41NHA-S4038 - SOW - 10-08.docx

Nevada State Purchasing Division Department of Administration 515 E Musser St Ste 300 Carson City, NV 89701 purchasing.nv.gov nevadaepro.com

41NHA-S4038 - Scope of Work

SCOPE OF WORK

PROGRAM ADMINISTRATION AND OPERATIONS

Federal and State Authority

The Contractor shall operate Program of All Inclusive Care for the Elderly (PACE) in accordance with all applicable Federal and State laws, regulations, and program policies that govern performance of the contractual agreements.

Governing Body and Participant Advisory Committee

The Governing Body for the Contractor shall include a minimum of seven members. Members of the Governing Body shall be free from conflict of interests, including financial, that would impair their ability to exercise independent oversight of the PACE Program. Members shall be appointed by the Contractor and shall represent diverse perspectives, including but not limited to:

Health care professions that are representative of PACE services;

Demonstrated experience working with the target PACE population; and

Time spent living and/or working in the Service Areas.

The Contract shall establish a Participant Advisory Committee (PAC), in accordance with Federal regulations. At minimum, the Contractor shall hold an annual PAC meeting. All participants and their authorized representatives shall receive advance notice of at least 60 days prior to the proposed date.

Membership of the PAC shall consist of PACE participants, family members, and caregivers of participants. The composition of the PAC shall reflect the diversity of the Contractor’s participant population and shall include, to the extent practicable, individuals representing a broad range of geographic, cultural, linguistic, racial, disability, sexual orientation, and gender identities, among other characteristics.

The Contractor shall ensure reasonable accommodation to attend the PAC is offered, including in-person and virtual meeting participation options, to support PACE participants and their authorized representatives in attending.

The Contractor may consider providing compensation such as travel or meal reimbursement to support participation in the PAC as permissible by federal and state law.

The Contractor must annually report to the NVHA a list of each meeting date, agenda topics discussed at each meeting, total participant attendance at each meeting and recommendations made by the committee. Minutes shall be made available to the NVHA upon request.

The annual report must also include the Contractor’s response to the Committee’s recommendations.

Pace Structure

PACE Program Director

The Contractor shall designate a Program Director with day-to-day operational authority over the PACE program. The Program Director must:

Reside in the state of Nevada.

Be available to the NVHA during regular business hours, and responses to NVHA leadership must not exceed two business days. In circumstances requiring immediate assistance, as determined and indicated by NVHA, the Program Director shall respond within 24 hours.

Key Personnel Changes and NVHA Approval

The Contractor shall notify the NVHA in advance of any executive personnel staffing changes, including Program Director. For permanent removals or resignations of executive staff, the Contractor shall submit resumes and references for a minimum of two qualified replacement candidates prior to hiring.

The NVHA reserves the right to accept, reject or request additional candidates within three business days of receipt of resumes.

A written transition plan shall be submitted to the NVHA and approved prior to implementation of any key personnel change. The NVHA shall approve the written transition plan which must include proposed effective date for new personnel, within 10 business days of receiving the plan.

Subcontractors

Subcontractors are defined as a third party, not directly employed by the Contractor, who provides any services identified in Attachment B - PACE Service Delivery Arrangements for successful PACE operations in Nevada. This may include clinical providers, specialty care providers, home and community-based services providers, transportation providers, and any delegated entities responsible for delivering or supporting participant services.

The Contractor must require the subcontractor to comply with any right of the NVHA for inspections, audits, records retention. If the Subcontractor is performing a function pursuant to this Contract which includes or is otherwise attached to specific reporting requirements per Section 1.5, the Contractor shall ensure reporting is performed in accordance with the specified reporting requirements.

If the Contractor seeks to subcontract any administrative duties, approval from the NVHA is required prior to subcontracting and must be included in the bidder’s proposal. The Contractor shall be liable for the full cost of services resulting from a prohibited referral or subcontract.

A written agreement between the Contractor and each subcontractor is required and shall clearly define the activities and responsibilities delegated to the subcontractor. Each agreement shall include procedures for revoking delegated authority or imposing other sanctions if the subcontractor’s performance is deemed inadequate.

Subcontracted providers must be monitored by the Contractor to ensure compliance with the terms and conditions of their subcontracts, track complaint resolution and promote delivery of courteous, safe, timely and efficient services. Each subcontract shall be reviewed no less than once every three years from the subcontractor’s effective date, or more frequently as necessary to address applicable programmatic, contractual, or regulatory changes.

