RFP NO. 2001-1-ABC
COMMONWEALTH OF PENNSYLVANIA
REQUEST FOR PROPOSAL (RFP) FOR ADULT BASIC COVERAGE INSURANCE PROGRAM SERVICES
Issuing Office:
Insurance Department 1326 Strawberry Square Harrisburg, PA 17120 Insurance Department Mr. Sandy Segal Project Coordinator (717) 705-6830 (717) 705-1643 abcrfp@ins.state.pa.us www.insurance.state.pa.us/abcrfp/index.htm
Project Office: Project Officer: Telephone No.: FAX No.: E-Mail: Website:
ABC REQUEST FOR PROPOSAL
TABLE OF CONTENTS
Page RFP Definitions RFP Acronyms Part I. General Information for the Offeror I-1. I-2. I-3. I-4. I-5. I-6. I-7. I-8. I-9. I-10. I-11. I-12. I-13. I-14. Purpose Issuing Office and Project Officer Scope Problem Statement Type of Contract Readiness Review Rejection of Proposals Incurring Costs Clarification of the RFP Addenda to the RFP Response Date Proposal Identification Proposal Rules of Procurement A. Technical Proposal B. Cost Proposal C. Contract Awards D. Independent Price Determination E. Subcontracts and Joint Proposals F. Protest of Intended Awards Information Concerning SERBs Contractor Representations and Authorizations Economy of Preparation Oral Presentation Prime Contractor Responsibility Proposal Contents Debriefing Conferences RFP Protest Procedure A. Who May File the Protest B. Time and Place for Filing C. Notice of Protest D. Stay of Procurement E. Procedures F. Decision 1 1 1 1 2 3 3 4 4 4 4 4 5 5 5 6 6 6 6 6 6 7 9 9 9 10 10 10 10 10 10 11 11 11 vii xiv
I-15. I-16. I-17. I-18 I-19 I-20 I-21 I-22
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I-23 I-24 I-25 I-26 Part II.
News Releases Enrollment List Restriction Commonwealth Participation Contract
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Information Required from the Offeror II-1. II-2. Mandatory Requirements Technical Proposal A. Transmittal Letter B. Tab 1: Executive Summary C. Tab 2: Corporate Background and Experience D. Tab 3: Key Administrative Positions and Organization E. Tab 4: Demonstration of Compliance with Work Statement F. Tab 5: Information on SERB Participation G. Tab 6: Additional Supporting Information Cost Proposal A. Rating Information by Contracted Service Area 1. Utilization Estimates 2. Cost Estimates 3. PMPM and Medical Rate 4. Administrative Expenses 5. Risk and Contingency 6. Total Rate 7. RCS Form 8. Other Information Required with the Cost Proposal B. Cost Proposal Oral Presentation Procedure for Evaluation and Scoring 13 13 14 14 14 14 15 17 19 19 20 20 23 26 27 27 27 27 28 30
II-3.
Part III.
Criteria for Selection III-1. General III-2. Criteria for Selection A. Cost B. Financial Condition C. Understanding of the Problem D. Soundness of Approach E. Contractor Qualifications F. Personnel Qualifications G. SERB Participation III-3. Enrollment Limits III-4. Ranking III-5. Special Terms and Conditions III-6. Rejection of Proposal 31 31 31 31 31 31 32 32 32 32 33 33 33
Part IV.
