RFP 250000002670 - Schedule J - Narrative Submission Questions.docx

SCHEDULE J – NARRATIVE SUBMISSION QUESTIONS

Request for Proposal No. MA 250000002670 Prepaid Inpatient Health Plan (PIHP)

INSTRUCTIONS

Bidders will be evaluated on the quality and completeness of their responses to the questions in Schedule J: Narrative Submission Questions. Responses to this Narrative Submission must demonstrate the Bidder’s full understanding of all contractual requirements contained in Schedule A: Statement of Work, including but not limited to those specifically referenced within the questions.

The Bidder must provide a specific response to the questions asked in this Schedule. In each response, Bidders are expected to discuss their:

1. Approach to addressing the issue in the narrative question, highlighting how their approach: will allow the Bidder to fulfill the contractual requirements; is a good fit for Michigan and tailored by region when requested; represents innovation and/or best practice; and considers health disparities and opportunities to advance health equity (e.g., discuss known health disparities; include strategies to identify, understand, and address health disparities; include how Bidder will ensure culturally and linguistically appropriate services and engage with enrollees/families in Bidder initiatives).

2. Capabilities needed to implement the Bidder’s proposed approach, which could include: organizational structure, staffing resources, operational infrastructure, established operational protocols, and technology infrastructure and resources (e.g., IT systems and system capabilities).

3. Experience related to the issue in the narrative question. When citing relevant experience, the Bidder must clearly state what coverage program(s), state(s) and year(s) the experience comes from and how it will translate to a Michigan Prepaid Inpatient Health Plan (PIHP) context (e.g., total enrollees in coverage program, covered populations, covered services). Bidders must cite behavioral health experience where possible, as well as describe outcomes associated with their prior experience.

Questions 1 and 2 ask Bidders to provide supplemental materials (e.g., submission of a Letter of Commitment, completion of a separate Schedule). Supplemental materials requested will be considered in the scoring of a Bidder’s overall response to a question and contribute to a single score applied across all regions.

Questions 1,2,3,4,5,6,7,8,9,10,12,13, 14 and 19 ask Bidders to describe how the Bidder’s approach will differ across various regions (e.g., region 1, 2, or 3), if the Bidder is applying to multiple regions.

Bidders will only be evaluated on their response to each question; responses to prior questions will not be considered in the evaluation of a later question.

PROPOSAL FORMAT

The submission requirements must follow the page limitation guidelines outlined below. All pages meeting the narrative submission requirements must be numbered and submitted in 11-point Arial font on 8 ½ X 11-inch paper, single spaced. The size and/or style of graphics, tabs, attachments, margin notes/highlights, etc. are at the Bidder’s discretion. All responses must be provided in the Bidder Response boxes provided below each question.

Schedule J responses must consist of all of the following components. Each component must be uniquely identified and limited to the maximum number of pages specified. Pages in excess of the stated page limits listed below (excluding supplemental pages allowed in Questions 1,2) will not be reviewed.

1. Bid Regions

2. Narrative Submission I. Strategic Pillar 1: Provide high quality and timely services

1) Network Adequacy and Letters of Commitment (5-page limit)

2) Delivery of high-quality care across systems (5-page limit)

3) Approach to addressing cultural and linguistic/communication needs (3-page limit)

4) Access to care for tribal communities (2-page limit)

5) Access to care for individuals from high-risk populations (5-page limit)

6) Access to care for individuals in need of emergency intervention services (5-page limit)

7) Access to Substance Use Disorder (SUD) services for priority populations (3-page limit)

8) Coordination with Medicaid Health Plans (MHPs) for shared enrollees (3-page limit) II. Strategic Pillar 2: Improve choice and consistency across regions

9) Care coordination programs and infrastructure (3-page limit)

10) Equitable access to care across regions (4-page limit) III. Strategic Pillar 3: Ensure accountability and transparency

11) Approach to operating as a payor-only entity without delegation of managed care functions (3-page limit)

12) Board structure composition (3-page limit)

13) Stakeholder engagement and implementation of feedback (3-page limit)