Contractor shall not discriminate, with respect to participation, reimbursement, or indemnification, against any provider who is acting within the scope of the provider’s license or certification, solely on the basis of that license or certification.

If the Contractor declines to pursue a subcontract with an individual provider or group of providers, the Contractor shall provide the affected provider(s) a written notice stating the reason(s) for the decision.

If the Contractor or the NVHA identifies material deficiencies related to the Subcontractor’s performance, the Contractor and the Subcontractor must take corrective action, including, at minimum, developing a Corrective Action Plan (CAP) which shall:

1. Be submitted to the State for review and approval prior to issuance;

2. Identify deficiencies and the corrective actions that will be taken to correct those deficiencies, responsible parties, monitoring methodology, and implementation timelines; and

3. Contain adequate consequences for continued noncompliance, including but not limited to penalties and possible termination of the Contractor’s agreement with the Subcontractor.

Whenever possible, the Contractor shall establish subcontracts with existing enrolled providers with Nevada Medicaid. A list of current Nevada Medicaid providers can be accessed on Nevada Medicaid’s fiscal agent’s website.

The Contractor shall not employ or subcontract with any individual who has been sanctioned for Medicaid fraud or abuse or is:

On the list of debarred individuals by the Office of the Inspector General (OIG) website and/or, Listed on the Federal Debar list on System for Award Management website.

In addition to all requirements of §460.64, the following are minimum requirements for any driver transporting PACE participant:

Be at least 18 years of age

Maintain a valid and appropriate Nevada driver’s license and have not had their driver’s license, commercial or other, suspended or revoked in the previous five years.

Have no more than one chargeable accident and no more than two moving violations within the last three years.

Use, possess, or be under the influence of alcohol, narcotics, marijuana (recreational or medical), illegal drugs or any substances that may impair ability to safely perform assigned duties. Drivers shall not smoke or vape in the presence of any participant.

Comply with all applicable laws regarding use of handheld wireless communication devices as required in NRS 484B.

Assist passengers as needed with boarding and seating including ensuring all seat belts are properly fastened and wheelchairs and wheelchair passengers are properly secured.

For participants who need a secure behavioral health transport, all safety protocols and driver training must be adhered to Nevada Administrative Code 433.415.

A bidder must complete Attachment B - PACE Service Delivery Arrangements with proposed subcontractors for solicitation.

If any changes are made, the Contractor must submit Attachment B - PACE Service Delivery Arrangements to the NVHA during the readiness review process but no later than 60 days prior to commencing services.

The Contractor shall submit Attachment B - PACE Service Delivery Arrangements annually as part of the reporting requirements outlined in Section 9.

Service Areas and PACE Centers

Only one PACE organization will be authorized per service area and only one PACE Center is authorized in the one service area. Bidders are allowed to submit proposals for multiple service areas. Bidders must specify within their proposal the Service Area(s) for which it seeks to provide PACE services Service Area.

Each PACE program will have a cap of 300 participants per PACE Center. The State has the right to increase participant caps at any time throughout the contract term.

Geography of Service Areas

Nevada is geographically bifurcated into urban areas (Clark County and Washoe County) and rural areas (all remaining 15 counties).

Three Service Areas are established in Clark County and one in Washoe County as prescribed in Section 1.1.4.D.

Rural Service Area(s) will be established based upon the bidders’ proposal.

Urban Service Areas have been designed to reflect NVHA priorities for implementing PACE in regions with sufficient Medicaid population density, provider availability, and infrastructure to support program readiness and participant access. The following are zip codes authorized in urban areas for each Service Area by County:

Clark County Service Area One: 89104, 89101, 89110, 89122, 89106, 89119, 89120, 89142

Clark County Service Area Two: 89121, 89107, 89109, 89102, 89103, 89146, 89147, 89117, 89145, 89169

Clark County Service Area Three: 89030, 89108, 89115, 89032, 89134, 89031, 89129, 89130, 89128, 89131, 89149, 89084, 89081, 89143, 89166

Washoe County Service Area 1: 89433, 89506, 89502, 89431, 89512, 89503, 89523, 89509, 89434, 89436, 89511, 89521, 89501, 89441, 89508, 89519, 89439, and 89510.

Rural Service Areas are designed to incentivize access to PACE services in Nevada’s rural and frontier communities. In order to be selected for Clark County Service Area Three, a bidder must submit a proposal to establish a PACE Center in at least one of the rural counties outlined in 1.1.4.D. A bidder may submit a proposal for only a rural county listed in 1.1.4.D which would not require a bid for an urban service area. For any rural service area, the NVHA may pursue applicable federal waivers or approvals necessary to support the development of PACE in a Nevada rural county. Award of a rural service area does not guarantee approval of any federal waiver or other required federal authorization.

