MO HealthNet Managed Care Program - Amendment 01.docx

STATE 0000000463SL Page 68

State of Missouri Office of Administration, Division of Purchasing

Request for Proposal (RFP) for MO HealthNet Managed Care Program

PROPOSAL DUE NO LATER THAN: September 2, 2026 AT 2:00 PM CENTRAL TIME Proposal response must be submitted electronically through MissouriBUYS, powered by MOVERS, at https://missouribuys.mo.gov.

E-mailed, mailed, courier, or hand-delivered proposal responses will not be accepted.

RFP CONTACT INFORMATION:

BUYER: Kristina Cramer

PHONE NO.: (573) 751-1695

EMAIL: Kristina.Cramer@oa.mo.gov See “RFP Questions” in Section 1 for appropriate communications during the procurement process.

DELIVER SUPPLIES/SERVICES FREE ON BOARD (FOB) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Social Services MO HealthNet Division 615 Howerton Court P.O. Box 6500 Jefferson City, MO 65102-6500

ATTENTION:

1. After reviewing the Request for Proposal (RFP), the vendor must complete and return Exhibit A, Proposal Signature Page and all other necessary exhibits.

2. Due to lead times for obtaining the information needed to complete the various Business Compliance Exhibits herein as explained in the RFP’s Vendor Response Exhibits, vendors are encouraged to IMMEDIATELY begin securing these verifications.

3. The vendor must be registered in MissouriBUYS, powered by MOVERS in a “Prospective” or “Spend Authorized” registration status to submit a proposal. The vendor must achieve “Approved” registration status in MissouriBUYS (WebProcure/Proactis) and “Spend Authorized” registration status in MissouriBUYS, powered by MOVERS to be considered for a contract award. Reference Section 5.

AMENDMENT #01 to STATE 0000000463SL

TITLE: MO HealthNet Managed Care Program

CONTRACT PERIOD: Effective Date of Contract through One Year

PLEASE BE ADVISED OF THE FOLLOWING CHANGES AND CLARIFICATIONS:

1. The following section title has been revised:

1.9

2. The following paragraphs have been revised:

1.9.1

1.9.1 a.

1.9.1 b.

1.9.1 c.

1.9.1 d.

1.9.2 1.9.3

Except for deletion of words, the changes are indicated in bold italics.

Vendors may review the revision(s) to the MissouriBUYS, powered by MOVERS electronic solicitation and the amendment document(s) at https://MissouriBUYS.mo.gov. You may be required to acknowledge the electronic amendment.

ATTENTION: IF YOU HAVE ALREADY SUBMITTED A RESPONSE TO THE SOLICITATION, ACCEPTANCE OF THE AMENDMENT AND RESUBMISSION YOUR SOLICITATION RESPONSE IS NECESSARY TO ENSURE THE STATE OF MISSOURI SUCCESSFULLY RECEIVES YOUR SOLICITATION RESPONSE.

Follow the instructions in the Reference Guide for How to Submit Response Online (https://missouribuys.mo.gov/media/pdf/movers-bid-response-instructions ) and outlined below if previously responded to the solicitation prior to the amendment issuance.

1) Log into MissouriBUYS, powered by MOVERS (https://missouribuys.mo.gov/).

2) Under Tasks click View Negotiations below Solicitations.

3) The Active Solicitations page will appear. Utilize the search filters and click on the Solicitation Number to open.

4) The Overview page will display. Click Create Response.

5) A Warning pop-up box will open. The supplier must click Yes to continue to view and acknowledge amendments.

6) The supplier should highlight the Amendment(s) and view the changes made via the amendment(s). Once the review is complete, select the Acknowledgement checkbox for each amendment and click Submit at the top right-hand corner of the page. NOTE: A Warning pop-up box will open if all amendments have not been acknowledged. Click Yes to continue.

7) A Confirmation pop-up box will open confirming amendments have been acknowledged. It will also warn that resubmission of the previously submitted response is necessary prior to response to the amendment. Click OK.

8) Supplier will need to click Create Response again and respond to the amended solicitation. NOTE: The Create Response step includes attaching the supplier’s response again.

STATE 0000000463SL Amendment No. 01 Page 2

State of Missouri Office of Administration, Division of Purchasing

Request for Proposal (RFP) for MO HealthNet Managed Care Program

PROPOSAL DUE NO LATER THAN: September 2, 2026 AT 2:00 PM CENTRAL TIME Proposal response must be submitted electronically through MissouriBUYS, powered by MOVERS, at https://missouribuys.mo.gov.

E-mailed, mailed, courier, or hand-delivered proposal responses will not be accepted.

RFP CONTACT INFORMATION:

BUYER: Kristina Cramer

PHONE NO.: (573) 751-1695

EMAIL: Kristina.Cramer@oa.mo.gov See “RFP Questions” in Section 1 for appropriate communications during the procurement process.

DELIVER SUPPLIES/SERVICES FREE ON BOARD (FOB) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Social Services MO HealthNet Division 615 Howerton Court P.O. Box 6500 Jefferson City, MO 65102-6500

ATTENTION:

1. After reviewing the Request for Proposal (RFP), the vendor must complete and return Exhibit A, Proposal Signature Page and all other necessary exhibits.