14) Infrastructure to collect and conduct analysis on data (2-page limit)

15) Compliance processes (2-page limit)

16) Grievances and appeals process (2-page limit)

17) Claims processing excellence (2-page limit) IV. Strategic Pillar 4: Simplify the system with reduced bureaucracy

18) Management Information Exchange (MIS) infrastructure (2-page limit)

19) Infrastructure to reduce administrative burdens for providers (3-page limit)

BID REGIONS:

Select the region(s) to which this bid applies. See Appendix 1 – PIHP region map for details. Select all that apply:

☐ Northern region ☐ Central region ☐ Metro region

QUESTIONS:

MDHHS PIHP Strategic Pillar 1: Provide high quality and timely services components Public stakeholder feedback on the PIHP and specialty behavioral health system shared with MDHHS has underscored the need to expand services for enrollees across regions, enhance quality and timeliness of access to care, and ensure services are properly provided to enrollees of diverse and unique backgrounds. Bidder must reflect the MDHHS PIHP Strategic Pillar to deliver high-quality services and ensure timely access to services within responses.

1. Network Adequacy and Monitoring: Topic referenced in Schedule A – General Requirements 1.1.E Access and Availability (5-page limit)

Bidder responses have two components (1) Detailed Network Adequacy Plan; and (2) Letters of Commitment:

Detailed network adequacy plan: Bidders must submit a detailed Network Adequacy Plan describing the region’s network, as introduced in Schedule A Section 1.1.E Access and Availability. Plans must at a minimum address the following:

· Description of expected provider network(s) by region(s) including strategy and timeline to meet network adequacy standards and provide all covered services to eligible enrollees

· Plan to monitor and enforce network adequacy requirements (e.g., maximum time and distance, provider to enrollee ratios, timely appointments)

· Strategy to proactively identify, report, and address potential network gaps in meeting the needs of enrollees

· Approach towards measuring network capacity of provider network(s) by region(s)

· Approach towards recruitment and retention of qualified providers in areas that network gaps may exist

· Approach for managing provider network reporting, transparency, and decision making to ensure consistency and manage risk

· Strategy to ensure provider network(s) meet the linguistic, cultural, and physical accessibility needs of all enrollees, including but not limited to:

i. Enrollees with limited English proficiency

ii. Enrollees with physical or mental disabilities (e.g., blind, deaf/hard of hearing, intellectual /developmental disabilities)

Provider Letters of Commitment (LOC): Bidders must also submit Letters of Commitment (LOC) labeled as “Letter of Commitment-Provider Name-Region” detailing on-going negotiations and/or initial discussions from providers within each region(s) the bidder is submitting a proposal, to demonstrate ability to provide specific services to enrollees. Bidders may submit LOC from any providers currently negotiating with/have contracts with, but must submit at least one LOC from a provider per each of the following areas:

· Emergency intervention services

· Intensive outpatient services (e.g., partial hospitalization)

· In-patient psychiatric hospitalization services

· Autism Spectrum Disorder (ASD) services (e.g., applied behavior analysis (ABA) therapists)

· Home and community-based services (HCBS)

· Youth services (e.g., Wraparound, respite services)

· Providers who can deliver SUD prevention, treatment, and recovery services, related to each of the American Society of Addiction Medicine (ASAM) treatment levels for both youth and adults (e.g., outpatient counselors, partial hospitalization program (PHP) centers, residential programs, or detox units)

Michigan.gov/MiProcurement Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 1:

2. Delivery of high-quality care across systems: Topic referenced in Schedule A – General Requirements 1.1.K Quality Improvement and Program Development and 1.1.R Program Integrity (5-page limit)

The Bidder must describe their overarching approach to ensuring the delivery of high-quality specialty behavioral health care across communities and regions, highlighting strategies to leverage technology, workforce training, integrated care, and community partnerships (e.g., HCBS) to enhance care and delivery of integrative services.

Bidder must also include details on utilization management processes, describing anticipated procedure for review of proposed denials or reductions of requested services (e.g., oversight, tracking, monitoring activities, and efforts to minimize or prevent any potential or perceived conflicts of interest). This section is inclusive of the Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUPTRS BG) requirement to ensure 12-month availability of services.

