RFP 40DHHS-S2224 EQRO External Quality Review Org.docx

STATE OF NEVADA

DEPARTMENT OF ADMINISTRATION

Purchasing Division 515 East Musser Street, Suite 300 │ Carson City, NV 89701 Phone: 775-684-0170 │ Fax: 775-684-0188

Request for Proposal: 40DHHS-S2224 For External Quality Review Organization (EQRO)

Release Date: 12/07/2022 Deadline for Submission and Opening Date and Time: 02/09/2022 @ 2:00 pm Refer to Proposal Timeline and Submission Requirements for complete RFP schedule and submission instructions

Single point of contact for the RFP:

Ryan Vradenburg, Purchasing Officer II Phone, 775-684-0197 Email Address, rvradenburg@admin.nv.gov

(TTY for Deaf and Hard of Hearing, 800-326-6868 Ask the relay agent to dial, 1-775-515-5173/V.)

TABLE OF CONTENTS

APPLICABLE REGULATIONS GOVERNING PROCUREMENT

All applicable Nevada Revised Statutes (NRS) and Nevada Administrative Code (NAC) documentation can be found at: www.leg.state.nv.us/law1.cfm.

Prospective vendors are advised to review Nevada’s ethical standards requirements, including but not limited to NRS 281A, NRS 333.800, and NAC 333.155.

PROJECT OVERVIEW

The State Purchasing Division, on behalf of the Department of Health and Human Services (DHHS), Division of Health Care Financing and Policy (DHCFP), is soliciting proposals from one (1) highly qualified and experienced External Quality Review Organization (EQRO) vendor for analysis and evaluation of aggregated information on quality, timeliness, and access to the health care services that a Managed Care Organization (MCO) or a Prepaid Ambulatory Health Plan (PAHP) entity furnish to Medicaid recipients.

This includes utilization and quality review functions of Division contracted MCOs pursuant to 42 CFR 438, Subpart E, in support of the Title XIX (Medicaid) and Title XXI Child Health Insurance Program (CHIP is also known as Nevada Check Up) medical assistance programs. Currently, DHCFP contracts with four (4) MCOs, one (1) PAHP, all of which serve the TANF/CHAP Medicaid populations and the Nevada Check Up/CHIP populations.

The current MCO and PAHP contracts are available via Nevadaepro.com.

Managed Care Organization – 40DHHS-S1457 Prepaid Ambulatory Health Plan / Dental Benefit Administrator – 40DHHS-S1834

The State intends to award one (1) contract in conjunction with this Request for Proposals (RFP), as determined in the best interests of the State. DHCFP shall administer contract(s) resulting from this RFP. The resulting contract(s) are expected to be for a contract term of four years, starting July 1, 2023 through June 30, 2027 with the option to renew for two (2) additonal one (1) years, if agreed upon by both parties, in the best interest of the state and subject to Board of Examiners approval.

MISSION

The mission of the Nevada DHCFP (Nevada Medicaid and Nevada Check Up) is to: purchase and provide quality health care services to low-income Nevadans in the most efficient manner; promote equal access to health care at an affordable cost to the taxpayers of Nevada; restrain the growth of health care costs; and review Medicaid and other State health care programs to maximize potential federal revenue.

Emphasizing preventive care, early intervention, appropriate utilization, and quality care;

Enhancing continuity of care through integrated medical, behavioral, and social care;

Ensuring a medical home for Medicaid and Nevada Check Up recipients; and Ensuring that each recipient can access high quality, comprehensive healthcare services within the recipient's service area.

DHCFP will accomplish this mission by contracting for measurable results that improve recipient access and satisfaction, maximize program efficiency, effectiveness, integrity, and quality and responsiveness.

GOALS AND OBJECTIVES

DHCFP Division’s objectives for the awarded vendor are too:

Provide an external, independent assessment and evaluation aggregated information on quality, timeliness, and access to the health care services provided by an MCO and the PAHP, or any of their contractors to Medicaid recipients;

Make recommendations for improving the quality of health care services furnished by each MCO and PAHP including how the State can target goals and objectives in the quality strategy; and Work collaboratively with DHCFP and the contracted vendors throughout the contract period.

BACKGROUND

In 2016, the Centers for Medicare and Medicaid Services (CMS) released the first update for the Medicaid and CHIP managed care regulations in over a decade. This final rule advances CMS mission of better care, smarter spending and healthier people. Key goals include:

Advance delivery system reform and improve the quality of care;

Strengthen the recipient experience of care and key recipient protections;

Strengthen program integrity by improving accountability and transparency; and Align key Medicaid and CHIP managed care requirements with other health coverage programs.