Rural Counties- Carson City, Churchill, Douglas, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Lyon, Mineral, Nye, Pershing, Storey, and White Pine.

Regardless of the Service Area(s) awarded, the Contractor must:

Only serve eligible PACE participants within its awarded Service Area up to the cap per Section 1.1.4.B.

Ensure reasonable access to the PACE Center inclusive of travel time up to a maximum of 60-minutes for participants living in the Service Area.

Services

In addition to the required services in § 460.92 and § 460.94, the Contractor must provide services equivalent, in amount, duration and frequency, to all Nevada Medicaid 1915(c) HCBS services under the Frail Elderly Waiver and Persons with Physical Disabilities Waiver.

Eligibility, Enrollment and Disenrollment

PACE eligibility includes the following components that must be met prior to authorizing services.

Participants interested in enrolling with Nevada PACE must meet the minimum requirements in §460.150 and have an income up to 300 percent of the Federal Benefit Rate.

Level of Care Determinations

Nevada Medicaid’s Nursing Facility Level of Care criteria is outlined in MSM 500.

The State of Nevada, Aging and Disability Services Division (ADSD) is the designated Area Agency on Aging for Nevada and operating agency for Nevada Medicaid’s 1915(c) Waivers for the Frail Elderly and Persons with Physical Disability Waiver.

As the operating agency for Nevada Medicaid’s 1915(c) HCBS waivers, ADSD conducts Nursing Facility LOC assessments for all HCBS Waiver applicants. A Nursing Facility LOC is completed in order to place an applicant on the HCBS waitlist. The Contractor may opt to use a 1915(c) HCBS LOC conducted by the ADSD to fulfill the LOC requirement for PACE eligibility.

Any applicant for a HCBS Waiver will have Notice of Decision (NOD) letter indicating they are placed on the HCBS Waitlist, and the Contractor would have to obtain a copy of the completed LOC for its records.

Additionally, the Contractor is encouraged to engage with ADSD for purposes of identifying potential PACE eligible participants who are on the HCBS Waiver waitlist.

If the Contractor conducts their own LOC, then the NVHA must approve the LOC assessment tool(s) used by the Contractor and the Contractor incurs all costs associated with the tool and associated technology.

The NVHA will audit a retrospective review of LOCs completed by the Contractor.

As part of the ongoing retrospective review, the NVHA will ensure that all approved LOCs and eligibility determinations conducted by the Contractor meet the requirements of the program. Should the Contractor render services to a participant who, upon the post review, is determined to be ineligible for PACE, any costs associated with the services rendered will be at the liability of the Contractor and subject to recoupment for any Medicaid reimbursement.

Enrollment Decision

As outlined in 42 CFR § 460.152, the Contractor shall develop, maintain, and comply with written policies and procedures governing the intake, assessment and authorization of PACE service requests. The Contractor shall implement mechanisms to ensure consistent, timely, and equitable authorization determinations in accordance with Medicaid requirements and the applicant’s medical and functional needs.

Additionally, a participant must receive information regarding transferring to another PACE Organization should a participant move to another location within Nevada that has a defined Service Area and approved PACE Organization.

If the Contractor denies an applicant for enrollment in PACE, the Contractor must send a NOD as outlined in Section 4.6 and refer the applicant to alternative services as appropriate.

Disenrollment from PACE

If the Contractor receives a request of voluntary disenrollment by a participant or their authorized representative, that participant must receive a termination NOD as outlined in Section 4.6.

If the Contractor seeks to involuntarily disenroll a participant in accordance with §460.164, the Contractor shall send a notification for involuntary disenrollments to PACE@nvha.nv.gov. The NVHA will respond within ten business days to confirm the disenrollment is permissible.

Upon disenrollment, the Contractor shall follow the appeals process outlined in Section 6. The Contractor must notify the participant of alternative service delivery models available to the participant based on their eligibility coverage. For participants who lose Medicaid eligibility, the Contractor shall provide the participant and applicable authorized representatives with information for the State of Nevada, Department of Human Services, Division of Social Services which processes Medicaid eligibility.

PACE Center

Licensure Requirements

In order to ensure the Contractor meets Nevada’s health and safety standards, awarded Contractors must apply for a Facility of Care for Adults During the Day licensure through the Bureau of Health Care Quality and Compliance, Division of Purchasing and Compliance.