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

In addition, to help showcase an approach to ensuring high-quality care, Bidders must provide proof of National Committee for Quality Assurance (NCQA) accreditation status attached as a supplemental document to this question. If the Bidder does not currently have NCQA accreditation, the Bidder must include a detailed plan to obtain accreditation by October 1, 2027, including a timeline for the application process, as part of the response to this question and in reference to Schedule A Section 1.1.K Quality Improvement and 1.1.R Program Integrity.

Bidder Response to Question 2:

3. Approach to addressing cultural and linguistic/communication needs: Topic referenced in Schedule A – General Requirements 1.1.E Access and Availability (3-page limit)

Provide a detailed outline, including Bidder past experiences where relevant, describing how Bidder will meet cultural, linguistic, and communication needs of enrollees. Specifically, address at a minimum, the following:

· Comprehensive strategy to provide enrollee-centered, plain language communication

· Ability to provide and facilitate the delivery of services in a culturally competent manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds, individuals with disabilities, individuals who are deaf, visually impaired, and regardless of gender, sexual orientation, or gender identity.

Provide strategy to provide language assistance services as needed, for example bilingual staff, interpreter services, and American Sign Language (ASL), for both the Contractor’s services and services delivered by Network Providers as outlined in Schedule A Section 1.1. E Access and Availability.

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 3:

4. Access to care for tribal communities: Topic referenced in Schedule A – General Requirements 1.1.E Access and Availability, 2.6 Key Personnel (2-page limit)

The Bidder must demonstrate the capacity to effectively serve enrollees from tribal communities. The Bidder must address, at a minimum, the following:

· Ability to collaborate with tribal leadership to ensure services meet specific population needs

· Workforce training and initiatives to address tribal-specific needs

· Plans to contract with tribal service providers, as appropriate

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 4:

5. Access to care for individuals from high-risk populations: Topic referenced in Schedule A – General Requirements 1.1.E Access and Availability (5-page limit)

The Bidder must demonstrate the capacity to effectively serve enrollees with specialty behavioral health needs from high-risk communities, including, but not limited to, enrollees associated with the corrections system, homeless individuals, and children and families involved in child welfare and/or juvenile justice systems, and other population groups that may encounter difficulties accessing PIHP services, as referred to in Schedule A Section 1.1.E Access and Availability.

The Bidder must address how they intend to provide services to individuals from high-risk communities, including, at minimum, the following:

· How the Bidder will ensure access, coordination, self-determination/self-directed service arrangements and service delivery to high-risk populations (e.g., how will the Bidder ensure availability of the Michigan Child and Adolescent Service (MICAS) array, how will the Bidder ensure individuals needs are met across the region)

· A data-driven approach for identifying enrollees for care management programs and how approaches vary for different populations

· Anticipated engagement rates and plans to innovate to increase engagement overtime

· Plan to collaborate with Michigan’s Certified Community Behavioral Health Clinics (CCBHCs) to support high-risk populations.

· Process for working with the Michigan Department of Corrections (MDOC) to coordinate the care of beneficiaries who are associated with the corrections system, including recently incarcerated beneficiaries: with serious mental illness; or substance use disorders.

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 5:

6. Access to care for individuals in need of emergency intervention services: Topic referenced in Schedule A – General Requirements 1.1.E Access and Availability (5-page limit)

Describe the Bidder’s anticipated process for ensuring the delivery of emergency intervention services to enrollees as referred to in Schedule A 1.1.E Access and Availability. At a minimum, include the following:

· Approach towards emergency intervention services care coordination, including integration and collaboration between physical and specialty behavioral health entities, and other emergency intervention services providers (e.g., outpatient mental health services or SUD services (including screenings), inpatient care with a BH specialty provider, visits to the emergency department or hospitalization, and emergency intervention services stabilization units)

· Approach for collaboration with CCBHCs for emergency intervention services

When describing the approach, Bidders must outline specific care plans for populations of high risk, including but not limited to:

· Child and adolescent enrollees (ages 21 years and younger), enrollees within the youth foster population, enrollees who have a mental illness, Intellectual and/or Developmental Disabilities (I/DD), and/or substance use disorder. Include in the description how this process will maximally support prevention and treatment efforts for children and adolescents.

