RFI_Medicaid EQRO Budget_FINAL.docx

BRAD LITTLE – GOVERNOR

DEAN CAMERON –Interim DIRECTOR

Staci Phelan, Administrator

DIVISION OF MANAGEMENT SERVICES

Contracting & Procurement Services

450 West State Street, 9th Floor P.O. Box 83720

Boise, Idaho 83720-0036

PHONE 208-334-5578

FAX 208-639-5694

The Idaho Department of Health and Welfare, Division of Medicaid, Bureau of Care Management (Department), has a requirement for information concerning the furnishing of services for Medicaid External Quality Review Organization Contract Budget. Information obtained from the responses to this RFI may be used to refine the requirements for a potential future Request for Proposal (RFP), assist us in projecting a budget for acquiring the services, and to identify potential vendors who may be interested in providing a competitive proposal.

It is important to note that this is a request for information only, not a solicitation. No award will be made based upon the information received.

I. Introduction and Background The Department has administered the state’s Medicaid program since 1967 under Title XIX of the Social Security Act, as amended. The program is funded by appropriations authorized by the Idaho State Legislature for each fiscal year, July 1st through June 30th.

Idaho Medicaid currently has four (4) plans requiring External Quality Review (EQR). EQR is required for the behavioral health prepaid ambulatory health plan (PAHP), dental PAHP, and two (2) Medicare/Medicaid dual managed care organizations (MCOs). The behavioral health PAHP is transitioning to a prepaid inpatient health plan (PIHP) and is anticipated to receive approval from Centers for Medicare & Medicaid Services (CMS) in 2024. The Department is also intending to complete an abbreviated review of the non-emergency medical transportation (NEMT) PAHP for program evaluation purposes.

Due to the timing of the last EQR Organization (EQRO) solicitation in 2023, CMS agreed to allow the 2024 EQR report to be submitted along with the 2025 report, no later than April 30, 2025. Further communication with CMS is necessary to solidify the extended timeline and finalize the RFP details.

II. Description of Items or Service Required An EQR is the analysis and evaluation by an EQRO of aggregated information on quality, timeliness, and access to the health care services that an MCO, or its contractors, furnish to Medicaid beneficiaries. The annual EQR results in the generation of an annual EQR technical report. Section 1932(c)(2) of the Social Security Act and 42 CFR §438.350-370 requires that each state that contracts with a MCO, including Medicaid and/or Children's Health Insurance Program (CHIP) MCO, PIHP, PAHP, or with primary care case management (PCCM) entities (described in §438.310(c)(2)) must ensure that a qualified EQRO performs an annual EQR for each such contracting managed care plan. The 2016 Medicaid and CHIP Managed Care Final Rule applies all EQR and EQRO requirements to CHIP plans in 42 CFR §457 Subpart L.

EQR-related activities are the mandatory and optional activities, as set forth in 42 CFR §438.358, which produce the data and information that the EQRO analyzes when performing the EQR. States have flexibility regarding who conducts the EQR-related activities, which may be performed by the state, a state agent that is not a managed care plan, or an EQRO. Regulations at 42 CFR 438.352 require CMS to issue protocols for the EQR-related activities. These protocols set forth guidelines for the EQR-related activities. For more information please visit: https://www.medicaid.gov/medicaid/quality-of-care/medicaid-managed-care-quality/quality-of-care-external-quality-review/index.html

EQR-related activities are intended to:

1. Improve states’ ability to oversee and manage the managed care plans they contract with for services.

2. Help managed care plans improve their performance with respect to quality, timeliness, and access to care.

There are three (3) mandatory activities which must be conducted on each managed care plan, and a fourth which will be mandatory once the protocol is created: For PCCM entities, only the performance measurement validation and a review, conducted within the previous three (3)-year period, to determine the MCO's, PIHP's, or PAHP's compliance with the standards set forth in subpart D must be conducted.

1. Performance Measurement Validation

2. Performance Improvement Project (PIP) Validation

3. A review, conducted within the previous three (3)-year period, to determine the MCO's, PIHP's, or PAHP's compliance with the standards set forth in subpart D

4. Network Adequacy Validation

There are six (6) optional activities. The state has discretion to determine which optional EQR-related activities, if any, it wishes to conduct and include in the annual EQR. The optional activities are:

1. Encounter data validation

2. Administration or validation of consumer or provider surveys of quality of care

3. Calculation of performance measures

4. Implementation of performance improvement projects

5. Focus studies on quality of care

6. Rating of managed care plans *CMS must first establish the Medicaid and CHIP Quality Rating System (MAC QRS) framework, and develop a protocol, before this activity can be used by states.

Idaho Medicaid would like to include EQR reporting for its NEMT contract. This report would be provided to the state only, as it is not a requirement of CMS. This abbreviated technical report would only include some mandatory and possibly some optional EQR activities.

The Idaho Medicaid EQRO RFP has been issued twice in 2023, but unfortunately, no bids were received on either occasion. To determine the most effective path forward for the EQRO project, we require crucial information regarding the allocated budget.

Next Steps:

· Budget Evaluation: Upon receiving budget details, we can assess the project's feasibility and explore various options including revising the RFP scope to better align with vendor capabilities and market offerings, and to allow for a comprehensive evaluation of the state’s managed care programs.

· A clear understanding of the budget is essential to determine the optimal course of action for the EQRO project. Once this information is available, we can develop a well-informed strategy to secure the necessary resources and move forward successfully.

