Questions submitted to Wisconsin Department of Health Services

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Questions submitted to Wisconsin Department of Health Services Powered By Docstoc
					                                 Wisconsin Department of Health Services
                                       Questions and Answers - #2
            Southeast Wisconsin Medicaid Managed Care Organizations RFP #1684 DHCAA-SM

Please note: This is a partial posting of questions and answers for this RFP. Additional questions and answers will be posted
                                        as completed as described in the 11/16/09 notice.

Question    RFP         RFP Section
Number      Page         Reference                       Question                                 DHS Answer
           Number
1                     General           What percentage of the membership in the    Data on number of BadgerCare Plus
                                        service area is under 21 and what           members enrolled in Standard and
                                        percentage is 21 and older?                 Benchmark Plans that are age 20 and under
                                                                                    and age 21 and over has been posted under
                                                                                    “Data Resources” on the website:
                                                                                    http://dhs.wisconsin.gov/medicaid/raterefor
                                                                                    m/managedcare/index.htm
2                     General           What's the split of members enrolled in     Data on the number of BadgerCare Plus
                                        standard vs. benchmark? Do we know how      members enrolled in Standard and
                                        many members are enrolled in the            Benchmark Plans has been posted under
                                        benchmark plan?                             “Data Resources” on the website:
                                                                                    http://dhs.wisconsin.gov/medicaid/raterefor
                                                                                    m/managedcare/index.htm
3                     General           What percentage of members in each          The Department does not have data on
                                        county does DHS expect to have the          enrollment projections available. Data on
                                        Standard Plan and what percentage will      current and historic enrollment in the
                                        have the Benchmark plan?                    BadgerCare Plus Standard and Benchmark
                                                                                    Plans can be found under “Data Resources”
                                                                                    on the website:
                                                                                    http://dhs.wisconsin.gov/medicaid/raterefor



                                                                                                                             1
                                                            m/managedcare/index.htm
4   General   Will the Department provide the HMOs          The Department plans to provide HMOs
              with any claim history for newly enrolled     with a predictive risk report similar to what
              members or any predictive model score         the Department currently provides HMOs
              similar to what is provided with the SSI      for members in the Medicaid SSI program.
              enrollment files? If so, will this            For more information on the report the
              information be provided as of the effective   Department currently produces for
              date of the RFP?                              Medicaid SSI members, see “SSI
                                                            predictive risk report” at
                                                            https://www.forwardhealth.wi.gov/WIPorta
                                                            l/Tab/42/icscontent/managed%20care%20o
                                                            rganization/reports_data/hmomatrix.htm.sp
                                                            age

                                                            At this time, the Department does not have
                                                            an estimated delivery date for this
                                                            information.
5   General   How will HMO’s awarded a contract under       Any HMO awarded a contract under this
              this RFP be able to serve the SSI Medicaid    RFP that also accepts the rates that are
              & BadgerCare Core Plan populations?           established under the SSI Medicaid and
                                                            BadgerCare Plus Core Plan programs and
                                                            meets DHS’ HMO certification
                                                            requirements may sign a contract with the
                                                            State to provide services to members in
                                                            these programs. The process for contracting
                                                            with the State to provide services to SSI
                                                            Medicaid and BadgerCare Plus Core Plan
                                                            members is handled separately from the
                                                            RFP process.
6   General   At the November 11 Vendors Conference,         Questions have been extracted from the
              it was stated that the state would be         transcript and their answers have either



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              providing a transcript of the conference. Is   already been or will be posted in Q&A
              this going to be provided?                     documents attendant to this process.
7   General   The Department’s response to question 17        Any answers to questions raised at the
              in Q&A Document #1 stated that all             Vendor Conference are not binding on the
              questions unaddressed at the Vendor’s          State until both the question and the answer
              conference will be posted in increments. At    are published through this Q&A process.
              the Vendor’s conference, the Department        Statements posted in the Q&A are the
              stated responses provided at the Vendor’s      official and binding response and supersede
              conference were not binding and written        any response given verbally or in writing
              responses would be issued to questions         previous to the official posting.
              raised during the Vendor’s conference.
              Please clarify.
8   General   After the provider listening sessions and      The requirements and specifications of the
              other discussions with DHS, we were told       RFP will remain as posted in this regard.
              that the contract would include
              administrative quality goals and penalties
              and maybe even require claims and
              customer service to be provided in SE
              Wisconsin. It appears including
              administrative quality requirements was left
              out of the contract and left out of the RFP
              technical proposal scoring. Was this an
              oversight?
9   General   What specific behavioral health services       For information on covered services under
              will be covered by the plans selected          the BadgerCare Plus Standard and
              through this procurement?                      Benchmark Plans, please refer to the
                                                             Provider Handbooks on the ForwardHealth
                                                             website:
                                                             http://dhs.wisconsin.gov/forwardhealth/
                                                             Also, please refer to the Provider Updates
                                                             for ongoing guidance on benefit policies.



