State of New Jersey JAMES E. MCGREEVEY DEPARTMENT OF THE TREASURY JOHN E. MCCORMAC, CPA Governor DIVISION OF PURCHASE AND PROPERTY State Treasurer PURCHASE BUREAU P.O. BOX 230 TRENTON, NJ 08625-0230 June 18, 2004 TO: All Bidders RE: RFP #: 05-X-34750 HEALTH BENEFITS COORDINATOR MEDICAID MANAGED CARE PROGRAMS Enclosed please find a complete set of bid documents for the above referenced solicitation. The following are the key dates for the project: Date Time Event July 13, 2004 5:00 p.m. Bidders' Questions Due Date (Refer to RFP Section 1.3.1 for more information) July 19, 2004 9:30 a.m. Mandatory Pre-Bid Conference (Refer to RFP Section 1.3.3 for more information) August 12, 2004 2:00 p.m. Bid Submission Due Date (Refer to RFP Section 1.3.4 for more information) Be advised that all addenda related to this procurement will be issued on the Purchase Bureau web site. Refer to RFP Section 1.4.1 for additional information. All questions concerning the RFP contents and the bidding process must be directed to the undersigned. Sincerely, Christine Weiland Christine Weiland Team Leader E-Mail Address: [email protected]Phone: (609) 984-6269 Fax: (609) 292-5170
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State of New Jersey JAMES E. MCGREEVEY DEPARTMENT OF THE TREASURY JOHN E. MCCORMAC, CPA
Governor DIVISION OF PURCHASE AND PROPERTY State Treasurer PURCHASE BUREAU P.O. BOX 230 TRENTON, NJ 08625-0230
June 18, 2004 TO: All Bidders RE: RFP #: 05-X-34750
HEALTH BENEFITS COORDINATOR MEDICAID MANAGED CARE PROGRAMS
Enclosed please find a complete set of bid documents for the above referenced solicitation. The following are the key dates for the project:
Date Time Event
July 13, 2004 5:00 p.m. Bidders' Questions Due Date (Refer to RFP Section 1.3.1 for more information)
July 19, 2004 9:30 a.m. Mandatory Pre-Bid Conference (Refer to RFP Section 1.3.3 for more information)
August 12, 2004 2:00 p.m. Bid Submission Due Date (Refer to RFP Section 1.3.4 for more information)
Be advised that all addenda related to this procurement will be issued on the Purchase Bureau web site. Refer to RFP Section 1.4.1 for additional information. All questions concerning the RFP contents and the bidding process must be directed to the undersigned. Sincerely, Christine Weiland Christine Weiland Team Leader E-Mail Address: [email protected] Phone: (609) 984-6269 Fax: (609) 292-5170
PURSUANT TO N.J.S.A. 52:34 - 12 AND N.J.A.C. 17:12 - 2.2, PROPOSALS WHICH FAIL TO CONFORM WITH THE
FOLLOWING REQUIREMENTS WILL BE AUTOMATICALLY REJECTED: 1) PROPOSALS MUST BE RECEIVED AT OR ON BEFORE THE PUBLIC OPENING TIME OF 2 pm ON 8/12/04 AT THE
FOLLOWING PLACE: DEPARTMENT OF THE TREASURY, PURCHASE BUREAU, PO BOX-230, 33 WEST STATE STREET, 9TH FLOOR, TRENTON, NEW JERSEY 08625-0230. TELEPHONE, TELEFACSIMILE OR TELEGRAPH PROPOSALS WILL NOT BE ACCEPTED.
2) THE BIDDER MUST SIGN THE PROPOSAL. 3) THE PROPOSAL MUST INCLUDE ALL PRICE INFORMATION. PROPOSAL PRICES SHALL INCLUDE DELIVERY OF ALL ITEMS, F.O.B. DESTINATION
OR AS OTHERWISE PROVIDED. PRICE QUOTES MUST BE FIRM THROUGH ISSUANCE OF CONTRACT. 4) ALL PROPOSAL PRICES MUST BE TYPED OR WRITTEN IN INK. 5) ALL CORRECTIONS, WHITE-OUTS, ERASURES, RESTRIKING OF TYPE, OR OTHER FORMS OF ALTERATION, OR THE APPEARANCE OF
ALTERATION, TO UNIT AND/OR TOTAL PRICES MUST BE INITIALED IN INK BY THE BIDDER. 6) THE BIDDER MUST SUBMIT WITH THE PROPOSAL BID SECURITY IN THE AMOUNT OF $ __0_____ OR __0____ %.
CHECK THE TYPE OF BID SECURITY SUPPLIED:
ANNUAL BID BOND ON FILE: ____________ BID BOND ATTACHED: ____________ CERTIFIED OR CASHIERS CHECK ATTACHED: ____________ LETTER OF CREDIT ATTACHED: ____________
7) THE BIDDER MUST COMPLETE AND SUBMIT, PRIOR TO THE SUBMISSION OF THE PROPOSAL, OR ACCOMPANYING THE PROPOSAL, THE
ATTACHED OWNERSHIP DISCLOSURE FORM. (SEE N.J.S.A. 52:25-24.2). SEE ATTACHMENT 1 8) THE BIDDER MUST ATTEND THE MANDATORY PRE-BID CONFERENCE(S) AND SITE VISIT(S) AT THE FOLLOWING DATE(S) AND TIME(S):
PRE-BID CONFERENCE 7/19/04 SITE INSPECTION: ____NONE______
21) BIDDER FEDERAL ID NO. ____________________________ 22) YOUR BID REFERENCE NO. __________________________
SIGNATURE OF THE BIDDER ATTESTS THAT THE BIDDER HAS READ, UNDERSTANDS, AND AGREES TO ALL TERMS, CONDITIONS, AND SPECIFICATIONS SET FORTH IN THE REQUEST FOR PROPOSAL, INCLUDING ALL ADDENDA, FURTHERMORE, SIGNATURE BY THE BIDDER SIGNIFIES THAT THE REQUEST FOR PROPOSAL AND THE RESPONSIVE PROPOSAL CONSTITUTES A CONTRACT IMMEDIATELY UPON NOTICE OF ACCEPTANCE OF THE PROPOSAL BY THE STATE OF NEW JERSEY FOR ANY OR ALL OF THE ITEMS BID, AND FOR THE LENGTH OF TIME INDICATED IN THE REQUEST FOR PROPOSAL. FAILURE TO ACCEPT THE CONTRACT WITHIN THE TIME PERIOD INDICATED IN THE REQUEST FOR PROPOSAL, OR FAILURE TO HOLD PRICES OR TO MEET ANY OTHER TERMS AND CONDITIONS AS DEFINED IN EITHER THE REQUEST FOR PROPOSAL OR THE PROPOSAL DURING THE TERM OF THE CONTRACT, SHALL CONSTITUTE A BREACH AND MAY RESULT IN SUSPENSION OR DEBARMENT FROM FURTHER STATE BIDDING. A DEFAULTING CONTRACTOR MAY ALSO BE LIABLE, AT THE OPTION OF THE STATE, FOR THE DIFFERENCE BETWEEN THE CONTRACT PRICE AND THE PRICE BID BY AN ALTERNATE VENDOR OF THE GOODS OR SERVICES IN ADDITION TO OTHER REMEDIES AVAILABLE. 23) ORIGINAL SIGNATURE OF BIDDER 24) NAME OF FIRM
HEALTH BENEFITS COORDINATOR MEDICAID MANAGED CARE PROGRAM
Date Issued: TBD Purchasing Agency State of New Jersey Department of the Treasury Division of Purchase and Property Purchase Bureau, PO Box 230 33 West State Street Trenton, New Jersey 08625-0230 Using Agency State of New Jersey Department of Human Services Division of Medical Assistance and Health Services PO Box 712 Trenton, New Jersey 08625
Table of Contents
1.0 INFORMATION FOR BIDDERS ................................................................................................................................................................. 11 1.1 PURPOSE AND INTENT....................................................................................................................................................................... 11 1.2 BACKGROUND ..................................................................................................................................................................................... 11 1.3 KEY EVENTS ........................................................................................................................................................................................ 14
1.3.1 QUESTIONS AND INQUIRIES...................................................................................................................................................... 14 1.3.1.1 CUT-OFF DATE FOR QUESTIONS AND INQUIRIES............................................................................................................... 14
1.4 ADDITIONAL INFORMATION ............................................................................................................................................................... 16 1.4.1 REVISIONS TO THIS RFP............................................................................................................................................................ 16 1.4.2 ADDENDUM AS A PART OF THIS RFP....................................................................................................................................... 16 1.4.3 ISSUING OFFICE.......................................................................................................................................................................... 16 1.4.4 BIDDER RESPONSIBILITY........................................................................................................................................................... 17 1.4.5 COST LIABILITY ........................................................................................................................................................................... 17 1.4.6 CONTENTS OF BID PROPOSAL ................................................................................................................................................. 17 1.4.7 PRICE ALTERATION .................................................................................................................................................................... 17 1.4.8 JOINT VENTURE .......................................................................................................................................................................... 17
2.0 DEFINITIONS ............................................................................................................................................................................................. 18 2.1 STANDARD DEFINITIONS ................................................................................................................................................................... 18 2.2 CONTRACT SPECIFIC DEFINITIONS.................................................................................................................................................. 19
3.0 SCOPE OF WORK ..................................................................................................................................................................................... 27 3.1 BASIC REQUIREMENTS ...................................................................................................................................................................... 27
3.1.1 CONTRACTOR SITE LOCATION................................................................................................................................................. 27 3.1.2 SPACE FOR STATE STAFF......................................................................................................................................................... 27 3.1.3 FURNISHINGS, EQUIPMENT AND SUPPLIES ........................................................................................................................... 27 3.1.4 POLICIES AND PROCEDURES ................................................................................................................................................... 28 3.1.5 FINANCIAL AND OPERATIONS AUDIT ....................................................................................................................................... 28 3.1.6 STATE NOTIFICATION................................................................................................................................................................. 28 3.1.7 DOCUMENT STORAGE ............................................................................................................................................................... 28 3.1.8 COUNTY OFFICE SPACE ............................................................................................................................................................ 29 3.1.9 HIPAA AND BBA COMPLIANCE .................................................................................................................................................. 29
3.2 STAFFING ............................................................................................................................................................................................. 29 3.2.1 STAFFING REQUIREMENTS....................................................................................................................................................... 29 3.2.2 ORGANIZATIONAL CHART.......................................................................................................................................................... 30 3.2.3 BACKGROUND CHECK DOCUMENTATION............................................................................................................................... 30 3.2.4 GENERAL EMPLOYEE PROFICIENCY ....................................................................................................................................... 31 3.2.5 REDUCTION IN FORCE APPROVAL........................................................................................................................................... 31
3.3 CUSTOMER SERVICE CALL CENTER OPERATIONS ....................................................................................................................... 31 3.3.1 TELEPHONE CALL CENTER ....................................................................................................................................................... 31
3.3.1.1 CALL CENTER FUNCTIONS AND ACTIVITIES................................................................................................................... 31 3.3.2 CALL CENTER FACILITY ............................................................................................................................................................. 32 3.3.3 TOLL FREE LINES........................................................................................................................................................................ 32 3.3.4 HOURS OF OPERATION.............................................................................................................................................................. 32 3.3.5 HOLIDAY SCHEDULE .................................................................................................................................................................. 33 3.3.6 CALL CENTER START ................................................................................................................................................................. 33 3.3.7 AFTER HOUR MESSAGE SYSTEM............................................................................................................................................. 33 3.3.8 CALL CENTER LOG ..................................................................................................................................................................... 33 3.3.9 CALL CENTER RESPONSE......................................................................................................................................................... 33 3.3.10 LANGUAGES UTILIZED ............................................................................................................................................................. 33 3.3.11 LANGUAGE PERSONNEL.......................................................................................................................................................... 33 3.3.12 AUTOMATED CALL DISTRIBUTION.......................................................................................................................................... 34 3.3.13 TDD ............................................................................................................................................................................................. 34 3.3.14 REAL TIME MONITORING ......................................................................................................................................................... 34 3.3.15 CALL CENTER QUALITY TRAINING ......................................................................................................................................... 34
3.3.16 CALL CENTER MANAGEMENT SYSTEM ................................................................................................................................. 34 3.3.17 STATE MONITORING SPACE.................................................................................................................................................... 34 3.3.18 CALL CENTER PERFORMANCE STANDARDS........................................................................................................................ 35 3.3.19 CALL CENTER SERVICE STANDARDS.................................................................................................................................... 35 3.3.20 PROBLEM IDENTIFICATION AND NOTIFICATION................................................................................................................... 35 3.3.21 CALL CENTER DAILY ACTIVITY REPORTS............................................................................................................................. 35 3.3.22 SUPERVISOR AVAILABILITY..................................................................................................................................................... 35 3.3.23 URGENT / PROBLEMATIC CALL CENTER CASES.................................................................................................................. 36 3.3.24 STATE APPROVAL..................................................................................................................................................................... 36 3.3.25 SUPERVISORY OVERSIGHT..................................................................................................................................................... 36 3.3.26 CALL CENTER TRAINING GUIDE ............................................................................................................................................. 36 3.3.27 CALL CENTER WEEKLY REPORT(S) ....................................................................................................................................... 36 3.3.28 CALL CENTER MONTHLY REPORT(S)..................................................................................................................................... 36 3.3.29 NATIONAL KIDS NOW LINE....................................................................................................................................................... 36
3.4 MAIL ROOM OPERATIONS.................................................................................................................................................................. 36 3.4.1 MAIL PROCESSING AND OPERATIONS .................................................................................................................................... 37
3.4.1.1 MAIL AND FAX RECEIPT..................................................................................................................................................... 37 3.4.1.2 MAIL AND FAX PROCESSING............................................................................................................................................. 37
3.5.1.1 NJFC DATA ENTRY AND PRELIMINARY ELIGIBILITY ASSESSMENT............................................................................. 37 3.5.1.2 PRELIMINARY ELIGIBILITY ASSESSMENT ....................................................................................................................... 37 3.5.1.3 CASE TRANSMISSION TO CWAS ...................................................................................................................................... 38 3.5.1.4 CONTRACTOR NON-PLAN A ELIGIBILITY RESPONSIBILITY .......................................................................................... 38 3.5.1.5 ELIGIBILITY TIMEFRAMES.................................................................................................................................................. 38 3.5.1.6 MISSING INFORMATION ..................................................................................................................................................... 38 3.5.1.7 ELECTRONIC TRACKING.................................................................................................................................................... 39 3.5.1.8 TRACKING SYSTEM UPGRADES....................................................................................................................................... 39 3.5.1.9 LANGUAGE REQUIREMENT............................................................................................................................................... 39 3.5.1.10 PRESUMPTIVE ELIGIBILITY DETERMINATION............................................................................................................... 39 3.5.1.11 ELECTRONIC NJ FAMILYCARE APPLICATION ............................................................................................................... 40 3.5.1.12 PROCESSING INITIATION................................................................................................................................................. 40 3.5.1.13 ELIGIBILITY CALCULATIONS............................................................................................................................................ 40 3.5.1.14 RETURNED DOCUMENTATION........................................................................................................................................ 40 3.5.1.15 ON SITE APPLICATION PROCEDURE ............................................................................................................................. 40 3.5.1.16 DISTRIBUTION POINTS..................................................................................................................................................... 41 3.5.1.17 ELIGIBILITY PROCESSING AND MANAGEMENT SYSTEM (EPMS).............................................................................. 41 3.5.1.18 URGENT CASES ................................................................................................................................................................ 41 3.5.1.19 SUBSEQUENT NJ FAMILYCARE CATEGORIES.............................................................................................................. 41 3.5.1.20 NJ FAMILYCARE GRIEVANCES/COMPLAINTS/APPEALS.............................................................................................. 41 3.5.1.21 NJ FAMILYCARE RENEWAL PROCESS........................................................................................................................... 41 3.5.1.22 RENEWAL NOTIFICATION ................................................................................................................................................ 41 3.5.1.23 CHANGE IN STATUS ......................................................................................................................................................... 42 3.5.1.24 RENEWAL PROCESSING TIME ........................................................................................................................................ 42 3.5.1.25 ANNUAL REQUIREMENT .................................................................................................................................................. 42 3.5.1.26 DATA AND INFORMATION COLLECTION AND ANALYSIS............................................................................................. 42 3.5.1.27 AUTHORITY TO OBTAIN INFORMATION ......................................................................................................................... 42 3.5.1.28 TERMINATION ACTIONS................................................................................................................................................... 42 3.5.1.29 CREDITABLE COVERAGE CERTIFICATE........................................................................................................................ 42 3.5.1.30 RENEWAL COMMUNICATION........................................................................................................................................... 43 3.5.1.31 RENEWAL RECORDS........................................................................................................................................................ 43
3.6 PROCESS REQUIREMENTS FOR MANAGED CARE PROGRAM ..................................................................................................... 43 3.6.1 MANAGED CARE ENROLLMENT SYSTEM (MCES) .................................................................................................................. 43
3.6.1.1 OUTREACH PLAN................................................................................................................................................................ 43 3.6.1.2 MANAGED CARE ................................................................................................................................................................. 43 3.6.1.3 MANAGED CARE MATERIALS............................................................................................................................................ 43 3.6.1.4 COMMUNITY EVENTS AND HEALTH FAIRS...................................................................................................................... 44 3.6.1.5 VOLUNTARY, MANDATORY AND PRE-MANDATORY, AND NEW CLIENT POPULATIONS.......................................... 44 3.6.1.6 MANAGED CARE POPULATIONS FOR MANDATORY ENROLLMENT............................................................................. 44 3.6.1.7 MANAGED CARE POPULATIONS FOR VOLUNTARY ENROLLMENT.............................................................................. 45 3.6.1.8 TARGETED POPULATIONS ................................................................................................................................................ 46 3.6.1.9 PRE- MANDATORY POPULATIONS ................................................................................................................................... 46
3.6.1.10 MANAGED CARE ASSOCIATION WITH CALL CENTER RESPONSIBILITIES................................................................ 46 3.6.1.11 UMBRELLA ORGANIZATIONS .......................................................................................................................................... 47 3.6.1.12 PROMOTIONAL CAMPAIGNS ........................................................................................................................................... 47 3.6.1.13 MANAGED CARE EDUCATIONAL CAMPAIGN................................................................................................................. 47 3.6.1.14 DRAFT STRATEGIES FOR GOVERNMENT AND CONSUMERS .................................................................................... 48 3.6.1.15 STATUS REPORTS OF OVERALL PROGRAM PERFORMANCE.................................................................................... 48 3.6.1.16 CLIENT MEETINGS............................................................................................................................................................ 48 3.6.1.17 HOME VISITS ..................................................................................................................................................................... 49 3.6.1.18 MASS MAILINGS ................................................................................................................................................................ 49 3.6.1.19 STATISTICAL DATA ........................................................................................................................................................... 49
3.6.2 COORDINATION AND CONTROL OF MANAGED CARE MATERIALS ...................................................................................... 49 3.6.2.1 EDUCATIONAL MATERIALS FOR MANAGED CARE......................................................................................................... 49 3.6.2.2 PAMPHLETS AND BOOKLETS............................................................................................................................................ 50
3.6.3 GENERAL PROVISIONS FOR MANAGED CARE TASKS........................................................................................................... 50 3.6.3.1 BENEFICIARY ENROLLMENT ASSISTANCE ..................................................................................................................... 50 3.6.3.2 MCO PROVIDER INFORMATION ........................................................................................................................................ 50 3.6.3.3 MCO SELECTION ASSISTANCE......................................................................................................................................... 50 3.6.3.4 MAINTENANCE OF MCO PROVIDER DIRECTORIES........................................................................................................ 50 3.6.3.5 MANAGED CARE APPLICATION REVIEW ......................................................................................................................... 51 3..6.3.6 MCO ENROLLMENT NOTIFICATION ................................................................................................................................. 51 3.6.3.7 PLAN SELECTION FORM FILE............................................................................................................................................ 51 3.6.3.8 MCO SELECTION ASSISTANCE......................................................................................................................................... 51 3.6.3.9 MANAGED CARE PLAN SELECTION FORM PROCESSING............................................................................................. 51 3.6.3.10 MANAGED CARE FORM DISCREPANCIES ..................................................................................................................... 52 3.6.3.11 MCO SELECTION............................................................................................................................................................... 52 3.6.3.12 HEALTH COVERAGE OPTIONS........................................................................................................................................ 52 3.6.3.13 INCOMPLETE PLAN SELECTION FORM REVIEW........................................................................................................... 52 3.6.3.14 NON-RESPONDENT CONTACT........................................................................................................................................ 52 3.6.3.15 NOTIFICATIONS................................................................................................................................................................. 53
3.6.4 MANAGED CARE ENROLLMENT TASKS ................................................................................................................................... 53 3.6.4.1 PLAN SELECTION FORM COMPLETION ........................................................................................................................... 53 3.6.4.2 MEDICAID AND NJ FAMILYCARE PLAN A ......................................................................................................................... 53 3.6.4.3 NJ FAMILYCARE PLAN B .................................................................................................................................................... 53 3.6.4.4 NJ FAMILYCARE PLAN B NOTIFICATION.......................................................................................................................... 53 3.6.4.5 NJ FAMILYCARE PLANS C, D AND OTHER NJFC PLANS................................................................................................ 53 3.6.4.6 NJ FAMILYCARE PLANS C, D AND OTHER NJFC PLANS VERIFICATION LETTERS..................................................... 53 3.6.4.7 BATCH UPDATE TO OIT...................................................................................................................................................... 53 3.6.4.8 PLAN SELECTION FORM (PSF) TRANSMISSION ............................................................................................................. 54 3.6.4.9 NJ FAMILYCARE NON-PAYMENT OF PREMIUMS ............................................................................................................ 54 3.6.4.10 NJ FAMILYCARE MCO DESIGNATION............................................................................................................................. 54 3.6.4.11 NJ FAMILYCARE PENDING STATUS................................................................................................................................ 54 3.6.4.12 MCO TRANSFER ASSISTANCE........................................................................................................................................ 54 3.6.4.13 DIS-ENROLLMENT AND RE-ENROLLMENT .................................................................................................................... 54 3.6.4.14 FORM COMPLETION ......................................................................................................................................................... 54 3.6.4.15 MCO NOTIFICATION.......................................................................................................................................................... 55 3.6.4.16 TRANSFER, DISENROLLMENT AND RE-ENROLLMENT FILES ..................................................................................... 55 3.6.4.17 BATCH UPDATE PROCESS .............................................................................................................................................. 56 3.6.4.18 MCO NOTIFICATION.......................................................................................................................................................... 56
3.8 CONSUMER ASSESSMENT OF HEALTH PLANS SURVEY (CAHPS)............................................................................................... 62 3.8.1 CAHPS SATISFACTION SURVEY ............................................................................................................................................... 62
3.9 GENRAL OPERATING PROCEDURES AND REQUIREMENTS ......................................................................................................... 62 3.9.1 GENERAL PROCEDURES AND REQUIREMENTS..................................................................................................................... 62
3.10 PROGRAM QUALITY ASSURANCE REQUIREMENTS..................................................................................................................... 63 3.10.1 QUALITY ASSURANCE PROCESS ........................................................................................................................................... 63
3.11 CONTRACT TRAINING REQUIREMENTS......................................................................................................................................... 65 3.11.1 HUMAN RESOURCE DEVELOPMENT AND TRAINING ........................................................................................................... 65 3.11.2 SELECTION AND DEVELOPING PROFESSIONAL TRAINING STAFF.................................................................................... 65 3.11.3 TECHNICAL AND PROGRAMMATIC TRAINING....................................................................................................................... 65 3.11.4 MAINTENANCE OF TRAINING RECORDS AND DATA ............................................................................................................ 66 3.11.5 PERIODIC REPORTS................................................................................................................................................................. 66 3.11.6 STATE MONITORING................................................................................................................................................................. 67 3.11.7 TRAINING PRODUCTION REQUIREMENT............................................................................................................................... 67 3.11.8 TRAINING PRODUCTION MONITORING.................................................................................................................................. 67
3.12 CONTRACT INTEGRITY AND SECURITY ......................................................................................................................................... 67 3.12.1 PROGRAM INTEGRITY REQUIREMENTS................................................................................................................................ 67
3.12.1.1 INTEGRITY AND SECURITY COORDINATOR.................................................................................................................. 67
5.17 LATE DELIVERY ................................................................................................................................................................................. 86 5.18.1 SYSTEM AVAILABILITY PERFORMANCE REQUIREMENTS .................................................................................................. 86 5.18.2 SYSTEM AVAILABILITY DAMAGES .......................................................................................................................................... 86 5.18.3 CALL CENTER PERFORMANCE STANDARDS........................................................................................................................ 86 5.18.4 CALL CENTER SERVICE STANDARDS.................................................................................................................................... 87 5.18.5 CALL CENTER DAMAGES......................................................................................................................................................... 87 5.18.6 TIMELINESS AND ACCURACY OF NJ FAMILYCARE ELIGIBILITY DETERMINATION ......................................................... 87 5.18.7 DAMAGES - ELIGIBILITY DETERMINATIONS .......................................................................................................................... 87 5.18.8 TIMELINESS AND ACCURACY OF HMO ENROLLMENT PROCESSING................................................................................ 88 5.18.9 DAMAGES – ENROLLMENT TRANSACTIONS......................................................................................................................... 88 5.18.10 PROGRAM ENROLLMENTS IN ERROR.................................................................................................................................. 88 5.18.11 DUPLICATE ENROLLMENTS................................................................................................................................................... 89 5.18.12 FAILED ENROLLMENTS .......................................................................................................................................................... 89
5.18.13 OPERATIONAL START DATE.................................................................................................................................................. 89 5.18.14 DAMAGES................................................................................................................................................................................. 89 5.18.15 FAILURE TO MEET TRANSITION REQUIREMENTS............................................................................................................. 89 5.18.16 MAINTENANCE OF THE FEDERAL WAIVER AND STATE PLANS........................................................................................ 90
5.19 RETAINAGE ........................................................................................................................................................................................ 90 5.20 STATE'S OPTION TO REDUCE SCOPE OF WORK.......................................................................................................................... 90 5.21 SUSPENSION OF WORK ................................................................................................................................................................... 90 5.22 CHANGE IN LAW ................................................................................................................................................................................ 90 5.23 CONTRACT PRICE INCREASE (PREVAILING WAGE)..................................................................................................................... 90 5.24ADDITIONAL WORK AND/OR SPECIAL PROJECTS......................................................................................................................... 90 5.25 FORM OF COMPENSATION AND PAYMENT ................................................................................................................................... 91 5.26 MODIFICATIONS AND CHANGES TO THE STANDARD TERMS AND CONDITIONS ................................................................... 91 5.26.1 PATENT AND COPYRIGHT INDEMNITY ........................................................................................................................................ 91 5.26.2 INDEMNIFICATION.......................................................................................................................................................................... 92 5.26.3 INSURANCE - PROFESSIONAL LIABILITY INSURANCE .............................................................................................................. 92
6.3.1 THE BIDDER'S GENERAL APPROACH AND PLANS IN MEETING THE REQUIREMENTS OF THIS RFP.............................. 93 6.3.2 THE BIDDER’S COST PROPOSAL.............................................................................................................................................. 93
6.4 CONTRACT AWARD............................................................................................................................................................................. 94 7.0 ATTACHMENTS, SUPPLEMENTS AND APPENDICES........................................................................................................................... 95 ATTACHMENT 1 - OWNERSHIP DISCLOSURE FORM ................................................................................................................................. 96 ATTACHMENT 2 - MACBRIDE PRINCIPLES FORM....................................................................................................................................... 98 ATTACHMENT 3 – AFFIRMATIVE ACTION SUPPLEMENT........................................................................................................................... 99 ATTACHMENT 4 - SUBCONTRACTOR SET ASIDE FORMS....................................................................................................................... 103 ATTACHMENT 5 - PRICE SCHEDULE.......................................................................................................................................................... 105 ATTACHMENT 5A - PRICE SCHEDULE FOR TRANSITION PERIOD WITHOUT ELIGIBILITY .................................................................. 106 ATTACHMENT 5B - PRICE SCHEDULE FOR TRANSITION PERIOD WITH ELIGIBILITY.......................................................................... 107 ATTACHMENT 5C – PRICE SCHEDULE WITHOUT ELIGIBILTY................................................................................................................. 108 ATTACHMENT 5D – PRICE SCHEDULE WITH ELIGIBILTY ........................................................................................................................ 109 APPENDIX 1 NJ STATE STANDARD TERMS AND CONDITIONS............................................................................................................... 111 APPENDIX 2 - SET-OFF FOR STATE TAX NOTICE..................................................................................................................................... 118 APPENDIX 3 - DETAIL FUNCTIONALITY CHECKLIST................................................................................................................................. 119
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1.0 INFORMATION FOR BIDDERS
1.1 PURPOSE AND INTENT This Request for Proposal (RFP) is issued by the Purchase Bureau, Division of Purchase and Property, Department of the Treasury, on behalf of the State of New Jersey. The purpose of this RFP is to solicit bid proposals from qualified bidders to screen and process applications, make determinations of NJ FamilyCare (NJFC) program eligibility, assess and collect premiums, provide outreach, marketing and education, and conduct and maintain enrollment with contracting Managed Care Organizations (MCOs) in accordance with program requirements of the Division of Medical Assistance and Health Services (DMAHS), New Jersey Care 2000+, New Jersey FamilyCare and Premium Support Programs. Additionally, the bidder shall demonstrate its ability to provide and operate a system capable of performing tasks required of both an Eligibility Processing and Management System (EPMS) and a Managed Care Enrollment System (MCES). Refer to RFP Section 3.0 (Scope of Work) for specific tasks to be performed under this contract. The intent of this RFP is to award a contract to that responsible bidder whose bid proposal, conforming to this RFP, is most advantageous to the State, price and other factors considered. Bidders shall provide two distinct proposals, one with the County Welfare Agencies (CWAs) performing eligibility and all its associated functions (Option 1) and the second with the contractor performing eligibility and all its associated functions (Option 2). The bid proposals shall be clearly identified as with eligibility and without eligibility. The State will award a contract based on one of the options, only. Two sets of price lines are established in ATTACHMENT 5 - PRICE SCHEDULE. Bidders must provide pricing for each option defined in accordance with the following criteria. Bidders should identify their proposed costs for Option 1 as those associated in meeting the requirements detailed in the scope of work as specified within this RFP. Option 1 therefore details all accountabilities, tasks, processes and procedures as being those required should the State’s twenty-one (21) County Welfare Agencies (CWAs) assume and perform eligibility processing for NJ FamilyCare Plan A cases as intended within the scope of work. In proposing costs for Option 2, bidders shall, in outlining their approach for meeting all requirements of the RFP’s scope of work, identify costs for Option 2 as being those associated with performing eligibility determinations and processing for all programs including AFDC Medicaid and NJ FamilyCare or as being in accordance with NJAC 10:69, NJAC 10:72, NJAC 10:78 and NJAC 10:79. Where appropriate or required, bidders proposals should detail any proposed revision that the implementation of Option 2 might necessitate in performing mail operations, imaging, screening or eligibility functions that are detailed within the scope of work. In evaluating and determining the revisions and or changes that implementation of Option 2 might require, specific scope of work tasks may require procedural alteration. For this reason, bidders may wish to be especially attentive to the following sections: Subsection 3.4.1.2 concerning Mail and Fax Processing Section 3.5.1.1 concerning NJFC Data Entry and Preliminary Eligibility Assessment Section 3.5.1.2 concerning Preliminary Eligibility Assessment Section 3.5.1.3 concerning Case Transmission to CWAs Section 3.5.1.4 concerning Vendor Non-Plan A Eligibility Responsibility Section 3.5.1.13 concerning Eligibility Calculations Subsection 3.6.4.14 concerning Incomplete Plan Selection Form Review
1.2 BACKGROUND
The Department’s New Jersey Care 2000+ and NJ FamilyCare programs were implemented in September 1995 and July 2000, respectively, with NJ FamilyCare having evolved from the NJ KidCare program that had been implemented in February 1998. They have been designed to achieve the following objectives:
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• to ensure the quality, continuity, and appropriateness of medical care; • to contract with qualified, established MCOs approved by Certificate of Authority for Medicaid
lines of business throughout New Jersey • to improve access to health care services by contracting with MCOs whose networks ensure full
access to their providers • to enhance cost effectiveness in health care delivery • to provide customer service with a “people first” focus
Currently, five (5) MCOs licensed in New Jersey serve approximately 650,000 Medicaid and NJ FamilyCare beneficiaries, or approximately 79% of the 830,000 Medicaid / NJ FamilyCare beneficiaries potentially eligible for managed care services. By enhancing access to care and by more closely managing the care provided to the Medicaid and NJ FamilyCare eligibles, these managed care programs are intended to result in a broader range of appropriately organized and more cost effective care for these populations. Under managed care, as envisioned in these programs, an individual enrolls in a managed care plan that makes available a primary care provider (PCP) to each member. This PCP assumes responsibility for coordinating all of the care needed by an individual beneficiary. Thus, MCO enrollees are ensured of enhanced access to needed medical services and benefit from greater coordination and continuity of care that result from having a PCP familiar with each beneficiary’s history. Managed care will improve upon the service delivery network available to serve these populations as compared to fee-for-service, ensuring access to “mainstream” medical services, particularly the care provided by PCPs, who deliver the prevailing source of care for enrollees within these programs. It will address reimbursement issues that have impacted provider recruitment efforts. It will address the tendency of Medicaid and other beneficiaries to utilize more costly settings, particularly hospital emergency rooms and outpatient departments, for health care services that may be episodic and crisis- driven. The objective of cost containment is addressed by reducing the reliance on high cost hospital-based sources of care. In addition, the Managed Care Organization, as envisioned under this Plan, is financially at risk for the cost of care, for certain populations, beyond the agreed upon payment and therefore more closely manages the utilization of services. The State is presently researching the feasibility of developing other models of managed care programs including those where the State would assume the financial risk for those individuals who utilize a higher than average proportion of health and medical services thereby minimizing the exposure of the MCOs to uncontrollable costs. MCOs will manage the delivery of health care for Medicaid and NJ FamilyCare beneficiaries. MCOs operating in the State have the necessary administrative structures and the potential for developing service delivery systems capable of providing more comprehensive managed care programs to these populations under a fully capitated model. Enrollee health care education efforts are essential to the success of managed care. Medicaid eligibles have developed patterns of obtaining health care that often include inappropriate use of hospital-based services. To support changing these entrenched patterns, DHS will require that health education be a key component of the HBC’s role and will, on an ongoing basis, evaluate and recommend a variety of marketing and education strategies.
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Populations Eligible:
October January January January 2003 2004 2005 2006 Actual Projection Projection Projection Medicaid
AFDC 200,276 204,805 207,888 207,888 ABD 51,242 52,031 52,590 52,827
Total Managed Care Enrollment 639,088 639,994 637,521 637,204
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1.3 KEY EVENTS
1.3.1 QUESTIONS AND INQUIRIES
It is the policy of the Division to accept questions and inquiries from all potential bidders receiving this RFP. Written questions can be mailed or e-mailed to the Purchase Bureau to the attention of the assigned Purchase Bureau buyer at the following address: Attn: Christine Weiland State of New Jersey Division of Purchase and Property Purchase Bureau PO Box 230 Trenton, New Jersey 08625-0230 E-Mail: [email protected] Fax Number: (609) 292-5170 Phone Number: 609-984-6269
1.3.1.1 CUT-OFF DATE FOR QUESTIONS AND INQUIRIES
A Mandatory Pre-Bid Conference has been scheduled for this procurement; therefore, the cut-off date for submission of written questions will be three working days prior to the date of the Mandatory Pre-Bid Conference. While all questions will be entertained at the Mandatory Pre-Bid Conference, it is strongly urged that questions be submitted in writing prior to the Mandatory Pre-Bid Conference. It is requested that bidders submit questions in writing at least three working days prior to the Mandatory Pre-Bid Conference so that answers can be prepared by the State for distribution at the Mandatory Pre-Bid Conference.
1.3.1.2 QUESTION PROTOCOL Questions should be submitted in writing to the attention of the assigned Purchase Bureau buyer. Written questions should be directly tied to the RFP by the writer. Questions should be asked in consecutive order, from beginning to end, following the organization of the RFP. Each question should begin by referencing the RFP page number and section number to which it relates. Short procedural inquiries may be accepted by telephone by the Purchase Bureau buyer, however, oral explanations or instructions given over the telephone shall not be binding upon the State. Bidders shall not contact the Using Agency directly, in person, or by telephone, concerning this RFP.
1.3.2 MANDATORY SITE VISIT Not applicable to this procurement.
1.3.3 MANDATORY PRE-BID CONFERENCE
A Mandatory Pre-Bid Conference has been scheduled for this procurement. The date, time and location are as follows:
DATE: July 19, 2004
TIME: 9:30 a.m.
LOCATION: PURCHASE BUREAU 9TH FLOOR BID ROOM 33 WEST STATE STREET TRENTON, NJ 08625
Directions to the pre-bid conference can be found on the following website: http://www.state.nj.us/treasury/purchase/faqdirs.htm
The purpose of the Mandatory Pre-Bid Conference is to provide a structured and formal opportunity for the State to accept questions from bidders regarding this RFP. Any revisions to the RFP resulting from the Mandatory Pre-Bid Conference will be formalized and issued on the Purchase Bureau web site as a written addendum to the RFP. Answers to deferred questions will also be issued on the Purchase Bureau web site as a written addendum to this RFP.
CAUTION: Bid proposals will be automatically rejected from any bidder that was not represented or failed to properly register at the Mandatory Pre-Bid Conference.
