REQUESTS FOR PROPOSALS
ISSUED BY THE NEW MEXICO HUMAN SERVICES DEPARTMENT
FOR
NEW MEXICO MEDICAID EXTERNAL QUALITY REVIEW ORGANIZATION
RFP #14-630-8000-0004
State of New MexicoHuman Services DepartmentMedical Assistance Division
P. O. Box 2348Santa Fe, New Mexico 87504
March 21, 2014
ContentsI. INTRODUCTION.......................................................................................................................1
A. PURPOSE OF THIS REQUEST FOR PROPOSALS.....................................................1B. SCOPE OF WORK SUMMARY.....................................................................................2C. SCOPE OF PROCUREMENT.........................................................................................3D. OFFEROR QUALIFICATIONS/CONFLICT OF INTEREST.......................................3E. PROCUREMENT MANAGER.......................................................................................4F. DEFINITION OF TERMINOLOGY................................................................................5G. BACKGROUND INFORMATION...............................................................................16H. PROCUREMENT LIBRARY…………………………………………………………19
II. CONDITIONS GOVERNING THE PROCUREMENT..........................................................21A. PROCUREMENT SCHEDULE.....................................................................................21B. EXPLANATION OF EVENTS......................................................................................21C. GENERAL REQUIREMENTS......................................................................................26
III. RESPONSE FORMAT AND ORGANIZATION.................................................................34A. NUMBER OF RESPONSES..........................................................................................34B. NUMBER OF COPIES..................................................................................................34C. PROPOSAL RESPONSIVENESS.................................................................................34D. ECONOMY OF PREPARATION.................................................................................34E. TECHNICAL PROPOSAL CONTENT AND FORMAT.............................................34F. COST PROPOSAL CONTENT AND FORMAT..........................................................38G. NEW MEIXCO MEPLOYEES HEALTH COVERAGE…………………………..…38H. CAMPAIGN CONTRIBUTION DISCLOSURE…………………...………...………38
IV. SCOPE OF WORK................................................................................................................39A. EQRO PROGRAM ADMINISTRATION.....................................................................39B. MEDICAID CONTRACTS FOR COVERED BENEFITS/SERVICES.......................47C. CENTENNIAL CARE CONTRACT REQUIREMENTS.............................................50
V. TECHNICAL DELIVERABLES............................................................................................53A. INTRODUCTION..........................................................................................................53B. REIMBURSABLE SERVICES......................................................................................54C. QUALITY OF EQRO SERVICES.................................................................................63D. OVERHEAD SERVICES NOT REIMBURSABLE.....................................................65
VI. EVALUATION OF PROPOSALS.......................................................................................67
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A. EVALUATION PROCESS............................................................................................67B. EVALUATION OF COST.............................................................................................68C. EVALUATION POINT SUMMARY............................................................................68
APPENDICES A-G.......................................................................................................................69APPENDIX A – REQUEST FOR PROPOSALS EXTERNAL QUALITY REVIEW ORGANIZATION ACKNOWLEGDEMENT OF RECEIPT FORM......................................70APPENDIX B – SAMPLE EQRO CONTRACT TERMS AND CONDITIONS....................71APPENDIX C – CENTENNIAL CARE POLICY MANUAL WEBSITE.............................107
APPENDIX D – COST PROPOSAL FORM..........................................................................108 APPENDIX E – CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
PROPOSED DEBARMENT AND OTHER RESPONSIBILITY MATTERS......................109APPENDIX F – NEW MEXICO EMPLOYEES HEALTH CARE COVERAGE FORM....111APPENDIX G – CAMPAIGN CONTRIBUTION DISCLOSURE FORM...........................112
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I. INTRODUCTION
A. PURPOSE OF THIS REQUEST FOR PROPOSALS
The State of New Mexico's Human Services Department (HSD) is requesting proposals for the performance of External Quality Review (EQR) activities for its Medicaid Managed Care contracts. New Mexico Medicaid has contracts with multiple entities that provide an array of Medicaid managed care and other health related services. The entities’ contracts contain quality of care and service standards specific to their populations and/or their specific services. EQR activities include the development of the methodology for the measurement of contract performance against applicable state and federal standards and policy, the actual measurement of performance using approved methodology, and several other related activities.
The Offeror will provide external quality review activities for the Centennial Care managed care organizations (MCOs). The MCOs include Blue Cross Blue Shield of New Mexico, Molina Health Care of New Mexico, Inc., Presbyterian Health Plan, Inc. and United Health Care Community Plan of New Mexico, Inc.
HSD will require successful Offerors to fully comply with all statements, promises and plans submitted within their proposal that are accepted by HSD.
History of the Medicaid External Quality Review Organization (EQRO) Program
Since the initiation of the Medicaid Managed Care program, on July 1, 1997, the State of New Mexico had a single EQRO contractor to oversee the integrated physical and behavioral health managed care contracts. Prior to that date, New Mexico operated a Medicaid fee-for-service program coupled with a primary care case management model.
Managed Care was mandated by the NM Legislature in 1994, through passage of House Bill 702, which required HSD to have a managed care program in place for all Medicaid recipients by July 1, 1995. The transition to a risk-based managed care model was an intensive process in which the program was developed and new policies were established. This was followed by a procurement to select MCOs that would carry out the defined, integrated managed care program, called Salud! The procurement led to development of contracts with three MCOs for an initial four-year contract cycle, which expired on June 30, 2001. On July 1, 2001 two year contracts were signed with all three MCOs, and all were extended for an additional two years, expiring on June 30, 2005.
Beginning July 1, 2005, when new Salud! contracts were signed, all Behavioral Health services were transitioned out of the Salud! integrated program and provided by a separate statewide entity. Additionally, a separate Coordination of Long Term Services (CoLTS) RFP was issued. Two contractors were chosen to deliver services coordinating the care for individuals requiring either Nursing Home level of care, Personal Care Options and/or Disabled and Elderly Home and Community-Based waiver services. Another entity for which the EQRO contractor was responsible for performing some external quality review and monitoring was the State Coverage Insurance (SCI) program. The SCI program offered affordable health care coverage to low-
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income working adults primarily through an employer-based system. Effective July 1, 2008, this contract was linked as a requirement to three of the Physical Health MCOs contracts, but was viewed by HSD as a distinct and separate population. Also effective July 1, 2008, a fourth Salud! MCO was added to the program.
On January 1, 2014, the State of New Mexico launched a newly redesigned statewide Medicaid program now known as Centennial Care. Under the management of the New Mexico Human Services Department, Centennial Care is designed to expand and streamline services. Centennial Care’s design creates a single, comprehensive delivery system through four managed care plans, allowing for greater administrative simplicity. It emphasizes care coordination so that recipients will receive the right care, in the right place, at the right time, leading to better health outcomes.
HSD has continued its efforts to increase the quality of care, improve member access, and streamline the administration of the program. This comprehensive external quality review (EQR) Request for Proposal (RFP) is an effort to better consolidate administrative oversight of the HSD Medical Assistance Division products.
B. SCOPE OF WORK SUMMARY
The selected Offeror will have auditing oversight, reporting requirements, program improvement recommendations and corrective action plans and/or quality improvement plans, for the following activities:
1. Provision of services described in the Medicaid managed care benefit package and other programs as assigned listed under Section IV Scope of Work.
2. Auditing of all Centennial Care services. Including the following elements:
a. Coordination of all health care services delivered to Medicaid managed care members across an array of contractors as described in Section IV Scope of Work;
b. Active promotion of preventive care, early intervention, disease management, and attainment of public health benchmarks;
c. Provision of access to appropriate and timely services for individuals with special health care needs; and
d. Operation of quality assurance and utilization management programs to ensure access to quality health care.
3. Utilization of industry statistical standards of sampling in methodology to follow at a minimum of a ninety-five (95) percent confidence interval and standard error rate of no more than .05 percent.
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4. Ensuring performance compliance of fee-for-service contractors, such as the Fee For Service (FFS) /Utilization Review (UR) or Third Party Assessor (TPA) contractors.
5. Completion of requested ad hoc reports and audits necessary for the provision of quality Medicaid services.
C. SCOPE OF PROCUREMENT
The initial scope of work shall consist of performing EQR activities as described in Section IV, Detailed Scope of Work. The contract resulting from this RFP shall begin upon approval by the State of New Mexico’s Department of Finance and Administration (DFA) on July 1, 2014. The term of the contract signed as a result of this RFP will be for two (2) years with two (2) option years not to exceed four (4) years.
D. OFFEROR QUALIFICATIONS/CONFLICT OF INTEREST
This RFP is open to any Offeror capable of performing the work described in Section IV, Detailed Scope of Work, subject to the following stipulations:
1. Pursuant to 42 U.S.C. 1396a (30) (c), an Offeror must be one of the following entities:
a. A Quality Improvement Organization (QIO), formerly known as a Peer Review Organization (PRO) under contract to the Center for Medicare and Medicaid Services (CMS); or
b. An organization that is not currently under contract, but that meets the requirements for a QIO as defined in 42 CFR 431.630 (Medicaid QIO regulation).
2. An Offeror must not be a New Mexico Medicaid provider of services, or be an owner of, or have any proprietary interest in a business that is a provider of New Mexico Medicaid services. An Offeror may not be employed by or contract with a New Mexico Medicaid provider.
3. An Offeror must be completely independent of any MCO subcontractor or of an MCO that is contracted with the State of New Mexico. Specifically, an Offeror must not be an MCO or subcontractor of an MCO that is contracted with the State of New Mexico or be an owner of, have a proprietary interest in, or be a subsidiary of a business that is an MCO or subcontractor of an MCO that is contracted with the State of New Mexico. An Offeror may not function as an auditor, consultant, claims preparer or otherwise be employed by an MCO or subcontractor of an MCO that is contracted with the State of New Mexico. The potential Offeror is bound to the Sample EQRO Contract Terms and Conditions (Appendix B).
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4. An Offeror shall ensure that no elected or appointed officer or other employee of the State of New Mexico shall benefit financially or materially from the successful award of the contract to the Offeror and that no individual employed by the State of New Mexico shall be permitted to own any share or part of the contract or to in any material way benefit from that award.
5. The burden is on the Offeror to present sufficient assurances to the State that the award of the contract to the Offeror will not create a conflict of interest.
6. During the State’s RFP review process, additional points will be given for an Offeror with dedicated New Mexico presence and staffing.
E. PROCUREMENT MANAGER
The HSD designated Procurement Manager, responsible for the conduct of this procurement, is:
Elizabeth C. Cassel, Ph.D.Medical Assistance DivisionHuman Services Department2025 South Pacheco StreetSanta Fe, New Mexico 87504Telephone Number: (505) 827-7715Fax Number: (505) 827-3126
All deliveries via express carrier should be addressed to the Procurement Manager.
Elizabeth C. Cassel, Ph.D.Medical Assistance DivisionHuman Services Department2025 South Pacheco StreetSanta Fe, New Mexico 87504Telephone Number: (505) 827-7715Fax Number: (505) [email protected]
Inquiries or requests regarding this procurement should be submitted only to the Procurement Manager, and in writing via hard copy or e-mail. Questions shall be clearly labeled and shall cite the specific RFP or policy. Offerors may contact only the Procurement Manager regarding the procurement. Other state employees do not have the authority to respond on behalf of HSD. HSD shall not assume responsibility for any answers or clarifications received from other HSD staff or any other state staff. HSD shall impose the following penalties upon Offerors that contact other state employees in violation of this requirement:
1. For a first violation, the Offeror shall lose ten percent of the score resulting from proposal evaluation. If finalists have not yet been selected, the points shall be
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subtracted from the initial proposal evaluation. If oral presentation/best and final offers are under way, the points shall be subtracted from the Offeror's final score.
2. For a second violation, the Offeror shall be excluded from further participation in the procurement.
3. The decision for exclusion from participation in the procurement by the Procurement Manager shall be final.
F. DEFINITION OF TERMINOLOGY
This section contains definitions that are used throughout this procurement document, including appropriate abbreviations. Medicaid regulations are subject to change and the Offeror is responsible for following all changes to Medicaid definitions, laws and regulations on their effective dates.
Definitions
“Abuse” means provider practices inconsistent with sound fiscal, business, or medical practices that result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program.
“Action” refers to the denial or limited authorization of a requested service, including the type of level of services; reduction, suspension, modification or termination of a previously authorized service; denial, in whole or in part, of payment for a service; or the failure to provide services in a timely manner. An untimely service authorization constitutes a denial and is thus considered an action.
“Ad hoc” means a request of information for a specific purpose.
“Agency” refers to an administrative government department, such as HSD, Children Youth and Families Department, Department of Health or any of the departments participating in Medicaid managed care.
“Appeal” refers to a request from a member or provider for review by the MCO of an MCO action.
“Appeal Process” refers to the formal process or method for members or providers to appeal an MCO action.
“Authorization” is an initial or concurrent review decision, which yields approval for payment of a requested Medicaid service and/or level of care based on medical necessity and relevant clinical criteria.
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“Behavioral Health (BH)” refers to both mental health (MH) and substance abuse (SA), including co-occurring MH and SA disorders.
“Behavioral Health Purchasing Collaborative (BHPC)” refers to an interagency behavioral health care system that encourages the behavioral health and welfare of children, individuals and families and creates an efficient delivery of care that is readily accessible. The following entities will be involved: Department of Health (DOH), Children, Youth, & Families Department (CYFD), Human Services Department (HSD), New Mexico Corrections Department (NMCD), Aging & Long Term Services Department (ALTSD), Public Education Department (PED), Department of Finance & Administration (DFA), Department of Transportation (DOT), Department of Labor (DOL), Division of Vocational Rehabilitation (DVR), Administrative Office of Courts, Mortgage Finance Authority, Indian Affairs Department (IAD), Health Policy Commission, Developmental Disabilities Planning Council, Governor’s Commission on Disability, Governor’s Health Policy Coordinator and the Public Defender’s Office.
“Beneficiary” refers to one who receives a benefit, as in funds or services.
“Benefit Package” means Medicaid covered services, which shall be furnished by the MCO and for which payment is included in the capitation rate.
“Capitation” means a per member monthly payment to an MCO that covers contracted services and is paid in advance of service delivery.
“Care Coordination” means a service to assist member with special/complex care needs. It is an office based administrative function that is performed across all populations who need this assistance. It is member-centered, family focused, and culturally competent. Care coordination is a single point of contact within the MCO for individuals who need help accessing and/or coordinating care across multiple providers. Refer to NMAC [8.305.1.7]
“Case” refers to a household that Medicaid treats as a unit for purposes of eligibility determination, e.g. a parent and child, legal guardian and child, a set of siblings.
“Centennial Care” refers to New Mexico’s Medicaid Managed Care program. Centennial Care provides a single, comprehensive delivery system through four managed care plans, allowing for greater administrative simplicity. It emphasizes care coordination so that recipients will receive the right care, in the right place, at the right time, leading to better health outcomes.
“Centennial Care Policy Manual” means the State of New Mexico Medical Assistance Division Program Policy Manual. See Appendix C for access.
“Center for Medicare and Medicaid Services (CMS)” means the federal agency within the Health and Human Services (HHS) that is responsible for the Federal-level
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administration of the Title XIX (Medicaid) and Title XXI (CHIP) programs. CMS was formerly known as the Health Care Financing Administration (HCFA).
“Children with Special Health Care Needs (CSHCN)” refers to individuals under 21 years of age, who have, or are at an increased risk for, a chronic physical, developmental, behavioral or emotional condition, and who also require health and related services of a type and amount beyond that required by children generally.
“Code of Federal Regulations (CFR)” refers to a codification set of documents of Public Health Statutes published by the Office of the Federal Register, National Archives and Records Administration. Most references for Medicaid, Medicare programs and policies are found in Chapter 42 of the Code.
“Community-Based” refers to a system of care that seeks to provide services in or near the member’s home community to the greatest extent possible. Community-based services are non-institutional services.
“Consumer Assessment of Healthcare Providers and Systems (CAHPS)” refers to the National Committee for Quality Assurance (NCQA) standardized Adult and Child/Family survey, conducted and provided by the MCOs to HSD.
“Continuous Quality Improvement (CQI)” means a process for improving quality which assumes that opportunities for improvement are unlimited, is customer-oriented, is data driven, results in implementation of improvements, requires continual measurement of implemented improvements, and results in modification of improvements as indicated.
"Contract" means an agreement for the procurement of items of tangible personal property or services.
“Contract Administrator” means the individual selected by HSD to manage all aspects of the contract resulting from this RFP.
“Contract Year” means the twelve-month period commencing with the effective date of the contract or its subsequent anniversary dates.
"Contractor" means successful Offeror who enters into a binding contract.
“Corrective Action Plan (CAP)” means a list of actions and an associated timetable for implementation to remedy a specific problem.
“Critical Indicator Monitoring” means monitoring of identified populations through utilization data analysis for early identification and interventions of quality of care and/or health and safety issues.
“Cultural Competence” requires individuals and systems to develop and expand their ability to provide services effectively to people of all cultures, races, ethnic backgrounds
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and religions in a manner that respects the worth of the individual and protects and preserves their dignity.
“Days” refers to calendar days, unless otherwise specified in this RFP. The first day is excluded and the last day is included. Timelines or due dates falling on a weekend or holiday shall be extended to the first working day after the weekend or holiday.
“Deeming” refers to the process by which a standard or requirement may be considered met.
"Desirable": The terms "may", "can", "preferably", or "prefers" identify a desirable or discretionary item or factor.
“Determination” means the written documentation of a decision of a procurement including findings of fact supporting a decision. A determination becomes part of the procurement file to which it pertains.
“Disease Management (DM)” means a strategy implemented by a managed care contractor for delivering health services using interdisciplinary clinical teams, continuous data analysis, and cost effective technology to improve the health outcomes of members with specific diseases. Examples of such diseases include but are not limited to: diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), asthma and obesity.
“Diversity” refers to persons, cultures, communities or geographical areas that are distinct in kind, have variety, or are unique.
“Early Periodic Screening, Diagnosis and Treatment (EPSDT)” refers to Medicaid services for individuals less than 21 years of age.
“Eligible” means a client who has been determined to be eligible for a Medicaid managed care program based on the combination of eligibility category and federal match code.
“Enhanced Service” refers to those services offered by a managed care contractor to their members, in addition to the required Medicaid benefit package.
“Enrollee” refers to a Medicaid recipient who is currently enrolled in a managed care organization in a given managed care program.
“Enrollment” means the process of enrolling eligible clients with an MCO for purposes of management and coordination of health care delivery.
"Evaluation Committee" means a body appointed by HSD management to perform the evaluation of Offeror proposals.
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“Evaluation Committee Report” means a report prepared by the Procurement Manager and the evaluation committee for submission to the Secretary of HSD for contract award that contains all written decisions resulting from the conduct of a procurement requiring the evaluation of competitive sealed proposals.
“Excluded” means client participation in managed care is prohibited based on the combination of eligibility category and federal match code.
“Exempt” or “Exemption” refers to the enrollment status of a client who is not mandated to enroll in managed care.
“External Quality Review Organization (EQRO)” refers to an independent organization with clinical and health services expertise that is capable of reviewing health care delivery systems and their internal quality assurance mechanisms.
“Fee-for-Service (FFS)” means a payment mechanism wherein payment is made after services are rendered and billed.
"Finalist" is an Offeror who meets all the mandatory specifications of the RFP and whose score on evaluation factors is sufficiently high to qualify that Offeror for further consideration by the Evaluation Committee.
“Fiscal Agent” is a contractor who primarily receives, processes, and pays claims for provider reimbursement for rendered Medicaid services; receives and processes encounter data submitted by MCOs; and renders reports to HSD based on the data accumulated from these activities.
“Fraud” means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or to some other person. It includes any act that constitutes fraud under applicable federal or state law.
“Frontier” refers to the following counties in New Mexico: Catron, Harding, DeBaca, Union, Guadalupe, Hidalgo, Socorro, Mora, Sierra, Lincoln, Torrance, Colfax, Quay, San Miguel, Cibola and Rio Arriba.
“Full Risk Contracts” refers to contracts wherein the contractor assumes the full financial risk for providing services and care to its eligible population and assumes any loss it might incur.
“Grievance” refers to an oral or written statement expressing dissatisfaction with any aspect of the MCO or its operations.
“Grievance Process” refers to the MCO internal process to hear and resolve member and provider grievances.
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“Grievance System” refers to a formal system that an entity creates through written policies and procedures to handle the filing of grievances in an organized and timely manner.
“Health Home” means a conceptual model that facilitates the provision of quality care that is accessible, family-centered, continuous, coordinated, compassionate and culturally competent. (See also “Medical Home”)
“Healthcare Effectiveness Data and Information Set (HEDIS)” means a standardized set of MCO performance measures developed and updated by the National Committee for Quality Assurance (NCQA).
“HEDIS-Like” means a standardized set of MCO performance measures based on NCQA performance measures.
“Health Insurance Portability & Accountability Act of 1996” (HIPAA) means a US law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.
“High Needs” refers to those individuals, both children and adults, who have behavioral and/or physical health needs of a type or amount, which require services beyond that which is generally required by individuals.
“Human Services Department (HSD)” means the executive department in New Mexico responsible for the administration of Title XIX (Medicaid) and Title XXI (CHIP) programs. The term HSD may also indicate the Department’s designee, as applicable.
“Independent Assessment (IA)” means utilizing CMS protocol to perform an evaluation of the State’s Medicaid Managed Care program for beneficiary access to services, quality of services, and cost effectiveness of the Waiver(s).
“Letter of Direction (LOD)” means a letter from the HSD Procurement Manager to the contractor that directs specific work to be performed within a specified time period pursuant to the terms of the contract and is required for payment to be made to the contractor for any work performed under the contract.
“Managed Care Organization (MCO)” means an organization licensed to manage, coordinate, and assume financial risk on a capitated basis for the delivery of a specified set of services to enrolled members in a given geographic area. It also referred to as a managed care plan and managed care program.
“Managed Care Policy Manual” refers to the New Mexico Medicaid managed care policy section, which defines the scope of responsibilities of the MCOs.
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"Mandatory": The terms "must", "shall", "will", "is required", or "are required", identify a mandatory item or factor. Failure to meet a mandatory item or factor may result in the rejection of the Offeror’s proposal.
“Marketing” refers to the act or process of promoting a business or commodity. Marketing includes brochures, leaflets, internet, newspaper, magazine, radio, television, billboard materials, MCO yellow page advertisements, and any other presentation materials used by an MCO, MCO representative, or MCO subcontractor to attract or retain Medicaid enrollment.
“Medicaid” means the medical assistance program authorized under Title XIX furnished to New Mexico residents who meet specific eligibility requirements.
“Medicaid Behavioral Health Level of Care Guidelines” means the Level of Care guidelines that include the definition of medical necessity, service definitions for each level of care, and a listing of admission, continued stay and discharge criteria.
“Medicaid Fraud Control Unit (MFCU)” refers to a federally required unit within each State Attorney General’s office.
“Medicaid School-Based Service (MSBS)” refers to the program, which targets children who qualify for special education services under the Individuals with Disabilities Education Act (IDEA) and receive care based on an Individualized Education Plan (IEP) and/or an Individualized Family Service Plan (IFSP)”.
“Medical Assistance Division (MAD)” means the Division within the HSD that administers the State’s Medicaid program.
“Medical Home” means a conceptual model that facilitates the provision of quality care that is accessible, family-centered, continuous, coordinated, compassionate and culturally competent. (See also “Health Home”)
“Medically Necessary Services”a. Medically necessary services are clinical and rehabilitative physical, mental or
behavioral health services that: (1) Are essential to prevent, diagnose or treat medical conditions or are
essential to enable the individual to attain, maintain or regain functional capacity;
(2) Are delivered in the amount, duration, scope and setting that is clinically appropriate to the specific physical, mental and behavioral health care needs of the individual. (See NMAC 8.305.1.7)
b. Application of the definition: (1) A determination that a health care service is medically necessary does not mean
that the health care service is a covered benefit or an amendment, modification or expansion of a covered benefit;
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(2) The HSD or its designee making the determination of the medical necessity of clinical, rehabilitative and supportive services consistent with the Medicaid benefit package applicable to an eligible individual shall do so by:(a) Evaluating individual physical, mental and behavioral health information provided by qualified professionals who have personally evaluated the individual within their scope of practice, who have taken into consideration the individual’s clinical history including the impact of previous treatment and service interventions and who have consulted with other qualified health care professionals with applicable specialty training, as appropriate; (b) Considering the views and choices of the individual or the individual’s legal guardian, agent or surrogate decision maker regarding the proposed covered service as provided by the clinician or through independent verification of those views; and (c) Considering the services being provided concurrently by other service delivery systems;
(3) Physical, mental and behavioral health services shall not be denied solely because the individual has a poor prognosis. Required services may not be arbitrarily denied or reduced in amount, duration or scope to an otherwise eligible individual solely because of the diagnosis, type of illness or condition;
(4) Decisions regarding benefit coverage for individuals under age 21 shall be governed by the EPSDT coverage rules.
“Member” means an eligible individual (client) who is enrolled in an MCO.
“Member Month” refers to a calendar month in which a member is enrolled.
“Mental Health Statistics Improvement Program (MHSIP)” means a consumer-oriented mental health report card developed to assess: access to services, satisfaction of services, appropriateness of services as well as the outcome of the services as assessed by the Medicaid client. “National Committee for Quality Assurance (NCQA)” means a national organization, which, among other services, develops and updates quality standards for use in managed care, accredits MCOs, and develops and updates a standardized set of MCO performance indicators, such as the Healthcare Effectiveness Data and Information Set (HEDIS).
“Network Provider” means an individual provider, clinic, group, association, or facility, which is employed or subcontracts with the MCO(s) to furnish health care services to members under the provisions of the Medicaid managed care contract.
“Nursing Facility Level of Care (NF LOC)” means the intensity of medical care being provided by the physician or health care facility. Generally, LOC determinations include either an assessment of certain functional needs (the need for assistance with Activities of Daily Living [ADLs]); an assessment of certain clinical needs; or both. LOC determinations may also include consideration of other factors which, while not
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ADLs per se, nonetheless impact a person’s ability to live safely and independently in the community, such as: • Communication;• Cognitive status; • Behavior; or • The ability to self-administer medications.
