Schedule A Statement of Work.docx

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STATE OF MICHIGAN

Request For Proposal No. 210000000821 Mail Order Incontinence Supplies and Services

SCHEDULE A

STATEMENT OF WORK

CONTRACT ACTIVITIES

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.

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.

BACKGROUND

The purpose of this Request for Proposal (RFP) is to establish Contracts for mail order incontinence supplies and services for eligible Medicaid beneficiaries in the states of Michigan and Wisconsin, excluding beneficiaries enrolled in a Medicaid Health Plan. The Contracts will be administered by the Michigan Department of Health and Human Services (MDHHS) and the Wisconsin Department of Health Services (WI DHS). Michigan is the lead state conducting the solicitation for this procurement, in collaboration with the state of Wisconsin. All references to MDHHS apply to WI DHS and all references to MDHHS Program Manager apply to WI Contract Monitor unless otherwise specified for particular contract. Approximately 18,000 Beneficiaries are currently served monthly for the state of Michigan and approximately 8,000 Beneficiaries for the state of Wisconsin. The Contracts offer a wide variety of product lines and require the availability of various product options to meet the medical needs of beneficiaries shipped on a monthly basis to the beneficiary’s residence.

SCOPE

The successful Contractor must be able to provide mail order incontinence supplies and services to eligible Medicaid beneficiaries pursuant to the requirements listed herein. Refer to Schedule C – Michigan Average Product and Beneficiary Usage and Schedule C – Wisconsin Average Product and Beneficiary Usage. Usage may change during the Contract term due to changes in law. Bidders must bid on requirements for both states, Michigan and Wisconsin. Separate Contracts for each state will result from this solicitation and will be executed by the parties.

The resulting Contracts will have a term of three (3), four (4), or five (5) years, to be determined during the evaluation process and will be based on a best value award recommendation. The Contractor must begin providing all services, without interruption, no later than the Effective Date (anticipated July 1, 2021). The estimated timeframe for implementation and transition will be determined upon Contract award notification. No payment will be made to the Contractor during the transition period.

The State reserves the right to add additional Contract Activities.

REQUIREMENTS

1. General Requirements

1.1. Contractor Requirements:

A. The Contractor must be eligible and enrolled in Medicare prior to the first shipping date.

The Contractor must maintain their enrollment as a Michigan Medicaid Provider during this Contract and comply with all policies, requirements, and conditions of participation as provided in the Michigan Medicaid Provider Manual (http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf).

The Contractor must maintain their enrollment as a Wisconsin Medicaid Provider during this Contract and comply with all policies, requirements, and conditions of participation as provided in the Wisconsin Administrative Code DHS 101-108 and Wisconsin Medicaid Online Disposable Medical Supplies Handbook (https://www.forwardhealth.wi.gov/WIPortal/Default.aspx)

Bidder must check the box below to acknowledge acceptance of requirement 1.1. A.

I have reviewed the above requirements and agree.

B. In the provision of services under the Contract, the Contractor must not subcontract with any entity that has been suspended by Medicare or Medicaid.

Bidder must check the box below to acknowledge acceptance of requirement 1.1. B.

I have reviewed the above requirements and agree.

C. Product Quality/Specifications Refer to Medical Supplier chapter of the Medicaid Provider Manual.

1. All products must meet American Medical Association (AMA), Food & Drug Administration (FDA), and other applicable national standards such as National Association For Continence (NAFC).

Brands or trade names listed in Schedule B - Pricing are for identification purposes only and do not limit the Contractor to such brands or trade names, provided, the products are equal in quality, composition, and function to those specified.

Bidder needs to either propose the current products listed, alternatives, or a combination of both. For each proposed product, Bidder needs to list:

1. Specific manufacturers/brands

2. Stock numbers

A variety of options for each Healthcare Common Procedure Coding System (HCPCS) code must be offered to meet the needs of, and allow, beneficiary choice, unless there is only one brand available.

1. Paper products – at least three options

2. Catheters/bags – at least two options

If alternate products from those listed in Schedule B - Pricing are proposed, Bidder must clearly describe all variances from the specifications and the proposal must include manufacturer provided descriptive literature that contains complete specifications as specified in Section 6. Inclusion of Product Data for Alternate Products in the Electronic Proposal Response of the Proposal Instructions.

Also refer to Section 7. Delivery of Product Samples for Alternate Products of the Proposal Instructions.

Samples will not be requested for products bid as exact matches to the referenced brands/manufacturers in Schedule B – Pricing.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.C.1. and describe in detail how this will be accomplished:

2. The brands of diapers provided must include at least the following components:

· Lining/Topsheet

· Absorbent Inner Layers

· Backsheet

· Leg Gathers

· Adhesive

Refastenable, self-adherent tab fasteners (adult sizes must have at a minimum two sets of tabs).

Bariatric sizes must include waist gathers (with significant stretch).

