilization Monitoring which can be Financial Reviews conducted under the
easily done by the HP), is there a new contract.
date by which these programs must be
in place?
- ------------------------------------------------------------------------------------------------------------------------------------
282 Gen Does AHCCCSA intend to now, or at any In lieu of specific standards by
quest time during the contract term, install geographic area, AHCCCS is utilizing
geographic access standards for the community access standard as the
specialists? guideline for network development.
Essentially, this means that services
that are generally available to the
population of a given community,
should be equally available to the
AHCCCS members residing in that same
community. Additional specific
requirements are not currently
anticipated.
- ------------------------------------------------------------------------------------------------------------------------------------
283 Gen Will the performance bond and The Offeror should assume that they
quest capitalization levels remain will remain constant.
consistent during the period of the
financial statement forecast?
- ------------------------------------------------------------------------------------------------------------------------------------
284 Gen What years' growth assumptions should AHCCCSA will provide the estimates
quest be used of the overall AHCCCS used by the AHCCCS budget office at
population growth in the financial the bidder's conference.
statement forecast?
- ------------------------------------------------------------------------------------------------------------------------------------
285 Gen Should we assume our same mixture of This is a decision that the Offeror
quest membership by rate group as of now as will need to make based upon its
our mixture in the financial statement estimates.
forecast?
- ------------------------------------------------------------------------------------------------------------------------------------
Gen Should the margin on Financial The contractor should not factor the
quest Statement Forecast rates set by "margin" (risk/contingency) that is
AHCCCS' actuaries be included in the included in the capitation rate
financial statement forecast? development. They should report their
actual expected margin.
- ------------------------------------------------------------------------------------------------------------------------------------
286 Gen When setting the rates without Yes, some portion of the
quest pharmacy, will all administrative administrative costs will be borne by
costs related to the pharmacy benefit another entity. It is unknown at this
be borne by another entity? point the amount.
- ------------------------------------------------------------------------------------------------------------------------------------
287 Gen For the capitation rates set by AHCCCSA anticipates that the
quest AHCCCS' actuaries (PPC, HIV/AIDS, capitation rates in question will be
Title XIX Waiver, HIFA Parents, etc.) available April 1, 2003. Because the
when will that data be available? What PPC and TWG rates are reconciled, the
are the Offeror should estimate what their
profitability will
- ------------------------------------------------------------------------------------------------------------------------------------
50
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
inflationary assumptions used for the be for the TWG and PPC experience and
contract period? build that into their financial
projections. For the HIFA parents,
assume a rate that is 10% greater than
the applicable TANF rates.
- ------------------------------------------------------------------------------------------------------------------------------------
288 Gen When will the reinsurance adjustment The reinsurance offsets will be
quest table for plans with a deductible available by the end of February.
greater than $20,000 be available? Those offsets will be adjusted
Will this be consistent through out annually when additional date is
the contract period? analyzed including inpatient rate
adjustments, program changes, and
actual reinsurance claims paid.
- ------------------------------------------------------------------------------------------------------------------------------------
289 Gen Will the bidder be able to modify the The bidder can modify their capitation
quest capitation rates after they are input rate bids until 3:00 pm, March 31,
into the web site? If so, when will 2003.
they no longer be available for
modification?
- ------------------------------------------------------------------------------------------------------------------------------------
290 Gen Does AHCCCSA have any enrollment AHCCCSA will provide the estimates
quest projections for the acute care program used by the AHCCCS budget office at
over the next 1-5 years split by GSA the bidder's conference.
and/or eligibility category? If so,
please provide copies of what is
available.
- ------------------------------------------------------------------------------------------------------------------------------------
291 Gen Upon bidding for GSA 10, will separate The Offeror must submit a bid for the
quest capitation rates be quoted for Pima entire GSA. Capitation scoring will be
County and Santa Cruz County? based upon the blended capitation
rate. After all RFP scoring is
completed, the two bidders with the
highest overall scores will receive an
award for both Pima and Santa Cruz
counties. The next highest scorers
will receive an award in Pima County
only. The Pima County only Contractors
will be offered a rate that is their
bidded rate for both counties as
adjusted based upon a percentage
difference between the risk of the two
counties combined and Pima County only
as determined by Mercer. If the Pima
County awardee does not accept the
offered rate, then the next highest
scorer will be offered a rate until
all available Contractor slots are
awarded.
- ------------------------------------------------------------------------------------------------------------------------------------
292 Gen Will AHCCCSA make available experience The TPL experience is included in the
quest information regarding Third Party current health plan financial
Recoveries? statements.
- ------------------------------------------------------------------------------------------------------------------------------------
293 Gen Will AHCCCSA make available experience The amount of the copayments will be
quest information regarding member co pays? hard coded into the CRCS.
- ------------------------------------------------------------------------------------------------------------------------------------
294 Gen Is there a preferred form for the Please refer to the answer to question
quest actuarial certification? #1.
- ------------------------------------------------------------------------------------------------------------------------------------
295 Gen Can AHCCCSA provide guidance as to how AHCCCS will increase the hospital tier
quest CYE '04 reimbursement rates will vary per diems based on the 3rd quarter
from CYE '03, specifically identifying DRI. An estimate of this will be used
percentage changes to inpatient in developing the capitation rates.
hospital tiered per diems, outpatient AHCCCS will continue to freeze its fee
hospital reimbursement, and other fee- schedule for all other rates. This
for-service will be factored into the capitation
rate development.
- ------------------------------------------------------------------------------------------------------------------------------------
51
- ------------------------------------------------------------------------------------------------------------------------------------
QUEST
#R PAGE SECT PARAGRAPH QUESTION ANSWER
- ------------------------------------------------------------------------------------------------------------------------------------
reimbursement?
- ------------------------------------------------------------------------------------------------------------------------------------
296 Gen How many hospital supplement payments AHCCCS will provide total hospital
quest per 1,000 non-MED members occurred in supplemental payments for CYE '02 when
historical contract years? the rates are provided.
- ------------------------------------------------------------------------------------------------------------------------------------
297 Gen What aid code groups do the $15,000 The $15,000 applies to Title XIX
quest and $20,000 deductibles correspond to Waiver Group rates categories. The
in Exhibit U of the data supplement? $20,000 applies to all other rate
categories. See further definitions of
risk groups in the data supplement
and paragraph 2 of the RFP.
- ------------------------------------------------------------------------------------------------------------------------------------
298 Gen Will elements of the Capitation Rate AHCCCS will set the following items in
quest Calculation sheet be set by AHCCCS? If the CRCS:
so, please describe them. 1. reinsurance offsets
2. copayment amounts
- ------------------------------------------------------------------------------------------------------------------------------------
299 Gen Per instruction, all responses should Please refer to the answer to question
quest be limited to three pages unless #176.
indicated otherwise. Does this three
page limitation include attachments,
i.e. manual, sample reports,
handbooks, etc?
- ------------------------------------------------------------------------------------------------------------------------------------
300 Gen Can attachments be marked as such in Where attachments are permitted, yes.
quest the 1/2 inch margin around the page?
- ------------------------------------------------------------------------------------------------------------------------------------
302 Gen Is the response page limit to Page limits apply to the narrative.
quest narrative only? Do you want response Attachments which are specifically
attachments to be included? requested do not count toward the
limit.
- ------------------------------------------------------------------------------------------------------------------------------------
303 Gen How do you want attachments that are Attachments, which are specifically
quest not within the 8 1/2 x 11 requirements requested, may be submitted in hard
to be displayed? I.e. electronic file copy form in a sleeve, following the
(if available), Xerox copy of applicable narrative.
material, in sleeves, in separate
binder?
- ------------------------------------------------------------------------------------------------------------------------------------
304 Gen May we have a BID Rating Tool? No.
quest
- ------------------------------------------------------------------------------------------------------------------------------------
305 Gen Does AHCCCS intend to adjust its FFS No. AHCCCS will freeze its rate
quest schedule to reflect the Medicare Fee schedule.
schedule in 2003/2004
- ------------------------------------------------------------------------------------------------------------------------------------
306 Gen When using the rate worksheets on the Yes. After that, the bidder will be
quest web, are bidder's able to change them locked out.
up until 3/31/03, 3pm?
- ------------------------------------------------------------------------------------------------------------------------------------
307 Gen When using the rate worksheets on the Yes. More information will be provided
quest web, are these secured and at the bidder's conference.
confidential from other bidders?
- ------------------------------------------------------------------------------------------------------------------------------------
52
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
ATTACHMENT H (1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY
The Contractor shall have a written policy delineating its Grievance System
which shall be in accordance with applicable Federal and State laws, regulations
and policies, including, but not limited to 42 CFR Part 438 Subpart F. The
Contractor shall provide the Enrollee Grievance System Policy to all providers
and subcontractors at the time of contract. The Contractor shall also furnish
this information to its enrollees within a reasonable time after the Contractor
receives notice of the recipient's enrollment. Additionally, the Contractor
shall provide written notification of any significant change in this policy at
least 30 days before the intended effective date of the change.
The written information provided to enrollees describing the Grievance System
including the grievance process, enrollee rights, grievance system requirements
and timeframes, shall be in each prevalent non-English language occurring within
the Contractor's service area and in an easily understood language and format.
The Contractor shall inform enrollees that oral interpretation services are
available in any language, that additional information is available in prevalent
non-English languages upon request and how enrollees may obtain this
information.
Written documents, including but not limited to the Contractor's Notice of
Action, the Notice of Contractor's Appeal/Grievance Resolution, Notice of
Contractor Extension for Resolution, and Notice of Contractor Extension of
Notice of Action shall be translated in the enrollee's language if information
is received by the Contractor, orally or in writing, indicating that the
enrollee has a limited English proficiency. Otherwise, these documents shall be
translated in the prevalent non-English language(s) or shall contain information
in the prevalent non- English language(s) advising the enrollee that the
information is available in the prevalent non-English language(s) and in
alternative formats along with an explanation of how enrollees may obtain this
information. This information must be in large, bold print appearing in a
prominent location on the first page of the document.
At a minimum, the Contractor's Grievance System Standards and Policy shall
specify:
- That the Contractor shall maintain records of all grievances
and appeals.
- Information describing the grievance, appeal, and fair hearing
procedures and timeframes describing the right to hearing, the
method for obtaining a hearing, the rules which govern
representation at the hearing, definitions of "action,"
"grievance," and "appeal," the right to file grievances and
appeals and the requirements and timeframes for filing a
grievance or appeal.
- Information explaining that a provider acting on behalf of an
enrollee and with the enrollee's written consent, may file an
appeal or grievance.
- The availability of assistance in the filing process and the
Contractor's toll-free numbers that an enrollee can use to
file a grievance or appeal by phone if requested by the
enrollee.
- That an enrollee shall be given no less than 20 days (and no
more than 90 days) from the date of the Contractor's Notice of
Action to file an appeal.
- That the Contractor shall mail a Notice of Action: 1) at least
10 days before the date of a termination, suspension or
reduction of previously authorized AHCCCS services (include
exception situations, fraud, move out of state); 2) at the
time of any action affecting the claim when there has been a
denial of payments; 3) within 14 calendar days from receipt of
a request for a standard service authorization which has been
denied or reduced unless an extension is in effect; 4) within
three working days from receipt of an expedited service
authorization request unless an extension is in effect.
Acute Care RFP
Revised February 28, 2003
- 157 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
- That the Notice of Action must explain: 1) the action the
Contractor has taken or intends to take, 2) the reasons for
the action, 3) the enrollee's right to file an appeal with the
Contractor, 4) the enrollee's right to request a State fair
hearing if no exhaustion of the Contractor's appeal process is
required, 5) the procedures for exercising these rights, 6)
circumstances when expedited resolution is available and how
to request it and 7) the enrollee's right to request continued
benefits pending resolution of the appeal, how to request
continued benefits and the circumstances under which the
enrollee may be required to pay for the cost of these
services.
- That the Contractor shall permit both oral and written appeals
and grievances and that oral inquiries appealing an action are
treated as appeals and are confirmed in writing unless
expedited resolution is requested.
- That the Contractor shall acknowledge receipt of each
grievance and appeal, in writing, within five working days of
receipt, except for appeals which meet the criteria for
expedited resolution. The Contractor shall acknowledge receipt
of appeals, which meet the criteria for expedited resolution,
in writing, within one working day.
- The definition of a standard appeal and that the Contractor
shall resolve standard appeals no later than 45 days from the
date of receipt of the appeal.
- The definition of an expedited appeal and that the Contractor
shall resolve all expedited appeals not later than three
working days from the date the Contractor receives the appeal
where the Contractor determines, or the provider in making the
request on the enrollee's behalf indicates, that standard
resolution timeframe could seriously jeopardize the enrollee's
life or health or ability to attain, maintain or regain
maximum function. The Contractor shall make reasonable efforts
to provide oral notice to an enrollee regarding an expedited
resolution appeal.
- The standard and expedited resolution timeframes may be
extended up to 14 calendar days if the enrollee requests the
extension or if the Contractor establishes a need for
additional information and that the delay is in the enrollee's
interest.
- That if the Contractor extends the timeframe for resolution of
a grievance or appeal when not requested by the enrollee, the
Contractor shall provide the enrollee with written notice of
the reason for the delay.
- That an enrollee may file an appeal of: 1) the denial or
limited authorization of a requested service including the
type or level of service, 2) the reduction, suspension or
termination of a previously authorized service, 3) the denial
in whole or in part of payment for service, 4) the failure to
provide services in a timely manner, 5) the failure of the
Contractor to comply with the timeframes for dispositions of
grievances and appeals and 6) the denial of a rural enrollee's
request to obtain services outside the Contractor's network
when the Contractor is the only Contractor in the rural area.
- That benefits shall continue only if: 1) the enrollee files an
appeal before the later of a) 10 days from the mailing of the
Notice of Action or b) the intended date of the Contractor's
action, 2) the appeal involves the termination, suspension, or
reduction of a previously authorized course of treatment, 3)
the services were ordered by an authorized provider, 4) the
original period covered by the original authorization has not
expired, and 5) the enrollee requests a continuation of
benefits.
Acute Care RFP
Revised February 28, 2003
- 158 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
- That the Contractor continues extended benefits originally
provided to the enrollee until any of the following occurs: 1)
enrollee withdraws appeal, 2) enrollee has not specifically
requested continued benefits pending a hearing decision within
10 days of MCO/PIHP mailing appeal resolution notice, 3) State
hearing office issues decision adverse to enrollee or 4) time
period or service limits of a previously authorized service
has been met.
- That for appeals, the Contractor provides the enrollee a
reasonable opportunity to present evidence and allegations of
fact or law in person and in writing and that the Contractor
informs the enrollee of the limited time available in cases
involving expedited resolution.
- That for appeals, the Contractor provides the enrollee and his
representative the opportunity before and during the appeals
process to examine the enrollee's case file including medical
records and other documents considered during the appeals
process.
- That if the Contractor denies a request for expedited
resolution, it must make reasonable efforts to give the
enrollee prompt oral notice and follow-up within two calendar
days with a written notice of the denial of expedited
resolution.
- That the Contractor shall ensure that individuals who make
decisions regarding grievance and appeals are individuals not
involved in any previous level of review or decision making
and that individuals who make decisions regarding: 1) appeals
of denials based on lack of medical necessity, 2) a grievance
regarding denial of expedited resolution of an appeal or 3)
grievances or appeals involving clinical issues are health
care professionals as defined in 42 CFR 438.2 with the
appropriate clinical expertise in treating the enrollee's
condition or disease.
- That the Contractor shall provide written notice of the
disposition of each appeal which must contain: 1) the results
of the resolution process and the date it was completed, 2)
for appeals not resolved wholly in favor of enrollees: a) the
enrollee's right to request a State fair hearing and how to do
so, b) the right to receive benefits pending the hearing and
how to request continuation of benefits and c) information
explaining that the enrollee may be held liable for the cost
of benefits if the hearing decision upholds the Contractor.
- That if the Contractor's decision is appealed and a request
for hearing is filed, the Contractor must ensure that all
supporting documentation is received by the AHCCCSA, Office of
Legal Assistance, no later than five working days from the
date the Contractor receives the verbal or written request
from AHCCCSA, Office of Legal Assistance. The file sent by the
Contractor must contain a cover letter that includes:
1. Complainant's name
2. Complainant's AHCCCS I.D. number
3. Complainant's address
4. Complainant's phone number (if applicable)
5. date of receipt of grievance or appeal
6. summary of the Contractor's actions
undertaken to resolve the grievance and
basis of the determination
Acute Care RFP
Revised February 28, 2003
- 159 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
- The following material shall be included in the file sent by
the Contractor:
1. written request of the Complainant asking
for the request for hearing
2. copies of the entire file which includes the
investigations and/or medical records; and
the Contractor's resolution
3. other information relevant to the resolution
of the grievance or appeal
- That if the Contractor or the State fair hearing decision
reverses a decision to deny, limit or delay services not
furnished while the appeal was pending, the Contractor shall
authorize or provide the services promptly and as
expeditiously as the enrollee's health condition requires.
- That if the Contractor or State fair hearing decision reverses
a decision to deny authorization of services and the disputed
services were received pending appeal, the Contractor shall
pay for those services.
Acute Care RFP
Revised February 28, 2003
- 160 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
ATTACHMENT H (2): PROVIDER GRIEVANCE SYSTEM STANDARDS AND POLICY
The Contractor shall have in place a written grievance system policy for
providers regarding adverse actions taken by the Contractor. The policy shall be
in accordance with applicable Federal and State laws, regulations and policies.
The grievance policy shall include the following provisions:
a. The grievance policy shall be provided to all subcontractors at the time
of contract. For providers without a contract, the grievance policy may be
mailed with a remittance advice, provided the remittance is sent within 45
days of receipt of a claim.
b. The grievance policy must specify that all grievances, with the exception
of those challenging claim denials, must be filed with the Contractor no
later than 60 days from the date of the adverse action. Grievances
challenging claim denials must be filed in writing with the Contractor no
later that 12 months from the date of service, 12 months after the date of
eligibility posting or within 60 days after the date of a timely claim
submission, whichever is later.
c. Specific individuals are appointed with authority to require corrective
action and with requisite experience to administer the grievance process.
d. A log is maintained for all grievances containing sufficient information
to identify the Complainant, date of receipt, nature of the grievance and
the date the grievance is resolved. Separate logs must be maintained for
provider and member grievances
e. Within five working days of receipt, the Complainant is informed by letter
that the grievance has been received.
f. Each grievance is thoroughly investigated using the applicable statutory,
regulatory, contractual and policy provisions, ensuring that facts are
obtained from all parties.
g. All documentation received and mailed by the Contractor during the
grievance process is dated upon receipt.
h. All grievances are filed in a secure designated area and are retained for
five years following the Contractor's decision, the Administration's
decision, judicial appeal or close of the grievance, whichever is later.
i. A copy of the Contractor's decision will be communicated in writing to all
parties. [deleted] either hand-delivered or delivered by certified mail to
all parties whose interest has been adversely affected by the decision.
The decision shall be mailed to all other individuals by regular mail. The
date of the decision shall be the date of personal delivery or, if mailed,
the postmark date of the mailing. [deleted] The decision must include and
describe in detail, the following:
1. the nature of the grievance
2. the issues involved
3. the reasons supporting the Contractor's decision, [deleted]
explained in easy to understand terms for members, [deleted]
including references to applicable statute, rule, applicable
contractual provisions, policy and procedure
4. the Complainant's right to request a hearing by filing the request
for hearing to the Contractor no later than 30 days after the date
of the Contractor's decision.
j. If the Contractor's decision is appealed and a request for hearing is
filed, the Contractor must ensure that all supporting documentation is
received by the AHCCCSA, Office of Legal Assistance, no later than five
working days from the date the Contractor receives the verbal or written
request from AHCCCSA, Office of Legal Assistance. The file sent by the
Contractor must contain a cover letter that includes:
1. Complainant's name
2. Complainant's AHCCCS ID number
3. Complainant's address
4. Complainant's phone number (if applicable)
5. the date of receipt of grievance
6. a summary of the Contractor's actions undertaken to resolve the
grievance and basis of the determination
Acute Care RFP
Revised February 28, 2003
- 161 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
k. The following material shall be included in the file sent by the
Contractor:
1. written request of the Complainant asking for the request for
hearing
2. copies of the entire file which includes the investigations
and/or medical records; and the Contractor's decision
3. other information relevant to the resolution of the grievance
Acute Care RFP
Revised February 28, 2003
- 162 -
GENERAL GUIDANCE ON BIDDING CAPITATION RATES
WITH THE PRESCRIPTION DRUG BENEFIT CARVED OUT
The following information is provided as guidance to bidders for submitting a
capitation rate proposal with the prescription drug benefit carved out. AHCCCS
is currently in the process of hiring a consultant to perform an analysis of the
potential carve out. Part of that analysis will include a recommendation for the
design that will be used in the event that the benefit is carved out. AHCCCS
anticipates that the analysis will be completed in the Summer of 2003.
Therefore, the following should be considered a guide for preparing the
capitation rate bid submissions; however, it is subject to change. In any event
this information will help ensure that bidders are all using most of the same
assumptions when developing their capitation rate proposals for the carve out
option.
- Due to recent guidance from CMS, AHCCCS fully expects that there will
be a closed formulary. AHCCCS will solicit Contractor input in
developing the formulary as well as input from other required parties
as defined in the federal Medicaid Drug Rebate Program.
- AHCCCS in conjunction with its Contractors will develop statewide prior
authorization criteria for the Pharmacy Benefits Manager (PBM) that is
awarded a contract. It is anticipated that the prior authorization
requirements will be as effective as those currently used at the health
plans.
- In the Pharmacy RFP, AHCCCS will incorporate the requirement for the
PBM to send real time data to the Contractors. This process should be
similar to AHCCCS' current Contractor's data exchange protocols and
requirements with their PBM's.
- The real time access to data should ensure that the Contractor's will
continue to receive real time data for use in utilization management,
disease management programs, identification of drug-seeking members,
care coordination, case management, and provider profiling, etc.
- AHCCCS believes that there is a potential for a prescription drug carve
out to have an impact on the utilization of other services. This impact
will vary by plan and type of program (acute versus long term care).
Each bidder should factor its unique integration of pharmacy management
into their operations when determining secondary impacts. AHCCCS
expects that each plan will have a different estimate. They should
factor that into their capitation rate bidding.
- The bidder should also consider the impact the prescription drug carve
out will have to their administrative costs. For example, if the PBM
does all prior authorizations, how would that impact the Contractor
staffing? Conversely, because the plans will continue to perform
utilization management based upon PBM data, there may be no staffing
impact.
Please refer to the Question and Answer document that will be issued in the 2nd
RFP Amendment for further information on the potential prescription drug carve
out.
MEDICAID ELIGIBILITY VERIFICATION SYSTEM (MEVS)
Contract Awards under
RFP YH03-0005
CONTRACT # YH03-0005-01
Company: WEBMD-ENVOY
Contact: Wheeler Foster, Client Manager
Address: 26 Century Blvd., Suite 601
Nashville, TN 37214
Phone: (805) 496-3155
Fax: (805) 496-3077
E-mail: wfoster@webmd.net
CONTRACT # YH03-0005-02
Company: HEALTH DATA EXCHANGE (HDX)
Contact: Jonas Dahlen, Area Manager
Address: 467 Creamery Way
Exton, PA 19341
Phone: (610) 219-9099
Fax: (619) 219-1384
E-mail: JonasDahlen@siemens.com
CONTRACT # YH03-0005-03
Company: MEDIFAX EDI
Contact: Tommy Lewis, VP of Marketing
Address: 1283 Murfreesboro Road
Nashville, TN 37217
Phone: (615) 565-2158
Fax: (615) 565-2858
E-mail: tommy.lewis@medifax.com
Page 1 of 8
[AHCCCS LOGO]
SOLICITATION AMENDMENT
Solicitation Number: RFP YH04-0001
Amendment Number One
Solicitation Due Date: March 31, 2003, 3:00 PM (MST)
Arizona Health Care Cost
Containment System Administration
(AHCCCSA)
701 East Jefferson, MD 5700
Phoenix, Arizona 85034
Michael Veit, (602) 417-4762
A signed copy of this amendment must be included with the proposal, which must
be received by AHCCCSA no later than the Solicitation due date and time. This
solicitation is amended as follows:
1. REMOVE AND REPLACE: REMOVE page 58 and REPLACE with the attached
Revised Page 58, dated February 10, 2003.
2. REMOVE AND REPLACE: REMOVE page 99 and REPLACE with the attached
Revised Page 99, dated February 10, 2003.
3. REMOVE AND REPLACE: REMOVE all pages under Tab "B, "Program Changes",
and REPLACE with the attached four (4) revised pages of the DATA
SUPPLEMENT, dated February10, 2003.
4. REMOVE AND REPLACE: REMOVE the first sheet under Tab "T, "Reinsurance
Payments CYE 19 (2001)" and REPLACE with the attached revised page of
the DATA SUPPLEMENT, dated February 10, 2003.
5. All other terms and conditions remains the same, including the proposal
due date and time.
Offeror hereby acknowledges receipt and This Solicitation Amendment is hereby executed this 10th day
understanding of this Solicitation Amendment. of February, 2003, in Phoenix, Arizona.
- ----------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------
Signature Date
- ----------------------------------------------------------------------------------------------------------------------------
Signed Copy in File
- ----------------------------------------------------------------------------------------------------------------------------
Typed Name and Title Michael Veit
- ----------------------------------------------------------------------------------------------------------------------------
Contracts and Purchasing Administrator
- ----------------------------------------------------------------------------------------------------------------------------
Name of Company
- ----------------------------------------------------------------------------------------------------------------------------
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
INCENTIVE FUND: AHCCCSA may retain a specified percentage of capitation
reimbursement in order to distribute to Contractors based on their performance
measure outcomes. The incentive fund will not be implemented in CYE '04 and
contractors will be notified at least 60 days prior to implementation in a
future contract year.
58. REINSURANCE
Reinsurance is a stop-loss program provided by AHCCCSA to the Contractor for the
partial reimbursement of covered services, as described below, for a member with
an acute medical condition beyond an annual deductible level. AHCCCSA
"self-insures" the reinsurance program through a deduction to capitation rates
that is intended to be budget neutral. Refer to the AHCCCSA Reinsurance Claims
Processing Manual for further details on the Reinsurance Program.
INPATIENT REINSURANCE
Inpatient reinsurance covers partial reimbursement of covered inpatient facility
medical services. See the table below for applicable deductible levels and
coinsurance percentages. The coinsurance percent is the rate at which AHCCCSA
will reimburse the Contractor for covered inpatient services incurred above the
deductible. The deductible is the responsibility of the Contractor. Per diem
rates paid for nursing facility services provided within 30 days of an acute
hospital stay, including room and board, provided in lieu of hospitalization for
up to 90 days in any contract year shall be eligible for reinsurance coverage.
The following table represents deductible and coinsurance levels for CYE '04:
- --------------------------------------------------------------------------------------------
Title XIX Waiver Group
Annual Deductible* Annual Deductible
-----------------------------------------------------------------
Combined
Statewide Plan Prospective PPC and Prospective
Enrollment Reinsurance Reinsurance Coinsurance
- --------------------------------------------------------------------------------------------
0-34,999 $20,000 $15,000 75%
35,000-49,999 $35,000 $15,000 75%
50,000 and over $50,000 $15,000 75%
- --------------------------------------------------------------------------------------------
*applies to all members except for Title XIX Waiver Group members
a) PROSPECTIVE REINSURANCE: This coverage applies to prospective enrollment
periods. The deductible level is based on the Contractor's statewide AHCCCS
acute care enrollment (not including SOBRA Family Planning Extension services)
as of October 1st each contract year for all rate codes and counties, as shown
in the table above. AHCCCSA will adjust the Contractor's deductible level at the
beginning of a contract year if the Contractor's enrollment changes to the next
enrollment level. A Contractor at the $35,000 or $50,000 deductible level may
elect a lower deductible prior to the beginning of a new contract year. These
deductible levels are subject to change by AHCCCSA during the term of this
contract. Any change will have a corresponding impact on capitation rates.
b) PRIOR PERIOD COVERAGE REINSURANCE: Effective October 1, 2003, AHCCCSA will no
longer cover PPC inpatient expenses under the reinsurance program for any
members except Title XIX Waiver Group members. See section c) below for
additional information.
Acute Care RFP
Revised February 10, 2003
- 58 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
CAPACITY ANALYSIS/PLANNING AND DEVELOPMENT
8. Provide a copy of the Offeror's Network Development and
Management Plan. (No page limit)
Reference: Section D, Paragraph 27, Network Development
(Provider Network Development and Management Plan)
9. Provide a synopsis of the Offerer's Disaster Recovery Plan as
it relates to the provider network. (No page limit)
Reference: Section D, Paragraph 73, Business Continuity Plan
III. CAPITATION
Capitation is a fixed (per member) monthly payment to contractors for the
provision of covered services to members. It is an actuarially sound amount to
cover expected utilization and costs for the individual risk groups in a
risk-sharing managed care environment. The Offeror must demonstrate that the
capitation rates proposed are actuarially sound. In general terms, this means
that the Offeror who is awarded a contract should be able to keep utilization at
or near its proposed levels and that it will be able to contract for unit costs
that average at or near the amounts shown on the Capitation Rates Calculation
Sheet (CRCS). This requirement also applies to bids submitted in best and final
offer rounds.
Prior Period Coverage (PPC) and HIV/AIDS Supplement rates will be set by AHCCCS'
actuaries and not bid by the Contractor. Due to the lack of complete historical
data, the Title XIX Waiver Group and HIFA Parents' rates will also be set by
AHCCCS' actuaries, rather than bid by the Contractor. See Section D, Paragraph
53, Compensation, for information regarding risk sharing for the Title XIX
Waiver Group and PPC time period. All other rate codes, including the Delivery
Supplemental Payment, will be subject to competitive bidding.
To facilitate the preparation of its capitation proposals, AHCCCSA will provide
each Offeror with a Data Supplement. This data source should not be used as the
sole source of information in making decisions concerning the capitation
proposal. Each Offeror is solely responsible for research, preparation and
documentation of its capitation proposal.
REQUIRED SUBMISSION: CAPITATION
10. The Offeror must submit its capitation proposal using the
AHCCCSA bid web site. Instructions for accessing and using the
web site will be issued by March 1, 2003. The Offeror must
have an actuary who is a member of the American Academy of
Actuaries certify that the bid submission is actuarially
sound. This certification must be done with subsequent
submissions in Best and Final Offer rounds (if applicable).
The Offeror must also submit hard copy print outs of the web
site CRCS. Refer to Section B and Attachment E for more
details.
The Offeror must prepare and submit its capitation proposal
assuming a $20,000 deductible level for regular reinsurance,
for all rate codes, in all counties. AHCCCSA will provide a
table of per member per month reinsurance adjustments to be
made to capitation rates for those Contractors whose actual
deductible level exceeds $20,000.
Capitation rates shall be submitted two ways: first, assuming
all medical services are included in the capitation rates, and
second, assuming that prescription drugs will be carved out of
the capitation rates. Prescription drugs are defined as "FDA
approved legend or over the counter (OTC) products provided
upon receipt of a valid prescription order and dispensed by a
pharmacist in an outpatient setting." When bidding with
prescription drugs carved out, please factor the impact to the
other medical service and administrative categories. AHCCCSA
anticipates that in the event that prescription drugs are
carved
Acute Care RFP
Revised February 10, 2003
- 99 -
PROGRAM CHANGES
THE FOLLOWING PROGRAM CHANGES SHOULD BE CONSIDERED WHEN REVIEWING THE ENCOUNTER
UTILIZATION REPORTS AND FINANCIAL INFORMATION PROVIDED IN THE DATA SUPPLEMENT
FOR PREPARATION OF THE CAPITATION RATE BID SUBMISSIONS. THERE ARE ALSO PROGRAM
CHANGES THAT ARE NOT INCLUDED IN THIS DATA SUPPLEMENT. THESE CHANGES ARE EITHER
EFFECTIVE AFTER THE TIME PERIOD FOR WHICH ENCOUNTERS AND CLAIMS HAVE BEEN
GATHERED, OR WILL BE EFFECTIVE ON OR AFTER OCTOBER 1, 2003. BELOW IS A BRIEF
DESCRIPTION OF THE AHCCCS ACUTE PROGRAM CHANGES AND THEIR EFFECTIVE DATES:
GEOGRAPHIC SERVICE AREAS
AHCCCSA HAS REGROUPED ARIZONA COUNTIES INTO THE FOLLOWING GSA'S:
MAXIMUM NUMBER OF
GEOGRAPHIC SERVICE AREA (GSA) CONTRACTS
2. YUMA, LA PAZ 2
4. MOHAVE, COCONINO, APACHE, NAVAJO 2
6. YAVAPAI 2
8. PINAL, GILA 2
10. PIMA, SANTA CRUZ 5/2
12. MARICOPA 6
14. GRAHAM, GREENLEE, COCHISE 2
CONTRACTS WILL BE AWARDED BY GSA. FOR GSA #10, UP TO FIVE CONTRACTS WILL BE
AWARDED FOR PIMA COUNTY, AND UP TO TWO OF THOSE FIVE CONTRACTS WILL INCLUDE AN
AWARD FOR SANTA CRUZ COUNTY.
THE DATA SUPPLEMENT INFORMATION HAS BEEN REVISED TO REGROUP COUNTIES INTO THE
GSA'S PROPOSED FOR OCTOBER 1, 2003.
2ND NEWBORN SCREEN (PKU) TESTING
EFFECTIVE FEBRUARY 1, 2002, THE ARIZONA DEPARTMENT OF HEALTH SERVICES ADHS)
REQUIRES THAT A 2ND NEWBORN SCREEN TEST BE DONE ON ALL ARIZONA NEWBORNS. THE
CODE FOR THE TESTING IS S3620. THE COST OF THE TEST IS $20. IN ADDITION TO THE
COST OF THE TEST, THERE ARE ASSOCIATED HANDLING FEES THAT CONTRACTORS ARE
REQUIRED TO PAY TO THE PROVIDERS COLLECTING THE TEST. THE AHCCCS FEE FOR SERVICE
SCHEDULE FOR HANDLING FEES IS $4.25 FOR TESTS PERFORMED IN PHYSICIANS' OFFICES,
AND $10.00 FOR TESTS PERFORMED IN
CONTRACTED LABORATORY FACILITIES. THESE SERVICES ARE NOT INCLUDED IN THE DATA
SUPPLEMENT DUE TO LAG IN CAPTURING ENCOUNTER DATA.
CIRCUMCISIONS
EFFECTIVE OCTOBER 1, 2002 ELECTIVE CIRCUMCISIONS ARE NO LONGER A COVERED
SERVICE. CIRCUMCISION SERVICES HAVE BEEN REMOVED FROM THE ENCOUNTER UTILIZATION
REPORTS.
HOSPITAL PILOT PROGRAM
THE HOSPITAL PILOT PROGRAM IN MARICOPA AND PIMA COUNTIES WAS TERMINATED FOR CYE
'01 AND REINSTATED FOR CYE '02 AND CYE '03. THE PILOT PROGRAM STATES THAT IF A
HEALTH PLAN IN MARICOPA AND PIMA COUNTIES IS UNABLE TO CONTRACT WITH A HOSPITAL
FOR INPATIENT SERVICES, THEN THE HEALTH PLAN REIMBURSEMENT RATE IS 95% OF THE
AHCCCS TIER PER DIEMS. HEALTH PLAN COST INFORMATION FOR INPATIENT STAYS IN
MARICOPA AND PIMA COUNTIES WILL REFLECT THE TERMINATION OF THE PILOT PROGRAM FOR
CYE '01. EVEN THOUGH THE PROGRAM IS SCHEDULED TO TERMINATED CYE '04, BIDDERS
SHOULD ASSUME THAT THE PILOT PROGRAM WILL BE REINSTATED THROUGH LEGISLATION.
TITLE XIX WAIVER GROUP
EFFECTIVE APRIL 1, 2001, AHCCCS RECEIVED A WAIVER FROM CMS THAT CONVERTED THE
MEDICALLY NEEDY/MEDICALLY INDIGENT (MNMI) POPULATION FROM A STATE FUNDED ONLY
POPULATION TO A TITLE XIX FUNDED POPULATION. THIS GROUP WAS RENAMED THE TITLE
XIX WAIVER GROUP (TWG).
THIS POPULATION HAS TWO COMPONENTS. FIRST, EFFECTIVE OCTOBER 1, 2001, THE
ELIGIBILITY CRITERIA CHANGED TO INCREASE THE FEDERAL POVERTY LEVEL (FPL) FOR
DETERMINING TITLE XIX ELIGIBILITY TO INCOMES AT OR BELOW 100% OF THE FPL
(NON-MED'S) FROM 40% OF THE FPL. THE SECOND GROUP OF MEMBERS IS THE MEDICAL
EXPENSE DEDUCTION (MED). THESE MEMBERS HAVE INCOMES ABOVE 100% OF THE FPL, BUT
INCUR SUFFICIENT MEDICAL COSTS THAT CAUSE THEM TO "SPEND DOWN" TO BELOW 40% OF
THE FPL.
DUE TO THE HISTORICAL HIGH PERCENTAGE OF MNMI MEMBERS BECOMING ELIGIBLE WHILE
HOSPITALIZED, AHCCCSA CREATED A HOSPITALIZED SUPPLEMENTAL PAYMENT AS A METHOD OF
RISK ADJUSTMENT FOR THIS POPULATION. AFTER MONITORING THE ACTUAL PERCENTAGES OF
MEMBERS WHO BECOME ELIGIBLE WHILE HOSPITALIZED, EFFECTIVE OCTOBER 1, 2003,
AHCCCSA WILL NO LONGER PAY A HOSPITALIZED SUPPLEMENT FOR THE NON-MED PORTION OF
THE TITLE XIX WAIVER GROUP.
DUE TO UNCERTAINLY OF THE RISK OF THIS POPULATION, AHCCCSA WILL CONTINUE TO SET
THE CAPITATION RATES AND RECONCILE THE MEDICAL EXPENDITURES FOR CYE '04. THE
RECONCILIATION WILL INCLUDE A 2% RISK BAND. REFER TO THE TITLE XIX WAIVER GROUP
RECONCILIATION POLICY IN THE BIDDER'S LIBRARY FOR MORE DETAILS.
PRIOR PERIOD COVERAGE
FOR CYE '03, AHCCCS PLACED HEALTH PLANS AT FULL RISK FOR MEDICAL SERVICE
EXPENDITURES INCURRED DURING THE PRIOR PERIOD COVERAGE (PPC) TIME PERIOD. THERE
WILL NOT BE A RECONCILIATION FOR CYE '03 PPC EXPENDITURES.
EFFECTIVE CYE '04, AHCCCS WILL SET THE CAPITATION RATES FOR THE PPC TIME PERIOD
AND RECONCILE PPC MEDICAL EXPENSES TO SERVICE REVENUES PER THE PPC
RECONCILIATION POLICY FOUND IN THE BIDDER'S LIBRARY. THE RECONCILIATION WILL
INCLUDE A 2% RISK BAND.
BREAST AND CERVICAL CANCER TREATMENT PROGRAM
EFFECTIVE JANUARY 1, 2002, AHCCCS IMPLEMENTED THE BREAST AND CERVICAL CANCER
TREATMENT PROGRAM. FOR CYE '02, ALL MEDICAL COSTS ASSOCIATED WITH THIS
POPULATION WERE PAID THROUGH THE AHCCCS REINSURANCE PROGRAM. IN ADDITION, HEALTH
PLANS WERE PAID THE TANF 14-44F CAPITATION RATE ON A MONTHLY BASIS. FOR YEARS
BEGINNING WITH CYE '04, THE PLANS WILL BE AT FULL RISK FOR THIS POPULATION.
AHCCCSA WILL NO LONGER PAY FOR MEDICAL SERVICES THROUGH REINSURANCE. THE
ENCOUNTER UTILIZATION REPORTS FOR CYE '02 INCLUDE THE RATE CODES AND MEDICAL
EXPERIENCE FOR THE BCCTP POPULATION IN THE TANF 14-44F AND TANF 45+ RISK GROUPS.
HIFA PARENTS
EFFECTIVE JANUARY 1, 2003, AHCCCSA IMPLEMENTED ITS HIFA WAIVER WITH CMS THAT
PERMITS USING EXCESS TITLE XXI FUNDS TO THE COVER THE PARENTS OF KIDSCARE AND
SOBRA CHILDREN ELIGIBLE MEMBERS WHO ARE NOT OTHERWISE ELIGIBLE. THIS PROGRAM HAS
A LIMIT ON THE ENROLLMENT DUE TO THE AVAILABILITY OF EXCESS FUNDING. BECAUSE
THERE ARE CURRENTLY NO ENCOUNTERS FOR THIS POPULATION, AHCCCSA WILL SET THE
RATES FOR CYE '04.
KIDSCARE/TANF (1931) COMBINING
EFFECTIVE OCTOBER 1, 2002, AHCCCSA BLENDED THE COST AND UTILIZATION EXPERIENCE
OF THE HEALTH PLANS FOR THE PURPOSE OF ESTABLISHING ONE CAPITATION RATE FOR TANF
(1931)/ SOBRA/ AND KIDSCARE MEMBERS. THE
ENCOUNTER UTILIZATION REPORTS HAVE BEEN RESTATED TO INCLUDE THE KIDSCARE RATE
CODES IN THE TANF/SOBRA RISK GROUPS.
POPULATION GROWTH
WITH THE PASSAGE OF PROPOSITION 204 IN OCTOBER 2001 THAT INCREASED THE MEDICAID
ELIGIBILITY LEVEL TO 100% OF THE FPL, AHCCCS POPULATION HAS GROWN DRAMATICALLY.
IN ADDITION TO PROPOSITION 204, AHCCCS' MEMBERSHIP HAS GROWN DUE TO THE DOWNTURN
IN THE ECONOMY AS WELL AS NEW EFFICIENCIES IN THE ELIGIBILITY PROCESS. THIS
GROWTH IS REPRESENTED IN MEMBER MONTH AND ENROLLMENT INFORMATION PRESENTED IN
THIS SUPPLEMENT.
REINSURANCE PAYMENTS FOR CYE `01
This section presents the statewide reinsurance paid per member per month to
health plans for the period October 1, 2000 through September 30, 2001. When
estimating reinsurance, the bidder should consider all changes to the
reinsurance program effective October 1, 2003. The bidder should also consider
changes in rates and utilization from year to year.
See Section B, Program Changes, for reinsurance deductible level changes
effective October 1, 2003. The bidder should note that all bids should be
prepared assuming the deductible levels for statewide enrollment of 0-35,000
members ($20,000). If the health plan's statewide enrollment exceeds 35,000
members, their capitation rates will be adjusted upwards where applicable, to
offset the higher deductible levels.
[AHCCCS LOGO]
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
ACUTE CARE REQUEST FOR PROPOSAL
OCTOBER 1, 2003 - SEPTEMBER 30, 2006
[AHCCCS LOGO]
AHCCCS MISSION
REACHING ACROSS ARIZONA TO PROVIDE
COMPREHENSIVE, QUALITY HEALTH CARE FOR
THOSE IN NEED.
AHCCCS VISION
SHAPING TOMORROW'S MANAGED HEALTH CARE...FROM
TODAY'S EXPERIENCE, QUALITY AND INNOVATION.
AHCCCS CUSTOMER
DEPENDING ON THE CHANGING ROLE OF AHCCCS WE
RECOGNIZE DIFFERENT INTERNAL AND EXTERNAL
CUSTOMERS, BUT WE HAVE ONLY ONE FUNDAMENTAL
FOCUS THAT INSPIRES OUR EFFORTS:
OUR PRIMARY CUSTOMERS
ARE AHCCCS MEMBERS.
CONTRACT/RFP NO. YH04-0001
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
SOLICITATION, OFFER AND AWARD
REQUEST FOR PROPOSAL NUMBER YH04-0001
DATE ISSUED: FEBRUARY 3, 2003 ISSUED BY: AHCCCSA
CONTRACTS AND PURCHASING
SUBJECT OF SOLICITATION: 701 E. JEFFERSON AVE.
ACUTE CARE SERVICES PHOENIX, AZ 85034
TERM OF CONTRACT: 10/1/03- 9/30/06
QUESTIONS CONCERNING THIS SOLICITATION SHALL BE SUBMITTED TO MICHAEL VEIT,
(602) 417-4762 OR E-MAIL OF MJVEIT@AHCCCS.STATE.AZ.US
I. SOLICITATION
In accordance with A.R.S. Section 36-2901, which is incorporated herein by
reference, competitive sealed proposals will be received at the address above,
until 3:00 p.m. local time, March 31, 2003. Proposals must be in the actual
possession of AHCCCSA on or prior to the time and date and at the location
indicated above. LATE PROPOSALS WILL NOT BE CONSIDERED. Proposals must be
submitted in a sealed envelope or package (original and 7 copies) with the
Solicitation Number and the offeror's name and address clearly indicated on the
envelope or package. All proposals must be completed in ink or typewritten.
Additional instructions for preparing a proposal are included in this
solicitation document.
TABLE OF CONTENTS
A. SOLICITATION, OFFER AND AWARD............................. 1
B. RATES..................................................... 6
C. DEFINITIONS............................................... 7
D. PROGRAM REQUIREMENTS...................................... 15
E. CONTRACT CLAUSES.......................................... 73
F. INDEX..................................................... 81
G. REPRESENTATIONS & CERTIFICATIONS.......................... 84
H. EVALUATION FACTORS........................................ 93
I. INSTRUCTIONS TO OFFERORS.................................. 96
J. ATTACHMENTS............................................... 110
II. OFFER (Must be fully completed by Offeror)
The undersigned Offeror hereby agrees, if this offer is accepted within 120 days
of receipt of proposals, to provide all services in accordance with the terms
and requirements stated herein, including all attachments, amendments, and Best-
and-Final Offers (if any).
Name of Offeror:______________________________________Phone:____________________
Address:______________________________________________Fax:______________________
City/State/Zip:_______________________________________Email: ___________________
Printed Name of Person Authorized to Sign Offer:________________________________
Offeror's Signature:__________________________________Date:_____________________
III. AWARD (To be completed by AHCCCSA)
The offer, including all attachments, amendments and Best-and-Final Offers (if
any), contained herein, is accepted. Awarded this___________day of
_______________, 2003.
- -----------------------------------------------
Michael Veit, as AHCCCS Contracting Officer
- 1 -
Acute Care RFP
February 3, 2003
CONTRACT/RFP NO. YH04-0001
TABLE OF CONTENTS
SOLICITATION, OFFER AND AWARD ........................................ 1
SECTION B: CAPITATION RATES .......................................... 6
SECTION C: DEFINITIONS ............................................... 7
SECTION D: PROGRAM REQUIREMENTS ...................................... 15
1. TERM OF CONTRACT AND OPTION TO RENEW ............................. 15
2. ELIGIBILITY CATEGORIES ........................................... 16
3. ENROLLMENT AND DISENROLLMENT ..................................... 17
4. ANNUAL ENROLLMENT CHOICE ......................................... 19
5. OPEN ENROLLMENT .................................................. 20
6. AUTO-ASSIGNMENT ALGORITHM ........................................ 20
7. AHCCCS MEMBER IDENTIFICATION CARDS ............................... 20
8. MAINSTREAMING OF AHCCCS MEMBERS .................................. 20
9. TRANSITION OF MEMBERS ............................................ 21
10. SCOPE OF SERVICES ................................................ 21
11. SPECIAL HEALTH CARE NEEDS ........................................ 29
12. BEHAVIORAL HEALTH SERVICES ....................................... 29
13. AHCCCS MEDICAL POLICY MANUAL ..................................... 31
14. MEDICAID IN THE PUBLIC SCHOOLS (MIPS) ............................ 31
15. PEDIATRIC IMMUNIZATIONS AND THE VACCINE FOR CHILDREN PROGRAM ..... 31
16. STAFF REQUIREMENTS AND SUPPORT SERVICES .......................... 32
17. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS ................ 33
18. MEMBER INFORMATION ............................................... 33
19. MEMBER SURVEYS ................................................... 34
20. CULTURAL COMPETENCY .............................................. 34
21. MEDICAL RECORDS .................................................. 35
22. ADVANCE DIRECTIVES ............................................... 35
23. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM) ............ 36
24. PERFORMANCE STANDARDS ............................................ 37
25. GRIEVANCE AND REQUEST FOR HEARING PROCESS AND STANDARDS .......... 39
26. QUARTERLY GRIEVANCE REPORT ....................................... 39
27. NETWORK DEVELOPMENT .............................................. 39
28. PROVIDER AFFILIATION TRANSMISSION ................................ 41
29. NETWORK MANAGEMENT ............................................... 41
30. PRIMARY CARE PROVIDER STANDARDS .................................. 41
31. MATERNITY CARE PROVIDER STANDARDS ................................ 42
32. REFERRAL PROCEDURES AND STANDARDS ................................ 43
33. APPOINTMENT STANDARDS ............................................ 44
34. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) ........................ 45
35. PROVIDER MANUAL .................................................. 45
36. PROVIDER REGISTRATION ............................................ 46
37. SUBCONTRACTS ..................................................... 46
38. CLAIMS PAYMENT SYSTEM ............................................ 48
39. SPECIALTY CONTRACTS .............................................. 48
40. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT ........................ 49
41. NURSING FACILITY REIMBURSEMENT ................................... 49
42. PHYSICIAN INCENTIVES ............................................. 50
Acute Care RFP
February 3, 2003
- 2 -
CONTRACT/RFP NO. YH04-0001
43. MANAGEMENT SERVICES SUBCONTRACTORS ............................... 50
44. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS ......................... 51
45. MINIMUM CAPITALIZATION REQUIREMENTS .............................. 51
46. PERFORMANCE BOND OR BOND SUBSTITUTE .............................. 52
47. AMOUNT OF PERFORMANCE BOND ....................................... 52
48. ACCUMULATED FUND DEFICIT ......................................... 53
49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS ................... 53
50. FINANCIAL VIABILITY STANDARDS / PERFORMANCE GUIDELINES ........... 53
51. SEPARATE INCORPORATION ........................................... 54
52. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP ................... 54
53. COMPENSATION ..................................................... 54
54. PAYMENTS TO CONTRACTORS .......................................... 56
55. CAPITATION ADJUSTMENTS ........................................... 57
56. INCENTIVES ....................................................... 57
57. REINSURANCE ...................................................... 58
58. COORDINATION OF BENEFITS / THIRD PARTY LIABILITY ................. 61
59. COPAYMENTS ....................................................... 63
60. MEDICARE SERVICES AND COST SHARING ............................... 64
61. MARKETING ........................................................ 64
62. CORPORATE COMPLIANCE ............................................. 64
63. RECORDS RETENTION ................................................ 65
64. DATA EXCHANGE REQUIREMENTS ....................................... 65
65. ENCOUNTER DATA REPORTING ......................................... 66
66. ENROLLMENT AND CAPITATION TRANSACTION UPDATES .................... 67
67. PERIODIC REPORT REQUIREMENTS ..................................... 67
68. REQUESTS FOR INFORMATION ......................................... 68
69. DISSEMINATION OF INFORMATION ..................................... 68
70. OPERATIONAL AND FINANCIAL READINESS REVIEWS ...................... 68
71. OPERATIONAL AND FINANCIAL REVIEWS ................................ 68
72. SANCTIONS ........................................................ 69
73. BUSINESS CONTINUITY PLAN ......................................... 70
74. TECHNOLOGICAL ADVANCEMENT ........................................ 70
75. PENDING LEGISLATIVE / OTHER ISSUES ............................... 71
76. BALANCED BUDGET ACT OF 1997 (BBA) ................................ 71
77. HEALTHCARE GROUP OF ARIZONA ...................................... 72
SECTION E: CONTRACT CLAUSES .......................................... 73
1) APPLICABLE LAW ................................................... 73
2) AUTHORITY ........................................................ 73
3) ORDER OF PRECEDENCE .............................................. 73
4) CONTRACT INTERPRETATION AND AMENDMENT ............................ 73
5) SEVERABILITY ..................................................... 73
6) RELATIONSHIP OF PARTIES .......................................... 73
7) ASSIGNMENT AND DELEGATION ........................................ 73
8) GENERAL INDEMNIFICATION .......................................... 73
9) INDEMNIFICATION -- PATENT AND COPYRIGHT .......................... 74
10) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS ........... 74
11) ADVERTISING AND PROMOTION OF CONTRACT ............................ 74
12) PROPERTY OF THE STATE ............................................ 74
13) THIRD PARTY ANTITRUST VIOLATIONS ................................. 74
14) RIGHT TO ASSURANCE ............................................... 74
Acute Care RFP
February 3, 2003
- 3 -
CONTRACT/RFP NO. YH04-0001
15) TERMINATION FOR CONFLICT OF INTEREST ............................. 74
16) GRATUITIES ....................................................... 75
17) SUSPENSION OR DEBARMENT .......................................... 75
18) TERMINATION FOR CONVENIENCE ...................................... 75
19) TERMINATION FOR DEFAULT .......................................... 75
20) TERMINATION - AVAILABILITY OF FUNDS .............................. 76
21) RIGHT OF OFFSET .................................................. 76
22) NON-EXCLUSIVE REMEDIES ........................................... 76
23) NON-DISCRIMINATION ............................................... 76
24) EFFECTIVE DATE ................................................... 76
25) INSURANCE ........................................................ 76
26) DISPUTES ......................................................... 77
27) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS ...................... 77
28) INCORPORATION BY REFERENCE ....................................... 77
29) COVENANT AGAINST CONTINGENT FEES ................................. 77
30) CHANGES .......................................................... 77
31) TYPE OF CONTRACT ................................................. 77
32) AMERICANS WITH DISABILITIES ACT .................................. 77
33) WARRANTY OF SERVICES ............................................. 78
34) NO GUARANTEED QUANTITIES ......................................... 78
35) CONFLICT OF INTEREST ............................................. 78
36) DISCLOSURE OF CONFIDENTIAL INFORMATION ........................... 78
37) COOPERATION WITH OTHER CONTRACTORS ............................... 78
38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY ............................ 78
39) OWNERSHIP OF INFORMATION AND DATA ................................ 78
40) AHCCCSA RIGHT TO OPERATE CONTRACTOR .............................. 79
41) AUDITS AND INSPECTIONS ........................................... 79
42) LOBBYING ......................................................... 79
43) CHOICE OF FORUM .................................................. 80
SECTION F: INDEX - PROGRAM REQUIREMENTS AND CONTRACT CLAUSES ......... 81
SECTION G: REPRESENTATIONS AND CERTIFICATIONS OF OFFEROR ............. 84
SECTION H: EVALUATION FACTORS AND SELECTION PROCESS .................. 93
SECTION I: INSTRUCTIONS TO OFFERORS .................................. 96
SECTION J: LIST OF ATTACHMENTS ....................................... 110
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS ......................... 111
1) ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES ......... 111
2) AWARDS OF OTHER SUBCONTRACTS ..................................... 111
3) CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK AND
LABORATORY TESTING ............................................... 111
4) CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION .................. 111
5) CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 ............... 111
6) COMPLIANCE WITH AHCCCSA RULES RELATING TO AUDIT AND INSPECTION ... 111
7) COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS ...................... 112
8) CONFIDENTIALITY REQUIREMENT ...................................... 112
9) CONFLICT IN INTERPRETATION OF PROVISIONS ......................... 112
10) CONTRACT CLAIMS AND DISPUTES ..................................... 112
11) ENCOUNTER DATA REQUIREMENT ....................................... 112
Acute Care RFP
February 3, 2003
- 4 -
CONTRACT/RFP NO. YH04-0001
12) EVALUATION OF QUALITY, APPROPRIATENESS, OR
TIMELINESS OF SERVICES ........................................... 112
13) FRAUD AND ABUSE .................................................. 112
14) GENERAL INFORMATION .............................................. 112
15) INSURANCE ........................................................ 112
16) LIMITATIONS ON BILLING AND COLLECTION PRACTICES .................. 113
17) MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND
PROVIDE SERVICES ................................................. 113
18) NON-DISCRIMINATION REQUIREMENTS .................................. 113
19) PRIOR AUTHORIZATION AND UTILIZATION REVIEW ....................... 113
20) RECORDS RETENTION ................................................ 113
21) SEVERABILITY ..................................................... 113
22) SUBJECTION OF SUBCONTRACT ........................................ 114
23) TERMINATION OF SUBCONTRACT ....................................... 114
24) VOIDABILITY OF SUBCONTRACT ....................................... 114
25) WARRANTY OF SERVICES ............................................. 114
ATTACHMENT B: MINIMUM NETWORK STANDARDS .............................. 115
ATTACHMENT C: MANAGEMENT SERVICES SUBCONTRACTOR STATEMENT ............ 126
ATTACHMENT D (1): SAMPLE LETTER OF INTENT ............................ 132
ATTACHMENT D (2): NETWORK SUBMISSION REQUIREMENTS .................... 136
ATTACHMENT E: INSTRUCTIONS FOR PREPARING CAPITATION PROPOSAL ......... 150
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS ........................... 152
ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM .............................. 154
ATTACHMENT H (1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY ..... 157
ATTACHMENT H (2): PROVIDER GRIEVANCE SYSTEM STANDARDS AND POLICY ..... 161
ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS ...................... 163
ATTACHMENT J: EPSDT PERIODICITY SCHEDULE ............................. 166
ATTACHMENT K: OFFEROR'S CHECKLIST .................................... 169
Acute Care RFP
February 3, 2003
- 5 -
CAPITATION RATES CONTRACT/RFP NO. YH04-0001
SECTION B: CAPITATION RATES
PRE-CONTRACT AWARD
1. The Contractor shall assume in the capitation rate calculation
that services will be provided as described in this
solicitation.