III. Requested information It is requested that interested vendors provide the following information:

1. Briefly describe your company, services, history, ownership, financial information, and other information you deem relevant. Please provide a contact person’s name and telephone number for any clarifications.

2. Is your organization capable of or interested in furnishing the items or services described in this RFI? Please describe both your history of furnishing the items or services and your capabilities for furnishing them.

3. What issues do you feel need to be addressed to assure a successful acquisition of these items or services or preparation of an RFP?

4. From your experience in providing these items or services, what lessons learned can you share with us?

5. Cost estimate (This is a cost estimate only. Any information provided will be used to assist us in developing a budget for the acquisition. You will not be held to any information or prices provided):

a. Mandatory EQR Activities Cost Details

· Breakdown by Year and Plan: Please provide a breakdown of the estimated costs for the EQR activities by year for each plan (IBHP, Idaho Smiles, Idaho Medicare-Medicaid Coordinated Plan (MMCP), and Idaho Medicaid Plus (IMPlus).

· For the first year, the EQRO would have to complete an evaluation for state fiscal years 2023 and 2024 for the Idaho Behavioral Health Plan (IBHP) and Idaho Smiles dental plan for the April 30th, 2025, technical report. The EQRO would have to complete an evaluation for calendar years 2022 and 2023 for the MMCP, and the IMPlus Plan for the April 30th, 2025, technical report.

· By February 2024, states and EQROs must begin using Protocol 4 in the 2023 protocols (https://www.medicaid.gov/media/150731) to conduct the network adequacy validation (NAV) activity. Results from the NAV activity, conducted in accordance with Protocol 4, must be included in EQR technical reports due April 30, 2025.

· Basis for Cost Estimates: On what basis are these cost estimates for the mandatory EQR activities calculated? Are there any factors considered, such as plan size, complexity, or specific activities required for each plan?

b. Optional EQR Activities Details

· Cost Estimates and Descriptions: For each of the six (6) optional activities, please provide a detailed description of the activity and an estimated cost associated with it.

· Reasoning for Optional Choices: Why are these activities considered? Is it based on specific program characteristics or state discretion?

c. Open to Discussing the Inclusion of EQR Activities for Idaho Medicaid NEMT Program

· Cost Estimates and Descriptions: For each of the EQR activities (mandatory and optional), please provide a detailed description of the activity and an estimated cost associated with it.

· Report Details: Please elaborate on content of an EQR technical report for the NEMT program.

· Reasoning for Optional Choices: Why are these activities considered? Is it based on specific program characteristics or state discretion?

· Rationale for Abbreviation: The NEMT report may be abbreviated and will be furnished to the state only. What specific EQR activities (mandatory or optional) will be included or excluded from the NEMT program's abbreviated report, and why?

IV. Terms and Conditions A. All material submitted in response to this RFI becomes the property of the Department and shall not be returned to the responding vendor.

B. At the sole discretion of the Department the information provided may be used for the following purposes:

1. Identifying issues and refining the requirements for a solicitation which may be released later.

2. Assisting in projecting a budget for acquiring the services.

3. Identifying potential vendors who may be interested in providing a future competitive proposal.

C. The Idaho Public Records Law, Idaho Code §§9-337 through 9-348, allows the open inspection and copying of public records. Public records include any writing containing information relating to the conduct or administration of the public's business prepared, owned, used, or retained by a state or local agency regardless of the physical form or character. All, or most, of the information contained in your response will be a public record and as such will be subject to disclosure under the public records law. Certain exemptions from disclosure can apply, one of which may be for “trade secrets” as defined in the Idaho Public Records Act, Idaho Code § 9-340D(1), a copy of which is available for viewing on-line at: https://legislature.idaho.gov/statutesrules/idstat/Title74/T74CH1/SECT74-102/

1. Trade secrets include a formula, pattern, compilation, program, computer program, device, method, technique, or process that derives economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by other persons and is subject to the efforts that are reasonable under the circumstances to maintain its secrecy.

2. If you consider any element of your response to be a trade secret, or otherwise protected from disclosure, you must so indicate by marking each page of the pertinent document. Include the specific basis for your position that it be treated as exempt from disclosure.

3. Marking your response as exempt is not acceptable or in accordance with the Public Records Act and will not be honored. In addition, a legend or statement on one (1) page that all or substantially all the response is exempt from disclosure is not acceptable or in accordance with the Public Records Act and will not be honored. Prices quoted in your response are not a trade secret.

4. The Department, to the extent allowed by law and in accordance with these terms and conditions will honor a designation of nondisclosure. You will be required to defend any claim of trade secret or other basis for nondisclosure in the event of an administrative or judicial challenge to the Department’s nondisclosure. Any questions regarding the applicability of the Public Records Law should be addressed to the Department or should be presented to your own legal counsel - prior to submission.

D. THIS IS NOT A BID, NO AWARD WILL BE MADE.

V. Address for Responses

If you are interested in providing any of the information requested in this RFI, please submit your written response by close of business Friday, May 31, 2024, to:

*Responses will only be accepted by e-mail.*

**Do Not Submit Your Response Through IPRO/Luma - the eprocurement system.**

Idaho Department of Health and Welfare Attention: (RFIXXXX) Kristin Perry kristin.perry@dhw.idaho.gov 208-334-5603 image1.jpeg