Work Statement IV-1. Overview IV-2. Objectives IV-3. Nature and Scope of Project
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A. Contractor Responsibilities B. Default C. Compliance with Applicable State and Federal Laws and Departmental Instructions D. False Claims E. Major Disasters and Epidemics F. Performance Standards G. SERB Contract Requirements IV-4. Tasks A. In-Plan Services B. Optional Benefits C. Co-Payments D. Reportable Conditions E. Eligibility and Enrollment, Disenrollment and Member Services 1. Outreach 2. Eligibility, Enrollment and Renewal Procedures 3. Collection of Premiums 4. Member Handbook 5. Selection of Primary Care Provider 6. Identification Cards 7. Member Helpline 8. Disenrollment 9. Waiting List 10. Complaint and Grievance Procedures 11. Eligibility Review Process IV-5. Requirements A. General B Executive Management C. Administration 1. Contracts and Subcontracts 2. Records Retention 3. Fraud 4. Information Systems 5. Privacy 6. Patient Safety D. Provider Networks l. Adequacy 2. Cultural Competence 3. Selection of PCP 4. PCP Responsibility 5. CRNP As A PCP 6. Standing Referrals/Specialist as a PCP 7. PCP Teams 8. Physician Specialists 9. Credentialing and Recredentialing 10. Provider Terminations 11. Network Changes 12. Medical Necessity E. Provider Services F. Appointment Standards
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G. Quality Management and Improvement and Utilization Management Program Requirements 1. Objectives 2. General Requirements 3. Department Oversight 4. External Independent Assessment 5. Reporting Requirements IV-6. Program Outcomes IV-7. Financial and Reporting Requirements A. Financial Standards 1. Risk Protection for High Cost Cases 2. Equity Requirements 3. Medical Cost Accruals 4. Claims Processing and MIS 5. Financial Data Reporting 6. Financial Performance B. Acceptance of Rate Payments, Using the CHAPS Database C. Rate Adjustments For Third Year D. Performance Management and Reporting 1. General Requirements 2. Data Processing and Communications Capabilities
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APPENDICES Act 2001-77....................................................................................................APPENDIX A Rate Calculation Sheet Form............................................................................APPENDIX B Standard Contract Terms and Conditions .........................................................APPENDIX C Medical Guidelines to be Utilized......................................................................APPENDIX D Prior Authorization of Services .........................................................................APPENDIX E Draft Adult Basic Insurance Coverage Procedures Manual................................APPENDIX F Draft Application Document .............................................................................APPENDIX G Executive Management.....................................................................................APPENDIX H Contracted/Subcontracted Activities.................................................................APPENDIX I Contractor Responsibility Program (Management Directive #215.9)..................APPENDIX J Provisions Concerning the Americans with Disabilities Act.................................APPENDIX K Languages Spoken by Plan Physicians ..............................................................APPENDIX L Appointment Standards....................................................................................APPENDIX M Annual Statement Filings and Instructions..........................................................APPENDIX N
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REQUEST FOR PROPOSAL (RFP) DEFINITIONS For the purpose of this RFP, the definitions set forth shall apply. Adult Basic Coverage Insurance Program -- The adult basic coverage insurance program (referred throughout the body of this RFP as “the program”) established by the General Assembly and enacted as Act 77 of 2001 (the Act). Affiliate -- Any individual, corporation, partnership, joint venture, trust, unincorporated organization or association, or other similar organization (hereinafter "Person"), controlling, controlled by or under common control with contractor or its parent(s), whether such common control be direct or indirect. Without limitation, all officers or persons holding five percent (5%) or more of the outstanding ownership interests of contractor or its parent(s), directors or subsidiaries of contractor or parent(s) shall be presumed to be affiliates for purposes of this RFP. For purposes of this definition, "control" means the possession, directly or indirectly, of the power (whether or not exercised) to direct or cause the direction of the management or policies of a person, whether through the ownership of voting securities, other ownership interests, or by contract or otherwise including but not limited to the power to elect a majority of the directors of a corporation or trustees of a trust, as the case may be. Aggregated Data -- Data that is summarized from individual unduplicated records. Authorized Control Level Risk Based Capital (RBC) -- The amount of an insurer’s Authorized Control Level calculated under the RBC formula in accordance with the RBC instructions. Benefit Package -- Insurance coverage which provides the benefits set forth in Section 3(f)(2) of the Act and as specified in this proposal. Certificate of Authority -- A document authorizing an insurer to transact the business of insurance in Pennsylvania. Certified Registered Nurse Practitioner (CRNP) -- A registered nurse licensed in the Commonwealth of Pennsylvania who is certified by the Board in a particular clinical specialty area and who, while functioning in the expanded role as a professional nurse, performs acts of medical diagnosis or prescription of medical therapeutic or corrective measures in collaboration with and under the direction of a physician licensed to practice medicine in Pennsylvania. Children’s Health Insurance Program (CHIP) -- The name of the program that provides free and subsidized health care services in accordance with Act 1998-68. Complaint -- A dispute or objection regarding a participating health care provider or the coverage, operations or management policies of a managed care plan (or other insurer) which has not been resolved by the managed care plan (or other insurer) and has been filed with the plan or with the Department of Health or the Insurance Department. The term does not include a grievance. (See Section 2102 of Act 1998-68 relating to definitions). Contracted Service Area -- A geographic area for which an insurer is contracted to provide health care services.