2. The first page following this page must be a certification
that the capitation rates submitted by the Offeror are
actuarially sound by an actuary who is a member of the
American Academy of Actuaries.
3. The Capitation Rate Calculation Sheets (CRCS) will be
generated by the Web application, described in Attachment E.
The Offeror must complete two such CRCS for each risk group
and Geographical Service Area (GSA) it is bidding. One CRCS is
to be bid with Prescription Drug expenditures included and one
CRCS is to be bid without Prescription Drug expenditures. The
Offeror should insert a print out of the CRCS bid sheets after
the actuarial certification.
4. In the event that the Web application bid submission differs
from the bid submission included with this section, the bid
submitted via the Web application will prevail.
POST-CONTRACT AWARD
The Contractor shall provide services as described in this contract. In
consideration for these services, the Contractor will be paid the attached
Contractor specific rates for the term October 1, 2003 through September 30,
2004.
SEE ATTACHED.
Acute Care RFP
February 3, 2003
- 6 -
DEFINITIONS CONTRACT/RFP NO. YH04-0001
SECTION C: DEFINITIONS
1931 Eligible individuals and families under the 1931
provision of the Social Security Act, with household
income levels at or below 100% of the FPL.
ADHS Arizona Department of Health Services, the state
agency mandated to serve the public health needs of
all Arizona citizens.
ADHS BEHAVIORAL A Title XIX or Title XXI acute care member who is
HEALTH RECIPIENT eligible for, and is receiving, behavioral health
services through ADHS and its subcontractors.
AGENT Any person who has been delegated the authority to
obligate or act on behalf of another person or
entity.
AHCCCS Arizona Health Care Cost Containment System, which is
composed of the Administration, Contractors, and
other arrangements through which health care services
are provided to an eligible person, as defined by
A.R.S. Section 36-2902, et seq.
AHCCCS BENEFITS See "COVERED SERVICES".
AHCCCS MEMBER See "MEMBER".
AHCCCSA Arizona Health Care Cost Containment System
Administration.
ALTCS The Arizona Long Term Care System, a program under
AHCCCSA that delivers long term, acute, behavioral
health and case management services to members, as
authorized by A.R.S. Section 36-2932.
AMBULATORY Preventive, diagnostic and treatment services
CARE provided on an outpatient basis by physicians, nurse
practitioners, physician assistants and other health
care providers.
AMPM AHCCCS Medical Policy Manual.
ANNUAL The opportunity, given each member annually, to
ENROLLMENT change to another Contractor in their GSA.
CHOICE (AEC)
ARIZONA State regulations established pursuant to relevant
ADMINISTRATIVE statutes. For purposes of this solicitation, the
CODE (A.A.C.) relevant sections of the AAC are referred to
throughout this document as "AHCCCS Rules".
A.R.S. Arizona Revised Statutes.
BBA The Balanced Budget Act of 1997.
BCCTP Breast and Cervical Cancer Treatment Program, a Title
XIX eligibility expansion program for women who are
not otherwise Title XIX eligible and are diagnosed as
needing treatment for breast and/or cervical cancer
or lesions.
BIDDER'S LIBRARY A repository of manuals, statutes, rules and other
reference material located at the AHCCCS Central
office in Phoenix. A limited, virtual library is
located on the AHCCCS website at
www.ahcccs.state.az.us.
BOARD CERTIFIED An individual who has successfully completed all
prerequisites of the respective specialty board and
successfully passed the required examination for
certification.
Acute Care RFP
February 3, 2003
- 7 -
DEFINITIONS CONTRACT/RFP NO. YH04-0001
CAPITATION Payment to Contractor by AHCCCSA of a fixed monthly
payment per person in advance for which the
Contractor provides a full range of covered services
as authorized under A.R.S. Section 36-2904 and
Section 36-2907.
CATEGORICALLY Member eligible for Medicaid under Title XIX of the
LINKED TITLE XIX Social Security Act including those eligible under
MEMBER 1931 provisions of the Social Security Act, Sixth
Omnibus Budget Reconciliation Act (SOBRA),
Supplemental Security Income (SSI), SSI-related
groups. To be categorically linked, the member must
be aged 65 or over, blind, disabled, a child under
age 19, a parent of a dependent child, or pregnant.
CLEAN CLAIM A claim that may be processed without obtaining
additional information from the provider of service
or from a third party; but does not include claims
under investigation for fraud or abuse or claims
under review for medical necessity.
CMS (FORMERLY HCFA) Centers for Medicare and Medicaid Services, an
organization within the U.S. Department of Health and
Human Services, which administers the Medicare and
Medicaid programs and the State Children's Health
Insurance Program.
COMPETITIVE BID A state procurement system used to select Contractors
PROCESS to provide covered services on a geographic basis.
CONTINUING An AHCCCS Contractor during CYE 03 that submits a
OFFEROR proposal pursuant to this solicitation.
(INCUMBENT)
CONTRACT See "COVERED SERVICES".
SERVICES
CONTRACT YEAR Corresponds to Federal fiscal year (Oct. 1 through
(CY) Sept. 30). For example, Contract Year 04 is 10/01/03
- 9/30/04.
CONTRACTOR An organization or entity agreeing through a direct
contracting relationship with AHCCCSA to provide the
goods and services specified by this contract in
conformance with the stated contract requirements,
AHCCCS statute and rules and Federal law and
regulations.
CONVICTED A judgment of conviction has been entered by a
Federal, State or local court, regardless of whether
an appeal from that judgment is pending.
COPAYMENT A monetary amount specified by the Director that the
member pays directly to a Contractor or provider at
the time covered services are rendered, as defined in
R9-22-107.
COVERED SERVICES Health care services to be delivered by a Contractor
which are designated in Section D of this contract,
AHCCCS Rules R9-22, Article 2 and R9-31, Article 2
and the AMPM.
CRS The Children's Rehabilitative Services administered
by ADHS, as defined in R9-22-114.
CY See "CONTRACT YEAR".
CYE Contract Year Ending; same as "CONTRACT YEAR".
DAYS Calendar days unless otherwise specified as defined
in the text, as defined in R9-22-101.
DIRECTOR The Director of AHCCCSA.
Acute Care RFP
February 3, 2003
- 8 -
DEFINITIONS CONTRACT/RFP NO. YH04-0001
DISCLOSING ENTITY An AHCCCS provider or a fiscal agent.
DISENROLLMENT The discontinuance of a member's ability to receive
covered services through a Contractor.
DME Durable Medical Equipment, which is an item, or
appliance that can withstand repeated use, is
designated to serve a medical purpose, and is not
generally useful to a person in the absence of a
medical condition, illness or injury as defined in
R9-22-102.
DUAL ELIGIBLE A member who is eligible for both Medicare and
Medicaid.
ELIGIBILITY A process of determining, through a written
DETERMINATION application and required documentation, whether an
applicant meets the qualifications for Title XIX or
Title XXI.
EMERGENCY A medical condition manifesting itself by acute
MEDICAL symptoms of sufficient severity (including severe
CONDITION pain) such that a prudent layperson, who possesses an
average knowledge of health and medicine, could
reasonably expect the absence of immediate medical
attention to result in: a) placing the patient's
health (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious
jeopardy; b) serious impairment to bodily functions;
or c) serious dysfunction of any bodily organ or
part.
EMERGENCY Covered inpatient and outpatient services provided
MEDICAL SERVICE after the sudden onset of an emergency medical
condition as defined above. These services must be
furnished by a qualified provider, and must be
necessary to evaluate or stabilize the emergency
medical condition.
ENCOUNTER A record of a health care related service rendered by
a provider or providers registered with AHCCCSA to a
member who is enrolled with a Contractor on the date
of service.
ENROLLEE A Medicaid recipient who is currently enrolled with a
contractor.
ENROLLMENT The process by which an eligible person becomes a
member of a Contractor's health plan.
EPSDT Early and Periodic Screening, Diagnosis and
Treatment; services for persons under 21 years of age
as described in AHCCCS rules R9-22, Article 2.
FAMILY PLANNING A program that provides only family planning services
SERVICES for a maximum of 24 months to SOBRA women whose
EXTENSION pregnancy has ended and who are not otherwise
PROGRAM eligible for full Title XIX services.
FEDERALLY An entity which meets the requirements and receives a
QUALIFIED HEALTH grant and funding pursuant to Section 330 of the
CENTER (FQHC) Public Health Service Act. An FQHC includes an
outpatient health program or facility operated by a
tribe or tribal organization under the Indian
Self-Determination Act (PL 93-638) or an urban Indian
organization receiving funds under Title V of the
Indian Health Care Improvement Act.
FEE-FOR-SERVICE A method of payment to registered providers on an
(FFS) amount per service basis.
Acute Care RFP
February 3, 2003
- 9 -
DEFINITIONS CONTRACT/RFP NO. YH04-0001
FES Federal emergency services program covered under
R9-22-217, to treat an emergency medical condition
for a member who is determined eligible under A.R.S.
Section 36-2903.03 (D).
FFP Federal financial participation (FFP) refers to the
contribution that the Federal government makes to the
Title XIX and Title XXI program portions of AHCCCS as
defined in 42 CFR 400.203.
FISCAL YEAR (FY) The budget year - Federal Fiscal Year: October 1
through September 30; State fiscal year: July 1
through June 30.
FREEDOM TO WORK A Federal program that expands Title XIX eligibility
(TICKET TO WORK) to individuals, 16 through 64 years old, who are
disabled and whose earned income, after allowable
deductions, is at or below 250% of the Federal
Poverty Level.
GATEKEEPER Primary care provider who is primarily responsible
for all medical treatment rendered, who makes
referrals as necessary, and who coordinates and
monitors the member's treatment.
GEOGRAPHIC A specific county or defined grouping of counties
SERVICE AREA designated by AHCCCSA within which a Contractor
(GSA) provides, directly or through subcontract, covered
health care to members enrolled with that Contractor.
HEALTHCARE A prepaid medical coverage plan marketed to small,
GROUP OF ARIZONA uninsured businesses and political subdivisions
(HCG) within the state.
HEALTH Various forms of plan organization, including staff
MAINTENANCE and group models that meet the HMO licensing
ORGANIZATION requirements of the Federal and/or State government
(HMO) and offer a full array of health care services to
members on a capitated basis.
HEALTH PLAN See "CONTRACTOR".
HIFA Health Insurance Flexibility and Accountability Act,
a demonstration initiative by CMS, which targets
State Children's Health Insurance Program (Title XXI)
funding for populations with incomes below 200
percent of the Federal Poverty Level, seeking to
maximize private health insurance coverage options.
HIFA PARENTS Parents of Medicaid and KidsCare eligible children
who are eligible for AHCCCS benefits under the HIFA
Waiver. All eligible parents must pay a monthly
premium based on household income.
IBNR Incurred But Not Reported liability for services
rendered for which claims have not been received.
IHS Indian Health Service authorized as a Federal agency
pursuant to 25 U.S.C. 1661.
KIDSCARE Individuals under the age of 19, eligible under the
SCHIP program, in households with income at or below
200% FPL. Children, in households with incomes
between 150% and 200% of the FPL, may participate in
the program, but are required to pay a premium amount
based on the number of children in the family and the
gross family income.
Acute Care RFP
February 3, 2003
- 10 -
DEFINITIONS CONTRACT/RFP NO. YH04-0001
LIEN A legal claim, filed with the County Recorder's
office in which a member resides and in the county an
injury was sustained, for the purpose of ensuring
that AHCCCS receives reimbursement for medical
services paid. The lien is attached to any settlement
the member may receive as a result of an injury.
MANAGED CARE Systems that integrate the financing and delivery of
health care services to covered individuals by means
of arrangements with selected providers to furnish
comprehensive services to members; establish explicit
criteria for the selection of health care providers;
have financial incentives for members to use
providers and procedures associated with the plan;
and have formal programs for quality, utilization
management and the coordination of care.
MANAGEMENT A person or organization that agrees to perform any
SERVICES administrative function or service for the
SUBCONTRACTOR Contractor, specifically related to securing or
fulfilling the Contractor's obligations to AHCCCSA,
under the terms of this contract.
MANAGING A general manager, business manager, administrator,
EMPLOYEE director, or other individual who exercises
operational or managerial control over, or who
directly or indirectly conducts the day-to-day
operation of an institution, organization or agency.
MATERIAL Facts, data or other information excluded from a
OMISSION report, contract, etc., the absence of which could
lead to erroneous conclusions following reasonable
review of such report, contract, etc.
MEDICAID A Federal/State program authorized by Title XIX of
the Social Security Act, as amended.
MEDICAL EXPENSE Title XIX Waiver member whose family income is more
DEDUCTION (MED) than 100% of the Federal Poverty Level and has family
medical expenses that reduce income to or below 40%
of the Federal Poverty Level. MED's may have a
categorical link to a Title XIX program; however,
their income exceeds the limits of the Title XIX
program.
MEDICARE A Federal program authorized by Title XVIII of the
Social Security Act, as amended.
MEDICARE HMO A Health Maintenance Organization or Comprehensive
Medical Plan, which provides Medicare services to
Medicare beneficiaries pursuant to a Medicare risk
contract with CMS under Section 1876 of the Social
Security Act.
MEMBER An eligible person who is enrolled in the system, as
defined in A.R.S. Section 36-2901, A.R.S. Section
36-2981 and A.R.S. Section 36-2981.01.
NEW OFFEROR An organization or entity that submits a proposal in
response to this solicitation and which has not been
an AHCCCS Contractor during CYE 03.
NON-CONTRACTING A person who provides services as prescribed in
PROVIDER A.R.S. Section 36-2939 and who does not have a
subcontract with an AHCCCS Contractor.
OFFEROR An organization or other entity that submits a
proposal to the Administration in response to this
RFP, as defined in R9-22-106.
PERFORMANCE A set of standardized indicators designed to assist
STANDARDS AHCCCSA in evaluating, comparing and improving the
performance of its Contractors. Specific descriptions
of health services measurement goals are found in
Section D, Paragraph 24, Performance Standards.
Acute Care RFP
February 3, 2003
- 11 -
DEFINITIONS CONTRACT/RFP NO. YH04-0001
PMMIS AHCCCSA's Prepaid Medical Management Information
System.
POTENTIAL A Medicaid eligible recipient who is not enrolled
ENROLLEE with a contractor.
POST Medically necessary services, related to an emergency
STABILIZATION medical condition, provided after the member's
SERVICES condition is sufficiently stabilized so that the
member could alternatively be safely discharged or
transferred to another location. The services must be
provided at the site where the member was treated for
the emergency medical condition.
PRIMARY CARE An individual who meets the requirements of
PROVIDER (PCP) A.R.S. Section 36-2901, and who is PCP responsible
for the management of a member's health care. A PCP
may be a physician defined as a person licensed as an
allopathic or osteopathic physician according to
A.R.S. Title 32, Chapter 13 or Chapter 17 or a
practitioner defined as a physician assistant
licensed under A.R.S. Title 32, Chapter 25, or a
certified nurse practitioner licensed under A.R.S.
Title 32, Chapter 15.
PRIOR PERIOD The period of time, prior to the member's enrollment,
during which a member is eligible for covered
services. The time frame is from the effective date
of eligibility to the day a member is enrolled with a
Contractor.
PROVIDER Any person or entity who contracts with AHCCCSA or a
Contractor for the provision of covered services to
members according to the provisions A.R.S. Section
36-2901 or any subcontractor of a provider delivering
services pursuant to A.R.S. Section 36-2901.
QUALIFIED A person, eligible under A.R.S. Section 36-2971(6),
MEDICARE who is entitled to Medicare Part A insurance and
BENEFICIARY meets certain income and residency requirements of
(QMB) the Qualified Medicare Beneficiary program. A QMB,
who is also eligible for Medicaid, is commonly
referred to as a QMB dual eligible.
RATE CODE Eligibility classification for capitation payment
purposes.
REGIONAL An organization under contract with ADHS, who
BEHAVIORAL administers covered behavioral health services in a
HEALTH geographically specific area of the state. Tribal
AUTHORITY (RBHA) governments, through an agreement with ADHS, may
operate a tribal regional behavioral health authority
(TRBHA) for the provision of behavioral health
services to Native American members living
on-reservation.
REINSURANCE A risk-sharing program provided by AHCCCSA to
Contractors for the reimbursement of certain contract
service costs incurred for a member beyond a certain
monetary threshold.
RELATED PARTY A party that has, or may have, the ability to control
or significantly influence a Contractor, or a party
that is, or may be, controlled or significantly
influenced by a Contractor. "Related parties"
include, but are not limited to, agents, managing
employees, persons with an ownership or controlling
interest in the disclosing entity, and their
immediate families, subcontractors, wholly-owned
subsidiaries or suppliers, parent companies, sister
companies, holding companies, and other entities
controlled or managed by any such entities or
persons.
RISK GROUP Grouping of rate codes that are paid at the same
capitation rate.
RFP Request For Proposal is a document prepared by
AHCCCSA, which describes the services required and
instructs prospective offerors about how to prepare a
response (proposal), as defined in R9-22-106.
Acute Care RFP
February 3, 2003
- 12 -
DEFINITIONS CONTRACT/RFP NO. YH04-0001
SCHIP State Children's Health Insurance Program under Title
XXI of the Social Security Act.
SCOPE OF SERVICES See "COVERED SERVICES".
SES State emergency services program covered under
R9-22-217 to treat an emergency medical condition for
a qualified alien or non-citizen who is determined
eligible under A.R.S. Section 36-2901.06.
SOBRA Section 9401 of the Sixth Omnibus Budget and
Reconciliation Act, 1986, amended by the Medicare
Catastrophic Coverage Act of 1988, U.S.C.
1396a(a)(10)(A)(ii)(IX), November 5, 1990.
SPECIAL HEALTH Members with special health care needs are those
CARE NEEDS members who have serious and chronic physical,
developmental or behavioral conditions, and who also
require medically necessary health and related
services of a type or amount beyond that required by
members generally.
STATE The State of Arizona.
STATE PLAN The written agreements between the State and CMS
which describe how the AHCCCS program meets CMS
requirements for participation in the Medicaid
program and the State Children's Health Insurance
Program.
SUBCONTRACT An agreement entered into by the Contractor with a
provider of health care services, who agrees to
furnish covered services to members or with any other
organization or person who agrees to perform any
administrative function or service for the Contractor
specifically related to fulfilling the Contractor's
obligations to AHCCCSA under the terms of this
contract, as defined in R9-22-101.
SUBCONTRACTOR (1) A person, agency or organization with which the
Contractor has contracted or delegated some of its
management functions or responsibilities to provide
covered services to its members; or (2) A person,
agency or organization with which a fiscal agent has
entered into a contract, agreement, purchase order or
lease (or leases of real property) to obtain space,
supplies, equipment or services provided under the
AHCCCS agreement.
SUPPLEMENTAL Federal cash assistance program under Title XVI of
SECURITY INCOME the Social Security Act.
(SSI)
TEMPORARY A Federal cash assistance program under Title IV of
ASSISTANCE TO the Social Security Act established by the Personal
NEEDY FAMILIES Responsibility and Work Opportunity Act of 1996. It
(TANF) replaced Aid To Families With Dependent Children
(AFDC).
THIRD PARTY An individual, entity or program that is or may be
liable to pay all or part of the medical cost of
injury, disease or disability of an AHCCCS applicant
or member, as defined in R9-22-1001.
THIRD PARTY The resources available from a person or entity that
LIABILITY is, or may be, by agreement, circumstance or
otherwise, liable to pay all or part of the medical
expenses incurred by an AHCCCS applicant or member,
as defined in R9-22-1001.
Acute Care RFP
February 3, 2003
- 13 -
DEFINITIONS CONTRACT/RFP NO. YH04-0001
TITLE XIX MEMBER Member eligible for Federally funded Medicaid
programs under Title XIX of the Social Security Act
including those eligible under 1931 provisions of the
Social Security Act, Sixth Omnibus Budget
Reconciliation Act (SOBRA), Supplemental Security
Income (SSI), SSI-related groups, Title XIX Waiver
groups, Medicare Cost Sharing groups, Breast and
Cervical Cancer Treatment program and Freedom to
Work.
TITLE XIX WAIVER All MED (Medical Expense Deduction) members, and
MEMBER adults or childless couples at or below 100% of the
Federal Poverty Level who are not categorically
linked to another Title XIX program. This would also
include Title XIX linked individuals whose income
exceeds the limits of the categorical program.
TITLE XXI MEMBER Member eligible for acute care services under Title
XXI of the Social Security Act, referred to in
Federal legislation as the "State Children's Health
Insurance Program" (SCHIP and HIFA). The Arizona
version of SCHIP is referred to as "KidsCare."
TRIBAL FACILITY A facility that is operated by an Indian tribe and
(638 TRIBAL that is authorized to provide services pursuant to
FACILITY) Public Law 93-638, as amended.
WWHP Well Woman Healthcheck Program, administered by the
Arizona Department of Health Services and funded by
the Centers for Disease Control and Prevention.
YEAR See "Contract Year".
[END OF DEFINITIONS]
Acute Care RFP
February 3, 2003
- 14 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
SECTION D: PROGRAM REQUIREMENTS
1. TERM OF CONTRACT AND OPTION TO RENEW
The initial term of this contract shall be 10/1/03 through 9/30/06, with two
one-year options to renew. All contract renewals shall be through contract
amendment. AHCCCSA shall issue amendments prior to the end date of the contract
when there is an adjustment to capitation rates and/or changes to the scope of
service contained herein. Changes to scope of service include but are not
limited to changes in the enrolled population, changes in covered services,
changes in GSA's
If the Contractor has been awarded a contract in more than one GSA, each such
contract will be considered separately renewable. AHCCCSA may renew the
Contractor's contract in one GSA, but not in another. In addition, if the
Contractor has had significant problems of non-compliance in one GSA, it may
result in the capping of the Contractor's enrollment in all GSAs. Further,
AHCCCSA may require the Contractor to renew all currently awarded GSA's, or may
terminate the contract if the Contractor does not agree to renew all currently
awarded GSA's.
When AHCCCSA issues an amendment to the contract, the provisions of such renewal
will be deemed to have been accepted 60 days after the date of mailing by
AHCCCSA, even if the amendment has not been signed by the Contractor, unless
within that time the Contractor notifies AHCCCSA in writing that it refuses to
sign the renewal amendment. If the Contractor provides such notification,
AHCCCSA will initiate contract termination proceedings.
CONTRACTOR'S NOTICE OF INTENT NOT TO RENEW: If the Contractor chooses not to
renew this contract, the Contractor may be liable for certain costs associated
with the transition of its members to a different health plan. If the Contractor
provides AHCCCSA written notice of its intent not to renew this contract at
least 180 days before its expiration, this liability for transition costs may be
waived by AHCCCSA.
CONTRACT TERMINATION: In the event the contract, or any portion thereof, is
terminated for any reason, or expires, the Contractor shall assist AHCCCSA in
the transition of its members to other contractors, and shall abide by standards
and protocols set forth in Paragraph 9, Transition of Members. In addition,
AHCCCSA reserves the right to extend the term of the contract on a
month-to-month basis to assist in any transition of members. The Contractor
shall make provision for continuing all management and administrative services
until the transition of all members is completed and all other requirements of
this contract are satisfied. The Contractor shall be responsible for providing
all reports set forth in this contract and necessary for the transition process
and shall be responsible for the following:
a. Notification of subcontractors and members.
b. Payment of all outstanding obligations for medical care rendered to
members.
c. Until AHCCCSA is satisfied that the Contractor has paid all such
obligations, the Contractor shall provide the following reports to
AHCCCSA:
(1) A monthly claims aging report by provider/creditor including
IBNR amounts;
(2) A monthly summary of cash disbursements;
(3) Copies of all bank statements received by the Contractor.
d. Such reports shall be due on the fifth day of each succeeding month for
the prior month.
e. In the event of termination or suspension of the contract by AHCCCSA,
such termination or suspension shall not affect the obligation of the
Contractor to indemnify AHCCCSA for any claim by any third party
against the State or AHCCCSA arising from the Contractor's performance
of this contract and for which the Contractor would otherwise be liable
under this contract.
f. Any dispute by the Contractor, with respect to termination or
suspension of this contract by AHCCCSA, shall be exclusively governed
by the provisions of Section E, Paragraph 26, Disputes.
Acute Care RFP
February 3, 2003
- 15 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
g. Any funds, advanced to the Contractor for coverage of members for
periods after the date of termination, shall be returned to AHCCCSA
within 30 days of termination of the contract.
2. ELIGIBILITY CATEGORIES
AHCCCS is Arizona's Title XIX Medicaid program operating under an 1115 Waiver
and Title XXI program operating under Title XXI State Plan authority. Arizona
has the authority to require mandatory enrollment in managed care. All members
eligible for AHCCCS benefits, with few exceptions, are enrolled in acute care
health plans and paid for on a capitated basis. AHCCCSA pays for health care
expenses on a fee for service (FFS) basis for Title XIX and Title XXI eligible
members who receive services through the Indian Health Service; for Title XIX
eligible members who are entitled to emergency services under the Federal
Emergency Services (FES) program; for Medicare cost sharing beneficiaries under
QMB programs; and for the State Emergency Services (SES) Program.
The following describes the eligibility groups enrolled in the managed care
program and covered under this contract.
TITLE XIX
1931 (ALSO REFERRED TO AS TANF): Eligible individuals and families
under the 1931 provision of the Social Security Act, with household
income levels at or below 100% of the FPL.
SSI AND SSI RELATED GROUPS: Eligible individuals receiving Supplemental
Security Income (SSI) or who are aged, blind or disabled with household
income levels at or below 100% of the FPL.
FREEDOM TO WORK (TICKET TO WORK): Eligible individuals under the Title
XIX expansion program that extends eligibility to individuals, 16
through 64 years old who meet SSI disability criteria, whose earned
income, after allowable deduction, is at or below 250% of the FPL and
who are not eligible for any other Medicaid program. These members must
pay a premium to AHCCCSA ranging from $10 to $35, depending on income.
SOBRA: Under the Sixth Omnibus Budget and Reconciliation Act of 1986,
eligible pregnant women, with household income levels at or below 133%
of the FPL, and children in families with household incomes ranging
from below 100% to 133% of the FPL, depending on the age of the child.
SOBRA FAMILY PLANNING: Family planning extension program that covers
the costs for family planning services only, for a maximum of 24 months
following the loss of SOBRA eligibility.
BREAST AND CERVICAL CANCER TREATMENT PROGRAM (BCCTP): Eligible
individuals under the Title XIX expansion program for women with income
up to 250% of the FPL, who are diagnosed with and need treatment for
breast and/or cervical cancer or cervical lesions and are not eligible
for other Title XIX programs providing full Title XIX services.
Eligible members cannot have other creditable health insurance
coverage, including Medicare.
Acute Care RFP
February 3, 2003
- 16 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
TITLE XIX WAIVER GROUP
NON-MED: Eligible individuals and couples whose income is at or below
100% of the FPL, and who are not categorically linked to another Title
XIX program.
MED: Eligible individuals and families whose income is above 100% of
the FPL with medical expenses that reduce income to or below 40% of the
FPL.
TITLE XXI
KIDSCARE: Individuals under the age of 19, whose income does not exceed
200% FPL. Children, in households with incomes between 150% and 200% of
the FPL, may participate in the KidsCare program, but are required to
pay a premium amount to AHCCCSA based on the number of children in the
family and the gross family income.
HIFA PARENTS: Non-Title XIX-eligible parents of KidsCare children or
parents of Title XIX children who are eligible under the HIFA
demonstration initiative waiver. HIFA parents are required to pay a
premium to AHCCCSA ranging from $15 to $25 per parent (except Native
American members). Due to funding considerations, this program has an
enrollment cap.
3. ENROLLMENT AND DISENROLLMENT
AHCCCSA has the exclusive authority to enroll and disenroll members. The
Contractor shall not disenroll any member for any reason unless directed to do
so by AHCCCSA. The Contractor may request AHCCCSA to change the member's
enrollment in accordance with the AHCCCS Health Plan Change Policy. AHCCCSA will
disenroll the member when the member becomes ineligible for the AHCCCS program,
moves out of the health plan's service areas, changes contractors during the
member's open enrollment/annual enrollment choice period or when approved for a
health plan change through the AHCCCS Health Plan Change Policy. Eligibility for
the various AHCCCS coverage groups is determined by one of the following
agencies:
Social Security
Administration (SSA) SSA determines eligibility for the Supplemental
Security Income (SSI) cash program. SSI cash
recipients are automatically eligible for AHCCCS
coverage.
Department of Economic
Security (DES) DES determines eligibility for the families with
children under section 1931 of the Social Security
Act, pregnant women and children under SOBRA, the
Adoption Subsidy Program, Title IV- E foster care
children, Young Adult Transitional Insurance Program,
the Federal Emergency Services program (FES), HIFA
parents of SOBRA eligible children, the Title XIX
Waiver Members, and the State Emergency Services
(SES) program.
Acute Care RFP
February 3, 2003
- 17 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
AHCCCSA AHCCCSA determines eligibility for the SSI/Medical
Assistance Only groups, including the FES program for
this population (aged, disabled, blind), the Arizona
Long-Term Care System (ALTCS), the Qualified Medicare
Beneficiary program and other Medicare cost sharing
programs, BCCTP, the Freedom to Work program, the
Title XXI KidsCare program, and HIFA parents of
KidsCare children.
AHCCCS acute care members are enrolled with Contractors in accordance with the
rules set forth in R9-22, Article 17, R9-31-306, 307, 309 and 1719.
HEALTH PLAN CHOICE
All AHCCCS members eligible for services covered under this contract have a
choice of available health plans. Information about these health plans will be
given to each applicant during the application process for AHCCCS benefits. If
there is only one health plan available for the applicant's Geographic Service
Area, no choice is offered as long as the health plan offers the member a choice
of PCPs. Members who do not choose prior to AHCCCSA being notified of their
eligibility, are automatically assigned to a health plan based on family
continuity or the auto-assignment algorithm. See Section D, Paragraph 6,
Auto-Assignment Algorithm, for further explanation.
Exceptions to the above enrollment policies for Title XIX members include
previously enrolled members who have been disenrolled for less than 90 days.
These members will be automatically enrolled with the same Contractor, if still
available. Members who have less than 30 days of continued eligibility will not
be enrolled with a Contractor, but will be placed on Fee for Service. FES and
SES members are not enrolled with a health plan. Women, who become eligible for
the Family Planning Services Extension Program, will remain assigned to their
current health plan.
The effective date of enrollment for a new Title XIX member with the Contractor
is the day AHCCCSA takes the enrollment action, generally the day prior to the
date the Contractor receives notification from AHCCCSA via the daily roster.
However, the Contractor is responsible for payment of medically necessary
covered services retroactive to the member's beginning date of eligibility.
KidsCare members must select a health plan prior to being determined eligible
and therefore, will not be auto-assigned. If the HIFA parent does not choose,
they will be enrolled with their child's health plan following the enrollment
rules set forth in R9-31-1719. When a member is transferred from Title XIX to
Title XXI and has not made a health plan choice for Title XXI, the member will
remain with their current health plan and a choice notice will be sent to the
member. The member may then change plans no later than 16 days from the date the
choice notice is sent.
The effective date of enrollment for a Title XXI member, including HIFA parents,
will be the first day of the month following notification to the health plan,
with few exceptions.
PRIOR PERIOD COVERAGE: AHCCCS provides prior period coverage for the period of
time, prior to the Title XIX member's enrollment, during which a member is
eligible for covered services. The time frame is from the effective date of
eligibility to the day a member is enrolled with the Contractor. The Contractor
receives notification from the Administration of the member's enrollment. The
Contractor is responsible for payment of all claims for medically necessary
covered services provided to members during prior period coverage. This may
include services provided prior to the contract year (See Section D, Paragraph
53, Compensation, for a description of the Contractor's reimbursement from
AHCCCSA for this eligibility time period.)
Acute Care RFP
February 3, 2003
- 18 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
NEWBORNS: Newborns, born to AHCCCS eligible mothers enrolled at the time of the
child's birth, will be enrolled with the mother's contractor, when newborn
notification is received by AHCCCSA. The Contractor is responsible for notifying
AHCCCSA of a child's birth to an enrolled member. Capitation for the newborn
will begin on the date notification is received by AHCCCSA (except for cases of
births during prior period coverage). The effective date of AHCCCS eligibility
will be the newborn's date of birth, and the Contractor is responsible for all
covered services to the newborn whether or not AHCCCSA has received notification
of the child's birth. AHCCCSA is currently available to receive notification
calls 24 hours a day, 7 days a week. Eligible mothers of newborns are sent a
letter advising them of their right to choose a different contractor for their
child; the date of the change will be the date of processing the request from
the mother. If the mother does not request a change, the child will remain with
the mother's contractor.
Newborns of FES mothers are auto-assigned to a contractor and mothers of these
newborns are sent a letter advising them of their right to choose a different
contractor for their child. In the event the FES mother chooses a different
contractor, AHCCCS will recoup all capitation paid to the originally assigned
contractor and the baby will be enrolled retroactive to the date of birth in the
second contractor. The second contractor will receive prior period capitation
from the date of birth to the day before assignment and prospective capitation
from the date of assignment forward. The second contractor will be responsible
for all covered services to the newborn from date of birth.
ENROLLMENT GUARANTEES: Upon initial capitated enrollment as a Title XIX-eligible
member, the member is guaranteed a minimum of five full months of continuous
enrollment. Upon initial capitated enrollment as a Title XXI-eligible member,
the member is guaranteed a minimum of 12 full months of continuous enrollment.
Enrollment guarantees do not apply to HIFA parents. The enrollment guarantee is
a one-time benefit. If a member changes from one contractor to another within
the enrollment guarantee period, the remainder of the guarantee period applies
to the new contractor. The enrollment guarantee may not be granted or may be
terminated if the member is incarcerated or, if a minor child is adopted. AHCCCS
Rule R9-22, Article 17 and R9-31, Article 3 describes other reasons for which
the enrollment guarantee may not apply.
NATIVE AMERICANS: Native Americans, on or off-reservation, may choose to receive
services from Indian Health Service (IHS), a PL 93-638 tribal facility or any
available contractor. If a choice is not made within the specified time limit,
Native American Title XIX members living on-reservation will be assigned to IHS.
Native American Title XIX members living off-reservation will be assigned to an
available contractor using AHCCCS' Family Continuity Policy and auto-assignment
algorithm. Native American Title XXI members must make a choice prior to being
determined eligible. Title XXI HIFA parent members' enrollment will follow the
Title XIX enrollment rules. Native Americans may change from IHS to a contractor
or from a contractor to IHS at any time.
4. ANNUAL ENROLLMENT CHOICE
AHCCCSA conducts an Annual Enrollment Choice (AEC) for members on their annual
anniversary date. AHCCCSA may hold an open enrollment as deemed necessary.
During AEC, members may change contractors subject to the availability of other
contractors within their Geographic Service Area. Members are mailed a printed
enrollment form and other information required by the Balanced Budget Act of
1997 (BBA) 60 days prior to their AEC date and may choose a new contractor by
contacting AHCCCSA to complete the enrollment process. If the member does not
participate in the AEC, no change of contractor will be made (except for
approved changes under the Change of Plan Policy) during the new anniversary
year. This holds true if a contractor's contract is renewed and the member
continues to live in a contractor's service area. The Contractor shall comply
with the AHCCCS, Office of Managed Care Member Transition for Annual Enrollment
Choice, Open Enrollment and Other Plan Changes Policy and the AMPM.
Acute Care RFP
February 3, 2003
- 19 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
5. OPEN ENROLLMENT
In the event that AHCCCSA does not award a CYE '04 contract to an incumbent
contractor, AHCCCSA will hold an open enrollment for those members enrolled with
the exiting contractor. If those members do not elect to choose a contractor,
they will be auto assigned. In addition to open enrollment, AHCCCSA will make
changes to both annual enrollment choice materials and new enrollee materials
prior to October 1, 2003 to reflect the change in available health plans. The
auto assignment algorithm will be adjusted to exclude auto assignment of new
enrollees to exiting contractors(s). The exact dates for the open enrollment and
other changes described above have not yet been determined, but will be
communicated when they are finalized.
6. AUTO-ASSIGNMENT ALGORITHM
Members who do not exercise their right to choose and do not have family
continuity, are assigned to a contractor through an auto-assignment algorithm.
The algorithm is a mathematical formula used to distribute members to the
various contractors in a manner that is predictable and consistent with AHCCCSA
goals. The algorithm favors those contractors with lower capitation rates and
higher program scores in the latest contract award. For further details on the
AHCCCS Auto-Assignment Algorithm, refer to Attachment G. AHCCCSA may change the
algorithm at any time during the term of the contract in response to
contractor-specific issues (e.g. imposition of an enrollment cap). The
Contractor should consider this in preparing its response to this RFP.
Capitation rates may be adjusted to reflect changes to a contractor's risk due
to changes in the algorithm.
7. AHCCCS MEMBER IDENTIFICATION CARDS
Contractors are responsible for paying the costs of producing AHCCCS member
identification cards. The Contractor will receive an invoice the month following
the issue date of the identification card.
8. MAINSTREAMING OF AHCCCS MEMBERS
To ensure mainstreaming of AHCCCS members, the Contractor shall take affirmative
action so that members are provided covered services without regard to payer
source, race, color, creed, sex, religion, age, national origin, ancestry,
marital status, sexual preference, genetic information, or physical or mental
handicap, except where medically indicated. Contractors must take into account a
member's culture, when addressing members and their concerns, and must take
reasonable steps to encourage subcontractors to do the same. The Contractor must
make interpreters of any language available free of charge for all members to
ensure appropriate delivery of covered services. The Contractor must provide
members with information instructing them about how to access these services.
Examples of prohibited practices include, but are not limited to, the following:
a. Denying or not providing a member any covered service or access to an
available facility.
b. Providing to a member any covered service which is different, or is
provided in a different manner or at a different time from that
provided to other members, other public or private patients or the
public at large, except where medically necessary.
c. Subjecting a member to segregation or separate treatment in any manner
related to the receipt of any covered service; restricting a member in
any way in his or her enjoyment of any advantage or privilege enjoyed
by others receiving any covered service.
d. The assignment of times or places for the provision of services on the
basis of the race, color, creed, religion, age, sex, national origin,
ancestry, marital status, sexual preference, income status, AHCCCS
membership, or physical or mental handicap of the participants to be
served.
Acute Care RFP
February 3, 2003
- 20 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
If the Contractor knowingly executes a subcontract with a provider with the
intent of allowing or permitting the subcontractor to implement barriers to care
(i.e. the terms of the subcontract act to discourage the full utilization of
services by some members), the Contractor will be in default of its contract.
If the Contractor identifies a problem involving discrimination by one of its
providers, it shall promptly intervene and implement a corrective action plan.
Failure to take prompt corrective measures may place the Contractor in default
of its contract.
9. TRANSITION OF MEMBERS
The Contractor shall comply with the AMPM, and the AHCCCS, Office of Managed
Care Member Transition for Annual Enrollment Choice, Open Enrollment and Other
Plan Changes Policy standards for member transitions between health plans or
GSAs, enrollment in or discharge from CRS, to or from an ALTCS Program
Contractor, IHS, a PL 93-638 tribal entity, and upon termination or expiration
of a contract. The Contractor shall develop and implement policies and
procedures, which comply with these policies to address transition of:
a. Members with significant medical conditions such as a high-risk
pregnancy or pregnancy within the last 30 days, the need for organ or
tissue transplantation, chronic illness resulting in hospitalization or
nursing facility placement, etc.;
b. Members who are receiving ongoing services such as dialysis, home
health, chemotherapy and/or radiation therapy or who are hospitalized
at the time of transition;
c. Members who have received prior authorization for services such as
scheduled surgeries, out-of-area specialty services, nursing home
admission;
d. Prescriptions, DME and medically necessary transportation ordered for
the transitioning member by the relinquishing contractor; and
e. Medical records of the transitioning member (the cost, if any, of
reproducing and forwarding medical records shall be the responsibility
of the relinquishing AHCCCS contractor).
When relinquishing members, the Contractor is responsible for timely
notification to the receiving contractor regarding pertinent information related
to any special needs of transitioning members. The Contractor, when receiving a
transitioning member with special needs, is responsible for coordinating care
with the relinquishing contractor in order that services not be interrupted, and
for providing the new member with health plan and service information, emergency
numbers and instructions about how to obtain services.
10. SCOPE OF SERVICES
The Contractor shall provide covered services to AHCCCS members in accordance
with all applicable Federal, State and local laws, rules, regulations and
policies, including services listed in this document, listed by reference in
attachments, and AHCCCS policies referenced in this document. The services are
described in detail in AHCCCS Rules R9-22, Article 2 and the AHCCCS Medical
Policy Manual (AMPM), all of which are incorporated herein by reference, except
for provisions specific to the Fee-for-Service program, and may be found in the
Bidder's Library. The covered services must be medically necessary and are
briefly described below. Except for behavioral health and children's preventive
dental services, covered services must be provided by, or coordinated with, a
primary care provider. Services must be rendered by providers that are
appropriately licensed or certified, operating within their scope of practice,
and registered as an AHCCCS provider. The Contractor shall provide the same
standard of care for all members regardless of the member's eligibility
category. The Contractor may not arbitrarily deny or reduce the amount,
duration, or scope of a required service solely because of the diagnosis, type
of illness, or condition. The Contractor may place
Acute Care RFP
February 3, 2003
- 21 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
appropriate limits on a service on the basis of criteria such as medical
necessity; or for utilization control, provided the services furnished can
reasonably be expected to achieve their purpose.
The Contractor shall ensure that its providers are not restricted or inhibited
in any way from communicating freely with members regarding the members' health
care, medical needs and treatment options, even if needed services are not
covered by the Contractor.
AMBULATORY SURGERY AND ANESTHESIOLOGY: The Contractor shall provide surgical
services for either emergency or scheduled surgeries when provided in an
ambulatory or outpatient setting such as a freestanding surgical center or a
hospital based outpatient surgical setting.
AUDIOLOGY: The Contractor shall provide audiology services to members under the
age of 21 including the identification and evaluation of hearing loss and
rehabilitation of the hearing loss through medical or surgical means (i.e.
hearing aids). Only the identification and evaluation of hearing loss are
covered for members 21 years of age and older unless the hearing loss is due to
an accident or injury-related emergent condition.
BEHAVIORAL HEALTH: The Contractor shall provide behavioral health services as
described in Section D, Paragraph 12, Behavioral Health Services.
CHILDREN'S REHABILITATIVE SERVICES (CRS): The program for children with
CRS-covered conditions is administered by the Arizona Department of Health
Services (ADHS) for children who meet CRS eligibility criteria. The Contractor
shall refer children to the CRS program who are potentially eligible for
services related to CRS covered conditions, as specified in R9-22, Article 2 and
A.R.S. Title 36, Chapter 2, Article 3. Eligibility criteria and the referral
process are described in the CRS Policy and Procedures Manual available in the
Bidder's Library.
The Contractor shall monitor referrals to CRS to ensure covered services are
provided in a timely manner to eligible members. Referral to CRS does not
relieve the Contractor of the responsibility for providing medically necessary
services not covered by CRS to CRS enrolled members. The Contractor is also
responsible for initial care of newborn members, until those members become
enrolled in CRS. The Contractor must require the member's Primary Care Provider
(PCP) to coordinate their care with the CRS program.
A member with private insurance is not required to utilize CRS. If the member
uses their private insurance network for a CRS covered condition, and the member
is not enrolled with CRS, the Contractor is responsible for all applicable
deductibles and copays.
The Contractor remains ultimately responsible for the provision of all covered
services to its members, except for instances in which the CRS eligible member
refuses to receive CRS covered services through the CRS program. If the
Contractor becomes aware that CRS has failed to provide medically necessary CRS
covered services, the Contractor shall proceed as outlined in the CRS Medically
Necessary Appointment Policy located in the AMPM.
CHIROPRACTIC SERVICES: The Contractor shall provide chiropractic services to
members under age 21 when prescribed by the member's PCP and approved by the
Contractor in order to ameliorate the member's medical condition. Medicare
approved chiropractic services shall also be covered, subject to limitations
specified in CFR 410.22, for Qualified Medicare Beneficiaries if prescribed by
the member's PCP and approved by the Contractor.
DENTAL: The Contractor shall provide all members under the age of 21 with all
medically necessary dental services including emergency dental services, dental
screening and preventive services in accordance with the
Acute Care RFP
February 3, 2003
- 22 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
AHCCCS periodicity schedule, as well as therapeutic dental services, dentures,
and pre-transplantation dental services. The Contractor shall monitor compliance
with the EPSDT periodicity schedule for dental screening services. The
Contractor is required to meet specific utilization rates for members as
described in Section D, Paragraph 24, Performance Standards. The Contractor
shall ensure that members are notified when dental screenings are due if the
member has not been scheduled for a visit. If a dental screening is not received
by the member, a second notice must be sent. Members under the age of 21 may
request dental services without referral and may choose a dental provider from
the Contractor's provider network. For members who are 21 years of age and
older, the Contractor shall provide emergency dental care, medically necessary
dentures and dental services for transplantation services as specified in the
AMPM.
DIALYSIS: The Contractor shall provide medically necessary dialysis, supplies,
diagnostic testing and medication for all members when provided by
Medicare-certified hospitals or Medicare-certified end stage renal disease
(ESRD) providers. Services may be provided on an outpatient basis, or on an
inpatient basis if the hospital admission is not solely to provide chronic
dialysis services.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT): The Contractor
shall provide comprehensive health care services through primary prevention,
early intervention, diagnosis and medically necessary treatment to correct or
ameliorate defects and physical or mental illness discovered by the screenings
for members under age 21. The Contractor shall ensure that these members receive
required health screenings, including those for developmental/behavioral health,
in compliance with the AHCCCS periodicity schedule. The Contractor shall submit
all EPSDT reports to the AHCCCS Office of Medical Management, as required by the
AMPM. The Contractor is required to meet specific participation/utilization
rates for members as described in Section D, Paragraph 24, Performance
Standards.
The Contractor shall ensure the initiation and coordination of a referral to the
ADHS/RBHA system for members in need of behavior health services. The Contractor
shall follow up with the RBHA to monitor whether members have received these
health services.
EMERGENCY SERVICES: The Contractor shall have and/or provide the following as a
minimum:
a. Emergency services facilities adequately staffed by qualified medical
professionals to provide pre-hospital, emergency care on a
24-hour-a-day, 7-day-a-week basis, for the sudden onset of a medically
emergent condition. Emergency medical services are covered without
prior authorization. The Contractor is encouraged to contract with
emergency service facilities for the provision of emergency services.
The Contractor is also encouraged to contract with or employ the
services of non-emergency facilities (e.g. urgent care centers) to
address member non-emergency care issues occurring after regular office
hours or on weekends. The Contractor shall be responsible for educating
members and providers regarding appropriate utilization of emergency
room services including behavioral health emergencies. The Contractor
shall monitor emergency service utilization (by both provider and
member) and shall have guidelines for implementing corrective action
for inappropriate utilization;
b. All medical services necessary to rule out an emergency condition;
c. Emergency transportation; and
d. Member access by telephone to a physician, registered nurse, physician
assistant or nurse practitioner for advice in emergent or urgent
situations, 24 hours per day, 7 days per week.
Per the Balanced Budget Act of 1997, CFR 438.114, the following conditions apply
with respect to coverage and payment of emergency services:
The Contractor must cover and pay for emergency services regardless of whether
the provider that furnishes the service has a contract with the Contractor.
Acute Care RFP
February 3, 2003
- 23 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
The Contractor may not deny payment for treatment obtained under either of the
following circumstances:
1. A member had an emergency medical condition, including cases
in which the absence of medical attention would not have
resulted in the outcomes identified in the definition of
emergency medical condition CFR 438.114.
2. A representative of the Contractor (an employee or
subcontracting provider) instructs the member to seek
emergency medical services.
Additionally, the Contractor may not:
1. Limit what constitutes an emergency medical condition as
defined in CFR 438.114, on the basis of lists of diagnoses or
symptoms.
2. Refuse to cover emergency services based on the failure of the
provider, hospital, or fiscal agent to notify the Contractor
of the member's screening and treatment within 10 calendar
days of presentation for emergency services. This notification
stipulation is only related to the provision of emergency
services.
A member who has an emergency medical condition may not be held liable for
payment of subsequent screening and treatment needed to diagnose the specific
condition or stabilize the patient.
The attending emergency physician, or the provider actually treating the member,
is responsible for determining when the member is sufficiently stabilized for
transfer or discharge, and such determination is binding on the Contractor
responsible for coverage and payment. The Contractor shall comply with BBA
guidelines regarding the coordination of post-stabilization care.
EYE EXAMINATIONS/OPTOMETRY: The Contractor shall provide all medically necessary
emergency eye care, vision examinations, prescriptive lenses, and treatments for
conditions of the eye for all members under the age of 21. For members who are
21 years of age and older, the Contractor shall provide emergency care for eye
conditions which meet the definition of an emergency medical condition. Also
covered for this population is cataract removal, and medically necessary vision
examinations and prescriptive lenses, if required, following cataract removal
and other eye conditions as specified in the AMPM.
FAMILY PLANNING: The Contractor shall provide family planning services in
accordance with the AMPM, for all members who choose to delay or prevent
pregnancy. These include medical, surgical, pharmacological and laboratory
services, as well as contraceptive devices. Information and counseling, which
allow members to make informed decisions regarding family planning methods,
shall also be included. If the Contractor does not provide family planning
services, it must contract for these services through another health care
delivery system, which allows members freedom of choice in selecting a provider.
The Contractor shall provide services to members enrolled in the Family Planning
Services Extension Program, a program that provides family planning services
only, for a maximum of 24 months, to women whose SOBRA eligibility has
terminated. The Contractor is also responsible for notifying AHCCCSA when a
SOBRA woman is sterilized to prevent inappropriate enrollment in the SOBRA
Family Planning Services Extension Program. Notification should be made at the
time the newborn is reported or after the sterilization procedure is completed.
HEALTH RISK ASSESSMENT AND SCREENING: The Contractor shall provide these
services for non-hospitalized members, 21 years of age and older. These services
include, but are not limited to, screening for hypertension, elevated
cholesterol, colon cancer, sexually transmitted diseases, tuberculosis and
HIV/AIDS; nutritional assessment in cases when the member has a chronic
debilitating disease affected by nutritional needs; mammograms and prostate
screenings; physical examinations and diagnostic work-ups; and immunizations.
Acute Care RFP
February 3, 2003
- 24 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
Required assessment and screening services for members under age 21 are included
in the AHCCCS EPSDT periodicity schedule.
HOME HEALTH: This service shall be provided under the direction of a physician
to prevent hospitalization or institutionalization and may include nursing,
therapies, supplies and home health aide services. It shall be provided on a
part-time or intermittent basis.
HOSPICE: These services are covered for members under 21 years of age who are
certified by a physician as being terminally ill and having six months or less
to live. See the AMPM for details on covered hospice services.
HOSPITAL: Inpatient services include semi-private accommodations for routine
care, intensive and coronary care, surgical care, obstetrics and newborn
nurseries, and behavioral health emergency/crisis services. If the member's
medical condition requires isolation, private inpatient accommodations are
covered. Nursing services, dietary services and ancillary services such as
laboratory, radiology, pharmaceuticals, medical supplies, blood and blood
derivatives, etc. are also covered. Outpatient hospital services include any of
the above, which may be appropriately provided on an outpatient or ambulatory
basis (i.e. laboratory, radiology, therapies, ambulatory surgery, etc.).
Observation services may be provided on an outpatient basis, if determined
reasonable and necessary, when deciding whether the member should be admitted
for inpatient care. Observation services include the use of a bed and periodic
monitoring by hospital nursing staff and/or other staff to evaluate, stabilize
or treat medical conditions of a significant degree of instability and/or
disability.
IMMUNIZATIONS: The Contractor shall provide immunizations for adults (21 years
of age and older) to include diphtheria-tetanus, influenza, pneumococcus,
rubella, measles and hepatitis-B. For all members under the age of 21,
immunization requirements include diphtheria, tetanus, pertussis vaccine (DPT),
inactivated polio vaccine (IPV), measles, mumps, rubella (MMR) vaccine, H.
influenza, type B (HIB) vaccine, hepatitis B (Hep B) vaccine, varicella zoster
virus (VZV) vaccine and pneumococcal conjugate vaccine (PCV). The Contractor is
required to meet specific immunization rates for members under the age of 21,
which are described in Paragraph 24, Performance Standards.
INDIAN HEALTH SERVICE (IHS): AHCCCSA will reimburse claims on a FFS basis for
acute care services that are medically necessary, eligible for 100% Federal
reimbursement, and are provided to Title XIX members enrolled with the
Contractor, in an IHS or a 638 tribal facility. The Contractor is responsible
for reimbursement to IHS or tribal facilities for emergency services provided to
Title XXI Native American members enrolled with the Contractor. The Contractor
may choose to subcontract with an IHS or 638 tribal facility as part of their
provider network for the delivery of covered services, however, the Contractor
will be liable for the cost of the care in the event they choose to do so.
LABORATORY: Laboratory services for diagnostic, screening and monitoring
purposes are covered when provided by a CLIA (Clinical Laboratory Improvement
Act) approved free standing, hospital, clinic, physician office or other health
care facility laboratory.
Upon written request, the Contractor may obtain laboratory test data on members
from a freestanding laboratory or hospital- based laboratory subject to the
requirements specified in A.R.S. Section 36-2903(R) and (S). The data shall be
used exclusively for quality improvement activities and health care outcome
studies required and/or approved by the Administration.
MATERNITY: The Contractor shall provide pre-conception counseling, pregnancy
identification, prenatal care, treatment of pregnancy related conditions, labor
and delivery services, and postpartum care for members. Services may be provided
by physicians, physician assistants, nurse practitioners, or certified nurse
midwives.
