Barbara B. Vaughan - myflorida.com · Barbara B. Vaughan Barbara B. Vaughan, SMA Procurement Office...

RICK SCOTT GOVERNOR Better Health Care for all Floridians ELIZABETH DUDEK

SECRETARY

Vis i t AHCA on l ine a t h t tp : / /ahca. my f lo r ida .com

2727 Mahan Dr i ve • Mai l S top #15 Ta l lahassee, FL 32308

July 30, 2012

Prospective Vendor: Subject: Solicitation Number: AHCA ITN 001-12/13 Title: Statewide Medicaid Managed Care (SMMC) – Long Term Care (LTC) – Region 1

The enclosed information has been provided for consideration in the preparation of your response to the above mentioned ITN. All other terms and conditions of the ITN remain in effect. To the extent this Addendum gives rise to a protest, failure to file a protest within the time prescribed in section 120.57(3), Florida Statutes, shall constitute a waiver of proceedings under chapter 120, Florida Statutes.

Sincerely,

Barbara B. Vaughan

Barbara B. Vaughan, SMA Procurement Office

Enclosures: Addendum No. 2 (8 Pages) Exhibit 1 – HCBS NF Classification (1 Page) Exhibit 2 - Submission Requirement Component Character Space Allowance (2 Pages) Exhibit 3 - Questions and Answers (129 Pages) Exhibit 4 – Vendor Conference Sign-In Sheets (15 Pages) Exhibit 5 – Attachment D-II, Core Contract Provisions Exhibits, Exhibit 7, Table 1-A, LTC Provider Qualifications & Minimum Network Adequacy Requirements (8 Pages) Attachment D-II, Core Contract Provisions Exhibits, Exhibit 17, Liquidated Damages – LTC Plans (12 Pages) Attachment N – Cost Proposal (2 Pages) Attachment N-1 – Cost Proposal Rate Sheet (1 Page) Attachment N-2 – Capitation Rate Ranges (23 Pages)

AHCA ITN 001-12/13, Addendum No. 2, Page 1 of 8

AHCA ITN 001-12/13

STATEWIDE MEDICAID MANAGED CARE (SMMC) LONG TERM CARE (LTC) – REGION 1

ADDENDUM NO. 2

Item #1

Attachment C, Special Conditions, Section C.45, General Instructions for Response Preparation and Submission, is hereby amended as follows: • The third paragraph is hereby amended to now read:

An original and fifteen (15) duplicate paper copies, in a sealed package, must be submitted to the Issuing Officer identified in Section C.5 no later than the time indicated in Section C.6, Solicitation Timeline, for receipt of responses. The original sealed response shall be marked as the “original” on the outside of the binder and contain Item A., Mandatory Documentation, Item B., Financial Information, Item C., Past Performance – Client References and Item D., Cost Proposal, as outlined below. The box that contains the “original” response shall be marked “Contains Original” and shall contain all marked originals. Responses may be submitted via U.S. Mail, Courier, or hand delivery. Responses sent by fax or email will not be accepted. Responses received after the date and time specified in Section C.6, Solicitation Timeline, will not be considered and will be returned to the prospective vendor unopened.

• The ninth paragraph is hereby amended to now read:

Any portion of the submitted response which is asserted to be exempt from disclosure under Chapter 119, Florida Statutes, shall be clearly marked (by whatever means necessary, i.e. stamp) “exempt”, “confidential”, or “trade secret” (as applicable) and shall also contain the statutory basis for such claim on every page. Pages containing trade secrets shall be marked “trade secret as defined in Section 812.081, Florida Statutes”. Failure to identify such portions shall constitute a waiver of any claimed exemption and the Agency will provide such records in response to public records requests without notifying the respondent. Designating material simply as “proprietary” will not necessarily protect it from disclosure under Chapter 119, Florida Statutes.

• Eleventh paragraph, the first sentence is hereby amended to now read: The respondent shall also submit both a hard and an electronic redacted copy of the response suitable for release to the public in addition to the original and fifteen (15) copies.


Item #2

Attachment C, Special Conditions, Section C.45, General Instructions for Response Preparation and Submission, Item B., Financial Information, Item 1., Financial Statements – All Long-Term Care Managed Care Plans, is hereby amended to include the following: The respondent may include its audited financial statements on CD-ROM. The response must clearly indicate that the financial statements are included on CD-ROM as part of the submission.

Item #3

Attachment C, Special Conditions, Section C.45, General Instructions for Response Preparation and Submission, Item D., Cost Proposal, is hereby deleted in its entirety and replaced with the following: D. Cost Proposal

The respondent shall submit one (1) original Cost Proposal (Attachment N) with its original response. The Cost Proposal and Cost Proposal Rate Sheet, also referred to as the Cost Proposal, shall be labeled and tabbed separately. The intent of the Cost Proposal is for the respondent to provide a prospectively determined monthly capitation rate that reflects a blend of the HCBS and Non-HCBS rate components.

Instructions for completing Attachment N-1, Cost Proposal Rates Sheet, are as follows:

1. Requirements for Submission of Accompanying Narrative

A General Narrative must be provided that explains the respondent’s rate-setting methodology. See Attachment N, Cost Proposal, Exhibit 1, Sample General Narrative. The respondent must indicate how it arrived at the proposed rates by explaining the steps and the data included in the rate-development process. At a minimum, the following information shall be provided:

• The overall trend rate used, • Any adjustments to the populations or services reflected which differ from the base

data provided, and • Other adjustments.

2. Cost Proposal Rate Sheet

The respondent must utilize Attachment N-1, Cost Proposal Rate Sheet, to provide a detailed calculation of its capitated rate based on the formulas provided therein. Note: Attachment N-1, Cost Proposal Rate Sheet, is provided solely to facilitate completion of the Cost Proposal. It is the Respondent’s responsibility to validate the amounts resulting from the calculations performed by the formulas provided therein.


Column A of Attachment N-1, Cost Proposal Rate Sheet, contains the Categories of Service (COS) to be included as part of the capitation rates. The COS are described in the Data Book.

3. Completing Attachment N-1, Cost Proposal Rate Sheet

In completing the steps below, refer to the Data Book for clarification regarding the COS definitions and unit descriptions.

a. Utilization per 1,000 (columns B and E for Home and Community Based (HCBS)

and Non-HCBS, respectively, lines 1-28): Calculated by multiplying units of service by 12,000 and dividing by member months (MM). Enter for each COS.

b. Unit Cost (columns C and F for HCBS and Non-HCBS, respectively, lines 1-28):

Enter a cost per unit (expressed in dollars and cents) for each COS.

c. Per Member Per Month (PMPM) (columns D and G for HCBS and Non-HCBS, respectively, lines 1-28): Calculated by multiplying Utilization per 1,000 by Unit Cost and dividing the result by 12,000. Note that this calculation will be performed automatically by the formula entered in the electronic file provided.

d. Net Medical HCBS and Non-HCBS PMPM (line 29): Calculated by adding PMPM

costs for each COS. Note that this calculation will be performed automatically by the formula entered in the electronic file provided.

e. Adjustments (lines 30-31): Enter the amount for Administrative Charge and Margin

Charge. For each adjustment item, enter the percentage of total capitation for the adjustment in columns C and F. Provide additional information on the components of the Administrative and Margin Charge in the general narrative. Note that the PMPM adjustments will be calculated automatically in columns D and G by the formula entered in the electronic file provided.

f. HCBS and Non-HCBS Capitation Rate (line 32): Calculated as the sum of the Net

Medical PMPM and Adjustments for the HCBS and Non-HCBS components. Note that this calculation will be performed automatically by the formula entered in the electronic file provided.

g. HCBS/Non-HCBS Mix (line 33): Established by the State as the region-specific

percentage of members targeted to receive HCBS services in column D and the percentage of members targeted to receive Non-HCBS services (i.e., Nursing Facility and Hospice) in column G.

h. Total Blended HCBS/Non-HCBS Capitation Rate (line 34): Calculated as the HCBS

Capitation Rate multiplied by the percentage of members targeted to receive HCBS services PLUS the Non-HCBS Capitation Rate multiplied by the percentage of members targeted to receive Non-HCBS services. Note that this calculation will be performed automatically by the formula entered in the electronic file provided.


4. Exceptions for Fee-For-Service (FFS) Provider Service Networks (PSNs)

Respondents to this ITN who are responding as a Fee-for-Service Provider Service Network are exempt from submission of Attachments N and N-1. Pursuant to Section 409.968(2), F.S.: PSNs may be prepaid plans and receive per-member, per-month payments negotiated pursuant to the procurement process described in s. 409.966, F.S. Provider service networks that choose not to be prepaid plans shall receive fee-for-service rates with a shared savings settlement as specified in Attachment D-II, Exhibit 13, Method of Payment – LTC Plans, FFS LTC PSNs. The FFS option shall be available to a PSN only for the first two (2) years of its operation. A FFS PSN awarded a contract as a result of this ITN will receive payment at the capitated rate set by the Agency for Region 1 for transportation and, for other covered services, at the time that the FFS PSN transitions from FFS to capitation.

Attachment M, Data Book, which includes summaries that reflect certain adjustments (e.g., completion factors) made to the base data as a part of the rate development process, is provided to assist respondents with the preparation of the Cost Proposal. The Data Book includes a description of the adjustments. Respondents are not restricted to base data provided by the Agency for use in preparing the Cost Proposal. Respondents are encouraged to develop and use other data sources as needed to prepare a competitive Cost Proposal. Respondents are solely responsible for research and preparation of Attachment N, Cost Proposal and Attachment N-1, Cost Proposal Rate Sheet. Capitation rates must be developed in accordance with generally accepted actuarial principles and practices and must be appropriate for the populations covered and the services provided described in this ITN. Federal requirements stipulate that the Agency can only contract for rates that are within actuarially sound rate ranges. Attachment N-2, Capitation Rate Ranges, includes rate ranges that are within the actuarially sound rate ranges and represent the rate ranges in which AHCA is willing to contract. The respondent’s proposed capitation rates must be within the capitation rate ranges individually for each of the HCBS and Non-HCBS rate components, as identified in Attachment N-2, Capitation Rate Ranges, or THE RESPONSE WILL BE REJECTED. Note: The capitation rate ranges are being provided solely for this ITN. FAILURE TO SUBMIT ATTACHMENT N, COST PROPOSAL, INCLUDING ATTACHMENT N-1, COST PROPOSAL RATE SHEET, WILL RESULT IN THE REJECTION OF THE RESPONSE, UNLESS THE RESPONDENT IS RESPONDING AS A FFS PSN. ATTACHMENTS N AND N-1 ARE AVAILABLE FOR RESPONDENTS TO DOWNLOAD AT: http://ahca.myflorida.com/Procurements/index.shtml

http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400-0499/0409/Sections/0409.966.html

http://ahca.myflorida.com/Procurements/index.shtml


Item #4

Attachment C, Special Conditions, Section C.46, Other Required Documentation, Qualification of Plan Eligibility, second bullet, the first paragraph is hereby amended to now read: LTC Provider Service Network (PSN) which is majority owned (over 50%) by one or more

licensed nursing homes, assisted living facilities with 17 or more beds, home health agencies, community care for the elderly lead agencies, or hospices (s. 409.962(8), F.S.), and possess a Florida Third Party Administrator License or a subcontract/letter of agreement with a Florida-licensed Third Party Administrator.

Item #5

Attachment D-II, Core Contract Provisions, Section X, Administration and Management, Item B.1, Minimum Staffing Requirements, sub-items c. and j. are hereby amended to now read as follows: c. Medical Director*: The Medical Director shall be a full-time employee of the Managed Care

Plan and shall be a physician with an active unencumbered Florida license in accordance with Chapter 458 or 459, F.S., and shall have experience providing services to the population served under this Contract. The medical director shall oversee and be responsible for the proper provision of covered services to enrollees, the quality management program and the grievance system. The medical director cannot be designated to serve in any other position; however, if the Managed Care Plan has both a long-term care Contract and a medical assistance Contract with the Agency, the medical director can serve both Contracts. Under that circumstance, the medical director must then have experience serving both long-term care and medical assistance populations.

j. Compliance Officer*: The Managed Care Plan shall have a designated full-time person

qualified by training and experience in health care or risk management, to oversee the compliance program. The compliance officer shall also be qualified to oversee a fraud and abuse program designed to ensure program integrity through fraud and abuse prevention and detection pursuant to this Contract and state and federal law. If the Managed Care Plan has both a long-term care Contract and a medical assistance Contract with the Agency, the compliance officer can serve both Contracts.

Item #6

Attachment D-II, Core Contract Provisions, Section XVII, Liquidated Damages, Item B., Issues and Amounts, is hereby deleted and replaced as follows: B. Issues and Amounts (see Exhibit 17)


Item #7

Attachment D-II, Core Contract Provisions Exhibits, Exhibit 5, Covered Services — LTC Plans, Section V, Covered Services, Item A., Covered Services, sub-item 5.z., Transportation, the second sentence is hereby amended as follows: z. This non-emergency transportation service includes trips to and from services offered by the

LTC Managed Care Plan and includes trips to and from the Managed Care Plan’s expanded benefits.

Item #8

Attachment D-II, Core Contract Provisions Exhibits, Exhibit 5, Covered Services — LTC Plans, Section V, Covered Services, Item N., Monitoring of Care Coordination and Services, sub-item 5. Continuity of Care During Temporary Loss of Eligibility, is hereby included as follows: 5. Continuity of Care During Temporary Loss of Eligibility The Managed Care Plan must provide covered services to enrollees who lose eligibility for up to sixty (60) calendar days. Likewise, care coordination/case management services must continue for such enrollees for up to sixty (60) calendar days.

Item #9

Attachment D-II, Core Contract Provisions Exhibits, Exhibit 7, Provider Network — LTC Plans, Table 1 - LTC Provider Qualifications & Minimum Network Adequacy Requirements, is hereby deleted in its entirety and replaced with Table 1- A, LTC Provider Qualifications & Minimum Network Adequacy Requirements, attached hereto as Exhibit 5 to this addendum.

Item #10 Attachment D-II, Core Contract Provisions Exhibits, Exhibit 14, Sanctions — LTC Plans, first paragraph, Item 3., the second sentence is hereby amended to now read: If more than one (1) LTC Managed Care Plan leaves a region at the same time, the exiting managed care plans will share the costs in a manner proportionate to their enrollments.

Item #11 Attachment D-II, Core Contract Provisions Exhibits, Exhibit 15, Financial Requirements, Capitated LTC Plans, Section XV, Financial Requirements, Item G., Third Party Resources, sub-item 2.d. is hereby amended to now read: When the Agency has a fee-for-service lien against a third party resource and the Managed Care Plan has also extended services potentially reimbursable from the same third party resource, the Agency’s lien shall be entitled to priority.


Item #12

Attachment D-II, Core Contract Provisions Exhibits, Exhibit 15, Financial Requirements, FFS LTC PSNs Capitated for Transportation Services, Section XV, Financial Requirements, Item G., Third Party Resources, sub-item 2.d. is hereby amended to now read: When the Agency has a fee-for-service lien against a third party resource and the Managed Care Plan has also extended services potentially reimbursable from the same third party resource, the Agency’s lien shall be entitled to priority.

Item #13 Attachment D-II, Core Contract Provisions Exhibits, is hereby amended to include Exhibit 17, Liquidated Damages – LTC Plans, attached hereto and made a part of Addendum No. 2.

Item #14 Attachment E-1, Submission Requirements and Evaluation Criteria Components, Instructions to Respondents for the Completion of Attachment E-1, the fifth paragraph is hereby amended to include the following: Attachments related to a respective SRC may be placed collectively in a section labeled “Attachments” of the response.

Item #15 Attachment E-1, Submission Requirements and Evaluation Criteria, SRC # 32., Section VII – Provider Network, is hereby amended to correct the Florida Statute reference to s. 409.966(3)(c)1, F.S.

Item #16

Attachments J, Cost Proposal, Attachment J-1, Cost Proposal Rate Sheet – Eligibility Group 1, Attachment J-2, Cost Proposal Rate Sheet – Eligibility Group 2, Attachment J-3, Cost Proposal Rate Sheet – Eligibility Group 3, Attachment J-4, Cost Proposal Rate Sheet – Eligibility Group 4 and Attachment J-5, Capitation Rate Ranges, are hereby deleted in their entirety and replaced with the following, attached hereto and made a part of the ITN: Attachment N – Cost Proposal Attachment N-1 – Cost Proposal Rate Sheet Attachment N-2 – Capitation Rate Ranges


Item #17

Addendum No. 2, Exhibit 1, HCBS NF Classification, is attached hereto and made a part of the ITN.

Item #18

Addendum No. 2, Exhibit 2, Submission Requirement Component Character Space Allowance, is attached hereto and made a part of the ITN.

Item #19

Addendum No. 2, Exhibit 3, Questions and Answers, is attached hereto and made a part of the ITN.

Item #20

Addendum No. 2, Exhibit 4, Vendor Conference Sign-In Sheets, are attached hereto for informational purposes only.

Item #21

Attachment D-II, Core Contract Provisions Exhibits, Exhibit 5, Section V, Covered Services – LTC Plans, Item I, Care Coordination/Care Management, sub-item 5 d.(2), the second sentence is hereby amended to now read: The case manager must evaluate and document the home-like characteristics as part of the care planning process and update of the plan of care for enrollees residing in ALFs during face-to-face visits every ninety (90) calendar days.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA ITN 001-12/13, Addendum No. 2, Exhibit 1, Page 1 of 1

EXHIBIT 1

HCBS NF CLASSIFICATION

2010 / 2011Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11

Question 41 (a) NF NF NF NF HCBS HCBS HCBS HCBS HCBS HCBS

First Pass Criteria HCBS HCBS HCBS HCBS HCBS HCBSSecond Pass Criteria NF Short NF Short NF Short NF Short NF Short NF ShortFinal Disposition NF NF NF NF NF NF HCBS HCBS HCBS HCBS HCBS HCBS

Assumptions: The NF for July, August, October and November are Medicaid NF and not Medicare covered SNF.Recipient had Medicaid eligibility for the entire period between July 2010 and June 2011.


Question 41 (b) HCBS HCBS HCBS NF NF NF NF NF NF NF NF NF

First Pass Criteria HCBS HCBS HCBS HCBS HCBS HCBS HCBS HCBS HCBS HCBS HCBS HCBSSecond Pass Criteria NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF LongFinal Disposition HCBS HCBS HCBS NF NF NF NF NF NF NF NF NF

Assumptions: The NF is not a Medicare covered SNF in any month.Recipient had Medicaid eligibility for the entire period between July 2010 and June 2011.


Question 41 (c) NF NF NF NF NF NF NF NF NF NF NF NF

First Pass CriteriaSecond Pass Criteria NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF LongFinal Disposition NF NF NF NF NF NF NF NF NF NF NF NF

Assumptions: The NF is not a Medicare covered SNF in any month.Recipient had Medicaid eligibility for the entire period between July 2010 and June 2011.The recipient had hospice claims in May and June of 2011.


Question 41 (d) NF NF NF HCBS HCBS HCBS HCBS HCBS HCBS HCBS HCBS HCBS

First Pass Criteria HCBS HCBS HCBS HCBS HCBS HCBS HCBS HCBS HCBSSecond Pass Criteria NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF Long NF LongFinal Disposition NF NF NF NF NF NF NF NF NF NF NF NF

Assumptions: The NF is not a Medicare covered SNF in any month.Recipient had Medicaid eligibility for the entire period between July 2010 and June 2011.