· Other populations beyond this minimum set for which Bidders have identified a need to prioritize care management as well as other population health activities

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 6:

7. Access to SUD services for priority populations: Topic referenced in Schedule A – General Requirements 1.1.N Provider Services and 1.1.E Access and Availability (3-page limit)

Describe the Bidder’s anticipated process for ensuring the delivery of SUD services to priority populations. Priority populations include federal priority populations: (1) pregnant injecting drug users, (2) pregnant individuals with a substance use disorder diagnosis, (3) injecting drug users; Michigan State priority populations: (4) parents or guardians at risk of losing custody of their children due to substance use, (5) individuals recently released from incarceration or under community supervision (e.g., parole or probation); and (6) all other individuals meeting eligibility and medical necessity criteria, as referred to in Schedule A Sections 1.1.N Provider Services and 1.1.E Access and Availability. At a minimum, include the following:

· How the Bidder will ensure the delivery of SUD prevention, treatment (e.g., related to each of the ASAM treatment levels) for both youth and adults, including, but not limited to, outpatient counselors, PHP centers, residential programs, or withdrawal management units, and recovery services.

· A data-driven approach for identifying enrollees for care management programs and how approaches vary for different populations .

· How the bidder will maintain a dynamic Wait List for individuals who are not able to be immediately admitted to services, that includes the interim services provided, and priority population status.

· If bidder intends to enter into MDHHS grant agreements to support the services required under the within the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Substance Abuse Prevention and Treatment Block Grant (SAPT-BG) program, or describe how program will be funded.

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 7:

8. Coordination with Medicaid Health Plans (MHPs) for Shared Enrollees: Topic referenced in Schedule A – General Requirements 1.1.H Behavioral / Physical Health Integration (3-page limit)

PIHPs have an opportunity to promote timely and high-quality care delivered through the specialty BH system by collaborating with Michigan’s MHPs. Ensuring coordination of services between both systems may benefit beneficiaries receiving services as referred to in Schedule A Section 1.1.H Behavioral / Physical Health Integration. Describe the Bidder’s plan for working with MHPs to coordinate the care of enrollees who are served by both systems, including:

· Details on region’s approach to coordinate with MHPs, including but not limited to, conducting and facilitating referrals, generating a holistic care plan for enrollees receiving care from both systems, coordination of provider networks, and efforts to minimize or prevent any potential or perceived conflicts of interest

· Approach for innovations to support enrollees with receiving holistic and preventative care (e.g., annual physical exam) in addition to care received through PIHPs

· Approach to coordination of care for individuals enrolled in the SUD Health Home (SUDHH).

· Considerations for enrollees with serious mental illness, serious emotional disturbance, substance use disorder, or I/DD who have complex physical health care needs; and

· Considerations for enrollees with mild/moderate mental health care needs

· The Bidder’s response must describe how the Bidder will work with MHPs to ensure all shared enrollees’ needs are met in an adequate and timely manner. It must also include any known or anticipated challenges or barriers to coordinating care for those served by both systems and reflect how the Bidder’s proposed process will address each challenge or barrier identified

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 8:

MDHHS PIHP Strategic Pillar 2: Improve choice and consistency across regions Public stakeholder feedback on the PIHPs received by MDHHS identified an opportunity to increase enrollee choice and consistency across regions. Bidder must include details on how they will promote a system that improves choice in access to services across regions and promotes consistency across regions to ensure access to services regardless of where members reside.