Acute Care RFP
February 3, 2003
- 25 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
Members may select or be assigned to a PCP specializing in obstetrics. All
members, anticipated to have a low-risk delivery, may elect to receive labor and
delivery services in their home, if this setting is included in the allowable
settings of the Contractor and the Contractor has providers in its network that
offer home labor and delivery services. All members, anticipated to have a
low-risk prenatal course and delivery, may elect to receive prenatal care, labor
and delivery and postpartum care provided by licensed midwives, if these
providers are in the Contractor's network. All licensed midwife labor and
delivery services must be provided in the member's home, as licensed midwives do
not have admitting privileges in hospitals or AHCCCS registered freestanding
birthing centers. Members receiving maternity services from a licensed midwife
must also be assigned to a PCP for other health care and medical services. The
Contractor shall allow women and their newborns to receive up to 48 hours of
inpatient hospital care after a routine vaginal delivery and up to 96 hours of
inpatient care after a cesarean delivery. The attending health care provider, in
consultation with the mother, may discharge the mother or newborn prior to the
48-hour minimum length of stay. A normal newborn may be granted an extended stay
in the hospital of birth when the mother's continued stay in the hospital is
beyond the 48 or 96 hour stay.
The Contractor shall inform all assigned AHCCCS pregnant women of voluntary
prenatal HIV testing and the availability of medical counseling if the test is
positive. The Contractor shall provide information in the member handbook and
annually in the member newsletter, which encourages pregnant women to be tested
and provides instructions about where testing is available. Semi-annually, the
Contractor shall report to AHCCCS the number of pregnant women who have been
identified as HIV/AIDS positive. This report is due no later than 30 days after
the end of the second and fourth quarters of the contract year.
MEDICAL FOODS: Medical foods are covered within limitations defined in the AMPM
for members diagnosed with a metabolic condition included under the ADHS Newborn
Screening Program and specified in the AMPM. The medical foods, including
metabolic formula and modified low protein foods, must be prescribed or ordered
under the supervision of a physician.
MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT (DME), ORTHOTIC AND PROSTHETIC
DEVICES: These services are covered when prescribed by the member's PCP,
attending physician, practitioner, or by a dentist. Medical equipment may be
rented or purchased only if other sources, which provide the items at no cost,
are not available. The total cost of the rental must not exceed the purchase
price of the item. Reasonable repairs or adjustments of purchased equipment are
covered to make the equipment serviceable and/or when the repair cost is less
than renting or purchasing another unit.
NURSING FACILITY: The Contractor shall provide services in nursing facilities,
including religious non-medical health care institutions, for members who
require short-term convalescent care not to exceed 90 days per contract year. In
lieu of a nursing facility, the member may be placed in an assisted living
facility, an alternative residential setting, or receive home and community
based services (HCBS) as defined in R9-22, Article 2 and R9-28, Article 2 that
meet the provider standards described in R9-28, Article 5, and subject to the
limitations set forth in the AMPM.
Nursing facility services must be provided in a dually-certified
Medicare/Medicaid nursing facility, which includes in the per-diem rate: nursing
services; basic patient care equipment and sickroom supplies; dietary services;
administrative physician visits; non-customized DME; necessary maintenance and
rehabilitation therapies; over-the-counter medications; social, recreational and
spiritual activities; and administrative, operational medical direction
services. See Paragraph 41, Nursing Facility Reimbursement, for further details.
The Contractor shall notify the Assistant Director of the Division of Member
Services, in writing, when a member has been residing in a nursing facility for
75 days. This will allow AHCCCSA time to follow-up on the status of the ALTCS
application and to prepare for potential fee-for-service coverage, if the stay
goes beyond the 90-day maximum.
Acute Care RFP
February 3, 2003
- 26 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
NUTRITION: Nutritional assessments may be conducted as a part of the EPSDT
screenings for members under age 21, and to assist members 21 years of age and
older whose health status may improve with nutritional intervention. Assessment
of nutritional status on a periodic basis may be provided as determined
necessary, and as a part of the health risk assessment and screening services
provided by the member's PCP. AHCCCS covers nutritional therapy on an enteral,
parenteral or oral basis, when determined medically necessary to provide either
complete daily dietary requirements or to supplement a member's daily
nutritional and caloric intake and when AHCCCS criteria specified in the AMPM
are met.
PHYSICIAN: The Contractor shall provide physician services to include medical
assessment, treatments and surgical services provided by licensed allopathic or
osteopathic physicians.
PODIATRY: The Contractor shall provide podiatry services to include
bunionectomies, casting for the purpose of constructing or accommodating
orthotics, medically necessary orthopedic shoes that are an integral part of a
brace, and medically necessary routine foot care for patients with a severe
systemic disease which prohibits care by a nonprofessional person.
POST-STABILIZATION CARE SERVICES COVERAGE AND PAYMENT: Pursuant to 42 CFR
438.114, and 42 CFR 422.113(c), the following conditions apply with respect to
coverage and payment of post-stabilization care services:
The Contractor must cover and pay for post-stabilization care services without
authorization, regardless of whether the provider that furnishes the service has
a contract with the Contractor, for the following situations:
1. Post-stabilization care services that were pre-approved by the
Contractor; or,
2. Post-stabilization care services were not pre-approved by the
Contractor because the Contractor did not respond to the
treating provider's request for pre-approval within one hour
after being requested to approve such care or could not be
contacted for pre-approval.
3. The Contractor representative and the treating physician
cannot reach agreement concerning the enrollee's care and a
contractor physician is not available for consultation. In
this situation, the Contractor must give the treating
physician the opportunity to consult with a contractor
physician and the treating physician may continue with care of
the patient until a contractor physician is reached or one of
the criteria in CFR 422.113(c)(3) is met.
Pursuant to CFR 422.113(c)(3), the Contractor's financial responsibility for
post-stabilization care services that have not been pre-approved ends when:
1. A contractor physician with privileges at the treating
hospital assumes responsibility for the member's care;
2. A contractor physician assumes responsibility for the member's
care through transfer;
3. A contractor representative and the treating physician reach
an agreement concerning the member's care; or
4. The member is discharged.
PREGNANCY TERMINATIONS: AHCCCS covers pregnancy termination when it is the
result of rape or incest, or in circumstances where the member suffers from a
physical disorder, physical injury, or physical illness, including a life
endangering physical condition caused by or arising from the pregnancy itself,
that would, as certified by a physician, place the member in danger of death
unless the pregnancy is terminated. In addition, providers must submit to the
Contractor a Certificate of Medical Necessity for Pregnancy Termination. Prior
authorization is required. If the procedure is performed on an emergency basis,
documentation, outlined in the AMPM, is required for a member under eighteen
years of age or a member who is considered an incapacitated adult who seeks a
medically necessary pregnancy termination, as defined above. The scope of
medically
Acute Care RFP
February 3, 2003
- 27 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
necessary pregnancy termination coverage is currently in litigation and is
expected to be broadened. A copy of the Court's final judgment will be placed in
the Bidder's Library.
PRESCRIPTION DRUGS: Medications ordered by a PCP, attending physician or dentist
and dispensed under the direction of a licensed pharmacist are covered subject
to limitations related to prescription supply amounts, contractor formularies
and prior authorization requirements, as well as restrictions for
immunosuppressant drugs addressed in AHCCCS medical policies for
transplantations. Contractors may include over-the-counter medications in their
formulary. An appropriate over-the-counter medication may be prescribed, when it
is determined to be a lower-cost alternative to prescription drugs. See
Paragraph 75, Pending Legislative/Other Issues for more information regarding
the potential carve out of prescription drug benefits from capitation.
PRIMARY CARE PROVIDER (PCP): PCP services are covered when provided by a
physician, physician assistant or nurse practitioner selected by, or assigned
to, the member. The PCP provides primary health care and serves as a gatekeeper
and coordinator in referring the member for specialty medical services. The PCP
is responsible for maintaining the member's primary medical record, which
contains documentation of all health risk assessments and health care services
of which they are aware whether or not they were provided by the PCP.
RADIOLOGY AND MEDICAL IMAGING: These services are covered when ordered by the
member's PCP, attending physician or dentist and are provided for diagnosis,
prevention, treatment or assessment of a medical condition. Services are
generally provided in hospitals, clinics, physician offices and other health
care facilities.
REHABILITATION THERAPY: The Contractor shall provide occupational, physical and
speech therapies. Therapies must be prescribed by the member's PCP or attending
physician for an acute condition and the member must have the potential for
improvement due to the rehabilitation. Physical therapy for all members, and
occupational and speech therapies for members under the age of 21, are covered
in both inpatient and outpatient settings. For those members who are 21 and
over, occupational and speech therapies are covered in inpatient settings only.
RESPIRATORY THERAPY: This therapy is covered in inpatient and outpatient
settings when prescribed by the member's PCP or attending physician, and is
necessary to restore, maintain or improve respiratory functioning.
TRANSPLANTATION OF ORGANS AND TISSUE, AND RELATED IMMUNOSUPPRESSANT DRUGS: These
services are covered within limitations defined in the AMPM for members
diagnosed with specified medical conditions. Such limitations include: whether
the stage of the disease is such that the transplant can affect the outcome; the
member has no other conditions that substantially reduce the potential for
successful transplantation; and whether the member will be able to comply with
necessary and required regimens of treatment. Bone grafts are also covered under
this service. Services include pre-transplant inpatient or outpatient
evaluation; donor search; organ/tissue harvesting or procurement; preparation
and transplantation services; and convalescent care. In addition, if a member
receives, or has received, a transplant covered by a source other than AHCCCS,
medically necessary non-experimental services are provided, within limitations,
after the discharge from the acute care hospitalization for the transplantation.
AHCCCS has contracted with transplantation providers for the Contractor's use or
the Contractor may select its own transplantation provider.
TRANSPORTATION: These services include emergency and non-emergency medically
necessary transportation. Emergency transportation, including transportation
initiated by an emergency response system such as 911, may be provided by
ground, air or water ambulance to manage an AHCCCS member's emergency medical
condition at an emergency scene and transport the member to the nearest
appropriate medical facility. Non-emergency transportation shall be provided
for members who are unable to provide their own transportation for medically
necessary services.
Acute Care RFP
February 3, 2003
- 28 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
TRIAGE/SCREENING AND EVALUATION: These are covered services when provided by
acute care hospitals, IHS facilities and urgent care centers to determine
whether or not an emergency exists, assess the severity of the member's medical
condition and determine what services are necessary to alleviate or stabilize
the emergent condition. Triage/screening services must be reasonable, cost
effective and meet the criteria for severity of illness and intensity of
service.
11. SPECIAL HEALTH CARE NEEDS
The Contractor must implement mechanisms to identify persons with special health
care needs in accordance with the guidelines provided in the AMPM.
The Contractor must implement mechanisms to assess each member identified as
having special health care needs, in order to identify any ongoing special
conditions of the member which require a course of treatment or regular care
monitoring in accordance with the guidelines provided in the AMPM.
For members with special health care needs determined to need a specialized
course of treatment or regular care monitoring, the Contractor must have
procedures in place to allow members to directly access a specialist (for
example through a standing referral or an approved number of visits) as
appropriate for the member's condition and identified needs.
12. BEHAVIORAL HEALTH SERVICES
AHCCCS members are eligible for comprehensive behavioral health services. The
behavioral health benefit for these members is provided through the ADHS -
Regional Behavioral Health Authority (RBHA) system. The Contractor shall be
responsible for member education regarding these benefits; provision of limited
emergency inpatient services; and screening and referral to the RBHA system of
members identified as requiring behavioral health services.
MEMBER EDUCATION: The Contractor shall be responsible for educating members in
the member handbook and other printed documents about covered behavioral health
services and where and how to access services. Covered services include:
a. Behavior Management (behavioral health personal assistance, family
support, peer support)
b. Case Management Services
c. Emergency/Crisis Behavioral Health Services
d. Emergency Transportation
e. Evaluation and Screening
f. Group Therapy and Counseling
g. Individual Therapy and Counseling
h. Family Therapy and Counseling
i. Inpatient Hospital
j. Inpatient Psychiatric Facilities (residential treatment centers and
sub-acute facilities)
k. Institutions for Mental Diseases (with limitations)
l. Laboratory and Radiology Services for Psychotropic Medication
Regulation and Diagnosis
m. Non-Emergency Transportation
n. Partial Care (Supervised day program, therapeutic day program, and
medical day program)
o. Psychosocial Rehabilitation (living skills training; health promotion;
pre-job training, education and development; job coaching and
employment support)
p. Psychotropic Medication
q. Psychotropic Medication Adjustment and Monitoring
Acute Care RFP
February 3, 2003
- 29 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
r. Respite Care (with limitations)
s. Therapeutic foster care services
REFERRALS: As specified in Section D, Paragraph 10, Scope of Services, EPSDT,
the Contractor must provide developmental/behavioral health screenings for
members up to 21 years of age in compliance with the AHCCCS periodicity
schedule. The Contractor shall ensure the initiation and coordination of
behavioral health referrals of these members to the RBHA when determined
necessary through the screening process. The Contractor is responsible for RBHA
referral and follow-up collaboration, as necessary, for other members identified
as needing behavioral health evaluation and treatment. Members may also access
the RBHA system for evaluation by self-referral or be referred by schools, State
agencies or other service providers. The Contractor is responsible for providing
transportation to a member's first RBHA evaluation appointment if a member is
unable to provide his/her own transportation.
EMERGENCY SERVICES: For those members who are not ADHS behavioral health
recipients, the Contractor is responsible for up to three days of inpatient
behavioral health services per emergency episode, not to exceed 12 days per
contract year. A referral to the RBHA for evaluation and identification as an
ADHS behavioral health recipient should be initiated as soon as possible after
admission.
When members present in an emergency room setting, the Contractor is responsible
for all emergency medical services including triage, physician assessment and
diagnostic tests. For members who are not ADHS behavioral health recipients, the
Contractor is responsible to provide medically necessary psychiatric
consultations or psychological consultations in emergency room settings to help
stabilize the member or determine the need for inpatient behavioral health
services. ADHS is responsible for medically necessary psychiatric consultations
provided to ADHS behavioral health recipients in emergency room settings.
COORDINATION OF CARE: The Contractor is responsible for ensuring that a medical
record is established by the PCP when behavioral health information is received
from the RBHA or provider about an assigned member even if the PCP has not yet
seen the assigned member. In lieu of actually establishing a medical record,
such information may be kept in an appropriately labeled file but must be
associated with the member's medical record as soon as one is established. The
Contractor shall require the PCP to respond to RBHA/provider information
requests pertaining to ADHS behavioral health recipient members including, but
not limited to, current diagnosis, medication, pertinent laboratory results,
last PCP visit, and last hospitalization. For prior period coverage, the
Contractor is responsible for payment of all claims for medically necessary
covered behavioral health services to members who are not ADHS behavioral health
recipients.
MEDICATION MANAGEMENT SERVICES: The Contractor shall allow PCPs to provide
medication management services (prescriptions, medication monitoring visits,
laboratory and other diagnostic tests necessary for diagnosis and treatment of
behavioral disorders) to members with diagnoses of depression, anxiety and
attention deficit hyperactivity disorder. The Contractor shall make available,
on the Contractor's formulary, medications for the treatment of these disorders.
The Contractor shall ensure that training and education are available to PCPs
regarding behavioral health referral and consultation procedures. The Contractor
shall establish policies and procedures for referral and consultation and shall
describe them in its provider manual.
The Contractor shall ensure that its quality management program incorporates
monitoring of the PCP's management of behavioral health disorders.
Acute Care RFP
February 3, 2003
- 30 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
13. AHCCCS MEDICAL POLICY MANUAL
The AHCCCS Medical Policy Manual (AMPM) is hereby incorporated by reference into
this contract. The Contractor is responsible for complying with the requirements
set forth within. The AMPM, with search capability and linkages to AHCCCS rules,
statutes and other resources, is available to all interested parties through the
AHCCCS Home Page on the Internet (www.ahcccs.state.az.us). Upon adoption by
AHCCCSA, AMPM updates will be available through the Internet at the beginning of
each month. The Contractor shall be responsible for maintaining a copy current
with these updates.
14. MEDICAID IN THE PUBLIC SCHOOLS (MIPS)
Pursuant to an Intergovernmental Agreement with the Department of Education, and
a contract with a Third Party Administrator, AHCCCSA reimburses participating
school districts for specifically identified Medicaid services when provided to
Medicaid eligible children who are included under the Individuals with
Disabilities Education Act (IDEA). The Medicaid services must be identified in
the member's Individual Education Plan (IEP) as medically necessary for the
child to obtain a public school education.
MIPS services are provided in a school setting or other approved setting
specifically to allow children to receive a public school education. They do not
replace medically necessary services provided outside the school setting or
other MIPS approved alternative setting. Currently, services include therapies
(OT, PT and speech/language); behavioral health evaluation and counseling;
nursing and attendant care; and specialized transportation. The Contractor's
evaluations and determinations, about whether services are medically necessary,
should be made independent of the fact that the child is receiving MIPS
services.
Contractors and their providers must coordinate with schools and school
districts that provide MIPS services to the Contractor's enrolled members.
Services should not be duplicative. Contractor case managers, working with
special needs children, should coordinate with school or school district case
managers/special education teachers, working with these members. Transfer of
member medical information and progress toward treatment goals between the
Contractor and the member's school or school district is required and should be
used to enhance the services provided to members.
15. PEDIATRIC IMMUNIZATIONS AND THE VACCINE FOR CHILDREN PROGRAM
Through the Vaccine for Children Program, the Federal and State governments
purchase, and make available to providers free of charge, vaccines for AHCCCS
children under age 19. The Contractor shall not utilize AHCCCS funding to
purchase vaccines for members under the age of 19. If vaccines are not available
through the VFC Program, the Contractor shall contact the AHCCCSA Office of
Medical Management, Clinical Quality Management Unit. Any provider, licensed by
the State to administer immunizations, may register with ADHS as a "VFC
provider" and receive free vaccines. The Contractor shall comply with all VFC
requirements and monitor its providers to ensure that, if providing
immunizations to AHCCCS members under the age of 19, the providers are
registered with ADHS/VFC.
Arizona State law requires the reporting of all immunizations given to children
under the age of 19. Immunizations must be reported at least monthly to the
ADHS. Reported immunizations are held in a central database known as ASIIS
(Arizona State Immunization Information System), which can be accessed by
providers to obtain complete, accurate immunization records. Software is
available from ADHS to assist providers in meeting this reporting requirement.
Contractors are encouraged to educate their provider network about these
reporting requirements and the use of this resource.
Acute Care RFP
February 3, 2003
- 31 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
16. STAFF REQUIREMENTS AND SUPPORT SERVICES
The Contractor shall have in place the organization, management and
administrative systems capable of fulfilling all contract requirements. For the
purposes of this contract, the Contractor shall not employ or contract with any
individual that has been debarred, suspended or otherwise lawfully prohibited
from participating in any public procurement activity. At a minimum, the
following staff is required:
a. A full-time ADMINISTRATOR/CEO/COO who is available at all times to
fulfill the responsibilities of the position and to oversee the entire
operation of the health plan. The Administrator shall devote sufficient
time to the Contractor's operations to ensure adherence to program
requirements and timely responses to AHCCCS Administration.
b. A MEDICAL DIRECTOR who shall be an Arizona-licensed physician. The
Medical Director shall be actively involved in all-major clinical
programs and QM/UM components of the Contractor. The Medical Director
shall devote sufficient time to the Contractor to ensure timely medical
decisions, including after-hours consultation as needed.
c. A CHIEF FINANCIAL OFFICER/CFO who is available at all times to fulfill
the responsibilities of the position and to oversee the budget and
accounting systems implemented by the Contractor.
d. A QUALITY MANAGEMENT/UTILIZATION MANAGEMENT COORDINATOR who is an
Arizona-licensed registered nurse, physician or physician's assistant.
e. A MATERNAL HEALTH/EPSDT COORDINATOR who shall be an Arizona-licensed
registered nurse, physician or physician's assistant; or have a
Master's degree in health services, public health or health care
administration or other related field.
f. A BEHAVIORAL HEALTH COORDINATOR who shall be a behavioral health
professional as described in Health Services Rule R9-20. The Behavioral
Health Coordinator shall devote sufficient time to ensure that the
Contractor's behavioral health referral and coordination activities are
implemented per AHCCCSA requirements.
g. PRIOR AUTHORIZATION STAFF to authorize health care 24 hours per day, 7
days per week. This staff shall include an Arizona-licensed registered
nurse, physician or physician's assistant.
h. CONCURRENT REVIEW STAFF to conduct inpatient concurrent review. This
staff shall consist of an Arizona- licensed registered nurse,
physician, physician's assistant or an Arizona-licensed practical nurse
experienced in concurrent review and under the direct supervision of a
registered nurse, physician or physician's assistant.
i. MEMBER SERVICES MANAGER AND STAFF to coordinate communications with
members and act as member advocates. There shall be sufficient Member
Service staff to enable members to receive prompt resolution to their
inquiries/problems, and to meet the Contractor's standards for
resolution, telephone abandonment rates and telephone hold times.
j. PROVIDER SERVICES MANAGER AND STAFF to coordinate communications
between the Contractor and its subcontractors. There shall be
sufficient Provider Services staff to enable providers to receive
prompt resolution to their problems or inquiries and appropriate
education about participation in the AHCCCS program.
k. A CLAIMS ADMINISTRATOR AND CLAIMS PROCESSORS to ensure the timely and
accurate processing of original claims, re-submissions and overall
adjudication of claims.
l. ENCOUNTER PROCESSORS to ensure the timely and accurate processing and
submission to AHCCCSA of encounter data and reports.
m. A GRIEVANCE MANAGER who is responsible for oversight of the
Contractor's grievance system for members and providers.
n. A COMPLIANCE OFFICER who will implement and oversee the Contractor's
compliance program. The compliance officer shall be a senior, on-site
official, available to all employees, with designated and recognized
authority to access records and make independent referrals to the
AHCCCSA, Office of Program Integrity.
Acute Care RFP
February 3, 2003
- 32 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
o. HEALTH PLAN STAFF sufficient to implement and oversee compliance with
both the Contractor's Cultural Competency Plan and the AHCCCS Cultural
Competency Policy, and to oversee compliance with all AHCCCS
requirements pertaining to limited English proficiency (LEP).
p. CLERICAL AND SUPPORT STAFF to ensure appropriate functioning of the
Contractor's operation.
The Contractor shall inform AHCCCS, Office of Managed Care, in writing within
seven days, when an employee leaves one of the key positions listed below. The
name of the interim contact person should be included with the notification. The
name and resume of the permanent employee should be submitted as soon as the new
hire has taken place.
Administrator Member Services Manager
Medical Director Provider Services Manager
Chief Financial Officer Claims Administrator
Maternal Health/ EPSDT Coordinator Quality Management/Utilization Management
Grievance Manager Coordinator
Compliance Officer Behavioral Health Coordinator
The Contractor shall ensure that all staff have appropriate training, education,
experience and orientation to fulfill the requirements of the position.
17. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
The Contractor shall develop and maintain written policies, procedures and job
descriptions for each functional area of its health plan, consistent in format
and style. The Contractor shall maintain written guidelines for developing,
reviewing and approving all policies, procedures and job descriptions. All
policies and procedures shall be reviewed at least annually to ensure that the
Contractor's written policies reflect current practices. Reviewed policies shall
be dated and signed by the Contractor's appropriate manager, coordinator,
director or administrator. All medical and quality management policies must be
approved and signed by the Contractor's Medical Director. Job descriptions shall
be reviewed at least annually to ensure that current duties performed by the
employee reflect written requirements.
18. MEMBER INFORMATION
The Contractor shall be accessible by phone for general member information
during normal business hours. All enrolled members will have access to a toll
free phone number. All informational materials, prepared by the Contractor,
shall be approved by AHCCCSA prior to distribution to members. The reading level
and name of the evaluation methodology used should be included.
All materials shall be translated when the Contractor is aware that a language
is spoken by 3,000 or 10%, whichever is less, of the Contractor's members, who
also have limited English proficiency (LEP).
All vital materials shall be translated when the Contractor is aware that a
language is spoken by 1,000 or 5%, whichever is less, of the Contractor's
members, who also have LEP. Vital materials must include, at a minimum, notices
for denials, reductions, suspensions or terminations of services, vital
information from the member handbooks and consent forms.
All written notices informing members of their right to interpretation and
translation services in a language shall be translated when the Contractor is
aware that 1,000 or 5% (whichever is less) of the Contractor's members speak
that language and have LEP.
Acute Care RFP
February 3, 2003
- 33 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
Oral interpretation services must be available and free of charge to all members
regardless of the prevalence of the language. The Contractor must notify all
member of their right to access oral interpretation services and how to access
them. Refer to the AHCCCS, Office of Managed Care Member Information Policy.
The Contractor shall make every effort to ensure that all information prepared
for distribution to members is written at a 4th grade level. Regardless of the
format chosen by the Contractor, the member information must be printed in a
type, style and size, which can easily be read by members with varying degrees
of visual impairment. The Contractor must notify its members that alternative
formats are available and how to access them.
When there are program changes, notification shall be provided to the affected
members at least 30 days before implementation.
The Contractor shall produce and provide the following printed information to
each member or family within 10 days of receipt of notification of the
enrollment date:
I. A member handbook which, at a minimum, shall include the items listed
in the AHCCCS, Office of Managed Care Member Information Policy.
The Contractor shall review and update the Member Handbook at least
once a year. The handbook must be submitted to AHCCCS, Office of
Managed Care for approval by September 1st of each contract year, or
within four weeks of receiving the annual renewal amendment, whichever
is later.
II. A description of the Contractor's provider network, which at a minimum,
includes those items listed in the AHCCCS, Office of Managed Care
Member Information Policy.
The Contractor must give written notice about termination of a contracted
provider, within 15 days after receipt or issuance of the termination notice, to
each member who received their primary care from, or is seen on a regular basis
by, the terminated provider. Affected members must be informed of any other
changes in the network 30 days prior to the implementation date of the change.
The Contractor shall have information available for potential enrollees as
described in the AHCCCS, Office of Managed Care Member Information Policy.
19. MEMBER SURVEYS
Unless waived by AHCCCSA, the Contractor shall perform its own annual general or
focused member survey. All such contractor surveys, along with a timeline for
the project, shall be approved in advance by AHCCCS Office of Managed Care. The
results and the analysis of the results shall be submitted to the Operations
Unit within 45 days of the completion of the project. AHCCCSA may require
inclusion of certain questions.
AHCCCSA may periodically conduct a survey of a representative sample of the
Contractor's membership. AHCCCSA will consider suggestions from the Contractor
for questions to be included in each survey. The results of these surveys,
conducted by AHCCCSA, will become public information and available to all
interested parties upon request.
20. CULTURAL COMPETENCY
The Contractor shall have a Cultural Competency Plan that meets the requirements
of the AHCCCS Cultural Competency Policy. An annual assessment of the
effectiveness of the plan, along with any modifications to
Acute Care RFP
February 3, 2003
- 34 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
the plan, must be submitted to the Office of Managed Care, no later than 45 days
after the start of each contract year.
21. MEDICAL RECORDS
The member's medical record is the property of the provider who generates the
record. Each member is entitled to one copy of his or her medical record free of
charge. The Contractor shall have written policies and procedures to maintain
the confidentiality of all medical records.
The Contractor is responsible for ensuring that a medical record is established
when information is received about a member. If the PCP has not yet seen the
member, such information may be kept temporarily in an appropriately labeled
file, in lieu of establishing a medical record, but must be associated with the
member's medical record as soon as one is established.
The Contractor shall have written policies and procedures for the maintenance of
medical records so that those records are documented accurately and in a timely
manner, are readily accessible, and permit prompt and systematic retrieval of
information.
The Contractor shall have written standards for documentation on the medical
record for legibility, accuracy and plan of care, which comply with the AMPM.
The Contractor shall have written plans for providing training and evaluating
providers' compliance with the Contractor's medical records standards. Medical
records shall be maintained in a detailed and comprehensive manner, which
conforms to good professional medical practice, permits effective professional
medical review and medical audit processes, and which facilitates an adequate
system for follow-up treatment. Medical records must be legible, signed and
dated.
When a member changes PCPs, his or her medical records or copies of medical
records must be forwarded to the new PCP within 10 working days from receipt of
the request for transfer of the medical records.
AHCCCSA is not required to obtain written approval from a member, before
requesting the member's medical record from the PCP or any other agency. The
Contractor may obtain a copy of a member's medical records without written
approval of the member, if the reason for such request is directly related to
the administration of the AHCCCS program. AHCCCSA shall be afforded access to
all members' medical records whether electronic or paper within 20 working days
of receipt of request.
Information related to fraud and abuse may be released so long as protected
HIV-related information is not disclosed (A.R.S. Section 36-664(I)).
22. ADVANCE DIRECTIVES
The Contractor shall maintain policies and procedures addressing advanced
directives for adult members that specify:
a. Each contract or agreement with a hospital, nursing facility, home
health agency, hospice or organization responsible for providing
personal care, must comply with Federal and State law regarding advance
directives for adult members. Requirements include:
(1) Maintaining written policies that address the rights of adult
members to make decisions about medical care, including the
right to accept or refuse medical care, and the right to
execute an
Acute Care RFP
February 3, 2003
- 35 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
advance directive. If the agency/organization has a
conscientious objection to carrying out an advance directive,
it must be explained in policies. (A health care provider is
not prohibited from making such objection when made pursuant
to A.R.S. Section 36-3205.C.1.)
(2) Provide written information to adult members regarding each
individual's rights under State law to make decisions
regarding medical care, and the health care provider's written
policies concerning advance directives (including any
conscientious objections).
(3) Documenting in the member's medical record whether or not the
adult member has been provided the information and whether an
advance directive has been executed.
(4) Not discriminating against a member because of his or her
decision to execute or not execute an advance directive, and
not making it a condition for the provision of care.
(5) Providing education to staff on issues concerning advance
directives including notification of direct care providers of
services, such as home health care and personal care, of any
advanced directives executed by members to whom they are
assigned to provide services.
b. Contractors shall require subcontracted PCPs, which have agreements
with the entities described in paragraph a. above, to comply with the
requirements of subparagraphs a. (2) through (5) above. Contractors
shall also encourage health care providers specified in subparagraph a.
to provide a copy of the member's executed advanced directive, or
documentation of refusal, to the member's PCP for inclusion in the
member's medical record.
c. The Contractor shall provide written information to adult enrollees
that describe the following:
(1) A member's rights under State law, including a description of
the applicable State law
(2) The organization's policies respecting the implementation of
those rights, including a statement of any limitation
regarding the implementation of advance directives as a matter
of conscience.
(3) The member's right to file complaints directly with the state
(4) Changes to State as soon as possible, but no later than 90
days after the effective date of the change
23. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM)
QUALITY MANAGEMENT (QM): The Contractor shall provide quality medical care to
members, regardless of payer source or eligibility category. The Contractor
shall execute processes to assess, plan, implement and evaluate quality
management and improvement activities, as specified in the AMPM, that include at
least the following:
- - Conducting Quality Improvement Projects (QIPs);
- - QM monitoring and evaluation activities;
- - Credentialing and recredentialing processes;
- - Investigation, analysis, tracking and trending of quality of care
issues, abuse and/or complaints; and
- - AHCCCS mandated performance indicators.
The Contractor shall submit, within timelines specified in Attachment F, a
written QM plan that addresses its strategies for quality improvement and
conducting the quality management activities described in this section. The
Contractor shall conduct quality improvement projects as required by the AMPM.
The Contractor may combine its plan for quality improvement and quality
management activities with the plan that addresses utilization management as
described below.
Acute Care RFP
February 3, 2003
- 36 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
UTILIZATION MANAGEMENT (UM): The Contractor shall execute processes to assess,
plan, implement and evaluate utilization management activities, as specified in
the AMPM, that include at least the following:
- - Pharmacy Management;
- - Prior authorization;
- - Concurrent review;
- - Continuity and coordination of care;
- - Monitoring and evaluation of over and/or under utilization of services;
- - Evaluation of new medical technologies, and new uses of existing
technologies;
- - Development and/or adoption of practice guidelines; and
- - Consistent application of review criteria.
The Contractor shall maintain a written UM plan that addresses its plan for
monitoring UM activities described in this section. The plan must be submitted
for review by AHCCCS Office of Medical Management (OMM) within timelines
specified in Attachment F.
24. PERFORMANCE STANDARDS
All Performance Standards described below apply to all member populations.
Contractors must meet AHCCCS stated Minimum Performance Standards. However, it
is equally important that Contractors continually improve their performance
indicator outcomes from year to year. Contractors shall strive to meet the
ultimate standard, or benchmark, established by AHCCCS.
Any statistically significant drop in the Contractor's performance level for any
indicator must be explained by the Contractor in its annual quality management
program evaluation. If a Contractor has a significant drop in any indicator
without a justifiable explanation, it will be required to submit a corrective
action plan and may be subject to sanctions.
AHCCCS has established three levels of performance:
MINIMUM PERFORMANCE STANDARD - A Minimum Performance Standard is the
minimal expected level of performance by the Contractor. If a Contractor
does not achieve this standard, or any indicator declines to a level
below the AHCCCS Minimum Performance, the Contractor will be required to
submit a corrective action plan and may be subject to sanctions.
GOAL - A Goal is a reachable standard for a given performance indicator
for the Contract Year. If the Contractor has already met or exceeded the
AHCCCS Minimum Performance Standard for any indicator, the Contractor
must strive to meet the established Goal for the indicator(s).
BENCHMARK - A Benchmark is the ultimate standard to be achieved.
Contractors that have already achieved or exceeded the Goal for any
performance indicator must strive to meet the Benchmark for the
indicator(s). Contractors that have achieved the Benchmark are expected
to maintain this level of performance for future years.
A Contractor that has not shown demonstrable and sustained improvement toward
meeting AHCCCS Performance Standards shall develop a corrective action plan. The
corrective action plan must be received by AHCCCS, Office of Medical Management
within 30 days of receipt of notification from AHCCCS. This plan must be
approved by AHCCCS prior to implementation. AHCCCS may conduct one or more
follow-up onsite
Acute Care RFP
February 3, 2003
- 37 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
reviews to verify compliance with a corrective action plan. Failure to achieve
adequate improvement may result in sanction imposed by AHCCCS.
PERFORMANCE INDICATORS: The Contractor shall comply with AHCCCS quality
management requirements to improve performance for all AHCCCS established
performance indicators. Complete descriptions of these indicators can be found
in the Technical Specifications section of the most recently published Health
Plan Performance Standards Results and Analysis documents for perinatal,
pediatric and adult/adolescent services. The indicators for postpartum visits
and low birth weight have been eliminated as contractual performance standards.
The Contractor shall continue to monitor rates for postpartum visits and low
birth weights and implement interventions as necessary to improve or sustain
these rates. These activities will be monitored by AHCCCSA during the
Operational and Financial Review.
CMS has been working in partnership with states in developing core performance
measures for Medicaid and SCHIP programs. The current AHCCCS established
performance indicators may be subject to change when these core measures are
finalized and implemented.
In addition, AHCCCS has established standards for the following indicators:
EPSDT PARTICIPATION: The Contractor shall take affirmative steps to increase
member participation in the EPSDT program. The participation rate is the number
of children younger than 21 years receiving at least one medical screen during
the contract year, compared to the number of children expected to receive at
least one medical screen. The number of children expected to receive at least
one medical screen is based on the AHCCCS EPSDT periodicity schedule and the
average period of eligibility.
PEDIATRIC IMMUNIZATIONS: The Contractor shall ensure members under age 21
receive age-appropriate immunizations as specified in the AMPM.
The Contractor shall participate in immunization audits, at intervals specified
by AHCCCSA, based on random sampling to assess and verify the immunization
status of two-year-old members. AHCCCS will provide the Contractor the selected
sample, specifications for conducting the audit, the AHCCCSA reporting
requirements, and technical assistance. The Contractor shall identify each
child's PCP, conduct the assessment, and report to AHCCCSA, in the required
format, all immunization data for the two-year-old children sampled. If medical
records are missing for more than 5 percent of the sample group, the Contractor
is subject to sanctions by AHCCCSA. An External Quality Review Organization
(EQRO) may conduct a study to validate the Contractor's reported rates.
The following table identifies the Minimum Performance Standards, Goals and
Benchmarks for each indicator:
- ------------------------------------------------------------------------------------------------
Benchmark *
CYE 04 Minimum CYE 04 (Healthy
Performance Indicator Performance Standard Goal People Goals)
- ------------------------------------------------------------------------------------------------
Immunization of two-year-olds 3 antigen series 78% 82% 90%
(4:3:1)
- ------------------------------------------------------------------------------------------------
Immunization of two-year-olds 5 antigen series 67% 73% 90%
(4:3:1:2:3)
- ------------------------------------------------------------------------------------------------
Immunizations of two-year-olds
DtaP 4 doses 82% 85% 90%
- ------------------------------------------------------------------------------------------------
Polio 3 doses 88% 90% 90%
- ------------------------------------------------------------------------------------------------
MMR - 1 dose 88% 90% 90%
- ------------------------------------------------------------------------------------------------
Hib 2 doses 85% 90% 90%
- ------------------------------------------------------------------------------------------------
HBV 3 doses 81% 87% 90%
- ------------------------------------------------------------------------------------------------
Acute Care RFP
February 3, 2003
- 38 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
- ------------------------------------------------------------------------------------------------
Benchmark *
CYE 04 Minimum CYE 04 (Healthy
Performance Indicator Performance Standard Goal People Goals)
- ------------------------------------------------------------------------------------------------
Varicella 1 dose 73% 80% 90%
- ------------------------------------------------------------------------------------------------
Dental visits 45% 55% 56%
- ------------------------------------------------------------------------------------------------
Well-child Visits 15 Months 58% 64% 90%
- ------------------------------------------------------------------------------------------------
Well-child Visits 3-6 Years 48% 64% 80%
- ------------------------------------------------------------------------------------------------
EPSDT Participation 58% 80% 80%
- ------------------------------------------------------------------------------------------------
Children's Access to PCP's 77% 80% 97%
- ------------------------------------------------------------------------------------------------
Cervical Cancer Screening (3-yr period) 57% 60% 90%
- ------------------------------------------------------------------------------------------------
Breast Cancer Screening 55% 60% 70%
- ------------------------------------------------------------------------------------------------
Adolescent Well-care Visits 48% 49% 50%
- ------------------------------------------------------------------------------------------------
Adult Ambulatory/Preventive Care 78% 80% 96%
- ------------------------------------------------------------------------------------------------
Prenatal Care in the First Trimester 59% 65% 90%
- ------------------------------------------------------------------------------------------------
*Benchmarks for each performance indicator are based on Healthy People 200 or
2010 goals for health promotion and disease prevention, as determined by the
U.S. Department of Health and Human Services.
25. GRIEVANCE AND REQUEST FOR HEARING PROCESS AND STANDARDS
The Contractor shall have in place a written grievance process for enrollees and
providers, which defines their rights regarding disputed matters with the
Contractor. The Contractor shall provide the appropriate personnel to establish,
implement and maintain the necessary functions related to the grievance systems
process. Refer to Attachment H(1) and H(2) for Enrollee Grievance System
Standards and Policy and Provider Grievance System Standards and Policy,
respectively.
The grievance process shall be in accordance with applicable Federal and State
laws, regulations and policies, including, but not limited to 42 CFR Part 438
Subpart F. The Contractor shall ensure compliance with Attachment H. Contractor
shall also ensure that it timely provides written information to both enrollees
and providers, which clearly explains the grievance system requirements.
Information to enrollees must meet cultural competency and limited English
proficiency requirements as specified in the AHCCCS Cultural Competency Policy
and Section D, Paragraph 18, Member Information.
The Contractor shall be responsible to provide the necessary professional,
paraprofessional and clerical services for the representation of the Contractor
in all issues relating to the grievance system and any other matters arising
under this contract which rise to the level of administrative hearing or a
judicial proceeding.
26. QUARTERLY GRIEVANCE REPORT
The Contractor shall submit a Quarterly Grievance Report to AHCCCSA, Office of
Legal Assistance, using the Quarterly Grievance System Report Format. The
Quarterly Grievance System Report must be received by the AHCCCSA, Office of
Legal Assistance, no later than 45 days from the end of the quarter.
27. NETWORK DEVELOPMENT
The Contractor shall develop and maintain a provider network that is sufficient
to provide all covered services to AHCCCS members. It shall ensure covered
services are provided promptly and are reasonably accessible in terms of
location and hours of operation. There shall be sufficient personnel for the
provision of covered services, including emergency medical care on a
24-hour-a-day, 7-days-a-week basis. The proposed network shall be
Acute Care RFP
February 3, 2003
- 39 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
sufficient to provide covered services within designated time and distance
limits. For Maricopa and Pima Counties only, this includes a network such that
95% of its members residing within the boundary area of metropolitan Phoenix and
Tucson do not have to travel more than 5 miles to see a PCP, dentist or
pharmacy. Ninety-five percent of its members residing outside the boundary area
must not have to travel more than 10 miles to see such providers. PCPs and
specialists who provide inpatient services to the Contractor's members shall
have admitting and treatment privileges in a minimum of one general acute care
hospital within the Contractor's service area. Hospitalists may satisfy this
requirement. Contractors in Maricopa and/or Pima counties must have at least one
hospital contract in each of the service districts specified in Attachment B.
Contractors must provide a comprehensive provider network that ensures its
membership has access at least equal to, or better than, community norms.
Services shall be as accessible to AHCCCS members in terms of timeliness,
amount, duration and scope as those services are to non-AHCCCS persons within
the same service area. The Contractor is expected to consider the full spectrum
of care when developing its network. The Contractor must also consider
communities whose residents typically receive care in neighboring states. If the
Contractor is unable to provide those services locally, it must so demonstrate
to AHCCCSA and shall provide reasonable alternatives for members to access care.
These alternatives must be approved by AHCCCSA. If the Contractor's network is
unable to provide medically necessary services required under contract, the
Contractor must adequately and timely cover these services through an out of
network provider until a network provider is contracted. The Contractor and out
of network provider must coordinate with respect to authorization and payment
issues in these circumstances.
The Contractor is also encouraged to develop non-financial incentive programs to
increase participation in its provider network.
The Contractor shall not discriminate with respect to participation in the
AHCCCS program, reimbursement or indemnification against any provider based
solely on the provider's type of licensure or certification. In addition, the
Contractor must not discriminate against particular providers that service
high-risk populations or specialize in conditions that require costly treatment.
This provision, however, does not prohibit the Contractor from limiting provider
participation to the extent necessary to meet the needs of the Contractor's
members. This provision also does not interfere with measures established by the
Contractor to control costs consistent with its responsibilities under this
contract. If a Contractor declines to include individual or groups of providers
in its network, it must give the affected providers written notice of the reason
for its decision. The Contractor may not include providers excluded from
participation in Federal health care programs, under either section 1128 or
section 1128A of the Social Security Act.
See Attachment B, Minimum Network Requirements, for details on network
requirements by Geographic Service Area.
PROVIDER NETWORK DEVELOPMENT AND MANAGEMENT PLAN: The Contractor shall develop
and maintain a provider network development and management plan, which ensures
that the provision of covered services will occur as stated above. This plan
shall be updated annually and submitted to AHCCCSA, Office of Managed Care, 45
days from the start of each contract year. The plan shall identify the current
status of the Contractor's network, and project future needs based upon, at a
minimum, membership growth; the number and types (in terms of training,
experience and specialization) of providers that exist in the Contractor's
service area; the expected utilization of services, given the characteristics of
its population and its health care needs; the numbers of providers not accepting
new Medicaid patients; and access of its membership to specialty services as
compared to the general population of the community. The plan, at a minimum,
shall also include the following:
a. current network gaps;
b. immediate short-term interventions when a gap occurs,
including expedited or temporary credentialing;
c. interventions to fill network gaps and barriers to those
interventions;
Acute Care RFP
February 3, 2003
- 40 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
d. outcome measures/evaluation of interventions;
e. ongoing activities for network development;
f. coordination between internal departments;
g. coordination with outside organizations and
h. specialty populations.
28. PROVIDER AFFILIATION TRANSMISSION
The Contractor shall submit information quarterly regarding its provider
network. This information shall be submitted in the format described in the
Provider Affiliation Transmission User Manual on October 15, January 15, April
15, and July 15 of each contract year. The manual may be found in the Bidder's
Library. If the provider affiliation transmission is not timely, accurate and
complete, the Contractor may be required to submit a corrective action plan and
may be subject to sanction.
29. NETWORK MANAGEMENT
The Contractor shall have policies and procedures in place that pertain to all
service specifications described in the AMPM. In addition, the Contractor shall
have policies on how the Contractor will:
a. Communicate with the network regarding contractual and/or program
changes and requirements;
b. Monitor network compliance with policies and rules of AHCCCSA and the
Contractor, including compliance with all policies and procedures
related to the grievance process and ensuring the member's care is not
compromised during the grievance process;
c. Evaluate the quality of services delivered by the network;
d. Provide or arrange for medically necessary covered services should the
network become temporarily insufficient within the contracted service
area;
e. Monitor the adequacy, accessibility and availability of its provider
network to meet the needs of its members, including the provision of
care to members with limited proficiency in English; and
f. Process expedited and temporary credentials.
Contractor policies shall be subject to approval by AHCCCSA, Office of Managed
Care, and shall be monitored through operational audits.
All material changes in the Contractor's provider network must be approved in
advance by AHCCCSA, Office of Managed Care. A material change is defined as one
which affects, or can reasonably be foreseen to affect, the Contractor's ability
to meet the performance and network standards as described in this contract.
AHCCCSA will assess proposed changes in the Contractor's provider network for
potential impact on members' health care and provide a written response to the
Contractor. For emergency situations, AHCCCSA will expedite the approval
process.
The Contractor shall notify AHCCCSA, Office of Managed Care, within one working
day of any unexpected changes that would impair its provider network. This
notification shall include (1) information about how the change will affect the
delivery of covered services, and (2) the Contractor's plans for maintaining the
quality of member care, if the provider network change is likely to affect the
delivery of covered services.
30. PRIMARY CARE PROVIDER STANDARDS
The Contractor shall include in its provider network a sufficient number of PCPs
to meet the requirements of this contract. Health care providers designated by
the Contractor as PCPs shall be licensed in Arizona as
Acute Care RFP
February 3, 2003
- 41 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
allopathic or osteopathic physicians who generally specialize in family
practice, internal medicine, obstetrics, gynecology, or pediatrics; certified
nurse practitioners or certified nurse midwifes; or physician's assistants.
The Contractor shall assess the PCP's ability to meet AHCCCS appointment
availability and other standards when determining the appropriate number of its
members to be assigned to a PCP. The Contractor should also consider the PCP's
total panel size (i.e. AHCCCS and non-AHCCCS patients) when making this
determination. AHCCCS members shall not comprise the majority of a PCP's panel
of patients. AHCCCSA shall inform the Contractor when a PCP has a panel of more
than 1,800 AHCCCS members (assigned by a single Contractor or multiple
Contractors), to assist in the assessment of the size of their panel. This
information will be provided on a quarterly basis. The Contractor will adjust
the size of a PCP's panel, as needed, for the PCP to meet AHCCCS standards.
The Contractor shall have a system in place to monitor and ensure that each
member is assigned to an individual PCP and that the Contractor's data regarding
PCP assignments is current. The Contractor is encouraged to assign members with
complex medical conditions, who are age 12 and younger, to board certified
pediatricians. PCP's, with assigned members diagnosed with AIDS or as HIV
positive, shall meet criteria and standards set forth in the AMPM.
To the extent required by this contract, the Contractor shall offer members
freedom of choice within its network in selecting a PCP. The Contractor may
restrict this choice when a member has shown an inability to form a relationship
with a PCP, as evidenced by frequent changes, or when there is a medically
necessary reason. When a new member has been assigned to the Contractor, the
Contractor shall inform the member in writing of his enrollment and of his PCP
assignment within 10 days of the Contractor's receipt of notification of
assignment by AHCCCSA. The Contractor shall include with the enrollment
notification a list of all the Contractor's available PCPs, the process for
changing the PCP assignment, should the member desire to do so, as well as the
information required in the AHCCCS Office of Managed Care Member Information
Policy. The Contractor shall confirm any PCP change in writing to the member.
Members may make both their initial PCP selection and any subsequent PCP changes
either verbally or in writing.
At a minimum, the Contractor shall hold the PCP responsible for the following
gatekeeping activities:
a. Supervision, coordination and provision of care to each assigned
member;
b. Initiation of referrals for medically necessary specialty care;
c. Maintaining continuity of care for each assigned member; and
d. Maintaining the member's medical record, including documentation of all
services provided to the member by the PCP, as well as any specialty or
referral services.
The Contractor shall establish and implement policies and procedures to monitor
PCP gatekeeping activities and to ensure that PCPs are adequately notified of,
and receive documentation regarding, specialty and referral services provided to
assigned members by specialty physicians, and other health care professionals.
Contractor policies and procedures shall be subject to approval by AHCCCSA,
Office of Managed Care, and shall be monitored through operational audits.
31. MATERNITY CARE PROVIDER STANDARDS
The Contractor shall ensure that a maternity care provider is designated for
each pregnant member for the duration of her pregnancy and postpartum care and
that maternity services are provided in accordance with the AMPM. The Contractor
may include in its provider network the following maternity care providers:
a. Arizona licensed allopathic and/or osteopathic physicians who are
general practitioners or specialize in family practice or obstetrics
Acute Care RFP
February 3, 2003
- 42 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
b. Physician Assistants
c. Nurse Practitioners
d. Certified Nurse Midwives
Pregnant members may choose, or be assigned, a PCP who provides obstetrical
care. Such assignment shall be consistent with the freedom of choice
requirements for selecting health care professionals while ensuring that the
continuity of care is not compromised. Members who choose to receive maternity
services from a licensed midwife shall also be assigned to a PCP for medical
care, as primary care is not within the scope of practice for licensed midwives.
All physicians and certified nurse midwives who perform deliveries shall have OB
hospital privileges or a documented hospital coverage agreement for those
practitioners performing deliveries in alternate settings. Licensed midwives
perform deliveries only in the member's home. Labor and delivery services may
also be provided in the member's home by physicians, certified nurse
practitioners and certified nurse midwives who include such services within
their practice.
32. REFERRAL PROCEDURES AND STANDARDS
The Contractor shall have adequate written procedures regarding referrals to
specialists, to include, at a minimum, the following:
a. Use of referral forms clearly identifying the Contractor
b. A system for resolving disputes regarding the referrals
c. PCP referral shall be required for specialty physician services, except
that women shall have direct access to in-network GYN providers,
including physicians, physician assistants and nurse practitioners
within the scope of their practice, without a referral for preventive
and routine services. In addition, for members with special health care
needs determined to need a specialized course of treatment or regular
care monitoring, the Contractor must have a mechanism in place to allow
such members to directly access a specialist (for example through a
standing referral or an approved number of visits) as appropriate for
the member's condition and identified needs. Any waiver of this
requirement by the Contractor must be approved in advance by AHCCCSA.
d. Specialty physicians shall not begin a course of treatment for a
medical condition other than that for which the member was referred,
unless approved by the member's PCP.
e. A process in place that ensures the member's PCP receives all
specialist and consulting reports and a process to ensure PCP follow-up
of all referrals including EPSDT referrals for behavioral health
services
f. A referral plan for any member who is about to lose eligibility and who
requests information on low-cost or no-cost health care services
g. Referral to Medicare HMO including payment of copayments
h. Allow for a second opinion from a qualified health care professional
within the network, or if one is not available in network, arrange for
the member to obtain one outside the network, at no cost to the member.
The Contractor shall comply with all applicable physician referral requirements
and conditions defined in Sections 1903(s) and 1877 of the Social Security Act.
Upon finalization of the regulations, the Contractor shall comply with all
applicable physician referral requirements and conditions defined in 42 CFR Part
411, Part 424, Part 435 and Part 455. Sections 1903(s) and 1877 of the Act
prohibits physicians from making referrals for designated health services to
health care entities with which the physician or a member of the physician's
family has a financial relationship. Designated health services include:
a. Clinical laboratory services
b. Physical therapy services
c. Occupational therapy services
Acute Care RFP
February 3, 2003
- 43 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
d. Radiology services
e. Radiation therapy services and supplies
f. Durable medical equipment and supplies
g. Parenteral and enteral nutrients, equipment and supplies
h. Prosthetics, orthotics and prosthetic devices and supplies
i. Home health services
j. Outpatient prescription drugs
k. Inpatient and outpatient hospital services
33. APPOINTMENT STANDARDS
For purposes of this section, "urgent" is defined as an acute, but not
necessarily life-threatening disorder, which, if not attended to, could endanger
the patient's health. The Contractor shall have procedures in place that ensure
the following standards are met:
a. Emergency PCP appointments - same day of request
b. Urgent care PCP appointments - within 2 days of request
c. Routine care PCP appointments - within 21 days of request
For SPECIALTY REFERRALS, the Contractor shall be able to provide:
a. Emergency appointments - within 24 hours of referral
b. Urgent care appointments - within 3 days of referral
c. Routine care appointments - within 45 days of referral
For DENTAL APPOINTMENTS, the Contractor shall be able to provide:
a. Emergency appointments - within 24 hours of request
b. Urgent care appointments - within 3 days of request
c. Routine care appointments - within 45 days of request
For MATERNITY CARE, the Contractor shall be able to provide initial prenatal
care appointments for enrolled pregnant members as follows:
a. First trimester - within 14 days of request
b. Second trimester - within 7 days of request
c. Third trimester - within 3 days of request
d. High risk pregnancies - within 3 days of identification of high risk by
the Contractor or maternity care provider, or
immediately if an emergency exists
If a member needs non-emergent medically necessary transportation, the
Contractor shall require its transportation provider to schedule the
transportation so that the member arrives on time for the appointment, but no
sooner than one hour before the appointment; does not have to wait more than one
hour after making the call to be picked up; nor have to wait for more than one
hour after conclusion of the appointment for transportation home.
The Contractor shall actively monitor the adequacy of its appointment processes
and reduce the unnecessary use of alternative methods such as emergency room
visits. The Contractor shall actively monitor and ensure that a member's waiting
time for a scheduled appointment at the PCP's or specialist's office is no more
than 45 minutes, except when the provider is unavailable due to an emergency.
Acute Care RFP
February 3, 2003
- 44 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
The Contractor shall have written policies and procedures about educating its
provider network regarding appointment time requirements. The Contractor must
assign a specific staff member or unit within its organization to monitor
compliance with appointment standards. The Contractor must develop a corrective
action plan when appointment standards are not met; if appropriate, the
corrective action plan should be developed in conjunction with the provider.
Appointment standards shall be included in the Provider Manual. The Contractor
is encouraged to include the standards in the provider subcontract.
34. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)
The Contractor is encouraged to use FQHCs in Arizona to provide covered services
and must comply with the Federal mandates. Section 4712(b)(2) of the Balanced
Budget Act requires that "rates of payment between FQHCs/RHCs and MCOs shall not
be less than the amount of payment for a similar set of services with a non-
FQHC/RHC." The intention of this provision is to ensure that contractors
negotiate rates of payment with FQHCs that are comparable to the rates paid to
providers that provide similar services.
Contractors are required to submit member information for Title XIX members for
each FQHC on a quarterly basis to the AHCCCSA Office of Managed Care. AHCCCSA
will perform periodic audits of the member information submitted. Contractors
should refer to the AHCCCS Office of Managed Care's policy on FQHC reimbursement
for further guidance. The following FQHCs are currently recognized by CMS:
Canyonlands Community Health Care
Chiricahua Community Health Centers, Inc.