EXHIBIT 2 SUBMISSION REQUIREMENTS COMPONENT (SRC) CHARACTER SPACE ALLOWANCE

SRC # SRC TITLE CHARACTER SPACE

ALLOWANCE * Table of Contents 15524 * Executive Summary 19405 1 Qualifications and Experience 7762 2 Qualifications and Experience 19405 3 Qualifications and Experience 11643 4 Qualifications and Experience 7762 5 Qualifications and Experience 3881 6 Qualifications and Experience 7762 7 Qualifications and Experience 7762 8 Qualifications and Experience 7762 9 Qualifications and Experience 7762 10 Qualifications and Experience 11643 11 Qualifications and Experience 7762 12 Qualifications and Experience Unlimited 13 Qualifications and Experience Unlimited 14 Qualifications and Experience Unlimited 15 Qualifications and Experience Unlimited 16 Section IV - Enrollee Services, Community Outreach and Marketing 7762 17 Section IV - Enrollee Services, Community Outreach and Marketing 7762 18 Section IV - Enrollee Services, Community Outreach and Marketing 7762 19 Section IV - Enrollee Services, Community Outreach and Marketing 15524 20 Section IV - Enrollee Services, Community Outreach and Marketing 7762 21 Section IV - Enrollee Services, Community Outreach and Marketing 7762 22 Section V - Covered Services 7762 23 Section V - Covered Services 3881 24 Section V - Covered Services 15524 25 Section V - Covered Services 7762 26 Section V - Covered Services 7762 27 Section V - Covered Services 11643 28 Section VI - Behavioral Health Care 7762 29 Section VII - Provider Network 7762 30 Section VII - Provider Network 11643 31 Section VII - Provider Network 7762 32 Section VII - Provider Network 7762 33 Section VIII - Quality Management 23286


SRC # SRC TITLE CHARACTER SPACE

ALLOWANCE 34 Section VIII - Quality Management 7762 35 Section VIII - Quality Management 7762 36 Section VIII - Quality Management 7762 37 Section VIII - Quality Management 7762 38 Section VIII - Quality Management 15524 39 Section VIII - Quality Management 3881 40 Section VIII - Quality Management 3881 41 Section VIII - Quality Management 3881 42 Section VIII - Quality Management 7762 43 Section VIII - Quality Management 11643 44 Section IX - Grievance System 11643 45 Section X - Administration and Management 3881 46 Section X - Administration and Management 11643 47 Section X - Administration and Management 11643 48 Section X - Administration and Management 7762 49 Section X - Administration and Management 15524 50 Section X - Administration and Management 11643 51 Section XI - Information Management and Systems 32767 52 Section XI - Information Management and Systems 11643 53 Section XI - Information Management and Systems 15524 54 Section XI - Information Management and Systems 15524 55 Section XI - Information Management and Systems 15524 56 Section XII - Reporting Requirements 15524 57 Qualifications and Experience 11643 58 Qualifications and Experience 7762 59 Qualifications and Experience 7762 60 Section V - Covered Services 7762 61 Section V - Covered Services 3881 62 Section V - Covered Services 7762 63 Section VII - Provider Network 23286 64 Section VII - Provider Network 27167 65 Section VII - Provider Network 7762 66 Section VII - Provider Network 11643 67 Section VII - Provider Network Unlimited

EXHIBIT 3 - QUESTIONS AND ANSWERS


VENDOR NAMEITN

ATTACHMENT IDENTIFIER

ATTACHMENT EXHIBIT

IDENTIFIER (IF APPLICABLE)

SECTION/SUBSECTION

CITE REFERENCE

PRIMARY LEAD QUESTION ANSWER

2

Simply Healthcare

Attachment C Section C.23 Medicaid Services

. The ITN, at Attachment C.23, Page 9, Section C.23, states that a successful vendor may only subcontract with those subcontractors identified in its response to the ITN, absent the prior written consent of the Agency. (a) Where and how should a prospective vendor identify any proposed subcontractors in its response to the ITN?(b) What information is required to be included in the ITN for any proposed subcontractors?(c) Does a prospective vendor need to include in its response to the ITN a letter from a proposed subcontractor or other evidence of the proposed subcontractor committing to provide services as a subcontractor to the proposed vendor if it is awarded a contract arising out of the ITN?(d) Please confirm that the qualifications and experience of any proposed subcontractors identified in a prospective vendor's response to the ITN will be considered by the evaluators in scoring the prospective vendor's response.More general questions based on the understanding that the ITN permits responding to the ITN as a "joint venture/legal partnership": • What do the terms "joint venture/legal partnership" mean for purposes of submitting a response to the ITN?• Is structuring a relationship between two (or more) entities such that the relationship meets the definition of a "joint venture/legal partnership," as these terms are used in the ITN, the only means by which AHCA will consider the qualifications of both entities in determining whether to award a contract under the ITN to a responding vendor?• Can AHCA provide clarification on alternative ways to structure a relationship between two entities such that the qualifications of both entities are evaluated under the ITN?

a) Service contracts reference the contracts a health plan has with service providers that are responsible for providing direct services to enrollees. Administrative contracts reference the contracts a health plan has with entities that are not responsible for providing direct services to enrollees, such as a fiscal employer agent, claims processing agent, TPA, etc AND service subcontractors (e.g., case management subcontracted entities ) Respondents should list prospective subcontractors, both administrative and services. Respondents should submit a list of network providers as directed in Attachment E-1, question 67 and E-1, Exhibit 1. (b) Information on administrative subcontractors should include name, officers, description of their duties under the subcontract and length of subcontractor relationship. (c) A letter of intent or first and signature pages of a contract would be preferred. (d) Evaluation questions found in Attachment E-1 will be evaluated based on the evaluation criteria found in the last column of each question.

3

Simply Healthcare Attachment C Section C.49 Legal

The ITN, at Attachment C, Page 29, Section C.49, indicates that a joint venture can be the respondent to the ITN. Does the reference to a “joint venture” include two entities that have entered into a teaming agreement or contractual relationship for purposes of the ITN, without having created a separate legal entity?

Yes



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

CITE REFERENCE


4

Simply Healthcare

Attachment C Section C.49 Legal

The ITN, at Attachment C, Page 29, Section C.49, indicates that a joint venture can be the respondent to the ITN, but that each party to the joint venture must submit all attachments or documentation required of a respondent unless otherwise stated. Attachment K would require a certification by each joint venture partner that their company is an eligible plan. Does this mean that the joint venture itself is not required to be an eligible plan provided that each member of the joint venture is an eligible plan?

If all members of the Joint Venture are eligible plans then the Agency will consider the Joint Venture eligible unless otherwise barred by Florida law. Section 409.966(1), F.S. (2012) requires that services be provided by eligible plans. Attachment C. paragraph 46 defines eligible plans. Thus, a joint venture must comprise eligible plans.

5

Amerigroup Florida Attachment D-II Exhibit 7

Table 1, LTC Provider Qualifications & Minimum Network Adequacy Requirements Table

Medicaid Services

The required bed count for NH, ALF and Assistive Care Facilities is indicated by Region not by county. How should Respondents calculate the required licensed bed for each enrollee in each county for each region? Is it acceptable to combine the total bed count to include: NH, ALF and Assistive Care?

Please see Addendum No. 2, Item # 9.

6

Wellcare Attachment D-II Exhibit 3HSD/Choice Counseling

Related to initial enrollment of long-term care eligibles in each Region of the State, how does the Agency intend to stage or phase-in initial enrollee notifications and enrollment during initial implementation?

It is the intent that each region's initial LTC plan enrollment will occur in accordance with Attachment C.20, Table 1- Anticipated Regional Roll-Out Schedule and in the Table 1 - Regional Start-Up Schedule provided in Attachment D-I, Exhibit 2. Successful bidders will be informed of the transition process for Nursing Home residents during the implementation phase. CARES will be involved only to the extent that a level of care determination may be necessary for the nursing home resident to be enrolled in the LTC's HCBS program option.

7

Wellcare Attachment D-II Exhibit 5, 5.c.HSD/Choice Counseling

Related to the onsite visit requirements for initial care plan development of 5 business days for an enrollee in the community or 7 business days for an enrollee in a nursing facility in Attachment D-II, can the Agency describe how phase in of enrollment will occur in a sample Region of the State based on both the anticipated enrollment level and number of contracted health plans.

It is the intent that each region's initial LTC plan enrollment will occur in accordance with Attachment C.20, Table 1- Anticipated Regional Roll-Out Schedule and in the Table 1 - Regional Start-Up Schedule provided in Attachment D-I, Exhibit 2.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

CITE REFERENCE


8

Wellcare Attachment D-II Exhibit 5, 5.c. Medicaid Services

Also related to the onsite visit requirements for initial care plan development, in addition to the minimum number of qualified case managers included in a plan's network submission, can the contractor use additional subcontracted and similarly qualified case management agencies or nursing agencies to meet the initial care plan development timelines?

Yes, a long-term care managed care plan can use additional subcontracted case management agencies or nursing agencies to meet the initial care plan development timelines. The case managers must meet all qualifications as specified in Attachment D-II, Exhibit 5, Section V, Covered Services, Item I., Care Coordination/Case Management.

9

Amerigroup Florida Attachment D-II NA

Section VIII, Quality Management, B. Utilization Management

Medicaid Services

Please clarify expectations for utilization management program in light of the fact that SMMC-LTC plans are not responsible to cover acute care services.

Utilization management of all covered services, as indicated in Attachment D-II, Exhibit 5, is required by the LTC plans. An effective utilization management program ensures that each enrollee receives all medically necessary services in the appropriate scope, amount, frequency and duration.

10

Simply Healthcare

Attachment D-II CORE

CONTRACT PROVISIONS

Exhibit 7

Table 1 Medicaid Services

For these provider types, assisted living facilities, assistive care services and nursing care facilities, in addition to 2 providers of each type in each county, AHCA requires 1 licensed bed for each enrollee in the applicable maximum enrollment for the region. This is almost 3,000 beds in region 1 and 7,000 beds in region 11.

Questions:1. Is the bed number a requirement for submission?2. Is this a total of all bed types combined in a region, i.e. 3,000 total ALFs, ACSs and NCFs combined? Or 3,000 of each type? 3. Since only 2 providers of each type can be listed in the exhibit, how does the plan represent the bed requirements in the application?

Please see Addendum No. 2, Item # 9.

11

Simply Healthcare

Attachment D-II CORE CONTRACT PROVISIONS

Exhibit 7 Table 1 Procurement

In the template provided on the AHCA website: http://ahca.myflorida.com/Procurements/index.shtml for many of the cells it is stated that “Response (Response narrative is limited to the space provided in this cell with no attachments.”

Question: Can AHCA advise of the number of words and/or characters allowed for these cells where the content is limited?

See Addendum No. 2, Exhibit #18.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

CITE REFERENCE


12

Simply Healthcare

Attachment E Exhibit 2 and Exhibit 3

Medicaid Services

The Agency allows a signature page only for contracts but appears to request the full letter for Letters of Agreement (LOA). Would the Agency allow submission of the signature page for LOAs as well?

Submission of a signature page for contracts and Letters of Agreement (LOA) are acceptable if all required elements are reflected.

13

Simply Healthcare

Attachment E Exhibit 2 and Exhibit 3

Duplicate question/Medicaid Services

The Agency allows a signature page only for contracts but appears to request the full letter for Letters of Agreement (LOA). Would the Agency allow submission of the signature page for LOAs as well?


14

Simply HealthcareATTACHMENT E-1, SUBMISSION

REQUIREMENTS AND

EVALUATION CRITERIA

COMPONENTS

Procurement

In the template provided on the AHCA website: http://ahca.myflorida.com/Procurements/index.shtml for many of the cells it is stated that “Response (Response narrative is limited to the space provided in this cell with no attachments.”

Question: Can AHCA advise of the number of words and/or characters allowed for these cells where the content is limited?

See Addendum No. 2, Exhibit #18.

15

Simply Healthcare

ATTACHMENT E-1, SUBMISSION REQUIREMENTS AND EVALUATION CRITERIA COMPONENTS

Duplicate question/Medicaid Services

For these provider types, assisted living facilities, assistive care services and nursing care facilities, in addition to 2 providers of each type in each county, AHCA requires 1 licensed bed for each enrollee in the applicable maximum enrollment for the region. This is almost 3,000 beds in region 1 and 7,000 beds in region 11. Questions:1. Is the bed number a requirement for submission?2. Is this a total of all bed types combined in a region, i.e. 3,000 total ALFs, ACSs and NCFs combined? Or 3,000 of each type? 3. Since only 2 providers of each type can be listed in the exhibit, how does the plan represent the bed requirements in the application?

Please see Addendum No. 2, Item #9.



VENDOR NAMEITN


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SECTION/SUBSECTION

CITE REFERENCE


16

Coventry Health Care of Florida C C. 11 Item 1 Location of

Services LegalIs the definition of "parent organization" limited to that entity which wholly owns the respondent in the event the respondent is, in fact, wholly owned?

That would depend on whether the owner of the Respondent is a subsidiary of another. The Agency wants the corporation that has a controlling interest in respondent. Depending on the scenario this could be the entity which wholly owns the Respondent, or it could be the entity which controls the entity which wholly owns the respondent.

17

Coventry Health Care of Florida C C.14 Item 3 Litigation Legal

Is respondent entitled to the 4 points to be awarded under this item if sought or awarded damages are covered by insurance or reserves in only those cases it deems significant and therefore possibly less than 100% of the cases listed pursuant to this Question 14?

No. The criteria for this question are listed in Attachment E-1, Question 14. What Respondent deems significant is not a listed criterion.

18

C C.24 Performance Bond

Procurement/Legal

C.24 - Performance Bond. Please clarify if the amount of the bond to be assessed as damages is the total amount of the performance bond for the respective region of $1,000,000; or a specific assessment amount against the bond to cover the costs of issuing a new solicitation and selecting a new vendor.

The amount assessed would be $1,000,000 per region.

19C C.24 Performance

BondProcurement

C.24 - Performance Bond. Can the performance bond be written on an annual bond form for each Contract Year as follows: 8/1/13 - 8/31/14; 9/1/14 - 8/31/15; 9/1/15 - 8/31/16; 9/1/16 - 8/31/17; 9/1/17 - 8/31/18?

The performance bond shall cover the term of the contract. The bond may be renewed on an annual basis.

20

Coventry Health Care of Florida C C.24 Performance

Bond

Can the performance bond be written on an annual bond form for each Contract Year, as follows:August 1, 2013 through August 31, 2014September 1, 2014 through August 31, 2015September 1, 2015 through August 31, 2016September 1, 2016 through August 31, 2017September 1, 2017 through August 31, 2018

The performance bond shall cover the term of the contract. The bond may be renewed on an annual basis.

21

Coventry Health Care of Florida C C.24 Performance

Bond

Please clarify if the amount of bond to be assessed as damages is the total amount of the performance bond for the respective region of $1,000,000; or a specific assessment amount against the bond to cover the costs of issuing a new solicitation and selecting a new vendor.

The amount assessed would be $1,000,000 per region.

22C C.45.C. Past

PerformanceProcurement

Would AHCA consider allowing one Evaluation Questionnaire for Past Performance document to be completed by each reference to suffice for all regions bid rather than having them fill out possibly 11 forms.

The Past Performance Evaluation must be completed per region.



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23

C C.45.D

General Instructions for Response Preparation and Submission

Procurement

Attachments J1 - J-4 must be excluded from the submission of each region's 17 copies and 1 redacted copy of the ITN and must only be submitted in the original copy?

Yes.

24

Coventry Health Care of Florida C C.45.D

General Instructions for Response Preparation and Submission

Procurement

Attachments J1, J2, J3 and J4 must be excluded from the submission of each region's 17 copies and 1 redacted copy of the ITN and must only be submitted in the original copy?

Yes.

25

Amerigroup Florida C NA C.16 Legal/Procurement

Please confirm our understanding of the requirements of Section C.16. If a Managed Care Plan is awarded a Region and declines the award, will AHCA return the Managed Care Plan's proposal guarantee money submitted with their proposal? In what scenarios are performance guarantee amounts NOT returned to the Managed Care Plan? The proposal guarantee requires that Respondents submit a “cash instrument,” please clarify whether AHCA will cash and hold the funds through the notification of award and the anticipated timeframes associated with negotiations. If so, please provide clarification of how interest accrued on the funds will be considered and whether the return of funds to the Respondent will include such interest.

Pursuant to Attachment A, Item 14, Firm Response, the Agency may make an award within sixty (60) days after the date of the opening, during which period responses shall remain firm and shall not be withdrawn. If award is not made within sixty (60) days, the response shall remain firm until either the Agency awards the Contract or the Agency receives from the respondent written notice that the response is withdrawn. Any response that expresses a shorter duration may, in the Agency's sole discretion, be accepted or rejected. Also, pursuant to Attachment C, Section C.16, Proposal Guarantee, if the successful vendor fails to execute a Contract within ten (10) consecutive calendar days after a Contract has been presented to the successful vendor for signature, the proposal guarantee shall be forfeited to the State. The Agency holds the proposal guarantee and does not redeem it, unless it is forfeited to the State.



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CITE REFERENCE


26

Sunshine State Health Plan - Tango

C NA

C.45, General Instructions for Response Preparation and Submission

Procurement

The ITN requires that responses be in 11 pt Arial font. Is it acceptable to use 8-10 pt font in tables, charts, and diagrams - for example, 11 point font in organizational charts, and various types of flowcharts and diagrams is fairly uncommon. In addition, tables that include numbers or that are structured to compare or group certain types of information in text are often more readable in 8-10 point Arial font. FU Question: At the vendor conference, we appreciate AHCA stating that respondents could use a minimum of 8 pt font for tables, charts and diagrams. Unfortunately, the submission template does not allow any formatting, tables, bullets, etc. Would ACHA consider refining the submission template to allow respondents to use tables and formatting to improve narrative presentation for evaluators.

A response within a cell is required to be Arial 11 pt. font. Any chart, table or graph within an attachment is allowed to be no less than 8 pt. font.

27


C NA


Duplicate question/Procurement

The ITN requires that responses be in 11 pt Arial font. Is it acceptable to use 8-10 pt font in tables, charts, and diagrams - for example, 11 point font in organizational charts, and various types of flowcharts and diagrams is fairly uncommon. In addition, tables that include numbers or that are structured to compare or group certain types of information in text are often more readable in 8-10 point Arial font. FU Question: At the vendor conference, we appreciate AHCA stating that respondents could use a minimum of 8 pt font for tables, charts and diagrams. Unfortunately, the submission template does not allow any formatting, tables, bullets, etc. Would ACHA consider refining the submission template to allow respondents to use tables and formatting to improve narrative presentation for evaluators.

DUPLICATE



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

CITE REFERENCE


28

Amerigroup Florida

D-II Exhibit 6

B. Responsibilities of the Health Plan

Medicaid Services

Among the ITN requirements and exhibits there appears to be conflicting information about coverage of behavioral health services. Please clarify the specific behavioral health services that are to be included in the SMMC-LTC Program and whether respondents are expected to contract directly with behavioral health providers

References: ITN Attachment D-II, Exhibit 6 "Behavioral Health - LTC Plans" states that, "The Managed Care Plan is responsible for coordinating with other entities available to provide behavioral health services," and not directly providing the service; However, Attachment D-II, Section V “Covered Services,” indicates coverage of Behavioral Management, which is defined as providing “behavioral health care services to address mental health or substance abuse needs of long-term-care plan members. These services are in excess of those listed in the Community Behavioral Health Services Coverage and Limitations Handbook and the Mental Health Targeted Case Management Coverage and Limitations Handbook. The services are used to maximize reduction of the enrollee’s disability and restoration to the best possible functional level and may include, but are not limited to: an evaluation of the origin and trigger of the presenting behavior; development of strategies to address the behavior; implementation of an intervention by the provider; and assistance for the caregiver in being able to intervene and maintain the improved behavior.”