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.C.2. and describe in detail how this will be accomplished:

3. The Contractor must annually communicate information regarding the product and services provided under this Contract to the medical community through the Contractor’s Website or any other appropriate media. The Contractor must submit all such communications to the Program Manager for review and obtain written approval prior to transmission. The Contractor’s Website must be available to beneficiaries for product information only.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.C.3 and describe in detail how this will be accomplished:

4. If an incorrect product or quantity (under-quantity) is shipped to the Beneficiary, the Contractor must ship the correct product to the Beneficiary, at no additional cost to the State or the Beneficiary. Upon notice from the Beneficiary or their authorized representative the Contractor must:

a. Deliver the correct product within 24 hours to the Beneficiary’s residence (as specified under Section 2.1)

b. Deliver the quantity balance of product within 24 hours to the Beneficiary’s residence (as specified under Section 2.1 Delivery and Timeframes).

c. Simultaneously issue a call tag for pick-up of incorrect product(s) by the Carrier. Service Level Agreement credit(s) will be applied per Schedule A, Section 11. Service Level Agreement (SLA) and Service Level Credit Table.

d. Document the shipment of the incorrect product/quantity in the Beneficiary’s file.

e. Document the shipment of the incorrect product/quantity in the summary report to Program Manager as specified in Reporting Section 2.3.4.c.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.C.4 and describe in detail how this will be accomplished:

5. The Contractor must have a provision for Beneficiaries to obtain emergency products within 24 hours of notification (by the Beneficiary or their representative), when conditions arise that unexpectedly exhaust the product’s supply prior to the next delivery date.

a. The amount being provided in these situations must be added to the amount previously provided during the current month.

b. If the amount being added to the current month's supply exceeds the monthly limit indicated in Schedule B - Pricing a Prior Authorization must be requested from Medicaid with documentation of medical need for over quantity.

c. In cases where the emergency supply plus the amount previously supplied during the current month does not exceed the monthly limit, Prior Authorization is also required due to billing frequency.

d. Refer to MDHHS web site http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf for information on Prior Authorization requirements

Refer to Wisconsin Medicaid Online Disposable Medical Supplies Handbook at https://www.forwardhealth.wi.gov/WIPortal/Default.aspx for information on Wisconsin Medicaid Prior Authorization requirements.

e. Documentation of medical necessity that explains the need for additional supplies must be indicated in the Beneficiary’s file for audit purposes.

f. If the Contractor is not able to deliver within 24 hours of notification of an emergency need by the Beneficiary, representative, or their physician, the Contractor must be able to arrange for delivery or customer pick-up of the emergency product. through a Contractor-arranged alternate source at no additional cost to the State.

g. Upon Beneficiary request, the Contractor must have a provision for the Beneficiary to pick up emergency products at a location closest to the Beneficiary.

h. In situations where a Prior Authorization is required from MDHHS, shipments must be sent within one business day after the Prior Authorization has been granted. Refer to the Michigan Medicaid Provider Manual, General Information and Medical Supplier chapters.

In situations where a Prior Authorization is required from WI DHS, shipments must be sent within one business day after the Prior Authorization has been granted Refer to the Wisconsin Medicaid Online Disposable Medical Supplies Handbook, Prior Authorization Chapter.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.C.5. and describe in detail how this will be accomplished:

6. The Contractor must include in each shipment, at no additional cost to the State, educational information on proper skin care and product use as well as any other pertinent medical information to all new Beneficiaries and when the Beneficiary receives a product with a procedure code which has not been previously used by the Beneficiary.

a. At a minimum, the materials must:

i. Describe how to use the product,

ii. Specify the rights, responsibilities, and benefits of Beneficiaries,

iii. Outline the process for obtaining services including emergency services,

iv. Include the Beneficiaries responsibilities for notifying the Contractor of any address or requested order changes within one business day of Contractor completing a nursing assessment and at least 10 calendar days prior to scheduled delivery day.

v. Include the Contractor's toll-free telephone and toll-free teletype (TTY) numbers must be included in the information.

vi. Include an instructional flyer on how to file a complaint with the Contractor and/or the State.

vii. Be updated with any changes by the manufacturer.

b. When a new product is added to the Contract, educational material regarding that product must be developed by the Contractor.

c. Beneficiary educational material must be approved by the Program Manager, in writing, prior to distribution.

d. The Contractor must provide translation and interpretation assistance of all product communication, both written and verbal, via an approved translation/interpretation service or on-staff translator/interpreter. Product communications include, but are not limited to: Contractor’s phone number, pamphlets, State approved educational materials, etc.

e. The Contractor must be able to accommodate beneficiaries with special needs when providing educational materials, such as use of Braille for beneficiaries with visual impairments.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.C.6. and describe in detail how this will be accomplished:

7. The Contractor must provide translation and interpretation assistance of all product communication, both written and verbal, via an approved translation/interpretation service or on-staff translator/interpreter. Product communications include, but are not limited to: phone number, pamphlets, State approved educational materials, etc.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.C.7. and describe in detail how this will be accomplished:

D. Service Capabilities

1. Call Center

a. The Contractor must have an appropriately staffed, HIPAA-compliant customer service call center including toll-free telephone number, toll-free TTY number, website, email, fax, translation services and other special means (such as but not limited to Braille accommodation). The hours of operation of the toll-free service must be available Monday through Friday except for State holidays from 8:00 a.m. – 5 p.m. EST for Michigan, and 7:00 am – 6:00 p.m. CST for Wisconsin, and it must have sufficient capacity to handle the volume of inquiries required to service Beneficiaries under this Contract.

b. The Contractor must maintain service capabilities, telephone logs, and monitoring as specified in Section 2.3, including:

i. The Contractor must maintain an average phone wait time of three minutes or less.

ii. The Contractor must maintain an average phone time to abandonment of three minutes or less.

c. The Contractor’s customer service staff must follow-up on all voicemail messages within one business day.

d. The Contractor must assure that no calls will be answered by clearing the queue (i.e., answering only to ask callers to call back at a later time) or by busy signals, disconnections, or other technical problems that prevent the caller from receiving help from staff.

e. The Contractor must have a back-up plan for servicing Beneficiaries in case of an unplanned shutdown of call center phone lines for greater than one hour.

i. The back-up system must allow Beneficiaries to contact and be contacted by the Contractor via phone.

ii. The back-up system must be available immediately or at a minimum within one hour from any unplanned shutdown.

iii. The Contractor must notify the impacted State(s) Program Manager or designee within one hour of any unplanned shutdown, and when normal operations resume.

f. The Contractor must provide after-hour phone access for emergency situations, 24 hours per day, seven days per week. After-hour calls from Beneficiaries will be forwarded to an answering service and then to the designated on-call Contractor staff for servicing.

g. In addition to call center access, the Contractor must have an interactive website available 24/7/365 for all beneficiaries, where they can view and track shipments, request changes to their account, send messages to staff, log complaints and confirm the need for their supplies when required by their insurance plan.

h. The call center must be able to:

i. Respond to inquiries from Beneficiaries regarding intake of new requests, insurance changes, general questions, etc.

ii. Respond to inquiries from Beneficiaries regarding product use, skin care, etc.

iii. Receive emergency requests for products for medical situations that occur that are expected to deplete supplies prior to the next shipment date.

iv. Register complaints, identify problems, inquire about benefits, etc.

i. At each point of contact with the beneficiaries, the Contractor will inquire to be sure that the quantity of supplies is meeting the needs of the beneficiary without producing an overstock.

j. The Contractor must create and maintain call center operations that offer Wisconsin beneficiaries an option to file a complaint with Wisconsin Member Services in addition to the Contractor’s complaint process.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.D.1. and describe in detail how this will be accomplished:

2. Intake

a. The Contractor may receive referrals for intake and to receive prescriptions via:

i. Faxed from ordering practitioner’s office.

ii. Phone contact from ordering practitioner’s office or Beneficiary

iii. Other HIPAA-compliant electronic formats may be considered.

b. At the time of initial contact with any new Beneficiary, the Contractor must do all of the following:

i. The Contractor’s customer service representative (CSR) must screen Beneficiaries for all insurance information.

1. The CSR will complete the initial Medicaid verification of eligibility.

2. The CSR will advise the Beneficiary that prior to each month shipment, eligibility will be verified.

ii. The CSR must obtain the ordering practitioner’s information from the Beneficiary in order to obtain or clarify a prescription or medical documentation, or for other questions as needed. (refer to Service Capabilities Section D.3 Documentation for Prescription Requirements)

iii. The CSR must intake the Beneficiary’s current Product request. All requests beyond the limits and guidelines of this Contract must be referred to the nurse immediately for an assessment.

iv. The CSR will provide the Beneficiary with toll free number and information on emergency procedures.

v. The CSR will advise the Beneficiary that general program information and Product information will be mailed within one business day of the completed nursing assessment.

c. Within one business day of receiving the prescription (prescription requirements as specified in Section 3. Documentation, the registered nurse or licensed practical nurse must complete a nursing assessment (as specified in Service Capabilities Section D.3 Documentation) for all new Beneficiaries by utilizing the nursing assessment tool approved by the State (Attachment 2).

d. Beneficiaries without a telephone or Beneficiaries who are hearing impaired must be contacted through written correspondence or through the use of a TTY. If the Beneficiary does not respond within 15 calendar days, the Contractor must send a final notice.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.D.2. and describe in detail how this will be accomplished:

3. Documentation

A. Prescription Requirements:

1. All prescriptions require the following elements to be:

a. Beneficiary name

b. Beneficiary ID number

c. Beneficiary Date of Birth

d. Ordering practitioner name, address, and telephone number

e. Primary Diagnosis (condition causing incontinence)

f. Secondary Diagnosis (condition causing incontinence)

g. Specific product prescribed

h. Duration of need

i. Anticipated Frequency (range) the item requires replacement.

j. Signature of physician, physician assistant, or nurse practitioner (i.e., ordering practitioner)

i. Wet, digital, and electronic signatures are acceptable.

ii. Stamped or co-signed signatures are not allowed.

k. Date of signature

l. Start date of order if different from the ordering practitioner’s signature date.