The Contractor must notify Nevada Medicaid via email to PACE@nvha.nv.gov within 24 hours of the event of a closure, suspension or adverse action taken by HCQC. The notification must include any applicable corrective action plan required by HCQC.

For any Personal Care Services, Home Health, Private Duty Nursing or Hospice services which are not subcontracted to an enrolled Medicaid provider, the Contractor must be individually licensed through HCQC for all applicable in-home services prior to rendering care.

The Contractor and any subcontracted providers must also enroll with Nevada Medicaid under the appropriate provider type. A unique National Provider Identification number is required for each PACE Center.

Staffing Requirements

The Contractor shall maintain sufficient levels of staff, including supervisory, administrative, and support staff, with appropriate training, experience, and qualifications necessary to meet all contractual requirements.

Disaster Recovery Plan

Due to the critical nature of PACE services and the potential impact of service disruption on participants, the Contractor shall maintain documented Business Continuity and Disaster Recovery Plans sufficient to support continuation and timely restoration of critical services, systems, data, facilities, and operational functions.

The Contractor shall submit its current Business Continuity Plan and Disaster Recovery Plan, or applicable portions acceptable to NVHA, with its RFP response. At a minimum, the plans shall:

Identify critical systems, services, business processes, facilities, personnel, third parties, and external dependencies necessary to support PACE operations;

Define recovery time objectives (RTOs) and recovery point objectives (RPOs) appropriate to the criticality of each service or system;

Address backup, restoration, alternate processing, communications, staffing, and continuity procedures;

Address disruption of cloud services, telecommunications, utilities, facilities, critical vendors, and other dependencies;

Provide for secure backup and recovery of State and participant data;

Include procedures for maintaining essential participant services during degraded or unavailable system conditions;

Be tested at least annually, with documented results, identified deficiencies, and corrective actions;

Be reviewed and updated following material system, operational, hosting, or organizational changes; and

Be made available to NVHA upon request, including summaries of testing results and remediation activities.

Primary, backup, disaster recovery, and alternate processing resources used to store or process State data shall be located within the United States unless otherwise approved in writing by NVHA.

The Contractor shall notify NVHA promptly of any disaster, outage, continuity event, or material service disruption that affects or is reasonably expected to affect PACE services, State data, or contractual operations, and shall provide status updates through restoration of normal operations.

Information Systems and Technical Requirements

Security Framework Requirement

The Contractor shall implement and maintain an information security program aligned with NIST SP 800-53 (Moderate baseline) HIPAA Security Rule requirements, and applicable State of Nevada and NVHA security requirements. Administrative, technical, and physical safeguards shall apply to all systems, environments, personnel, and third parties that store, process, transmit, or access NVHA data, including Protected Health Information (PHI) and Personally Identifiable Information (PII).

Minimum Technical Safeguards

At a minimum, the Contractor shall implement and maintain:

Encryption of sensitive State data at rest and in transit using current, industry-accepted cryptographic standards and FIPS 140-3 validated cryptographic modules where applicable;

Multi-factor authentication for remote access, privileged or administrative access, and access to systems containing sensitive State data;

Role-based access controls, unique user identification, least privilege, and appropriate separation of duties;

Centralized security logging, monitoring, and alerting sufficient to identify unauthorized access, privileged activity, security events, and anomalous activity;

Endpoint protection, secure configuration, and device hardening for systems and devices used to access or process State data; and

Vulnerability and patch management processes that include regular vulnerability scanning and risk-based remediation.

Security Assessment and Authorization

Prior to production use, and thereafter as required by NVHA based on risk or material system change, the Contractor shall:

Complete and maintain a documented Security Risk Assessment;

Provide current evidence of independent security assessment, such as a SOC 2 Type II report, HITRUST certification, or other evidence acceptable to NVHA;

Provide security documentation reasonably requested by NVHA, including applicable security plans, architecture and data-flow documentation, penetration test summaries, vulnerability-management information, and remediation plans; and Undergo NVHA security review and receive approval prior to production implementation and following material changes that significantly affect the system's security posture.

Subcontractor Security Flow-Down

The Contractor shall remain responsible for the security and compliance of all subcontractors, sub processors, hosting providers, affiliates, and other third parties supporting the contracted services or accessing State systems or data. The Contractor shall ensure that applicable security, privacy, confidentiality, and Business Associate requirements are contractually flowed down to such entities and shall:

Identify material third parties that store, process, transmit, or access State data;

Conduct appropriate risk-based security assessments;

Require safeguards no less protective than those applicable to the Contractor; and

Notify NVHA of material changes to third parties that may affect the security, availability, storage, processing, or regulatory obligations associated with State data

Incident Response Requirements

The Contractor shall maintain and annually review a formal Incident Response Plan aligned with applicable NIST and NVHA requirements. The Contractor shall notify NVHA within the timeframe established by NVHA following discovery of a suspected or confirmed security incident that affects, or has a reasonable likelihood of affecting, State data, systems, services, or contractual operations. Notification shall not be delayed pending completion of the Contractor's investigation or a determination that a reportable breach has occurred.