1.3.4 SUBMISSION OF BID PROPOSAL In order to be considered for award, the bid proposal must be received by the Purchase Bureau of the Division of Purchase and Property at the appropriate location by the required time. ANY BID PROPOSAL NOT RECEIVED ON TIME AT THE RIGHT PLACE WILL BE REJECTED. THE DATE, TIME AND LOCATION ARE:
DATE: August 12, 2004
TIME: 2:00 p.m.
LOCATION: BID RECEIVING ROOM - 9TH FLOOR PURCHASE BUREAU DIVISION OF PURCHASE AND PROPERTY DEPARTMENT OF THE TREASURY 33 WEST STATE STREET, P.O. BOX 230 TRENTON, NJ 08625-0230 Directions to the Purchase Bureau can be found on the following website: http://www.state.nj.us/treasury/purchase/faqdirs.htm
1.3.5 DOCUMENT REVIEW
The State has established a document review room to provide bidders with the opportunity to review supplemental materials relevant to this procurement. The document review room has been established to allow bidders access to information that may be needed to prepare and submit accurate and comprehensive bid proposals. Such review, while recommended, is not mandatory. The document review room will be located at: Quakerbridge Plaza , Bldg. 5, 2nd floor and will be accessible from 9 a.m. to 4 p.m. on the following dates: June 22, 2004 through July 13, 2004 The document review shall contain the following information:
• Title XIX Social Security Act – Medicaid • Title XXI Social Security Act – FamilyCare • New Jersey DMAHS Health Maintenance Organization (HMO) Contract • NJ FamilyCare Enrollment Materials • NJ FamilyCare Sample Program Letters • NJ FamilyCare Disenrollment Survey • NJ FamilyCare Sample Invoice • Data Base Dictionary • NJHBC Sample Program Monthly Report
• 1915b Waiver • AFDC Related Medicaid Manual • NJ Medicaid Eligibility System Sample Transaction Report • Sample of CAHPS (Consumer Assessment Health Plan’s Survey) • Sample Statewide Program Enrollment Data • Sample HMO Provider Directories • Chapter 78 NJ FamilyCare Manual • Chapter 79 NJ KidCare Manual • List of County Welfare Agencies • Sample Listing of Umbrella Organizations • New Jersey Care 2000+ Managed Care Enrollment Packet
Additional information that may be helpful for bid proposal information can be obtained at the following sites: http://www.state.nj.us/humanservices/dmahs/manuals.html http://www.njfamilycare.org/index.html http://www.cms.hhs.gov/ Title XIX, Title XXI, HIPAA NOTE: Bidders are prohibited from removing any materials from the bookroom. The Purchase Bureau will not provide for the photocopying of any materials contained in the bookroom. Bidders, however, are permitted to bring photocopy equipment for the purpose of copying materials. Bidders should contact DMAHS designated contact, Ms. Cynthia Marriott, who may be reached at (609) 588-7910 to arrange a specific review time. IMPORTANT NOTE: No questions or inquiries regarding the substance of the RFP will be accepted or answered during the bookroom review. All questions must be submitted in accordance with RFP section 1.3.1.
1.4 ADDITIONAL INFORMATION
1.4.1 REVISIONS TO THIS RFP In the event that it becomes necessary to clarify or revise this RFP, such clarification or revision will be by addendum. ALL RFP ADDENDA WILL BE ISSUED ON THE PURCHASE BUREAU WEB SITE. TO ACCESS ADDENDA THE BIDDER MUST SELECT THE BID NUMBER ON THE PURCHASE BUREAU BIDDING OPPORTUNITIES WEB PAGE AT THE FOLLOWING ADDRESS: HTTP://WWW.STATE.NJ.US/TREASURY/PURCHASE/BID/SUMMARY/BID.SHTML. There are no designated dates for release of addenda. Therefore interested bidders should check the Purchase Bureau "Bidding Opportunities" website on a daily basis from time of RFP issuance through bid opening. It is the sole responsibility of the bidder to be aware of all addenda related to this procurement.
1.4.2 ADDENDUM AS A PART OF THIS RFP Any addenda to this RFP shall become part of this RFP and part of any contract resulting from this RFP.
1.4.3 ISSUING OFFICE This RFP is issued by the Purchase Bureau, Division of Purchase and Property. The buyer noted in Section 1.3.1 is the sole point of contact between the bidder and the State for purposes of this RFP.
1.4.4 BIDDER RESPONSIBILITY The bidder assumes sole responsibility for the complete effort required in this RFP. No special consideration shall be given after bids are opened because of a bidder's failure to be knowledgeable of all the requirements of this RFP. By submitting a bid proposal in response to this RFP, the bidder represents that it has satisfied itself, from its own investigation, of all the requirements of this RFP.
1.4.5 COST LIABILITY The State assumes no responsibility and bears no liability for costs incurred by bidders before the award of the contract resulting from this RFP.
1.4.6 CONTENTS OF BID PROPOSAL The entire content of every bid proposal will be publicly opened and becomes a public record. This is the case notwithstanding any statement to the contrary made by a bidder in its bid proposal. All bid proposals, as public records, are available for public inspection. Interested parties can make an appointment with the Purchase Bureau buyer to inspect bid proposals received in response to this RFP.
1.4.7 PRICE ALTERATION Bid prices must be typed or written in ink. Any price change (including "white-outs") must be initialed. Failure to do so may preclude an award being made to the bidder.
1.4.8 JOINT VENTURE If a joint venture is submitting a bid proposal, the agreement between the parties relating to such joint venture should be submitted with the joint venture’s bid proposal. Authorized signatories from each party comprising the joint venture must sign the bid proposal. A separate Ownership Disclosure Form, Affirmative Action Employee Information Report, MacBride Principles Certification, and business registration must be supplied for each party to a joint venture.
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2.0 DEFINITIONS The following definitions shall be part of any contract awarded or order placed as result of this RFP.
2.1 STANDARD DEFINITIONS
Addendum – Written clarification or revision to this RFP issued by the Purchase Bureau. All Inclusive Hourly Rate – Must include all direct and indirect costs including, but not limited to: overhead, fee or profit, clerical support, travel expenses, safety equipment, materials, supplies, managerial support and all documents, forms, and reproductions thereof. Hourly rates also include portal to portal expenses. Time spent in traveling to and from the work site or employee’s normal work station should not be included in this rate. Amendment – A change in the scope of work to be performed by the contractor. An amendment is not effective until it is signed by the Director, Division of Purchase and Property. Bidder - An individual or business entity submitting a bid proposal in response to this RFP. Contract - This RFP, any addendum to this RFP, and the bidder’s proposal submitted in response to this RFP, as accepted by the State. Contractor - The contractor is the bidder awarded a contract. Director - Director, Division of Purchase and Property, Department of the Treasury. By statutory authority, the Director is the chief contracting officer for the State of New Jersey. Division - The Division of Purchase and Property Evaluation Committee - A committee established by the Director to review and evaluate bid proposals submitted in response to this RFP and to recommend a contract award to the Director. Fixed Price - A price that is all-inclusive of direct cost and indirect costs, including, but not limited to, direct labor costs, overhead, fee or profit, clerical support, equipment, materials, supplies, managerial (administrative) support, all documents, reports, forms, travel, reproduction and any other costs. No additional fees or costs shall be paid by the State unless there is a change in the scope of work. May - Denotes that which is permissible, not mandatory. Project - The undertaking or services that are the subject of this RFP. Request for Proposal (RFP) – This document which establishes the bidding and contract requirements and solicits bid proposals to meet the purchase needs of the Using Agencies as identified herein. Shall or Must – Denotes that which is a mandatory requirement. Failure to meet a mandatory requirement will result in the rejection of a bid proposal as materially non-responsive. Should - Denotes that which is recommended, not mandatory. State Contract Manager – The individual responsible for the approval of all deliverables, i.e., tasks, sub-tasks or other work elements in the Scope of Work. Subtasks – Detailed activities that comprise the actual performance of a task. State - State of New Jersey. Task - A discrete unit of work to be performed. Using Agency or Agency - The entity for which the Division has issued this RFP and will enter into a contract.
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2.2 CONTRACT SPECIFIC DEFINITIONS ABD - The Aged, Blind, or Disabled population of the Medicaid Program. Abuse - Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid/NJ FamilyCare 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 enrollee practices that result in unnecessary cost to the Medicaid/NJ FamilyCare program. (See 42 C.F.R. 455.2) Advocacy - The act of pleading or arguing in favor of something, such as a cause, idea, or policy; active support.
Advocate - A person or entity that gives support to another person or protects their rights. AFDC or AFDC-Related Medicaid - Means the Aid to Families with Dependent Children as a joint federal/State program that provides medical services to families. It is administered by counties under State supervision. Medicaid regulations are found in N.J.A.C. 10:69. Agency - An administrative division of a government body. Application - Form used to apply for enrollment in any Medicaid or NJ FamilyCare program . Assignment - Process by which a Medicaid enrollee receives a Primary Care Provider (PCP) if the enrollee has not self-selected a PCP. Audit - An official examination and verification of accounts and records. Authorized person - A person authorized to make medical determinations for an enrollee, including, but not limited to, enrollment/disenrollment decisions. It also refers to the person who completes the application on behalf of a child. Auto-assignment - The enrollment of an eligible person, for whom enrollment is mandatory, in a managed care plan chosen by the New Jersey Department of Human Services. Bachelors - A degree awarded by an accredited college or university to a person who has completed four year undergraduate studies. BBA - Balanced Budget Act of 1997 Beneficiary - The person who has been determined as eligible for assistance in accordance with the State Plan(s) under Title XIX and Title XXI of the Social Security Act and/or other New Jersey medical assistance programs. Bureau of Program Integrity – DMAHS unit that addresses program security issues. Business day - The part of a day during which most businesses are operating, usually from 9 a.m. to 5 p.m., Monday through Friday. Calendar day - A day reckoned from midnight to midnight (12:00 a.m. to 11:59 p.m.)
Call Center - Telephone facility with toll-free dedicated “800” telephone lines and corresponding numbers, which is staffed for the purpose of meeting customer service needs. Operation includes, but is not limited to: answering general questions of callers; handling requests for application packages, enrollment materials, marketing requests, etc. Caretaker - The authorized, responsible adult or adults residing with the children for whom the application for NJ FamilyCare is being made. Case - A household consisting of one or more Medicaid, New Jersey Care…Special Medicaid Program, or NJ FamilyCare beneficiaries.
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Certificate of Credible Coverage – DMAHS Premium Support Program (PSP) form that assures continuity of coverage for PSP beneficiaries, usually in situations of pre-existing conditions. CMS or Centers for Medicare and Medicaid Services - Formerly known as Health Care Financing Administration (HCFA). The agency of the Federal Department of Health and Human Services that is responsible for the administration of the Medicare and Medicaid programs in the United States. Commissioner’s Referral - An inquiry (by way of letter, e-mail, telephone, fax, etc) assigned to DMAHS by the DHS Commissioner’s office requiring research and a response written for the Commissioner’s signature. These referrals are to be given a high priority, and require a timely response as indicated on the referral cover sheet. Completed application - An application that has been brought to disposition as described in N.J.A.C. 10:78 and 10:79. The disposition can be approved, denied, dismissed, or withdrawn. Completed redetermination - A redetermination that has been brought to disposition as described in N.J.A.C. 10:78 and 10:79. The disposition can be approved, denied, dismissed, or withdrawn. Contract Effective Date - Date of award of contract to successful bidder. Contract Operational Date - A date six (6) months after the Contract Effective Date when the contractor is expected to have fully implemented its transition plan and the contract program is fully operational. Contract Transition Period - The six (6) month period from the contract effective date to the contract operational date during which the contractor performs its mobilization and transition plan. Co-payment - The part of a cost-sharing requirement in which a fixed monetary amount is paid for certain services/items received from MCO providers. County Welfare Agency (CWA) - Agency of county government that is charged with the responsibility for determining eligibility for public assistance programs. Depending on the county, the county welfare agency might be identified as the Board of Social Services, the Welfare Board, the Division of Family Development, or the Division of Social Services. Day - Unless otherwise noted, all references to day shall mean calendar day. Determination of eligibility - After verification of all factors related to eligibility, the decision of the State eligibility determination agency that the applicant has met the financial and non-financial requirements of program eligibility in accordance with N.J.A.C. 10:78 and N.J.A.C. 10:79. DDD/CCW - Division of Developmental Disabilities/Community Care Waiver DDS - Division of Disability Services within the Department of Human Services. DFD - Division of Family Development within the New Jersey Department of Human Services DHS - New Jersey Department of Human Services. DHSS - New Jersey Department of Health and Senior Services. Director’s Referral - An inquiry (by way of letter, e-mail, telephone, fax, etc) assigned by the DMAHS Director’s office requiring research and a response written for the DMAHS Director’s signature. These referrals are to be given a high priority, and require a timely response as indicated on the referral cover sheet. Disenrollment - The act to end participation with an HMO, voluntarily or involuntarily. DMAHS - Division of Medical Assistance and Health Services within the New Jersey Department of Human Services. DOBI - New Jersey Department of Banking and Insurance.
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Dual eligible - Persons who are entitled to Medicare (Part A and/or Part B) and who are also eligible for Medicaid.
DYFS - Division of Youth and Family Services within the New Jersey Department of Human Services. Eligible - The determination that an individual is qualified to receive benefits in certain programs. Eligibility Determination Agency - An entity, including, but not limited to, a public or private agency, either governmental, non-profit, or for profit, with which the Division of Medical Assistance and Health Services has a contract or agreement to perform some or all of the eligibility related functions for Medicaid /NJ FamilyCare. Enrollee - A Medicaid, New Jersey Care…Special Medicaid Program, or NJ FamilyCare beneficiary who has enrolled in an MCO for the provision of health care services. Enrollment - The process by which a Medicaid eligible person becomes a member of a managed care plan. Enrollment data refer to the managed care plan's information on individuals who are plan members. The managed care plan gets its enrollment data from the Medicaid program's eligibility system and from the Plan Selection Form. EP&MS - Eligibility Processing and Management System Exemption – Individuals who are not required to enroll in an MCO, including but not limited to the categories defined in this RFP. Exclusions – Categories of individuals who are precluded from MCO enrollment due to:
• residence in an institutional environment • enrollment in a waiver program other than the DDD/CCW • categorization as medically needy • Presumptive Eligibility for pregnant women and children • out-of-state placements • enrollment in an MCO not under contract with the DHS or • any other category that may be specified by the DHS.
Federally Qualified Health Center (FQHC) - A facility located in a medically under-served area that provides beneficiaries preventive primary medical care under the general supervision of a physician. These health centers have been approved by the government to provide low cost health care. Medicaid pays for some health services in FQHCs that are not usually covered, like preventive care. FQHCs include community health centers, tribal health clinics, migrant health services, and health centers for the homeless. Federally Qualified HMO - An HMO that CMS has determined is a qualified HMO under section 1310(d) of the Public Health Services Act. Final Disposition - Final status to be eligible or ineligible for program enrollment. Fixed cost - A cost that does not vary depending on production level. Form - A document with blank spaces to be filled in with particular information before it is executed. Fraud - Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. Geographic Access - Software mapping programs that visually map providers and beneficiaries based on zip code.
Governing Unit - Any state, municipal or local authority, including school boards, water and sewage authorities, as well as any state college or university system that is required or authorized by statute to provide a group health plan for active or retired employees.
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Governor‘s referral - An inquiry (by way of letter, e-mail, telephone, fax, etc) assigned to DMAHS by the Governor’s office requiring research and a response written for the Governor’s signature. These referrals are to be given a high priority, and require a timely response as indicated on the referral cover sheet. Head of household - means the individual who is recognized by other members of the household as having primary responsibility for financial control and direction of the household. Health Benefits Coordinator (HBC) - Contractor awarded the Contract resulting from this RFP or a staff member of the contractor serving as a Health Benefits Coordinator. Health Care Financing Administration - See CMS Health Insurance - Benefits or services provided for the diagnosis, cure, mitigation, treatment or prevention of disease or other problems with the structure or function of the body, and transportation primarily for and essential to the provision of such medical care, provided pursuant to the terms of a contract issued to an individual or group health plan by a carrier or other third party within the meaning of N.J.S.A. 30:4D-3m. Health Joint Insurance Fund - A fund for the provision of health care services or benefits authorized in accordance with N.J.S.A. 40A:10-36 et seq. and N.J.A.C. 11:15-3 regardless whether the benefits and services are self funded by the participants or purchased under a contract of health insurance.
Health Maintenance Organization (HMO) - Any entity which contracts with providers and furnishes at least basic comprehensive health care services on a prepaid basis to enrollees in a designated geographic area pursuant to N.J.S.A. 26:2J-1 et seq., and is either:
• A Federally Qualified HMO; or • Meets the State’s definition of an HMO, which includes, at a minimum, the following requirements:
-It is organized primarily for the purpose of providing health care services; -It makes the services it provides to its Medicaid enrollees as accessible to them (in terms of timeliness, amount, duration, and scope) as those services are provided to non-enrolled Medicaid eligible individuals within the area served by the HMO; -It makes provision, satisfactory to DMAHS, to the Department of Insurance and Banking, and the Department of Health and Senior Services, against the risk of insolvency, and ensures that Medicaid enrollees will not be liable for the HMO’s debts if it does become insolvent; and -It has a Certificate of Authority granted by the State of New Jersey to operate in all or selected counties in the State.
HIPAA - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) which was signed into law on August 21, 1996. HIPPA requires that all protected patient information be safeguarded in specific ways to prevent accidental or purposeful disclosure, loss or misuse. Home visit - A face to face visit by a HBC employee in the home of a Medicaid or NJ FamilyCare client, usually for those who are homebound or need assistance. Household Unit - Those persons whose income is counted in the determination of eligibility under the provisions of N.J.A.C. 10:78 and N.J.A.C. 10:79. Lock-box - Lock-box truncation is the conversion of a paper check, received in the mail, to an electronic deposit. The paper item becomes an EFT (electronic funds transfer) and travels through the Federal Reserve’s Automated Clearing House (ACH) network. Lobby - Group of persons engaged in lobbying, especially as representatives of a particular interest group. MACC - Medical Assistance Customer Center Mail room - A room in which incoming and outgoing mail is handled. Managed care enrollment - See enrollment Managed Care Organization (MCO) - An entity that has, or is seeking to qualify for, a comprehensive risk contract, and that is:
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• A Federally Qualified HMO that meets the advance directives requirements of 42 CFR 489 subpart I; or • Any public or private entity that meets the advance directive requirements and is determined to also meet
the following conditions: -Makes the services it provides to its Medicaid enrollees as accessible (in terms of timeliness, amount, duration, and scope) as those services are to other Medicaid recipients within the area served by the entity. -Meets the solvency standards of 42 CFR 438.116. -Mandatory Enrollment – the process whereby an individual eligible for Medicaid or NJ FamilyCare is required to enroll in an HMO, unless otherwise exempted or excluded, to receive the services described in the standard benefits package as approved by DMAHS through necessary Federal approval.
Marketing - Any activity by or means of communication from the contractor, subject to approval and direction from the State, intended to advise, inform, or educate the program applicants, enrollees, or other interested parties, as necessary, of issues pertaining to New Jersey Care 2000+, New Jersey Family Care, and the PSP. Marketing Materials - Materials that are produced in any medium by the contractor at the direction and approval of the State, and can reasonably be interpreted as intended to market information to potential enrollees. MCE - Managed Care Entity; described in the Social Security Act (section 1903(m)(1)(A); includes HMOs. Medicaid - State-administered, Federally and State-funded medical assistance program as authorized in Title XIX of the Social Security Act.
Medicaid Eligibility Identification Number - Twelve- (12) digit identification number, comprised of ten (10) digits plus a two- (2) digit person number. Medicaid Managed Care Program - Program known as the New Jersey Care 2000+ Program that is outlined in this RFP. Medicaid Special - Covers children up to the age of 21 using AFDC standards. Medicare - The federal health insurance program for: people 65 years of age or older, individuals disabled for 24 months, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD). MEI Card - Medicaid Eligibility Identification Card. MEIN - Medicaid Eligibility Identification Number, the twelve- (12) digit identification number, comprised of ten (10) digits plus a two- (2) digit person number. Modification – A minor change in the manner of performance of the contractor under the contract. A modification must be agreed to in writing by the State Contract Manager. Municipality code - Numeric code used to identify a particular city, town, or village, incorporated for local self-government. N.J.A.C. - New Jersey Administrative Code.
New Jersey Care…Special Medicaid Programs - Programs for pregnant women and children up to age 1 with incomes at or below 185 percent of the federal poverty level (FPL) and aged, blind and disabled individuals with income below 100 percent of the federal poverty level (FPL). New Jersey State Plan or the “State Plan” - DHS/DMAHS document, filed and approved by CMS, that describes the New Jersey Medicaid program. NJ FamilyCare - Plan A - State-operated program that provides comprehensive, managed care coverage to:
• Uninsured children below the age of 19 with family incomes up to and including 133 percent of the federal poverty level;
• Children under the age of one year and pregnant women eligible under the New Jersey Care…Special Medicaid Programs;
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• Pregnant women up to 200 percent of the federal poverty level; • AFDC eligibles who are in work-related extensions.
In addition to covered managed care services, eligibles under this program may access certain other services that are paid fee-for-service by the State. NJ FamilyCare - Plan B - State-operated program that provides comprehensive, managed care coverage to uninsured children below the age of 19 with family incomes above 133 percent and up to and including 150 percent of the federal poverty level. In addition to covered managed care services, eligibles under this program may access certain other services that are paid fee-for-service. NJ FamilyCare - Plan C - State-operated program that provides comprehensive managed care coverage to uninsured children below the age of 19 with family incomes above 150 percent and up to and including 200 percent of the federal poverty level. Eligibles are required to participate in cost sharing in form of monthly premiums and a personal contribution to care for most services. Exception: Both Eskimos and Native American Indians under the age of 19 years old, identified by Race Code 3, shall not participate in cost sharing, and shall not be required to pay a personal contribution to care. In addition to covered managed care services, eligibles may access certain other services that are paid fee-for-service. NJ FamilyCare - Plan D - State-operated program that provides managed care coverage to uninsured: In accordance with N.J.A.C. Parents/caretakers with children below the age of 19 who do not qualify for AFDC or AFDC/Related Medicaid with family incomes up to and including 133 percent of the federal poverty level; and Children below the age of 19 with family incomes between 201 percent and up to and including 350 percent of the federal poverty level Eligibles with incomes above 150 percent of the federal poverty level are required to participate in cost sharing in the form of monthly premiums and co-payments for most services. Exception: Both Eskimos and Native American Indians under the age of 19 years old, identified by Race Code 3, shall not participate in cost sharing, and shall not be required to pay co-payments. In addition to covered managed care services, eligibles may access certain other services that are paid fee-for-service. NJ FamilyCare - Plan I - State-operated program that provides certain benefits on a fee-for-service basis through the DMAHS for Plan D parents/caretakers with a program status code of 380. NJHA - New Jersey Hospital Association Non-Covered MCO Services - Services that are not covered in the MCO’s benefits package. Non-Covered Medicaid Services - All services that are not covered by the New Jersey Medicaid State Plan.
Non-Participating Provider - Provider of service that does not have a contract with an MCO. Notice - A formal announcement, notification, or warning, including an announcement of one's intention to withdraw from an agreement OIS - Office of Information Systems within DMAHS. OIT - New Jersey Office of Information Technology within the Department of the Treasury. OIT is responsible for the maintenance of the Medicaid and NJ Family Care Eligibility file. Organization - A structure through which individuals cooperate systematically to conduct business. Penalty - Punishment, especially a sum of money, required as forfeiture for an offense. Person Number - The last two (2) digits of the MEI number, which designate the specific individual within an eligible Medicaid or NJ Family Care case.
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Personal Contribution to Care (PCC) -Portion of the cost-sharing requirement for NJ FamilyCare Plan C and Plan D enrollees in which a fixed monetary amount is paid for certain services/items received from MCO providers.
Pharmacy Lock-in - Program designed for those Medicaid and NJFC beneficiaries determined to have misused, abused, or overutilized their benefits and are required to use one pharmacy for all of their prescription drugs. Overutilization occurs when a beneficiary has utilized Medicaid/NJFC services or items at a frequency or in an amount that is not medically necessary. Examples of misuse or abuse include, but are not limited to, medically harmful or inappropriate use of different drugs, or forgery/alteration of prescriptions.
Plan Selection Form (PSF) - The form used to select the managed care organization. Population - The total number of inhabitants constituting a particular group in a specified area. Pre-Mandatory Enrollment - Enrollments of TANF/AFDC, AFDC-related, SSI and SSI-related clients into managed care programs before such clients have received a mandatory enrollment package. Premium - A payment contribution, a responsibility incurred by the enrollee, towards the purchase of health insurance.
Program Integrity - Those activities that protect the programs administered in whole or in part by DMAHS from fraud, abuse, waste and error.
Project – The undertaking or services that are the subject of this RFP and the awarded contract. PSF - See Plan Selection Form (above), form used to select an MCO. PSP - A program designed to assist working NJ Family Care families to purchase available employer-sponsored health insurance when health coverage is available through the beneficiary’s employment, but the premiums are unaffordable to the employee. Quality Control Review - Process, mechanism and/or report whereby the appropriateness and correctness of standards, as defined and prescribed by this contract, are measured, evaluated, and reported with an emphasis to improve and correct any discovered deficiencies. Recipient - Beneficiary who receives services. Redetermination - The examination of all facts and circumstances relating to the beneficiary's application for continuation of Medicaid/ NJ FamilyCare eligibility.
Renewal - See Redetermination. Report - A formal account of the proceedings or transactions of a group. Retention Program - An initiative to maximize the response to the renewal process. Activities include but are not limited to:
• calling customers who do not respond to information sent through the mail • assisting families with the completion of enrollment or renewal packages • making home visits to families not responding to the renewal process • preparing all required activity reporting.
Retention Unit - A staff of HBCs and supervisors responsible for implementing the Retention Program.
Sponsoring Adult - An individual 18 years of age or older who may assist in making an application for NJ FamilyCare children.
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SSI - Supplemental Security Income program, administered by the Social Security Administration, which provides cash assistance and full Medicaid benefits for individuals who meet the definition of aged, blind, or disabled and who meet the SSI financial needs criteria. SSI-related - Programs that use SSI eligibility methodology. TANF - Temporary Assistance for Needy Families, which replaced the federal AFDC program with regard to cash assistance. Title XIX – Medicaid Component of the Social Security Act. Title XXI - CHIP Component of the Social Security Act. Third Party Liability - When any third party is liable to pay part or all of medical costs. This includes, but is not limited to, medical insurance, tort and no-fault auto insurance (PIP) payments. Transfers - Occurs when an enrollee wishes to change MCOs resulting from dissatisfaction with an MCO, difficulties with the PCP or other medical professionals, or as a result of moving so that obtaining services from the MCO is not feasible. Umbrella Organization - An organization that provides information regarding local or state advocacy/service groups to assist beneficiaries in the assessment of medical, social or educational services. Voluntary Enrollment - Enrollment of those individuals who enroll in an MCO before they are required to do so, or those who enroll in an MCO who are not required to be enrolled in an MCO due to their categorical status in the Medicaid program. Waiver – An approved Federal waiver of portions of the Social Security Act that permits the State to mandatorily enroll certain individuals into managed care programs. WFNJ/GA - Work First New Jersey/General Assistance.
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3.0 SCOPE OF WORK
It is the intent of this RFP, and subsequent contract, to consolidate all the Health Benefits Coordinator Services performed on behalf of New Jersey Medicaid Managed Care (otherwise known as the New Jersey Care 2000+), NJ FamilyCare and PSPs). These services generally encompass outreach, education, eligibility and/or premium determination, enrollment, premium collection and billing services. Unless specifically indicated, all outlined requirements, tasks and / or services apply and are utilized by all three programs. For each specified requirement, service and/or task, the contractor shall provide a plan that demonstrates its intended methods and ways of accomplishing the requirement, service and / or tasks and subtasks. Further, where applicable, the contractor shall identify the resources it will employ to complete or perform the given requirement, services and / or tasks and subtasks. This shall include the contractor proposed and recommended qualifications for the staff assigned to the project. NOTE: No solutions proposing the use of off-shore resources shall be considered.
3.1 BASIC REQUIREMENTS
3.1.1 CONTRACTOR SITE LOCATION
The contractor shall establish an office and operations center to perform all contractor functions as the Health Benefits Coordinator for the New Jersey Care 2000+ (Medicaid) and NJ FamilyCare Programs. For the purpose of the convenience of DMAHS staff, the Contractor’s office, operations and management site facilities shall be located in New Jersey and within a thirty mile radius of the present DMAHS facility located at Quakerbridge Road in Hamilton, New Jersey. The contractor shall operate a toll free number to be fully active Monday through Friday from 8:00 a.m. until 5:00 p.m. in addition to at least two late evenings per week from 5:00 p.m. until 8:00 p.m. The contractor shall maintain hours of business so as to ensure that operations, at a minimum, are maintained on the same schedule as the State.
3.1.2 SPACE FOR STATE STAFF
The contractor shall establish and provide separate office space for the use and occupancy of DMAHS’ Contractor Management Office. Space allocated shall include fully enclosed, lockable and private management offices for five (5) FTEs, work stations for three (3) support FTEs, a conference or meeting room sufficient in size to accommodate twenty (20) persons and capable of guaranteeing the privacy and confidentiality of the meeting attendees. The facility area to be allocated to the Contractor Management Office shall be in such a location as to guarantee privacy and ensure confidentiality separate and apart from the contractor’s operations.
3.1.2.1 The contractor shall also provide space and work stations sufficient in size and number to support the occupancy of approximately one (1) supervisory and twelve (12) additional DMAHS FTEs that will be located at the contractor’s site for purposes such as contract monitoring, training and/or liaison. The area to be allocated to this use shall be in such a location as to guarantee complete facility privacy (including common rooms, rest rooms etc.) and ensure confidentiality separate and apart from the contractor’s operations. 3.1.2.2 The contractor shall provide personal computers, printers, copiers, fax machines, telephone equipment, furnishings, lockable file cabinets and supplies necessary to support the DMAHS personnel assigned to both the Contractor Management Office and the workstations to be occupied by the DMAHS contract monitoring and liaison staff.
3.1.3 FURNISHINGS, EQUIPMENT AND SUPPLIES
The contractor shall provide all office furnishings, supplies, and equipment, including telephones, typewriters, copying equipment or capability, personal computers, facsimile equipment and any audio-video equipment necessary, including e-mail access between the contractor and State staff, for the successful operation of the contract.
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3.1.4 POLICIES AND PROCEDURES
The contractor shall develop and implement, subject to State approval, a policies and procedures manual that governs all operations in effect under the contract and that shall become a part of this contract.
3.1.4.1 The final, State approved Policies and Procedures Manual, containing all State determined revisions, additions and other changes as made by the State, shall be due within thirty (30) business days prior to the end of the Contract Transition Period.
3.1.5 FINANCIAL AND OPERATIONS AUDIT
The contractor shall secure annually the services of an independent certified public accounting (CPA) firm to conduct a financial and operations audit of the contractor’s overall performance. A copy of this annual report and any supporting documentation shall be submitted to the State Contract Manager for review and approval. 3.1.5.1 Copies of the independently conducted, financial and operations audit shall be submitted and due the State Contract Manager on the first day of the third quarter of the subsequent year of operation. Therefore, the following schedule shall govern the document’s submission: Operation Year Audit Submission Due Date 2004 July 1, 2005 2005 July 1, 2006 2006 July 1, 2007 3.1.5.2 Should this independent audit find potential and/or actual evidence of fraud and/or abuse, the contractor shall, at the State’s direction, secure and/or pay the State for the services of a forensic auditor to conduct a forensic investigation and audit to determine the extent of fraud and/or abuse which is the subject of the finding of the independent audit.
3.1.6 STATE NOTIFICATION
The contractor shall notify immediately by telephone and by email, the State Contract Manager of any and all problems when discovered that may affect the daily operations of the contract and/or any area impacting the contractor’s operations.
3.1.6.1 Any and all reports, notifications, operational status summaries or other documentation or information requested by the State that apply to the corrective action plan shall be supplied, at no additional cost and within a twenty –four hour period. The State Contract Manager will accept or modify the corrective action plan within forty-eight hours.
3.1.7 DOCUMENT STORAGE
Records shall be maintained for applicants/enrollees in accordance with Federal Medicaid Regulations 45 Code of Federal Regulations (CFR), Part 74, and HIPAA Confidentiality of the applicant/enrollee files shall be ensured.
3.1.7.1 The contractor shall secure facility space sufficient in size to physically maintain the custody of all records further creating and employing a process to identify and retrieve all files or records, and transmitting them to the State, within two business days of any request. 3.1.7.2 The contractor shall, in accordance with 45 CFR Part 74, maintain and store all records and files for a period of not less than five (5) years or the total duration of the contract, at a facility within the State. The facility shall be accessible, upon request, to representatives of DMAHS, and other agencies of the State and/or federal government. 3.1.7.3 The contractor shall be responsible for transporting any record and/or file, and provide its ultimate delivery, resulting from a request that may be generated by the State, government agency or authorized individual, including its subsequent return to the storage facility.
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3.1.7.4 The contractor shall organize and transport all records and files to DMAHS or a replacement contractor upon completion of the contract.
3.1.8 COUNTY OFFICE SPACE
The contractor shall establish handicapped-accessible offices in all New Jersey counties, which will be used to conduct face-to-face meetings on an individual basis. Such offices shall provide convenient access to Medicaid and NJFC applicants and beneficiaries. Operational hours shall be consistent with those utilized by the CWA office(s) in the county within which they are operating.
3.1.11.1 The contractor may establish an arrangement with individual CWAs for the utilization of space. However, many of the 21 CWAs may possess limited space to accommodate at most one (1) or two (2) contractor Health Benefits Coordinators. In such instances, it is incumbent on the contractor to arrange its own county-specific office space. County office space may be used to meet with those (a) those who need assistance with their eligibility or managed care program issues, (b) are new to Medicaid, (c) who need to transfer enrollment between MCOs, or (d) perform intake functions for NJFC.
3.1.11.2 The need for a Health Benefits Coordinator at all of the CWAs will be evaluated by the State Contract Manager.
3.1.11.3 All contractor field personnel shall be equipped with appropriate equipment and technology so as to afford them the ability to communicate information, copy materials, enter information and process information to assist applicants for NJFC.
3.1.9 HIPAA AND BBA COMPLIANCE
The contractor shall, at all times, in the performance of this contract, ensure that it maintains compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and Balanced Budget Act of 1997 governing the protection of patient information.
3.1.9.1 Such regulatory compliance shall include the erasure and deletion of all personal, confidential information that may be contained on all personal computers and their drives prior to the disposal, or any other disposition that may be required, of such informational technology equipment as per requirements as set forth by the US Department of Defense (DoD) 5220.22-M Standard. See
http://www.hipaadvisory.com/tech/data_removal.htm ( for additional information) for additional information.
3.2 STAFFING
3.2.1 STAFFING REQUIREMENTS
The contractor shall provide, at a minimum the following levels of staffing:
3.2.1.1 One (1) project manager who should preferably possess, at minimum, a masters degree, from an accepted and accredited college or university, in an appropriate field (i.e., MBA, MPA or MHA). The Project Manager shall possess at least 6 years of management experience in healthcare administration and management, and further possess direct knowledge of Medicaid in a managed care environment and the Federal Children’s Health Insurance Program (CHIP). Knowledge of the New Jersey health care, social service, geographic and demographic environments are mandatory.
3.2.1.2 Deputy Project Directors, project supervisors, managers, and supervisors shall possess bachelor’s degree(s) and have experience in the appropriate field (as identified in Section 3.2.1.1 above). 3.2.1.3 Health Benefits Coordinator (HBCs) shall have customer service experience in a healthcare field and knowledge of Medicaid and managed care programs. HBCs shall have experiential knowledge of the State’s health care and social service environment. HBCs shall possess direct knowledge of New Jersey’s geographic and demographic structure and/or composition. HBCs shall possess a two (2) year Associates degree from an accredited college or university and additionally possess two (2) years of appropriate customer service experience, as previously indicated, in a healthcare field.
3.2.1.4 HBCs shall have multi-lingual capabilities to be able to communicate effectively with the diverse populations in New Jersey. The number of such personnel shall be sufficient to effectively administer all aspects of the contract and meet the performance standards specified in this contract.
3.2.1.5 Registered Nurses (RN) with a minimum three years clinical experience who can review health status questions and make determinations whether exemptions (based on DMAHS criteria) from enrollment should be recommended. The number of such personnel shall be sufficient so as to guarantee the meeting of the performance standards specified in this contract.
3.2.1.6 The contractor shall submit a complete organizational chart that will be subject to State approval, reflecting all positions and full time equivalents (FTEs). Supervisory personnel shall be sufficient in number to ensure adequate managerial control of activities and processes required by this contract.
3.2.2 ORGANIZATIONAL CHART
The contractor shall submit the complete organizational chart, as specified above, to the State Contract Manager thirty (30) days prior to the end of the Contract Transition Period.
3.2.2.1 The contractor shall submit a revised, up-to-date organization chart to the State Contract Manager by the first of every month and obtain State approval for organizational changes prior to implementation.
3.2.3 BACKGROUND CHECK DOCUMENTATION
As a condition of employment and for purposes of determining a person's qualifications for employment, the contractor shall undertake a criminal history record background check for all contractor and subcontractor personnel assigned to work on this contract pursuant to regulations promulgated under N.J.A.C. 13:59-1.1 et seq. The contractor shall submit to the New Jersey State Police Bureau of Identification (SBI) an "application" fingerprint card, a request for criminal history record information form (SBI-212B), and the appropriate fee for all contractor and subcontractor personnel it may assign to work on this contract. The contractor shall not permit any newly hired, re-hired or transferred personnel to work on this contract until the SIB has furnished the results of the criminal history record background check to the contractor.