2. Due to lead times for obtaining the information needed to complete the various Business Compliance Exhibits herein as explained in the RFP’s Vendor Response Exhibits, vendors are encouraged to IMMEDIATELY begin securing these verifications.

3. The vendor must be registered in MissouriBUYS, powered by MOVERS in a “Prospective” or “Spend Authorized” registration status to submit a proposal. The vendor must achieve “Approved” registration status in MissouriBUYS (WebProcure/Proactis) and “Spend Authorized” registration status in MissouriBUYS, powered by MOVERS to be considered for a contract award. Reference Section 5.

RFP Organization:

RFP Sections:

RFP Vendor Response Exhibits (Return these exhibits with the proposal):

Business Compliance Exhibits

RFP Attachments (Separate Documents) – Do not return these documents with response:

Separate Documents: The vendor is advised that the separate documents to this document referenced above provide additional requirements, information, and/or instruction. The separate documents must be downloaded from the Division of Purchasing’s MissouriBUYS, powered by MOVERS, website at: https://missouribuys.mo.gov/. The separate documents are downloadable from the same web page where the solicitation document is downloadable. It shall be the sole responsibility of the vendor to obtain each of the separate documents. The vendor shall not be relieved of any responsibility for performance under the subsequent contract due to the failure of the vendor to obtain a copy of the separate documents.

INTRODUCTION AND BACKGROUND INFORMATION SECTION

Introduction:

Purpose: This document constitutes a request for competitive, sealed proposals for providers of “the MO HealthNet Division (MHD)” Managed Care Program for all regions in the State of Missouri, and foster care children who are in the State of Missouri’s custody who may reside out of state. The MHD Managed Care Program contains a General Plan, hereinafter referred to as the “General Plan” and a Specialty Plan, hereinafter referred to as the “Specialty Plan.” Where specifically noted herein, certain provisions, including the capitated rate structure and the enrollment process for the General Plan will be implemented on a regional basis. All proposals shall cover all MHD Managed Care Program regions encompassing the State of Missouri as follows:

Central Region: Adair, Andrew, Atchison, Audrain, Benton, Bollinger, Boone, Buchanan, Butler, Caldwell, Callaway, Camden, Cape Girardeau, Carroll, Carter, Chariton, Clark, Clinton, Cole, Cooper, Crawford, Daviess, DeKalb, Dent, Dunklin, Gasconade, Gentry, Grundy, Harrison, Holt, Howard, Iron, Knox, Laclede, Lewis, Linn, Livingston, Macon, Maries, Marion, Mercer, Miller, Mississippi, Moniteau, Monroe, Montgomery, Morgan, New Madrid, Nodaway, Osage, Pemiscot, Pettis, Phelps, Pulaski, Putnam, Ralls, Randolph, Reynolds, Ripley, Saline, Schuyler, Scotland, Scott, Shelby, Stoddard, Sullivan, Wayne, and Worth counties;

Eastern Region: Franklin, Jefferson, Lincoln, Madison, Perry, Pike, St. Charles, St. Francois, Ste. Genevieve, St. Louis, Warren, and Washington counties, and St. Louis City;

Southwestern Region: Barry, Barton, Christian, Dade, Dallas, Douglas, Greene, Hickory, Howell, Jasper, Lawrence, McDonald, Newton, Oregon, Ozark, Shannon, Stone, Taney, Texas, Webster, and Wright counties;

Western Region: Bates, Cass, Cedar, Clay, Henry, Jackson, Johnson, Lafayette, Platte, Polk, Ray, St. Clair, and Vernon counties.

Minimum Experience Qualifications: There are minimum experience qualifications in the RFP (See Section 2.2, Minimum Experience Requirements in Section 2: Scope of Work – General Plan and Section 3.2, Minimum Experience Requirements Section 3: Scope of Work Specialty Plan).

Titles: Titles of paragraphs used herein are for the purpose of facilitating reference only and shall not be construed to infer a contractual construction of language.

Background Information and Description of MO HealthNet

The State of Missouri, Department of Social Services (DSS), operates the MHD Managed Care Program statewide, in all regions of the State of Missouri. The goals of the Managed Care Program are to improve access to needed services and the quality of health care services for the Managed Care and state aid eligible populations, while controlling the Managed Care Program’s rate of cost increase.

MHD intends to achieve these goals by enrolling participants who are eligible for the Managed Care Program in comprehensive, qualified health plans that contract with the State of Missouri to provide a specified scope of benefits to each enrolled member in return for a capitated payment made on a per-member, per-month basis (PMPM).

An open enrollment period will be conducted prior to the full implementation of all contracts, which will result from this Request for Proposal (RFP).

DSS/MHD has identified nine guiding principles for the Managed Care Program as follows:

All members must be linked with a Primary Care Provider (PCP), as defined herein, of their choice.

Attention to wellness of the individual (e.g., education) and prevention of disease.

Chronic care management.

Care management (resources focused on people receiving the services they need, not necessarily because the service is available).