The new rules require the extension of quality provisions to all plan types and extension of most quality provisions, including external quality review (EQR) requirements to CHIP.

The state Medicaid agency must develop and implement a written strategy to assess and improve the quality of managed care services (42 CFR 438.340). The strategy must comply with the provisions established by the DHHS issued in the Federal Register. The state quality strategy is located at the State’s DHCFP Division’s link online: https://dhcfp.nv.gov/Resources/AdminSupport/Reports/CaseloadData/ The DHCFP monitoring protocols to monitor MCOs and validate performance improvement projects, along with National Committee for Quality Assurance (NCQA) and DHCFP standards are used to evaluate the DHCFP contracted MCOs and PAHPs.

HOW MEDICAID AND NEVADA CHECK UP OPERATE IN NEVADA

DHCFP administers the Medicaid and Nevada Check Up Programs in accordance with the applicable Title XIX and Title XXI State Plans, all applicable Nevada Revised Statutes (NRS), the Social Security Act, Code of Federal Regulations (CFR’s), the United States Code (USC) and the Nevada Administrative Code (NAC). DHCFP may adopt such regulations and policies as deemed necessary and may also amend the Title XIX or Title XXI State Plans at its sole discretion, in accordance with federal law. An Administrator, appointed by the Director of DHHS, manages DHCFP.

Nevada operates both a fee-for-service system and managed care delivery system.

The DHCFP’s managed care program currently offers a risk-based capitated rate program operated through contracts with MCOs. DHCFP contracts with MCOs to provide covered medically necessary services for eligible enrollees at an actuarially sound risk-based capitation rate.

Enrollment in a MCO is mandatory for TANF and CHAP enrollees when there is more than one managed care option from which to choose in a particular geographic service area. Managed care enrollment is mandatory for all CHIP enrollees when an option is available in their service area.

The eligibility and enrollment functions for the Medicaid and Nevada Check Up programs are the responsibility of DHCFP and the Nevada State Division of Welfare and Supportive Services (DWSS). The DWSS determines Medicaid enrollee eligibility for the TANF and CHAP programs. The State’s fiscal agent provides all enrollment broker like activities.

The DHCFP currently has a single PAHP for a Dental Benefits Administrator (DBA). All recipients enrolled in mandatory managed care are also enrolled in the DBA/PAHP.

DHCFP currently contracts with a fiscal agent for FFS claims processing and related functions. This fiscal agent acts as a Quality Improvement Organization-like Vendor (QIO) for FFS payment authorization, concurrent and retrospective review and related functions. Other independent contractors provide services, which include but are not limited to external quality review, DBA/PAHP, actuarial services, non-emergency medical transportation (NEMT) services, and other clinical and administrative services.

The DHCFP Medical Care Advisory Committee (MCAC) was established, in accordance with 42 CFR 431.12, to ensure adequate community and provider input is obtained regarding decisions affecting the levels and types of services covered under the program. The MCAC is comprised of members who include, but are not limited to, health care professionals, other providers, and consumers, all of whom offer specialized advice on various components of the program.

VENDOR DUTIES AND RESPONSIBILITIES

The Vendor’s senior staff and other key staff, as identified by the Vendor, shall participate in all meetings scheduled by the DHCFP. The purpose of these meetings is to discuss contract compliance and any other applicable issues concerning administration and management of the contract as well as program quality and service delivery. The frequency of such meetings may include, at a minimum, monthly teleconferences and/or video conferences in addition to quarterly on-site meetings. The location of the on-site meetings will be at either the DHCFP administrative office in Carson City or a site in Las Vegas. It is the expectation of DHCFP that the Vendor will collaborate with the Division in assisting to identify agenda items, meeting minutes and presentation of special topics as appropriate. It is the sole responsibility of the DHCFP to provide reasonable advanced notice of such meetings, including location, time, date and agenda items for discussion.

COMPENSATION AND BILLING

The vendor shall submit monthly updates on work performed, billable amounts due, budget balance and estimate of work remaining.

All invoices shall be submitted monthly by the vendor for approval from the DHCFP. Upon review and acceptance by the State, payments for invoices are normally made within 30-45 days of receipt, providing all required information, documents and/or attachments have been received.

ATTACHMENTS

ATTACHMENTS INCORPORATED BY REFERENCE.

Terms and Conditions for Services Federal Laws and Authorities

ATTACHMENTS FOR REVIEW. To be read and not returned (unless redlining).

Standard Form Contract Insurance Schedule

PROPOSAL ATTACHMENTS. To be completed, responded to, and returned.