A prescription received without all the mandatory requirements, as outlined above and in the Michigan Medicaid Provider Manual, will be deemed invalid. The Contractor must not accept the prescription, nor process the order. The Contractor must notify the ordering practitioner that the prescription is invalid and a new, valid prescription is required.

2. A prescription from an appropriate subspecialist is required for Beneficiaries enrolled in Children’s Special Health Care Services (CSHCS) only.

3. The Contractor must maintain all prescriptions in the beneficiary’s file for audit purposes.

4. If a prescription is accepted by telephone, the Contractor is responsible for obtaining a written prescription to be maintained in the Beneficiary’s file.

5. The prescription must be renewed every 12 months, or more frequently if indicated by medical change.

6. Prescription Renewals

a. The Contractor must send a prescription request to the Beneficiary’s ordering practitioner 60 calendar days before the current prescription expires.

b. If no reply is received in 30 calendar days, the Contractor must send a second request for a prescription to the Beneficiary’s ordering practitioner.

c. If a reply is not received within 15 calendar days of the second request, the Contractor must contact the ordering practitioner by telephone to request the prescription.

d. At the time the ordering practitioner is contacted by telephone because there has been no response to the second request, the Contractor must notify the Beneficiary and request the Beneficiary’s assistance in obtaining the prescription.

e. The following prescription requirements may be completed by the Contractor for the ordering practitioner:

i. Beneficiary name

ii. Beneficiary ID number

iii. Beneficiary Date of Birth

iv. Ordering practitioner name, address, and telephone number

v. Specific product item(s) prescribed

vi. Anticipated Frequency (range) the item requires replacement based upon current quantity usage

f. The following requirements must be completed by the ordering practitioner:

i. Primary Diagnosis

ii. Secondary Diagnosis

iii. Duration

iv. Signature of physician, physician assistant, or nurse practitioner (i.e., ordering practitioner)

1. Wet, digital, and electronic signatures are acceptable.

2. Stamped or co-signed signatures are not allowed.

v. Date of signature

vi. Start date of order if different from the ordering practitioner’s signature date.

B. Nursing Assessment Tool

1. The Contractor must develop and maintain a nursing assessment documentation tool. Please refer to Attachment 2 to Schedule A - Nursing Assessment Tool.

2. The tool and any subsequent revisions must be approved in writing by the Program Manager prior to implementation.

3. The completed Nursing Assessment Tool(s) must be maintained in the beneficiary record.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.D.3. and describe in detail how this will be accomplished:

4. Verification Services

1. The Contractor must verify the Michigan Medicaid, CSHCS and other insurance eligibility of each Beneficiary via options available through the Community Health Automated Medicaid Processing System (CHAMPS), at multiple points in the account management process including the following:

a. Initial set up of the new account.

b. Each subsequent contact with the beneficiary; and

c. Within one business day prior to each monthly shipment.

The Contractor must verify the Wisconsin Medicaid and other insurance eligibility of each Member via the Enrollment Verification System (EVS) at multiple points in the account management process, including the following:

a. Initial set up of the new account

b. Each subsequent contact with the beneficiary; and

c. Within one business day prior to each monthly shipment.

2. The Contractor must maintain documentation in the beneficiary health record, of current eligibility on the date of service.

a. Refer to the Michigan Medicaid Provider Manual, regarding verification of eligibility. http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf

Refer to the Wisconsin Medicaid Disposable Medical Supply Online Handbook regarding verification of eligibility https://www.forwardhealth.wi.gov/WIPortal/Default.aspx

b. The State will not reimburse the Contractor for shipments to Beneficiaries that are not eligible one business prior to the date the Contractor ships the order.

c. The date the Contractor verifies Medicaid eligibility will be the date of service.

3. Beneficiaries are also asked to provide any additional insurance information that may not be reported in the CHAMPS file. Refer to the Medicaid Provider Manual, Coordination of Benefits Chapter.

NOTE: If 38 or 89 appear on the Medicaid eligibility system as the other insurance code, the Contractor must obtain specific insurance relative to the insurance company and type of coverage information from the Beneficiary.

a. When not reported in the CHAMPS file, a request is submitted to CHAMP’s Third Party Liability (TPL) department for investigation of other insurance.

When Wisconsin Medicaid member information is not reported in the EVS file, Contractor is requested to submit an Other Coverage Discrepancy Report. Refer to the ForwardHealth Online Disposable Medical Supplies Handbook, Topic 4942, Reporting Discrepancies.

b. Eligibility for all insurances provided is verified and the coverage order is determined using industry standard guidelines, with Medicaid being the payer of last resort.

c. Beneficiaries that are dually enrolled in Medicare and Medicaid are required to participate in the acquisition of services and products under this Contract for products not covered by Medicare. The Contractor may only bill for products not covered by Medicare.

d. Michigan beneficiaries with other insurance must follow the rules of their primary insurance, they are not required to receive products under this Contract if the products are covered by the other insurance. If the product is not covered by other insurance, the Beneficiary must obtain the product through the Contractor for Medicaid coverage. If the Contractor does not receive payment from Medicaid, Medicaid Healthy Michigan Plan (MA-HMP), or CSHCS for a Beneficiary with other insurance, the Contractor may pursue payment from the Beneficiary or the other insurance; however, the Beneficiary must be notified in writing of their possible responsibility prior to servicing.

e. The following exception applies for Wisconsin beneficiaries. Wisconsin Medicaid members who have commercial HMO insurance are still required to receive supplies from the Contract even if their commercial HMO does not consider the Contractor as an in-network provider. Wisconsin Medicaid will cover services provided by the Contractor if the commercial HMO denies claims for the services.

