Scope of Work 40DHHS-S2224 Revised 12.22.22.docx

Scope of work

The services to be provided under the resulting contract include multiple tasks and deliverables that are consistent with applicable federal EQR regulations and protocols for MCOs and the DBA/PAHP(s). The contract will allow the DHCFP to be compliant with federal EQR regulations and rules. The specifications for deliverables required under this RFP may evolve from year to year in response to program changes.

The selected vendor will be required under the contract to perform tasks and functions identified in the contract and to perform them according to specified levels of quality and comprehensiveness as determined by DHCFP. These mandatory activities are as follows:

Performance Improvement Project Validation;

Performance Measurement Validation developed by the DHCFP and updated and maintained by the vendor;

A review, conducted within the previous 3-year period, to determine plans ‘compliance with the standards set forth in subpart D of 42 CFR 438 relating to access to care; structure and operations; quality assessment; performance improvement; care coordination; amount, duration, and scope of covered services and other plan standards;

Network Adequacy Validation;

Operational, information systems and financial management readiness review for MCOs and PAHP(s); and Independent assessments related to any continued 1915(b) waivers.

Independent evaluation of any federally approved 1115 waivers related to funding institutions of mental disease (IMDs), specifically regarding the impact of the IMD Waiver on health care service delivery, quality, health outcomes, and cost effectiveness and any other federally required areas of evaluation.

During the length of the contract, work requests may be made of the Vendor at the sole discretion of the DHCFP for optional activities described in 42 CFR 438.358(c) or comparable activities that assess the quality of care or provide for the control of utilization of the DHCFP fee-for-service program. Optional activities may include:

Validation of encounter data per CFR 438.242(d);

Administration or validation of consumer or provider surveys of quality of care;

Calculation of performance measures in addition to those reported by health plans consistent with child and adult core set measures for the FFS delivery program as required by CMS beginning reporting year 2024;

Validation of PIPs in addition to those conducted by health plans;

Conduct studies on quality that focus on a particular aspect of clinical or non-clinical services at a point in time;

Assistance with the Quality Rating System;

Development and/or review of quality metrics for state directed payments; and Assistance with quality related payment models for the state's value-based payment design efforts

Validation of MCO and DBA/PAHP Performance Indicators

Performance measures are calculated and submitted annually to the DHCFP by the contracted MCOs and the DBA/PAHP. The Contractor will evaluate the accuracy and the extent to which Medicaid-specific performance measures followed Health Effectiveness Data and Information Set (HEDIS®) Specifications for the calculation of performance measures using one of two methods: 1) A HEDIS® Compliance Audit™ Standards, Policies and Procedures or 2) the Center for Medicare and Medicaid (CMS) Validating Performance Measures Protocol.

Verification of methods used to collect HEDIS performance measures. The validation process will be accomplished through methods described in the most recent version of the National Committee for Quality Assurance (NCQA) HEDIS Compliance Audit™ Specifications or the CMS Validating Performance Measures protocol. The audit will be conducted for SFY contract years 2024 and each subsequent EQRO contract renewal years.

Validation of HEDIS and performance measures reported (as required by the State) during the preceding 12 months; inclusive of CMS required core set measures.

Audited HEDIS Data using Interactive Data Submission System (IDSS). Submit information to NCQA, if applicable.

HEDIS™ Comparative Analysis for SFY 2024 and each subsequent EQR contract renewal year.

The awarded vendor is required to submit a comparative analysis and production of a HEDIS report using HEDIS performance measures data submitted by each MCO and DBA/PAHP.

Validation of Performance Improvement Projects (PIPs). The awarded vendor will be required to annually evaluate and validate three (3) clinical PIPs and three non-clinical PIPs for the MCO; and one clinical PIP and one non-clinical PIP for the DBA/PAHP.

Validation of MCO and DBA/PAHP network adequacy during the preceding 12 months.