The Contractor shall support containment, eradication, recovery, forensic investigation, preservation of relevant evidence and logs, root-cause analysis, corrective actions, and coordination with NVHA. The Contractor shall provide subsequent updates and a final incident report as requested by NVHA.

Workforce Security

The Contractor shall:

Perform background checks appropriate to the individual's role and level of access shall be completed prior to granting access to State data or systems, unless otherwise expressly approved by NVHA. Requirements shall apply to Contractor and applicable subcontractor personnel.

Provide annual security and HIPAA training.

Enforce access provisioning and deprovisioning control.

Cloud and Hosting Requirements

Cloud services used to store, process, or transmit State data shall comply with applicable State of Nevada Cloud Security Requirements, including applicable GovRAMP or FedRAMP requirements, as determined by NVHA and the State. The Contractor shall disclose all cloud hosting providers, service models, hosting locations, and material sub processors supporting the contracted services.

State data, including production data, backups, replicas, and disaster-recovery copies, shall be hosted within the United States unless otherwise expressly approved in writing by NVHA. Remote administrative or support access to State data from outside the United States shall be disclosed and is subject to NVHA approval. The Contractor shall maintain documented shared-responsibility models for applicable cloud services.

Interface / Integration Security

All electronic interfaces and data exchanges, including APIs, managed file transfers, batch interfaces, and MMIS integrations, shall use NVHA-approved secure transmission methods, authentication, encryption, and appropriate integrity controls.

Audit and Right to Inspect

NVHA reserves the right to request and review security documentation, audit reports, assessment results, policies, plans, system evidence, and remediation status reasonably necessary to evaluate compliance with contractual security requirements. The Contractor shall address identified deficiencies within timeframes established by NVHA based on the severity and risk of the finding.

System Maintenance and MMIS Interface

The Contractor shall be responsible for all programming, system maintenance, and associated costs. The Contractor shall be responsible for developing any necessary interfaces with the Medicaid Management Information System (MMIS), including but not limited to the delivery of encounter data. Material system, interface, architecture, or hosting changes that may affect security or the handling of State data shall be subject to documented change management and notification to NVHA prior to implementation.

Communication with Participants and Stakeholders

Marketing

All marketing and informational materials must be approved by the NVHA prior to distribution.

The Contractor shall only begin marketing activities once Nevada Medicaid has approved all material and Centers for Medicare and Medicaid Services (CMS) approval has been received.

Written Materials and Distribution Standards

The Contractor shall maintain written materials about its PACE services, eligibility criteria, how to obtain services, authorization requirements, participant rights, grievance and fair hearing rights, the address and telephone number of the PACE Center and the days and hours of operation. The Contractor must receive prior approval from the NVHA of all written materials. This material must be made available to participants at no charge.

This written material must also be made available in the prevalent non-English language, which the State has determined to be Spanish. All written material must use a plain language format that does not exceed a sixth-grade reading level.

Notification of changes in PACE services that significantly affect participants, including but not limited to changes to operating hours, telephone numbers, and service delivery must be individually mailed to all PACE participants and posted on the Contractor’s website.

Translation and Language Assistance Services

The Contractor must make available and notify participants of free translation and language assistance services. Translation services shall be provided for all non-English languages, not just those that the State identifies as prevalent.

Accessible Communication and ADA Compliance

The Contractor must also provide appropriate communication accommodations for participants who are visually and hearing-impaired or have physical disabilities, in accordance with the requirements of the Americans with Disabilities Act of 1990 (ADA).

All online information shall meet all ADA accessibility requirements. All participants must be informed that this information is available in alternative formats and shall be provided with clear instructions on how to access those formats.

Prohibition on Payments or Remuneration for Referrals

PACE employees or subcontractors shall not offer or make any payment or other form of remuneration, including any kickback, rebate, cash, gifts, or service in kind to the Contractor, in order to influence referrals for PACE services provided to a participant.

Notices of Decisions

The Contractor shall notify each affected participant in writing of any denial, reduction in level of service or termination. The NOD must include the reason for the adverse action request within ten (10) business days of the adverse action.