The contractor will be required to retain the results of an individual's criminal history background check as long as that person is assigned to this contract. The results of the criminal history background check will be made available to the State Contract Manager by the contractor upon request.
If the contractor has had a State Police background, criminal and fingerprinting check performed for the employee that meets the exact criteria specified above, then the check may be accepted by the State Contract Manager at the State's sole discretion. Any such reference check must have been during the period of this contract or no later than six months from the contract begin date.
The contractor must ensure that all of its personnel and the personnel of any subcontractor observe all regulations in effect, including security sign-in/sign-out procedures. Under no circumstances will the contractor or its personnel represent themselves as employees of the State. The above mentioned sign-in procedure and sign-in sheet will be the official record of employees for all purposes of this contract. This shall be used by the State Contract Manager for contractor employee and work verification purposes.
The contractor must develop and maintain an ongoing and current written list of all contractor's personnel used on the contract. This list must be updated and supplied in writing to the State Contract Manager at least twenty- four (24) hours before a new employee reports for work on this contract. This list must include a current active list of the "pool" of back-up employees required under the various staffing requirements of this RFP. It must include the employee's full name, date of birth and social security number. When new personnel are assigned, this information must be given to the State Contract Manager immediately and clearly identified as an update to the initial list. The contractor shall undertake and receive the results of the criminal history record background check for all personnel prior to submitting the updated list to the State Contract Manager for approval and therefore, before assigning the employee to work on this contract.
The contractor is fully responsible for the conduct of its employees. If there is any need for intervention by the State security force or other State supervisory personnel because of behavior, security breaches or
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general misconduct, the contractor shall immediately remove the employee from the contract work and replace this employee on a permanent basis. Further occurrences will result in termination of the contract. All security procedures established by the State must be observed by the contractor and contractor's personnel.
3.2.4 GENERAL EMPLOYEE PROFICIENCY
The contractor shall ensure that, as a result of a comprehensive training process, contractor employees are familiar with all required responsibilities of the programs, including eligibility processing and managed care enrollment.
3.2.5 REDUCTION IN FORCE APPROVAL
The contractor shall advise, and obtain approval from the State, prior to instituting any Reduction-in-Force (RIF), as it may apply to this contract and/or project, further supplying the names and numbers of employees affected and how the contractor intends to meet contract performance standards with the potential decrease in employees that may result from the RIF.
3.3 CUSTOMER SERVICE CALL CENTER OPERATIONS
3.3.1 TELEPHONE CALL CENTER
3.3.1.1 CALL CENTER FUNCTIONS AND ACTIVITIES
The contractor Call Center shall provide information pertaining to the New Jersey Care 2000+, NJ FamilyCare and PSPs. The Call Center and Customer Service staffs shall possess the knowledge and capability to provide, at a minimum, the following: Overview of the New Jersey Care 2000+ Program:
• The ability to access and provide current information and assistance, including actual status, related to a beneficiary’s enrollment, and potential transfer between MCOs, in the New Jersey Care 2000+ and PSPs.
• The ability to access and provide assistance on all aspects of the Programs that may influence an individual’s enrollment, use of benefits and access to providers and care under the New Jersey Care 2000+ and PSPs.
• The ability to provide assistance in the selection of MCOs and both knowledge and expertise to provide all applicants and enrollees assistance with the managed care enrollment process.
• The ability to provide assistance and direction regarding an applicant’s obtaining any needed forms, brochures, educational materials or other documentation provided in the operation of the New Jersey Care 2000+ PSPs.
• The ability to ensure a prompt response and initiation, in response to a customer’s request, of the generation and mailing of all forms, brochures, educational materials or other documentation generated in relation to the New Jersey Care 2000+.
• The capability to both discern and provide assistance regarding the varying populations eligible for New Jersey’s managed care programs including the mandatory, voluntary and potentially pre-mandatory populations.
• The capability to both discern and provide assistance regarding the geographic settings in the State, specifically as they apply to the enrollment of individuals according to their inclusion in either a mandatory, voluntary or pre-mandatory population.
• The capability to provide assistance in any transfer process an enrollee may require between MCOs
• The capability to both discern and provide assistance, including actual status, to all applicants and enrollees, on issues involving the managed care exemption process.
• The ability to provide current information as to the providers, and networks, available to beneficiaries under the varying MCOs participating in the New Jersey Care 2000+ and NJ FamilyCare Programs.
• The ability to coordinate and provide assistance in the scheduling of any requested and/or needed home visitations to applicants and enrollees by field staff personnel.
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• The ability to coordinate and provide assistance in the scheduling of visitations between applicants, enrollees and field personnel at events, facilities, sites or other locations where the contractor physically may meet with a customer.
• The ability to provide assistance, if needed or directed by the State, with the grievance or complaint process as it relates to managed care and the New Jersey Care 2000+ Program.
• Any required or needed access to both the EPMS and MCES. • Any problems or issues that are beyond the scope of the HBC shall be forwarded to the
appropriate State operational staff to ensure a prompt resolution. Overview of the NJ FamilyCare Program:
• The ability to access and provide current information and assistance, including actual status, related to a beneficiary’s enrollment, and potential transfer between MCOs, in the NJ FamilyCare Program.
• The ability to access and provide assistance on all aspects of the Program that may influence an individual’s membership, use of healthcare benefits and access to providers and actual care under the NJ FamilyCare Program.
• The ability, knowledge and expertise to provide all applicants and enrollees assistance with selecting and enrolling in an MCO.
• The ability to provide assistance and direction regarding an applicant’s obtaining any needed application packets, forms, brochures, educational materials, renewal forms or other documentation provided in the operation of the NJ FamilyCare Program.
• The ability to ensure a prompt response and initiation, relative to a customer’s request, in the generating and mailing of all application packets, forms, brochures, educational materials, renewal forms or other documentation associated with the NJ FamilyCare Program.
• The ability to provide, any applicant, the current status of their application processing, Program Plan eligibility (Plans A, B, D etc.), enrollment in the NJ FamilyCare Program and effective date of enrollment.
• The knowledge necessary to provide assistance and information related to the renewal process, factors that influence any change in status concerning renewals, such as income, and where an individual may go to obtain renewal assistance.
• The ability to provide assistance on issues or status related to missing information. • The knowledge necessary to provide assistance concerning those cases involving eligibility
processing by the twenty-one (21) County Welfare Agencies. This may include technical issues associated with the screening, imaging or tracking of those cases referred to the CWAs.
• The knowledge necessary to provide assistance concerning any contributory premiums, including required amounts according to NJFC Plan, submission requirements, payment dates etc.
• The knowledge to provide assistance concerning the grievance process. • The knowledge to provide assistance concerning the presumptive eligibility process. • Any required or needed access to both the EPMS and MCES. • Any problems or issues that are beyond the scope of the HBC shall be forwarded to the
appropriate operational staff to ensure a prompt resolution
3.3.2 CALL CENTER FACILITY
The contractor shall establish, operate and maintain a telephone Call Center with toll-free dedicated “800” telephone lines, and corresponding numbers, for the New Jersey Care 2000+ and NJ FamilyCare programs. The currently established 800 numbers (1-800-701-0710, TTY 1-800-701-0720) will be retained. This facility shall be located in New Jersey in an area convenient to DMAHS staff.
3.3.3 TOLL FREE LINES
The contractor shall ensure that the number of toll free, dedicated “800” telephone lines are sufficient in number to accommodate the needs of the New Jersey Care 2000+, NJ FamilyCare programs, and any other program(s) that may be established. Indications of call volumes will be available in the program reports to be made available in the Document Review Room.
3.3.4 HOURS OF OPERATION
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The toll free number shall be fully active Monday through Friday from 8:00 a.m. until 5:00 p.m. in addition to at least two late evenings per week per the State’s direction.
3.3.5 HOLIDAY SCHEDULE
The contractor shall maintain hours of business on the same schedule as the State or as may be approved by the State.
3.3.6 CALL CENTER START
All toll-free numbers shall be fully operational upon the officially determined contractual start date.
3.3.7 AFTER HOUR MESSAGE SYSTEM
The contractor shall institute and utilize a Call Center phone mail system for the receipt of incoming calls received after established business hours.
3.3.1.7.1 The contractor shall develop, install and maintain a process whereby the after-hours phone mail system will allow sufficient time for the caller to leave a detailed message and will further contain prompts such as reminding the caller to leave his/her telephone number and account number or other identification number. Required menu prompts, or choices, shall be simple and minimal in number however shall include, at a minimum, examples and/or instructions for requesting an application, determining the status of an application, requesting information about a program etc. 3.3.1.7.2 All messages left on the after hour phone mail system, shall be returned within one business day. When a return call is made, and no answer is received or a voice mail message is heard, a second call shall be made within one business day of the first call.
3.3.8 CALL CENTER LOG
The contractor shall institute a process whereby all messages left on the after hour phone mail system shall be immediately recorded and documented electronically within an identifiable Call Center log within one business day. The Call Center log shall, at all times, include the date, time, name of caller, subject of call and additionally record the date, time, name of Call Center HBC further detailing the overall outcome or disposition of the return calls. The contractor shall institute a process to enable the State’s review of this Log upon request. The contractor shall further possess the ability to provide a reportable hard copy version of the log, detailing any day’s activity, upon request.
3.3.9 CALL CENTER RESPONSE
The contractor shall, at all times, respond quickly and efficiently to caller general questions, requests for application packages, enrollment materials, requests for marketing material, renewal materials, eligibility cards and invoices etc. The contractor shall mail all requests for materials within two business days of the customer’s request. No more than two (2) business days shall elapse between the time that the request was made and the postmark of the materials to the caller.
3.3.1.9.1 The contractor shall maintain an electronic/hardcopy Call Center mailing log/report that details and documents all information relative to the request and its disposition. 3.3.1.9.2 All mailings shall be sent within two business days from the time of the original request to the Call Center.
3.3.10 LANGUAGES UTILIZED
The contractor shall provide information to callers in both English and Spanish at all times. For beneficiaries requiring communication in another language, the contractor shall provide access to a translation service that accommodates all languages spoken by New Jersey residents. A listing of such languages may be made available for study in the Document Review Room.
3.3.11 LANGUAGE PERSONNEL
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The contractor shall employ English and Spanish speaking HBCs, in order to ensure compliance with all performance standards.
3.3.12 AUTOMATED CALL DISTRIBUTION
The contractor shall install and operate Automated Call Distribution (ACD) equipment capable of handling all call volumes, and capable of monitoring all Call Center telephone staff performance.
3.3.13 TDD
The contractor shall install and operate a TDD (Telephone Device for the Deaf) or TTY (Tech-Telephone) equipment capable of serving the hearing-impaired.
3.3.14 REAL TIME MONITORING
The contractor shall provide a mechanism for monitoring voice systems.
3.3.14.1 The contractor shall provide a capability for designated State staff to conduct real time and automated monitoring for both inbound and outbound generated telephone calls. 3.3.14.2 The contractor shall utilize a process for its Call Center supervisors to perform, real time monitoring for 10% of the daily call volume randomly selected. 3.3.14.3 The contractor shall track all telephone monitoring activities and provide a copy of the tracking report to the State Contract Monitor. 3.3.14.4 The contractor shall ensure that all Call Center monitoring evaluation forms include, at a minimum, and subject to State review and approval, the information contained on the sample available in the Document Review Room. 3.3.14.5 The contractor shall have supervisory personnel review all Call Center monitoring evaluation forms daily. The contractor shall discuss all problems, inconsistencies or discrepancies with the associated telephone HBC within one (1) business day. All meetings between Call Center HBCs and their respective supervisors shall be documented on the Call Center evaluation form which shall detail any need for corrective action. 3.3.14.6 The contractor shall produce all Call Center evaluation forms daily or immediately upon request by State staff, reflecting the prior day’s activities.
3.3.15 CALL CENTER QUALITY TRAINING
All Call Center HBCs who display poor performance or fail to be in compliance with performance requirements or standards shall receive coaching and/or refresher training by Call Center supervisory staff.
3.3.15.1The contractor shall provide written documentation to the State Contract Manager within one (1) business day confirming that the remedial coaching and/or training has occurred.
3.3.16 CALL CENTER MANAGEMENT SYSTEM
The contractor shall install and operate a Call Center performance management system capable of providing automated voice recording, synchronized screen capture, on-line evaluation and comprehensive reporting.
3.3.16.1 The contractor shall, at all times, guarantee that an adequate number of phone lines exist to handle all incoming calls in accordance with the performance standards. Currently the call center receives on average 4,500 calls per day.
3.3.17 STATE MONITORING SPACE
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The contractor shall provide a private office that will allow the direct monitoring of activities for Call Center operations. The office shall contain a personal computer, printer, telephone, and equipment, as required, to assess and manage all telephonic monitoring activities.
3.3.18 CALL CENTER PERFORMANCE STANDARDS
The contractor shall, at all times, adhere to the following performance standards and service levels to be evaluated weekly on an aggregate basis.
• Call Center Service Levels shall be maintained at 95% of telephone calls answered within 90 seconds
for all calls in the queue. • Call Center abandonment rates shall not exceed 3% of all calls contained in the queue. • Call Center average speeds to answer all calls will not exceed 30 seconds for all calls in the queue. • Call Center busy rates, on all incoming calls, will not exceed 5%. • Waiting times in the queue shall not exceed three (3) minutes.
3.3.19 CALL CENTER SERVICE STANDARDS
The contractor shall develop a process to measure and correct any deficiencies in Call Center HBC performance. This process shall ensure that operators adhere and perform in accordance with the following minimum standards. All Call Center staff, shall:
• provide courteous, prompt attention to the caller’s needs. • respect the caller’s privacy during all communications and calls. • maintain sensitivity to the diversity inherent in all cultures. • display and communicate a complete professional demeanor at all times. • Ensure the dissemination of accurate information to all callers. • Ensure a maximum hold time will not exceed 45 seconds, after a call has been answered.
3.3.20 PROBLEM IDENTIFICATION AND NOTIFICATION
The contractor shall develop a problem identification and notification system to enable State and contractor staff to identify, through routine monitoring, the dissemination of incorrect information, wrong procedures, errors or oversights by the Call Center, or any other contractor unit.
3.3.20.1 The contractor shall generate a written alert, describing the problem along with the correct information on procedures to be followed, to be distributed, subject to prior authorization by the State Contract Manager, within one (1) business day of any incident.
3.3.21 CALL CENTER DAILY ACTIVITY REPORTS
The contractor shall provide a Call Center Daily Activity reporting the previous day’s activity, to the State Contract Manager for review against contract standards .
3.3.22 SUPERVISOR AVAILABILITY
The contractor shall provide any caller access to a supervisor when requested by the caller. In the event a Call Center supervisor is not available, the call shall be transferred to the Call Center supervisor’s voice mail. The supervisor shall return all voice mail messages within one (1) business day after the call was received. If initial contact is not made, two (2) additional return calls shall be made within five (5) business days of the initial customer call.
3.3.22.1 A manual or system generated log, with a supporting report, shall be produced by the contractor each day documenting:
• when the call was received, • when the call was returned, • the beneficiary/client who made the call • outcome of the call • if a follow-up call was required and when it was made.
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3.3.23 URGENT / PROBLEMATIC CALL CENTER CASES
The contractor shall develop a process whereby urgent and acute case calls, received by the Call Center, will be recorded systemically in an urgent call log for processing within one (1) business day.
3.3.23.1 The contractor shall develop and implement a procedure whereby all Call Center cases that have been identified as either urgent or problematic in nature will be processed to final disposition, and appropriately recorded within a Call Center log, within three (3) business days. Cases of this nature may include those that have been in a pending status, have necessitated multiple contacts by the beneficiary or where difficulty has been encountered with the receipt of faxes or other information.
3.3.23.2 The log shall be forwarded to the State on a weekly basis.
3.3.23.4 Weekly phone outreach and follow up shall be conducted by the HBC and recorded in the log until a final determination is made.
3.3.24 STATE APPROVAL
The contractor shall, at all times, notify the State to obtain approval of any proposed Call Center reorganization, restructure, revised policies or procedures, etc. before any such changes are implemented.
3.3.25 SUPERVISORY OVERSIGHT
The contractor shall at all times, consistent with overall staffing requirements, provide supervisory oversight for all Call Center personnel sufficient in number so as to ensure that all Call Center performance standards are met. The contractor shall perform ongoing monitoring of Call Center personnel and report to the State monthly on problems identified and corrective action taken. The total staffing plan for the Call Center, including management and supervision, shall remain subject to State review and approval. A ratio of one supervisor to every ten (10) HBC Call Center personnel shall be the minimum ratio.
3.3.26 CALL CENTER TRAINING GUIDE
The contractor shall develop and maintain a training guide containing all current training materials, policies and procedures, directives, alerts and any other memoranda or documentation pertaining to Call Center operations.
3.3.26.1 A Training Guide shall be provided to all Call Center personnel upon employment.
3.3.26.2 The training guide, all updates, revisions, amendments and changes shall be approved by the State Contract Manager.
3.3.27 CALL CENTER WEEKLY REPORT(S)
The contractor shall construct and provide a weekly report to the State Contract Manager that demonstrates the contractor has complied with all Call Center contract requirements.
3.3.28 CALL CENTER MONTHLY REPORT(S)
The contractor shall construct and provide a monthly report to the State Contract Manager that demonstrates the contractor has complied with all Call Center contract requirements.
3.3.29 NATIONAL KIDS NOW LINE
The contractor’s Call Center and phone lines shall be able to accommodate all calls transferred from the National Kids Now toll free telephone number (1-877-KIDS-NOW). The Kids Now Hotline automatically connects callers to their State’s Children’s Health Insurance Program or Medicaid Program. The contractor shall establish and ensure that an operational, seamless connection exists between the National Kids Now Hotline and the contractor’s designated toll free number. Call Center volumes will be available in the Document Review Room.
3.4 MAIL ROOM OPERATIONS
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3.4.1 MAIL PROCESSING AND OPERATIONS
3.4.1.1 MAIL AND FAX RECEIPT
The contractor shall accept all mailed and faxed enrollment forms, exemption forms, applications, missing information, grievances, renewals, Plan Selection Forms, supporting documentation and all program related materials and process them in accordance with contract specifications identified herein.
3.4.1.2 MAIL AND FAX PROCESSING
The contractor shall establish and maintain a work-flow process whereby any new case material or any document received via mail, or fax, shall be imaged and assigned a tracking number . If mail is not delivered directly to the contractor’s physical plant (i.e., mail is delivered to a lock box or post office box), the contractor shall retrieve and process the mail daily, Monday through Saturday as follows: a) Upon receipt of any document the contractor shall open, date stamp and electronically image all forms, applications and supporting documentation. Imaged forms, applications, and supporting documents shall be assigned a Tracking Number so as to ensure immediate electronic case access of the record at all times during the contract’s operation. b) The opening, imaging and tracking number assignment and linkage of all imaged documents, shall be performed and completed within one business day of receipt by the contractor. c) The contractor shall ensure that, all State and contractor employees have access to all imaged documents following the imaged documents’ entry on to the contractor’s system.
3.5 NJFC APPLICATION AND ELIGIBILITY PROCESSING
3.5.1 OVERALL REQUIREMENT
For the purposes of processing all NJFC applications and MCO enrollments, including the receipt of all information on behalf of the NJ FamilyCare program, the contractor shall be considered the appropriate State agency for referral and contact unless otherwise specified. The contractor shall accept all applications, enrollment forms and supporting documentation, and be capable of processing them quickly and accurately in accordance with existing or amended federal and state statute and regulation.
Contractor shall accept and process applications determining initial eligibility of applicants including amount of applicable premium in accordance with established State statute and/or regulation further utilizing any applicable business rules as established by the DMAHS.
3.5.1.1 NJFC DATA ENTRY AND PRELIMINARY ELIGIBILITY ASSESSMENT
The contractor shall establish and operate a NJ FamilyCare Data Entry and Preliminary Eligibility Assessment area for the purpose of conducting a preliminary eligibility assessment of NJ FamilyCare applications. Upon calculation of the applicants’ submitted information, the contractor shall determine and separate NJ FamilyCare Plan A cases from all other applications. As a function of this process, the contractor shall further screen applications for existing Medicaid coverage.
3.5.1.2 PRELIMINARY ELIGIBILITY ASSESSMENT
The contractor shall perform, within two (2) business days of receipt, a preliminary eligibility assessment. The contractor shall determine the appropriate NJFC Plan. If the Plan is determined to be Plan A , the contractor shall send the case to the appropriate CWA for processing. For all other NJFC Plans, the contractor shall retain all applications, and associated documents, and process to final disposition.
a) The contractor shall, within five (5) business days of receipt of application, generate and mail a notification to all applicants advising them of the receipt of their application, and when appropriate, the transferring of their application to the designated CWA for processing.
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b) For NJ FamilyCare Plan A cases, screened as Plan A, the notification to the applicant of case transfer to the CWA shall, at minimum, include the date on which the application was received, date of forwarding to the CWA, the address and telephone number of the CWA to which the application was referred.
c) In performing any initial eligibility assessment, the contractor shall abide by the business rules established by DMAHS for governing program eligibility.
d) During the process of the data entry assessment and initial eligibility screen, applications reporting no income (“0” income cases) shall, by default be forwarded by the contractor to the CWA within the applicant’s county of residence. Any case with the income section left blank should also default to the County Boards of Social Services unless verification of income is attached.
3.5.1.3 CASE TRANSMISSION TO CWAS
The contractor shall, upon preliminary determination of the applicant’s eligibility for NJ FamilyCare Plan A, forward all Plan documentation to the applicant’s CWA for eligibility processing.
a) The contractor shall utilize a geo-access tracking system based on mail zip-code, municipal code of residence or other acceptable industry process, for forwarding NJ FamilyCare Plan A cases to the respective and appropriate CWA.
b) The Contractor shall forward all NJ FamilyCare Plan A applications to the appropriate CWAs on a daily basis.
c) Through use of the Eligibility Processing and Management System (EPMS), the contractor shall ensure that all application source documentation, as discovered, imaged and tracking number assigned within the initial mail room process, will be matched to all Plan A case applications for forwarding to the appropriate CWA.
3.5.1.4 CONTRACTOR NON-PLAN A ELIGIBILITY RESPONSIBILITY
The contractor shall assume full responsibility for determining an applicant’s eligibility for the NJ FamilyCare non-Plan A programs. Applications shall be processed in the order in which received.
a) The contractor shall, upon initial determination of the applicant’s eligibility for any of the NJ FamilyCare non-Plan A programs electronically, retain all non-Plan A documentation for internal completion of the final eligibility determination by the contractor’s eligibility processing unit.
b) In performing any initial eligibility assessment, the contractor shall abide by the business rules established by DMAHS for governing program eligibility. c) The contractor shall generate and mail a notification of application receipt, data entry and screening to all applicants within two (2) business days following their imaging and entry on to the contractor’s system.
3.5.1.5 ELIGIBILITY TIMEFRAMES
Applications shall be reviewed for eligibility in the order in which received. Complete applications shall be reviewed and processed to final disposition (either eligible or ineligible) within five (5) business days of receipt. The contractor shall generate an appropriate notice of eligibility within one (1) business day of the contractor having completed the eligibility determination.
3.5.1.6 MISSING INFORMATION
When information is missing that is needed to process the application or enrollment forms, one request for the needed information shall be mailed to the applicant within two (2) business days of the initial review. If no response is received, or incomplete information remains outstanding, after fifteen (15) calendar days, the contractor shall generate a second letter requesting all missing or incomplete information. If within
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fifteen (15) calendar days of the second letter and neither a response nor the requested information has been received, a letter terminating further action on the application shall be generated detailing the reason for ceasing any further action within two (2) business days in accordance with applicable federal and State statute and/or regulation.
a) Additional information received shall be processed within three (3) business days of receipt. An application shall be considered complete when either a written denial of eligibility is mailed to the applicant or a written statement of eligibility, along with determination of the applicant’s premium, if applicable, is mailed.
b) The contractor shall develop and implement a process and procedure of outreach to applicants for incomplete and/or missing information that may be faxed to the contractor. This process shall also include the ability for applicants to submit the information in person at a location where the contractor is present.
3.5.1.7 ELECTRONIC TRACKING
The contractor shall provide the State, in association with the development of the EPMS, an electronic tracking capability for all NJ FamilyCare applications and Plan Selection Forms received. Electronic tracking shall begin with receipt of application and other program-related materials. Access to the EPMS shall be available at both the contractor’s and State’s facilities.
a) The contractor’s tracking system shall be able to provide the current status of all NJ FamilyCare applications or MCO Plan Selection Forms. b) The contractor’s tracking system shall provide detail sufficient to explain the exact status of an application or Plan Selection Form at the time of inquiry.
c) The contractor’s tracking system shall, at a minimum, provide the following data if not missed from the forms:
• Date(s) of receipt of application and Plan Selection Form. • Date(s) of processing. • The application and Plan Selection Form’s status due to missing information. • Date(s) applicant / beneficiary outreached for missing information. • Date(s) of all telephone or mail outreach for missing information. • Name of beneficiary or applicant and Medicaid ID# or NJFC policy #. • For Plan Selection Form, MCO choice and primary care provider identification. • Type of missing information and name of person it concerns. • Reconciliation between documents imaged and documents data entered. • Application Site number.
3.5.1.8 TRACKING SYSTEM UPGRADES
In accordance with general contract development requirements, the contractor shall provide any recommendations, suggestions or revisions associated with the development of the tracking system capability that would enhance its overall capabilities.
3.5.1.9 LANGUAGE REQUIREMENT
The contractor shall generate any and all notices and/or correspondence to the beneficiary/applicant in the language as specified on the application, currently provided in English and Spanish.
3.5.1.10 PRESUMPTIVE ELIGIBILITY DETERMINATION
The contractor shall identify NJ FamilyCare presumptive eligibility cases, properly and accurately, complete the presumptive eligibility disposition forms forwarded to the DMAHS and return the disposition forms to DMAHS no later then one (1) business week or five (5) business days after the date of the termination of latest eligibility segment.
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3.5.1.11 ELECTRONIC NJ FAMILYCARE APPLICATION The contractor shall establish a link to the NJ FamilyCare web-site by the Contract Operational Date upon completion of the transition period.
a) The link must lead applicants to an electronic NJ FamilyCare application by the Contract Operational Date.
b) Any and all required documentation associated with the submission of electronically transmitted application will be requested by the Contractor through the sending and mailing of self-addressed envelopes to all applicants within two (2) business days of receipt of the electronic application.
3.5.1.12 PROCESSING INITIATION
The contractor shall process all completed applications within five (5) business days of receipt of all information. Based on contract monitoring activities, the contractor shall process applications with a 97% accuracy rate.
3.5.1.13 ELIGIBILITY CALCULATIONS
The contractor shall determine financial eligibility for all potential NJFC non Plan A applicants.
a) The contractor shall utilize a computer-based program, developed using a commercially available and non-proprietary language, that shall perform the eligibility calculations according to all appropriate State law and/or regulation and/or policy.
b) For all NJFC applicants, the contractor shall utilize material obtained from the NJ State Department of Labor for wage, unemployment and disability files to obtain or validate financial data relating to eligibility. The contractor must secure access to Department of Labor files for these data.
3.5.1.14 RETURNED DOCUMENTATION
For all returned mail, the contractor, as the State’s designated agency, shall make, within two (2) business days, an attempt to contact the beneficiary/applicant to verify the mailing address. Contact shall be attempted by telephone, fax or other accepted modality for the purpose of obtaining the corrected and viable mailing address.
a) If the contractor is unable to contact the beneficiary/applicant, for the purpose of securing a correct address, the contractor shall document, electronically and with a hardcopy, any and all correspondence associated with the case to date.
b) Where NJFC identification cards are returned to the contractor due to an undeliverable/insufficient address, the contractor shall attempt a telephone contact (call) to verify the correct and current beneficiary address. If telephone contact cannot be made, the contractor shall generate and mail a letter to the beneficiary advising him/her to contact the contractor in order to verify the correct and current address. If no response is received from the beneficiary within twenty (20) days of the date of the letter, the beneficiary shall be advised that his/her eligibility will be terminated.
3.5.1.15 ON SITE APPLICATION PROCEDURE
The contractor shall have a procedure to accommodate local community application intake (i.e., at churches, schools, community centers etc.), by the Contract Operational Date. a) The contractor shall, at these various sites, assist eligible applicants with the application and managed care enrollment process, including explaining the differences between the various Managed Care Organizations (MCOs).
b) The contractor shall explain other health coverage choices and special programs which may be available to the applicant or enrollee in a manner that is unbiased as to the choice the individual should make.
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c) In orienting applicants to NJ FamilyCare, the contractor shall obtain information on any health insurance that the applicants may possess or be capable of obtaining outside the scope of NJ FamilyCare.
3.5.1.16 DISTRIBUTION POINTS
The contractor shall maintain periodic contact with specified distribution points for the program’s application packages and marketing material to ensure that the distribution sites are supplied adequately to avoid any depletion of stock.
a) The contractor shall serve as the primary point of distribution for mass mailings of application packages and marketing material as requested or required.
3.5.1.17 ELIGIBILITY PROCESSING AND MANAGEMENT SYSTEM (EPMS)
As applied to the processing and determination of eligibility, the contractor shall design, develop and implement, by the Contract Operational Date, an EPMS that, at a minimum, shall be capable of assuring and providing the following capabilities:
a) The ability to perform any and all calculations required or necessary in the processing of an application; b) The ability to generate and record all notifications and pertinent documents, including documentation of all actual dates of mailing; c) The ability to electronically track, record and amend, as necessary, any and all applicable beneficiary premium payments; d) The ability to generate any and all Plan-specific required letters, notices, invoices or other correspondence; e) A computer-based program that will perform the eligibility calculations according to all appropriate State law and/or regulation and/or policy; and f) Generate any and all reports as may be required or requested for the administration and operation of the program.
3.5.1.18 URGENT CASES
The contractor shall ensure that urgent high priority cases identified by the State shall be handled as directed by the State.
3.5.1.19 SUBSEQUENT NJ FAMILYCARE CATEGORIES
As necessary, the contractor shall assume responsibility for the determination of an applicant’s eligibility for subsequent NJ FamilyCare eligibility category or Plan in accordance with any federal and /or State statute, law, regulation, business rule or directive.
The contractor shall address and maintain records regarding complaints and grievances received regarding the application and redetermination process, and further shall maintain records concerning the disposition of those complaints and grievances (which may include referral to appropriate responding party).
a) The contractor shall issue notices of a beneficiary’s right to appeal any Program termination due to a loss of eligibility. b) The contractor shall notify the applicant/beneficiary of the receipt of all complaints and grievances within two (2) business days of receipt. c) The contractor shall notify applicants/beneficiaries of the resolution of the complaint or grievance within thirty (30) business days of the receipt of the complaint/grievance.
3.5.1.21 NJ FAMILYCARE RENEWAL PROCESS
The contractor shall develop and initiate a process for the annual renewal of each beneficiary’s program eligibility and premium contribution status.
3.5.1.22 RENEWAL NOTIFICATION
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The contractor shall generate and mail a letter to all NJ FamilyCare beneficiaries advising them of their impending renewal after their tenth (10th) month of enrollment.
a) The contractor’s renewal notification letter shall contain information advising the enrollees of their need to complete all forms necessary to guarantee their continued coverage for the enrollees and their families. b) The contractor shall conduct follow-up telephone outreach to those NJ FamilyCare enrollees who have failed to provide the necessary and required information associated with their annual renewal of coverage. c) The contractor shall develop a process whereby the supplemental telephone outreach shall occur thirty (30) days before the final date the enrollee’s completed renewal forms are due to be returned to the contractor.
3.5.1.23 CHANGE IN STATUS
Redeterminations of eligibility must occur in the event of a status change. For any change in circumstance(s) (e.g. changes in financial or family status), the contractor shall establish whether a redetermination of eligibility or premium level is required. If any status change in a beneficiary’s circumstances is required, the date for the next required annual renewal shall be twelve (12) months from the date of the last status change, establishing a new anniversary date for renewal. Redeterminations of eligibility must occur within three (3) business days in the event of a reported status change.
3.5.1.24 RENEWAL PROCESSING TIME
Within two (2) business days of imaging the returned renewal documents, the contractor shall review and process all beneficiary responses.
3.5.1.25 ANNUAL REQUIREMENT
The contractor shall perform all renewals annually for all NJ FamilyCare Plans as required, ensuring that all completed renewals are processed within thirty (30) days of receipt. Timeframes associated with prior instructions concerning missing information shall apply to the processing of all renewals and redeterminations.
3.5.1.26 DATA AND INFORMATION COLLECTION AND ANALYSIS
The contractor shall conduct a review and analysis of the information and data collected in accordance with State requirements. The contractor shall ensure that such audits include pertinent demographic data (as may be specified by the State), including household income information from all beneficiaries. All data and information will be obtainable from other sources as permissible by State law and regulation (i.e. social security information, wage data etc.)
3.5.1.27 AUTHORITY TO OBTAIN INFORMATION
The contractor shall request all information from beneficiaries, as well as from other sources, as permissible by State law and regulation if there is reason to believe that a change in financial and/or family status has occurred but not been reported or has been incorrectly reported.
3.5.1.28 TERMINATION ACTIONS
Prior to a beneficiary’s termination, the contractor shall ensure that necessary documentation has been collected or that the attempts for collection have been properly performed, and documented.
a) The contractor shall ensure that the beneficiary has received a clear and specific notification of the termination, including all applicable instructions, if any, for the manner by which the termination/disenrollment and loss of coverage may be prevented. b) The contractor shall notify all beneficiaries of the intended termination at least ten (10) working days prior to the termination. c) The contractor shall update the NJFC eligibility file and notify the appropriate MCO of the termination. d) The contractor shall update, and record all documentation related to the termination, within both the MCES and EPMS.
3.5.1.29 CREDITABLE COVERAGE CERTIFICATE
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The contractor shall develop and implement a process, so as to ensure, that all applicable terminated NJ FamilyCare cases shall be notified of the availability of a certificate of Credible Coverage.
3.5.1.30 RENEWAL COMMUNICATION
The contractor shall conduct all verbal communication with the beneficiary in English or Spanish, or the language specific to the enrollee in question. Each written communication shall be in English or Spanish and include instructions on how to contact the contractor for any additional explanation.
3.5.1.31 RENEWAL RECORDS
The contractor shall maintain records of all transactions relative to renewals, continued enrollment and terminations, guaranteeing a process that ensures all materials related to terminations remain and are kept confidential.
3.6 PROCESS REQUIREMENTS FOR MANAGED CARE PROGRAM
3.6.1 MANAGED CARE ENROLLMENT SYSTEM (MCES)
In addition to all tasks, processes and responsibilities indicated within this section relating to managed care enrollment, the contractor shall design, develop and implement, by the Contract Operational Date, a comprehensive “MCES” capable of systemically and electronically performing all functions associated with the managed care enrollment process. At a minimum, the MCES shall be capable of:
• imaging and recording all managed care documents; • assigning identifiers and conducting complete case tracking; • linking all managed care enrollments with program as well as managed care eligibility; • performing associated banking and lock-box linkages; • generating and recording all notifications and pertinent documents; • transmitting and communicating all files necessary between the contractor, the State (including OIT),
the County Welfare Agencies and all participating MCOs; • maintaining, storing, revising and manipulating any and all program and relative statistical and
healthcare information in accordance with universally accepted data-base functions; • generating any and all reports as may be required or requested for the administration and operation
of the program(s); • recording the reasons associated with all disenrollments; and • performing all data entry associated with, and the transfer of, all information related to Plan Selection
Forms.
3.6.1.1 OUTREACH PLAN
The contractor shall develop and implement an overall outreach plan, in conjunction with the State advertising contractor, for Medicaid beneficiaries and the NJ FamilyCare programs’ enrollees that orients all potential enrollees to the process by which health care is accessed within a managed care environment.
3.6.1.2 MANAGED CARE
The contractor shall conduct outreach and education on all aspects of the Medicaid and NJ FamilyCare programs. Areas of information shall include, but not be limited to, potential benefits, eligibility and enrollment criteria, managed care provisions, participating MCOs, MCO networks, grievance and appeal processes and all other social programs and benefits for which an enrollee may be entitled or eligible that are not a part of managed care.
3.6.1.3 MANAGED CARE MATERIALS
The contractor shall maintain, control and coordinate the dissemination of all outreach, educational materials and information to be generated or utilized in the operation of the Medicaid and NJ FamilyCare programs.
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a) The contractor shall be responsible for the dissemination and control of any and all materials used in any DMAHS directed mailing campaigns. b) The contractor shall be responsible for the dissemination and control of any and all materials used in any DMAHS directed community events as set forth below.
3.6.1.4 COMMUNITY EVENTS AND HEALTH FAIRS
The contractor shall, in conjunction with the State approved advertising contractor, at the direction of the DMAHS, be present and disseminate appropriate information at all community, civic, faith-based, employee-related or other events where the outreach and education of the Medicaid and NJ FamilyCare programs may be necessary, required or warranted. The contractor shall facilitate at least two health fairs per year where competing MCOs can present products directly to eligibles.