The only behavioral health covered service required by LTC MCPs is behavior management, as defined in Attachment D-II, Exhibit 5. The LTC Managed Care Plans are responsible for coordination of additional behavioral health services (not covered by the LTC plan) as indicated in Attachment D-II, Exhibit 6.

29

Amerigroup Florida

D-II Exhibit 8

Section VIII, Quality Management, Item C., Transition of Care

Medicaid Services

How will members transition out of NH’s? Will CARES be involved as they are now OR will the Plan be responsible for working with the NH to move people to a less restrictive setting? Successful bidders will be informed of the transition

process for Nursing Home residents during the implementation phase.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

CITE REFERENCE


30

Amerigroup Florida D-II NA Section XIV Sanctions

Medicaid Services

The evaluation criteria included in Questions 12 through 15 does not account for the size of a business, the number of contract or the years of experience represented. It appears that the criteria will value no experience or a new entity without any sanctions or other adverse events over those organizations that have extensive experience over many years of operations but may have some adverse events to report. Will AHCA consider revising the evaluation criteria to better adjust the scoring for long-term and experienced organizations?

No, the evaluation criteria will not be revised for this ITN.

31

Amerigroup Florida

D-II NASection XVII, Liquidated Damages, B. Issues and Amounts, #22

Medicaid Services

ITN Attachment D-II, Section XVII, "Liquidated Damages," states that there must be face-to-face contact between the Managed Care Plan case manager and each enrollee at least every three (3) months and/or ninety (90) days or following a significant change. Please clarify whether it is three months or ninety days, as these are two possibly different timeframes since not all months are 30 days long.

The correct time frame is ninety (90) days. See Addendum No. 2. Item #13 and Item #108.

32

Coventry Health Care of Florida E.1 E.1 Exhibit 1

Regional Network Contracts and Agreements Completion Instructions

Medicaid Services

Should vendors submit additional provider documentation, aside from the two providers for each service for each county? If yes, how would the State like to receive this information (for example, listed in an Excel spreadsheet or copies of contract signature pages?)”

No, the Regional Network Contracts and Agreements tool is designed to provide Managed Care Plans with credit for establishing signed contracts or written agreements per 409.966(3)(a)7., F.S. During the plan readiness phase, as outlined in Attachment C, Exhibit 6, Managed Care Plans will be required to provide their complete provider network.

33

Amerigroup Florida E-1 Exhibit 7 NA Medicaid Services

In reporting the Network, can Adult Companion Services be delivered by a Nurse Registry?

Yes, Adult Companion Services can be provided by Nurse Registries licensed per 400.506, F.S. Individuals providing services through the Nurse Registry must be health care professionals practicing within the legal scope of their practice. See Addendum No. 2, Item #9.

34


E-1 NAE-1, Page 15 of 108, SRC 10

HSD

Please confirm that 'HEDIS and contract-required quality standards' refers to the specific quality measures and performance targets required by each state. If not, what quality standards are expected?

This is confirmed: 'HEDIS and contract-required quality standards' refers to the specific quality measures and performance targets required by each state.

35


E-1 NAE-1, Page 15 of 108, SRC 10

Duplicate question/HSD

Please confirm that 'HEDIS and contract-required quality standards' refers to the specific quality measures and performance targets required by each state. If not, what quality standards are expected?

This is confirmed: 'HEDIS and contract-required quality standards' refers to the specific quality measures and performance targets required by each state.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


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CITE REFERENCE


36


E-1 NA E-1, Page 4 of 108, SRC 1 HSD

Please confirm that the documentation required is a current certificate from the accrediting entity, showing full or partial accreditation as specified (or please indicate what additional documentation is required).

The respondent is required to provide documentation of current accreditation that includes the information specified in Attachment E-1, page 4 of 108. Such documentation could be a certificate of current accreditation provided it includes the information specified in Attachment E-1, page 4 of 108.

37


E-1 NAE-1, Page 91 of 108, SRC 57

Medicaid Services

The definition of subcontractor appears to encompass not only managed long term care services, but also office cleaning, office supply, and likely many other subcontracts that are only indirectly related to managed long term care services. Also, we are concerned that providing qualifications and other required information for such a wide range of subcontractors (those related to and those not related to managed long term care) within the current character limit will not be feasible. We request that SRC 57 be limited to subcontractors providing managed long term care related services.

a) Service contracts reference the contracts a health plan has with service providers that are responsible for providing direct services to enrollees. Administrative contracts reference the contracts a health plan has with entities that are not responsible for providing direct services to enrollees, such as a fiscal employer agent, claims processing agent, TPA, etc. AND service subcontractors (e.g., case management subcontracted entities ) Respondents should list prospective subcontractors, both administrative and services. Respondents should submit a list of network providers as directed in Attachment E-1, question 67 and E-1, Exhibit 1. (b) Information on administrative subcontractors should include name, officers, description of their duties under the subcontract and length of subcontractor relationship. (c) A letter of intent or first and signature pages of a contract would be preferred. (d) Evaluation questions found in Attachment E-1 will be evaluated based on the evaluation criteria found in the last column of each question.

38


E-1 NAE-1, Page 92 of 108, SRC 58

Medicaid Services

Please confirm that the documentation required for an MMA or SNP contract with AHCA is the signature page (or other designated portion) of an applicable contract (and not the entire contract).

The documentation required for a Managed Care Plan (MCP) or Special Needs Plan (SNP) to provide evidence of a contract with AHCA is the signature page of the applicable contract.



VENDOR NAMEITN


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39


E-1 NAE-1, Pages 52-53 of 108, SRC 31

Medicaid Services

In the Evaluation criteria column, the attachment includes "Elements from NCQA," numbered 1 through 6, which appear to be elements for medical record audits rather than elements for credentialing (the same elements are also cited in SRC 35 regarding medical record audits). Please confirm whether the NCQA elements cited in SRC 31 should be replaced with NCQA credentialing elements.

Attachment E-1's Question 31 notes are for the ITN evaluator to use as a guide in evaluating responses to this question. The criteria detailed in the notes will not be revised for this ITN. Evaluators will receive training on the use of these criteria in reviewing these responses to this question.

40

E-1 NA Question 5 Procurement

Response narrative is limited to space provided in ten (10) cells. There are 11 question listed (a-k) should we have 11 cells or combine two of the questions.

The Agency's intent was not to limit the character space in each cell to describe one contract per cell. This particular submission requirement allows ten (10) text field cells which is the equivalent of ten (10) pages. The Agency has determined that one page equals 3,881 character spaces based on a page allowance of 8.5 x 11, Arial point 11 size font with 1 inch margins. The entire submission requirement allows for 38,810 character spaces combined.

41

Cynthia T. Weinmann. APS Healthcare

E-1 Procurement

1. E-1 template – Please clarify/confirm given that the template is a locked document with fields for the ITN response how will proprietary/confidential or other exempt information be indicated in a separate section and marked on each page?

See Addendum No. 2, Item #1

42


E-1 Procurement

2. Please confirm that exempt information, located in a separate section in the binder, will also be part of the redacted copy.

No, See Attachment C, Special Conditions, Section C. 45, General Instructions for Response Submission, the eleventh paragraph.

43


E-1 Procurement

Exhibit 3 – Disclosure of Ownership and Control Interest Statement is a PDF. Can AHCA provide a copy that can be edited and submitted with the proposal?

No.

44


E-1 Procurement

Does AHCA have a page limit on attachments or a number of attachments for ITN items that permit attachments?

Each response section identifies the limitation of attachments.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

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45


E-1 Procurement

Fully populating the ITN response template yields a document that is 1,206 pages long. There are several factors that are responsible for this length – for example, the fact that the column width for the response expands once populated and other columns on the same row decrease in width, meaning that content in those columns then extends over multiple pages. The result is a lengthy document that is difficult to read and which may not fit in two binders given that attachments and pages identified as exempt must also be included in the two binders. We provide an example to illustrate the issue below. Can AHCA reformat the template to eliminate these problems?

No.

46 Universal E-1 Procurement

With regard to Attachment E-1 how should plans enter information? The cells do not appear to be formatted.

The response cells are formatted to Arial 11 pt. font. The entered text will automatically wrap.

47


F NA P1, 6th Past Performance.

Medicaid Services

Since respondents as a specific entity generally need FL licensure or registration, they technically do not operate in other states although they often operate similarly to and share best practices with affiliates (likewise for affiliates they operate in other states and not in FL). If AHCA prohibits affiliate references, that prevents access to valuable information on how Respondents affiliates have performed in other states. As a practical matter it may also mean that few if any meaningful references besides AHCA/DOEA can be submitted by most respondents. The result is that the agency must select contractors with less information than what is reasonably available and useful.

Attachment F's directions concerning past performance references will not be revised for this ITN.

48

Amerigroup Florida

General NA

NAMedicaid Services

Will contracts that Managed Care Plans currently hold with providers that have been approved by DOEA be recognized and counted as contracts in the scoring for the ITN? We would presume that these contracts would need to be amended after the ITN submission to include the program requirements for the new program.

In order to receive points in this section, respondents must submit signed contracts or signed letters of agreement specifically for the Managed Long-Term Care Program. Submission of a signature page for contracts and Letters of Agreement (LOA) are acceptable if all required elements are reflected.

49 General Procurement Please provide copies of the bidder's sign in sheets. See Addendum No. 2, Attachment #20

50

Coventry Health Care of Florida N/A N/A N/A MPA Can you please advise how expanded benefits will be treated in

the calculation of the achieved savings rebate?

Expanded benefits are to be included under the achieved savings rebate. The achieved savings rebate methodology will be reflected in a rule to be developed by the Agency. Expanded benefits must be Agency approved.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


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51

Wellcare N/A N/A N/A Medicaid Services

With respect to references, we interpret the ITN to allow references from state agencies that oversee respondent affiliates participating in programs covering the same or similar populations in other jurisdictions. Can the Agency please confirm this understanding? For example, “GreatCare HMO of Florida” is a respondent in the FL MLTC RFP and will submit a reference from the Commonwealth of Virginia as to “GreatCare HMO of Virginia” with respect to its participation in a Virginia MLTC program. Is this permissible?

Attachment F's directions state entities having an affiliation with the respondent (i.e., currently parent, subsidiary having common ownership, having common directors, officer, or agents or sharing profits or liabilities) may not be accepted as past performance reference under this ITN.

52

Wellcare N/A N/A N/A Legal

Section 641.315 (6) Prohibits contracts between managed care organizations and providers of health care services which restrict such health care provider from entering into a commercial contract with any other managed care organization.

Section 641.19 Defines “Provider” as any physician, hospital, or other institution, organization, or person that furnishes health care services and is licensed or otherwise authorized to practice in the state.

Based on the above, does the Agency concur that the exclusivity prohibition contained in F.S. 641.315 (6) does not apply to entities that do not meet the definition of provider as indicated in Section 641.19 and which do not, in fact, provide any health care services and are not licensed to do so?

No.

53

Wellcare N/A N/A N/A HSD

Outside of the 834 enrollment files, how will the Agency notify the managed care plan of whether a newly enrolled member is currently receiving Medicaid covered nursing facility services or Medicaid home and community based services? Will the Agency provide managed care plans with copies of existing HCBS care plans prior to an initial member's enrollment effective date?

Successful bidders will be informed of the notification process during the plan readiness phase of program implementation.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

CITE REFERENCE


54

Wellcare N/A N/A N/A Medicaid Services

Can the Agency confirm whether the SanData program will continue? If so, will plans be required to participate in the program as currently administered? If no, will plans be expected to replicate it?

The Agency's current contract for verifying the utilization and delivery of home health services is with Sandata. The Agency's current contract covers individuals receiving State Plan home health services in a fee-for-service environment only. As specified in Attachment D-II, Section X, Item E., as a part of their program integrity function, managed long-term care plans will be required to establish methods for verifying enrollees' identity and whether services billed by providers were actually received. The Agency is not requiring that managed long-term care plans contract with a specific vendor for electronic verification or biometric technology services. The Agency is not requiring that any single method be implemented for verification of enrollees' identity and if services billed by providers were actually received.

55

Heidi Pines Section VIII Item B Medicaid Services

It states that an LCSW is unable to make certain decisions in relation to Utilization Management. Who will be able to make these determinations? Will it be Medical Directors only? RN's? LPN's?

Attachment D-II, Exhibit 8, Item B. states that Licensed Clinical Social Workers are not permitted to reduce, deny, suspend, or terminate services. They are also not permitted to diagnose and treat individuals. These duties should be carried out by a physician licensed under Chapter 458 or 459, F.S.

56Procurement

Can all mandatory documents for signature be placed under one tab in ITN binder?

Yes. Respondents may include all mandatory documents requiring signature with the original response submission under one tab.

57Procurement

AHCA Medicaid Integrity Unit or Medicaid Fraud Waste and Abuse may be used as a non-AHCA or an AHCA Client References

Any unit and/or division used with the Agency for Health Care Administration as a client reference would be considered an "AHCA" Client Reference.

58Medicaid Services

If we receive a file from AHCA how will we receive the CARES information?

Successful bidders will be informed about the CARES information transfer during the plan readiness phase of program implementation.

59 ? For new members will we still be required to send that info to AHCA? Question is not clear as written.

60Procurement?

No matter how many regions you bid for there is only a check for $479,000 required, not one for each region. Question is not clear as written.

61Medicaid Services

Can a LTC Diversion contractor get a provider reference from the DOEA and CARES? Yes.

62Procurement

If a plan is bidding more than one region, do they need to submit complete separate proposals for each region? Yes.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


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63

Medicaid Services

How will the Agency address plans not willing to contract with providers on the required to contract provider list? If you only allow listing of 2 providers in the exhibit, how will the Agency verify that the plan's response meets all of the requirements of the ITN prior to award?

Section 409.982 (1) (c), F. S., requires LTC MCPs to offer service contracts to aging network providers. MCPs only have to establish that contracts were offered. The Regional Network Contracts and Agreements tool is designed to provide Managed Care Plans with credit for establishing signed contracts or written agreements per 409.966(3)(a)7., F.S. During the plan readiness phase, as outlined in Attachment C, Exhibit 6, Managed Care Plans will be required to provide their complete provider network.. Successful bidders will be required to submit their complete provider networks to establish provider network adequacy during the plan readiness phase of program implementation.

64

Legal

C.11, Item 1 - Location of Services. Is the definition of "parent organization" limited to that entity which wholly owns the respondent in the event the respondent is, in fact, wholly owned?

That would depend on whether the owner of the Respondent is a subsidiary of another. The Agency wants the corporation that has a controlling interest in respondent. Depending on the scenario this could be the entity which wholly owns the Respondent, or it could be the entity which controls the entity which wholly owns the respondent.

65

Procurement/Legal

If a Medicaid LTC Managed Care HMO does LTC business in another state under a different entity than that used by the bidding entity in Florida, will AHCA allow the Florida bidding entity to submit references for those LTC program state agencies?

The client reference should be for the Respondent only.

66

Procurement

Please confirm our understanding of the requirement of section C.16. If a MCP is awarded a region and declines the award will AHCA return the MCP's proposal guarantee submitted with their proposal? In what scenarios are performance guarantee amounts not returned to the MCP? The proposal guarantee requires that respondents submit a cash instrument. Please clarify whether AHCA will cash and hold funds through the notification of award and the anticipated timeframes associate with negotiations. If so, please provide clarification of how interest accrued on the funds will be considered and whether the return of funds to the respondent will include such interest.

DUPLICATE



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

CITE REFERENCE


67

Medicaid Services

The evaluation criteria included in Question 12 through 15 does not account for the size of business, the number of contracts or the years of experience represented. It appears that the criteria will value no experience or a new entity without any sanctions or other adverse events over those organizations that have extensive experience over many years of operations buy may have some adverse events to report. Will AHCA consider revising the evaluation criteria to better adjust the scoring for long term and experienced organizations?

No, the evaluation criteria will not be revised for this ITN.

68

Medicaid Services

Will contracts that MCP's currently hold with providers that have been approved by DOEA be recognized and counted as contracts in the scoring for the ITN? We would presume that these contracts would need to be amended after the ITN submission to include the program requirements of the new program.


69

Medicaid Services

Among the ITN requirements and exhibits there appears to be conflicting information about coverage of behavioral health services. Please clarify the specific behavioral health services that are included in the SMMC LTC program and whether respondents are expected to contract with behavioral health providers.

The only behavioral health covered service required by LTC MCPs is behavior management, as defined in Attachment D-II, Exhibit 5. The LTC Managed Care Plans are responsible for coordination of additional behavioral health services (not covered by the LTC plan) as indicated in Attachment D-II, Exhibit 6.

70Procurement/Legal

For a new LTC entity, can required references be from other related corporate LTC entities who do have experience? The client reference should be for the Respondent only.

71

Chris Bach MPA

Confirm there is no retro settlement of the revenue based on the actual waiver / non-waiver mix for the entire year. I.e., the final rates for the entire year will be based on the month 1 enrollment, with adjustments for new enrollees and terms only.

Because the payment rates will be adjusted monthly based on new enrollments and disenrollments, there will not be a retrospective settlement based on actual HCBS and Non-HCBS mix.

72

Chris Stagman. Brevard Alzheimer's Foundation

HSD

Could you further define an Exclusive Provider Organization (EPO). Would a current Nursing Home Diversion Managed Care Organization currently under contract with DOEA, be considered an EPO and could response to the ITN to provide services for a specific County

EPOs are defined in Attachment D-II, Section II, and are described in Attachment C, C.46. A current nursing home diversion managed care organization would be considered an EPO if it is licensed under s. 627.6472, F.S., and meets the financial requirements of either a long-term care capitated managed care plan or fee-for-service managed care plan, respective to its plan type. See Attachment D-II, Section XV, and Attachment D-II, Exhibit 15, for financial requirements.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

CITE REFERENCE


73

Joel Menges, Special Needs Consulting Services

Procurement

Will the responses to questions given verbally during today’s call be posted to the procurement website in writing? If so, when?

Only the questions that were e-mailed to the e-mail address outlined in Attachment C, Section C.9, Vendor Questions and/or written on the index cards provided at the Vendor Conference will be posted to the Vendor Bid System in an addendum. Also see Attachment C, Section C.6, Solicitation Timeline, for the "anticipated" date. See Addendum No. 2, Item # 19.

74

Universal Procurement

Which region should the core be attached to and how do you reference the core for the regions that don't need the core included?

See instructions outlined on Pages 1 and 2 of Attachment E-1, Submission Requirements and Evaluation Criteria Components. Respondents must complete Attachment E-1, Submission Requirements and Evaluation Criteria Components, in its entirety for each region for which it is responding. Respondents must include identical answers for all core submission requirements for each region.

75 Universal Procurement

Does the “original” submission need to say Original on each page?

No. The outside of the binder should be marked as the "original".

76

Universal Procurement

Can the assumptions page be part of the financials? How detailed are the financial statements supposed to be?

See Attachment C, Section C.45 General Instructions for Response Preparation and Submission, Item B., Financial Information. Yes, the assumptions for the financial projections can be part of the financials.

77

Universal Legal

With regard to Attachment E-1, sanctions (monetary and non-monetary) should plans include deficiencies noted during desk review or on-site audits if no sanction or punitive action was taken? Are requests for corrective action plans considered a sanction?

Sanctions are defined as any monetary and non-monetary (e.g., letters of non-compliance and involuntary enrollment freezes) punitive actions taken by regulatory bodies. Corrective Action Plans applied under Section XIV (Sanctions) are considered sanctions.

78

Medicaid Services

Is the Medical Director able to serve as the Medical Director for LTC and other program within the same plan?

The Vendor may use the same Medical Director and Compliance Officer for its long-term care plan and medical assistance plan; however, the Medical Director must then have experience serving both long-term care and medical assistance populations. See Addendum No. 2, Item # 5.