Each NOD must include, at a minimum, the following information:

A clear description of the action the Contractor or its PACE subcontractor has taken or intends to take.

The reason(s) for the action, including citation to the applicable regulation or policy supporting the decision.

Notice of the participant’s right to request a State Fair Hearing, instructions (including timeframes) on how to request such a hearing, and information on representation.

Grievances

Grievance Process Requirements

The Contractor is responsible for receiving and responding to all written (hard copy and electronic) or verbal grievances from participants, authorized representatives, providers, the NVHA, or other sources regarding the delivery of PACE services under this contract. The Contractor shall maintain a written grievance process. The NVHA will refer all participant grievances to the Contractor for resolution. The Contractor must provide information about its grievance process to all employees and subcontractors at the time they enter into a contract.

Grievance Resolution Standards

The Contractor shall resolve each grievance and provide notice as expeditiously as possible, at maximum no more than ninety (90) days from the date the grievance is received by the Contractor. In resolving grievances, the Contractor must:

Provide reasonable assistance to participants, in completing forms and taking other procedural steps, including interpreter services and access to toll-free numbers with TTY/TTD capability;

Acknowledge receipt of each grievance within 24 hours of verbal and 72 hours for written grievances;

Ensure that the individuals who make decisions on grievances were not involved in any previous level of review or decision-making; and

Issue written notice of the grievance resolution, including the decision and completion date.

Grievance Documentation

The Contractor must accept written or verbal grievances that are submitted directly by the participant as well as those that are submitted from other sources, including the NVHA. The Contractor must keep a written or electronic record of each grievance which must include:

A description of the issue;

The date filed;

The dates and nature of actions taken, and

The final resolution. The Contractor must issue a final decision, in writing, no later than ninety (90) days after a grievance is filed.

Grievance Monitoring and Quality Improvement

Grievance Handling Procedures

The Contractor shall establish and maintain standardized, written procedures for handling all grievances, including documentation requirements. Investigations shall entail obtaining as much factual information about the grievance as is made available during the course of the investigation. The Contractor shall make reasonable efforts to resolve each grievance.

Grievance Tracking and Documentation

The Contractor shall maintain a log of all grievances, whether verbal or written, including documentation of the grievance and action taken to resolve the grievance.

Data Analysis and Quality Improvement

The Contractor shall compile and analyze grievance data on a monthly basis to assess quality of services to participants and identify patterns or trends. The Contractor shall analyze the grievance data for quality improvement as an integral part of its Quality Assurance (QA) Monitoring Plan.

Appeals

Appeal Process Requirements

The Contractor shall establish and maintain a formal appeal process to review any decision denying, terminating or reducing services. The review of appeals shall be performed by parties other than those making the original decision and who possess the authority to uphold, modify, or reverse the original decision.

The Contractor’s policies and procedures must be approved by the NVHA prior to implementation and at any time thereafter if the appeals policies and procedures are revised.

Submission and Documentation of Appeals

The Contractor must accept written or verbal appeals submitted directly by participants and providers as well as those submitted from other sources.

A verbal appeal must be followed by a written, signed appeal; however, the date of the verbal appeal shall serve as the initial date of appeal.

The Contractor shall maintain a written or electronic record of each appeal, including a description of the issue, the date filed, the dates and nature of actions taken, and the final resolution. A written final decision must be issued by the Contractor no later than 30 days after an appeal is filed.

Participant State Fair Hearing Rights

The State Fair Hearing process is outlined in Medicaid Services Manual Chapter 3100. Whenever the Contractor takes an adverse action on a participant’s PACE request for services, the Contractor shall provide a NOD including information on how to request a State Fair Hearing per Section 4.6.2.C.

Participant Issues Eligible for State Fair Hearing

Adverse actions eligible for the State Fair Hearing include, but not limited to:

Denial or limited authorization of a requested service;

Reduction, suspension or termination of a previously authorized service, and

Failure of the Contractor to meet specified timeframes for authorizations.

Excluded Issues

The NVHA will not accept requests for State Fair Hearings regarding provider enrollment, provider termination, or other contractual disputes between the Contractor and its providers or subcontractors.

FISCAL REQUIREMENTS

Reimbursement for PACE Services

NVHA will establish the initial Medicaid PACE capitation rate using historical Medicaid expenditures for a comparable population that meets PACE eligibility criteria. The rate will reflect the projected cost of Medicaid-covered services for this population, including long-term services and supports, acute and primary care, behavioral health, pharmacy, transportation, and other applicable services.