                                                                                                          3
                                                             These updates can be found on the
                                                             ForwardHealth Provider page at:
                                                             https://www.forwardhealth.wi.gov/WIPorta
                                                             l/Home/Provider%20Login/tabid/37/Defaul
                                                             t.aspx
10   General   Are craniofacial abnormality surgeries        For information on covered services under
               covered under the medical benefit or dental   the BadgerCare Plus Standard and
               benefit?                                      Benchmark Plans, please refer to the
                                                             Provider Handbooks on the ForwardHealth
                                                             website:
                                                             http://dhs.wisconsin.gov/forwardhealth/
                                                             Also, please refer to the Provider Updates
                                                             for ongoing guidance on benefit policies.
                                                             These updates can be found on the
                                                             ForwardHealth Provider page at:
                                                             https://www.forwardhealth.wi.gov/WIPorta
                                                             l/Home/Provider%20Login/tabid/37/Defaul
                                                             t.aspx
11   General   We understand the present plans use a         The BadgerCare Plus contract requires
               “global budgeting” approach for dental        HMOs to pay at least FFS rates to dental
               reimbursement. Is such a strategy precluded   providers. Any reimbursement strategy that
               in this RFP?                                  does not meet this requirement will be
                                                             prohibited by the Department.
12   General   I’d ask that you give serious consideration   HMOs are allowed to contract with dental
               to requiring the new contractor certify and   hygienists as a provider category.
               reimburse dental hygienists the same way
               that dentists are and the same way that the
               state does with hygienists around the state
               that bill using the fee-for-service system.
13   General   Is the RFP a guarantee that the HMO           Current HMO contracts in the RFP region
               contracts will expire?                        will not be renewed and will be replaced by



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                                                             this procurement process.

               Do you know if that means there will only     The State intends to award at least three
               be ONE MCO?                                   contracts through this procurement.

               How likely is it that the new MCO will be     All HMOs in the RFP region will be
               utilizing a FFS payment system? Especially    required to cover dental services in each of
               with regards to dental services? Any chance   the RFP counties.
               the dental services will be “carved out” of
               the new MCO’s responsibilities?
14   General   What is the Medicaid fee for orthodontic       Orthodontic services are manually priced at
               coverage?                                      the time of Prior Authorization. There is a
                                                              general fee that is applied which is spread
                                                              out over the course of recommended
                                                              treatment.
15   General   Is there any chance if you don't get the price The State reserves the right to reject any
               that you're looking for that you won’t         and all proposals.
               procure?
16   General   One of the goals of the managed care RFP       The Department will develop a plan for
               (on page 3 of the Power Point “Background transitioning Core Plan members to SSI
               Presentation”) is BadgerCare Plus Core         HMOs after the successful Proposals from
               Plan and SSI Medicaid members will be          the RFP are selected.
               linked and will receive services from
               current SSI Medicaid HMOs. When will
               SE Wisconsin Core Plan members be
               moved to SSI Medicaid HMOs?
17   General   How will a health assessment be done for       DHS enrollment specialists administer, by
               those who do not enroll online?                phone, the health assessment to members
                                                              who do not enroll online. .