Clinica Adelante, Inc.
Community Health Center of West Yavapai
Desert Senita Community Health Center
El Rio Health Center
Inter-Tribal Health Care Center
Marana Health Center
Mariposa Community Health Center, Inc.
Mountain Park Health Center
Native American Community Health Center, Inc.
Native Americans for Community Action Family Health Center
North Country Community Health Center
Sun Life Family Health Center
Sunset Community Health Center (formerly Valley Health
Center, Inc.)
United Community Health Center, Inc.
35. PROVIDER MANUAL
The Contractor shall develop, distribute and maintain a provider manual. The
Contractor shall ensure that each contracted provider is issued a copy of the
provider manual and is encouraged to distribute a provider manual to any
individual or group that submits claim and encounter data. The Contractor
remains liable for ensuring that all providers, whether contracted or not, meet
the applicable AHCCCS requirements such as covered services, billing, etc. At a
minimum, the Contractor's provider manual must contain information on the
following:
a. Introduction to the Contractor which explains the Contractor's organization
and administrative structure
b. Provider responsibility and the Contractor's expectation of the provider
c. Overview of the Contractor's Provider Service department and function
Acute Care RFP
February 3, 2003
- 45 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
d. Listing and description of covered and non-covered services, requirements
and limitations including behavioral health services
e. Emergency room utilization (appropriate and non-appropriate use of the
emergency room)
f. EPSDT Services - screenings include a comprehensive history,
developmental/behavioral health screening, comprehensive unclothed physical
examination, appropriate vision testing, hearing testing, laboratory tests,
dental screenings and immunizations
g. Dental services
h. Maternity/Family Planning services
i. The Contractor's policy regarding PCP assignments
j. Referrals to specialists and other providers, including access to
behavioral health services provided by the ADHS/RBHA system
k. Grievance and request for hearing rights of providers and enrollees
l. Billing and encounter submission information
m. Information about policies and procedures relevant to the providers
including, but not limited to, utilization management and claims submission
n. Reimbursement, including reimbursement for dual eligibles (i.e. Medicare
and Medicaid) or members with other insurance
o. Cost sharing responsibility
p. Explanation of remittance advice
q. Prior authorization and notification requirements
r. Claims medical review
s. Concurrent review
t. Fraud and Abuse
u. Formularies (with updates and changes provided in advance to providers,
including pharmacies)
v. AHCCCS appointment standards
w. Americans with Disabilities Act (ADA) requirements and Title VI, as
applicable
x. Eligibility verification
y. Cultural competency information, including notification about Title VI of
the Civil Rights Act of 1964. Providers should also be informed of how to
access interpretation services to assist members who speak a language other
the English or who use sign language.
z. Peer review and appeal process.
36. PROVIDER REGISTRATION
The Contractor shall ensure that all of its subcontractors register with AHCCCSA
as an approved service provider and receive an AHCCCS Provider ID Number. A
Provider Participation Agreement must be signed by each provider who does not
already have a current AHCCCS ID number. The original shall be forwarded to
AHCCCSA. This provider registration process must be completed in order for the
Contractor to report services a subcontractor renders to enrolled members and
for the Contractor to be paid reinsurance.
37. SUBCONTRACTS
The Contractor shall be legally responsible for contract performance whether or
not subcontracts are used. No subcontract shall operate to terminate the legal
responsibility of the Contractor to assure that all activities carried out by
the subcontractor conform to the provisions of this contract. Subject to such
conditions, any function required to be provided by the Contractor pursuant to
this contract may be subcontracted to a qualified person or organization. All
such subcontracts must be in writing. See the AHCCCS Claims Processing by
Subcontracted Providers Policy in the Bidder's Library.
Acute Care RFP
February 3, 2003
- 46 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
All subcontracts entered into by the Contractor are subject to prior review and
approval by AHCCCS, Office of Managed Care, and shall incorporate by reference
the terms and conditions of this contract. The following subcontracts shall be
submitted to AHCCCS, Office of Managed Care for prior approval at least 30 days
prior to the beginning date of the subcontract:
a. Automated data processing
b. Third-party administrators
c. Management Services (See also Section D, Paragraphs 43 & 44)
d. Model subcontracts
e. Capitated or other risk subcontracts requiring claims processing by the
subcontractor
f. Hospitals
g. Requests for Proposal issued by the Contractor for the procurement of
medical services.
The Contractor shall maintain a fully executed original of all subcontracts,
which shall be accessible to AHCCCSA within two working days of request by
AHCCCSA. A subcontract is voidable and subject to immediate cancellation by
AHCCCSA in the event any subcontract pertinent to "a" through "g" above is
implemented without the prior written approval of AHCCCSA. All subcontracts
shall comply with the applicable provisions of Federal and State laws,
regulations and policies.
The Contractor shall not include covenant-not-to-compete requirements in its
provider agreements. Specifically, the Contractor shall not contract with a
provider and require that the provider not provide services for any other AHCCCS
Contractor.
The Contractor must enter into a written agreement with any provider (including
out-of-state providers) the Contractor reasonably anticipates will be providing
services on its behalf more than 25 times during the contract year. Exceptions
to this requirement include the following:
a. If a provider who provides services more than 25 times during the contract
year refuses to enter into a written agreement with the Contractor, the
Contractor shall submit documentation of such refusal to AHCCCS, Office of
Managed Care within seven days of its final attempt to gain such agreement.
b. If a provider performs emergency services such as an emergency room
physician or an ambulance company, a written agreement is not required.
c. Individual providers as detailed in the AMPM.
d. Hospitals, as discussed in Section D, Paragraph 40, Hospital Subcontracting
and Reimbursement.
These and any other exceptions to this requirement must be approved by AHCCCS,
Office of Managed Care. Each subcontract must contain verbatim all the
provisions of Attachment A, Minimum Subcontract Provisions. In addition, each
subcontract must contain the following:
a. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor.
b. Identification of the name and address of the subcontractor.
c. Identification of the population, to include patient capacity, to be
covered by the subcontractor.
d. The amount, duration and scope of medical services to be provided, and for
which compensation will be paid.
e. The term of the subcontract including beginning and ending dates, methods
of extension, termination and re-negotiation.
f. The specific duties of the subcontractor relating to coordination of
benefits and determination of third-party liability.
g. A provision that the subcontractor agrees to identify Medicare and other
third-party liability coverage and to seek such Medicare or third party
liability payment before submitting claims to the Contractor.
h. A description of the subcontractor's patient, medical and cost record
keeping system.
Acute Care RFP
February 3, 2003
- 47 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
i. Specification that the subcontractor shall cooperate with quality
management/quality improvement programs, and comply with the utilization
management and review procedures specified in the AMPM.
j. A provision stating that a merger, reorganization or change in ownership of
a subcontractor that is related to or affiliated with the Contractor shall
require a contract amendment and prior approval of AHCCCSA.
k. Procedures for enrollment or re-enrollment of the covered population (may
also refer to the Provider Manual).
l. A provision that the subcontractor shall be fully responsible for all tax
obligations, Worker's Compensation Insurance, and all other applicable
insurance coverage obligations which arise under this subcontract, for
itself and its employees, and that AHCCCSA shall have no responsibility or
liability for any such taxes or insurance coverage.
m. A provision that the subcontractor must obtain any necessary authorization
from the Contractor or AHCCCSA for services provided to eligible and/or
enrolled members.
n. A provision that the subcontractor must comply with encounter reporting and
claims submission requirements as described in the subcontract.
38. CLAIMS PAYMENT SYSTEM
The Contractor shall develop and maintain a claims payment system capable of
processing, cost avoiding and paying claims in accordance with ARS 36-2904(H)
and (J), AHCCCS Rules R9-22-705, and R9-22-709, a copy of which may be found in
the Bidder's Library. In the absence of a subcontract provision to the contrary,
claims submission deadlines shall be calculated from the date of service or the
effective date of eligibility posting, whichever is later. Remittance advices
accompanying the Contractor's payments to providers must contain, at a minimum,
adequate descriptions of all denials and adjustments, the reasons for such
denials and adjustments, the amount billed, the amount paid, and grievance and
request for hearing rights. The Contractor's claims payment system, as well as
its prior authorization and concurrent review process, must minimize the
likelihood of having to recoup already-paid claims. Any recoupment in excess of
$50,000 per provider within a contract year must be approved in advance by
AHCCCSA, Office of Managed Care.
In accordance with the Balanced Budget Act of 1997, unless a subcontract
specifies otherwise, the Contractor shall ensure that 90% of all clean claims
are paid within 30 days of receipt of the clean claim and 99% are paid within 90
days of receipt of the clean claim. Additionally, unless a subcontract specifies
otherwise, the Contractor shall not require providers to initially submit claims
earlier than 6 months after date of service or to submit clean claims earlier
than 12 months after date of service for which payment is claimed. The receipt
date of the claim is the date stamp on the claim. The paid date of the claim is
the date on the check or other form of payment.
39. SPECIALTY CONTRACTS
AHCCCSA may at any time negotiate or contract on behalf of the Contractor and
AHCCCSA for specialized hospital and medical services. AHCCCSA will consider
existing Contractor resources in the development and execution of specialty
contracts. AHCCCSA may require the Contractor to modify its delivery network to
accommodate the provisions of specialty contracts. Specialty contracts shall
take precedence over, and supersede, existing and future subcontracts for
services that are subject to specialty contracts. AHCCCSA may consider waiving
this requirement in particular situations if such action is determined to be in
the best interest of the State; however, in no case shall reimbursement exceed
that payable under the relevant AHCCCSA specialty contract.
During the term of specialty contracts, AHCCCSA may act as an intermediary
between the Contractor and specialty contractors to enhance the cost
effectiveness of service delivery. AHCCCSA reserves the right to make direct
payments to specialty contractors on behalf of the Contractor. Adjudication of
claims related to such payments provided under specialty contracts shall remain
the responsibility of the Contractor. AHCCCSA may provide technical assistance
prior to the implementation of any specialty contracts.
Acute Care RFP
February 3, 2003
- 48 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
Currently, AHCCCSA only has specialty contracts for transplant services. AHCCCSA
shall provide at least 60 days advance written notice to the Contractor prior to
the implementation of any specialty contract.
40. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
MARICOPA AND PIMA COUNTIES ONLY: Legislation authorizes the Hospital
Reimbursement Pilot Program (Pilot), which is effective from October 1, 2001,
through September 30, 2003. Legislation to extend the Pilot may be introduced
for CYE '04. The Pilot, as defined by AHCCCS Rule R9-22-718, requires hospital
subcontracts to be negotiated between health plans in Maricopa and Pima counties
and hospitals to establish reimbursement levels, terms and conditions.
Subcontracts shall be negotiated by the Contractor and hospitals to cover
operational concerns, such as timeliness of claims submission and payment,
payment of discounts or penalties and legal resolution which may, as an option,
include establishing arbitration procedures. These negotiated subcontracts shall
remain under close scrutiny by AHCCCSA to ensure availability of quality
services within specific service districts, equity of related party interests
and reasonableness of rates. The general provisions of this program encompass
acute care hospital services and outpatient hospital services that result in an
admission. The Contractor shall submit all hospital subcontracts and any
amendments to AHCCCSA, Office of Managed Care. For non-emergency patient-days,
the Contractor shall ensure that at least 65% of its members use contracted
hospitals. AHCCCSA reserves the right to subsequently adjust the 65% standard.
Further, if in AHCCCSA's judgment the number of emergency days at a particular
non-contracted hospital becomes significant, AHCCCSA may require a subcontract
at that hospital.
ALL COUNTIES EXCEPT MARICOPA AND PIMA: The Contractor shall reimburse hospitals
for member care in accordance with AHCCCS Rule R9-22-705. The Contractor is
encouraged to obtain subcontracts with hospitals in all GSA's and must submit
copies of these subcontracts, including amendments, to AHCCCSA, Office of
Managed Care, at least seven days prior to the effective dates thereof.
OUT-OF-STATE HOSPITALS: The Contractor shall reimburse out-of-state hospitals in
accordance with AHCCCS Rule R9-22-705. Contractors serving border communities
(excluding Mexico) are strongly encouraged to establish contractual agreements
with those out-of-state hospitals that are identified by GSA in Attachment B.
HOSPITAL RECOUPMENTS: The Contractor may conduct prepayment and post-payment
medical reviews of all hospital claims including outlier claims. Erroneously
paid claims are subject to recoupment. If the Contractor fails to identify lack
of medical necessity through concurrent review and/or prepayment medical review,
lack of medical necessity identified during post-payment medical review shall
not constitute a basis for recoupment by the Contractor. This prohibition does
not apply to recoupments that are a result of an AHCCCS reinsurance audit. See
also Section D, Paragraph 38, Claims Payment System. For a more complete
description of the guidelines for hospital reimbursement, please consult the
Bidder's Library for applicable statutes and rules.
41. NURSING FACILITY REIMBURSEMENT
The Contractor shall not deny nursing facility services if the nursing facility
is unable to obtain prior authorization in situations where acute care
eligibility and ALTCS eligibility overlap and the member is enrolled with an
AHCCCS acute care contractor. In such situations, the Contractor shall impose
reasonable authorization requirements. The Contractor's payment responsibility,
described above, applies only in situations where the nursing facility has not
been notified in advance of the member's enrollment with an AHCCCS acute care
contractor. When ALTCS eligibility overlaps AHCCCS acute care enrollment, the
acute care enrollment takes precedence. Although the member could be ALTCS
eligible for this time period, there is no ALTCS enrollment that occurs on the
same days as AHCCCS acute enrollment.
Acute Care RFP
February 3, 2003
- 49 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
The Contractor shall provide medically necessary nursing facility services for
any member who has a pending ALTCS application, who is currently residing in a
nursing facility and is eligible for services provided under this contract. If
the member becomes ALTCS eligible and is enrolled with an ALTCS Program
Contractor before the end of the maximum 90 days per contract year of nursing
facility coverage, the Contractor is only responsible for nursing facility
coverage during the time the member is enrolled with the Contractor. Nursing
facility services, covered by a third party insurer (including Medicare) while
the member is enrolled with the Contractor, shall be applied to the 90 day per
contract year limitation.
The Contractor shall notify the Assistant Director of the Division of Member
Services in writing, when a member has been residing in a nursing facility for
75 days. This will allow AHCCCSA time to follow-up on the status of the ALTCS
application process and to prepare for potential fee-for-service coverage if the
stay goes beyond the 90-day per contract year maximum.
42. PHYSICIAN INCENTIVES
The Contractor must comply with all applicable physician incentive requirements
and conditions defined in 42 CFR 417.479. These regulations prohibit physician
incentive plans that directly or indirectly make payments to a doctor or a group
as an inducement to limit or refuse medically necessary services to a member.
The Contractor is required to disclose all physician incentive agreements to
AHCCCSA and to AHCCCS members who request them.
The Contractor shall not enter into contractual arrangements that place
providers at significant financial risk as defined in CFR 417.479 unless
specifically approved in advance by the AHCCCSA Office of Managed Care. In order
to obtain approval, the following must be submitted to the AHCCCSA Office of
Managed Care 45 days prior to the implementation of the contract:
1. A complete copy of the contract
2. A plan for the member satisfaction survey
3. Details of the stop-loss protection provided
4. A summary of the compensation arrangement that meets the substantial
financial risk definition.
The Contractor shall disclose to AHCCCSA the information on physician incentive
plans listed in 42 CFR 417.479(h)(1) through 417.479(I) upon contract renewal,
prior to initiation of a new contract, or upon request from AHCCCSA or CMS.
Please refer to the Physician Incentive Plan Disclosure by Contractors Policy in
the Bidder's Library for details on providing required disclosures.
The Contractor shall also provide for compliance with physician incentive plan
requirements as set forth in 42 CFR 422. These regulations apply to contract
arrangements with subcontracted entities that provide utilization management
services.
43. MANAGEMENT SERVICES SUBCONTRACTORS
All proposed management services subcontracts and/or corporate cost allocation
plans must be approved in advance by AHCCCSA, Office of Managed Care, as
described in Section D, Paragraph 37, Subcontracts. Cost allocation plans must
be submitted with the proposed management fee agreement. AHCCCSA reserves the
right to perform a thorough review of actual management fees charged and/or
corporate allocations made. If the fees or allocations actually paid out are
determined to be unjustified or excessive, amounts may be subject to repayment
to the Contractor. The Contractor may be placed on monthly financial reporting,
and/or financial sanctions may be imposed.
Acute Care RFP
February 3, 2003
- 50 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
44. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS
All management services subcontractors that have oversight responsibilities for
the Contractor's program operations (such as third-party administrators) are
required to have an annual financial audit. A copy of this audit shall be
submitted to AHCCCSA, Office of Managed Care, within 120 days of the
subcontractor's fiscal year end. If services billed by a consultant or actuary
are less than $50,000 annually, AHCCCSA will waive the requirement for an audit
of that consultant or actuary.
45. MINIMUM CAPITALIZATION REQUIREMENTS
In order to be considered for a contract award, the Offeror must meet a minimum
capitalization requirement for each GSA bid. The capitalization requirement for
both new and continuing offerors must be met within 30 days after contract
award.
Minimum capitalization requirements by GSA are as follows:
CAPITALIZATION CAPITALIZATION
GEOGRAPHIC SERVICE AREA (GSA) REQUIREMENT-- REQUIREMENT--
NEW CONTRACTORS EXISTING CONTRACTORS
Mohave/Coconino/Apache/Navajo $4,400,000 $3,000,000
La Paz/Yuma $3,000,000 $2,000,000
Maricopa $5,000,000 $4,000,000
Pima/Santa Cruz $4,500,000 $3,000,000
Cochise/Graham/ Greenlee $2,150,000 $2,000,000
Pinal/Gila $2,400,000 $2,000,000
Yavapai* $1,600,000 $1,600,000
*Yavapai's minimum capitalization requirement for both new and existing offerors
is limited to $150 times the estimated number of members.
NEW OFFERORS: To be considered for a contract award in a given GSA or group of
GSA's, a new offeror must meet the minimum capitalization requirements listed
above. The capitalization requirement is subject to a $10,000,000 ceiling
regardless of the number of GSA's awarded. This requirement is in addition to
the Performance Bond requirements defined in Paragraphs 46 and 47 below and must
be met with cash with no encumbrances, such as a loan subject to repayment. The
capitalization requirement may be applied toward meeting the equity per member
requirement (see Section D, Paragraph 50, Financial Viability
Standards/Performance Guidelines) and is intended for use in operations of the
Contractor.
CONTINUING OFFERORS: Continuing offerors that are bidding a county or GSA in
which they currently have a contract must meet the equity per member standard
(see Section D, Paragraph 50, Financial Viability Standards/Performance
Guidelines) for their current membership. Continuing offerors that do not meet
the equity standard must fund, through capital contribution, the necessary
amount to meet the minimum capitalization requirement. Continuing offerors that
are bidding a new GSA must provide the additional capitalization for the new GSA
they are bidding. The amount of the required capitalization for continuing
offers may differ from that for new offerors due to size of the existing
offerors current enrollment. (See the table of requirements by GSA above).
Continuing offerors will not be required to provide additional capitalization if
they currently meet the equity per member standard with their existing
membership and their excess equity is sufficient to cover the proposed
additional members, or they have at least $10,000,000 in equity.
Acute Care RFP
February 3, 2003
- 51 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
46. PERFORMANCE BOND OR BOND SUBSTITUTE
The Contractor shall be required to provide a performance bond of standard
commercial scope issued by a surety company doing business in this State, an
irrevocable letter of credit, or a cash deposit ("Performance Bond") to AHCCCSA
for as long as the Contractor has AHCCCS-related liabilities of $50,000 or more
outstanding, or 15 months following the effective date of this contract,
whichever is later, to guarantee: (1) payment of the Contractor's obligations to
providers, non-contracting providers, and non-providers; and (2) performance by
the Contractor of its obligations under this contract. The Performance Bond
shall be in a form acceptable to AHCCCSA as described in the AHCCCS Performance
Bond Policy available in the Bidder's Library.
In the event of a default by the Contractor, AHCCCSA shall, in addition to any
other remedies it may have under this contract, obtain payment under the
Performance Bond or substitute security for the purposes of the following:
a. Paying any damages sustained by providers, non-contracting providers and
non-providers by reason of a breach of the Contractor's obligations under
this contract,
b. Reimbursing AHCCCSA for any payments made by AHCCCSA on behalf of the
Contractor, and
c. Reimbursing AHCCCSA for any extraordinary administrative expenses incurred
by reason of a breach of the Contractor's obligations under this contract,
including, but not limited to, expenses incurred after termination of this
contract for reasons other than the convenience of the State by AHCCCSA.
In the event AHCCCSA agrees to accept substitute security in lieu of the
Performance Bond, irrevocable letter of credit or cash deposit, the Contractor
agrees to execute any and all documents and perform any and all acts necessary
to secure and enforce AHCCCSA's security interest in such substitute security
including, but not limited to, security agreements and necessary UCC filings
pursuant to the Arizona Uniform Commercial Code. In the event such substitute
security is agreed to and accepted by AHCCCSA, the Contractor acknowledges that
it has granted AHCCCSA a security interest in such substitute security to secure
performance of its obligations under this contract. The Contractor is solely
responsible for establishing the credit-worthiness of all forms of substitute
security. AHCCCSA may, after written notice to the Contractor, withdraw its
permission for substitute security, in which case the Contractor shall provide
AHCCCSA with a form of security described above. The Contractor may not change
the amount, duration or scope of the performance bond without prior written
approval from AHCCCSA, Office of Managed Care.
The Contractor shall not leverage the bond for another loan or create other
creditors using the bond as security.
47. AMOUNT OF PERFORMANCE BOND
The initial amount of the Performance Bond shall be equal to 80% of the total
capitation payment expected to be paid to the Contractor in the month of October
2003, or as determined by AHCCCSA. The total capitation amount shall include
delivery and hospital supplemental payments. This requirement must be satisfied
by the Contractor no later than 30 days after notification by AHCCCSA of the
amount required. Thereafter, AHCCCSA shall evaluate the enrollment statistics of
the Contractor on a monthly basis to determine if the Performance Bond must be
increased. The Contractor shall have 30 days following notification by AHCCCSA
to increase the amount of the Performance Bond. The Performance Bond amount that
must be maintained after the contract term shall be sufficient to cover all
outstanding liabilities and will be determined by AHCCCSA. The Contractor may
not change the amount of the performance bond without prior written approval
from AHCCCS, Office of Managed Care. Refer to the Performance Bond/Equity Per
Member Policy for more details.
Acute Care RFP
February 3, 2003
- 52 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
48. ACCUMULATED FUND DEFICIT
The Contractor and its owners shall fund any accumulated fund deficit through
capital contributions in a form acceptable to AHCCCSA within 30 days after
receipt by AHCCCSA of the final audited financial statements, or as otherwise
requested by AHCCCSA. AHCCCSA may, at its option, impose enrollment caps in any
or all GSA's as a result of an accumulated deficit, even if unaudited.
49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
The Contractor shall not, without the prior approval of AHCCCSA, make any
advances to a related party or subcontractor. The Contractor shall not, without
similar prior approval, make any distribution, loan or loan guarantee to any
entity, including another fund or line of business within its organization. All
investments, other than investments in U.S. Government securities or
Certificates of Deposit, also require AHCCCSA prior approval. (See the Reporting
Guide for Acute Care Contractors for alternatives to the prior approval of
individual investments.) All requests for prior approval are to be submitted to
the AHCCCSA Office of Managed Care.
50. FINANCIAL VIABILITY STANDARDS/PERFORMANCE GUIDELINES
AHCCCSA has established financial viability standards/performance guidelines. On
a quarterly basis, AHCCCSA will review the following ratios with the purpose of
monitoring the financial health of the Contractor. The two financial viability
standards, the Current Ratio and Equity per Member, are the standards that best
represent the financial solvency of the Contractor. Therefore, the Contractor
must comply with these two financial viability standards.
AHCCCSA will also monitor the Medical Expense Ratio, the Administrative Cost
Percentage, and the RBUC's Days Outstanding. These guidelines are analyzed as
part of AHCCCSA's due diligence in financial statement monitoring. Sanctions may
not be imposed if the Contractor does not meet these performance guidelines.
AHCCCSA takes into account Contractors' unique programs for managing care and
improving the heath status of members when analyzing medical expense and
administrative ratio results. However, if a critical combination of the
Financial Viability Standards and Performance Guidelines are not met, or if a
Contractor's experience differs significantly from other Contractors',
additional monitoring, such as monthly reporting, may be required.
FINANCIAL VIABILITY STANDARDS
CURRENT RATIO Current assets divided by current
liabilities. "Current assets" includes any
long-term investments that can be converted
to cash within 24 hours without significant
penalty (i.e., greater than 20%).
Standard: At least 1.00
If current assets include a receivable from
a parent company, the parent company must
have liquid assets that support the amount
of the inter-company loan.
Acute Care RFP
February 3, 2003
- 53 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
EQUITY PER MEMBER Equity, less on-balance sheet performance
bond, divided by the number of non-SOBRA
Family Planning Extension Services members
enrolled at the end of the period.
Standard: At least $150 for Contractors with
enrollment < 100,000
$100 for Contractors with
enrollment of 100,000+
For purposes of this measurement, the equity
to be measured must be supported by
unencumbered current assets.
(Failure to meet this standard may result in
an enrollment cap being imposed in any or
all contracted GSAs.)
PERFORMANCE GUIDELINES
MEDICAL EXPENSE RATIO Total medical expenses divided by total
capitation + Delivery Supplement + Hospital
Supplemental Payment +TPL+ Reinsurance +
HIV/AIDS Supplement
Standard: At least 80%
ADMINISTRATIVE COST PERCENTAGE Total administrative expenses (excluding
income taxes), divided by total capitation +
Delivery Supplement + Hospital Supplemental
Payment + TPL + Reinsurance + HIV/AIDS
Supplement.
Standard: No more than 10%
RECEIVED BUT UNPAID CLAIMS Received but unpaid claims divided by the
(DAYS OUTSTANDING) average daily medical expenses for the
period, net of sub-capitation expense.
Standard: No more than 30 days
51. SEPARATE INCORPORATION
Within 60 days of contract award, a non-governmental contractor shall have
established a separate corporation for the purposes of this contract, whose sole
activity is the performance of contract function with AHCCCS.
52. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
A proposed merger, reorganization or change in ownership of the Contractor shall
require prior approval of AHCCCSA and a subsequent contract amendment. The
Contractor must submit a detailed merger, reorganization and/or transition plan
to AHCCCSA, Office of Managed Care, for review. The purpose of the plan review
is to ensure uninterrupted services to members, evaluate the new entity's
ability to support the provider network, ensure that services to members are not
diminished and that major components of the organization and AHCCCS programs are
not adversely affected by such merger, reorganization or change in ownership.
53. COMPENSATION
The method of compensation under this contract will be Prior Period Coverage
(PPC) capitation, prospective capitation, delivery supplement, hospitalized
supplement for Medical Expense Deduction (MED) members, HIV-AIDS supplement,
reinsurance and third party liability, as described and defined within this
contract and appropriate laws, regulations or policies.
Acute Care RFP
February 3, 2003
- 54 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
Capitation rates awarded with the RFP will be effective for the period October
1, 2003 through September 30, 2004. Actuaries establish the capitation rates
using practices established by the Actuarial Standards Board. AHCCCS provides
the following data to its actuaries to establish rates for the purposes of
rebasing the capitation rates.
a. Utilization and unit cost data derived from reported encounters
b. Audited financial statements reported by Contractors
c. Local market basket inflation trends
d. AHCCCS fee for service schedule pricing adjustments
e. Programmatic changes that affect reimbursement
f. Additional administrative requirements for Contractors
g. Other changes to medical practices that affect reimbursement
AHCCCS adjusts its rates to best match payment to risk. This further ensures the
actuarial basis for the capitation rates. The following risk factors will be
included for CYE '04:
a. Reinsurance (as described in Paragraph 57)
b. HIV/AIDS supplemental payment
c. Age/Gender for the 1931(b), SOBRA, KidsCare and BCCTP eligibility
groups
d. Medicare enrollment for SSI members
e. Delivery supplemental payment
f. Hospitalized supplemental payments for MED members
g. Geographic Service Area adjustments
h. Risk sharing for Title XIX Waiver Group reimbursement
i. Risk sharing for PPC reimbursement
j. Member choice statistic for Title XIX Waiver Group
The above information is reviewed by AHCCCS' actuaries in renewal years to
determine if adjustments are necessary to maintain actuarially sound rates. A
Contractor may cover services for members that are not covered under the State
Plan; however those services are not included in the data provided to actuaries
for setting capitation rates. In addition to the above data used to review the
appropriateness of capitation rates, during renewal years, AHCCCS may look at
other factors that potentially impact appropriate reimbursement including the
medical cost experience of members who exercise their right to choose a health
plan upon initial enrollment versus those who are auto assigned to a health
plan.
PROSPECTIVE CAPITATION: The Contractor will be paid capitation for all
prospective member months, including partial member months. This capitation
includes the cost of providing medically necessary covered services to members
during the prospective period coverage.
PRIOR PERIOD COVERAGE (PPC) CAPITATION: Except for KidsCare members and HIFA
Parents, the Contractor will be paid capitation for all PPC member months,
including partial member months. This capitation includes the cost of providing
medically necessary covered services to members during prior period coverage.
The PPC capitation rates will be set by AHCCCSA and will be paid to the
Contractor along with the prospective capitation described below. Contractors
will not receive PPC capitation for newborns of members who were enrolled at the
time of delivery.
RECONCILIATION OF PPC COSTS TO REIMBURSEMENT: For CYE '04, AHCCCSA will
reconcile the Contractor's PPC medical cost expenses to PPC capitation paid to
the Contractor during the year. This reconciliation will limit the Contractor's
profits and losses to 2%. Any losses in excess of 2% will be reimbursed to the
Contractor, and likewise, profits in excess of 2% will be recouped. Encounter
data will be used to determine medical expenses. Refer to the AHCCCS Office of
Managed Care's PPC Reconciliation Policy for further details.
Acute Care RFP
February 3, 2003
- 55 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
RISK SHARING FOR TITLE XIX WAIVER MEMBERS: For CYE '04, AHCCCSA will reconcile
the Contractor's PPC and prospective medical cost expenses to PPC capitation,
prospective capitation, hospitalized supplemental payments, delivery
supplemental payments and HIV/AIDS supplemental payments paid to the Contractor
during the year. This reconciliation will limit the Contractor's profits and
losses to 2%. Any losses in excess of 2% will be reimbursed to the Contractor,
and likewise, profits in excess of 2% will be recouped. Encounter data will be
used to determine medical expenses. Refer to the AHCCCS Office of Managed Care's
Title XIX Waiver Reconciliation Policy for further details.
DELIVERY SUPPLEMENT: When the Contractor has an enrolled woman who delivers
during a prospective enrollment period, the Contractor will be entitled to a
supplemental payment. Supplemental payments will not apply to women who deliver
in a prior period coverage time period. AHCCCSA reserves the right at any time
during the term of this contract to adjust the amount of this payment for women
who deliver at home. The delivery supplemental payment is not made if the
hospitalized supplemental payment has already been paid.
HOSPITALIZED SUPPLEMENTAL PAYMENT: If an MED member is an inpatient on the date
of application for AHCCCS eligibility, and the date of application falls within
the member's eligibility period, the Contractor is entitled to a supplemental
payment to help defray costs related to the inpatient stay. The payment is a
one-time supplement that is paid when the member is enrolled with the Contractor
and is subject to review during the term of the contract.
HIV-AIDS SUPPLEMENT: On a quarterly basis, the Contractor shall submit to
AHCCCSA, Office of Managed Care, an unduplicated monthly count of members, by
rate code, who are using approved HIV/AIDS drugs along with the supporting
pharmacy log. The report shall be submitted, along with the quarterly financial
reporting package, within 60 days after the end of each quarter. AHCCCSA
reserves the right to recoup any amounts paid for ineligible members as well as
an associated penalty for incorrect encounter reporting.
Refer to the AHCCCS, Office of Managed Care HIV/AIDS Supplemental Payment and
Review Policy for further details and requirements.
54. PAYMENTS TO CONTRACTORS
Subject to the availability of funds, AHCCCSA shall make payments to the
Contractor in accordance with the terms of this contract provided that the
Contractor's performance is in compliance with the terms and conditions of this
contract. Payment must comply with requirements of A.R.S. Title 36. AHCCCSA
reserves the option to make payments to the Contractor by wire or National
Automated Clearing House Association (NACHA) transfer and will provide the
Contractor at least 30 days notice prior to the effective date of any such
change.
Where payments are made by electronic funds transfer, AHCCCSA shall not be
liable for any error or delay in transfer or indirect or consequential damages
arising from the use of the electronic funds transfer process. Any charges or
expenses imposed by the bank for transfers or related actions shall be borne by
the Contractor. Except for adjustments made to correct errors in payment, and as
otherwise specified in this section, any savings remaining to the Contractor as
a result of favorable claims experience and efficiencies in service delivery at
the end of the contract term may be kept by the Contractor.
All funds received by the Contractor pursuant to this contract shall be
separately accounted for in accordance with generally accepted accounting
principles.
Except for funds received from the collection of permitted copayments and
third-party liabilities, the only source of payment to the Contractor for the
services provided hereunder is the Arizona Health Care Cost Containment System
Fund. An error discovered by the State with or without an audit in the amount of
fees paid to the
Acute Care RFP
February 3, 2003
- 56 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
Contractor will be subject to adjustment or repayment by the Contractor making a
corresponding decrease in a current Contractor's payment or by making an
additional payment by AHCCCSA to the Contractor.
No payment due the Contractor by AHCCCSA may be assigned or pledged by the
Contractor. This section shall not prohibit AHCCCSA at its sole option from
making payment to a fiscal agent hired by Contractor.
55. CAPITATION ADJUSTMENTS
Except for changes made specifically in accordance with this contract, the rates
set forth in Section B shall not be subject to re-negotiation or modification
during the contract period. AHCCCSA may, at its option, review the effect of a
program change and determine if a capitation adjustment is needed. In these
instances the adjustment will be prospective with assumptions discussed with the
Contractor prior to modifying capitation rates. The Contractor may request a
review of a program change if it believes the program change was not equitable;
AHCCCSA will not unreasonably withhold such a review.
If the Contractor is in any manner in default in the performance of any
obligation under this contract, AHCCCSA may, at its option and in addition to
other available remedies, adjust the amount of payment until there is
satisfactory resolution of the default. The Contractor shall reimburse AHCCCSA
and/or AHCCCSA may deduct from future monthly capitation for any portion of a
month during which the Contractor was not at risk due to, for example:
a. death of a member
b. member's incarceration (not eligible for AHCCCS benefits from the date of
incarceration)
c. duplicate capitation to the same Contractor
d. adjustment based on change in member's contract type
e. voluntary withdrawal
If a member is enrolled twice with the same Contractor, recoupment will be made
as soon as the double capitation is identified. AHCCCSA reserves the right to
modify its policy on capitation recoupments at any time during the term of this
contract.
56. INCENTIVES
AHCCCSA will be implementing an incentive program that utilizes financial and/or
non-financial incentives to promote program quality. AHCCCSA will use contractor
clinical performance indicators in the development of an incentive program.
Examples of incentive programs are listed below.
AUTO ASSIGNMENT ALGORITHM: Effective CYE '06, AHCCCSA will adjust the auto
assignment algorithm methodology to incorporate contractor's clinical
performance indicator results in the calculation of target percentages. AHCCCSA
will use the following performance indicators:
Prenatal Care in the First Trimester
Well-Child Visits 3-6 Years
ADMINISTRATIVE REQUIREMENTS: Effective CYE '06, AHCCCSA may elect to reduce
Operational Financial Review (OFR) requirements for high performing contractors.
USE OF WEBSITE: Contractors will be required to post their clinical performance
indicators compared to AHCCCS standard and statewide averages on their website.
In addition, AHCCCSA will post contractor performance indicators on its website.
Acute Care RFP
February 3, 2003
- 57 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
INCENTIVE FUND: AHCCCSA may retain a specified percentage of capitation
reimbursement in order to distribute to Contractors based on their performance
measure outcomes. The incentive fund will not be implemented in CYE '04 and
contractors will be notified at least 60 days prior to implementation in a
future contract year.
57. REINSURANCE
Reinsurance is a stop-loss program provided by AHCCCSA to the Contractor for the
partial reimbursement of covered services, as described below, for a member with
an acute medical condition beyond an annual deductible level. AHCCCSA
"self-insures" the reinsurance program through a deduction to capitation rates
that is intended to be budget neutral. Refer to the AHCCCSA Reinsurance Claims
Processing Manual for further details on the Reinsurance Program.
INPATIENT REINSURANCE
Inpatient reinsurance covers partial reimbursement of covered inpatient facility
medical services. See the table below for applicable deductible levels and
coinsurance percentages. The coinsurance percent is the rate at which AHCCCSA
will reimburse the Contractor for covered inpatient services incurred above the
deductible. The deductible is the responsibility of the Contractor. Per diem
rates paid for nursing facility services provided within 30 days of an acute
hospital stay, including room and board, provided in lieu of hospitalization for
up to 90 days in any contract year shall be eligible for reinsurance coverage.
The following table represents anticipated deductible and coinsurance levels for
CYE '04. These deductibles and coinsurance percentages are under review by
actuaries and are subject to change, at the discretion of AHCCCSA, prior to
contract awards. Any change will have a corresponding impact on capitation
rates.
TITLE XIX WAIVER GROUP
ANNUAL DEDUCIBLE* ANNUAL DEDUCIBLE
----------------------------------------------------------------------
COMBINED
STATEWIDE PLAN PROSPECTIVE PPC AND PROSPECTIVE
ENROLLMENT REINSURANCE REINSURANCE COINSURANCE
- ----------------------------------------------------------------------------------------------------
0-49,999 $35,000 $35,000 75%
50,000-99,999 $50,000 $35,000 75%
100,000 and over $75,000 $35,000 75%
*applies to all members except for Title XIX Waiver Group members
a) PROSPECTIVE REINSURANCE: This coverage applies to prospective enrollment
periods. The deductible level is based on the Contractor's statewide AHCCCS
acute care enrollment (not including SOBRA Family Planning Extension services)
as of October 1st each contract year for all rate codes and counties, as shown
in the table above. AHCCCSA will adjust the Contractor's deductible level at the
beginning of a contract year if the Contractor's enrollment changes to the next
enrollment level. A Contractor may not elect a lower deductible. These
deductible levels are subject to change by AHCCCSA during the term of this
contract. Any change will have a corresponding impact on capitation rates.
b) PRIOR PERIOD COVERAGE REINSURANCE: Effective October 1, 2003, AHCCCSA will no
longer cover PPC inpatient expenses under the reinsurance program for any
members except Title XIX Waiver Group members. See section c) below for
additional information.
Acute Care RFP
February 3, 2003
- 58 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
c) TITLE XIX WAIVER MEMBERS: A separate reinsurance deductible for the Title XIX
Waiver Group applies for both the prospective and prior period coverage time
periods. There can only be one reinsurance case for prior period and prospective
enrollment.
CATASTROPHIC REINSURANCE
The reinsurance program includes a special Catastrophic Reinsurance program.
This program encompasses members diagnosed with hemophilia, von Willebrand's
Disease, and Gaucher's Disease. For additional detail and restrictions refer to
the AHCCCS Reinsurance Claims Processing Manual and the AMPM. There are no
deductibles for catastrophic reinsurance cases. All medically necessary covered
services provided during the contract year shall be eligible for reimbursement
at 85% of the Contractor's paid amount. All catastrophic claims are subject to
medical review by AHCCCSA.
The Contractor shall notify AHCCCSA, Office of Managed Care, Reinsurance Unit,
of cases identified for catastrophic reinsurance coverage within 30 days of (a)
initial diagnosis, (b) enrollment with the Contractor, and (c) the beginning of
each contract year. Catastrophic reinsurance will be paid for a maximum 30-day
retroactive period from the date of notification to AHCCCSA. The determination
of whether a case or type of case is catastrophic shall be made by the Director
or designee based on the following criteria; 1) severity of medical condition,
including prognosis; and 2) the average cost or average length of
hospitalization and medical care, or both, in Arizona, for the type of case
under consideration.
HEMOPHILIA: Catastrophic reinsurance coverage is available for all members
diagnosed with Hemophilia (ICD9 codes 286.0, 286.1, 286.2).
VON WILLEBRAND'S DISEASE: Catastrophic reinsurance coverage is available for all
members diagnosed with von Willebrand's Disease who are non-DDAVP responders and
dependent on Plasma Factor VIII.
GAUCHER'S DISEASE: Catastrophic reinsurance is available for members diagnosed
with Gaucher's Disease classified as Type I and are dependent on enzyme
replacement therapy.
TRANSPLANTS
This program covers members who are eligible to receive covered major organ and
tissue transplantation including bone marrow, heart, heart/lung, lung, liver,
kidney, and other organ transplantation. Bone grafts and cornea transplantation
services are not eligible for transplant reinsurance coverage but are eligible
under the regular inpatient reinsurance program. Refer to the AMPM for covered
services for organ and tissue transplants. Reinsurance coverage for transplants
is limited to 85% of the AHCCCS contract amount for the transplantation services
rendered, or 85% of the Contractor's paid amount, whichever is lower. The AHCCCS
contracted transplantation rates may be found in the Bidder's Library. When a
member is referred to a transplant facility for an AHCCCS-covered organ
transplant, the Contractor shall notify AHCCCSA, Office of Medical Management.
OTHER
For all reinsurance case types other than transplants, Contractors will be
reimbursed 100% for all medically necessary covered expenses provided in a
contract year, after the reinsurance case reaches $650,000. Transplant case
types have another risk limitation methodology described in the AHCCCSA
Reinsurance Claims Processing Manual.
Acute Care RFP
February 3, 2003
- 59 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
ENCOUNTER SUBMISSION AND PAYMENTS FOR REINSURANCE
a) ENCOUNTER SUBMISSION: A Contractor shall prepare, review, verify, certify,
and submit, encounters for consideration to AHCCCSA. Upon submission, the
Contractor certifies that the services listed were actually rendered. The
encounters must be submitted in the format prescribed by AHCCCSA. The Contractor
must initiate and evaluate an encounter for probable 1st and 3rd party liability
before submitting the encounter for reinsurance consideration, unless the
encounter involves underinsured or uninsured motorist liability insurance, 1st
and 3rd party liability insurance or a tort feasor.
The Contractor must maintain evidence that costs incurred have been paid by the
Contractor before submitting reinsurance encounters. This information is subject
to AHCCCSA review. Collections from 1st and 3rd parties should be reflected by
the Contractor as reductions in the encounters submitted on a dollar-for-dollar
basis. For purposes of AHCCCSA reinsurance, payments made by
Contractor-purchased reinsurance are not considered 1st and 3rd party
collections.
All reinsurance claims must reach a clean claim status within fifteen months
from the end date of service, or date of eligibility posting, whichever is
later.
b) ENCOUNTER PROCESSING: AHCCCSA will accept for processing only those
encounters that are submitted directly by an AHCCCS Contractor and that comply
with the AHCCCSA Encounter Reporting User Manual.
c) PAYMENT OF INPATIENT AND CATASTROPHIC REINSURANCE CASES: AHCCCSA will
reimburse a Contractor for costs incurred in excess of the applicable deductible
level, subject to coinsurance percentages. Amounts in excess of the deductible
level shall be paid based upon costs paid by the Contractor, minus the
coinsurance unless the costs are paid under a subcapitated arrangement. In
subcapitated arrangements, the Administration shall base reimbursement of
reinsurance encounters on the lower of the AHCCCS allowed amount or the reported
health plan paid amount, minus the coinsurance and Medicare/TPL payment and
applicable quick pay discounts.
Reimbursement for these reinsurance benefits will be made to the Contractor each
month. AHCCCSA will also provide a reconciliation of reinsurance payments in the
case where encounters used in the calculation of reinsurance benefits are
subsequently adjusted or voided.
When a member with an annual enrollment choice changes Contractors within a
contract year, for reinsurance purposes, all eligible inpatient costs, nursing
facility costs and inpatient psychiatric costs incurred for that member will
follow the member to the receiving health plan. Therefore, all submitted
encounters from the health plan the member is leaving (for dates of service
within the current contract year) will be applied toward, but not exceed, the
receiving health plan's deductible level. For further details regarding this
policy and other reinsurance policies refer to the AHCCCS Reinsurance Claims
Processing Manual.
d) PAYMENT OF TRANSPLANT REINSURANCE CASES: Reinsurance benefits are based upon
the lower of the AHCCCS contract amount or the Contractor's paid amount, subject
to coinsurance percentages. While encounter data is not currently used to
determine reinsurance payments for transplant services, in the future,
encounters may be required in order for Contractors to receive reinsurance
payments for transplants. Contractors are required to encounter all medical
services provided for which a financial liability is incurred. Please refer to
the AHCCCS Reinsurance Claims Processing Manual for the appropriate billing of
transplant services. Reimbursement for these reinsurance benefits will be made
to the Contractor each month.
Acute Care RFP
February 3, 2003
- 60 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
REINSURANCE AUDITS
PRE-AUDIT: Medical audits on prospective and prior period coverage reinsurance
cases will be determined based on statistically valid retrospective random
sampling. For closed contracts, a 100% audit will be conducted. AHCCCSA, Office
of Managed Care, Reinsurance Unit, will generate the sampling and will notify
the Contractor of documentation needed for the retrospective medical audit
process to occur at the Contractor's offices.
ON-SITE AUDIT: AHCCCSA will give the Contractor at least 45 days advance notice
of any on-site audit. The Contractor shall have all requested medical records
and financial documentation on-site and available to the nurse auditors. Any
documents not requested in advance by AHCCCSA shall be made available upon
request of the Audit Team during the course of the audit. The Contractor
representative shall be available to the Audit Team at all times during AHCCCSA
on-site audit activities. While on-site, the Contractor shall provide the Audit
Team with workspace, access to a telephone, electrical outlets and privacy for
conferences.
AUDIT CONSIDERATIONS: Reinsurance consideration will be given to inpatient
facility contracts and hearing decisions rendered by the Office of Legal
Assistance. Pre-hearing and/or hearing penalties discoverable during the review
process will not be reimbursed under reinsurance.
Per diem rates may be paid for nursing facility and rehabilitation services
provided the services are rendered within 30 days of an acute hospital stay,
including room and board, provided in lieu of hospitalization for up to 90 days
in any contract year. The services rendered in these sub-acute settings must be
of an acute nature and, in the case of rehabilitative or restorative services,
steady progress must be documented in the medical record.
AUDIT DETERMINATIONS: The Contractor will be furnished a copy of the Reinsurance
Post-Audit Results letter approximately 60 days after the onsite audit and given
an opportunity to comment and provide additional medical or financial
documentation on any audit findings. AHCCCSA may limit reinsurance reimbursement
to a lower or alternative level of care if the Director or designee determines
that the less costly alternative could and should have been used by the
Contractor. A recoupment of reinsurance reimbursements made to the Contractor
may occur based on the results of the medical audit sampling. The results of the
medical audit sampling may be separately extrapolated to the entire prospective
and prior period coverage reinsurance reimbursement populations in the audit
timeframe for the Contractor.
A Contractor whose reinsurance case is reduced or denied shall be notified in
writing by AHCCCSA and will be informed of rationale for reduction or denial
determination and the applicable grievance and appeal process available.
58. COORDINATION OF BENEFITS / THIRD PARTY LIABILITY
By law, AHCCCSA is the payer of last resort. This means AHCCCSA shall be used as
a source of payment for covered services only after all other sources of payment
have been exhausted. The two methods used in the coordination of benefits are
cost avoidance and post payment recovery. The Contractor shall use these methods
as described in A.A.C. R9-22-1001. (See also Section D, Paragraph 60, Medicare
Services and Cost Sharing).
COST AVOIDANCE: The Contractor shall cost-avoid all claims or services that are
subject to third-party payment and may deny a service to a member if it knows
that a third party (i.e. other insurer) will provide the service. However, if a
third-party insurer (other than Medicare) requires the member to pay any
copayment, coinsurance or deductible, the Contractor is responsible for making
these payments, even if the services are provided outside of the Contractor's
network. The Contractor's liability for copayments, coinsurance and deductibles
is limited to what the Contractor would have paid for the entire service
pursuant to a written contract with the provider or the AHCCCS fee-for-service
rate, less any amount paid by the third party. (The
Acute Care RFP
February 3, 2003
- 61 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
Contractor must decide whether it is more cost-effective to provide the service
within its network or pay coinsurance and deductibles for a service outside its
network. For continuity of care, the Contractor may also choose to provide the
service within its network.) If the Contractor refers the member for services to
a third-party insurer (other than Medicare), and the insurer requires payment
in advance of all copayments, coinsurance and deductibles, the Contractor must
make such payments in advance.
If the Contractor knows that the third party insurer will neither pay for nor
provide the covered service, and the service is medically necessary, the
Contractor shall not deny the service nor require a written denial letter. If
the Contractor does not know whether a particular service is covered by the
third party, and the service is medically necessary, the Contractor shall
contact the third party and determine whether or not such service is covered
rather than requiring the member to do so.
The requirement to cost-avoid applies to all AHCCCS covered services. For
prenatal care and preventive pediatric services, AHCCCS may require the
Contractor to provide such service and then coordinate payment with the
potentially liable third party ("pay and chase"). In emergencies, the Contractor
shall provide the necessary services and then coordinate payment with the
third-party payer. The Contractor shall also provide medically necessary
transportation so the member can receive third-party benefits. Further, if a
service is medically necessary, the Contractor shall ensure that its cost
avoidance efforts do not prevent a member from receiving such service and that
the member shall not be required to pay any coinsurance or deductibles for use
of the other insurer's providers.
POSTPAYMENT RECOVERIES: Postpayment recovery is necessary in cases where the
Contractor was not aware of third-party coverage at the time services were
rendered or paid for, or was unable to cost-avoid. The Contractor shall identify
all potentially liable third parties and pursue reimbursement from them except
in the circumstances below. The Contractor shall not pursue reimbursement in the
following circumstances unless the case has been referred to the Contractor by
AHCCCSA or AHCCCSA's authorized representative:
Uninsured/underinsured motorist insurance Restitution Recovery
First-and third-party liability insurance Worker's Compensation
Tortfeasors, including casualty Estate recovery
Special Treatment Trusts recovery
The Contractor shall report any cases involving the above circumstances to
AHCCCSA's authorized representative should the Contractor identify such a
situation. See AHCCCS Rule R9-22-1002 and R9-31-1002. The Contractor shall
cooperate with AHCCCSA's authorized representative in all collection efforts. In
joint cases involving both AHCCCS fee-for-service or reinsurance and the
Contractor, AHCCCSA's authorized representative is responsible for performing
all research, investigation and payment of lien-related costs, subsequent to the
referral of any and all relevant case information to AHCCCSA's authorized
representative by the Contractor. AHCCCSA's authorized representative is also
responsible for negotiating and acting in the best interest of all parties to
obtain a reasonable settlement in joint cases and may compromise a settlement in
order to maximize overall reimbursement, net of legal and other costs. The
Contractor will be responsible for their prorated share of the contingency fee.
The Contractor's share of the contingency fee will be deducted from the
settlement proceeds prior to AHCCCSA remitting the settlement to the Contractor.
For total plan cases involving only payments from the Contractor, the Contractor
is responsible for performing all research, investigation, the filing of liens
and payment of lien filing fees and other related costs. The Contractor shall
use the cover sheet as prescribed by AHCCCS when filing liens.
The Contractor may retain up to 100% of its third-party collections if all of
the following conditions exist:
a. Total collections received do not exceed the total amount of the
Contractor's financial liability for the member
Acute Care RFP
February 3, 2003
- 62 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
b. There are no payments made by AHCCCS related to fee-for-service,
reinsurance or administrative costs (i.e. lien filing and contingency fees,
etc.)
c. Such recovery is not prohibited by State or Federal law
REPORTING: The Contractor may be required to report case level detail of
third-party collections and cost avoidance, including number of referrals on
total plan cases. In addition, upon AHCCCSA's request, the Contractor shall
provide an electronic extract of the Casualty cases, including open and closed
cases. Data elements include, but are not limited to: the member's first and
last name; AHCCCS ID; date of incident; claimed amount; paid/recovered amount;
and case status. The AHCCCSA TPL Section shall provide the format and reporting
schedule for this information to the Contractor. The Contractor shall notify
AHCCCSA's authorized representative within five working days of the
identification of a third-party liability case with reinsurance. Failure to
report reinsurance cases may result in one of the remedies specified in Section
D, Paragraph 72, Sanctions. The Contractor shall communicate any known change in
health insurance information, including Medicare, to AHCCCS Administration,
Division of Member Services, not later than 10 days from the date of discovery
using the AHCCCS Third-Party Coverage Form found in the Bidder's Library.
AHCCCSA will provide the Contractor, on an agreed upon schedule, with a complete
file of all third-party coverage information (other than Medicare) for the
purpose of updating the Contractor's files. The Contractor shall notify AHCCCSA
of any known changes in coverage within deadlines and in a format prescribed by
AHCCCSA.
TITLE XXI (KIDSCARE), HIFA PARENTS AND BCCTP: Eligibility for KidsCare, HIFA
Parents and BCCTP benefits require that the applicant/member not be enrolled
with any other creditable health insurance plan. If the Contractor becomes aware
of any such coverage, the Contractor shall notify AHCCCSA immediately. AHCCCSA
will determine if the other insurance meets the creditable definition in A.R.S.
36-2982(G).
CONTRACT TERMINATION: Upon termination of this contract, the Contractor will
complete the existing third party liability cases or make any necessary
arrangements to transfer the cases to AHCCCSA's authorized TPL representative.
59. COPAYMENTS
The Contractor is responsible for the collection of copayments from members in
accordance with AHCCCS Rules R9-22-711 and R9-31-711, and 42 CFR 447. Services
may not be denied for inability to pay the copayment. Any required copayments
collected shall belong to the Contractor or its subcontractors.
The Contractor may not collect copayments for the following services:
a. Prenatal care including all obstetrical visits;
b. Well-baby and EPSDT care;
c. Care in nursing facilities and intermediate care facilities for the
mentally retarded;
d. Visits scheduled by a primary care physician or practitioner, and not
at the request of a member;
e. Drugs and medications;
f. Family planning services;
g. Translation and interpreter services.
A provider shall not bill a member for more than the statutory copayment amount.
Refer to Section D, Paragraphs 58, Coordination of Benefits/Third Party
Liability, Paragraph 60, Medicare Services and Cost Sharing, and R9-22-702 for
exceptions.
Acute Care RFP
February 3, 2003
- 63 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
60. MEDICARE SERVICES AND COST SHARING
AHCCCS has members enrolled who are eligible for both Medicaid and Medicare.
These members are referred to as "dual eligibles". Generally, Contractors are
responsible for payment of Medicare coinsurance and/or deductibles for covered
services provided to dual eligible members. However, there are different cost
sharing responsibilities that apply to dual eligible members based on a variety
of factors. Unless prior approval is obtained from AHCCCSA, the Contractor must
limit their cost sharing responsibility according to the AHCCCS Medicare Cost
Sharing Policy. The Contractor shall have no cost sharing obligation if the
Medicare payment exceeds what the Contractor would have paid for the same
service of a non-Medicare member.
61. MARKETING
The Contractor shall submit all proposed marketing and outreach materials and
events that will involve the general public to the AHCCCS Marketing Committee
for prior approval in accordance with the AHCCCS Health Plan Marketing Policy.
The Contractor must have signed contracts with PCPs, specialists, dentists, and
pharmacies in order for them to be included in marketing materials.