3.6.1.5 VOLUNTARY, MANDATORY AND PRE-MANDATORY, AND NEW CLIENT POPULATIONS
The contractor shall, recognize the distinction amongst the populations covered and affected by the New Jersey Care 2000+ and NJ FamilyCare programs. The New Jersey Care 2000+, beneficiaries are categorized as follows:
• Voluntary – Beneficiaries who, though eligible for enrollment in managed care, are not required to
enroll. Typically, these include Division of Youth and Family Services (DYFS) clients and Dual Eligibles, i.e., clients with both Medicaid and Medicare coverage.
• Mandatory – Beneficiaries who, in order to receive health care benefits, are required to receive their health care coverage through enrollment in a participating MCO. Beneficiaries considered mandatory may receive an exemption from required enrollment in managed care subject to approval by the DMAHS.
• Pre-Mandatory – Beneficiaries who are targeted to enroll in managed care but are not yet mandated to enroll and are subject to county by county phase in schedules for mandatory enrollment per the approval and direction of DMAHS.
• New Clients – Individuals newly eligible for Medicaid in an eligibility category targeted for mandatory managed care enrollment.
3.6.1.6 MANAGED CARE POPULATIONS FOR MANDATORY ENROLLMENT
By direction of the DMAHS, the contractor shall conduct outreach to those populations specifically targeted for managed care enrollment in accordance with program objectives. The following populations are in the eligibility categories for which enrollment is considered mandatory:
• Aid to Families with Dependent Children (AFDC)/Temporary Assistance for Needy Families
(TANF) • AFDC/TANF-Related, New Jersey Care…New Jersey Special Medicaid Program for Pregnant
Women and Children under one • SSI-Aged, Blind, Disabled, and Essential Spouses • New Jersey Care…Special Medicaid programs for the Aged, Blind and Disabled • Division of Developmental Disabilities Clients including the Division of Developmental Disabilities
Community Care Waiver • Medicaid only or SSI-related Aged, Blind, and Disabled • Uninsured parents/caretakers and children who are covered under NJ FamilyCare • Insured Children covered under NJ FamilyCare
a) The contractor shall, dependent upon the needs and under the direction of the State, modify operational processes associated with the enrollment of all mandatory populations, modifying its processes for this task depending on State directed changes in these eligibility categories. b) The contractor shall, as an agent of DMAHS, enroll individuals in designated eligibility categories, explain the programs of all contracted MCOs in a manner that is unbiased as to the choice the enrollee should make, explain health coverage choices available, answer beneficiary questions and assist eligible individuals, or their authorized representative, in selecting an MCO.
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c) The contractor shall, as directed by the State and/or outlined within the tasks of this RFP, conduct all Automatic Assignment processes for those individuals who fail to voluntarily choose an MCO yet belong to a mandatory population.
d) The contractor shall, as identified and detailed within this RFP, conduct all tasks associated with the enrollment of mandatory eligibility categories to include, but not be limited to, the following:
• Maintain staffing levels necessary to accommodate the targeted population; • Conduct all required mass mailings as defined in Section 3.6.1.18; • Arrange and provide for client meetings, either in a group or one-on-one setting; • Ensure a capability for meetings at CWAs, Medical Assistance Customer Centers (MACC)
offices, churches, schools, provider sites, community centers, public housing centers etc., and including handicapped-accessible facilities;
• Establish a liaison and working relationship with community-based advocacy and service groups; • Possess the capacity to provide all required client assistance; • Facilitate and conduct any and all directed, or required, health fairs; • Provide plan selection form completion assistance; • Provide assistance with the MCO selection process; • Check all forms for missing information and completion; • Ensure expeditious enrollment processing; • Meet all enrollment processing timeframes; • Notify all appropriate agencies of discrepancies discovered during form review; • Process, as directed, and maintain logs of all undeliverable mail; • Conduct follow-up telephone or mail contact with beneficiaries to minimize the necessity of MCO
auto-assignment; • Conduct, as required and directed, enrollment notifications to all MCOs; • Produce and mail all required confirmation and disposition letters; • Maintain an electronic file of all processed and unprocessed plan selection forms; and • As directed, and in accordance with State specifications, compile, maintain and report all pertinent
statistical data associated with the managed care enrollment of the mandatory eligibility categories.
e) The contractor shall provide every new Medicaid client who is included in the mandated managed care population the opportunity to personally visit with an agent of the contractor. These visits may be in a group or one-on-one basis and may be given as presentations in the CWA offices, MACCs, community centers and other venues, including handicapped-accessible facilities.
3.6.1.7 MANAGED CARE POPULATIONS FOR VOLUNTARY ENROLLMENT
By direction of DMAHS, the contractor shall provide outreach to those populations specifically targeted for managed care enrollment in accordance with program objectives. The following populations are the eligibility categories for which enrollment is considered voluntary (non-mandated) and therefore excluded from the Automatic Assignment process:
• Individuals whose Medicaid eligibility will terminate within three (3) months or less after the
projected date of effective enrollment; • Individuals enrolled in or covered by either a Medicare or commercial MCO who will not be
enrolled in New Jersey Care 2000+ unless the New Jersey Care 2000+ MCO and the Medicare / commercial MCO are the same;
• Individuals in the Pharmacy Lock-in or Provider Warning or Hospice programs; • Individuals in eligibility categories other than AFDC / TANF, AFDC / TANF-related New Jersey
Care Pregnant Women and Children under the age of one (1), SSI-Aged, Blind and Disabled populations, New Jersey Care – Aged, Blind and Disabled, the DDD/CCW population or NJ FamilyCare Plan A;
• Children awaiting adoption through a private agency; • Individuals identified as having more than one active eligible Medicaid number; • The DYFS population; and
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• As directed or determined by the State, individuals in an eligibility category who live in a county where mandatory enrollment is not yet required based on a phase-in schedule.
a) The contractor shall, dependent upon the needs and under the direction of the State, modify operational processes associated with the enrollment of all voluntary populations, modifying its processes for this task depending on State directed changes in these eligibility categories.
b) The contractor shall, as an agent of DMAHS, enroll individuals in designated eligibility categories, explain the programs of all contracted MCOs in a manner that is unbiased as to the choice the enrollee should make, explain health coverage choices available, answer beneficiary questions and assist eligible individuals, or their authorized representative, in selecting an MCO.
c) The contractor shall, as identified and detailed within this RFP, conduct all tasks associated with the enrollment of voluntary eligibility categories to include, but not be limited to, the following:
• Maintain staffing levels necessary to accommodate the targeted population; • Arrange and provide for client meetings, either in a group or one-on-one setting; • Ensure a capability for meetings at CWAs, MACC offices, churches, schools, provider sites,
community centers, public housing centers etc., and including handicapped accessible facilities; • Establish a liaison and working relationship with community based advocacy and service groups; • Conduct all required mass mailings; • Possess the capacity to provide all required client assistance; • Facilitate and conduct any and all directed, or required, health fairs; • Assist and provide enrollment form assistance; • Provide assistance with the MCO selection process; • Check all forms for missing information and completion; • Ensure expeditious enrollment processing; • Meet all enrollment processing timeframes; • Notify all appropriate agencies of discrepancies discovered during form review; • Process, as directed, and maintain logs of all undeliverable mail; • Conduct follow-up telephone or mail contact with beneficiaries to minimize the necessity of MCO
auto-assignment; • Conduct, as required and directed, enrollment notifications to all MCOs; • Produce and mail all required confirmation and disposition letters; • Maintain a file of all processed and unprocessed plan selection forms; • As directed, and in accordance with State specifications, compile, maintain and report all pertinent
statistical data associated with the managed care enrollment of the mandatory eligibility categories; and
• Provide MCO transfer assistance that will assist clients with the MCO transfer process, discuss available options and encourage voluntary or pre-mandatory populations to remain enrolled.
3.6.1.8 TARGETED POPULATIONS
By direction of DMAHS, the contractor shall provide outreach to those populations that may become specifically targeted for mandatory managed care enrollment as the result of changes in either the Medicaid or NJ FamilyCare programs.
3.6.1.9 PRE- MANDATORY POPULATIONS
The contractor shall, by direction of DMAHS, be prepared to conduct all tasks required that may be necessary to facilitate the enrollment of pre-mandatory managed care populations. Managed care enrollment of any pre-mandatory managed care population might occur according to a county-by-county phase-in schedule that would be established by DMAHS.
3.6.1.10 MANAGED CARE ASSOCIATION WITH CALL CENTER RESPONSIBILITIES
In accordance with the overall requirements for the operation of the call center, the contractor shall ensure that all call center personnel are trained and competent in responding to any inquiries, complaints, educational or enrollment needs of beneficiaries as they specifically relate to managed care.
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3.6.1.11 UMBRELLA ORGANIZATIONS
The contractor shall maintain, update, coordinate and disseminate information related to the listing of any and all “umbrella organizations” that may be able to provide information on community or statewide based advocacy / service groups currently assisting either Medicaid and NJ FamilyCare beneficiaries in accessing medical, social and educational services.
a) The contractor shall provide appropriate documentation so attesting to DMAHS that an update of all statewide “umbrella organizations” is performed on an annual basis.
3.6.1.12 PROMOTIONAL CAMPAIGNS
As may be required by the State in operation of the program, the contractor shall work with the State contractor for DHS advertising and public relations services on promotional campaigns. This shall include initial and subsequent years of operation, avenues for distribution of materials and possibly market surveys to determine if the promotional objectives are being achieved and amend strategies as necessary to correct promotions that are inadequate.
3.6.1.13 MANAGED CARE EDUCATIONAL CAMPAIGN
Beyond the overall education initiatives outlined in this Section, the contractor shall develop a comprehensive managed care education and awareness program that is to be conducted on an annual basis. This initiative shall reach every Medicaid beneficiary, including Aged, Blind and Disabled, Developmentally Disabled populations and individuals with communication-affected disorders, subject to mandatory enrollment in a managed care program; and those Medicaid clients who may wish to voluntarily enroll to orient these beneficiaries to the managed care program. The contractor shall design and implement this program in accordance with the following provisions:
a) The program shall address the needs of all Medicaid and NJ FamilyCare eligibility groups and enrollees and be designed to be understandable by the targeted populations.
b) The program shall illustrate the ways and methods for maximizing benefits and services within a managed care environment.
c) The materials shall be designed at a fifth (5th) grade reading level to ensure that at least 90% of the targeted populations can be expected to comprehend the materials.
d) The program shall be designed in bi-lingual English and Spanish with a capability to be further presented in other languages as needed or directed by the State.
e) The program shall be able to be modified so as to be presented at community events or other such venues as required.
f) The program shall be conducted, contingent on projected audience or enrollee attendance in accordance with DMAHS criteria, on a county-by-county basis.
g) In addition to the outreach and education tasks of this section, the contractor shall submit a comprehensive education program for all eligibility groups on how to navigate the managed care delivery system. This program must be designed to provide enrollees with a basic understanding of how to most effectively utilize managed care services. The program may be presented in a seminar or workshop environment or other community events and venues and must include how to access and use the referral process, the use of facilities and ancillary providers and health care provided under the regular fee-for-service Medicaid program as well as managed care.
h) Relative to this program, at all times, the DMAHS shall reserve the right to determine the need for the program’s implementation, as well as, any change or modification in the scope of work related to this task.
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i) All verbal communication with the enrollee must be in English or Spanish or the language specific to the applicant in question. Each written communication must include instructions on how the contractor may be contacted for any explanations, or other assistance, that may be required.
j) The contractor shall ensure that at least 50% of the outreach population will respond in such a manner that an automatic (pre-nominated) assignment to a predetermined MCO will not be required.
k) The contractor shall involve community-based advocacy/service groups which are involved in programs and activities targeted to Medicaid beneficiaries. Such groups may offer the best access to effectively reach and educate Medicaid beneficiaries about the Medicaid Managed Care Program (MMCP).
l) The contractor shall reach out to the parents/guardians of every potentially eligible NJ FamilyCare beneficiary to educate them on the use of the managed care benefits available through the NJ FamilyCare Program. This shall be accomplished through mailing educational material, providing activities that promote and provide for managed care enrollment with community, civic, employment, service and faith- based organizations.
m) The contractor shall provide technical information to the DHS advertising contractor for the design of informational materials, including at a minimum, the following:
• Brochures describing the Medicaid Managed Care Program • Brochures describing the NJ FamilyCare Program • Posters, flyers and advertisements • MCO enrollments, by mail, letter and instruction
3.6.1.14 DRAFT STRATEGIES FOR GOVERNMENT AND CONSUMERS
Two (2) months after the contractual start date, the contractor shall provide draft strategies regarding specific education for the legislative offices and other government agencies that are most likely to receive significant inquiries regarding any aspect of the program. These strategies shall include, for example, seminars, roundtables, and development of training manuals with flow charts to accompany the educational pamphlets, booklets, etc. One month after receiving State approval, the contractor shall have these materials ready for distribution to all designated parties. Also, two (2) months after the contractual start date, the contractor shall develop, and submit to the State for approval, draft strategies regarding general educational managed care and targeted managed care educational materials for the New Jersey Care 2000+ and NJ FamilyCare Programs to the various consumer populations.
3.6.1.15 STATUS REPORTS OF OVERALL PROGRAM PERFORMANCE
By the Contract Operational Date, the contractor shall develop and submit drafts of the format of the periodic status reports for the program’s overall performance.
3.6.1.16 CLIENT MEETINGS
The contractor shall provide every beneficiary, not to be limited to those included in a mandated population, the opportunity to personally visit with an HBC.
a) The contractor shall provide the capability to conduct all visits on a group or one-on-one basis, which may be given as presentations in CWA or MACC offices, churches, schools, community centers, public housing sites, provider sites and other venues including handicapped-accessibility facilities.
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3.6.1.17 HOME VISITS
When necessary or as required or directed by DMAHS, the contractor shall conduct home visits (average 125 per month) for the purposes of education, and/or application intake or enrollment associated with the Medicaid or NJ FamilyCare programs. Applications and/or Plan Selection Forms completed during home visits must be delivered to the contractor’s central office mail room within three (3) business days of the home visit.
3.6.1.18 MASS MAILINGS
As required to enroll targeted populations into managed care, the contractor shall conduct mass mailing using eligibility files supplied by DMAHS so that each beneficiary receives an enrollment package or other required information.
a) The contractor shall ensure that all enrollment packages, distributed in association with mass mailings, including a required annual mass mailing to voluntary populations, contain, at minimum, a letter, Plan Selection Form, instructions for completion, an informational brochure on Medicaid managed care, information on each participating MCO, information on toll-free telephone access numbers and a calendar of events listing the dates, places and times for all personal / group presentations that would afford additional assistance. Other materials may be added as required or directed by the State.
b) The contractor shall conduct mass mailings associated with the dissemination of other required program information or notices shall be conducted in accordance with requirements and dates established by the State.
c) The contractor shall develop and implement an automated mailing, tracking and data entry system with the following capabilities:
• ability to accept the complete OIT Medicaid eligibility file; • ability to generate beneficiary-specific enrollment forms (with some information already pre-
printed); • ability to control volumes in each mailing wave; • interface with OIT in ascertaining eligibility status; • on-line tracking of return mail (status tracking); • interface with OIT in processing beneficiary selections, exemption/exclusion data. (these
transactions will emanate both the work of the contractor, as well as, the MCOs); • ability to produce confirmation letters to eligibles after verifying that enrollment transactions were
accepted by the OIT eligibility system; • produce reports to the DMAHS; • incorporate labor-saving automation methods that have the potential to facilitate administration of
the enrollment process while minimizing costs; and • ability to track and report exact status of applications and enrollment forms at the time of inquiry,
including but not limited to, date of application or PSF received, date processed, application/PSF pending due to missing information, specific information missing, date beneficiary outreached for missing information, dates of all telephone and mail outreach.
3.6.1.19 STATISTICAL DATA
The contractor shall systemically record, manage, produce and report statistical data, information and reports monthly to DMAHS or as necessary and required, by DMAHS, as it pertains to managed care.
3.6.2 COORDINATION AND CONTROL OF MANAGED CARE MATERIALS
3.6.2.1 EDUCATIONAL MATERIALS FOR MANAGED CARE
The contractor shall provide technical information to the State and the DHS advertising contractor for the design of material primarily intended to educate various audiences about the Medicaid Managed Care and NJ FamilyCare programs, their goals, how they function and how to obtain additional, detailed information. Audiences include, but shall not be limited to, the Medicaid / NJ FamilyCare beneficiaries, the general
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public, State and federal legislative leaders and their staffs, government agencies, the press, insurance carriers and health care providers. Also, the contractor shall provide technical information to DHS’ contractor for advertising and marketing, for the design of periodic educational material setting forth the progress of the Medicaid managed care and NJ FamilyCare programs, its successes and improvements.
3.6.2.2 PAMPHLETS AND BOOKLETS
The contractor shall provide technical information to DHS’ advertising contractor, within two (2) months of Contractual Operational Date, to develop a series of draft educational pamphlets, booklets etc., designed to address the needs of the target populations as necessary.
a) The contractor shall distribute of all written pamphlets, brochures or other materials as directed by the State, or supplied by MCOs, including information on participating MCOs. Postage shall be a pass-through expense as indicated.
b) The contractor shall be responsible for maintaining a sixty (60) day supply of the program’s application packages and educational materials. When the supply reaches the specified sixty (60) days, the contractor shall notify the State Contract manager to order more. The contractor shall serve as the primary point of distribution for mass mailings of application packages and educational materials, utilizing the State designated printing contractor as requested or required.
3.6.3 GENERAL PROVISIONS FOR MANAGED CARE TASKS
3.6.3.1 BENEFICIARY ENROLLMENT ASSISTANCE
The contractor shall assist and explain, to all eligible beneficiaries during the enrollment process, the differences among the various MCOs and delivery systems offered by the participating MCOs under contract with DHS in a manner that is unbiased toward any plan or delivery system. The contractor must also explain other health coverage choices that may be available to the applicant or enrollee in a manner that is unbiased as to choice the individual should make, but shall encourage the individual to seek coverage or remain covered.
3.6.3.2 MCO PROVIDER INFORMATION
The contractor shall answer all beneficiary’s questions concerning the composition of MCO provider networks accurately.
3.6.3.3 MCO SELECTION ASSISTANCE
The contractor shall assist all Medicaid and NJ FamilyCare beneficiaries in selecting an MCO that best meets the needs of themselves and their family. The contractor shall assist beneficiaries in completing the Plan Selection Form.
a) The contractor shall ensure that any assistance provided in selecting an MCO does not discriminate or favor any particular MCO, and is based solely on serving the interests of the beneficiary. This process shall obtain information, to be included on the plan selection forms, that pertains to any existing provider-beneficiary relationships for each member of the family enrolled.
b) In providing MCO selection assistance, the contractor shall review and aid the beneficiary in choosing an MCO network, in which health care providers participate, that will best meet the needs of each member of the beneficiary’s family who are enrolled in Medicaid and NJ FamilyCare.
3.6.3.4 MAINTENANCE OF MCO PROVIDER DIRECTORIES
The contractor shall be the resource in developing and maintaining an electronic, automated directory of participating providers. At a minimum, this directory shall include, for each participating MCO:
• Primary Care Providers
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• Specialists • Hospitals • Ancillary Providers
a) The contractor shall use this directory as the source for assisting Medicaid and NJ FamilyCare clients on providers participating in each MCO’s network. b) The contractor shall implement a system, and ensure the capability for receiving updated provider network information electronically using provider network specifications consistent with the file layouts for the database established by DMAHS. .
3.6.3.5 MANAGED CARE APPLICATION REVIEW
The contractor shall process all completed Plan Selection Forms received, either via mail, fax or other electronic transmission within two (2) business days of receipt.
a) The contractor shall:
• review forms for completeness • capture and data enter of all required information • process all completed forms to enrollment • verify enrollment data transmissions have been updated to the OIT eligibility system
3..6.3.6 MCO ENROLLMENT NOTIFICATION
The contractor shall develop and implement, by the contract operational start date, a process to notify and update all participating MCOs of their specific managed care enrollments in accordance with DMAHS approved timelines and specifications.
a) The contractor shall, dependent upon the capability of the specific MCO, provide all managed care enrollment notifications either through electronic transmission or the hard-copy transfer of files.
b) The contractor will forward copies of all Plan Selection Forms received, specific to that MCO, in accordance with DMAHS approved timelines and specifications. c) The contractor shall maintain, on file, copies of all signed Plan Selection Forms received and a signed receipt for the copies given each MCO.
3.6.3.7 PLAN SELECTION FORM FILE
The contractor shall systemically maintain a separate file for all processed and unprocessed plan selection forms.
3.6.3.8 MCO SELECTION ASSISTANCE
The contractor shall assist all Medicaid and NJ FamilyCare beneficiaries in selecting an MCO that best meets their health care needs and is in the best interests of the beneficiary.
a) Any assistance provided by the contractor, to the beneficiary, shall be given in an unbiased manner that neither discriminates, creates a bias nor favors any specific MCO.
b) The contractor shall ensure that, in securing any beneficiary information, it develops a process that obtains information the beneficiary related concerning existing provider-beneficiary relationships. This shall include, on the enrollment forms, the same information for each member of the family/household to be enrolled.
c) The contractor shall provide assistance, as necessary or required, to all beneficiaries in the actual completion of the MCO enrollment or Plan Selection Form.
3.6.3.9 MANAGED CARE PLAN SELECTION FORM PROCESSING
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The contractor shall process all completed Plan Selection Forms received either via mail or directly from Medicaid eligibles within two (2) business days of receipt. It is expected that one day will be required to (a) review forms for completeness and (b) forward (via courier service, if necessary) to a centralized data entry site. Two (2) work days are allowed for data entry and verification. In the case of potential exemptions, it is expected that 95% will be validated and processed within thirty (30) calendar days, 97% will be validated and processed within sixty (60) calendar days and 99% will be validated and processed within ninety (90) calendar days.
3.6.3.10 MANAGED CARE FORM DISCREPANCIES
The contractor shall notify the State Contract Manager of any discrepancies that may be discovered during the enrollment process. As examples, discrepancies or inconsistencies may include date-of-birth, name, sex or other forms of information as may be discovered.
3.6.3.11 MCO SELECTION
The State recognizes a beneficiary as being enrolled in an MCO when the beneficiary MCO choice is on the OIT eligibility file.
a) The contractor shall complete the enrollment processing and update to the OIT eligibility file within one (1) business day of the completion of the enrollment process.
3.6.3.12 HEALTH COVERAGE OPTIONS
The contractor shall explain other health coverage options that may be available to the beneficiary maintaining objectivity that is unbiased toward any MCO involved in the programs operated under the auspices of DMAHS.
3.6.3.13 INCOMPLETE PLAN SELECTION FORM REVIEW
The contractor shall review any and all forms associated with the enrollment process ensuring all form fields, as established and defined by DMAHS, have been completed and are accurate according to defined DMAHS parameters.
a) For those cases involving missing information, the contractor shall contact the beneficiary, in writing, within two (2) business days, requesting the missing information. If no response is received or incomplete information remains outstanding due from the beneficiary after fifteen (15) calendar days, the contractor shall generate and mail a second follow-up letter again requesting all missing or incomplete information. If within an additional fifteen (15) calendar days (the 30th calendar day from the mailing date of the original missing information notification), neither a response nor the requested information has been received, a letter terminating further action on the Plan Selection Form shall be generated and mailed detailing the reason for ceasing any further action within two (2) business days, in accordance with applicable federal and State statute and/or regulation. For all mandatory populations, the contractor shall ensure that the required notice states that an MCO shall be chosen for the beneficiary for failure to timely submit a complete Plan Selection Form.
b) For New Jersey Care 2000+ and NJ FamilyCare, the contractor shall develop a procedure whereby all mail returned or undeliverable due to bad addresses, shall be identified with attempts made to resolve the cause of the bad address within five (5) business days of the mail’s return to the contractor. The contractor shall document all steps undertaken to resolve any incorrect address including telephone contacts attempted. If after fifteen (15) business days no resolution has been achieved, the contractor shall place the undelivered mail in a pending status to await potential contact by the beneficiary. If after thirty (30) business days no further contact has been made by the beneficiary, no further action shall be taken. The CWAs shall be notified of all NJFC Plan A cases within this category.
c) The contractor shall, weekly, record and report all non processed Plan Selection Forms by name, appropriate case tracking number, date, reason not processed, MCO chosen and any other information as may be pertinent.
3.6.3.14 NON-RESPONDENT CONTACT
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The contractor shall conduct follow-up communication to all non-respondents within the mandatory managed care populations, either via telephone or mail, so as to minimize the need for auto-assignment to a pre-determined MCO.
3.6.3.15 NOTIFICATIONS
The contractor shall, at all times, produce and mail confirmation letters to each enrollee stating the MCO the beneficiary has selected or been assigned to and the effective date of the enrollment.
3.6.4 MANAGED CARE ENROLLMENT TASKS
3.6.4.1 PLAN SELECTION FORM COMPLETION
The contractor shall ensure, in the course of conducting all managed care enrollments, that beneficiary eligibility is not finalized until the Plan Selection Form has been properly completed, received by the contractor and specifies the applicant’s MCO of choice.
3.6.4.2 MEDICAID AND NJ FAMILYCARE PLAN A
Medicaid and NJ FamilyCare Plan A applicants, who have been determined eligible for NJ FamilyCare, shall only become an enrollee upon:
• Their notification to the contractor of their MCO selection. • The contractor updating of the eligibility file through the Batch Update Process.
3.6.4.3 NJ FAMILYCARE PLAN B
NJ FamilyCare Plan B applicants, who have been determined eligible for NJ FamilyCare, shall only become an enrollee upon:
• Their notification to the contractor of their MCO selection. • The contractor updating of the eligibility file through the Batch Update process.
3.6.4.4 NJ FAMILYCARE PLAN B NOTIFICATION
Upon completion of the enrollment process for NJ FamilyCare Plan B beneficiaries, the contractor shall generate an appropriate letter to the beneficiaries advising them of their eligibility and enrollment, containing verification of participation in their selected MCO and other information as may be deemed warranted by DMAHS.
3.6.4.5 NJ FAMILYCARE PLANS C, D AND OTHER NJFC PLANS
NJ FamilyCare Plan C and D applicants, who have been determined eligible for NJ FamilyCare, shall only become an enrollee upon:
• Their selection of an MCO • Their notification to the contractor of their MCO selection • Receipt of the beneficiary’s appropriate premium • The contractor updating of the eligibility file through the Batch Update process
3.6.4.6 NJ FAMILYCARE PLANS C, D AND OTHER NJFC PLANS VERIFICATION LETTERS
Upon completion of the enrollment process for NJ FamilyCare Plans C, D or other NJFC Plan beneficiaries, the contractor shall generate an appropriate letter to the beneficiaries advising them of their eligibility, enrollment, effective date of enrollment and required premium. The letter shall further contain verification of their participation in their selected MCO and other information as may be deemed warranted by DMAHS.
3.6.4.7 BATCH UPDATE TO OIT
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Utilizing a batch update process, the contractor shall daily electronically transmit all NJ FamilyCare enrollments to the Office of Information Technology (OIT) for updating within the eligibility file.
a) Managed care enrollments shall only become effective upon the actual updating to the eligibility file.
3.6.4.8 PLAN SELECTION FORM (PSF) TRANSMISSION
The contractor shall, through use of the Managed Care Enrollment System, electronically transmit all Plan Selection Forms, with updated beneficiary enrollment information, to the participating MCOs on a daily basis.
3.6.4.9 NJ FAMILYCARE NON-PAYMENT OF PREMIUMS
The contractor shall not enroll any NJ FamilyCare cases prior to the receipt of any required or applicable premium.
3.6.4.10 NJ FAMILYCARE MCO DESIGNATION
The contractor shall treat all NJ FamilyCare non Plan A Selection Forms submitted without designation of an MCO as a missing information case incapable of being processed.
3.6.4.11 NJ FAMILYCARE PENDING STATUS
The contractor shall place all NJ FamilyCare cases that have Plan Selection Forms without either MCO selection or premium submission in pending status for a period to be determined by the State.
3.6.4.12 MCO TRANSFER ASSISTANCE
The contractor shall provide, upon request, any needed assistance to eligible applicants or enrollees on the potential disenrollment and/or transfer from and to participating MCOs. This shall include the explanation of the differences between the various plans and delivery systems offered by the participating MCOs in a manner that is unbiased toward any specific MCO.
a) The contractor shall, as appropriate, explain other health care coverage options or choices that may be available to the applicant or enrollee in a manner that is unbiased as to the choice that is being offered.
b) The contractor shall advise and encourage all voluntary enrollees to seek or remain covered.
3.6.4.13 DIS-ENROLLMENT AND RE-ENROLLMENT
The contractor shall maintain awareness, and develop and implement appropriate processes for activities associated with disenrollments and re-enrollments of Medicaid and NJ FamilyCare beneficiaries resulting from:
• the beneficiary’s desire to change his/her MCO selection during the first ninety (90) days of
enrollment (as allowed under federal regulations); • the beneficiary’s desire to change his/her MCO selection after twelve (12) months of enrollment
(the end of the lock-in period under federal regulation); • the beneficiary’s moving from one county to another county; • the beneficiary’s having been disenrolled for good cause at any time, or at any time for the ABD
population; and • the beneficiary’s having become exempt from participating in the Medicaid Managed Care
Program (Medicaid only).
3.6.4.14 FORM COMPLETION
The contractor shall provide all beneficiaries assistance, as needed or required, in completing any transfer, disenrollment or re-enrollment form(s).
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a) The contractor shall furnish all beneficiaries a copy of their transfer, disenrollment or re-enrollment form(s).
3.6.4.15 MCO NOTIFICATION
The contractor shall advise all beneficiaries requesting transfer, disenrollment or re-enrollment in an MCO that they need to notify the MCO under which they are presently enrolled of their reasons for requesting the change.
3.6.4.16 TRANSFER, DISENROLLMENT AND RE-ENROLLMENT FILES
The contractor shall, in accordance with the overall case tracking and management process, maintain and update a daily file/log of all transfers, disenrollments and re-enrollment requests. This file/log shall record these actions according to case name, tracking number, Medicaid#, NJFC ID#, current MCO, new MCO choice and all associated critical dates (i.e., date of request, date enrollment processed, effective date etc.).
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3.6.4.17 BATCH UPDATE PROCESS Utilizing a batch update process, the contractor shall on a daily basis electronically transmit all Medicaid and NJ FamilyCare transfers, disenrollments and re-enrollments to OIT for updating within the eligibility file.
3.6.4.18 MCO NOTIFICATION
The contractor shall, within two (2) working days of receipt of all completed and processed transfer, disenrollment and re-enrollment forms, notify and submit to each MCO impacted, copies of the forms with the resulting effect the action has on an MCO’s membership.
a) The contractor shall maintain a file of signed receipts attesting to the transmission for all copies given an MCO.
b) The contractor shall maintain a file of all processed forms.
3.6.5 EXEMPTIONS FROM MANAGED CARE ENROLLMENT
3.6.5.1 AFFECTED POPULATIONS
The contractor shall be aware that exemptions from managed care shall apply only to Medicaid Beneficiaries or as otherwise directed by the DMAHS.
3.6.5.2 EXEMPTION RECEIPT
The contractor, upon receipt of an applicant’s exemption request, shall scan, record and appropriately assign an identification number, through use of the tracking system, to the exemption form and documentation.
3.6.5.3 MAILING OF EXEMPTIONS
The contractor shall mail to the applicant all exemption request forms, within two (2) business days of the initial request.
3.6.5.4 EXEMPTION TRACKING
The contractor shall record the mailing of all exemption request forms through use of the tracking system.
a) Upon receipt of all exemption request forms, the contractor shall record the receipt of all exemption form packets through use of the tracking system.
3.6.5.5 EXEMPTION INFORMATION
The contractor shall conduct all research necessary for determining the completeness and accuracy of information on exemption requests, within thirty (30) business days of receipt of the forms and required documentation.
a) The contractor shall place all applicants awaiting a determination of their exemption request into "pending exempt" status on the eligibility file.
b) The contractor shall also record the “pending exempt” status of all applicants within the tracking system.
3.6.5.6 EXEMPTION APPROVAL / DENIAL
Within thirty (30) days of receipt of any completed exemption request packet, the contractor shall make a recommendation as to approval or denial and forward the packet, with a transmittal sheet, to the appropriate Medical Assistance Customer Center (MACC). This is to be recorded in the tracking system.
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3.6.5.7 EXEMPTION DOCUMENTATION The contractor shall document all contacts with the applicant, their provider(s), or any other required party or authority, in the appropriate case record and on the tracking system.
3.6.5.8 MACC EXEMPTION REVIEW
MACC staff will review all cases for final determination and disposition. All final dispositions are recorded on the transmittal form and faxed to the contractor who shall make the appropriate entry in the case tracking system.
3.6.5.9 EXEMPTION NOTIFICATION
The contractor, upon receipt of an exemption disposition from a MACC, will complete and mail, within two (2) business days, an appropriate letter to the applicant notifying him/her of the decision.
a) The contractor shall complete all required data entry to OIT and the tracking system within the same two (2) business day period.
3.6.5.10 EXEMPTION PROCESSING STANDARDS
The contractor shall implement the overall exemption process in such a manner as to ensure that:
Ninety-five percent (95%) of all exemption requests shall be validated and processed within thirty (30) calendar days of receipt.
3.6.5.11 EXEMPTION ADDITIONS / REVISIONS
All additions and revisions added to any database shall be compatible with the DMAHS database.
a) The contractor shall electronically prepare, in a format acceptable to the State, the transmission of exemption information to the Office of Customer Service for inclusion to its database by the fifth business day of each month. This is used for reconciliation purposes.
3.6.6 PREMIUM ASSIGNMENT AND COLLECTION FOR NJ FAMILYCARE
3.6.6.1 ASSIGNMENT OF PREMIUMS
The contractor shall develop and implement a process to assign the appropriate, related premium contribution required for appropriate NJ FamilyCare beneficiaries.
3.6.6.2 PREMIUM NOTICE
The contractor shall generate an appropriate bill for required premium contributions due from all appropriate NJ FamilyCare beneficiaries at least thirty (30) business days prior to the date that the contribution is due, performing this function on a monthly basis.
3.6.6.3 PREMIUM FILE
The contractor shall produce a billing mail file that correctly identifies, at a minimum, beneficiaries and the amount of remittance, payment due date, month for which the remittance is to be applied and the total remittance of the beneficiary/enrollee. .
3.6.6.4 CHECK/MONEY ORDER RECEIPT
The contractor shall develop and implement a process to receive all beneficiary premium contributions either by check, money order or funds transfer.
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3.6.6.5 CREDIT CARDS The contractor shall develop and implement a process and capability to accept the remittance of premiums through the use of credit cards, including the receipt of credit card information communicated over the telephone.
3.6.6.6 PREMIUM COLLECTION
The contractor shall develop, implement and administer a process for recording all NJ FamilyCare beneficiaries’ premium contribution remittances due and payable on a monthly basis.
3.6.6.7 PREMIUM REFUND
The contractor shall develop and implement a process for the prompt refund of any overpayment within five (5) business days of discovery according to established business rules.
a) In the case of a refund as identified above, the contractor shall provide instructions to the beneficiary on how coverage may be continued or how the beneficiary may re-apply for managed care enrollment.
3.6.6.8 RECEIPT OF PREMIUM CONTRIBUTION
The contractor shall develop, implement and administer a process whereby all premium contribution remittances due and payable are received in accordance with timeframes and dates established and set by DMAHS.
3.6.6.9 PREMIUM CONTRIBUTIONS NOT RECEIVED
For all premium contributions due, but not received, the contractor shall generate beneficiary notices in accordance with timelines, dates and procedures as established and directed by the State.
3.6.6.10 LOCK-BOX
The contractor shall implement an appropriate “lock-box” banking operation for the acceptance, security and transfer of beneficiary premium contributions received.
a) The contractor shall guarantee that any subcontractor charged with “Lock-Box” operations transfers all mail, notes or other correspondence received to the contractor for immediate action by appropriate contractor personnel.
3.6.7 NJ FAMILYCARE RETENTION PROCESS
3.6.7.1 RETENTION INTENT
The contractor shall create a Retention Unit and process for the NJ FamilyCare Program, the purpose of which is to provide outreach to establish communication with NJ FamilyCare beneficiaries and families so as to maintain levels of enrollment, or retention, within the program.
3.6.7.2 RETENTION PERSONNEL
The contractor shall assign FTEs sufficient in number, and dedicated to outreach either through telephone calls, correspondence, home visits or other means, beneficiaries who have been non-responsive to prior contact by the program concerning their renewal application.
a) The contractor shall determine the effectiveness of its outreach efforts by taking appropriate samples from the population through acceptable statistical methods in order to verify the success of its outreach efforts.
3.6.7.3 TELEPHONE SURVEY
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The contractor shall conduct a telephone survey for those NJ FamilyCare beneficiaries who have completed six months of enrollment within the program for the purpose of assessing their overall consumer satisfaction with NJ FamilyCare.
3.6.7.4 RETENTION PROGRAM DATA COLLECTION
The contractor shall gather, compile and report data and information associated with all surveys and outreach efforts conducted on behalf of the NJ FamilyCare retention process.
3.6.7.5 RETENTION PROGRAM REPORTING
The contractor shall design, generate and distribute reports, based upon all data and information collected, that are needed to measure the effectiveness and administer the NJ FamilyCare retention process.
a) The contractor shall construct, generate and submit reports containing data and information as required or directed by the State.
3.6.7.6 DISENROLLMENT SURVEY
The contractor shall generate a written survey, to include a postage- paid, self-addressed return envelope, to all NJ FamilyCare beneficiaries for the purpose of assessing their overall satisfaction with the NJ FamilyCare Program. This survey shall be sent within fourteen (14) days of the date of their disenrollment from the program.
