Texas Health and Human Services Texas Health and Human Services Commission (HHSC Commission (HHSC ) ) Medicaid / Children with Special Health Care Medicaid / Children with Special Health Care Needs Claims Processing, Primary Care Case Needs Claims Processing, Primary Care Case Management and Pharmacy Claims and Rebate Management and Pharmacy Claims and Rebate Administration Administration Request for Proposals # 529-08- Request for Proposals # 529-08- 0159 0159
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Texas Health and Human Texas Health and Human Services Commission (HHSCServices Commission (HHSC))
Medicaid / Children with Special Health Care Medicaid / Children with Special Health Care Needs Claims Processing, Primary Care Case Needs Claims Processing, Primary Care Case
Management and Pharmacy Claims and Rebate Management and Pharmacy Claims and Rebate AdministrationAdministration
Request for Proposals # 529-08-Request for Proposals # 529-08-01590159
Vendor Conference September 23, Vendor Conference September 23, 20082008
WelcomeWelcome
IntroductionsIntroductions Lyn Peters, Enterprise Contract and Lyn Peters, Enterprise Contract and
Procurement Services (ECPS)Procurement Services (ECPS) David Brown, Assistant General CounselDavid Brown, Assistant General Counsel Tim Seelig, Deputy Director, Medicaid/CHIP Tim Seelig, Deputy Director, Medicaid/CHIP
Procurement and Contract Services Procurement and Contract Services Robert Hall, Director/HUB Coordinator, Robert Hall, Director/HUB Coordinator,
Administrative Services Development Administrative Services Development (ASD)(ASD)
Larry Fisher, Senior Financial Analyst, Larry Fisher, Senior Financial Analyst, HHS System Budget and Fiscal PolicyHHS System Budget and Fiscal Policy
Housekeeping ItemsHousekeeping Items
HHSC Procurement RolesHHSC Procurement Roles
ECPSECPS- Responsible for procurement - Responsible for procurement activityactivity
HUBHUB- Responsible for HUB activity - Responsible for HUB activity ProgramProgram- Responsible for project scope, - Responsible for project scope,
Submission RequirementsSubmission Requirements Solicitation ChangesSolicitation Changes Screening & EvaluationScreening & Evaluation Award InformationAward Information
HHSC Point of Contact
Lyn Peters, Contract AdministratorEnterprise Contract and Procurement Services (ECPS) Division4405 N. Lamar Blvd. Austin, Texas 78756-3422(512) 206-5504 Fax (512) [email protected] communications relating to this RFP must be directed to the HHSC contact person. All communications between respondents and other HHSC staff members concerning this RFP are strictly prohibited. Failure to comply with these requirements may result in proposal disqualification.
Medicaid / Children with Special Health Care Needs Claims Processing, Primary Care Case Management and Pharmacy Claims
and Rebate Administration
Procurement Schedule
RFI Release Date January 25, 2008
Comments to RFI Due February 26, 2008
RFP Release Date August 15, 2008
Vendor Conference September 23, 2008
Vendor Questions Due September 26, 2008
HHSC Posts Responses to Vendor Questions October 17, 2008
Proposals Due November 19, 2008
Deadline for Proposal Withdrawal November 19, 2008
Tentative Award Announcement July 1, 2009
Anticipated Contract Start Date July 10, 2009
RFP Overview
Background Mission Scope of Work Performance Goals Performance Measures Compensation
Medicaid / Children with Special Health Care Needs Claims Processing, Primary Care Case Management and Pharmacy Claims
and Rebate Administration
BackgroundBackground Since 1991, HHSC has overseen and
coordinated the planning and delivery of health and human service programs in Texas. HHSC is established in accordance with Texas Government Code Chapter 531 and is responsible for the oversight of all Texas health and human service agencies (HHS Agencies). HHSC’s chief executive officer is Albert Hawkins, Executive Commissioner of the Health and Human Services Commission.
BackgroundBackground
Current Contracts The current contracts for administering
the operations of the Texas Medicaid Management Information System (TMMIS) are set to terminate in August 2009. The contracts may be extended up to one additional year, expiring no later than August 31, 2010.
BackgroundBackground
HHSC is seeking a vendor(s) who can:
1) Take over operations of the current TMMIS, including the processing of MTP claims;
2) Manage the Pharmacy Claims and Rebate Administration functions; and
3) Provide a CHIP PCCM option.