LOC determinations may also take into consideration the applicant’s medical or clinical needs such as the need for skilled nursing or rehabilitative care.
"Offeror" means any person, corporation, or partnership that submits a proposal in response to this RFP.
“Peer Consultant” is a person with the same or equivalent professional degree as the professional provider that has provided the justification for the medical necessity and/or the appropriateness of a requested service.
“Pend” means a prior authorization request for which a decision is delayed due to lack of documentation, inability to contact the parties involved, or other reason which delays finalized action. A decision to “pend” does not extend or modify required utilization review decision timelines.
“Potential Offeror” means any person, corporation, or partnership that acknowledges receipt of this RFP and continues to participate in the procurement process as specified in the RFP until the submittal of a proposal, after which time that entity becomes an Offeror.
“Primary Care Provider (PCP)” means a provider who agrees to manage and coordi-nate the care provided to members in the managed care program
“Prior Authorization Request (PA)” is a request for approval of a procedure, service or item prior to provision of the procedure, service or item to the recipient. "Procurement Manager" means the person or designee authorized by HSD to manage or administer a procurement requiring the evaluation of competitive sealed proposals.
“Quality Assurance Reform Initiative (QARI) Guidelines” means A Health Care Quality Improvement System for Medicaid Managed Care: A Guide for the States, Medicaid Bureau, Health Care Financing Administration, U.S. Department of Health and Human Services, July 6, 1993.
“Quality Bureau (QB)” – The bureau within MAD responsible for oversight of all activities related to the quality of healthcare services provided to Medicaid recipients.
“Quality Improvement System for Managed Care (QISMC)” means the interim standards and guidelines released by Health Care Financing Administration (HCFA),
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now CMS, in September, 1998 to assist the States in implementing the quality assurance provisions of the Balanced Budget Act (BBA) of 1997.
“Quality Management (QM) / Quality Improvement (QI)” refers to ‘quality management/quality improvement’ processes that are planned, systemic, clearly defined, and at least as stringent as federal requirements.
"Request for Proposals (RFP)” means all documents, including those attached or incorporated by reference, used for soliciting proposals.
"Responsible Offeror" means an Offeror who submits a responsive proposal and who has furnished, when required, information and data to prove that its financial resources, production or service facilities, personnel, service reputation and experience are adequate to make satisfactory delivery of the services or items of tangible personal property described in the RFP.
"Responsive Offer" or "Responsive Proposal" means an offer or proposal, which conforms in all material respects to the requirements set forth in the request for proposals. The term “material respects” includes, but is not limited to, price, quality, quantity or delivery requirements.
“Risk-Based Contract” refers to a managed care contract that is based on the possibility that MCO revenues will not be sufficient to cover expenditures incurred in the delivery of contractual services. This is due to the MCO acquiring a large number of members, some of whom may have a much higher acuity (with related costs) than other members.
“Rural” refers to the following counties: Chavez, Curry, Grant, Lea, Luna, McKinley, Otero, Roosevelt, Sandoval, San Juan, Taos, Valencia and Eddy.
"Selected Offeror" means the Offeror chosen to enter into a contract with HSD based on the results of the evaluation of all responses to the RFP.
“State Children’s Health Insurance Program (CHIP)” means a federal program to help states expand health care coverage to uninsured children. CHIP is jointly financed by the Federal and State governments and is administered by the States. Within broad Federal guidelines, each State determines the design of its program, eligibility groups, benefit packages, payment levels for coverage, and administrative and operating procedures.
“State Fiscal Year (FY)” means July 1st through June 30th.
“State Plan” means a state-wide plan for Medicaid services submitted for approval to CMS under Title XIX of the federal Social Security Act.
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"State Purchasing Agent (SPA)" refers to the purchasing agent for the State of New Mexico or a designated representative.
“Strength-Based Treatment” means a therapeutic treatment approach, which places emphasis on individual and family strengths versus building on an individual’s illness or perceived weaknesses. Strength-based treatment focuses on the individual, family and support system’s strengths and respects diversity.
“Subcontractor” means a third party who contracts with the contractor for the provision of services for which the contractor has contracted with HSD to perform.
“Suspicious Activity” means any activity that, in one’s professional judgment, appears as if fraud or abuse may have occurred.
“System of Care” means a child/adolescent-focused service delivery model, targeted to children across multiple systems including Medicaid, Juvenile Justice, social services, and behavioral health providers. Some of the most common tools used in this model include: uniform screening and assessment protocols; individualized service plans that follow a child through various services; expansion of formal and informal services; as well as planning the services around the "whole child" and making the families participants in treatment in their communities.
“Temporary Assistance for Needy Families (TANF)” means the New Mexico Temporary Assistance for Needy Families (TANF) program, known as NM Works, provides cash assistance and job training to eligible New Mexico families. This monthly cash assistance benefit should be used to meet family needs such as housing, utilities, and clothing costs.
“Third Party Assessor (TPA)” means the contractor that performs utilization review and assessment functions for Medicaid services and/or programs provided in the fee-for-service environment, including Medicaid Alternative Benefit Plan (ABP) services. The TPA functions consist of medical necessity reviews, prior authorizations, medical eligibility/level of care determinations, and Individual Service Plan /Service and Support Plan and budget reviews, and ABP exemptions.
“Title XIX” refers to the Medicaid title of the Social Security Act (SSA).
“Title XXI” refers to the CHIP title of the Social Security Act (SSA). “Urban” refers to the following counties: Bernalillo, Santa Fe, Dona Ana, and Los Alamos.
“Waiver” refers to a request for an exception to certain federal regulations frequently associated as an alternative to institutionalization, such as Home and Community-based waivers.
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“1915(i)” is a State Plan option created for home and community based services (State Plan HCBS). This allows the state to create a package of services, similar to service packages available under the Section 1915(c) waivers, and makes them available to individuals through the State Plan.
G. BACKGROUND INFORMATION
This provides background on HSD, MAD, and the Medicaid managed care program that may be helpful to the Offeror in preparing a proposal. The information is provided as an overview and is not intended to be a complete and exhaustive description.
1. HSD Mission and Roles
To reduce the impact of poverty on people living in New Mexico by providing support services that help families break the cycle of dependency on public assistance.
To reduce the impact of poverty on the state of New Mexico.
To impact positively the social and economic health of New Mexico.
To assure low-income and disabled individuals in New Mexico equal participation in the life of the community.
2. HSD Resources and Locations
Estimated SFY 2013 Medicaid spending was about $3.7 billion. Approximately seventy percent (70%) of HSD revenue to support the Medicaid spending is from federal sources, twenty-four percent (24%) is from the State general fund, and six percent (6%) is from other revenue sources.
HSD has more than 1,900 employees, and it contracts with community-based service providers throughout the State. There are approximately forty (40) HSD/ISD field office locations statewide. HSD’s central offices are located in the following Santa Fe office buildings: Pollon Plaza Building (Office of the Secretary, ISD, CSED and Office of General Counsel); Ark Plaza Building (MAD); Rodeo Road Building (ASD and the Office of Inspector General); and the Siler Road Building (ITD).
3. Organization of HSD
HSD is a cabinet-level agency in the Executive Branch of the New Mexico state government, headed by a Secretary who is appointed by the Governor and confirmed by the New Mexico Senate. HSD consists of the Office of the Secretary, Administrative Services Division, Behavioral Health Services Division, Child Support Enforcement Division, Income Support Division, Information Technology Division and Medical Assistance Division.
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a. Office of the Secretary
The Office of the Secretary consists of the Secretary of Human Services, the Deputy Secretary for Programs, the Deputy Secretary for Finance and Administration, the Office of General Counsel and the Office of Inspector General.
The Secretary provides cabinet-level direction for HSD and serves as a point of appeal when contractual disputes arise. The Office of General Counsel provides legal support for the Medicaid Managed Care contract and also works with contracts other than MCOs, personnel and union issues, fair hearing representation, legislation and other matters. The Office of Inspector General investigates and pursues cases of fraud and abuse, and administers the fair hearing process.
b. Administrative Services Division (ASD)
ASD provides skilled financial and technical support to agency programs to assist them in meeting their programmatic goals. Services include accounting, budget management, grant management, general services, procurement support and fiscal training.
c. Behavioral Health Services Division (BHSD)
The BHSD’s primary role is to serve as the adult Mental Health and Substance Abuse State Authority for the State of New Mexico. The Authority's role is to address needs, services, and the planning, monitoring and continuous quality systemically for all adults across the state. BHSD’s performance measures include youth on probation, youth suicide and children served who demonstrate improved functioning on a couple of measures.
The Human Services Department is a member of the New Mexico Behavioral Health Purchasing Collaborative (Collaborative) and BHSD works with the Collaborative in establishing policy and in its contractual relationship with the Statewide Entity to implement strategies to manage the adult behavioral health system.
d. Child Support Enforcement Division (CSED)
CSED provides child support enforcement services to the general public and to recipients of TANF and Medicaid. The division was created to establish and enforce support obligations owed by absent parents and/or their financial assets, legally establishing paternity and support obligations, collecting and distributing child support payments according to Federal and State regulations and enforcing support obligations through income withholding, tax refund inception and other remedies.
e. Income Support Division (ISD)
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ISD determines financial eligibility for all programs administered by HSD, including Medicaid. The division's field staff members are administered through district operations offices under the direction of a Deputy Director. Field staff is responsible for interviewing clients, determining financial eligibility and issuing benefits for the SNAP, TANF, Medicaid and other assistance programs.
f. Information Technology Division (ITD)
Under the direction of the HSD Chief Information Officer (CIO), the HSD Information Technology Division (ITD) provides timely and cost-effective information technology services to the department, its programs, divisions and offices, enabling them to fulfill the mission of HSD in an efficient and responsive manner and ensuring that HSD gains full benefit from its current and future investments in technology.
g. Medical Assistance Division (MAD)
The Medical Assistance Division (MAD) is the direct administrator of the New Mexico Medicaid program. On January 1, 2014, Medicaid launched the new Centennial Care program. MAD also has a Fee For Service (FFS), non-managed care component.
4. Overview of the Medicaid Program
The Medicaid Program will change periodically as a result of Congressional mandates, issuance of new Federal regulations, considerations given to Federal financial participation in certain program services, State legislative actions and State program and budget considerations. As a result, the configuration of the Medicaid Program may differ at any given time from the description, which follows.
a. Medicaid Eligibility
Eligibility for all Medicaid programs requires that individuals meet certain state and federal guidelines. These guidelines include citizenship, residency, medical and financial criteria.
b. Administration of the Medicaid Program
MAD is predominately responsible for all Medicaid activities and oversight. MAD also works collaboratively with the Department of Health (DOH) in administration of the Home and Community-based waiver services for specific populations.
5. Centennial Care
Centennial Care is the new name of the New Mexico Medicaid managed care program, authorized through a federal section 1115 demonstration waiver. Centennial Care began on January 1, 2014. Centennial Care services are provided through the MCOs. These services include physical health, behavioral health, and long term care services.
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6. Inter-Organizational Relationships and Coordination
MAD operates in a complex organizational environment that involves state and federal funding and reporting relationships and contracts with many service providers. Much of MAD's work is coordinated with the Managed Care Organizations, New Mexico State Government, the Federal Government, Fiscal Agents, and other organizations.
a. New Mexico State Government
New Mexico's governor is elected for a four-year term. The State government includes the largest state agencies as cabinet-level agencies. State government agencies receive annual appropriations from the Legislature for operations from general tax revenue, earmarked funds, Federal revenues and transfer funds.
b. Federal Government
Most of the programs administered by HSD are funded in whole or in part by the federal government. These programs are identified below.
1. U.S. Department of Health and Human Services (HHS)
2. U.S. Department of Agriculture (USDA)
c. Fiscal Agent
The contracted fiscal agent’s primary functions are to maintain and upgrade the Medicaid Management Information System (MMIS), maintain eligibility and provider files, process and pay claims, make capitation payments, issue enrollment rosters, collect and maintain claims-based utilization data from the fee-for-service program and encounter data from MCOs, and render recurring and ad hoc reports.
d. Other Organizations
MAD enters into contractual arrangements with a variety of public and private organizations. These organizations include, but are not limited to, local governments, educational institutions, nonprofit organizations and businesses.
H. PROCUREMENT LIBRARY
The procurement library is an on-line resource and provides the information at the following links:
1. General Information:http://www.cms.hhs.gov
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2. CFR resource information at:http://www.gpoaccess.gov/cfr/index.html
3. Quality Improvement Organization Manual, available at: http://www.cms.hhs.gov/QualityImprovementOrgs
Other documents that may be relevant to the procurement are available as follows:
a. OBRA 1989, PL 101-239 – Available at:NM State Library – 1209 Camino Carlos Rey, Santa FeNM Supreme Court Law Library – 237 Don Gaspar Ave., Santa Fe
http://www.law.cornell.edu/
b. 25 U.S.C. 1601 et. Seq. – Available at:NM State Library – 1209 Camino Carlos Rey, Santa FeNM Supreme Court Law Library – 237 Don Gaspar, Santa Fe
http://www.law.cornell.edu/
c. Balanced Budget Act of 1997 - Available at:NM State Library – 1209 Camino Carlos Rey, Santa Fe
http://www.law.cornell.edu/
d. New Mexico Administrative Code (NMAC) 1.4.1 State Procurement Code Regulations
e. New Mexico Statutes, Chapter 13 Public Purchases and Property
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II. CONDITIONS GOVERNING THE PROCUREMENT
This section of the RFP contains the schedule for the procurement, describes the major procurement events and the conditions governing the procurement.
A. PROCUREMENT SCHEDULE
The following schedule shall be followed in the procurement of the services described in this RFP. HSD will attempt to perform all activities on or about the date described, however, the dates are subject to change at the discretion of HSD:
Action Responsibility Date *1. Issue of RFP Agency March 21, 20142. Distribution List Response Agency March 27, 20143. Pre-Proposal Conference Potential Offerors March 27, 20144. Deadline To Submit Additional Questions Potential Offerors April 3, 20145. Response to Written Questions Agency April 10, 20146. Deadline for Submission of Proposal Offerors April 24, 20147. Proposal Evaluation Evaluation Committee April 25-May 1,
20148. Selection of Finalists Evaluation Committee May 2, 20149. Best and Final Offers from Finalists Offerors May 9, 201410. Oral Presentation by Finalists (At HSD’s
Discretion)Offerors/Evaluation Committee
May 14-15, 2014
11. Finalize Contract Agency/Offeror May 23, 201412. Contract Award Agency May 29, 201413. Protest Deadline Offerors 15 days following
the contract award14. Effective Date of Contract (Approximate) Agency July 1, 2014
* Dates subject to change at the discretion of the DepartmentB. EXPLANATION OF EVENTS
The following paragraphs describe the activities listed in the sequence of events shown above.1. Issue of RFP
This RFP is being issued by HSD. The RFP may be obtained from the HSD website under the RFP category (http://www.hsd.state.nm.us/LookingForInformation/open-rfps.aspx).
2. Acknowledgment of Receipt of Request for Proposals Form Due
Potential Offerors should hand deliver or return by facsimile, registered or certified mail, or by email with the attachment in Word format, the Acknowledgment of Receipt Form that accompanies this document (Appendix A) to have their organization placed on the procurement distribution list. The form should be signed by an authorized representative of the organization,
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who shall be the sole contact for the Procurement Manager. The form shall be dated and returned to the Procurement Manager as stated in Section II.
The acknowledgment form is used to develop the procurement distribution list. The distribution list shall be used for the distribution of written or e-mailed responses to questions and any RFP amendments. Failure to return this form shall constitute a presumption of receipt and rejection of the RFP and the potential Offeror's organization name shall not appear on the distribution list. Submission of an acknowledgment form does not commit an Offeror to respond to the RFP.
3. Pre-Proposal Conference
A pre-proposal conference shall be held on as stated in Section II, A. PROCUREMENT SCHEDULE at 1:00 P.M. Mountain Time, at the HSD MAD Ark Plaza, South Conference Room, 2025 South Pacheco in Santa Fe, New Mexico or at a location as designated by the Procurement Manager. The conference will allow verbal discussion and clarification of the RFP and the procurement in general. Potential Offerors are encouraged to submit written questions to the Procurement Manager seven (7) calendar days in advance of the conference. Questions can be either e-mailed or sent by hard copy. Any e-mail attachments must be in Word format. If questions are submitted in hard copy, the Offeror must also submit them via email in a Word document attachment. If the Offeror does not have access to word processing software meeting these requirements, questions shall be submitted on non-letterhead paper in clear 12 point or larger font, to facilitate scanning. Questions shall be clearly labeled and shall cite the specific section(s) in the RFP, the contract, or other attachments to the RFP that form the basis of the question. The identity of the organization submitting the question(s) shall not be publicly revealed.
Additional written questions may be submitted at the conference. Written questions submitted up to the date of the conference may be answered at the conference. Offerors shall not rely on verbal answers provided during the pre-proposal conference. Final written answers to all questions shall be issued by HSD as stated in Section II or at a date determined by the Procurement Manager. All potential Offerors of this RFP are invited to participate. A public log shall be kept of the names of potential Offerors that attended the pre-proposal conference. Attendance at the pre-proposal conference is not a prerequisite for submission of a proposal.
4. Deadline to Submit Additional Written Questions
Potential Offerors may submit additional written questions as to the intent or clarity of this RFP as stated in Section II, A. PROCUREMENT SCHEDULE, by 5:00 P.M., Mountain Time. Any questions received after the due date and time will not be acknowledged by HSD. The Procurement Manager will provide a copy of both questions and answers and/or clarifications to all potential Offerors no later than as stated in Section II. HSD will be bound only to answers and/or clarifications provided in writing by the Procurement Manager. Questions can be initially either e-mailed or sent by hard copy. Any e-mail attachments must be in Word format. If questions are submitted in hard copy, the Offeror must also submit them via email in a Word document attachment. If the Offeror does not have access to word processing
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software meeting these requirements, questions shall be submitted on non-letterhead paper in clear 12 point or larger font, to facilitate scanning. Questions shall be clearly labeled and shall cite the specific section(s) in the RFP, the contract, or other attachments to the RFP that form the basis of the question. The identity of the organization submitting the question(s) shall not be publicly revealed.
5. Response to Written Questions
Written responses to written questions and any RFP amendments will be distributed on the date listed in the Sequence of Events in Section II, A. PROCUREMENT SCHEDULE to all potential Offerors whose organization name appears on the procurement distribution list. HSD shall make every effort to meet this timeline or provide answers as close to the deadline as possible.
An Acknowledgement of Receipt Form will accompany the distribution package. The form should be signed by the Offeror’s representative, dated, and hand-delivered or returned by facsimile or by registered or certified mail by the date indicated thereon. Failure to return this form shall constitute a presumption of receipt and withdrawal from the procurement process. Therefore, the Offeror’s organization name shall be deleted from the procurement distribution list.
6. Submission of Proposal
The Procurement Manager or designee must receive all Offeror proposals for review and evaluation no later than 2:00 P.M., Mountain Time as stated in Section II, A. PROCUREMENT SCHEDULE. Proposals shall be addressed to the Procurement Manager and delivered to the Procurement Manager as stated in Section II. Proposals received after this deadline shall not be accepted. The date and time shall be recorded on each proposal as it is received. Substitute proposals, modifications to, or addenda to the original proposals received by the Procurement Manager after the specified date and time shall not be accepted. Proposals shall be sealed and labeled on the outside of the package to clearly indicate that they are in response to the EQRO RFPs. Proposals submitted by facsimile or e-mail shall not be accepted. A public log shall be kept of the names of all Offeror organizations that submitted proposals. (Pursuant to Section 13-1-116 NMSA 1978, the contents of any proposal shall not be disclosed to competing Offerors prior to contract award.)Proposals shall be submitted by mail or in person to:
Elizabeth C. Cassel, Ph.D.Medical Assistance DivisionHuman Services Department2025 South Pacheco StreetSanta Fe, New Mexico 87504
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7. Proposal Evaluation
The evaluation of proposals shall be performed by an Evaluation Committee appointed by HSD management. This evaluation process shall take place as stated in Section II, A. PROCUREMENT SCHEDULE. During this time, the Procurement Manager may at her option, initiate discussions with Offerors who submit responsive or potentially responsive proposals for the purpose of clarifying aspects of the proposals, but proposals may be accepted and evaluated without such discussion. Discussions shall not be initiated by the Offerors.
8. Selection of Finalists
The Evaluation Committee shall select the finalists as stated in Section II, A. PROCUREMENT SCHEDULE. The Procurement Manager shall notify the finalist Offerors in writing (electronic) by 5:00 P.M., Mountain Time, of their selection as finalists and shall transmit HSD's response to the finalist Offerors' alternative terms and conditions. Only finalists shall be invited to participate in the subsequent steps of the procurement. The Evaluation Committee shall finalize the remainder of the procurement schedule at this time.
9. Best and Final Offers From Finalists
Finalist Offerors may be asked to submit revisions to their proposals for the purpose of obtaining best and final offers. Best and final offers may be submitted, clarified and amended before the finalist Offeror’s oral presentation but no later than 5:00 P.M. Mountain Time, as stated in Section II, A. PROCUREMENT SCHEDULE.
10. Oral Presentation Finalists
At HSDs discretion, Finalist Offerors may be required to present their proposals, demonstrations, and designated members of the proposed staff to the Evaluation Committee at a specific time as stated in Section II. All oral presentations shall be held at Ark Plaza, 2025 South Pacheco Street, Santa Fe, New Mexico, and shall be limited in duration to no more than two hours per finalist. The Procurement Manager may contact each finalist to schedule the time for each Offeror's presentation. Oral presentations shall be held at a specific date as stated in Section II. Offerors may not initiate contact seeking information about the finalists. Failure to comply shall result in the assessment of penalties as described in Section I.
11. Finalize Contract
The contract will be finalized with the most advantageous Offeror during the calendar period as stated in Section II, A. PROCUREMENT SCHEDULE. In the event that mutually agreeable terms cannot be reached within the time specified, HSD reserves the right to finalize a contract with the next most advantageous Offeror without undertaking a new procurement process. The Procurement Manager shall contact the successful Offeror. Offerors may not initiate contact with any HSD or other State of New Mexico personnel.
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12. Contract Awards
After review of the Evaluation Committee Report, the recommendation of HSD's management and the negotiated, signed contract, HSD shall award the contract as stated in Section II, A. PROCUREMENT SCHEDULE. This date is subject to change at the discretion of HSD. The location will be determined at a later date.
HSD reserves the right to reject any or all of the offers if HSD determines that an insufficient number of the offers meet the needs of HSD. None of the evaluation factors, including the cost factor, is outcome determinative. Should HSD determine that all the offers meet HSD’s needs, then the contract shall be awarded to the Offeror whose proposal is most advantageous, taking into consideration the evaluation factors set forth in the RFP. A proposal shall be considered the "most advantageous" if HSD determines the proposal shall best meet HSD's needs. The most advantageous proposal may or may not have received the most points.
The award may be subject to the successful completion of additional contract negotiations and appropriate State and Federal approvals.
HSD also reserves the right to request further clarification on information provided in proposals and to allow for correction of errors contained in proposals submitted by Offerors.
13. Protest D ea dline
Any protest by an Offeror must be timely and in conformance with NMSA 1978, Section 13-1-172 and applicable procurement regulations. The fifteen (15) calendar day protest period for responsive Offerors shall begin on the day after notification of the contract award and will end as of close of business as stated in Section II. Protests must be written and must include the name and address of the protestor and the request for proposals number. It must also contain a statement of grounds for protest including appropriate supporting exhibits, and it must specify the ruling requested from the Secretary. The protest must be physically delivered no later than 5:00 P.M. Mountain Standard Time on the 15th day of protest period to:
Office of General CounselPollon Plaza
2009 South PachecoSanta Fe, New Mexico 87505
Mailing Address:P.O. Box 2348
Santa Fe, New Mexico 87504-2348
Protests received after the deadline will not be accepted.
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C. GENERAL REQUIREMENTS
This procurement will be conducted in accordance with the NM Procurement Code and all applicable state and federal regulations and laws.
1. Acceptance of Conditions Governing the Procurement
Offerors must indicate their acceptance of the Conditions Governing the Procurement section in their letter of transmittal. Submission of a proposal constitutes acceptance of the Evaluation Factors contained in this RFP.
2. Incurring Cost
Any cost incurred by the Offeror in preparation, transmittal, presentation of any proposal or material submitted in response to this RFP shall be borne solely by the Offeror.
3. Prime Contractor Responsibility
Any contract that may result from this RFP shall specify that the prime Contractor is solely responsible for fulfillment of the contract with the Department. The Department will make contract payments to only the prime Contractor. The Contractor will be required to comply with all Department-related security and privacy directives, standards and policies, including the codes of conduct. Required HSD online training will be provided on an annual basis.
4. Subcontractors
Use of subcontractors must be clearly explained in the proposal, and major subcontractors must be identified by name. The prime Contractor shall be wholly responsible for the entire performance whether or not subcontractors are used. Subcontractors will be required to comply with various Department-related security and privacy directives, standards and policies, including the codes of conduct. Required HSD online training will be provided on an annual basis.
5. Amended Proposals
An Offeror may submit an amended proposal before the deadline for receipt of proposals. Such amended proposals must be complete replacements for a previously submitted proposal and must be clearly identified as such in the transmittal letter. The Department personnel will not merge, collate, or assemble proposal materials.
6. Offeror’s Rights to Withdraw Proposal
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Offerors will be allowed to withdraw their proposals at any time prior to the deadline for receipt of proposals. The Offeror must submit a written withdrawal request signed by the Offeror's duly authorized representative and addressed to the Procurement Manager.
The approval or denial of withdrawal requests received after the deadline for receipt of the proposals is governed by the applicable procurement regulations.
7. Proposal Offer Firm
Responses to this RFP, including proposal prices, will be considered firm for one hundred twenty (120) days after the due date for receipt of proposals.