Scope of Work 40DHHS-S2224 Cost Schedule S2224 Proposed Staff Resume Reference Questionnaire Attachments for Signature S2224

Vendor Information Response Vendor Certifications Certification Regarding Lobbying Confidentiality and Certification of Indemnification Business Associate Addendum

PROPOSAL TIMELINE

All questions regarding this RFP shall be submitted using the Bid Q&A feature in NevadaEPro by the deadline below.

The following represents the proposed timeline for this project.

All times stated are Pacific Time (PT).

These dates represent a tentative schedule of events.

The State reserves the right to modify these dates at any time.

PROPOSAL EVALUATION PROCESS

Proposal evaluation and scoring is conducted in accordance with NRS 333.335 and NAC 333.160-333.165.

Proposals shall be kept confidential until a contract is awarded.

In the event the RFP is withdrawn prior to award, proposals remain confidential.

The evaluation committee is an independent committee established to evaluate and score proposals submitted in response to the RFP.

Financial stability shall be scored on a pass/fail basis.

Proposals shall be consistently evaluated and scored based upon the following factors and relative weights.

Cost proposals will be evaluated based on the following formula.

Cost Factor Weight x (Lowest Cost Submitted by a Vendor / Proposer Total Cost) = Cost Score

Presentations

Following the evaluation and scoring process specified above, the State may require vendors to make a presentation of their proposal to the evaluation committee or other State staff, as applicable.

The State, at its option, may limit participation in vendor presentations to vendors above a natural break in the relative scores from technical and cost scores.

Following the presentations, the combined technical, cost, and presentation scores will become the final score for a proposal.

The State reserves the right to add additional criteria or presentations.

The State reserves the right to forego vendor presentations and select vendor(s) based on the written proposals submitted.

MANDATORY MINIMUM REQUIREMENTS

Pursuant to NRS 333.311 a contact cannot be awarded to a proposal that does not comply with the requirements listed in this section.

NEVADA LAW AND STATE INDEMNITY. Pursuant to SB 445 of the 81st Session of the Nevada Legislature, any contract that is entered into may not: (1) Require the filing of any action or the arbitration of any dispute that arises from the contract to be instituted or heard in another state or nation; or (2) Require the State to indemnify another party against liability for damages.

NO BOYCOTT OF ISRAEL. Pursuant to NRS 333.338, the State of Nevada cannot enter a contract with a company unless that company agrees for the duration of the contract not to engage in a boycott of Israel. By submitting a proposal or bid, vendor agrees that if it is awarded a contract it will not engage in a boycott of Israel as defined in NRS 333.338(3)(a).

INDEMNIFICATION. Confirm vendor agrees to comply with required contract terms on Indemnification: "To the fullest extent permitted by law, Contractor shall indemnify, hold harmless and defend, not excluding the State’s right to participate, the State from and against all liability, claims, actions, damages, losses, and expenses, including, without limitation, reasonable attorneys’ fees and costs, arising out of any breach of the obligations of Contractor under this contract, or any alleged negligent or willful acts or omissions of Contractor, its officers, employees and agents. Contractor’s obligation to indemnify the State shall apply in all cases except for claims arising solely from the State’s own negligence or willful misconduct. Contractor waives any rights of subrogation against the State. Contractor’s duty to defend begins when the State requests defense of any claim arising from this Contract."

LIMITED LIABILITY. Confirm vendor agrees to comply with required contract terms on Limited Liability: "The State will not waive and intends to assert available NRS Chapter 41 liability limitations in all cases. Contract liability of both parties shall not be subject to punitive damages. Damages for any State breach shall never exceed the amount of funds appropriated for payment under this Contract, but not yet paid to Contractor, for the Fiscal Year budget in existence at the time of the breach. Contractor’s tort liability shall not be limited."

CONTRACT RESPONSIBILITY. Awarded vendor shall be the sole point of contract responsibility. The State shall look solely to the awarded vendor for the performance of all contractual obligations which may result from an award based on this RFP, and the awarded vendor shall not be relieved for the non-performance of any or all subcontractors.

DATA ENCRYPTION. Confirm vendor will comply with State IT requirement that data be encrypted in transit and in rest.

STATESIDE DATA. Confirm vendor will comply with State IT requirement that State data assets must be maintained stateside and data will not be held offshore.

NEVADA BUSINESS LICENSE. Pursuant to NRS 353.007, prior to contract execution awarded vendor must hold a State business license pursuant to NRS chapter 76 unless exempted by NRS 76.100(7)(b).

DISCLOSURE. Each vendor shall include in its proposal a complete disclosure of any alleged significant prior or ongoing contract failures, contract breaches, any civil or criminal litigation or investigations pending which involves the vendor or in which the vendor has been judged guilty or liable.