18   General   Are you going to maintain the six-month       Yes.



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               rule where if a member loses eligibility and
               regains it within six months, they'll be put
               back in the same plan?
19   General   There appears to be a difference in the         Awarded Vendors must sign a contract
               contract effective date stated in the RFP       with the State by June 1, 2010 (estimated).
               (June 1, 2010) and the date shown on the        Once the contract is signed the Department
               cover of the contract (August 1, 2010),         will begin the process of enrolling
               please explain the difference between the       members into that HMO. The HMO must
               two dates?                                      begin providing to members the services
                                                               outlined in the BadgerCare Plus contract
                                                               (Appendix A to this RFP) on August 1,
                                                               2010 (estimated). The first month for
                                                               which the HMO will receive payment for
                                                               services provided to members is August,
                                                               2010.
20   General   How are you going to score proposals that       The Department will evaluate proposals
               the Department knows are below the              based on their demonstrated ability to
               benchmark of the agencies quality               manage and provide high quality health
               standards in this region but the proposal       care to a Medicaid population in similar
               reflects a higher quality in other              MSAs to that of the RFP region. As part of
               markets/states they may be doing business       Addendum 2, the Department provided a
               in?                                             list of MSAs that it defines as comparable
                                                               to the MSAs in the RFP region. Examples
                                                               or data provided for experience with
               How will the agency compare competing           Medicaid populations in any of the MSAs
               quality scores and quality strategies from      listed in Addendum 2 will be weighted and
               different states given that so many variables   scored at a level equating to experience
               exist among the programs in different           demonstrated in the RFP region. However,
               states?                                         proposals providing examples or data based
                                                               on experience with populations in areas
                                                               other than the MSAs listed in Addendum 2



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                                                            or the RFP region will receive less scoring
                                                            weight than experience demonstrated with
                                                            a population located within an MSA listed
                                                            in Addendum 2.

                                                            Proposers may submit examples and data
                                                            for the logical geographical area (ie.
                                                            regional or county level) nearest to one of
                                                            the MSAs listed in Addendum 2. Such
                                                            examples and data will be treated equally
                                                            to examples and data submitted for
                                                            Medicaid populations in the MSAs listed in
                                                            Addendum 2, provided the below criteria is
                                                            met. If a Proposer chooses to submit
                                                            examples or data for the nearest logical
                                                            geographical area to an MSA, the Proposer
                                                            must demonstrate through written narrative
                                                            that the nearest logical geographical area is
                                                            a close approximation to the identified
                                                            MSA based on population density. In this
                                                            case, a close approximation is defined as a
                                                            geographic area that incorporates a
                                                            Medicaid population not exceeding 110%
                                                            of the Medicaid population of the identified
                                                            MSA. The Department does not consider a
                                                            close approximation to be data reported on
                                                            a state level.
21   General   How are you going to weight the scoring      All of the proposals will be scored using
               with your incumbent plans, those of us who   the same methodology regardless of their
               have experience in the state of Wisconsin,   previous experience in the State of
               versus our experience in other states?       Wisconsin (or lack thereof). The



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                                                                  methodology used in the scoring tool
                                                                  developed for this RFP affords fair and
                                                                  equitable scoring for all proposals
                                                                  submitted.

                   Is there going to be any weighting with        See answer above.
                   your Wisconsin data?
22   13   2.7      How much notification time will be given       The Department is currently in
                   to members before the August 1, 2010           development of a member outreach
                   transition phase begins informing them they    strategy.
                   will need to make a new choice?
23   13   2.7      In regard to the enrollment timeline and       30 calendar days.
                   process outlined in section 2.7, how many
                   days will members be given to choose an
                   HMO before they are auto-assigned?
24   20   4.3      Will you disclose the actual points that may   No.
                   be awarded in the quality section or in the
                   past experience section at this point in the
                   process?
25   21   4.5      The RFP states: The award may be granted       The degree of responsiveness and
                   to the highest scoring responsive and          responsibility of the Proposal will be
                   responsible Proposers.                         evaluated as a package by the Evaluation
                   How will the Department ensure that            Committee.
                   proposers submitting the lowest
                   administrative PMPM are submitting a
                   “responsible” PMPM (meaning the PMPM
                   is neither unrealistic nor unachievable)?
26   24   5 - #4   How should health plans with a single          Proposers must provide all of the requested
                   Medicaid managed care contract handle          information required of the RFP. If the
                   responses to Section 5, Question 4             Proposer has held only one managed care
                   References and Section 6.1, Question 2A        contract, the Proposer’s responses should



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                      and all of the questions which are related to   address the Proposer’s experience with that
                      it?                                             contract.

                      If a health plan’s only managed care            Yes.
                      contract is with Wisconsin Medicaid, can
                      the plan submit references from providers
                      and community-based organizations?

                      Or will Wisconsin Medicaid provide the          Wisconsin Medicaid may be used as a
                      required reference?                             reference.


27   26   6.1 - #2A   Under “For each contract described in 1)      That is correct.
                      and 2) provide,” we assume that the second
                      item “Brief description of the scope of work
                      and services provider” should be
                      “…services provided”.
28   27   6.1 - #4A   Amendment 2 states: “If you do not have
                      results for a particular measure or year,
                      please provide the results you do have and
                      explain why certain data is not available. If
                      data is not available for your Medicaid
                      population, please submit commercial data
                      in that state and explain why Medicaid data
                      is not available.”