To accomplish the above, HHSC is seeking vendors who can perform the following business functions:
BackgroundBackground• General Operational Requirements • Primary Care Case Management (PCCM)
Administration• Integrated Care Management (ICM) • Provider Services• Client Services • Call Centers• Administrative Cost Containment • Health Care Cost Containment• Medical/Dental Policy • Program Policy• Prior Authorization (PA) • Fair Hearings• Surveillance/Utilization Review (SUR) • Third Party Resources (TPR)• Claims Processing • Health Insurance Premium Payments (HIPP) &
Insurance • Reference Data Maintenance Premium Payment Assistance (IPPA)• Financial Management • Recipient Eligibility Maintenance and Eligibility
Verification• Provider Reimbursement • Management and Administrative Reporting• Ad Hoc Reporting • System Maintenance and Modification• System Operations, Disaster Recovery, • Long Term Care Online Portal and Integrated Test Facility • Long Term Care (LTC) Programs• Medical Transportation Program (MTP) • Children with Special Health Care Needs (CSHCN)
Services•Family Planning (FP) Program• County Indigent Health Care Program (CIHCP) • Medically Needy Program (MNP); and
• Pharmacy Claims and Drug Rebate Administration (PCRA)
MissionMission
HHSC’s mission for this procurement is to provide quality and necessary health care services to the segment of the Texas population with health benefits covered by the Texas Medicaid Program, Primary Care Case Management (PCCM), Department of State Health Services Family Planning (DSHS Family Planning), Texas Health Steps Programs (THSteps), the Children with Special Health Care Needs (CSHCN) Services Program and the Vendor Drug Program.
Scope of WorkScope of Work
Requirements OverviewSection 7: General Contract and Turnover RequirementsSection 8: Operations Requirements
General Operational Requirements; Primary Care Case Management (PCCM) Administration;Integrated Care Management;Provider Services; Client Services; Call Centers;Administrative Cost Containment;Health Care Cost Containment;Medical/Dental Policy;Program Policy;Prior Authorization (PA);Fair Hearings;
Scope of WorkScope of WorkRequirements Overview Section 8: Operations Requirements Surveillance and Utilization Review; Third Party Resources (TPR); Health Insurance Premium Payment (HIPP) System
and Insurance Premium Payment Assistance (IPPA); Claims Processing; Financial Management; Provider Reimbursement; Management and Administrative Reporting (MAR); Ad Hoc Reporting; Reference Data Maintenance; Recipient Eligibility Maintenance;
Scope of WorkScope of WorkRequirements OverviewSection 8: Operations Requirements Eligibility Verification; System Maintenance and Modification; System Operations, Disaster Recovery, and Integrated Test
Facility; Long Term Care (LTC) Online Portal; Long Term Care (LTC) Programs; Children with Special Health Care Needs (CSHCN) Services
Program; Family Planning (FP); County Indigent Health Care Program (CIHCP); Medically Needy Program (MNP); Medical Transportation Program (MTP); and Pharmacy Claims and Drug Rebate Administration (PCRA).
Section 9: Transition Phase Scope of Work
Performance GoalsPerformance Goals
HHSC will monitor the performance of the contract(s) issued under this RFP. All services and deliverables under the contract shall be provided at an acceptable quality level and in a manner consistent with acceptable industry standards, customs and practices. Failure to produce deliverables in such a manner could result in remedies as outlined in Appendix D.
CompensationCompensation The State has chosen to use a “Fixed Price” approach related to the The State has chosen to use a “Fixed Price” approach related to the
administrative services and a “Fiscal Agent” approach related to the administrative services and a “Fiscal Agent” approach related to the medical benefit costs / pharmacy benefit costs included in the medical benefit costs / pharmacy benefit costs included in the Contract or Contract(s) resulting from this RFP. Normally, the Contract or Contract(s) resulting from this RFP. Normally, the medical benefit costs for Medicaid recipients enrolled in a Medicaid medical benefit costs for Medicaid recipients enrolled in a Medicaid Managed Care Health Maintenance Organization (HMO) will not be Managed Care Health Maintenance Organization (HMO) will not be included with the Fiscal Agent medical benefit funds. The pharmacy included with the Fiscal Agent medical benefit funds. The pharmacy benefit costs for Medicaid recipients enrolled in a Medicaid HMO will benefit costs for Medicaid recipients enrolled in a Medicaid HMO will be included with the Fiscal Agent pharmacy benefit funds.be included with the Fiscal Agent pharmacy benefit funds.
