1. Introduction


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1. Introduction

  1. 1. HHSC Medicaid Disease Management RFP RFP No. 529-03-298 1. Introduction The Texas Health and Human Services Commission (HHSC) issues this Request for Proposals (RFP) to solicit responses from qualified vendors to provide services in support of the Title XIX Texas Medical Assistance Program (Medicaid) Disease Management Program. The successful Vendor will provide to Medicaid recipients specific evidence-based information, medical equipment, and/or support to follow their physician’s plan of care and practice health behaviors in a cost effective, customer service-focused, and quality-driven manner. Specific requirements are contained in this RFP. The Vendors selected as a result of this procurement will serve as the Medicaid program’s exclusive provider(s) for disease management services described in this RFP. This exclusive provider relationship is contingent upon final adoption of Medicaid Disease Management program rules. The proposed terms of the award may be subject to changes in administrative rules that govern the Medicaid Disease Management program. A qualified vendor is one that can deliver the services requested in an efficient and effective manner while ensuring the highest standards of performance, integrity, customer service, and fiscal accountability. HHSC wishes to contract with a vendor that understands the importance of the tasks and the impact they have on the lives of Texas Medicaid recipients. HHSC will enter into a contract(s) that will include the delivery of a holistic approach to managing certain disease state populations by attending to the complexities of multiple co-morbidities. Note: The requirements of this RFP do not include Medicaid Managed Care clients that are receiving services through a Health Maintenance Organization (HMO). Only organizations that participated in the Texas Disease Management Letter of Intent (LOI) to Bid are eligible to respond to this RFP. Vendors must submit separate proposals to provide disease management for either: • The specified grouping of common chronic diseases (diabetes, CAD and CHF), or • The specified grouping of respiratory diseases (asthma and COPD). HHSC will not accept single disease approaches for this statewide program. HHSC will consider vendor proposals for the entire state or specific geographic sections of the state. See Exhibit A – Assumptions and Conditions for Texas Medicaid. 1-1
  2. 2. HHSC Medicaid Disease Management RFP RFP No. 529-03-298 1.1 Organizations Eligible to Submit Proposals To be eligible to submit a proposal for the Texas Medicaid disease management program, a Vendor must provide documentation as specified below: 1. The state or federal government has not sanctioned the Vendor in the last ten (10) years. 2. The Vendor has a minimum of three years experience in providing disease management services for the specific chronic illnesses listed in the RFP. 1.2 Eligible Disease Management Population and Disease Groups The Texas Fee-For-Service (FFS) population includes several program types. For purposes of this RFP, the vendor will focus on the Disabled population (with the exclusion of STAR+PLUS in Houston), and the TANF population in non- managed care areas of the state. See Exhibits A - for Assumptions and Conditions, Exhibit B – Quality Variables, Exhibit C – Texas Price Proposal and Exhibit D – Explanations of Terms for the Texas Medicaid Disease Management program. General HHSC reports are available for various eligibility and beneficiary data on the HHSC website at www.hhsc.state.tx.us NOTE: During the 78th Texas Legislative Session the State Legislature mandated the expansion of Medicaid managed care on a statewide basis based on a cost effectiveness assessment. In the event that it is not cost effective to implement managed care in all areas of the State then some areas may remain in the fee-for-service model. This assessment is expected to be complete in mid-October 2003. The Vendor’s response must clearly demonstrate how the vendor’s business solution will accommodate a potential statewide implementation of managed care. (Refer to Section 1.8) Within their proposals, vendors must submit business impact and solutions to the following possible scenarios: a) FFS disease management participants are transitioned to a Primary Care Case Management (PCCM) model. b) FFS disease management participants are transitioned into a Health Maintenance Organization (HMO) model. c) FFS disease management participants are transitioned into a Prepaid Health Plan (PHP) model d) FFS disease management participants are transitioned into an Exclusive Provider Organization (EPO) model. 1-2
  3. 3. HHSC Medicaid Disease Management RFP RFP No. 529-03-298 1.3 Purpose The State of Texas-Health and Human Services Commission (HHSC), Division of Medicaid and CHIP requests proposals from experienced, responsive, responsible and financially sound disease management organizations (herein after referred to “Vendor”) to provide components and services involved in the disease management programs as follows: • Identification of and Outreach to Eligible Beneficiaries • Health Assessment and Risk Stratification • Enrollment and Withdrawal of Eligible/Ineligible Beneficiaries • Education - Beneficiary/Provider/Staff • Quality Assurance • Care Management • Outcomes Measurement The successful Vendor will demonstrate the ability to consistently provide these benefits to the State and will be evaluated, in part, by the degree to which the Vendor shows how it will achieve these benefits. 1.4 Mission The mission of the Texas Medicaid program is to improve the health of Texans by: • Emphasizing prevention. • Promoting continuity of care. • Providing a medical home for Medicaid recipients. • Ensuring that each recipient can receive high quality, comprehensive health care services within the recipient's community. Through this procurement, the state accomplishes its mission by contracting for measurable results that improve client access and satisfaction, maximize program efficiency, effectiveness, and responsiveness, and reduce operational and service costs. 1.5 Goals The goals of the Disease Management (DM) Program include improved health status and reduction in cost of care for Texas’ Medicaid Fee-For-Service (FFS) clients. 1-3