Validation of the Nevada DHCFP State Quality Assessment and Performance Improvement Strategy (QAPIS) in SFY 2024 and each subsequent EQRO contract renewal year. The comprehensive quality assessment and performance improvement program must include PIPs; collection and submission of performance measurement data; mechanisms to detect both underutilization and overutilization of services; and mechanisms to assess the quality and appropriateness of care furnished to recipients with special health care needs as defined by the State in the quality strategy under 438.340.

The awarded vendor will evaluate the completeness of the state quality assessment and performance improvement strategy, examining strengths, limitations, and recommending improvements in the description or implementation of the strategy.

The awarded vendor will provide technical assistance to the Division as needed to incorporate changes and recommendations for the development of the Quality Strategy and performance tracking tool for the MCOs and DBA/PAHP(s).

The evaluation in each year should include information about the State’s progress and status of goals; trends in clinical or service quality performance improvement programs; corrective actions and sanctions; progress and status of value-based purchasing; and an assessment of the overall structure and process of the State Quality Assessment and Performance Improvement Strategy. Findings from this assessment will be incorporated as a chapter in the EQR Technical Report described below, entitled “External Quality Review Technical Report”.

DHCFP requires an electronic copy of the final report in PDF and Word Format annually and three (3) hard copies of the final report for distribution.

Annual External Quality Review Technical Report – The vendor will be required to produce a detailed technical report that must include:

Objectives; technical methods of data collection and analysis; description of data obtained, including validated performance measure data for each activity; and conclusions drawn from the data.

An assessment of each MCO's and DBA/PAHP(s) strengths and weaknesses for the quality, timeliness, and access to health care services furnished to Medicaid beneficiaries.

Recommendations for improving the quality of health care services furnished by each MCO and DBA/PAHP(s) including how the State can target goals and objectives in the quality strategy, to better support improvement in the quality, timeliness, and access to health care services furnished to Medicaid recipients.

Methodologically appropriate, comparative information about all MCOs and DBA/PAHP(s), consistent with guidance included in the EQR protocols issued in accordance with §438.352(e).

An assessment of the degree to which each MCO and PAHP, has effectively addressed the recommendations for quality improvement made by the EQRO during the previous year's EQR.

Revision: States may not substantively revise the content of the final EQR technical report without evidence of error or omission.

Availability of information: The State must contract with a qualified EQRO to produce and submit to the State an annual EQR technical report in accordance with paragraph (A) of this section. The State must finalize the annual technical report by April 30th of each year.

Each year the Vendor will include a Chapter in the EQR Technical Report summarizing the findings from the assessment of the DHCFP’s implementation of the State Quality Assessment, Performance Improvement Strategy and Performance Tracking Tool. DHCFP requires an electronic copy of the final report in PDF and Word Format annually and three (3) hard copies of the final report for distribution.

Conduct a compliance review evaluating the effectiveness of the quality strategy within the previous 3 years. This review will be broken out in sections to be reviewed annually.

Year One

(SFY 2024)

Year Two

(SFY 2025)

Year Three

(SFY 2023)

Review of Standards/Elements that received a Not Met score during the SFY 2024 and 2025 reviews.

Standard VIII—Provider Selection ü

Standard IX—Confidentiality ü

Standard X—Grievance and Appeal Systems ü

Standard XI—Sub contractual Relationships and Delegation ü

Standard XII—Practice Guidelines ü

Standard XIII—Health Information Systems ü

Standard XIV—Quality Assessment and Performance Improvement Program ü

Technical Assistance and Optional Activities

The vendor may be required to provide technical assistance and/or optional activities described in 42 CFR 438.358(c) or comparable activities that assess the quality or utilization of services in the fee-for-service program to DHCFP and the participating MCOs and PAHP(s) during the contract period. The specific nature of the technical assistance will be defined on a case-by-case basis, but at a minimum, may include educational sessions to enhance the use of EQR results, identification of healthcare trends or “best practices” in performance measures or quality improvement activities; providing clinical consultation and/or expertise; and conducting evaluations of health care initiatives. Optional activities described in 42 CFR 438.358(c) may include:

Nevada Medicaid FFS population activities such as:

Clinical focused studies;

Healthcare Effectiveness Data and Information Set (HEDIS®) or HEDIS like calculations and audits;

Encounter data validation and omission studies; and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys.