4. For Beneficiaries with CSHCS only, the Contractor must verify, through CHAMPS, that the prescribing subspecialist physician is listed as an approved provider for the CSHCS Beneficiary who is receiving products, prior to rendering services.

a. If the prescribing subspecialist physician is not listed on CHAMPS as a CSHCS approved provider for the Beneficiary, the Contractor must notify the Beneficiary and the prescribing physician to contact CSHCS through the Beneficiary’s local health department for the physician subspecialist to be added to the Beneficiary’s list of CSHCS approved providers.

b. Urological products are the only covered benefit under this Contract for Beneficiaries with Children’s Special Health Care Services (CSHCS) only.

5. Special attention must be given to determine if a beneficiary is residing in a nursing home, hospice, or other Level of Care (LOC), as products may be considered within the Medicaid per diem for these programs.

6. Beneficiaries enrolled in a Medicaid Health Plan (MHP) are excluded from obtaining services through the Contractor under this Contract. However, the Contractor may contract with a MHP to provide services and products covered by this Contract. If the Contractor has an exclusive contract with a MHP the Contractor must offer the prices that are effective under this Contract for comparable services.

a. The Contractor must provide written and/or documented verbal notification to Beneficiaries enrolled in a Medicaid Managed Health Care Plan that they are excluded from obtaining services through the Contractor under any Contract resulting from this RFP.

7. At the Contractor’s option, the Contractor may ship products to Beneficiaries whose Medicaid or CSHCS eligibility is pending. However, if eligibility is denied, the Beneficiary, and not the State, is responsible for payment for all products received, and the Beneficiary must be billed directly. The Beneficiary must be notified in writing of their possible responsibility prior to servicing.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.D.4. and describe in detail how this will be accomplished:

5. Nursing Assessments

1. The Contractor is required to have licensed nurses functioning within their scope of practice and state licensure requirements, to perform and document telephonic nursing assessments for determining appropriate products, product brands, product quantities and other necessary information for each individual Beneficiary.

a. The Contractor must have a minimum of three licensed nurses with one additional licensed nurse for every 2,000 beneficiaries thereafter.

b. Michigan Requirements: Registered Nurses must perform the nursing assessments on beneficiaries under age 21. Licensed Practical Nurses may perform nursing assessments on beneficiaries age 21 and over. Any licensed practical nurses performing nursing assessments/reassessments and/or responding to Beneficiary inquiries, must be supervised by a licensed registered nurse.

Wisconsin Requirements: Wisconsin practice laws (Wisconsin Administrative Code N 6.03) and the Nurse Licensure Compact, require registered nurses to perform the nursing assessments for all age groups. Licensed practical nurses may assist with the collection of data, assist with the development and revision of a nursing care plan, and reinforce the teaching provided by the registered nurse and provide basic health care instruction.

c. The Contractor must provide translation and interpretation assistance via an approved translation/interpretation service or on-staff, to conduct complete nursing assessments/re-assessments for non-English speaking beneficiaries and those with hearing and speech impairments.

d. The initial nursing assessment must be completed within one business day of the intake and verification. The process utilized to complete the assessment is as follows:

i. The Contractor must contact the Beneficiary within one business day of receiving a request from the Beneficiary, their caregiver, or ordering practitioner for supplies. The Contractor will attempt to contact the beneficiary by phone to complete assessment on two separate occasions: one morning call and one afternoon call with no more than three (3) days in-between each call. If voicemail is available, a message must be left with the Contractor’s phone number.

ii. Beneficiaries who are hearing impaired or who do not have access to telephone are contacted through TTY, written form, or other MDHHS-approved electronic format with a follow up within 15 days if the Contractor have not received a response.

iii. If there is no response to messages left for the Beneficiary, Contractor will send a contact letter to the Beneficiary and follow up in seven (7) days. If there is no response to the contact letter within seven (7) days, Contractor will make one more call to attempt to reach the beneficiary. If there is still no response, Contractor will leave the account active for 30 days from the last attempt to contact the Beneficiary. If there is still no response from the Beneficiary, the Contractor will send a final letter notifying the Beneficiary that their request has been closed and the ordering practitioner will be cc'd.

iv. Once Beneficiary contact has been made, a product assessment will be completed utilizing the MDHHS approved nursing assessment tool (refer to Service Capabilities Section D.3 Documentation)

v. Samples, educational material and a request for prescription will be sent after completion of the assessment. Contractor must send customized sample packs at Contractor’s expense to beneficiaries prior to shipping the orders, which allows the Beneficiary to participate in the process of choosing the product for their care.

vi. Product quantities required to manage a beneficiary’s incontinence needs are determined during the nursing assessment, based on the changing condition of the beneficiary.