8. Disclosure of Proposal Contents
The proposals will be kept confidential until a contract is awarded. At that time, all proposals and documents pertaining to the proposals will be made available for public inspection, except for the material that is labeled by the Offeror as proprietary or confidential. The Procurement Manager will generally not disclose or make public any pages of a proposal on which the Offeror has stamped or imprinted "proprietary" or "confidential" subject to the following requirements:
i. Proprietary or confidential data shall be readily separable from the proposal in order to facilitate eventual public inspection of the non-confidential portion of the proposal. Offeror shall insure that the designated proprietary or confidential information shall also be separable in the electronic versions of the proposal.
ii. Confidential data is normally restricted to confidential financial information concerning the Offeror's organization and data that qualifies as a trade secret in accordance with the Uniform Trade Secrets Act NMSA 1978, Sections 57-3A-1 to 57-3A-7.
iii. The price of products offered or the cost of services proposed shall not be designated as proprietary or confidential information.
iv. If a request is received for disclosure of data for which an Offeror has made a written request for confidentiality, the Secretary or the Secretary’s designee shall examine the Offeror's request and make a written determination, consistent with applicable laws, that specifies which portions of the proposal should be disclosed. Unless the Offeror takes legal action to prevent the disclosure, the proposal will be so disclosed. The proposal shall be open to public inspection subject to any continuing prohibition on the disclosure of confidential data.
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9. No Obligation
This procurement in no manner obligates the State of New Mexico or any of its agencies to the use of any proposed professional services until a valid written contract is awarded and approved by the appropriate authorities.
10. Termination
This RFP may be canceled at any time and any and all proposals may be rejected in whole or in part when the Department determines such action to be in the best interest of the State of New Mexico. 11. Sufficient Appropriation
Any contract awarded as a result of this RFP process may be terminated or adjusted if sufficient appropriations or authorizations do not exist or are reduced. Such termination or adjustment will be effected by sending written notice to the Contractor. The Department's decision as to whether sufficient appropriations and authorizations are available will be accepted by the Contractor as final. For the purposes of this procurement, this may include reducing the number of systems to be replaced or the scope of project management offices services required to meet the Department’s requirements.
12. Compliance with Procurement Requirements
The Department requires that all Offerors agree to be bound by the General Requirements contained in this RFP. Any Offeror concerns must be promptly brought to the attention of the Procurement Manager.
13. Governing Law
This procurement and any agreement with Offerors that may result shall be governed by the laws of the State of New Mexico.
14. Basis for Proposal
Only information supplied by the Department in writing through the Procurement Manager or in this RFP should be used as the basis for the preparation of Offeror proposals.
15. Sample Contract Terms and Conditions
The Contract between the Department and a Contractor will follow the format specified by the Department and may generally contain the terms and conditions set forth in the sample provided in "Sample Contract Terms and Conditions." However, the Department reserves the right to negotiate with a successful Offeror provisions in addition to those contained in this RFP.
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The contents of this Request for Proposal, as revised and/or supplemented, and the successful Offeror's Final Accepted Proposal will be incorporated into and become part of the Contract.
Should an Offeror object to any of the Department's terms and conditions, as contained in this Section or in Appendix 3-A, the Offeror must propose specific, alternative language (see Offeror’s Additional Terms and Conditions form in Appendix 1-K). The Department may or may not accept the alternative language. General references to the Offeror's terms and conditions or attempts at complete substitutions are not acceptable to the Department and will result in disqualification of the Offeror's proposal.
Offerors must provide a brief discussion of the purpose and impact, if any, of each proposed change followed by the specific proposed alternate wording.
All contracts for professional services are subject to the review and approval of DFA pursuant to NMSA 1978, Section 13-1-118 and DFA Rule 2.40.2 NMAC.
16. Offeror Terms and Conditions
Offerors may request changes in the HSD contract terms and conditions. Offerors must submit with the proposal a complete set of any additional terms and conditions which they request to have included in a contract negotiated with the Department, using Appendix 1-K Offerors Additional Terms and Conditions Form. Offerors should not rely on acceptance of any changes in terms or conditions.
17. Contract Deviations
Any additional terms and conditions, which may be the subject of negotiation, will be discussed only between the Department and the selected Offeror and shall not be deemed an opportunity to amend the Offeror's proposal.
18. Offeror Qualifications
The Evaluation Committee may make such investigations as necessary to determine the ability of the Offeror to adhere to the requirements specified within this RFP. The Evaluation Committee will reject the proposal of any Offeror who is not a responsible Offeror or fails to submit a responsive offer as defined in NMSA 1978, Sections 13-1-83 and 13-1-85.
19. Right to Waive Minor Irregularities
The Evaluation Committee reserves the right to waive minor irregularities. The Evaluation Committee also reserves the right to waive mandatory requirements provided that all or the majority of the otherwise responsive proposals failed to meet the mandatory requirements and/or doing so does not otherwise materially affect the procurement. This right is at the sole discretion of the Evaluation Committee.
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20. Change in Contractor Representatives
The Department reserves the right to require a change in Contractor representatives if the assigned representatives are not, in the opinion of the Department, meeting its needs adequately.
21. Notice
The Procurement Code, NMSA 1978, Sections 13-1-28 through 13-1-199, imposes civil and misdemeanor criminal penalties for its violation. In addition, the New Mexico criminal statutes impose felony penalties for bribes, gratuities and kickbacks.
22. Department Rights
The Department reserves the right to accept all or a portion of an Offeror's proposal.
23. Right to Publish
Throughout the duration of this procurement process and contract term, potential Offerors and Contractors must secure from the Department written approval prior to the release of any information that pertains to the potential work or activities covered by this procurement or the subsequent contract. Failure to adhere to this requirement may result in disqualification of the Offeror's proposal or termination of the contract.
24. Ownership of Proposals
All documents submitted in response to this Request for Proposals shall become the property of the Department and the State of New Mexico.
25. Electronic Mail Address Required
A large part of the communication regarding this procurement will be conducted by electronic mail (e-mail). Offerors must have a valid e-mail address to receive this correspondence.
26. Use of Electronic Versions of this RFP
This RFP is being made available by electronic means. If accepted by such means, the Offeror acknowledges and accepts full responsibility to maintain consistency with the original RFP and amendments as issued. In the event of conflict between a version of the RFP in the Offeror’s possession and the version maintained by the Department, the version maintained by the Department shall govern.
27. Disclosure Regarding Responsibility
Any prospective Offeror and/or any of the Principals that seek to enter into a contract greater than twenty thousand dollars ($20,000.00) with any state agency or local public body for
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professional services, tangible personal property, services or construction agrees to disclose whether they, or any principal of their company:
a. Are presently debarred, suspended, proposed for debarment or declared ineligible for award of contract by any federal entity, state agency or local public body.
b. The taxpayer is delinquent in making payment. A taxpayer is delinquent if the taxpayer has failed to pay the tax liability when full payment was due and required. A taxpayer is not delinquent in cases where enforced collection action is precluded.
c. Are presently indicted for, or otherwise criminally or civilly charged by any (Federal, state or local) government entity with commission of any offenses.
d. Have preceding this offer, been notified of any delinquent federal or state taxes in an account that exceeds three thousand dollars ($3,000.00) of which the liability remains unsatisfied. Taxes are considered delinquent if both of the following criteria apply:
1) The tax liability is finally determined. The liability has been finally determined if it has been assessed. A liability is not finally determined if there is a pending administrative or judicial challenge. In the case of a judicial challenge of the liability, the liability is not finally determined until all judicial appeal rights have been exhausted.
2) The taxpayer is delinquent in making payment. A taxpayer is delinquent if a taxpayer has failed to pay the tax liability when full payment was due and required. A taxpayer is not delinquent in cases where enforced collection action is precluded.
e. Have within a three year period preceding this offer, had one or more contracts terminated for default by any federal or state agency or local public body.
Principal, for the purpose of this disclosure, means an officer, director, owner partner, or a person having primary management or supervisory responsibilities within a business entity or related entities.
The Offeror shall provide immediate written notice to the Procurement Manager if, at any time prior to contract award, the Offeror learns that its disclosure was erroneous when submitting or became erroneous by reason of changed circumstances.
A disclosure that any of the items in this requirement exist will not necessarily result in withholding an award under this solicitation. However, the disclosure will be considered in the determination of the Offeror’s responsibility. Failure of the Offeror to furnish a disclosure or provide additional information as requested will render the Offeror nonresponsive.
Nothing contained in the foregoing shall be construed to require establishment of a system of record in order to render, in good faith, the disclosure required by this RFP. The knowledge and
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information of an Offeror is not required to exceed that which is the normally possessed by a prudent person in the ordinary course of business dealings.
The disclosure requirement provided is a material representation of fact upon which reliance was placed when making an award and is a continuing material representation of the facts. If during the performance of the contract, the Offeror is indicted for or otherwise criminally or civilly charged by any government entity (federal, state or local) with commission of any offenses named in this document the Offeror must provide immediate written notice to the Procurement Manager. If it is later determined that the Offeror knowingly rendered an erroneous disclosure, in addition to other remedies available to the Government, the Secretary may terminate the involved contract for cause. Still further the Secretary may suspend or debar the Offeror from eligibility for further solicitations until such time as the matter is resolved to the satisfaction of the Secretary.
28. New Mexico Employees Health Coverage
a. If Contractor has, or grows to, six (6) or more New Mexico employees who work, or who are expected to work, an average of at least 20 hours per week over a six (6) month period during the term of the Contract, Contractor certifies, by signing this agreement, to have in place, and agree to maintain for the term of the contract, health insurance for those employees and offer that health insurance to those employees if the expected annual value in the aggregate of any and all contracts between Contractor and the State exceed two hundred and fifty thousand dollars ($250,000).
b. Contractor agrees to maintain a record, subject to review and audit by a representative of the state, of the number of employees who have:
1) accepted health insurance; 2) declined health insurance due to other health insurance coverage already in place;
or 3) declined health insurance for other reasons.
c. Contractor agrees to advise all employees of the availability of state publicly financed health care coverage programs by providing each employee with, as a minimum, the following web site link to additional information: http://www.hsd.state.nm.us/mad/
29. Employee Pay Equity Reporting
Contractor agrees if it has ten (10) or more New Mexico employees OR eight (8) or more employees in the same job classification, at any time during the term of this Contract, to complete and submit the PE 10-249 form on the annual anniversary of the initial report submittal for contracts up to one (1) year in duration. If Contractor has two hundred and fifty (250) or more employees, Contractor must complete and submit the PE 250 form on the annual anniversary of the initial report submittal for contracts up to one (1) year in duration. For contracts that extend beyond one (1) calendar year, or are extended beyond one (1) calendar
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year, Contractor also agrees to complete and submit the PE 10-249 or PE 250 form, whichever is applicable, within thirty (30) days of the annual contract anniversary date of the initial submittal date or, if more than one hundred and eighty (180) days has elapsed since submittal of the last report, at the completion of the contract, whichever comes first.
Should Contractor not meet the size requirement for reporting at contract award but subsequently grows such that they meet or exceed the size requirement for reporting, Contractor agrees to provide the required report within ninety (90 days) of meeting or exceeding the size requirement. That submittal date shall serve as the basis for submittals required thereafter. Contractor also agrees to levy this requirement on any subcontractor(s) performing more than ten percent (10%) of the dollar value of this Contract if said subcontractor(s) meets, or grows to meet, the stated employee size thresholds during the term of the contract. Contractor further agrees that, should one or more subcontractor not meet the size requirement for reporting at contract award but subsequently grows such that they meet or exceed the size requirement for reporting, Contractor will submit the required report, for each such subcontractor, within ninety (90 days) of that subcontractor meeting or exceeding the size requirement. Subsequent report submittals, on behalf of each such subcontractor, shall be due on the annual anniversary of the initial report submittal. Contractor shall submit the required form(s) to the State Purchasing Division of the General Services Department, and other departments as may be determined, on behalf of the applicable subcontractor(s) in accordance with the schedule contained in this paragraph. Contractor acknowledges that this subcontractor requirement applies even though Contractor itself may not meet the size requirement for reporting and be required to report itself. Notwithstanding the foregoing, if this Contract was procured pursuant to a solicitation, and if Contractor has already submitted the required report accompanying their response to such solicitation, the report does not need to be re-submitted with this Agreement.
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III. RESPONSE FORMAT AND ORGANIZATION
A. NUMBER OF RESPONSES
Offerors shall submit only one proposal.
B. NUMBER OF COPIES
Offerors shall deliver one (1) original and five (5) identical copies of their technical proposal (binder1), one (1) original and two (2) identical copies of the cost proposal (binder 2) and five (5) copies of supporting documentation (binder 3), to the location specified in Section I, Paragraph E on or before the closing date and time for receipt of proposals. Original binders must be identified.
C. PROPOSAL RESPONSIVENESS
HSD will make the final determination as to a proposal’s completeness or responsiveness. Any proposal that does not adhere to this format and that does not address each specification and requirement within the RFP may be deemed non-responsive and rejected on that basis. HSD is not responsible for any costs incurred in the preparation or submission of a proposal. All material submitted in response to this RFP becomes the property of the State of New Mexico.
D. ECONOMY OF PREPARATION
Proposals should be prepared simply and economically, providing a straightforward, concise description of the Offeror’s ability to meet the requirements of the RFP.
E. TECHNICAL PROPOSAL CONTENT AND FORMAT
All technical proposals shall be typewritten on standard 8 1/2 x 11 inch paper, size 12 font and placed in a three ring binder with tabs delineating each section. Larger paper is permissible for charts, spreadsheets and other graphics.
Within each section of the Technical Proposal, the Offeror must address the items in the order in which they appear in this RFP. All discussion of proposed costs, rates or expenses must not be discussed in the Technical Proposal and must be confined to the Cost Proposal only.
1. Technical Proposal Organization
The technical proposal shall be organized, numbered individually by section and indexed in the following format and shall contain, as a minimum, all listed items in sequence:
a. Letter of Transmittalb. Table of Contentsc. Compliance and Acceptance Statementd. Proposal Summary e. Offeror’s Non-Financial Qualificationsf. Key Personnel
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g. Work Plan h. Scope of Work: Response to Mandatory Requirements i. Response to Suspension and Debarment Requirementj. Other Supporting Material (Optional)
2. Letter of Transmittal
Each proposal shall be accompanied by a letter of transmittal that shall:
a. Identify the submitting organization.b. Identify the name, title and telephone number of the person authorized by the
organization to be contacted for clarification of the proposal, to negotiate the contract on behalf of the organization, and to contractually obligate the organization.
c. Explicitly indicate acceptance of the Conditions Governing the Procurement stated in Section II.
d. Be signed by the person authorized to contractually obligate the organization.e. Acknowledge receipt of any and all amendments to this RFP, if applicable.
3. Table of Contents
The Table of Contents should contain a list of all required and optional sections of the Technical Proposal and the corresponding page numbers.
4. Compliance and Acceptance Statement
The Technical Proposal shall include a signed statement which explicitly indicates acceptance of the Conditions Governing the Procurement stated in Section II of the RFP, and that the Offeror agrees to comply with all requirements as described in this RFP, including all appendices, attachments, written clarifications, and amendments provided during the procurement process.
a. The Offeror shall specifically address the Sample EQRO Contract Terms And Conditions (Appendix B), and the Centennial Care Policy Manual (Appendix C).
b. The Offeror shall provide an affirmative response that it agrees with all terms and conditions presented in the contract. Should an Offeror object to any of HSDs terms and conditions as contained in Appendix B that Offeror must propose specific alternative language. HSD may or may not accept the alternative language. General references to the Offerors terms and conditions or attempts at complete substitutions are not acceptable to HSD and will result in disqualification of the Offerors proposal. Offerors must provide a brief discussion of the purpose and impact, if any, of each proposed change followed by the specific proposed alternative wording.
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5. Proposal Summary
A Technical Proposal summary will provide the Evaluation Committee with an overview of the technical and business features of the Technical Proposal.
6. Offeror’s Non-Financial Qualifications
In the Technical Proposal, the Offeror must demonstrate its qualifications for ensuring successful and timely completion of all requirements as stated in this RFP and the Technical Proposal. Areas to be highlighted should include, but not be limited to, the following.
a. Organization: The Offeror must provide a description and an organizational chart displaying the Offeror's overall governance and management structure. The Offeror should also describe how its organization operates within the framework of the principles of continuous quality improvement (CQI).
b. Prior Experience: The Offeror must state previous relevant experience with contracted efforts similar to the one proposed in this RFP. The Offeror must also include identifying information on individuals and organizations that may be contacted by HSD concerning those contracts. The discussion of relevant prior experience should address each major part of the Detailed Scope of Work outlined in Section IV of this RFP and be presented in the same order.
c. References: The Offeror must provide at least three (3) references concerning its relevant prior experience who may be contacted by HSD concerning recent contractor performance.
d. Eligibility of Offeror: A summary of the Offeror's eligibility qualification according to the criteria outlined in Section I of this RFP.
7. Key Personnel
The Offeror shall include a description of the key staff members who will organize and manage the project. At a minimum, this must include:
a. Key personnel to be assigned to the planning and development of the project including each individual's name, responsibilities, and relevant past experience;
b. Key personnel to be assigned to the operation and execution of the project including each individual's responsibilities and the relationship of this project to the Offeror’s overall organizational structure; the key personnel should include at least the following:
1. Chief Executive Officer of the organization;
2. Project Manager for the project covered by this RFP;
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3. Medical Director (licensed Physician);
4. Person(s) possessing experience and expertise in auditing, accounting, research design, sampling, and biostatistics and in the epidemiological and statistical measurement of health and service status indicators in defined populations;
5. First line staff reporting directly to the Project Manager;
6. A HIPAA compliance officer who is familiar with all issues relating to the development, implementation, maintenance of, and adherence to the organization’s policies and procedures covering HIPAA; and
7. Others in the organization who the Offeror considers key in the operation and execution of the project.
c. Personal resumes of the project manager and other key personnel, including their previous experience relative to the project.
8. Work Plan
The Offeror shall describe in narrative form the manner in which the organizational capacity of the Offeror shall be organized and directed to accomplish the items in Section IV, Detailed Scope of Work. The work plan narrative shall be organized in the following manner:
a. Planning and Development Activities - The Offeror shall identify the manner in which necessary resources, including personnel and equipment, shall be allocated, and identify key activities and tasks necessary for a smooth implementation. The Offeror shall identify responsibilities for implementing the various activities, and provide a schedule for completion of the activities.
b. Transition Activities : The Offeror shall describe the activities to be completed during the transition phase to accomplish the requirements identified in the RFP and as proposed in the Offeror’s response. The Offeror shall identify activities to establish the program, and to set in place the supporting systems, procedures, and other elements of infrastructure. The Offeror shall associate the activities and responsibilities with key personnel identified in Section III of this RFP.
c. Operations Activities : The Offeror shall identify the manner in which specific functions delineated in the Scope of Work of the RFP shall be organized and managed. The description shall incorporate organizational charts and other references that demonstrate how the organizational resources will be devoted to accomplishing the specified requirements.
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9. Scope of Work: Response to Mandatory Requirements
The items identified as Mandatory Requirements in Section IV, Scope of Work, are contractual issues that must be implemented. The Offeror must include documentation to demonstrate that the mandatory functions will be in place by the beginning of the contract period unless otherwise agreed upon by HSD. The responses should be organized and numbered in the same manner as delineated in the RFP. Supporting documentation and material that is included in the proposal shall be cross-indexed to the specific area.
10. Response to Suspension and Debarment Requirement
The Offeror must complete the form set out in Appendix E to certify compliance with the Federal Regulations relating to Suspension and Debarment.
11. Other Supporting Material (Optional)
The Offeror may provide attachments necessary to demonstrate its ability to meet the requirements of this section of the RFP. Such attachments shall be identified and attached to the provided response.
F. COST PROPOSAL CONTENT AND FORMAT
Offerors shall utilize the Cost Proposal Form, Appendix D, to provide the information required in the Cost Proposal. The evaluation of the Cost Proposals by HSD shall be based on information included on this form and the response to methodology questions on the development of the Cost Proposal. The Cost Proposal must be sealed separate from the Technical Proposal.
G. NEW MEXICO EMPLOYEES HEALTH COVERAGE
The Offeror must agree with the terms and submit a signed New Mexico Employees Health Coverage Form with the submittal of their proposal. (See Appendix F of this RFP.)
H. CAMPAIGN CONTRIBUTION DISCLOSURE
The Offeror must complete the Campaign Disclosure form (See Appendix G of this RFP.)
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IV. SCOPE OF WORK
In this section, HSD lists the major categories of contract deliverables the Offerors must address in the technical proposal. Offerors must meet all mandatory requirements listed in the RFP and Appendix B. The Offeror must provide a detailed explanation of how the Offeror will meet all mandatory requirements in the scope of work. Failure to meet this requirement may result in a determination of non-responsiveness by the procurement manager.
A. EQRO PROGRAM ADMINISTRATION
General Requirements
Expectations
EQRO program requirements are linked to the federal requirement for adherence to specific quality of care and service standards as well as state and federal regulations. An Offeror must be a Quality Improvement Organization (QIO) or meet the requirements for a QIO in accordance with 42 CFR 431.630 (Medicaid QIO Regulation).
Offerors shall demonstrate the existence of a fully staffed, professionally qualified organization that is capable of managing a complex EQR program overseeing and monitoring a diverse set of Medicaid contracts. The organization, and its subcontractors, must be able to meet all administrative requirements related to appropriate state licensure, solvency, reporting, payment to providers and compliance with all applicable federal and state laws and regulations.
Offerors shall demonstrate experience utilizing the NCQA standards as applied to a Medicaid managed care program.
Mandatory Requirements
The Offeror shall:
Be an entity that meets the competence and independence criteria defined in 42 CFR 438 for an EQR;
Submit a detailed professional organizational structure, which demonstrates the abilities to fulfill all of the requirements noted in this RFP. Include all key positions that would be involved in work products such as Encounter Data Validation and statistical analysis and research design;
Demonstrate a staff with experience and knowledge of:
o Medicaid recipients, policies, data systems, encounter data validation and processes.
o Managed Care delivery systems, organizations, and financing.o Quality assessment and improvement methods.
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o Research design and methodology, including statistical analysis, and non-traditional funding methodologies and approaches to allow for effective evaluation and monitoring.
o Disease management strategies and interventions chronic diseases.
Demonstrate sufficient physical, technological, and financial resources to conduct EQR or EQR-related activities;
Demonstrate other clinical and non-clinical skills necessary to carry out EQR or EQR-related activities and to oversee the work of any subcontractor;
Submit an overview work plan for the provision of the various external quality review activities that include quality oversight and monitoring of:
o The Centennial Care MCOs o The FFS/UR Agent
Demonstrate the employment of appropriately trained professional staff with relevant qualifications and applicable experience. This shall include clinical expertise in these specialized contracts, such as experience with Centennial Care MCO programs and FFS-UR services. Professional licensure such as nurses, physicians, and other professional staff must meet the specialty requirements of this contract (See Section III);
Demonstrate the capability to meet all applicable requirements and standards delineated under State or Federal law, regulations, and/or policy.
EQRO Administrative Burdens
Expectations
The Offeror must maintain administrative resources within the state of New Mexico to adequately provide effective delivery of work products, trainings, and regular meetings with the MAD staff and managed care contractors. The Offeror must be able to segregate all quality review information related to the various Medicaid contracts. The EQRO will be responsible for performing directed quality oversight for other product lines of Medicaid business. The Offeror must report the information in a manner that is consistent with the needs of HSD. Submission of all draft EQRO reports will undergo strict internal reviews before submission to the state with the understanding that all reports are potentially made public other than those with protected health information (PHI). The EQRO will consistently identify areas of the quality review that demonstrate opportunities for improvement.
HSD expects the EQRO to review and make recommendations for cost containment initiatives when opportunities for cost saving are identified in the course of monitoring activities performed for this contract. In particular, the EQRO should include specific recommendations for opportunities for cost saving to be given in the body of the EQRO review reports.
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A format for standardizing the various reporting documents will be jointly agreed upon by HSD and the contractor.
Mandatory Requirements
The Offeror shall:
1. Demonstrate dedicated administrative resources, physically within the state of New Mexico, to meet all contract deliverables.
2. Use current technology to minimize administrative burdens for the contractors and state staff, as well as any subcontracted delegates.
3. Be proficient in all required CMS deliverables for Medicaid managed care contracts.
4. Be proficient in HEDIS-Like / HEDIS-related reporting analysis.
5. Be proficient in Nursing Facility Level of Care (NF LOC) rating determination review and reporting analysis.
6. Be proficient in Centennial Care service plan reporting analysis.
7. Demonstrate prior experience in the utilization of the National Committee for Quality Assurance (NCQA) standards for the review, auditing and monitoring of the managed care contracts.
8. Be proficient in the current industry standards for Medicaid encounter data to ensure a comprehensive encounter data validation study for the state of the various Medicaid contractors included in the scope of this contract.
9. Have the capacity to perform a comprehensive Independent Assessment (IA) of MAD Programs, as required by CMS.
10. Have policies and procedures on confidentiality, including a provision that all materials concerning Medicaid members will be made available to HSD.
EQRO Monitoring Requirements
Expectations
HSD is required by CMS to contract with an EQRO for the performance of all required EQR activities for the purpose of monitoring the Medicaid MCO programs. EQRO activities include the development of the methodology for the measurement of MCO performance against standards that are contained in the MCO contracts, those standards that have been promulgated as New Mexico state regulations, as well as the NCQA standards for managed care
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organizations. The EQRO contractor shall adopt industry statistical standards of random sampling in their methodology to follow at a minimum of a ninety-five (95) percent confidence interval and standard error rate of no more than .05 percent. The annual evaluation of the MCOs will allow a comparison of performance among the contracted MCOs. When comparisons are included, the EQRO will ensure that the performance measured is for the same time period for all MCOs.
Other EQR mechanisms for quality monitoring may be included in the scope of work for this contract, such as monitoring the managed care required performance measurements, monitoring and evaluating the MCOs’ compliance with HSD’s encounter data standards through the use of an encounter validation study, as well as consumer and provider satisfaction surveys.