Utilization of the appropriate setting at the right cost.

Emphasis on the individual person.

Evidence-based guidelines for improved quality of care and use of resources.

Encouragement of responsibility and investment on the part of the member to ensure wellness.

Participation in the Medicaid Reform and Transformation Program, which includes personal responsibility (member incentives), state provider incentive program, Value-Based Purchasing Strategies, the Alternative Payment Model long-term strategy, and requirements for increased accountability and transparency.

Ensuring that the needs of vulnerable Missourians are addressed in a financially sustainable manner.

A listing of reporting templates and vendor documents for MO HealthNet is located at: https://mydss.mo.gov/mhd/templates-vendor-docs. The state agency periodically updates the website and the listed documents.

A listing of acronyms for MO HealthNet is located at: https://mydss.mo.gov/media/pdf/mhd-mo-healthnet-acronyms.

Program Management and Oversight:

In the State of Missouri, DSS/MHD is officially designated with administration, provision, and payment for medical assistance under the Federal Medicaid (Title XIX) and the State Children’s Health Insurance (Title XXI) Program (CHIP). The Family Support Division (FSD) is designated for the administration and determination of eligibility for the two programs. In addition to DSS/MHD oversight, the Centers for Medicare and Medicaid Services (CMS) also monitors DSS/MHD Managed Care Program activities through its regional office in Kansas City, Missouri and its Center for Medicaid and CHIP Services and the Survey Operations Group, and the Quality, Safety, and Oversight Group in Baltimore, Maryland.

MO HealthNet Managed Care Program Eligibility Groups:

For purposes of this RFP, the MHD Managed Care Program population consists of different eligibility groups that have been combined for the purpose of rate setting. The qualifications for the program are based on a combination of factors, including family composition, income level, insurance status, age, or pregnancy, depending on the eligibility group in question. The eligibility groups and their current estimated sizes are described below and summarized in Attachment 1, MO HealthNet Managed Care Eligibility Groups.

Covered Under the MHD Managed Care Program General Plan – The following individuals are covered and receive their services under the MHD Managed Care General Plan. Those eligible are defined by their MHD Managed Care Program Medicaid Eligibility (ME) code as specified in Attachment 1, MO HealthNet Managed Care Eligibility Groups.

Parents, Caretakers, and Children – Individuals covered under the MHD Managed Care Program within this group are as follows:

Parents, Caretakers, and Children eligible under the MHD Managed Care Program for Families, and the MHD Managed Care Program for Transitional Assistance;

Children eligible under the MHD Managed Care Program for Poverty Level Children;

Individuals who are eligible under the above-referenced groups and are participants in the following Developmental Disabilities (DD) waivers: Partnership for Hope, DD Comprehensive, DD Community Support, and Autism; and

Children who are determined eligible for Medicaid or CHIP at initial application or a regularly scheduled annual renewal remain eligible for Medicaid or CHIP for 12 months after the month of approval or renewal. This is called the Continuous Eligibility (CE) period. Children remain eligible during the CE period regardless of most changes in circumstances (CIC) that may affect eligibility, such as:

· Changes in income or household composition

· Loss of Supplemental Security Income (SSI) for children eligible for Medicaid based on their eligibility for SSI;

· Obtaining other health insurance for children enrolled in CHIP; and

· Failing to pay a premium after the first premium has been paid.

Pregnant Women –

Individuals eligible under the MHD Managed Care Program for Pregnant Women are pregnant women and 12-month post-partum women; and

Low-income pregnant women and their unborn children with household income up to 300% of the Federal Poverty Level (FPL) who are not eligible under the MHD Managed Care Program for Pregnant Women are eligible under the Show-Me Healthy Babies Program (SMHB).

State Child Health Plan – Missouri has an approved combination State Child Health Plan under Title XXI of the Social Security Act (the Act) for the Children’s Health Insurance Program (CHIP). Missouri’s CHIP State Child Health Plan uses funds provided under Title XXI to both expand eligibility under Missouri’s State Medicaid plan and to obtain coverage that meets the requirements for a separate child health program that must include:

Twelve months of continuous eligibility (CE) for children under the age of 19 in Medicaid and the Children’s Health Insurance Program (CHIP), starting with the month in which the child is approved for coverage, or the month in which the child's regularly scheduled annual renewal is completed.

Adult Expansion Group (AEG) – Those eligible under this group are adults aged 19-64 with income up to 138% of FPL.

MHD Managed Care Program eligible individuals in the above-referenced eligibility groups may voluntarily disenroll from the Managed Care Program or choose not to enroll in the Managed Care Program if they:

Are eligible for Supplemental Security Income (SSI) under Title XVI of the Act;

Are described in Section 501(a)(1)(D) of the Act; or

Are described in Section 1902-(e)(3) of the Act.

Covered Under the MHD Managed Care Program Specialty Plan – The following individuals are covered and receive their services under the MHD Managed Care Program Specialty Plan. Those who are eligible are defined by their MHD Managed Care Program Medical Eligibility (ME) Code as specified in Attachment 1, MO HealthNet Managed Care Eligibility Groups:

All children in the care and custody of DSS, all children receiving adoption subsidy assistance, and all children receiving non-medical assistance (i.e., living assistance) that are in the legal custody of DSS.