62. CORPORATE COMPLIANCE
In accordance with A.R.S. Section 36-2918.01, all contractors are required to
notify the AHCCCS, Office of Program Integrity immediately of all suspected
fraud or abuse. The Contractor agrees to promptly (within ten working days of
discovery) inform the Office of Program Integrity in writing of instances of
suspected fraud or abuse. This shall include acts of suspected fraud or abuse
that were resolved internally but involved AHCCCS funds, contractors or
sub-contractors.
As stated in A.R.S. Section 13-2310, incorporated herein by reference, any
person who knowingly obtains any benefit by means of false or fraudulent
pretenses, representations, promises, or material omissions is guilty of a Class
2 felony.
The Contractor agrees to permit and cooperate with any onsite review. A review
by the AHCCCS, Office of Program Integrity may be conducted without notice and
for the purpose of ensuring program compliance.
Effective October 1, 2003, the Contractor shall be in compliance with 42 CFR
438.608. The Contractor must have a mandatory compliance program, supported by
other administrative procedures, that is designed to guard against fraud and
abuse.
The compliance program, which shall both prevent and detect suspected fraud or
abuse, must include:
1. Written policies, procedures, and standards of conduct that articulate
the organization's commitment to and processes for complying with all
applicable federal and state standards.
2. The designation of a compliance officer and a compliance committee.
3. Effective training and education.
4. Effective lines of communication between the compliance officer and
the organization's employees.
5. Enforcement of standards through well-publicized disciplinary
guidelines.
6. Provision for internal monitoring and auditing.
7. Provision for prompt response to problems detected.
The Contractor is required to research potential overpayments identified by the
AHCCCS, Office of Program Integrity. After conducting a cost benefit analysis to
determine if such action is warranted, the Contractor
Acute Care RFP
February 3, 2003
- 64 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
should attempt to recover any overpayments identified. The AHCCCS Office of
Program Integrity shall be advised of the final disposition of the research and
advised of actions, if any, taken by the Contractor.
63. RECORDS RETENTION
The Contractor shall maintain books and records relating to covered services and
expenditures including reports to AHCCCSA and working papers used in the
preparation of reports to AHCCCSA. The Contractor shall comply with all
specifications for record keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as required by AHCCCS Rules
and policies. Records shall include but not be limited to financial statements,
records relating to the quality of care, medical records, prescription files and
other records specified by AHCCCSA.
The Contractor agrees to make available, at all reasonable times during the term
of this contract, any of its records for inspection, audit or reproduction by
any authorized representative of AHCCCSA, State or Federal government. The
Contractor shall be responsible for any costs associated with the reproduction
of requested information.
The Contractor shall preserve and make available all records for a period of
five years from the date of final payment under this contract.
If this contract is completely or partially terminated, the records relating to
the work terminated shall be preserved and made available for a period of five
years from the date of any such termination. Records which relate to grievances,
disputes, litigation or the settlement of claims arising out of the performance
of this contract, or costs and expenses of this contract to which exception has
been taken by AHCCCSA, shall be retained by the Contractor for a period of five
years after the date of final disposition or resolution thereof.
64. DATA EXCHANGE REQUIREMENTS
The Contractor is authorized to exchange data with AHCCCSA relating to the
information requirements of this contract and as required to support the data
elements to be provided AHCCCSA in the formats prescribed by AHCCCSA and in
formats prescribed by the Health Insurance Portability and Accountability Act
(HIPAA). Details for the formats may be found in the draft HIPAA Transaction
Companion Documents & Trading Partner Agreements, and in the AHCCCS Technical
Interface Guidelines, available in the Bidder's Library.
The information so recorded and submitted to AHCCCSA shall be in accordance with
all procedures, policies, rules, or statutes in effect during the term of this
contract. If any of these procedures, policies, rules, regulations or statutes
are hereinafter changed both parties agree to conform to these changes following
appropriate notification to both parties by AHCCCSA.
The Contractor is responsible for any incorrect data, delayed submission or
payment (to the Contractor or its subcontractors), and/or penalty applied due to
any error, omission, deletion, or erroneous insert caused by
Contractor-submitted data. Any data that does not meet the standards required by
AHCCCSA shall not be accepted by AHCCCSA.
The Contractor is responsible for identifying any inconsistencies immediately
upon receipt of data from AHCCCSA. If any unreported inconsistencies are
subsequently discovered, the Contractor shall be responsible for the necessary
adjustments to correct its records at its own expense.
Acute Care RFP
February 3, 2003
- 65 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
The Contractor shall accept from AHCCCSA original evidence of eligibility and
enrollment in a form appropriate for electronic data exchange. Upon request by
AHCCCSA, the Contractor shall provide to AHCCCSA updated date-sensitive PCP
assignments in a form appropriate for electronic data exchange.
The Contractor shall be provided with a Contractor-specific security code for
use in all data transmissions made in accordance with contract requirements.
Each data transmission by the Contractor shall include the Contractor's security
code. The Contractor agrees that by use of its security code, it certifies that
any data transmitted is accurate and truthful, to the best of the Contractor's
Chief Executive Officer, Chief Financial Officer or designee's knowledge. The
Contractor further agrees to indemnify and hold harmless the State of Arizona
and AHCCCSA from any and all claims or liabilities, including but not limited to
consequential damages, reimbursements or erroneous billings and reimbursements
of attorney fees incurred as a consequence of any error, omission, deletion or
erroneous insert caused by the Contractor in the submitted input data. Neither
the State of Arizona nor AHCCCSA shall be responsible for any incorrect or
delayed payment to the Contractor's AHCCCS services providers (subcontractors)
resulting from such error, omission, deletion, or erroneous input data caused by
the Contractor in the submission of AHCCCS claims.
The costs of software changes are included in administrative costs paid to the
Contractor. There is no separate payment for software changes. A PMMIS systems
contact will be assigned after contract award. AHCCCSA will work with the health
plans as they evaluate Electronic Data Interchange options.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA): The Contractor
shall comply with the Administrative Simplification requirements of Subpart F of
the HIPAA of 1996 (Public Law 107-191, 110 Statutes 1936) and all Federal
regulations implementing that Subpart that are applicable to the operations of
the Contractor by the dates required by the implementing Federal regulations.
65. ENCOUNTER DATA REPORTING
The accurate and timely reporting of encounter data is crucial to the success of
the AHCCCS program. AHCCCSA uses encounter data to pay reinsurance benefits, set
fee-for-service and capitation rates, determine disproportionate share payments
to hospitals, and to determine compliance with performance standards. The
Contractor shall submit encounter data to AHCCCSA for all services rendered,
including services provided during prior period coverage. This requirement is a
condition of the CMS grant award.
A Contractor shall prepare, review, verify, certify, and submit, encounters for
consideration to AHCCCSA. Upon submission, the Contractor certifies that the
services listed were actually rendered. The encounters must be submitted in the
format prescribed by AHCCCSA.
Encounter data must be provided to AHCCCSA by electronic media and must be
submitted in the PMMIS AHCCCSA supplied formats. Specific requirements for
encounter data are described in the AHCCCSA Encounter Reporting User Manual, a
copy of which may be found in the Bidder's Library. The Encounter Submission
Requirements are included herein as Attachment I. Refer to Paragraph 64, Data
Exchange Requirements, for further information.
An Encounter Submission Tracking Report must be maintained and made available to
AHCCCSA upon request. The Tracking Report's purpose is to link each claim to an
adjudicated or pended encounter returned to the Contractor. Further information
regarding the Encounter Submission Tracking Report may be found in The AHCCCSA
Encounter Reporting User's Manual.
Each month AHCCCSA provides the Contractor with full replacement files
containing provider and medical procedure coding information. These files should
be used to assist the Contractor in accurate Encounter Reporting. Refer to
Paragraph 64, Data Exchange Requirements, for further information.
Acute Care RFP
February 3, 2003
- 66 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
66. ENROLLMENT AND CAPITATION TRANSACTION UPDATES
AHCCCSA produces daily enrollment transaction updates identifying new members
and changes to members' demographic, eligibility and enrollment data, which the
Contractor shall use to update its member records. The daily enrollment
transaction update, which is run prior to the monthly enrollment and capitation
transaction update, is referred to as the "last daily" and will contain all rate
code changes made for the prospective month, as well as any new enrollments and
disenrollments.
AHCCCSA also produces a daily Manual Payment Transaction, which identifies
enrollment or disenrollment activity that was not included on the daily
enrollment transaction update due to internal edits. The Contractor shall use
the Manual Payment Transaction in addition to the daily enrollment transaction
update to update its member records.
A weekly capitation transaction will be produced to provide contractors with
member-level capitation payment information. This file will show changes to the
prospective capitation payments, as sent in the monthly file, resulting from
enrollment changes that occur after the monthly file is produced. This file will
also identify mass adjustments to and/or manual capitation payments that
occurred at AHCCCS after the monthly file is produced.
The monthly enrollment and monthly capitation transaction updates are generally
produced two days before the end of every month. The update will identify the
total active population for the Contractor as of the first day of the next
month. These updates contain the information used by AHCCCSA to produce the
monthly capitation payment for the next month. The Contractor will reconcile
their member files with the AHCCCS monthly update.
After reconciling the monthly update information, the Contractor resumes
posting daily updates beginning with the last two days of the month. The last
two daily updates are different from the regular daily updates in that they pay
and/or recoup capitation into the next month. If the Contractor detects an error
through the monthly update process, the Contractor shall notify AHCCCSA, Office
of Managed Care.
Refer to Paragraph 64, Data Exchange Requirements, for further information.
67. PERIODIC REPORT REQUIREMENTS
AHCCCSA, under the terms and conditions of its CMS grant award, requires
periodic reports, encounter data, and other information from the Contractor. The
submission of late, inaccurate, or otherwise incomplete reports shall constitute
failure to report subject to the penalty provisions described in this contract.
Standards applied for determining adequacy of required reports are as follows:
a. Timeliness: Reports or other required data shall be received on or
before scheduled due dates.
b. Accuracy: Reports or other required data shall be prepared in
strict conformity with appropriate authoritative sources and/or
AHCCCS defined standards.
c. Completeness: All required information shall be fully disclosed in
a manner that is both responsive and pertinent to report intent
with no material omissions.
AHCCCS requirements regarding reports, report content and frequency of
submission of reports are subject to change at any time during the term of the
contract. The Contractor shall comply with all changes specified by AHCCCSA.
The Contractor shall be responsible for continued reporting beyond the term of
the contract. For example, processing claims and reporting encounter data will
likely continue beyond the term of the contract because of lag time in filing
source documents by subcontractors.
Acute Care RFP
February 3, 2003
- 67 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
The Contractor shall comply with all financial reporting requirements contained
in the Reporting Guide for Acute Health Care Contractors with the Arizona Health
Care Cost Containment System, a copy of which may be found in the Bidder's
Library. The required reports, which are subject to change during the contract
term, are summarized in Attachment F, Periodic Report Requirements.
68. REQUESTS FOR INFORMATION
AHCCCSA may, at any time during the term of this contract, request financial or
other information from the Contractor. Upon receipt of such requests for
information, the Contractor shall provide complete information as requested no
later than 30 days after the receipt of the request unless otherwise specified
in the request itself.
69. DISSEMINATION OF INFORMATION
Upon request, the Contractor shall assist AHCCCSA in the dissemination of
information prepared by AHCCCSA or the Federal government to its members. The
cost of such dissemination shall be borne by the Contractor. All advertisements,
publications and printed materials that are produced by the Contractor and refer
to covered services shall state that such services are funded under contract
with AHCCCSA.
70. OPERATIONAL AND FINANCIAL READINESS REVIEWS
AHCCCSA may conduct Operational and Financial Readiness Reviews on all
successful offerors and will, subject to the availability of resources, provide
technical assistance as appropriate. The Readiness Reviews will be conducted
prior to the start of business. The purpose of Readiness Reviews is to assess
new Contractors' readiness and ability to provide covered services to members at
the start of the contract year and current Contractors' readiness to expand to
new geographic service areas. A new Contractor will be permitted to commence
operations only if the Readiness Review factors are met to AHCCCSA's
satisfaction.
71. OPERATIONAL AND FINANCIAL REVIEWS
In accordance with CMS requirements, AHCCCSA, or an independent external agent,
will conduct annual Operational and Financial Reviews for the purpose of (but
not limited to) ensuring operational and financial program compliance. The
reviews will identify areas where improvements can be made and make
recommendations accordingly, monitor the Contractor's progress towards
implementing mandated programs and provide the Contractor with technical
assistance if necessary. The Contractor shall comply with all other medical
audit provisions as required by AHCCCS Rule R9-22-521 and R9-31-521.
The type and duration of the Operational and Financial Review will be solely at
the discretion of AHCCCSA. Except in cases where advance notice is not possible
or advance notice may render the review less useful, AHCCCSA will give the
Contractor at least three weeks advance notice of the date of the on-site
review. In preparation for the on-site Operational and Financial Reviews, the
Contractor shall cooperate fully with AHCCCSA and the AHCCCSA Review Team by
forwarding in advance such policies, procedures, job descriptions, contracts,
logs and other information that AHCCCSA may request. The Contractor shall have
all requested medical records on-site. Any documents, not requested in advance
by AHCCCSA, shall be made available upon request of the Review Team during the
course of the review. The Contractor personnel, as identified in advance, shall
be available to the Review Team at all times during AHCCCSA on-site review
activities. While on-site, the Contractor shall provide the Review Team with
workspace, access to a telephone, electrical outlets and privacy for
conferences. Certain documentation submission requirements may be waived at the
discretion of AHCCCSA, if the Contractor has obtained accreditation from NCQA,
JCAHO or any other
Acute Care RFP
February 3, 2003
- 68 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
nationally recognized accrediting body. The Contractor must submit the entire
accreditation report to AHCCCSA for such waiver consideration.
The Contractor will be furnished a draft copy of the Operational and Financial
Review Report and given an opportunity to comment on any review findings prior
to AHCCCSA publishing the final report. Operational and Financial Review
findings may be used in the scoring of subsequent bid proposals by that
Contractor. Recommendations, made by the Review Team to bring the Contractor
into compliance with Federal, State, AHCCCS, and/or RFP requirements, must be
implemented by the Contractor. AHCCCSA may conduct a follow- up Operational and
Financial Review to determine the Contractor's progress in implementing
recommendations and achieving program compliance. Follow-up reviews may be
conducted at any time after the initial Operational and Financial Review.
AHCCCSA may conduct an Operational and Financial Review in the event the
Contractor undergoes a merger, reorganization, change in ownership or makes
changes in three or more key staff positions within a 12-month period.
72. SANCTIONS
AHCCCSA may impose monetary sanctions, suspend, deny, refuse to renew, or
terminate this contract or any related subcontracts in accordance with AHCCCS
Rules R9-22-606 and the terms of this contract and applicable Federal or State
law and regulations. Written notice will be provided to the Contractor
specifying the sanction to be imposed, the grounds for such sanction and either
the length of suspension or the amount of capitation prepayment to be withheld.
The Contractor may appeal the decision to impose a sanction in accordance with
A.A.C. 22, Article 8. Intermediate sanctions may be imposed, but are not limited
to the following actions:
a. Substantial failure to provide medically necessary services that the
Contractor is required to provide under the terms of this contract to its
enrolled members.
b. Imposition of premiums or charges in excess of the amount allowed under the
AHCCCS 1115 Waiver.
c. Discrimination among enrollees on the basis of their health status of need
for health care services.
d. Misrepresentation or falsification of information furnished to CMS or
AHCCCSA.
e. Misrepresentation or falsification of information furnished to an enrollee,
potential enrollee, or provider.
f. Failure to comply with the requirement for physician incentive plan as
delineated in Paragraph 42.
g. Distribution directly, or indirectly through any agent or independent
contractor, of marketing materials that have not been approved by AHCCCSA
or that contain false or materially misleading information.
h. Failure to meet AHCCCS Financial Viability Standards.
i. Material deficiencies in the Contractor's provider network.
j. Failure to meet quality of care and quality management requirements.
k. Failure to meet AHCCCS encounter standards.
l. Violation of other applicable State or Federal laws or regulations.
m. Failure to fund accumulated deficit in a timely manner.
n. Failure to increase the Performance Bond in a timely manner.
o. Failure to comply with any provisions contained in this RFP.
AHCCCSA may impose the following types of intermediate sanctions:
a. Civil monetary penalties
b. Appointment of temporary management for a Contractor as provided in 42 CFR
438.706 and A.R.S. Section 36-2903 (M).
c. Granting enrollees the right to terminate enrollment without cause and
notifying the affected enrollees of their right to disenroll.
d. Suspension of all new enrollment, including auto assignments after the
effective date of the sanction.
Acute Care RFP
February 3, 2003
- 69 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
e. Suspension of payment for recipients enrolled after the effective date of
the sanction until CMS or AHCCCSA is satisfied that the reason for
imposition of the sanction no longer exists and is not likely to recur.
f. Additional sanctions allowed under statue or regulation that address areas
of noncompliance, such as termination of the contract.
CURE NOTICE PROCESS: Prior to the imposition of a sanction for non-compliance,
AHCCCSA may provide a written cure notice to the Contractor regarding the
details of the non-compliance. The cure notice will specify the period of time
during which the Contractor must bring its performance back into compliance with
contract requirements. If, at the end of the specified time period, the
Contractor has complied with the cure notice requirements, AHCCCSA will take no
further action. If, however, the Contractor has not complied with the cure
notice requirements, AHCCCSA will proceed with the imposition of sanctions.
The Sanctions policy is currently being drafted and will be in the Bidders
Library when finalized.
73. BUSINESS CONTINUITY PLAN
The Contractor shall adhere to all elements of the AHCCCS, Office of Managed
Care Business Continuity Plan Policy. This plan is currently under review and
will be placed in the Bidder's Library upon completion. The Contractor shall
develop a Business Continuity Plan to deal with unexpected events that may
affect its ability to adequately serve members. This plan shall, at a minimum,
include planning and training for:
- Healthcare facility closure/loss of a major provider
- Electronic/telephonic failure at the Contractor's main place of
business
- Complete loss of use of the main site
- Loss of primary computer system/records
- Communication between the Contractor and AHCCCSA in the event of a
business disruption
The Business Continuity Plan shall be updated annually. All key staff shall be
trained and familiar with the Plan.
74. TECHNOLOGICAL ADVANCEMENT
The Contractor shall implement the following technological measures according to
the applicable time frame:
April 1, 2004:
- Contractors must have a website with links to the following
information:
1. Formulary
2. Provider manual
3. Policies
4. Member handbook
5. Provider listing
- Contractors must have enrollment verification via website fully
operational
- Contractors must have claims inquiry via website fully operational
Acute Care RFP
February 3, 2003
- 70 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
75. PENDING LEGISLATIVE / OTHER ISSUES
The following constitute pending items that will be resolved after the initial
issuance of the RFP document. Any program changes due to the resolution of the
issues will be reflected in future amendments to the RFP. Final awarded
capitation rates may also be adjusted to reflect the financial impact of program
changes.
PRESCRIPTION DRUGS: The Governor of Arizona issued an Executive Order, available
on the AHCCCS website, requiring AHCCCSA to explore carving out the prescription
drug benefit from capitation in order to participate in the Federal Drug Rebate
Program. As a result, the Contractor is required to submit two capitation rate
proposals, one with and one without prescription drug costs and utilization.
Refer to the Section C, Definitions and Section I, Instructions to Offerors, for
more detail.
HOSPITAL REIMBURSEMENT PILOT PROGRAM: Legislation to extend the Pilot program
may be introduced effective for contract years beginning CYE '04. See Paragraph
40, Hospital Subcontracting and Reimbursement, for additional information on the
Hospital Reimbursement Pilot Program. The Pilot program is scheduled to
terminate September 30, 2003.
HOSPICE SERVICES FOR MEMBERS AGE 21 AND OLDER: AHCCCSA is considering adding
hospice services as a benefit for members age 21 and older and is undergoing the
approval process, which includes an amendment to AHCCCS' state plan with CMS.
TRANSPLANT CONTRACTS: AHCCCSA is currently negotiating new contracts for organ
and tissue transplants, to be effective October 1, 2003. Contracted rates will
be published as soon as they are finalized.
TRANSPLANTS: AHCCCSA may evaluate carving out transplant services from the
compendium of services for which AHCCCS Contractors are responsible. If AHCCCSA
determines that carving out the responsibility for transplant services is
appropriate, an RFP will be issued for the program. AHCCCSA does not anticipate
a carve out in CYE '04.
TRANSPORTATION: AHCCCSA is evaluating its methodology, under capitation, for
providing transportation services to its members. Options may include
contracting with a centralized transportation broker to provide services to all
AHCCCS members. AHCCCSA does not anticipate a carve out in CYE '04.
MEMBER COST SHARING: AHCCCSA submitted a report to the Arizona Legislature on
possibilities for increasing AHCCCS' member cost sharing responsibilities. This
report may be found on the AHCCCS website. Changes include increases to
copayment amounts and collection of premiums. AHCCCSA is seeking CMS approval to
expand member cost sharing responsibility. Refer to the AHCCCS website for a
copy of the Cost Sharing Report.
76. BALANCED BUDGET ACT OF 1997 (BBA)
In August of 2002, CMS issued final regulations for the implementation of the
BBA. AHCCCS is currently reviewing all areas of the regulations to ensure full
compliance with the BBA; however, there are some issues that require further
clarification from CMS. The following items related to the BBA regulations are
pending. Any program changes due to the resolution of the issues will be
reflected in amendments to the RFP. Final awarded capitation rates may be also
be adjusted to reflect the financial impact of the program changes.
GRIEVANCES: AHCCCSA has not reached a final decision on whether it will
implement the option for a member to request an expedited hearing directly from
AHCCCSA. The final decision will be communicated through a future amendment to
this RFP.
Acute Care RFP
February 3, 2003
- 71 -
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH04-0001
SPECIAL HEALTHCARE NEEDS: AHCCCSA is in the process of determining the impact of
the BBA regulations regarding individuals with special healthcare needs. The
AMPM will be expanded to address policies related to this population.
PPC TIME PERIOD FOR MED POPULATION: AHCCCSA is determining how to handle
reimbursement to the Contractor for the day a member meets spend down
requirements.
POLICIES: AHCCCSA is currently revising policies, as needed, to reflect the BBA
regulations. As the policies are updated, they will be issued to all offerors
via the AHCCCS web under "Bidder's Library". If a policy is finalized after the
contracts bids are awarded, they will be issued to all Contractors, both via the
website and in hard copy. Examples of AHCCCS policies currently under revision
include the AMPM, Sanctions Policy, Member Information Policy and the Health
Plan Marketing Policy.
77. HEALTHCARE GROUP OF ARIZONA
AHCCCSA encourages all Contractors to participate in the Healthcare Group (HCG)
program. Legislation was passed in 2002 that shifted administrative
responsibilities from HCG contractors to AHCCCSA. Additionally, effective
February 1, 2003, HCG's service package and premium structure has been
redesigned to better reflect the small group product in the Arizona marketplace.
HCG has created a niche market, as insurance companies are moving away from the
Health Maintenance Organization market. HCG hopes to expand its enrollment
significantly during the next two years, which will result in a solid membership
base to spread risk, thereby increasing the attractiveness of the HCG product.
For additional information, contact AHCCCSA, Office of the Director.
[END OF SECTION D]
Acute Care RFP
February 3, 2003
- 72 -
CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
SECTION E: CONTRACT CLAUSES
1) APPLICABLE LAW
ARIZONA LAW - The law of Arizona applies to this contract including, where
applicable, the Uniform Commercial Code, as adopted in the State of Arizona.
IMPLIED CONTRACT TERMS - Each provision of law and any terms required by law to
be in this contract are a part of this contract as if fully stated in it.
2) AUTHORITY
This contract is issued under the authority of the Contracting Officer who
signed this contract. Changes to the contract, including the addition of work or
materials, the revision of payment terms, or the substitution of work or
materials, directed by an unauthorized state employee or made unilaterally by
the Contractor are violations of the contract and of applicable law. Such
changes, including unauthorized written contract amendments, shall be void and
without effect, and the Contractor shall not be entitled to any claim under this
contract based on those changes.
3) ORDER OF PRECEDENCE
The parties to this contract shall be bound by all terms and conditions
contained herein. For interpreting such terms and conditions the following
sources shall have precedence in descending order: The Constitution and laws of
the United States and applicable Federal regulations; the terms of the CMS 1115
waiver for the State of Arizona; the Constitution and laws of Arizona, and
applicable State rules; the terms of this contract, including all attachments
and executed amendments and modifications; AHCCCSA policies and procedures.
4) CONTRACT INTERPRETATION AND AMENDMENT
NO PAROL EVIDENCE - This contract is intended by the parties as a final and
complete expression of their agreement. No course of prior dealings between the
parties and no usage of the trade shall supplement or explain any term used in
this contract.
NO WAIVER - Either party's failure to insist on strict performance of any term
or condition of the contract shall not be deemed a waiver of that term or
condition even if the party accepting or acquiescing in the non- conforming
performance knows of the nature of the performance and fails to object to it.
WRITTEN CONTRACT AMENDMENTS - The contract shall be modified only through a
written contract amendment within the scope of the contract signed by the
procurement officer on behalf of the State.
5) SEVERABILITY
The provisions of this contract are severable to the extent that any provision
or application held to be invalid shall not affect any other provision or
application of the contract, which may remain in effect without the invalid
provision, or application.
6) RELATIONSHIP OF PARTIES
The Contractor under this contract is an independent contractor. Neither party
to this contract shall be deemed to be the employee or agent of the other party
to the contract.
7) ASSIGNMENT AND DELEGATION
The Contractor shall not assign any right nor delegate any duty under this
contract without prior written approval of the Contracting Officer, who will not
unreasonably withhold such approval.
8) GENERAL INDEMNIFICATION
The Contractor shall defend, indemnify and hold harmless the State from any
claim, demand, suit, liability, judgment and expense (including attorney's fees
and other costs of litigation) arising out of or relating to injury, disease, or
death of persons or damage to or loss of property resulting from or in
connection with the
Acute Care RFP
February 3, 2003
- 73 -
CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
negligent performance of this contract by the Contractor, its agents, employees,
and subcontractors or anyone for whom the Contractor may be responsible. The
obligations, indemnities and liabilities assumed by the Contractor under this
paragraph shall not extend to any liability caused by the negligence of the
State or its employees. The Contractor's liability shall not be limited by any
provisions or limits of insurance set forth in this contract. The State shall
reasonably notify the Contractor of any claim for which it may be liable under
this paragraph. The Administration shall bear no liability for subcontracts that
a Contractor executes with other parties for the provision of administrative or
management services, medical services or covered health care services, or for
any other purposes.
9) INDEMNIFICATION -- PATENT AND COPYRIGHT
The Contractor shall defend, indemnify and hold harmless the State against any
liability including costs and expenses for infringement of any patent, trademark
or copyright arising out of contract performance or use by the State of
materials furnished or work performed under this contract. The State shall
reasonably notify the Contractor of any claim for which it may be liable under
this paragraph.
10) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
The Contractor shall comply with all applicable Federal and State laws and
regulations including Title VI of the Civil Rights Act of 1964; Title IX of the
Education Amendments of 1972 (regarding education programs and activities); the
Age Discrimination Act of 1975; and the Americans with Disabilities Act; EEO
provisions; Copeland Anti-Kickback Act; Davis-Bacon Act; Contract Work Hours and
Safety Standards; Rights to Inventions Made Under a Contract or Agreement; Clean
Air Act and Federal Water Pollution Control Act; Byrd Anti-Lobbying Amendment.
The Contractor shall maintain all applicable licenses and permits.
11) ADVERTISING AND PROMOTION OF CONTRACT
The Contractor shall not advertise or publish information for commercial benefit
concerning this contract without the prior written approval of the Contracting
Officer.
12) PROPERTY OF THE STATE
Any materials, including reports, computer programs and other deliverables,
created under this contract are the sole property of AHCCCSA. The Contractor is
not entitled to a patent or copyright on those materials and may not transfer
the patent or copyright to anyone else. The Contractor shall not use or release
these materials without the prior written consent of AHCCCSA.
13) THIRD PARTY ANTITRUST VIOLATIONS
The Contractor assigns to the State any claim for overcharges resulting from
antitrust violations to the extent that those violations concern materials or
services supplied by third parties to the Contractor toward fulfillment of this
contract.
14) RIGHT TO ASSURANCE
If AHCCCSA, in good faith, has reason to believe that the Contractor does not
intend to perform or continue performing this contract, the procurement officer
may demand in writing that the Contractor give a written assurance of intent to
perform. The demand shall be sent to the Contractor by certified mail, return
receipt required. Failure by the Contractor to provide written assurance within
the number of days specified in the demand may, at the State's option, be the
basis for terminating the contract.
15) TERMINATION FOR CONFLICT OF INTEREST
AHCCCSA may cancel this contract without penalty or further obligation if any
person significantly involved in initiating, negotiating, securing, drafting or
creating the contract on behalf of AHCCCSA is, or becomes at any time while the
contract or any extension of the contract is in effect, an employee of, or a
consultant to, any other party to this contract with respect to the subject
matter of the contract. The cancellation shall be effective when the Contractor
receives written notice of the cancellation unless the notice specifies a later
time.
Acute Care RFP
February 3, 2003
- 74 -
CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
16) GRATUITIES
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that employment or a gratuity was offered or made by
the Contractor or a representative of the Contractor to any officer or employee
of the State for the purpose of influencing the outcome of the procurement or
securing the contract, an amendment to the contract, or favorable treatment
concerning the contract, including the making of any determination or decision
about contract performance. AHCCCSA, in addition to any other rights or
remedies, shall be entitled to recover exemplary damages in the amount of three
times the value of the gratuity offered by the Contractor.
17) SUSPENSION OR DEBARMENT
The Contractor shall not employ, consult, subcontract or enter into any
agreement for Title XIX services with any person or entity who is debarred,
suspended or otherwise excluded from Federal procurement activity. This
prohibition extends to any entity which employs, consults, subcontracts with or
otherwise reimburses for services any person substantially involved in the
management of another entity which is debarred, suspended or otherwise excluded
from Federal procurement activity.
The Contractor shall not retain as a director, officer, partner or owner of 5%
or more of the Contractor entity, any person, or affiliate of such a person, who
is debarred, suspended or otherwise excluded from Federal procurement activity.
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that the Contractor has been debarred, suspended or
otherwise lawfully prohibited from participating in any public procurement
activity.
18) TERMINATION FOR CONVENIENCE
AHCCCSA reserves the right to terminate the contract in whole or in part at any
time for the convenience of the State without penalty or recourse. The
Contracting Officer shall give written notice by certified mail, return receipt
requested, to the Contractor of the termination at least 90 days before the
effective date of the termination. In the event of termination under this
paragraph, all documents, data and reports prepared by the Contractor under the
contract shall become the property of and be delivered to AHCCCSA. The
Contractor shall be entitled to receive just and equitable compensation for work
in progress, work completed and materials accepted before the effective date of
the termination.
19) TERMINATION FOR DEFAULT
AHCCCSA reserves the right to terminate this contract in whole or in part due to
the failure of the Contractor to comply with any term or condition of the
contract or failure to take corrective action as required by AHCCCSA to comply
with the terms of the contract. If the Contractor is providing services under
more than one contract with AHCCCSA, AHCCCSA may deem unsatisfactory performance
under one contract to be cause to require the Contractor to provide assurance of
performance under any and all other contracts. In such situations, AHCCCSA
reserves the right to seek remedies under both actual and anticipatory breaches
of contract if adequate assurance of performance is not received. The
Contracting Officer shall mail written notice of the termination and the
reason(s) for it to the Contractor by certified mail, return receipt requested.
In the event the Contractor requests a hearing prior to termination, AHCCCSA is
required by the Balanced Budget Act of 1997 to oversee the operation of the
Contractor entity through appointment of temporary management prior to the
hearing.
Upon termination under this paragraph, all documents, data, and reports prepared
by the Contractor under the contract shall become the property of and be
delivered to AHCCCSA on demand.
Acute Care RFP
February 3, 2003
- 75 -
CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
AHCCCSA may, upon termination of this contract, procure, on terms and in the
manner that it deems appropriate, materials or services to replace those under
this contract. The Contractor shall be liable for any excess costs incurred by
AHCCCSA in re-procuring the materials or services.
20) TERMINATION - AVAILABILITY OF FUNDS
Funds are not presently available for performance under this contract beyond the
current fiscal year. No legal liability on the part of AHCCCSA for any payment
may arise under this contract until funds are made available for performance of
this contract.
21) RIGHT OF OFFSET
AHCCCSA shall be entitled to offset against any amounts due the Contractor any
expenses or costs incurred by AHCCCSA concerning the Contractor's non-conforming
performance or failure to perform the contract.
22) NON-EXCLUSIVE REMEDIES
The rights and the remedies of AHCCCSA under this contract are not exclusive.
23) NON-DISCRIMINATION
The Contractor shall comply with State Executive Order No. 99-4, which mandates
that all persons, regardless of race, color, religion, sex, national origin or
political affiliation, shall have equal access to employment opportunities, and
all other applicable Federal and state laws, rules and regulations, including
the Americans with Disabilities Act and Title VI. The Contractor shall take
positive action to ensure that applicants for employment, employees, and persons
to whom it provides service are not discriminated against due to race, creed,
color, religion, sex, national origin or disability.
24) EFFECTIVE DATE
The effective date of this contract shall be the date that the Contracting
Officer signs the award page (page 1) of this contract.
25) INSURANCE
A certificate of insurance naming the State of Arizona and AHCCCSA as the
"additional insured" must be submitted to AHCCCSA within 10 days of notification
of contract award and prior to commencement of any services under this contract.
This insurance shall be provided by carriers rated as "A+" or higher by the A.M.
Best Rating Service. The following types and levels of insurance coverage are
required for this contract:
a. Commercial General Liability: Provides coverage of at least $1,000,000 for
each occurrence for bodily injury and property damage to others as a result
of accidents on the premises of or as the result of operations of the
Contractor.
b. Commercial Automobile Liability: Provides coverage of at least $1,000,000
for each occurrence for bodily injury and property damage to others
resulting from accidents caused by vehicles operated by the Contractor.
c. Workers Compensation: Provides coverage to employees of the Contractor for
injuries sustained in the course of their employment. Coverage must meet
the obligations imposed by Federal and State statutes and must also include
Employer's Liability minimum coverage of $100,000. Evidence of qualified
self- insured status will also be considered.
d. Professional Liability (if applicable): Provides coverage for alleged
professional misconduct or lack of ordinary skills in the performance of a
professional act of service.
The above coverages may be evidenced by either one of the following:
a. The State of Arizona Certificate of Insurance: This is a form with the
special conditions required by the contract already pre-printed on the
form. The Contractor's agent or broker must fill in the pertinent policy
information and ensure the required special conditions are included in the
Contractor's policy.
Acute Care RFP
February 3, 2003
- 76 -
CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
b. The Accord form: This standard insurance industry certificate of insurance
does not contain the pre- printed special conditions required by this
contract. These conditions must be entered on the certificate by the agent
or broker and read as follows:
The State of Arizona and Arizona Health Care Cost Containment System are
hereby added as additional insureds. Coverage afforded under this
Certificate shall be primary and any insurance carried by the State or any
of its agencies, boards, departments or commissions shall be in excess of
that provided by the insured Contractor. No policy shall expire, be
canceled or materially changed without 30 days written notice to the State.
This Certificate is not valid unless countersigned by an authorized
representative of the insurance company.
26) DISPUTES
The exclusive manner for the Contractor to assert any claim, grievance, dispute
or demand against AHCCCSA shall be in accordance with A.A.C. 22, Article 8.
Pending the final resolution of any disputes involving this contract, the
Contractor shall proceed with performance of this contract in accordance with
AHCCCSA's instructions, unless AHCCCSA specifically, in writing, requests
termination or a temporary suspension of performance.
27) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
AHCCCSA may, at reasonable times, inspect the part of the plant or place of
business of the Contractor or subcontractor that is related to the performance
of this contract, in accordance with A.R.S. Section 41-2547.
28) INCORPORATION BY REFERENCE
This solicitation and all attachments and amendments, the Contractor's proposal,
best and final offer accepted by AHCCCSA, and any approved subcontracts are
hereby incorporated by reference into the contract.
29) COVENANT AGAINST CONTINGENT FEES
The Contractor warrants that no person or agency has been employed or retained
to solicit or secure this contract upon an agreement or understanding for a
commission, percentage, brokerage or contingent fee. For violation of this
warranty, AHCCCSA shall have the right to annul this contract without liability.
30) CHANGES
AHCCCSA may at any time, by written notice to the Contractor, make changes
within the general scope of this contract. If any such change causes an increase
or decrease in the cost of, or the time required for, performance of any part of
the work under this contract, the Contractor may assert its right to an
adjustment in compensation paid under this contract. The Contractor must assert
its right to such adjustment within 30 days from the date of receipt of the
change notice. Any dispute or disagreement caused by such notice shall
constitute a dispute within the meaning of Section E, Paragraph 26, Disputes,
and be administered accordingly.
When AHCCCSA issues an amendment to modify the contract, the provisions of such
amendment will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the amendment has not been signed by the Contractor, unless
within that time the Contractor notifies AHCCCSA in writing that it refuses to
sign the amendment. If the Contractor provides such notification, AHCCCSA will
initiate termination proceedings.
31) TYPE OF CONTRACT
Firm Fixed-Price
32) AMERICANS WITH DISABILITIES ACT
People with disabilities may request special accommodations such as
interpreters, alternative formats or assistance with physical accessibility.
Requests for special accommodations must be made with at least three days prior
notice by calling Michael Veit at (602) 417-4762.
Acute Care RFP
February 3, 2003
- 77 -
CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
33) WARRANTY OF SERVICES
The Contractor warrants that all services provided under this contract will
conform to the requirements stated herein. AHCCCSA's acceptance of services
provided by the Contractor shall not relieve the Contractor from its obligations
under this warranty. In addition to its other remedies, AHCCCSA may, at the
Contractor's expense, require prompt correction of any services failing to meet
the Contractor's warranty herein. Services corrected by the Contractor shall be
subject to all of the provisions of this contract in the manner and to the same
extent as the services originally furnished.
34) NO GUARANTEED QUANTITIES
AHCCCSA does not guarantee the Contractor any minimum or maximum quantity of
services or goods to be provided under this contract.
35) CONFLICT OF INTEREST
The Contractor shall not undertake any work that represents a potential conflict
of interest, or which is not in the best interest of AHCCCSA or the State
without prior written approval by AHCCCSA. The Contractor shall fully and
completely disclose any situation that may present a conflict of interest. If
the Contractor is now performing or elects to perform during the term of this
contract any services for any AHCCCS health plan, provider or Contractor or an
entity owning or controlling same, the Contractor shall disclose this
relationship prior to accepting any assignment involving such party.
36) DISCLOSURE OF CONFIDENTIAL INFORMATION
The Contractor shall not, without prior written approval from AHCCCSA, either
during or after the performance of the services required by this contract, use,
other than for such performance, or disclose to any person other than AHCCCSA
personnel with a need to know, any information, data, material, or exhibits
created, developed, produced, or otherwise obtained during the course of the
work required by this contract. This nondisclosure requirement shall also
pertain to any information contained in reports, documents, or other records
furnished to the Contractor by AHCCCSA.
37) COOPERATION WITH OTHER CONTRACTORS
AHCCCSA may award other contracts for additional work related to this contract
and Contractor shall fully cooperate with such other contractors and AHCCCSA
employees or designated agents, and carefully fit its own work to such other
contractors' work. The Contractor shall not commit or permit any act which will
interfere with the performance of work by any other contractor or by AHCCCSA
employees.
38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY
This contract is voidable and subject to immediate cancellation by AHCCCSA upon
the Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or assigning rights or obligations
under this contract without the prior written consent of AHCCCSA.
39) OWNERSHIP OF INFORMATION AND DATA
Any data or information system, including all software, documentation and
manuals, developed by the Contractor pursuant to this contract, shall be deemed
to be owned by AHCCCSA. The Federal government reserves a royalty-free,
nonexclusive, and irrevocable license to reproduce, publish, or otherwise use
and to authorize others to use for Federal government purposes, such data or
information system, software, documentation and manuals. Proprietary software
which is provided at established catalog or market prices and sold or leased to
the general public shall not be subject to the ownership or licensing provisions
of this section.
Data, information and reports collected or prepared by the Contractor in the
course of performing its duties and obligations under this contract shall be
deemed to be owned by AHCCCSA. The ownership provision is in consideration of
the Contractor's use of public funds in collecting or preparing such data,
information and reports. These items shall not be used by the Contractor for any
independent project of the Contractor or publicized by the Contractor without
the prior written permission of AHCCCSA. Subject to applicable state
Acute Care RFP
February 3, 2003
- 78 -
CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
and Federal laws and regulations, AHCCCSA shall have full and complete rights to
reproduce, duplicate, disclose and otherwise use all such information. At the
termination of the contract, the Contractor shall make available all such data
to AHCCCSA within 30 days following termination of the contract or such longer
period as approved by AHCCCSA, Office of the Director. For purposes of this
subsection, the term "data" shall not include member medical records.
Except as otherwise provided in this section, if any copyrightable or patentable
material is developed by the Contractor in the course of performance of this
contract, the Federal government, AHCCCSA and the State of Arizona shall have a
royalty-free, nonexclusive, and irrevocable right to reproduce, publish, or
otherwise use, and to authorize others to use, the work for state or Federal
government purposes. The Contractor shall additionally be subject to the
applicable provisions of 45 CFR Part 74 and 45 CFR Parts 6 and 8.
40) AHCCCSA RIGHT TO OPERATE CONTRACTOR
If, in the judgment of AHCCCSA, the Contractor's performance is in material
breach of the contract or the Contractor is insolvent, AHCCCSA may directly
operate the Contractor to assure delivery of care to members enrolled with the
Contractor until cure by the Contractor of its breach, by demonstrated financial
solvency or until the successful transition of those members to other
contractors.
If AHCCCS undertakes direct operation of the Contractor, AHCCCS, through
designees appointed by the Director, shall be vested with full and exclusive
power of management and control of the Contractor as necessary to ensure the
uninterrupted care to persons and accomplish the orderly transition of persons
to a new or existing Contractor, or until the Contractor corrects the Contract
Performance failure to the satisfaction of AHCCCS. AHCCCS shall have the power
to employ any necessary assistants, to execute any instrument in the name of the
Contractor, to commence, defend and conduct in its name any action or proceeding
in which the Contractor may be a party.
All reasonable expenses of AHCCCS related to the direct operation of the
Contractor, including attorney fees, cost of preliminary or other audits of the
Contractor and expenses related to the management of any office or other assets
of the Contractor, shall be paid by the Contractor or withheld from payment due
from AHCCCS to the Contractor.
41) AUDITS AND INSPECTIONS
The Contractor shall comply with all provisions specified in applicable AHCCCS
Rule R9-22-519, -520 and - 521 and AHCCCS policies and procedures relating to
the audit of the Contractor's records and the inspection of the Contractor's
facilities. The Contractor shall fully cooperate with AHCCCSA staff and allow
them reasonable access to the Contractor's staff, subcontractors, members, and
records.
At any time during the term of this contract, the Contractor's or any
subcontractor's books and records shall be subject to audit by AHCCCSA and,
where applicable, the Federal government, to the extent that the books and
records relate to the performance of the contract or subcontracts.
AHCCCSA, or its duly authorized agents, and the Federal government may evaluate
through on-site inspection or other means, the quality, appropriateness and
timeliness of services performed under this contract.
42) LOBBYING
No funds paid to the Contractor by AHCCCSA, or interest earned thereon, shall be
used for the purpose of influencing or attempting to influence an officer or
employee of any Federal or State agency, a member of the United States Congress
or State Legislature, an officer or employee of a member of the United States
Congress or State Legislature in connection with awarding of any Federal or
State contract, the making of any Federal or State grant, the making of any
Federal or State loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment or modification of any Federal or
State contract, grant, loan, or cooperative agreement. The Contractor shall
disclose if any funds, other than those paid to the Contractor by
Acute Care RFP
February 3, 2003
- 79 -
CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
AHCCCSA, have been used or will be used to influence the persons and entities
indicated above and will assist AHCCCSA in making such disclosures to CMS.
43) CHOICE OF FORUM
The parties agree that jurisdiction over any action arising out of or relating
to this contract shall be brought or filed in a court of competent jurisdiction
located in the State of Arizona.
[END OF SECTION E]
Acute Care RFP
February 3, 2003
- 80 -
INDEX - PROGRAM REQUIREMENTS
AND CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
SECTION F: INDEX - PROGRAM REQUIREMENTS AND CONTRACT CLAUSES
A
Accumulated Fund Deficit, 53
Advance Directives, 35
Advances, 53
Ambulatory, 7, 22, 25, 39
Annual Enrollment, 19
Appointment Standards, 44
Auto-Assignment, 18, 19, 20
Auto-Assignment Algorithm, 18, 19, 20
B
BBA, 7, 19, 23, 24, 45, 48, 71, 72, 75
Behavioral Health, 7, 12, 21, 22, 23, 25, 29, 30, 31, 32, 33, 43, 46
Breast and Cervical Cancer, 7, 14, 16, 18, 55, 63
Business Continuity Plan, 70
C
Capitalization, 51
Capitation, 6, 8, 12, 15, 19, 20, 31, 52, 54, 55, 56, 57, 58, 66, 67, 69, 70
Chiropractic, 22
Claims
Clean, 48, 60
Payment, 48, 49
Compensation, 54
Contraceptive, 24
Convalescent Care, 26, 28
Coordination of Care, 30
Copayment, 8, 43, 56, 61, 63, 71
Copayment, 8
Copayments, 63
Cost Avoidance, 61
Cost Sharing, 14, 16, 18, 33, 46, 61, 62, 63, 64, 71
Covered Services, 7, 8, 13, 21, 30
Credentialing, 36, 40
CRS, 8, 21, 22
Cultural Competency, 34
Cure Notice, 70
D
Data Exchange, 65
Dialysis, 21, 23
Disenrollment, 67
Distributions, 53
DME, 9, 21, 26
Dual Eligibles, 46, 64
E
Eligibility
CRS, 22
Determination, 9
Dual, 9, 33
Emergency, 9, 10, 13, 16, 23, 24, 25, 29, 44, 47
Encounter, 9, 32, 45, 46, 48, 55, 56, 60, 66, 67, 69, 70
Enrollment, 7, 9, 17, 19, 20, 67
Annual, 7, 17, 19, 20, 21, 60
Guarantees, 19
Open, 17, 19, 20
EPSDT, 9, 23, 25, 27, 30, 32, 33, 38, 39, 43, 46, 63
F
Family Planning, 9, 16, 18, 24, 33, 46, 54, 63
Fee-for-Service, 9, 19, 21, 26, 50, 61, 62, 63, 66
FFP, 10
Financial Viability Standards, 53
Formulary, 28, 30, 70
FQHC, 9, 45
Freedom to Work, 10, 14, 16, 18, 72
G
Geographic Service Area, 6, 7, 10, 15, 18, 19, 40, 49, 51, 53, 55, 68
Grievance, 39
H
HIFA, 10, 14, 17, 18, 19, 31, 55, 63
HIFA Parents, 10, 17, 18, 19, 55, 63
Acute Care RFP
February 3, 2003
- 81 -
INDEX - PROGRAM REQUIREMENTS
AND CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
HIFA PARENTS, 10, 17, 18, 19, 31, 63
HIPAA, 65, 66
HIV/AIDS, 24, 26, 33, 35, 42, 54, 55, 56
Home Health, 21, 25, 35, 36, 44
Hospice, 25, 35, 71
Hospital Subcontracting, 49
I
IBNR, 10, 15, 21
Identification Cards, 20
Immunizations, 24, 25, 31, 33, 38, 46
Indian Health Service, 10, 16, 17, 19, 21, 25, 29, 31
Inpatient, 9, 23, 25, 26, 28, 29, 30, 32, 40, 42, 44, 56, 58, 59, 60, 61
Investments, 53
K
KidsCare, 10, 14, 17, 18, 22, 31, 55, 63
L
Laboratory, 24, 25, 29, 30, 33, 43, 46
Limited English Proficiency (LEP), 33, 39
Loans, 53
M
Management Services, 7, 11, 29, 30, 47, 50, 51, 74
Maternity, 25, 33, 42, 43, 44, 46
Medicaid in the Public Schools (MIPS), 31
Medical Expense Deduction, 11, 14, 54
Medical Foods, 26
Member
Education, 29
Mainstreaming, 20
Surveys, 34
Transition, 21
Midwives, 25, 43
N
Network Management, 41
Non-Contracting Provider, 11, 52
Nurse Practitioners, 7, 25, 42, 43
Nursing Facility, 21, 26, 35, 49, 50, 58, 60, 61
Nutrition, 27
O
Observation, 25
Omission, 11, 65, 66
Optometry, 24
Outpatient, 7, 9, 22, 23, 25, 28, 44, 49
P
Performance Standards, 11, 23, 25, 37, 38, 66
Periodicity Schedule, 23, 25, 30, 38
Pharmacy, 37, 40, 56
Physician Assistants, 7, 25, 42, 43
Physician Incentives, 50
Podiatry, 27
Postpartum Care, 25, 38, 42
Post-stabilization, 24, 27
Pregnancy, 9, 21, 24, 25, 26, 27, 42
Prenatal Care, 25, 26, 33, 39, 44, 57, 62, 63
Prescription Drugs, 6, 28, 44, 65, 71
Prescription Medication, 23, 28, 29, 30, 44, 65
Primary Care Physician, 10, 12, 22, 23, 25, 26, 27, 28, 30, 33, 35, 36, 38, 39,
40, 42, 43, 44, 46, 63, 66
Prior Authorization, 21, 23, 27, 28, 37, 46, 48, 49
Prior Period Coverage, 12, 18, 19, 30, 54, 55, 56, 58, 59, 61, 66
Provider, 11, 12, 41, 42, 45, 46
Provider Manual, 45, 48
Provider Registration, 46
Q
QMB, 12, 18
Quality Management, 31, 32, 33, 36
R
Radiology, 25, 28, 29, 44
Rate Code, 12, 56, 58, 67
RBHA, 12, 23, 29, 30, 33, 46
Referral, 10, 22, 23, 29, 30, 32, 33, 42, 43, 44, 46, 62, 63
Acute Care RFP
February 3, 2003
- 82 -
INDEX - PROGRAM REQUIREMENTS
AND CONTRACT CLAUSES CONTRACT/RFP NO. YH04-0001
Rehabilitation, 22, 26, 28, 29, 61
Reinsurance, 12, 46, 49, 54, 55, 56, 58, 59, 60, 61, 62, 63, 66
Related Party, 12, 49, 53
Reporting Requirements, 66, 67
Respiratory, 28
Reviews, 68
RFP, 11, 12, 20, 24, 55, 69, 71
Risk Sharing, 24, 56
Roster, 18, 67
S
Sanctions, 37, 38, 50, 53, 63, 69, 70, 72
SOBRA, 8, 9, 10, 13, 14, 16, 17, 24, 31, 52, 54, 55, 58
SOBRA Family Planning, 16, 24, 54, 58
SSI, 8, 13, 14, 16, 17, 18, 55, 72
Staff Requirements, 32
Sterilization, 24
Subcontract, 10, 11, 13, 21, 25, 45, 46, 47, 48, 49, 75
Subcontractor, 11, 12, 13, 21, 46, 47, 48, 51, 53, 77, 79
Supplies, 13, 23, 25, 26, 44
T
TANF, 13, 16, 31
Technological Advancement, 70
Third Party, 8, 13, 15, 21, 26, 31, 47, 50, 54, 61, 62, 63, 74
Third Party Liability, 13, 61, 63
Ticket to Work, 10, 16, 18, 72
Title XIX, 7, 8, 9, 10, 11, 14, 16, 17, 18, 19, 22, 23, 25, 29, 30, 31, 45, 54,
55, 56, 58, 59, 63, 72, 75
Title XIX Waiver, 11, 14, 17, 54, 55, 56, 58, 59
Title XXI, 7, 9, 10, 13, 14, 16, 17, 18, 19, 23, 25, 29, 30, 31, 63
Transplants, 21, 23, 28, 59, 60, 71
Transportation, 21, 23, 28, 29, 30, 31, 33, 44, 62, 71
Triage, 29, 30
U
Utilization Management, 32, 33, 37 Vaccine for
Children, 31
Vision, 24, 33, 46
Acute Care RFP
February 3, 2003
[END OF SECTION F]
- 83 -
REPRESENTATIONS AND CERTIFICATIONS CONTRACT/RFP NO. YH04-0001
SECTION G: REPRESENTATIONS AND CERTIFICATIONS OF OFFEROR
THE OFFEROR MUST COMPLETE ALL INFORMATION REQUESTED BELOW.
1. CERTIFICATION OF ACCURACY OF INFORMATION PROVIDED
By signing this offer, the Offeror certifies, under penalty of law, that the
information provided herein is true, correct and complete to the best of the
Offeror's knowledge and belief. The Offeror also acknowledges that, should
investigation at any time disclose any misrepresentation or falsification, any
subsequent contract may be terminated by AHCCCSA without penalty to or further
obligation by AHCCCSA.
2. CERTIFICATION OF NON-COERCION
By signing this offer, the Offeror certifies, under penalty of law, that it has
not made any requests or inducements to any provider not to contract with
another potential program contractor in relation to this solicitation.
3. CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK / LABORATORY TESTING
By signing this offer, the Offeror certifies that it has not engaged and will
not engage in any violation of the Medicare Anti-Kickback or the "Stark I" and
"Stark II" laws governing related-entity and compensation there from. If the
Offeror provides laboratory testing, it certifies that it has complied with, and
has sent to AHCCCSA, simultaneous copies of the information required to be sent
to the Centers for Medicare and Medicaid Services. (See 42 USC Section 1320a-7b,
PL 101-239, PL 101-432, and 42 CFR Section 411.361.)
4. AUTHORIZED SIGNATORY
Authorized Signatory for _________________________________________________
[OFFEROR'S Name]
___________________________________ _______________________________
[INDIVIDUAL'S Name] [Title]
is the person authorized to sign this contract on behalf of the Offeror.
5. OFFEROR'S MAILING ADDRESS
AHCCCSA should address all notices relative to this offer to the attention of:
___________________________________________________________________
Name Title
___________________________________________________________________
Address Telephone Number
___________________________________________________________________
Fax Number Email Address
___________________________________________________________________
City State ZIP
Acute Care RFP
February 3, 2003
- 84 -
REPRESENTATIONS AND CERTIFICATIONS CONTRACT/RFP NO. YH04-0001
OFFEROR GENERAL INFORMATION (Page 1 of 2)
1. ORGANIZATION CHART: Attach a copy of the Offeror's staff organization
chart, down to the supervisor level, setting forth lines of authority,
responsibility and communication which will pertain to this proposal. Provide an
overall organizational chart and separate organizational charts for each
functional area, which includes the number of current or proposed full-time
employees in each area.
2. IF OTHER THAN A GOVERNMENTAL AGENCY, WHEN WAS YOUR ORGANIZATION
FORMED?_______________________
3. LICENSE/CERTIFICATION: Attach a list of all licenses and certifications
(e.g. federal HMO status or State certifications) your organization maintains.
Use a separate sheet of paper listing the license requirement and the renewal
dates.
Have any licenses been denied, revoked or suspended within the past 10 years?
Yes _____ No _____
If yes, please explain.
________________________________________________________________________________
________________________________________________________________________________
4. CIVIL RIGHTS COMPLIANCE DATA: Has any federal or state agency ever made a
finding of noncompliance with any civil rights requirements with respect to your
program? Yes _____ No_____ If yes, please explain.
