RFP 240000001827 - Schedule A - Statement of Work.docx

SCHEDULE A - STATEMENT OF WORK CONTRACT ACTIVITIES

Request for Proposal No. 240000001827 Statewide Medicaid Long Term Services and Supports Eligibility and Quality Reviews for MDHHS This schedule identifies the anticipated requirements of any Contract resulting from this RFP. The term “Contractor” in this document refers to a bidder responding to this RFP, as well as the Contractor who is awarded the contract. The term “Bidder” is used to identify where specific responses to the RFP are required.

The Contractor must respond to each requirement or question and explain how it will fulfill each requirement. Attach any supplemental information and appropriately reference within your response.

IMPORTANT NOTE TO CONTRACTORS/BIDDERS: There are specific requirements for which acceptance must be simply acknowledged through a checkbox(es), and others that require further explanation. Click the appropriate checkbox and complete the entries as appropriate.

BACKGROUND

MDHHS is the single State agency responsible for health policy, the purchase of health care services, and accountability of those services to ensure only appropriate, medically necessary services are provided to the Medicaid population. Further, MDHHS has a vested interest to ensure that the services being provided and funded by Medicaid are delivered with quality assurances.

SCOPE

The purpose of this Contract is:

A. To have a qualified Contractor conduct timely Verification Reviews of a sample of Level of Care Determination (LOCD) assessments performed by long-term care program providers (nursing facilities, MI Choice waiver agents, PACE organizations and MI Health Link Integrated Care Organizations).

B. Conduct Secondary Reviews when requested by the provider or beneficiary when an individual is determined ineligible for long-term services and supports based on an LOCD.

C. When an LOCD decision made by the Contractor is appealed, the Contactor must provide a written report of the basis for their decision and participate in the State Fair Hearing process.

D. Provide written notification of decisions to providers and beneficiaries on LOCD reviews per Medicaid policy.

E. Conduct Expanded Home Help Services reviews for the Home Help program for cases that exceed 84 hours per two weeks to ensure individuals are receiving the services they need to remain in their own home. Provide a completed Home Help Nurse Review form summarizing the assessment.

F. Conduct Home Help quality reviews from a designated spreadsheet to assess the appropriateness of services being provided.

G. Participate in the State Fair Hearing process to testify when a client requests a hearing based on the contractor’s completed assessment.

Attachment A lists MDHHS definitions that are seen within the body of this Contract and when performing the Contract’s requirements.

1. Requirements

1.1. General Requirements

a. Contract activities for LOCD reviews must be completed as per the policy requirements set forth in the Nursing Facility Level of Care Determination (LOCD) Chapter of the Medicaid Provider Manual (Attachment B). The LOCD Policy Chapter describes the MDHHS LOCD assessment, eligibility requirements, processes, criteria, and appeal rights. The Michigan Medicaid Nursing Facility LOCD Field Definitions Guidelines (Attachment C) prescribes how providers are to conduct the LOCD and interpret the criteria.

Contract activities for Expanded Home Help Services (EHHS) reviews Home Help quality reviews must be completed as per the policy requirements set forth in the Adult Services Manual ASM 121 Functional Assessment Definitions and Ranks (Attachment D) and ASM 120 Adult Services Comprehensive Assessment (Attachment E). The assessment must be completed using the Home Help Worksheet Nurse Review (Attachment F) with a final decision being documented on the Policy Decision (Attachment G).

b. The Contractor must follow the above policy and guidelines to execute the following reviews:

1. LOCD Verification Review

2. LOCD Secondary Review

3. Expanded Home Help Services (EHHS) Review

4. Home Help Quality Review

c. MDHHS reserves the right to adjust the number of LTSS reviews with a 30-day notice to the Contractor. The State reserves the right to change/cancel the review process.

List all exception(s):

Bidder must describe their overall understanding of policy and procedures governing LOCD and Home Help assessments.

1. LOCD Verification Review (LOCD-VR)

a. Review Amount: The Community Health Automated Processing System (CHAMPS) system will randomly select approximately 800 LOCD records annually to be reviewed by the Contractor. LOCD records will be selected daily in real-time.

b. Review Description: Annually, MDHHS will use CHAMPS to randomly select a sample of LOCDs for review. The purpose of this review is to determine if the LOCD was conducted properly according to MDHHS LOCD policy standards and resulted in the correct determination of eligibility or ineligibility. When a LOCD is submitted in the CHAMPS system, the provider will receive a real-time pop-up alert informing them that their LOCD has been selected for review. The provider will then have one business day to upload supporting documentation in CHAMPS to the LOCD record. The third-party designee will be responsible for the review of LOCDs where documentation has been provided and will provide a determination within two business days of receiving the documentation upload in CHAMPS. LOCDs selected for Verification Review are not considered complete until the Contractor informs the provider and beneficiary of the result of the review.