79Medicaid Services

When calculating the number of beds required for facility based services in a geographic region, is there an additional breakdown for requirement by county?

Please see Addendum 2, Item #9.



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80Procurement

Can we ask an AHCA representative ahead of time if they will be our client reference, in order to get their contact info? No. Permission is not required.

81Medicaid Services

Can we submit a model LOI, and then only signature spaces to reduce size of response?


82Medicaid Services

Is the plan responsible for covering all Medicaid Services (medical) which are not covered by Medicare, is a component of the LTC program?

Utilization management of all covered services, as indicated in Attachment D-II, Exhibit 5, is required by the LTC plans.

83

Medicaid Services

In the event the planner had negative experience with a required provider, especially if it relates to accelerated number of services and/or regulatory compliance, must the plan alter a contract?

Long-Term Care Managed Care Plans (MCPs) are expected to manage their provider networks as well as provide the necessary covered services. Service providers who fail to provide services as authorized may be subject to corrective action plans and termination after the first year of operations. Service providers in the aging network only have to be offered a contract. See Section 409.982 (1) (c), F. S.

84Legal Is the performance bond and financial guarantee, which is in

excess of $400,000 be required for each region bid?

A proposal guarantee is required for each ITN, as each region has its own ITN. A plan which submits a bid in response to the ITNs in multiple Regions must submit proposal guarantees for each of the ITNs.

85

Medicaid Services

In terms of providing services, if a provider is not listed as a qualified provider type, yet the staff member that will provide the services has the proper license or qualifications as listed in the ITN table, can that provider provide the services, i.e. Care Giver Training and Centers for Independent living?

Unless the provider qualifications chart, as updated by Addendum No. 2, Item #9, lists a provider type as a qualified service provider, the MCP may not authorize program services with this service provider.



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86

Medicaid Services

Will it be mandatory for "the plan" to use Sandata, or a home health aide verification system?

The Agency's current contract for verifying the utilization and delivery of home health services is with Sandata. The Agency's current contract covers individuals receiving State Plan home health services in a fee-for-service environment only. As specified in Attachment D-II, Section X, Item E., as a part of their program integrity function, managed long-term care plans will be required to establish methods for verifying enrollees' identity and whether services billed by providers were actually received. The Agency is not requiring that managed long-term care plans contract with a specific vendor for electronic verification or biometric technology services. The Agency is not requiring that any single method be implemented for verification of enrollees' identity and if services billed by providers were actually received.

87

Medicaid Services

How will the "phase out" process be carried out in the event a current LTC diversion program does not get an invitation to negotiate? How long will this process take? How long does the Agency anticipate this phase out to last?

DOEA will inform providers in the current waiver programs of the phase out process as the program begins the implementation phase.

88Medicaid Services

When developing a transition plan to accept clients from agencies with clients who do not get invited to negotiate a contract, how long will that process take?

DOEA will inform providers in the current waiver program of the phase out process as the program begins the implementation phase.

89

Medicaid Services

What is the total allowable caseload per case manager, taking into account a community-based client facility-based client mix?

The ITN specifies that each plan ensure that caseloads do not exceed a ratio of sixty (60) enrollees to one case manager for enrollees that reside in the community and no more than a ratio of one-hundred (100) enrollees to one (1) case manager for enrollees that reside in a nursing facility. At the time of the ratio development for enrollees in the community, the Agency did not account for different residential settings.

90

Medicaid Services

Please clarify what is meant by "nursing care facility"? Is this the same as an Assisted Living Facility? If not, is the 60 enrollee to case manager ratio for community enrollees include enrollees that reside in an ALF?

Nursing care facilities are facilities licensed either under Chapter 400, Part II, F S., or hospital -based skilled nursing facilities licensed under Chapter 395, F. S. This facility definition does not include an assisted living facility. The case manager ratio for community enrollees includes enrollees residing in ALFs.



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91

Medicaid Services

When submitting the Provider Network Listing can you include providers outside the county if they meet the 30 or 60 mile rule? This question pertains to ADC, ALF, and SNF.

The Regional Network Contracts and Agreements tool, found in Attachment E-I, Exhibit 1 is designed to provide Managed Care Plans with credit for establishing signed contracts or written agreements per 409.966(3)(a)7., F.S. During the plan readiness phase, as outlined in Attachment C, Exhibit 6, Managed Care Plans will be required to provide their complete provider network. A complete provider network listing is not required as part of this ITN.

92HSD In definition of LTC PSN it indicates you must have a Cert. of

Auth., or a K w/ a TPA, where is this requirement drawn from?

The definition for a LTC PSN does not include the requirement of a Certificate of Authority. The TPA requirement is specified in order to ensure the entity processing claims has the Florida licensure to do so.

93

Medicaid Services

Under Provider Qualifications for occupational therapy an Occupational Aide meets the criteria. Should this state Occupational Assistant. An Occupational Aide is a clerical position. If it is supposed to be Assistant can it be added to Physical Therapy also?

See Addendum No. 2, Item #9. The provider qualifications chart is revised to eliminate occupational aide and include occupational assistant as a qualified provider of this service.

94

HSD

If a PSN Qualified Provider (Home Health Care Agency or Nursing Home) has a contracted CTC provider network, but is owned by another entity, that is not a provider, does it meet the qualifications of being a CTC PSN? Ie: Individuals or a corporation own the entity

The ownership requirements for a LTC PSN are described in Attachment C.46 and in s. 409.962(8), F.S.

95

Medicaid Services

What is planned transition approach for members currently receiving "excluded services", as they go into MLTC?

Successful bidders will be advised of the transition plan for plan members that receive excluded services under the new program. “Successful bidders will be provided with information regarding this issue during the plan readiness phase of program implementation”

96

HSD

Would a joint venture comprised of one or more long term care (LTC) partners such as a SNF, ALF, and/or hospice and a non-reform capitated PSN meet the definition of a LTC PSN and considered an eligible plan to respond to LTC ITN?

Section 409.966(1), F.S. (2012) requires that services be provided by eligible plans. Attachment C. paragraph 46 defines eligible plans. Thus, a joint venture must comprise eligible plans. Section 409.981(1), F.S. (2012) mandates that a PSN must be a long-term care PSN. If a Joint Venture is made up solely of LTC PSNs then it may enter as a LTC PSN. If the Joint Venture combines an LTC PSN with another eligible plan, then it must enter the other eligible plan type.



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97HSD What is the process of establishing a LTC PSN?

Meeting the requirements for long-term care provider service networks as specified in Attachment C, sub-item C.45., B., Financial Information, and sub-item C.46.

98

Legal AND part 2 reassigned to MS

C.14 Han 3 - Litigation Is respondent entitled to the 4 points to be awarded under this item if sought or awarded damages are covered by insurance or reserves in only those cases it deems significant and therefore possibly less and under 100% of the cases listed pursuant to this question 14? E1 exhibit 1 - Regional network contracts. Should vendors submit additional provider documentation, aside from the two providers for each service for each county? If yes, how would the state like to reserve this information (for example, listed on excel spreadsheet or copies of contract signature pages?)

1) No. The criteria for this question are listed in Attachment E-1, Question 14. What Respondent deems significant is not a listed criterion. 2) No, the ITN Provider network tool is designed to provide MCPs with credit for assembling the minimal provider network the program requires. During the plan readiness phase, successful bidders will be required to provide their complete provider networks.

99

Legal

AHCA made clear today in response to a question that the Medicaid contract for this LTC program and section 641.315 (6), Fla, Stat., prohibit Medicaid health plans from requiring providers to be exclusive to only one health plan. Does this prohibition on exclusivity apply to Medicaid health plans - contracted arrangements with companies that arrange for the provision of certain services (e.g., transportation or behavioral health) to the Medicaid health plans members?

The contract provision alluded to applies to provider contracts. The contract definition of provider and the specific contract provision follow: Provider — A person or entity eligible to provide Medicaid services. MMA and LTC PSN FFS providers must have an active Medicaid provider agreement. All other providers must be eligible for a Medicaid provider agreement. Attachment D-II, Page 23 of 168. cc. Contain no provision that in any way prohibits or restricts the provider from entering into a commercial contract with any other Managed Care Plan (see s. 641.315, F.S.) Attachment D-II, Page 74 of 168



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100

MPA

Please discuss the telephonic savings adjustment applied to home health costs. Specifically, how will this program be implemented and who is responsible for implementation (State or Health Plan)? Will implementation be fully completed in all regions prior to membership effective dates?

The Agency's current contract for verifying the utilization and delivery of home health services is with Sandata. The Agency's current contract covers individuals receiving State Plan home health services in a fee-for-service environment only. As specified in Attachment D-II, Section X, Item E., as a part of their program integrity function, managed long-term care plans will be required to establish methods for verifying enrollees' identity and if services billed by providers were actually received. The Agency is not requiring that managed long-term care plans contract with a specific vendor for electronic verification or biometric technology services. The Agency is not requiring that any single method be implemented for verification of enrollees' identity and if services billed by providers were actually received. The cost associated with service review requirements, as specified in Attachment D-11, core Contract, Section X, E.S.C. (4)(b), are the responsibility of the plan.

101

Medicaid Services

In determining whatever case management ratios are met, can support staff be included in meeting such ratios? Can management be included?

Please see Attachment D-II, Exhibit 5, Section V., Item I for Case Management and Case Management Supervisor qualifications. Only staff who meet these qualifications will be acceptable when calculating required staffing ratios.

102

Medicaid Services

For purposes of estimating network capacity to meet network requirements, could you clarify Table One, Attachment E, Page 5 of 7, regarding the # of plans that will be contracted per region. Does the total # shown include or exclude PSNS?

PSN are included in the total maximum number of plans with which the Agency will contract.

103

Medicaid Services

The ITN states that cost share, (patient responsibility), must either all be collected through the providers or all be collected from the member. We use a combination of these two methods in other states depending on the members location (institutionalized versus home based). What is the rationale for only allowing the use of one or the other method?

AHCA established the MCP patient responsibility policy for administrative convenience in developing this new program.



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104HSD Will the 834 provide the cost share (patient responsibility),

amounts per month for each member?

The 834 will not provide the patient responsibility amount. Successful bidders will be informed of the process by which plans will receive this information during the plan readiness phase of the program.

105

MPA/Medicaid Services

How often does the cost share amount change retro-actively for members? How many months back do you go when you charge the cost share retrospectively?

For plan members receiving only Social Security income, patient responsibility changes occur at most once per year. For plan members with other income sources, changes may occur as often as the income changes. The Notice of Case Action detailing the patient responsibility will state the retroactive period.

106

Medicaid Services

If a member is enrolled in a health plan and is in a nursing facility and the health plan moves the member back into the community, but in doing so, the member moves into a region in which the health plan doesn't have a contract, does the plan lose this member? Example: member moves to a child's house in another area of the state.

Per s. 409.969(2)(d), F.S., on the first day of the month after receiving notice from a recipient that the recipient has moved to another region, the Agency shall automatically disenroll the recipient from the managed care plan the recipient is currently enrolled in and treat the recipient as if the recipient is a new Medicaid enrollee. At that time, the recipient may choose another plan pursuant to the enrollment process. If the recipient does not make an active plan choice, the Agency will assign the recipient to a health plan based on the criteria in s. 409.984(2), F.S. If the health plan in the region where the member was previously residing moves to another region in which the plan does not have a contract, then the plan will lose that member.

107

Medicaid Services

How many waiver slots are available in the State? Are there enough slots to increase the number of members in HCBS services to the ultimate state goal of 65%?

he waiver funding approved for the four HCBS waivers is being merged into the new LTC managed care program. Individuals in nursing facilities enrolled in the he plan will be able to transition to HCB services in the community without regard to the availability of waiver "slots."

108

Medicaid Services

ITN Attachment D-11, Section XVII, "Liquidated Damages" states that there must be face to face contact between one Managed Care Case Manager and each enrollee at least every 3 months and/or ninety days or following a significant change. Please clarify whether it is three months or 90 days, as these are possibly two different time frames since not all months are 30 days. D-11, Section XVII B. #22.

The correct time frame is ninety (90) days. See Addendum No. 2. Item #13 and Item #21.



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109

Medicaid Services

How may members transition out of nursing homes? Will CARES be involved as they are now, or will the plan be responsible for working with nursing homes to move people to a less restrictive setting?

Successful bidders will be informed of the transition process for Nursing Home residents during the implementation phase.

110

Medicaid Services

The required bed count for NH, ALF and Assistive Care Facilities is indicated by region and not by county. How should respondents calculate the required license bed for each enrollee in each county for each region?


111Medicaid Services

Is it acceptable to combine to total bed count to include: NH, ALF and Assistive Care? Please see Addendum No. 2, Item #9.

112

Medicaid Services

Attachment E-1 Question #7 The question is asking for lessons learned from respondent. Are lessons learned and relevant experience from affiliates also included in this question? This requirement would seem to limit applicable respondents to those participating in nursing home diversion as Florida LTC managed care experience. Client references and qualification/experience are sometimes limited to respondent. Please consider references and qualification/experience from affiliates as well. Specific qualifications/experience examples from Attachment E-1 are #4,5,6,7,8,9,10

Respondent is bound by the terms of Question #7 which will not be modified. When the ITN specifically asks for information related to “affiliates and subsidiaries or its parent company, or its affiliates and subsidiaries,” as in E-1 Question #12, it is clear.

113MPA

Published capitation rate ranges are not in the same categories as the rates required by Me ITN, Should the 8 rate cells be weighted to arrive at the final bid range? If so, what would be the basis for weighing?

Please see Addendum No. 2, Item #3 and Item #16.

114

MPA

Our understanding is that the LTC places should submit bids with the rate values in Appendix B. However as stated the current Appendix B does not include the impact of Hospice or Nursing Home fee charges and the addition of behavioral management, medication management and medication administration services. Will AHCA or AHCA's actuary be printing updated rate values prior to the August 28 bid submission?

No. The rate ranges provided in Appendix B of Attachment N-2 are the rate ranges that bidders should review in developing their cost proposals. See Addendum No. 2, Item # 3 and Item #16.

115

Medicaid Services

In reporting the network can adult companion services be delivered by a Nurse Registry?

Yes, Adult Companion Services can be provided by Nurse Registries licensed per 400.506, F.S. Individuals providing services through the Nurse Registry must be health care professionals practicing within the legal scope of their practice. See Addendum No. 2, Item #9.



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116

Coventry Health Care of Florida

Coventry is requesting a client reference from DOEA to include in our MLTC ITN response. We were referred to Barbara Vaughan to provide direction as to the best and most appropriate way to accomplish this

A respondent shall list the Department of Elder Affairs (DOEA) client reference(s) on Attachment F, Past Performance – Client Reference Form, Page 5 of 7. For purposes of this ITN, the Agency will be coordinating with one (1) point of contact at DOEA to ensure an evaluator or negotiator is not contacted.

117WorldNet MPA 7/13-Addendum 1 changed the required of rate bids to

submitted-will schedule J-5 changes match the addendum?Please see Addendum No. 2, Item 16, Attachments N-1 and N-2. Please also see Addendum No. 2, Item #3.

118

WorldNet MPA In developing rate ranges, what period of time was used for rate trends? Was it the full contract term? (About 5 years)

The base data were trended from January 1, 2011 (the midpoint of the base year) to the midpoint of the applicable contract enrollment period, which varies by region and is outlined in Appendix A, Table 3 of Attachment N-2. See Addendum No.2, Item # 16. Please also see Addendum No. 2, Item #3.

119

WorldNet MPA

Can you explain if members get reclassified at the beginning of each year between HCBS and non-HCBS for payment purposes? If so, what will be basis for determining reclassification? Example-someone starts as HCBS but later becomes nursing home. Is there a reset beginning of next contract year?

The Agency will be tracking the HCBS/non-HCBS status of each recipient, and will use this information to reset a recipient's classification at the beginning of the next year. The Agency expects continued transitions over time; however, the Agency required transitions will be re-evaluated annually.

120

WorldNet MPA

The rate submission requirements (attachment J, including J-1 through J-4) is designed assuming separate rates for duals and non-duals and age group (18-64 and 64+) How are the submission requirements changed now that the rate cells for duals and non-duals and age groups have been reduced to one rate cell? Will AHCA reissue the cost proposal template rate sheet(s) which are pre-populated with SFY10-11 member months by HCBS and non-HCBS?

Please see Addendum No. 2, Item # 16, Attachments N-1 and N-2. Please also see Addendum No. 2, Item #3.

121

WorldNet

J-5 Addendum

MPA

Please confirm if the negotiated rate will be adjusted for changes in the state FFS fee schedule for nursing facility and hospice services between Jan-June 2012 and July to Dec 2013?

See Section 4, Attachment N-2, Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

122

WorldNet MPA

The rate range addendum indicates no updates will be made to the rates for NH and hospice rates changes beyond those in effect 8/31/2014. Why will no changes be made for FFS changes between 1/1/2014 and 8/31/2104?

We do not understand the question.



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123

Coventry MPA 1.) what trend rates were used to trend SFY 10 to SFY 11?

Base data was blended as described in Section 2 of Attachment N-2. Highlights are: Assisted Living: Utilization 1.5%; Unit Cost 5.0%Case Management: Utilization 1.0%; Unit Cost 0.0%HCBS: Utilization 2.0%; Unit Cost 0.0%Hospice: Utilization 0.0%; Unit Cost 0.0%Nursing Facility: Utilization 1.0%; Unit Cost 0.0%. See Section 2, Attachment N-2, Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

124

Coventry MPA

2.) Adjustments applied in the data book appear to be missing from the rate range certification (eg., IBNR, encounter data adjustments) How were these adjustments factored into the rate ranges?

IBNR and encounter data adjustments were applied to the base data, and those base data were used to develop the rate ranges. Therefore, these adjustments are reflected in the rate ranges.

125

Coventry MPA

3.) Risk Adjustment. How will the benchmark mix of NH/HCBS work after year 1? For plans that do not achieve the required rebalancing, will they start at a higher cap rate since they have more NF? For successful plans, will year 2 require additional 2-3% beyond the initial mix of 2-3% beyond their achieved level?


126

Coventry

J-5 Addendum

MPA 4.) Risk adjustment. Please explain in more detail the 'pre-enrollment benchmark'?

The pre-enrollment benchmark PMPM is established by blending the negotiated HCBS and non-HCBS rates at the actual regional mix, adjusted for the Agency-required transition. The regional population mix is determined by analyzing 12 months of historical data 3 months prior to enrollment using the segmentation logic used in the Data Book, as described on page 11 of Attachment N-2. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

127

Coventry MPA

5.) Risk adjustment. For initial classification of a newly eligible LTC recipient, after program start. If they qualify and go immediately to NF, how will they have a chance to have a Medicaid paid NF claim?

An LTC eligible will be classified as a NF recipient only when there is a Medicaid paid NF claim. This ensures to the State that we have appropriately identified recipients who had a Medicaid-covered custodial NF claim since these NF recipients contribute a higher rate to the plan’s blended capitation rate.

128 Coventry MPA 6.) Will rates be adjusted if the program start dates are delayed? Yes



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129

Coventry MPA7.) Please explain and provide an example of the trend for patient responsibility. The rate states that it is not compounded but the ratio of 3:6:1 is stated as annual?

The adjustment is not compounded because COLA has been 0.0% for CY10 and CY11 but 3.6% for CY12. The adjustment to patient liability is 3.6% (3.6% = (1+0.0%)*(1+0.0%)*(1+3.6%)-1) from the base period to the contract year.

130Coventry MPA

8.) Please share the calculation of applying the admin on PMPM and percentage margin. Is it (claims+PMPM admin) over (1-risk margin%)

(Net LTC PMPM + Administration PMPM) / (1 - Margin)

131

Coventry MPA 9.) Regions 10 and 11 have a much higher starting HCBS mix. How was this factored into the ability to achieve rebalancing?