Historical costs may be adjusted for changes in utilization, reimbursement, covered benefits, program policy, and other factors necessary to project expected costs. The resulting rate will be established on a per-member, per-month (PMPM) basis and must remain below the amount Nevada Medicaid estimates it would otherwise pay for comparable services outside of PACE.

The capitation PMPM rate begins once CMS and NVHA approval is received.

The Contractor must ensure that no compensation arrangements with individuals or entities performing utilization management activities under this contract create incentives to deny, limit, or discontinue medically necessary services for any participant.

The Contractor must ensure timely payment to each subcontractor for authorized services rendered. Full payment of all authorized services shall be issued within 60 calendar days of receipt of a verified request for payment. The Contractor shall maintain adequate safeguards to protect against fraudulent activity by subcontractors and participants.

Performance Security Deposit

Performance Security Requirement

The Contractor is required to provide a performance security deposit to the NVHA, in the form of a bond furnished by a surety company authorized to conduct business in the State of Nevada, to guarantee fulfillment of the Contractor’s obligations under this contract. Alternative forms of security may be considered with the approval from the State’s Risk Management Division. The performance security deposit may be utilized by NVHA to remedy any breach of contract or to satisfy sanctions imposed on the Contractor.

Performance Security Deposit Amount and Timing

Deposit Amount

The amount of the performance security deposit shall be one million five hundred thousand dollars ($1,500,000).

Deposit Deadline

The Contractor shall deposit the required performance security amount with the State Treasurer within fifteen (15) calendar days following the end of the first quarter of the contract term.

Surety Bond Qualifications

If the Contractor elects to satisfy the performance security to the NVHA through a surety bond, the issuing surety company must meet all of the following criteria:

Be rated A-VII or higher by A.M. Best;

Be certified by the U.S. Department of Treasury, Financial Management Service, for operation in the state of Nevada; and

Be licensed by the Nevada Department of Business and Industry, Insurance Division.

Post-Contract Maintenance

The Contractor must maintain the performance security deposit after the contract term for a length of time, to be determined by the NVHA, in order to cover all outstanding liabilities.

Monetary Penalties

General Provisions

In the event that the Contractor fails to comply with this contract, NVHA may impose, at the State’s discretion monetary penalties described in this section which are in addition to civil monetary penalties outlined in § 460.46. This includes withholding funds or taking back funds if the Contractor’s costs do not meet the service delivery goal of ensuring the most cost-efficient and appropriate transportation services.

The NVHA, at its discretion, may direct the Contractor to expend any portion of monetary penalties for PACE development and enhancement activities that will directly benefit participants.

The NVHA reserves the right to waive the application of penalties at its discretion if the NVHA determines that such waiver is in the best interest of the NVHA.

Assessment and Application of Penalties

All penalties and fees assessed to the Contractor on behalf of the NVHA shall result in a reduction in the Contractor’s payment.

Program Requirements and PACE Penalties

Payment of Outstanding Penalties

In circumstances where the NVHA does not reduce the payment in advance of it being issued, the Contractor shall submit a check to the NVHA for payment of any outstanding penalties and charges.

QUALITY, ASSESSMENT AND PERFORMANCE IMPROVEMENT

The Contractor shall maintain a comprehensive, formal Quality Improvement (QI) Program consistent with all federal requirements under 42 CFR §460.130–§460.138 and the following requirements established by NVHA.

Quality Work Plan

The Contractor shall maintain a written QI Work Plan that uses objective, data driven measures to monitor performance and demonstrate continuous quality improvement aligned with the needs of Nevada PACE participants. This Work Plan shall include:

Annual goals for improving participant experience, care coordination, and autonomy, with specific objectives tailored to Nevada’s demographic and geographic context.

Chronic and preventative care indicators aligned with CMS requirements, plus any NVHA identified priorities such as vaccination targets, preventative screenings, medication reconciliation, or condition specific initiatives.

Identification and reduction of disparities in access or outcomes, including if appropriate based on the service location, analysis of rural access challenges and population specific needs.

The QI Work Plan must be submitted after the first year of operations and annually thereafter as outlined in Section 9.1.4.

Quality Measurement System

The Contractor shall maintain an internal quality measurement system that tracks essential indicators of care timeliness, service reliability, participant safety, and access to needed services. The system shall enable early detection of operational or clinical issues and support NVHA’s quality oversight. Metrics monitored through this system shall be incorporated into required reporting and used to guide continuous improvement activities.