List all exception(s):

Bidder must describe their experience doing LOCD reviews or similar reviews and how they will comply with the above requirement(s):

c. Possible outcomes and Contractor responsibilities depending on determination: Approved (eligible record): When the Contractor, based on a review of the LOCD data entries and the uploaded documentation, determines that the record properly reflects LOCD eligibility, the Contractor must “approve” the LOCD record. When the Contractor approves an eligible record, the Contractor is stating that they agree that the individual is eligible, and the Door selection is accurate. The door selection determines what criteria the individual is eligible to receive services. The status of the LOCD record changes to “review complete”. The Contractor will write up a synopsis of how they came to their conclusion and upload the synopsis and all reviewed documentation into the appropriate Application ID number in CHAMPS.

Rejected (eligible record): When the Contractor determines that the individual is eligible, but the Door selected is not an accurate reflection of the individual’s functionality, the Contractor must “reject” the LOCD record. Once the record is rejected, the Contractor must complete a new LOCD record to reflect the accurate LOCD qualifying Door. The Contractor will write up a synopsis of how they came to their conclusion and upload the synopsis and all reviewed documentation into the approved record. The Contractor is also responsible for providing the appropriate Action Notice to the provider and the beneficiary or their representative. The notice will also be uploaded into the appropriate Application ID number in CHAMPS.

Documents Not Available (eligible/ineligible record): When the provider uploads incomplete supporting documentation in CHAMPS within one business day, the Contractor must act upon the selected LOCD record and deem it as “Documents not available.” Once this status is placed on the LOCD record, any subsequent LOCD done for the beneficiary will be selected for review until supporting documentation is provided.

Approved (ineligible record): If the Contractor determines that the LOCD data accurately reflects that the beneficiary is ineligible for the nursing facility level of care (a Door 0), then the Contractor must mark the record as approved. The Contractor must then complete a new Door 0 record to reflect the reviewer’s determination. The Contractor will write up a synopsis of how they came to their conclusion and upload the synopsis and all reviewed documentation into the approved record. The Contractor is also responsible for providing the appropriate Action Notice to the provider and the beneficiary or their representative. The notice will also be uploaded into the appropriate Application ID number in CHAMPS.

Rejected (ineligible record): If the Contractor determines that the individual does meet LOCD eligibility through a qualifying Door (1-8), the Contractor must reject the Door 0 record and complete a new LOCD to reflect the appropriate qualifying Door. The Contractor will write up a synopsis of how they came to their conclusion and upload the synopsis and all reviewed documentation into the appropriate Application ID number in CHAMPS.

List all exception(s):

Bidder must describe the key points to include in the synopsis that supports their conclusion regarding the LOCD determination.

d. Beneficiary Appeal Process:

An individual who has been deemed ineligible for the nursing facility level of care may appeal after the Contractor has issued an adverse action notice to the individual within the guidelines stated in policy. When the individual requests a State Fair Hearing, the Contractor must provide the written reports and make direct testimony available to MDHHS as MDHHS deems necessary by the employee that completed the review. An appeals form (Attachment H - Hearing Request) and an addressed stamped envelope must accompany the adverse action notice. The adverse action notice and appeal form must be sent to the individual the day of the adverse action. The Contractor must provide a written report and the employee who completed the review must telephonically participate in the State Fair Hearing. If the employee is unable to participate, the Contractor must have prior approval by MDHHS. Hearings typically last approximately one hour or less; occasionally a hearing may last two or more hours.

List all exception(s):

Bidder must describe any related experience they have in participating in an administrative process and how they will comply with the above requirement(s):

2. LOCD Secondary Review

a. Review Description: The provider or the individual (or their legal representative) may request an LOCD Secondary Review. The review is completed by the Contractor to ensure full consideration of LOCD eligibility options. The review is available only when an LOCD is entered in CHAMPS and results in Door 0, indicating ineligibility. The Secondary Review examines the documentation for all Doors of eligibility. Estimated number of Secondary reviews is 31 per month or 372 per year.