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Definitions (continued) Contractor -- A successful offeror or its successor as approved by the Department. County of Primary Care Provider (PCP) -- County where the member’s PCP is located. County of Residence -- County of the member’s principal residence. County of Service -- County where the program eligible service was provided. Cultural Competency -- The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Responsiveness may be reflected, for example, in the organization's pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit minority staff at least in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. Deliverables -- Those documents, records and reports required to be furnished to the Department for review and/or approval pursuant to the terms of this RFP. Demographics -- Social statistics about enrollees, such as race, date of birth, household income, ethnicity, gender, county of residence, marital status and occupation. Denial of Services -- Any determination made by an insurer in response to a provider's request for approval to provide health care services of a specific duration and scope which: disapproves the request completely; approves provision of the requested service(s), but for a lesser scope or duration than requested by the provider; or disapproves provision of the requested service(s), but approves provision of an alternative service(s). An approval of a requested service which includes a requirement for a concurrent review by the insurer during the authorized period does not constitute a denial. Department -- The Insurance Department of the Commonwealth of Pennsylvania. Electronic File Format (EFF) -- Data base file, comma delimited or tab delimited text file format are examples of electronic file format. Eligibility Review -- An impartial review by the Department of a decision by a contractor that an applicant is not eligible for the program or that an enrollee is no longer eligible
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Definitions (continued) Eligible Adult -- A person applying for coverage who meets the criteria set forth in Section 1302 of Act 2001-77 (relating to Definitions). Emergency Enrollee Issue -- A problem of an enrollee (including problems related to whether an individual is an enrollee), the resolution of which should occur immediately or before the beginning of the next business day in order to prevent a denial or medically significant delay in care to the enrollee that could precipitate a medical emergency or need for urgent care. Emergency Service -- Any health care service provided to an enrollee after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: (l) placing the health of the enrollee or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (2) serious impairment of bodily functions; or (3) serious dysfunction of any bodily organ or part. Emergency transportation and related emergency services provided by a licensed ambulance service shall constitute an emergency service. (See Section 2102 of Act 1998-68 relating to Definitions). Enrollee -- An adult who has been determined to be eligible for the program and is enrolled with a contractor. Grievance -- A request by an enrollee or a health care provider, with the written consent of the enrollee, to have the contractor or a utilization review entity reconsider a decision solely concerning the medical necessity and appropriateness of a health care service. A grievance may be filed regarding a decision that: (1) disapproves full or partial payment for a health care service; (2) approves the provision of a health care service for a lesser scope or duration than requested; or (3) disapproves payment for the provision of a health care service but approves payment for the provision of an alternative health care service. The term grievance does not include a complaint. Health Care Service -- Any covered treatment, admission, procedure, medical supply, equipment or other service or supply prescribed or otherwise provided or proposed to be provided by a health care provider to an enrollee. Health Maintenance Organization (HMO) -- An entity which combines delivery and financing of health care and provides basic health services to enrolled members for a fixed, prepaid fee, and which holds a Certificate of Authority issued by the Department and the Department of Health. In-Plan Services -- Services which are included in the rate and the payment for which are the responsibility of the contractor. Inquiry -- An enrollee's request for administrative service or information, or expression of an opinion. Whenever specific corrective action is requested by the enrollee, or determined to be necessary by the insurer, it should be classified as a complaint or grievance, as appropriate.