  4. 4. HHSC Medicaid Disease Management RFP RFP No. 529-03-298 1.6 Objectives The Objectives of this procurement are: • Cost savings to Medicaid resulting from improved care and support Adherence to national, evidence-based guidelines in order to improve clients’ health status; Identification, evaluation, and inclusion of co-morbid conditions in management of clients included in this project; Increased access to preventive care; Establishment of a medical home; Overall reduction of medical costs by a minimum of five percent of total medical expenditures for the eligible population served; Reduction in unnecessary hospital admissions, number of days in the hospital, unnecessary or inappropriate medication and inappropriate emergency room use; Improved coordination of care with other HHSC agencies; Increased client education; Increased client self-management skills; Increased client satisfaction with health care; Client satisfaction with the Disease Management Program, Increased provider satisfaction with medical care and with interaction between providers’ offices, state and program staff; Provider satisfaction with the Disease Management Program, Establishment of collaboration between care providers, case managers and other state resources, the client, the client’s family, and the community; and, Improved continuity of care for Medicaid clients. 1.7 Inducements HHSC submits this RFP setting forth certain information regarding the objectives of the Texas Medicaid Disease Management Program and HHSC’s desire to mitigate risk throughout the life of the Contract by use of expert vendor services. Therefore, HHSC will consider all representations contained in a proposal as the 1-4
  5. 5. HHSC Medicaid Disease Management RFP RFP No. 529-03-298 Vendor’s response to this RFP. HHSC will also consider any oral or written presentations, correspondence, discussions, and negotiations as representations of the Vendor’s expertise in performing similar activities for entities such as HHSC. HHSC accepts these representations as inducements to enter into a mutually beneficial relationship with the Vendor under the terms and conditions of this RFP. 1.8 How Medicaid Operates in Texas The Texas Health and Human Services Commission (HHSC), State Medicaid/CHIP Division, is responsible for administering medical assistance programs for all eligible recipients enrolled in the Texas Medicaid program. The Texas Medicaid program is a combination of Federally-mandated minimum coverage and state-determined optional coverage. Single State Agency Federal Medicaid regulations require each state to designate a single state agency responsible for the Medicaid program. The Texas Health and Human Services Commission (HHSC) has been the single state agency for the Medicaid program since January 1993. Within HHSC, the State Medicaid Director administers the Medicaid program. As the single state agency, HHSC has final authority for Medicaid policies and operations. HHSC administers the Medical Assistance Program in Texas in accordance with Texas Government Code Ch. 531.021(a). The Medicaid/CHIP Division within HHSC manages operations. A State Medical Care Advisory Committee (MCAC) has been established, in accordance with Texas Human Resources Code 32.022, to ensure adequate community and provider input is obtained on decisions affecting the levels and types of services covered under the program. This MCAC comprises medical professionals, various providers, other professionals, and consumers who offer specialized advice on various components of the program. HHSC’s organizational structure includes the following divisions: Legislative and Legal Affairs, Medicaid/CHIP Operations, Financial Services, Planning and Evaluation, Systems Operations, and Investigations and Enforcement. A Commissioner appointed by the Governor manages HHSC. HHSC also contracts with Affiliated Computer Services (ACS) for the implementation, operation, and maintenance of a Medicaid Fraud and Abuse Detection System (MFADS) based on neural network and learning technology. ACS operates MFADS as an enhancement to the Surveillance Utilization Review Subsystem (SURS) of the MMIS. Texas operates a fee-for-service and a managed care delivery system. The State of Texas’ managed care program is collectively known as the State of Texas Access Reform (STAR) program. The STAR program comprises two predominant models. The risk-based capitated program operates through contracts with Health Maintenance Organizations (HMOs). HHSC contracts with HMOs to provide client care at established capitation rates. The second 1-5
  6. 6. HHSC Medicaid Disease Management RFP RFP No. 529-03-298 STAR program model is the Primary Care Case Management (PCCM) model, wherein HHSC contracts with a Network Administrator that provides a wide range of administrative tasks associated with the operation of a PCCM system. The PCCM system is known as the Texas Health Network. HHSC currently contracts with Affiliated Computer Services (ACS) for Medicaid claims processing and related functions and for Texas Health Network Administration. HHSC also contracts with MAXIMUS, Inc. for Enrollment Broker services and ICHP for External Quality Review functions. Collectively these vendors are referred to as the Texas Medicaid Administrative System (TMAS) contractors. 1.9 Cost Containment/Avoidance Initiatives HHSC expects the successful Vendor to work proactively with the State in developing cost-containment and avoidance initiatives that positively impact health outcomes but result in cost-savings to the State. In this procurement, HHSC seeks a Vendor/Vendors to provide Disease Management services to eligible Medicaid clients in Texas. The Vendor who best demonstrates the ability to successfully manage the statewide Disease Management program and offer the required cost-savings and improved client health outcomes will be selected through this procurement. 1.9.1 Current Texas Medicaid DM-Related and Cost/Utilization Containment Initiatives There are two major current initiatives in the Texas Medicaid program: Texas Medicaid/CHIP Pediatric Asthma Pilot At the commencement of the disease management program, the successful vendor for management of respiratory illnesses will be required to include participants of the current Texas Medicaid/CHIP Pediatric Asthma Management Pilot in their patient census for the duration of the pilot ending on August 31, 2004. The asthma pilot participants will receive the appropriate level of vendor’s services as determined by severity of illness. The respiratory vendor will administer the standard and appropriate array of DM services and will not be required to manage the pilot as it is currently structured. The vendor will receive the designated level of PM/PM for management of these clients until August 31, 2004. After August 31, 2004, only those pilot participants that meet the eligibility criteria for disease management 1-6
