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Welcome to Montana Department of Health and Human Services

Pre-Proposal Conference

July 14, 201510:00 a.m. to 12:00 p.m.

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Montana Health and Economic Livelihood Partnership (HELP)

Third Party Administration

RFP Number: RFP16-2896P

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Agenda Items

• Introductions• Project Background/TPA Services• Procurement Process• Evaluation Process• Confidential Materials• RFP Schedule of Events• RFP Submittal Requirements• RFP High Level Overview• Upcoming RFP Changes• Remaining Question & Answer Period

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Project Background

• The Medicaid HELP Program is a result of the 2015 Montana Legislature enacted Senate Bill 405, the Montana Health and Economic Livelihood Partnership (HELP) Act.

• The HELP Program is intended to improve access to health care services and control health care costs.

• Provides for the expansion of health care services to approximately 45,000 - 70,000 adults.• Participants may be exempt from coverage through the TPA and will be enrolled in Medicaid State

Plan services.

• Third party administrator (TPA) will assist in administering the delivery of health care services to eligible participants enrolled in the HELP Program.

• The HELP Benefit Plan is the term used throughout this RFP in reference to all services in the Alternative Benefit Plan (ABP).

• HELP Program participants will be subject to copayments and premiums.

• The HELP Program effective date is January 1, 2016, and is contingent upon CMS approval. 

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Third party Administrative (TPA) Services

• The contract period for system and delivery implementation is three months, beginning October 1, 2015, and delivery of HELP TPA Services will begin on January 1, 2016.

 • The TPA must provide all services in this RFP and comply with all State and

Federal Medicaid requirements.

• The TPA must have the ability to:• establish and administer the comprehensive HELP Benefit Plan;• develop and maintain sufficient provider networks;• track, notice, and coordinate participant premiums, copayments, and total out of pocket caps

for all services;• maintain a robust claims payment system;• provide effective utilization review;• implement a quality wellness program;• provide excellent administrative services; and• electronically interface with DPHHS systems.

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Procurement Officer

• All communications concerning RFP must be addressed to the RFP Officer:

Procurement Officer: Penny Moon

Phone: (406) 444-3313

Fax: (406) 444-2529

E-mail: pmoon@mt.gov

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Procurement Process

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Evaluation Process

• Evaluation Committee and Meetings• ADA accessible location• Public is welcome• Quorum of committee members• Meeting minutes

• Structured Evaluation Method• Use stated criteria

• Evaluation• Determine if proposals are responsive• All responses need to be thoroughly evaluated

• Finalize the Evaluation• Submit scoring sheets, meeting minutes, and the committee recommendation to

procurement officer

• Notify the Offerors• Issue the Contract

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Confidential Materials

2.3.2 Procurement Officer Review of Proposals.

• Upon opening the proposals in response to this RFP, the procurement officer will review the proposals for information that meets the exceptions in Section 2.3.1, providing the following conditions have been met:• Confidential information (including any provided in electronic media) is clearly marked and

separated from the rest of the proposal.• The proposal does not contain confidential material in the cost or price section.• An affidavit from the offeror's legal counsel attesting to and explaining the validity of the trade

secret claim as set out in Title 30, chapter 14, part 4, MCA, is attached to each proposal containing trade secrets. Counsel must use the State of Montana "Affidavit for Trade Secret Confidentiality" form in requesting the trade secret claim. This affidavit form is available on the OneStop Vendor Information website at: http://svc.mt.gov/gsd/OneStop/GSDDocuments.aspx or by calling (406) 444-2575.

• Information separated out under this process will be available for review only by the procurement officer, the evaluator/evaluation committee members, and limited other designees. Offerors shall pay all of its legal costs and related fees and expenses associated with defending a claim for confidentiality should another party submit a "right to know" (open records) request.

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Questions and Written Response

• Offerors with questions or requiring clarification or interpretation of any Section within this RFP must address these questions in writing or via e-mail to the procurement officer on or before July 20, 2015.

• The State will provide an official written response by July 31, 2015. The State’s response will be by formal written addendum.

• Any formal written addendum will be posted on the State’s website alongside the posting of the RFP at http://svc.mt.gov/gsd/onestop/Solicitations.aspx?args=A9ADF86D88792B5D8EA9104FBEAC3A8D by the close of business on the date listed.

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RFP Questions Format

• Please use the format below to submit questions to the State regarding RFP16-2896P

 Section Number Page Question

     

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RFP Schedule of Events

Deadline for Receipt of Written Questions July 20, 2015

 Deadline for Posting Written Response to State Website July 31, 2015

 RFP Response Due Date August 18, 2015

 Contract Begin Date October 1, 2015

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RFP Submittal Requirements• Appendix C: Client Reference Form (note: missing from RFP page 3)• Appendix E: Maximum Allowable Amounts• Attachment A: Provider Network Adequacy (Due 12/1/15)• Attachment B: TPA Provider Contracts• Attachment C: HELP Program Benefit Plan Evidence of Coverage (EOC)• Attachment D: Participant Materials• Attachment E: Comparable Participant Guide• Attachment F: Participant Wellness Newsletter• Attachment G: Self Audit Tool• Attachment H: Administrative Services• Attachment I: Comprehensive Work Plan• Attachment K: Financial Stability • Attachment L: Offeror Licensure• Attachment M: Offeror Organization Chart and Resumes• Attachment N: Utilization Review Plan• Attachment O: IT Project Management Plan• Attachment P: System Security Plan (Due 12/1/15)• Attachment Q: Disaster Recovery (DR) Plan (Due 12/1/15)

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RFP High Level Overview

• Section 1: Introduction and Instructions• Section 2: RFP Standard Information• Section 3: Scope of Services• Section 4: Offeror Qualifications• Section 5: Cost Proposal• Section 6: Evaluation Criteria• Appendices/Attachments

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Section 1: Introduction and Instructions

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Section 2: RFP Standard Information

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Section 3: Scope of Services

3.2.1 Provider Networks• Establish a sufficient provider network for adequate access.• Must meet federal requirements for provider compliance,

screening, credentialing, and enrollment methods.