Persons under 26 years of age, who were in foster care on their 18th birthday and were covered by the MHD Managed Care Program, and who meet other eligibility criteria, are eligible under this category of assistance;

Persons under 26 years of age, who were in foster care on their 18th birthday and were covered by Medicaid from another state but are not eligible for Medicaid coverage under another mandatory coverage group, and who meet other eligibility criteria, are eligible under this category of assistance; and

There shall be no option for a child in the care and custody of the state to choose a different health plan.

The following individuals may voluntarily enroll and receive services through the MHD Managed Care Program Specialty Plan:

Individuals under the age of 21 who are assessed and authorized for Private Duty Nursing (PDN) services.

MHD Managed Care Program eligible individuals in the above-referenced eligibility groups may voluntarily disenroll from the Managed Care Program or choose not to enroll in the Managed Care Program if they:

Are eligible for Supplemental Security Income (SSI) under Title XVI of the Act;

Are described in Section 501(a)(1)(D) of the Act; or

Are described in Section 1902-(e)(3) of the Act.

Covered Under the Fee-for-Service Program – The following individuals receive their services through the MHD Fee-for-Service Program:

Permanently and Totally Disabled and Aged Individuals eligible under ME codes 04 (Permanently and Totally Disabled), 13 (MO HealthNet-PTD), 16 (Nursing Care-PTD), 11 (MHD Spenddown and Non-Spenddown), 14 (Nursing Care-OAA), and 01 (Old Age Assistance-OAA);

Individuals under ME codes 23 and 41 (MA ICF-MR Poverty) residing in a State Mental Institution or an Intermediate Care Facility for the Intellectually Disabled (ICF/ID);

Individuals eligible under ME codes 28, 49, and 67 (Children placed in foster homes or residential care by the Department of Mental Health);

Youth eligible under Medical Assistance for Children in Care (Juvenile Court), ME codes 30, 64, 69, and 70;

Pregnant women eligible under ME codes 58, 59, and 94, the Presumptive Eligibility Program for ambulatory prenatal care only;

Individuals eligible under ME codes 2, 3, 12, and 15 (Aid to the Blind and Blind Pension);

AIDS Waiver participants (individuals 21 years of age and over);

Any individuals who are eligible and receiving either or both Medicare Part A and Part B, or Part C benefits;

Individuals eligible under ME codes 33 and 34 (MO Children with Developmental Disabilities Waiver);

Individuals Eligible under ME code 55 (Qualified Medicare Beneficiary-QMB);

Children eligible under ME code 65, placed in residential care by their parents, if eligible for the MHD Managed Care Program on the date of placement;

Uninsured women losing their MHD Managed Care Program eligibility at the end of the 12th month after the last day of pregnancy may be eligible under ME code 89 or another category of aid;

Women who are eligible for Women's Health Services and ME code 89.

Individuals with ME code 81 (Temporary Assignment Category);

Individuals eligible under ME code 82 (MoRx);

Women eligible under ME codes 83 and 84 (Breast and Cervical Cancer Treatment);

Individuals eligible under ME code 87 (Presumptive Eligibility for Children); and

Individuals eligible under ME code 88 (Voluntary Placement).

Organizational Definitions:

For purposes of this document, a “managing employee,” as defined in 42 CFR 455.101, shall be a general manager, business manager, administrator, 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.

For purposes of this document, a “person with an ownership or control interest” means a person or corporation that (1) has an ownership interest totaling five percent or more of the vendor’s organization; (2) has an indirect ownership interest equal to five percent or more of the vendor’s organization; (3) has a combination of direct and indirect ownership interests equal to five percent or more in the vendor’s organization; (4) owns an interest of five percent or more in any mortgage, deed of trust, note, or other obligation secured in whole or in part by the vendor’s organization or by its property or assets, if that interest equals at least five percent of the total property and assets of the vendor’s organization; (5) is an officer or director of the vendor’s organization (if it is organized as a corporation); or (6) is a partner in the vendor’s organization (if it is organized as a partnership).

The percentage of direct ownership or control is calculated by multiplying the percent of interest which a person owns by the percent of the vendor’s assets used to secure the obligation (e.g., if a person owns 10% of a note secured by 60% of the vendor’s assets, the person owns six percent of the vendor).

The percentage of indirect ownership or control is calculated by multiplying the percentages of ownership in each organization (e.g., if a person owns 10% of the stock in a corporation that owns 80% of the stock of the vendor’s organization, the person owns eight percent of the vendor’s organization).

Current Contract and Previous Bid Information:

Current contracts exist for the services being obtained via this RFP. A copy of the contracts can be viewed and printed from the Division of Purchasing’s Awarded Bid & Contract Document Search System located on the Internet at: https://purch.oa.mo.gov/bidding-contracts/awarded-bid-contract-document-search. In addition, all proposal and evaluation documentation leading to the award of the contracts may also be viewed and printed from the Division of Purchasing’s Awarded Bid & Contract Document Search System. Please reference the Bid number RFPS30034902200777 or the contract number CS220777001 through CS220777003 when searching for these documents.