The RFP is comprised of two specific component service areas for The RFP is comprised of two specific component service areas for which the Vendor may propose solutions:which the Vendor may propose solutions:
Medicaid/CSHCN Services Program Claims/PCCM AdministratorMedicaid/CSHCN Services Program Claims/PCCM Administrator Pharmacy Claims/Pharmacy Rebate Administrator.Pharmacy Claims/Pharmacy Rebate Administrator.
The various program types included in the Medicaid/CSHCN Services Program Claims/PCCM Administrator component service area are as follows:
(1) Core Title XIX - (includes all services not otherwise covered by programs below);
(2) Children with Special Health Care Needs (CSHCN) Services Program;(3) Family Planning (FP) Title V, X, and XX;(4) Long Term Care (LTC); and(5) Medical Transportation Program (MTP).
The various program types included in the Pharmacy Claims/Pharmacy Rebate Administrator component service area are as follows:
(1) Core Title XIX – (including pharmacy claims for Medicaid managed care clients);
(2) Children’s Health Insurance Program (CHIP);(3) CSHCN Services Program; and(4) Kidney Health Care Program (KHC).
A Vendor may choose to propose a solution A Vendor may choose to propose a solution for one or both of the RFP components.for one or both of the RFP components.
A Vendor that proposes solutions for more A Vendor that proposes solutions for more than one RFP component must submit than one RFP component must submit pricing proposals for each component type pricing proposals for each component type separately and a pricing proposal for both separately and a pricing proposal for both components together (3 separate components together (3 separate proposals in total).proposals in total).
The Vendor’s accounting records and procedures are subject to State approval. Accruals of expenses or liabilities are subject to State review and approval. The State will not recognize as valid costs, any accruals that it deems inappropriate. For example, lease agreement costs beyond the effective date of termination or completion of the Contract, or lease cancellation expenses resulting from termination or completion of the Contract, will not represent valid allowable costs.
A Vendor must keep separate financial records for each of the two (2) component service areas administered under the Contract or Contracts resulting from the RFP:(1) Medicaid/CSHCN Services Program Claims/PCCM Administrator; and(2) Pharmacy Claims / Pharmacy Rebate Administrator.
A Vendor must keep separate financial records for the following Medicaid/CSHCN Services Program Claims/PCCM Administrator sub-component program types:• Core Title XIX;• CSHCN Services Program;• Family Planning Title V, X, and XX (FP);• Long Term Care (DADS-LTC); and• Medical Transportation Program (MTP).
A Vendor must keep separate financial records for the following Pharmacy Claims/Pharmacy Rebate Administrator sub-component program types:• Pharmacy Claims Administration; and• Pharmacy Rebate Administration.
A Vendor must provide monthly financial statements depicting the Vendor’s operation under this Contract or Contracts resulting from this RFP no later than the twenty-fifth (25th) calendar day following the end of the previous month. HHSC reserves the right to request financial information in a format that will allow the State to most efficiently comply with its State and Federal financial reporting requirements.
A Vendor must provide a monthly report that shows daily cash balances in each of the bank accounts described in this Request for Proposal.
A Vendor must provide a monthly report that details all of the types of deposits made by the Vendor into each applicable bank account.
The Medicaid/CSHCN Services Program Claims/PCCM Administrator Vendor will receive funds weekly from the State to pay medical benefit claims the Vendor has determined are ready for payment. The Vendor will receive payments monthly as compensation for the applicable administrative services required in the RFP.
Costs for administrative services provided by the Medicaid/CSHCN Services Program Claims/PCCM Administrator Vendor will be based on fixed fee (s) and variable fee formulas for two (2) of the program types. The costs for administrative services for three (3) program types will be based on fixed fee (s) only.
HHSC requires that no more than 50% of the administrative fees for the DADS Long Term Care services will be paid utilizing fixed fees and a minimum of 50% of the administrative fees for the DADS Long Term Care services will be paid utilizing variable fees. HHSC reserves the right to determine the final percentage of fixed fees and variable fees in the contract for the DADS Long Term Care services.
HHSC requires that no more than 65% of the administrative fees for the Core Title XIX services will be paid utilizing fixed fees and a minimum of 35% of the administrative fees for the Core Title XIX services will be paid utilizing variable fees. HHSC reserves the right to determine the final percentage of fixed fees and variable fees in the contract for the Core Title XIX services.