Additionally, HSD has historically used its contract with an EQRO to expand the scope beyond annual MCO evaluations. For example, the EQRO may audit periodic samples of UR denial decisions. These audits are intended to determine if authorized service levels are appropriate with respect to accepted standards of clinical care as well as evaluation of the correct application of the state’s definition for medically necessary services. The EQRO may also be requested to perform other activities which are not related to the Medicaid Managed Care requirements. For example, the EQRO may be directed to audit the state’s FFS/UR agent’s execution of utilization review procedures.
Mandatory Requirements
The Offeror shall:
1. Follow NCQA guidelines for the annual MCO compliance audits.
2. Be able to assist in provider satisfaction surveys of a statistically valid sample of all in-network providers as requested by HSD.
3. Report the information from consumer and/or provider surveys to HSD with recommendations for targeted improvements as requested by HSD.
4. Evaluate and make recommendations to the state regarding the MCOs’ QM/QI Effectiveness Evaluation as requested.
5. Review and make recommendations for quality improvement and cost containment initiatives when opportunities are identified in the course of monitoring activities performed for this contract.
6. Provide technical assistance and guidelines to the managed care contractors, as requested by HSD.
7. Perform HSD-directed quality and/or performance ad hoc review activities. EQRO performance activities may include any of the following:
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a. Specific standard or set of standards;b. Special defined population of members;c. Specific age or other demographic group;d. Specific geographic area;e. Specific MCO, subcontractor of an MCO, or provider group or individual
provider in the network of one or more MCOs;f. Specific diagnosis or group of diagnoses or health conditions; andg. Other parameters.
EQRO Encounter Data Monitoring
Expectations
The state has placed significant emphasis on the use of and reliance on accurate and credible encounter data as a means of monitoring the various Medicaid contracts. HSD shall utilize the EQRO contract to assist with the evaluation, technical assistance, monitoring and reevaluation of various contractors’ encounter data.
It is imperative that the EQRO be able to demonstrate the capabilities (data management systems, hardware and software capabilities, qualified and trained personnel, data reporting capabilities) to collect, maintain, and manage all required encounter data elements. The Offeror must collect specifically requested sets of encounter data for the purpose of evaluating the quality of care and provider compliance with billing standards. Serious levels of inaccurate and/or incomplete data submission would require prompt reporting to the state to enable appropriate and timely interventions to occur either at the MCO or provider level.
Mandatory Requirements
The Offeror shall:
1. Have administrative expertise and capabilities for developing and conducting comprehensive Encounter Data Validation (EDV) studies utilizing accepted industry standards for these studies.
2. Have a formal monitoring and reporting system to evaluate encounter data from the various managed care contracts when requested by the state as part of scope of this RFP. Include mechanisms to assess the timeliness of submissions, accuracy and completeness of data.
3. Analyze encounter data as a mechanism for evaluating quality of care and provider compliance with billing standards. Serious levels of inaccuracy and/or incompleteness of data submission can result in sanctions impacting the Medicaid contractor and/or provider.
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4. Have appropriate technical expertise in EDV studies to provide targeted recommendations for systems’ changes to address areas of necessary improvement in the accuracy of encounter data.
5. Comply with the most current federal standards for encryption of any data that is transmitted via the Internet.
6. Comply with CMS and HIPAA standards for electronic transmission, security, and privacy of all data.
EQRO Data System Evaluation Requirements
Expectations
The Offeror may be responsible for periodic review and evaluation of Medicaid contractors’ Management Information Systems (MMIS) sufficient to meet the system requirements outlined in this RFP as directed by the state. The Offeror may also be requested by the state to ensure that the MCO subcontractors and delegates have sufficient systems capability to meet HSD’s data system requirements. The EQRO must meet the system requirements as outlined in 4.20 of the Centennial Care Contract. The EQRO must have mechanisms to allow for comprehensive evaluation of procedures for sharing clinical information between the MCO providers. HSD may require the Offeror to assist with the evaluation of these mechanisms for information sharing to ensure all HIPAA and confidentially requirements are being met.
Mandatory Requirements
The Offeror shall:
1. Have the technical ability, systems, and tools to facilitate data transfers to and from the MCO contractors, the state, and EQRO.
2. Have an adequate data system for evaluating and reporting specific data capacities required in the multiple managed care contract requirements.
3. Maintain system hardware, software, and Information Systems (IS) resources sufficient to meet all of the EQRO contract requirements.
4. Adhere to all current HIPAA confidentiality requirements.
5. Transmit reports and data electronically via Internet systems to HSD as directed.
6. Maintain a web site to be able to receive communications electronically and respond when appropriate.
7. Maintain a data system backup and recovery plan for all essential data.
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EQRO Program Integrity Requirement
Expectations
Program integrity within Medicaid is a priority of HSD. Achieving program integrity requires the active involvement of every component of MAD, and effective coordination with our partners, including contractors, the EQRO contractor, the providers, beneficiaries, and law enforcement. The state’s plan for program integrity is composed of several initiatives, some targeting program management areas and others targeting specific benefit categories. A key requirement for an effective fraud and abuse plan is a mechanism for timely and accurate reporting to the HSD staff from the EQRO regarding any indications of potential fraud and abuse noted during any of the Medicaid quality monitoring initiatives. Any indication of suspicious activity identified by the EQRO must be reported to HSD immediately. In particular, during annual reviews of the managed care contracts or during utilization management (UM) audits, the EQRO must be able to review for any evidence of over and under utilization of services.
Mandatory Requirements
The Offeror shall:
1. Have systems that can monitor service utilization and encounters for evidence of fraud and abuse.
2. Report all suspected fraud and abuse to HSD promptly.
3. Have policies and procedures for submitting to HSD, on a monthly basis, any providers identified with aberrant utilization during the course of EQRO monitoring activities.
4. Not use its organization’s determination as to whether questionable patterns in provider profiles are acceptable or not as a basis to withhold this information from HSD.
EQRO Quality Improvement/Quality Assurance (QI/QA) Program Structure and Operations
Expectations:
Quality management is an integrated approach that links knowledge, structure, and processes together throughout an EQRO’s organization to assess and improve quality. The goal of quality improvement activities is to improve the quality of clinical monitoring and oversight of Medicaid MCO and other health related contracts.
A quality management and improvement program structure provides the framework within which the EQRO assesses and improves the various contract’s quality of care and service. This structure includes a clear definition of the authority of the QI program, including the governing body and any appropriate group within the organization to which it may designate oversight of quality matters. It also describes the scope and content of the program, the roles and
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responsibilities of individuals involved in the program, how the program will be evaluated, and it describes the role, structure, and function of the QI committee and associated committees. The quality management and improvement program is broad in scope, and reflects the range of clinical monitoring and oversight activities to be performed by the EQRO of the various MCOs and other programs.
Mandatory Requirements
The Offeror shall:
1. Have a QM/QI program, including goals, objectives, structure and policies, that will result in continuous quality improvement of all EQRO-contracted work products.
2. Evaluate the overall effectiveness of the QI program and demonstrate improvements in the quality of clinical oversight and monitoring activities.
3. Have a QI work plan that includes immediate objectives for each contract for the entire contract period. Include the scope of the objectives, activities planned, timeframe and other relevant information.
4. Have policies and procedures for all Medicaid medical records review documentation conducted during the course of this contract.
5. Have policies and procedures for monitoring the effectiveness of the MCOs’ targeted disease management (DM) protocols and procedures for chronic diseases and/or conditions such as asthma, diabetes, hypertension, arthritis, coronary disease, bipolar disorder, depression, Attention Deficit Hyperactivity Disorder (ADHD), and schizophrenia.
6. Have policies and procedures for evaluating the MCOs’ procedures for quarterly tracking of indicators of the efficacy of the DM interventions.
7. Have policies and procedures for monitoring the effectiveness of the MCOs’ care coordination of high-need members.
EQRO Utilization Management (UM) and Utilization Review (UR) Standards
Expectations
Appropriate Utilization Management (UM) standards must be implemented as well as activities performed so that excellent services are provided in a coordinated fashion with neither over- nor under-utilization. The EQRO contractor’s evaluation of any of the managed care or fee-for-service contractors’ UM programs will be based on clinical criteria approved by the state, established and implemented consistently across the state by the MCOs, and which is congruent with HSD’s medically necessary service definition, see 8.305.1.7 NMAC.
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The expectation for the EQRO is to monitor and evaluate compliance of these criteria during the annual and ad hoc audits as directed by HSD. Additionally, the EQRO will be expected to evaluate the efficacy of the contractors’ policies and procedures for the targeted proactive identification and outreach of vulnerable, complex and/or high-needs clients as well as care coordination activities ensuring comprehensive and coordinated care.
Mandatory Requirements
The Offeror shall:
1. Have policies and procedures for reviewing utilization decisions, made by the MCOs, to ensure they meet Medicaid’s medical necessity criteria.
2. Have policies and procedures to ensure inter-rater reliability among the EQRO UM audit staff. Internal monitoring activities must be included in the EQRO/UM program design.
3. Have policies and procedures that comply with NCQA Standards for MCO UM and follow NCQA timeliness standards for routine, urgent and emergent situations, unless they differ with current Medicaid quality standards.
4. Have policies and procedures for reviewing the state’s FFS/UR contractor’s UR decisions (including inter-rater reliability processes) to ensure they are based on state approved clinical criteria.
5. Have policies and procedures that ensure that the MCOs’ UM functions are appropriately implemented without barriers to timely access to care and monitored by the EQRO contractor.
6. Ensure the use of appropriately licensed medical professionals on all clinical denials by the managed care contractors’ UM staff.
7. Ensure the provision and implementation of procedures for sharing of clinical information among the MCO providers.
8. Apply the state’s managed care standards to the MCOs’ UM processes during all compliance reviews.
B. MEDICAID CONTRACTS FOR COVERED BENEFITS/SERVICES
Expectations
The EQRO contractor will be utilized for EQR and monitoring of Medicaid contractors.
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The delivery model for the Medicaid benefit package entails a physical health (PH), behavioral health (BH) and long term care (LTC) delivery system managed by all Centennial Care MCOs. The benefit package reflects the covered services. The following is a list of benefit services:
Non-Community Benefit Services Included Under Centennial Care
Accredited Residential Treatment Center ServicesAdaptive Skills Building (Autism)Adult Psychological Rehabilitation ServicesAmbulatory Surgical Center ServicesAnesthesia ServicesAssertive Community Treatment ServicesBehavior Management Skills Development ServicesBehavioral Health Professional Services: outpatient behavioral health and substance abuse servicesCase ManagementCommunity Interveners for the Deaf and BlindComprehensive Community Support ServicesDay Treatment ServicesDental ServicesDiagnostic Imaging and Therapeutic Radiology ServicesDialysis ServicesDurable Medical Equipment and SuppliesEmergency Services (including emergency room visits and psychiatric ER)Experimental or Investigational Procedures, Technology or Non-Drug Therapies1Early and Periodic Screening, Diagnosis and Treatment (EPSDT)EPSDT Personal Care ServicesEPSDT Private Duty NursingEPSDT Rehabilitation ServicesFamily PlanningFamily Support (Behavioral Health)Federally Qualified Health Center ServicesHearing Aids and Related EvaluationsHome Health ServicesHospice ServicesHospital Inpatient (including Detoxification services)Hospital OutpatientInpatient Hospitalization in Freestanding Psychiatric HospitalsIntensive Outpatient Program ServicesIV Outpatient ServicesLaboratory ServicesMedication Assisted Treatment for Opioid DependenceMidwife ServicesMulti-Systemic Therapy ServicesNon-Accredited Residential Treatment Centers and Group HomesNursing Facility ServicesNutritional ServicesOccupational ServicesOutpatient Hospital based Psychiatric Services and Partial HospitalizationOutpatient and Partial Hospitalization in Freestanding Psychiatric HospitalOutpatient Health Care Professional Services
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Pharmacy ServicesPhysical Health ServicesPhysical TherapyPhysician VisitsPodiatry ServicesPregnancy Termination ProceduresPreventive ServicesProsthetics and OrthoticsPsychosocial Rehabilitation ServicesRadiology FacilitiesRecovery Services (Behavioral Health)Rehabilitation Option ServicesRehabilitation Services ProvidersReproductive Health ServicesRespite (Behavioral Health)Rural Health Clinics ServicesSchool-Based ServicesSmoking Cessation ServicesSpeech and Language TherapySwing Bed Hospital ServicesTelehealth ServicesTot-to-Teen Health ChecksTransplant ServicesTransportation Services (medical)Treatment Foster CareTreatment Foster Care IIVision Care Services
Agency-Based Community Benefit Services IncludedUnder Centennial Care
Adult Day HealthAssisted LivingBehavior Support ConsultationCommunity Transition ServicesEmergency ResponseEmployment SupportsEnvironmental ModificationsHome Health AidePersonal Care ServicesPrivate Duty Nursing for AdultsRespiteSkilled Maintenance Therapy Services
Self-Directed Community Benefit Services IncludedUnder Centennial Care
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Behavior Support ConsultationCustomized Community SupportEmergency ResponseEmployment SupportsEnvironmental ModificationsHome Health AideHomemaker/Personal CareNutritional CounselingPrivate Duty Nursing for AdultsRelated GoodsRespiteSkilled Maintenance Therapy ServicesSpecialized TherapiesTransportation (non-medical)
Mandatory Requirements
The Offeror shall:
1. Have policies and procedures to assess compliance of each managed care contractor for the provision of medically necessary services to all Medicaid clients who meet the clinical criteria for the required service.
2. Have policies and procedures for the consistent application and evaluation of New Mexico’s clinical criteria and definition of medically necessary services during all EQRO evaluation processes. It is imperative that the EQRO apply the state –approved clinical criteria and definition consistently and uniformly in all quality reviews.
3. Have policies and procedures for the provision of technical assistance to contractors related to appropriate application of clinical criteria and the definition for medically necessary services.
4. Have dedicated medical staff with appropriate specialized training and experience to meet the requirements of the specialized managed care contracts. Specifically, the Offeror will have dedicated, specialized physicians to include a board certified Psychiatrist, a physician with Long Term Care/Geriatric Medicine experience, as well as an Internist with disease management expertise.
C. CENTENNIAL CARE CONTRACT REQUIREMENTS Expectations
The Offeror will demonstrate that its staff has extensive current knowledge of the requirements of this Scope of Work, the HSD-specific quality standards and applicable Federal regulations and other guidance from CMS. This must include knowledge and understanding of the Medicaid Physical Health, Behavioral Health, and Long Term Care services.
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The Offeror must demonstrate knowledge of NCQA Standards and its accreditation process, current version of HEDIS, principles governing best practices related to Disease Management strategies, as well as QI interventions targeted at HEDIS-Like / HEDIS indicators. The Offeror will have a medical director who is a physician currently licensed to practice medicine and is knowledgeable regarding health service delivery within the State of New Mexico.The Offeror must have experience and expertise in the epidemiological and statistical measurement of health and service status indicators in defined populations. This must include in-depth understanding of the scope and methodologies of data collection, the interpretation of data, and the social and economic factors that affect the interpretation of the data. This expertise must ensure that the activities described in this request for proposal are conducted in accordance with generally accepted principles of research design and statistical analysis in order to produce valid, reliable, and generalizable information.
EQRO activities include the development of the methodology for the measurement of MCO performance against standards that are contained in the MCO contracts, and those standards that have been promulgated as New Mexico state regulations. The annual EQRO onsite compliance audit evaluates the MCOs’ compliance with all applicable standards that measure quality of care, access to care and timeliness of care. The state expects full cooperation with the EQRO on all state-directed quality review activities.
Other mechanisms for quality monitoring may be included in the EQRO scope of work for this contract such as monitoring the MCOs’ performance measurement effectiveness, and monitoring and evaluating the MCOs’ compliance with the state’s encounter data standards through the use of an encounter validation study, as well as provider satisfaction surveys. The Offeror may also be required to evaluate closely, in accordance with contract requirements in the MCO contracts, the coordination of care between/among all involved providers. The Offeror may be utilized to evaluate issues related to these contract requirements for care coordination. The Offeror will focus on quality of care indicators. The following specific areas are critical contract matters related to the provision of Medicaid services:
1. Quality: utilization management and quality performance 2. Member issues: access, outreach, satisfaction, grievances and appeals3. Care Coordination: transitions of care from institutional to community levels of care 4. Administrative issues: credentialing and claims payment5. Organizational capacity: systems, staffing, and networks.
Mandatory Requirements
The Offeror shall:
1. Describe the procedures for linking data identified in report findings.
2. Have policies and procedures for monitoring and evaluating the required reports giving specific examples of recommendations for amending interventions intended as Quality
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Improvement technical assistance; reports include, but may not be limited to, the following:
a. Performance Measure (PM)/Performance Improvement Project
(PIP) (annual) b. Compliance Report (annual)c. Independent Assessment (IA) (biennial)d. Nursing Facility Level of Care (NF LOC) (quarterly)e. Individualized Service Plan (ISP) (annual)f. HEDIS-Like Report (quarterly)
3. Submit an analysis of the annual results of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Adult and Child/Family survey, conducted and provided by the MCOs to HSD.
4. Provide an example of a QI/CAHPS program recommendation used in a prior contract for targeted improvement.
5. Incorporate procedures for evaluating the effectiveness of the MCOs’ disease management strategies and interventions including a review of the MCOs’ periodic data tracking of its DM program effectiveness.
6. Describe how the Offeror will conduct monitoring activities for MCOs’ nursing facility level of care (NF LOC) determinations, service plans and credentialing and/or verification policies.
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V. TECHNICAL DELIVERABLES
A. INTRODUCTION
1. Reimbursable Services and Services Not Reimbursable:
The Technical Deliverables/Scope of Work is divided into two broad groups: Reimbursable Services (Section V) and Overhead Services Not Reimbursable (Section V). EQRO payment will be made only for the Reimbursable Services. The reimbursement for each of the Reimbursable Services is to be stated as a part of the Cost Proposal (Section III). The Overhead Services Not Reimbursable is a part or parts of the Offeror’s expense involved in performance of the Reimbursable Services. Overhead Services Not Reimbursable will not be specifically reimbursed.
2. Program Direction and Flexibility:
The Offeror must be able to perform all services described in Section IV and meet the level of effort and quality identified in the RFP. HSD may direct that not all of the Reimbursable Services be performed. Each Reimbursable Service to be performed will be specifically directed by HSD through a Letter of Direction (LOD). Only work that is specified in a LOD will be reimbursed by HSD.
The deliverables presented in Section V are only an estimate. These estimates are presented for purposes of evaluating the Cost Proposals using absolute numbers for proposed reimbursement rates. This also allows the Offeror to understand the scope of expected activity.
HSD intends to direct a flexible and responsive EQRO effort by periodically adjusting the focus of work toward areas of greatest benefit. HSD reserves the right to change EQRO activities from one Reimbursable Service to another, to change the timing and/or frequency of directed services, and in other ways that affect the EQRO’s work volume. HSD reserves the right to change the scope of work, and as a result of that change, to amend the contract and hold price negotiations with the EQRO. These adjustments may result in changes in the volumes estimated for the Reimbursable Service affected. The EQR contractor must be responsive to these changes and perform at the level determined by HSD.
The EQRO must be able to perform ad hoc audits within 48 hours of direction by HSD. Should any work be deemed unacceptable by HSD, the EQRO shall submit a Plan of Correction within 14 calendar days of the notice by HSD that the submitted work was unacceptable.
Although the EQRO will never be asked to modify its actual findings, it may be requested to address findings through a Corrective Action Plan for the entity it is auditing.
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B. REIMBURSABLE SERVICES
Most of the services described in this section deal with the evaluation and/or measurement of MCO performance against HSD-determined quality standards. The MCOs are bound to those standards that are contained in their contracts; those standards are in the “Centennial Care Policy Manual”. (See Appendix C) HSD formally promulgates all managed care standards as state regulations. The MCOs are bound to the state regulations and to all updates, revisions, substitutions and replacements. The successful Offeror must follow quality and other managed care standards to which the MCOs are bound. During this procurement process for the EQRO contract, any change to the standards or regulations will be sent to all potential Offerors in the form of an amendment to the RFP. Reviews must be performed in accordance with the Medicaid Provisions under the Balanced Budget Act of 1997, Managed Care provisions. These reviews are as follows:
1. Design, Conduct and Report on Performance Measurement Program (PM)/ Performance Improvement Projects (PIP)
Each Medicaid managed care contractor monitored by the EQRO is contractually required to have an annual review of its performance measurement (PM) program and performance improvement projects (PIPs). The MCOs are required to initiate PIPs annually with specifically defined achievement targets. The focus of each PIP may either be on clinical and non-clinical areas.
The EQRO must review the MCOs’ performance program, including the MCOs’ performance on the contract-required PMs on which the contractor is required to report during a given year, as well as the results of the specific MCOs’ performance improvement projects. If the EQRO deems that the MCOs’ performance interventions are ineffective, recommendations for improvements shall be rendered by the EQRO.
2. Design, Conduct and Report on Individual Case Reviews
HSD may direct individual case reviews by specific Letters of Direction under unique clinical circumstances, among which are the following:
a. The occurrence of the circumstance is too infrequent to make judgments about patterns of care or to analyze performance to detect statistical significance; or
b. The effect of the circumstance on an individual or individuals is so serious as to warrant individual attention.
Cases for review will be determined by HSD with input from the EQRO and the MCOs. For reimbursement purposes, an Individual Case Review will be the review of a complete episode of illness pertaining to a specified Medicaid member. An episode of illness includes all clinical events associated with a particular diagnosis or group of diagnoses or other clinical condition(s) relevant to reason for the review. A single
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Individual Case Review constitutes a single unit of work for reimbursement purposes. The estimated number of reviews is 20 individual case reviews per year.
3. Design, Conduct and Report on Compliance Audit
MCOs are required to meet the Medicaid managed care standards contained in State and Federal regulation and all contractual requirements of the agreement with HSD. HSD is required to annually evaluate MCO compliance against these standards through the EQRO. The results of these evaluations are used to improve the compliance and quality of contractor performance through a system of incentives and/or contract enforcement measures. Among other things, the overall measured quality of performance can influence contract-specific incentives through its auto-assignment algorithm. The assignment algorithm assigns a Medicaid member to a specific contractor in a case in which the client does not exercise his or her choice. That is, the number of members who are auto-assigned to a particular MCO contractor may be proportional to the performance score of that MCO.
In response to a Letter of Direction, the EQRO will develop the measurement and scoring methodology required for the evaluations of MCO compliance performance that address all state and federal standards as well as those specifically requested in addition to the standards.
In the design of the reviews, the EQRO will follow professionally accepted standards of auditing, accounting, research design, sampling, and biostatistics such that statistically reasonable scores will result. The EQRO must ensure that the results of the reviews will allow HSD to accurately interpret MCO performance, focus and refine its managed care contract enforcement efforts, and produce reliable information.
This Reimbursable Service will include the initial delivery of the measurement and scoring methodology, the rationale for each standard, the scoring criteria, all forms to be used for measurement and scoring, the detailed procedures to be followed for the measurement and scoring, and any subsequent updates to these.
a. Measurement and Scoring Methodology
To allow a system of scores and sub-scores, the EQRO will break down the prescribed managed care standards, as well as those specifically requested by HSD into separately measurable items without changing their substance. The EQRO will assign numerical values to each item to be measured based on a scale determined by the EQRO and approved by HSD.
The methodology will result in individual weighted scores for each standard and substandard to be measured. Each contractor will receive an overall score for compliance performance against all of the standards. A combined, absolute score will reflect overall MCO compliance among. Each overall contractor score will
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enable that contractor’s performance to be expressed in terms relative to the mean score of all of the MCOs. HSD shall determine the levels of compliance relative to the overall scores.
The measurement of MCO performance against some of the standards will require the EQRO to review individual medical records. The EQRO will develop the random sampling methodologies to meet a 95% confidence interval with no more than a standard error rate of .05 to allow statistically valid measurements of performance and that also allow for valid comparison among the MCOs. HSD will provide encounter data to the EQRO upon request.
b. Rationale for Each Standard
The EQRO will develop the written rationale for each standard, describing the intent of the standard and its relationship to quality of care. The written rationale must be approved by HSD.
c. Scoring Criteria
The EQRO will develop the scoring criteria that will be used to determine each score on the scale for each standard and substandard to be scored. This must specify the level of performance that would result in a particular numeric score. The scoring criteria must be approved by HSD.
d. Detailed Procedures and Forms to be Used for Measure ment and Scoring
The EQR will develop the detailed procedures, forms, and guidelines for the evaluator that will be used to perform the evaluations of MCO performance against the quality standards. These documents must be approved by HSD.
e. Conduct and Report
In response to a Letter of Direction, the EQRO will measure and score the performance of each managed care contractor against all applicable managed care standards. This will be done by applying the Measurement and Scoring Methodology that was developed in accordance with Section V above. Normally the compliance performance of more than one MCO for the same population will be evaluated to allow comparison of performance among MCOs. When this is done, the EQRO will ensure that the compliance performance measured is for the same time period for all MCOs. A complete review of a single MCO against all or specified applicable standards and the written report of that review constitutes a single unit of work for reimbursement purposes. The content and format of the report will be proposed by the EQRO and approved by HSD before performance measurements begin.
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4. Follow-Up Review and Performance Measurement Activity
From time to time, HSD may direct the EQRO to perform an ad hoc review or performance measurement activity. This may be in many different forms. Among these are the following:
a. Follow-up Reviews Related to the Activity Described in Sec tion V;
b. Focused Measurement of Performance Applied to any Combination of the Following, including but not limited to:
(1) Specific standard or set of standards;
(2) Special defined population of members;
(3) Specific age or other demographic group;
(4) Specific geographic area;
(5) Specific MCO, subcontractor of an MCO, or provider group or individual provider in the network of one or more MCOs;
(6) Specific diagnosis or group of diagnoses or health conditions; and
(7) Other parameters.
c. Follow-up Focused Cross Validation Audits of Encounter Data Described in Section V.
This activity will be reimbursed on a per-follow up review basis. The specific activities, their timing, reports, and the number of reimbursable reviews will be discussed between HSD and the EQRO in advance and specified in Letters of Direction from HSD. This activity is subject to 48 hours advance notice from HSD.