RFP Questions:

Buyer is Single Point of Contact for Solicitation: Vendors and their agents (including subcontractors, employees, consultants, or anyone else acting on their behalf) must direct all of their questions or comments regarding the RFP, the evaluation, etc., to the buyer indicated on the first page of this RFP. It is preferred that questions be emailed to the buyer.

Except as noted herein, vendors and their agents are instructed not to contact any other state employee regarding any of these matters during the solicitation and evaluation process. Inappropriate contacts are grounds for suspension and/or exclusion from specific procurements. Vendors can be sanctioned for unauthorized contact with any evaluator under 1 Code of State Regulation (CSR) 40-1.060(8)(G) and (H) available at http://www.sos.mo.gov/adrules/csr/csr.asp.

Minority Business Enterprise/Women Business Enterprise (MBE/WBE) and Service-Disabled Veteran Enterprise certification or subcontract questions should be directed to the Office of Equal Opportunity (OEO) at http://oeo.mo.gov.

Vendor is Responsible for Asking Questions About the RFP: It is the vendor’s responsibility to ask questions, request changes or clarifications, or otherwise advise the Division of Purchasing if the vendor believes that any language, specifications, or requirements are: (1) ambiguous, (2) contradictory or arbitrary, (3) violate any state or federal law or regulation, (4) restrict or limit the requirements to a single source, or (5) restrict or limit the vendor’s ability to submit a proposal.

Vendor Question Deadline: Every attempt shall be made to ensure that the vendor receives an adequate and prompt response. However, in order to maintain a fair and equitable procurement process, all vendors will be advised, via the issuance of an amendment to the RFP, of any relevant or pertinent information related to the procurement. All questions and issues should be submitted no later than ten (10) calendar days prior to the proposal closing date and time of the proposals. If not received prior to ten (10) calendar days before the proposal closing date and time, the Division of Purchasing may not be able to fully research and consider the respective questions or issues.

State’s Response to Vendor Questions: Upon the Division of Purchasing’s consideration of questions and issues, if the Division of Purchasing determines that changes are necessary, the resulting changes will be included in a subsequently issued RFP amendment(s); absence of such response indicates that the questions and issues were considered but deemed unnecessary for an RFP amendment. All vendors will be advised of any change to the RFP’s language, specifications, or requirements by a formal amendment to the RFP. There will be no posted written records of the questions/communications (i.e., formal question/answer document).

RFP is State’s Only Official Position: The only official position of the State of Missouri shall be that which is contained in the RFP and any amendments thereto.

Amendments:

If the Division of Purchasing determines that changes to the RFP are necessary, the resulting changes will be included in a subsequently issued RFP amendment(s) prior to the proposal closing date and time.

Section Title revised by Amendment #01 (text deleted)

Pre-Proposal Conference:

Paragraph revised by Amendment #01

Pre-proposal Conference Date and Time: A pre-proposal conference regarding this RFP will be held on Tuesday, July 21, 2026 at 9:00 A.M. Central Time. Vendors may attend the pre-proposal conference either in person at the Howerton State Office Building, located at 615 Howerton Court, 2nd Floor, Room 202, Jefferson City, Missouri 65109, OR via teleconference (telephone number to dial-in and/or webinar). Vendors are encouraged to participate in the pre-proposal conference as it will be used as the forum for questions, communications, and discussions regarding the RFP. The vendor should become familiar with the RFP and develop all questions prior to the pre-proposal conference in order to ask questions and otherwise participate in the public communications regarding the RFP.

Paragraph revised by Amendment #01

0. Pre-Proposal Conference Agenda: The vendor should have a copy of the RFP for the pre-proposal conference. The agenda for the pre-proposal conference will be the RFP followed by a presentation from Mercer Health and Benefits, LLC regarding the Managed Care rate development.

Paragraph revised by Amendment #01 (text deleted)

0. Communication Prior to the Conference: The vendor is encouraged to review the RFP prior to the pre-proposal conference and may submit written communications and/or questions regarding the RFP, which reference the RFP paragraph numbers, to the buyer identified on page one. Such prior communication will provide the State of Missouri with insight into areas of the RFP which may be brought up for discussion during the conference and which may require clarification.

Paragraph revised by Amendment #01 (text deleted)

0. Communication During the Conference: During the pre-proposal conference, it shall be the sole responsibility of the vendor to orally address all issues previously presented to the buyer by the vendor, including any questions regarding the RFP or areas of the RFP requiring clarification.

Paragraph revised by Amendment #01 (text deleted)

0. Amendment to the RFP: Any modifications needed to the RFP as a result of discussions from the pre-proposal conference will be accomplished as an amendment to the RFP. Neither formal minutes of the pre-proposal conference nor written records of the questions/communications will be maintained.

Paragraph revised by Amendment #01 (text deleted)

0. Pre-Proposal Conference Special Accommodations: Vendors are strongly encouraged to advise the Division of Purchasing within five (5) state business days of the scheduled pre-proposal conference of any special accommodations needed for people with health conditions or impairments who will be participating in the pre-proposal conference so that these accommodations can be made.