________________________________________________________________________________
________________________________________________________________________________
5. ACCESSIBILITY ASSURANCE: Does your organization provide assurance that no
qualified person with a disability will be denied benefits of, or excluded from,
participation in a program or activity because the Offeror's facilities
(including subcontractors) are inaccessible to, or unusable by, persons with
disabilities? (Note: Check local zoning ordinances for accessibility
requirements). Yes____ No____ If yes, describe how such assurance is provided or
how your organization is taking affirmative steps to provide assurance.
________________________________________________________________________________
________________________________________________________________________________
6. PRIOR CONVICTIONS: List all felony convictions within the past 15 years of
any key personnel (i.e., Administrator, Medical Director, financial officers,
major stockholders or those with controlling interest, etc.). Failure to make
full and complete disclosure shall result in the rejection of your proposal.
________________________________________________________________________________
________________________________________________________________________________
7. FEDERAL GOVERNMENT SUSPENSION/EXCLUSION: Has the Offeror been suspended or
excluded from any federal government programs for any reason? Yes_____ No_____
If yes, please explain.
________________________________________________________________________________
________________________________________________________________________________
8. WAS AN ACTUARIAL FIRM USED TO ASSIST IN DEVELOPING CAPITATION RATES?
Yes_____ No_____
If yes, what is name of the actuarial firm?_____________________________________
Acute Care RFP
February 3, 2003
- 85 -
REPRESENTATIONS AND CERTIFICATIONS CONTRACT/RFP NO. YH04-0001
OFFEROR GENERAL INFORMATION (Page 2 of 2)
9. DID A FIRM OR ORGANIZATION PROVIDE THE OFFEROR WITH ANY ASSISTANCE IN
MAKING THIS OFFER (TO INCLUDE DEVELOPING CAPITATION RATES OR PROVIDING ANY OTHER
TECHNICAL ASSISTANCE)? Yes_____ No_____ If yes, what is the name of this firm or
organization?
________________________________________________________________________________
Name
________________________________________________________________________________
Address City State
10. HAS THE OFFEROR CONTRACTED OR ARRANGED FOR MANAGEMENT INFORMATION SYSTEMS,
SOFTWARE OR HARDWARE, FOR THE TERM OF THE CONTRACT? Yes_____ No_____ If yes, is
the Management Information System being obtained from a vendor? Yes _____
No_____ If yes, please provide the vendor's name, the vendor's background with
AHCCCSA, the vendor's background with other HMOs, and the vendor's background
with other Medicaid programs.
________________________________________________________________________________
________________________________________________________________________________
Acute Care RFP
February 3, 2003
- 86 -
REPRESENTATIONS AND CERTIFICATIONS CONTRACT/RFP NO. YH04-0001
FINANCIAL DISCLOSURE STATEMENT (PAGE 1 OF 2)
The Offeror must provide the following information as required by 42 CFR
455.103. This Financial Disclosure Statement shall be prepared as of 12/31/02 or
as specified below. However, continuing offerors who have filed the required
Financial Disclosure Statement within the last 12 months need not complete this
section if no significant changes have occurred since the last filing.
1. OWNERSHIP: List the name and address of each person with an ownership or
controlling interest, as defined by 42 CFR 455.101, in the entity submitting
this offer:
Percent of
Name Address Ownership or Control
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2. SUBCONTRACTOR OWNERSHIP: List the name and address of each person with an
ownership or control interest in any subcontractor in which the disclosing
entity has direct or indirect ownership of 5% or more:
Percent of
Name Address Ownership or Control
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Names of above persons who are related to one another as spouse, parent, child
or sibling:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3. OWNERSHIP IN OTHER ENTITIES: List the name of any other entity in which a
person with an ownership or control interest in the Offeror entity also has an
ownership or control interest:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Acute Care RFP
February 3, 2003
- 87 -
REPRESENTATIONS AND CERTIFICATIONS CONTRACT/RFP NO. YH04-0001
FINANCIAL DISCLOSURE STATEMENT (PAGE 2 OF 2)
4. LONG-TERM BUSINESS TRANSACTIONS: List any significant business
transactions, as defined in 42 CFR 455.101, between the Offeror and any
wholly-owned supplier or between the Offeror and any subcontractor during the
five-year period ending on the Contractor's most recent fiscal year end:
Describe Ownership Type of Business Dollar Amount
of Subcontractors Transaction with Provider of Transaction
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
5. CRIMINAL OFFENSES: List the name of any person who has ownership or control
interest in the Offeror, or is an agent or managing employee of the Offeror and
has been convicted of a criminal offense related to that person's involvement in
any program under Medicare, Medicaid or the Title XIX or Title XXI services
program since the inception of those programs:
Name Address Title
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
6. CREDITORS: List name and address of each creditor whose loans or mortgages
exceed 5% of total Offeror equity and are secured by assets of the Offeror's
company.
Description Amount
Name Address of Debt of Security
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Acute Care RFP
February 3, 2003
- 88 -
REPRESENTATIONS AND CERTIFICATIONS CONTRACT/RFP NO. YH04-0001
RELATED PARTY TRANSACTIONS (PAGE 1 OF 2)
1. BOARD OF DIRECTORS: List the names and addresses of the Board of Directors
of the Offeror.
Name/Title Address
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2. HIGHEST-COMPENSATED MANAGEMENT: List names and titles of the 10 highest
compensated management personnel including but not limited to the Chief
Executive Officer, the Chief Financial Officer, Board Chairman, Board Secretary,
and Board Treasurer:
Name Title
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3. RELATED PARTY TRANSACTIONS: Describe transactions between the Offeror and
any related party in which a transaction or series of transactions during any
one fiscal year exceeds the lesser of $10,000 or 2% of the total operating
expenses of the disclosing entity. List property, goods, services and facilities
in detail noting the dollar amounts or other consideration for each transaction
and the date thereof. Include a justification as to (1) the reasonableness of
the transaction, (2) its potential adverse impact on the fiscal soundness of the
disclosing entity, and (3) that the transaction is without conflict of interest:
a) THE SALE, EXCHANGE OR LEASING OF ANY PROPERTY:
Description of Name of Related Party Dollar Amount for
Transaction and Relationship Reporting Period
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Justification:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Acute Care RFP
February 3, 2003
- 89 -
REPRESENTATIONS AND CERTIFICATIONS CONTRACT/RFP NO. YH04-0001
RELATED PARTY TRANSACTIONS (PAGE 2 OF 2)
b) THE FURNISHING OF GOODS, SERVICES OR FACILITIES FOR CONSIDERATION:
Description of Name of Related Party Dollar Amount for
Transaction and Relationship Reporting Period
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Justification:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
c) DESCRIBE ALL TRANSACTIONS BETWEEN OFFEROR AND ANY RELATED PARTY WHICH
INCLUDES THE LENDING OF MONEY, EXTENSIONS OF CREDIT OR ANY INVESTMENT IN A
RELATED PARTY. This type of transaction requires review and approval in advance
by the Office of the Director:
Description of Name of Related Party Dollar Amount for
Transaction and Relationship Reporting Period
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Justification:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
d) LIST THE NAME AND ADDRESS OF ANY INDIVIDUAL WHO OWNS OR CONTROLS MORE THAN
10% OF STOCK OR THAT HAS A CONTROLLING INTEREST (i.e., FORMULATES, DETERMINES OR
VETOES BUSINESS POLICY DECISIONS):
Has Controlling
Owner Or Interest?
Name Address Controller Yes / No
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Acute Care RFP
February 3, 2003
- 90 -
REPRESENTATIONS AND CERTIFICATIONS CONTRACT/RFP NO. YH04-0001
OFFEROR'S ADMINISTRATIVE FUNCTIONS SUBCONTRACTORS (PAGE 1 OF 1)
The Offeror must identify any organizational or administrative functions (e.g.
claims processing, marketing, automated data processing, accounting) or key
personnel (e.g. administrator, medical director, chief financial officer, etc.)
which are subcontracted.
Subcontractor's Name:___________________________________________________________
Address:________________________________________________________________________
Method Of Payment:______________________________________________________________
Function Performed:_____________________________________________________________
Estimated Value Of Contract: 10/1/03 - 9/30/04 $______________________
10/1/04 - 9/30/05 $______________________
10/1/05 - 9/30/06 $______________________
Subcontractor's Name:___________________________________________________________
Address:________________________________________________________________________
Method Of Payment:______________________________________________________________
Function Performed:_____________________________________________________________
Estimated Value Of Contract: 10/1/03 - 9/30/04 $______________________
10/1/04 - 9/30/05 $______________________
10/1/05 - 9/30/06 $______________________
Subcontractor's Name:___________________________________________________________
Address:________________________________________________________________________
Method Of Payment:______________________________________________________________
Function Performed:_____________________________________________________________
Estimated Value Of Contract: 10/1/03 - 9/30/04 $______________________
10/1/04 - 9/30/05 $______________________
10/1/05 - 9/30/06 $______________________
Subcontractor's Name:___________________________________________________________
Address:________________________________________________________________________
Method Of Payment:______________________________________________________________
Function Performed:_____________________________________________________________
Estimated Value Of Contract: 10/1/03 - 9/30/04 $______________________
10/1/04 - 9/30/05 $______________________
10/1/05 - 9/30/06 $______________________
Acute Care RFP
February 3, 2003
- 91 -
REPRESENTATIONS AND CERTIFICATIONS CONTRACT/RFP NO. YH04-0001
OFFEROR'S KEY PERSONNEL (PAGE 1 OF 1)
Indicate the names of the persons filling the following positions and the date
(month/year) they began, or will begin, their staff assignment. In addition, the
Offeror must attach detailed professional resumes (two pages maximum) and job
descriptions for all key personnel to include, at a minimum, the following
positions. If any of the following positions are filled by employees who do not
spend their full time on the AHCCCS program, please describe their other duties.
If personnel are not in place, submit minimum qualifications in place of
resumes.
POSITION: NAME: STARTING DATE: # OF HOURS PER
WEEK DEDICATED TO
AHCCCS PROGRAM
Administrator
- -------------------------------------------------------------------------------------------
Medical Director
- -------------------------------------------------------------------------------------------
Chief Financial Officer
- -------------------------------------------------------------------------------------------
Claims Administrator
- -------------------------------------------------------------------------------------------
QM/UM Coordinator
- -------------------------------------------------------------------------------------------
Provider Services Manager
- -------------------------------------------------------------------------------------------
Member Services Manager
- -------------------------------------------------------------------------------------------
Behavioral Health Coordinator
- -------------------------------------------------------------------------------------------
Maternal Health/ EPSDT
Coordinator
- -------------------------------------------------------------------------------------------
Grievance Coordinator
- -------------------------------------------------------------------------------------------
Compliance Officer
- -------------------------------------------------------------------------------------------
[END OF SECTION G]
Acute Care RFP
February 3, 2003
- 92 -
EVALUATION FACTORS AND SELECTION PROCESS CONTRACT/RFP NO. YH04-0001
SECTION H: EVALUATION FACTORS AND SELECTION PROCESS
AHCCCSA has established a scoring methodology which is designed to evaluate
fairly an offeror's ability to provide cost-effective, high-quality contract
services in a managed care setting in accordance with the AHCCCS overall mission
and goals. The following factors will be evaluated and weighted in the order
listed:
1. Provider Network
2. Capitation
3. Program
4. Organization
5. Extra Credit (optional)
It is anticipated that Capitation and the network development portion of
Provider Network will be scored by Geographic Service Area. The remaining
submission areas: the network management portion of Provider Network, Program,
Organization and Extra Credit, are anticipated to be scored statewide, not
specific to any Geographic Service Area (GSA). The scores received for each of
the four required components will be weighted separately and combined to derive
a final score for the Offeror, by GSA, prior to adding any extra credit earned.
Contracts will be awarded to qualified offerors whose proposals are deemed to be
most advantageous to the State in accordance with Section I, Paragraph 9, Award
of Contract.
In the case of negligible differences between two or more competing proposals
for a particular GSA, in the best interest of the state, AHCCCSA may consider
the following factors in awarding the contract:
- an Offeror who is an incumbent health plan and has performed in
an adequate manner (in the interest of continuity of care);
and/or
- an Offeror who participates satisfactorily in other lines of
AHCCCS business; and/or
- an Offeror's past performance with AHCCCS.
Offerors are encouraged to submit a bid for more than one GSA and/or for more
than just urban GSAs.
AHCCCSA reserves the right to waive immaterial defects or omissions in this
solicitation or submitted proposals. The Offeror should note that, if
successful, it must meet all AHCCCS requirements, irrespective of what is
requested and evaluated through this solicitation. The proposal provided by the
Offeror will become part of the contract with AHCCCS.
All of the components listed below will be evaluated against relevant statutes,
AHCCCSA rules and policies and the requirements contained in this RFP. The
Offeror's Checklist (Attachment K) contains RFP references for each of these
items:
1. PROVIDER NETWORK
The provider network will be evaluated and scored with reference to the
Offeror's network development and network management. Network development is
defined as the process of developing contractual arrangements with a sufficient
number of providers capable of delivering all covered services to AHCCCS members
in accordance with AHCCCSA standards (e.g., appointment times). AHCCCSA will use
contracts and/or completed Letters of Intent with other required materials to
evaluate and score network development. A signed Letter of Intent will receive
the same weight and consideration as a signed contract. The Offeror's network
will be evaluated by service and by site in each GSA bid by the Offeror. The
Offeror should note that Attachment B of this solicitation identifies minimum
geographic standards for a provider network.
Acute Care RFP
February 3, 2003
- 93 -
EVALUATION FACTORS AND SELECTION PROCESS CONTRACT/RFP NO. YH04-0001
Network management is defined as the process by which the Offeror certifies,
monitors, evaluates and communicates with its network. AHCCCSA anticipates
evaluating and scoring the Offeror's submitted materials relative to the
following areas:
a. Monitoring and management of network
b. Network communication
c. Capacity analysis, planning and development
2. CAPITATION
The Offeror shall submit initial capitation bids by risk group within a GSA.
These initial bids will be evaluated and scored. The lowest bid within each GSA
and risk group will receive the maximum allowable points. If a bid is below the
actuarial rate range, the bid will be evaluated as if it were at the bottom of
the actuarial rate range. No additional points will be given for bids below the
actuarial rate range. Conversely, the highest bid (within or above the actuarial
rate range) will receive the least number of points.
If AHCCCSA requests best and final offers, these offers will be scored using the
same methodology as was used to score the initial bids. The initial bid will be
weighted 60% and the final bid 40%.
Offerors should note that AHCCCSA may not offer the opportunity to submit best
and final offers.
3. PROGRAM
AHCCCSA will evaluate the Offeror's responsiveness to the requirements of this
solicitation and AHCCCSA policies. In particular, it is anticipated that the
Offeror's proposal regarding the following will be evaluated:
a. Quality Management
b. Utilization Management
c. Disease Prevention/Health Maintenance
d. Focused Health Needs
e. Member Services
4. ORGANIZATION
Organization refers to the Offeror's prospective ability to perform the
administrative tasks necessary to support the requirements identified in this
solicitation. It is anticipated that the following areas will be evaluated:
a. Organization and Staffing
b. Corporate Compliance
c. Grievance and Appeals
d. Claims (includes TPL)
e. Encounters
f. Financial Standards (includes Performance Bond)
g. Liability Management (IBNR and RBUCs)
5. EXTRA CREDIT
The Offeror will have the option of submitting, in its proposal, descriptions of
programs/initiatives it has implemented or will implement within the first year
of the contract. These programs/initiatives should be ones that go beyond the
requirements of this RFP. AHCCCSA's purpose in allowing these submissions is to
introduce innovations to improve the AHCCCS program. The programs/initiatives
should fit into one of the following three categories:
Acute Care RFP
February 3, 2003
- 94 -
EVALUATION FACTORS AND SELECTION PROCESS CONTRACT/RFP NO. YH04-0001
a. Use of Technology
b. Reduction of Hassle Factors for Providers
c. Community Involvement
The Offeror may submit up to three programs/initiatives, but should be aware
that the total of extra credit points is limited, regardless of the number
submitted. Offeror's should be aware that the points earned through extra credit
responses may be significant enough to determine the outcome of contract awards.
Responses for extra credit will be scored by a group experienced in Medicaid
managed care at the national level.
Submission of these programs/initiatives is optional. If extra credit is
awarded, the proposed programs/initiatives will be included in the successful
Offeror's special terms and conditions to the contract.
[END OF SECTION H]
Acute Care RFP
February 3, 2003
- 95 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
SECTION I: INSTRUCTIONS TO OFFERORS
TABLE OF CONTENTS
1. CONTENTS OF OFFEROR'S PROPOSAL......................................................... 97
2. PROSPECTIVE OFFERORS' INQUIRIES........................................................ 104
3. PROSPECTIVE OFFERORS' CONFERENCE AND TECHNICAL INTERFACE MEETING....................... 105
4. LATE PROPOSALS......................................................................... 105
5. WITHDRAWAL OF PROPOSAL................................................................. 105
6. AMENDMENTS TO RFP...................................................................... 105
7. ON-SITE REVIEW......................................................................... 105
8. BEST AND FINAL OFFERS.................................................................. 105
9. AWARD OF CONTRACT ..................................................................... 107
10. FEDERAL DEADLINE FOR SIGNING CONTRACT ................................................ 108
11. RFP MILESTONE DATES................................................................... 108
12. AHCCCS BIDDER'S LIBRARY............................................................... 109
13.OFFEROR'S INABILITY TO MEET REQUIREMENTS............................................... 109
Acute Care RFP
February 3, 2003
- 96 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
1. CONTENTS OF OFFEROR'S PROPOSAL
All proposals (original and seven copies) shall be organized with strict
adherence to the Offeror's Checklist (Attachment K), as described in this
section and submitted using the forms and specifications provided in this RFP.
All pages of the Offeror's proposal must be numbered sequentially with documents
placed in sturdy 3-inch, 3-ring binders. All responses shall be in 10 point font
or larger with borders no less than 1/2". Unless otherwise specified, responses
to each submission requirement should be limited to three 8 1/2" x 11" one
sided, single spaced, type written pages. Erasures, interlineations or other
modifications in the proposal must be initialed in original ink by the
authorized person signing the offer. A policy, brochure, or reference to a
policy or manual does not constitute an adequate response. AHCCCSA will not
reimburse the Offeror the cost of proposal preparation.
It is the responsibility of the Offeror to examine the entire RFP, seek
clarification of any requirement that may not be clear, and check all responses
for accuracy before submitting its proposal. The proposal becomes a part of the
contract; thus, what is stated in the proposal may be evaluated either during
the proposal evaluation process or during other reviews. Proposals may not be
withdrawn after the published due date and time.
All proposals will become the property of AHCCCSA. The Offeror may designate
certain information to be proprietary in nature by typing the word "proprietary"
on top of every page for which nondisclosure is requested. Final determinations
of nondisclosure, however, rest with the AHCCCSA Director. Regardless of such
determinations, all portions of the Offeror's proposal, even pages that are
proprietary, will be provided to CMS and its evaluation contractor.
All proposals shall be organized according to the following major categories:
I. General Matters
II. Provider Network
III. Capitation
IV. Program
V. Organization
VI. Extra Credit
Each section shall be separated by a divider and contain all information
requested in this solicitation. Numbering of pages should continue in sequence
through each separate section. For example, "Provider Network" would begin with
the page number following the last page number in "General Matters". Each
section shall begin with a table of contents.
Proposals that are not submitted in conformance with the guidelines described
herein will not be considered. References to various sections of the RFP
document in Section I and Section K are intended to be of assistance and are not
intended to represent all requirements. Other possible resources may be found in
the Bidder's Library.
All responses incorporating examples of past performance and/or outcome data
must comply with the following requirements:
- Incumbents must submit based on their AHCCCS acute care line of
business
- New Offerors currently operating as Managed Care Organizations (MCO),
must submit all historical information from the same MCO/line of
business
- New Offerors without current managed care operations are not expected
to respond to historical submission requirements.
Acute Care RFP
February 3, 2003
- 97 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
I. GENERAL MATTERS
See the Offeror's Checklist (Attachment K) for information to be submitted under
this section.
II. PROVIDER NETWORK
The Offeror shall have in place an adequate network of providers capable of
meeting contract requirements. Attachment B lists minimum geographic network
requirements by GSA. The following specifies the submission requirements.
REQUIRED SUBMISSIONS: PROVIDER NETWORK DEVELOPMENT
1. The provider network must be submitted on a 3.5" floppy disk according
to the specifications found in Attachment D (2). Supporting signed
letters of intent or contracts must be available for review by
AHCCCSA, when requested, as evidence of an understanding between the
Offerer and provider (See Attachment D (1)). Letters of intent and/or
contracts should NOT be included with the Offerors proposal. AHCCCSA
may verify any or all referenced letters of intent or contracts. Do
not send letters of intent or contracts to AHCCCSA until instructed to
do so.
Reference: Attachment D (1)
2. For each network hospital, provide a list of contracted physicians who
have admitting privileges to that facility.
References: Section D, Paragraph 27, Network Development; Attachment
B: Geographic Service Area/Minimum Network Standards
3. Provide a list of network deficiencies in each GSA.
References: Section D, Paragraph 27, Network Development; Attachment
B: Geographic Service Area/Minimum Network Standards
REQUIRED SUBMISSIONS: PROVIDER NETWORK MANAGEMENT
MONITORING AND MANAGING THE NETWORK
4. Describe the process of monitoring and managing the provider network
for compliance with AHCCCS network standards. Identify the staff
involved in the process. (Limit 5 pages)
References: Section D, Paragraph 16, Staff Requirements and Support
Services, Paragraph 27, Network Development, Paragraph 29, Network
Management, Paragraph 30, Primary Care Provider Standards, Paragraph
31, Maternity Care Provider Standards and Paragraph 33, Appointment
Standards
5. Describe how the results obtained through monitoring are used to
manage the network and identify how provider issues are communicated
within the organization.
Reference: Section D, Paragraph 29, Network Management
NETWORK COMMUNICATION
6. Explain the provider communication process. Address health plan
accessibility to providers (including internal benchmarks), and
provider orientation, education and training.
References: Paragraph 27, Network Development and Paragraph 29,
Network Management
7. Describe how provider satisfaction is/will be assessed. What results
were obtained and what changes were implemented after the last
assessment?
Acute Care RFP
February 3, 2003
- 98 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
CAPACITY ANALYSIS/PLANNING AND DEVELOPMENT
8. Provide a copy of the Offeror's Network Development and Management
Plan. (No page limit)
Reference: Section D, Paragraph 27, Network Development (Provider
Network Development and Management Plan)
9. Provide a synopsis of the Offerer's Disaster Recovery Plan as it
relates to the provider network. (No page limit)
Reference: Section D, Paragraph 73, Business Continuity Plan
III. CAPITATION
Capitation is a fixed (per member) monthly payment to contractors for the
provision of covered services to members. It is an actuarially sound amount to
cover expected utilization and costs for the individual risk groups in a
risk-sharing managed care environment. The Offeror must demonstrate that the
capitation rates proposed are actuarially sound. In general terms, this means
that the Offeror who is awarded a contract should be able to keep utilization at
or near its proposed levels and that it will be able to contract for unit costs
that average at or near the amounts shown on the Capitation Rates Calculation
Sheet (CRCS). This requirement also applies to bids submitted in best and final
offer rounds.
Prior Period Coverage (PPC) and HIV/AIDS Supplement rates will be set by AHCCCS'
actuaries and not bid by the Contractor. Due to the lack of complete historical
data, the Title XIX Waiver Group and HIFA Parents' rates will also be set by
AHCCCS' actuaries, rather than bid by the Contractor. See Section D, Paragraph
53, Compensation, for information regarding risk sharing for the Title XIX
Waiver Group and PPC time period. All other rate codes, including the Delivery
Supplemental Payment, will be subject to competitive bidding.
To facilitate the preparation of its capitation proposals, AHCCCSA will provide
each Offeror with a Data Supplement. This data source should not be used as the
sole source of information in making decisions concerning the capitation
proposal. Each Offeror is solely responsible for research, preparation and
documentation of its capitation proposal.
REQUIRED SUBMISSION: CAPITATION
10. The Offeror must submit its capitation proposal using the AHCCCSA bid
web site. Instructions for accessing and using the web site will be
issued by March 1, 2003. The Offeror must have an actuary who is a
member of the American Academy of Actuaries certify that the bid
submission is actuarially sound. This certification must be done with
subsequent submissions in Best and Final Offer rounds (if applicable).
The Offeror must also submit hard copy print outs of the web site
CRCS. Refer to Section B and Attachment E for more details.
The Offeror must prepare and submit its capitation proposal assuming a
$35,000 deductible level for regular reinsurance, for all rate codes,
in all counties. AHCCCSA will provide a table of per member per month
reinsurance adjustments to be made to capitation rates for those
Contractors whose actual deductible level exceeds $35,000.
Capitation rates shall be submitted two ways: first, assuming all
medical services are included in the capitation rates, and second,
assuming that prescription drugs will be carved out of the capitation
rates. Prescription drugs are defined as "FDA approved legend or over
the counter (OTC) products provided upon receipt of a valid
prescription order and dispensed by a pharmacist in an outpatient
setting." When bidding with prescription drugs carved out, please
factor the impact to the other medical service and administrative
categories. AHCCCSA anticipates that in the event that prescription
drugs are carved
Acute Care RFP
February 3, 2003
- 99 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
out, the entity with which AHCCCSA contracts will provide real time
prescription drug data to the health plans in a standard National
Council for Prescription Drug Programs (NCPDP) format The Offeror is
expected to continue an integrated approach, including the use of
prescriptive data, in the management of the member's care.
The Offeror's rate proposal will be deemed by AHCCCSA to include the
costs of administrative adjustments required during the term of this
contract.
References: Section D, Paragraph 53, Compensation, Paragraph 57,
Reinsurance and Paragraph 75, Pending Legislative / Other Issues
(Prescription Drugs)
IV. PROGRAM
REQUIRED SUBMISSIONS: PROGRAM
QUALITY MANAGEMENT
11. Describe the process the Offeror uses to identify opportunities for
quality improvements. In addition, include a description of a recent
quality improvement project including initial identification,
interventions and results of improvement efforts. (Limit 5 pages)
References: Section D, Paragraph 23, Quality Management and
Utilization Management (QM/UM) and Paragraph 24, Performance Standards
12. Describe how peer review is utilized in your organization and
incorporated into your quality management process.
Reference: Section D, Paragraph 23, Quality Management and Utilization
Management (QM/UM)
13. Describe how quality of care complaints are handled including how they
are identified, researched and resolved.
Reference: Section D, Paragraph 23, Quality Management and Utilization
Management (QM/UM)
UTILIZATION MANAGEMENT
14. Describe the Offeror's process for monitoring utilization, development
of intervention strategies for identified utilization issues and how
the effectiveness of these interventions is monitored. Include
examples of data and reports used to identify utilization trends.
(Limit 5 pages text and no more than 5 sample report attachments)
Reference: Section D, Paragraph 23, Quality Management and Utilization
Management (QM/UM)
15. Describe the strategies used for pharmacy management, including the
identification and management of members with unusual utilization
patterns.
Reference: Section D, Paragraph 23, Quality Management and Utilization
Management (QM/UM)
16. Discuss the process for provider profiling including methods, criteria
and actions taken based on profiling activities.
Reference: Section D, Paragraph 23, Quality Management and Utilization
Management (QM/UM)
17. Describe the process for ensuring consistent application of clinical
criteria used in the authorization process for both outpatient and
inpatient care.
Reference: Section D, Paragraph 23, Quality Management and Utilization
Management (QM/UM)
Acute Care RFP
February 3, 2003
- 100 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
18. Describe the Medical Director's role in utilization management
activities, including availability to internal and external customers.
Reference: Section D, Paragraph 23, Quality Management and Utilization
Management (QM/UM)
DISEASE PREVENTION/HEALTH MAINTENANCE
19. Describe planned health promotion, outreach, monitoring and evaluation
of adult preventive services including well woman, well man and adult
immunizations.
References: Section D, Paragraph 10, Scope of Services, Paragraph 23,
Quality Management and Utilization Management (QM/UM) and Paragraph
24, Performance Standards
20. Describe planned outreach, monitoring and evaluation strategies for
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and
explain how the EPSDT program is integrated within the organization.
In addition to overall strategies, address activities aimed at healthy
children aged 3 through 6 and adolescents. (Limit 5 pages)
References: Section D, Paragraph 10, Scope of Services, Paragraph 15,
Pediatric Immunizations and the Vaccine for Children's Program,
Paragraph 23, Quality Management and Utilization Management (QM/UM)
and Paragraph 24, Performance Standards
21. Describe strategies, both implemented and those planned for
implementation, to improve utilization of dental services to ensure
increased member participation and increased provider participation.
Include the process used to develop the strategies.
References: Section D, Paragraph 10, Scope of Services and Paragraph
24, Performance Standards
22. Describe how utilization of family planning services for all members
is monitored and benchmarked.
References: Section D, Paragraph 10, Scope of Services and Paragraph
23, Quality Management and Utilization Management (QM/UM)
FOCUSED HEALTH NEEDS
23. Describe how members with special health needs are identified and how
the information is used to provide comprehensive case or disease
management.
References: Section D, Paragraph 11, Special Health Care Needs and
Paragraph 23, Quality Management and Utilization Management (QM/UM)
24. Describe the Offeror's disease management programs, including how
outcomes are assessed.
Reference: Section D, Paragraph 23, Quality Management and Utilization
Management (QM/UM)
25. Describe how the Offeror ensures culturally competent care and specify
how translation services are made available and provided to members
with limited English proficiency.
References: Section D, Paragraph 18, Member Information and Paragraph
20, Cultural Competency
26. Describe planned outreach strategies for children with special health
care needs and other hard to reach populations. Include the process
used to develop the strategies.
References: Section D, Paragraph 10, Scope of Services, Paragraph 11,
Special Health Care Needs and Paragraph 23, Quality Management and
Utilization Management (QM/UM)
27. Discuss the maternity program and how processes are directed at
achieving good birth outcomes. Response should include, but is not
limited to prenatal care entry process, identification and assessment
of high-risk maternity patients, case management, outreach and
monitoring activities.
Acute Care RFP
February 3, 2003
- 101 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
References: Section D, Paragraph 10, Scope of Services, Paragraph 23,
Quality Management and Utilization Management (QM/UM), Paragraph 24,
Performance Standards, Paragraph 31, Maternity Care Provider Standards
and Paragraph 33, Appointment Standards
MEMBER SERVICES
28. Describe the member complaint and resolution process, including
communications with other departments, benchmarks used and the average
speed for resolution of complaints.
References: Section D, Paragraph 18, Member Information, Paragraph 23,
Quality Management and Utilization Management (QM/UM), Paragraph 25,
Grievance and Request for Hearing Process and Standards and Attachment
H (1), Enrollee Grievance System Standards and Process
29. Explain the member communication process, addressing Offeror
accessibility to members (including internal benchmarks), the
development and distribution of written materials and member
orientation and education.
References: Section D, Paragraph 8, Mainstreaming of AHCCCS Members,
Paragraph 16, Staffing Requirements and Support Services, Paragraph
18, Member Information and Paragraph 20, Cultural Competency
30. Describe how the Offeror assesses member satisfaction. What changes
were implemented after the last assessment?
References: Section D, Paragraph 4, Annual Enrollment Choice,
Paragraph 19, Member Surveys, Paragraph 23, Quality Management and
Utilization Management (QM/UM), Paragraph 25, Grievance and Request
for Hearing Process and Standards and Attachment H (1), Enrollee
Grievance System Standards and Process
V. ORGANIZATION
Organization refers to the Offeror's ability to perform the administrative tasks
necessary to support the requirements identified throughout this RFP. The
following identifies the submission requirements.
REQUIRED SUBMISSIONS: ORGANIZATION
ORGANIZATION AND STAFFING
31. Describe the Offeror's experience providing similar services to
similar populations. Include any experience working with federally
funded programs such as Medicare and Medicaid, and with managed care
organizations.
32. Describe the organization's various committees. Include the purpose
and composition (by title and functional area) of each committee.
Describe how committee information flows within the organization.
33. Submit a copy of the organization's Disaster Recovery Plan. (No page
limit)
Reference: Section D, Paragraph 73, Business Continuity Plan
CORPORATE COMPLIANCE
34. Describe the role of the Compliance Officer (CO). Identify the CO's
major responsibilities, other than those related to corporate
compliance, if any. What percentage of time will the CO spend on the
AHCCCS program corporate compliance activities?
References: Section D, Paragraph 62, Corporate Compliance
Acute Care RFP
February 3, 2003
- 102 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
35. Describe how fraud is detected and reported including, but not limited
to, how employees, members and providers will learn about fraud, and
the process for reporting (both internally and externally) suspected
fraud.
References: Section D, Paragraph 62, Corporate Compliance
GRIEVANCE AND APPEALS
36. Provide a flowchart and written description of the grievance and
appeals processes; include both the informal and formal processes and
general timeframes. Identify the staff that will be involved at each
phase and provide their qualifications.
References: Section D, Paragraph 25, Grievance and Request for Hearing
Process and Standards, Attachment H (1), Enrollee Grievance System
Standards and Policy and Attachment H (2), Provider Grievance System
Standards and Policy
37. Describe the process that will be used to ensure corrective action is
taken with respect to deficiencies identified through the grievance
system.
References: Section D, Paragraph 25, Grievance and Request for Hearing
Process and Standards, Attachment H (1), Enrollee Grievance System
Standards and Policy and Attachment H (2), Provider Grievance System
Standards and Policy
CLAIMS
38. Describe your claims process including, but not limited to, how timely
and accurate claims payments are ensured, the remediation process when
the Offeror's standards are not met, how coordination of benefits/TPL
is done and how provider claims inquiries are handled.
References: Section D, Paragraph 38,ClaimsPayment System and Paragraph
58, Coordination of Benefits/Third Party Liability
39. What system is used to process claims? Are claims adjudication and
payment outsourced from the Offeror's organization?
40. Submit October, November, and December 2002 month end claims aging.
ENCOUNTERS
41. Describe your encounter submissions process including, but not limited
to, how accuracy, timeliness and completeness are ensured and the
remediation process when the Offeror's standards are not met.
References: Section D, Paragraph 64, Data Exchange Requirement,
Paragraph 65, Encounter Data Reporting and Attachment I, Encounter
Submission Requirements
FINANCIAL STANDARDS
42. Submit the Offeror's plan for meeting the Performance Bond or Bond
Substitute requirement including the type of bond to be posted, source
of funding and timeline for meeting the requirement.
References: Section D, Paragraph 46, Performance Bond or Bond
Substitute and Paragraph 47, Amount of Performance Bond
43. Submit a plan for meeting the minimum capitalization requirement.
Reference: Section D, Paragraph 45, Minimum Capitalization
Requirements
Acute Care RFP
February 3, 2003
- 103 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
44. Provide the organization's two most recent audited financial
statements. Include the parent company's most recent statements as
well, if applicable. (No page limit)
45. Submit verification of any contributions provided to the Offeror to
improve its financial position after the audit (copies of bank
statements and deposit slips), if applicable. (No page limit)
46. Provide enrollment figures for the two most recent audited financial
statements.
47. Provide the organization's last four unaudited internally prepared
quarterly financial statements with preparation dates indicated. (No
page limit)
48. Submit financial forecasts for the first three years of the contract
starting with October 1, 2003, including a balance sheet and a
statement of revenues, expenses and changes in equity in at least the
level of detail specified for annual audited financial statements as
outlined in the Reporting Guide for Acute Care Contractors with the
Arizona Health Care Cost Containment System. Include all assumptions
used for the forecasts. (No page limit)
49. Submit financial viability calculations and results for the three-year
financial projections.
Reference: Section D, Paragraph 50, Financial Viability
Standards/Performance Guidelines
50. Describe the cost allocation plan, if applicable.
Reference: Section D, Paragraph 43, Management Services Subcontractors
LIABILITY MANAGEMENT
51. Describe the Offeror's RBUC/IBNR calculation methodology.
Reference: Section D, Paragraph 50, Financial Viability
Standards/Performance Guidelines
VI. EXTRA CREDIT
OPTIONAL SUBMISSIONS: EXTRA CREDIT
52. Submit a description of a program/initiative(s), which goes beyond the
requirements of this RFP and fits into one or more of the following
categories; Use of Technology, Reduction of Hassle Factors for
Providers or Community Involvement. With the description please
include actual or anticipated results, how the program/initiative will
be evaluated, and a high level timeline. (Limit of three pages, plus
the timeline for each program/initiative submitted. There is a limit
of three program/initiatives that may be submitted.)
2. PROSPECTIVE OFFERORS' INQUIRIES
Any questions related to this solicitation must be directed to Michael Veit,
AHCCCSA Contracts and Purchasing. Offerors shall not contact or ask questions of
other AHCCCSA staff unless authorized by the Contracting Officer. Questions
shall be submitted on disk, saved as a text file (.txt), along with a hard copy
printout, prior to the Prospective Offerors' Conference (submit by 5:00 p.m. on
February 14, 2003). Offerors must submit inquiries using Microsoft Word.
Questions submitted by the deadline above may be addressed at the Prospective
Offerors' Conference. The envelope must be marked "RFP Questions- Acute Care".
Questions arising during the Conference, or those that cannot be answered at the
Prospective Offerors' Conference, will be answered within a reasonable period in
writing. Any correspondence pertaining to this RFP must refer to the appropriate
page, section and paragraph number.
Acute Care RFP
February 3, 2003
- 104 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
3. PROSPECTIVE OFFERORS' CONFERENCE AND TECHNICAL INTERFACE MEETING
A New Offerors' Conference will be held on February 21, 2003, from 8:30 a.m.
until 9:30, at AHCCCS' 701 E. Jefferson building in the Gold Room on the 3rd
Floor. The purpose of this conference will be to orient new offerors to AHCCCS.
Continuing offerors are welcome to attend, but the agenda will assume no prior
familiarity with the AHCCCS program. From 10:00 a.m. to 12:30 p.m., there will
be a Prospective Offerors' conference for all new and continuing offerors. The
purpose of this conference is to clarify the contents of this solicitation and
to avoid any misunderstandings regarding AHCCCSA requirements. Any doubt as to
the contents and requirements of this solicitation or any apparent omission or
discrepancy should be presented at this conference. AHCCCSA will then determine
the action necessary and issue a written amendment to the solicitation, if
appropriate.
Also on February 21, 2003, from 2:00 p.m. until 5:00 p.m., a Technical Interface
meeting will be held. The purpose of this meeting is to orient prospective
offerors to the AHCCCS PMMIS system requirements and to answer any technical
questions.
4. LATE PROPOSALS
Late proposals will not be considered.
5. WITHDRAWAL OF PROPOSAL
At any time prior to the proposal due date and time, the Offeror (or designated
representative) may withdraw its proposal. Withdrawals must be provided in
writing and submitted to Michael Veit, AHCCCSA, Contracts and Purchasing.
6. AMENDMENTS TO RFP
Amendments may be issued subsequent to the issue date of this solicitation.
Receipt of solicitation amendments must be acknowledged by signing and returning
the signature page of the amendment to Michael Veit, AHCCCS, Contracts and
Purchasing.
7. ON-SITE REVIEW
Prior to contract award, all Offerors may be subject to on-site review(s) to
determine that an infrastructure is in place that will support the provision of
services to the acute population within the GSAs bid.
8. BEST AND FINAL OFFERS
AHCCCSA reserves the right to accept any or all initial offers without further
negotiation and may choose not to request a best and final offer (BFO). Offerors
are therefore advised to submit their most competitive offers at the outset.
However, if it is considered in the best interest of the State, AHCCCSA may
issue a written request to all offerors for a best and final offer in a
particular geographic service area or areas. The purpose of a BFO request is to
allow offerors an opportunity to resubmit bids for rate codes not previously
accepted by AHCCCSA. This request will notify them of the date, time and place
for the submission of their offers. In addition, AHCCCSA will disclose to each
offeror which of its bid rates are acceptable (within or below actuarial rate
range), and which are not acceptable (above the actuarial rate range). All
offerors whose final bid rates fall below the bottom of the actuarial rate range
will have their rates increased to the bottom of that rate range after the final
BFO. If an offeror does not submit a notice of withdrawal or a best and final
offer, its immediate previous offer will be considered its best and final offer.
All BFOs must be submitted via the AHCCCS website, as well as in accordance with
Section B of the RFP. AHCCCSA will limit the number of BFO rounds if it is in
the best interest of the State. Offerors will be
Acute Care RFP
February 3, 2003
- 105 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
permitted, within the restrictions and limitations defined below, to adjust
upward, a capitation rate for a rate code that was previously accepted to offset
the reduction of a capitation rate in another rate code in the first BFO round
only. These restrictions and limitations include, but are not limited to:
a. An offeror will be allowed to adjust upward a previously
accepted rate code bid only during the first BFO round;
b. The weighted amount of BFO increase cannot exceed the weighted
amount of BFO reduction. AHCCCSA will furnish the Offeror, in
the Data Supplement, the enrollment percentages, by rate code,
by GSA, to be used in determining the weighted amount. Should
the weighted amount of the adjustment exceed the weighted
amount of the BFO reduction, AHCCCSA shall reject the first
BFO and the adjustment (costing the Offeror the loss of the
first BFO round in that GSA). Since a rate code can only be
adjusted during the first BFO round, the Offeror will lose the
opportunity to make an upward capitation adjustment to
previously accepted rate code bids in that GSA.
For example, assume that SSI w/o Medicare was the rate code
where a BFO was needed and the offeror reduced this rate by
$10 PMPM. Also assume the SSI w/o Medicare rate code accounted
for 9% of the members in the GSA.
Weighted Average Capitation Reduction - 9% X $10.00 = $.90
Assume the rate code adjusted upward was TANF and this rate
code was increased by $2.00 PMPM. Also assume this rate code
accounted for 50% of the members in the GSA.
Weighted Average Capitation Increase - 50% X $2.00 = $1.00
Therefore, the BFO would be rejected because the weighted
amount of the BFO adjustment exceeded the weighted amount of
the BFO reduction.
c. Offerors will not be allowed to decrease a bid in a BFO round
if the initial bid was below the bottom of the rate range. If
such a BFO is submitted it will be rejected.
d. If an adjustment during the initial BFO round causes the
Offeror to exceed the upper range of any rate code, AHCCCSA
will reject the adjustment and return the (adjusted) rate code
to the initial capitation rate bid by the Offeror. Since a
previously accepted rate code bid can only be adjusted during
the first BFO round, the Offeror will lose the opportunity to
make an upward capitation adjustment for this rate code.
e. AHCCCSA reserves the sole right to accept or reject any
adjustment. The Offeror by submitting an adjustment to a rate
code is requesting approval by AHCCCSA; such approval shall
not be automatic. If an initial bid is below the bottom of a
rate range, it cannot be adjusted downward by the Offeror in a
BFO round.
CAPITATION RATES OFFERED AFTER THE BFOs: As stated above, AHCCCSA may limit the
number of BFO rounds. After the final BFO round is complete, provided it is in
the best interest of the State, AHCCCSA will cease issuing BFO requests. At this
point, should the Offeror have a rate code(s) without an accepted capitation
rate, AHCCCSA shall offer a capitation rate to the Offeror. The capitation rate
offered should be somewhere in the bottom half of the rate range (specific
placement to be determined by AHCCCSA and its actuaries). Note that all rates
offered in this manner shall be identical for all offerors in the same GSA and
rate code.
Acute Care RFP
February 3, 2003
- 106 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
9. AWARD OF CONTRACT
AHCCCSA has determined that the provision of covered services to eligible
populations in the Geographic Service Areas as described below will stabilize
risk sharing. The Offeror must therefore bid on at least one entire GSA in order
to be considered for a contract award. Although AHCCCSA encourages Offerors to
bid on multiple GSAs, AHCCCSA may limit the number of GSA's awarded to any one
offeror, if deemed in the best interest of the State.
Notwithstanding any other provision of this solicitation, AHCCCSA expressly
reserves the right to:
a. Waive any immaterial mistake or informality;
b. Reject any or all proposals, or portions thereof; and/or
c. Reissue a Request for Proposal
If two plans or their parents merge after obtaining contract awards, AHCCCSA
retains the right to address each merger issue on an individual basis according
to what is deemed in the best interest of the State.
If there are significant compliance issues with a current plan or a plan's
contract in a particular county has been previously terminated, AHCCCSA retains
the right to address each compliance or termination issue on an individual basis
according to what is deemed in the best interest of the State. A new bid
proposal may not be accepted until it has been determined that the reason for
the significant compliance or termination issue has been resolved and there is a
reasonable assurance that it will not recur.
A response to this Request for Proposals is an offer to contract with AHCCCSA
based upon the terms, conditions, scope of work and specifications of the RFP.
All of the terms and conditions of the contract are contained in this
solicitation, solicitation amendments and subsequent contract amendments, if
any, signed by the Contracting Officer. Proposals do not become contracts unless
and until they are accepted by the Contracting Officer. A contract is formed
when the AHCCCSA Contracting Officer signs the award page and provides written
notice of the award(s) to the successful offeror(s), and the Offeror accepts any
special provisions to the contract and the final rates awarded. AHCCCSA may
also, at its sole option, modify any requirements described herein. All offerors
will be promptly notified of award.
AHCCCSA reserves the right to specify and/or modify the number of contracts to
be awarded in any GSA. AHCCCSA anticipates awarding contracts as follows:
GSA #: County or Counties Number of Awards:
- ------- ------------------------------------ -----------------
2 Yuma, La Paz Maximum of 2
4 Apache, Coconino, Mohave, and Navajo Maximum of 2
6 Yavapai Maximum of 2
8 Gila, Pinal Maximum of 2
10 Pima, Santa Cruz* Maximum of 5
12 Maricopa Maximum of 6
14 Graham, Greenlee, Cochise Maximum of 2
Note: *AHCCCS anticipates awarding up to five contracts in the Pima County
portion of the Pima/Santa Cruz GSA. Contracts will be awarded to two of the five
Pima contract awardees in Santa Cruz.
An existing contractor in Maricopa or Pima County who is not awarded a new
contract may request to have its enrollment capped and to continue providing
services under the terms and condition of this new RFP. AHCCCSA may, at its sole
option, grant or deny such a request. If AHCCCSA approves such an enrollment
cap,
Acute Care RFP
February 3, 2003
- 107 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
the Contractor would continue to serve its existing members but would not
receive any new members. The enrollment cap will not be lifted during the term
of this or any subsequent contract period unless one of the following conditions
exist:
a. Another contractor is terminated and increased member capacity
is needed, or
b. Legislative action creates a sudden and substantial increase
in the overall AHCCCS population, or
c. Extraordinary and unforeseen circumstances make such an action
necessary and in the best interest of the State.
If an existing contractor is not awarded a new or capped (as mentioned above)
contract, an open enrollment will be held, as described in Section D, Paragraph
5 of this document. The costs of this open enrollment shall be shared by each of
the Contractors within the pertinent GSA and AHCCCSA.
Subsequent to the award of contracts, in the event of significant non-compliance
issues with a Contractor in a particular GSA, AHCCCSA may refer back to the
results of the evaluation of this solicitation and select another Contractor for
a particular GSA that is considered to be in the best interest of the State.
Finally, successful bidders should be prepared to submit sample subcontracts for
approval as soon as possible after the contract award. AHCCCSA will expedite the
approval process.
10. FEDERAL DEADLINE FOR SIGNING CONTRACT
The Center for Medicare and Medicaid Services (CMS) has imposed strict deadlines
for finalization of contracts in order to qualify for federal financial
participation. This contract, and all subsequent amendments, must be completed
and signed by both parties, and must be available for submission to CMS prior to
the beginning date for the contract term (October 1, 2003). All public entity
Offerors must ensure that the approval of this contract is placed on appropriate
agendas well in advance to ensure compliance with this deadline. Any withholding
of federal funds caused by the Offeror's failure to comply with this requirement
shall be borne in full by the Offeror.
11. RFP MILESTONE DATES
The following is the schedule of events regarding the solicitation process:
Activity Date
- ---------------------------------------------------------------- -----------------
RFP Issued February 3, 2003
Technical Assistance and RFP Questions Due February 14, 2003
New Offerors Orientation February 21, 2003
Prospective Offerors Conference and Technical Assistance Session February 21, 2003
PMMIS Technical Interface Meeting February 21, 2003
RFP Amendment Issued, if necessary February 28, 2003
Access to Web-Based Capitation Bid Submission Available March 3, 2003
Second Set of Technical Assistance Questions Due March 7, 2003
Second RFP Amendment Issued, if necessary March 14, 2003
Proposals Due by 3:00 P.M. March 31, 2003
Contracts Awarded May 1, 2003
Readiness Reviews Begin July 1, 2003
New Contracts Effective October 1, 2003
Acute Care RFP
February 3, 2003
- 108 -
INSTRUCTIONS TO OFFERORS CONTRACT/RFP NO. YH04-0001
12. AHCCCS BIDDER'S LIBRARY
The Bidders Library contains critical reference material on AHCCCS policies and
performance requirements. References are made throughout this solicitation to
material in the Bidder's Library and offerors are responsible for the contents
of such referenced material as if they were printed in full herein. All such
material is incorporated into the contract by reference. The Bidder's Library is
located at 701 E. Jefferson, Phoenix, AZ. Please contact Michael Veit at (602)
417-4762 for further information or appointment times. Portions of the material
contained in the Library are also available on the AHCCCS website at
www.ahcccs.state.az.us.
13. OFFEROR'S INABILITY TO MEET REQUIREMENTS
If a potential offeror cannot meet the minimum capitalization requirements, the
performance bond requirements, or the minimum network standards described
herein, AHCCCSA requests that the potential offeror not submit a bid.
[END OF SECTION I]
Acute Care RFP
February 3, 2003
- 109 -
LIST OF ATTACHMENTS CONTRACT/RFP NO. YH04-0001
SECTION J: LIST OF ATTACHMENTS
Attachment A: Minimum Subcontract Provisions
Attachment B: Geographic Service Area; Minimum Network Requirements
Attachment C: Management Services Subcontractor Statement
Attachment D: Sample Letter of Intent: Network Submission Requirements
Attachment E: Instructions for Preparing Capitation Proposal
Attachment F: Periodic Reporting Requirements
Attachment G: Auto-Assignment Algorithm
Attachment H: Grievance System Standards and Policy
Attachment I: Encounter Submission Requirements
Attachment J: EPSDT Schedules
Attachment K: Offeror's Checklist
Acute Care RFP
February 3, 2003
- 110 -
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS CONTRACT/RFP NO. YH04-0001
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
[The following provisions must be included verbatim in every subcontract.]
1) ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
No payment due the Subcontractor under this subcontract may be assigned without
the prior approval of AHCCCSA. No assignment or delegation of the duties of this
subcontract shall be valid unless prior written approval is received from
AHCCCSA. (AAC R2-7-305)
2) AWARDS OF OTHER SUBCONTRACTS
AHCCCSA and/or the Contractor may undertake or award other contracts for
additional or related work to the work performed by the Subcontractor and the
Subcontractor shall fully cooperate with such other Contractors, subcontractors
or state employees. The Subcontractor shall not commit or permit any act which
will interfere with the performance of work by any other contractor,
subcontractor or state employee. (AAC R2-7-308)
3) CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK AND LABORATORY TESTING
By signing this subcontract, the Subcontractor certifies that it has not engaged
in any violation of the Medicare Anti-Kickback statute (42 USC Sections
1320a-7b) or the "Stark I" and "Stark II" laws governing related-entity
referrals (PL 101-239 and PL 101-432) and compensation there from. If the
Subcontractor provides laboratory testing, it certifies that it has complied
with 42 CFR Section 411.361 and has sent to AHCCCSA simultaneous copies of the
information required by that rule to be sent to the Health Care Financing
Administration. (42 USC Sections 1320a-7b; PL 101-239 and PL 101-432; 42 CFR
Section 411.361)
4) CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
By signing this subcontract, the Subcontractor certifies that all
representations set forth herein are true to the best of its knowledge. No
payment due the Contractor under this subcontract may be assigned without the
prior approval of AHCCCSA. No assignment or delegation of the duties of this
subcontract shall be valid unless prior written approval is received from
AHCCCSA.
5) CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires
laboratories and other facilities that test human specimens to obtain either a
CLIA Waiver or CLIA Certificate in order to obtain reimbursement from the
Medicare and Medicaid (AHCCCS) programs. In addition, they must meet all the
requirements of 42 CFR 493, Subpart A.
To comply with these requirements, AHCCCSA requires all clinical laboratories to
provide verification of CLIA Licensure or Certificate of Waiver during the
provider registration process. Failure to do so shall result in either a
termination of an active provider ID number or denial of initial registration.
These requirements apply to all clinical laboratories.
Pass-through billing or other similar activities with the intent of avoiding the
above requirements are prohibited. The Contractor may not reimburse providers
who do not comply with the above requirements. (CLIA of 1988; 42 CFR 493,
Subpart A)
6) COMPLIANCE WITH AHCCCSA RULES RELATING TO AUDIT AND INSPECTION
The Subcontractor shall comply with all applicable AHCCCS Rules and Audit Guide
relating to the audit of the Subcontractor's records and the inspection of the
Subcontractor's facilities. If the Subcontractor is an inpatient facility, the
Subcontractor shall file uniform reports and Title XVIII and Title XIX cost
reports with AHCCCSA.
(ARS 41-2548; 45 CFR 74.48 (d))
Acute Care RFP
February 3, 2003
- 111 -
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS CONTRACT/RFP NO. YH04-0001
7) COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
The Subcontractor shall comply with all federal, State and local laws, rules,
regulations, standards and executive orders governing performance of duties
under this subcontract, without limitation to those designated within this
subcontract. (Requirement for FFP, 42 CFR 434.70)
8) CONFIDENTIALITY REQUIREMENT
Confidential information shall be safeguarded pursuant to 42 CFR Part 431,
Subpart F, ARS Section 36-107, 36-2903, 41-1959 and 46-135, AHCCCS Rules and
Health Insurance Portability and Accountability Act (Public Law 107- 191, 110
Statutes 1936).
9) CONFLICT IN INTERPRETATION OF PROVISIONS
In the event of any conflict in interpretation between provisions of this
subcontract and the AHCCCS Minimum Subcontract Provisions, the latter shall take
precedence.
10) CONTRACT CLAIMS AND DISPUTES
Contract claims and disputes arising under A.R.S. Section Title 36, Chapter 29
shall be adjudicated in accordance with AHCCCS Rules. (A.R.S. Section Title 36,
Chapter 29; AAC R2-7-916; AAC R9-22-802)
11) ENCOUNTER DATA REQUIREMENT
If the Subcontractor does not bill the Contractor (e.g., Subcontractor is
capitated), the Subcontractor shall submit encounter data to the Contractor in a
form acceptable to AHCCCSA.
12) EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
The Arizona Health Care Cost Containment System Administration (AHCCCSA) or the
U.S. Department of Health and Human Services may evaluate, through inspection or
other means, the quality, appropriateness or timeliness of services performed
under this subcontract. (ARS 36-2903. C., (8.); ARS 36-2903.02; AAC 9-22-522)
13) FRAUD AND ABUSE
If the Subcontractor discovers, or is made aware, that an incident of potential
fraud or abuse has occurred, the Subcontractor shall report the incident to the
prime Contractor as well as to AHCCCSA, Office of Program Integrity. Incidents
involving potential member eligibility fraud should be reported to AHCCCSA,
Office of Managed Care, Member Fraud Unit. All other incidents of potential
fraud should be reported to AHCCCSA, Office of the Director, Office of Program
Integrity. (ARS 36-2918.01; AAC R9-22-511.)
14) GENERAL INFORMATION
The parties to this contract agree that AHCCCS shall be indemnified and held
harmless by the Contractor and Subcontractor for the vicarious liability of
AHCCCS as a result of entering into this contract. However, the parties further
agree that AHCCCS shall be responsible for its own negligence. Each party to
this contract is responsible for its own negligence.