3.7 PSP
3.7.1 IDENTIFICATION OF OTHER INSURANCE
The contractor shall identify, through a review of a beneficiary’s submitted information, occurrences where the applicant has indicated access to other health insurance, employer-sponsored insurance or employment information indicative of the possibility for other insurance.
3.7.1.1 The contractor shall additionally conduct a review for other insurance at the time of all renewals or at the time of any change of status in an enrollee’s circumstances.
3.7.1.2 The contractor’s review for additional insurance shall also include all other members of the household.
3.7.2 NOTIFICATION TO STATE
The contractor shall advise the State, through direct contact with the PSP Office, of all cases involving the potential of other insurance on a weekly basis in a format to be defined by the State.
3.7.3 PSP INFORMATION
The contractor shall, when available, provide the following information for all cases forwarded to the PSP Office:
• Beneficiary’s name, address and telephone number • NJ FamilyCare ID number / SSN # • The name of the other insurance and ID number • Household members covered under the policy • Employer name, address and telephone number • Other information that may be deemed necessary or relevant
This information shall be inclusive for all members of the household including non-eligible adult parent/caregivers.
3.7.4 PSP ELIGIBILITY SEGMENT
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3.7.4.1 The contractor shall perform all enrollments and disenrollments, and other file maintenance activities to support program participation on PSP cases.
3.7.4.2 The contractor shall provide a monthly report of all such open eligibility segments of PSP cases showing active and terminated cases. The report shall show the year-to-date status of all PSP cases.
3.7.5 DIS-ENROLLED PSP CASES
The contractor shall develop and implement procedures to coordinate and expedite the selection of a managed care plan for cases disenrolled from the PSP in an expedited fashion. All disenrolled PSP cases will be fast-tracked through the managed care plan selection process within thirty (30) business days of PSP termination.
3.7.5.1 The contractor shall record and submit reports to the State verifying all transactions and activities associated with the PSP disenrollment process on a weekly basis.
3.7.6 PREMIUM SUPPRESSION
The contractor shall develop and implement a process whereby the collection of monthly premiums would be suppressed.
3.7.7 NON-RECEIPT OF PREMIUM
The contractor shall develop and implement a procedure whereby PSP cases will not be terminated for non-receipt of the monthly premium contribution.
3.7.8 PSP PROGRAM CODING
The PSP special program code must be recognized on the contractor’s eligibility file.
3.7.9 PSP ELIGIBILITY CARDS
The contractor shall produce and disseminate NJ FamilyCare replacement eligibility cards for PSP cases.
3.7.10 PSP INQUIRY CAPABILITY
The contractor shall provide on-line inquiry access to the contractor’s NJ FamilyCare database for PSP office staff.
3.7.10.1 The contractor shall provide ten (10) inquiry access lines.
3.7.10.2 Inquiry access lines must be available through the State staff’s personal computers (PCs),
3.7.11 PSP CASE TERMINATION
The contractor shall process monthly transactions and terminations for all NJ FamilyCare cases that fail to cooperate with PSP requirements.
3.7.11.1 The contractor shall develop and institute all required program logic and procedures necessary to terminate adult household members while assuring the continued eligibility for all enrolled children within the household.
3.7.11.2 The contractor shall track all child only cases within the PSP program, until the case is up for renewal or redetermination.
3.7.11.3 The contractor shall, at the time of all case renewals, collect all employment and insurance information and transmit such information to the State in both electronic and hardcopy format.
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3.7.11.4 In situations where the beneficiary fails to cooperate regarding PSP program requirements, the contractor shall develop and implement a process to terminate remaining eligible children on the case at the time of the renewal.
3.7.11.5 At all times, the contractor shall notify the State of all actions initiated by the contractor involving the termination of a PSP case on a weekly basis, the medium of which is to be determined by the State (disk, paper, etc.).
3.7.11.6 The contractor shall electronically process all terminations and provide the State an acknowledgement and confirmation of all termination transactions on a weekly cycle.
3.7.12 PSP TRAINING
The contractor shall develop and implement a training program, subject to State approval, for all appropriate State and contractor personnel in order to ensure comprehensive employee knowledge and proficiency with the PSP.
3.7.13 PSP PROGRAM OUTREACH
The contractor shall provide complete information to all interested parties and beneficiaries on PSP at the time of any and all outreach and education efforts associated with the NJ FamilyCare program and report the contacts and number of beneficiaries contacted on each encounter.
3.7.14 PSP EDUCATIONAL EFFORTS
The contractor shall distribute and mail, subject to State approval, educational materials associated with PSP.
3.7.15 PSP EXPENDITURE TRACKING
The contractor shall manage and track the cost-sharing expenditures paid by individuals.
3.7.16 PSP OVERCHARGES
The contractor shall refund any inappropriate or overcharged premium assessment(s) to the beneficiary once he/she is enrolled in PSP within ten (10) business days of discovery.
3.7.17 PROGRAM INQUIRIES
The contractor shall attempt to respond to all beneficiary or provider questions and inquiries, through all modalities (telephone, letter, fax etc.) on the same day on which they are received.
3.7.18 CONTRACTOR LIAISON
The contractor shall designate, subject to State approval, a member of its management staff to act as liaison to the State’s PSP Office.
3.7.19 PSP REPORTING
The contractor shall develop, produce and submit, subject to State approval, summary activity reports of PSP case activity so as to ensure complete reconciliation with all PSP records.
3.7.19.1 The contractor’s submission of all PSP required reports shall be transmitted in accordance with a schedule to be established by the State’s PSP Office.
3.7.20 PSP MEETINGS
The contractor shall routinely schedule and hold, subject to State approval, meetings with the State’s PSP Office for the purpose of discussing PSP operations.
3.7.21 PSP FILE ACCESS
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The contractor shall guarantee immediate access to any and all PSP records, files and cases, by State staff, at any and all times as requested by the State.
3.7.22 PSP STAFFING
In accordance with the overall staffing requirements of the contract, the contractor shall ensure the assignment and commitment to provide staffing of the PSP so as to guarantee the meeting of all performance standards associated with its operation(s).
3.8 CONSUMER ASSESSMENT OF HEALTH PLANS SURVEY (CAHPS)
3.8.1 CAHPS SATISFACTION SURVEY
The contractor shall implement an annual CAHPS member satisfaction survey which addresses enrollees’ experiences with their chosen or assigned MCO. The survey shall be issued annually to a statistically valid, random sample of all enrollees (per each contracting MCO). Preliminary work on the survey should begin no later than January 2, 2005 for the survey covering CY 2004, and no later than January 2, 2006 for the survey covering CY 2005. The survey should be undertaken no later than February 1, 2005 for the survey covering CY 2004 and February 1, 2006 for the survey covering CY 2005. The above timeline may be altered in accordance with the needs of the State.
3.8.1.1 The contractor shall determine the appropriate sampling methodology including the number of clients to be surveyed. DMAHS shall have final approval over the survey methodology. DMAHS will ensure that the contractor has access to client names and addresses.
3.8.1.2 The contractor shall ensure that the survey incorporates the following issues, at a minimum: overall satisfaction with MCO; overall satisfaction with primary care physician; knowledge of beneficiary rights and responsibilities (including whether they received a written copy of the MCO’s policies and procedures upon enrollment); knowledge of grievance procedures available to beneficiaries, whether they have had occasion to use such procedures and whether the outcome was satisfactory; accessibility of services, including the point of access to their PCP, specialists, ancillary services, waiting times for appointments, travel times, ease in procedure for referrals and for changing their PCP; perceived problems in quality of care rendered; perceptions of their health status, both before and after enrollment; changes in health behavior as a result of health education; what they like or dislike about their MCO relative to their experiences under a fee-for-service delivery system; what factors were involved in their decision to choose their MCO over other available MCOs; whether they receive reminders for check-ups or return appointments from their PCP or MCO and whether such reminders are complied with (if not, why); language or cultural problems; and suggestions or concerns they may have. The final survey form must be approved by the State Contract Manager.
3.8.1.3 Distribution of the survey shall be direct mail, telephone interview or face-to-face interview, or other method approved by the State Contract Manager.
3.8.1.4 The contractor should be prepared to instruct enrollees on how to complete the survey to ensure the most complete and accurate responses possible.
3.8.1.5 The contractor shall complete reports on: (1) the statistical analysis of the survey results using commonly accepted compilation and cross-tabulation methodologies, (2) technical analysis; (3) biweekly progress reports to DMAHS throughout the survey process, (4) HMO report card for client use in selecting HMOs. The results should be reported on a total basis, an MCO level and all other meaningful bases, with comparisons to other variables. Reports are due no later than six (6) months after the start of the survey process.
3.9 GENRAL OPERATING PROCEDURES AND REQUIREMENTS
3.9.1 GENERAL PROCEDURES AND REQUIREMENTS
The contractor shall complete and comply with the following procedures and requirements:
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3.9.1.1 Utilize the OIT system (or any other eligibility systems used by the State) to verify necessary client eligibility information, client MCO choices, exemption/exclusion reasons, effective dates and other critical information as required to properly enroll clients in managed care plans.
a) The contractor shall conduct a reconciliation of MCO membership, at minimum on a monthly basis, to ensure the contractor’s data files match those of OIT.
b) Cooperate with the NJ DMAHS State Contract Manager in the retrieval of information or resolution of problems.
c) Submit to NJ DMAHS for approval all literature, forms, policies and procedures formulated to carry out all contractor activities.
d) Obtain written approval from each participating MCO and DMAHS for any new marketing materials prepared by the contractor which describe the MCOs.
e) Submit to DMAHS, for approval, all forms, letters, logs, or other materials formulated to carry out contractor activities. Additionally, all schedules must be submitted to the NJ DMAHS for approval before implementation of any activities.
f) Design and maintain an inquiry/complaint log and inquiry/complaint forms to record all verbal or written inquiries/complaints received against contractor operations or personnel, and maintain records of all contacts, correspondence, and action taken to resolve such inquiries/complaints. All records must be available for DMAHS review.
g) Maintain an adequate supply of and distribute all materials furnished by participating MCOs (including, but not limited to, informational brochures and provider listings).
h) Answer general inquiries from Medicaid and NJ FamilyCare clients regarding the mandatory enrollment program and direct specific inquiries about particular MCOs to the MCOs for response. Be prepared to answer questions regarding languages spoken, special services as they pertain to specific MCOs participating in the managed care program.
i) Administer the exclusions and exemptions listed in Exhibit 5, and as may be amended by the DMAHS.
j) Cooperate with NJ DMAHS liaison in revising these procedures described herein, as necessary.
k) Develop and present a one-half day training/education session related to managed care and Health Benefits Coordinator implementation/operating issues. Such sessions will be offered at three sites statewide (North, Central and South), at least two times per year. The audience for these sessions would include County Welfare Agency staff, Medicaid Assistance Customer Center staff, staff of other governmental entities, provider groups, advocacy groups and community organizations.
l) Maintain confidentiality of provider, recipient and any other proprietary information. All documents thus considered confidential shall be discarded in a manner consistent with maintaining this confidentiality.
m) Alert the NJ DMAHS liaison in writing to problems and trends as they arise.
n) The contractor shall, at all times, adhere to and follow the directives and instructions of the State regarding the development and implementation of all processes, procedures, tasks, timelines and deliverables as they apply to the operation of those programs specified within the RFP/Contract.
3.10 PROGRAM QUALITY ASSURANCE REQUIREMENTS
3.10.1 QUALITY ASSURANCE PROCESS
The contractor shall develop and implement a dedicated Quality Assurance (QA) process designed to assess operations, identify problems and coordinate efforts for resolution of all errors, mistakes or difficulties associated with operation of the programs. The QA process shall encompass, but not be limited in scope to, the following areas:
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• Mail Room Operations • Call Center Operations • Information Systems • Eligibility Screening • Data Entry • Eligibility Processing • Managed Care Enrollment and Exemptions • Fiscal Operations • Training • Mail House Activities • Human Resources • Subcontractors • Printing • Notices, Information and Educational Materials • Translation Services
3.10.1.1 QUALITY ASSURANCE APPROVAL
The contractor shall submit, annually, a revised and updated QA plan, summarizing all goals and initiatives for the upcoming year to the State for approval.
a) The contractor shall submit QA plan upon implementation (contractual start date) of the contract.
3.10.2 QUALITY ASSURANCE POLICY AND PROCEDURE MANUAL
The contractor shall annually, or as required or directed by the State, submit, for approval by the State, a Quality Assurance Policy and Procedure Manual with all necessary updates.
3.10.3 QUALITY ASSURANCE POLICIES AND PROCEDURES
The contractor shall design and implement policies and procedures for:
• Monitoring and evaluating all areas specified in the QA plan • Gathering and trending data discovered as a result of the QA process • Notifying management and State of needed corrective actions, the corrective action plan, and
ongoing progress to correct until fully resolved • Assuring the allocation of personnel necessary for contract operation • Overseeing and assessing all human resource recruitment • Determining any required population samples and data measures according to universally accepted
statistical standards • The timely review of all cases, managed care enrollments, disenrollments, renewals, missing
information cases, mailings, premium invoices, premium refunds or other subjects common to the operation of the programs.
3.10.4 QUALITY ASSURANCE REPORTING
The contractor shall design, prepare and submit quarterly reports on QA activities. The QA report shall address, but not be limited to, the following QA initiatives and monitoring activities:
• Problem areas identified • Compliance and Non Compliance of Contract requirements • Contractual policies and procedures • Corrective Actions implemented • Corrective Actions to be implemented with time frames. • Progress on correcting specific problems • Resolution of all actual problems
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3.10.4.1 The contractor shall include all relative aggregate and trended data collected during the QA and monitoring process in the QA quarterly report.
3.10.4.2 The contractor shall, after the first and in all subsequent quarterly QA reports, compare and indicate data collected to that of the prior month’s report.
3.10.5 QUALITY CONTROL REVIEW
The contractor shall be subject to quality control review monitoring by the State.
3.11 CONTRACT TRAINING REQUIREMENTS 3.11.1 HUMAN RESOURCE DEVELOPMENT AND TRAINING
3.11.1.1 The contractor shall provide and maintain the necessary training space, equipment and supplies, (e.g., lecture/meeting rooms, computer training rooms, personal computer per trainee, operator headphones per trainee, manual binders, audio/visual equipment, etc.) required for the effective and efficient operation of its training programs.
3.11.1.2 The contractor’s organization and management of the training unit shall be subject to State approval prior to contract implementation and at anytime a change in staffing, policy or procedures is anticipated or occurs.
3.11.2 SELECTION AND DEVELOPING PROFESSIONAL TRAINING STAFF
3.11.2.1 The Training Manager/supervisor must possess a Bachelor’s degree from an accredited college or university. The supervisor must also have a minimum of three (3) years professional experience in the field of human resource development and training.
3.11.2.2 Trainers must possess a Certificate of Training or Human Resource Development from an accredited college, university or training institute.
3.112.3 As approved by the State on a case by case basis, the training manager and supervisor applicants who do not possess the required education may substitute additional experience as indicated on a year-for-year basis with thirty (30) semester hour credits being equal to one (1) year of experience.
3.11.2.4 All job vacancy announcements, applicant resumes and hiring of training staff is subject to State approval prior to implementation of any activities.
3.11.3 TECHNICAL AND PROGRAMMATIC TRAINING
The contractor shall submit to the State for prior approval a complete training plan, curriculum, tools, materials and any other items to be used in the design, development, delivery and evaluation of the human resource development training program 60 days prior to the Operational Start Date.
3.11.3.1 The Instructional Design (ID) of the contractor’s technical and programmatic training modules shall be created in accordance with the Instructional Systems Design (ISD) and include all basic elements of the ADDIE Model (i.e., analysis, design, development, implementation and evaluation).
3.11.3.2 All new hires to the contractor’s staff shall participate in and successfully complete a comprehensive initial training regimen consisting of both technical and programmatic training modules before assuming professional job responsibilities.
Training courses for the appropriate personnel shall include, but not be limited to, the following subjects:
• New Jersey Care 2000+ • NJ FamilyCare • PSP • Customer Service • Roles of Program Stakeholders
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• Quality Performance • Supervisory Skills • Principles of Managed Care • Effective Communication Skills • HBC Operations to include
o Call Center o Mail Room o NJFC Application and Eligibility Process o Managed Care Enrollment Process o Exemptions and Exclusions from Managed Care Enrollment o Premium Assignment and Collection for NJ FamilyCare o Renewal and Redetermination Process o NJ FamilyCare Retention Process o Quality Assurance Process o PSP o HBC Management Information Systems (MIS) o Program Integrity, Security, Fraud and Abuse o Record Management o Confidentiality and HIPPA Requirements
3.11.3.3 The contractor shall provide ongoing refresher and remedial training as required by program/operational changes and updates and identified employee performance discrepancies.
3.11.3.4 Training staff shall solicit multi-level employee input in the establishment and maintenance of the training program.
3.11.3.5 The transfer of the appropriate skills and knowledge to contractor employees through the administration of the training program shall reflect a consistent modeling and corroboration of the importance of quality in all areas of contractor operations.
3.11.3.6 All aspects of the contractor’s ID shall be subject to initial and ongoing approval by the State.
3.11.4 MAINTENANCE OF TRAINING RECORDS AND DATA
The contractor shall use a commercially available computerized Training and Development Information System (TDIS) to establish and maintain training records and data.
3.11.4.1 At minimum, the TDIS shall have the capability of producing module descriptions, training session announcements, training schedules, document training attendance, document training evaluation, assess employee performance, define training tasks, maintain HRD&T program accuracy and integrity, align training strategy with State goals, ensure organization-wide standards, as well as maintain a variety of other training and development records.
3.11.4.2 The system shall be used to aid the contractor to define the required employee competencies, assess performance, present options on how to close performance gaps, and document training as delivered.
3.11.4.3 The contractor’s selection, purchase and use of a TDIS shall be subject to the prior approval of the State.
3.11.5 PERIODIC REPORTS
The contractor shall produce periodic reports of training needs assessment, training operations, employee/organization performance and improvement, HRD&T program planning, development, delivery and evaluation, and other training related matters as determined by the State.
3.11.5.1 The contractor shall be required to provide these reports to the State regularly on a monthly basis or within five (5) business days of the State’s request.
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3.11.5.2 Training session descriptions, session announcements, and training schedules shall be provided to the State at least one month in advance of the date of the training event.
3.11.6 STATE MONITORING
The contractor shall cooperate with and at all times allow State staff to monitor all aspects of the contractor’s training programs.
3.11.6.1 The contractor shall at all times cooperate fully with State monitoring staff in their performance of monitoring functions.
3.11.6.2 The contractor shall cooperate with State monitoring staff who shall be allowed to conduct unannounced audits of training program presentations.
3.11.6.3 State monitoring staff shall meet weekly with the contractor’s training managers, supervisors and trainers to discuss training matters.
3.11.7 TRAINING PRODUCTION REQUIREMENT
The contractor shall at all times ensure that both personnel and time allocated for training shall neither impede nor otherwise cause a reduction in either contractual performance or production standards. At no time shall personnel in training be considered production staff nor shall production or performance standards be reduced due to contract training requirements.
3.11.8 TRAINING PRODUCTION MONITORING
The contractor shall at all times ensure that personnel being trained in either live or actual production functions, (i.e., assuming live telephone calls, performing actual client service etc..) shall be continuously and correctly monitored so as to guarantee adherence to correct processes, procedures and/or overall contract requirements.
3.12 CONTRACT INTEGRITY AND SECURITY
3.12.1 PROGRAM INTEGRITY REQUIREMENTS 3.12.1.1 INTEGRITY AND SECURITY COORDINATOR
The contractor shall designate either the Project Director, Deputy Project Director, as the contractor representative responsible for all contractual and operational program security, integrity and internal controls.
a) Meetings
The contractor shall schedule and hold monthly meetings with the Division of Medical Assistance and Health Service’s Office of Program Integrity Administration and Office of Contractor Management for the purpose of discussing any issue related to the prevention or management control of program integrity, fraud and abuse, contract violations, operational control and internal controls.
b) Employee Status
The contractor shall recognize that, regarding all contract requirements related to program integrity, these conditions apply equally to both regular, part-time (per-diem) and temporary employees.
c) Application Review Unit
The contractor shall establish or designate a specific unit to review applications submitted for any DMAHS administered program where the address indicated by the potential program applicant is the same as that of any contractor employee, employee family member, employee relative, employee friend or acquaintance or other individuals who may be living at the same address or where there is any other reason to believe that an applicant for benefits falls within any of these categories.
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The application review unit will institute steps, including but not limited to, the separation of functions to ensure that the review of the applications / cases indicated above are conducted by employees in such a manner as to ensure the integrity of the review process.
d) Integrity Notification
The contractor shall develop and distribute, subject to State approval, routine notifications to all employees of procedures to be followed in situations where they, as the employee, may either know or be familiar with a potential program applicant. This should further include a listing of possible disciplinary consequences for any infraction of this policy, up to and including termination.
e) Integrity Referral
The contractor shall notify all employees of the procedures to be followed in cases where they may either know or be familiar with a potential program applicant. This should include immediate referral to an appropriate supervisor.
f) Disclosure
The contractor shall institute and distribute, both at time of hiring and on an annual basis, a disclosure form to be completed by all employees instructing them of possible conflict of interest situations and their responsibility to notify the contractor of such situations. This should also include a listing of possible disciplinary consequences for any infraction of this policy, up to and including termination.
g) Employee Match
The contractor shall conduct quarterly system generated searches through the enrollment files for potential information matches between program beneficiaries and contractor employees. One match shall be made using the beneficiary’s social security number, the other match shall utilize the beneficiary’s home address.
h) Integrity Adherence
The contractor shall ensure that there is comprehensive adherence to all program integrity requirements, of this contract, for any employees identified as eligible Medicaid or NJ FamilyCare beneficiaries. In the case of any identified or potential violation, immediate and appropriate notifications shall be made to the BPI, and any other agencies as may be required by law, .
If a contractor employee is identified as a program beneficiary, the contractor shall investigate to determine that all of the provisions contained in this section on Program Integrity Requirements have been complied with. If a contract violation is identified, in addition to any other agencies that must be notified, the contractor must refer the matter to the Bureau of Program Integrity within the DMAHS’ Office of Program Integrity Administration within five business days of discovery.
i) Public Records Verification
The contractor shall utilize, either through purchase or other arrangement, access to commercially available public records data bases in order to identify income-generating assets and other potential eligibility problems.
• The contractor, at minimum and as permitted by law, shall utilize the above indicated public
records data base search on all contractor employees receiving State program benefits. • The contractor shall utilize, as permitted by law, the above indicated public records data base
search on a random, sampling structured basis for all non-employee applicants and beneficiaries.
k) Social Security Records
The contractor shall utilize, either through purchase or other arrangement, access to the Social Security Death Index in order to conduct, on a quarterly basis, a search for matches between the contents of this data base and the enrollment file of program applicant or beneficiaries and contractor employees. If a
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match with a deceased individual’s Social Security Records is identified, the contractor must refer the matter to the Bureau of Program Integrity within five (5) business days of discovery.
l) Independent External Audit
The contractor shall, for each State fiscal year and due the first day of the following fiscal year, secure the services of a forensic auditor to conduct an examination of the contractor’s policies, procedures and performance as it relates to program integrity and security.
• The contractor shall coordinate all activities related to the forensic audit with the DMAHS’ Office of
Program Integrity Administration. • The contractor shall submit a copy of the annual forensic audit to the State for review and
approval. Copies of all supporting workpapers must also be submitted to the State upon request.
m) Systems Security Audit
The contractor shall conduct an annual security audit of all information systems and data bases so as to guarantee no breaches in systems security such as password theft, failure of system edits, etc.
The contractor shall submit a copy of the annual systems audit to the State for review and approval.
n) Compliance Program
The contractor shall establish a corporate compliance program for the purpose of addressing internal controls, program integrity, fraud and abuse issues and any other operational problems or vulnerabilities that may be identified.
The contractor shall ensure that the compliance program is consistent with the guidelines promulgated by the Office of the Inspector General of the US Department of Health and Human Services.
n) Background Checks
The contractor shall conduct background checks of all future employees including management staff and all other applicants for employment.
The contractor shall conduct the above indicated background checks on both regular and part-time or temporary employees.
Background checks must include, at a minimum, checks for the following:
• Convictions for any State or federal crimes or offenses, including disorderly persons offenses • Civil or administrative judgments that may adversely affect the employee’s integrity, a professional
license etc. • Financial problems that may lead to criminal activity or corruption • Exclusions by the Office of Inspector General and/or New Jersey Consolidated Disbarment
Report.
o) Integrity Hotline
The contractor shall have available a toll-free, hot line whereby members of the public, contractor employees and others may report evidence of fraud, abuse, violations of internal controls and any ethical violation that will be immediately reported to DMAHS’ Bureau of Program Integrity. Callers should be permitted to remain anonymous if they wish. The contractor shall disclose and disseminate information concerning the availability and public access to this number.
p) System Integrity Controls
The contractor shall ensure that informational security steps are implemented concerning the control, access, change or modification of all system related passwords, employee information, beneficiary information etc.. At a minimum, the contractor’s information security should include edits to (a) prevent the
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contractor’s employees from having the capability to change, update or delete the eligibility file of the employee, the employee’s known family members, relatives, friends or neighbors; and (b) prevent any contractor employee from altering, deleting or changing the history of any program beneficiary. The contractor must also institute a strong back-up policy for computer records and retention that ensures that the contractor’s system captures all historical changes to its program eligibility files.
q) Password Access
The contractor shall institute steps to appropriately limit access to all passwords and logons of all program systems including preventative measures against the sharing of passwords and logons.
r) State Monitoring
The contractor shall at all times guarantee the State access to perform audits, reviews, and announced and unannounced inspections of all operational and program related functions. The contractor must fully cooperate with the State in all such audits, reviews and inspections.
s) Requests
The contractor shall comply with, at all times, any request by the State for records associated with contractor’s computer files or data base(s).
The contractor shall ensure that all requests, as indicated above, are in the format as requested by the State, including a PC-compatible format.
The contractor shall submit all responses, as indicated above within ten (10) business days of the request from the State.
t) Off Hours Supervision
The contractor shall demonstrate to the satisfaction of the DMAHS that it has adequate supervisory staff in the off hours, i.e., evenings and weekends.
u) Law Enforcement Reports
The contractor shall immediately notify and submit to the State any and all reports and/or incident submissions that may be filed with local police, or other law enforcement agencies, as may be required or necessitated. Examples could include, but are not limited to, reports filed for theft of property, trespass at the facility site, disturbances, confrontations etc.
SECTION 3.13 REGULATORY COMPLIANCE SUMMARY
3.13.1 GENERAL COMPLIANCE
In addition to all terms, tasks and/or conditions specified within this RFP/contract, the contractor shall at all times ensure complete compliance with all federal and State statutes and regulations. These shall include, but not be limited, to the following: a) Independence The contractor shall at all times guarantee that it is independent of, and has no relationship with, any MCO and health care provider that provides coverage in the same state within which the contractor is contracted to perform enrollment broker functions. b) Freedom from Conflict of Interest
The contractor shall ensure that any person who is an owner, employee or consultant of the contractor, or subcontractor contracted with the contractor, is free from any conflict of interest and guarantees the individuals indicated meet the following conditions:
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• They have no direct or indirect financial interest in any entity or health care provider that furnishes services in the State of New Jersey;
• They have never been excluded from participation under title XVIII, or XIX, or XXI of the Social Security Act (SSA);
• They have never been debarred by any federal agency; or • They ever have, or are now, subject to civil money penalties under the SSA.
c) CMS Approval The contractor shall at all times recognize that the services specified under this RFP/contract are at all times subject to CMS approval. d) Conflict of Interest Safeguards The contractor shall recognize that activities related to the services specified under this RFP/contract may or shall at all times be subject to conflict-of-interest safeguards or conditions specified by the State of New Jersey.
e) Enrollment Discrimination The contractor shall ensure that all choice counseling, enrollment activities and services specified under this RFP/contract shall be free from any and all discrimination. f) Voluntary Enrollment The contractor shall ensure that, with the exception of mandatory enrollment programs, all enrollment shall be considered voluntary. g) Health Status Discrimination The contractor shall not discriminate against any individual, eligible for enrollment and health benefit coverage, nor conduct counseling and enrollment activities to allow MCO entities to discriminate on the basis of health status or the need for health services. h) General Discrimination The contractor shall not allow any discrimination to occur related to enrollment activities nor use any policy or practice that has the effect of discriminating based on race, color, national origin. i) Contracting Rule Compliance The contractor shall ensure that the services specified under this RFP/contract are in compliance with 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. j) Terminology In addition to terms and definitions used elsewhere within this RFP/contract, the contractor shall recognize that, as specified by the federal government: Enrollee shall mean a Medicaid recipient who is currently enrolled in an MCO, Prepaid Inpatient Health Plan (PIHP), Prepaid Ambulatory Health Plan (PAHP) or Primary Care Case Management (PCCM) in a given managed care program. Potential Enrollee shall mean a Medicaid recipient who is subject to mandatory enrollment or who may voluntarily elect to enroll in a given managed care program, but is not yet an enrollee of a specific MCO.
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Choice Counseling shall mean any activity associated with answering questions or providing information, in an unbiased manner, on available MCO, PIHP or PCCM delivery system options and advising on the factors associated with making that choice. Enrollment Activities shall mean, but not be limited to, distributing, collecting and processing enrollment materials and taking enrollments by phone or in person. Enrollment Broker shall mean an individual or entity that performs choice counseling, enrollment activities or both. Enrollment Services shall mean choice counseling, enrollment activities, or both.
Prevalent language shall mean a non-English language spoken by a significant number or percentage of potential enrollees and enrollees in the State. k) Basic Rules The contractor shall ensure that it provides all enrollment notices, informational materials and instructional materials relating to enrollees and potential enrollees in a manner and format that are easily understood. l) Mechanism The contractor shall recognize its responsibility, as specified under this RFP/contract, to help enrollees and potential enrollees understand the State’s managed care program. m) Language The contractor shall ensure, as instructed by the State, that it possesses a process for identifying non-English speaking enrollees and potential enrollees. n) Language Identification The contractor shall develop, as instructed or directed by the State, a process for identifying and collecting information about race, ethnicity and primary language spoken for each enrollee and provide of this information electronically to all applicable MCOs. o) Accessing Services The contractor shall ensure that all enrollees and potential enrollees are advised of benefits to which they are entitled in a written and prominent manner, including how these benefits may be accessed both under the MCO and in the fee-for-service Medicaid program. p) Language Requirements The contractor shall ensure, as instructed or directed by the State, that all written information be made available in the prevalent, non-English language that may be required. q) Interpretation Services The contractor shall make oral interpretation services available, free of charge, to each enrollee or potential enrollee. r) Interpretation Notification The contractor shall notify all enrollees and potential enrollees that oral interpretation services are available for any language and written information is available in prevalent languages and shall further advise enrollees how to access those services. s) Interpretation Access
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The contractor shall advise all enrollees and potential enrollees how they may access any and all required interpretation services. t) Format Requirements The contractor shall ensure that all written materials are available in easily understandable language and format and that all enrollment notices, and informational and instructional materials are available upon request. u) Alternative Formats The contractor shall ensure that, as requested or necessary, written materials are made available in alternative formats to address those beneficiaries with special needs such as the visual impairments and limited reading proficiency. v) Alternative Format Notification The contractor shall ensure that all enrollees and potential enrollees are advised on how to access materials available in alternative formats. w) Information Timeframes The contractor shall ensure that all enrollees and potential enrollees are advised of their capability to obtain information or materials, including in alternative formats, at:
• The time the potential enrollee first becomes eligible to enroll in a voluntary program, or is first required to enroll in a mandatory enrollment program.
• Or in accordance with a timeframe that enables the potential enrollee to use the information in choosing among available MCOs, PIHPs, PAHPs or PCCMs.
x) Information Content The contractor shall ensure that information given potential enrollees include:
• The basic features of managed care • Populations excluded from enrollment, subject to mandatory enrollment or free to voluntarily enroll • MCO, PIHP, PAHP or PCCM responsibilities for coordination of care • Information specific to each MCO. PIHP, PAHP or PCCM including; -Benefits covered -Cost sharing, if any -Service area -Names, locations, telephone numbers of, and non-English languages spoken by contracted providers, including whether accepting new patients -Information on PCPs, specialists and hospitals -Benefits available under the State Plan but not covered under the contract, including how and where they may be obtained -Other information that may be needed or appropriate as directed by the State
y) General Information for All Enrollees The contractor shall, as instructed or directed by the State, notify and provide the following:
• Information on disenrollment rights. • Information related to an enrollee’s freedom of choice among network providers. • Information on rights and protections. • Information on grievance and fair hearing procedures. • Information on out-of-network providers, including family planning. • Information on cost-sharing, if any.
z) Information on Restrictions to Freedom of Choice
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The contractor shall inform each recipient, at the time of enrollment, of the enrollee’s rights to change providers or disenroll/transfer MCOs at any time for cause. aa) Chart Format The contractor, as directed or instructed by the State, shall provide information on MCOs in a comparative, chart-like format so as to allow an enrollee or potential enrollee to more effectively compare MCOs. The information that must be presented shall include, at a minimum:
• The MCOs’ service area • The benefits covered under the MCO • Any cost sharing that may be imposed or required • To the extent available, performance indicators, including enrollee satisfaction
This information shall be provided when:
• The potential enrollee first becomes eligible to enroll in a voluntary program or is first required to enroll in a mandatory enrollment program
• And in a timeframe where, the potential enrollee can best utilize the information in choosing an MCO • It is requested by the enrollee
bb) Limitations on Enrollment The contractor shall, as specified in this RFP or otherwise instructed or directed by the State, adhere to enrollment limitations as they apply to specific groups. cc) Enrollment Priorities The contractor shall, in conducting enrollment activities as instructed or directed by the State, ensure that recipients already enrolled in an MCO are given priority to continue that enrollment if the MCO does not have the capacity to accept all those seeking enrollment under the program. dd) Auto Assignment The contractor shall comply with a mechanism, as specified in this RFP, to assign beneficiaries to an MCO who are mandated to enroll but fail to choose an MCO in the timeframes allowed, and distribute the beneficiaries equitably among qualified MCOs available. ee) Disenrollment Requirements The contractor shall, as required and as instructed or directed by the State, assist with any disenrollment functions. ff) Disenrollment Functions The contractor shall adhere to performing specific disenrollment functions as specified in this RFP and as instructed or directed by the State. The contractor shall disenroll/transfer enrollees in accordance with the State’s policies for allowable reasons for disenrollment/transfer, with or without cause, automatic reenrollment, annual disenrollment/transfer rights; MCO requests for transfer (only upon State approval); or as instructed by the State. The contractor shall adhere to the timeframes to process a disenrollment/transfer as specified in this RFP and instructed by the State. gg) Enrollment Functions The contractor shall adhere to performing specific enrollment and reenrollment functions specified in this RFP and as directed by the State in its procedures for enrollment.
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hh) Disenrollment Actions Concerning the disenrollment process, the contractor shall, as instructed or directed by the State, completely document its actions relating to disenrollment/transfer of enrollees.
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4.0 PROPOSAL PREPARATION AND SUBMISSION
4.1 GENERAL
The bidder must follow instructions contained in this RFP and in the bid cover sheet in preparing and submitting its bid proposal. The bidder is advised to thoroughly read and follow all instructions. The information required to be submitted in response to this RFP has been determined to be essential in the bid evaluation and contract award process. Any qualifying statements made by the bidder to the RFP’s requirements could result in a determination that the bidder’s proposal is materially non-responsive. Each bidder is given wide latitude in the degree of detail it elects to offer or the extent to which plans, designs, systems, processes and procedures are revealed. Each bidder is cautioned, however, that insufficient detail may result in a determination that the bid proposal is materially non-responsive or, in the alternative, may result in a low technical score being given to the bid proposal.
4.2 PROPOSAL DELIVERY AND IDENTIFICATION
In order to be considered, a bid proposal must arrive at the Purchase Bureau in accordance with the instructions on the RFP cover sheet. Bidders submitting proposals are cautioned to allow adequate delivery time to ensure timely delivery of proposals. State regulation mandates that late bid proposals are ineligible for consideration. The exterior of all bid response packages must be labeled with the bid identification number, final bid opening date and the buyer’s name. All of this information is set forth at the top of the RFP cover sheet (page 3 of the RFP).
4.3 NUMBER OF BID PROPOSAL COPIES
Each bidder must submit one (1) complete ORIGINAL bid proposal, clearly marked as the “ORIGINAL” bid proposal. Each bidder should submit 12 full, complete and exact copies of the original. Bidders failing to provide the requested number of copies will be charged the cost incurred by the State to produce the required number of copies. It is suggested that the bidder make and retain a copy of its bid proposal.
4.4 PROPOSAL CONTENT
The bid proposal should be submitted in one volume and that volume divided into four (4) sections as follows:
The following Table describes the format of the bid proposal that should be prepared with tabs (separators), and the content of the material located behind each tab.
TAB CONTENTS RFP SECTION REFERENCE COMMENTS
Cover sheet Completed and signed cover sheet (Page 3 of this RFP)
In the event the bidder is a corporation or partnership, the bidder must complete the attached Ownership Disclosure Form. A completed Ownership Disclosure Form must be received prior to or accompany the bid proposal. Failure to do so will preclude the award of the contract. The Ownership Disclosure Form is attached as Attachment 1 to this RFP.
4.4.1.2 MACBRIDE PRINCIPLES CERTIFICATION
The bidder must complete the attached MacBride Principles Certification evidencing compliance with the MacBride Principles. Failure to do so may result in the award of the contract to another vendor. The MacBride Principles Certification Form is attached as Attachment 2 to this RFP.