The Agency-required transition is outlined in Table 8 of Attachment N-2. The transition percentage is adjusted to reflect the various enrollment dates. Region 10 and 11 were adjusted in the same manner as all other regions. Please see of Addendum No 2., Item #16. Please also see Addendum No. 2, Item #3.

132

Coventry MPA10.) For grouping of regions, was total cost the only factor used? In many cases, the gross (with patient responsibility) differs for the selected groups?

Regional groupings were established by first collapsing rate cells within each region, as described in Attachment N-2 of Addendum No 2., Item #16. The determination of which regions should be grouped was made by reviewing the net PMPM costs in each region and grouping those with similar costs. Please also see Addendum No. 2, Item #3.

133 Coventry MPA 11.) With Attachment J be modified to capture new rate cell grouping and the different rebalancing by region?

Please see Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

134

MPA

Please elaborate on the rate true-up process: a.) Inclusion of behavioral management, medication administration and medication management b.) unit cost changes in institutional settings.

See Section 4 of N-2, Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

135

MPA

Published capitation rate ranges are not in the same categories as the rates required by the ITN. Should the 8 rates cells be weighted to arrive at the final bid range? If so, what would be the basis for weighting?




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136

MPA How do you learn about the patient responsibility component?

Patient responsibility is any member income in excess of the personal needs allowance and is used to cover some of the member's medical costs if he or she is institutionalized for 30 or more days. Patient responsibility may be applied to nursing home claims, hospice claims, and to long-term inpatient hospital claims (stays of 30 days or more).

137

MPA Why is the reduction of short-term stays from 6.2% to 3.&% from FY 2009 to FY 2010?

The discrepancy is likely due to the fact that for FY 2008/2009, the months of May and June 2008 were not available as part of the base data selection criteria and assignment of long term and short term NF clients.

The outlier results for FY 2008/2009 was a contributing factor in choosing FY2009/2010 and 2010/2011 for the base data utilized for rate development.

138

MPAMr. Williams indicated voluntary populations costs are anticipated to be the same. Is there any evident to support that the costs between the voluntary and mandatory populations?

If voluntary populations enroll in the program, their costs would not have a significant impact on the average.

139

MPA

Would quality related expenses be captured in achieved savings rebates or will such expenses be considered 'administrative expenses' that will not be included in the achieved savings rebate calculation?

Quality related expenses will be captured as part of the achieved savings rebate and will be reflected as part of the rule development process.

140

MPA

Based on your earlier responses today, are we correct in assuming that services not directly in a diversion waiver program (ie. Assisted Living for Channeling waiver members) are the included in the rate ranges presented for HCBS group and released on July 13th, Addendum #1?

The rate ranges released in the July 13th addendum were developed using the base data from the Data Book, as described in Section 2 of Attachment N-2. The Data Book data reflect historical costs and utilization from the predecessor HCBS waiver programs superseded by the SMMC LTC program, as described in Appendix B of Attachment M. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.



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141

MPA

Our understanding is that the LTC plans should submit bids with the rate ranges in Appendix B. However as stated the current Appendix B does not include the impact of hospice and nursing home lee changes and the addition of behavioral management, medication management and medication administration services. Will AHCA and AHCA's actuary be printing updated rate ranges prior to the Aug 28 bid submission?

No, please refer to Section 4 of Attachment N-2, Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

142

MPA

Please provide further classification regarding the development of the 45% downward utilization adjustment to home health services in region 11 in the SFY2010/2011 base data. Our experience doesn't indicate such a drastic decrease in health services utilization. We request that AHCA's actuary review this rate methodology using a wider subset of data.

When comparing monthly paid claims for home health services in FY 2010/2011 to FY 2009/2010, AHCA observed decreases ranging from 41% to 50%. The overall annual average decrease was 46%, consistent with the adjustment applied in rate development was 45%.

143

MPA IOR requires the profit margin to be 2%. Why is this amount not included in the rates in accordance with law?

The Agency understands that OIR anticipates, in a retrospective review of plans’ experience across all of their lines of business, that the plans achieve a 2% profit. There will be variance between the rate assumptions and actual plan experience. The Agency cannot guarantee that any plan will realize any predefined level of margin. Given the likely variance between rate assumptions and actual plan experience, the Agency believes plans have a reasonable opportunity to achieve results that allow them to meet OIR’s plan-wide expectations.

144

MPA

The rate ranges include an assumption that patient responsibility (cost share) is trended at 3.6%. This amount is much higher than historical averages which have been as follows: 2005 4.1%; 2006 3.3%; 2007 2.3%; 2008 5.8%; 2009 0.0%; 2010 0.0%; 2011 3.69%. 5 year average = 2.3% and 7 year average= 2.7%. Social security increases which should match patient responsibility changes (09-11). By overinflating this amount, the net rates are lowered significantly to levels that are not actuarially sound. Please revise this assumption to be more reflective of historic experience.




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145

MPA

Are patient responsibility amounts for members in HCBS services a more fixed amount that does not increase with the member's increases in their social security checks? If so, the trend used should be even lower than the average social security payment trends.

Patient responsibility is any member income in excess of the personal needs allowance and is used to cover some of the member's medical costs if he or she is institutionalized for 30 or more days. Patient responsibility does not apply to HCBS services but may be applied to nursing home claims, hospice claims, and to long-term inpatient hospital claims (stays of 30 days or more). The state calculates patient responsibility and these amounts may be referenced in Attachment M, the Long-Term Care Managed Care Data Book.

146

MPA

Patient responsibility (cost share) is a monthly amount per person and can be used to pay for acute medical services in addition to HCBS services. Since two separate plans will be covering these services, how will plans coordinate collection of these amounts or will they be assigned to only one plan (the LTC plan)?


147 MPA Given that there will now be two rate cells instead of four, will exhibits J1-J4 be revised?

Yes. Please see Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

148

MPA

Also given that the transition percentages vary now by region, will that adjustment in the J exhibits be revised? The variance amounts are because some of the plan years are short and the 2% is an annual number.

Yes. Please see Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.



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149

MPA Attendant care units costs are ~$5 in the databook, why is this lower than the ADA Waiver rate of $10?

The difference is due to reporting anomalies in the actual service expenditures and units across the different waivers that are aggregated into the base data for the SMMC LTC program. The unit cost for attendant care observed in the data for the ADA Waiver is approximately $10. However, the service expenditures and utilization from the capitated programs (Nursing Home Diversion and Channeling) result in a lower unit cost for these services, which yields a lower unit cost when the data is aggregated.

150

MPADual and non-dual costs are significantly different, so plans who attract more of one type member will be disadvantaged. Please reconsider splitting rates between these groups.

Medicare covered services represent a small portion of the expenditures under the SMMC LTC program, approximately 0.1 to 0.2% of total nursing home service category expenditures. The impact of Medicare covered skilled nursing facility should not be significant due to the proportion of Dually eligible and Medicaid only clients.

151

MPA

Will you start the risk adjustment calculations over each year, so plans will start behind each year or will you consider a member who was HCBS eligible on the first day of the program on the HCBS member for the entire 5 years of the contract. Same questions applies for NF members.

Reset annually, no five year classification.

152

MPAWe didn't understand the response to the telephonic services. How much was built into each region to provide this services on a PMPM basis in the rate ranges?

The cost associated with service review requirements, as specified in Attachment D-11, Core Contract, Section X, E.S.C. (4)(b), are the responsibilities of the plan.

153

MPA

Attachment J-5 mentions that patient responsibility was added back into the base costs. Can you provide the bidders with a distribution as to which categories of service were impacted by this and by how much?




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154

MPA

Please confirm that the rate ranges incorporate the January-June 2012 fee schedules for hospice and nursing facility services. Can the bidders be provided with any similar fee schedules for assisted living, case management and HCBS services to assist with developing our rate ranges?

Section 2 of Attachment N-2 of the Addendum No. 2, Item #16 indicates that the rate ranges presented in Appendix B include the Nursing Facility and Hospice fee schedules effective January 1, 2012 - June 30, 2012. Fee schedule information is available at http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/tabId/39/Default.aspx. Please also see Addendum No. 2, Item #3.

155 MPA Will the state release new cost proposal rate sheets that will accommodate the new format?


156

MPA Are there any costs related to telephonic services for the LTC plan sponsor?

The Agency's current contract for verifying the utilization and delivery of home health services is with Sandata. The Agency's current contract covers individuals receiving State Plan home health services in a fee-for-service environment only. As specified in Attachment D-II, Section X, Item E., as a part of their program integrity function, managed long-term care plans will be required to establish methods for verifying enrollees' identity and whether services billed by providers were actually received. The Agency is not requiring that managed long-term care plans contract with a specific vendor for electronic verification or biometric technology services. The Agency is not requiring that any single method be implemented for verification of enrollees' identity and if services billed by providers were actually received. The cost associated with service review requirements, as specified in Attachment D-11, Core Contract, Section X, E.S.C. (4)(b), are the responsibilities of the plan.

157MPA

Please describe why there are no differences in costs between duals and non-duals given difference in Medicare costs for SNF, hospice, etc…

The majority of services provided under SMMC LTC are HCBS and custodial care nursing facility services.

158 MPA What are expected costs for behavioral management, administration management?

The adjustment for these services will be available before August 1, 2013.



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159

MPA What is the significance in rates or enrollment between long term and short term stays?

The short-term and long-term stays were measured to understand the impact on program costs and utilization. Under SMMC LTC, short-term nursing home stays qualify recipients eligible for mandatory enrollment in the SMMC LTC program.

160

MPA Are the existing rate ranges compliant with the 5% savings requirement? Can you share analysis?

Yes, the rate ranges provided include the 5% savings. AHCA has considered the rate ranges in the ITN in developing a savings estimate. The savings estimate is not part of this ITN.

161 MPA Can you share the actuarial memorandum associated to the rate range development? No

162

MPA

We noticed in the rate range addendum that regions 1, 2, 3, 4 and 6 were combined for the non-HCBS population. The lower end of the rate ranges for these regions were all the same even though some have different effective dates. Can you confirm that the correct number of trend months were used in calculating the low end of the rate ranges for these regions?

The correct number of trend months were used for these regions. The rate differences are minor due to the bottom of the range prospective trend and program change assumptions for the Non-HCBS population.

163

MPA Will AHCA calculate a patient's responsibility for cost sharing purposes or will that be required of the plan?




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164

MPAWhat was the historical trend applied to SFY2009/2010 in developing the base period data used to calculate that actuarially sound rate ranges?

Base data was blended as described in Section 2 of Attachment N-2. Highlights are: Assisted Living: Utilization 1.5%; Unit Cost 5.0%Case Management: Utilization 1.0%; Unit Cost 0.0%HCBS: Utilization 2.0%; Unit Cost 0.0%Hospice: Utilization 0.0%; Unit Cost 0.0%Nursing Facility: Utilization 1.0%; Unit Cost 0.0%. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

165

MPAIf AHCA increases nursing facility per diems such that a plan's negotiated capitation would still fall within the actuarial rate ranges, will AHCA adjust the plan's capitation accordingly?

No, if the rate falls within the updated rate range, it will not be adjusted.

166MPA As non-HCBS enrollees are converted to HCBS, will additional

HCBS 'slot' be created to accommodate the convertees?For recipients already enrolled in the program, transitions to the HCBS setting are not limited by slots.

167

MPA Can you provide current and historical nursing facility and hospice rates in excel format?

Both Nursing Facility and Hospice current and historical rates as initially published can be found on the Agency’s website. The Hospice rates are posted in excel; Nursing Facility rates are PDF. The links to the rates are provided below.Nursing Facility: http://ahca.myflorida.com/Medicaid/cost_reim/nh_rates.shtmlHospice: http://ahca.myflorida.com/Medicaid/cost_reim/hospice_rates.shtml

168MPA How are capitated rates determined after the 2nd year for a

PSN as they are required to go capitated after 2 years?

AHCA will determine how capitation rates in future contract years will be developed and that methodology will be communicated to contractors.

169

MPACan you confirm that the statutory 2% shift from NF to HCBS will be based on actual plan enrollment? If so, when will enrollees be 're-tagged' with a new status?

The Agency-required transition will be applied to actual plan enrollment as described in Section 5 of Attachment N-2, Addendum No. 2, Item 16. Enrollees will be "re-tagged" when setting rates for each subsequent year.



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170

MPA

It was stated that the actuarial rate ranges effectively represents the required 5% cost reduction. For plans that are requested to negotiate final rates, can you confirm that negotiated rates will still be required to be within the actuarially sound rate ranges?

Rates negotiated with plans will be within the actuarially sound rate ranges.

171MPA

With regard to the 3-year proforma requirement, is this required for just the SMMC LTC program or all lines of business for a plan within the state?

The 3-year proforma requirement is just for the SMMC LTC within Florida.

172Amerigroup Florida J-1 thru J-5 NA

NAMPA

Will the State release new Cost Proposal Rate Sheets that will accommodate the new format? (i.e., the collapsing of the rate cells)


173

Amerigroup Florida Attachment J-5 NA

Table 5: Average Annual Range of Utilization/1,000 and Unit Cost Trend

MPA

There is a note at the bottom of Table 5 (pg. 17) of the Attachment J-5 document that says, “* Patient responsibility is trended according to the Cost of Living Adjustment and is not applied as a compounded trend factor.” If it’s not compounded, then does that imply that the patient responsibility was not trended for a longer period of time from FY10 than it would be from FY11?


174

Amerigroup Florida Attachment J-5 NA

Appendix A

MPA There are slight rate range variations among regions in the same groupings. What is the cause of these variations?

The number of trend months influence the PMPMs slightly. For example, Non-HCBS regions 1, 2, 3, 4, and 6 were aggregated to form the base data however regions 1 and 2 have 39 months of trend and regions 3 and 4 have 41 months of trend.

175

Amerigroup Florida Attachment C NA

C.45, D. Cost Proposal

MPA

In Attachment C., C.45, Section D "Cost Proposal," it states that respondents should "submit one (1) original Cost Proposal (Attachment J) and for each Eligibility Group a Cost Proposal Rate Sheet (Attachments J-1 thru J-4), with its original response." Earlier in C.45, it states that "An original and seventeen (17) duplicate paper copies, in a sealed package, must be submitted" and "Responses may not exceed two (2) binders in length." Please provide more details on how to submit the Cost Proposal. Is the Cost Proposal to be submitted as a section in our response (separated by a Tab) or should it be placed in a binder separate from our main response (E-1 responses)? If included in a separate binder, does the Cost Proposal count as one of the two binders? Are respondents expected to provide one original and 17 copies of the Cost Proposal?

Respondents are expected to provide 1 original of their cost proposal with their original response.



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176

Chris Bach MPA Who collects the patient responsibility amount under the new program – the provider or the plan?

Patient responsibility is any member income in excess of the personal needs allowance and is used to cover some of the member's medical costs if he or she is institutionalized for 30 or more days. Patient responsibility does not apply to HCBS services but may be applied to nursing home claims, hospice claims, and to long-term inpatient hospital claims (stays of 30 days or more). The state calculates patient responsibility and these amounts may be referenced in Attachment M, the Long-Term Care Managed Care Data Book. Please refer to Attachment D-11, Exhibit 15, page 113.

177

Chris Bach MPA

Can a plan bid different rates for the 4 categories of aid, and/or for regions within a grouping as long as the blended rate falls within the stated rate ranges? Or must all proposed rates be within a grouping (groupings as provided with the rate ranges) be equal to each other? If the rates within a grouping are allowed to vary, can they vary outside the rate range as long as the weighted average is within the rate range?

Bidders must bid rates consistent with the structure in the rate ranges found in Appendix B of Attachment N-2. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

178

Coventry Health Care of Florida Addendum #1

Table 5

MPA

The 3.6% adjustment to Patient Liability states it is annual but footnote says it is not compounded? Is it 3.6% from base period to rating period total? or is it 3.6% per year? if per year or "annual" why would it not get compounded?


179

Mat Delillo, Milliman (Coventry) Attachment M Page 13 MPA Please confirm that all cost for those HCBS Medicaid Pending

have been included in the Data Book and factored into the rates.The data book contains information on those who are Medicaid eligible for whom we have cost history.

180

Mat Delillo, Milliman (Coventry) Attachment M MPA What is the historical volume of HCBS Medicaid Pending?

What percentage were ultimately approved for Medicaid?

The historical volume exact number of Medicaid Pending is not readily available. The percentage of individuals who choose Medicaid Pending and eventually become eligible for Medicaid has been approximately 97 percent.



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181

Mat Delillo, Milliman (Coventry) MPA

Please see Page 13, Attachment M which is the Data Book. The first bullet under 6: Adjustments states that Plans that “choose” to render services to a potential member….. the use of the word “choose” makes it sound as if this is an option but my understanding is that this is a mandatory population. Please clarify what the Data Book is referencing at the top of page 13. Thank you.

LTC MCPs will be required to cover all services listed in Attachment D-II, Exhibit 5 to all recipients enrolled to the MCP, including those recipients who choose the Medicaid Pending option as part of the eligibility process.

182

Mat Delillo, Milliman (Coventry) Attachment J-5 MPA Base Data Trends: What trend rates were used to trend the

SFY 2010 to the SFY 2011 period?

Base data was blended as described in Section 2 of Attachment N-2. Highlights are: Assisted Living: Utilization 1.5%; Unit Cost 5.0%Case Management: Utilization 1.0%; Unit Cost 0.0%HCBS: Utilization 2.0%; Unit Cost 0.0%Hospice: Utilization 0.0%; Unit Cost 0.0%Nursing Facility: Utilization 1.0%; Unit Cost 0.0%. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

183

Mat Delillo, Milliman (Coventry) Attachment J-5 MPA

Data Book Adjustments. Adjustments identified in the Data Book appear to be missing from certification of rate range (e.g. encounter data under-reporting, IBNR, etc.). How were these adjustments factored into the rate ranges?

IBNR and encounter data adjustments were applied to the base data, and those base data were used to develop the rate ranges. Therefore, these adjustments are reflected in the rate ranges.

184


Region Groupings. Were the region groupings selected purely based on cost? Were location, networks, etc. factored into the selection? Was the cost basis before or after patient responsibility?

Regional groupings were established by first collapsing rate cells within each region, as described in Attachment N-2. The determination of which regions should be grouped was made by reviewing the net PMPM costs in each region and grouping those with similar costs. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

185


Prospective Changes. Please explain why the negotiated rates will only move if they fall outside of the revised range? If the range changes by X% and all rates are adjusted by X%, then the rate would remain in the same position within the range as intended by the initial offer.

The Agency can contract within the actuarially sound rate range.

186


Prospective Changes-Decreases. Please explain the apparent inconsistency of handling if the rate range decreases due to legislated changes. What occurs if the legislated changes result in a decrease below the actuarially sound range?

The Agency can contract within the actuarially sound rate range.



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187


Risk Adjustment Approach – Base Period. How will the selection of a base period work after year 1? For plans that do not achieve the rebalancing, will they start at a higher rate since they have more NH? For successful plans, will year 2 require an additional 2-3% beyond the initial mix or 2-3% beyond their achieved level?


188

Mat Delillo, Milliman (Coventry) Attachment J-5 MPA Risk Adjustment Approach – Pre-enrollment Benchmark.

Please explain in more detail the “pre-enrollment benchmark”.

The pre-enrollment benchmark PMPM is established by blending the negotiated HCBS and non-HCBS rates at the actual regional mix, adjusted for the Agency-required transition. The regional population mix is determined by analyzing 12 months of historical data 3 months prior to enrollment using the segmentation logic used in the Data Book, as described In Attachment N-2. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

189


Risk Adjustment Approach - Recalibration. Budget neutrality appears to be based on the initial base data mix of NF and HCBS. Does this imply that more new enrollment of NH or more dis-enrollment of HCBS will be the risk of the plans? How are they able to manage this risk for the number of dis-enrollments?

