Inquiries and Answers RFI 2027-0010.docx

SOLICITATION # UHHA 2027-0010:

Medical Frailty Determination Services Response to Inquiries Is there currently a vendor providing these services?

There is no incumbent vendor, this is new mandatory work that came out of HR-1 to comply with Work Requirements/Community Engagement requirements.

Is there an estimated value of a potential contract that may be awarded?

The Department is attempting to estimate the cost of the proposed work through the RFI process and market research.

Is there a projected timeline for this project beyond the RFI stage?

The Department estimates that a vendor would be necessary to begin work by October 2027. We will be moving into an RFP phase in the next 3-9 months.

The RFI requests that all proprietary data be pulled out and placed in a separate document. May the respondent retain all proprietary data, marked as such in the main response and then provide a redacted document for use in public disclosure, instead of separating and pulling out the data into a separate document?

There is not a portion of the RFI that indicates parts of the response must be “pulled out” and placed in a separate document. Please re-read section 5.3.8 and in particular, section 5.3.8.4. of the RFI which outlines the following: A complete redacted response should also be included along with an unredacted Response and confidentiality justification.

Sections 1.2.3 and 2.3.2: Would HCPF consider the use of AI-assisted tools for document classification, clinical evidence extraction, source-linked summarization, and case triage when a qualified clinician retains responsibility for the final determination? If so, what approval, validation, auditability, human oversight, data-use, and ongoing monitoring requirements would apply?

HCPF will consider the use of AI assisted tools used in the process of a determination. However, the final determination must be made by a qualified clinician. Respondents are encouraged to provide details of how they would propose to use AI tools, what tools they would use, and what guardrails and security protocols they would put in place to ensure AI tools are used responsibly and appropriately for this work and how they would ensure that all final determinations would be made by a qualified clinician.

Sections 1.3.2 and 2.2.1–2.2.3: Will HCPF provide the final medical frailty criteria, evidence thresholds, and approved functional assessment instruments, or does HCPF expect the contractor to develop and recommend these standards for approval?

If the Department selects a vendor through a future solicitation to perform this work, the Department will approve the final medical frailty criteria, evidence thresholds, and assessment instruments. The Department may either procure a vendor through a separate solicitation to develop these criteria and instruments or include this work in a future solicitation for independent medical frailty determination services. Respondents to this RFI are encouraged to recommend criteria, standards, and assessment instruments in their responses.

Exactly how medically frail approval, denial, and appeal notices will be issues to applicants and beneficiaries has yet to be determined. The Department anticipates that the vendor will make the medical frailty determination and may be required to issue approval and denial notices directly to applicants and beneficiaries. The Department’s eligibility system makes the final determination of eligibility and will issue formal eligibility notices to applicants and beneficiaries. It is expected that if an applicant/beneficiary wishes to appeal the medical frailty determination the vendor would be responsible for representing the Department through that process.

Sections 2.1.1.3, 2.1.1.4, and 2.4.2: Will the contractor be responsible for contacting members and providers to obtain additional documentation or conduct interviews? How will turnaround time be calculated when information is incomplete, and will the service clock pause while required documentation is outstanding?

It is anticipated that the vendor will be responsible for contacting members and providers to obtain additional documentation (including medical records) and to conduct interviews with applicants/beneficiaries. Respondents are encouraged to describe how they would measure their turnaround time. In addition, respondents are encouraged to propose how they would manage to establish timelines (which have yet to be determined at this time) and where they may have potential challenges in meeting established timelines.

Sections 2.2.3 and 2.3.2: What data and systems will be available to the contractor? Will the contractor receive a complete referral packet, or have access to Medicaid claims, pharmacy data, eligibility information, health information exchange data, electronic health records, or other state systems?

Existing SSI/SSDI, VA, long-term-care, or other recognized disability determinations can serve as conclusive or presumptive evidence of medical frailty. The Department does envision that some cases could be approved administratively without a comprehensive clinical review. If the Department selects a vendor through a future solicitation to perform this work, a process will be established to refer applicants/beneficiaries who may meet the SSI disability standard so that disability determination process can be completed.

Sections 2.3.1.2 and 2.3.1.3: What minimum qualifications and licensure requirements does HCPF anticipate for reviewers? Must clinicians be licensed in Colorado, and would physician or specialty review be required for denials, behavioral health or substance use cases, complex cases, or appeals?

Minimum qualifications and licensure requirements have not been established. Respondents are encouraged to provide suggestions on those qualifications and licensure requirements in their response.

Sections 2.3.2 and 2.8.1: Does HCPF anticipate requiring a state-hosted technology environment, or may the contractor use its own HIPAA-compliant environment? Are there specific hosting, certification, data-residency, retention, or system-integration standards respondents should assume?

Respondents are encouraged to describe their proposed technology solution in their response. Respondents should assume that vendor-hosted technology solutions will be necessary and that the technology solution will need integration with existing State systems to receive and send various data points, including claims information, medical records, referrals, appeals, and medically frail determinations. Details on any state specific interfaces, hosting, certification, data-residency, retention, or system-integration standards are not available through this RFI.

Section 2.4.2.2: What circumstances will qualify a case for expedited review, and which entities will be authorized to request expedited processing?

Specific details on an expedited review process are not available through this RFI. Respondents are encouraged to propose processes and timelines, including the impact on cost/pricing, for expedited reviews in their response.

Section 2.5.1(a)(vii–ix): How will temporary and permanent medical frailty designations be defined? Will HCPF establish standard review or recertification intervals by condition, or should the contractor recommend the review date for each case? Comment by Flores-Brennan, Adela: Making stuff up here but could we say something like we will use our clinical team to support identifying conditions for temporary and permanent and will also await further information from CMS. In the meantime, yes we would appreciate a recommendation.