Paragraph revised by Amendment #01

0. Pre-Proposal Conference Dial-In Information: If planning to attend the pre-proposal via teleconference, the vendor should contact the buyer from the Division of Purchasing as indicated on the first page of this RFP to obtain dial-in instructions. The vendor will be provided with a telephone number to dial and/or webinar information to access, to listen and participate in the pre-proposal conference. The vendor shall refrain from contacting anyone other than the buyer to obtain the dial-in information.

Glossary of Terms and Acronyms:

Whenever the following terms and acronyms appear in the RFP document or any amendment thereto, the definitions or meanings described below shall apply.

General Glossary, Acronyms, and Abbreviations:

Agency and/or State Agency means the statutory unit of state government in the State of Missouri for which the equipment, supplies, and/or services are being purchased by the Division of Purchasing (Purchasing). The agency is also responsible for payment, unless otherwise specified herein.

Amendment means a written, official modification to a solicitation or contract.

Attachment applies to all documents which are included with an RFP to incorporate any informational data or requirements related to the performance requirements and/or specifications.

Business Day (or State Business Day) means Monday through Friday, 8:00 A.M. to 5:00 P.M. Central Time, excluding weekends and official holidays observed by the State of Missouri.

Buyer means the procurement staff member of Purchasing.

Code of State Regulation (CSR) contains the current administrative rules of executive agencies of Missouri government. The regulations are arranged by agency rather than by subject.

Contract means a legal and binding agreement between two or more competent parties, for a consideration for the procurement of equipment, supplies, and/or services.

Contractor means a supplier, offeror, person, health plan, or organization who is a successful vendor as a result of an RFP and who enters into a contract.

Exhibit applies to forms which are included with an RFP for the vendor to complete and submit with their proposal prior to the specified closing date and time.

May means that a certain feature, component, or action is permissible, but not required.

Must means that a certain feature, component, or action is a mandatory condition.

Party refers to either the State of Missouri or the contractor as an entity that may enter into a contract pursuant to the terms herein.

Pricing Page(s) applies to the form(s) on which the vendor must state the price(s) applicable for the equipment, supplies, and/or services required in the RFP. The pricing pages must be completed and submitted by the vendor with the proposal prior to the specified proposal closing date and time.

Proposal Closing Date and Time and similar expressions mean the exact deadline required by the RFP for the receipt of sealed proposals.

Purchase Order means the authorized document issued by the state agency to the contractor indicating descriptions, quantities, and agreed prices for products and/or services.

Reasonable, Necessary or Proper as used herein shall be interpreted solely by the State of Missouri.

Request for Proposal (RFP) means the solicitation document issued by Purchasing to potential vendors for the purchase of equipment, supplies, and/or services as described in the document. The definition includes the following sections: Introduction and Background Information; Scope of Work; Terms and Conditions (“terms and conditions” and “Terms and Conditions” are used interchangeably throughout the RFP); General Contractual Requirements; and Vendor Submission, Evaluation, and Award Information; and the RFP Vendor Response Exhibits, Attachments, and Amendments of the RFP.

RSMo (Revised Statutes of Missouri) refers to the body of laws enacted by the Legislature which govern the operations of all agencies of the State of Missouri. Chapter 34 of the statutes is the primary chapter governing the operations of Purchasing.

Shall has the same meaning as the word must.

Should means that a certain feature, component and/or action is desirable but not mandatory.

State collectively referring to the state government and/or the agencies thereof.

Supplier has the same meaning as the word, vendor.

Vendor means the supplier, offeror, person, or organization that responds to an RFP by submitting a proposal with prices to provide the equipment, supplies, and/or services as required in the RFP document.

Accuracy of Background Information:

Although an attempt has been made to provide accurate and up-to-date information, the State of Missouri does not warrant or represent that the background information provided herein reflects all relationships or existing conditions related to this RFP.

****END OF INTRODUCTION AND BACKGROUND INFORMATION SECTION****

SCOPE OF WORK SECTION – GENERAL PLAN

General Requirements:

The contractor (hereinafter referred to as the health plan) shall provide a managed care medical service delivery system for the Department of Social Services, MO HealthNet Division (hereinafter referred to as the state agency), located in the State of Missouri, in accordance with the provisions and requirements stated herein and to the sole satisfaction of the state agency.

The health plan shall adhere to all applicable local, state, and federal requirements regarding operation of the state agency Managed Care Program.

The health plan shall cooperate with the state agency, as directed, in the implementation of the requirements of the federal or state law. Any federal or state law requirements altering the obligations of the health plan under the contract shall be accomplished through contract provisions, which may differ from the terms of the contract to the extent that relevant federal guidance is issued after the effective date of the contract; or through a contract amendment, as required herein, to the extent that relevant federal guidance is issued during the term of the contract. The state agency may issue Affordable Care Act (ACA) requirements that affect the health plan’s operations, but do not directly alter its contractual obligations, through the issuance of a provider bulletin.