                      In some instances, data is not available due    Yes, that is correct.
                      to contract start-up – lack of sufficient
                      time/members to report data. This is an
                      expected and acceptable reason why a
                      Proposer might have data for 2 out of 3



                                                                                                                9
                      years of the required reporting period, for
                      example. We believe the submission of
                      commercial data is not needed in these
                      instances. Is that correct?
29   27   6.1 - #4A   Amendment 2 revised the HEDIS                  Proposers may submit administrative
                      requirement to request “administrative”        and/or hybrid HEDIS data.
                      HEDIS data for three measures.
                      Since the contract allows hybrid data
                      (Addendum VI Performance Requirements
                      A.1.b), please confirm that this is
                      acceptable for the response to Section 6.1
                      4A.
30   27   6.1 - #4A   Amendment 2, item 4, references an
                      addition to Section 6.1, item 4A. The third
                      primary bullet requires Proposers to submit
                      HEDIS data for each MSA in which they
                      have a Medicaid contract (or commercial
                      data if Medicaid data is not available for
                      that MSA).

                      a) Does this requirement apply to health       Yes.
                      plans that are submitting NCQA-certified
                      data?

                      b) Certified HEDIS data is developed on a      The Department’s preference is to receive
                      health plan basis rather than on an MSA        HEDIS data reported on a Metropolitan
                      basis. Therefore, HEDIS data is not            Statistical Area (MSA) basis following the
                      available on an MSA-specific basis. If it is   chart in Addendum 2 to the RFP. However,
                      not possible to break out the MSA-specific     proposers may submit HEDIS data for the
                      HEDIS results, please confirm that it will     logical geographical area (ie. regional or
                      be acceptable to submit the HEDIS data         county level) nearest to one of the MSAs



                                                                                                            10
                              corresponding to the nearest logical          listed in Addendum 2. Such examples and
                              geographical area.                            data will be treated equally to examples
                                                                            and data submitted for Medicaid
                                                                            populations in the MSAs listed in
                                                                            Addendum 2, provided the below criteria is
                                                                            met. If a Proposer chooses to submit data
                                                                            for the nearest logical geographical area to
                                                                            an MSA, the Proposer must demonstrate
                                                                            through written narrative that the nearest
                                                                            logical geographical area is a close
                                                                            approximation to the identified MSA based
                                                                            on population density. In this case, a close
                                                                            approximation is defined as a geographic
                                                                            area that incorporates a Medicaid
                                                                            population not exceeding 110% of the
                                                                            Medicaid population of the identified
                                                                            MSA. The Department does not consider a
                                                                            close approximation to be data reported on
                                                                            a state level.
31   27-30   6.1 - #4A-#14A   The state has clarified (Q&A #46) that        The Proposer should submit information
                              proposers are to identify Medicaid,           from SCHIP-only plans the same way as
                              Medicaid/SCHIP and SCHIP-only plans for       they would for other Medicaid plans. It is
                              item 2A. Does the state also want the         not necessary for the Proposer to
                              Proposer to include SCHIP-only plans for      distinguish between Medicaid and SCHIP
                              items 4A and 5A and for items 6A through      plans in Addendum 2. Proposers should
                              14A?                                          label any SCHIP-only plans as Medicaid.
                              If so, should the Proposer revise the HEDIS
                              data Excel file column (Addendum 2) from
                              “Medicaid or Commercial” to “Medicaid,
                              SCHIP-only or Commercial”?
32   29      6.1 – #11A       The RFP poses questions (e.g. Section 6.1,    Proposers are to respond to all



                                                                                                                     11
                      11A) related to the bidder describing their   requirements of the RFP, including section
                      experience managing chronic conditions;       6.1 #11A. Awarded Vendors will be
                      however, requirements that mirror this        required to meet the requirements detailed
                      question do not appear in the Quality         in the BadgerCare Plus Contract (Appendix
                      Performance Strategy Section 6.2 or, in the   A to this RFP).
                      Draft HMO Contract. Does the State
                      require this information and will the level
                      of service based on past experience be
                      required going forward?