5. Design, Conduct and Report on Member Satisfaction Survey
HSD may choose to conduct member satisfaction surveys, directly or through its designated agent. Pursuant to a Letter of Direction, the EQRO will develop the survey instrument as a ready-to-perform product. This will include all necessary forms, data management application files for processing the results, the detailed procedures for conducting the survey, and an estimate of the types and amounts of resources needed for its conduct.
Each survey will pertain to the specifically-served Medicaid membership and address at least, but not limited to the following modules:
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Overall measures of satisfaction/dissatisfaction; Member characteristics (demographics, etc.); Health status; Use of health services; Access to ambulatory care (primary care, specialists, behavioral health care,
dental, etc.); Access related to language/race/ethnicity/cultural issues; Barriers to service access, including convenience, safety, and comfort for program
recipients; Wait times; Office/clinic responsiveness to phone calls; Culturally competent and member-centered service delivery; MCOs’ grievance processes; Understanding of managed care procedures; Technical quality of care; Quality care related to interpersonal communications (caring attitude, etc.); and, Quality of customer service.
The survey must allow a comparison of member satisfaction among the managed care contractors when there is more than one contractor serving the specified population. For the multiple contractor comparisons, data is to be stratified according to the major categories of Medicaid eligibility and the identified parameters of the survey.
The detailed content, scope, focus, and type of the survey will ultimately be determined by HSD. However, the EQRO will provide the survey design expertise necessary for a valid survey and facilitate the HSD decision process to determine the survey parameters.
The EQRO will conduct a member satisfaction survey on behalf of HSD pursuant to a Letter of Direction. The survey will be conducted using the HSD approved product of Section V. A completed survey includes the report of its results delivered to and approved by HSD. The report will include quantification of the statistical significance of the results including a discussion of any sampling bias and its significance.
6. Design, Conduct and Report on Periodic Utilization Review Denial Audits
The EQRO will conduct periodic Utilization Review denial audits on behalf of HSD pursuant to a Letter of Direction.
7. Design, Conduct and Report on Cross Validation Audits of Encounter Data
The contracted MCOs are required to submit encounter data on a routine basis. Encounter data is very similar to the data associated with provider claims for payment. HSD will use this data as input to a number of decisions, and the data will be available to the public in aggregate form. Serious levels of inaccuracy and/or incompleteness can result in erroneous decisions and
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conclusions by the State and/or the public, especially if the nature and degree of these inaccuracies and/or voids of data are unknown.
In the design of the audits, the EQRO will follow professionally accepted standards of auditing, accounting, research design, sampling, and biostatistics such that statistically valid and defensible data, rates, and conclusions will result. The EQRO must ensure that the results of the audits will allow HSD to accurately interpret the encounter data, make statistically valid corrections to aggregate encounter data, focus its MCO contract enforcement efforts, and produce reliable and generalized information.
HSD will direct each design of a validation audit by a Letter of Direction, determine the dates of service ranges for validation measurement, and provide the encounter data and other data or reports. The EQRO will develop the detailed encounter data cross validation audit methodology including the detailed procedures for HSD approval prior to conduct of the audit. This will include specifying the data and its format that HSD will provide to the EQRO.
The EQRO will perform cross validation audits of encounter data submitted by each MCO. These audits will involve measuring the consistency between submitted encounter data and corresponding health record entries. The data from a sample of encounters will be validated against the corresponding provider health record for accuracy and completeness, and the data from a sample of provider health records will be validated against the appropriate submitted encounter data. The samples may include all provider types and specialties and all segments of the Medicaid managed care membership. The EQRO will identify and analyze significant discrepancies to determine error/incompleteness rates by provider and provider type and specialty in detail and in the aggregate for each MCO and render a report of the results to HSD for approval.
The format of the report will be developed by the EQRO and must be approved by HSD before the conduct of the audit.
A completed cross validation audit will include the analysis of the results and the HSD-approved report of the audit, including EQRO recommendations for encounter data systems improvements.
8. Design and Conduct Ad Hoc Audits
HSD may wish to conduct audits of MCOs addressing unique and timely issues that require design sophistication, designer expertise, and auditor qualifications similar to that described for Cross Validation Audits of Encounter Data. In the design and conduct of each audit, the EQRO will follow professionally accepted standards of auditing, accounting, research design, sampling and biostatistics such that statistically valid and defensible data, rates and conclusions will result. The EQRO must ensure that the results of the audits will allow HSD to accurately interpret the data, focus its MCO contract enforcement effort and produce reliable and generalized informa-tion. Ad hoc audits will be reimbursed at the contracted hourly rate for this type of activity. HSD will initiate each ad hoc audit by a Letter of Direction that specifies its parameters and authorizes the maximum number of hours that will be reimbursed. The EQRO will develop
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detailed audit methodology, including specific procedures for HSD approval prior to conduct of the audit. A completed audit will include the design, audit and analysis of the results, as well as the HSD-approved report of the audit.
HSD may request special ad hoc reports to be derived from the EQRO’s activity database. These special reports require ad hoc systems programming and are considered Reimbursable Services. They are distinguished from routine EQRO reports to the state, which are considered an Overhead Service Not Reimbursable. HSD may also request targeted technical assistance on a state-defined topic. Regardless of the requesting agency, reimbursement for a special ad hoc report or technical assistance will be made by HSD only if it is specifically initiated by a Letter of Direction and will be reimbursed on an hourly basis at the contracted rate for this activity. After discussion with the EQRO, the Letter of Direction will specify, at a minimum, the report content, the maximum number of hours to be reimbursed and the report due date. 9. Design, Conduct and Report on Provider Satisfaction Survey
HSD may wish the EQRO to develop a provider satisfaction survey. Pursuant to a Letter of Direction, the EQRO will develop the survey instrument as a ready-to-perform product. This will include all necessary forms, data management application files for processing the results and the detailed procedures for the conduct of the survey. A survey may be directed to include a broad cross section of provider types or be focused on one or a narrow range of provider types. The content, scope, focus, type and timing of the survey will be determined by HSD and will be included in the pertinent Letter of Direction. The EQRO will provide the design expertise necessary for a valid survey and will lead the HSD decision process to determine the survey parameters.
Pursuant to a Letter of Direction, HSD may ask the EQRO to conduct a provider satisfaction survey. The survey will be conducted using the product of Section V. A completed survey includes the report of its results delivered to and approved by HSD. The report will include quantification of the statistical significance of the results including a discussion of any sampling bias and its significance.
10. Design, Conduct and Report on Independent Assessments
HSD will require the EQRO to conduct an Independent Assessment (IA) of the State’s activities and efforts to monitor the managed care contracts. The IA is not a duplication of effort by the EQRO to assess the State’s Medicaid managed care program, and the EQRO shall rely on documents already produced by the State’s independent actuarial contractors and independent financial auditors in addition to surveys and evaluations that have already been produced by the EQRO to the greatest extent possible.
The IA will make recommendations as well as report results to be used by the State in order to improve Medicaid oversight activities related to each of the managed care contracts. There are three federally required elements of the IA Report: access to care, quality of care, and cost effectiveness. Each of these components is discussed in detail below.
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a. Element 1 – Access to ServicesThe EQRO will take into consideration as many of the following as are practicable and appropriate:
Evaluation of the program’s access monitoring and analysis Enrollment information Education and customer service information Provider capacity Urgent/Emergent care Travel and wait times for primary care and specialty
Referrals
b. Element 2 – Quality of Services The EQRO will take into consideration as many of the following as are practicable and appropriate:
Evaluation of the program’s quality monitoring elements and analysis and review of EQRO reports
Clinical review of utilization patterns Grievances including appeals Beneficiary, provider and subcontractor satisfaction State quality improvement measures
c. Element 3 – Cost Effectiveness The EQRO will take into consideration as many of the following as are practicable and appropriate:
Calculate the cost-effectiveness of the managed care program for the previous time period of the program
Review of the State’s Upper Payment Limit (UPL) calculation, rate setting, and cost-effectiveness monitoring processes
Analysis of the source of the cost savings in the program Analysis of possible cost-shifting from capitated service utilization to fee-for-
service utilization Assess whether CMS and the State are paying MCO providers appropriately
for services Perform an analysis of the State’s capitation payment system in paying
capitation to the MCOs.
The minimum requirement for IA review is two (2) surveys per four (4) year contract period, or biannually. The state could require an additional one to two IA’s per waiver contract period. An IA report must be submitted with the State’s Waiver renewal request ninety (90) days before the expiration of the approved waiver program. The IA will be reimbursed on a per survey basis.
11. Design, Conduct and Report on Nursing Facility Level of Care
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Random monthly reviews of Nursing Facility (NF) Level of Care (LOC) ratings assigned to recipients shall be conducted to ensure that NF LOC criteria are applied consistently and equitably across the New Mexico Medicaid program. Data will be collected from the health plans to the contractor through a secure transmission system. Data will be analyzed and resulting reports will be compiled and provided to HSD on a quarterly basis. Deliverables include the following:
a. Define and develop a project plan for conducting desk reviews of NF LOC rating determinations made by Centennial Care MCOs.
b. Develop random sampling methodology according to specifications from HSD to complete NF LOC determinations collected from the MCOs for NF LOC rating determinations. This includes both approvals and denials.
c. Conduct random external quarterly reviews of each MCO based on MCO NF LOC instructions and tool guidelines by collecting member-specific data used to determine NF LOC ratings from MCOs using secure file transition and storage.
d. Develop review tools for capturing data on the following elements:1. Accuracy of NF LOC decisions;2. Timeliness of NF LOC decisions;3. If the denials went through physician review;4. Reasons for denials.
e. Report findings to HSD on a quarterly basis.f. Make recommendations for improvement in the process.g. Evaluate the project results and note trends.
12. Design, Conduct and Report on Individualized Service Plans
The State’s EQRO contractor shall monitor MCO compliance with specific requirements of CMS Special Terms and Conditions for New Mexico Centennial Care. The Contractor shall monitor and annually evaluate the MCOs’ performance on the HCBS requirements under Centennial Care to ensure that MCOs are appropriately creating and implementing service care plans based on enrollee’s identified needs.
13. Design, Conduct and Report on HEDIS-Like Measures
HEDIS-Like measure data shall be collected from Centennial Care MCOs to establish thresholds, baselines and re-measurements for each HEDIS-Like measure. Data shall be analyzed and reported to HSD on a quarterly basis by either administrative or hybrid methodology and transmitted from the health plans to the contractor through a secure transmission system. Deliverables include the following:
a. Design a project plan including defining project roles and responsibilities;b. Develop methodology for quarterly reporting of data collected from the MCOs for
measures identified by HSD;c. Develop in-house programming software to report identified measures;d. Test the developed in-house software prior to the roll out;e. Provide technical assistance and training to health plan staff on data selection;
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f. Collect member-specific data from health plans on a quarterly basis using secure file transition and storage;
g. Perform validation of data reported by MCOs;h. Perform validation of medical record review abstractions for measures selected for
hybrid methodology reporting and reconciliation of processes prior to final reporting;i. Maintain annual license to NCQA Quality Compass® Medicaid data for
benchmarking comparisons and include these indicators/results in the quarterly reports to HSD;
j. Provide training to MCOs to capture the information needed to provide Medicaid-required reporting and the ability to use MCO data to create quarterly reports;
k. Develop procedures and training manuals for contractor’s staff members to understand and accomplish the tasks outlined in the proposal;
l. Provide training and facilitation of the process for the HSD staff to include the following program services: 1) Quality improvement strategies2) NCQA HEDIS reporting requirements3) Comprehensive care management4) Care coordination5) Health promotion6) Comprehensive transitional care7) EQRO activities and relationship to Centennial Care
m. Monitor the program data on a quarterly basis by:1. Conducting quality improvement analysis and compiling quarterly reports for the
State; and2. Working with the MCOs on quality improvement interventions to improve
outcomes and achieve State-established program goals.
n. Evaluate of the project and its impact
14. Future Services at Negotiated Rate
The EQRO will perform services not otherwise specified in the contract, including special projects, as directed by specific Letters of Direction from HSD. The specific work requirements and the reimbursement for such services will be negotiated between the EQRO and HSD. These services may include special projects that may arise as a result of Congressional, Legislative or HSD actions.
C. QUALITY OF EQRO SERVICES
1. Quality of Staff
a. The EQRO will demonstrate that its staff members possess sufficient current knowledge of the requirements of this Scope of Work, the quality standards and applicable Federal regulations and other guidance from CMS. This must include
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knowledge and understanding of the NCQA Standards for Accreditation for all Centennial Care MCOs and their accreditation processes, current HEDIS and subsequent versions, and Mental Health Statistics Improvement Program (MHSIP) Consumer Report Card.
b. The EQRO will have a medical director who is a physician currently licensed to practice medicine. The EQRO will also have a licensed Psychiatrist on staff to evaluate the quality of MCO performance of Medicaid BH services. (See Section III)
c. The EQRO must have experience and expertise in the epidemiological and statistical measurement of health and service status indicators. This must include in-depth under-standing of the scope and methodologies of data collection, the interpretation of data, and the social and economic factors that affect the interpretation of the data. The EQRO must ensure that the activities described in the Section IV are conducted in accordance with generally accepted principles of research design and statistical analysis in order to produce valid, reliable, and generalizable information.
d. The EQRO must be able to demonstrate a working knowledge of New Mexico-specific Medicaid experience as evidenced by an in-state presence, readily accessible to the main HSD office in Santa Fe.
2. Approved Detailed Procedures
a. The EQRO will develop written detailed internal procedures for all reviews, audits, performance measurements, and surveys described in Section V. The procedures must specify all steps in each process. The style and level of detail in the EQRO’s detailed procedures should be aimed at the EQRO’s staff. The detailed procedures for a given activity must be approved by HSD before the EQRO begins performing that activity. Within fourteen (14) calendar days of the pertinent Letter of Direction, the EQRO will forward written detailed procedures for the directed activity. The EQRO may request an extension to this for specific directed activity, and HSD will reasonably consider such requests.
b. Due to HSD-directed policy changes and other changes in the external environment, the EQRO should anticipate changes and must respond to HSD-directed changes by forwarding revised detailed procedures for approval to the HSD within fourteen (14) calendar days of the date of the written request. The EQRO will follow the most current approved version of the detailed procedures. The EQRO will ensure that each page of the detailed procedures is dated with the effective date of HSD approval.
3. Documentation
The EQRO will document each review, audit, performance measurement, and survey in such a way that an uninvolved reader can completely reconstruct the activity. The EQRO must maintain this documentation for a total of five (5) years unless transfer is specifically directed by HSD or by the terms of the contract resulting from this RFP.
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Upon request from HSD, the EQRO must produce the documentation within five (5) working days.
4. Internal Quality Management Program
The EQRO will establish and maintain its own internal quality management program following the basic principles of Continuous Quality Improvement, which are presently used throughout most industries. This program will be applied to all aspects of the EQRO’s performance under the contract resulting from this RFP. The EQRO will submit to HSD for review a detailed description of its internal quality management program and its associated processes and procedures within sixty (60) calendar days of the effective date of the RFP contract.
HSD reserves the right to determine the level of acceptable quality of any and all EQRO deliverables. Reimbursement by HSD will be made for only those deliverables deemed by HSD to be of acceptable quality.
D. OVERHEAD SERVICES NOT REIMBURSABLEB.
The Overhead Services Not Reimbursable described in the following paragraphs will be performed by the EQRO as overhead and will not be specifically reimbursed by HSD unless otherwise stated in this RFP:
1. Services and work associated with the requirements of Quality of Reviews are considered to be EQRO overhead expenses. See Section V.
2. Rendering of the Annual Report of the Review of Quality of the Services furnished through each MCO contract. This report will be based on the activities described in Section V. The report must be forwarded to HSD no later than sixty (60) calendar days after each one-year period. The first one-year period will be defined by HSD before its start date, and subsequent one-year periods will be the anniversary dates of the first period.
3. Computer hardware, software and systems programming expenses are considered to be overhead expenses. The EQRO must be capable of reading electronic files from HSD and its Fiscal Agent and producing electronic files in a format usable by HSD. Although upgrades and/or changes in versions will be inevitable, HSD currently uses the MICROSOFT WINDOWS XP with MICROSOFT OFFICE 2007 products. This will phase out early 2014 to WINDOWS 7 with MICROSOFT OFFICE 2010. To that end, Offerors should consider their ability to switch formats on a parallel schedule with HSD in order to prevent disruption of communications or file transfers.
The EQRO will have computer hardware, software and systems programming abilities that will consist of a hardware and software multimedia package with the
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ability to generate and receive sound, video and text for interfacing with existing and possible future developments concerning usage of the internet.
The EQRO will maintain a HIPAA compliant web portal with the abilities of video, sound and text.
4. The EQRO will arrange and bear the cost of the shipping, transporting, or transmitting of any materials required unless otherwise specified by the contract resulting from this RFP.
5. The EQRO will participate in monthly management meetings with HSD personnel in Santa Fe. A meeting session could last up to three (3) days, but would normally be one day per month arranged for the convenience of both HSD and the EQRO staff members. Additionally, upon HSD request, the EQRO will participate in approximately four monthly ad hoc meetings within New Mexico.
6. Upon the request of HSD, the successful Offeror will be required to provide testimony in person or in the form of depositions for HSD administrative hearings and judicial hearings concerning protests of actions taken as a result of EQRO reviews and/or provide testimony at State legislative hearings.
7. The successful Offeror will cooperate with the HSD’s Contract Management Program by making documentation available (Section V), providing access to EQRO staff members, and providing working space for HSD to perform On-Site Program Integrity Reviews to validate the EQRO’s performance. In addition to evaluating the successful Offeror’s compliance with the contract resulting from this RFP, HSD will evaluate the quality, effectiveness and utility of the HSD-directed activity and the HSD-approved procedures.
8. The EQRO will fully cooperate with the New Mexico Attorney General Medicaid Fraud Control Unit (MFCU), the HSD Office of the Inspector General, the Federal Bureau of Investigation and any other investigative agencies as directed by HSD, subject to the terms of this contract.
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VI. EVALUATION OF PROPOSALS
EVALUATION
HSD will conduct a comprehensive, fair, and impartial evaluation of proposals received in response to this RFP. All proposals shall be reviewed for compliance with the mandatory requirements as stated within the RFP. Proposals deemed non-responsive, missing key elements or received after the deadline shall be eliminated from further consideration and a letter will be generated to the Offeror, stating the reason for elimination. MAD management shall appoint an Evaluation Committee, which shall evaluate each responsive proposal on the basis of its technical merit. HSD reserves the right to use technical advisors in this process.
A. EVALUATION PROCESS
Each committee member shall review and score each Technical Proposal against criteria established within the RFP. The weighting of the scores will be in accordance with the table in Section VI. The Cost Proposals will be opened and scored at the conclusion of the review and scoring of the Technical Proposal. Subsequently, the total score will consist of the Cost Proposal points and those from the evaluation of the Technical Proposals.
Finalists may be asked to submit revised proposals for the purpose of obtaining their best and final offer. HSD reserves the right to invite each finalist to provide an oral presentation. Finalists who are asked or choose to submit revised proposals for the purpose of obtaining best and final offers will have their points recalculated accordingly. Points awarded from the oral presentations will be added to the previously assigned points.
HSD reserves the right to reject all of the proposals if HSD, at its sole discretion, determines that none of the proposals meet the current and/or long term needs of HSD. None of the mandatory requirements, including the cost factor, is outcome determinative. Should HSD determine that one or more of the proposals do meet the HSD’s current and long-term needs, then the contract shall be awarded to the Offeror whose proposal is most advantageous, taking into consideration the mandatory requirements set forth in the RFP.
A Proposal will be considered the most advantageous if HSD, at its sole discretion, believes the proposal will best meet HSD’s current and long-term needs. The most advantageous proposal may or may not have received the most points, or contained the lowest cost, but will meet HSD’s current and long-term needs.
The award may be subject to the successful completion of additional contract negotiations and is subject to appropriate State and Federal approvals.
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B. EVALUATION OF COST
The cost factor is based on the Total Cost Proposal (bottom line) contained in the Reimbursable Services Total Cost Proposal Form (Appendix D). For the purposes of this RFP, cost is defined as the total of Federal and State expenditures, regardless of mix, incurred in carrying out the services detailed in the RFP.
Each Offeror’s technical proposal will be adjusted, or normalized, using the following formula: (Lowest Offeror Proposed Cost) divided by (This Offeror's Proposed Cost) multiplied by 250 to produce the (Total Award Points).
Lowest Offeror Proposed Cost Offeror’s Points = ----------------------------------------X 250 Points Allowed
Offeror's Proposed Cost
This will earn the Lowest Offeror Proposed Cost the highest cost award of 250 points. Each of the other Offerors will earn a declining proportional level of points based on the cost proposed in their offer.
C. EVALUATION POINT SUMMARY
The following is a summary of the evaluation factors and the point value assigned to each. These weighted factors will be used by HSD in the evaluation of the individual Offeror proposals.
Factor Points Available
Technical Proposal.……...…………………………………………….……150Qualifications ………………………………………………………...….…100Work Plan ………………………………………………………………..100Scope of Work ……………………………………………………………..350New Mexico Presence ………………………………………………………50Cost Proposal …………………………………………………………….250
TOTAL: 1000
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APPENDICES A-G
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APPENDIX A
REQUEST FOR PROPOSALS
EXTERNAL QUALITY REVIEW ORGANIZATION
ACKNOWLEDGEMENT OF RECEIPT FORM
In acknowledgement of receipt of this Request for Proposal the undersigned agrees that he/she has received a complete copy, beginning with the title page and table of contents, and ending with the last Appendix of this document.
The acknowledgement of receipt should be signed and returned to the Procurement Manager no later than close of business as per Section II, Paragraph A. Only potential Offerors who elect to return this form completed with the indicated intention of submitting a proposal will receive copies of all Offeror written questions and the Department's written responses to those questions as well as RFP amendments, if any are issued.
FIRM NAME: ______________________________________________________________________________
REPRESENTED BY: ________________________________________________________________________
TITLE: ________________________________ PHONE NO.: ____________________________
E-MAIL: ______________________________ FAX NO.: _______________________________
ADDRESS: ________________________________________________________________________________
CITY: ______________________________________ STATE: ________ ZIP CODE: _________
SIGNATURE: ___________________________________ DATE: _________________
This name and address will be used for all correspondence related to the Request for Proposal.The above named firm DOES or DOES NOT (circle one) intend to respond to this Request for Proposals.
Please return this document by mail, fax, or email (scanned PDF format) to:
Elizabeth C. Cassel, Ph.D.Medical Assistance DivisionHuman Services Department2025 South Pacheco StreetSanta Fe, New Mexico 87504Telephone Number: (505) 827-7715Fax Number: (505) 827-3126
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APPENDIX B
SAMPLE EQRO CONTRACT TERMS AND CONDITIONS
Contract No. PSC _________________________
This Agreement (“Agreement”) is made between the New Mexico Human Services Department, hereinafter referred to HSD and _______________________, hereinafter referred to as the CONTRACTOR, and sets forth the terms and conditions under which the CONTRACTOR will provide External Quality Review (“EQR”) services for HSD’s Medical Assistance Division, hereinafter referred to as HSD/MAD.
Upon becoming effective, the term of this Agreement shall be from July 1, 2014 through June 30, 2016, unless amended or terminated under the terms set forth herein. Pursuant to the Request for Proposal (“RFP”), HSD may extend this Agreement for two (2) additional one-year periods by giving the CONTRACTOR written notice of at least one hundred eighty calendar days prior to the expiration of the then current terms. In no case will this Agreement exceed a total of four (4) years in duration.
THIS AGREEMENT SHALL NOT BECOME EFFECTIVE UNTIL APPROVED IN WRITING BY NEW MEXICO DEPARTMENT OF FINANCE AND ADMINISTRATION, AND THE NEW MEXICO ATTORNEY GENERAL.
The term “days” refers to calendar days, unless otherwise specified within this Agreement. In computing any period of time set forth in this Agreement, the first day the time period begins to run is excluded, and the last day of the time period is included. Timeliness or due dates falling on a weekend or a state or federal holiday shall be extended to the first business day after the weekend or holiday.
ARTICLE 1 – RECITALS
1.1 All services provided pursuant to this Agreement are subject to the New Mexico Procurement Code and 1.4.1 NMAC, unless specifically provided otherwise herein.
1.2 All services purchased under this Agreement shall be subject to the following provisions for administration of the New Mexico Medicaid program, which are incorporated herein by reference and shall include:
(A) HSD/MAD program eligibility and provider policy manuals, including all updates, revision, substitutions and replacements;
(B) Title XIX and Title XXI of the Social Security Act and Code of Federal Regulations, Title 42 Parts 430 to end, as revised or otherwise amended;
(C) The Request for Proposal (“RFP”), all RFP Amendments, CONTRACTOR’s Questions and State’s Answers, and the State’s written Clarifications;
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(D) The CONTRACTOR’s Best and Final Offer;
(E) The CONTRACTOR’s Proposal (including any and all written materials presented in the oral portions of the procurement process) where not inconsistent with this Agreement and subsequent amendments to this Agreement; and
(F) The HSD/MAD Policy Manual, including all updates and revisions thereto, or substitutions and replacements thereof, duly adopted in accordance with applicable law. All defined terms used within the Agreement shall have the meanings given them in the Policy Manual.
1.3 HSD has contracted with Managed Care Organizations (MCOs) for its Centennial Care program for all services to Medicaid eligible Members. These are all full risk contracts for which the MCOs are paid on a capitated basis. HSD must ensure that Medicaid Members receive through the MCOs the necessary amount and quality of the contracted services. HSD/MAD is responsible for the monitoring and enforcing the quality of care, service, and access standards to which the MCOs are contractually bound. To accomplish this, independent EQR activities are required.
1.4 HSD needs to retain the professional services offered by a CONTRACTOR with expertise in EQR. The CONTRACTOR shall possess the required authorization and expertise to meet the terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of the mutual promises contained herein, HSD and the CONTRACTOR agree as follows:
ARTICLE 2 – CONTRACTOR RESPONSIBILITIES
The CONTRACTOR shall perform professional services, including but not limited to, the following:
2.1 COMPLIANCE
The CONTRACTOR must, to the satisfaction of the State, comply with:
(A) All provisions set forth in this Agreement; and
(B) All applicable provisions of federal and State laws, regulations, waivers, and variances, including the implementation of compliance plan.