9. Care coordination programs and infrastructure: Topic referenced in Schedule A – General Requirements 1.1.F Covered Services and 1.1.N Provider Services (3-page limit)

Provide information on the care coordination and management programs(s), including:

· The name of care management program or system

· Plan to support all enrollees through that system

· Technology infrastructure supporting care coordination programs (e.g., Information Technology (IT) Platforms, Vendor portals)

· Ability for care coordination programs to be utilized by entities other than the contractor (e.g., Network Providers)

If the Bidder has experience utilizing the program, or a different care management program, describe lessons learned (including decision to change programs), implementation methods, and risk guardrails utilized previously as referenced in Schedule A Sections 1.1.F Covered Services and 1.1.N Provider Services.

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 9:

10. Equitable access to care across regions Topic referenced in Schedule A – E. Access and Availability 8 (Access Standards) and 10 (Cultural Competence) (4-page limit)

MDHHS seeks to ensure that essential services are rendered equally and effectively across populations of Michigan residents by addressing disparities in services. Describe the Bidder’s approach to:

· Addressing health disparities (based on race/ethnicity, disability status, geography, etc.) including initiatives previously used

· Methods and innovations to ensure choice in providers to enrollees and monitor enrollee decisions across the region

· Understanding considerations specific to the region or local area and plan to incorporate considerations into program design (e.g., telehealth, other innovations)

· Utilizing the outcomes of those initiatives to effectuate data driven service improvements

· Future planning of monitoring of disparities in health outcomes

· Ensuring that each individual is offered choice of provider, and that Charitable Choice in the Code of Federal Regulations is followed for individuals supported by SUPTRS BG

· Ensuring consistency in availability of equitable services across the region

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 10:

MDHHS PIHP Strategic Pillar 3: Ensure accountability and transparency MDHHS is dedicated to upholding accountability and transparency as a PIHP Strategic Pillar throughout the duration of the PIHP contract. Bidders must demonstrate their ability to increase accountability and transparency through enhanced oversight and outcomes-centered performance management (e.g., claims processing systems, grievance and appeals procedures), and remove structural conflict of dual payor and provider responsibilities (e.g., governing board structure). In addition, stakeholder engagement and implementation of feedback is a critical aspect of ensuring that PIHPs are accountable to providing services that address the full continuum of care necessary for enrollees.

11. Approach providing all managed care functions to beneficiaries and ensuring those functions are not delegated to contracted network providers: Topic referenced in Schedule A – General Requirements 1.1, Schedule G- Definitions – Explanation of Terms (3-page limit)

The bidder must describe their overarching approach to provide managed care functions and ensure those functions are not delegated to contracted network providers. Functions to include in response must include: eligibility and coverage verification, utilization management network development, provider training, claims processing, quality improvement, and fraud prevention.

In addition, the bidder must describe their payment arrangements with network providers.

Bidder Response to Question 11:

12. Board structure composition: Topics referenced in Schedule A – General Requirements 1.1.G Contractor Governance and Board Requirements and 2.10 Open Meetings Act and FOIA (3-page limit)

Describe the Bidder’s approach to establishing a governing board by including the following:

· How the Bidder will meet board structure requirements outlined in Schedule A – General Requirements 1.1.G Contractor Governance and Board Requirements

· Approach for how the Bidder plans to minimize and prevent potential or perceived conflict of interest when selecting board members and conducting board activities

· Plans for board involvement with PIHP operations (e.g., meeting cadence, key areas of input and oversight)

· How the Bidder intends to comply with the standards in the open meetings act and FOIA.

Bidder Response to Question 12:

13. Stakeholder engagement and implementation of feedback: Topic referenced in Schedule A – General Requirements 1.1.K Quality Improvement and Program Development (3-page limit)

Describe the Bidder’s plan for stakeholder engagement and implementation of enrollee and stakeholder feedback by, at a minimum, including the following:

· How the Bidder will collect and analyze enrollee and beneficiary feedback as a part of ongoing quality improvement before, during, and after care (e.g., type of feedback collected, frequency of feedback intake, tools and IT infrastructure to facilitate data collection, analysis methodology)

· How the Bidder will specifically assess other stakeholder feedback (e.g., provider, community members) to inform program implementation and ongoing evaluation whilst minimizing or preventing any potential or perceived conflicts of interest