33   32   6.2 - #4B   Section 6 (4B) Primary Care Management        The Department will provide HMOs with
                      asks for a proposed method of assigning       Health Needs Assessment data for any of
                      PCPs by chronic condition. Since a new        the HMOs’ members who completed the
                      member to the HMO has no claim                assessment. The Department also produces
                      experience with that HMO, does DHS            a pharmacy extract that contains each
                      anticipate providing claim history on new     member’s pharmacy claim detail record,
                      members in order to identify those with       member ID, member name/DOB/gender,
                      chronic conditions (i.e. those members who    claim status, prescription number, drug
                      are not new to BadgerCare and thus would      name, diagnosis code, days supply, billed
                      not have NEHNA data provided at time of       amount, pharmacy and prescribing provider
                      enrollment)?                                  ID. This extract will be available
                                                                    electronically to the HMOs on a daily
                                                                    basis.

                                                                    The Department plans to provide HMOs
                                                                    with a predictive risk report similar to what
                                                                    the Department currently provides HMOs
                                                                    for members in the Medicaid SSI program.
                                                                    For more information on the report the
                                                                    Department currently produces for
                                                                    Medicaid SSI members, see “SSI



                                                                                                              12
                                                                        predictive risk report” at
                                                                        https://www.forwardhealth.wi.gov/WIPorta
                                                                        l/Tab/42/icscontent/managed%20care%20o
                                                                        rganization/reports_data/hmomatrix.htm.sp
                                                                        age

                                                                        Additional claims history information on
                                                                        members may also be provided to HMOs
                                                                        based on data availability and Department
                                                                        resources.
34   35   6.3.3 - #2C   While the Medical Home Pilot Strategy           The Proposer may partner with more than
                        requires the submission of names of three       one clinic as part of their Medical Home
                        clinics that would be potential partners, is    Pilot Strategy.
                        there a requirement that only one clinic is
                        selected as a partner, or can a health plan
                        implement the pilot with more than one
                        clinic?
35   35   6.3.3 - #2C   The Medical Home Pilot requires that            No. The member must be enrolled in the
                        members be enrolled within the first 16         health plan within the first 16 weeks of
                        weeks of pregnancy. If a pregnant member        pregnancy.
                        is not effective with the health plan until
                        after this 16 week period, can she still be
                        included if she has had a visit to the
                        Medical Home clinic prior to her effective
                        date in the health plan (likely under fee for
                        service)?

36   37   7             What is the expected ramp up time for           If the Proposer intends to function as an
                        bidders to be able to implement as an IDS if    IDS as part of its proposal, it must have
                        they so choose?                                 IDS functions in place no later than
                                                                        January 1, 2011.



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37   37-39   7     The second paragraph of 7.2 says: “Those         Any Proposer may choose to respond to
                   HMOs who are organized as an IDS or              this section regardless of its organizational
                   meet the attributes of an IDS may be             structure. Responses will be evaluated
                   eligible for additional points towards their     based on whether they meet the criteria
                   overall RFP score.” We assume “attributes”       outlined in Section 7.
                   here refers to the six attributes of an ideal
                   health system listed above this paragraph. If
                   so, then it seems a non-IDS HMO should be
                   allowed to make a case in its proposal that
                   it provides these six attributes as well as or
                   better than an IDS. We believe the section 7
                   evaluation criteria should be modified to
                   allow a non-IDS HMO to respond and be
                   eligible for the maximum points.
38   38      7.3   In reviewing the Elements of an IDS, please
                   clarify the following about Element 5:

                   1. Does the use of the phrase "Proposer has      This phrase means that the HMO
                   an Electronic Medical Records system"            (Proposer) would have an electronic
                   mean a provider, like Aurora, would partner      medical records system implemented
                   with an HMO and the HMO would link into          which is accessed and used by some, but
                   the provider’s system (similar to how            not necessarily all, of the HMO’s clinics.
                   Aurora’s clinics are currently linked in the     Through this system, the HMO and the
                   Milwaukee area)?                                 participating clinics would be able to share
                                                                    information contained in medical records
                                                                    electronically.