No. Enrollments and disenrollments are addressed separately from the base rate, as described in Section 5 of Attachment N-2. Budget neutrality is designed to ensure the PMPM cost remains constant once the enrollment threshold has been reached. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

190


Risk Adjustment Approach – Initial Classification. A person is determined newly eligible after the program start date and they go into nursing home. What period is reviewed for a Medicaid paid NF claim if they are newly eligible? A period before they were eligible?

An LTC eligible will be classified as a NF recipient only when there is a Medicaid paid NF claim. This ensures to the State that we have appropriately identified recipients who had a Medicaid-covered custodial NF claim since these NF recipients contribute a higher rate to the plan’s blended capitation rate.

191


Certification. How did Mercer determine that the Agency required 2% rebalancing was actuarially sound? What information is available to the plans to support this conclusion?

In the unmanaged fee-for-service environment, AHCA observes more than 2% nursing facility transitions and expects the SMMC LTC plans to be able to achieve similar or better results when managing the care.



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192

Mat Delillo, Milliman (Coventry) Attachment J-5 MPA Certification. How were the differing HCBS/NF percentages by

region factored into the ability to move the 2% to HCBS?

The Agency-required transition is outlined in Table 8 of Attachment N-2. The transition percentage is adjusted to reflect the various enrollment dates. Region 10 and 11 were adjusted in the same manner as all other regions. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

193

Mat Delillo, Milliman (Coventry) Attachment J-5 MPA Certification. How will Mercer adjust the rates if the contract

payment periods are changed?

If a contract period changed from those outlined in Appendix A, the rate ranges will be adjusted to reflect the revised contract period.

194

Mat Delillo, Milliman (Coventry) Attachment J-5 MPA Admin/Margin. What basis is the margin loading percentage?

Percent of total cap? (Net LTC PMPM + Administration PMPM) / (1 - Margin)

195


Trend-Patient Responsibility. Please explain the footnote regarding the trending of the patient responsibility. Is the 3.6% an annual number or the cumulative impact from base period to contract period?


196


Trend-Case Management. The annual trend on CM is 0.5%-1.0% annually. This does not take into account the additional services that will be required to transition (and maintain) individuals in a HCBS setting. How were CM costs not in the data added into the calculation? Do all of the waivers and plans include a CM amount in the claims data?

Though case management costs were not increased outside of trend in the development of the rate ranges, there were no adjustments made to decrease the costs of services that would be offset by increases in case management. All waivers include case management and this is part of the claims data.

197Wellcare Attachment J-5 Capitation Rate

Ranges AllMPA Please confirm that all 11 Attachment J-5s are intended to be

identical.

Yes, each of the N-2 attachments documents for the 11 regions are identical. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

198

Wellcare Attachment J-5 Base Data Adjustments

Section 2 Page 3

MPA

Please confirm that the Rate Ranges incorporate the January - June 2012 Fee schedules for Hospice Services and Nursing Facility Services. Can the bidders be provided with similar fee schedule changes for Assisted Living, Case Management, and HCBS services to assist us in developing our rate ranges?

Section 2 of Attachment N-2 of the Addendum No. 2, Item #16 indicates that the rate ranges presented in Appendix B include the Nursing Facility and Hospice fee schedules effective January 1, 2012 - June 30, 2012. Fee schedule information is available at http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/tabId/39/Default.aspx. Please also see Addendum No. 2, Item #3.



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199

Wellcare Attachment J-5Hospice and

Nursing Facility Rate Changes

Section 2 Page 3

MPA

Attachment J-5 mentions that Patient Responsibility was added back into the base costs, trended forward then subtracted out in developing the rate ranges. Can you provide the bidders with a distribution as to what categories of service are impacted by patient responsibility? A similar breakout to the actual claims would be helpful.

Patient responsibility amounts impact Nursing Facility and Hospice services. Patient responsibility is the portion of a Medicaid recipients monthly income that the recipient is responsible to pay to nursing home claims, hospice claims, and to long-term inpatient hospital claims (stays of 30 days or more). Patient responsibility does not apply to HCBS services. Additionally, the amount of patient responsibility for the HCBS population is in aggregate less than $0.50 PMPM.

200

Wellcare Attachment J-5

Prospective Program Changes,

Adjustments for the addition of new

services. Section 4 Page 10

MPA

Neither the databook, nor Attachment J-5 provide any information surrounding the potential costs of the Behavioral Management, Medication Management, or Medication Administration services. In order to provide an accurate bid, the bidders need to have some idea of the costs of these services. Can you provide an estimate of the costs of these services similar to what was provided for the Non-Emergent transportation or with greater level of detail, if available?

The adjustment for these services will be available before August 1, 2013.

201

Wellcare Attachment J-5 Rate Ranges

Appendix B

MPA

The rate ranges have been rolled up to include all population subcategories (18-64 Duals, 65+ Duals, 18-64 Non-Duals, and 65+ Non-Duals) within the same range. This is in spite of the fact that 18-64 population has consistently higher HCBS Costs than 65+ population and Duals have consistently lower Facility expenses than non-Duals. Would it be possible for the actuaries to apply factors to the rate ranges that recognize these differences so as to not require plans to bid within rate ranges that are not actuarially sound for certain subsets of the overall population. Failure to do so would unfairly reward or penalize participants who have a disproportionate share of lower or higher cost groups. As an alternative methodology, these differences could also be adjusted for through the risk adjustment mechanism.

AHCA intends to keep the rate ranges in the same structure as outlined in Attachment N-2. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

202

Wellcare MPA Will the 834 provide the cost share amounts per month for each member?

No, the 834 enrollment file will not provide cost share amounts. Successful bidders will be informed of the process by which plans will receive this information during plan readiness phase of the program.



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203

Wellcare MPAHow often is the cost share amount changed retroactively for members? How many months back do you go when you change he cost share retrospectively?

For plan members receiving only Social Security income, patient responsibility changes occur at most once per year. For plan members with other income sources, changes may occur as often as the income changes. The Notice of Case Action detailing the patient responsibility will state the retroactive period.

204

Wellcare MPA

The ITN states that cost share must either ALL be collected through the providers or ALL collected from the member. We use a combination of these two methods in other states depending on the members location (institutional versus home based). What is the rationale for only allowing the use of one method?

AHCA established the MCP patient responsibility policy for administrative convenience in developing this new program.

205

WellcareAttachment J-5,

Attachments J-1 to J-4

Transition Percentages: Attachment J5

Table 8Page 18

MPA

The ITN states that cost share must either ALL be collected through the providers or ALL collected from the member. We use a combination of these two methods in other states depending on the members location (institutional versus home based). What is the rationale for only allowing the use of one method?

DUPLICATE QUESTION

206

Wellcare Attachment M Attachment 1

data book

MPA Can you please confirm that the unit cost for Region 10 and 11 Home Accessibility Adaptations is $1.00 for the 65+ population?

In the Data Book, unit cost is calculated to be $1.00 for the 65+ Non-Dual population in Regions 10 and 11. This service has very few expenditures and low utilization. Consequently, there is more variability observed in the reported data due to reporting anomalies in the actual service expenditures and units across the different waivers that are aggregated into the base data for the SMMC LTC program.

207


data book

MPA Can you please confirm the utilization and unit cost for Region 11 Nutritional Assessment & Risk Reduction SFY10-11?

Utilization and cost, as reported in the Data Book, vary by population and region. This service has very few expenditures and low utilization. The expenditures and utilization for this service presented in the Data Book represent the actual data reported for the various waiver programs, adjusted for the items outlined in Attachment N-2. Consequently, there is more variability observed in the reported data due to reporting anomalies in the actual service expenditures and units across the different waivers that are aggregated into the base data for the SMMC LTC program. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.



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208


data book

MPA

Nutritional Assessment & Risk Reduction unit cost in the Aged and Disabled Waiver fee schedule is $12.00 per 15 minute unit. The unit cost in the databook range up to $92.00. Can you please explain what is driving the variance?

This service has very few expenditures and low utilization. Consequently, there is more variability observed in the reported data due to reporting anomalies in the actual service expenditures and units across the different waivers that are aggregated into the base data for the SMMC LTC program. The unit cost for this service is approximately $12 in the data reported for the A&D waiver. The high unit costs are driven by the expenditures and units reported for the Nursing Home Diversion Waiver.

209


data book

MPA

Respite Care (facility) unit cost in the Aged and Disabled Waiver fee schedule is $2.50 per 15 minute unit. The unit cost in the databook range up to $210.00. Can you please explain what is driving the variance?

This service has very few expenditures and low utilization. Consequently, there is more variability observed in the reported data due to reporting anomalies in the actual service expenditures and units across the different waivers that are aggregated into the base data for the SMMC LTC program. The unit cost for this service is about $2.30 in the aggregated data reported for the A&D waiver. The high unit costs are driven by the expenditures and units reported for the Nursing Home Diversion Waiver.

210

Wellcare Attachment M Chapter 7

pg 16 of 183

MPA

The databook narrative says that the historical Hospice and Nursing Facility costs will be retrospectively repriced and the adjustment will be provided. We do not see the adjustment information in the databook. Where can we find that imperative piece of information.

Please refer to Appendix A: Tables 1 and 2 of Attachment N-2. See Addendum No. 2, Item #16. Please also see Addendum No. 2, Item #3.

211


data book

MPA

Attendant Care unit cost in the Aged and Disabled Waiver fee schedule is $10.00 per 15 minute unit. The unit cost in the databook is approximately $5.00. Can you please explain what is driving the variance?




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212

Wellcare Attachment M: Data book Attachment 1

data book

MPARegion 10, 65+ Non-Duals Adult Day Health Care SFY 08-09 unit cost are $53.75 versus an average of $2.50 for the rest of the population. Can you please explain the variance?

This service has very few expenditures and low utilization. Consequently, there is more variability observed in the reported data due to reporting anomalies in the actual service expenditures and units across the different waivers that are aggregated into the base data for the SMMC LTC program.

213


data book

MPA Attendant Care unit costs are ~$5.00 in the data book, why is this lower than the ADA Waiver rate of $10.00?


214

Aetna Better Health of Florida ATTACHMENT C NA C.46 BMHC /

HSD

The ITN requires a bidder to be a "Health Maintenance Organization (HMO) and possess a current Florida Certificate of Authority and Health Care Provider Certificate (641 Part III) or a Florida Certificate of Authority and a Limited Health Care Provider Certificate (641.2018 and 641 Part III) in at least one (1) Florida county." Would AHCA consider a bidding entity that has submitted an application for a COA and HCPC that is currently under review eligible to bid?

The ITN provisions remain as written. A Provider must posses a current Florida Certificate of Authority and Health Care Provider Certificate (641 Part III) or a Florida Certificate of Authority and a Limited Health Care Provider Certificate (641.2018 and 641 Part III) in at least one (1) Florida county at the time their response is submitted

215

WellCare of Florida ATTACHMENT D-II N/A

Section III. Item B.1.d. Enrollment

HSD

"Each month the Managed Care Plan shall review its X12-834 enrollment files to ensure that all enrollees are residing in the same region in which they were enrolled." Does this imply that a reconciliation to the MCP's last known address for a beneficiary should occur? Is there a communication method to notify AHCA of the discrepancy?

No, this does not imply a reconciliation should be made. If a Medicaid recipient's address changes, the recipient is required to report that change to the Department of Children and Families or the Social Security Administration, as appropriate. Review of the X12-834 enrollment files allows the plans to determine if there are systemic errors in the file and to determine which enrollees must be sent a notice of disenrollment pursuant to Attachment D-II, Section III, C.5.



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Prestige Health Choice LLC ATTACHMENT C NA HSD

According to the LTC-ITN an HMO can respond to the ITN. On the assumption that a PSN is excluded from responding, on what basis does the Agency exclude a Capitated PSN?

Only provider service networks that are long-term care provider service networks may be considered for awards under this long-term care procurement. See s. 409.981, F.S. Pursuant to s. 409.981(1), F.S., titled Eligible Long-Term Care Plans, provider service networks must be long-term care provider service networks. Section 409.962, F.S., defines long-term care provider service networks. Capitated provider service networks that are not long-term care provider service networks are not included as eligible long-term care plans. A LTC PSN can be capitated or FFS.

217

Amerigroup Florida ATTACHMENT D-II

Section XVI.U.5.a HSD

Attachment D-II, Section XVI.U.5.a requires that the plan submit, prior to the execution of a contract, complete sets of fingerprints for the principals of the plan. Will the Agency please confirm that if fingerprints are already on file for the principals that the existing records will be acceptable?

Existing fingerprint records on file with the Agency are acceptable provided the screening on file occurred within the past twelve months.

218

Amerigroup Florida ATTACHMENT D-II Exhibit 14 Section XIV,

Item C.3 HSD

Attachment, D-11, Exhibit 14, Section XIV. Item C.3 states that “If more than one MMA or LTC Managed Care Plan leaves a region at the same time, the existing managed care plans will share the costs in a manner proportionate to their enrollments. Should the word “existing” in this reference be “exiting”?


219

Prestige Health Choice LLC ATTACHMENT C NA Section c.45 HSD Can a capitated PSN enter into a partnership relationship with a

Long Term Care PSN?

Yes, provided the resulting vendor meets the statutory requirements for a long-term care provider service network.

220

Freedom Health Plan ATTACHMENT C Page 27 - C.46

Other Required Documents - Qualifications of Plan eligibility

HSD Can a Medicare Advantage Plan apply for the ITN or must it be a Medicaid HMO?

To be a vendor for this procurement, a Medicare Advantage Plan must be a Florida-licensed health maintenance organization, Florida-licensed exclusive provider organization, a Medicare Advantage special needs plan, or a long-term care provider service networks as defined in s. 409.981(1), F.S.



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Florida Pace Centers,Inc dba project Independence @home

ATTACHMENT C NA Qualification of Plan Eligibility HSD Can an existing PSN submit an application to this ITN or only

LTC PSN's qualify to submit a bid to AHCA ITN 010&011-12/13

Only provider service networks that are long-term care provider service networks may be considered for awards under this long-term care procurement. See s. 409.981, F.S. Pursuant to s. 409.981(1), F.S., titled Eligible Long-Term Care Plans, provider service networks must be long-term care provider service networks. Section 409.962, F.S., defines long-term care provider service networks. Capitated provider service networks that are not long-term care provider service networks are not included as eligible long-term care plans. A LTC PSN can be capitated or FFS.

222

WellCare of Florida ATTACHMENT D-II Exhibit 13 Section B.1 HSD

Can the Agency please clarify if capitated Managed Care Plans would be required to submit monthly payment requests as described in this section, or would the capitation payment come automatically based on the active membership with the plan?

The monthly capitation payment from the Agency will be sent electronically through the fiscal agent. Managed care plans do not have to submit payment requests.

223

Little Havana Activities and Nutrition Centers of Dade County

ATTACHMENT E Formatted Submission Q. 58 HSD Does diversion program count as a Medicaid medical

assistance health plan?

For purposes of Attachment E, question 58. of this procurement, a nursing home diversion plan does not count as a Medicaid medical assistance health plan.

224WellCare of Florida ATTACHMENT C N/A C.37 HSD

Does use of E-Verify Employment Eligibility also apply to workers hired by participants in the participant directed care program?

Yes, all employees must be processed through the E-Verify Employment Eligibility system.



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Prestige Health Choice LLC ATTACHMENT C

ATTACHMENT_C_EXHIBIT_1.xlsx regarding applicant for ITN

HSD

Eligible Plan — In accordance with s. 409.962(6), F.S., a health insurer authorized under Chapter 624, an exclusive provider organization (EPO) authorized under Chapter 627, a health maintenance organization (HMO) authorized under Chapter 641, F.S., or an accountable care organization (ACO) authorized under federal law. For purposes of the medical assistance (MMA) component of the SMMC program, the term also includes a provider service network (PSN) authorized under s. 409.912(4)(d), and the Children's Medical Services Network authorized under Chapter 391. For purposes of the long-term care component of the SMMC program, the term also includes entities qualified under 42 CFR Part 422 as Medicare Advantage Preferred Provider Organizations, Medicare Advantage Provider-sponsored Organizations, and Medicare Advantage Special Needs Plan, Program of All-Inclusive Care for the Elderly, and long-term care PSNs, in accordance with s. 409.981(1), F.S.Background and Analysis: 1. Pursuant to s. 409.962(6), F.S., “Eligible Plan” includes a PSN authorized under s. 409.912(4)(d). 2. Pursuant to 409.962(7), F.S., “Long-Term Care Plan” includes a “managed care plan that provides the services described in s. 409.98 for the long-term care managed care program.” 3. S. 409.981(1), F.S., provides in pertinent part “Eligible Plans.-…Other eligible plans may be long-term care plans or comprehensive long-term care plans. 4. Thus, we believe that the term “Eligible Plan” as defined in S. 409.962(6), F.S., includes PSNs that are managed care programs which provide the services described in 409.98, F.S.

Pursuant to s. 409.981(1), F.S., titled Eligible Long-Term Care Plans, provider service networks must be long-term care provider service networks. Section 409.962, F.S., defines long-term care provider service networks. Accordingly, provider service networks that are not long-term care provider service networks are not eligible to be long-term care plans.



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ATTACHMENT E-1 2 and 3

Network Contracts and Agreements Facility Services and Non-Facility Services, following page 2 of 2

HSD

How should we list multiple providers in the same service provider type if more than two are contracted? Should we attach additional sheets or expand the lines for the provider type in the table?

In accordance with s. 409.966(3), F.S., the Agency is required to consider evidence of a LTC managed care plan’s written agreements or signed contracts with providers as a part of this ITN. This is the sole purpose of this Exhibit. The maximum number of providers per provider type that can be submitted for this Exhibit is two. The complete network will be reviewed during plan readiness prior to implementation in each region.

227

Physicians United Plan ATTACHMENT C NA Qualification of

Plan Eligibility HSD

I have reviewed the guidance on participation of Medicare Advantage SNP plans in the Statewide Medicaid Managed Care LTC component. We are interested in participating in the ITN as a SNP plan but I am still uncertain as to whether we qualify. Currently, we have a Coordination of Benefits Agreement with AHCA. Are we able to participate in this ITN? I am unsure if participants are required to be a Licensed Florida Medicaid Health Plan. From the Updated Guidance Statement, released on June 8, 2012 I believe the below is the option we would like to pursue if we qualify. “Medicare Advantage Special Needs Plans (SNPs) that wish to contract with the Agency to provide managed long term care services must choose one of these three options for participation: Submit a bid in response to the Statewide Medicaid Managed Long Term Care Invitation to Negotiate (ITN). If the SNP receives a contract award as a result of the ITN, the SNP can participate as a managed long term plan open to all enrollees. Plans would be able to receive voluntary enrollment and mandatory assignments of new enrollees.”

Yes.

228

WellCare of Florida ATTACHMENT D-II Exhibit 5 Section V Item

I.5.c HSD

In order to be more effective in completing the initial assessment and developing the care plan and scheduling services prior to the member’s effective date, can the Agency please clarify when we will receive the new member on an 834 file relative to the effective date? Is it possible to receive the member when they choose our plan or when they are auto assigned, vs. on their effective date?

At a minimum, the Agency will send the 834 enrollment file to the managed care plans on a monthly basis. The 834 file provides information relative to the enrollment date of recipients.



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WellCare of Florida ATTACHMENT D-II Exhibit 3

Section III Item C.1.f General Provisions

HSD

In order to provide maximum continuity of care for members, if a member moves to a new region and the health plan is in the new region, will the member automatically be assigned to the same health plan?