· The Bidder’s approach to articulating feedback / data collected, and plans to share feedback back to enrollees, beneficiaries, and other stakeholders (e.g., how feedback will be shared, frequency of communication, type of analyses shared)

· Approach for implementing program changes based on analysis of feedback and innovative ideas for ongoing program improvement

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 13:

14. Infrastructure to collect and conduct analysis on data: Topic referenced in Schedule A – General Requirements 1.1.K Quality Improvement and Program Development (2-page limit)

Bidders must develop a comprehensive plan for leveraging data and conducting complex analysis to drive continuous improvement, monitor performance, manage population health needs, and deliver measurable, person-centered outcomes (e.g., before, during, and after care) including consideration of the following:

· How does Bidder plan to develop and implement data systems and tools that enable sophisticated analytics, including names of specific tools or programs used to facilitate data collection and analysis

· What strategies does Bidder propose for improving PIHP performance based on the utilization of technology, data and analytics

· Explain how Bidder will ensure compliance when handling sensitive data provided by the Department as referenced in Schedule A Section 3.2 Reporting

· Plan for aligning outcome measurements with standardized performance metrics (e.g., NCQA, QAPIP (Quality Insurance and Performance Improvement Program), CMS Medicaid Behavioral Health Core Set)

· If possible, show past examples of compliance, as well as mitigation steps if the Bidder has dealt with a breach

If possible, describe a recent example(s) of using data analysis to inform and/or design strategies and to improve the health status of targeted populations. For each example, identify the types of data sources leveraged, explain how an issue was identified, what interventions were developed, how the impacts of the interventions were assessed and what outcomes were achieved. Bidders must include consideration of:

· Data quality

· Strategy to promote equitable outcomes; and

· Social Determinants of Health and enrollee Health Related Social Needs (including monitoring referrals to community-based social services and other resources to address social needs, tracking referral outcomes [e.g., confirmation that service was delivered as well as the type of service delivered to the enrollee], and ensuring this information is shared with an Enrollee’s care team to meet health related needs)

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder Response to Question 14:

15. Compliance processes: Topic referenced in Schedule A – General Requirements 1.1.E Access and Availability, 1.1.J Parity and Benefits, 1.1.K Quality Improvement and Program Development, 1.1.O Management Information Systems, 1.1.R Program Integrity, 3.2 Reporting (2-page limit)

For each of the following categories, describe actions that the Bidder has taken or will take to avoid deficiencies within areas of compliance obligations throughout the duration of the contract. Address each category separately and describe operational plan of action, previous experience / lessons learned if applicable. Address each category separately:

· Recipient rights, including enrollee access to covered services (e.g., Compliance Actions related to inappropriate pattern of denials, inadequate provider network, inadequate access to care)

· Provider Network Issues (e.g., Compliance Actions related to claims payment, provider directory accuracy, credentialing)

· Quality Performance (e.g., Compliance Actions related to failure to meet quality performance requirements)

· Compliance reviews (e.g., waiver, External Quality Review Organization (EQRO))

· Access to MDHHS Approved Data Systems (e.g., Behavioral Health Treatment Episode Data Set (BH-TEDS), Community Health Automated Medicaid Processing System (CHAMPS), CareConnect 360, Waiver Support Application)

· Encounter Data (e.g., Compliance Actions related to encounter data requirements)

· Critical or Sentinel events

Bidder must also describe their approach to staffing an adequate and efficient team capable of ensuring compliance capabilities.

Office of the Inspector General (OIG) Compliance Activities: For each of the following categories, describe actions that the Bidder has taken or will take to ensure that the following requirements are met:

A. Establishing a special investigative unit (SIU) with staff who are knowledgeable and adequately trained contributes to the overall success of investigations related to Fraud Waste and Abuse (FWA).

· How will the Contractor structure their SIU and ensure that individual staff have a relevant background in fraud, waste, and abuse/program integrity as it relates to healthcare? How will relevant trainings be identified/created and conducted?

· How will the Contractor guarantee routine audits and investigations are conducted to ensure proper oversight of all providers in their network?