                   2. Also, the option of a "patient registry",     The Department defines patient registry
                   does this mean merely a serial list with a       according to AHRQ’s definition found in
                   discrete number for each patient, and/or, is     Registries for Evaluating Patient
                   it meant to be further broken down by            Outcomes: A User’s Guide



                                                                                                               14
                disease or treatment classifications?          (http://www.effectivehealthcare.ahrq.gov/e
                                                               hc/products/21/11/PatOutcomes.pdf).
                                                               Specifically, a patient registry is “an
                                                               organized system that uses observational
                                                               study methods to collect uniform data
                                                               (clinical and other) to evaluate specified
                                                               outcomes for a population defined by a
                                                               particular disease, condition, or exposure,
                                                               and that serves one or more predetermined
                                                               scientific, clinical, or policy purpose(s).”
39   39   7.3   The Proposer is to submit signed letters of    The signed Letter of Intent should
                intent from any medical groups or hospitals    specifically note that the medical group or
                demonstrating intent to function as an IDS     hospital intends to function as an IDS with
                with the proposer. The RFP states: “If the     the Proposer by fulfilling the nine elements
                Proposer fails to provide adequate             of an IDS listed in Section 7.3 of the RFP
                documentation regarding these letters of       on pages 38 and 39.
                intent, it will fail to meet the requirements
                for this section…” Is a LOI that includes a
                statement to function as an IDS adequate
                documentation?
40   39   7.3   Please clarify whether LOIs are required for Yes, Letters of Intent are required for
                urgent care clinics.                          urgent care clinics as well as medical
                                                              groups and hospitals.
41   40   8     Please provide more details on how the        The formula that Department plans to use
                points for the cost proposal will be given –  to allocate points for the cost proposal is as
                i.e. distribution of points across proposers  follows:
                based on cost?
                                                               If 20 points are the maximum points
                                                                  available to be received, the lowest bid
                                                                  gets 20 points.




                                                                                                          15
                                                                      The next lowest bid is divided into the
                                                                       lowest bid to get a percentage which is
                                                                       multiplied by the total number points
                                                                       allowed for a score: (Lowest cost bid/
                                                                       proposed bid) x maximum points
                                                                       available = score

                                                                   For example:
                                                                   $300 is the lowest cost proposal and
                                                                   therefore receives all 20 points.

                                                                   $350 is the next lowest cost proposal and
                                                                   receives 17 of the 20 points:
                                                                   (300/ 350 =.86 x 20 = 17 pts [rounded])

                                                                   $375 is the third lowest cost proposal and
                                                                   receives 16 of the 20 points.

                                                                   $500 is the fourth lowest and receives 12 of
                                                                   the 20 points.
                                                                   Etc.
42   40   8.2   The RFP requests a fixed PMPM admin                No.
                cost. However, admin costs and risk vary
                by age and eligibility/risk group, as do
                staffing requirements. Since a health plan's
                mix of membership will vary, the required
                staffing and admin load would also differ.
                Would the state accept a percentage admin
                as a proxy to reflect this cost differential (as
                it does for regions 1-4)?
43   40   8.3   The capitation rate development does not           The administrative cost proposal should



                                                                                                               16
                   include a specific allowance for risk margin    reflect the funding necessary for the HMO
                   or risk based capital. Is the bid               to cover all of the non-medical costs
                   administrative rate developed in Cost           required of the BadgerCare Plus Contract.
                   Proposal Appendix B expected to include a       The medical component of the rate consists
                   risk margin?                                    of all anticipated medical costs.
                                                                   Incorporation of components addressing
                                                                   risk margin into the proposed
                                                                   administrative rate is at the Proposer’s
                                                                   discretion.

                                                                   Assessment of an HMO’s risk-based
                                                                   capital is performed by the Office of the
                                                                   Commissioner of Insurance as part of the
                                                                   process for securing a Certificate of
                                                                   Incorporation and Certificate of Authority.
44   40      8.3   Should the administrative cost proposal         The administrative cost proposal should
                   include functions that serve to control the     reflect the funding necessary for the HMO
                   utilization and severity of encounters such     to cover all of the non-medical costs
                   as medical management, health and               required of the BadgerCare Plus Contract
                   wellness and 24 hour nurse hotline?             found in Appendix A of the RFP.
                   Several Medicaid programs in other states       Information on the functions included in
                   price these activities in the claims            the medical costs components of the rates
                   component of rate setting, while some           can be found in Appendix E-1 and E-2 of
                   include these costs in administrative           the RFP.
                   expense, resulting in inconsistent treatment
                   across plans.
45   42      8.3   Can you confirm that that 5% above the          Yes, that is confirmed.
                   managed care equivalent has been removed
                   from the rates that are to be affected in the
                   RFP?
46   44-45   8.3   Section 8.3 of the RFP refers to the            To determine the HMO’s chronicity or