3.2.2 HELP Plan Benefit and Reimbursement• Provide the TPA services portion of the HELP Benefit Plan

and reimbursement.• Some HELP Benefit Plan services processed by DPHHS.• Establish an Evidence of Coverage (EOC) for the entire HELP

Benefit Plan.

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Section 3 continued

3.2.3 HELP TPA Enrollment and Eligibility• Issue participant ID cards.• Provide methods of eligibility verification.

3.2.4 HELP TPA Participants Copayment and Premium• Identify and track copayments and premiums up to maximum amounts.

3.2.5 HELP TPA Claims Administration• Process medical and behavioral claims.

3.2.6 HELP TPA UR for Medical and Behavioral Health Services• Focus on UR strategies for reducing overutilization, provide prior

authorization, prospective and retrospective services review.

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Section 3 continued

3.2.7 HELP TPA Administrative Services and Management Information• Participant communications• Reporting• Invoice for claims and TPA services• HELP Program participant guide• Customer service center• Process TPL

3.2.8 HELP Wellness Program• Develop and implement innovative models of care, participant education,

participant wellness incentives, and provider performance incentives.• Outcomes must demonstrate increased healthy behaviors, decreased

utilization, and cost, and decreased use of ED services.

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Sections 3.3 and 3.4: Information Technology Requirements

Overarching IT goals• Data exchange using national standards and frameworks

like ASC X12, HIPAA, and NIEM, etc…• Real-time exchange of data using web services.• All data including data supporting reports is transmitted to

DPHHS.• Allow selected authorized DPHHS employees access to

the TPA’s administrative and claims processing system(s)

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IT Requirements continued

Out of Pocket Clearinghouse

Objective: Minimize excess out of pocket charges• DPHHS will use a real-time exchange of data to synchronize charges.• Provide reconciliation process for overages where participants have

reached their maximums.

Web Portals – Provider and Participants

Security – NIST and HIPAA

ICD-10

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Section 4: Offeror Qualifications

• On-Site Project Resources• The Contract Administrator must be available on site at the Contractor’s

primary project site in Helena, MT during normal business hours, Monday through Friday, 8:00 a.m. to 5:00 p.m., Mountain Time

• The following key resources must be available by phone or in-person as needed:• Customer Service Liaison• Case Management Lead• Business Analyst/Systems Lead

• For any resources not located in Helena, MT, the Contractor must identify the specific location (city, state, country) and describe the type of work to be performed, the total hours for each type of work at that location, and the percent of total hours for that type of work at that location.

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Section 5: Cost Proposal

• TPA All Inclusive PMPM Fee: January 1, 2016 through December 31, 2017

Number of HELP Program Participants

PMPM FeeIndicate your all-inclusive (all services throughout this RFP and the resulting contract) HELP TPA Services

per member per month fee.

January 1, 2016 – June 30,2016  

Up to 15,000 Participants  

15,001  - 20,000 Participants  

20,001  - 25,000 Participants  

25,001 – 30,000 Participants  

30,001 – 35,000 Participants  

35,001  - 40,000 Participants  

40,001 – 45,000 Participants  

45,001 – 50,000 Participants  

50,001 – 55,000 Participants  

55,001 – 60,000 Participants  

60,001 – 65,000 Participants  

65,001 – 70,000 Participants  

70,001 Participants and Above  

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Cost continued

• Renewal PMPM Fee Rates Increase (if renewed)

Program Year PMPM Percent Increase

Third Year (2018-2019)- not to exceed 3% above the second year rates

 

Fourth Year (2019-2020)- not to exceed 3% above third year rates

 

Fifth Year (2020-2021)- not to exceed 3% above fourth year rates

 

Sixth Year (2021-2022)- not to exceed 3% above fifth year rates

 

Seventh Year (2022-2023)- not to exceed 3% above sixth year rates

 

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Cost continued

• Separately Priced Items of the All Inclusive PMPM Fee

Of your all-inclusive TPA PMPM fee proposed for January 1, 2016; indicate the dollar amount of your

PMPM attributed to:Dollar amount of the PMPM Fee

1. Nurse Advice Line  

2. Wellness Program (broken out by each proposed wellness program component)

 

3. UR Case Management  

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Cost continued

• Separately Priced Retroactive Enrolled Participant Claims PMPM Fee

Indicate your TPA PMPM fee for claims processing services only for retroactively enrolled participants.

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Cost continued

• Separately Priced Information Technology Development Cost

DPHHS may have the ability to reimburse the TPA for IT development costs for HELP TPA Services. Indicate your IT development cost for the October 1, 2015 – December 31, 2015 period.

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Section 6: Evaluation Process

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Upcoming RFP Changes

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Questions & Answers