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Definitions (continued) Insurer -- A Health Plan Corporation (Article A, Part III, Special Provisions Relating to Particular Classes of Insurers, 40 Pa. C.S.§§ 6101 et seq. and 6301 et seq.), a health maintenance organization (Health Maintenance Organization Act, Act of December 29, 1972, as amended, 40 P.S.§§ 1551 et seq.), a financial risk-assuming preferred provider organization (Insurance Company Law, Act of May 17, 1921, 40 P.S. § 764a, and 31 Pa. Code § 152.2), or an insurance company authorized to transact the accident and health class of insurance (40 P.S. § 382(a)(2) and (c)(2) of the Insurance Company Law). MCPs are included within this definition. Issuing Office -- Pennsylvania Insurance Department. Low Income Adult -- An individual who is at least 19 years of age but less than 65 years of age and whose household income is less than 200% of the Federal Poverty Level at the time of eligibility determination. Section 1302 of Act 2001-77 (relating to Definitions). Managed Care Plan (MCP) -- A health care plan that uses a gatekeeper to manage the utilization of health care services, integrates the financing and delivery of health care services to enrollees by arrangements with health care providers selected to participate on the basis of specific standards, and provides financial incentives for enrollees to use the participating health care providers with procedures established by the plan. A Managed Care Plan includes entities operating under any of the following: (1) Section 630 of the act of May 17, 1921 (P.L. 682, No. 284), known as the “Insurance Company Law of 1921”. (2) The act of December 29, 1972 (P.L. 1701, No. 364), known as the “Health Maintenance Organization Act”. (3) The act of December 14, 1992 (P.L. 835, No. 134), known as the “Fraternal Benefits Societies Code”. (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations). (5) 40 Pa.C.S. Ch. 63 (relating to professional health services plan corporations). The term includes an entity, including a municipality, whether licensed or unlicensed, that contracts with or functions as a managed care plan to provide health care services to enrollees. The term does not include ancillary service plans or an indemnity arrangement which is primarily fee for service. Medical Necessity – Whether a treatment, admission, procedure, medical supply or equipment, or any otherwise covered service or supply is medically necessary. Determinations of medical necessity, whether made on a prior authorization, concurrent review or post-utilization basis, shall be in writing and provided to the enrollee promptly. The contractor shall base its determination on medical information provided by the enrollee, the enrollee's family/caregiver and the PCP, as well as any other providers, programs and agencies that have evaluated the enrollee.
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Definitions (continued) Medical necessity determinations must be made by qualified and trained providers and be appropriate and consistent with the diagnosis and in accordance with generally accepted standards of medical practice. Satisfaction of any one of the following standards will result in coverage of the care or service: • The care or service will, or is reasonably expected to, prevent the onset of an illness, condition or disability. • The care or service will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. • The care or service will assist the member to achieve maximum functional capacity in performing daily activities, taking into account both the functional capacity of the member and those functional capacities that are appropriate for members of the same age. • The care or service is one that a prudent physician would provide to a patient for the purpose of diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (1) In accordance with generally accepted standards of medical practice; (2) Clinically appropriate in terms of type, frequency, level, site and duration; and (3) Not primarily for the convenience of the patient, physician, or other health care provider. Member -- An enrollee. Member-level Data -- Record level data that contains information about individual members. Microsoft Office Software -- Components of the Microsoft Office software suite: Word, Excel, Access and PowerPoint. Minority Business Enterprise (MBE) -- A business concern that is: • A sole proprietorship, owned and controlled by a minority; • A partnership or joint venture controlled by minorities in which fifty-one percent (51%) of the beneficial ownership interest is held by minorities; or • A corporation or other entity controlled by minorities in which fifty-one percent (51%) of the voting interest and fifty-one percent (51%) of the beneficial ownership interest are held by minorities. Net Worth (Equity) -- The residual interest in the assets of an entity that remains after deducting its liabilities. Offeror -- An insurer that submits a proposal in response to the Department’s Request for Proposal.
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Definitions (continued) Out-of-Area Services – Health care services provided enrollees outside of the contracted service are that are covered because they meet one (1) or more of the following criteria: • An emergency that occurs while outside the contracted service area. • The health of the enrollee would be endangered if the person returned to the contracted service area for needed services. • The provider is located outside the contracted service area but is nonetheless a subcontractor regularly providing medical services to enrollees at the request of the insurer. • The needed health care services are not available in the contracted service area. Out-of-Network Provider -- A health care professional who does not have a written provider agreement with an insurer and is therefore not included or identified as being in the insurer's provider network. Out-of-Plan Services -- Services which are are not the responsibility of the insurer under the benefit package for the program. Pre-Existing Condition -- A disease or physical condition for which medical advice or treatment has been received prior to the effective date of coverage. Preferred Provider Organization (PPO) -- A financial risk-assuming entity which establishes, operates, maintains or underwrites in whole or in part a preferred provider arrangement. Primary Care Provider (PCP) -- A licensed health care provider under contract with or employed by a contractor who, within the scope of the provider’s practice, supervises, coordinates, prescribes or otherwise provides or proposes to provide health care services to an enrollee, initiates a referral for specialist care and maintains continuity of care. Prior Authorization -- Any review of a service or request for service which must be conducted as a condition of the service being delivered or covered. Program -- The adult basic coverage insurance program. Project Officer -- Sole point of contact in the Department for this RFP. Proposer -- An offeror submitting a proposal under this RFP. Prospective Utilization Review -- A review by a contractor or utilization review entity of all reasonably necessary supporting information that occurs prior to the delivery or provision of a health care service and results in a decision to approve or deny coverage or payment for the health care service. Provider Network -- The health care providers designated by an insurer to provide health care services. Quality Management -- An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care.