                                                                                                            17
                       CY2010 cap rate being adjusted                  Chronic Illness and Disability Payment
                       retrospectively for chronicity, and CY 2011     System (CDPS) score for CY 2011,
                       and future years being adjusted annually.       October 2010 HMO enrollment and CY
                       This implies that CY2011 will not be            2009 claims and encounter experience will
                       adjusted retrospectively. If so, what time      be used. The Department anticipates
                       period of data will be used to determine this   issuing HMOs’ CDPS scores for CY 2011
                       chronicity, and by what date will this be       prior to December 31, 2010.
                       determined?
47   45   8.3          Does the 3.25 % holdback also pertain to        Yes.
                       the maternity kick payments?
48   45   8.3          Please confirm that the 3.25% withhold is       The 3.25% withhold is based on capitation
                       based on just capitation, not on capitation     plus admin and maternity kick payments.
                       plus admin.
49   33   Appendix A   In the HMO Contract Art III E, 1. indicates     The HMO will be responsible for common
                       that a transportation broker will begin in      carrier transportation in all six counties
                       CY 2011 and that HMOs in all six counties       effective 1/1/11. For the members receiving
                       will then be required to provider common        services through the HMO in the six RFP
                       carrier transportation. Isn’t the vendor        counties, these services will be carved-out
                       going to do this? If not, will the HMOs be      of the Non-Emergency Medical
                       financially liable for these costs that are     Transportation initiative. Prior to 1/1/11,
                       being arranged by the transportation            however, the HMOs will be responsible for
                       vendor?                                         common carrier transportation only in
                                                                       Milwaukee county.
50   34   Appendix A   Please clarify the responsibility of the new    For information on the division of
                       HMO for orthodontic and prosthodontic           responsibilities, please see the table titled
                       treatment when a member converts from           “Responsibility for Payment of
                       FFS, or from HMO covering dental, or            Orthodontic and Prosthodontic Treatment
                       from HMO not covering dental.                   When There is an Eligibility Status Change
                                                                       During the Course of Treatment” on p. 36
                                                                       of the Badger Care Plus contract in
                                                                       Appendix A of the RFP.



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51   49   Appendix A -   The RFP and related attachments do not           Specific to Appendix A – Article III
          III.H.3        appear to define facilities. In the past DHS     Section H.3, “Written Standards for
                         has considered "facility" in the context of      Accessibility of Care,” waiting times for
                         the HMO monitoring access standards to be        care at facilities refers to locations where
                         PCP sites such as FQHCs and RHCs.                members receive any services covered in
                         Please confirm if "facility" in the context of   the BadgerCare Plus contract in Appendix
                         the HMO monitoring access standards will         A to the RFP, including, but not limited to,
                         continue to be defined in the same manner.       primary care clinics, outpatient hospital
                                                                          services, specialty clinics, behavioral health
                                                                          centers/clinics, and dental clinics.
52   54   Appendix A –   On page 54 of the contract under the             Please see Amendment 3 to this RFP for
          Art III H.7    provider to member ratio requirements we         hospital network requirements.
                         do not see any hospital requirements for
                         number of hospitals and types of hospitals.
                         What are the requirements?
53   54   Appendix A –   In regard to Article III, H., 7, Provider        The Department declines to respond to this
          Art III H.7    Network and Access Requirements, can you         question in the context of this RFP. See
                         please clarify why there are specific            Amendment 3 to this RFP for a current
                         Provider to Member Ratios for Nuclear            listing of specialties with provider to
                         Medicine and Pathology? These are not            member ratio requirements.
                         specialties that members will be referred to
                         or call to schedule appointments. In the
                         case of Nuclear Medicine, members are
                         typically referred to a hospital for these
                         tests, or may be referred to a Cardiologist
                         who provides these scans in their office, but
                         not to an individual physician with this
                         specialty. The physicians that interpret
                         these nuclear tests are in fact often
                         Radiologists. As for Pathology, the same
                         scenario exists - these physicians are



                                                                                                                     19
                            “hospital based” and therefore not
                            necessarily under contract with the health
                            plans separate from the contract with the
                            hospital. If a member is referred to an in-
                            network hospital for lab testing, the
                            Pathologists at that hospital will provide
                            care on an in-network basis regardless of if
                            they are contracted. Is DHS actually more
                            interested in the number of labs that are in-
                            network? Most commercial and Medicaid
                            health plans do not list hospital-based
                            providers in their printed or on-line
                            provider directory for this very reason –
                            that members cannot call these providers
                            and set up any kind of appointment or test.
                            Most of these physicians do not even have a
                            phone number. In reviewing the
                            “physician” section of the Milwaukee
                            Yellow Pages, there is only one physician
                            listed under Nuclear Medicine, and none
                            under Pathology. I would recommend that
                            DHS review this and remove these provider
                            types for the ratio requirements.
54   54   Appendix A - III. The language states "The HMO must             See Amendment 3 to this RFP for the
          H.7               maintain a provider network so that the       current language.
                            ratio of provider to Member Years (member
                            months X 12) does not exceed the ratios for
                            the corresponding provider types in the
                            table following." Should the language read
                            "The HMO must maintain a provider
                            network so that the ratio of provider to