How temporary and permanent medical frailty designations will be established have not been determined. Respondents are encouraged to provide suggestions on recertification intervals in their response.

Sections 2.5.1(b)(6) and 2.7.1: What demographic, clinical, and operational data will HCPF make available to support monitoring of consistency, fairness, and potential disparities across population subgroups?

Information on which demographic, clinical, and operational data will be made utilized to support monitoring has not been determined. Respondents are encouraged to provide suggestions in their response.

Sections 2.7.1.3 and 2.7.1.4: What level of appeal support is anticipated? Will this include supplemental record review, preparation of written clinical rationales, hearing attendance, expert testimony, or reconsideration by a reviewer who was not involved in the original determination?

It is expected that if an applicant/beneficiary wishes to appeal the medical frailty determination the vendor would be responsible for representing the Department through that process. Respondents are encouraged to provide suggestions on how they would handle all aspects of that appeal process which may include supplemental record review, preparation of written clinical rationales, hearing attendance, expert testimony, or reconsideration by a reviewer who was not involved in the original determination.

Section 2.1.1 For medical frailty determinations that require periodic review, please clarify whether the one-year review period begins on the referral receipt date, the date all required documentation is received, or the date the determination is issued.

The Department expects that beneficiaries will have medical frailty verified annually. The Department has not determined the process and cannot provide additional information at this time.

5.3.1. The RFI states, "Information about costs and pricing is submitted voluntarily and is non-binding on the respondent." However, the requested Responses under Items 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, and 3.3 do not appear to request cost or pricing information. Please confirm if respondents should include cost and pricing information in responses or if that information should be reserved for a potential RFP to be issued at a later date? If cost or pricing information is required or recommended, please confirm it is acceptable to include this information as an attachment to the RFI responses submission.

The Department is attempting to estimate the cost of the proposed work through this RFI process and market research. Respondents are encouraged to submit what price information is available for any portion of the RFI, including providing cost and pricing information. The Respondent may include this information as an attachment to the RFI responses, or include them as part of a single response document.

The RFI indicates that the estimated annual referral volume is approximately 100,000 determinations. Please confirm that a reasonable assumption is that the initial number of applications will exceed 100,000.

See response to Inquiry 7.

2.2.3. What historical data will HCPF make available to support determinations, including medical claims, pharmacy claims, diagnosis history, eligibility spans, demographic fields, behavioral health claims, long-term services and supports indicators, encounter data, and prior coverage history?

See response to Inquiry 10.

Has HCPF developed preliminary medical frailty criteria and determination standards, or is the Department seeking vendor recommendations regarding clinical review methodologies?

See response to Inquiry 6.

Would HCPF like respondents to recommend staffing models, quality measures, service levels, and governance structures for a future program?

Yes, respondents are encouraged to recommend staffing models, quality measures, service levels, and governance structure based on the information provided through this RFI. In addition, respondents are encouraged to provide how modifications to their recommendations will impact costs and or pricing.

Does HCPF have an interest in vendor-hosted technology solutions (SaaS platforms) or should respondents assume integration with existing State systems?

The Department is interested in hearing how respondents can meet the requirements, whether it is a vendor-hosted solution, integrating with existing State systems, or a hybrid approach.

Does the Department anticipate all medical frailty referrals requiring manual clinical review, or would it consider approaches that leverage existing Medicaid claims and encounter data to support a standardized, auditable, and scalable determination framework?

The Department is open to all approaches and does not necessarily anticipate that every medical frailty referral would require manual clinical review. Respondents are encouraged to propose approaches that balance automation and data-driven methods with appropriate clinical review to ensure accurate and consistent determinations.

Is the Department also seeking vendor recommendations regarding standardized algorithm methodologies for defining and identifying medically frail populations Yes. The Department is open to vendor recommendations regarding standardized methodologies and approaches for defining and identifying medically frail populations, provided that any proposed approach aligns with applicable CMS guidance and federal requirements for medical frailty determinations.

Does the Department anticipate publishing a list of vendors that submit responses to this RFI, or otherwise disclosing respondent identities before issuance of any future solicitation? This could help with potential partnering opportunities for any future procurement related to this initiative.

Respondents are encouraged to include ideas for collaboration in a response, but ultimately all parts of an RFI, including the respondent list are considered confidential until such time as an RFP is awarded or the Department chooses not to move forward with an RFP process.

2.3 Would the vendor be responsible for developing medical frailty determination tools to use during the review/evaluation of members since this process currently does not exist in Colorado’s system? If not, does the Department have any tools identified that will be used?

See response to Inquiry 6.

2.3.2 Would the vendor be utilizing state technology platforms and systems to schedule, conduct and store medical frailty determination records or would the vendor need to supply the technology platform?

See response to Inquiry 13.

2.3.2. If the vendor must supply a technology platform to schedule, conduct and store medical frailty determination records, would the vendor be able to establish electronic data transfer processes with state systems to both receive and transmit data and files?

See response to Inquiry 13.

2.3.1.3. Does the state have any minimum credentialing or licensing requirements for staff who will make determination of medical frailty? If so, what are the minimum requirements?

See response to Inquiry 12.

2.1.1. Does the 100,000 anticipated annual volume include legacy members who are already receiving benefits? How will legacy members already receiving services be reviewed for medical frailty?

See response to Inquiry 7.

How often do service recipients need to be reviewed to determine continued medical frailty?

The Department expect that beneficiaries will have medical frailty verified annually.

2.3.1.8. If interviews of individuals are needed, can these be conducted via telephone or virtual meetings? Would some interviews need to be completed in person?

This has not been determined. Respondents are encouraged to provide recommendations in their response to this RFI.

What is the projected timeline for implementation of this program in Colorado?

See response to inquiry 3.

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