2.2 CONTRACT MANAGEMENT
(A) The CONTRACTOR must employ a qualified individual to serve as the Contract Manager for New Mexico operations. The Contract Manager must be primarily dedicated to the CONTRACTOR’s programs, hold a senior management position
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in the CONTRACTOR’s organization, and be authorized and empowered to represent the CONTRACTOR on all matters pertaining to the CONTRACTOR’s program and specifically this Agreement. The Contract Manager must act as a liaison between the CONTRACTOR, the State, and other state agencies and has responsibilities that include but are not limited to the following:
(1) Ensuring the CONTRACTOR’s compliance with the terms of this Agreement, including securing and coordinating resources necessary for such compliance;
(2) Overseeing all activities by the CONTRACTOR and its subcontractors;
(3) Receiving and responding to all inquiries and requests by the State, or any State or Federal agency, in time frames and formats reasonably acceptable to the parties;
(4) Meeting with representatives of HSD/MAD and other Agencies, on a periodic or as-needed basis and resolving issues that arise;
(5) Attending and participating in regular meetings with HSD/MAD, and other Agencies;
(6) Making best efforts to promptly resolve any issues related to this Agreement identified by the State, or the CONTRACTOR; and
(8) Working cooperatively with other State of New Mexico contracting partners, including but not limited to: (1) All Centennial Care Managed Care Organizations; and (2) other identified contractors as, from time-to-time may be identified by the State.
(B) Personnel commitments identified in the CONTRACTOR's Proposal shall be considered material to the work to be performed. Staffing must include those individuals as proposed. No changes of key personnel shall be made by the CONTRACTOR without prior written consent of the Contract Administrator or his/her designee. The CONTRACTOR warrants and represents that all employees to be assigned to the performance of this Agreement shall be assigned in accordance with the staffing plan in the CONTRACTOR's Proposal.
(C) Replacement of any CONTRACTOR personnel shall be with personnel of equal ability, experience, and qualifications Key personnel shall include the Project Manager and those personnel identified in the CONTRACTOR’s Proposal. In each case, HSD/MAD will be provided with a resume of the proposed substitution and the opportunity to interview that person prior to giving its approval.
(D) Performance by the CONTRACTOR will not be contingent upon time availability of HSD/MAD personnel or resources with the exception of specific
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responsibilities stated in the RFP and the normal cooperation that can be expected in such an Agreement. The CONTRACTOR's access to HSD/MAD personnel will be granted as freely as possible. However, the competency/sufficiency of HSD/MAD staff will not be reason for relieving the CONTRACTOR of any responsibility for failing to meet required deadlines or producing unacceptable deliverables.
(E) The State reserves the right to require the CONTRACTOR to make changes in its staff assignments if the assigned staff is/are not, in the opinion of the State, meeting the needs of Members or the needs of the State in implementing and enforcing the terms of this Agreement, provided that such CONTRACTOR staff changes shall comport with the CONTRACTOR’s personnel policies and procedures.
(F) The CONTRACTOR may not have an employment, consulting or other agreement with a person who has been convicted of crimes specified in Section 1128 of the Social Security Act for the provision of items and services that are significant and material to the CONTRACTOR’s obligations under this Agreement.
2.3 SCOPE OF WORK
The CONTRACTOR shall have auditing oversight, reporting requirements, program improvement recommendations and corrective action plans and/or quality improvement plans, for the following activities. Letters of direction for the specific reimbursable scope of work deliverables will be issued by HSD per the EQRO RFP (Section IV).
(A) Provision of services described in the Medicaid managed care benefit package and other programs as assigned listed under Section IV Scope of Work, Subsection B Medicaid Contract for Covered Benefits/Services.
(B) Auditing of all Centennial Care services, including physical health, behavioral health and long term care services that include the following elements:
(1) Coordination of all health care services delivered to Medicaid managed care members across an array of contractors as described in Section IV Scope of Work, Subsection B Medicaid Contract for Covered Benefits/Services;
(2) Active promotion of preventive care, early intervention, disease management, and attainment of public health benchmarks;
(3) Provision of access to appropriate and timely services for individuals with special health care needs; and
(4) Operation of quality assurance and utilization management programs to ensure access to quality health care.
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(C) Utilization of industry statistical standards of sampling in methodology to follow at a minimum of a ninety-five (95) percent confidence interval and standard error rate of no more than .05 percent.
(D) Ensuring performance compliance of fee-for-service contractors, such as the Fee For Service (FFS) /Utilization Review (UR) or Third Party Assessor (TPA) contractors, and other health related program services.
(E) Completion of requested ad hoc reports and audits necessary for the provision of quality Medicaid services.
2.4 REIMBURSABLE SERVICES
Most of the services described in this section deal with the evaluation and/or measurement of MCO performance against HSD-determined quality standards. The MCOs are bound to those standards that are contained in their contracts; those standards are in the “Centennial Care Policy Manual”. (See Appendix C) HSD formally promulgates all managed care standards as state regulations. The MCOs are bound to the state regulations and to all updates, revisions, substitutions and replacements. The successful Offeror must follow quality and other managed care standards to which the MCOs are bound. During this procurement process for the EQRO contract, any change to the standards or regulations will be sent to all potential Offerors in the form of an amendment to the RFP. Reviews must be performed in accordance with the Medicaid Provisions under the Balanced Budget Act of 1997, Managed Care provisions. These reviews are as follows:
(A) Design, Conduct and Report on Performance Measurement Program (PM)/ Performance Improvement Projects (PIP)
Each Medicaid managed care contractor monitored by the EQRO is contractually required to have an annual review of its performance measurement (PM) program and performance improvement projects (PIPs). The MCOs are required to initiate PIPs annually with specifically defined achievement targets. The focus of each PIP may either be on clinical and non-clinical areas.
The EQRO must review the MCOs’ performance program, including the MCOs’ performance on the contract-required PMs on which the contractor is required to report during a given year, as well as the results of the specific MCOs’ performance improvement projects. If the EQRO deems that the MCOs’ performance interventions are ineffective, recommendations for improvements shall be rendered by the EQRO.
(B) Design, Conduct and Report on Individual Case Reviews
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HSD may direct individual case reviews by specific Letters of Direction under unique clinical circumstances, among which are the following:
(1) The occurrence of the circumstance is too infrequent to make judgments about patterns of care or to analyze performance to detect statistical significance; or
(2) The effect of the circumstance on an individual or individuals is so serious as to warrant individual attention.
Cases for review will be determined by HSD with input from the EQRO and the MCOs. For reimbursement purposes, an Individual Case Review will be the review of a complete episode of illness pertaining to a specified Medicaid member. An episode of illness includes all clinical events associated with a particular diagnosis or group of diagnoses or other clinical condition(s) relevant to reason for the review. A single Individual Case Review constitutes a single unit of work for reimbursement purposes. The estimated number of reviews is 20 individual case reviews per year.
(C) Design, Conduct and Report on Compliance Audit
MCOs are required to meet the Medicaid managed care standards contained in State and Federal regulation, and all contractual requirements of the agreement with HSD. The introductory paragraph of this section (Section V) describes this. HSD is required to annually evaluate MCO compliance against these standards through the EQRO. The results of these evaluations are used to improve the compliance and quality of contractor performance through a system of incentives and/or contract enforcement measures. Among other things, the overall measured quality of performance can influence contract-specific incentives through its auto-assignment algorithm. The assignment algorithm assigns a Medicaid member to a specific contractor in a case in which the client does not exercise his or her choice. That is, the number of members who are auto-assigned to a particular MCO contractor may be proportional to the performance score of that MCO.
In response to a Letter of Direction, the EQRO will develop the measurement and scoring methodology required for the evaluations of MCO compliance performance that address all state and federal standards as well as those specifically requested in addition to the standards.
In the design of the reviews, the EQRO will follow professionally accepted standards of auditing, accounting, research design, sampling, and biostatistics such that statistically reasonable scores will result. The EQRO must ensure that the results of the reviews will allow HSD to accurately interpret MCO performance, focus and refine its managed care contract enforcement efforts, and produce reliable information.
This Reimbursable Service will include the initial delivery of the measurement and scoring methodology, the rationale for each standard, the scoring criteria, all forms to be used for measurement and scoring, the detailed procedures to be followed for the measurement and scoring, and any subsequent updates to these.
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(1) Measurement and Scoring Methodology
To allow a system of scores and sub-scores, the EQRO will break down the prescribed managed care standards, as well as those specifically requested by HSD into separately measurable items without changing their substance. The EQRO will assign numerical values to each item to be measured based on a scale determined by the EQRO and approved by HSD.
The methodology will result in individual weighted scores for each standard and substandard to be measured. Each contractor will receive an overall score for compliance performance against all of the standards. A combined, absolute score will reflect overall MCO compliance among. Each overall contractor score will enable that contractor’s performance to be expressed in terms relative to the mean score of all of the MCOs. HSD shall determine the levels of compliance relative to the overall scores.
The measurement of MCO performance against some of the standards will require the EQRO to review individual medical records. The EQRO will develop the random sampling methodologies to meet a 95% confidence interval with no more than a standard error rate of .05 to allow statistically valid measurements of performance and that also allow for valid comparison among the MCOs. HSD will provide encounter data to the EQRO upon request.
(2) Rationale for Each Standard
The EQRO will develop the written rationale for each standard, describing the intent of the standard and its relationship to quality of care. The written rationale must be approved by HSD.
(3) Scoring Criteria
The EQRO will develop the scoring criteria that will be used to determine each score on the scale for each standard and substandard to be scored. This must specify the level of performance that would result in a particular numeric score. The scoring criteria must be approved by HSD.
(4) Detailed Procedures and Forms to be Used for Measure ment and Scoring
The EQR will develop the detailed procedures, forms, and guidelines for the evaluator that will be used to perform the evaluations of MCO performance against the quality standards. These documents must be approved by HSD.
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(5) Conduct and Report
In response to a Letter of Direction, the EQRO will measure and score the performance of each managed care contractor against all applicable managed care standards. This will be done by applying the Measurement and Scoring Methodology that was developed in accordance with Section V above. Normally the compliance performance of more than one MCO for the same population will be evaluated to allow comparison of performance among MCOs. When this is done, the EQRO will ensure that the compliance performance measured is for the same time period for all MCOs. A complete review of a single MCO against all or specified applicable standards and the written report of that review constitutes a single unit of work for reimbursement purposes. The content and format of the report will be proposed by the EQRO and approved by HSD before performance measurements begin.
(D) Follow-Up Review and Performance Measurement Activity
From time to time, HSD may direct the EQRO to perform an ad hoc review or performance measurement activity. This may be in many different forms. Among these are the following:
(1) Follow-up Reviews Related to the Activity Described in Sec tion V;
(2) Focused Measurement of Performance Applied to any Combination of the Following, including but not limited to:
(a) Specific standard or set of standards;
(b) Special defined population of members;
(c) Specific age or other demographic group;
(d) Specific geographic area;
(e) Specific MCO, subcontractor of an MCO, or provider group or individual provider in the network of one or more MCOs;
(f) Specific diagnosis or group of diagnoses or health conditions; and
(g) Other parameters.
(3) Follow-up Focused Cross Validation Audits of Encounter Data Described in Section V.
This activity will be reimbursed on a per-follow up review basis. The specific activities, their timing, reports, and the number of reimbursable reviews will be
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discussed between HSD and the EQRO in advance and specified in Letters of Direction from HSD. This activity is subject to 48 hours advance notice from HSD.
(E) Design, Conduct and Report on Member Satisfaction Survey
HSD may choose to conduct member satisfaction surveys, directly or through its designated agent. Pursuant to a Letter of Direction, the EQRO will develop the survey instrument as a ready-to-perform product. This will include all necessary forms, data management application files for processing the results, the detailed procedures for conducting the survey, and an estimate of the types and amounts of resources needed for its conduct.
Each survey will pertain to the specifically-served Medicaid membership and address at least, but not limited to the following modules:
Overall measures of satisfaction/dissatisfaction; Member characteristics (demographics, etc.); Health status; Use of health services; Access to ambulatory care (primary care, specialists, behavioral health care,
dental, etc.); Access related to language/race/ethnicity/cultural issues; Barriers to service access, including convenience, safety, and comfort for program
recipients; Wait times; Office/clinic responsiveness to phone calls; Culturally competent and member-centered service delivery; MCOs’ grievance processes; Understanding of managed care procedures; Technical quality of care; Quality care related to interpersonal communications (caring attitude, etc.); and, Quality of customer service.
The survey must allow a comparison of member satisfaction among the managed care contractors when there is more than one contractor serving the specified population. For the multiple contractor comparisons, data is to be stratified according to the major categories of Medicaid eligibility and the identified parameters of the survey.
The detailed content, scope, focus, and type of the survey will ultimately be determined by HSD. However, the EQRO will provide the survey design expertise necessary for a valid survey and facilitate the HSD decision process to determine the survey parameters.
The EQRO will conduct a member satisfaction survey on behalf of HSD pursuant to a Letter of Direction. The survey will be conducted using the HSD approved product of Section V. A completed survey includes the report of its results delivered to and approved by HSD. The report will include quantification of the statistical significance of the results including a discussion of any sampling bias and its significance.
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(F) Design, Conduct and Report on Periodic Utilization Review Denial Audits The EQRO will conduct periodic Utilization Review denial audits on behalf of HSD pursuant to a Letter of Direction.
(G) Design, Conduct and Report on Cross Validation Audits of Encounter Data
The contracted MCOs are required to submit encounter data on a routine basis. Encounter data is very similar to the data associated with provider claims for payment. HSD will use this data as input to a number of decisions, and the data will be available to the public in aggregate form. Serious levels of inaccuracy and/or incompleteness can result in erroneous decisions and conclusions by the State and/or the public, especially if the nature and degree of these inaccuracies and/or voids of data are unknown.
In the design of the audits, the EQRO will follow professionally accepted standards of auditing, accounting, research design, sampling, and biostatistics such that statistically valid and defensible data, rates, and conclusions will result. The EQRO must ensure that the results of the audits will allow HSD to accurately interpret the encounter data, make statistically valid corrections to aggregate encounter data, focus its MCO contract enforcement efforts, and produce reliable and generalized information.
HSD will direct each design of a validation audit by a Letter of Direction, determine the dates of service ranges for validation measurement, and provide the encounter data and other data or reports. The EQRO will develop the detailed encounter data cross validation audit methodology including the detailed procedures for HSD approval prior to conduct of the audit. This will include specifying the data and its format that HSD will provide to the EQRO.
The EQRO will perform cross validation audits of encounter data submitted by each MCO. These audits will involve measuring the consistency between submitted encounter data and corresponding health record entries. The data from a sample of encounters will be validated against the corresponding provider health record for accuracy and completeness, and the data from a sample of provider health records will be validated against the appropriate submitted encounter data. The samples may include all provider types and specialties and all segments of the Medicaid managed care membership. The EQRO will identify and analyze significant discrepancies to determine error/incompleteness rates by provider and provider type and specialty in detail and in the aggregate for each MCO and render a report of the results to HSD for approval.
The format of the report will be developed by the EQRO and must be approved by HSD before the conduct of the audit.
A completed cross validation audit will include the analysis of the results and the HSD-approved report of the audit, including EQRO recommendations for encounter data systems improvements.
(H) Design and Conduct Ad Hoc Audits
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HSD may wish to conduct audits of MCOs addressing unique and timely issues that require design sophistication, designer expertise, and auditor qualifications similar to that described for Cross Validation Audits of Encounter Data. In the design and conduct of each audit, the EQRO will follow professionally accepted standards of auditing, accounting, research design, sampling and biostatistics such that statistically valid and defensible data, rates and conclusions will result. The EQRO must ensure that the results of the audits will allow HSD to accurately interpret the data, focus its MCO contract enforcement effort and produce reliable and generalized informa-tion. Ad hoc audits will be reimbursed at the contracted hourly rate for this type of activity. HSD will initiate each ad hoc audit by a Letter of Direction that specifies its parameters and authorizes the maximum number of hours that will be reimbursed. The EQRO will develop detailed audit methodology, including specific procedures for HSD approval prior to conduct of the audit. A completed audit will include the design, audit and analysis of the results, as well as the HSD-approved report of the audit.
HSD may request special ad hoc reports to be derived from the EQRO’s activity database. These special reports require ad hoc systems programming and are considered Reimbursable Services. They are distinguished from routine EQRO reports to the state, which are considered an Overhead Service Not Reimbursable. HSD may also request targeted technical assistance on a state-defined topic. Regardless of the requesting agency, reimbursement for a special ad hoc report or technical assistance will be made by HSD only if it is specifically initiated by a Letter of Direction and will be reimbursed on an hourly basis at the contracted rate for this activity. After discussion with the EQRO, the Letter of Direction will specify, at a minimum, the report content, the maximum number of hours to be reimbursed and the report due date. (I) Design, Conduct and Report on Provider Satisfaction Survey
HSD may wish the EQRO to develop a provider satisfaction survey. Pursuant to a Letter of Direction, the EQRO will develop the survey instrument as a ready-to-perform product. This will include all necessary forms, data management application files for processing the results and the detailed procedures for the conduct of the survey. A survey may be directed to include a broad cross section of provider types or be focused on one or a narrow range of provider types. The content, scope, focus, type and timing of the survey will be determined by HSD and will be included in the pertinent Letter of Direction. The EQRO will provide the design expertise necessary for a valid survey and will lead the HSD decision process to determine the survey parameters.
Pursuant to a Letter of Direction, HSD may ask the EQRO to conduct a provider satisfaction survey. The survey will be conducted using the product of Section V. A completed survey includes the report of its results delivered to and approved by HSD. The report will include quantification of the statistical significance of the results including a discussion of any sampling bias and its significance.
(J) Design, Conduct and Report on Independent Assessments
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HSD will require the EQRO to conduct an Independent Assessment (IA) of the State’s activities and efforts to monitor the managed care contracts. The IA is not a duplication of effort by the EQRO to assess the State’s Medicaid managed care program, and the EQRO shall rely on documents already produced by the State’s independent actuarial contractors and independent financial auditors in addition to surveys and evaluations that have already been produced by the EQRO to the greatest extent possible.
The IA will make recommendations as well as report results to be used by the State in order to improve Medicaid oversight activities related to each of the managed care contracts. There are three federally required elements of the IA Report: access to care, quality of care, and cost effectiveness. Each of these components is discussed in detail below.
(1) Element 1 – Access to ServicesThe EQRO will take into consideration as many of the following as are practicable and appropriate:
Evaluation of the program’s access monitoring and analysis Enrollment information Education and customer service information Provider capacity Urgent/Emergent care Travel and wait times for primary care and specialty
Referrals
(2) Element 2 – Quality of Services The EQRO will take into consideration as many of the following as are practicable and appropriate:
Evaluation of the program’s quality monitoring elements and analysis and review of EQRO reports
Clinical review of utilization patterns Grievances including appeals Beneficiary, provider and subcontractor satisfaction State quality improvement measures
(3) Element 3 – Cost Effectiveness The EQRO will take into consideration as many of the following as are practicable and appropriate:
Calculate the cost-effectiveness of the managed care program for the previous time period of the program
Review of the State’s Upper Payment Limit (UPL) calculation, rate setting, and cost-effectiveness monitoring processes
Analysis of the source of the cost savings in the program Analysis of possible cost-shifting from capitated service utilization to fee-for-
service utilization
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Assess whether CMS and the State are paying MCO providers appropriately for services
Perform an analysis of the State’s capitation payment system in paying capitation to the MCOs.
The minimum requirement for IA review is two (2) surveys per four (4) year contract period, or biannually. The state could require an additional one to two IA’s per waiver contract period. An IA report must be submitted with the State’s Waiver renewal request ninety (90) days before the expiration of the approved waiver program. The IA will be reimbursed on a per survey basis.
(K) Design, Conduct and Report on Nursing Facility Level of Care
Random monthly reviews of Nursing Facility (NF) Level of Care (LOC) ratings assigned to recipients shall be conducted to ensure that NF LOC criteria are applied consistently and equitably across the New Mexico Medicaid program. Data will be collected from the health plans to the contractor through a secure transmission system. Data will be analyzed and resulting reports will be compiled and provided to HSD on a quarterly basis. Deliverables include the following:
(1) Define and develop a project plan for conducting desk reviews of NF LOC rating determinations made by Centennial Care MCOs.
(2) Develop random sampling methodology according to specifications from HSD to complete NF LOC determinations collected from the MCOs for NF LOC rating determinations. This includes both approvals and denials.
(3) Conduct random external quarterly reviews of each MCO based on MCO NF LOC instructions and tool guidelines by collecting member-specific data used to determine NF LOC ratings from MCOs using secure file transition and storage.
(4) Develop review tools for capturing data on the following elements:(a) Accuracy of NF LOC decisions;(b) Timeliness of NF LOC decisions;
(c) If the denials went through physician review;(d) Reasons for denials.
(5) Report findings to HSD on a quarterly basis.(6) Make recommendations for improvement in the process.(7) Evaluate the project results and note trends.
(L) Design, Conduct and Report on Individualized Service PlansThe State’s EQRO contractor shall monitor MCO compliance with specific requirements of CMS Special Terms and Conditions for New Mexico Centennial Care. The Contractor shall monitor and annually evaluate the MCOs’ performance on the HCBS requirements under Centennial Care. These include service plans to ensure that MCOs are appropriately creating and implementing service care plans based on enrollee’s identified needs.
(M) Design, Conduct and Report on HEDIS-Like Measures
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HEDIS-Like measure data shall be collected from Centennial Care MCOs to establish thresholds, baselines and re-measurements for each HEDIS-Like measure. Data shall be analyzed and reported to HSD on a quarterly basis by either administrative or hybrid methodology and transmitted from the health plans to the contractor through a secure transmission system. Deliverables include the following:
(1) Design a project plan including defining project roles and responsibilities;(2) Develop methodology for quarterly reporting of data collected from the MCOs for
measures identified by HSD;(3) Develop in-house programming software to report identified measures;(4) Test the developed in-house software prior to the roll out;(5) Provide technical assistance and training to health plan staff on data selection;(6) Collect member-specific data from health plans on a quarterly basis using secure file
transition and storage;(7) Perform validation of data reported by MCOs;(8) Perform validation of medical record review abstractions for measures selected for
hybrid methodology reporting and reconciliation of processes prior to final reporting;(9) Maintain annual license to NCQA Quality Compass® Medicaid data for
benchmarking comparisons and include these indicators/results in the quarterly reports to HSD;
(10) Provide training to MCOs to capture the information needed to provide Medicaid-required reporting and the ability to use MCO data to create quarterly reports;
(11) Develop procedures and training manuals for contractor’s staff members to understand and accomplish the tasks outlined in the proposal;
(12) Provide training and facilitation of the process for the HSD staff to include the following program services:
(a) Quality improvement strategies (b) NCQA HEDIS reporting requirements
(c) Comprehensive care management (d) Care coordination (e) Health promotion (f) Comprehensive transitional care (g) EQRO activities and relationship to Centennial Care
(13) Monitor the program data on a quarterly basis by:(a) Conducting quality improvement analysis and compiling quarterly reports for the State; and(b) Working with the MCOs on quality improvement interventions to improve outcomes and achieve State-established program goals.
(14) Evaluate of the project and its impact
(N) Future Services at Negotiated RateThe EQRO will perform services not otherwise specified in the contract, including special projects, as directed by specific Letters of Direction from HSD. The specific work requirements and the reimbursement for such services will be negotiated between the EQRO and HSD. These
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services may include special projects that may arise as a result of Congressional, Legislative or HSD actions.
2.5 QUALITY OF CONTRACTOR SERVICES
(A) Quality of Staff.
The CONTRACTOR:
(1) Will demonstrate that its staff possesses sufficient current knowledge of the requirements of this Scope of Work, the quality standards contained in state regulations, and applicable Federal regulations and other guidance from CMS. This must include knowledge and understanding of the NCQA Standards for Accreditation and its accreditation process, HEDIS 3.0 and subsequent versions, MHSIP Consumer Report Card, and A Health Care Quality Improvement System for Medicaid Managed Care, A Guide for the States, U.S. DEPARTMENT of Health and Human Services, Centers for Medicare and Medicaid Services, Medicaid Bureau, July 6, 1993.
(2) Will have a medical director who is a physician currently licensed to practice medicine.
(3) Must have experience and expertise in the epidemiologic and statistical measurement of health and service status indicators, including behavioral health, in defined populations. This must include in depth understanding of the scope and methodologies of data collection, the interpretation of data, and the social and economic factors that affect the interpretation of the data. This expertise must insure that the activities described in the Article 2.4 are conducted in accordance with generally accepted principles of research design and statistical analysis in order to produce valid, reliable, and generalizable information.
(B) Approved Detailed Work Plans.(1) The CONTRACTOR will develop written detailed internal work plans for
all reviews, audits, performance measurements, and surveys described in Article 2.4. The work plans must specify all steps in each process. The style and level of detail in the CONTRACTOR’s detailed work plans should be aimed at the CONTRACTOR’s staff. The detailed work plans for a given activity must be approved by HSD/MAD before the CONTRACTOR begins performing that activity. Within fourteen (14) calendar days of the pertinent Letter of Direction, the CONTRACTOR will forward written detailed work plans for the directed activity. The CONTRACTOR may request an extension to this for specific directed activity, and HSD/MAD will reasonably consider such requests.
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(2) Due to HSD/MAD directed policy changes and other changes in the external environment, the CONTRACTOR should anticipate changes and must respond HSD/MAD directed changes by forwarding revised detailed work plans for approval to HSD/MAD within fourteen (14) calendar days of the date of the written request. The CONTRACTOR will follow the most current approved version of the detailed work plans. The CONTRACTOR will insure that each page of the detailed work plans is dated with the effective date of HSD/MAD’s approval.
(C) Documentation.