                                                                                                                20
                            Member Years (member months / 12) does
                            not fall below the ratios for the
                            corresponding provider types in the table
                            following."?
55   75      Appendix A –   The Medical Home Pilot requires that              No, this does not include post-partum
             Art III K      members must attend at least 10                   visits. The member must attend ten (10)
                            appointments with the Ob-care provider.           appointments prior to delivery.
                            Does this include post-partum visits, and if
                            so, what is the cut-off date? 60 days post-
                            partum?
56   75      Appendix A –   Can you please define what the Department         Any clinic, single or multi-specialty, may
             Art III K      considers a clinic as it relates to the Medical   be eligible to participate in the Medical
                            Home Pilot? Is a single-specialty Ob/Gyn          Home Pilot provided that it meets the
                            group considered a clinic, or does a clinic       requirements stated in Appendix A –
                            have to be a multi-specialty primary care         Article III.R.2.
                            group, or multi-specialty primary care and
                            specialty care group?
57   85-86   Appendix A     How frequently will HMOs receive “data            The BadgerCare Plus contract indicates
                            provided by the Department to facilitate          that the Department may provide this data.
                            outreach, assessment and care for                 Additional information on the availability
                            individuals with special health care needs”?      of such data will be distributed by the
                            In what format and please specify the data        Department after the BadgerCare Plus
                            provider?                                         contract has been executed.
58   228     Appendix A –   In the past, when evaluating quality              Yes, that is confirmed.
             Addendum VI    measurements against benchmarks DHS has
                            considered confidence intervals at 95% as
                            an important component to eliminate
                            statistical variation. Please confirm if DHS
                            will continue to use 95% confidence
                            intervals in evaluating quality measures.
59   2       Appendix D     With regards to submission of all contracts       Proposers should submit contracts or letters



                                                                                                                        21
                          as a component of network submission,         of intent from hospitals that are part of a
                          please provide your desired naming            health system with the following file name:
                          convention for contracts for hospitals that   (hospitalname)_(healthsystemname).pdf.
                          do not have individual contracts and are,     This pdf file should contain the contract or
                          instead, contracted as part of a health       letter of intent signature page that was
                          system.                                       signed by the health system.
60   2    Appendix D      With regards to submission of all contracts   For providers that are part of a medical
                          as a component of network submission,         group and are included in the Proposer’s
                          please provide your desired naming            XML file, the Proposer must submit only
                          convention for providers that do not have     one signature page of the contract or letter
                          individual contracts and are, instead,        of intent that was signed by the given
                          contracted as part of a large medical group   medical group. This file should be named
                          or IPA.                                       the following: (medicalgroupname).pdf.
61        Appendix D      The provider network file specification, in   The Proposer must complete the “Accepts
                          Appendix D, requires a response for if a      New Patients” field for every provider
                          provider accepts new patients. Does this      listed in the XML file, regardless of
                          requirement also apply to specialists or to   specialty.
                          primary care providers only?
62        Appendix D      Should dentists be included as part of the    Yes.
                          providers included XML file?
63   3    Appendix E2     Several items in the CMS Rate Setting         N/A is defined as not applicable in this
                          Checklist, page 3 of Appendix E2, are         table.
                          indicated as NA. We assume this means not
                          available. Will the Department provide this
                          information, e.g. checklist item AA.3.12,
                          Utilization and Cost Assumptions, and
                          other items used to develop the MCE
                          estimates?
64   18   Attachment E2   Please confirm that the State plans to        No, this is not confirmed. The rate
                          include the Managed Care Equivalent           adjustment on p. 18 of Attachment E-2 is
                          (MCE) adjustments referenced in               additional funding for the CY 2009 rates



                                                                                                                   22
Attachment E2, specifically on page 18, in   above the MCE. The rates for the RFP
its final rates for this contract.           region in CY 2010 are listed in section 8.3
                                             of the RFP and reflect the MCE for
                                             services provided.




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