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Definitions (continued) Rate -- A fee the Department pays to a contractor for each enrollee under a contract with that contractor for the provision of insurance coverage for health care services. Retrospective Review -- A review conducted by the insurer to determine whether services were delivered as prescribed and consistent with the insurer’s coverage and payment policies and procedures. Risk Based Capital (RBC) after Covariance -- An adjustment in the Authorized Control Level RBC formula that allows for discounts to individual risk components of the formula in recognition that not all risk events for which RBC is required would occur simultaneously. Socially/Economically Restricted Business (SERB) -- A business whose economic growth and development has been restricted based on social and economic bias. Specialist -- A licensed individual health care provider whose practice is not limited to primary health care services and who has additional postgraduate or specialist training, and has board certification in a specialized area of health care. The term includes an individual health care provider who is not classified by a plan solely as a PCP. Start Date -- The first date on which members are eligible for medical services under the operational contract, and on which insurers are at risk for providing medical services to enrollees. Subcontract -- Any contract (except for utilities and salaried employees) between the contractor and a subcontractor to perform part or all of the insurer's responsibilities under the contract. Urgent Medical Condition -- Any illness, injury or severe condition which under reasonable standards of medical practice would be diagnosed and treated within a twenty-four (24) hour period and if left untreated, could rapidly become a crisis or emergency medical condition. Additionally, it includes situations such as when a person's discharge from a hospital will be delayed until services are approved or a person's ability to avoid hospitalization depends upon prompt approval of services. Utilization Management -- An objective and systematic process for planning, organizing, directing and coordinating health care resources to provide medically necessary quality health care in a timely and cost effective manner. Utilization Review -- A system of prospective, concurrent or retrospective utilization review performed by a utilization review entity of the medical necessity of health care services prescribed, provided or proposed to be provided to an enrollee. The term does not include any of the following: (1) requests for clarification of coverage, eligibility or health care service verification; and (2) a health care provider’s internal quality assurance or utilization review process unless the review results in denial of payment for a health care service.
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Definitions (continued) Women's Business Enterprise -- A business concern that is: • A sole proprietorship owned and controlled by a woman. • A partnership or joint venture controlled by women in which fifty-one percent (51%) of the beneficial ownership interest is held by women. • A corporation or other entity controlled by women in which fifty-one percent (51%) of the voting interest and fifty-one percent (51%) of the beneficial ownership interest is held by women.
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RFP ACRONYMS: For the purpose of this RFP, the acronyms set forth shall apply. ADA ANSI CAPS CFO CHAPS CRNP DOH EDI EFF EMS ER FIPS FPL GAAP HEDIS HMO IBNR MA MBE MCP PCP PMPM QARI QM QM/UMP RBC RBUC RCS RFP SAP SERB TTY UM WBE X12 -– -----– --------------------------– Americans with Disabilities Act The American National Standards Institute Client Application Processing System Chief Financial Officer Client Healthcare Processing System Certified Registered Nurse Practitioner Department of Health (of the Commonwealth of Pennsylvania) Electronic Data Interchange Electronic File Format Emergency Medical Services Emergency Room Federal Information Processing Standards Federal Poverty Level Generally Accepted Accounting Principles Healthplan Employer Data and Information Set Health Maintenance Organization Incurred But Not Reported Medical Assistance (also Medicaid) Minority Business Enterprise Managed Care Plan Primary Care Provider Per Member Per Month Quality Assurance Reform Initiative Quality Management Quality Management and Utilization Management Program Risk Based Capital Reported But Unpaid Claim Rate Calculation Sheet Request for Proposal Statutory Accounting Principles Socially/Economically Restricted Business Text Telephone Typewriter Utilization Management Women's Business Enterprise Standards developed for data exchanged via EDI transactions
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