Transition costs to meet the requirements of the RFP will be paid on a fixed fee basis. Transition costs in excess of the final fixed price amount(s) included in the Contract(s) will not be paid by the State. Any expenses incurred by a vendor after the commencement of the operational phase of the contract(s) to complete transition activities or correct any defects from the Transition Phase must not be recorded as an operational expense and will not be considered an allowable expense for the Retrospective Cost Settlement provision of the Contract.
Separate transition costs will be proposed, negotiated, and paid for the following program types of the Medicaid/CSHCN Services Program Claims/PCCM Administrator component service area:• Core Title XIX services;• CSHCN Services Program services;• Family Planning Title V, X, and XX services;• Long Term Care Program services;• Medical Transportation Program services; and• Children’s Health Insurance Program (CHIP) – for CHIP PCCM option.
Transition costs to meet the requirements of the RFP will be paid on a fixed fee basis. Transition costs in excess of the final fixed price amount(s) included in the Contract will not be paid by the State.
Transition costs will be proposed to allow the Pharmacy Claims/Pharmacy Rebate Administrator Vendor to assume the responsibilities of the RFP effective no later than September 1, 2010.
Transition costs will not be paid as an element of operational administrative costs. Transition costs will be paid to the Vendor retrospectively.
• Ownership of all nonexpendable capital items Ownership of all nonexpendable capital items FUNDEDFUNDED by the contract resulting from this RFP by the contract resulting from this RFP will pass to the State at the expiration of the will pass to the State at the expiration of the contract.contract.
• Actual expenditures for Pass-Through Items made Actual expenditures for Pass-Through Items made on the State’s behalf will be paid without on the State’s behalf will be paid without allocation of any indirect charges (general & allocation of any indirect charges (general & administrative expenses, overhead, etc.) or profit.administrative expenses, overhead, etc.) or profit.
• A complete listing of expenditures designated as A complete listing of expenditures designated as Pass-Through Items is documented at Section Pass-Through Items is documented at Section 6.8.3.2 of the RFP.6.8.3.2 of the RFP.
• Administrative fees paid to the Vendor during Administrative fees paid to the Vendor during each Operational Contract Year will consist of: each Operational Contract Year will consist of: • Fixed Administrative Fees Fixed Administrative Fees • Variable Administrative Fees Variable Administrative Fees • Administrative Fees for the Additional Periodic Administrative Fees for the Additional Periodic
ActivitiesActivities• Administrative Fees for Additional Recurring Administrative Fees for Additional Recurring
Activities Activities
• The sum of the four Fee components will be The sum of the four Fee components will be referred to as the referred to as the “Fee Ceiling”“Fee Ceiling”..
• The total maximum cost of the Services and The total maximum cost of the Services and Deliverables supplied by the Vendor to HHSC Deliverables supplied by the Vendor to HHSC during each Operational Contract Year will not during each Operational Contract Year will not exceed the lesser of exceed the lesser of
(a) the Vendor’s Fees (Fee Ceiling) or (a) the Vendor’s Fees (Fee Ceiling) or
(b) the sum of the Allowable Costs incurred by (b) the sum of the Allowable Costs incurred by the Vendor plus the allowable administrative the Vendor plus the allowable administrative service fee during the subject Operational service fee during the subject Operational Contract Year.Contract Year.
• Forms substantially similar to those Forms substantially similar to those described in the RFP must provide the described in the RFP must provide the component costs of the Firm Fixed Prices component costs of the Firm Fixed Prices quoted for providing the services and quoted for providing the services and deliverables set forth in the RFP.deliverables set forth in the RFP.• Attachment A, Appendix A-1 contains Attachment A, Appendix A-1 contains
Transitional Pricing Schedules Transitional Pricing Schedules • Attachment A, Appendix A-2 contains Attachment A, Appendix A-2 contains
Operational Pricing SchedulesOperational Pricing Schedules• Attachment A, Appendix A-3 contains Attachment A, Appendix A-3 contains
• The potential Vendor must structure its pricing quotation The potential Vendor must structure its pricing quotation to allow HHSC a method to map the proposed costs for to allow HHSC a method to map the proposed costs for the cost proposal submitted back to the Vendor’s the cost proposal submitted back to the Vendor’s Detailed Work Plan for the initial term of the Contract. Detailed Work Plan for the initial term of the Contract.
• The Vendor must provide separate Transitional Costs The Vendor must provide separate Transitional Costs through the proposed transition period. through the proposed transition period.
• The Vendor must provide the required projected monthly The Vendor must provide the required projected monthly costs for the entire operations period. costs for the entire operations period.