Per s. 409.969(2)(d), F.S., on the first day of the month after receiving notice from a recipient that the recipient has moved to another region, the Agency shall automatically disenroll the recipient from the managed care plan the recipient is currently enrolled in and treat the recipient as if the recipient is a new Medicaid enrollee. At that time, the recipient may choose another plan pursuant to the enrollment process. If the recipient does not make an active plan choice, the Agency will assign the recipient to a health plan based on the criteria in s. 409.984(2), F.S.

230

Prestige Health Choice LLC ATTACHMENT C NA Section c.46 HSD

On what basis is the agency not including a capitated PSN currently operating in the Medicaid program like an HMO as an eligible bidder for the managed long-term care program?

Pursuant to s. 409.981(1), F.S., titled Eligible Long-Term Care Plans, provider service networks must be long-term care provider service networks. Section 409.962, F.S., defines long-term care provider service networks. All LTC PSNs may be capitated or FFS but must meet the requirement of 409.981, F.S.



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ATTACHMENT D-II 10 SECTION X,

Item C HSD

Please confirm if the timely processing parameters referenced in this section (X.C) are only applicable to PSN plans and if the parameters in Section X.C.2 (Claims and Provider Payment - Claims for Services for which Capitation is Received from the Agency) are only applicable to FFS plans. If there is a cross between both sections, please clarify the requirements for timely processing parameters.

Attachment D-II, Section X, C.1., of this procurement, applies to all plan types. Attachment D-II, Section I, defines capitated managed care plans as follows:

Capitated Managed Care Plan — A managed care plan that is licensed or certified as a fully risk-bearing entity, or qualified pursuant to s. 409.912(4)(d), F.S., in the state, and is paid a prospective per-member, per-month payment by the Agency.

If a particular requirement is specified for a capitated managed care plan, the requirement will specify such.

Attachment D-II, Section X, C.2., of this procurement, applies to fee-for-service provider service networks in regard to services for which they receive a capitation payment (transportation) and to capitated managed care plans.

Attachment D-II, Exhibit 10, C.1., of this procurement, applies to fee-for-service long-term care provider service networks.

232

WorldNet Services Corp. ATTACHMENT E-I NA Item 58 HSD

Please confirm that AHCA includes current Nursing Home Diversion contractors as an existing Florida Medicaid medical assistance health plan as described in item (a) of the evaluation criteria in this section.

For purposes of Attachment E-1, question 58. of this procurement, a nursing home diversion plan is not considered as a Medicaid medical assistance health plan.



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ATTACHMENT E NA

E.8 Contract Negotiations, TABLE 1, 5 of 7

HSD

Please confirm that the column titled "# For Contract" does not include PSNs (the paragraph says PSNs are not included in the total of 56 plans selected for negotiation, but does not address the 34 plan total).

For Areas 1 & 2, the column does include PSNs as the "# for contract" is equal to the maximum # of plans allowable per s. 409. 981(2), F.S.

For areas 3 -11, if no PSN is included in the top ranked vendors selected to fulfill the “# for contract”, an additional contract will be awarded to a long-term care provider service network which submits a responsive reply and negotiates a rate acceptable to the Agency. However, in no instance will the number of awards for a region exceed the statutory maximum for the region specified in s. 409.974(1)(a) through (k), F.S.

234

SIMPLY ATTACHMENT D-II NA Section II.C.5 HSD

Please explain the established algorithm to assignment mandatory potential enrollees who do not select a Managed Care Plan.

If the recipient does not make an active choice to enroll in a LTC managed care plan, the Agency will assign the recipient to a LTC managed care plan based on the criteria outlined in s. 409.984(2), F.S.

235

Humana ATTACHMENT C C.20.3) Enrollment Levels HSD

Please further clarify the formula rationale for determining the enrollment level for each region. Specifically, what does the "X 2" represent?

The enrollment level formula was determined to ensure that a region would be adequately covered and adequate choice would be available to recipients regardless of whether a managed care plan(s) failed to come to contract or withdrew from a region. “X 2” represents multiplied times two.

236

Amerigroup Florida ATTACHMENT CSection C.20: Regional Roll-out Schedule

HSD Please further describe the process of how the Regional Roll-out Schedule is determined.

The Agency considered each region's managed care experience, the number of eligible recipients in the region, provider referral patterns and the number of TLC plans with which the Agency intends to award a contract.

237

Prestige Health Choice LLC ATTACHMENT C NA

ATTACHMENT_C_EXHIBIT_1.xlsx regarding applicant for ITN

HSD

Pursuant to s.409.912 (4)(d), a PSN can apply in response to the Managed Long Term Care ITN. Accordingly, can a capitated PSN that meets the Agency Long Term Care requirements be an applicant for the long term care ITN, and are they included in the definition of Eligible Plan set out in the ITN as set forth below?

Pursuant to s. 409.981(1), F.S., titled Eligible Long-Term Care Plans, provider service networks must be long-term care provider service networks. Section 409.962, F.S., defines long-term care provider service networks. Capitated provider service networks that are not long-term care provider service networks are not included as eligible long-term care plans. A LTC PSN can be capitated or FFS.



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Amerigroup Florida ATTACHMENT D-II Section II.C.5 HSD

Section II.C.5 identifies that the Agency will use an “established” algorithm to assign mandatory potential enrollees who do not select a Managed Care Plan during their choice period. Will the state please provide a description of this algorithm?


239

WellCare of Florida ATTACHMENT D-II N/A Section III

C.1.d HSD

This section refers to "maximum enrollment levels." Can the Agency please clarify if it would be a plan responsibility to reconcile enrollment to maximum levels, or will AHCA track and manage the plan assignment accordingly?

The Agency will track the managed care plan’s enrollment level.

240

Amerigroup Florida ATTACHMENT E-1

Section V, Question #58: Covered Services

HSD

Under Attachment E-1, Question #58, it appears that in the case of plan that is not operating in the region that a SNP contract is being given equal weight as existing Medicaid contracts in the State. Please confirm that this is the correct interpretation.

The interpretation is correct.

241

American Eldercare, Inc. ATTACHMENT C Section C.46 HSD

Under F.S. 409.962(8) - “Long-term care provider service network” means a provider service network a controlling interest of which is owned by one or more licensed nursing homes, assisted living facilities with 17 or more beds, home health agencies, community care for the elderly lead agencies, or hospices. ||||| However, in C.46 when defining LTC PSNs the proposal states "majority owned (over 50%) by licensed nursing homes, assisted living facilities with 17 or more beds, home health agencies, community care for the elderly lead agencies, or hospices" which appears to indicate a requirement that the LTC PSN be owned by more than one long-term care provider. Is this inadvertent and the requirement is one or more, or must the LTC PSN be owned by multiple long-term care providers to qualify as a LTC PSN?

For purposes of meeting the controlling-interest provider requirement, the long-term care provider service network must be majority-owned by one or more of the specified long-term care providers in s. 409.962(8), F.S. Please see Addendum No. 2, Item #4.

242

WellCare of Florida ATTACHMENT C N/A C.19 HSD

We understand that the Agency has chosen to select a statutory minimum number of plans. Would the Agency consider increasing the number of plans awarded up to the statutorily defined maximum to increase enrollee choice options if there are a greater number of qualified plans that apply?

The Agency has considered and the procurement requirements remain as is.

243

WorldNet Services Corp.

ATTACHMENT D-II NA Section 2, C.5 HSD

What is the established algorithm for assigning mandatory potential enrollees who do not select a Managed Care Plan during the 30 day choice period?




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SIMPLY ATTACHMENT C NASection C.20.3 Enrollment Levels

HSD Why are enrollment levels multiplied by 2 in each region?

The enrollment level formula was determined to ensure that a region would be adequately covered and adequate choice would be available to recipients regardless of whether a managed care plan(s) failed to come to contract or withdrew from a region.

245

WellCare of Florida ATTACHMENT D-II N/A Section B Item

1.d Enrollment HSD

Will the 834 membership file include information about the member’s location (i.e.. NF, ALF or in the community) and if in a facility, what facility they are residing in? Will we receive information about which of the Medicaid waivers the member was previously enrolled in?

The 834 enrollment file will include the residence address that is on file with the Department of Children and Families. If a recipient is residing in a facility and the Department of Children and Families is aware, the residence address on the 834 enrollment file will reflect the facility address. The 834 enrollment file will not contain information about the recipient's previous waiver enrollment.

246

Amerigroup Florida ATTACHMENT D-II Section X.B.1 HSD / MS

Attachment D-II, Section X.B.1 outlines the minimum staffing requirements. For the Medical Director and Compliance Officer positions, will the Agency clarify whether or not these positions must be fully dedicated to the LTC program, or if they can also perform work under the standard Medical Assistance programs?

The Vendor may use the same Medical Director and Compliance Officer for its long-term care plan and medical assistance plan; however, the Medical Director must then have experience serving both long-term care and medical assistance populations. See Addendum No. 2, Item #5.

247

Aetna Better Health of Florida

ATTACHMENT E-1, Submission requirements and Evaluation Criteria Components

N/ACore, 23. Covered Services.

Legal

Health plans are encouraged/required to work with each other in order to coordinate non-covered LTC services, i.e. "coordinate with other plans and insurers to provide necessary services that are not covered by the long-term care managed care plan." What are the HIPAA implications for this type of collaboration amongst the plans/insurers?

Pursuant to the ITN and Federal law, all involved parties must remain HIPAA compliant.



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Amerigroup Florida ATTACHMENT A Section 1 Legal

Attachment A, Section 1 defines the “Respondent” as "the entity that submits materials to the Buyer in accordance with these instructions.” Please confirm that for the purposes of responding to the ITN questions regarding experience, including the client reference section, accreditation, award, and certification information, that the Respondent may include the contracts held by affiliates/parent organizations of the bidding entity. For example, a new entrant may be a licensed entity in FL with experience in other states through its parent and affiliate health plans. For the purposes of demonstrating experience and meeting the qualifications of being contracted in another state to provide Medicaid managed care services, such an organization would offer the experience of one of the affiliate health plans currently contracted and operating in other states. Please confirm that this meets the requirements of the bidder's minimum qualifications.

Respondent is defined in the ITN, Attachment A, Page 1. When parents and affiliates are meant to be included they are mentioned. Each element mentioned in your question (i.e., experience, client reference, accreditation, award, certification) is explained in the ITN.

249GovWin fromDEltak NA NA NA Legal Will AHCA procure for independent Verification & Validation (IV

& V) services or Quality Assurance (QA) services? There is no plan for this at this time

250


ATTACHMENT E Formatted Submission Q.15 Legal

Please explain the types of situations which are intended to be encompassed by a 'civil investigation' by a state or federal agency. Does this include non-financial complaints by a patient or member that have resulted in a visit by an agency or does this include only complaints initiated by a state or federal agency due to their own internal reviews or audits? Please provide a variety of examples in different contexts so that the question may be answered appropriately."

Refer to Attachment E-1, Question 15, Evaluation Criteria #1.

251

Molina Healthcare of Florida

Attachment D-II - Core Contract Provisions

Section V Covered Services, E.2.cc

Legal

The plan's provider contracts must "Contain no provision that in any way prohibits or restricts the provider from entering into a commercial contract with any other Managed Care Plan (see s. 641.315, F.S.)" Does AHCA take the position that Medicaid health plans responding to this are prohibited under Section 641.315, F.S., from requiring a provider to be exclusive to only one health plan?

Reference to statute is for clarification. Any awardee will be expected to comply with the contract.



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Section XVII Liquidated Damages, A, 8

Legal

This section states that the Deputy Secretary will decide the dispute under the "reasonableness standard." Please explain what the "reasonableness standard" is, as that is not a defined term in Section I of the contract.

If reasonable [persons] could differ as to the propriety of the action taken . . . . then the action is not unreasonable. See E. R. Squibb and Sons, Inc. v. Farnes, 697 So. 2d 825, 827 (Fla. 1997)

253



Section XVII Liquidated Damages, A, 9

Legal

This section makes Leon County Circuit Court the "exclusive venue" for disputes arising out of the contract between AHCA and each selected plan. It further states that the Circuit Court "can only review the final decision [of AHCA] for reasonableness, and Florida law shall apply." Please explain what this means, as "reasonableness" is not typically a recognized standard of review for courts under Florida law.

(a) If reasonable [persons] could differ as to the propriety of the action taken . . . . then the action is not unreasonable. See E. R. Squibb and Sons, Inc. v. Farnes, 697 So. 2d 825, 827 (Fla. 1997) (b) When language states "Florida law shall apply", it is intended to mean Florida law shall apply in an action brought under this section in the Circuit Court of Leon County and not that of another jurisdiction (such as Georgia or New York).

254


Attachment E-1 Submission Requirements and Evaluation Criteria Components

Question 14 - Qualifications and Experience; Past Seven Years of Litigation Experience

Legal

The request appears overbroad and could include numerous small matters disputing the reasonable and customary value of services in different venues for non-contracted providers. Does the state have an identified purpose for the question, or a materiality threshold (amount) over which litigation should be reported?

The question, as part of the evaluation, will assist the Agency in determining the appropriate vendors with which to negotiate subject to other provisions within the ITN.

255SIMPLY ATTACHMENT C NA

Section C.46 Business Relationship

Legal Can a respondent respond as both a Health Plan and a PSN in the same Region? And will an award be given to both if both rank the highest in the Region?

(a) No. (b) The evaluated rank is one method to determine who will be invited to negotiate.

256 SIMPLY ATTACHMENT C NA Section C.49 Legal Under a joint venture scenario, who will be considered the "respondent"? See Attachment C, Paragraph C.49, page 29 of 165

257


ATTACHMENT D-II NA

Section VII, Provider Network, E. Provider Contract Requirements, 2. cc, pages 74 of 168

Legal Please confirm that bidders' contracts that do not comply with this provision and s. 641.315, F.S. will not be considered valid for the purposes of the ITN

Responses which meet the mandatory criteria of the ITN's will be evaluated.

See Attachment E-1, Submission Requirements and Evaluation Criteria Components, Item 67.



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WellCare of Florida ATTACHMENT C N/A C.45.F Legal

Please clarify that innovative concepts will not be part of evaluation process but may potentially be included during negotiation process. What does the Agency define as an "innovative concept"?

The Agency will not evaluate innovative concepts as part of the evaluation process, but may address innovative concepts during negotiations.. The Agency is requesting the Respondents identify and propose innovative concepts which exceed the minimum requirements of this ITN.

259WellCare of Florida General N/A N/A Legal Does the Agency anticipate having Oral Boards prior to award? There is no mention of an "oral board" in the ITN. The

Agency anticipates negotiations pursuant to this ITN.

260

WorldNet Services Corp. ATTACHMENT E-I NA Core 12, 13,

14 and 15 Legal For current affiliates who were not affiliates the whole period of time in question what period of time should be covered in the response?

Pursuant to Attachment E-1, Questions 12-15, "the past seven (7) years."

261



N/ACore, 32. Provider Network.

Medicaid

The SRC/question provides that "Pursuant to s. 409.4966(3)(c)1., F.S. response to this submission requirement will be considered for negotiations." We are unable to find the referenced Florida Statute or other information in support of "negotiations" related to the content of this SRC/question (i.e. this SRC/questions is related to educating and training long-term care providers about claims submission and payment processes which appear to be clearly outlined in the Core Contract found in Attachment D-II of the ITN documents).

Attachment E-1 should read, "Pursuant to s. 409.966(3)(c)1, F.S., response to this submission requirement will be considered for negotiations." Please see Addendum No. 2, Item #15.



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N/A

Core, 1. Qualifications and Experience.

Medicaid

The evaluation criteria for this SRC/question provides that "1. For the Managed Care Plan that will provide services under this ITN, whether the respondent has: a. Full accreditation by a nationally recognized accreditation body…" The section that follows goes on to state that "This section is worth a maximum of 10 raw points using the scoring scale outlined below: 5) 5 additional points for full accreditation with NCQA." The authorizing legislation provides the following: " Florida Statutes, 409.966 Eligible plans; selection.—(3) QUALITY SELECTION CRITERIA.— (a) The invitation to negotiate must specify the criteria and the relative weight of the criteria that will be used for determining the acceptability of the reply and guiding the selection of the organizations with which the agency negotiates. In addition to criteria established by the agency, the agency shall consider the following factors in the selection of eligible plans: 1. Accreditation by the National Committee for Quality Assurance, the Joint Commission, or another nationally recognized accrediting body." The authorizing legislation found at F.S. 409.966 does not provide that the Agency will excerpt "preference," i.e. issuance of additional award points, for accreditation achieved through NCQA as opposed to full accreditation by another/other nationally recognized accrediting body. It simply states "Accreditation by the National Committee for Quality Assurance, the Joint Commission, or another nationally recognized accrediting body." [emphasis on the "or"]. For Respondent's who are new entrants into the market, would AHCA award full credit for this question for those Respondents whose affiliated companies have current accreditations?

No. Points will be awarded to respondents who are accredited at the time of submission of the response.



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N/A

Regional, 58. Qualifications and Experience.

Medicaid

The SRC/question provides that "The respondent shall provide documentation that it has experience operating as a Florida Medicaid medical assistance health plan in the region in which it plans to provide long-term care services or in any other region in the state of Florida." A reference is made in this SRC/question to s. 409.981.(3)(c) F.S. Section 409.981(3)(c), Florida Statutes provides that "In addition to the criteria established in s. 409.966, the agency shall consider the following factors in the selection of eligible plans. (c) Whether a plan is proposing to establish a comprehensive long-term care plan and whether the eligible plan has a contract to provide managed medical assistance services in the same region.

1. We understand that the Managed Medical Assistance program of the SMMCC is not presently in effect and note an alternate reference to "Florida Medicaid medical assistance health plan" but we are unable to find the definition of a "Florida Medicaid medical assistance health plan." Please clarify which plans qualify as a "Florida Medicaid medical assistance health plan" for the purpose of this SRC/question. 2. The referenced statute provides that "the agency shall consider the following factors in the selection of eligible plans...whether a plan is proposing to establish a comprehensive long-term care plan..." We are unable to find any Evaluation Criteria or otherwise that provides Respondents with an opportunity to advise the Agency of its intent to establish a comprehensive long-term care plan." Please provide additional information.

(1) A Florida Medicaid medical assistance health plan is a plan operating under s. 409.912(3) (non-reform), s. 409.912(4)(d), or 409.91211 (reform), Florida Statutes.

(2) The Managed Medical Assistance program will not be established, per statute, until 2014. Comprehensive plans must provide Managed Medical Assistance services as outlined in s. 409.973. Preference will be given in this ITN for plans with existing Medicaid medical assistance plan contracts as defined above or who hold contracts with the state to operate Medicare Advantage Special Need plans.

264Aetna Better Health of Florida General Question NA NA Medicaid Will there be preference given to a Respondent bidding on both

MMA and LTC contracts? Not in this procurement.



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Amerigroup Florida ATTACHMENT C Section B Medicaid Please explain how the fee-for-service provider service network plans will be evaluated in the scoring and evaluation process.

Fee-for-service provider service networks are exempt from submission of Attachments N and N-1, therefore FFS PSNs will have no cost proposals for review in the scoring and evaluation process. Clarifying information will be provided in updated instructions specific to Attachment C, Special Conditions, Section C.45. Please see Addendum No. 2, Item #3 and Addendum No. 2, Item #16.

266


Question #57: Qualifications and Experience

Medicaid Please clarify if only direct subcontractors of the respondent are to be reported for this Question #57.

Identify all subcontractors Prospective vendors which the Respondent expects to make payments of $25,000 or more in one year including administrative (ex. TPAs, credentialing contractors, administrative management subcontractors) as well as service subcontractors (ex. case management subcontractors).

267

Amerigroup Florida ATTACHMENT CSection C. 19: Number of Awards

MedicaidPlease describe the elements of the "negotiation" as articulated in the selection process. Is the negotiation related only to cost or will there be other elements included as well.