Incident Reporting System

The Contractor shall identify all Serious Occurrences and notify NVHA within 24 hours of discovery. Notification must include a description of the event, immediate actions taken to ensure participant safety, and any urgent mitigations initiated by the Contractor. Serious Occurrences include, but not limited to:

Allegations or confirmed cases of abuse, neglect, or elopement.

Medication errors resulting in harm, emergent care, or hospitalization.

Equipment or assistive device failures that adversely impact participant safety.

Motor vehicle accidents involving participants during PACE provided or contracted transportation.

Any event generating media or public safety attention related to participant care or facility operations.

Threats or acts of violence, including active assailant or hostage situations.

Immediate Notification Requirements

Upon learning of a Critical Incident, the Contractor shall notify the NVHA Long Term Services and Supports Social Services Chief 3 and Deputy Administrator as soon as possible, but no less than 24 hours after the incident.

Corrective Action Procedures

The Contractor shall develop and implement CAPs to address any quality deficiencies identified through internal monitoring, NVHA oversight activities, or CMS audits. CAPs must be designed to remediate the identified issue, prevent recurrence, and ensure sustained compliance with federal and State.

Upon identification of a deficiency or area requiring improvement, the Contractor shall document the finding(s) and develop a written CAP within ten (10) business days of discovery.

Each CAP shall:

Root cause analysis identifying the underlying factors contributing to the deficiency.

Corrective and preventative strategies detailing actions required to remediate and prevent recurrence.

Designated responsible staff and clearly defined implementation timelines.

Monitoring methodology outlining how progress and sustained compliance will be assessed.

Establish a remediation timeframe commensurate with the nature and severity of the deficiency. The remediation timeframe shall not exceed thirty (30) calendar days unless an alternative timeframe is required by applicable State or Federal requirements or is approved by the NVHA.

NVHA Oversight and Quality Assurance Reviews

The Contractor must monitor a subcontractor’s performance on an ongoing basis and is subject to formal review by the NVHA. The NVHA reserves the right to conduct quality assurance reviews of all services under this contract. These reviews may be conducted in an anonymous manner and without advance notice.

REPORTING REQUIREMENTS

The Contractor must comply with all reporting requirements outlined in this section as well as any additional reporting requirements upon request by the NVHA. Additional reporting requirements may be imposed on the Contractor if the NVHA identifies any area of concern with regard to a particular aspect of the Contractor’s performance under this Contract.

Ad Hoc and Event Based Reporting

Fraud, Waste, and Abuse Reporting

Pursuant to 42 CFR 460.63 the Contractor must report all suspected fraud, waste, and abuse information to the NVHA. At a minimum, the Contractor shall report all complaints warranting preliminary investigation to the NVHA. For each reportable incident, the Contractor must provide to the Nevada Medicaid Inspector General’s Office:

The provider or participant name and Medicaid ID number;

The source of the complaint;

The type of provider;

The nature of the complaint;

Approximate dollars involved, and

Legal and administrative disposition of the case.

Annual Reporting Requirements

Annual reports shall be submitted no later than February 15 of the following calendar year and in a format approved by the NVHA. The NVHA may ask for a similar report to be completed and submitted during the course of the contract year. Annual reporting shall include the following data:

Utilization and cost trends analysis;

Complaints, grievances, appeals summary;

Admissions, denials and discharges report (with trend analysis);

QI Program as outlined in CFR 460.134;

CAP summary;

Preventative care and clinical outcomes review;

Incident trend analysis;

Technology/system integrity review;

Annual Financial Submission including a financial statement summarizing revenue, service cost expenses, and administrative expenses; and

Attachment B - PACE Service Delivery Arrangements

Monthly Reporting Requirements

Encounter Data Submission

The Contractor shall electronically submit monthly Encounter Data for all completed and authorized PACE services. Encounter Data shall include, at a minimum: participant’s name, Medicaid ID number, date of service and provider name and type of service.

Encounter Data reporting requirements and data element specifications are subject to change based on CMS guidance. The Contractor shall comply with all additional data elements or reporting requirements as directed by the NVHA.

Encounter Data Format, Timeliness, and Corrections

Encounter Data shall be submitted in ANSI X12 837 format, or what format may supplant that specification designated by the NVHA. The Contractor shall comply with required upgrades to encounter data formats upon a minimum of 60 calendar days’ written notice from the NVHA.

Encounter data shall be submitted to the NVHA within fifteen (15) business days following the close of each month, using the transmission method and format specified by the NVHA.

In the event the data submission contains erroneous data as determined by the NVHA, the Contractor has thirty (30) days to correct the errors and resubmit the data.

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