• The pricing quotations for each specific component must The pricing quotations for each specific component must agree with the Firm Fixed Pricesagree with the Firm Fixed Prices proposed by the Vendor proposed by the Vendor (Fixed and Variable Prices).(Fixed and Variable Prices).
Transition Pricing Schedules:Transition Pricing Schedules:• The potential Vendor’s transitional cost proposal The potential Vendor’s transitional cost proposal
sheets for this RFP must identify the proposed “Key sheets for this RFP must identify the proposed “Key Milestones” the Vendor will accomplish during the Milestones” the Vendor will accomplish during the Transitional period (Appendix A-1).Transitional period (Appendix A-1).
• The State is requesting each prospective Vendor to The State is requesting each prospective Vendor to identify the “Key Milestones” the Vendor believes identify the “Key Milestones” the Vendor believes would be pertinent and appropriate as a Key Milestone would be pertinent and appropriate as a Key Milestone during the Transition period. during the Transition period.
• The State reserves the option to add, delete and/or The State reserves the option to add, delete and/or modify Key Milestones included in the Vendor’s modify Key Milestones included in the Vendor’s transitional cost proposal sheets.transitional cost proposal sheets.
• The potential Vendor’s operational The potential Vendor’s operational cost proposal sheets (Appendix A-2) cost proposal sheets (Appendix A-2) for each of the operational for each of the operational components must be delineated by components must be delineated by the primary business functions the primary business functions (functional areas) documented in the (functional areas) documented in the RFP for each component.RFP for each component.
• Instructions for completing each schedule are Instructions for completing each schedule are included in the RFP. included in the RFP.
• Summary forms should be supported by the Summary forms should be supported by the detailed information contained on monthly detailed information contained on monthly schedules. schedules.
• Amounts shown on the monthly schedules must Amounts shown on the monthly schedules must agree with the cumulative amounts shown on the agree with the cumulative amounts shown on the summary forms. summary forms.
• In addition to paper copies of the Vendor’s Cost In addition to paper copies of the Vendor’s Cost Proposal and Price Summary sheets, Vendors Proposal and Price Summary sheets, Vendors must submit electronic versions in an MS Excel must submit electronic versions in an MS Excel format.format.
• The State will be providing prospective Vendors The State will be providing prospective Vendors with an electronic version of the required Cost with an electronic version of the required Cost Proposal and Price Summary sheets in an MS Proposal and Price Summary sheets in an MS Excel format on or before October 6, 2008 (when Excel format on or before October 6, 2008 (when answers to questions are posted to the website). answers to questions are posted to the website). The file will posted in the procurement library.The file will posted in the procurement library.
• Any electronic version of the pricing forms must Any electronic version of the pricing forms must contain any and all formulas used to calculate contain any and all formulas used to calculate pricing information contained on the forms and pricing information contained on the forms and include any and all links to other worksheets / include any and all links to other worksheets / forms included in the Vendor’s Cost Proposal.forms included in the Vendor’s Cost Proposal.
• Vendors must separately identify value-Vendors must separately identify value-added benefits, cost-savings and cost-added benefits, cost-savings and cost-avoidance methods and measures, and avoidance methods and measures, and the effect of such methods on the Cost the effect of such methods on the Cost Proposal and Scope of Work.Proposal and Scope of Work.
• The cost proposal should include any The cost proposal should include any business, economic, legal, programmatic, business, economic, legal, programmatic, or practical assumptions that underlie the or practical assumptions that underlie the Cost Proposal. HHSC reserves the right to Cost Proposal. HHSC reserves the right to accept or reject any assumptions.accept or reject any assumptions.
Administrative Services Administrative Services Development HUB Program Development HUB Program
OfficeOffice Robert L. Hall, C.P.M.Robert L. Hall, C.P.M. Director of Administrative Services DevelopmentDirector of Administrative Services Development
1:00 p.m. - 2:00 p.m. Notary Public 1:00 p.m. - 2:00 p.m. Notary Public Available to Sign Non-Disclosure Available to Sign Non-Disclosure
Statements.Statements.
2:00 p.m. – 3:00 p.m. Non-Binding 2:00 p.m. – 3:00 p.m. Non-Binding Answers to VendorAnswers to Vendor Q Questions.uestions.
Questions and AnswersQuestions and Answers
Non-binding verbal answers to vendor Non-binding verbal answers to vendor questions.questions.
Binding responses will be posted on the Binding responses will be posted on the procurement website by October 17, 2008.procurement website by October 17, 2008.