1. The quantity for a 30-day

2. supply is derived from the frequency of product usage or garment changes per day, multiplied by 30 days.

3. The final 30-day quantity will also take into consideration manufacturer packaging, so that only full packages are delivered to the Beneficiary.

vii. The Contractor must ship the requested product(s) as soon as a valid prescription (refer to Service Capabilities Section D.3 Documentation) is received from the ordering practitioner and the beneficiary has chosen a sampled product.

viii. The first re-assessment must be completed 6 months after the initial assessment, for all beneficiaries. Subsequent re-assessments must be completed, for all beneficiaries, every 12 months thereafter unless otherwise indicated by MDHHS or in Policy.

ix. The nurse will determine appropriate Product, anticipated frequency, appropriate monthly quantities, appropriate alternate diaper brand, and make revisions as deemed necessary, prior to the first shipment.

x. The nurse must ask the Beneficiary if they are having any difficulty that may require further nurse involvement.

xi. Nursing assessments/re-assessments must monitor the usage to ensure the appropriate quantity is being sent without producing an overstock.

xii. Overstock situations are resolved by placing a temporary hold on subsequent orders until the excess is consumed, and by re-assessing the monthly need, to prevent a reoccurrence of the overstock.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.D.5.1. and describe in detail how this will be accomplished, including differences in requirements for Michigan and Wisconsin:

2. The Contractor’s licensed nurse must perform a telephonic nursing reassessment and follow-up call(s) within two business days of a Beneficiary requesting products(s) for a change in medical condition (e.g. successful bowel/bladder training, acute incontinence or other change in condition(s)) In these situations, follow-up assessments of the Beneficiary’s changing medical status must be made once every six months or as determined by the MDHHS Program Manager in consult with MDHHS Office of Medical Affairs (OMA).

For Wisconsin members, Wisconsin practice laws (Wisconsin Administrative Code N 6.03) and the Nurse Licensure Compact requires a registered nurse to perform the nursing assessments/reassessments. Licensed practical nurse may assist with the collection of data, assist with the development and revision of a nursing care plan, and reinforce the teaching provided by the registered nurse and provide basic health care instruction.

3. Beneficiaries who need a product quantity that exceeds Contract limits must be reassessed every 12 months or as determined by the MDHHS Program Manager.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.D.5.2. through 1.1.D.5.3. and describe in detail how this will be accomplished, including differences in requirements for Michigan and Wisconsin:

4. Pull-on brief renewal:

a. MDHHS requires nursing reassessment according the following time frames (refer to the Medicaid Provider Manual, Medical Supplier chapter, section on incontinent supplies for pull-on coverage and non-coverage criteria):

i. Beneficiaries ages 3-20 who are receiving pull-ons and are in a bowel and bladder training program must be assessed every six months or as determined by the MDHHS Program Manager. Beneficiaries who attend school are required to submit a school letter for all pull-on reviews detailing the toilet training program and success rate.

ii. Beneficiaries who are ages 3-20 with a permanent medical condition causing bladder/bowel incontinence, for whom the established quantity of pull-ons is adequate, must be reassessed every 24 months or as determined by the MDHHS Program Manager.

iii. Medicaid Beneficiaries ages 21 and over require a nursing reassessment if there is a change in quantity or medical status, or a Prior Authorization is required. A change in medical status includes discharge from a nursing home or hospital.

iv. Beneficiaries ages 21 and over with a progressive/degenerative illness (such as Parkinson’s, Alzheimer’s, Senile Dementia, Multiple Sclerosis), where there could be change in incontinence level over time, must be reassessed every 12 months.

v. Beneficiaries with a chronic condition must be reassessed every 12 months or as determined by the MDHHS Program Manager.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.D.5.4.a. and describe in detail how this will be accomplished:

b. WI DHS requires a renewal nursing assessment for purchase of protective underwear and pull-on briefs according the following time frames (refer to the Medicaid Medicaid Online Disposable Medical Supplies Handbook, Topic 15437):

i. Wisconsin Medicaid members ages 3 through the lifespan with the cognitive ability to independently care for their toileting needs must be assessed every 12 months.

ii. Wisconsin Medicaid members ages 3 through the lifespan, actively participating and demonstrating definitive progress in a bowel or bladder program must be reassessed every 6 months.

iii. Medicaid Beneficiaries ages 21 and over require a nursing reassessment if there is a change in quantity or medical status, or a Prior Authorization is required. A change in medical status includes discharge from a nursing home or hospital.

iv. Beneficiaries ages 21 and over with a progressive/degenerative illness (such as Parkinson’s, Alzheimer’s, Senile Dementia, Multiple Sclerosis), where there could be change in incontinence level over time, must be reassessed every 12 months.

v. Beneficiaries with a chronic condition must be reassessed every 12 months or as determined by the Wisconsin Medicaid Contract Monitor.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.D.5.4.b. and describe in detail how this will be accomplished:

E. Product Changes and Substitutions

1. Product Changes (permanent)

i. Changes due to change in medical condition.

a. Appropriate changes in products and quantities for the Beneficiary must be:

i. made in accordance with a change in the medical condition.

ii. documented in the Beneficiary’s record.

iii. Consistent with a nursing reassessment to determine the appropriate change (quantity, product)

b. All monthly quantity limits and prior authorization requirements apply.