B. Data mining efforts are crucial in identifying potential targets for audit.

· How will the Contractor implement data mining algorithms and/or scenarios and review them for efficacy?

· How will the Contractor ensure the routine development of new algorithms and/or scenarios based on FWA trends?

C. Maintenance of a Regulatory Compliance Committee is important to oversee the Contractor’s compliance program and its compliance with requirements under the contract.

· How will the Contractor structure their Regulatory Compliance Committee which must be comprised of individuals from senior management?

Bidder Response to Question 15:

16. Grievance and appeals process: Topic referenced in Schedule A – General Requirements 1.1.L Grievance and Appeals Process for Beneficiaries (2-page limit)

Describe the Bidder’s Grievance and Appeals process for specialty behavioral health services. The response must outline the Bidder's process for meeting the requirements of 42 CFR 438.406 and 42. CFR 438.408 in the handling of Grievances and Appeals, including but not limited to:

· Approach for ensuring that enrollees understand their recipient rights prior to and during receipt of services

· How the Bidder gives enrollees “reasonable assistance” in completing forms and taking other procedural steps related to a Grievances and Appeals.

· How the Bidder plans to ensure that enrollees are notified of resolutions within the required timeframes.

If possible, provide a summary of previous de-identified contracts, including the number and nature of appeals, on:

· Whether outcomes were favorable to the enrollee

· The percent of unfavorable Appeals taken to state fair hearings, and;

· The percentage of decisions overturned in state fair hearings

· Steps Bidder took to minimize or prevent any potential or perceived conflicts of interest

Bidder response to Question 15:

17. Claims processing excellence: Topic referenced in Schedule A – General Requirements 1.1.O Management Information Systems (2-page limit)

Describe Bidder’s anticipated claims processing system for reimbursing providers for Covered Services and producing encounters. Provide information on the Bidder’s claims system, including:

a. Its name

b. Years used

c. Number of enrollees currently to be processed by Bidder on the same system and version If Bidder will use a new system, provide:

· The name of that system

· Number of enrollees processed on that system

· Owner of that system

· Stage of contract negotiations

· Projected effective date

Provide Bidder’s plan to submit Encounter Data electronically in compliance with the State's standards, including submitting accurate Encounter Data within specified timeframes and ensuring data accuracy, completeness, and truthfulness.

Provide Bidder’s plan to submit Financial Status Reports (FSR) for grant funded activities that effectively translates encounter data into the FSR format for submission into the electronic grants management system. Include submission timeframe required of contracted providers.

Bidder response to Question 17:

MDHHS PIHP Strategic Pillar 4: Simplify the system with reduced bureaucracy Stakeholder feedback highlighted the importance of streamlining administrative operations to ensure timely and efficient delivery of care and services. The Bidder must describe their plan(s) to support MDHHS initiatives to decrease bureaucracy and administrative burden, thus improving efficiency for providers as well as members accessing care.

18. Management Information System (MIS) Infrastructure: Topic referenced in Schedule A – General Requirements 1.1.F Covered Services, 1.1.O.7 Management Information Systems (2-page limit)

Describe the Bidder's plan to maintain a Management Information System (MIS). Describe how the MIS will support care management and coordination; reduce Fraud, Waste and Abuse; and improve communications between systems of care.

The Bidder must also detail how they will use Health Information Exchange (HIE) to improve beneficiary care and treatment outcomes.

Bidder response to Question 18:

19. Infrastructure to reduce administrative burdens for providers: Topic referenced in Schedule A – General Requirements 1.1.X Innovation (3-page limit)

Describe your plan to support MDHHS initiatives to reduce administrative burdens and increase efficiencies, as specified in Section X. Innovation.

Describe any additional initiatives and/or strategies you intend to implement to help reduce administrative burdens through programmatic operations (e.g., reducing duplication, minimizing paperwork). Bidder must describe anticipated implementation process and potential impacts of initiatives.

Bidder must describe how their approach would vary for each region to which they are bidding, providing region-specific details that address the unique needs, challenges, and requirements of each area.

Bidder response to Question 19:

image1.png