The CONTRACTOR will document each review, audit, performance measurement, and survey in such a way that an uninvolved reader can completely reconstruct the activity. The CONTRACTOR must maintain this documentation for a total of five (5) years unless transfer is specifically directed by HSD/MAD or by the terms of the contract. Upon request from HSD/MAD, the CONTRACTOR must be able to produce the documentation within five (5) business days.
(D) Internal Quality Management Program.
The CONTRACTOR will establish and maintain its own internal quality management program following the basic principles of Continuous Quality Improvement that are presently used throughout most industries. This program will be applied to all aspects of the CONTRACTOR’s performance under this contract. The CONTRACTOR will submit to HSD/MAD for review a detailed description of its internal quality management program and its associated processes and procedures within sixty (60) calendar days of the effective date of this Agreement.
(E) Overall Quality of CONTRACTOR Performance.
HSD/MAD reserves the right to determine the level of acceptable quality of any and all CONTRACTOR deliverables. Reimbursement by HSD/MAD will be made for only those deliverables deemed by the HSD/MAD to be of acceptable quality.
2.6 OVREHEAD SERVICES NOT REIMBURSED
The Overhead Services Not Reimbursable described in the following paragraphs will be performed by the CONTRACTOR as overhead and will not be specifically reimbursed by HSD/MAD unless otherwise stated in this Agreement:
(A) Services and work associated with the requirements of Quality of Reviews are considered to be CONTRACTOR overhead expenses.
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(B) Rendering of the Annual Report of the Review of Quality of the Services furnished through each MCO contract. This report will be based on the activities described in Article 2.4. The report must be forwarded to HSD/MAD no later than sixty (60) calendar days after each one-year period. The first one-year period will be defined by HSD/MAD before its start date, and subsequent one-year periods will be the anniversary dates of the first period.
(C) Computer hardware, software and systems programming that may be required to perform the Scope of Work (Article 2) are considered to be overhead expenses. The CONTRACTOR must be capable of reading electronic files from HSD and its Fiscal Agent and producing electronic files in a format usable by HSD. Although upgrades and/or changes in versions will be inevitable, HSD currently uses the MICROSOFT WINDOWS XP with MICROSOFT OFFICE 2007 products. This will phase out early 2014 to WINDOWS 7 with MICROSOFT OFFICE 2010. To that end, Offerors should consider their ability to switch formats on a parallel schedule with HSD in order to prevent disruption of communications or file transfers.
(D) The CONTRACTOR will have computer hardware, software and systems programming abilities that will consist of a hardware and software multimedia package having the ability to generate and receive video teleconference (VTC) feeds for interfacing with existing and possible future developments concerning usage of the internet.
(E) The CONTRACTOR agrees to conduct its business with HSD/MAD in accordance with all applicable laws and regulations, including HIPAA and the regulations promulgated hereunder, and State confidentiality laws and regulations. The CONTRACTOR further agrees to comply with all policies and procedures adopted by HSD/MAD related to use, transmission, and disclosure of Protected Health Information for the work described pursuant to a Letter of Direction.
(F) The CONTRACTOR will arrange and bear the cost of the shipping, transporting, or transmitting of any materials required unless otherwise specified by this Agreement.
(G) The CONTRACTOR will participate in monthly management meetings with HSD/MAD personnel in Santa Fe. Additionally and upon request of HSD/MAD, the CONTRACTOR will participate in approximately four (4) monthly ad-hoc meetings within New Mexico.
(H) Upon the request of HSD/MAD, the CONTRACTOR will be required to provide testimony in person or in the form of depositions for HSD administrative hearings and judicial hearings concerning protests of actions taken as a result of CONTRACTOR reviews and/or provide testimony at State legislative hearings.
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(I) The CONTRACTOR will cooperate with HSD/MAD MCO contract staff by making documentation available, providing access to CONTRACTOR staff, and providing working space for HSD/MAD personnel to perform On-Site Program Integrity Reviews to validate the CONTRACTOR’s performance. In addition to evaluating the CONTRACTOR’s compliance with the contract, HSD/MAD will evaluate the quality, effectiveness and utility of HSD/MAD directed activity and the HSD/MAD approved procedures.
(J) The CONTRACTOR will fully cooperate with the State Medicaid Fraud Unit, the HSD’s Office of the Inspector General, the Federal Bureau of Investigation and other investigative agencies as directed by HSD/MAD, subject to the terms of this Agreement.
ARTICLE 3 – LIMITATION OF COST
3.1 The total amount for the first two years of this Agreement shall not exceed $________________________. This amount is exclusive of New Mexico gross receipts tax and any other taxes that must be reported and paid by the CONTRACTOR to any state or federal taxing agency.
ARTICLE 4 – HSD/MAD RESPONSIBILITY
4.1 HSD/MAD shall compensate the CONTRACTOR as specified in Article 5 – Compensation and Payment.
4.2 HSD/MAD shall task, supervise, review and provide access to all information necessary for the CONTRACTOR to perform its functions. Any and all work included under Reimbursed Services in the Scope of Work, Article 2.4, will be specifically directed by HSD/MAD by Letters of Direction issued to the CONTRACTOR. Only the work that is so directed will be reimbursed.
ARTICLE 5 – COMPENSATION AND PAYMENT
5.1 HSD/MAD shall pay to the CONTRACTOR, in full payment for services satisfactorily performed pursuant to the Scope of Work, Article 2.4, a total not to exceed ________________________, for the period of ___________through __________, excluding gross receipts tax. The carryover of unspent funds between state fiscal years is not permitted.
5.2 HSD/MAD shall compensate the CONTRACTOR for Reimbursed Services as detailed in Article 2.4. Payment will be made only for completed reviews and other activities that meet the timeliness requirements set forth therein.
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5.3 HSD/MAD shall compensate the CONTRACTOR for work performed under this Agreement at the agreed upon rates listed on Appendix D.
5.4 The CONTRACTOR will submit a complete monthly invoice to HSD/MAD no later than the fifteen (15) business days following the acceptance of a completed HSD/MAD directed Reimbursable Service.
5.5 Within fifteen (15) business days after the date HSD/MAD receives written notice from the CONTRACTOR that payment is requested for services or items of tangible personal property delivered on site and received, HSD/MAD shall issue a written certification of complete or partial acceptance or rejection of the services or items of tangible personal property. If HSD/MAD finds that the services or items of tangible personal property are not acceptable, it shall, within thirty days after the date of receipt of written notice from the CONTRACTOR that payment is requested, provide to the CONTRACTOR a letter of exception explaining the defect or objection to the services or delivered tangible person property along with details of how the CONTRACTOR may proceed to provide remedial action. Upon certification by HSD/MAD that the services or items of tangible personal property have been received and accepted, payment shall be tendered to the CONTRACTOR within thirty (30) calendar days after the date of certification. If payment is made by mail, the payment shall be deemed tendered on the date it is postmarked. No late payment charges shall be paid on the unpaid balance due on the Agreement to the CONTRACTOR.
ARTICLE 6 – PENALTIES AND WITHHOLDING OF PAYMENT
6.1 If the CONTRACTOR does not submit to HSD/MAD any deliverable specified throughout this Agreement within the specified time period, HSD/MAD will impose a penalty of $50.00 per day until that deliverable is submitted. Notice of intent to apply penalties will be issued by the Director of the Medical Assistance Division. If the CONTRACTOR disagrees with the penalty imposition, it may appeal as specified in Article 14, Disputes.
6.2 HSD/MAD shall notify the CONTRACTOR of obvious errors in reports such as failure to provide a complete report, improper format, or improper labeling. The CONTRACTOR shall correct or make a good faith effort to correct these errors within twenty (20) business days from the date of notification by HSD/MAD. Reports found to contain CONTRACTOR error will be corrected by the CONTRACTOR upon notification by HSD/MAD. If the reports are not corrected within the specified twenty (20) day period, HSD/MAD may impose a penalty of $50.00 per day until necessary corrections are made and submitted to HSD/MAD. Notices of intent to apply penalties will be issued by the Director of the Medical Assistance Division. If the CONTRACTOR disagrees with the penalty imposition, it may appeal as specified in Article 14, Disputes.
ARTICLE 7 - CONTRACT ADMINISTRATOR’S DUTIES
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7.1 HSD shall notify the CONTRACTOR of any changes in the identity of the Contract Administrator. The Contract Administrator is empowered and authorized to represent HSD in all matters related to this Agreement, except those reserved to other HSD/MAD personnel by this Agreement. Notwithstanding the above, the Contract Administrator does not have the authority to amend the terms and conditions of this Agreement. All events, problems, concerns or requests affecting this Agreement shall be reported by the CONTRACTOR to the Contract Administrator. The Contract Administrator will issue the Letters of Direction for all matters so designated in this Agreement. The designated Contract Administrator for HSD is:
Elizabeth C. Cassel, Ph.D.Medical Assistance DivisionHuman Services Department2025 South Pacheco StreetSanta Fe, New Mexico 87504Telephone Number: (505) 827-7715Fax Number: (505) 827-3126
ARTICLE 8 – CONTRACT MANAGEMENT PROGRAM
8.1 The CONTRACTOR shall participate in and cooperate with the Contract Management Program as specified in Article 2, Detailed Scope of Work, the Request for Proposal, and as further structured and formalized by the Contract Administrator.
ARTICLE 9 – TERMINATION
9.1 This Agreement may be terminated as follows:
(A) By mutual written agreement of HSD and CONTRACTOR upon such terms and conditions as they may agree.
(B) By HSD for convenience, upon not less than ninety (90) days written notice to the CONTRACTOR.
(C) By HSD for cause upon failure of the CONTRACTOR to materially comply with the terms and conditions of this Agreement. HSD shall give the CONTRACTOR written notice specifying the CONTRACTOR's failure to comply. The CONTRACTOR shall correct the failure within thirty (30) calendar days or begin in good faith to correct the failure and thereafter proceed diligently to complete or cure the failure. If within thirty (30) calendar days the CONTRACTOR has not initiated or completed corrective action, HSD may serve written notice stating the date of termination and work stoppage arrangements.
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(D) By HSD, if required by changes in state or federal law, by court order, or because of insufficient appropriations made available by the U.S. Congress and/or the State Legislature for the performance of this Agreement. HSD's decision as to whether sufficient appropriations are available shall be accepted by the CONTRACTOR and shall be final. If HSD terminates this Agreement pursuant to this subsection, HSD shall provide the CONTRACTOR written notice of such termination at least ninety (90) calendar days prior to the effective date of the termination.
(E) By the Contract Administrator, if in his/her sole opinion, the replacement key personnel do not meet the equal abilities, experience, and qualifications set forth in the RFP and this Agreement.
9.2 By termination pursuant to this article, neither party may nullify obligations already incurred for performance of services prior to the date of notice.
ARTICLE 10 - TERMINATION AGREEMENT
10.1 When HSD has reduced to writing and delivered to the CONTRACTOR notice of termination, the effective date, and reasons therefore (if any), HSD, in addition to other rights provided in this Article, may require the CONTRACTOR to deliver, and/or make readily available to HSD, property in which HSD has a financial interest and any and all data, inventions or property specifically produced or acquired under this Agreement.
10.2 In the event this Agreement is terminated by HSD, immediately as of the termination date, the CONTRACTOR shall:
(A) Incur no further financial obligations for materials, services, or facilities under this Agreement without prior written approval of the HSD.
(B) Terminate all purchase (procurement) orders and subcontracts and stop all work to the extent specified in the notice of termination, except as HSD may direct for orderly completion of this Agreement.
(C) Agree that HSD is not liable for any costs arising out of termination. HSD is liable only for tasks assigned in writing prior to the Agreement termination date and approved pursuant to the Contract Management Program.
(D) Take such action as HSD may direct for the protection and preservation of all property and all records related to, and required by, this Agreement.
(E) Cooperate fully with any transition required so as to permit continuity in the administration of the EQR program.
10.3 In the event that the Agreement is terminated for any reason, the Contract Administrator or designee will issue an immediate work stoppage notice to the CONTRACTOR that
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will be effective immediately upon CONTRACTOR receipt. The Agreement will terminate on the work stoppage date. The Contract Management Program will apply to all tasks submitted to the Project Manager prior to the work stoppage date. The CONTRACTOR will be paid solely for Reimbursable Services directed by Letters of Direction by the Contract Administrator prior to the termination date and approved pursuant to the Contract Management Program.
ARTICLE 11 - RIGHTS UPON TERMINATION OR EXPIRATION
11.1 In the event this Agreement is terminated for any reason, or upon expiration, and in addition to all other rights to property set forth in this Agreement, HSD shall retain ownership of all work products and documentation created pursuant to this Agreement.
11.2 In the event the Agreement expires or is terminated, HSD shall pay the CONTRACTOR all amounts due for services completed through the effective date of such termination or expiration and approved pursuant to the Contract Management Program. HSD shall not pay any costs arising out of termination or expiration. HSD may deduct from amounts otherwise payable to the CONTRACTOR money determined to be due HSD from the CONTRACTOR.
11.3 In the event the CONTRACTOR's course of performance results in reductions in HSD’s receipt of program funds from any governmental agency, the CONTRACTOR shall remit to HSD, as liquidated damages, such funds as are necessary to make HSD whole.
11.4 Should the CONTRACTOR terminate the Agreement, it shall reimburse the HSD for all costs arising from delays, for hiring new CONTRACTOR/subcontractors at potentially higher rates and for other costs incurred.
11.5 In the event this Agreement is terminated for any reason, or upon expiration, the CONTRACTOR shall assist and cooperate with HSD in the orderly and timely transfer of files, computer software, documentation and other materials, whether provided by HSD or created by the CONTRACTOR under this Agreement, to HSD, to follow-on vendor or the State's host data center as directed by HSD. At the request of the Contract Administrator, the CONTRACTOR shall provide to HSD a copy of the most recent versions of all files, software and documentation and other materials whether provided by HSD or created by the CONTRACTOR under this Agreement, in a format acceptable to HSD.
11.6 In the event this Agreement is terminated for any reason, or upon expiration, the CONTRACTOR, upon the request of HSD, shall provide training for HSD staff, follow-on CONTRACTOR, or other agency determined by HSD, on procedures and guidelines used by the CONTRACTOR in performing the services under this Agreement. The training must be sufficient to enable the transition to the follow-on agency to be nearly transparent to MCOs, providers, and recipients. This training will be provided at no additional charge to HSD. Should a training period be required, the CONTRACTOR and
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HSD will negotiate a mutually acceptable training plan subsequent to the termination date.
ARTICLE 12 – INTELLECTUAL PROPERTY
12.1 HSD and the CONTRACTOR acknowledge that performance of this Agreement may result in the development of new proprietary and secret concepts, methods, techniques, processes, adaptations, and ideas. The parties agree that the same shall belong solely and exclusively to HSD, without regard to the origin thereof and that the CONTRACTOR will not, other than in the performance of this Agreement, make use of or disclose the same to anyone without the written consent and participation of HSD.
12.2 The CONTRACTOR warrants that all materials produced hereunder will be of original development by CONTRACTOR, and will be specifically developed for the fulfillment of this Agreement and will not infringe upon or violate any patent, copyright, trade secret or other property right of any third party, and the CONTRACTOR will indemnify and hold HSD harmless from and against any loss, cost, liability, or expense arising out of breach or claimed breach of this warranty.
12.3 In the event the CONTRACTOR shall elect to use or incorporate in the materials to be produced any components of a system already existing, the CONTRACTOR shall first notify HSD, who after investigation may direct the CONTRACTOR not to incorporate such components. If HSD shall not object, and after the CONTRACTOR obtains written consent of the party owning the same, and furnishing a copy to HSD, the CONTRACTOR may incorporate such components. The CONTRACTOR warrants that such incorporation will not infringe upon or violate any patent, copyright, trade secret or other property right of any third party, and the CONTRACTOR will indemnify and hold HSD harmless from and against any loss, cost, liability, or expense arising out of breach or claimed breach of this warranty.
12.4 All materials, work papers, meeting notes, and design documents produced by the CONTRACTOR shall be the property of HSD. The original and one copy of all such documents shall be indexed and bound and delivered to the Contract Administrator at the conclusion or termination of the Agreement.
12.5 All materials developed or acquired by the CONTRACTOR under this Agreement shall become the property of the State of New Mexico and shall be delivered to HSD no later than the termination date of this Agreement.
12.6 Nothing produced, in whole or in part, by the CONTRACTOR under this Agreement shall be the subject of an application for copyright by or on behalf of the CONTRACTOR.
ARTICLE 13 - APPROPRIATIONS
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13.1 The terms of this Agreement are contingent upon sufficient appropriations or authorizations made by either the Legislature of New Mexico, CMS, or the U.S. Congress for performance of this Agreement. If sufficient appropriations and authorizations are not made by either the Legislature, CMS, or the U. S. Congress, this Agreement shall be subject to termination or amendment. HSD’s decision as to whether sufficient appropriations or authorizations exist shall be accepted by the CONTRACTOR and shall be final and binding. Any changes to the Scope of Work and compensation paid to the CONTRACTOR affected pursuant to Article 13.1 shall be negotiated, reduced to writing and signed by the parties in accordance with Article 38 (Amendments) to this Agreement and any other applicable State or Federal statutes, rules, or regulations.
13.2 To the extent CMS, legislation or congressional action impacts the amount of appropriation available for performance under this Agreement, HSD has the right to amend the Scope of Work, in its discretion, which shall be effected by HSD sending written notice to the CONTRACTOR. Any changes to the Scope of Work and compensation paid to the CONTRACTOR affected pursuant to Article 13.1 shall be negotiated, reduced to writing and signed by the parties in accordance with Article 38 (Amendments) to this Agreement and any other applicable State or Federal statutes, rules, or regulations.
ARTICLE 14 – DISPUTES AND DISPUTE RESOLUTION
14.1 General
In the event of a dispute under the Agreement, applicable documents will be referred to for the purpose of clarification or for additional detail in the following order of precedence:
(A) Amendments to the Agreement in reverse chronological order, followed by;
(B) The Agreement, including Scope of Work, followed by;
(C) The CONTRACTOR's Best and Final Offer, if applicable, followed by;
(D) The Request for Proposals, including attachments thereto and written responses to written questions and written clarifications.
(E) The CONTRACTOR's Response to the Request for Proposals (including both the technical and cost portions).
14.2 Dispute Procedure.
(A) This Agreement is not subject to arbitration.
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(B) Any dispute unresolved by the Contract Administrator concerning performance by the parties shall be reported in writing to the Director of the Medical Assistance Division within thirty (30) calendar days of the discovery of activity or incident giving rise to the dispute. The decision of the Director shall be delivered to the parties in writing within thirty (30) calendar days of receipt of the written dispute and shall be final and conclusive unless, within fifteen (15) calendar days from the date of the decision, either party files with the Secretary or a designee a written appeal of the decision of the Director.
(1) Failure to file a timely appeal shall be deemed acceptance of the Director's decision and waiver of any further claim.
(2) In any appeal under this Article, the CONTRACTOR and the Medical Assistance Division shall be afforded an opportunity to be heard and to offer evidence and argument in support of their position to the Secretary of HSD or a designee. The Secretary or designee may seek information from other sources, if appropriate. The appeal may include an informal hearing that shall not be recorded or transcribed, and is not subject to formal rules of evidence or procedure.
(C) The Secretary or a designee will review the issues and evidence presented and will issue a determination in writing that will conclude the administrative process available to the parties. The Secretary or a designee will notify the parties of the decision within forty-five (45) calendar days of notice of the appeal, unless otherwise agreed to by the parties in writing.
(D) Pending decision by the Secretary or her designee, both parties shall proceed diligently with performance of the Agreement in accordance with its terms.
(E) Failure to initiate or participate in any part of this process shall be deemed waiver of any claim that the CONTRACTOR may have had.
ARTICLE 15- APPLICABLE LAW
15.1 This Agreement shall be governed by the laws of the State of New Mexico. All legal proceedings arising from unresolved disputes under this Agreement shall be brought in the First Judicial District Court in Santa Fe, New Mexico.
15.2 Each party agrees that it shall perform its obligations hereunder in accordance with all applicable Federal and State laws, rules and regulations now or hereafter in effect, including but not limited the Deficit Reduction Act of 2005, the Clean Air Act and the Federal Water Pollution Act.
15.3 If any provision of this Agreement is determined to be invalid, unenforceable, illegal or void, the remaining provisions of this Agreement shall not be affected, providing the
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remainder of the Agreement is capable of performance, the remaining provisions shall be binding upon the parties thereto, and shall be enforceable, as though said invalid, unenforceable, illegal or void provision were not contained herein.
ARTICLE 16 – STATUS OF CONTRACTOR
16.1 The CONTRACTOR is an independent CONTRACTOR performing professional services for the State of New Mexico and is not an employee of the State. The CONTRACTOR shall not accrue leave, retirement, insurance, bonding, use of State vehicles, or any other benefits afforded to employees of the State of New Mexico as a result of this Agreement.
16.2 The CONTRACTOR shall be solely responsible for all applicable taxes, insurance, licensing, and other costs of doing business. Should the CONTRACTOR’s default in these or other responsibilities, jeopardizing the CONTACTOR’s ability to perform services, this Agreement may be terminated immediately upon written notice.
16.3 The CONTRACTOR shall not purport to bind the State, its officers or employees nor the State of New Mexico to any obligation not expressly authorized herein unless the State has expressly given the CONTRACTOR the authority to do so in writing.
ARTICLE 17 – ASSIGNMENT
17.1 The CONTRACTOR shall not assign, transfer or delegate any rights, obligations, duties or other interest in this Agreement or assign any claim for money due or to become due under this Agreement except with prior written consent of HSD.
ARTICLE 18 – SUBCONTRACTING
18.1 The CONTRACTOR is solely responsible for fulfillment of this Agreement with HSD. HSD will make Agreement payments only to the CONTRACTOR.
18.2 The CONTRACTOR shall not subcontract any portion of the services to be performed under this Agreement without the prior written approval of HSD. Major subcontractors must be identified by name. HSD must approve subcontract forms or agreements, prior to use.
ARTICLE 19 – CHANGE ORDERS
19.1 HSD may make changes or revisions in the Scope of Work by written Letters of Direction as specified in Article 2.4.
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ARTICLE 20 – RELEASE
20.1 Upon final payment of the amounts due under this Agreement, the CONTRACTOR shall release HSD, its officers and employees and the State of New Mexico from all such payment obligations whatsoever under this Agreement. The CONTRACTOR agrees not to purport to bind the State of New Mexico.
20.2 Payment to the CONTRACTOR by HSD shall not constitute final release of the CONTRACTOR. Should audit or inspection of the CONTRACTOR’s records or the complaints subsequently reveal outstanding CONTRACTOR liabilities or obligations, the CONTRACTOR shall remain liable to HSD for such obligations. Any payment by HSD to the CONTRACTOR shall be subject to any appropriate recoupment by HSD.
20.3 Notice of any post-termination audit or investigation of complaint by HSD shall be provided to the CONTRACTOR, and such audit or investigation shall be initiated in with federal requirements. HSD shall notify the CONTRACTOR of any claim or demand within thirty (30) calendar days after completion of the audit or investigation or as otherwise authorized by CMS.
ARTICLE 21 - RECORDS AND AUDIT
21.1 The CONTRACTOR shall maintain books, records, documents, and other evidence pertaining to performance under this Agreement to the extent necessary to properly reflect all costs, direct and indirect, of labor, materials, equipment, supplies and services, and other costs and expenses of whatever nature for which payment is made under the Agreement. These records shall be maintained in accordance with generally accepted accounting principles and shall be easily separable from any other records.
21.2 CONTRACTOR agrees to preserve all records created or obtained in the course of this Agreement for a period of not less than ten (10) years from the date of final payment or resolution of any pending audit, whichever is later. Records involving matters of litigation, audit, or audit resolution shall be kept not less than ten (10) years following the termination of litigation or resolution of audit.
21.3 During the term of this Agreement and for a period of ten (10) years after expiration or termination of this Agreement, state and federal government representatives shall be given full access during normal business hours to the CONTRACTOR's financial and business records. Such access may include both announced and unannounced inspections, on-site audits and other evaluation or monitoring activities. Such access shall be extended upon the understanding that all information obtained will be afforded confidentiality as permitted under applicable law.
ARTICLE 22 - INDEMNIFICATION
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22.1 The CONTRACTOR agrees to indemnify, defend, and hold harmless the State of New Mexico, its officers, agents and employees from any and all claims and losses accruing or resulting to any and all CONTRACTORs, employees, or agents, subcontractors, laborers, and any other person, association, partnership, entity, or corporation furnishing or supplying work, services, materials, or supplies in connection with the performance of this Agreement, and from any and all claims and losses accruing or resulting to any person, association, partnership, entity, or corporation who may be injured, damaged or suffer any loss by the CONTRACTOR in the performance of the Agreement.
22.2 The CONTRACTOR shall indemnify and hold harmless HSD against any and all liability, loss, damage, costs or expenses that HSD may sustain, incur or be required to pay (1) By reason of any person suffering personal injury, death or property loss or damage of any kind either while participating with or receiving care or services from the CONTRACTOR under this Agreement, or while on premises owned, leased, or operated by the CONTRACTOR or while being transported to or from said premises in any vehicle owned, operated, leased, chartered, or otherwise contracted for or in the control of the CONTRACTOR or any officer, agent, subcontractor or employee thereof; or (2) By reason of any CONTRACTOR employee, agent, subcontractor or person within its scope of authority causing injury to, or damage to the person or property of another person including but not limited to HSD or CONTRACTOR, their employees or agents, during any time when the CONTRACTOR or any officer, agent, employee or subcontractor thereof has undertaken or is furnishing services called for under this Agreement.
ARTICLE 23 – INSURANCE
23.1 The CONTRACTOR shall procure and maintain in full force and effect during the term of this Agreement insurance as is required herein. Policies of insurance shall be written by companies authorized to write such insurance in New Mexico.
23.2 The CONTRACTOR shall furnish HSD/MAD copies of certificates of required insurance in a form satisfactory to HSD/MAD (or copies of insurance policies if HSD/MAD calls for them) within fifteen (15) calendar days after signing this Agreement. HSD/MAD shall immediately be notified if the insurance is canceled, materially changed or not renewed.