4.4.1.3 AFFIRMATIVE ACTION
The bidder must complete the attached Affirmative Action Employee Information Report, or, in the alternative, supply either a New Jersey Affirmative Action Certificate or evidence that the bidder is operating under a Federally approved or sanctioned affirmative action program. The requirement is a precondition to entering into a valid and binding contract. The Affirmative Action Forms are attached as Attachment 3 to this RFP.
4.4.1.4 SET ASIDE CONTRACTS
This is a contract with set aside subcontracting goals for Small Businesses. All bidders must include in their bid proposal a completed and signed Notice of Intent to Subcontract form (Attachment 4). Bidders intending to utilize subcontractors must also include a completed and signed Subcontractor Utilization Plan form (Attachment 4). Failure to submit the required forms shall result in a determination that the bid is materially nonresponsive. Bidders seeking eligible small businesses should contact the New Jersey Commerce and Economic Growth Commission at (609) 292-2146.
4.4.1.5 BID BOND
Not applicable to this procurement
4.4.2 SECTION 2 - TECHNICAL PROPOSAL In this Section, the bidder shall describe its approach and plans for accomplishing the work outlined in the Scope of Work Section, i.e., Section 3.0. The bidder must set forth its understanding of the requirements of this RFP and its ability to successfully complete the contract. This Section of the bid proposal should contain at least the following information: Note: Specifically the Bidder should submit as part of its Bid proposal examples of all system generated reports.
4.4.2.1 MANAGEMENT OVERVIEW
The bidder shall set forth its overall technical approach and plans to meet the requirements of the RFP in a narrative format. This narrative should convince the State that the bidder understands the objectives that the contract is intended to meet, the nature of the required work and the level of effort necessary to successfully complete the contract. This narrative should convince the State that the bidder’s general approach and plans to undertake and complete the contract are appropriate to the tasks and subtasks involved. Mere reiterations of RFP tasks and subtasks are strongly discouraged, as they do not provide insight into the bidder's ability to complete the contract. The bidder’s response to this section should be designed to convince the State that the bidder’s detailed plans and approach proposed to complete the Scope of Work
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are realistic, attainable and appropriate and that the bidder’s bid proposal will lead to successful contract completion. The bidder should propose a marketing and communications plan that it believes will result in a more effective mandated managed care program as well as be adaptable to accommodate new programs with similar functions and /or change existing and new programs for the New Jersey Medicaid and NJ FamilyCare Programs. For each specified requirement, service and / or task specified in Section 3.0, the bidder shall provide a plan that demonstrates its intended methods and ways of accomplishing the requirement, services and/or tasks and subtasks. Further, where applicable, the bidder shall identify the resources it will employ to complete or perform the given requirement, services and / or tasks and subtasks. This shall include the bidder’s proposed and recommended qualifications for the staff assigned to the project.
4.4.2.2 CONTRACT MANAGEMENT
The bidder should describe its specific plans to manage, control and supervise the contract to ensure satisfactory contract completion according to the required schedule. The plan should include the bidder's approach to communicate with the State Contract Manager including, but not limited to, status meetings, status reports, etc.
4.4.2.3 CONTRACT SCHEDULE
The bidder should include a contract schedule. If key dates are a part of this RFP, the bidder’s schedule should incorporate such key dates and should identify the completion date for each task and sub-task required by the Scope of Work. Such schedule should also identify the associated deliverable item(s) to be submitted as evidence of completion of each task and/or subtask. The bidder should identify the contract scheduling and control methodology to be used and should provide the rationale for choosing such methodology. The use of Gantt, Pert or other charts is at the option of the bidder.
4.4.2.4 MOBILIZATION AND IMPLEMENTATION PLAN
It is essential that the State move forward quickly to have the Contract in place. Therefore, the vendor must include, as a part of its proposal and to assure compliance with its Transition Plan, a mobilization and implementation plan, beginning with the date of notification of Contract Effective Date.
The implementation and mobilization plan, to include regularly scheduled status updates to the State, shall include the following elements:
(a) A detailed timetable for the mobilization and implementation period of six (6) months from date of contract award. This timetable shall be designed to demonstrate how the bidder shall have the contract up and operational within the six (6) month transition period. (b) The bidder’s plan for the deployment and use of management, supervisory or other key personnel during the mobilization and implementation period. The plan shall show all management, supervisory or other key personnel that will be assigned to manage, supervise and monitor the bidder’s mobilization and implementation of the contract within the six (6) month transition period. NOTE: The bidder should clearly identify management, supervisory or other key staff that will be assigned only during the mobilization and implementation period. The bidder should submit a plan for the purchase and distribution of equipment, inventory, supplies, materials, etc. that will be required to fully implement the contract on the Contract Operational Date. The bidder should submit a plan for the use of subcontractor(s), if any, on this contract. Emphasis should be on how any subcontractor identified will be involved in the mobilization and implementation plan.
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The bidder should provide its intended plan for the implementation of all informational technology platforms to be installed and utilized during both the transitional period and upon the contract’s actual operational start. This plan should detail all intended hardware, software, peripherals to be utilized and further include the submission of all required system’s documentation required for both the installation, implementation and operation of the contract’s deliverables and tasks. If applicable, this plan should further identify and detail any anticipated difficulties and problems foreseen in the communication and transmission of information between the vendor, the State, the prior contractor or other agencies involved with the programs. This plan shall further address any difficulties either discovered, identified, anticipated or encountered regarding the format, transmission and integrity of the data that is to be transferred between the contractor, exiting contractor and other parties.
4.4.2.4 POTENTIAL PROBLEMS
The bidder should set forth a summary of any and all problems that the bidder anticipates during the term of the contract. For each problem identified, the bidder should provide its proposed solution.
4.4.3 SECTION 3 - ORGANIZATIONAL SUPPORT AND EXPERIENCE
The bidder should include information relating to its organization, personnel, and experience, including, but not limited to, references, together with contact names and telephone numbers, evidencing the bidder's qualifications, and capabilities to perform the services required by this RFP. The bidder shall provide samples of all reports, forms and other data type documents it intends to use during the course of this contract. The bidder shall provide its plan for recruitment of staff required to provide all services required by the RFP on the contract start date at the end of the mobilization and implementation period covering the six month transition period.
a) The bidder shall document that it is an established organization with knowledge and experience with Medicaid, managed care programs and CHIP yet shall not be categorized as one of the following:
• a managed care organization. • a provider of health care services. • an association of health care plans. • an association of providers of health care services.
b) Organizational Knowledge The bidder shall demonstrate and document its overall knowledge and experience according to the following:
• Medicaid and FamilyCare eligibility determinations • CHIP eligibility determinations • determining the collection of premiums • outreach and education of clients on managed care. • Medicaid managed care enrollment in MCOs. • public/private partnerships in health care. • The bidder shall demonstrate its organizational knowledge relative to the maintenance, operation
and administration of a comprehensive management information system that is capable of performing all of the systems requirements of this RFP. This shall include, but not be limited to, producing reports, maintaining a comprehensive provider network database, client mailing, tracking, enrollment and premium collection, and eligibility determination systems and has the ability to make immediate modifications and adjustments to correct errors and maintain smooth operational status at all times.
• The bidder shall demonstrate its knowledge and ability to implement a program in keeping with the requirements of this RFP on a statewide basis.
• The bidder shall demonstrate its knowledge of strategic planning and project management as specifically proven in the implementation of statewide programs affecting multiply diverse populations.
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• The bidder shall demonstrate its knowledge and thorough understanding and direct experience with market research and general marketing principles so as to assure the successful implementation of a marketing campaign to targeted populations.
• The bidder shall complete and submit as part of its bid proposal the Detail Functionality Checklist provided as Appendix 3 of this RFP.
4.4.3.1 LOCATION
The bidder should include the location of the bidder's office that will be responsible for managing the contract. The bidder should include the telephone number and name of the individual to contact. The bidder shall include its plan and site location for all facilities to be utilized during the course of the contract.
4.4.3.2 ORGANIZATION CHART (CONTRACT SPECIFIC)
The bidder should include a contract organization chart, with names showing management, supervisory and other key personnel (including sub-contractor's management, supervisory or other key personnel) to be assigned to the contract. The chart should include the labor category and title of each such individual. The bidder shall also furnish an organizational chart with the names of the proposed management, supervisory staff, and other key personnel, including subcontractor management, supervisory or other key personnel that shall be directly working on and performing all tasks related to the New Jersey Care 2000+ and NJ FamilyCare programs. The chart shall further include the labor category and title of each such individual.
4.4.3.3 RESUMES
Detailed resumes should be submitted for all management, supervisory and key personnel to be assigned to the contract. Resumes should be structured to emphasize relevant qualifications and experience of these individuals in successfully completing contracts of a similar size and scope to those required by this RFP. Resumes should include the following:
• Clearly identify the individual's previous experience in completing similar contracts. • Beginning and ending dates should be given for each similar contract. • A description of the contract should be given and should demonstrate how the individual's work on
the completed contract relates to the individual's ability to contribute to successfully providing the services required by this RFP.
• With respect to each similar contract, the bidder should include the name and address of each reference together with a person to contact for a reference check and a telephone number.
4.4.3.4 BACKUP STAFF
The bidder should include a list of backup staff that may be called upon to assist or replace primary individuals assigned. Backup staff must be clearly identified as backup staff. In the event the bidder must hire management, supervisory and/or key personnel if awarded the contract, the bidder should include, as part of its recruitment plan, a plan to secure backup staff in the event personnel initially recruited need assistance or need to be replaced during the contract term.
4.4.3.5 ORGANIZATION CHART (ENTIRE FIRM)
The bidder should include an organization chart showing the bidder’s entire organizational structure. This chart should show the relationship of the individuals assigned to the contract to the bidder's overall organizational structure.
4.4.3.6 EXPERIENCE OF BIDDER ON CONTRACTS OF SIMILAR SIZE AND SCOPE
The bidder should provide a comprehensive listing of contracts of similar size and scope that it has successfully completed, as evidence of the bidder’s ability to successfully complete the services required by
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this RFP. Emphasis should be placed on contracts that are similar in size and scope to the work required by this RFP. A description of all such contracts should be included and should show how such contracts relate to the ability of the firm to complete the services required by this RFP. For each such contract, the bidder should provide the name and telephone number of a contact person for the other contract party. Beginning and ending dates should also be given for each contract.
4.4.3.7 FINANCIAL CAPABILITY OF THE BIDDER
The bidder shall provide proof its financial capacity and capabilities to undertake and successfully complete the contract. To satisfy this requirement, the bidder shall submit a certified financial statement, including applicable notes, reflecting the bidder’s assets, liabilities, net worth, revenues, expenses, profit or loss, and cash flow for the most recent calendar year or the bidder’s most recent fiscal year; or, if a certified financial statement is not available, then either a reviewed or compiled statement from an independent accountant setting forth the same information required for the certified financial statement. In addition, the bidder must submit a bank reference.
4.4.3.8 SUBCONTRACTOR(S)
A. Should the bidder propose to utilize a subcontractor(s) to fulfill any of its obligations, the bidder shall be responsible for the subcontractor’s(s): (a) performance; (b) compliance with all of the terms and conditions of the contract; and (c) compliance with the requirements of all applicable laws. B. Should the bidder propose to utilize a subcontractor(s) to fulfill any of its obligations, the bidder shall be responsible for the subcontractor’s(s’): (a) performance; (b) compliance with all of the terms and conditions of the contract; and (c) compliance with the requirements of all applicable laws. C. The bidder must provide a detailed description of services to be provided by each subcontractor, referencing the applicable Section or Subsection of this RFP. D. The bidder should provide detailed resumes for each subcontractor’s management, supervisory and other key personnel that demonstrate knowledge, ability and experience relevant to that part of the work which the subcontractor is designated to perform. E. The bidder should provide documented experience demonstrate that each subcontractor has successfully performed work on contracts of a similar size and scope to the work that the subcontractor is designated to perform in the bidder’s proposal.
4.4.4 SECTION 4 - COST PROPOSAL The price schedule is attached as Attachment 5 to this RFP. The bidder must submit all requested pricing information. Failure to submit all requested pricing information may result in the bidder’s proposal being considered materially non-responsive. Each bidder must hold its price(s) firm through issuance of contract to permit the completion of the evaluation of bid proposals received and the contract award process.
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5.0 CONTRACTUAL TERMS AND CONDITIONS
5.1 PRECEDENCE OF CONTRACTUAL TERMS AND CONDITIONS
The contract shall consist of this RFP, Addendum to this RFP and the vendor’s bid proposal, and the State’s Notice of Acceptance. Unless specifically noted within this RFP, the Special Terms and Conditions, take precedence over the Standard Terms and Conditions, attached as Appendix 1. In the event of a conflict between the provisions of this RFP, including the Standard Terms and Conditions and the Special Terms and Conditions, and any addendum to the RFP, the addendum shall govern. In the event of a conflict between the provisions of this RFP, including any addendum to this RFP, and the bidder’s proposal, the RFP and/or the addendum shall govern.
5.2 PERFORMANCE BOND
Not Applicable to this contract.
5.3 BUSINESS REGISTRATION
See Standard Terms & Conditions, Section 1.1.
5.4 CONTRACT TERM AND EXTENSION OPTION
The term of the contract shall be for a period of three (3) years and six months. The anticipated “Contract Effective Date” is provided on the cover sheet of this RFP (page 3 of this RFP). If delays in the bid process result in an adjustment of the anticipated Contract Effective Date, the bidder agrees to accept a contract for the full term of the contract. The contract may be extended for two additional periods of up to one (1) year or portion thereof, by mutual written consent of the contractor and the Director at the same terms, conditions and pricing. The length of each extension shall be determined when the extension request is processed.
5.5 CONTRACT TRANSITION
In the event services end by either contract expiration or termination, it shall be incumbent upon the contractor to continue services, if requested by the Director, until new services can be completely operational. The contractor acknowledges its responsibility to cooperate fully with the replacement contractor and the State to ensure a smooth and timely transition to the replacement contractor. Such transitional period shall not extend more than 120 days beyond the expiration date of the contract, or any extension thereof. The contractor will be reimbursed for services during the transitional period at the rate in effect when the transitional period clause is invoked by the State.
5.6 AVAILABILITY OF FUNDS
The State's obligation to pay the contractor is contingent upon the availability of appropriated funds from which payment for contract purposes can be made. No legal liability on the part of the State for payment of any money shall arise unless funds are made available each fiscal year to the Using Agency by the Legislature.
5.7 CONTRACT AMENDMENT
Any changes or modifications to the terms of the contract shall only be valid when they have been reduced to writing and executed by the contractor and the Director.
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5.8 CONTRACTOR RESPONSIBILITIES
The contractor shall have sole responsibility for the complete effort specified in the contract. Payment will be made only to the contractor. The contractor shall have sole responsibility for all payments due any subcontractor. The contractor is responsible for the professional quality, technical accuracy and timely completion and submission of all deliverables, services or commodities required to be provided under the contract. The contractor shall, without additional compensation, correct or revise any errors, omissions, or other deficiencies in its deliverables and other services. The approval of deliverables furnished under this contract shall not in any way relieve the contractor of responsibility for the technical adequacy of its work. The review, approval, acceptance or payment for any of the services shall not be construed as a waiver of any rights that the State may have arising out of the contractor’s performance of this contract.
5.9 SUBSTITUTION OF STAFF
If it becomes necessary for the contractor to substitute any management, supervisory or key personnel, the contractor will identify the substitute personnel and the work to be performed. The contractor must provide detailed justification documenting the necessity for the substitution. Resumes must be submitted evidencing that the individual(s) proposed as substitution(s) have qualifications and experience equal to or better than the individual(s) originally proposed or currently assigned. The contractor shall forward a request to substitute staff to the State Contract Manager for consideration and approval. No substitute personnel are authorized to begin work until the contractor has received written approval to proceed from the State Contract Manager.
5.10 SUBSTITUTION OR ADDITION OF SUBCONTRACTOR(S)
This Subsection serves to supplement but not to supersede Section 3.11 of the Standard Terms and Conditions of this RFP. If it becomes necessary for the contractor to substitute and/or add a subcontractor, the contractor will identify the proposed new subcontractor and the work to be performed. The contractor must provide detailed justification documenting the necessity for the substitution or addition. The contractor must provide detailed resumes of the proposed subcontractor’s management, supervisory and other key personnel that demonstrate knowledge, ability and experience relevant to that part of the work which the subcontractor is to undertake. In the event a subcontractor is proposed as a substitution, the proposed subcontractor must equal or exceed the qualifications and experience of the subcontractor being replaced. In the event the subcontractor is proposed as an addition, the proposed subcontractor’s qualifications and experience must equal or exceed that of similar personnel proposed by the contractor in its bid proposal.
The contractor shall forward a written request to substitute or add a subcontractor to the State Contract Manager for consideration. If the State Contract Manager approves the request, the State Contract Manager will forward the request to the Director for final approval. No substituted or additional subcontractors are authorized to begin work until the contractor has received written approval from the Director.
5.11 OWNERSHIP OF MATERIAL
All data, technical information, materials gathered, originated, developed, prepared, used or obtained in the performance of the contract, including, but not limited to, all reports, surveys, plans, charts, literature, brochures, mailings, recordings (video and/or audio), pictures, drawings, analyses, graphic representations, software computer programs and accompanying documentation and print-outs, notes and memoranda, written procedures and documents, regardless of the state of completion, which are prepared for or are a result of the services required under this contract shall be and remain the property of the State of New
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Jersey and shall be delivered to the State of New Jersey upon 30 days notice by the State. With respect to software computer programs and/or source codes developed for the State, the work shall be considered “work for hire”, i.e., the State, not the contractor or subcontractor, shall have full and complete ownership of all software computer programs and/or source codes developed. To the extent that any of such materials may not, by operation of law, be a work made for hire in accordance with the terms of this Agreement, contractor or subcontractor hereby assigns to the State all right, title and interest in and to any copyright, and the State shall have the right to obtain and hold in its own name any copyrights, registrations and any other proprietary rights that may be available.
5.11.1 Title to all materials and computer programs created under this contract shall be transferred to the State, including portions (e.g., documentation) as they are created during the development tasks or as they are used in the operation or turnover of the system. All system development (software) must be fully documented and that documentation delivered to the State.
5.11.2 The contractor shall submit to DMAHS copies of system documentation, operating instructions and procedures, system failure or disaster recovery plans and all data processing programs or portions thereof, to the extent that such programs are requested by the DMAHS and have been developed by the employees of the contractor or any subcontractor as part of this contract or transferred and modified from another MMCP by this contract and any subcontract. Such documents shall be delivered to the State on the effective operational start date of this contract, end of the transitional period or other date(s) that may be specified by the State.
5.11.4 The State of New Jersey shall own and retain unlimited rights to use, disclose, or duplicate all information and data (copyrighted or otherwise) developed, derived, documented, stored, or furnished by the contractor under the contract for HBC services. 5.11.5 The State shall further retain ownership of all policy and procedure manuals, training material, evaluation forms, notes, documentation, correspondence and other such materials developed during the course of this contract.
5.12 DATA CONFIDENTIALITY
All financial, statistical, personnel and/or technical data supplied by the State to the contractor are confidential. The contractor is required to use reasonable care to protect the confidentiality of such data. Any use, sale or offering of this data in any form by the contractor, or any individual or entity in the contractor’s charge or employ, will be considered a violation of this contract and may result in contract termination and the contractor’s suspension or debarment from State contracting. In addition, such conduct may be reported to the State Attorney General for possible criminal prosecution.
5.13 NEWS RELEASES
The contractor is not permitted to issue news releases pertaining to any aspect of the services being provided under this contract without the prior written consent of the Director.
5.14 ADVERTISING
The contractor shall not use the State’s name, logos, images, or any data or results arising from this contract as a part of any commercial advertising without first obtaining the prior written consent of the Director.
5.15 LICENSES AND PERMITS
The contractor shall obtain and maintain in full force and effect all required licenses, permits, and authorizations necessary to perform this contract. The contractor shall supply the State Contract Manager with evidence of all such licenses, permits and authorizations. This evidence shall be submitted subsequent to the contract award. All costs associated with any such licenses, permits and authorizations must be considered by the bidder in its bid proposal.
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5.16 CLAIMS AND REMEDIES 5.16.1 CLAIMS
All claims asserted against the State by the contractor shall be subject to the New Jersey Tort Claims Act, N.J.S.A. 59:1-1, et seq., and/or the New Jersey Contractual Liability Act, N.J.S.A. 59:13-1, et seq.
5.16.2 REMEDIES
Nothing in the contract shall be construed to be a waiver by the State of any warranty, expressed or implied, or any remedy at law or equity, except as specifically and expressly stated in a writing executed by the Director.
5.16.3 REMEDIES FOR NON-PERFORMANCE
In the event the contractor fails to comply with any material contract requirement, the Director may take steps to terminate the contract in accordance with State contract terms . In this event, the Director may authorize the delivery of contract items by any available means, with the difference between the price paid and the defaulting contractor’s price either being deducted from any monies due the defaulting contractor or being an obligation owed the State by the defaulting contractor.
5.17 LATE DELIVERY
The contractor must immediately advise the State Contract Manager of any circumstance or event that could result in late delivery of any task or subtask called for to be completed on a date certain. Notification must also be provided to the Director at the address below: The State of New Jersey Director, Division of Purchase and Property Purchase Bureau PO Box 230 33 West State St. Trenton, New Jersey 08625-0230 If the contractor cannot meet the contract completion date for any task or subtask required to be completed by a specific scheduled date, the contractor may be held liable to the State on a per diem basis.
5.18.1 SYSTEM AVAILABILITY PERFORMANCE REQUIREMENTS
Recognizing the critical importance and overall project dependence upon the creation and maintenance of a reliable systems and informational technology platform, the State shall reduce the monthly cost of the contract by an appropriate percentage (%) for any services not received, and within the control of the contractor.
5.18.2 SYSTEM AVAILABILITY DAMAGES
The State will reduce payment to reflect the value of costs of services not received due to a systems failure determined to be within the control of the contractor, occurring for any three (3) continuous business day period or more.
5.18.3 CALL CENTER PERFORMANCE STANDARDS
The contractor shall, at all times, adhere to the following performance standards and service levels to be evaluated on a daily basis:
• Call Center Service Levels shall be maintained at 95% of telephone calls answered within 60
seconds for all calls within the queue. • Call Center abandonment rates shall not exceed 3% of all calls contained within the queue. • Call Center busy signals will not exceed 5%.
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• Waiting times within the queue, after being answered shall not exceed three (3) minutes.
5.18.4 CALL CENTER SERVICE STANDARDS
The contractor shall, at all times, adhere to the following performance standards and service levels to be evaluated on a monthly basis: The contractor shall develop a process as a result of real time, automated monitoring, to measure and correct any deficiencies in Call Center HBC performance. This process will ensure that operators adhere to, and perform in accordance with, the following minimum standards. All Call Center HBCs, or operators, shall:
• provide courteous, prompt attention to the caller’s needs • respect the caller’s privacy during all communications and calls • maintain sensitivity to the diversity inherent in all cultures • display and communicate a completely professional demeanor at all times • assure the dissemination of accurate information to all callers
5.18.5 CALL CENTER DAMAGES
For failure to meet the call center performance standards, the State may reduce the monthly cost of the contract by a percentage for each day the standards are not met. For example, for the service level of 95% of calls answered within 90 seconds, if only 80% of the calls met the standard during any five (5) continuous business day period, a monthly cost reduction for Call Center service damages of 15% could be assessed for a corresponding time period. These performance failures and corresponding damages could reflect failed emergency communications from beneficiaries, enrollment delays and difficulties caused beneficiaries, receipt of beneficiary complaints, and a negative image to the State, the DHS and DMAHS.
5.18.6 TIMELINESS AND ACCURACY OF NJ FAMILYCARE ELIGIBILITY DETERMINATION
As specified, applications shall be reviewed for eligibility in the order in which received. Complete applications will be reviewed and processed to final disposition (either eligible or ineligible) within five (5) business days of receipt.
5.18.7 DAMAGES - ELIGIBILITY DETERMINATIONS
The contractor will be responsible for producing timely and accurate eligibility determinations. An error will arise and damages assessed if either (a) the eligibility determinations are not timely or (b) the enrollment transactions contain an error, as defined within the scope of work. Since achieving successful and correct managed care enrollment of New Jersey Care 2000+ and NJ FamilyCare beneficiaries is dependent upon the correct and timely determination of beneficiary eligibility, the productional objective and rationale for eligibility processing shall be subject to the following schedule of performance levels: Error Rate Applicable Percentage of Monthly Payment 0% - 4.99% 100% 5%- 9.99% 95% 10%-14.99% 90% 15%-19.99% 85% 20%-24.99% 80% 25%-29.99% 75% 30%-34.99% 70% 35%-39.99% 65% 40%-44.99% 60% 45%-49.99% 55% 50%-54.99% 50% 55%-59.99% 45% 60%-64.99% 40% 65%-69.99% 35% 70%-74.99% 30% 75%-79.99% 25%
5.18.8 TIMELINESS AND ACCURACY OF HMO ENROLLMENT PROCESSING
All enrollments in a MCO become effective on the first (1st) of each month. To allow for all parties to be properly notified, all error-free enrollment transactions must be processed and ready for transmittal to the MCO and to the DMAHS by the fifteenth (15th) of the preceding month. It is expected that the contractor will meet this critical target each month. Therefore, it is required that all completed applications received by the 13th of the month will be input by the 15th of the month. All enrollment transactions suspended for any reason must be resolved within thirty (30) calendar days from the original suspend date, unless DMAHS provides written approval for specific enrollments or classes of enrollments exceeding the thirty (30) day limit at the sole discretion of the DMAHS. All enrollment transactions and adjustments made by the contractor must be made on behalf of eligible clients, to eligible managed care providers, for covered enrollment periods, and in accordance with the eligibility rules and other policies of the State of New Jersey. Ninety-five percent (95% ) of all enrollments must be processed accurately according to the eligibility rules and policies of the State of New Jersey.
5.18.9 DAMAGES – ENROLLMENT TRANSACTIONS
The contractor is responsible for producing timely and accurate enrollment transactions. An error will arise and damages assessed if either (a) the enrollment is not timely or (b) the enrollment transaction contains an error, according to the directions defined above. Since achieving successful and correct enrollment of New Jersey Care 2000+ and NJ FamilyCare beneficiaries into MCOs are the two (2) Program’s productional objective and rationale for the importance of performance goals, the following schedule of performance levels and damages will be applied : Error Rate Applicable Percentage of Monthly Payment 0% - 4.99% 100% 5%- 9.99% 95% 10%-14.99% 90% 15%-19.99% 85% 20%-24.99% 80% 25%-29.99% 75% 30%-34.99% 70% 35%-39.99% 65% 40%-44.99% 60% 45%-49.99% 55% 50%-54.99% 50% 55%-59.99% 45% 60%-64.99% 40% 65%-69.99% 35% 70%-74.99% 30% 75%-79.99% 25% 80%-84.99% 20% 85%-89.99% 15% 90%-94.99% 10% 95%-99.99% 5% 100% 0%
5.18.10 PROGRAM ENROLLMENTS IN ERROR
Where, due to errors or failures by the contractor to appropriately adhere to the practices and procedures mandated for the enrollment of individuals into the New Jersey Care 2000+, NJ FamilyCare or Premium Support Programs, individuals are wrongfully enrolled into MCOs, damages shall be assessed in
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accordance with losses incurred by the State in paying capitation, and other charges or fees, associated with the provision of health benefits and services rendered ineligible individuals.
5.18.11 DUPLICATE ENROLLMENTS
Where, due to errors or failures by the contractor to appropriately adhere to the practices and procedures mandated for the enrollment of individuals into the New Jersey Care 2000+, NJ FamilyCare or Premium Support Programs, individuals are enrolled twice into MCOs, resulting in duplicate enrollments, damages shall be assessed in accordance with losses incurred by the State in paying capitation, and other charges or fees, associated with the provision of health benefits and services rendered ineligible individuals.
5.18.12 FAILED ENROLLMENTS
Where, due to errors or failures by the contractor to appropriately adhere to the practices and procedures mandated for the enrollment of individuals into the New Jersey Care 2000+, NJ FamilyCare or Premium Support Programs, individuals fail to be enrolled who otherwise warranted enrollment, in accordance with operational processing time frames and requirements specified within this Contract, damages shall be assessed for emergency or other health care expenditures assumed by the State through the Medicaid Fee -for- Service, New Jersey Care 2000+ or NJ FamilyCare programs.
5.18.13 OPERATIONAL START DATE It is the State’s intent to have the new contractor operational within six (6) months of actual Contract Effective Date. Operational means to begin enrollment in approved MCOs under contract with the New Jersey Medicaid Program and NJ FamilyCare maintaining all system files; producing all required reports; and performing all other contractor responsibilities specified in this RFP. Compliance with this key date is critical to the State’s interest. Therefore, the contractor shall be responsible for the differences in any costs absorbed by the State as set forth below in Section 5.18.14 if this date is not met, except for delays caused solely by the State.
5.18.14 DAMAGES
If the contractor does not fully meet the Operational Start Date, and a contract modification or amendment delaying this key date or a portion of the processing requirements has not been approved, then the contractor shall be liable for the differences in any per diem costs incurred by the State, to maintain the contractor currently acting as Health Benefits Coordinator or, in the absence of an external vendor acting as the Health Benefits Coordinator, the per diem cost incurred directly by the State for performing all tasks, functions and/or other operational needs required to maintain all roles of the Health Benefits Coordinator.
5.18.15 FAILURE TO MEET TRANSITION REQUIREMENTS
The purpose of these damages is to ensure adherence to the performance requirements in the contract. It is agreed by the State and the contractor that in the event of a failure to meet the performance requirements as listed within this RFP and contract, damage shall be sustained by the State. Damages applied shall be the difference in per diem costs incurred directly by the State in maintaining the current HBC contractor in order to assure the continued performance of all tasks, functions and other operational needs required in maintaining the needs of the New Jersey Care 2000+, NJ FamilyCare and Premium Support Programs. Upon the completion of the transition period, the normal operational performance standards shall apply. Written notification of each failure to meet a performance requirement will be given by the State Contract Manager to the contractor. Unless otherwise specified, the contractor shall have five (5) working days from the date of receipt of written notification of a failure to perform to specifications to cure the failure. However, the State Contract Manager may approve additional days as deemed necessary if the cure cannot be performed within five (5) working days.
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5.18.16 MAINTENANCE OF THE FEDERAL WAIVER AND STATE PLANS The contractor shall be liable for actual damages that would cause the State to lose its federal waiver for the MCO or State Plan or legislation, because of substandard performance or non-performance of the tasks performed under this contract. The contractor shall ensure that all federal and State requirements continue to be met. The contractor shall also ensure that future federal and State requirements are maintained. Should the State sustain actual damages due to contractor performance prior to contract termination or the ending date of any subsequent contract extensions, the contractor shall be liable for actual damages. The contractor shall be liable for actual damages during performance of the contract.
5.19 RETAINAGE
The amount of retainage is noted on the RFP cover sheet (Page 3 of this RFP). The using agency shall retain the stated percentage of each invoice submitted. At the end of each three (3) month period, the using agency shall review the contractor’s performance. If the performance has been satisfactory, the using agency shall release 90% of the retainage for the preceding three (3) month period. Following certification by the State Contract Manager that all services have been satisfactorily performed, the balance of the retainage shall be released to the contractor.
5.20 STATE'S OPTION TO REDUCE SCOPE OF WORK
The State has the option, in its sole discretion, to reduce the scope of work for any task or subtask called for under this contract. In such an event, the Director shall provide advance written notice to the contractor. Upon receipt of such written notice, the contractor will submit, within five (5) working days to the Director and the State Contract Manager, an itemization of the work effort already completed by task or subtask. The contractor shall be compensated for such work effort according to the applicable portions of its cost proposal.
5.21 SUSPENSION OF WORK The State Contract Manager may, for valid reason, issue a stop order directing the contractor to suspend work under the contract for a specific time. The contractor shall be paid until the effective date of the stop order. The contractor shall resume work upon the date specified in the stop order, or upon such other date as the State Contract Manager may thereafter direct in writing. The period of suspension shall be deemed added to the contractor's approved schedule of performance. The Director and the contractor shall negotiate an equitable adjustment, if any, to the contract price.
5.22 CHANGE IN LAW Whenever an unforeseen change in applicable law or regulation affects the services that are the subject of this contract, the contractor shall advise the State Contract Manager and the Director in writing and include in such written transmittal any estimated increase or decrease in the cost of its performance of the services as a result of such change in law or regulation. The Director and the contractor shall negotiate an equitable adjustment, if any, to the contract price.
5.23 CONTRACT PRICE INCREASE (PREVAILING WAGE)
If the Prevailing Wage Act (N.J.S.A. 34:11-56 et seq.) is applicable to the contract, the contractor may apply to the Director, on the anniversary of the effective date of the contract, for a contract price increase. The contract price increase will be available only for an increase in the prevailing wages of trades and occupations covered under this contract during the prior year. The contractor must substantiate with documentation the need for the increase and submit it to the Director for review and determination of the amount, if any, of the requested increase, which shall be available for the upcoming contract year. No retroactive increases will be approved by the Director
5.24ADDITIONAL WORK AND/OR SPECIAL PROJECTS The contractor shall not begin performing any additional work or special projects without first obtaining written approval from both the State Contract Manager and the Director.
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In the event of additional work and/or special projects, the contractor must present a written proposal to perform the additional work to the State Contract Manager. The proposal should provide justification for the necessity of the additional work. The relationship between the additional work and the base contract work must be clearly established by the contractor in its proposal. The contractor’s written proposal must provide a detailed description of the work to be performed broken down by task and subtask. The proposal should also contain details on the level of effort, including hours, labor categories, etc., necessary to complete the additional work. The written proposal must detail the cost necessary to complete the additional work in a manner consistent with the contract. The written cost proposal must be based upon the hourly rates, unit costs or other cost elements submitted by the contractor in the contractor’s original bid proposal submitted in response to this RFP. Whenever possible, the cost proposal should be a firm, fixed cost to perform the required work. The firm fixed price should specifically reference and be tied directly to costs submitted by the contractor in its original bid proposal. A payment schedule, tied to successful completion of tasks and subtasks, must be included. Upon receipt and approval of the contractor’s written proposal, the State Contract Manager shall forward same to the Director for the Director’s written approval. Complete documentation from the Using Agency, confirming the need for the additional work, must be submitted. Documentation forwarded by the State Contract Manager to the Director must all include all other required State approvals, such as those that may be required from the State of New Jersey’s Office of Management and Budget (OMB) and Office of Information and Technology (OIT). No additional work and/or special project may commence without the Director’s written approval. In the event the contractor proceeds with additional work and/or special projects without the Director’s written approval, it shall be at the contractor’s sole risk. The State shall be under no obligation to pay for work performed without the Director’s written approval.
5.25 FORM OF COMPENSATION AND PAYMENT This Section supplements Section 4.5 of the RFP’s Standard Terms and Conditions. The contractor must submit official State invoice forms to the Using Agency with supporting documentation evidencing that work for which payment is sought has been satisfactorily completed. Invoices must reference the tasks or subtasks detailed in the Scope of Work section of the RFP and must be in strict accordance with the firm, fixed prices submitted for each task or subtask on the RFP pricing sheets. When applicable, invoices should reference the appropriate RFP price sheet line number from the contractor’s bid proposal. All invoices must be approved by the State Contract Manager before payment will be authorized. Invoices must also be submitted for any special projects, additional work or other items properly authorized and satisfactorily completed under the contract. Invoices shall be submitted according to the payment schedule agreed upon when the work was authorized and approved. Payment can only be made for work when it has received all required written approvals and has been satisfactorily completed. The contractor will be paid a monthly fixed payment for each month of the contract. The contract length is three years and six months. The first six months of the contract are defined as the transition period. Transition payments will be made monthly, in accordance with Transitional Period Price Lines, to offset implementation costs incurred by the contractor prior to the Contract Operational Date. Payments for the six-month transition period shall not exceed 15 percent of the three-year operational contract price. After the Contract Operational Date, the contractor will be paid a monthly fixed amount for the following 36 operational months. The contractor will also be reimbursed monthly for DMAHS approved postage costs.
5.26 MODIFICATIONS AND CHANGES TO THE STANDARD TERMS AND CONDITIONS 5.26.1 PATENT AND COPYRIGHT INDEMNITY
Section 2.1 of the State's Standard Terms and Conditions is deleted and replaced with the following:
2.1 Patent and Copyright Indemnity
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a. The Contractor shall hold and save the State of New Jersey, its officers, agents, servants and employees, harmless from liability of any nature or kind for or on account of the use of any copyrighted or uncopyrighted composition, secret process, patented or unpatented invention, article or appliance furnished or used in the performance of the contract. b. The State of New Jersey agrees: (1) to promptly notify the Contractor in writing of such claim or suit; (2) that the Contractor shall have control of the defense of settlement of such claim or suit; and (3) to cooperate with the Contractor in the defense of such claim or suit, to the extent that the interests of the Contractor and the State are consistent. c. In the event of such claim or suit, the Contractor, at its option, may: (1) procure for the State of New Jersey the legal right to continue the use of the product; (2) replace or modify the product to provide a non-infringing product that is the functional equivalent; or (3) refund the purchase price less a reasonable allowance for use that is agreed to by both parties.