The awarded vendor may be asked to assist with the development and/or implementation of the Medicaid managed care quality rating system within 3 years of the date of the final notice in the FEDERAL REGISTER by:

Adopting the Quality Rating System developed by CMS, in consultation with States and other stakeholders and after providing public notice and opportunity to comment, will identify performance measures and a methodology for a Medicaid managed care quality rating system that aligns with the summary indicators of the qualified health plan quality rating system; or Adopting an alternative Medicaid managed care rating system approved by CMS that utilizes different performance measures or applies a different methodology as long as the ratings generated by the alternative rating system yield information regarding the MCOs, and PAHP(s) performance is substantially comparable to that yielded by the system developed by CMS.

The awarded vendor may be asked to perform the following quality activities for a new Nevada Medicaid Aged Blind and Disabled (ABD) managed care expansion program. Tasks may include:

Provide consulting to DHCFP for ABD performance measures. The EQRO will identify/recommend new or revised performance measures applicable to the ABD population;

Conduct an Information Systems (IS) Readiness Review on selected ABD MCO Vendors; and Evaluate implementation of performance measures.

The awarded vendor may be asked to perform the following quality activities for expansion of Managed Care for the TANF/CHAP and CHIP populations into the rural counties. The awarded vendor may be asked to provide consulting to DHCFP’s MCOs. Tasks may include:

Provide consulting for expansion performance measures applicable to the TANF/CHAP and CHIP populations;

Conduct an Information Systems (IS) Readiness Review on selected expansion MCO Vendor(s);

Provide technical assistance to the MCOs on the development of performance measures; and Conduct a HEDIS Compliance Audit or validate the measures using the CMS Validating Performance Measures protocol on the contracted MCOs.

At the discretion of the DHCFP, the EQRO may be asked to provide additional technical assistance or consultative services related to EQR activities. All requests for technical assistance or consultative services shall be transmitted in writing from the DHCFP to the EQRO. Each request, at a minimum, will include the following:

A description of the major functions, tasks, and activities required;

The timeline/due date for any reports or identified deliverables;

Specifications as to the medium and/or format of the desired deliverable;

A listing of the EQRO's project requirements; and Any other instructions, definitions, specifications, requirements, outcomes, tangible items, or projects expected.

The EQRO will submit to the DHCFP, for approval, its cost proposal for completing the technical assistance or consultative project according to the scope of work detailed in the DHCFP's request.

DHCFP is in the process of procuring a Centralized Credentialing vendor and may need technical assistance with moving credentialing efforts from the Managed Care entities to the State selected vendor.

DHCFP operates a pay for performance withhold with the Managed Care entities and may need technical assistance in the design and revision of this annual activity.

DHCFP has multiple State Directed Payment requirements and will need EQRO assistance tracking and reporting on quality efforts described in each State Directed Payment.

QUALIFICATIONS OF EXTERNAL QUALITY REVIEW ORGANIZATIONS

The following are mandatory requirements needed to successfully meet the minimum standards of this RFP. These items are not negotiable.

The vendor and all subcontractors must meet all requirements of 42 CFR 438.354 and the mandatory DHCFP contract requirements as follows:

The vendor must have staff with demonstrated experience, knowledge and skills of Medicaid recipients, policies, data systems, and processes, and managed care delivery systems, organizations, and financing.

Quality assessment and improvement methods; and Research design and methodology, including statistical analysis.

Sufficient physical, technological, and financial resources to conduct EQR or EQR-related activities.

Other clinical and nonclinical skills necessary to carry out EQR or EQR-related activities and to oversee the work of any subcontractors.

Independence. The EQRO and its subcontractors must be independent from the MCO or PAHP entities. To qualify as “independent”:

A State agency, department, university, or other State entity:

May not have Medicaid purchasing or managed care licensing authority; and Must be governed by a Board or similar body the majority of whose members are not government employees.