23.3 The CONTRACTOR shall procure and maintain during the life of this Agreement a comprehensive general liability and automobile insurance policy and liability limits in amounts not less than Five Hundred Thousand Dollars ($500,000) combined single limit of liability for bodily injury, including death, and property damage in any one occurrence. Said policies of insurance must include coverage for all operations performed for HSD by the CONTRACTOR, coverage for the use of all owned, non-owned, hired automobiles, vehicles, and other equipment both on and off work and contractual liability coverage shall specifically insure to hold harmless provisions of the Agreement. HSD shall be named an additional insured.
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23.4 HSD shall not be liable to claim or subrogation by the CONTRACTOR’s insurance carriers and all such insurance shall be deemed for the protection of the HSD as well as the CONTRACTOR.
ARTICLE 24 - EQUAL OPPORTUNITY COMPLIANCE
24.1 The CONTRACTOR agrees to abide by all Federal and State laws, rules, regulations and executive orders of the Governor of the State of New Mexico and the President of the United States pertaining to equal opportunity including title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972 (regarding education programs and activities), the Age Discrimination Act of 1975, the Rehabilitation Act of 1973 and the Americans with Disabilities Act. In accordance with all such laws, rules, and regulations, and executive orders, the CONTRACTOR agrees to ensure that no person in the United States shall, on the grounds of race, color, national origin, sex, sexual preference, age, trans-gender, handicap or religion be excluded from employment with, participation in, be denied the benefit of, or otherwise be subjected to discrimination under any program or activity performed under this Agreement. If the State finds that the CONTRACTOR is not in compliance with this requirement at any time during the term of this Agreement, the State reserves the right to terminate this Agreement pursuant to Article 9 or take such other steps it deems appropriate to correct said problem.
ARTICLE 25 - RIGHTS TO PROPERTY
25.1 All equipment and other property provided or reimbursed to the CONTRACTOR by HSD is the property of HSD and shall be turned over to HSD at the time of termination or expiration of this Agreement, unless otherwise agreed to in writing. In addition, in regard to the performance of experimental, developmental or research done by the CONTRACTOR, HSD shall determine the rights of the Federal Government and the parties to this Agreement in any resulting investigation.
ARTICLE 26 - ERRONEOUS ISSUANCE OF PAYMENT OR BENEFITS
26.1 In the event of an error, which causes payment(s) to the CONTRACTOR to be issued by HSD, the CONTRACTOR shall reimburse HSD within thirty (30) days of written notice of such error for the full amount of the payment. Interest shall accrue at the statutory rate on any amounts not paid and determined to be due after the thirtieth (30th) day following the notice.
ARTICLE 27 - EXCUSABLE DELAYS
27.1 The CONTRACTOR shall be excused from performance hereunder for any period that it is prevented from performing any services hereunder in whole or in part as a result of an act of nature, war, civil disturbance, epidemic, court order, or other cause beyond its reasonable control, and such nonperformance shall not be a default hereunder or ground for termination of the Agreement.
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27.2 The CONTRACTOR shall be excused from performance hereunder during any period for which the State of New Mexico has failed to enact a budget or appropriate monies to fund the managed care program, provided that the CONTRACTOR notifies HSD, in writing, of its intent to suspend performance and HSD is unable to resolve the budget or appropriation deficiencies within forty-five (45) calendar days.
27.3 In addition, the CONTRACTOR shall be excused from performance hereunder for insufficient payment by HSD, provided that the CONTRACTOR notifies HSD in writing of its intent to suspend performance and HSD is unable to remedy the monetary shortfall within forty-five (45) calendar days.
ARTICLE 28 – PUBLICITY
28.1 The CONTRACTOR shall not use HSD’s name or refer to the External Quality Review Project directly or indirectly in any advertisement, news release, professional trade or business presentation without prior written approval from HSD. Nothing in this Article shall prevent the CONTRACTOR from using HSD as a reference.
ARTICLE 29 - PROHIBITION OF BRIBES, GRATUITIES & KICKBACKS
29.1 Pursuant to Sections NMSA 1978, § 13-1-191, 30-24-1 et seq., 30-41-1, and 30-41-3, the receipt or solicitation of bribes, gratuities and kickbacks is strictly prohibited.
29.2 No elected or appointed officer or other employee of the State of New Mexico shall benefit financially or materially from this Agreement. No individual employed by the State of New Mexico shall be admitted to any share or part of the Agreement or to any benefit that may arise there from.
29.3 HSD may, by written notice to the CONTRACTOR, immediately terminate the right of the CONTRACTOR to proceed under the Agreement if it is found, after notice and hearing by the Secretary of HSD or his/her duly authorized representative, that gratuities in the form of entertainment, gifts or otherwise were offered or given by the CONTRACTOR or any agent or representative of the CONTRACTOR to any officer or employee of the State of New Mexico with a view toward securing the Agreement or securing favorable treatment with respect to the award or amending or making of any determinations with respect to the performing of such Agreement. In the event the Agreement is terminated as provided in this section, the State of New Mexico shall be entitled to pursue the same remedies against the CONTRACTOR as it would pursue in the event of a breach of contract by the CONTRACTOR and as a penalty in addition to any other damages to which it may be entitled by law.
ARTICLE 30 - LOBBYING
30.1 The CONTRACTOR certifies, to the best of its knowledge and belief, that:
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(A) No Federally appropriated funds have been paid or shall be paid, by or on behalf of the CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, or an employee of a member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(B) If any funds other than Federally appropriated funds have been paid or shall be paid to any person for influencing or attempting to influence an officer or employee of any agency, member of Congress, an officer or employee of Congress or an employee of a member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the CONTRACTOR shall complete and submit Standard Form-LLL "Disclosure Form to Report Lobbying," in accordance with its instructions.
30.2 The CONTRACTOR shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.
30.3 This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed under 31 USC §1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than ten thousand dollars ($10,000) and not more than one hundred thousand dollars ($100,000) for such failure.
ARTICLE 31 - CONFLICT OF INTEREST
31.1 The CONTRACTOR warrants that it presently has no interest and shall not acquire any interest, direct or indirect, which would conflict in any manner or degree with the performance of services required under this Agreement, and further warrants that signing of this Agreement shall not be creating a violation of the Governmental Conduct Act, NMSA 1978, § 10-16-1 et seq. or be at least equal to Federal safeguards 41 USC 423, section 27.
31.2 If during the term of this Agreement and any extension thereof, the CONTRACTOR becomes aware of an actual or potential relationship, which may be considered a conflict of interest, the CONTRACTOR shall immediately notify the Contract Administrator in writing. Such notification includes when the CONTRACTOR employs or contracts with a person, on a matter related to this Agreement, and that person is a former State employee who has an obligation to comply with NMSA 1978, § 10-16-1 et. seq.
31.3 The CONTRACTOR shall not be a Medicaid provider of services or be the owner of or have a proprietary interest in a business entity that is a provider of Medicaid services. An
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Offeror may not function as an auditor, consultant, claims preparer or otherwise be employed by a Medicaid provider.
31.4 The CONTRACTOR must be must be completely independent of any MCO or subcontractor of an MCO that is contracted with the State of New Mexico. Specifically, the CONTRACTOR must not be a MCO or subcontractor of an MCO that is contracted with the State of New Mexico or be an owner of, have a proprietary interest in, or be a subsidiary of a business that is a MCO or subcontractor of an MCO that is contracted with the State of New Mexico. The CONTRACTOR may not function as an auditor, consultant, claims preparer or otherwise be employed by a MCO or subcontractor of an MCO that is contracted with the State of New Mexico.
31.5 The CONTRACTOR shall comply with the provisions of Section 10-16-1 et seq., NMSA 1978, that require disclosure to the Office of the Secretary of State when a CONTRACTOR receives more than $5,000.00 from the State or its agencies in any one twelve (12) month period.
ARTICLE 32 – CONFIDENTIALITY
32.1 Any confidential information, as defined in state or federal law, code, rules or regulations regarding HSD/MAD's recipients, providers, or contracted MCOs provided to or developed by the CONTRACTOR shall not be made available to any individual or organization by the CONTRACTOR without the prior written approval of HSD/MAD.
32.2 If the CONTRACTOR is a Utilization and Quality Control Peer Review Organization (PRO) as defined in 42 CFR Part 462, disclosure of external review information is governed by Section 1160 of the Social Security Act, “Protection Against Disclosure of Information”.
32.3 The CONTRACTOR warrants that it will maintain the confidentiality of all information derived from HSD/MAD, and will neither use or disclose it to any person or entity without the explicit written permission of HSD/MAD, and that each and every employee, agent or subcontractor of the CONTRACTOR has executed the binding agreement attached hereto as Attachment A to the same effect. The CONTRACTOR recognizes that irreparable harm can be occasioned to HSD/MAD and Medicaid recipients by disclosure of confidential information and accordingly, the CONTRACTOR will be solely responsible for any violations.
32.4 The CONTRACTOR shall treat all information and, in particular, information relating to recipients of HSD/MAD's services, that is obtained through its performance under this Agreement as confidential information in accordance with the provisions of 45 C.F.R. §205.50 and all other applicable federal and state laws and regulations, and shall not use any information so obtained in any manner except as otherwise permitted by this Agreement and as necessary for the proper discharge of its obligations and securing of its rights hereunder. The CONTRACTOR assumes responsibility for all liability caused by
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any breach of this Article and shall indemnify HSD and the State of New Mexico against all such liability accordingly.
32.5 The CONTRACTOR shall (1) Notify HSD/MAD promptly of any unauthorized possession, use, knowledge, or attempt thereof, of HSD/MAD's data files or other confidential information, (2) Promptly furnish HSD/MAD full details of the unauthorized possession, use of knowledge or attempt thereof, and assist investigating or preventing the recurrence thereof.
32.6 Under the Privacy Act and the Internal Revenue Code, CONTRACTOR personnel can be held personally liable (civil and criminal) for disclosure or abuse of confidential data. The CONTRACTOR must advise in writing its employees and/or subcontractors of the liability prior to their employment on activities related to this Agreement.
ARTICLE 33 - WAIVERS
33.1 No term or provision of this Agreement shall be deemed waived and no breach excused, unless such waiver or consent shall be in writing by the party claimed to have waived or consented.
33.2 A waiver by any party hereto of a breach of any of the covenants, conditions, or agreements to be performed by the other shall not be construed to be a waiver of any succeeding breach thereof or of any other covenant, condition, or Agreement herein contained.
ARTICLE 34 – NOTICE
34.1 A notice shall be deemed duly given upon delivery, if delivered by hand, or three (3) calendar days after posting if sent by first-class mail, with proper postage affixed. Notice may also be tendered by facsimile transmission, with original to follow by first class mail.
34.2 All notices required to be given to HSD/MAD under this Agreement shall be sent to the HSD/MAD Contract Administrator or her designee:
Elizabeth C. Cassel, Ph.D.Medical Assistance DivisionHuman Services Department2025 South Pacheco StreetSanta Fe, New Mexico 87504Telephone Number: (505) 827-7715Fax Number: (505) [email protected]
34.3 All notices required to be given to the CONTRACTOR under this Agreement shall be sent to:
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ARTICLE 35 - AMENDMENTS
35.1 This Agreement shall not be altered, changed or amended other than by an instrument in writing executed by the parties to this Agreement. Amendments shall become effective and binding when signed by the parties, approved by the Department of Finance and Administration, and written approvals have been obtained from any necessary State and Federal agencies. All necessary approvals shall be attached as exhibits to the Agreement.
ARTICLE 36 – SUSPENSION, DEBARMENT AND OTHER RESPONSIBILITY MATTERS
36.1 Pursuant to 45 C.F.R. Part 76 and other applicable federal regulations, the CONTRACTOR certifies by signing this Agreement, that it and its principals, to the best of its knowledge and belief: (1) are not debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal department or agency; (2) have not, within a three-year period preceding the effective date of this Agreement, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) contract or subcontract; violation of Federal or State antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property; (3) have not been indicted for, or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with, commission of any of the offenses enumerated above in this Article; (4) have not, within a three-year period preceding the effective date of this Agreement, had one or more public agreements or transactions (Federal, State or local) terminated for cause or default; and (5) have not been excluded from participation from Medicare, Medicaid, Federal health care programs or Federal behavioral health care programs pursuant to Title XI of the Social Security Act, 42 U.S.C. § 1320a-7 and other applicable federal statutes.
36.2 The CONTRACTOR’S certification in Article 36.1 is a material representation of fact upon which the State relied when this Agreement was entered into by the parties. The CONTRACTOR shall provide immediate written notice to HSD/MAD, if, at any time during the term of this Agreement, the CONTRACTOR learns that its certification in Article 36.1 was erroneous on the effective date of this Agreement or has become erroneous by reason of new or changed circumstances. If it is later determined that the CONTRACTOR’S certification in Article 36.1 was erroneous on the effective date of this Agreement or has become erroneous by reason of new or changed circumstances, in addition to other remedies available to HSD, HSD may terminate the Agreement.
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36.3 As required by 45 C.F.R. Part 76 or other applicable federal regulations, the CONTRACTOR shall require each proposed first-tier subcontractor whose subcontract will equal or exceed twenty-five thousand dollars ($25,000), to disclose to the CONTRACTOR, in writing, whether as of the time of award of the subcontract, the subcontractor, or its principals, is or is not debarred, suspended, or proposed for debarment by any Federal department or agency. The CONTRACTOR shall make such disclosures available to the State when it requests subcontractor approval from HSD/MAD under the terms set forth in this Agreement. If the subcontractor, or its principals, is debarred, suspended, or proposed for debarment by any Federal department or agency, HSD/MAD may refuse to approve the use of the subcontractor.
ARTICLE 37 - ENTIRE AGREEMENT
37.1 This Agreement incorporates all the agreements, covenants, and understandings between the parties hereto concerning the subject matter hereof, and all such covenants, agreements and understandings have been merged into this written Agreement. No prior agreement or understanding, verbal or otherwise, of the parties or their agents shall be valid or enforceable unless embodied in this Agreement.
ARTICLE 38 – DUTY TO COOPERATE
38.1 The parties agree that they will cooperate in carrying out the intent and purpose of this Agreement. This duty includes specifically, an obligation by both parties, in the event they identify any possible errors or problems associated with the performance of their respective obligations under this Agreement.
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IN WITNESS WHEREOF, the parties have executed this Agreement as of the date of execution by the State Contracts Officer, below.
CONTRACTOR
By: Date: __________________
Title:
STATE OF NEW MEXICO
By: ____ Date: __________________ Sidonie Squier, Secretary
Human Services Department
Approved as to Form and Legal sufficiency:
By: _ Date: __________________ Raymond Mensack, Chief Legal CounselHuman Services Department
DEPARTMENT OF FINANCE AND ADMINISTRATION
By: Date: __________________ State Contracts Officer
The records of the Taxation and Revenue Department reflect that the CONTRACTOR is registered with the Taxation and Revenue Department of the State of New Mexico to pay gross Receipts and compensating taxes.
TAXATION AND REVENUE DEPARTMENT
ID Number:
By: Date: _________________
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APPENDIX C
CENTENNIAL CARE POLICY MANUAL WEBSITE
The Medical Assistance Division has a Centennial Care Policy Manual. This document is in PDF format and can be downloaded with Adobe Acrobat Reader from any Personal Computer. The document is posted to the HSD website http://www.hsd.state.nm.us or can be obtained electronically by contacting the HSD/MAD Contract Administrator via email: Dr. Elizabeth Cassel at [email protected]
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APPENDIX D
COST PROPOSAL FORM
EQRO RFP 2014
Item Unit of Measure
Cost per Unit of Measure per Year
Design, Conduct, Report on Performance Measurement Program (PM)/ Performance Improvement Projects (PIP) for All MCOs
PerAnnualReport
Individual Case Reviews Per ReportDesign, Conduct, Report on Compliance Audits
Per Annual Report
Follow Up Review and (Individual) Performance Measurement Activity Per Report
Design, Conduct, Report on Member Satisfaction Survey Per Report
Design, Conduct, Report on Periodic Utilization Review Denial Review Per Report
Design, Conduct, Report Cross Validation Audit of Encounter Data Per Report
Design, Conduct, Report on Ad-hoc Audits Per ReportDevelop, Conduct, and Report on Provider Satisfaction Survey Per Report
Design, Conduct and Report on Independent Assessment of Medicaid(Biennial)
Per Report
Design, Conduct and Report on NF LOC Per Quarterly
ReportDesign, Conduct and Report on Individualized Service Plan Review
Per AnnualReport
Design, Conduct and Report on HEDIS-Like Review
Per Quarterly
ReportTOTAL COST FOR ONE YEARTOTAL COST FOR TWO YEARS
* Each Scope of Work cost proposal item shall be inclusive of all Medicaid Contractors and shall not be priced on per contractor basis.
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APPENDIX E
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER RESPONSIBILITY MATTERS
The entering of a contract between the HSD and the successful Offeror pursuant to this RFP is a “covered transaction,” as defined by 45 C.F.R. Part 76 and other applicable federal regulations. The HSD’s contract with the successful Offeror shall contain a provision relating to debarment, suspension, and responsibility. See Article 37 of the Contract Terms and Conditions. All Offerors must provide as a part of their proposals a certification to the HSD in the form provided below. Failure of an Offeror to furnish a certification or provide such additional information as requested by the Procurement Manager for this RFP will render the Offeror nonresponsible. Furthermore, the Offeror shall provide immediate written notice to the Procurement Manager for this RFP if, at any time prior to contract award, the Offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
Although the HSD may review the veracity of the certification through the use of the federal Excluded Parties Listing System or by other means, the certification provided by the Offeror in paragraph (a), below, is a material representation of fact upon which the HSD will rely when making a contract award. If it is later determined that the Offeror knowingly rendered an erroneous certification, in addition to other remedies available to the HSD, the HSD may terminate the contract resulting from this request for proposals for default.
The certification provided by the Offeror in paragraph (a), below, will be considered in connection with a determination of the Offeror's responsibility. A certification that any of the items in paragraph (a), below, exists may result in rejection of the Offeror’s proposal for non-responsibility and the withholding of an award under this RFP. If the Offeror’s certification indicates that that any of the items in paragraph (a), below, exists, the Offeror shall provide with its proposal a full written explanation of the specific basis for, and circumstances connected to, the item; the Offeror’s failure to provide such explanation will result in rejection of the Offeror’s proposal. If the Offeror’s certification indicates that that any of the items in paragraph (a), below, exists, the HSD in its sole discretion, may request, that the U.S. Department of Health and Human Services and any other applicable federal agency grant an exception under 45 C.F.R. §§ 76.120 and 76.305 and any other applicable federal regulations if the HSD believes that the procurement schedule so permits and an exception is applicable and warranted under the circumstances. In no event will the HSD award a contract to an Offeror if the requested exception is not granted for the Offeror.
(a)(1) By signing and submitting a proposal in response to this RFP, the Offeror certifies, to the best of its knowledge and belief, that:
{Check the appropriate box}
(i) The Offeror and/or any of its Principals- (A) Are are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal department or agency; (B) Have have not , within a three-year period preceding the date of the Offeror’s proposal, been convicted of or had a civil judgment rendered against them for: commission of fraud or a
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criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property; (C) Are are not presently indicted for, or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with, commission of any of the offenses enumerated in paragraph (a)(1)(i)(B) of this certification; (D) Have have not , within a three-year period preceding the date of Offeror’s proposal, had one or more public agreements or transactions (Federal, State or local) terminated for cause or default; and(E) Have have not been excluded from participation from Medicare, Medicaid, other federal health care programs or other federal behavioral health care programs pursuant to Title XI of the Social Security Act, 42 U.S.C. § 1320a-7 and other applicable federal statutes.
(ii) "Principal," for the purposes of this certification, shall have the meaning set forth in 45 C.F.R. § 76.995 and shall include an officer, director; owner, partner, principal investigator, or other person having management or supervisory responsibilities related to a covered transaction. “Principal” also includes a consultant or other person, whether or not employed by the participant or paid with Federal funds, who: is in a position to handle Federal funds; is in a position to influence or control the use of those funds; or occupies a technical or professional position capable of substantially influencing the development or outcome of an activity required to perform the covered transaction.
(iii) For the purposes of this certification, the terms used in the certification, such as covered transaction, debarred, excluded, exclusion, ineligible, ineligibility, participant, and person have the meanings set forth in the definitions and coverage rules of 45 C.F.R. Part 76 and other applicable federal regulations.
(iv)Nothing contained in the foregoing certification shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and information of an Offeror is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
OFFEROR: ______________________________________
SIGNED BY: _____________________________________
TITLE: __________________________________________
DATE: ___________________________________________
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APPENDIX F
NEW MEXICO EMPLOYEES HEALTH COVERAGE FORM
1. For all contracts solicited and awarded on or after January 1, 2008: If the Offeror has, or grows to, six (6) or more employees who work, or who are expected to work, an average of at least 20 hours per week over a six (6) month period during the term of the contract, Offeror must agree to:
(a) have in place, and agree to maintain for the term of the contract, health insurance for those employees and offer that health insurance to those employees no later than July 1, 2008 if the expected annual value in the aggregate of any and all contracts between Contractor and the State exceed one million dollars or;
(b) have in place, and agree to maintain for the term of the contract, health insurance for those employees and offer that health insurance to those employees no later than July 1, 2009 if the expected annual value in the aggregate of any and all contracts between Contractor and the State exceed $500,000 dollars or
(c) have in place, and agree to maintain for the term of the contract, health insurance for those employees and offer that health insurance to those employees no later than July 1, 2010 if the expected annual value in the aggregate of any and all contracts between Contractor and the State exceed $250,000 dollars.
2. Offeror must agree to maintain a record of the number of employees who have (a) accepted health insurance; (b) decline health insurance due to other health insurance coverage already in place; or (c) decline health insurance for other reasons. These records are subject to review and audit by a representative of the state.
3. Offeror must agree to advise all employees of the availability of State publicly financed health care coverage programs by providing each employee with, as a minimum, the following web site link to additional information http://insurenewmexico.state.nm.us/.
4. For Indefinite Quantity, Indefinite Delivery contracts (price agreements without specific limitations on quantity and providing for an indeterminate number of orders to be placed against it); these requirements shall apply the first day of the second month after the Offeror reports combined sales (from state and, if applicable, from local public bodies if from a state price agreement) of $250,000, $500,000 or $1,000,000.
Signature of Offeror: _________________________ Date________
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APPENDIX G
CAMPAIGN CONTRIBUTION DISCLOSURE FORM
Pursuant to NMSA 1978, § 13-1-191.1 (2006), any person seeking to enter into a contract with any state agency or local public body for professional services, a design and build project delivery system, or the design and installation of measures the primary purpose of which is to conserve natural resources must file this form with that state agency or local public body. This form must be filed even if the contract qualifies as a small purchase or a sole source contract. The prospective Contractor must disclose whether they, a family member or a representative of the prospective Contractor has made a campaign contribution to an applicable public official of the state or a local public body during the two years prior to the date on which the Contractor submits a proposal or, in the case of a sole source or small purchase contract, the two years prior to the date the Contractor signs the contract, if the aggregate total of contributions given by the prospective Contractor, a family member or a representative of the prospective Contractor to the public official exceeds two hundred and fifty dollars ($250) over the two year period.
Furthermore, the state agency or local public body shall void an executed contract or cancel a solicitation or proposed award for a proposed contract if: 1) a prospective Contractor, a family member of the prospective Contractor, or a representative of the prospective Contractor gives a campaign contribution or other thing of value to an applicable public official or the applicable public official’s employees during the pendency of the procurement process or 2) a prospective Contractor fails to submit a fully completed disclosure statement pursuant to the law.
THIS FORM MUST BE FILED BY ANY PROSPECTIVE CONTRACTOR WHETHER OR NOT HE/SHE/IT, HIS/HER/ITS FAMILY MEMBER, OR REPRESENTATIVE HAS MADE ANY CONTRIBUTIONS SUBJECT TO DISCLOSURE.
The following definitions apply:
“Applicable public official” means a person elected to an office or a person appointed to complete a term of an elected office, who has the authority to award or influence the award of the contract for which the prospective Contractor is submitting a competitive sealed proposal or who has the authority to negotiate a sole source or small purchase contract that may be awarded without submission of a sealed competitive proposal.
“Campaign Contribution” means a gift, subscription, loan, advance or deposit of money or other thing of value, including the estimated value of an in-kind contribution, that is made to or received by an applicable public official or any person authorized to raise, collect or expend contributions on that official’s behalf for the purpose of electing the official to either statewide or local office. “Campaign Contribution” includes the payment of a debt incurred in an election campaign, but does not include the value of services provided without compensation or unreimbursed travel or other personal expenses of individuals who volunteer a portion or all of their time on behalf of a candidate or political committee, nor does it include the administrative or solicitation expenses of a political committee that are paid by an organization that sponsors the committee.
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“Family member” means spouse, father, mother, child, father-in-law, mother-in-law, daughter-in-law or son-in-law. “Pendency of the procurement process” means the time period commencing with the public notice of the request for proposals and ending with the award of the contract or the cancellation of the request for proposals.
“Person” means any corporation, partnership, individual, joint venture, association or any other private legal entity.
“Prospective Contractor” means a person who is subject to the competitive sealed proposal process set forth in the Procurement Code or is not required to submit a competitive sealed proposal because that person qualifies for a sole source or a small purchase contract.
“Representative of a prospective Contractor” means an officer or director of a corporation, a member or manager of a limited liability corporation, a partner of a partnership or a trustee of a trust of the prospective Contractor.
DISCLOSURE OF CONTRIBUTIONS:Item Description
Contribution Made By
Relation to Prospective Contractor
Name of Applicable Public Official
Date Contribution(s) Made
Amount(s) of Contribution(s)
Nature of Contribution(s)
Purpose of Contribution(s)
(Attach extra pages if necessary)________________________ ________________________ ______________Signature Title (Position) Date─OR─NO CONTRIBUTIONS IN THE AGGREGATE TOTAL OVER TWO HUNDRED FIFTY DOLLARS ($250) WERE MADE TO AN APPLICABLE PUBLIC OFFICIAL BY ME, A FAMILY MEMBER OR REPRESENTATIVE.
_____________________________ ______________________ ______________Signature Title (Position) Date
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