2. Changes due to Manufacturer Caused Discontinuation or Prolonged Unavailability of Products

a. The Contractor must provide the Beneficiary with a written or documented verbal explanation of any product change, prior to the monthly shipment, unless this requirement is waived or modified by the MDHHS Program Manager.

b. Additionally, the Contractor's nurses must be available, at a minimum, during toll-free telephone and TTY hours as specified in Section 1.1.D. Service Capabilities, 1. Call Center; to respond to Beneficiary inquiries regarding product change, use, skin care, etc.

c. The Contractor must notify the MDHHS Program Manager of all discontinuation of products and temporary replacements. See also Section 7 Acceptance of New Product.

3. Product Substitutions due to Manufacturer Caused Discontinuation or Prolonged Unavailability of Products. There may be circumstances (out of the Contractor’s or Beneficiary’s control) for which the Contractor must temporarily substitute products.

a. the Contractor must provide the Beneficiary with samples of substitute product listed in this Contract, which have not been previously used by the Beneficiary. A sample quantity, determined by the nursing assessment/reassessment, to establish the appropriate size, fit and customer satisfaction, must be sent to the beneficiary.

b. The Contractor must contact the Beneficiary to determine if the substitute product is acceptable. If the product is acceptable, the Contractor must pick up the original product from the Beneficiary and arrange for a complete shipment of the new product. This shall be at no cost to the State or Beneficiary.

c. If no substitute product listed in this Contract is acceptable to the Beneficiary and a non-Contract product is required, the Contractor must document reason for the non-Contract substitution.

i. The substitute product must be comparable quality and the least costly alternative to the original Contract product.

ii. For a non-Contract product, the State agrees to pay the Contractor’s acquisition cost plus 20%, which must be supported by the manufacturer invoice and other documentation, as determined by the Program Manager. This applies only if Prior Authorization was granted by the Program Manager. Documentation must be maintained in the beneficiary record.

4. If the Beneficiary is not satisfied with the product provided by the Contractor, the Contractor’s first course of action must be to perform a nursing reassessment in order to evaluate the problems and recommend solutions. If necessary, the Contractor must also pursue the following remedies until the Beneficiary is satisfied:

a. Contact the Beneficiary’s physician to discuss recommended solutions.

b. Send the Beneficiary sample(s) of applicable other products available under this Contract for evaluation.

c. Identify a product brand for Beneficiaries not available under this Contract. The Contractor must submit a request for Prior Authorization for review by the MDHHS Program Manager.

d. The Contractor must follow up within seven calendar days to determine, if the non-Contract product resolves the Beneficiary’s problems.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.E. and describe in detail how this will be accomplished:

F. Prior Authorization Procedures The Contractor must submit a request for Prior Authorization on a rare occasion when:

1. A Beneficiary needs a product not listed on Contract.

2. A Beneficiary needs a quantity of product which exceeds the maximum monthly quantity limit specified in Schedule B – Pricing of the Contract.

The Contractor must submit Prior Authorization Requests to MDHHS via Direct Data Entry (DDE) through the Community Health Automated Medicaid Processing System (CHAMPS).

The Contractor must submit Prior Authorization Requests to Wisconsin Medicaid via DDE through the Wisconsin Portal.

The DDE Prior Authorization Request in CHAMPS and in the Wisconsin Portal must include attachment of the following documents:

a. A copy of the most recent nursing assessment/reassessment (completed within the past 12 months or less).

b. Copies of the Contractor’s documentation of the product the Beneficiary is currently receiving and the problems the Beneficiary is experiencing with the product.

c. Documentation that the Contractor provided the Beneficiary with substitute products (samples) listed in the Contract which had not been used by the Beneficiary, without satisfactory results.

d. Physician documentation stating the medical reason for the non-Contract product. This documentation should contain the letter of medical necessity that specifies the products that have been tried, any adverse reaction or outcome, and the product(s) requested.

e. Products requiring PA due to quantity exceeding the monthly allowable will be reimbursed according to normal Schedule B pricing.

f. For non-Contract product, the Contractor must submit the manufacturer’s invoice for pricing. This invoice must be maintained in the beneficiary record.

Michigan Medicaid requests will be reviewed by MDHHS staff. Based on documentation submitted, the PA request is either approved, denied or returned for more information. Results of the request are viewable by the Contractor in CHAMPS Archived Documents. The Contractor must notify the beneficiary of the approval or denial of the PA request within one business day.

Refer to the Michigan Medicaid Provider Manual (http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf) for more detailed information on Prior Authorization requirements.