As described in (described in §438.354(c)(2)) an EQRO may not:

Review any MCO, PIHP, or PAHP entity or a competitor operating in the State, over which the EQRO exerts control, or which exerts control over the EQRO through:

Stock ownership;

Stock options and convertible debentures;

Voting trusts;

Common management, including interlocking management; and Contractual relationships.

Deliver any health care services to Medicaid beneficiaries;

Conduct, on the State's behalf, ongoing Medicaid managed care program operations related to oversight of the quality of MCO and PAHP entity services, except for the related activities specified in §438.358;

Review any MCO or PAHP entity for which it is conducting or has conducted an accreditation review within the previous 3 years; or Have a present, or known future, direct or indirect financial relationship with an MCO or PAHP entity that it will review as an EQRO.

The vendor must designate a contract manager to work with the assigned DHCFP program specialist or contract monitor(s).

The awarded vendor is, or will subcontract with, a National Committee for Quality Assurance (NCQA) certified Consumer Assessment of Health Plans Survey (CAHPS) vendor, if this optional activity is assigned.

The awarded vendor is or has on staff, or will subcontract with, an NCQA- Certified Health Employer Data Information Set (HEDIS) Compliance Auditor.

Contractor must maintain current International Classification of Diseases (ICD) and Electronic Data Interchange (EDI) compliance as defined by CMS regulation and policy and no funding will be provided for contractor's compliance.

To demonstrate financial viability, the vendor must submit the following documents to DHCFP each State Fiscal Year:

Profit and Loss Statement Balance Statement

VENDOR OPERATING STRUCTURE AND STAFFING

The vendor must assure DHCFP that the organization is adequately staffed with experienced, qualified personnel. The vendor shall provide such assurances as follows:

Provide DHCFP with an updated organizational chart whenever a significant change in the organization occurs. The organizational chart must depict each functional unit of the organization, numbers and types of staff for each function identified, lines of authority governing the interaction of staff, and relationships with all subcontractors. The organizational chart must also identify key personnel and senior-level management staff and clearly delineate lines of authority over all functions of the Contract. The names of key personnel must be shown on the organizational chart;

The vendor must have in place the organizational, management, and administrative systems capable of fulfilling all contract requirements; and The vendor is accountable for and must oversee all subcontractor functions.

IMPLEMENTATION

The vendor shall develop and submit to DHCFP for approval, no later than one month after notification that the vendor has been awarded the Contract, a detailed work plan and timeline for performing the obligations set forth in the Contract for the first contract year.

Provide DHCFP with updates to the initial work plan and timeline, identifying adjustments that have been made to either and describing the vendor’s current stage of readiness to perform all Contract obligations. All such updates shall be reviewed and approved by the DHCFP.

Unless otherwise agreed to by the DHCFP, submit to the DHCFP, within a minimum of ten (10) working days of the service start date, all deliverables to permit any DHCFP identified modifications. The DHCFP will have a maximum of twenty (20) working days upon receipt in which to respond with modifications to the vendor. If the DHCFP does not respond by the twentieth workday after receipt of the deliverable, the DHCFP’s approval of the submission will be assumed to be granted.

PRESENTATION OF FINDINGS

The awarded vendor must obtain DHCFP’s approval prior to publishing or making formal public presentations of statistical or analytical material that includes information about enrolled recipients. This material must protect specific individual recipient privacy and confidentiality to the extent required by both federal and state law and regulation.

HIPAA COMPLIANCE REQUIREMENTS

The vendor represents and warrants that:

It will conform to all applicable Health Insurance Portability and Accountability Act (HIPAA) requirements and regulations no later than the compliance date of each of those requirements or regulations;

It will ensure compliance with all HIPAA standards for themselves and any Business Associate(s), including transaction, code sets, identifier, privacy, confidentiality, and security standards, by the effective date of those rules;

As a Business Associate, the Vendor and all subcontractors will comply with the Business Associate Addendum, (“BAA”) found in Attachments and is made a part of the contract.

Scope of Work EQRO Page 1 of 6 RFP 40DHHS-S2224