Prior to performing services in each county listed herein, the health plan shall:

Have and maintain a certificate of authority from the Department of Commerce and Insurance (DCI) to establish and operate a health maintenance organization (HMO) in all the counties specified herein by the date of contract award or by no later than February 1, 2027, whichever date comes later, so that the state agency may proceed with open enrollment with only health plans that are appropriately licensed. In the event the health plan fails to achieve appropriate licensure by the date of contract award or by February 1, 2027, whichever comes later, the contract shall be cancelled in its entirety;

Understand that federal approval of the contract is required prior to commitment of the federal financing share of funds under the contract;

Participate in readiness reviews anticipated to begin January 1, 2027, through March 30, 2027. The state agency will conduct an on-site readiness review of all health plans in order to document the status of the health plans with respect to meeting the requirements herein. The state agency will monitor the health plan’s implementation of the requirements of the readiness review, including but not limited to:

The readiness review shall also include a review of targeted requirements outlined in the contract, including the health plan’s provider network, the health plan’s care management and disease management program, and any other requirements of interest identified by the state agency.

The requirements covered in the readiness review shall be determined at the state agency’s discretion and shall be communicated to the health plan prior to the onsite review. The health plan shall submit all requested documentation and complete the self-reporting tool, as requested by the state agency.

The health plan is subject to a desk audit validation of the submitted documentation, which is performed by the state agency.

In addition to the readiness review, the state agency reserves the right to review all items reviewed during the readiness review on an annual basis. Any tools used by the state agency during the readiness review are subject to review and modification by the state agency at its discretion.

Submit to the state agency all policies and procedures that require prior approval as requested by the state agency. The required policies and procedures can be accessed at https://mydss.mo.gov/media/file/mhd-policies-procedures-requiring-prior-approval (Policies and Procedures Requiring Prior Approval). The health plan shall access the Policy Submission Form at https://mydss.mo.gov/media/file/managed-care-policy-submission-form to submit all modifications, additions, or deletions to such policies and procedures to the state agency at least 30 calendar days prior to implementation. The health plan shall operate in accordance with such policies and procedures. The health plan shall incorporate and implement any revisions identified by the state agency to the health plan’s policies and procedures within the timeframe specified by the state agency. All other policies and procedures required herein shall be submitted to the state agency upon request.

The health plan(s) shall provide services to individuals determined eligible by the state agency for the Managed Care Program on a statewide basis in all Missouri counties, in the following four designated regions:

Central Region:

Adair County;

Andrew County;

Atchison County;

Audrain County;

Benton County;

Bollinger County;

Boone County;

Buchanan County;

Butler County;

Caldwell County;

Callaway County;

Camden County;

Cape Girardeau County;

Carrol County;

Carter County;

Chariton County;

Clark County;

Clinton County;

Cole County;

Cooper County;

Crawford County;

Daviess County;

DeKalb County;

Dent County;

Dunklin County;

Gasconade County;

Gentry County;

Grundy County;

Harrison County;

Holt County;

Howard County;

Iron County;

Knox County;

Laclede County;

Lewis County;

Linn County;

Livingston County;

Macon County;

Maries County;

Marion County;

Mercer County;

Miller County;

Mississippi County;

Moniteau County;

Monroe County;

Montgomery County;

Morgan County;

New Madrid County;

Nodaway County;

Osage County;

Pemiscot County;

Pettis County;

Phelps County;

Pulaski County;

Putnam County;

Ralls County;

Randolph County;

Reynolds County;

Ripley County;

Saline County;

Schuyler County;

Scotland County;

Scott County;

Shelby County;

Stoddard County;

Sullivan County;

Wayne County; and Worth County.

Eastern Region:

Franklin County;

Jefferson County;

Lincoln County;

Madison County;

Perry County;

Pike County;

St. Charles County;

St. Francois County;

Ste. Genevieve County;

St. Louis County;

Warren County;

Washington County; and St. Louis City.

Southwestern Region:

Barry County;

Barton County;

Christian County;

Dade County;

Dallas County;

Douglas County;

Greene County;

Hickory County;

Howell County;

Jasper County;

Lawrence County;

McDonald County;

Newton County;

Oregon County;

Ozark County;

Shannon County;

Stone County;

Taney County;

Texas County;

Webster County; and Wright County.

Western Region:

Bates County;

Cass County;

Cedar County;

Clay County;

Henry County;

Jackson County;

Johnson County;

Lafayette County;

Platte County;

Polk County;

Ray County;

St. Clair County; and Vernon County.

The state agency will notify the health plan, via a contract amendment, if:

There are any significant changes in services, benefits, geographic areas, or payments; or

The state agency requires enrollment of a new population in the health plan.

Medicaid Reform and Transformation – The health plan shall provide programs involving personal responsibility, promoting efficiency through state provider incentives, Value-Based Purchasing Strategies and Alternative Payment Models designed to engage members, providers, and the health plan in transforming the state agency’s service delivery system, and increasing accountability and transparency.

Personal Responsibility – The health plan shall offer member incentives to members to promote responsible behavior and encourage efficient use of health care services.