List all exception(s):

Bidder must describe why a secondary review of Door 0 is important and how they will comply with the above requirement(s):

b. Review Process: A request for Secondary review must be made telephonically to the Contractor by the provider (following a Door 0 record but prior to adverse action notice) or by the individual (or their representative) (following a Door 0 record and after the provider gives adverse action notice) within thirty calendar days of notice. After getting the request for Secondary Review, the Contractor must contact the provider and instruct them to upload supporting documentation in CHAMPS within one business day for review. The Contactor should also contact the beneficiary or their representative to obtain any relevant documentation or observations. Following review of the documentation, the Contractor must make a determination of eligibility (Doors 1-8) or ineligibility (Door 0). The Secondary Review has to be determined within three business days from the date of receipt of all relevant documentation. The Contractor must contact all parties with the results of the review (provider – telephonic) (individual/representative – written notice if ineligible and telephonic if eligible). An appeals form (Attachment H - Hearing Request) and an addressed stamped envelope must accompany the adverse action notice. The adverse action notice and appeal form must be sent to the individual the day of the adverse action. The Contractor is responsible for uploading a synopsis of their determination along with all documentation and the adverse Action Notice (Attachment I) into the appropriate Application ID number in CHAMPS.

List all exception(s):

Bidder must describe what types of information may be needed from the beneficiary or their representative and how they will comply with the above requirement(s):

c. Beneficiary Appeal Process: An individual who has been deemed ineligible for the nursing facility level of care may appeal after the Contractor issues an adverse action notice within the guidelines stated in policy. When an appeal is made, the Contractor must provide any additional written documentation that may not be in CHAMPS and make direct testimony available to MDHHS as MDHHS deems necessary. The Contract employee who conducted the review must telephonically participate in the State Fair Hearing. If the employee is unable to participate, the Contractor must have prior approval by MDHHS. Hearings typically last approximately one hour or less; occasionally a hearing may last two or more hours.

List all exception(s):

3. Home Help EHHS Reviews The State may request the Contractor to complete Home Help EHHS Reviews. Contract Activities must be completed as per the policy requirements set forth in the Adult Services Manual and the Adult Services Comprehensive Assessment. The assessment must be completed using the Home Help Worksheet Nurse Review with a final decision being documented on the Policy Decision. If the State requests these reviews, the Contractor must meet the following requirements.

a. Review Amount: The Home Help Policy Section will identify up to 20 EHHS records annually to be reviewed by the Contractor.

b. Review Description: The Home Help Policy section will identify clients who qualify for Expanded Home Help Services biweekly to be reviewed by the Contractor. The Contractor must complete the review within thirty calendar days from the receipt of the referral.

c. Review Process: The Home Help Policy section will share the last client assessment, if available, along with any supporting documents for the assessment to be completed. The Contractor will have access to MiAIMS to review current information about the client. The Contractor must complete an assessment with the individual, the adult services worker, and anyone else the adult services worker determines necessary (guardian, provider, etc.) to conduct a thorough and accurate assessment of the client. The contractor must document their assessment, and any changes in the client’s condition on the Home Help Nurse Review worksheet. The Contractor may request additional medical documentation from the worker if needed to complete the assessment. The adult services worker will make the final decision on total hours if it remains under the EHHS threshold. All Home Help documents (Attachment F – Home Help Worksheet Nurse Review and Attachment G – Policy Decision Document) must be forwarded to the Home Help Policy Section for review and uploaded into the MiAIMS system for future reference.

d. Beneficiary Appeal Process: A client who has been denied additional services or receives a reduction in approved services may appeal after the adult services worker issues a negative action notice. The Contractor’s nurse reviewer must be available to testify as to the results of the assessment at any administrative hearing or judicial proceeding. If the employee is unable to participate, the Contractor must have prior approval by MDHHS. The Contractor representation at the appeals will be at the request of MOAHR for MDHHS.

List all exception(s):

Bidder must describe their understanding of Expanded Home Help Assessments and the process to complete these reviews .

4. Home Help Quality Reviews

a. Review Amount: The Home Help Policy Section will identify approximately 180 Home Help quality records annually to be reviewed by the Contractor.

b. Review Description: The Home Help Policy section will identify a list of individuals that may be underassessed based on diagnosis codes. The Contractor must do an initial review of information in MiAIMS to determine if the assessment looks appropriate and complete based on the Contractor’s medical knowledge of the individual’s diagnosis and commonly required care for that diagnosis. Where concerns are noted, the Contractor must complete a full review as noted below in the same month as the client’s next regularly scheduled review unless an agreement is reached with MDHHS staff for a different date.