Wisconsin Medicaid requests will be reviewed by WI DHS staff. Based on documentation submitted, the PA request is either approved, denied or returned for more information. Results of the request are viewable by the Contractor in Wisconsin Portal. The Contractor must notify the beneficiary of the approval or denial of the PA request within one business day.

Refer to the Wisconsin Medicaid Online Disposable Medical Supplies, Prior Authorization chapter (https://www.forwardhealth.wi.gov/WIPortal/Default.aspx) for more detailed information on Prior Authorization requirements.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.F. and describe in detail how this will be accomplished:

G. Denial (Negative Action) Process

1. A denial may result from:

a. Review of a prior authorization request for a specific brand that is not covered under the Contract, or a reduction in quantity as a result of unsubstantiated medical necessity for larger quantities.

b. MDHHS review of a pull-on request, that does not meet policy coverage criteria.

2. Beneficiary notification of a denial must be provided in writing by:

a. MDHHS Program Review Division for denied prior authorization requests.

b. The Contractor for denied pull-on requests.

3. When a request is denied, by either review, the beneficiary is notified of the denial verbally by the Contractor’s nurse.

4. When a request is denied, by either review, the beneficiary is also notified in writing through the Denial Process outlined below.

a. If the denial resulted from a review of a prior authorization request for a specific brand that is not covered under the Contract, or a reduction in quantity as a result of unsubstantiated medical necessity for larger quantities, the beneficiary will receive a denial letter from MDHHS notifying the Beneficiary of the denial and their appeal rights.

b. If a denial resulted from a pull-on review, the Contractor must send a denial letter notifying the Beneficiary of the denial and their appeal rights.

i. For denials of requests for Medicaid and Medicaid/CSHCS dually enrolled Beneficiaries:

1. The Contractor must send a Notification of Denial, Request for Administrative Hearing letter, utilizing the template prepared by the State, to utilizing the appropriate denial statement.

2. An appeals form (MDHHS’s DCH-0092-MOAHR) Request for Hearing for Medicaid Enrollees, PACE Enrollees or Waiver Applicants) and addressed stamped envelope provided by the State must accompany the denial letter.

3. The denial letter and appeal form must be sent to the Beneficiary within one business day of the denial.

4. The Contractor must send copies of all denial letters to the Program Manager via email.

ii. For denial of requests for CSHCS-only Beneficiaries:

1. The Contractor must send a Notification of Denial, Request for Departmental Review letter, utilizing the template prepared by the State, utilizing the appropriate denial statement.

2. A departmental review form (MDHHS’s DCH-0892 Request for a Department Review) and addressed stamped envelope provided by the State must accompany the denial letter.

3. The denial letter and departmental review form must be sent to the Beneficiary within one business day of the denial.

4. The Contractor must send copies of all denial letters the Program Manager via email.

iii. The Contractor must keep a copy of the denial letter in the beneficiary’s electronic record.

iv. The Contractor must provide information and be available for resultant hearings/departmental reviews, if requested by the State.

v. Contractor will provide any resources requested by the State to support the hearing/departmental review and appeal process, including allocating key personnel and documentation as needed.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.G. and describe in detail how this will be accomplished:

H. WI DHS Denial (Negative Action) Process

1. When a PA request is denied, both the provider and the member are notified.

a. The provider receives a PA decision notice, including the reason for PA denial.

b. The member receives, in the mail from WI DHS, a Notice of Appeal Rights letter that includes a brief statement of the reason PA was denied and information about their right to a fair hearing to the Wisconsin Division of Hearings and Appeals. Only the member, or authorized person acting on behalf of the member, can appeal the denial.

2. The Contractor is required to discuss a denied PA request with the member and are encouraged to help the member understand the reason the PA request was denied.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.H. and describe in detail how this will be accomplished:

I. Complaint Process The Contractor must maintain a complaint process for Beneficiaries. The grievance process must include at a minimum:

1. A toll-free telephone and TTY access for patients.

2. A complaint resolution process involving the Program Manager

3. The Contractor must provide translation and interpretation assistance, via an approved translation/interpretation service or on-staff to handle complaints from non-English speaking beneficiaries, those with hearing and speech impairments.

4. Complaint documentation, resolution, and promptness:

a. The Contractor must inform and provide copies of all complaint details and resolutions to the Program Manager as specified in Section 2.3 Reporting.

b. If a resolution cannot be obtained within 7 calendar days, the complaint and copies of all information and documentation must be turned over to the Program Manager for resolution.

c. The Contractor must maintain these records for seven years beyond the end of the Contract and make these records available upon request by the State.

Bidder response: Bidder must acknowledge acceptance to requirement 1.1.I. and describe in detail how this will be accomplished:

1.2. Quality Assurance Program

The Contractor must explain its Quality Assurance Program(s).

1. Beneficiary Records

a. The Contractor must develop and maintain HIPAA-compliant records of Beneficiary information necessary to perform activities under this Contract; records must be available upon MDHHS request

b. Utilization of an electronic health record is required.

c. It is preferred that electronic…