  7. 7. HHSC Medicaid Disease Management RFP RFP No. 529-03-298 services will continue to receive disease management services from the vendor. (See Appendix 4 for asthma pilot description and legislative directives.) Note: HHSC acknowledges the successful vendor for management of respiratory illnesses will meet the objectives of the pilot as outlined in Appendix 4 through administration of the vendor’s standard and appropriate array of DM services. Heritage Information Systems, Inc. Texas has contracted with Heritage Information Systems for a Cost Containment and Physician Profiling Initiative (See Appendix 5). Heritage Information Systems, a major pharmacy initiative, is a new system for handling certain state- funded prescription drugs. Heritage Information Systems has been retained by the State of Texas to work with prescribers and managing prescriptions for those receiving Medicaid drug benefits. Because of these contracted pharmacy-centered efforts, the Disease Management Program is not intended to focus cost containment on prescription drugs. 1.10 CONTRACT AWARDS HHSC intends to contract with organizations for HHSC specified disease management initiatives. The Medicaid Disease Management program is not intended to serve clients who have Medicare, or other primary Third Party Insurance Coverage. A. HHSC will award contracts from this RFP for a statewide Medicaid Disease Management model that serves eligible FFS clients with multiple diseases and conditions. These clients may be receiving services from other divisions within HHSC. We encourage collaboration between bidders and will consider awarding contracts for proposals showing collaboration between two or more bidders. B. Period of Performance The anticipated start date of the contract(s) resulting from this RFP and beginning date for eligible client enrollment is 91 days from HHSC Commissioner’s approval of vendor selection. The contract end date is August 31, 2006. There is potential for up to three one-year extensions, at the discretion of HHSC. 1-7
  8. 8. HHSC Medicaid Disease Management RFP RFP No. 529-03-298 1.11 Implementation Period The need to implement the Disease Management Program requirements of this RFP necessitates expediting the contract process. As a result, the implementation period will be limited. The Vendor selected as a result of this procurement will be required to begin operations within 91 days from HHSC Commissioner’s approval date of vendor selection. The state will consider reimbursing a percentage of the vendor’s transitional start-up costs if there is a documented or demonstrated need (see Appendix 3). The State of Texas will enter into a contract(s) that will include the provision of the following implementation deliverables: • Finalized comprehensive Work Plan and Schedule • Back-up and Recovery Plan • Monthly written progress reports 1.12 FUNDING The Legislature has assumed that total medical expenditures for FFS clients eligible for enrollment in the Medicaid Disease Management program will be reduced by a minimum of 5% of the total annual cost for that population. The Legislature assumed using a reimbursement method of per member per month fee in order to achieve net savings. The Vendor will be expected to: A. Specify the method of enrolling clients with default assignment to the DMO based on eligibility and a 30-day “opt-out” client option. B. Specify a reimbursement rate of per member per month for the eligible population with default assignment; C. Specify how commitments from the provider, to serve as the identified client(s)’ primary care provider or medical home will be obtained; D. Provide a guarantee of at least 5% savings in the total medical costs of the eligible population. HHSC is willing to consider price proposals including proposals with higher cost savings guarantees. 1-8
  9. 9. HHSC Medicaid Disease Management RFP RFP No. 529-03-298 The Health and Human Services Commission will fund and obtain an external evaluation conducted by an evaluator selected by HHSC. Vendors will not be required to contribute to the cost of the evaluation. The method used to determine cost savings with this RFP is described in Exhibit H. 1.13 External Factors Any contract resulting from this procurement is subject to the availability of State and Federal funds. HHSC certifies that, as of the issuance of the RFP, budgeted funds are available to reasonably fulfill the requirements of the RFP. If, however, funds become unavailable, HHSC reserves the right to withdraw this RFP or terminate the resulting contract without penalty. 1.14 Legal and Regulatory Constraints 1.14.1 Delegation of Authority All vendors responding to this RFP should be aware that State and Federal law generally limit the ability of HHSC to delegate certain decisions to a contractor. Specifically, the functions that may not be delegated to a contractor include policy-making authority and original decision-making authority regarding acceptance of contracted services. 1.14.2 Conflicts of Interest All vendors responding to this RFP may not have any personal or business interest that would present an actual, potential or apparent conflict of interest with the performance of the contract, and the successful Vendor will not reasonably create an appearance of impropriety. 1-9