The health plan shall establish a member incentive program with the following activities in mind:

· To promote healthy behaviors and encourage members to take ownership of their health care by seeking early preventative care in appropriate settings;

· To promote the adoption of healthier personal habits, including, at a minimum, tobacco cessation, behaviors that lead to reducing obesity, controlling asthma, and controlling diabetes;

· To promote enhanced engagement and greater health literacy among members; and

· To promote appropriate use of emergency room services.

The health plan’s member incentives:

· Must be directly related to a health plan quality initiative;

· Must be measurable and demonstrate improved health outcomes for members;

· Cannot be used in conjunction with the health plan’s marketing activities; and

· Cannot be convertible to cash or be eligible for redemption in any way for alcohol, tobacco products, firearms, or ammunition.

The health plan shall understand and agree that the member incentive program submitted in the health plan’s awarded proposal shall be subject to the state agency’s final review and approval. Contract award does not constitute approval or acceptance of the member incentive program proposed in the health plan’s awarded proposal. Member incentive programs from prior contracts will not be exempt from approval. The state agency’s approval process includes an evaluation of the health plan’s member incentive program using a format provided by the state agency. The health plan shall submit the member incentive proposal to the state agency for review at least 30 calendar days prior to the anticipated start date of the incentive program. The Member Incentive Template is located at https://mydss.mo.gov/media/file/mhd-member-incentive-template.

· The health plan shall develop educational and outreach materials for members, parents/guardians, and providers that educate about how the member incentive programs shall be administered and provide information about any administrative requirements (e.g., prior authorization requirements, etc.).

· The outreach or education materials related to the proposed member incentives are subject to a compliance audit at the discretion of the state agency. Any activities that are passive in nature and not explicitly designed to promote greater member engagement will not be approved by the state agency. Marketing activities shall not be utilized in a way that could be construed as incentives to join a particular health plan.

The health plan shall document its efforts to inform all members about the opportunity to participate in the member incentive program. The health plan shall ensure that, at a minimum:

· Fifteen percent (15%) of eligible members shall participate in the member incentive program. The health plan shall maintain documentation demonstrating compliance with this requirement. Such documentation is subject to audit.

Member incentive gifts related to the delivery of preventive care services as defined by the US Preventive Services Taskforce shall be limited to a value of $50.00 or less per eligible member, per month, per incentive.

Member incentive gifts not related to preventive care services as defined by the US Preventive Services Taskforce shall be limited to a value of $25.00 each or an aggregate annual value of $125.00.

The health plan shall regularly monitor their member incentive program to ensure that the member incentive program has met the health plan’s quality initiative and to evaluate on an ongoing basis the effectiveness of the member incentive program based on the program goals submitted to and approved by the state agency. At a minimum, monitoring activities may include state agency audits and secret shopper activities. Member incentive programs that do not show progress must be revised annually or discontinued.

Annually, the health plan shall report the status and state fiscal year results of the member incentive programs to the state agency.

State Provider Incentive Programs –

The health plan shall use the state provider incentive program with providers and provider groups to promote and achieve the following goals:

· Improve members’ health outcomes;

· Promote delivery of trauma-informed care;

· Decrease inappropriate utilization of services; and

· Decrease health risk factors in the populations the providers and provider groups serve.

The health plan shall require that all subcontractors, including any health care services subcontractors, comply with all provider incentive requirements outlined herein.

The health plan shall agree that the state provider incentive program submitted in the health plan’s awarded proposal shall be subject to the state agency’s final review and approval. Contract award does not constitute approval or acceptance of the state provider incentive proposal proposed in the health plan’s awarded proposal. The health plan shall submit a plan for its state provider incentive program to the state agency for approval prior to implementation. The Provider Incentive Program Tool, located on the state agency website, must be used by health plans to submit their plan.

· The health plan must ensure ten percent (10%) of the defined providers participate in the provider incentive program. The health plan shall maintain documentation demonstrating compliance with this requirement. The documentation is subject to audit.

The health plan’s state provider incentive program shall include, at a minimum, the following information:

· Effective date of the state provider incentive program;

· Type of state provider incentive program;

· Percent of withhold or bonus applied, if applicable;

· If rendering provider or provider group is at substantial financial risk, proof that the rendering provider or provider group has adequate stop-loss coverage;

· Amount and type of stop-loss protection, if applicable;

· Patient panel size;

· If patient panel is pooled, a description of the approved method;

· Computations of significant financial risk; and

· Name, address, phone number, and other contact information for a person from the health plan who may be contacted with questions regarding the incentive program.

Once the state agency has approved the submitted state provider incentive program plan, the state agency will regularly monitor the health plan’s activities based on the approved plan. Monitoring activities may include, at a minimum, audits and secret shopper activities conducted by the state agency.

The health plan shall submit an annual disclosure plan to the state agency indicating whether there have been changes to the health plan’s state provider incentive program plan. If no changes have been made to the state provider incentive program plan, the health plan shall submit a statement certifying no changes were made. The disclosure plan or statement certifying no changes may be submitted in the health plan’s chosen format.

The health plan shall maintain all state provider incentive program plan reporting and disclosures in the health plan’s files for review by the state agency upon request.

The health…