c. Review Process: The Contractor will have access to MiAIMS to review current information about the client. The Contractor must contact the worker to schedule a time for a phone interview to be completed with the client, the adult services worker, the guardian (if applicable) and any other individuals the client feels can assist with the assessment. The Contractor may also need to request a copy of the DHS-54A, Medicaid Needs form from the worker. If the DHS-54A does not support the clients’ current assessment, or does not have new diagnoses on it, then the Contractor will need to request that the worker obtain a new one. The Contractor must complete an assessment with the individual, the adult services worker, and anyone else the adult services worker determines necessary (guardian, provider, etc.) to conduct a thorough and accurate assessment of the client. The contractor must document their assessment, and any changes in the client’s condition on the Home Help Nurse Review worksheet. If hours are increased, the Contractor will complete a Policy Decision Notice and send to the Home Help Policy Section for approval if it remains under the EHHS threshold before forwarding to the adult services worker so the additional hours can be added to the client’s approved hours. If it remains under the EHHS threshold ,the contractor can share the results with the adult services worker so they can finalize the amount for the assessment. All Home Help Nurse Review documents, once they are completed and signed, must be uploaded into the MiAIMS system.

d. Beneficiary Appeal Process: A client who has been denied additional services or receives a reduction in approved services may appeal after the adult services worker issues a negative action notice. The Contractor’s nurse reviewer must be available to testify as to the results of the assessment at any administrative hearing or judicial proceeding. The Contractor representation at the appeals will be at the request of MOAHR for MDHHS.

List all exception(s):

Bidder must describe how the Home Help Assessment process will differ from EHHS assessments and how they will comply with the above requirement(s):

5. Additional Contractor Requirements

a. The following are the mandatory elements for the Contract.

1. Responsibility for the authorization must be implemented no later than the effective date of this Contract.

2. The telephone and computer systems must be available from 8:00 am – 5:00 pm EST Monday through Friday except for State approved holidays.

3. Telephonic and Computer Electronic systems must be in place on the Contract effective date.

4. The Contractor must assign staff to represent MDHHS in the Appeal Process.

5. The Contractor must have a system or process in place that allows the validation of all, LOCD, Expanded Home Help Services and Home Help Reviews.

6. The Contractor must utilize CHAMPS, MiAIMS, and FileNet.

7. Potential quality of care issues will be referred to MDHHS Program Managers for review.

b. A copy of the information received from the provider for all LOCD, must be reviewed and validated by the Contractor. The information received from the provider for all LOCD specified reviews must be stored electronically in CHAMPS.

c. A copy of the Review Coordinator’s summary for all LOCD and Home Help specified reviews must be stored electronically either in CHAMPS or MiAIMS.

d. All LTSS specified reviews must be performed based on current Michigan Medicaid Nursing Facility Level of Care Determination criteria.

e. As with any benefit denial, an individual may request a State Fair Hearing. The Administrative Tribunal provides an administrative hearing to appellants requesting a hearing who do not agree with the decision made by MDHHS or a MDHHS contracted agency that either determines eligibility for department program, or delivers a service provided under a department program to a beneficiary, patient, or resident. The MOAHR issues timely, clear, concise, and legally accurate hearing decisions and orders. (See Attachment J - Administrative Hearing Pamphlet).

f. The Contractor must maintain absolute confidentiality of providers and beneficiaries assuring that no disclosure of information that may identify beneficiaries or providers is shared inappropriately.

List all exception(s):

1.2. Transition

Contractor must work with MDHHS to ensure no interruption or adverse effect on services during the transition from the present Contractor and new Contractor (if applicable). Additionally, the Contractor must ensure the following mechanisms are in place:

1. Readiness for Implementation

a. The Contractor must have an operational system in place no later than the effective date of this Contract including, but not limited to, sufficient staff.

b. The Contractor must demonstrate to the satisfaction of MDHHS, no later than one month from the effective date of the Contract, that the Contractor is fully capable of performing all duties under this Contract, including demonstration of the following:

i. A sufficient number of RNs and Physicians experienced in the areas of LTSS to perform the review duties as specified herein. The RNs performing these review functions cannot perform reviews for any other business entities outside this Contract. The MDHHS expects the Contractor to designate separate staff for these review categories.

ii. The Contractor has thoroughly trained its staff on the specifics of LOCD and Home Help assessments and the Contractor’s staff has knowledge to make eligibility determinations.

iii. The Contractor has the ability to accept, review, and utilize the CHAMPS system for documentation of LOCDs that have been completed and upload documents to support the LOCD review.

iv. The Contractor has the ability to review and utilize the MiAIMS system for documentation review and uploading documents for Home Help assessments that have been completed.

v. The Contractor has quality assurance procedures in place that assures it follows all State and federal laws for confidentiality.

c. The Contractor’s inability to demonstrate to the satisfaction of MDHHS and as provided herein, that the Contractor is fully capable of performing all duties under this Contract no later than the effective date of the Contract, including, but not limited to staff, will be grounds for the immediate termination of this Contract by the State in accordance with the terms specified herein.

List all exception(s):

Bidder must describe what actions they need to take to meet the requirements above by the effective date of the Contract and what support they will need from the State.