5.26.2 INDEMNIFICATION
Section 2.2 of Appendix 1, the New Jersey Standard Terms and Conditions, is deleted and replaced with the following:
2.2 Indemnification The contractor's liability to the State for actual, direct damages resulting from the contractor's performance or non-performance, or in any manner related to the contract, for any and all claims, shall be limited in the aggregate to 500 % of the value of the contract, except that such limitation of liability shall not apply to the following: 1. The contractor's obligation to indemnify the State of New Jersey and its employees from and against any claim, demand, loss, damage or expense relating to bodily injury or the death of any person or damage to real property or tangible personal property, incurred from the work or materials supplied by the contractor under the contract caused by negligence or willful misconduct of the contractor; 2. The contractor's breach of its obligations of confidentiality; and, 3. Contractor's liability with respect to copyright indemnification. The contractor's indemnification obligation is not limited by but is in addition to the insurance obligations contained in Section 2.3 of the Standard Terms and Conditions. The contractor shall not be liable for special, consequential, or incidental damages.
5.26.3 INSURANCE - PROFESSIONAL LIABILITY INSURANCE
Section 2.3 of Appendix 1, the State of New Jersey Standard Terms and Conditions regarding insurance is modified with the addition of the following section regarding Professional Liability Insurance. Add the following to Section 2.3 of Appendix 1 d) Professional Liability Insurance: The Contractor shall carry Errors and Omissions, Professional Liability Insurance and/or Professional Liability Malpractice Insurance sufficient to protect the Contractor from any liability arising out the professional obligations performed pursuant to the requirements of the Contract. The insurance shall be in the amount of not less than $5,000,000 and in such policy forms as shall be approved by the State. If the Contractor has claims-made coverage and subsequently changes carriers during the term of the Contract, it shall obtain from its new Errors and Omissions, Professional Liability Insurance and/or Professional Malpractice Insurance carrier an endorsement for retroactive coverage.
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6.0 PROPOSAL EVALUATION/CONTRACT AWARD
6.1 PROPOSAL EVALUATION COMMITTEE
Bid proposals may be evaluated by an Evaluation Committee composed of members of affected departments and agencies together with representative(s) from the Purchase Bureau. Representatives from other governmental agencies may also serve on the Evaluation Committee. On occasion, the Evaluation Committee may choose to make use of the expertise of outside consultant in an advisory role.
6.2 ORAL PRESENTATION AND/OR CLARIFICATION OF BID PROPOSAL
A bidder may be required to give an oral presentation to the Evaluation Committee concerning its bid proposal. The Evaluation Committee may also require a bidder to submit written responses to questions regarding its bid proposal. The purpose of such communication with a bidder, either through an oral presentation or a letter of clarification, is to provide an opportunity for the bidder to clarify or elaborate on its bid proposal. Original bid proposals submitted, however, cannot be supplemented, changed, or corrected in any way. No comments regarding other bid proposals are permitted. Bidders may not attend presentations made by their competitors. It is within the Evaluation Committee’s discretion whether to require a bidder to give an oral presentation or require a bidder to submit written responses to questions regarding its bid proposal. Action by the Evaluation Committee in this regard should not be construed to imply acceptance or rejection of a bid proposal. The Purchase Bureau buyer will be the sole point of contact regarding any request for an oral presentation or clarification.
6.3 EVALUATION CRITERIA
The following evaluation criteria categories, not necessarily listed in order of significance, will be used to evaluate bid proposals received in response to this RFP. The evaluation criteria categories may be used to develop more detailed evaluation criteria to be used in the evaluation process:
6.3.1 THE BIDDER'S GENERAL APPROACH AND PLANS IN MEETING THE REQUIREMENTS OF THIS RFP
A. The bidder's general approach and plans in meeting the requirements of this RFP. B. The bidder's detailed approach and plans to perform the services required by the Scope of Work of this
RFP. C. The bidder’s documented experience in successfully completing contracts of a similar size and scope to
the work required by this RFP. D. The qualifications and experience of the bidder’s management, supervisory or other key personnel
assigned to the contract, with emphasis on documented experience in successfully completing work on contracts of similar size and scope to the work required by this RFP.
E. The overall ability of the bidder to mobilize, undertake and successfully complete the contract. This
judgment will include, but not be limited to, the following factors: the number and qualifications of management, supervisory and other staff proposed by the bidder to complete the contract, the availability and commitment to the contract of the bidder’s management, supervisory and other staff proposed and the bidder’s contract management plan, including the bidder’s contract organizational chart.
6.3.2 THE BIDDER’S COST PROPOSAL
For evaluation purposes, bidders will be ranked according to the total bid price in Attachment 5.
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6.4 CONTRACT AWARD
The contract shall be awarded with reasonable promptness by written notice to that responsible bidder whose bid proposal, conforming to the RFP, will be most advantageous to the State, price and other factors considered. Any or all bids may be rejected when the State Treasurer or the Director of the Division of Purchase and Property determines that it is in the public interest so to do.
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7.0 ATTACHMENTS, SUPPLEMENTS AND APPENDICES ATTACHMENTS - To be submitted with bid proposal. 1. Ownership Disclosure Form 2. MacBride Principles Form 3. Affirmative Action Supplement Forms 4. Subcontractor Set Aside Forms 5. Price Schedule 6. Reciprocity Form (Optional) APPENDICES 1. New Jersey Standard Terms and Conditions 2. Set-Off for State Tax Notice
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ATTACHMENT 1 - OWNERSHIP DISCLOSURE FORM OWNERSHIP DISCLOSURE FORM
DEPARTMENT OF THE TREASURY BID NUMBER: 04-X-35654 DIVISION OF PURCHASE & PROPERTY STATE OF NEW JERSEY BIDDER: __________________________________________ 33 W. STATE ST., 9TH FLOOR PO BOX 230 __________________________________________ TRENTON, NEW JERSEY 08625-0230 INSTRUCTIONS: Provide below the names, home addresses, dates of birth, offices held and any ownership interest of all officers of the firm named
above. If additional space is necessary, provide on an attached sheet. OWNERSHIP INTEREST NAME HOME ADDRESS DATE OF BIRTH OFFICE HELD (Shares Owned or % of Partnership) ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ INSTRUCTIONS: Provide below the names, home addresses, dates of birth, and ownership interest of all individuals not listed above, and any partnerships, corporations and any other owner having a 10% or greater interest in the firm named above. If a listed owner is a corporation or partnership, provide below the same information for the holders of 10% or more interest in that corporation or partnership. If additional space is necessary, provide that information on an attached sheet. If there are no owners with 10% or more interest in your firm, enter “None” below. Complete the certification at the bottom of this form. If this form has previously been submitted to the Purchase Bureau in connection with another bid, indicate changes, if any, where appropriate, and complete the certification below. OWNERSHIP INTEREST NAME HOME ADDRESS DATE OF BIRTH OFFICE HELD (Shares Owned or % of Partnership) ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
COMPLETE ALL QUESTIONS BELOW YES NO 1. Within the past five years has another company or corporation had a 10% or greater interest in the firm identified above?
(If yes, complete and attach a separate disclosure form reflecting previous ownership interests.) _____ _____
2. Has any person or entity listed in this form or its attachments ever been arrested, charged, indicted or convicted in a criminal or disorderly persons matter by the State of New Jersey, any other State or the U.S. Government? (If yes, attach a detailed explanation for each instance.) _____ _____
3. Has any person or entity listed in this form or its attachments ever been suspended, debarred or otherwise declared ineligible by any agency of government from bidding or contracting to provide services, labor, material, or supplies? (If yes, attach a detailed explanation for each instance.) _____ _____
4. Are there now any criminal matters or debarment proceedings pending in which the firm and/or its officers and/or managers are
involved? (If yes, attach a detailed explanation for each instance.) _____ _____
5. Has any Federal, State or Local license, permit or other similar authorization, necessary to perform the work applied for herein and
held or applied for by any person or entity listed in this form, been suspended or revoked, or been the subject or any pending proceedings specifically seeking or litigating the issue of suspension or revocation? (If yes, attach a detailed explanation for each instance.) _____ _____
CERTIFICATION: I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge that the State of New Jersey is relying on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of this certification through the completion of any contracts with the State to notify the State in
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writing of any changes to the answers or information contained herein. I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I recognize that I am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the State of New Jersey and that the State at its option, may declare any contract(s) resulting from this certification void and unenforceable. I, being duly authorized, certify that the information supplied above, including all attached pages, is complete and correct to the best of my knowledge, I certify that all of the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. Company Name: _____________________________
___________________________________________(Signature) Address: ___________________________________ PRINT OR TYPE:
______________________________________________(Name) ___________________________________ PRINT OR TYPE:
_______________________________________________(Title) FEIN/SSN#: ________________________________ Date __________________________________________ PB-ODF.1 R4/29/96
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ATTACHMENT 2 - MACBRIDE PRINCIPLES FORM
NOTICE TO ALL BIDDERS REQUIREMENT TO PROVIDE A CERTIFICATION IN COMPLIANCE WITH MACBRIDE PRINCIPLES
AND NORTHERN IRELAND ACT OF 1989 Pursuant to Public Law 1995, c. 134, a responsible bidder selected, after public bidding, by the Director of the Division of Purchase and Property, pursuant to N.J.S.A. 52:34-12, or the Director of the Division of Building and Construction, pursuant to N.J.S.A. 52:32-2, must complete the certification below by checking one of the two representations listed and signing where indicated. If a bidder who would otherwise be awarded a purchase, contract or agreement does not complete the certification, then the Directors may determine, in accordance with applicable law and rules, that it is in the best interest of the State to award the purchase, contract or agreement to another bidder who has completed the certification and has submitted a bid within five (5) percent of the most advantageous bid. If the Directors find contractors to be in violation of the principles which are the subject of this law, they shall take such action as may be appropriate and provided by law, rule or contract, including but not limited to, imposing sanctions, seeking compliance, recovering damages, declaring the party in default and seeking debarment or suspension of the party. I certify, pursuant to N.J.S.A. 52:34-12.2 that the entity for which I am authorized to bid: ____ has no ongoing business activities in Northern Ireland and does not maintain a physical presence therein
through the operation of offices, plants, factories, or similar facilities, either directly or indirectly, through intermediaries, subsidiaries or affiliated companies over which it maintains effective control; or
____ will take lawful steps in good faith to conduct any business operations it has in Northern Ireland in
accordance with the MacBride principles of nondiscrimination in employment as set forth in N.J.S.A. 52:18A-89.8 and in conformance with the United Kingdom’s Fair Employment (Northern Ireland) Act of 1989, and permit independent monitoring of their compliance with those principles.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment.
Signature of Bidder
Name (Type or Print)
Title Name (Type or Print)
Name of Company Name (Type or Print)
Date
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ATTACHMENT 3 – AFFIRMATIVE ACTION SUPPLEMENT
AFFIRMATIVE ACTION TERM CONTRACT - ADVERTISED BID PROPOSAL DEPT OF THE TREASURY DIVISION OF PURCHASE & PROPERTY STATE OF NEW JERSEY 33 WEST STATE STREET, 9TH FLOOR PO BOX 230 TRENTON, NEW JERSEY 08625-0230
BID NUMBER: 04-X-35654 NAME OF BIDDER: _________________________________________
SUPPLEMENT TO BID SPECIFICATIONS
DURING THE PERFORMANCE OF THIS CONTRACT, THE CONTRACTOR AGREES AS FOLLOWS:
1. THE CONTRACTOR OR SUBCONTRACTOR, WHERE APPLICABLE, WILL NOT DISCRIMINATE AGAINST ANY EMPLOYEE OR APPLICANT FOR EMPLOYMENT BECAUSE OF AGE, RACE, CREED, COLOR, NATIONAL ORIGIN, ANCESTRY, MARITAL STATUS, SEX, AFFECTIONAL OR SEXUAL ORIENTATION. THE CONTRACTOR WILL TAKE AFFIRMATIVE ACTION TO ENSURE THAT SUCH APPLICANTS ARE RECRUITED AND EMPLOYED, AND THAT EMPLOYEES ARE TREATED DURING EMPLOYMENT, WITHOUT REGARD TO THEIR AGE, RACE, CREED, COLOR, NATIONAL ORIGIN, ANCESTRY, MARITAL STATUS, SEX, AFFECTIONAL OR SEXUAL ORIENTATION. SUCH ACTION SHALL INCLUDE, BUT NOT BE LIMITED TO THE FOLLOWING: EMPLOYMENT, UPGRADING, DEMOTION, OR TRANSFER; RECRUITMENT OR RECRUITMENT ADVERTISING; LAYOFF OR TERMINATION; RATES OF PAY OR OTHER FORMS OF COMPENSATION; AND SELECTION FOR TRAINING, INCLUDING APPRENTICESHIP. THE CONTRACTOR AGREES TO POST IN CONSPICUOUS PLACES, AVAILABLE TO EMPLOYEES AND APPLICANTS FOR EMPLOYMENT, NOTICES TO BE PROVIDED BY THE PUBLIC AGENCY COMPLIANCE OFFICER SETTING FORTH PROVISIONS OF THIS NONDISCRIMINATION CLAUSE;
2. THE CONTRACTOR OR SUBCONTRACTOR, WHERE APPLICABLE WILL, IN ALL SOLICITATIONS OR ADVERTISEMENTS, FOR EMPLOYEES PLACED BY OR ON BEHALF OF THE CONTRACTOR, STATE THAT ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO AGE, RACE, CREED, COLOR, NATIONAL ORIGIN, ANCESTRY, MARITAL STATUS, SEX, AFFECTIONAL OR SEXUAL ORIENTATION.
3. THE CONTRACTOR OR SUBCONTRACTOR, WHERE APPLICABLE, WILL SEND TO EACH LABOR UNION OR REPRESENTATIVE OR WORKERS WITH WHICH IT HAS A COLLECTIVE BARGAINING AGREEMENT OR OTHER CONTRACT OR UNDERSTANDING, A NOTICE, TO BE PROVIDED BY THE AGENCY CONTRACTING OFFICER ADVISING THE LABOR UNION OR WORKERS' REPRESENTATIVE OF THE CONTRACTOR'S COMMITMENTS UNDER THIS ACT AND SHALL POST COPIES OF THE NOTICE IN CONSPICUOUS PLACES AVAILABLE TO EMPLOYEES AND APPLICANTS FOR EMPLOYMENT.
4. THE CONTRACTOR OR SUBCONTRACTOR, WHERE APPLICABLE, AGREES TO COMPLY WITH THE REGULATIONS PROMULGATED BY THE TREASURER PURSUANT TO P.L. 1975, C. 127, AS AMENDED AND SUPPLEMENTED FROM TIME TO TIME AND THE AMERICANS WITH DISABILITIES ACT.
5. THE CONTRACTOR OR SUBCONTRACTOR AGREES TO ATTEMPT IN GOOD FAITH TO EMPLOY MINORITY AND FEMALE WORKERS CONSISTENT WITH THE APPLICABLE COUNTY EMPLOYMENT GOALS PRESCRIBED BY N.J.A.C. 17:27-5.2 PROMULGATED BY THE TREASURER PURSUANT TO P.L. 1975, C. 127, AS AMENDED AND SUPPLEMENTED FROM TIME TO TIME OR IN ACCORDANCE WITH A BINDING DETERMINATION OF THE APPLICABLE COUNTY EMPLOYMENT GOALS DETERMINED BY THE AFFIRMATIVE ACTION OFFICE PURSUANT TO N.J.A.C. 17:27-5.2 PROMULGATED BY THE TREASURER PURSUANT TO P.L. 1975, C. 127, AS AMENDED AND SUPPLEMENTED FROM TIME TO TIME.
6. THE CONTRACTOR OR SUBCONTRACTOR AGREES TO INFORM IN WRITING APPROPRIATE RECRUITMENT AGENCIES IN THE AREA, INCLUDING EMPLOYMENT AGENCIES, PLACEMENT BUREAUS, COLLEGES, UNIVERSITIES, LABOR UNIONS, THAT IT DOES NOT DISCRIMINATE ON THE BASIS OF AGE, CREED, COLOR, NATIONAL ORIGIN, ANCESTRY, MARITAL STATUS, SEX, AFFECTIONAL OR SEXUAL ORIENTATION, AND THAT IT WILL DISCONTINUE THE USE OF ANY RECRUITMENT AGENCY WHICH ENGAGES IN DIRECT OR INDIRECT DISCRIMINATORY PRACTICES.
7. THE CONTRACTOR OR SUBCONTRACTOR AGREES TO REVISE ANY OF ITS TESTING PROCEDURES, IF NECESSARY, TO ENSURE THAT ALL PERSONNEL TESTING CONFORMS WITH THE PRINCIPLES OF JOB-RELATED TESTING, AS ESTABLISHED BY THE STATUTES AND COURT DECISIONS OF THE STATE OF NEW JERSEY AND AS ESTABLISHED BY APPLICABLE FEDERAL LAW AND APPLICABLE FEDERAL COURT DECISIONS.
8. THE CONTRACTOR OR SUBCONTRACTOR AGREES TO REVIEW ALL PROCEDURES RELATING TO TRANSFER, UPGRADING, DOWNGRADING AND LAYOFF TO ENSURE THAT ALL SUCH ACTIONS ARE TAKEN WITHOUT REGARD TO AGE, CREED, COLOR, NATIONAL ORIGIN, ANCESTRY, MARITAL STATUS, SEX, AFFECTIONAL OR SEXUAL ORIENTATION, AND CONFORM WITH THE APPLICABLE EMPLOYMENT GOALS, CONSISTENT WITH THE STATUTES AND COURT DECISIONS OF THE STATE OF NEW JERSEY, AND APPLICABLE FEDERAL LAW AND APPLICABLE FEDERAL COURT DECISIONS.
THE CONTRACTOR AND ITS SUBCONTRACTORS SHALL FURNISH SUCH REPORTS OR OTHER DOCUMENTS TO THE AFFIRMATIVE ACTION OFFICE AS MAY BE REQUESTED BY THE OFFICE FROM TIME TO TIME IN ORDER TO CARRY OUT THE PURPOSES OF THESE REGULATIONS, AND PUBLIC AGENCIES SHALL FURNISH SUCH INFORMATION AS MAY BE REQUESTED BY THE AFFIRMATIVE ACTION OFFICE FOR CONDUCTING A COMPLIANCE INVESTIGATION PURSUANT TO SUBCHAPTER 10 OF THE ADMINISTRATIVE CODE (NJAC17:27).
___ * NO FIRM MAY BE ISSUED A PURCHASE ORDER OR CONTRACT WITH THE STATE UNLESS THEY COMPLY WITH THE
AFFIRMATIVE ACTION REGULATIONS
PLEASE CHECK APPROPRIATE BOX (ONE ONLY) I HAVE A CURRENT NEW JERSEY AFFIRMATIVE ACTION CERTIFICATE, (PLEASE ATTACH A COPY TO YOUR PROPOSAL). I HAVE A VALID FEDERAL AFFIRMATIVE ACTION PLAN APPROVAL LETTER, (PLEASE ATTACH A COPY TO YOUR PROPOSAL). I HAVE COMPLETED THE ENCLOSED FORM AA302 AFFIRMATIVE ACTION EMPLOYEE INFORMATION REPORT.
REV. 12/90
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INSTRUCTIONS FOR COMPLETING THE AFFIRMATIVE ACTION EMPLOYEE INFORMATION REPORT
(FORM AA302)
IMPORTANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM. PRINT OR TYPE ALL INFORMATION. FAILURE TO PROPERLY COMPLETE THE ENTIRE FORM MAY DELAY ISSUANCE OF YOUR CERTIFICATE.
Item 1 - Enter the Federal Identification Number assigned to the Contractor or vendor by the Internal Revenue Service, or if a Federal Employer Identification Number has been applied for, but not yet issued, write the words “applied for”, or If your business is such that you have not, or will not receive a Federal Employee Identification Number, enter the Social Security Number assigned to the single owner or to a partner, in case of partnership. Item 2 - Check the box appropriate to your TYPE OF BUSINESS. If you are engaged in more than one type of business, check the predominant one. If you are a manufacturer deriving more than 50% of your receipts from your own retail outlets, check “Retail”. Item 3 - Enter the total “number” of employees in the entire company, including part-time employees. This number shall include all facilities in the entire firm or corporation. Item 4 - Enter the name by which the company is identified. If there is more than one company name, enter the predominant one. Item 5 - Enter the physical location of the company, include City, County, State and Zip Code. Item 6 - Enter the name of any parent or affiliated company including City, State and Zip Code. If there is none, so indicate by entering “None” or N/A. Item 7 - Check the appropriate box for the total number of employees in the entire company. “Entire Company” shall include all facilities in the entire firm or corporation, including part-time employees, not use those employees at the facility being awarded the contract. Item 8 - Check the box appropriate to your type of company establishment. Single-establishment Employer shall include an employer whose business is conducted at more than one location. Item 9 - If multi-establishment was entered in Item 8, enter the number of establishments within the State of New Jersey. Item 10 - Enter the total number of employees at the establishment being awarded the contract.
Item 11 - Enter the name of the Public Agency awarding the contract. Include City, State and Zip Code. Item 12 - Enter the appropriate figures on all lines and in all columns. THIS SHALL ONLY INCLUDE EMPLOYMENT DATA FROM THE FACILITY THAT IS BEING AWARDED THE CONTRACT. DO NOT list the same employee in more than one job category. Racial/Ethnic Groups w ill be so defined: Black: Not of Hispanic origin. Persons have origin in any of the Black racial groups of Africa. Hispanic: Persons of Mexican, Puerto Rican, Cuban or Central or South American or other Spanish culture or origin, regardless of race. American Indian or Alaskan Native: Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. Asian or Pacific Islander: Persons having origin in any of the peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes for example, China, Japan, the Philippine Islands and Samoa. Item 13 - Check the appropriate box, if the race or ethnic group information was not obtained by 1 or 2, specify by what other means this was done in 3. Item 14 - Enter the dates of the payroll period used to prepare the employment data presented in Item 12. Item 15 - If this is the first time an Employee Information Report has been submitted for this company, check block “Yes”. Item 16 - If the answer to Item 15 is “No”, enter the date when the last Employee Information Report was submitted by this company. Item 17 - Print or type the name of the person completing this form. Include the signature, title and date. Item 18 - Enter the physical location where the form is being completed. Include City, State, Zip Code and Phone Number.
101
State of New Jersey AFFIRMATIVE ACTION EMPLOYEE INFORMATION REPORT
IMPORTANT - READ INSTRUCTIONS ON PRIOR PAGE CAREFULLY BEFORE COMPLETING FORM. TYPE OR PRINT SHARP BALL POINT PEN. FAILURE TO PROPERLY COMPLETE THE ENTIRE FORM MAY DELAY ISSUANCE OF YOUR CERTIFICATE.
SECTION A - COMPANY IDENTIFICATION 1. FID. NO. OR SOCIAL SECURITY 2. TYPE OF BUSINESS
1. MFG. 2. SERVICE 3. WHOLESALE 4. RETAIL 5. OTHER
3. TOTAL NO. OF EMPLOYEES IN THE ENTIRE COMPANY
4. COMPANY NAME
5. STREET CITY COUNTY STATE ZIP CODE
6. NAME OF PARENT OR AFFILIATED COMPANY (IF NONE, SO INDICATE) CITY STATE ZIP CODE
7. DOES THE ENTIRE COMPANY HAVE A TOTAL OF AT LEAST 50 EMPLOYEES? YES NO
8. CHECK ONE: IS THE COMPANY: SINGLE-ESTABLISHMENT EMPLOYER MULTI-ESTABLISHMENT EMPLOYER
9. IF MULTI-ESTABLISHMENT EMPLOYER, STATE THE NUMBER OF ESTABLISHMENTS IN N.J. : [ ]
10. TOTAL NUMBER OF EMPLOYEES AT THE ESTABLISHMENT WHICH HAS BEEN AWARDED THE CONTRACT: [ ] 11. PUBLIC AGENCY AWARDING CONTRACT: CITY STATE ZIP CODE
OFFICIAL USE ONLY DATE RECEIVED OUT OF STATE PERCENTAGES ASSIGNED CERTIFICATION NUMBER
MO/DAY/YR COUNTY MINORITY FEMALE
SECTION B - EMPLOYMENT DATA 12. Report all permanent, temporary and part-time employees ON YOUR OWN PAYROLL. Enter the appropriate figures on all lines and in all columns.
Where there are no employees in a particular category, enter a zero. Include ALL employees, not just those in minority categories, in columns 1, 2, & 3.
ALL EMPLOYEES MINORITY GROUP EMPLOYEES (PERMANENT) JOB Col. 1 Col. 2 Col. 3 MALE FEMALE
CATEGORIES TOTAL (Cols. 2&3)
MALE FEMALE BLACK HISPANIC AMERICAN INDIAN
ASIAN BLACK HISPANIC AMERICAN INDIAN
ASIAN
Officials and Managers
Professionals
Technicians
Sales Workers
Office and Clerical
Craftworkers (Skilled)
Operatives (Semi-skilled)
Laborers (Unskilled)
Service Workers
TOTAL Total employment from Previous Report (if any)
The data below shall NOT be included in the request for the categories above. Temporary and Part-time Employees
13. HOW WAS INFORMATION AS TO RACE OR ETHNIC GROUP IN SECTION B OBTAINED?
1. VISUAL SURVEY 2. EMPLOYMENT RECORD 3. OTHER (SPECIFY)
15. IS THIS THE FIRST EMPLOYEE INFORMATION REPORT (AA.302) SUBMITTED?
16. IF NO, DATE OF LAST REPORT SUBMITTED
14. DATES OF PAYROLL PERIOD USED 1. YES 2. NO | MO. | DAY | YEAR |
SECTION C - SIGNATURE AND IDENTIFICATION 17. NAME OF PERSON COMPLETING FORM (PRINT OR
STATE OF NEW JERSEY DIVISION OF PURCHASE AND PROPERTY (DPP)
NOTICE OF INTENT TO SUBCONTRACT FORM
THIS NOTICE OF INTENT TO SUBCONTRACT FORM MUST BE COMPLETED AND INCLUDED AS PART OF EACH BIDDER’S PROPOSAL. FAILURE TO SUBMIT THIS FORM WILL BE CAUSE FOR REJECTION OF THE BID AS NON-RESPONSIVE.
i Solicitation Number: Solicitation Title:
Name and Address:
INSTRUCTIONS: PLEASE CHECK ONE OF THE BELOW LISTED BOXES:
If awarded this contract, I will engage subcontractors to provide certain goods
and/or services.
ALL BIDDERS THAT INTEND TO ENGAGE SUBCONTRACTORS MUST ALSO SUBMIT A COMPLETED AND CERTIFIED SUBCONTRACTOR UTILIZATION PLAN WITH THEIR BID PROPOSALS.
If awarded this contract, I do not intend to engage subcontractors to provide any goods and/or services.
ALL BIDDERS THAT DO NOT INTEND TO ENGAGE SUBCONTRACTORS MUST ATTEST TO THE FOLLOWING CERTIFICATION:
I hereby certify that if the award is granted to my firm and if I determine at any time during the course of the contract to engage subcontractors to provide certain goods and/or services, pursuant to Section 3.11 of the Standard Terms and Conditions, I will submit the Subcontractor Utilization Plan (Plan) for approval to the Division of Purchase and Property in advance of any such engagement of subcontractors. Additionally, I certify that in engaging subcontractors, I will make a good faith effort to achieve the subcontracting set-aside goals established for this contract, and I will attach to the Plan documentation of such efforts in accordance with NJAC 17:13-4 and the Notice to All Bidders.
REQUIRED SUBMISSION IF BIDDER INTENDS TO SUBCONTRACT
STATE OF NEW JERSEYλDIVISION OF PURCHASE AND PROPERTY (DPP)
SUBCONTRACTOR UTILIZATION PLAN
(REFERENCED IN RFP STANDARD TERMS AND CONDITIONS)
DPP Solicitation No.:
NOTE: If utilizing subcontractors, failure to submit this properly completed form will be
sufficient cause for rejection of the bid as non-responsive.
DPP Solicitation Title:
Bidder’s Name and Address:
• Bidder’s Telephone No.:____________________
• Bidder’s Contact Person:____________________
INSTRUCTIONS: List all businesses to be used as subcontractors. This form may be duplicated for extended lists.
REGISTERED WITH NJ COMMERCE AND ECONOMIC
GROWTH COMMISSION * SMALL BUSINESS CATEGORY
SUBCONTRACTOR’S NAME
ADDRESS, ZIP CODE TELEPHONE
NUMBER AND VENDOR ID
NUMBER
I II III
TYPE(S) OF GOODS OR SERVICES TO BE
PROVIDED
ESTIMATED VALUE OF SUBCONTRACTS
* For those Bidders listing Small Business Subcontractors: Attach copies of NJ Commerce & Economic Growth Commission registration for each subcontractor listed. If bidder has not achieved established subcontracting set-aside goals, also attach documentation of good faith
effort to do so in the relevant category in accordance with NJAC17:13-4 and the Notice to All Bidders.
I hereby certify that this Subcontractor Utilization Plan (Plan) is being submitted in good faith. I certify that each subcontractor has been notified that it has been listed on this Plan and that each subcontractor has consented, in writing, to its name being submitted for this
contract. Additionally, I certify that I shall notify each subcontractor listed on the Plan, in writing, if the award is granted to my firm, and I shall make all documentation available to the Division of Purchase and Property upon request.
I further certify that all information contained in this Plan is true and correct and I acknowledge that the State will rely on the truth of the
The pricing sheet labeled “Without Eligibility” will be used to price the scope of work as specified within this RFP without eligibility determination. The pricing sheet labeled “With Eligibility” will be used to price the scope of work as specified within this RFP with eligibility determination for the NJ FamilyCare Plan A population. Implementation Pricing Pricing Sheets 5A and 5B shall be used to price the cost of implantation of this project. Costs shall be all inclusive for the Transition Period to ensure Operational Start Date will be met.
Variable Pricing for Fluctuations in Enrollment.
The contract uses a fixed monthly price (one twelfth of the yearly firm fixed price), assuming the number of beneficiaries enrolled in Managed Care will remain fairly constant. The Managed Care Population is expected to remain fairly consistent, with an average enrollment of 638,000. The fixed payment shall remain in effect as long as the number of beneficiaries enrolled in Managed Care remains within a range of 600,000 to 680,000. If the population should fluctuate outside the borders of this range, the payment method may change to variable for the following payment categories: Call Center, Mailroom Operations, Managed Care Enrollment, Quality Assurance, Training, and Program Integrity. The variable price will be set at a price per person enrolled in Managed Care. The price per person will be equal to the fixed monthly payment divided by 638,000. The monthly Managed Care Enrollment Report generated by the Office of Statistical Analysis and Managed Care Reimbursement will serve as the official report to determine Managed Care Enrollment
The NJ FamilyCare Managed Care Population is expected to decline from 202,000 to 198,000 over the contracted three-year period, with an average enrollment of 200,000. The fixed payment shall remain in effect as long as the number of beneficiaries enrolled in NJ FamilyCare Managed Care remains within a range of 180,000 to 220,000. If the population should fluctuate outside the borders of this range, the payment method would change to variable pricing. The variable price will be set at a price per person enrolled in Managed Care for NJ FamilyCare. The price per person will be equal to the fixed monthly payment divided by 200,000. The monthly Managed Care Enrollment Report generated by the Office of Statistical Analysis and Managed Care Reimbursement will serve as the official report to determine Managed Care Enrollment.
Postage costs shall be passed through as direct costs to the State, and no administrative service fees may be
charged as part of the direct postage fee. The contractor shall use pre-sort and other automation measures that provide the lowest effective postage costs. The contractor shall take advantage of postage discounts made available for volume, sorted and batch mail.
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ATTACHMENT 5A - PRICE SCHEDULE FOR TRANSITION PERIOD WITHOUT ELIGIBILITY
Bid Item Description Unit Year 1 Year 2 Year 3 Total Price
1. All Inclusive Firm Fixed Price for Definition of Business Requirements Task
$
2. All Inclusive Firm Fixed Price for Software Development During Transition Period
Task
$
3. All Inclusive Firm Fixed Price to Establish Telecommunications Functionality
Each
$
4.
All Inclusive Firm Fixed Price for Operational Procedure and Policy Manual (development, completion and acceptance by DMAHS)
Each
$
5. Fully Loaded Firm Fixed Price for Parallel Testing and Transition Task
$
6. Fully Loaded Firm Fixed Price for Staff Training to Ensure Operational Start Date is Met
Task
$
Total Transition Price $ $
107
ATTACHMENT 5B - PRICE SCHEDULE FOR TRANSITION PERIOD WITH ELIGIBILITY
Bid Item Description Unit Year 1 Year 2 Year 3 Total Price
7. All Inclusive Firm Fixed Price for Definition of Business Requirements Task
$
8. All Inclusive Firm Fixed Price for Software Development During Transition Period
Task
$
9. All Inclusive Firm Fixed Price to Establish Telecommunications Functionality
Each
$
10.
All Inclusive Firm Fixed Price for Operational Procedure and Policy Manual (development, completion and acceptance by DMAHS)
Each
$
11. Fully Loaded Firm Fixed Price for Parallel Testing and Transition Task
$
12. Fully Loaded Firm Fixed Price for Staff Training to Ensure Operational Start Date is Met
Task
$
Total Transition Price $ $
108
ATTACHMENT 5C – PRICE SCHEDULE WITHOUT ELIGIBILTY
Bid Item Description Unit Year 1 Year 2 Year 3 Total Price
13. Fully Loaded Firm Fixed Price for One Year - Managed Care Enrollment Effort Without Eligibility Campaign
Year
$
Total Annual Price $ $
Bid Item Description Unit Year 1 Year 2 Year 3 Total Price
14.
Fully Loaded Firm Fixed Price for Each Home Visit Above the Estimated 125 per month for Enrollment without Eligibility
Each
$
15. Pass Through Mailing Costs Each
$
109
ATTACHMENT 5D – PRICE SCHEDULE WITH ELIGIBILTY
Bid Item Description Unit Year 1 Year 2 Year 3 Total Price
16. Fully Loaded Firm Fixed Price for One Year - Managed Care Enrollment Effort With Eligibility Campaign
Year
$
Total Annual Price $ $
Bid Item Description Unit Year 1 Year 2 Year 3 Total Price
17. Fully Loaded Firm Fixed Price for Each Home Visit Above the Estimated 125 per month for Enrollment With Eligibility
Each
$
18. Pass Through Mailing Costs
$
110
ATTACHMENT 6 - RECIPROCITY FORM (Optional Submission)
RECIPROCITY FORM
IMPORTANT NOTICE TO ALL BIDDERS Effective October 7, 1991 in accordance with N.J.S.A. 52:32-1.4 and N.J.A.C. 17:12-2.13, the State of New Jersey will invoke reciprocal action against an out-of-State bidder whose State or locality maintains a preference practice for their bidders. For States having preference laws, regulations, or practices, New Jersey will use the annual surveys compiled by the Council of State Governments, National Association of State Purchasing Officials, or the National Institute of Governmental Purchasing to invoke reciprocal actions. The State may obtain additional information anytime it deems appropriate to supplement the above survey information. Any bidder may submit information related to preference practices enacted for a local entity outside the State of New Jersey. This information may be submitted in writing as part of the bid response proposal, and should be in the form or resolutions passed by an appropriate governing body, regulations, a Notice to Bidders, laws, etc. It is the responsibility of the bidder to provide the documentation with the bid proposal or submit it to the Director, Division of Purchase and Property within five (5) working days of the public bid opening. Written evidence for a specific procurement that is not provided to the Director within five working days of the public bid opening will not be considered in the evaluation of that procurement, but will be retained and considered in the evaluation of subsequent procurements. Any bidder having evidence of out-of-State local entities invoking preference practices should complete the form below, with a copy of appropriate documentation. The form and documentation may be submitted with you bid response proposal.
Name of Locality having preference practices:
City /Town/Authority
County
State
Documentation Attached
Resolution Regulations/Laws Notice to Bidder Other _________________________
Name of Firm Submitting this information _____________________________________________ Please Print
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APPENDIX 1 NJ STATE STANDARD TERMS AND CONDITIONS
STATE OF NEW JERSEY STANDARD TERMS AND CONDITIONS
I. Unless the bidder is specifically instructed otherwise In the Request for Proposal, the following terms and
conditions will apply to all contracts or purchase agreements made with the State of New Jersey. These terms are in addition to the terms and conditions set forth in the Request for Proposal (RFP) and should be read in conjunction with same unless the RFP specifically indicates otherwise. If a bidder proposes changes or modifications or takes exception to any of the State's terms and conditions, the bidder must so state specifically in writing in the bid proposal. Any proposed change, modification or exception in the State's terms and conditions by a bidder will be a factor in the determination of an award of a contractor purchase agreement.
II. All of the State's terms and conditions will become a part of any contract(s) or order(s} awarded as a result of the Request for
Proposal, whether stated in part, in summary or by reference. In the event the bidder's terms and conditions conflict with the State's, the State's terms and conditions will prevail, unless the bidder is notified in writing of the State's acceptance of the bidder's terms and conditions.
III. The statutes, laws or codes cited are available for review at the New Jersey State Library, 185 West State Street, Trenton, New
Jersey 08625. IV. If awarded a contract or purchase agreement, the bidder's status shall be that of any independent principal and not as an
employee of the State.