CRITICAL ITEMS

In addition to the Scope of Work and Attachments, the items listed in this section are critical to the success of the project. These items will be used in evaluating and scoring the proposal. Vendor proposal should address items in this section in enough detail to provide evaluators an accurate understanding of vendor capabilities. Proposals that fail to sufficiently respond to these items may be considered non-responsive.

CONTRACT FORM. The State strongly prefers vendors agree to the terms of the attached Contract Form as is. Ability to agree to contract terms is a high priority to the State. Vendors who cannot agree to the contract as is must include a redlined Word version of the attached Contract Form with their proposal response.

INSURANCE SCHEDULE.

Confirm vendor will comply with attached Insurance Schedule. If not, please explain which areas are causing non-compliance and attach a red line if necessary.

Awarded vendor shall maintain, for the duration of the contract, insurance coverages as set forth in the fully executed contract.

Work on the contract shall not begin until after the awarded vendor has submitted acceptable evidence of the required insurance coverages.

Failure to maintain any required insurance coverage or acceptable alternative method of insurance shall be deemed a breach of contract.

VENDOR BACKGROUND

Company background/history and why vendor is qualified to provide the services described in this RFP.

Provide a brief description of the length of time vendor has been providing services described in this RFP to the public and/or private sector.

VENDOR STAFF RESUMES

A resume shall be included for each proposed key personnel, see Proposed Staff Resume.

A resume shall also be included for any proposed key subcontractor personnel.

SUBCONTRACTORS

Subcontractors are defined as a third party, not directly employed by the contractor, who shall provide services identified in this RFP. This does not include third parties who provide support or incidental services to the contractor.

Proposal should include a completed Vendor Information Response form for each subcontractor.

Vendor shall not allow any subcontractor to commence work until all insurance required of the subcontractor is provided to the vendor.

Vendor proposal shall identify specific requirements of the project for which each subcontractor shall perform services.

How the work of any subcontractor(s) shall be supervised How channels of communication shall be maintained How compliance with contracts terms and conditions will be assured Previous experience with subcontractor(s)

VENDOR FINANCIAL INFORMATION

The information requested in this section is designated as confidential business information by the Administrator pursuant to NRS 333.020(5)(b) and is not public information pursuant to NRS 333.333.

This information should be submitted as a separate attachment, flagged as confidential in NevadaEPro.

Proposing vendor shall provide the following financial information and documentation:

Dun and Bradstreet Number Federal Tax Identification Number The last two (2) full years and current year interim:

1. Profit and Loss Statements

2. Balance Statements

BUSINESS REFERENCES

The information requested in this section is designated as confidential business information by the Administrator pursuant to NRS 333.020(5)(b) and is not public information pursuant to NRS 333.333.

Vendors shall provide a minimum of three (3) business references from similar projects performed for private and/or public sector clients within the last five (5) years, see Reference Questionnaire.

The purpose of these references is to document relevant experience and aid in the evaluation process.

Business references should return Reference Questionnaire directly to Single Point of Contact via email.

Business references will not be accepted directly from proposing vendor.

The State will not disclose submitted references, but will confirm if a reference has been received.

The State reserves the right to contact references during evaluation.

SUBMISSION CHECKLIST

This section identifies documents that shall be submitted to be considered responsive. Vendors are encouraged to review all RFP requirements to ensure all requested information is included in their response.

Proposals must be submitted as a Quote through NevadaEPro, https://NevadaEPro.com.

Vendors are encouraged to submit a single file attachment per proposal section if possible.

Technical proposal information and Cost proposal information shall not be included in the same attachment.

Cost proposal attachment shall not be flagged as confidential in NevadaEPro.

Additional attachments may be included if necessary, but are discouraged and should be kept to a minimum.

TECHNICAL PROPOSAL

Title Page Table of Contents Response to Mandatory Minimum Requirements Response to Critical Items Response to Scope of Work Proposed Staff Resumes Other Informational Material

PROPRIETARY INFORMATION. If necessary. Attachment should be flagged confidential in NevadaEPro.

Title Page Table of Contents Trade Secret information, cross referenced to the technical proposal

COST PROPOSAL

VENDOR FINANCIAL INFORMATION. Attachment should be flagged confidential in NevadaEPro.

SIGNED ATTACHMENTS

Vendor Information Response Vendor Certifications Confidentiality and Certification of Indemnification Certification Regarding Lobbying

OTHER ATTACHMENTS. If necessary, not recommended.

REFERENCE QUESTIONNAIRES. Not submitted directly by vendor.

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