15) INSURANCE
[This provision applies only if the Subcontractor provides services directly to
AHCCCS members]
The Subcontractor shall maintain for the duration of this subcontract a policy
or policies of professional liability insurance, comprehensive general liability
insurance and automobile liability insurance in amounts that meet AHCCCS
requirements. The Subcontractor agrees that any insurance protection required by
this subcontract, or otherwise obtained by the Subcontractor, shall not limit
the responsibility of Subcontractor to indemnify, keep and save harmless and
defend the State and AHCCCSA, their agents, officers and employees as provided
herein. Furthermore, the Subcontractor shall be fully responsible for all tax
obligations, Worker's Compensation Insurance, and all other applicable insurance
coverage, for itself and its employees, and AHCCCSA shall have no responsibility
or liability for any such taxes or insurance coverage. (45 CFR Part 74)
Acute Care RFP
February 3, 2003
- 112 -
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS CONTRACT/RFP NO. YH04-0001
16) LIMITATIONS ON BILLING AND COLLECTION PRACTICES
The Subcontractor shall not bill, nor attempt to collect payment directly or
through a collection agency from a person claiming to be AHCCCS eligible without
first receiving verification from AHCCCSA that the person was ineligible for
AHCCCS on the date of service, or that services provided were not AHCCCS covered
services.
(AAC R9-22-702 and R9-22-201(J))
17) MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
The Subcontractor shall be registered with AHCCCSA and shall obtain and maintain
all licenses, permits and authority necessary to do business and render service
under this subcontract and, where applicable, shall comply with all laws
regarding safety, unemployment insurance, disability insurance and worker's
compensation.
18) NON-DISCRIMINATION REQUIREMENTS
The Contractor shall comply with State Executive Order No. 99-4, which mandates
that all persons, regardless of race, color, religion, sex, national origin or
political affiliation, shall have equal access to employment opportunities, and
all other applicable Federal and state laws, rules and regulations, including
the Americans with Disabilities Act and Title VI. The Contractor shall take
positive action to ensure that applicants for employment, employees, and persons
to whom it provides service are not discriminated against due to race, creed,
color, religion, sex, national origin or disability. (Federal regulations, State
Executive order # 99-4 & AAC R9-22-513)
19) PRIOR AUTHORIZATION AND UTILIZATION REVIEW
The Contractor and Subcontractor shall develop, maintain and use a system for
Prior Authorization and Utilization Review that is consistent with AHCCCS Rules
and the Contractor's policies. (AAC R9-22-522)
20) RECORDS RETENTION
a. The Contractor shall maintain books and records relating to
covered services and expenditures including reports to AHCCCSA and
working papers used in the preparation of reports to AHCCCSA. The
Contractor shall comply with all specifications for record keeping
established by AHCCCSA. All books and records shall be maintained
to the extent and in such detail as required by AHCCCS Rules and
policies. Records shall include but not be limited to financial
statements, records relating to the quality of care, medical
records, prescription files and other records specified by
AHCCCSA.
b. The Contractor agrees to make available at its office at all
reasonable times during the term of this contract and the period
set forth in the following paragraphs, any of its records for
inspection, audit or reproduction by any authorized representative
of AHCCCSA, State or Federal government.
c. The Contractor shall preserve and make available all records for a
period of five years from the date of final payment under this
contract.
d. If this contract is completely or partially terminated, the
records relating to the work terminated shall be preserved and
made available for a period of five years from the date of any
such termination. Records which relate to grievances, disputes,
litigation or the settlement of claims arising out of the
performance of this contract, or costs and expenses of this
contract to which exception has been taken by AHCCCSA, shall be
retained by the Contractor for a period of five years after the
date of final disposition or resolution thereof. (45 CFR 74.53;
ARS 41-2548)
21) SEVERABILITY
If any provision of these standard subcontract terms and conditions is held
invalid or unenforceable, the remaining provisions shall continue valid and
enforceable to the full extent permitted by law.
Acute Care RFP
February 3, 2003
- 113 -
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS CONTRACT/RFP NO. YH04-0001
22) SUBJECTION OF SUBCONTRACT
The terms of this subcontract shall be subject to the applicable material terms
and conditions of the contract existing between the Contractor and AHCCCSA for
the provision of covered services.
23) TERMINATION OF SUBCONTRACT
AHCCCSA may, by written notice to the Subcontractor, terminate this subcontract
if it is found, after notice and hearing by the State, that gratuities in the
form of entertainment, gifts, or otherwise were offered or given by the
Subcontractor, or any agent or representative of the Subcontractor, to any
officer or employee of the State with a view towards securing a contract or
securing favorable treatment with respect to the awarding, amending or the
making of any determinations with respect to the performance of the
Subcontractor; provided, that the existence of the facts upon which the state
makes such findings shall be in issue and may be reviewed in any competent
court. If the subcontract is terminated under this section, unless the
Contractor is a governmental agency, instrumentality or subdivision thereof,
AHCCCSA shall be entitled to a penalty, in addition to any other damages to
which it may be entitled by law, and to exemplary damages in the amount of three
times the cost incurred by the Subcontractor in providing any such gratuities to
any such officer or employee. (AAC R2-5-501; ARS 41- 2616 C.; 42 CFR 434.6, a.
(6))
24) VOIDABILITY OF SUBCONTRACT
This subcontract is voidable and subject to immediate termination by AHCCCSA
upon the Subcontractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or upon assignment or delegation of
the subcontract without AHCCCSA's prior written approval.
25) WARRANTY OF SERVICES
The Subcontractor, by execution of this subcontract, warrants that it has the
ability, authority, skill, expertise and capacity to perform the services
specified in this contract.
Acute Care RFP
February 3, 2003
- 114 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
ATTACHMENT B: MINIMUM NETWORK STANDARDS
MINIMUM NETWORK STANDARDS
(BY GEOGRAPHIC SERVICE AREA)
INSTRUCTIONS:
Contractors shall have in place an adequate network of providers capable of
meeting contract requirements. The information that follows describes the
minimum network requirements by Geographic Service Area (GSA). In some GSAs
there are required service sites located outside of the geographical boundary of
a GSA. The reason for this relates to practical access to care. In certain
instances, a member must travel a much greater distance to receive services
within their assigned GSA, if the member were not allowed to receive services in
an adjoining GSA or state.
Split zip codes occur in some counties. Split zip codes are those which straddle
two different counties. Enrollment for members residing in these zip codes is
based upon the county and GSA to which the entire zip code has been assigned by
AHCCCS. The Contractor shall be responsible for providing services to members
residing in the entire zip code that is assigned to the GSA for which the
Contractor has agreed to provide services. The split zip codes GSA assignments
are as follows:
SPLIT BETWEEN COUNTY ASSIGNED
ZIP CODE THESE COUNTIES TO ASSIGNED GSA
- -------- -------------------- --------------- ------------
85220 Pinal and Maricopa Maricopa 12
85242 Pinal and Maricopa Maricopa 12
85292 Gila and Pinal Gila 8
85342 Yavapai and Maricopa Maricopa 12
85358 Yavapai and Maricopa Maricopa 12
85390 Yavapai and Maricopa Maricopa 12
85643 Graham and Cochise Cochise 14
85645 Pima and Santa Cruz Santa Cruz 10
85943 Apache and Navajo Navajo 4
86336 Coconino and Yavapai Yavapai 6
86351 Coconino and Yavapai Coconino 4
86434 Mohave and Yavapai Yavapai 6
86340 Coconino and Yavapai Yavapai 6
If outpatient specialty services (OB, family planning, internal medicine and
pediatrics) are not included in the primary care provider contract, at least one
subcontract is required for each of these specialties in the service sites
specified.
In Tucson (GSA 10) and Metropolitan Phoenix (GSA 12), the Contractor must
demonstrate its ability to provide PCP, dental and pharmacy services so that
members do not have to travel more than 5 miles from their residence.
Metropolitan Phoenix is defined on the Minimum Network Standard page specific to
GSA # 12.
Acute Care RFP
February 3, 2003
- 115 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
At a minimum, the Contractor shall have a physician with admitting and treatment
privileges with each hospital in its network. Contractors in GSA 10 and/or GSA
12 must contract with physicians with admitting privileges in at least one
hospital in each service district (see specific GSA requirements). Should the
Hospital Reimbursement Pilot Program be renewed as discussed in Section D,
Paragraph 40, Hospital Subcontracting and Reimbursement, the Contractor shall
contract with at least one hospital in each service district.
Provider categories required at various service delivery sites included in the
Service Area Minimum Network Standards are indicated as follows:
H Hospitals
P Primary Care Providers (physicians, certified nurse practitioners
and physician assistants)
D Dentists
PH Pharmacies
Acute Care RFP
February 3, 2003
- 116 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
HOSPITALS IN PHOENIX METROPOLITAIN AREA (BY SERVICE DISTRICT, BY ZIP CODE)
DISTRICT 1
85006 Good Samaritan Regional Medical Center
St. Luke's Medical Center
85008 Maricopa Medical Center
85013 St. Joseph's Hospital & Medical Center
85020 John C. Lincoln Hospital - North Mountain
DISTRICT 2
85015 Phoenix Baptist Hospital & Medical Center
85027 John C. Lincoln Hospital - Deer Valley
85306 Thunderbird Samaritan Medical Center
85308 Arrowhead Community Hospital & Medical Center
85351 Walter O. Boswell Memorial Hospital
85375 Del E. Webb Memorial Hospital
85031 Maryvale Hospital Medical Center
DISTRICT 3
85032 Paradise Valley Hospital
85054 Mayo Clinic Hospital
85251 Scottsdale Healthcare - Osborn
85261 Scottsdale Healthcare - Shea
DISTRICT 4
85201 Mesa General Hospital Medical Center
Mesa Lutheran Hospital
85202 Desert Samaritan Medical Center
85206 Valley Lutheran Hospital
85224 Chandler Regional Hospital
85281 Tempe St. Luke's Hospital
Acute Care RFP
February 3, 2003
- 117 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
HOSPITALS IN TUCSON METROPOLITAN AREA (BY SERVICE DISTRICT, BY ZIP CODE)
DISTRICT 1
85719 University Medical Center
85741 Northwest Hospital
85745 Carondelet St. Mary's Hospital
DISTRICT 2
85711 Carondelet St. Joseph's Hospital
85712 El Dorado Hospital
Tucson Medical Center
85713 Kino Community Hospital
Acute Care RFP
February 3, 2003
- 118 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
COUNTIES: LA PAZ AND YUMA GEOGRAPHIC SERVICE AREA 2
HOSPITALS
Blythe, CA
Lake Havasu City
Parker
Yuma
PRIMARY CARE PROVIDERS
Blythe, CA
Lake Havasu City
Parker
San Luis
Somerton
Wellton
Yuma
DENTISTS
Blythe, CA
Lake Havasu City
Parker
San Luis
Yuma
PHARMACIES
Blythe, CA
Lake Havasu City
Parker
Somerton
San Luis
Yuma
[GEOGRAPHIC SERVICE AREA 2 MAP]
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
Acute Care RFP
February 3, 2003
- 119 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
COUNTIES: APACHE, COCONINO,
MOHAVE, AND NAVAJO GEOGRAPHIC SERVICE AREA 4
HOSPITALS
Bullhead City
Flagstaff
Gallup, NM
Kanab, UT
Kingman
Lake Havasu City
Needles, CA
Page
Payson
Show Low
Springerville
St. George, UT
Winslow
PRIMARY CARE PROVIDERS
Ash Fork/Seligman
Bullhead City
Colorado City/Hilldale/ Kanab, UT
Flagstaff
Fort Mohave
Gallup, NM
Holbrook
Kingman
Lake Havasu City
Page
Payson
Sedona
Show Low/Pinetop/Lakeside
Snowflake/Taylor
Springerville/Eager
St. George, UT/Mesquite, NV
St. Johns
Williams
Winslow
DENTISTS
SAME AS PRIMARY
CARE PROVIDERS
(except for Fort Mohave,
no dentist required)
PHARMACIES
SAME AS PRIMARY
CARE PROVIDERS
[GEOGRAPHIC SERVICE AREA 4 MAP]
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
Acute Care RFP
February 3, 2003
- 120 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
COUNTY: YAVAPAI GEOGRAPHIC SERVICE AREA 6
HOSPITALS
Cottonwood
Flagstaff
Phoenix
Prescott
PRIMARY CARE PROVIDERS
Ash Fork/Seligman
Camp Verde
Cottonwood
Phoenix/Wickenburg
Prescott
Prescott Valley
Sedona
DENTISTS
SAME AS PRIMARY CARE
PROVIDERS
PHARMACIES
SAME AS PRIMARY CARE
PROVIDERS
(except for Ash Fork/Seligman,
no pharmacy required)
[GEOGRAPHIC SERVICE AREA 6 MAP]
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
Acute Care RFP
February 3, 2003
- 121 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
COUNTIES: PINAL AND GILA GEOGRAPHIC SERVICE AREA 8
HOSPITAL
Casa Grande
Globe
Mesa
Payson
PRIMARY CARE PROVIDERS
Apache Junction
Casa Grande
Coolidge/Florence
Eloy
Globe/Miami/Claypool
Kearney
Mammoth/San Manuel/Oracle
Mesa
Payson
DENTISTS
Apache Junction
Casa Grande
Coolidge/Florence
Eloy
Globe/Miami/Claypool
Kearney
Mammoth/San Manuel/Oracle
Mesa
Payson
PHARMACIES
Apache Junction
Casa Grande
Coolidge/Florence
Globe/Miami/Claypool
Kearney
Mammoth/San Manuel/Oracle
Mesa
Payson
[GEOGRAPHIC SERVICE AREA 8 MAP]
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
Acute Care RFP
February 3, 2003
- 122 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
COUNTY: PIMA AND SANTA CRUZ GEOGRAPHIC SERVICE AREA 10
HOSPITAL
Tucson
District 1
Contract Required
District 2
Contract Required
Nogales
Physician(s) w/admit and
treatment privileges required
PRIMARY CARE PROVIDERS
Ajo
Green Valley
Marana
Nogales
Oro Valley
Tucson
DENTISTS
SAME AS PRIMARY CARE
PROVIDERS
PHARMACIES
SAME AS PRIMARY CARE
PROVIDERS
[GEOGRAPHIC SERVICE AREA 10 MAP]
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
Acute Care RFP
February 3, 2003
- 123 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
COUNTY: MARICOPA GEOGRAPHIC SERVICE AREA 12
HOSPITAL
Metropolitan Phoenix*
District 1
Contract Required
District 2
Contract Required
District 3
Contract Required
District 4
Contract Required
PRIMARY CARE PROVIDERS
Buckeye
Cave Creek/Carefree
Gila Bend
Goodyear/Litchfield Park
Metropolitan Phoenix*
Queen Creek
Wickenburg
DENTISTS
Buckeye/Goodyear/Litchfield Park
Metropolitan Phoenix*
Wickenburg
PHARMACIES
Buckeye
Cave Creek/Carefree
Goodyear/Litchfield Park
Metropolitan Phoenix*
Wickenburg
[GEOGRAPHIC SERVICE AREA 12 MAP]
*For Purposes of this RFP, Metropolitan Phoenix encompasses the following:
Apache Junction, Avondale, Chandler, El Mirage, Fountain Hills, Gilbert,
Glendale, Mesa, Paradise Valley, Peoria, Phoenix, Scottsdale, Sun City/Sun City
West, Surprise, Tempe, Tolleson, and Youngtown. Within this area, distance
standards must be met as specified in Attachment B.
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
Acute Care RFP
February 3, 2003
- 124 -
ATTACHMENT B: GEOGRAPHIC SERVICE AREA CONTRACT/RFP NO. YH04-0001
MINIMUM NETWORK REQUIREMENTS
COUNTIES: COCHISE, GRAHAM GEOGRAPHIC SERVICE AREA 14
AND GREENLEE
HOSPITAL
Benson
Bisbee
Douglas
Safford
Sierra Vista
Tucson
Willcox
PRIMARY CARE PROVIDERS
Benson
Bisbee
Douglas
Morenci/Clifton
Safford
Sierra Vista
Willcox
DENTISTS
Benson/Willcox
Bisbee
Douglas
Morenci/Clifton
Safford
Sierra Vista
PHARMACIES
Benson
Bisbee
Douglas
Morenci/Clifton
Safford/Thatcher
Sierra Vista
Willcox
[GEOGRAPHIC SERVICE AREA 14 MAP]
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
Acute Care RFP
February 3, 2003
- 125 -
ATTACHMENT C: MANAGEMENT SERVICES CONTRACT/RFP NO. YH04-0001
SUBCONTRACTOR STATEMENT
ATTACHMENT C: MANAGEMENT SERVICES SUBCONTRACTOR STATEMENT
INSTRUCTIONS: A Management Services Subcontractor is defined as a marketing
organization or any other organization or person agreeing to perform any
administrative function or service for the Contractor specifically related to
securing or fulfilling the Contractor's obligations to AHCCCSA. This includes,
but is not limited to, third-party administrators, firms or persons who manage
operations of the Contractor such as marketing, automatic data processing,
claims processing, quality management, utilization management, prior
authorization and other management functions.
All Management Services Subcontractors are required to have an annual financial
audit. A copy of this audit must be filed with AHCCCSA within 120 days of the
Subcontractor's fiscal year end. Failure to file a copy may result in withdrawal
of AHCCCSA approval.
Attach to this proposal a signed copy of the Management Subcontract for Contract
Year 04 (10/1/03 - 9/30/04) in addition to all information requested below. If
the existing subcontract is for multiple terms, attach the original management
subcontract and all amendments. When making attachments to this section, please
refer to the question number and the item heading.
*******
MANAGEMENT SERVICES SUBCONTRACTOR STATEMENT
NAME OF BUSINESS _______________________________________________________________
ADDRESS ______________________ CITY _____________ STATE ____ ZIP_____
PHONE NO. ____________________________________
1. TYPE OF BUSINESS (check appropriate box)
[ ] Individual [ ] Partnership [ ] Corporation [ ] Joint Venture
[ ] Government [ ] Other (Describe)
If a corporation, indicate type:_______________________________________
2. INCORPORATED IN THE STATE OF:________________________
If incorporated in a state other than Arizona, do you have a certificate to
do business in the State of Arizona? Yes_____ No_____. If yes, type of
certificate and with what agency or administration is it filed:
_________________________.
3. WHO IS YOUR STATUTORY AGENT FOR THE STATE OF ARIZONA:
Name_______________________________________Phone___________________________
Address_________________________Stata:_______________ Zip:________________
4. PARENT COMPANY AND EMPLOYER IDENTIFICATION NUMBER
Acute Care RFP
February 3, 2003
- 126 -
ATTACHMENT C: MANAGEMENT SERVICES CONTRACT/RFP NO. YH04-0001
SUBCONTRACTOR STATEMENT
For the purpose of this RFP, a parent company is defined as one which
either owns or controls the activities and basic business policies of the
Management Services Subcontractor. To own another company means the parent
company must own at least a majority (more than 50%) of the voting rights
in the company. To control another company, such ownership is not required;
if such company is able to formulate, determine, or veto business policy
decisions of the Management Services Subcontractor, such other company is
considered the parent company of the Management Services Subcontractor.
Is the Management Services Subcontractor owned or controlled by a parent
company as described above? Yes_____ No_____. If yes, insert in the space
below the name and main office address of the parent company.
Name_______________________________________________________________________
Address______________________________________ State _______ Zip_________
5. ORGANIZATION CHART
Attach a copy of your staff functional organizational chart, setting forth
lines of authority, responsibility and communication which will pertain to
this proposal.
6. IF OTHER THAN A GOVERNMENT AGENCY, WHEN WAS YOUR ORGANIZATION
FORMED?_____________________
If your organization is a corporation, attach a list of the names and
addresses of the Board of Directors.
7. LICENSE/CERTIFICATION
Attach a list of all licenses and certifications your organization is
required to maintain. Use a separate sheet of paper using the following
format:
SERVICE COMPONENT LICENSE/REQUIREMENT RENEWAL DATE
If any licenses have been denied, revoked or suspended within the past 10
years, please explain.
8. ADMINISTRATIVE AGENTS
Is your agency acting as the administrative agent for any other agency
organization? Yes____ No____
If yes, describe the relationship in both legal and functional aspects.
9. CIVIL RIGHTS COMPLIANCE DATA
Has any federal or state agency ever made a finding of noncompliance with
any relevant civil rights requirement with respect to your company?
Yes_____ No_____. If yes, please explain.
Acute Care RFP
February 3, 2003
- 127 -
ATTACHMENT C: MANAGEMENT SERVICES CONTRACT/RFP NO. YH04-0001
SUBCONTRACTOR STATEMENT
10. PRIOR CONVICTIONS
Are there any felony convictions of any key personnel (i.e., Chief
Executive Officer, Plan Managers, Financial Officers, major stockholders or
those with controlling interest, etc.) within the past 15 years?
Yes_____ No_____. If yes, please explain.
11. DOES YOUR COMPANY HAVE ANY OWNERSHIP OR CONTROL INTEREST OF 5% OR MORE
(i.e., able to formulate, determine, vote or influence business policy
decisions, etc.) in another organization?
Yes______ No______. If yes, list each organization's name, address and the
percentage of ownership and/or control.
PERCENT OF
NAME ADDRESS OWNERSHIP OR CONTROL
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
12. DO THOSE WHO OWN OR CONTROL YOUR COMPANY HAVE ANY OWNERSHIP OR CONTROL
INTEREST OF 5% OR MORE (i.e., able to formulate, determine, veto or
influence business policy decisions, etc.) in another organization?
Yes_____ No_____. If yes, list each organization's name and address, the
percentage of ownership or control, and the names of those with the common
ownership or control interest:
PERCENT OF
NAME ADDRESS OWNERSHIP OR CONTROL
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
13. HAS YOUR COMPANY EVER BEEN SUSPENDED OR EXCLUDED FROM ANY FEDERAL PROGRAM
FOR ANY REASON? Yes_____ No_____. If yes, please attach explanation.
14. SUBCONTRACTOR'S CUSTOMER DESCRIPTION: For each of your principal customers
(i.e. one that generates 5% or more of Subcontractor's gross annual
revenue), please provide the following information:
a. Customer's name and address
b. Customer's percentage of Subcontractor revenue
c. Percent of Subcontractor's time managing customer
d. Customer's principal business
15. SUBCONTRACTOR'S PERSONNEL EXPERIENCE STATEMENT
Please provide resumes for all key personnel describing professional
experience and education including continuing educational courses taken
during the last three years.
16. SUBCONTRACTOR CONTROLLING INTEREST STATEMENT
Acute Care RFP
February 3, 2003
- 128 -
ATTACHMENT C: MANAGEMENT SERVICES CONTRACT/RFP NO. YH04-0001
SUBCONTRACTOR STATEMENT
Please provide the name and address of any individuals or organizations
with an ownership or controlling interest in the Subcontractor company
(i.e., able to formulate, determine or veto business policy decisions,
etc.). You may include those whose ownership or control interest is less
than 5%.
PERCENT OF
NAME ADDRESS OWNERSHIP OR CONTROL
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
17. SUBCONTRACTOR FINANCIAL STATEMENT
a. Is your accounting system based on a cash or accrual method?
Cash [ ]
Accrual [ ]
Other [ ] (Give a brief explanation.)
b. Does your organization prepare an annual financial statement? Yes_____
No _____. If yes, provide a copy of the latest report.
c. Are interim financial statements prepared? Yes_____ No_____. If yes,
how often are they prepared? ____________________________
Are footnotes and supplementary schedules an integral part of the
statements? Yes _____ No_____.
Provide a copy of the latest statements including all necessary data
to support your answers above.
d. Is your organization audited by an independent accounting firm or
accountant? Yes_____ No_____. If yes, how often are audits
conducted?________________.
By whom are they conducted? Provide name, address and telephone number
and attach a copy of the latest audited financial statements.
e. Do you have any uncorrected audit exceptions? Yes_____ No_____.
If yes, please explain the action being taken to correct the
exceptions.
f. Does your organization have an accounting manual? Yes_____ No_____.
If no, please explain if you have proper accounting policies and
procedures, and how you provide for the dissemination of such
accounting policies and procedures within your organization and what
controls exist to ensure the integrity of your financial information.
The Subcontractor agrees to furnish copies of such written accounting
policies and procedures for inspection upon request from AHCCCSA.
g. Are management letters on internal controls issued by the accounting
firm? Yes_____ No_____.
Acute Care RFP
February 3, 2003
- 129 -
ATTACHMENT C: MANAGEMENT SERVICES CONTRACT/RFP NO. YH04-0001
SUBCONTRACTOR STATEMENT
If yes, attach a copy of the management letter from the latest audit.
This must be on the auditor's letterhead and the Subcontractor, by its
submission, certifies the letter is unaltered.
If no, please provide a comprehensive description of internal control
systems. (You are responsible for instituting adequate procedures
against irregularities and improprieties and enforcing adherence to
generally accepted accounting principles.)
h. Does your organization have a formal basis to distribute or allocate
costs reflected in your financial statement? Yes_____ No_____. Please
explain principal allocation techniques used or proposed to be used.
Indicate the allocation base used for each type of cost allotment.
i. Indicate the types of liability insurance your organization maintains.
State the amount of coverage and the name and address of the carrier.
j. Please attach a complete analysis of revenues and expenses by business
segment (lines of business) and by geographic area (within Arizona and
outside Arizona) for your company or your company's owners.
k. Are there any suits, judgments, tax deficiencies, or claims pending
against your organization? Yes_____ No_____.
If yes, briefly describe each item and indicate the dollar amount,
either actual or estimated.
l. In the last 12 months has your firm or organization paid any bonuses,
provided any gifts over a dollar value of $500, or in any other way
provided a financial reward, over and above salary, to any staff
member, board member or other personnel associated with the firm or
organization? Yes_____ No_____. If yes, describe to whom it was given,
the type of reward, its value and source(s) of revenue.
18. SUBCONTRACTOR'S BACKGROUND CHECK INFORMATION
All Management Services Subcontractors must provide sufficient information
concerning key personnel to enable AHCCCSA to conduct background checks.
Please provide a list of all key personnel giving the following information
for each:
a. Name
b. All other names ever used
c. Social Security Account Number
d. Date of Birth
e. Place of Birth
f. All addresses for the last 10 years
g. Ever suspended from any federal program for any reason? If yes, please
explain.
Acute Care RFP
February 3, 2003
- 130 -
ATTACHMENT C: MANAGEMENT SERVICES CONTRACT/RFP NO. YH04-0001
SUBCONTRACTOR STATEMENT
19. SUBCONTRACTOR RESTRICTION OF COMPETITION STATEMENT
In connection with the Management Services Subcontractor's participation in
this procurement, the Management Services Subcontractor (to include its
employees) to the best of its knowledge and belief:
a. has not disclosed and will not knowingly disclose the prices, or any
matter relating to such prices, to any other offeror, subcontractor or
competitor;
b. has not attempted and will not make any attempt to induce any other
person or firm to submit or not to submit a proposal for the purpose
of restricting competition.
______________________________________________________________________
Management Services Subcontractor Signature
______________________________________________________________________
Print Name and Title
The Management Services Subcontractor shall insert in the applicable space
below, if the Management Services Offeror has no parent company, its own
employer's identification number (Federal social security number used on
employer's quarterly federal tax return, U.S. Treasury Department Form
941), or, if the Subcontractor has a parent company, the employer's
identification number of the parent company.
Management Services Subcontractor
Employer Identification No. ____________________________________________
Parent Company's
Employer Identification No. ____________________________________________
Acute Care RFP
February 3, 2003
- 131 -
ATTACHMENT D (1): SAMPLE LETTER OF INTENT CONTRACT/RFP NO. YH04-0001
ATTACHMENT D (1): SAMPLE LETTER OF INTENT
The following information is provided as early notification for Offerors'
benefit. However, complete instructions regarding this Letter of Intent will be
provided when the RFP is released. Do not send completed Letter of Intent to
AHCCCSA at this time. Only instructions included in the RFP are considered
official.
LETTER OF INTENT INSTRUCTIONS
The following is the mandated format for the Arizona Health Care Cost
Containment System, Contract Year Ending 2004, Letter of Intent (LOI). It is to
be used to show a provider's intention to enter into a contract with an Offeror.
No alterations or changes are permitted, except for shaded areas, which identify
the Offeror. The completed LOI or an executed contract will be acceptable
evidence of an Offeror's proposed network. For purposes of the RFP, no scoring
distinction will be made between an LOI and executed contracts.
If a provider has multiple sites that offer identical services, only one LOI
should be signed, with additional service site information (items 1 to 6)
attached to the LOI. If services differ between sites, a separate LOI must be
obtained for each service site.
If a representative signs an LOI on behalf of a provider, evidence of authority
for the representative must be available upon request.
Acute Care RFP
February 3, 2003
- 132 -
ATTACHMENT D (1): SAMPLE LETTER OF INTENT CONTRACT/RFP NO. YH04-0001
[OFFEROR'S LOGO]
PLEASE DO NOT SIGN THIS LETTER OF INTENT UNLESS YOU SERIOUSLY INTEND TO ENTER
INTO NEGOTIATIONS WITH THE HEALTH PLAN MENTIONED BELOW.
NO ALTERATIONS OR CHANGES ARE PERMITTED, EXCEPT FOR SHADED AREAS WHICH IDENTIFY
THE OFFEROR. THIS LETTER IS SUBJECT TO VERIFICATION BY THE ARIZONA HEALTH CARE
COST CONTAINMENT SYSTEM ADMINISTRATION (AHCCCSA).
THE PROVIDER SIGNING BELOW IS WILLING TO ENTER INTO CONTRACT NEGOTIATIONS WITH
(OFFEROR'S NAME), FOR PROVISION OF COVERED SERVICES TO AHCCCS MEMBERS ENROLLED
WITH (OFFEROR'S NAME). THIS PROVIDER INTENDS TO SIGN A CONTRACT WITH (OFFEROR'S
NAME) IF (OFFEROR'S NAME) IS AWARDED AN AHCCCS CONTRACT BEGINNING OCTOBER 1,
2003 IN THE PROVIDER'S SERVICE AREA AND AN ACCEPTABLE AGREEMENT CAN BE REACHED
BETWEEN THE PROVIDER AND (OFFEROR'S NAME). SIGNING THIS LETTER OF INTENT DOES
NOT OBLIGATE THE PROVIDER TO SIGN A CONTRACT WITH (OFFEROR'S NAME) HOWEVER,
PLEASE DO NOT SIGN THIS LETTER OF INTENT UNLESS YOU SERIOUSLY INTEND TO ENTER
INTO NEGOTIATIONS WITH THE ABOVE MENTIONED HEALTH PLAN.
THE FOLLOWING INFORMATION IS FURNISHED BY THE PROVIDER:
1. AHCCCS PROVIDER IDENTIFICATION NUMBER___________________________________
2. PROVIDER'S PRINTED NAME__________________\_______________________________
3. ADDRESS (WHERE SERVICES WILL BE PROVIDED)________________________________
_____________________________________________________ZIP CODE___________________
4. COUNTY____________________ 5. TELEPHONE__________________ 6. FAX ________
__ PLEASE CHECK HERE IF ADDITIONAL SERVICE SITE INFORMATION IS ATTACHED TO THE
LETTER OF INTENT
7. CHECK ALL THAT APPLY
___ A. PRIMARY CARE PHYSICIAN ___ FAMILY PRACTICE SERVICES ___ EPSDT
___ GENERAL PRACTICE ___ OB
___ PEDIATRICS
___ INTERNAL MEDICINE
___ B. PRIMARY CARE NURSE PRACTITIONER
___ FAMILY PRACTICE SERVICES: ___ EPSDT
___ ADULT ___ OB
___ PEDIATRICS
___ MIDWIFE
___ C. PRIMARY CARE PHYSICIAN'S ASSISTANT SERVICES: ___ EPSDT
___ OB
___ D. PHYSICIAN - SPECIALIST - (SPECIFY)_______________________________________
___ E. HOSPITAL
Acute Care RFP
February 3, 2003
- 133 -
ATTACHMENT D (1): SAMPLE LETTER OF INTENT CONTRACT/RFP NO. YH04-0001
___ F. URGENT CARE FACILITY
___ G. PHARMACY
___ H. LABORATORY
___ I. MEDICAL IMAGING
___ J. MEDICALLY NECESSARY TRANSPORTATION
___ K. NURSING FACILITY
___ L. DENTIST
___ M. THERAPY (SPECIFY PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH,
RESPIRATORY)____________
___ N. BEHAVIORAL HEALTH PROVIDER (SPECIFY)____________________________________
___ O. DURABLE MEDICAL EQUIPMENT
___ P. HOME HEALTH AGENCY
___ Q. OTHER (PLEASE SPECIFY)__________________________________________________
8. LANGUAGES SPOKEN BY THE PROVIDER (OTHER THAN ENGLISH)____________________
________________________________________________________________________________
9. NAME OF HOSPITAL(S) WHERE PHYSICIAN HAS ADMITTING PRIVILEGES ____________
________________________________________________________________________________
________________________________________________________________________________
NOTICE TO PROVIDERS: THIS LETTER OF INTENT WILL BE USED BY AHCCCSA IN ITS BID
EVALUATION AND CONTRACT AWARD PROCESS. YOU SHOULD ONLY SIGN THIS LETTER OF
INTENT IF YOU INTEND TO ENTER INTO CONTRACT NEGOTIATIONS WITH (OFFEROR'S NAME)
SHOULD THEY RECEIVE A CONTRACT AWARD. IF YOU ARE SIGNING ON BEHALF OF A
PHYSICIAN, PLEASE PROVIDE EVIDENCE OF YOUR AUTHORITY TO DO SO.
DO NOT RETURN COMPLETED LETTER OF INTENT TO AHCCCSA. COMPLETED LETTER OF INTENT
NEEDS TO BE RETURNED TO (OFFEROR'S NAME).
10. PROVIDER'S SIGNATURE____________________________________ DATE ___________
11. PRINTED NAME OF SIGNER__________________________________TITLE ___________
Acute Care RFP
February 3, 2003
- 134 -
ATTACHMENT D (1): SAMPLE LETTER OF INTENT CONTRACT/RFP NO. YH04-0001
[OFFEROR'S LOGO]
ADDITIONAL SERVICE SITES
1. AHCCCS PROVIDER IDENTIFICATION NUMBER____________________________________
2. PROVIDER'S PRINTED NAME__________________________________________________
3. ADDRESS (WHERE SERVICES WILL BE PROVIDED)________________________________
_____________________________________________________ZIP CODE__________________
4. COUNTY____________________ 5. TELEPHONE________________ 6. FAX ______
3. ADDRESS (WHERE SERVICES WILL BE PROVIDED)________________________________
_____________________________________________________ZIP CODE___________________
4. COUNTY____________________ 5. TELEPHONE_______________ 6. FAX ______
3. ADDRESS (WHERE SERVICES WILL BE PROVIDED)________________________________
_____________________________________________________ZIP CODE___________________
4. COUNTY____________________ 5. TELEPHONE_______________ 6. FAX ______
3. ADDRESS (WHERE SERVICES WILL BE PROVIDED)________________________________
_____________________________________________________ZIP CODE___________________
4. COUNTY____________________ 5. TELEPHONE_______________ 6. FAX ______
Acute Care RFP
February 3, 2003
- 135 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
ATTACHMENT D (2): NETWORK SUBMISSION REQUIREMENTS
The entire provider network must be submitted on a 3.5" floppy disk in a .dbf
format. The disk must be clearly labeled with the Offeror's name and the number
of records contained on the disk. The disk must be accompanied by the Provider
Network Submission Form found on the last page of this attachment.
The Offeror should note that while the layout and fields for this submission are
similar to those of the quarterly Provider Affiliation Transmission, there are
differences in the information and fields which are required.
The Offeror's provider network must be submitted to AHCCCSA using the layout and
specifications found in this attachment.
Acute Care RFP
February 3, 2003
- 136 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
DEFINITION OF TERMS
- - City The city where the provider performs
services.
- - County Code An AHCCCSA assigned code that
identifies a particular county within
Arizona or identifies a location as
out-of-state.
- - EPSDT Indicator Indicates whether or not the
provider performs early and periodic
screening, diagnosis and treatment
services.
- - Language Spoken Code A code associated with a specific
language, other than English, used by the
provider.
- - OB Indicator Indicates whether or not the provider
delivers obstetric services.
- - PCP Indicator Indicates whether or not the provider is
available as a primary care provider to
the general membership.
- - Provider Type Code An AHCCCSA assigned code that identifies
services that may be rendered by the
provider. For example, 07 (Dentist), 08
(Allopathic Physician - MD), 10
(Podiatrist), 19 (Registered Nurse
Practitioner), and 31 (Osteopathic
Physician - DO).
- - Service Provider ID An AHCCCSA assigned number identifying
the provider.
- - Service Provider Name The name of the service provider.
- - Specialty Code AHCCCSA assigned codes that are subsets
of the Provider Type Codes.
- - Service Street Address The physical street address where the
provider performs services. PO BOXES MUST
NOT BE USED. If a street address does not
exist, you may use a physical
description/location as long as it would
serve to direct members to where care is
provided. Providers who are Hospitalists
should use the hospital address as their
service street address.
- - Service City The city that coincides with the Service
Street Address.
- - Service ZIP Code The ZIP code that coincides with the
Service Street Address and Service City.
- - Provider Contract Status An AHCCCSA assigned number identifying
the provider's contract status.
- - Total Record Count The total number of records submitted by
the Offeror.
Acute Care RFP
February 3, 2003
- 137 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
RULES AND ASSUMPTIONS
- - Service Provider ID is required and must be a valid registered AHCCCSA
provider. Submit ID numbers for individuals, as opposed to group provider
IDs.
- - All text should be in upper case.
- - A Service Provider with multiple service sites requires a separate record
for each service site.
- - Service Provider Name is required. Providers which are entities should be
identified by the entity name followed by any individual identifier (i.e.
AAA Pharmacy #111). Providers which are persons should be identified by
last name, a forward slash, first name, a space, middle initial followed by
a period if applicable (i.e. Smith/John A.).
- - Service Street Address is required. To provide a uniform method to
abbreviate an address, use the street abbreviations found in the Service
Street Address table. Secondary unit abbreviations used in the Service
Street Address must be taken from the Secondary Unit Abbreviation Table.
- - Service City is required.
- - Service ZIP Code is required and should be submitted as a 5 digit code.
- - All of the following yes/no indicators must contain a valid 'Y' or 'N'
value.
- PCP Indicator
- EPSDT Indicator
- OB Indicator
- - Language Spoken Codes must be valid as defined by the Language Spoken Code
table (maximum of two language codes are permitted). If no other languages
than English are spoken the field should be left blank.
- - Specialty Codes must be valid as defined by the Specialty Code table (a
maximum of five Specialty Codes are permitted). Specialty Codes are
required for the following provider types:
- 07 Dentist
- 08 Allopathic Physician (MD)
- 19 Registered Nurse Practitioner
- 31 Osteopathic Physician (DO)
Specialty Codes are not required for provider types other than those listed
above. In cases where Specialty Codes are not required, the field may be
left blank. In cases where more fields exist than are necessary for a
particular provider, the remaining, unnecessary fields should be left
blank.
- - Provider Contract Status must be valid as defined by the Provider Contract
Status Codes table.
Acute Care RFP
February 3, 2003
- 138 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
FILE SPECIFICATIONS
FILE DETAIL
- ---------------------------------------------------------------------------------------------------------------------------
FIELD LENGTH
NAME FIELD DESCRIPTION OF FIELD DEMAND REQUIRED INFORMATION
- ---------------------------------------------------------------------------------------------------------------------------
A SERVICE PROVIDER ID 6 Characters Required An active provider
- ---------------------------------------------------------------------------------------------------------------------------
B SERVICE PROVIDER NAME 25 Characters Required Name of active provider
- ---------------------------------------------------------------------------------------------------------------------------
C SERVICE STREET ADDRESS 25 Characters Required See lists of valid abbreviations in this document
- ---------------------------------------------------------------------------------------------------------------------------
D SERVICE CITY 25 Characters Required Name of city where services are performed
- ---------------------------------------------------------------------------------------------------------------------------
E SERVICE ZIP CODE 5 Characters Required 5 digit number
- ---------------------------------------------------------------------------------------------------------------------------
F COUNTY CODE 2 Characters Required See list of valid codes in this document
- ---------------------------------------------------------------------------------------------------------------------------
G PCP INDICATOR 1 Character Required 'Y' or 'N'
- ---------------------------------------------------------------------------------------------------------------------------
H OB INDICATOR 1 Character Required 'Y' or 'N'
- ---------------------------------------------------------------------------------------------------------------------------
I EPSDT INDICATOR 1 Character Required 'Y' or 'N'
- ---------------------------------------------------------------------------------------------------------------------------
J LANGUAGE CODE 1 2 Characters Optional See list of valid codes in this document
- ---------------------------------------------------------------------------------------------------------------------------
K LANGUAGE CODE 2 2 Characters Optional See list of valid codes in this document
- ---------------------------------------------------------------------------------------------------------------------------
L PROVIDER TYPE CODE 2 Characters Required See list of valid codes in this document
- ---------------------------------------------------------------------------------------------------------------------------
M SPECIALTY CODE 1 3 Characters Conditional See list of valid codes in this document
- ---------------------------------------------------------------------------------------------------------------------------
N SPECIALTY CODE 2 3 Characters Conditional See list of valid codes in this document
- ---------------------------------------------------------------------------------------------------------------------------
O SPECIALTY CODE 3 3 Characters Conditional See list of valid codes in this document
- ---------------------------------------------------------------------------------------------------------------------------
P SPECIALTY CODE 4 3 Characters Conditional See list of valid codes in this document
- ---------------------------------------------------------------------------------------------------------------------------
Q SPECIALTY CODE 5 3 Characters Conditional See list of valid codes in this document
- ---------------------------------------------------------------------------------------------------------------------------
R PROVIDER CONTRACT STATUS 2 Characters Required See list of valid codes in this document
- ---------------------------------------------------------------------------------------------------------------------------
Acute Care RFP
February 3, 2003
- 139 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
FILE SAMPLE
- ------------------------------------------------------------------------------------------------------------------------------------
A B C D E F G H I J K L M N O P Q R
- ------------------------------------------------------------------------------------------------------------------------------------
010101 AAA PHARMACY #111 222 WEST MAIN ST PHOENIX 85000 13 N N N 03 01
- ------------------------------------------------------------------------------------------------------------------------------------
020202 SMITH/JOHN A. 111 EAST CENTER TUCSON 85000 19 Y N Y 01 08 150 156 02
- ------------------------------------------------------------------------------------------------------------------------------------
121212 DOE/JANE 333 NORTH OAK FLAGSTAFF 85000 05 Y Y Y 01 15 31 089 01
- ------------------------------------------------------------------------------------------------------------------------------------
SOME FIELD LENGTHS IN FILE SAMPLE ARE NOT REPRESENTATIONAL OF REQUIREMENTS.
Acute Care RFP
February 3, 2003
- 140 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
SERVICE STREET ABBREVIATIONS
- --------------------------------------------------------------
PRIMARY NAME APPROVED ABBREVIATION
- --------------------------------------------------------------
Avenue AVE
- --------------------------------------------------------------
Boulevard BLVD
- --------------------------------------------------------------
Center CTR
- --------------------------------------------------------------
Circle CIR
- --------------------------------------------------------------
Court CT
- --------------------------------------------------------------
Drive DR
- --------------------------------------------------------------
Expressway EXPY
- --------------------------------------------------------------
Freeway FWY
- --------------------------------------------------------------
Highway HWY
- --------------------------------------------------------------
Junction JCT
- --------------------------------------------------------------
Lane LN
- --------------------------------------------------------------
Parkway PKWY
- --------------------------------------------------------------
Place PL
- --------------------------------------------------------------
Road RD
- --------------------------------------------------------------
Roadway RDWY
- --------------------------------------------------------------
Route RT
- --------------------------------------------------------------
Square SQ
- --------------------------------------------------------------
Station STA
- --------------------------------------------------------------
Street ST
- --------------------------------------------------------------
Terrace TER
- --------------------------------------------------------------
Trail TRL
- --------------------------------------------------------------
SECONDARY UNIT ABBREVIATIONS
- --------------------------------------------------------------
DESCRIPTION APPROVED ABBREVIATION
- --------------------------------------------------------------
Administration ADMN
- --------------------------------------------------------------
Annex ANX
- --------------------------------------------------------------
Apartment APT
- --------------------------------------------------------------
Branch BR
- --------------------------------------------------------------
Building BLDG
- --------------------------------------------------------------
Company CO
- --------------------------------------------------------------
Convalescent CONVAL
- --------------------------------------------------------------
Department DEPT
- --------------------------------------------------------------
Division DIV
- --------------------------------------------------------------
Floor FL
- --------------------------------------------------------------
Hospice HSPC
- --------------------------------------------------------------
Hospital HOSP
- --------------------------------------------------------------
Laboratory LAB
- --------------------------------------------------------------
Lobby LBBY
- --------------------------------------------------------------
Office OFC
- --------------------------------------------------------------
Room RM
- --------------------------------------------------------------
Space SPC
- --------------------------------------------------------------
Suite STE
- --------------------------------------------------------------
Trailer TRLR
- --------------------------------------------------------------
Acute Care RFP
February 3, 2003
- 141 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
C O U N T Y C O D E S
- ----------------------
CODE DESCRIPTION
- ----------------------
01 APACHE
- ----------------------
03 COCHISE
- ----------------------
05 COCONINO
- ----------------------
07 GILA
- ----------------------
09 GRAHAM
- ----------------------
11 GREENLEE
- ----------------------
13 MARICOPA
- ----------------------
15 MOHAVE
- ----------------------
17 NAVAJO
- ----------------------
19 PIMA
- ----------------------
21 PINAL
- ----------------------
23 SANTA CRUZ
- ----------------------
25 YAVAPAI
- ----------------------
27 YUMA
- ----------------------
29 LA PAZ
- ----------------------
99 OUT-OF-STATE
- ----------------------
LANGUAGE SPOKEN CODES
- -------------------------------------------------------
CODE DESCRIPTION AREA OF ORIGIN
- -------------------------------------------------------
01 SPANISH
- -------------------------------------------------------
02 ALBANIAN
- -------------------------------------------------------
03 AMERICAN SIGN LANGUAGE
- -------------------------------------------------------
04 APACHE
- -------------------------------------------------------
05 ARABIC
- -------------------------------------------------------
06 ARMENIAN
- -------------------------------------------------------
07 BOSNIAN
- -------------------------------------------------------
08 CHINESE
- -------------------------------------------------------
09 CROATIAN
- -------------------------------------------------------
10 CZECH
- -------------------------------------------------------
11 DANISH
- -------------------------------------------------------
12 DUTCH
- -------------------------------------------------------
13 EDO NIGERIA
- -------------------------------------------------------
14 FINNISH
- -------------------------------------------------------
15 FRENCH
- -------------------------------------------------------
16 GERMAN
- -------------------------------------------------------
17 GREEK
- -------------------------------------------------------
18 GUJARATI INDIA
- -------------------------------------------------------
19 HEBREW
- -------------------------------------------------------
20 HINDI, INDIAN, EAST INDIAN
- -------------------------------------------------------
21 HOPI
- -------------------------------------------------------
22 IRANIAN, PERSIAN, FARSI
- -------------------------------------------------------
Acute Care RFP
February 3, 2003
- 142 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
LANGUAGE SPOKEN CODES (CONT'D)
- ------------------------------------------------------------------------------
CODE DESCRIPTION AREA OF ORIGIN
- ------------------------------------------------------------------------------
23 ITALIAN
- ------------------------------------------------------------------------------
24 JAPANESE
- ------------------------------------------------------------------------------
25 KANNADA INDIA
- ------------------------------------------------------------------------------
26 KOREAN
- ------------------------------------------------------------------------------
27 MARATHI AFGHANISTAN, BANGLADESH, INDIA, IRAN,
NEPAL, PAKISTAN, AND SRI LANKA
- ------------------------------------------------------------------------------
28 NAVAJO
- ------------------------------------------------------------------------------
29 NIGERIAN
- ------------------------------------------------------------------------------
30 NORWEGIAN
- ------------------------------------------------------------------------------
31 IGBO NIGERIA
- ------------------------------------------------------------------------------
32 POLISH
- ------------------------------------------------------------------------------
33 PORTUGUESE
- ------------------------------------------------------------------------------
34 PUNJABI PAKISTAN
- ------------------------------------------------------------------------------
35 ROMANIAN
- ------------------------------------------------------------------------------
36 RUSSIAN
- ------------------------------------------------------------------------------
37 SERBIAN
- ------------------------------------------------------------------------------
38 SINGHALESE SRI LANKA
- ------------------------------------------------------------------------------
39 SWEDISH
- ------------------------------------------------------------------------------
40 TAGALOG (FILIPINO)
- ------------------------------------------------------------------------------
41 TAIWANESE
- ------------------------------------------------------------------------------
42 TAMIL INDIA
- ------------------------------------------------------------------------------
43 THAI, SIAMESE
- ------------------------------------------------------------------------------
44 TOHONO O'ODHAM
- ------------------------------------------------------------------------------
45 UKRANIAN
- ------------------------------------------------------------------------------
46 URDU, PAKISTANI
- ------------------------------------------------------------------------------
47 VIETNAMESE
- ------------------------------------------------------------------------------
48 YAQUI
- ------------------------------------------------------------------------------
49 YORUBA WESTERN AFRICA
- ------------------------------------------------------------------------------
99 OTHER
- ------------------------------------------------------------------------------
Acute Care RFP
February 3, 2003
- 143 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
PROVIDER TYPE CODES
- -------------------------------------------------
CODE DESCRIPTION
- -------------------------------------------------
02 HOSPITAL
- -------------------------------------------------
03 PHARMACY
- -------------------------------------------------
04 LABORATORY
- -------------------------------------------------
05 URGENT CARE CENTER
- -------------------------------------------------
07 DENTIST
- -------------------------------------------------
08 MD-PHYSICIAN ALLOPATH
- -------------------------------------------------
09 CERTIFIED NURSE-MIDWIFE
- -------------------------------------------------
12 CERTIFIED REGISTERED NURSE ANESTHETIST
- -------------------------------------------------
16 CHIROPRACTOR
- -------------------------------------------------
18 PHYSICIAN'S ASSISTANT
- -------------------------------------------------
19 REGISTERED NURSE PRACTITIONER
- -------------------------------------------------
22 NURSING HOME
- -------------------------------------------------
23 HOME HEALTH AGENCY
- -------------------------------------------------
28 NON-EMERGENCY TRANSPORTATION PROVIDERS
- -------------------------------------------------
30 DME SUPPLIER
- -------------------------------------------------
31 DO-PHYSICIAN OSTEOPATH
- -------------------------------------------------
35 HOSPICE
- -------------------------------------------------
41 DIALYSIS CLINIC
- -------------------------------------------------
48 NUTRITIONIST
- -------------------------------------------------
62 AUDIOLOGIST
- -------------------------------------------------
65 HOSPITAL OUTPATIENT SURGERY CENTER
- -------------------------------------------------
69 OPTOMETRIST
- -------------------------------------------------
84 LICENSED MIDWIFE
- -------------------------------------------------
99 OTHER
- -------------------------------------------------
Acute Care RFP
February 3, 2003
- 144 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
SPECIALTY CODES
- ----------------------------------------
CODE DESCRIPTION
- ----------------------------------------
010 ALLERGIST/IMMUNOLOGIST
- ----------------------------------------
011 ALLERGIST
- ----------------------------------------
012 IMMUNOLOGIST
- ----------------------------------------
020 ANESTHESIOLOGIST
- ----------------------------------------
030 SURGERY-COLON/RECTAL
- ----------------------------------------
040 DERMATOLOGIST
- ----------------------------------------
050 FAMILY PRACTICE
- ----------------------------------------
055 GENERAL PRACTICE
- ----------------------------------------
060 INTERNAL MEDICINE
- ----------------------------------------
062 CARDIOVASCULAR MEDICINE
- ----------------------------------------
063 ENDOCRINOLOGIST
- ----------------------------------------
064 GASTROENTEROLOGIST
- ----------------------------------------
065 HEMATOLOGIST
- ----------------------------------------
066 INFECTIOUS DISEASES
- ----------------------------------------
067 NEPHROLOGIST
- ----------------------------------------
068 PULMONARY DISEASES
- ----------------------------------------
069 RHEUMATOLOGIST
- ----------------------------------------
070 SURGERY-NEUROLOGY
- ----------------------------------------
075 NEUROLOGIST
- ----------------------------------------
076 PEDIATRIC NEUROLOGIST
- ----------------------------------------
080 NUCLEAR MEDICINE
- ----------------------------------------
082 GERONTOLOGIST
- ----------------------------------------
083 PSYCHOLOGIST
- ----------------------------------------
084 RN FAMILY NURSE PRACTITIONER
- ----------------------------------------
085 RN SCHOOL NURSE PRACTITIONER
- ----------------------------------------
086 RN PEDIATRIC NURSE ASSOCIATE
- ----------------------------------------
087 RN PEDIATRIC NURSE PRACTITIONER
- ----------------------------------------
088 RN GERIATRIC NURSE PRACTITIONER
- ----------------------------------------
089 OBSTETRICIAN AND GYNECOLOGIST
- ----------------------------------------
090 GYNECOLOGIST
- ----------------------------------------
091 OBSTETRICIAN
- ----------------------------------------
092 MATERNAL AND FETAL MEDICINE
- ----------------------------------------
093 REPRODUCTIVE ENDOCRINOLOGIST
- ----------------------------------------
094 RN MIDWIFE
- ----------------------------------------
095 WOMEN'S HC/OB-GYN NP
- ----------------------------------------
096 NEONATAL NURSE PRACTITIONER
- ----------------------------------------
097 RN ADULT NURSE PRACTITIONER
- ----------------------------------------
100 OPHTHALMOLOGIST
- ----------------------------------------
110 SURGERY-ORTHOPEDIC
- ----------------------------------------
120 OTOLARYNGOLOGIST
- ----------------------------------------
122 LARYNGOLOGIST
- ----------------------------------------
124 OTOLOGIST
- ----------------------------------------
125 RHINOLOGIST
- ----------------------------------------
150 PEDIATRICIAN
- ----------------------------------------
151 PEDIATRIC CARDIOLOGIST
- ----------------------------------------
152 PEDIATRIC HEMATOLOGIST
- ----------------------------------------
Acute Care RFP
February 3, 2003
- 145 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
SPECIALTY CODES (CONT'D)
- --------------------------------------------------
CODE DESCRIPTION
- --------------------------------------------------
153 SURGERY-PEDIATRIC
- --------------------------------------------------
154 PEDIATRIC NEPHROLOGIST
- --------------------------------------------------
155 PEDIATRIC NEONATAL/PERINATAL
- --------------------------------------------------
156 PEDIATRIC ENDOCRINOLOGIST
- --------------------------------------------------
157 PEDIATRIC ALLERGIST
- --------------------------------------------------
158 RADIOLOGY PEDIATRIC
- --------------------------------------------------
159 PEDIATRIC PULMONARY
- --------------------------------------------------
160 PHYSICAL MEDICINE/REHABILITATION
- --------------------------------------------------
161 OSTEOPATHIC MANIPULATIVE THERAPY
- --------------------------------------------------
165 THERAPIST-SPEECH
- --------------------------------------------------
166 THERAPIST-OCCUPATIONAL
- --------------------------------------------------
167 THERAPIST-PHYSICAL
- --------------------------------------------------
170 SURGERY-PLASTIC
- --------------------------------------------------
171 SURGERY-PLASTIC, OTOLARYNGOLOGICAL FACIAL
- --------------------------------------------------
175 ACUPUNCTURIST
- --------------------------------------------------
176 ADOLESCENT MEDICINE
- --------------------------------------------------
181 SURGERY-OBSTETRICAL
- --------------------------------------------------
182 PREVENTIVE MEDICINE
- --------------------------------------------------
183 OCCUPATIONAL MEDICINE
- --------------------------------------------------
187 NUTRITIONIST
- --------------------------------------------------
188 PHARMACOLOGIST
- --------------------------------------------------
191 PEDIATRIC-PSYCHIATRIST
- --------------------------------------------------
192 PSYCHIATRIST
- --------------------------------------------------
195 PSYCHIATRIST AND NEUROLOGIST
- --------------------------------------------------
200 RADIOLOGY
- --------------------------------------------------
201 RADIOLOGY-DIAGNOSTIC
- --------------------------------------------------
205 RADIOLOGY-THERAPEUTIC
- --------------------------------------------------
210 SURGERY
- --------------------------------------------------
211 SURGERY-ABDOMINAL
- --------------------------------------------------
212 SURGERY-CARDIOVASCULAR
- --------------------------------------------------
213 SURGERY-HAND
- --------------------------------------------------
214 SURGERY-HEAD AND NECK
- --------------------------------------------------
215 SURGERY-MAXILLOFACIAL
- --------------------------------------------------
216 SURGERY-TRAUMA
- --------------------------------------------------
217 SURGERY-UROLOGICAL
- --------------------------------------------------
218 SURGERY-VASCULAR
- --------------------------------------------------
219 SURGERY-GYNECOLOGICAL
- --------------------------------------------------
220 SURGERY-THORACIC
- --------------------------------------------------
230 UROLOGIST
- --------------------------------------------------
241 ONCOLOGIST
- --------------------------------------------------
250 EMERGENCY MEDICINE
- --------------------------------------------------
251 CRITICAL CARE MEDICINE
- --------------------------------------------------
441 SURGERY-OPHTHALMOLOGICAL
- --------------------------------------------------
484 SURGERY-PODIATRIST
- --------------------------------------------------
490 IMMUNOHEMATOLOGY
- --------------------------------------------------
503 PHYSIOLOGICAL TESTING
- --------------------------------------------------
Acute Care RFP
February 3, 2003
- 146 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
SPECIALTY CODES (CONT'D)
- --------------------------------------
CODE DESCRIPTION
- --------------------------------------
600 OPTOMETRIST
- --------------------------------------
650 PODIATRIST
- --------------------------------------
714 EYE (LOW VISION SPECIALIST)
- --------------------------------------
798 PHYSICIAN ASSISTANT
- --------------------------------------
800 DENTIST-GENERAL
- --------------------------------------
801 DENTIST-ORTHODONTURE
- --------------------------------------
802 DENTIST-ENDODONTIST
- --------------------------------------
803 DENTIST-ORAL PATHOLOGIST
- --------------------------------------
804 DENTIST-PEDODONTIST
- --------------------------------------
805 DENTIST-PROSTHODONTIST
- --------------------------------------
806 DENTIST-PERIODONTIST
- --------------------------------------
808 DENTIST-ORAL SURGEON
- --------------------------------------
809 DENTIST-ANESTHESIOLOGIST
- --------------------------------------
900 PROCEDURES-ANY CERTIFIED LAB
- --------------------------------------
901 EMERGENCY ROOM PHYSICIANS
- --------------------------------------
925 AUDIOLOGIST
- --------------------------------------
927 CARDIOLOGIST
- --------------------------------------
935 OTORHINOLARYNGOLOGIST (ENT)
- --------------------------------------
943 PEDIATRIC ORTHOPEDIST
- --------------------------------------
950 ORTHOPEDIST
- --------------------------------------
958 GYNECOLOGICAL ONCOLOGY
- --------------------------------------
963 PEDIATRIC HEMATOLOGY-ONCOLOGY
- --------------------------------------
999 OTHER
- --------------------------------------
Acute Care RFP
February 3, 2003
- 147 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
PROVIDER CONTRACT STATUS CODES
- -------------------------------------------------------------
CODE PROVIDER CONTRACT STATUS
- -------------------------------------------------------------
01 PROVIDER CURRENTLY CONTRACTED WITH OFFEROR
- -------------------------------------------------------------
02 PROVIDER HAS SIGNED LETTER OF INTENT WITH OFFEROR
- -------------------------------------------------------------
Acute Care RFP
February 3, 2003
- 148 -
ATTACHMENT D (2): NETWORK SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
PROVIDER NETWORK SUBMISSION FORM
OFFEROR NAME _________________________________________
TOTAL RECORD COUNT ________________________
THIS SUBMISSION INCLUDES A NETWORK FOR THE FOLLOWING GSA(s)
- ---------------------------
Yes No
- ---------------------------
GSA 2
- ---------------------------
GSA 4
- ---------------------------
GSA 6
- ---------------------------
GSA 8
- ---------------------------
GSA 10
- ---------------------------
GSA 12
- ---------------------------
GSA 14
- ---------------------------
Acute Care RFP
February 3, 2003
- 149 -
ATTACHMENT E: INSTRUCTIONS FOR PREPARING CONTRACT/RFP NO. YH8-0001
CAPITATION PROPOSAL
ATTACHMENT E: INSTRUCTIONS FOR PREPARING CAPITATION PROPOSAL
All capitation rate bid proposals (including and best and final offers, if
applicable) must be submitted to AHCCCSA via the AHCCCS Web Based Capitation
Rate Proposal application. A Capitation Rate Calculation Sheet (CRCS) must be
completed for every risk group in each Geographic Service Area (GSA) in which
the Offeror bids.