1.3. Training

The Contractor must ensure applicable staff is trained in the use of MDHHS policy as related to contract covered services, call center operations, and medical review processes. The Contractor must provide documentation that the applicable trainings are completed.

MDHHS staff will provide initial CHAMPS, MiAIMS, and FileNet system training. All Contractor staff will be required to complete all MDHHS security/privacy trainings.

MDHHS staff will provide additional training, on an as-needed basis, on-site (either at Contractor’s site or at a State site), by email, by facsimile, or by conference calls regarding Medicaid policy, Medicaid policy interpretation and/or additional education necessary for the Contractor to perform proper review.

Upon request from the MDHHS Program Manager, the Contractor must provide all documentation and training materials that are used to train the Contractor’s staff to perform the Contract activities.

List all exception(s):

Bidder must explain their process for onboarding staff for this Contract to include training.

1.4. Specific Standards

IT Policies, Standards and Procedures (PSP) Contractors are advised that the State has methods, policies, standards and procedures that have been developed over the years. Contractors are expected to provide proposals that conform to State IT policies and standards. All services and products provided as a result of this RFP must comply with all applicable State IT policies and standards. Contractor is required to review all applicable links provided below and state compliance in their response.

Public IT Policies, Standards and Procedures (PSP):

DTMB - IT Policies, Standards & Procedures (michigan.gov)

List all exception(s):

Acceptable Use Policy To the extent that Contractor has access to the State’s computer system, Contractor must comply with the State’s Acceptable Use Policy, see 1340.00.130.02 Acceptable Use of Information Technology (michigan.gov). All Contractor Personnel will be required, in writing, to agree to the State’s Acceptable Use Policy before accessing the State’s system. The State reserves the right to terminate Contractor’s access to the State’s system if a violation occurs.

List all exception(s):

Bidder must explain their process for ensuring only staff who need information have access to the system and what safeguards are in place to protect PI and HIPPA information.

SOM Digital Standards All software items provided by the Contractor must adhere to the State of Michigan Application/Site Standards which can be found at www.michigan.gov/standards.

List all exception(s):

ADA Compliance The State is required to comply with the Americans with Disabilities Act of 1990 (ADA) and has adopted standards and procedures regarding accessibility requirements for websites and software applications. All websites, applications, software, and associated content and documentation provided by the Contractor as part of the Solution must comply with Level AA of the World Wide Web Consortium (W3C) Web Content Accessibility Guidelines (WCAG) 2.0.

List all exception(s):

Bidder must acknowledge their agreement with this section and provide details for how they will meet the requirements:

1.5. End-User Operating Environment

The SOM environment is X86 VMware, IBM Power VM, MS Azure/Hyper-V and Oracle VM, with supporting platforms, enterprise storage, monitoring and management.

Contractor must accommodate the latest browser versions (including mobile browsers) as well as some pre-existing browsers. To ensure that users with older browsers are still able to access online services, applications must, at a minimum, display and function correctly in standards-compliant browsers and the state standard browser without the use of special plugins or extensions. The rules used to base the minimum browser requirements include:

· Over 2% of site traffic, measured using Sessions or Visitors (or)

· The current browser identified and approved as the State of Michigan standard This information can be found at https://www.michigan.gov/browserstats. Please use the most recent calendar quarter to determine browser statistics. Support is required for desktop and mobile and tablet browsers identified with over 2% of site traffic.

Contractor must support the current and future State standard environment at no additional cost to the State.

List all exception(s):

Bidder must describe any State system access requirements that are necessary for the Bidder to perform its obligations on a timely basis, including but not limited to, physical or remote access to State networks, servers, or individual workstations:

1.6. Hosting

For any data that is hosted on the Contractor’s network, the Contractor must maintain and operate a backup and disaster recovery plan to achieve a Recovery Point Objective (RPO) of 24 hours, and a Recovery Time Objective (RTO) of 24 hours.

List all exception(s):

Bidder must review the State’s standard Contractor Hosted Software and Services attached as Schedule D - Service Level Agreement for Hybrid Purchases. Bidder must note any exceptions to the Service Level Agreements (SLA) by redlining Schedule D - Service Level Agreement for Hybrid Purchases.

Bidder must include a copy of its Disaster Recovery Plan either in this response box or identified here as an attachment to this RFP labelled as “Disaster Recovery Plan”.

2. Acceptance To determine acceptance of the Contract Activities, MDHHS will at a minimum, through monthly/annual Contract reviews and periodic audits, determine if Contractor has met deliverable criteria and if work was performed according to the Contract Specifications.