1. STATE LAW REQUIRING MANDATORY COMPLIANCE BY ALL CONTRACTORS
1.1 BUSINESS REGISTRATION - All New Jersey and out of State Corporations must obtain a Business Registration Certificate (BRC) from the Department of the Treasury, Division of Revenue prior to conducting business in the State of New Jersey. Proof of valid business registration with the Division of Revenue, Department of the Treasury, State of New Jersey, should be submitted by the bidder and, if applicable, by every subcontractor of the bidder, with the bidder's bid. No contract will be awarded without proof of business registration with the Division of Revenue. Any questions in this regard can be directed to the Division of Revenue at (609) 292-1730. Form NJ-REG. can be filed online at. http://www.state.nj.us/treasury/revenue/gettingregistered.htm#busentity
1.2 ANTI-DISCRIMINATION - All parties to any contract with the State of New Jersey agree not to discriminate in employment
and agree to abide by all anti-discrimination laws including those contained within N.J.S.A. 10:2-1 through N.J.S.A. 10:2-4, N.J.S.A.l0:5-1 et seq. and N.J.S.A.l0:5-31 through 10:5-38, and all rules and regulations issued there under.
1.3 PREVAILING WAGE ACT - The New Jersey Prevailing Wage Act, N.J.S.A. 34: 11-56.26 et seq. is hereby made part of
every contract entered into on behalf of the State of New Jersey through the Division of Purchase and Property, except those contracts which are not within the contemplation of the Act. The bidder's signature on this proposal is his guarantee that neither he nor any subcontractors he might employ to perform the work covered by this proposal has been suspended or debarred by the Commissioner, Department of Labor for violation of the provisions of the Prevailing Wage Act.
1.4 AMERICANS WITH DISABILITIES ACT - The contractor must comply with all provisions of the Americans With Disabilities
Act (ADA), P.L 101-336, in accordance with 42 U.S.C. 12101 et seq. 1.5 THE WORKER AND COMMUNITY RIGHT TO KNOW ACT - The provisions of N.J.S.A. 34:5A-l et seq. which require the
labeling of all containers of hazardous substances are applicable to this contract. Therefore, all goods offered for purchase to the State must be labeled by the contractor in compliance with the provisions of the Act.
1.6 OWNERSHIP DISCLOSURE - Contracts for any work, goods or services cannot be issued to any corporation or partnership
unless prior to or at the time of bid submission the bidder has disclosed the names and addresses of all its owners holding 10% or more of the corporation or partnership's stock or interest. Refer to N.J.S.A. 52:25-24.2.
1.7 COMPLIANCE - LAWS - The contractor must comply with all local, state and federal laws, rules and regulations applicable
to this contract and to the goods delivered and/or services performed hereunder. 1.8 COMPLIANCE - STATE LAWS - It is agreed and understood that any contracts and/or orders placed as a result of this
proposal shall be governed and construed and the rights and obligations of the parties hereto shall be determined in accordance with the laws of the STATE OF NEW JERSEY.
1.9 COMPLIANCE - CODES - The contractor must comply with NJUCC and the latest NEC70, B.O.C.A. Basic Building code,
OSHA and all applicable codes for this requirement. The contractor will be responsible for securing and paying all necessary permits, where applicable.
2.1 LIABILITY - COPYRIGHT - The contractor shall hold and save the State of New Jersey, its officers, agents, servants and employees, harmless from liability of any nature or kind for or on account of the use of any copyrighted or uncopyrighted composition, secret process, patented or unpatented invention, article or appliance furnished or used in the performance of his contract.
2.2 INDEMNIFICATION - The contractor shall assume all risk of and responsibility for, and agrees to indemnify, defend, and
save harmless the State of New Jersey and its employees from and against any and all claims, demands, suits, actions, recoveries, judgments and costs and expenses in connection therewith on account of the loss of life, property or injury or damage to the person, body or property of any person or persons whatsoever, which shall arise from or result directly or indirectly from the work and/or materials supplied under this contract. This indemnification obligation is not limited by, but is in addition to the insurance obligations contained in this agreement.
2.3 INSURANCE - The contractor shall secure and maintain in force for the term of the contract liability insurance as provided
herein. The contractor shall provide the State of New Jersey with current certificates of insurance for all coverages and renewals thereof which must contain the proviso that the insurance provided in the certificate shall not be canceled for any reason except after thirty days written notice to:
STATE OF NEVV JERSEY
Purchase Bureau - Bid Ref.#
The insurance to be provided by the contractor shall be as follows. a. General liability policy as broad as the standard coverage forms currently in use in the State of New Jersey which shall
not be circumscribed by any endorsements limiting the breadth of coverage. The policy shall be endorsed to include:
1. BROAD FORM COMPREHENSIVE GENERAL LIABILITY 2. PRODUCTS/COMPLETED OPERATIONS 3. PREMISES/OPERATIONS
The limits of liability for bodily injury and property damage shall not be less than $1 million per occurrence as a combined single limit. b. Automobile liability insurance which shall be written to cover any automobile used by the insured. Limits of liability for
bodily Injury and property damage shall not be less than $1 million per occurrence as a combined single limit. c. Worker's Compensation Insurance applicable to the laws of the State of New Jersey and Employers Liability Insurance
with limits not less than $100,000 BODILY INJURY, EACH OCCURRENCE $100,000 DISEASE EACH EMPLOYEE $500,000 DISEASE AGGREGATE LIMIT
3. TERMS GOVERNING ALL PROPOSALS TO NEW JERSEY PURCHASE BUREAU
3.1 CONTRACT AMOUNT - The estimated amount of the contract(s), when stated on the Advertised Request for Proposal
form, shall not be construed as either the maximum or minimum amount which the State shall be obliged to order as the result of this Request for Proposal or any contract entered into as a result of this Request for Proposal.
3.2 CONTRACT PERIOD AND EXTENSION OPTION - If, in the opinion of the Director of the Division of Purchase and
Property, it is in the best interest of the State to extend an contract entered into as a result of this Request for Proposal, the contractor will be so notified of the Director s Intent at least 30 days prior to the expiration date of the existing contract. The contractor shall have 15 calendar days to respond to the Director's request to extend the contract. If the contractor agrees to the extension, all terms and conditions of the original contract, including price, will be applicable.
3.3 BID AND PERFORMANCE SECURITY
a. Bid Security - If bid security is required, such security must be submitted with the bid in the amount listed in the Request
for Proposal, see N.J.A.C. 17: 12- 2.4. Acceptable forms of bid security are as follows: 1. A properly executed individual or annual bid bond issued by an insurance or security company authorized to do
business in the State of New Jersey, a certified or cashier's check drawn to the order of the Treasurer, State of New Jersey, or an irrevocable letter of credit drawn naming the Treasurer, State of New Jersey as beneficiary issued by a federally insured financial institution.
113
2. The State will hold all bid security during the evaluation process. As soon as is practicable after the completion of the evaluation, the State will: a. Issue an award notice for those offers accepted by the State; b. Return all bond securities to those who have not been issued an award notice.
All bid security from contractors who have been issued an award notice shall be held until the successful execution of all required contractual documents and bonds (performance bond, insurance, etc. If the contractor fails to execute the required contractual documents and bonds within thirty (30) calendar days after receipt of award notice, the contractor may be found in default and the contract terminated by the State. In case of default, the State reserves all rights inclusive of, but not limited to, the right to purchase material and/or to complete the required work in accordance with the New Jersey Administrative Code and to recover any actual excess costs from the contractor. Collection against the bid security shall be one of the measures available toward the recovery of any excess costs.
b. Performance Security - If performance security is required, the successful bidder shall furnish performance security in
such amount on any award of a term contractor line item purchase, see N.J.A.C. 17: 12- 2.5. Acceptable forms of performance security are as follows: 1. The contractor shall be required to furnish an irrevocable security in the amount listed in the Request for Proposal
payable to the Treasurer, State of New Jersey, binding the contractor to provide faithful performance of the contract. 2. The performance security shall be in the form of a properly executed individual or annual performance bond issued
by an insurance or security company authorized to do business in the State of New Jersey, a certified or cashier's check drawn to the order of the Treasurer, State of New Jersey, or an irrevocable letter of credit drawn naming the Treasurer, State of New Jersey as beneficiary issued by a federally insured financial institution.
The Performance Security must be submitted to the State within 30 days of the effective date of the contract award and cover the period of the contract and any extensions thereof. Failure to submit performance security may result in cancellation of contract for cause pursuant to provision 3.5b,1, and nonpayment for work performed.
3.4 VENDOR RIGHT TO PROTEST - INTENT TO AWARD - Except in cases of emergency, bidders have the right to protest
the Director's proposed award of the contract as announced in the Notice of Intent to Award, see N.J.A.C. 17:12-3.3. Unless otherwise stated, a bidder's protest must be submitted to the Director within 10 working days after receipt of written notification that his bid has not been accepted or that an award of contract has been made. In the public interest, the Director may shorten this protest period, but shall provide at least 48 hours for bidders to respond to a proposed award. In cases of emergency, stated in the record, the Director may waive the appeal period. See N.J.A.C. 17: 12- 3 et seq.
3.5 TERMINATION OF CONTRACT
a. Change of Circumstances
Where circumstances and/or the needs of the State significantly change, or the contract is otherwise deemed no longer to be in the public interest, the Director may terminate a contract entered into as a result of this Request for Proposal, upon no less than 30 days notice to the contractor with an opportunity to respond.
In the event of such termination, the contractor shall furnish to the using agency, free of charge, such reports as may be required,
b. For cause:
1. Where a contractor fails to perform or comply with a contract, and/or fails to comply with the complaints procedure in N.J.A.C. 17: 12-4.2 et seq., the Director may terminate the contract upon 10 days notice to the contractor with an opportunity to respond.
2. Where a contractor continues to perform a contract poorly as demonstrated by formal complaints, late delivery, poor
performance of service, short-shipping etc., so that the Director is repeatedly required to use the complaints procedure in N.J.A.C. 17:12-4.2 et seq. the Director may terminate the contract upon 10 days notice to the contractor with an opportunity to respond.
c. In cases of emergency the Director may shorten the time periods of notification and may dispense with an opportunity to
respond. d. In the event of termination under this section, the contractor will be compensated for work performed in accordance with
the contract, up to the date of termination. Such compensation may be subject to adjustments.
3.6 COMPLAINTS - Where a bidder has a history of performance problems as demonstrated by formal complaints and/or contract cancellations for cause pursuant to 3.5b a bidder may be bypassed for this award. See N.J.A.C. 17:12-2.8.
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3.7 EXTENSION OF CONTRACT QUASI-STATE AGENCIES - It is understood and agreed that in addition to State Agencies,
Quasi-State Agencies may also participate in this contract. Quasi-State Agencies are defined in N.J.S.A. 52:27B-56.1 as any agency, commission, board, authority or other such governmental entity which is established and is allocated to a State department or any bi-state governmental entity of which the State of New Jersey is a member.
3.8 EXTENSION OF CONTRACTS TO POLITICAL SUBDIVISIONS, VOLUNTEER FIRE DEPARTMENTS AND FIRST AID
SQUADS, AND INDEPENDENT INSTITUTIONS OF HIGHER EDUCATION - N.J.S.A. 52:25-16.1 permits counties, municipalities and school districts to participate in any term contract{s), that may be established as a result of this proposal.
N.J.S.A. 52:25-16.2 permits volunteer fire departments, volunteer first aid squads and rescue squads to participate in any term contract(s) that may be established as a result of this proposal. N.J.S.A. 52:25-16.5 permits independent institutions of higher education to participate in any term contract(s) that may be established as a result of this proposal, provided that each purchase by the Independent Institution of higher education shall have a minimum cost of $500. In order for the State contract to be extended to counties, municipalities, school districts, volunteer fire departments, first aid squads and independent institutions of higher education the bidder must agree to the extension and so state in his bid proposal. The extension to counties municipalities, school districts, volunteer fire departments, first aid squads and Independent Institutions of higher education must 'be under the same terms and conditions, including price, applicable to the State.
3.9 EXTENSIONS OF CONTRACTS TO COUNTY COLLEGES - N.J.S.A. 18A:64A - 25. 9 permits any college to participate in any term contract(s) that may be established as a result of this proposal.
3.10 EXTENSIONS OF CONTRACTS TO STATE COLLEGES - N.J.S.A. 18A:64- 60 permits any State College to participate in
any term contract{s) that may be established as a result of this proposal. 3.11 SUBCONTRACTING OR ASSIGNMENT - The contract may not be subcontracted or assigned by the contractor, in whole
or in part, without the prior written consent of the Director of the Division of Purchase and Property. Such consent, if granted, shall not relieve the contractor of any of his responsibilities under the contract.
In the event the bidder proposes to subcontract for the services to be performed under .the terms of the contract award, he shall state so in his bid and attach for approval a list of said subcontractors and an Itemization of the products and/or services to be supplied by them. Nothing contained in the specifications shall be construed as creating any contractual relationship between any subcontractor and the State.
3.12 MERGERS, ACQUISITIONS - If, subsequent to the award of any contract resulting from this Request for Proposal, the contractor shall merge with or be acquired by another firm, the following documents must be submitted to the Director, Division of Purchase & Property.
a. Corporate resolutions prepared by the awarded contractor and new entity ratifying acceptance of the original contract,
terms, conditions and prices.
b. State of New Jersey Bidders Application reflecting all updated information including ownership disclosure, pursuant to provision 1.5.
c. Vendor Federal Employer Identification Number. The documents must be submitted within thirty (30) days of completion of the merger or acquisition. Failure to do so may result in termination of contract pursuant to provision 3.5b. If subsequent to the award of any contract resulting from this Request for Proposal, the contractor's partnership or corporation shall dissolve, the Director, Division of Purchase & Property must be so notified. All responsible parties of the dissolved partnership or corporation must submit to the Director in writing, the names of the parties proposed to perform the contract, and the names of the parties to whom payment should be made. No payment should be made until all parties to the dissolved partnership or corporation submit the required documents to the Director.
3.13 PERFORMANCE GUARANTEE OF BIDDER - The bidder hereby certifies that:
a. The equipment offered is standard new equipment, and is the manufacturer's latest model in production, with parts regularly used for the type of equipment offered; that such parts are all in production and not likely to be discontinued; and that no attachment or part has been substituted or applied contrary to manufacturer's recommendations and standard practice.
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b. All equipment supplied to the State and operated by electrical current is UL listed where applicable. c. All new machines are to be guaranteed as fully operational for the period stated in the Request For Proposal from time of
written acceptance by the State. The bidder will render prompt service without charge, regardless of geographic location.
d. Sufficient quantities of parts necessary for proper service to equipment will be maintained at distribution points and
service headquarters. e. Trained mechanics are regularly employed to make necessary repairs to equipment in the territory from which the
service request might emanate within a 48-hour period or within the time accepted as industry practice. f. During the warranty period the contractor shall replace immediately any material which is rejected for failure to meet the
requirements of the contract. g. All services rendered to the State shall be performed in strict and full accordance with the specifications stated in the
contract. The contract shall not be considered complete until final approval by the State's using agency is rendered. 3.14 DELIVERY GUARANTEES - Deliveries shall be made at such time and in such quantities as ordered in strict accordance
with conditions contained in the Request for Proposal.
The contractor shall be responsible for the delivery of material in first class condition to the State's using agency or the purchaser under this contract and in accordance with good commercial practice. Items delivered must be strictly in accordance with the Request for Proposal. In the event delivery of goods or services is not made within the number of days stipulated or under the schedule defined in the Request for Proposal, the using agency may be authorized to obtain the material or service from any available source, the difference in price, if any, to be paid by the contractor failing to meet his commitments.
3.15 DIRECTOR'S RIGHT OF FINAL BID ACCEPTANCE - The Director reserves the right to reject any or all bids, or to award
in whole or in part if deemed to be in the best interest of the State to do so. The Director shall have authority to award orders or contracts to the vendor or vendors best meeting all specifications and conditions in accordance with N.J.S.A. 52:34-12. Tie bids will be awarded by the Director in accordance with N.J.A.C.17:12-2.1D.
3.16 BID ACCEPTANCES AND REJECTIONS - The provisions of N.J.A.C. 17:12-2.9, relating to the Director's right, to waive
minor elements of non-compliance with bid specifications and N.J.A.C. 17: 12- 2.2 which defines causes for automatic bid rejection, apply to all proposals and bids.
3.17 STATE'S RIGHT TO INSPECT BIDDER'S FACILITIES - The State reserves the right to inspect the bidder's establishment
before making an award, for the purposes of ascertaining whether the bidder has the necessary facilities for performing the contract.
The State may also consult with clients of the bidder during the evaluation of bids. Such consultation is intended to assist the State in making a contract award which is most advantageous to the State.
3.18 STATE'S RIGHT TO REQUEST FURTHER INFORMATION - The Director reserves the right to request all information
which may assist him or her in making a contract award, including factors necessary to evaluate the, bidder s financial capabilities to perform the contract. Further, the Director reserves the right to request a bidder to explain, in detail, how the bid price was determined.
3.19 MAINTENANCE OF RECORDS - The contractor shall maintain records for products and/or services delivered against the
contract for a period of three (3) years from the date of final payment. Such records shall be made available to the, State upon request for purposes of conducting an audit or for ascertaining information regarding dollar volume or number of transactions.
4. TERMS RELATING TO PRICE QUOTATION
4.1 PRICE FLUCTUATION DURING CONTRACT - Unless otherwise noted by the State, all prices quoted shall be firm
through issuance of contract or purchase order and shall not be subject to increase during the period of the contract.
In the event of a manufacturer's or contractor's price decrease during the contract period, the State shall receive the full benefit of such price reduction on any undelivered purchase order and on any subsequent order placed during the contract period. The Director of Purchase and Property must be notified, in writing, of any price reduction within five (5) days of the effective date. Failure to report price reductions will result in cancellation of contract for cause, pursuant to provision 3.5b.1.
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4.2 DELIVERY COSTS - Unless otherwise noted in the Request for Proposal, all prices for items in bid proposals are to be submitted F.O.B. Destination. Proposals submitted other than F.O.B. Destination may not be considered. Regardless of the method of quoting shipments, the contractor shall assume all costs, liability and responsibility for the delivery of merchandise in good condition to the State's using agency or designated purchaser.
F.O.B. Destination does not cover "spotting" but does include delivery on the receiving platform of the ordering agency at any destination in the State of New Jersey unless otherwise specified. No additional charges will be allowed for any additional transportation costs resulting from partial shipments made at contractor's convenience when a single shipment is ordered. The weights and measures of the State's using agency receiving the shipment shall govern.
4.3 C.O.D. TERMS - C.O.D. terms are not acceptable as part of a bid proposal and will be cause for rejection of a bid. 4.4 TAX CHARGES - The State of New Jersey is exempt from State sales or use taxes and Federal excise taxes. Therefore,
price quotations must not include such taxes. The State's Federal Excise Tax Exemption number is 22-75-0050K. 4.5 PAYMENT TO VENDORS - Payment for goods and/or services purchased by the State will only be made against State
Payment Vouchers. The State bill form in duplicate together with the original Bill of Lading, express receipt and other related papers must be sent to the consignee on the date of each delivery. Responsibility for payment rests with the using agency which will ascertain that the contractor has performed in a proper and satisfactory manner in accordance with the terms and conditions of the award. Payment will not be made until the using agency has approved payment.
For every contract the term of which spans more than one fiscal year, the State's obligation to make payment beyond the current fiscal year is contingent upon legislative appropriation and availability of funds. The State of New Jersey now offers State contractors the opportunity to be paid through the MasterCard procurement card (p-card). A contractor's acceptance and a State Agency's use of the p-card, however, is optional. P-card transactions do not require the submission of either a contractor invoice or a State payment voucher. Purchasing transactions utilizing the p-card will usually result in payment to a contractor in three days. A Contractor should take note that there will be a transaction processing fee for each p-card transaction. To participate, a contractor must be capable of accepting the MasterCard card. For more information, call your bank or any merchant services company.
4.6 NEW JERSEY PROMPT PAYMENT ACT - The New Jersey Prompt Payment Act N.J.S.A. 52:32-32 et seq. requires state
agencies to pay for goods and services within sixty (60) days of the agency's receipt of a properly executed State Payment Voucher or within sixty (60) days of receipt and acceptance of goods and services, whichever is later. Properly executed performance security, when required, must be received by the state prior to processing any payments for goods and services accepted by state agencies. Interest will be paid on delinquent accounts at a rate established by the State Treasurer. Interest will not be paid until it exceeds $5.00 per properly executed invoice.
Cash discounts and other payment terms included as part of the original agreement are not affected by the Prompt Payment Act.
4.7 RECIPROCITY - In accordance with N.J.S.A. 52:32-1.4 and N.J.A.C. 17: 12- 2. 13, the State of New Jersey will invoke
reciprocal action against an out-of-State bidder whose state or locality maintains a preference practice for their bidders.
5. CASH DISCOUNTS - Bidders are encouraged to offer cash discounts based on expedited payment by the State. The State will make efforts to take advantage of discounts, but discounts will not be considered in determining the lowest bid.
a. Discount periods shall be calculated starting from the next business day after the recipient has accepted the goods or
services received a properly signed and executed State Payment Voucher form and, when required, a properly executed performance security, whichever is latest.
b. The date on the check issued by the State in payment of that Voucher shall be deemed the date of the State's response to
that Voucher.
6. STANDARDS PROHIBITING CONFLICTS OF INTEREST - The following prohibitions on vendor activities shall apply to all contracts or purchase agreements made with the State of New Jersey, pursuant to Executive Order No. 189 (1988).
a. No vendor shall pay, offer to pay, or agree to pay, either directly or indirectly, any fee, commission, compensation, gift,
gratuity, or other thing of value of any kind to any State officer or employee or special State officer or employee, as defined by N.J.S.A. 52:13D-13b and e., in the Department of the Treasury or any other agency with which such vendor transacts or offers or proposes to transact business, or to any member of the immediate family, as defined by N.J.S.A. 52:13D-13i., of any such officer or employee, or partnership, firm or corporation with which they are employed or associated, or in which such officer or employee has an interest within the meaning of N.J.S.A. 52: 13D-13g.
b. The solicitation of any fee, commission, compensation, gift, gratuity or other thing of value by any State officer or employee or
special State officer or employee from any State vendor shall be reported in writing forthwith by the vendor to the Attorney General and the Executive Commission on Ethical Standards.
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c. No vendor may, directly or indirectly, undertake any private business, commercial or entrepreneurial relationship with, whether or not pursuant to employment, contract or other agreement, express or implied, or sell any interest in such vendor to, any State officer or employee or special State officer or employee or special State officer or employee having any duties or responsibilities in connection with the purchase, acquisition or sale of any property or services by or to any State agency or any instrumentality thereof, or with any person, firm or entity with which he is employed or associated or in which he has an interest within the meaning of N.J.S.A. 52: 130-13g. Any relationships subject to this provision shall be reported in writing forthwith to the Executive Commission on Ethical Standards, which may grant a waiver of this restriction upon application of the State officer or employee or special State officer or employee upon a finding that the present or proposed relationship does not present the potential, actuality or appearance of a conflict of interest.
d. No vendor shall influence, or attempt to influence or cause to be influenced, any State officer or employee or special State
officer or employee in his official capacity in any manner which might tend to impair the objectivity or independence of judgment of said officer or employee.
e. No vendor shall cause or influence, or attempt to cause or influence, any State officer or employee or special State officer or employee to use, or attempt to use, his official position to secure unwarranted privileges or advantages for the vendor or any other person.
f. The provisions cited above in paragraph 6a through 6e shall not be construed to prohibit a State officer or employee or
Special State officer or employee from receiving gifts from or contracting with vendors under the same terms and conditions as are offered or made available to members of the general public subject to any guidelines the Executive Commission on Ethical Standards may promulgate under paragraph 6c.
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APPENDIX 2 - SET-OFF FOR STATE TAX NOTICE
NOTICE TO ALL BIDDERS SET-OFF FOR STATE TAX NOTICE
Please be advised that, pursuant to P.L 1995, c. 159, effective January 1, 1996, and notwithstanding any provision of the law to the contrary, whenever any taxpayer, partnership or S corporation under contract to provide goods or services or construction projects to the State of New Jersey or its agencies or instrumentalities, including the legislative and judicial branches of State government, is entitled to payment for those goods or services at the same time a taxpayer, partner or shareholder of that entity is indebted for any State tax, the Director of the Division of Taxation shall seek to set off that taxpayer’s or shareholder’s share of the payment due the taxpayer, partnership, or S corporation. The amount set off shall not allow for the deduction of any expenses or other deductions which might be attributable to the taxpayer, partner or shareholder subject to set-off under this act. The Director of the Division of Taxation shall give notice to the set-off to the taxpayer and provide an opportunity for a hearing within 30 days of such notice under the procedures for protests established under R.S. 54:49-18. No requests for conference, protest, or subsequent appeal to the Tax Court from any protest under this section shall stay the collection of the indebtedness. Interest that may be payable by the State, pursuant to P.L. 1987, c.184 (c.52:32-32 et seq.), to the taxpayer shall be stayed.
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APPENDIX 3 - DETAIL FUNCTIONALITY CHECKLIST
Instructions for completing Detailed Functionality Checklist
1. Please provide a numeric answer within the non-shaded response cells. 2. The legend for providing your responses is listed below. Failure to adhere to this scale may cause disqualification from the selection process.
Response Scale: 0 – The requested functionality is not available, nor will it be available in the future. If requested by the client, this functionality could be added . 2 – The requested functionality is not currently available but will be added in the near future. 3 – The requested functionality is currently available in the product.
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RFP Section
Functionality Checklist Response Vendor Comments
3.3.1.1 Call Center Functions and Activities 3.3.1.1 Ability of system to provide actual status of
beneficiary’s enrollment in NJFC, premium status, potential transfer between MCOs and exemption status.
3.3.1.1 Ability of system to generate for mailing, customer requested forms, brochures, educational material, applications, renewals, eligibility cards, invoices, etc.
3.3.1.1 Ability to generate reports on Missing Information (MI) required and MI received.
3.3.1.1 Ability of system to provided images of scanned information received including, but not limited to Applications, PSFs, Renewals, MI, Grievances, etc.
3.3.7 3.3.8
Ability for phone system to receive incoming calls after established business hours with electronic documentation of calls in a log.
3.3.1.9.1 Ability of system to provide an electronic/hard copy log of all calls and information requested and mailed.
3.3.12 Ability to install and operate Automated Call Distribution Equipment capable of handling all call volumes.
3.3.13 Ability to install and operate a TTD or TTY equipment for the hearing impaired.
3.3.14.1 Ability to provide a system that conducts real time and automated monitoring for inbound/outbound calls for State/Contractor staff to utilize.
3.3.16 Ability to provide monitoring system that provides automated voice recording, synchronized screen capture, on-line evaluation and comprehensive reporting.
3.3.16 Ability to upgrade phone lines to accommodate increasing call volumes.
3.3.22.1 Provide a daily system generated log with a supporting report each day for return calls made by Call Center Supervisors.
3.3.23 Ability for urgent and acute case calls received by the Call Center to be recorded systemically in an urgent call log for processing.
3.3.28 Ability to provide a system generated monthly report to the State, demonstrating contract compliance with Call Center requirements.
3.3.29 Ability for Call Center phone lines to accommodate all calls transferred from the National Kids Now Hotline.
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RFP Section
Functionality Checklist Response Vendor Comments
Mail Room Operations 3.4.1.2 Ability for any case materials/documents
received by mail or fax to be imaged and assigned a tracking number.
3.4.1.2 Ability of all State and Contractor Staff to have access to all imaged documents after imaging and entered onto contractor’s system.
NJFC Application and Eligibility Processing
3.5.1 Ability to accept all applications, enrollment forms, and supporting documentation and process them accurately in accordance with existing or amended Federal and State statutes and regulations.
3.5.1 Ability to process applications determining initial eligibility of applicants and premium amounts in accordance with existing or amended Federal and State statutes and regulations and any applicable DMAHS business rule.
Preliminary Eligibility Assessment 3.5.1.2 Operate a NJFC Data Entry and Preliminary
Eligibility Assessment area to calculate and determine NJFC Plan A cases from all other applications.
3.5.1.2 Ability to send Plan A cases to appropriate CWA.
3.5.1.2 3.5.1.4
Ability to process all other non Plan A applications to final disposition.
3.5.1.2 3.5.1.4
Ability to generate mailings to applicants regarding the receipt of the application, and when appropriate, the transferring of the application to the appropriate CWA for processing.
3.5.1.2 Ability to forward applications reporting no income, or when the application income section is left blank, to the appropriate CWA.
Case Transmission to CWAs 3.5.1.3 Ability to utilize a geo-access tracking system
based on mail zip code, municipal code of residence or other acceptable industry process, for forwarding Plan A cases to appropriate CWA for processing.
3.5.1.3
Ability to develop an Eligibility Processing and Management System (EPMS).
3.5.1.3 Ability to use the EPMS so all application source documentation is matched to Plan A Case Applications for forwarding to appropriate CWA.
Contractor Non Plan A Eligibility Responsibility
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RFP Section
Functionality Checklist Response Vendor Comments
3.5.1.4 Ability for system to generate and mail a notification of application, receipt, data entry, and screening to all applicants following their imaging and entry on to the system.
Eligibility Time Frames 3.5.1.5 Ability to generate a notice of eligibility
upon eligibility determination.
Missing Information 3.5.1.6 Ability to generate missing information
letters.
3.5.1.6 Ability to generate a letter terminating further action on application if missing information is not received.
Electronic Tracking 3.5.1.7 Ability to develop in association with the
EPMS, an electronic tracking capability for all NJFC applications and PSFs received.
3.5.1.7 Ability to track electronically current status of NJFC applications and PSFs and detailed status at time of inquiry.
3.5.1.7 Provide reconciliation between documents imaged and documents data entered.
Language Requirement 3.5.1.9 Ability to generate correspondence to
beneficiary/applicant in language specified on application, currently in English or Spanish.
Electronic NJFC Application 3.5.1.11 Ability to establish a link to the NJFC web-
site.
Eligibility Calculations 3.5.1.13 5.5.1.17
Utilize a computer-based program, developed using a commercially available and non-proprietary language, that performs eligibility calculations in accordance with State law, regulation or policy.
3.5.1.13 Ability to Secure access to the Depart of Labor files for wage, unemployment and disability files to validate/obtain financial data relation to eligibility.
Returned Documentation 3.5.1.14 Ability to electronically record in the
system, all attempts to outreach beneficiaries whose mail/ ID cards have been returned.
Eligibility Processing and Management System (EPMS)
3.5.1.17 3.5.13
Ability to design, develop, and implement and EPMS.
3.5.1.17 EPMS will have ability to perform all calculation for processing applications.
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RFP Section
Functionality Checklist Response Vendor Comments
3.5.1.17 EPMS will have ability to generate and record all notifications and pertinent documents, including documentation of all actual dates of mailing.
3.5.1.17 EPMS will have ability to electronically track, record and amend, as necessary, all applicable beneficiary premium payments.
3.5.1.17 EPMS will have ability to generate all Plan specific required letters, notices, invoices or other correspondence.
3.5.1.17 EPMS will have ability to generate any and all reports as may be required or requested for the administration and operation of the program.
NJFC Grievance/Complaints 3.5.1.20 Ability to maintain grievance records and
generate appropriate letters pertaining to the grievance/complaint process.
NJFC Renewal Process 3.5.1.21 3.5.1.23
Ability to develop and initiate an annual renewal process.
3.5.1.22 Ability to generate and document all renewal mailings.
3.5.1.26 Ability to conduct a review and analysis of renewal information collected in accordance with State requirements.
3.5.1.28 Ability to notify beneficiary and MCO of renewal termination.
3.5.1.28 Ability to record all documentation related to the renewal and/or termination, within both the MCES and EPMS.
3.5.1.29 Ability to notify beneficiary of the availability of a Certificate of Credible Coverage.
3.5.1.31 Ability to maintain records of all transactions relative to renewals, continued enrollment and terminations.
Managed Care Enrollment System (MCES)
3.6.1 Ability to design, develop, and implement a comprehensive Managed Care Enrollment System (MCES) capable of systemically and electronically performing all functions associated with the managed care enrolment process.
3.6.1 Ability of MCES to image and record all managed care documents.
3.6.1 Ability of MCES to assign identifiers and conduct complete case tracking.
3.6.1 Ability of MCES to link all managed care enrollments with program as well as managed care eligibility.
RFP Section
Functionality Checklist Response Vendor Comments
3.6.1 Ability of MCES to perform associated banking and lock-box linkages.
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3.6.1 Ability of MCES to generate and record all notifications and pertinent documents.
3.6.1 3.6.4.11
Ability of MCES to transmit and communicate all files necessary between the contractor, the State (including OIT), the County Welfare Agencies and all participating MCOs.
3.6.1 Ability of MCES to maintain, store, revise and manipulate any and all program and relative statistical and healthcare information in accordance with universally accepted data-base functions.
3.6.1 Ability of MCES to generate any reports that may be required or requested for the administration and operation of the program.
3.6.1 Ability of MCES to record disenrollment reasons.
3.6.1 Ability of MCES to perform all data entry associated with, and the transfer of, all information related to the Plan Selection Forms.
3.6.1.6 Maintain an electronic file of all processed and unprocessed PSFs.
3.6.1.3 3.6.1.6
Disseminate and control of any and all mailings/outreach pertaining to managed care.
Maintain managed care business rules. Online tracking of return/undeliverable
mail.
3.6.4.15 Ability to produce confirmation letters of MCO enrollment to beneficiaries.
3.6.5.6 Ability to produce enrollment and eligibility letters.
3.6.4.6 3.6.5.8
Ability to provide electronic enrollment verification to other systems.
3.6.5.11 Ability to track and report exact status of PSFs at the time of inquiry, including but not limited to, date received and processed, specific missing information that is pending, date of outreach to customer for missing information (telephone and mail).
3.6.5.16 Ability to produce a log of transfers, disenrollments and reenrollments.
3.6.1.19 3.6.4.13
Ability to provide add-hoc reports for the administration and operation of the programs.
Ability to track PSF processing, mailings and telephone calls.
RFP Section
Functionality Checklist Response Vendor Comments
Ability to track all telephone calls received from clients.
Ability to image and record all managed care documents.
3.6.1.6 3.6.1.7
Ability to distinguish between voluntary and mandatory managed care populations and
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mail appropriate education and outreach materials.
3.6.1.6 Conduct all automatic assignment processes
3.6.4.7 3.6.1.6
Maintain an electronic file of all processed and unprocessed Plan Selection Forms/HMO Choice forms/transfer and disenrollment forms.
3.6.1.19 Compile, maintain and report all pertinent statistical data associated with the managed care enrollment of the mandatory population.
3.6.4.4 Develop and maintain an electronic automated directory of participating providers for each participating MCO, including but not limited primary care providers, specialists, hospitals and ancillary providers.
3.6.4.4 Implement a system and have the capability for receiving updated provider information electronically using provider network specifications consistent with the file layouts for the database established by DMAHS.
3.6.1.11 Maintain listing of “umbrella organizations.” 3.6.1.18 Interface with OIT to ascertain eligibility
status.
3.6.1.18 Ability to generate beneficiary specific enrollment forms with preprinted case information.
3.6.1.18 Interface with OIT in processing beneficiary selections, exemptions/exclusion data.
3.6.4.13 System should have capability of generating all required letters, as specified by the State.
3.6.4.13 Generate weekly report of all non-processed PSFs by name, appropriate case tracking number, date, reason not processed, MCO chosen and any other information as may be pertinent.
3.6.5.17 Ability to electronically update all MCO transfers, disenrollments and reenrollments to another State system for eligibility file update.
3.6.6.2 3.6.6.3 3.6.6.4
Ability to scan, track and assign an identification number for all exemption requests and use that identification number on the exemption form mailed to the client.
3.6.6.5 Ability to place all beneficiaries awaiting a determination of their request into “pending exempt” status on the eligibility file and the tracking system.
RFP Section
Functionality Checklist Response Vendor Comments
3.6.6.6 3.6.6.7 3.6.6.8
Ability of tracking system to track and report exact status of exemption request, including final dispositions, and all contacts with the beneficiary concerning his/her
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exemption request. 3.6.6.9 Ability to send disposition notification
received from the MACC to the beneficiary and update eligibility file with final disposition.
3.6.6.11 Ability to electronically transmit exemption information to the Office of Customer service.
Premium Collection and Assignment for NJFC
3.6.7.3 Ability to produce a billing mail file that identifies beneficiaries and the amount of remittance, payment due date, month for which remittance is to be applied, and total remittance due and remittance received date.
3.6.7.7 Ability to identify and generate refunds through a fully integrated system which links the Eligibility Processing and Management System (EPMS) and accounting files.
Retention Program Reporting 3.6.8.5 Ability to generate and submit reports
containing retention program data as directed by the State.
Disenrollment Survey 3. 6.8.6 Ability to generate a disenrollment survey. Premium Support Program 3. 7.3 Ability to report to the State, on a weekly
basis, information on an initial application or a renewal concerning other health insurance.
3.7.5.1 Ability to record and submit reports to the State verifying all transactions for PSP.
Utilize State eligibility system to verify necessary client eligibility information.
Conduct reconciliation between contractor’s EPMS, MCES and the state eligibility file.
Maintain electronic file of all verbal and written complaints/inquiries against the contractor. Maintain records of contacts, correspondence and action taken to resolve the complaints/inquiries. Generate report to the state monthly.
Maintain confidentiality of provider, recipient and any other proprietary information.
3.10.4 Ability to generate QA reports that contain trended data and statistics, in all of the contractor’s areas of operation.
RFP Section
Functionality Checklist Response Vendor Comments
3.11.4 Ability to use commercially available computerized Training and Development Information System (TDIS).
Program Integrity Requirements 3.12.1 Ability to conduct system generated
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searches of the NJFC enrollment files for matches between beneficiaries and the contractor’s employees. Criteria for matches with SSN and home address.
3.12.1 Ability to match Social Security Death Index on a quarterly bases with NJFC eligibility file and contractor employees.
3.12.1 Ability to provide system security integrity controls to prevent altering of eligibility files by maintaining history of all updated system records.