The Offeror must also use the Web application to print and submit Section B,
Capitation Rates, of the Request for Proposal (RFP). In the event that the Web
application bid submission differs from the bid submission included with Section
B of the RFP, the bid submitted via the Web application will prevail. The first
page of Section B should be the certification that the capitation rates are
actuarially sound by an actuary who is a member of the American Academy of
Actuaries.
The Web application will present the CRCS bid screens by:
a. Pharmacy expenditures included and without pharmacy expenditures
b. Geographic Service Area (GSA), and
c. Risk Group
The following is a list of the seven GSAs and the fifteen counties associated to
each GSA that will be effective 10/1/03.
- ----------------------------------------------
GSA County or Counties
- ----------------------------------------------
2 Yuma, La Paz
- ----------------------------------------------
4 Apache, Coconino, Mohave, and Navajo
- ----------------------------------------------
6 Yavapai
- ----------------------------------------------
8 Gila, Pinal
- ----------------------------------------------
10 Pima, Santa Cruz
- ----------------------------------------------
12 Maricopa
- ----------------------------------------------
14 Graham, Greenlee, Cochise
- ----------------------------------------------
The following is a listing of the nine risk groups for which capitation rates
need to be bid. All nine risk groups apply to each GSA.
1. TANF <1
2. TANF 1-13
3. TANF 14-44 Female
4. TANF 14-44 Male
5. TANF 45+
6. SSI with Medicare
7. SSI without Medicare
8. SOBRA Family Planning
9. Delivery Supplemental Payment
Note: 1931s, KidsCare, SOBRA Children, SOBRA Mothers, and Breast and Cervical
Cancer Treatment Program populations are included in TANF risk groups. See the
Data Supplement for the roll up of rate codes in the nine risk groups.
Acute Care RFP
February 3, 2003
- 150 -
ATTACHMENT E: INSTRUCTIONS FOR PREPARING CONTRACT/RFP NO. YH8-0001
CAPITATION PROPOSAL
Detailed instructions for the Web application will be included within the Web
application at the time it becomes available. Instructions will also be made
available via a solicitation amendment. These instructions will include general
guidelines for the usage of the Web application as well as the following items:
- Process to receive a unique ID and password for the Web application
- Application software requirements
- Customer technical support desk phone number
Acute Care RFP
February 3, 2003
- 151 -
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS CONTRACT/RFP NO. YH04-0001
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
The following table is a summary of the periodic reporting requirements for
AHCCCS acute care contractors and is subject to change at any time during the
term of the contract. The table is presented for convenience only and should not
be construed to limit the Contractor's responsibilities in any manner.
"Reporting Guide" refers to the Reporting Guide for Acute Health Care
Contractors with the Arizona Health Care Cost Containment System.
- --------------------------------------------------------------------------------------------------------------------
AHCCCS
REPORT WHEN DUE SOURCE/REFERENCE CONTACT:
- --------------------------------------------------------------------------------------------------------------------
Monthly Financial 30 days after the end of Reporting Guide Financial
Reporting Package the month, as applicable Manager
- --------------------------------------------------------------------------------------------------------------------
Quarterly Financial 60 days after the end of Reporting Guide Financial
Reporting Package each quarter Manager
- --------------------------------------------------------------------------------------------------------------------
Draft Annual Financial 90 days after the end of Reporting Guide Financial
Reporting Package each fiscal year Manager
- --------------------------------------------------------------------------------------------------------------------
Final Annual Financial 120 days after the end of Reporting Guide Financial
Reporting Package each fiscal year Manager
- --------------------------------------------------------------------------------------------------------------------
Management Services 120 days after the end of Reporting Guide Financial
Subcontractor Audit Report the subcontractor's fiscal Manager
(if services > $50,000) year
- --------------------------------------------------------------------------------------------------------------------
Physician Incentive Plan To be determined RFP Section D, Paragraph 42 Financial
(PIP) reporting Manager
- --------------------------------------------------------------------------------------------------------------------
Provider Affiliation 15 days after the end of PMMIS Provider-to-Health OMC, Health
Transmission each quarter Plan FTP submission and Plan Operations
processing
- --------------------------------------------------------------------------------------------------------------------
Corrected Pended Monthly, according to Encounter Manual Encounter
Encounter Data established schedule Administrator
- --------------------------------------------------------------------------------------------------------------------
New Day Encounter Monthly, according to Encounter Manual Encounter
established schedule Administrator
- --------------------------------------------------------------------------------------------------------------------
Medical Records for Data 90 days after the request RFP Attachment I, Encounter Encounter
Validation received from Submission Requirements Administrator
AHCCCSA
- --------------------------------------------------------------------------------------------------------------------
Quarterly Grievance and 45 days after the end of RFP Section D, Paragraph 26 Office of Legal
Appeals Report each quarter Assistance
- --------------------------------------------------------------------------------------------------------------------
Comprehensive EPSDT Annually on December RFP Section D, Paragraph 24 OMM/CQM
Plan including Dental 15th
- --------------------------------------------------------------------------------------------------------------------
EPSDT Progress Report 15 days after the end of AMPM, Chapter 400 OMM/CQM
including Dental - Quarterly each quarter
Update
- --------------------------------------------------------------------------------------------------------------------
Quarterly Inpatient Hospital 15 days after the end of State Medicaid Manual and OMM CSM
Showing each quarter the AMPM, Chapter 1000
- --------------------------------------------------------------------------------------------------------------------
Quality Management Annually on December AMPM, Chapter 900 OMM/CQM
Utilization Management 15th
Plan and Evaluation
- --------------------------------------------------------------------------------------------------------------------
Monthly Pregnancy End of the month AMPM, Chapter 400 OMM/CQM
Termination Report following the pregnancy
termination
- --------------------------------------------------------------------------------------------------------------------
Acute Care RFP
February 3, 2003
- 152 -
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS CONTRACT/RFP NO. YH04-0001
- -------------------------------------------------------------------------------------------------------------------------
Maternity Care Plan Annually on December AMPM, Chapter 400 OMM/CQM
15th
- -------------------------------------------------------------------------------------------------------------------------
Semi-annual report of 30 days after the end of AMPM, Chapter 400 OMM/CQM
number of pregnant women the 2nd and 4th quarter
who are HIV/AIDS positive of each contract year
- -------------------------------------------------------------------------------------------------------------------------
Provider Network 45 days after the first day RFP Section D, Paragraph 27 OMC, Health
Development and of a new contract year Plan Operations
Management Plan
- -------------------------------------------------------------------------------------------------------------------------
Cultural Competency Plan 45 days after the first day AHCCCS Cultural OMC, Health
of a new contract year Competency Policy Plan Operations
- -------------------------------------------------------------------------------------------------------------------------
Quality Improvement Annually on December AMPM, Chapter 900 OMM/CQM
Project Proposal 15th
(initial/baseline year of the
project)
- -------------------------------------------------------------------------------------------------------------------------
Quality Improvement Annually on December AMPM, Chapter 900 OMM/CQM
Project Interim Report 15th
(intervention/measurement
year(s) of the project)
- -------------------------------------------------------------------------------------------------------------------------
Quality Improvement Within 180 days of the AMPM Chapter 900 OMM/CQM
Project Final Report end of the project, as
defined in the project
proposal approved by
AHCCCS OMM
- -------------------------------------------------------------------------------------------------------------------------
Provider Fraud/Abuse Immediately following RFP Section D, Paragraph 62 Office of
Report discovery Program Integrity
Manager
- -------------------------------------------------------------------------------------------------------------------------
Eligible Person Immediately following RFP Section D, Paragraph 62 Office of
Fraud/Abuse Report discovery Program Integrity
Manager
- -------------------------------------------------------------------------------------------------------------------------
Non-Transplant Annually, within 30 days RFP Section D, Paragraph 57 OMC
Catastrophic Reinsurance of the beginning of the Reinsurance
covered Diseases contract year, enrollment Manager
to the plan, and when
newly diagnosed.
- -------------------------------------------------------------------------------------------------------------------------
Prescription Drug Monthly, within 45 days AMPM Pharmacy
Utilization Report* of month end Program
Administrator
- -------------------------------------------------------------------------------------------------------------------------
*Applicable in the event that the prescription drug benefit remains the
responsibility of the Contractor - see Paragraph 75, Pending Legislation / Other
Issues, for more information.
Acute Care RFP
February 3, 2003
- 153 -
ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM CONTRACT/RFP NO. YH04-0001
ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
Members who do not have the right to choose a Contractor or members who have the
right to choose but do not exercise this right, are assigned to a Contractor
through an auto-assignment algorithm. The algorithm is a mathematical formula
used to distribute members to the various Contractors in a manner that is
predictable and consistent with AHCCCSA goals.
The algorithm employs a data table and a formula to assign cases (a case may be
a member or a household of members) to Contractors using the target percentages
developed. The algorithm data table consists of all the geographic service areas
(GSA) in the state, all Contractors serving each GSA, and the target percentages
by risk group within each GSA.
The Contractor farthest away from its target percentage within a GSA and risk
group, the largest negative difference, is assigned the next case for that GSA.
The equation used is:
(t/T) - P = d
t = The total members assigned to the GSA, per risk group category, for the
Contractor
T = The total members assigned to the GSA, per risk group category, all
Contractors combined
P = The target percentage of members per risk group for the Contractor
d = The difference
The algorithm is calculated after each assignment to give a new difference for
each Contractor. When more than one Contractor has the same difference, and
their differences are greater than all other Contractors, the Contractor with
the lowest Health Plan I.D. Number will be assigned the case.
Assignment by the algorithm applies to:
1. Members that are newly eligible to the AHCCCS program that did not
choose a Contractor within the prescribed time limits.
2. Members whose assigned health plan is no longer available after the
member moves to a new GSA and did not choose a new Contractor within
the prescribed time limits.
3. Members whose assigned plan is no longer available at the beginning of
a contract cycle that did not choose a Contractor within the prescribed
time limits.
All Contractors, within a given geographic service area (GSA) and for each risk
group, will have a placement in the algorithm and will receive members
accordingly. A Contractor with a more favorable target percentage in the
algorithm will receive proportionally more members. Conversely, a Contractor
with a lower target percentage in the algorithm will receive proportionally
fewer members. The algorithm favors Contractors with both lower final bids and
awarded rates. The algorithm also favors those Contractors with programs that
score higher based on AHCCCSA's evaluation criteria.
For Contractors in the Maricopa and Pima/Santa Cruz GSAs with fewer than 25,000
members statewide, a temporary adjustment will be made to the algorithm formula
in order to ensure a minimum membership (see the discussion entitled "Adjustment
Methodology for Contractors with Fewer than 25,000 Members" for more
information).
Acute Care RFP
February 3, 2003
- 154 -
ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM CONTRACT/RFP NO. YH04-0001
DEVELOPMENT OF THE TARGET PERCENTAGES
For the first year of the contract, the algorithm target percentages will be
developed using the methodology described below. However, for subsequent years,
AHCCCS reserves the right to change the algorithm methodology to assure
assignments are made in the best interest of the AHCCCS program and the State.
A Contractor's placement in the algorithm is based upon the following three
factors, which are weighted as follows:
- -----------------------------------------------------------------------------------------------------
# FACTOR WEIGHTING
- -----------------------------------------------------------------------------------------------------
1 The final capitation rate bid submitted by the Contractor. Final bids 30%
that are below the bottom of the rate range will be assigned to the bottom
of the rate range for development of the target percentages.
- -----------------------------------------------------------------------------------------------------
2 The Contractor's final awarded rate from AHCCCSA. 30%
- -----------------------------------------------------------------------------------------------------
3 The Contractor's score on the Program component of the proposal. 40%
- -----------------------------------------------------------------------------------------------------
Points will be assigned to each Contractor by risk group by GSA. Based on the
rankings of the final bid rates and the final awarded rates, each Contractor
will be assigned a number of points for each of these two components separately
as follows:
TABLE FOR FACTORS #1 AND #2
- ----------------------------------------------------------------------------------------
2nd 3rd 4th 5th 6th 7th
NUMBER OF AWARDS LOWEST LOWEST LOWEST LOWEST LOWEST LOWEST LOWEST
IN GSA RATE RATE RATE RATE RATE RATE RATE
- ----------------------------------------------------------------------------------------
2 60 40
- ----------------------------------------------------------------------------------------
3 44 32 24
- ----------------------------------------------------------------------------------------
4 35 28 22 15
- ----------------------------------------------------------------------------------------
5 30 25 20 15 10
- ----------------------------------------------------------------------------------------
6 26 23 19 15 11 6
- ----------------------------------------------------------------------------------------
7 25 20 17 14 11 8 5
- ----------------------------------------------------------------------------------------
Contractors that have equal bids in a GSA for the same risk group will be given
an equal percentage of the points for all of the positions combined.
The third component of the calculation, program scores, will be assigned a
number of points based on the Contractor's ranking among the scores. The higher
the score, the more points assigned. For this component, points will be assigned
as follows:
TABLE FOR FACTOR #3
- -----------------------------------------------------------------------------------------
2nd 3rd 4th 5th 6th 7th
NUMBER OF HIGHEST HIGHEST HIGHEST HIGHEST HIGHEST HIGHEST HIGHEST
AWARDS IN PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM
GSA SCORE SCORE SCORE SCORE SCORE SCORE SCORE
- -----------------------------------------------------------------------------------------
2 60 40
- -----------------------------------------------------------------------------------------
3 44 32 24
- -----------------------------------------------------------------------------------------
4 35 28 22 15
- -----------------------------------------------------------------------------------------
5 30 25 20 15 10
- -----------------------------------------------------------------------------------------
6 26 23 19 15 11 6
- -----------------------------------------------------------------------------------------
7 25 20 17 14 11 8 5
- -----------------------------------------------------------------------------------------
Acute Care RFP
February 3, 2003
- 155 -
ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM CONTRACT/RFP NO. YH04-0001
Contractors that have equal program scores will be given an equal percentage of
the points for all of the positions combined.
The points awarded for the three components will be combined as follows to give
the target percentage for each Contractor by GSA by risk group:
(Final Bid Points (.30) + Awarded Bid Points (.30) + Program Score Points (.40)
/ 100 = TARGET PERCENTAGE
ADJUSTMENT METHODOLOGY FOR CONTRACTORS WITH FEWER THAN 25,000 MEMBERS
At the beginning of the new contract cycle, the auto-assignment algorithm for
the Maricopa and Pima/Santa Cruz GSAs will be adjusted to favor Contractors with
fewer than 25,000 members statewide. The adjusted algorithm will be utilized
until a target membership of 25,000 members statewide, per Contractor, is
reached.
The adjustment will be made to the final percentages developed using the
methodology above. A pre-determined percentage, based on the table below, will
be added to the affected Contractor(s) and subtracted evenly from the other
Contractors.
- --------------------------------------------------------------------------------------
PERCENTAGE ADDED
TO PERCENTAGE TO BE EVENLY
NUMBER OF CONTRACTORS BELOW 25,000 TARGETED SUBTRACTED FROM REMAINING
STATEWIDE MINIMUM ENROLLMENT CONTRACTORS BIDDERS
- --------------------------------------------------------------------------------------
1 20% 20%
- --------------------------------------------------------------------------------------
2 15% 30%
- --------------------------------------------------------------------------------------
3 10% 30%
- --------------------------------------------------------------------------------------
*In the event that there are more than three affected Contractors, AHCCCS will
disclose adjustment methodology by July 1, 2003.
In the event that a Contractor only receives an award in rural GSAs, AHCCCS
reserves the right to make a temporary adjustment to the auto-assignment target
to favor the new Contractor until a minimum enrollment is reached.
AHCCCSA reserves the right to adjust capitation rates for potential changes to
the populations risk due to the adjusted algorithm.
Acute Care RFP
February 3, 2003
- 156 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
ATTACHMENT H (1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY
The Contractor shall have a written policy delineating its Grievance System
which shall be in accordance with applicable Federal and State laws, regulations
and policies, including, but not limited to 42 CFR Part 438 Subpart F. The
Contractor shall provide the Enrollee Grievance System Policy to all providers
and subcontractors at the time of contract. The Contractor shall also furnish
this information to its enrollees within a reasonable time after the Contractor
receives notice of the recipient's enrollment. Additionally, the Contractor
shall provide written notification of any significant change in this policy at
least 30 days before the intended effective date of the change.
The written information provided to enrollees describing the Grievance System
including the grievance process, enrollee rights, grievance system requirements
and timeframes, shall be in each prevalent non-English language occurring within
the Contractor's service area and in an easily understood language and format.
The Contractor shall inform enrollees that oral interpretation services are
available in any language, that additional information is available in prevalent
non-English languages upon request and how enrollees may obtain this
information.
Written documents, including but not limited to the Contractor's Notice of
Action, the Notice of Contractor's Appeal/Grievance Resolution, Notice of
Contractor Extension for Resolution, and Notice of Contractor Extension of
Notice of Action shall be translated in the enrollee's language if information
is received by the Contractor, orally or in writing, indicating that the
enrollee has a limited English proficiency. Otherwise, these documents shall be
translated in the prevalent non-English language(s) or shall contain information
in the prevalent non- English language(s) advising the enrollee that the
information is available in the prevalent non-English language(s) and in
alternative formats along with an explanation of how enrollees may obtain this
information. This information must be in large, bold print appearing in a
prominent location on the first page of the document.
At a minimum, the Contractor's Grievance System Standards and Policy shall
specify:
- That the Contractor shall maintain records of all grievances and
appeals.
- Information describing the grievance, appeal, and fair hearing
procedures and timeframes describing the right to hearing, the method
for obtaining a hearing, the rules which govern representation at the
hearing, definitions of "action," "grievance," and "appeal," the right
to file grievances and appeals and the requirements and timeframes for
filing a grievance or appeal.
- Information explaining that a provider acting on behalf of an enrollee
and with the enrollee's written consent, may file an appeal or
grievance.
- The availability of assistance in the filing process and the
Contractor's toll-free numbers that an enrollee can use to file a
grievance or appeal by phone if requested by the enrollee.
- That an enrollee shall be given no less than 20 days (and no more than
90 days) from the date of the Contractor's Notice of Action to file an
appeal.
- That the Contractor shall mail a Notice of Action: 1) at least 10 days
before the date of a termination, suspension or reduction of
previously authorized AHCCCS services (include exception situations,
fraud, move out of state); 2) at the time of any action affecting the
claim when there has been a denial of payments; 3) within 14 calendar
days from receipt of a request for a standard service authorization
which has been denied or reduced unless an extension is in effect; 4)
within three working days from receipt of an expedited service
authorization request unless an extension is in effect.
Acute Care RFP
February 3, 2003
- 157 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
- That the Notice of Action must explain: 1) the action the Contractor
has taken or intends to take, 2) the reasons for the action, 3) the
enrollee's right to file an appeal with the Contractor, 4) the
enrollee's right to request a State fair hearing if no exhaustion of
the Contractor's appeal process is required, 5) the procedures for
exercising these rights, 6) circumstances when expedited resolution is
available and how to request it and 7) the enrollee's right to request
continued benefits pending resolution of the appeal, how to request
continued benefits and the circumstances under which the enrollee may
be required to pay for the cost of these services.
- That the Contractor shall permit both oral and written appeals and
grievances and that oral inquiries appealing an action are treated as
appeals and are confirmed in writing unless expedited resolution is
requested.
- That the Contractor shall acknowledge receipt of each grievance and
appeal.
- The definition of a standard appeal and that the Contractor shall
resolve standard appeals no later than 45 days from the date of
receipt of the appeal.
- The definition of an expedited appeal and that the Contractor shall
resolve all expedited appeals not later than three working days from
the date the Contractor receives the appeal where the Contractor
determines, or the provider in making the request on the enrollee's
behalf indicates, that standard resolution timeframe could seriously
jeopardize the enrollee's life or health or ability to attain,
maintain or regain maximum function. The Contractor shall make
reasonable efforts to provide oral notice to an enrollee regarding an
expedited resolution appeal.
- The standard and expedited resolution timeframes may be extended up to
14 calendar days if the enrollee requests the extension or if the
Contractor establishes a need for additional information and that the
delay is in the enrollee's interest.
- That if the Contractor extends the timeframe for resolution of a
grievance or appeal when not requested by the enrollee, the Contractor
shall provide the enrollee with written notice of the reason for the
delay.
- That an enrollee may file an appeal of: 1) the denial or limited
authorization of a requested service including the type or level of
service, 2) the reduction, suspension or termination of a previously
authorized service, 3) the denial in whole or in part of payment for
service, 4) the failure to provide services in a timely manner, 5) the
failure of the Contractor to comply with the timeframes for
dispositions of grievances and appeals and 6) the denial of a rural
enrollee's request to obtain services outside the Contractor's network
when the Contractor is the only Contractor in the rural area.
- That benefits shall continue only if: 1) the enrollee files an appeal
before the later of a) 10 days from the mailing of the Notice of
Action or b) the intended date of the Contractor's action, 2) the
appeal involves the termination, suspension, or reduction of a
previously authorized course of treatment, 3) the services were
ordered by an authorized provider, 4) the original period covered by
the original authorization has not expired, and 5) the enrollee
requests a continuation of benefits.
Acute Care RFP
February 3, 2003
- 158 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
- That the Contractor continues extended benefits originally provided to
the enrollee until any of the following occurs: 1) enrollee withdraws
appeal, 2) enrollee has not specifically requested continued benefits
pending a hearing decision within 10 days of MCO/PIHP mailing appeal
resolution notice, 3) State hearing office issues decision adverse to
enrollee or 4) time period or service limits of a previously
authorized service has been met.
- That for appeals, the Contractor provides the enrollee a reasonable
opportunity to present evidence and allegations of fact or law in
person and in writing and that the Contractor informs the enrollee of
the limited time available in cases involving expedited resolution.
- That for appeals, the Contractor provides the enrollee and his
representative the opportunity before and during the appeals process
to examine the enrollee's case file including medical records and
other documents considered during the appeals process.
- That if the Contractor denies a request for expedited resolution, it
must make reasonable efforts to give the enrollee prompt oral notice
and follow-up within two calendar days with a written notice of the
denial of expedited resolution.
- That the Contractor shall ensure that individuals who make decisions
regarding grievance and appeals are individuals not involved in any
previous level of review or decision making and that individuals who
make decisions regarding: 1) appeals of denials based on lack of
medical necessity, 2) a grievance regarding denial of expedited
resolution of an appeal or 3) grievances or appeals involving clinical
issues are health care professionals as defined in 42 CFR 438.2 with
the appropriate clinical expertise in treating the enrollee's
condition or disease.
- That the Contractor shall provide written notice of the disposition of
each appeal which must contain: 1) the results of the resolution
process and the date it was completed, 2) for appeals not resolved
wholly in favor of enrollees: a) the enrollee's right to request a
State fair hearing and how to do so, b) the right to receive benefits
pending the hearing and how to request continuation of benefits and c)
information explaining that the enrollee may be held liable for the
cost of benefits if the hearing decision upholds the Contractor.
- That if the Contractor's decision is appealed and a request for
hearing is filed, the Contractor must ensure that all supporting
documentation is received by the AHCCCSA, Office of Legal Assistance,
no later than five working days from the date the Contractor receives
the verbal or written request from AHCCCSA, Office of Legal
Assistance. The file sent by the Contractor must contain a cover
letter that includes:
1. Complainant's name
2. Complainant's AHCCCS I.D. number
3. Complainant's address
4. Complainant's phone number (if applicable)
5. date of receipt of grievance or appeal
6. summary of the Contractor's actions undertaken to
resolve the grievance and basis of the determination
Acute Care RFP
February 3, 2003
- 159 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
- The following material shall be included in the file sent by the
Contractor:
1. written request of the Complainant asking for the
request for hearing
2. copies of the entire file which includes the
investigations and/or medical records; and the
Contractor's resolution
3. other information relevant to the resolution of the
grievance or appeal
- That if the Contractor or the State fair hearing decision reverses a
decision to deny, limit or delay services not furnished while the
appeal was pending, the Contractor shall authorize or provide the
services promptly and as expeditiously as the enrollee's health
condition requires.
- That if the Contractor or State fair hearing decision reverses a
decision to deny authorization of services and the disputed services
were received pending appeal, the Contractor shall pay for those
services.
Acute Care RFP
February 3, 2003
- 160 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
ATTACHMENT H (2): PROVIDER GRIEVANCE SYSTEM STANDARDS AND POLICY
The Contractor shall have in place a written grievance system policy for
providers regarding adverse actions taken by the Contractor. The policy shall be
in accordance with applicable Federal and State laws, regulations and policies.
The grievance policy shall include the following provisions:
a. The grievance policy shall be provided to all subcontractors at the time of
contract. For providers without a contract, the grievance policy may be
mailed with a remittance advice, provided the remittance is sent within 45
days of receipt of a claim.
b. The grievance policy must specify that all grievances, with the exception
of those challenging claim denials, must be filed with the Contractor no
later than 60 days from the date of the adverse action. Grievances
challenging claim denials must be filed in writing with the Contractor no
later that 12 months from the date of service, 12 months after the date of
eligibility posting or within 60 days after the date of a timely claim
submission, whichever is later.
c. Specific individuals are appointed with authority to require corrective
action and with requisite experience to administer the grievance process.
d. A log is maintained for all grievances containing sufficient information to
identify the Complainant, date of receipt, nature of the grievance and the
date the grievance is resolved. Separate logs must be maintained for
provider and member grievances
e. Within five working days of receipt, the Complainant is informed by letter
that the grievance has been received.
f. Each grievance is thoroughly investigated using the applicable statutory,
regulatory, contractual and policy provisions, ensuring that facts are
obtained from all parties.
g. All documentation received and mailed by the Contractor during the
grievance process is dated upon receipt.
h. All grievances are filed in a secure designated area and are retained for
five years following the Contractor's decision, the Administration's
decision, judicial appeal or close of the grievance, whichever is later.
i. A copy of the Contractor's decision will be either hand-delivered or
delivered by certified mail to all parties whose interest has been
adversely affected by the decision. The decision shall be mailed to all
other individuals by regular mail. The date of the decision shall be the
date of personal delivery or, if mailed, the postmark date of the mailing.
The decision must include and describe in detail, the following:
1. the nature of the grievance
2. the issues involved
3. the reasons supporting the Contractor's decision, explained in easy to
understand terms for members, including references to applicable
statute, rule, applicable contractual provisions, policy and procedure
4. the Complainant's right to request a hearing by filing the request for
hearing to the Contractor no later than 30 days after the date of the
Contractor's decision.
j. If the Contractor's decision is appealed and a request for hearing is
filed, the Contractor must ensure that all supporting documentation is
received by the AHCCCSA, Office of Legal Assistance, no later than five
working days from the date the Contractor receives the verbal or written
request from AHCCCSA, Office of Legal Assistance. The file sent by the
Contractor must contain a cover letter that includes:
1. Complainant's name
2. Complainant's AHCCCS ID number
3. Complainant's address
Acute Care RFP
February 3, 2003
- 161 -
ATTACHMENT H: CONTRACT/RFP NO. YH04-0001
GRIEVANCE SYSTEM AND STANDARDS
4. Complainant's phone number (if applicable)
5. the date of receipt of grievance
6. a summary of the Contractor's actions undertaken to resolve the
grievance and basis of the determination
k. The following material shall be included in the file sent by the
Contractor:
1. written request of the Complainant asking for the request for hearing
2. copies of the entire file which includes the investigations and/or
medical records; and the Contractor's decision
3. other information relevant to the resolution of the grievance
Acute Care RFP
February 3, 2003
- 162 -
ATTACHMENT I: ENCOUNTER SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS
The Contractor will be assessed sanctions for noncompliance with encounter
submission requirements. AHCCCSA may also perform special reviews of encounter
data, such as comparing encounter reports to the Contractor's claims files. Any
findings of incomplete or inaccurate encounter data may result in the imposition
of sanctions or requirement of a corrective action plan.
PENDED ENCOUNTER CORRECTIONS
The Contractor must resolve all pended encounters within 120 days of the
original processing date. Sanctions will be imposed according to the following
schedule for each encounter pended for more than 120 days unless the pend is due
to AHCCCSA error:
0 - 120 days 121 - 180 days 181 - 240 days 241 - 360 days 361 + days
No sanction $ 5 per month $ 10 per month $ 15 per month $ 20 per month
"AHCCCSA error" is defined as a pended encounter, which (1) AHCCCSA acknowledges
to be the result of its own error, and (2) requires a change to the system
programming, an update to the database reference table, or further research by
AHCCCSA. AHCCCSA reserves the right to adjust the sanction amount if
circumstances warrant.
When the Contractor notifies AHCCCSA, in writing, that the resolution of a
pended encounter depends on AHCCCSA rather than the Contractor, AHCCCSA will
respond in writing within 30 days of receipt of such notification. The AHCCCSA
response will report the status of each pending encounter problem or issue in
question.
Pended encounters will not qualify as AHCCCSA errors if AHCCCSA reviews the
Contractor's notification and asks the Contractor to research the issue and
provide additional substantiating documentation, or if AHCCCSA disagrees with
the Contractor's claim of AHCCCSA error. If a pended encounter being researched
by AHCCCSA is later determined not to be caused by AHCCCSA error, the Contractor
may be sanctioned retroactively.
Before imposing sanctions, AHCCCSA will notify the Contractor, in writing, of
the total number of sanctionable encounters pended more than 120 days. Pended
encounters shall not be deleted by the Contractor as a means of avoiding
sanctions for failure to correct encounters within 120 days. The Contractor
shall document deleted encounters and shall maintain a record of the deleted
CRNs with appropriate reasons indicated. The Contractor shall, upon request,
make this documentation available to AHCCCSA for review.
ENCOUNTER VALIDATION STUDIES
Per CMS requirement, AHCCCSA will conduct encounter validation studies of the
Contractor's encounter submissions, and sanction the Contractor for
noncompliance with encounter submission requirements. The purpose of encounter
validation studies is to compare recorded utilization information from a medical
record or other source with the Contractor's submitted encounter data. Any and
all covered services may be validated as part of these studies. Encounter
validation studies will be conducted at least yearly.
AHCCCSA may revise study methodology, timelines, and sanction amounts based on
agency review or as a result of consultations with CMS. The Contractor will be
notified in writing of any significant change in study methodology.
Acute Care RFP
February 3, 2003
- 163 -
ATTACHMENT I: ENCOUNTER SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
AHCCCSA will conduct two encounter validation studies. Study "A" examines
non-institutional services (form HCFA 1500 encounters), and Study "B" examines
institutional services (form UB-92 encounters).
AHCCCSA will notify the Contractor in writing of the sanction amounts and of the
selected data needed for encounter validation studies. The Contractor will have
90 days to submit the requested data to AHCCCSA. In the case of medical records
requests, the Contractor's failure to provide AHCCCSA with the records requested
within 90 days may result in a sanction of $1,000 per missing medical record. If
AHCCCSA does not receive a sufficient number of medical records from the
Contractor to select a statistically valid sample for a study, the Contractor
may be sanctioned up to 5% of its annual capitation payment.
The criteria used in encounter validation studies may include timeliness,
correctness, and omission of encounters. These criteria are defined as follows:
Timeliness: The time elapsed between the date of service and the date that the
encounter is received at AHCCCS. All encounters must be received by AHCCCSA no
later than 240 days after the end of the month in which the service was
rendered, or the effective date of enrollment with the Contractor, whichever is
later. For all encounters for which timeliness is evaluated, a sanction per
encounter error extrapolated to the population of encounters may be assessed if
the encounter record is received by AHCCCSA more than 240 days after the date
determined above. It is anticipated that the sanction amount will be $1.00 per
error extrapolated to the population of encounters; however, sanction amounts
may be adjusted if AHCCCSA determines that encounter quality has changed, or if
CMS changes sanction requirements. The Contractor will be notified of the
sanction amount in effect for the studies at the time the studies begin.
Correctness: A correct encounter contains a complete and accurate description of
AHCCCS covered services provided to a member. A sanction per encounter error
extrapolated to the population of encounters may be assessed if the encounter is
incomplete or incorrectly coded. It is anticipated that the sanction amount will
be $1.00 per error extrapolated to the population of encounters; however,
sanction amounts may be adjusted if AHCCCSA determines that encounter quality
has changed, or if CMS changes sanction requirements. The Contractor will be
notified of the sanction amount in effect for the studies at the time the
studies begin.
Omission of data: An encounter not submitted to AHCCCSA or an encounter
inappropriately deleted from AHCCCSA's pending encounter file or historical
files in lieu of correction of such record. For Study "A" and for Study "B", a
sanction per encounter error extrapolated to the population of encounters may be
assessed for an omission. It is anticipated that the sanction amount will be
$5.00 per error extrapolated to the population of encounters for Study "A" and
$10.00 per error extrapolated to the population of encounters for Study "B";
however, sanction amounts may be adjusted if AHCCCSA determines that encounter
quality has changed, or if CMS changes sanction requirements. The Contractor
will be notified of the sanction amount in effect for the studies at the time
the studies begin.
For encounter validation studies, AHCCCSA will select all approved and pended
encounters to be studied no earlier than 240 days after the end of the month in
which the service was rendered. Once AHCCCSA has selected the Contractor's
encounters for encounter validation studies, subsequent encounter submissions
for the period being studied will not be considered.
AHCCCSA may review all of the Contractor's submitted encounters, or may select a
sample. The sample size, or number of encounters to be reviewed, will be
determined using statistical methods in order to accurately estimate the
Contractor's error rates. Error rates will be calculated by dividing the number
of errors found by the number of encounters reviewed. A 95% confidence interval
will be used to account for limitations caused by sampling. The confidence
interval shows the range within which the true error rate is estimated to be. If
error rates are based on a sample, the error rate used for sanction purposes
will be the lower limit of the confidence interval.
Acute Care RFP
February 3, 2003
- 164 -
ATTACHMENT I: ENCOUNTER SUBMISSION
REQUIREMENTS CONTRACT/RFP NO. YH04-0001
Encounter validation methodology and statistical formulas are provided in the
AHCCCS Encounter Data Validation Technical Document, which is available in the
Bidders Library. This document also provides examples, which illustrate how
AHCCCSA determines study sample sizes, error rates, confidence intervals, and
sanction amounts.
Written preliminary results of all encounter validation studies will be sent to
the Contractor for review and comment. The Contractor will have a maximum of 30
days to review results and provide AHCCCSA with additional documentation that
would affect the final calculation of error rates and sanctions. AHCCCSA will
examine the Contractor's documentation and may revise study results if
warranted. Written final results of the study will then be sent to the
Contractor and communicated to CMS, and any sanctions will be assessed.
The Contractor may file a written challenge to sanctions assessed by AHCCCSA not
more than 35 days after the Contractor receives final study results from
AHCCCSA. Challenges will be reviewed by AHCCCSA and a written decision will be
rendered no later than 60 days from the date of receipt of a timely challenge.
Sanctions shall not apply to encounter errors successfully challenged. A
challenge must be filed on a timely basis and a decision must be rendered by
AHCCCSA prior to filing a grievance and request for hearing pursuant to Article
8 of AHCCCS Rules. Sanction amounts will be deducted from the Contractor's
capitation payment.
ENCOUNTER CORRECTIONS
Contractors are required to submit replacement or voided encounters in the event
that claims are subsequently corrected following the initial encounter
submission. This includes corrections as a result of inaccuracies identified by
fraud and abuse audits or investigations conducted by AHCCCSA or the Contractor.
Contractors shall refer to the Encounter Reporting User Manual for instructions
regarding submission of corrected encounters.
Acute Care RFP
February 3, 2003
- 165 -
ATTACHMENT J: EPSDT PERIODICITY SCHEDULE CONTRACT/RFP NO. YH04-0001
ATTACHMENT J: EPSDT PERIODICITY SCHEDULE
AHCCCS EPSDT PERIODICITY SCHEDULE
======================================================================================================================
INFANCY EARLY CHILDHOOD MIDDLE CHILDHOOD
------------------------------------------- -------------------------- ----------------
new 2-4 by 1 2 4 6 9 12 15 18 24 3 4 5 6 8
PROCEDURES born day mo mo mo mo mo mo mo mo mo yr yr yr yr yr
- ----------------------------------------------------------------------------------------------------------------------
History Initial/Interval x x x x x x x x x x x x x x x x
- ----------------------------------------------------------------------------------------------------------------------
Height & Weight x x x x x x x x x x x x x x x x
- ----------------------------------------------------------------------------------------------------------------------
Head Circumference x x x x x x x x x x x
- ----------------------------------------------------------------------------------------------------------------------
Blood Pressure x x x x x
- ----------------------------------------------------------------------------------------------------------------------
Nutritional Assessment x x x x x x x x x x x x x x x x
- ----------------------------------------------------------------------------------------------------------------------
Vision**
- ----------------------------------------------------------------------------------------------------------------------
Hearing**/Speech
- ----------------------------------------------------------------------------------------------------------------------
Dev./Behavioral Assess. x x x x x x x x x x x x x x x x
- ----------------------------------------------------------------------------------------------------------------------
Physical Examination x x x x x x x x x x x x x x x x
- ----------------------------------------------------------------------------------------------------------------------
Immunization <-x-----------> x x x <-----x------> <-----x----->
- ----------------------------------------------------------------------------------------------------------------------
Tuberculin Test + + + + + + + + +
- ----------------------------------------------------------------------------------------------------------------------
Hematocrit/Hemoglobin <----------------------x->
- ----------------------------------------------------------------------------------------------------------------------
Urinalysis x
- ----------------------------------------------------------------------------------------------------------------------
Lead Screen
- ----------------------------------------------------------------------------------------------------------------------
Verbal x x x x x x x x
- ----------------------------------------------------------------------------------------------------------------------
Blood x x x* x* x* x*
- ----------------------------------------------------------------------------------------------------------------------
Anticipatory Guidance x x x x x x x x x x x x x x x x
- ----------------------------------------------------------------------------------------------------------------------
Dental Referral**
======================================================================================================================
========================================================================
ADOLESCENCE
-------------------------------------------
10 12 14 16 18
PROCEDURES yr yr yr yr yr 20+up to 21 yr
- ------------------------------------------------------------------------
History Initial/Interval x x x x x x
- ------------------------------------------------------------------------
Height & Weight x x x x x x
- ------------------------------------------------------------------------
Head Circumference
- ------------------------------------------------------------------------
Blood Pressure x x x x x x
- ------------------------------------------------------------------------
Nutritional Assessment x x x x x x
- ------------------------------------------------------------------------
Vision**
- ------------------------------------------------------------------------
Hearing**/Speech
- ------------------------------------------------------------------------
Dev./Behavioral Assess. x x x x x x
- ------------------------------------------------------------------------
Physical Examination x x x x x x
- ------------------------------------------------------------------------
Immunization <---x------>
- ------------------------------------------------------------------------
Tuberculin Test + + + + + +
- ------------------------------------------------------------------------
Hematocrit/Hemoglobin <-----x--------------------------->
- ------------------------------------------------------------------------
Urinalysis <-----x--------------------------->
- ------------------------------------------------------------------------
Lead Screen
- ------------------------------------------------------------------------
Verbal
- ------------------------------------------------------------------------
Blood
- ------------------------------------------------------------------------
Anticipatory Guidance x x x x x x
- ------------------------------------------------------------------------
Dental Referral**
========================================================================
These are minimum requirements. If at any time other procedures, tests, etc. are
medically indicated, the physician is obligated to perform them. If a child
comes under care for the first time at any point on the schedule, or if any
items are not accomplished at the suggested age, the schedule should be brought
up to date at the earliest possible time.
Key: x = to be completed + = to be performed for members at risk when
indicated.
<----x----> = the range during which a service may be provided, with the x
indicating the preferred age.
* Members not previously screened who fall within this range (36 to 72 months
of age) must have a blood lead screen performed.
** See separate schedule for detail.
*** If American Academy of Pediatrics guidelines are used for the screening
schedule and/or more screenings are medically necessary, those additional
interperiodic screenings will be covered
Acute Care RFP
February 3, 2003
- 166 -
ATTACHMENT J: EPSDT PERIODICITY SCHEDULE CONTRACT/RFP NO. YH04-0001
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
DENTAL PERIODICITY SCHEDULE
==================================================================================================================================
MONTHS YEARS
- ----------------------------------------------------------------------------------------------------------------------------------
Birth thru 36 20+ up
Procedure months 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 to 21
- ----------------------------------------------------------------------------------------------------------------------------------
Dental + x x x x x x x x x x x x x x x x x x
Referral
==================================================================================================================================
REFERRALS FOR ROUTINE DENTAL VISITS SHOULD BEGIN AT AGE THREE (3). EARLIER
INITIAL DENTAL EVALUATIONS MAY BE APPROPRIATE FOR SOME CHILDREN. SUBSEQUENT
EXAMINATIONS AS PRESCRIBED BY DENTIST.
KEY: + = BIRTH TO 36 MONTHS IF INDICATED
x = TO BE COMPLETED
Acute Care RFP
February 3, 2003
- 167 -
ATTACHMENT J: EPSDT PERIODICITY SCHEDULE CONTRACT/RFP
NO. YH04-0001
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
VISION PERIODICITY SCHEDULE
====================================================================================================================================
MONTHS YEARS
- ------------------------------------------------------------------------------------------------------------------------------------
New 2 - 4 by 1 20 + up
Procedure born Days mo 2 4 6 9 12 15 18 24 3* 4 5 6 8 10 12 14 16 18 to 21 yr
- ------------------------------------------------------------------------------------------------------------------------------------
Vision +++ S S S S S S S S S S S O O O S S O O S S O S
====================================================================================================================================
THESE ARE MINIMUM REQUIREMENTS: IF AT ANY TIME OTHER PROCEDURES, TESTS, ETC. ARE
MEDICALLY INDICATED, THE PHYSICIAN IS
OBLIGATED TO PERFORM THEM.
KEY: S =SUBJECTIVE, BY HISTORY
O =OBJECTIVE, BY A STANDARD TESTING METHOD
* =IF THE PATIENT IS UNCOOPERATIVE, RESCREEN IN 6 MONTHS.
+++ =MAY BE DONE MORE FREQUENTLY IF INDICATED OR AT INCREASED RISK.
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
HEARING AND SPEECH PERIODICITY SCHEDULE
====================================================================================================================================
MONTHS YEARS
- ------------------------------------------------------------------------------------------------------------------------------------
New 2 - 4 by 1 20 + up
Procedure born Days mo 2 4 6 9 12 15 18 24 3 4 5 6 8 10 12 14 16 18 to 21 yr
- ------------------------------------------------------------------------------------------------------------------------------------
Hearing/ S/0 S S S S S S S S S S O O O S S O O S S O S
Speech +++
====================================================================================================================================
THESE ARE MINIMUM REQUIREMENTS: IF AT ANY TIME OTHER PROCEDURES, TESTS, ETC. ARE
MEDICALLY INDICATED, THE PHYSICIAN IS
OBLIGATED TO PERFORM THEM.
KEY: S =SUBJECTIVE, BY HISTORY
O =OBJECTIVE, BY A STANDARD TESTING METHOD
* =ALL CHILDREN, INCLUDING NEWBORNS, MEETING RISK CRITERIA FOR HEARING
LOSS SHOULD BE OBJECTIVELY SCREENED.
+++ =MAY BE DONE MORE FREQUENTLY IF INDICATED OR AT INCREASED RISK
Acute Care RFP
February 3, 2003
- 168 -
ATTACHMENT K: OFFEROR'S CHECKLIST CONTRACT/RFP NO. YH04-0001
ATTACHMENT K: OFFEROR'S CHECKLIST
Offerors must submit all items below, unless otherwise noted. In the column
titled "Offeror's Page #", the Offeror must enter the appropriate page numbers
from its proposal where the AHCCCS Evaluation Panel may find the Offeror's
response to that requirement.
I. GENERAL MATTERS
- -------------------------------------------------------------------------------
SUBJECT: REFERENCE OFFEROR'S PAGE #
- -------------------------------------------------------------------------------
Offeror's signature page (Front page) N/A
- -------------------------------------------------------------------------------
Offeror's Checklist (this attachment) N/A
- -------------------------------------------------------------------------------
Completion of all items in Section G of the RFP Section G
- -------------------------------------------------------------------------------
NOTE: The "Reqmt. #" shown below in Parts II, III, IV and V refers to the
numbered submission requirements outlined in Section I, Paragraph 1 of this RFP.
II. PROVIDER NETWORK
- ------------------------------------------------------------------------------
SECTION D
PARAGRAPH #S AND OFFEROR'S
SUBJECT: REQMT. # ATTACHMENTS PAGE #
- ------------------------------------------------------------------------------
Provider Network Development 1. Attachment D (1)
- ------------------------------------------------------------------------------
2. Paragraph 27, Attachment
B
- ------------------------------------------------------------------------------
3. Paragraph 27, Attachment
B
- ------------------------------------------------------------------------------
Provider Network Management:
- ------------------------------------------------------------------------------
Monitoring and Managing 4. Paragraph 16, 27, 29, 30,
31, 33
- ------------------------------------------------------------------------------
5. Paragraph 29
- ------------------------------------------------------------------------------
Network Communication 6. Paragraph 27, 29
- ------------------------------------------------------------------------------
7. N/A
- ------------------------------------------------------------------------------
Capacity Analysis/Planning and 8. Paragraph 27
Development
- ------------------------------------------------------------------------------
9. Paragraph 73
- ------------------------------------------------------------------------------
III. CAPITATION
- ------------------------------------------------------------------------------
SECTION D
PARAGRAPH #S AND OFFEROR'S
SUBJECT: REQMT. # ATTACHMENTS PAGE #
- ------------------------------------------------------------------------------
Capitation 10. Paragraph 53, 57, 75,
Section B, Attachment E
- ------------------------------------------------------------------------------
Acute Care RFP
February 3, 2003
- 169-
ATTACHMENT K: OFFEROR'S CHECKLIST CONTRACT/RFP NO. YH04-0001
IV. PROGRAM
- ------------------------------------------------------------------------------
SECTION D
PARAGRAPH #S AND OFFEROR'S
SUBJECT: REQMT. # ATTACHMENTS PAGE #
- ------------------------------------------------------------------------------
Quality Management 11. Paragraph 23, 24
- ------------------------------------------------------------------------------
12. Paragraph 23
- ------------------------------------------------------------------------------
13. Paragraph 23
- ------------------------------------------------------------------------------
Utilization Management 14. Paragraph 23
- ------------------------------------------------------------------------------
15. Paragraph 23
- ------------------------------------------------------------------------------
16. Paragraph 23
- ------------------------------------------------------------------------------
17. Paragraph 23
- ------------------------------------------------------------------------------
18. Paragraph 23
- ------------------------------------------------------------------------------
Disease Prevention/Health 19. Paragraph 10, 23, 24
Maintenance
- ------------------------------------------------------------------------------
20. Paragraph 10, 15, 23, 24
- ------------------------------------------------------------------------------
21. Paragraph 10, 24
- ------------------------------------------------------------------------------
22. Paragraph 10, 23
- ------------------------------------------------------------------------------
Focused Health Needs 23. Paragraph 11, 23
- ------------------------------------------------------------------------------
24. Paragraph 23
- ------------------------------------------------------------------------------
25. Paragraph 18, 20
- ------------------------------------------------------------------------------
26. Paragraph 10, 11, 23
- ------------------------------------------------------------------------------
27. Paragraph 10, 23, 24, 31,
33
- ------------------------------------------------------------------------------
Member Services 28. Paragraph 18, 23, 25,
Attachment H (1)
- ------------------------------------------------------------------------------
29. Paragraph 8, 16, 18, 20
- ------------------------------------------------------------------------------
30. Paragraph 4, 19, 23, 25,
Attachment H (1)
- ------------------------------------------------------------------------------
V. ORGANIZATION
- ------------------------------------------------------------------------------
SECTION D
PARAGRAPH #S AND OFFEROR'S
SUBJECT: REQMT. # ATTACHMENTS PAGE #
- ------------------------------------------------------------------------------
Organization and Staffing 31. N/A
- ------------------------------------------------------------------------------
32. N/A
- ------------------------------------------------------------------------------
33. Paragraph 73
- ------------------------------------------------------------------------------
Corporate Compliance 34. Paragraph 62
- ------------------------------------------------------------------------------
35. Paragraph 62
- ------------------------------------------------------------------------------
Grievance and Appeals 36. Paragraph 25, Attachment
H (1), Attachment H (2)
- ------------------------------------------------------------------------------
37. Paragraph 25, Attachment
H (1), Attachment H (2)
- ------------------------------------------------------------------------------
Acute Care RFP
February 3, 2003
- 170 -
ATTACHMENT K: OFFEROR'S CHECKLIST CONTRACT/RFP NO. YH04-0001
- ------------------------------------------------------------------------------
SECTION D
PARAGRAPH #S AND OFFEROR'S
SUBJECT: REQMT. # ATTACHMENTS PAGE #
- ------------------------------------------------------------------------------
Claims 38. Paragraph 38, 58
- ------------------------------------------------------------------------------
39. N/A
- ------------------------------------------------------------------------------
40. N/A
- ------------------------------------------------------------------------------
Encounters 41. Paragraph 64, 65,
Attachment I
- ------------------------------------------------------------------------------
Financial Standards 42. Paragraph 46, 47
- ------------------------------------------------------------------------------
43. Paragraph 45
- ------------------------------------------------------------------------------
44. N/A
- ------------------------------------------------------------------------------
45. N/A
- ------------------------------------------------------------------------------
46. N/A
- ------------------------------------------------------------------------------
47. N/A
- ------------------------------------------------------------------------------
48. N/A
- ------------------------------------------------------------------------------
49. Paragraph 50
- ------------------------------------------------------------------------------
50. Paragraph 43
- ------------------------------------------------------------------------------
Liability Management 51. Paragraph 50
- ------------------------------------------------------------------------------
VI. EXTRA CREDIT
- ------------------------------------------------------------------------------
SECTION D
PARAGRAPH #S AND OFFEROR'S
SUBJECT: REQMT. # ATTACHMENTS PAGE #
- ------------------------------------------------------------------------------
Optional Submissions:
- ------------------------------------------------------------------------------
Extra Credit 52. N/A
- ------------------------------------------------------------------------------
[END OF CHECKLIST]
Acute Care RFP
February 3, 2003
- 171 -