List all exception(s):

3. Staffing

3.1. Contractor Representative

The Contractor must appoint one Registered Nurse (RN) Contract Representative, specifically assigned to State of Michigan accounts, who will respond to State inquiries regarding the Contract Activities, answer questions related to ordering and delivery, etc. (the “Contractor Representative”).

The Contractor must notify the Contract Administrator at least 30 calendar days before removing or assigning a new Contractor Representative.

List all exception(s):

Bidder must identify its Contractor Representative:

3.2. Contract Administrator

The Contract Administrator for each party is the only person authorized to modify any terms of this Contract, and approve and execute any change under this Contract (each a “Contract Administrator”):

Marissa Gove 320 South Walnut Street Lansing, MI 48933 Govem1@michigan.gov 517-449-8952 [Name] [Street Address] [City, State, Zip] [Email] [Phone]

3.3. Program Manager

The Program Manager for each party will monitor and coordinate the day-to-day activities of the Contract (each a “Program Manager”):

Elaina Brown (Home Help) 400 South Pine Street Lansing, MI 48909 browne17@michigan.gov 517-335-3101 [Name] [Street Address] [City, State, Zip] [Email] [Phone]

Ian Lowers (LOCD) 400 South Pine Street Lansing, MI 48909 lowersi1@michigan.gov 517-335-8118 [Name] [Street Address] [City, State, Zip] [Email] [Phone]

3.4. Customer Service Number

The Contractor must maintain a customer service number.

a. The number must be maintained and staffed by RNs during normal working hours of Monday – Friday, 8:00 am to 5:00 pm EST except for State holidays.

b. The Contractor must answer all incoming phone calls promptly with an average time to answer of less than 90 seconds.

List all exception(s):

Bidder must identify its Customer Service Number:

3.5. Work Hours

The Contractor must provide Contract Activities during the State’s normal working hours Monday – Friday, 8:00 a.m. to 5:00 p.m. EST, excluding State holidays.

List all exception(s):

3.6. Key Personnel

The Contractor must appoint at a minimum, the following individuals who will be directly responsible for the day-to-day operations of the Contract (“Key Personnel”). Key Personnel must be specifically assigned to the State account, be knowledgeable on the contractual requirements, and respond to State inquiries within four hours.

The Contractor must ensure that none of the Key Personnel have a conflict of interest with any organization involved in the reviews Note: Below are the titles specified by the MDHHS, if your organization uses a different title for the required Key Personnel position, please also include that title as well.

1. RN Contractor Representative – This individual will be directly responsible for oversight of the day-to-day operations, contractual reporting requirements, supervision of RNs, and communication with MDHHS.

2. RN Reviewers – These individuals are responsible for staffing the customer service toll-free line, processing and performing reviews, and advancing requests to Physician Reviewers according to Contract requirements.

Contractor’s Key Personnel must perform all duties at Contractor’s offices and facilities. Requests for remote operations must be approved, in writing, by the MDHHS Program Manager.

The Reviewers must meet the following requirements:

1. Registered Nurse with a valid Michigan license.

2. Experience in long-term services and supports programs, such as nursing facilities, PACE programs, or home and community-based waiver programs.

3. Experience conducting long-term services and supports assessments, such as the Minimum Data Set or interRAI for Home Care assessment instruments.

The State has the right to recommend and approve in writing the initial assignment, as well as any proposed reassignment or replacement, of any Key Personnel. Before assigning an individual to any Key Personnel position, Contractor will notify the State of the proposed assignment, introduce the individual to the State’s Project Manager, and provide the State with a resume and any other information about the individual reasonably requested by the State. The State reserves the right to interview the individual before granting written approval. In the event the State finds a proposed individual unacceptable, the State will provide a written explanation including reasonable detail outlining the reasons for the rejection. The State may require a 30-calendar day training period for replacement personnel.

Contractor will not remove any Key Personnel from their assigned roles on this Contract without the prior written consent of the State. The Contractor’s removal of Key Personnel without the prior written consent of the State is an unauthorized removal (“Unauthorized Removal”). An Unauthorized Removal does not include replacing Key Personnel for reasons beyond the reasonable control of Contractor, including illness, disability, leave of absence, personal emergency circumstances, resignation, or for cause termination of the Key Personnel’s employment. Any Unauthorized Removal may be considered by the State to be a material breach of this Contract, in respect of which the State may elect to terminate this Contract for cause under the Termination for Cause section of the Standard Contract Terms. It is further acknowledged that an Unauthorized Removal will interfere with the timely and proper completion of this Contract, to the loss and damage of the State, and that it would be impracticable and extremely difficult to fix the actual damage sustained by the State as a result of any Unauthorized Removal. Therefore, Contractor and the State agree that in the case of any Unauthorized Removal in respect of which the State does not elect to exercise its rights under Termination for Cause, Contractor will issue to the State the corresponding credits set forth below (each, an “Unauthorized Removal Credit”):

(i) For the Unauthorized Removal of any Key Personnel designated in the applicable Statement of Work, the credit amount will be $25,000.00 per individual if Contractor identifies a replacement approved by the State and assigns the replacement to shadow the Key Personnel who is leaving for a period of at least 30-calendar days before the Key Personnel’s removal.

(ii) If Contractor fails to assign a replacement to shadow the removed Key Personnel for at least 30-calendar days, in addition to the $25,000.00 credit specified above, Contractor will credit the State $833.33 per calendar day for each day of the 30-calendar day shadow period that the replacement Key Personnel does not shadow the removed Key Personnel, up to $25,000.00 maximum per individual. The total Unauthorized Removal Credits that may be assessed per Unauthorized Removal and failure to provide 30-calendar days of shadowing will not exceed $50,000.00 per individual.

Contractor acknowledges and agrees that each of the Unauthorized Removal Credits assessed above: (i) is a reasonable estimate of and compensation for the anticipated or actual harm to the State that may arise from the Unauthorized Removal, which would be impossible or very difficult to accurately estimate; and (ii) may, at the State’s option, be credited or set off against any fees or other charges payable to Contractor under this Contract.

The Contractor must identify the Key Personnel, indicate where they will be physically located, describe the functions they will perform, and provide current chronological résumés.

List all exception(s):

Michigan.gov/MiProcurement A.

Version 2023-2 Page 2 B. The Contractor must identify all Key Personnel that will be assigned to this contract in the table below which includes the following:

1. Name and title of staff that will be designated as Key Personnel.

2. Key Personnel years of experience in the current classification.

3. Identify which of the required key personnel positions they are fulfilling.

4. Key Personnel’s roles and responsibilities, as they relate to this RFP, if the Contractor is successful in being awarded the Contract. Descriptions of roles should be functional and not just by title.

5. Identify if each Key Personnel is a direct, subcontract, or contract employee.

6. Identify if each Key Personnel staff member is employed full-time (FT), part-time (PT) or temporary (T), including consultants used for the purpose of providing information for the proposal.

7. List each Key Personnel staff member’s length of employment or affiliation with the Contractor’s organization.

8. Identify each Key Personnel’s percentage of work time for LOCD reviews and percentage of work time for Home Help reviews devoted to this Contract.

9. Identify where each Key Personnel staff member will be physically located (city and state) during the Contract performance.

<Add more rows below as needed> 1.

Name/Title 2.

Years of Experience in Current Classification 3.

Key Personnel Position Being Filled 4.

Role(s) / Responsibilities 5.

Direct / Subcontract/ Contract 6.

FT/ PT/ T

7.

Length of Employment 8.

% of Work Time 9.

Physical Location

C. The Contractor must provide detailed, chronological resumes of all proposed Key Personnel, including a description of their work experience relevant to their purposed role as it relates to the RFP.

Qualifications will be measured by education and experience with particular reference to experience on projects similar to that described in the RFP.

Bidder must provide the resumes and information as required above – either in this response box or identified here as an attachment to this RFP labelled as “Resumes”.

3.7. Organizational Chart

The Contractor must provide an overall organizational chart that details staff members, by name and title, and subcontractors.

Bidder must provide detailed information as required above – either in this response box or identified here as an attachment to this RFP labelled as “Organizational Chart”.

3.8. Disclosure of Subcontractors

If the Contractor intends to utilize subcontractors, the Contractor must disclose the following:

· The legal business name; address; telephone number; a description of subcontractor’s organization and the services it will provide; and information concerning subcontractor’s ability to provide the Contract Activities.

· The relationship of the subcontractor to the Contractor.

· Whether the Contractor has a previous working experience with the subcontractor. If yes, provide the details of that previous relationship.

· A complete description of the Contract Activities that will be performed or provided by the subcontractor

Bidder must provide detailed information as requested in the above requirement(s).

The legal business name, address, telephone number of the subcontractor(s).

A description of subcontractor’s organization and the services it will provide and information concerning subcontractor’s ability to provide the Contract Activities.

The relationship of the subcontractor to the Bidder.

Whether the Bidder has a previous working experience with the subcontractor.

If yes, provide the details of that previous relationship.

A complete description of the Contract Activities that will be performed or provided by the subcontractor.

Of the total bid, the price of the subcontractor’s work.

3.9. Security

The Contractor must explain any additional security measures in place to ensure the security of State facilities. The State may require the Contractor’s personnel to wear State issued identification badges.

The Contractor’s staff may be required to make deliveries to or enter State facilities. The Contractor must: (a) explain how it intends to ensure the security of State facilities, (b) whether it uses uniforms and ID badges, etc., (c) identify the company that will perform background checks, and (d) the scope of the background checks.

List all exception(s):

4. Project Management

4.1. Project Plan

The Contractor will carry out this project under the direction and control of the Program Manager. Within 30 calendar days of the Effective Date, the Contractor must submit a final project plan to the Program Manager for approval. The plan must include: (a) the Contractor's organizational chart with names and title of personnel assigned to the project, which must align with the staffing stated in accepted proposals; and (b) the project breakdown showing sub-projects, tasks, timeline, and resources required.

List all exception(s):

Bidder must submit a sample project plan as described above:

4.2. Meetings

The Contractor must meet/teleconference with the MDHHS Program Manager at least every other week during the first month of the Contract and at least every other month for the remainder of the Contract to review all reports, discuss issues, etc. unless mutually agreed upon to cancel.

The reviewer will participate in up to 10 monthly meetings annually of up to two hours each for the purpose of reviewing policy and operational issues necessary. The State may request up to three face-to-face meetings annually in Lansing, Michigan. The remaining meetings will be conducted virtually at the discretion of MDHHS. The Contractor will provide input and feedback to the revision of standard MDHHS LOCD documents and the development of Medicaid policy bulletins and numbered letters. This work will be conducted through virtual meetings and email.

The State may request other meetings, as it deems appropriate.

List all exception(s):

4.3. Reporting

The Contractor, unless specified otherwise, must submit reports and information to the MDHHS Program Manager at the address listed in this Contract. The MDHSS Program Manager will evaluate the reports submitted as described in this section for their completeness and adequacy.

1. The Contractor must submit Verification Review Reports: Reports must be provided electronically to the MDHHS Program Manager and designated MDHHS staff monthly, quarterly, and annually. Verification Review reports, must include:

a. Number of verification reviews performed.

b. The following information for each verification review:

i. Review determination date

ii. Beneficiary first and last name and Medicaid ID

iii. Provider’s NPI/Contractor ID and setting type (nursing facility, waiver, PACE, MI Health Link)

iv. Review Nurse’s name

v. Number approved

vi. Number rejected

vii. Number Documents Not Available

viii. Copies of Adverse Action Notices

ix. Number of Verification Reviews appealed

2. The Contractor must submit Secondary Review Reports: Reports must be provided electronically to the MDHHS Program Manager and designated MDHHS staff monthly, quarterly, and annually. Secondary Review reports, must include:

a. Number of secondary reviews performed

b. The following information for each secondary review:

i. Telephone contact date from the provider/beneficiary/representative

ii. Review determination date

iii. Beneficiary first and last name and Medicaid ID

iv. Provider’s NPI/Contractor ID and setting type (nursing facility, waiver, PACE, MI Health Link)

v. Review Nurse’s name

vi. Number approved

vii. Number rejected

viii. Number Documents Not Available

ix. Copies of Adverse Action Notices

x. Number of Secondary Reviews appealed

3. The Contractor must provide the following information to MDHHS staff in a shared spreadsheet to be updated at a minimum weekly:

a. Review Status of the assessment

b. Client Name

c. Log ID#

d. Type of Review (EHHS assessment or Quality Review)

e. Last Review Date for the client by the adult services worker

f. The assigned nurse to complete the review

g. The number of Home Help Hours approved prior to the nurse review

h. Client Diagnosis

i. Whether a full assessment is needed with the client after information is reviewed in MiAIMS.

j. The date the nurse completes the assessment with the client, if applicable

k. The assessment due date (30 days from the client interview date)

l. Date of the most recent Medical Needs Form (DHS-54A)

m. Date the Policy Decision Notice is approved by MDHHS

n. The new approved hours after the assessment is completed

o. Date documents are uploaded to MiAIMS

p. Total RN hours to complete the assessment

q. The month the hours to complete the assessment are billed to MDHHS

List all exception(s):

Bidder must explain its reporting capabilities and any reporting that is included in its proposal:

Bidder must provide samples of required reports as attachments to this RFP. List file names here.

5. Pricing

5.1. Price Term

Pricing is firm for the entire length of the Contract.

List all exception(s):

5.2. Price Changes

Adjustments will be based on changes in actual Contractor costs. Any request must be supported by written evidence documenting the change in costs. The State may consider sources, such as the Consumer Price Index; Producer Price Index; other pricing indices as needed; economic and industry data; manufacturer or supplier letters noting the increase in pricing; and any other data the State deems relevant.

Following the presentation of supporting documentation, both parties will have 30 days to review the information and prepare a written response.