The Agency will negotiate with eligible respondents to achieve cost savings as required by Section 409.966, F.S. and will consider the quality selection criteria for eligible plans based on the requirements of Sections 409.966 and 409.981, F.S., in order to obtain the best value to the state. Specific negotiation points will be made available to respondents who are invited to negotiations prior to entering into the negotiation process through the provision of an Agency developed agenda.

268

Amerigroup Florida GENERAL Medicaid

Given that certain information supporting the cost proposal has not yet been published, will plans have a separate opportunity to submit questions on additional materials posted or will a cost focused bidders conference be held?

Questions were accepted in writing at the vendor conference on 7/19/12.

269

Bank of America - Merrill Lynch ATTACHMENT C Qualification of

Plan Eligibility Medicaid I did not see a specific description of specialty plans and how they can bid for particular populations. Please explain. There is no allowance for specialty plans in this ITN.

270


ATTACHMENT D-II N/A SECTION

X.C.1.l Medicaid

This section states, "Each quarter the Managed Care Plan shall submit an aging claims summary in accordance with Attachment D-II, Section XII, Reporting Requirements." Please confirm if this report should be delineated from claims aging reports already submitted by the Health Plan (for the Medicaid line of business) or if the report may be combined.

Such specifications will be provided in the LTC Managed Care Plan Report Guide.



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Coventry Health Care of Florida D-1 B Populations to

be Served MedicaidDoes AHCA envision that a specialty plan would be appropriate for this population and receive preferential treatment in the auto assignment language and inclusion in Choice counseling?

There is no allowance for specialty plans in this ITN.

272

Freedom Health Plan

ATTACHMENT D-II

Exhibit 8 Page 70 #3 vs. Section VIII Quality Management page 87

Managed Care Plan QI Activities

Medicaid Exhibit 8 states 2 PIPs and Section Vlll states 4 PIPs - which is correct?

Attachment D-II, Exhibit 8, #3 is correct. Two (2) PIPs will be required for the long-term care plans. As indicated in the exhibit, the exhibit requirement replaces the requirement in section VIII.

273Humana ATTACHMENT C C.46

Attachment K, Required Statements

Medicaid Please provide further details about the technology around the Direct Secure Messaging application.

Please refer to the Florida Health Information Exchange website by visiting https://www.florida-hie.net/dsm.html

274 Humana General NA NA Medicaid Is there a limit to the number of regions the state will award to a single bidder?

There is no limit, providing the Respondent meets the qualifications outlined in the ITN.

275


ATTACHMENT C Pg. 21 C45. B. b) 3. Medicaid Define operating expense.

Operating expenses include all necessary and proper costs that are appropriate in developing and maintaining the operation of the managed care facilities and activities. Necessary and proper costs related to managed care are those costs which are common and accepted occurrences in the managed care operation.

276


ATTACHMENT CPg. 21/22 C.45 B. 3. & 4.a) & 5.b)

Medicaid Are financial requirement 3, 4a & 5a based on entity basis or line of business basis?

Items 3, & 4a are based on the entity as a whole. Item 5A is based on the Medicaid contract amount.

277


ATTACHMENT C 5 Medicaid Please define: "Qualified Vendor".

This Exhibit refers to "qualified entities." A qualified entity is one who meets the qualifications as outlined in this ITN. The list provided in Exhibit 5 may include providers that are not qualified to provide services under the new SMMC-LTC program. The list provided in Exhibit 5 contains all subcontracted providers that have received payment during the six (6) months preceding the release of the ITN.

278


ATTACHMENT C 5 Medicaid Please clarify of all "Qualified Vendors" must be offered a contract prior to the award?

No, all qualified vendors do not have to be offered a contract prior to the award. Managed care plans must offer contracts prior to plan readiness as specified in Attachment C, Exhibit 6; and Attachment K, Item 5.



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ATTACHMENT E Formatted Submission Q. 50 / 5 Medicaid Please describe biometrics.

Biometrics refers to technology that measures and analyzes individual physical characteristics for authentication purposes. Examples of physical characteristics include fingerprints, eye retinas and irises, facial patterns and hand measurements. Patient records would be matched based on the biometric imprint as opposed to an algorithm of demographic variables.

280

Molina Healthcare of Florida ATTACHMENT C

Exhibit 5 - Aging Network Service Provider List

MedicaidWhat is meant by the term "Qualified" vendor for purposes of this list?

This Exhibit refers to "qualified entities." A qualified entity is one who meets the qualifications as outlined in this ITN. The list provided in Exhibit 5 may include providers that are not qualified to provide services under the new SMMC-LTC program. The list provided in Exhibit 5 contains all subcontracted providers that have received payment during the six (6) months preceding the release of the ITN.

281

Molina Healthcare of Florida ATTACHMENT C Medicaid

Is it correct that cost will NOT be a factor in the process for determining who the Agency negotiates with? If so, will cost be a factor in the negotiation process?

In order to comply with s. 409.966(3)(d), F.S., the Agency will negotiate capitation rates with each plan in order to guarantee aggregate savings of at least 5 percent. The respondent’s proposed capitation rates must be within the capitation rate ranges for all Eligibility Groups identified in Attachment N-2, Capitation Rate Ranges, or the response will be rejected. Fee-for-service provider service networks are exempt from submission of Attachments N and N-1, therefore FFS PSNs will have no cost proposals for review in the scoring and evaluation process. Clarifying information will be provided in updated instructions specific to Attachment C, Special Conditions, Section C.45. Please see Addendum No. 2, Item #3 and Addendum No. 2, Item #16.

282

SIMPLY ATTACHMENT C NAC.45.B.3 Surplus Start up

Medicaid

Please confirm that 3 month's operating expense as referenced in this section refers to estimated 3 month's operating expense required for the proposed LTC product line and not entire Florida operations.

3 months of operating expenses are based on the plan's Florida operations from the balance sheet.

283SIMPLY ATTACHMENT D-

II Exhibit 13 Section F.2.b MedicaidTimeline for submission for plans regulated by OIR (March 1 per draft contract) is not consistent with OIR annual statement requirements for HMOs (April 1 per statute)

S. 409.967(3)(a)2, F.S. specifies March 1 submittal.



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ATTACHMENT D-II 3

Section III, Eligibility and Enrollment, Item A, Eligibility, 1.a.(16), page 5 of 114

Medicaid Please clarify what information will be provided to plans for new enrollees and in what format (hard copy or electronic)?

Please see Attachment D-II, Section II, C.7, page 35: "Notice to the Managed Care Plan will be by file transfer".

285


ATTACHMENT D-II 7 TABLE 1, 60

of 114 Medicaid Can AHCA provide bidders with a listing of what it considers rural and urban counties for the purposes of this ITN?

Please see Attachment D-II, Section I, "Definitions and Acronyms", page 25. Rural is defined as "An area with a population density of less than one hundred (100) individuals per square mile, or an area defined by the most recent United States Census as rural, i.e., lacking a metropolitan statistical area (MSA)."

Please see Attachment D-11, Section I, "Definitions and Acronyms", page 27. Urban is an area with a population density of greater than one-hundred (100) individuals per square mile or an area defined by the most recent United States Census as urban, i.e.,as having a metropolitan statistical area (MSA).

286

WellCare of Florida General N/A N/A Medicaid What is the process by which the Agency will grant Regulatory authority (HCPCs) for the LTC plans?

Please see January 18, 2012 Guidance Statement Regarding Statewide Medicaid Managed Care. Document can be accessed at the following link: http://ahca.myflorida.com/Medicaid/statewide_mc/pdf/SMMC_Guidance_Statement_HMO_cert_of_authority.pdf

287

WellCare of Florida ATTACHMENT E-1 N/A

Qualifications & Experience #1

Medicaid

The evaluation criteria states that plans that are fully accredited with one of the permissible entities (URAC, NCQA or AAAHC) may receive full credit (5 points); however, the criteria also suggest that an additional 5 points are available to plans that are fully accredited through NCQA for a total of 10 possible points. Please indicate why NCQA accreditation is singled out for additional/extra points.

The procurement is designed to allow the Agency to select plans that are responsive and offer the best value to the state.



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Qualifications & Experience #11

Medicaid

The administration has established clear priorities around the importance of driving economic value and jobs in the state of Florida. HB7107 demonstrated in 409.966 that the highest level of preference for that economic value should be awarded to organizations that are based in and perform operational functions in this state, by staff located in this state. While the Agency has incorporated the technical components of the law into the ITN as it relates to tiering of organizations and functions, the overall weighting of that economic value (<1% of total points in the scoring) and the relative value of Florida based companies (worth only 1 additional point) does not seem to reflect the intent or magnitude of the administration's priorities and corresponding legislative intent. Can you please describe the basis for the scoring on this component? Is there an opportunity to re-evaluate the weight of FL based preference by assigning a higher number of points to this criteria overall, as well as increase the point value differential for FL based companies who perform all functions within the state? Does the Agency intend to provide further preference for Florida based companies as required by 409.966 (3) (c) 3 in the selection of plans after negotiations are conducted and if so, what process will be used for evaluation?

Please refer to Attachment E. Submission Requirements and Evaluation Criteria Components, Core. 11 Qualifications and Experience and note that responses to this submission requirement will be considered for negotiations.

289


ATTACHMENT D-II NA Section X, B

1.a Medicaid Can Contract Manager and other key positions be the same person(s) for more than one region?

Yes, in accordance with the Evaluation Criteria in Attachment E-1, 45., of this procurement, this item/requirement is listed as “Core” and, therefore, the response applies to all regions.

290

WorldNet Services Corp. ATTACHMENT E-I NA

Item 1. Qualifications and Experience

Medicaid

The requirement specifies current accreditation by a nationally recognized accrediting body as indicated by the enabling legislation. The scores, however, are assigned disproportionately to the stated requirement, which does not distinguish between NCQA and any other nationally recognized accrediting body. Would AHCA align the requirement and scoring?

Please refer to Attachment E Core, 1. Qualifications and Experience for scoring related to accreditation.

291


General-Rate corridor not released until July 18

NA NA Medicaid Will bidders have the opportunity to ask questions regarding the capitation rates after they are released?

Questions were accepted in writing at the vendor conference scheduled for 7/19/12.



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Universal Health Care Group (Rcvd 501)

General Medicaid Will preference be given to respondent’s who have existing executed contracts in place over those who simply have LOAs/LOIs?

Please see s. 409.966, Florida Statutes, regarding the selection of eligibility criteria, and Attachment E-1, Item 67.

293


ATTACHMENT E NA

E.8 Contract Negotiations, TABLE 1, 5 of 7

Medicaid / HSD

Does the maximum number of plans for contract include the Bonus Region Plans from Area 1 &2, or would that be additional. For example, in Area 10, will there be 3 contracted plans plus potential bonus plans from Areas 1 and 2, or will the contract be limited to 3?

Please see Attachment C, Section C.19 of AHCA ITNs for Regions 3-11.

294

American Eldercare, Inc. ATTACHMENT C Section

C.45(D) MPA

Under Section C.45(D), the ITN indicates that an Attachment J must be submitted. However, there do not appear to be any special instructions for a FFS LTC PSN regarding Attachment J. Are FFS LTC PSNs to submit an Attachment J with a proposed capitation rate for transportation only, not submit an Attachment J, or submit an Attachment J with some other proposed rate? If the third option is accurate, what is the rate that the FFS LTC PSN must submit to be based on (and/or encompass)?

Fee-for-service provider service networks are exempt from submission of Attachments N and N-1. Clarifying information will be provided in updated instructions specific to Attachment C, Special Conditions, Section C.45. Please see Addendum No. 2, Item #3 and Item #16.



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Amerigroup Florida ATTACHMENT J Cost Proposal MPA

Please clarify the following regarding Attachment J:

• How are the cost proposals weighted in the final assessment of whether the vendor will be invited to negotiate?• Please describe the point allocation system for the cost proposal component of the ITN• How many points will be associated with premium rates?• How many points will be awarded for plans bidding the bottom of the range?• How many points will be awarded for plans bidding the top of the range?• How many points will be awarded for plans bidding the midpoint of the range?• Are the points given for one rate proposal contingent on other plans’ rate proposal?• Does the “place” that a plan bids (For example, 1st place, 2nd place, etc.) impact the number of points awarded, or is it just the rates?•If all vendors offer the same rate and score identically on the technical scores, how will AHCA determine which vendor will be selected for award? What are the differentiating factors? What is the process for evaluation?

Plan cost proposals are not being scored. Cost proposals must be within the LTC rate range for the bidder to be considered for negotiations. The Agency will negotiate with eligible respondents to achieve cost savings as required by Section 409.966, F.S., and will consider the quality selection criteria for eligible plans based on the requirements of Sections 409.966 and 409.981, F.S., in order to obtain the best value to the state. Specific negotiation points will be made available to respondents who are invited to negotiations through the provision of an Agency developed agenda prior to entering into the negotiation process.

296

Amerigroup Florida ATTACHMENT J-5

Capitation Rate Ranges MPA

Please clarify how the hospice and nursing home rates will be calculated. Will they be included in the capitation rate, and if so, how will changes in those rates be reconciled in the plan rate. If they will not be the method of payment, please clarify how the rates be accounted for.

Please refer to Sections 2, 3 and 4, as well as Appendix A of Attachment N-2. Please see Addendum No. 2, Item #3 and Item #16.



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Amerigroup Florida ATTACHMENT M Data Book MPA

Please clarify the following regarding Attachment M, Data Book:

• What is the formula for determining the patient’s financial responsibility? Will that change in the future? If so, please clarify how. • The total dollar amounts listed in the data book on pages 18 and 19 do not tie to each other ($436.58M vs. $440.02M). Please clarify the different between the numbers. • In the middle of page 7 it states, “Dual eligible recipients, who had never previously utilized any LTC related services but were identified as using a Medicare-covered SNF were not flagged as NF recipients.” Please confirm the reasoning of this requirement. • On page 19, please confirm if the $3.73M is included in the $440.02M?• There are 3 services (behavioral management, medication administration and medication management) for which there is no data because they’re new services. Further, we are expected to fund the services through “offsets in other services”. How are these items defined and how much will we expect them to cost?• There is no data for non-emergent transportation, but it will be priced into the rate ranges. Will the rate range development show us this explicitly or will it be implicit in the final product (the rate range)?• Are the data completed by dividing or multiplying the base claims by the completion factors in the data book?• The data book says that the data were adjusted to the July 2012 fee schedule. Does this apply for all services?

(1) The patient responsibility determination for the recipient is not expected to change under SMMC LTC from the current or historical process. The rate paid to SMMC LTC MCOs and PSNs will be net of patient responsibility. (2) The $3.44M dollars that are included on page 19 and not included on page 18 represent the expenditures for non-waiver services (i.e., paid through FFS) for the populations in the Assisted Living Facility, HCB - Aged/Disabled and Channeling waivers that were classified as HCBS in the Data Book. These expenditures are identified in the exhibit on page 19 on the lines for "FFS Waiver Programs - Assisted Living Facility" ($1.33M), "FFS Waiver Programs - HCB - Aged/Disabled + Adult Day Health Care" ($1.97M) and "Capitated Programs - Channeling" ($0.14M) and are included in the Data Book. (3) The program design does not allow for a dual eligible recipient who had not previously utilized any LTC services to be a trigger of enrollment in the SMMC LTC program because a CARES assessment is not performed. However, if the recipient is already in the program and requires Medicare-covered SNF, that is allowed and the recipient’s Medicaid portion of the costs and utilization were included in the Data Book data. (4) The $3.73M on page 19 are included in Data Book but are in addition to the $440.02M, as they are costs categorized under the Non-HCBS population. (5) The three services, behavioral management, medication administration and medication management, are addressed in Section 2 of the rate addendum to the ITN. (6) Non-emergent transportation has been included in the rate ranges. Please refer to Section 2 of the rate addendum to the ITN (7) The data are completed by



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Bank of America - Merrill Lynch

ATTACHMENT D-II

Exhibit 13 - Method of payment

MPA

The Agency expects to negotiate capitation rates in order to guarantee savings of at least five percent (5%). Determination of the amount of savings shall be calculated by comparison to the Medicaid rates that the Agency paid managed care plans for similar populations in the same areas in the prior year. Does this mean rates will be equivalent to prior year managed care rates minus 5%? If the actuarial margin included in the prior year rates is just 1%, how can a 5% reduction (implying a -4% margin) be actuarially sound?

The development of actuarially sound capitation rates is described in Attachment N-2. AHCA will measure savings by comparing the estimated cost of delivering LTC services under the SMMC LTC program and the estimated cost of delivering LTC services had the existing waiver and FFS programs continued. Please see Addendum No. 2, Item #3 and Item #16.

299


ATTACHMENT D-II Exh 13 Capitated LTC

Plans MPA

How will the State achieve the statutorily mandated 5% savings in Year 1 with 2% rebalancing? What is the formula that will be used to measure this savings? How will FFS administration be factored into the formula?


300


ATTACHMENT D-II Exh 13 F MPA

Has the achieved savings rebate methodology been approved by CMS? If not, what is anticipated in the case of a disapproval?

The achieved savings rebate methodology will be reflected in a rule to be developed by the Agency.

301


ATTACHMENT D-II Exh 13 F.7.b (5) MPA

Achieved savings rebate excludes expenses related to executive bonuses. Please define the term executive for purposes of this requirement.


302


ATTACHMENT D-II Exh 13 F.7.b (5) MPA Are staff/employee/non-executive bonuses included as

expenses in the achieved rebate calculation?

Administrative costs are not included in the calculation of the achieved savings rebate so bonuses paid to non-executive administrative staff would not be included.

303


ATTACHMENT D-II Exh 13 F.7.b (7) MPA

Achieved savings rebate excludes certain administrative costs. Please clarify that administrative expenses not listed in this section are included in the calculation of the achieved savings rebate.


304


ATTACHMENT D-II na B.4 MPA How will capitation rates be developed for periods beyond the

initial rating period?

The Agency will determine internally how future capitation rates will be developed (e.g., rebase rates annually, trend forward existing rates and adjust for additional anticipated transitions from NF to HCBS).

305

Coventry Health Care of Florida ATTACHMENT J4 na

Projected mix of HCBS/Facility

MPAWill the 2% rebalancing assumption change at an region level? If so, when and what criteria will be used to make higher or lower HCBS penetration assumptions?

Please see Attachment N-2, and Addendum No. 2, Item #3 and Item #16.



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ATTACHMENT M - DataBook na

2 - SMMC LTC Populations / Setting of Care

MPA

Please illustrate the classification of HCBS, Nursing Facility, and Hospice by month for the following sample individuals in SFY11. (a) individual is in NF in Jul-Aug, Oct-Nov; HCBS in Jan-Jun, (b) individual is in HCBS in Jul-Sep; NF in Oct-Jun, (c) individual is in NF in Jul-Jun; Hospice claims in May-Jun, (d) individual is in NF in Jul-Oct; HCBS in Nov-Jun.


307




MPA Please expand on the logic classifying NF and HCBS. Please provide examples. Please see Addendum No. 2, Item #17.

308




MPA How did you identify dual eligible recipients using a Medicare-covered SNF?

Using claim category of service provided in the historical FFS claims data and recipient eligibility.

309




MPA

The Data Book indicates that the amount of short-term NF recipients represents a "small portion of the total NF population". Please provide the specific information related to this subpopulation.

Short term for Hospice and NF are as follows:2008/2009 Period: 6.2% of total Non-HCBS member months2009/2010 Period: 3.7% of total Non-HCBS member months2010/2011 Period: 3.6% of total Non-HCBS member months

310



7 - Developing Actuarially Sound Contract Rates / Programmatic Changes

MPA

Are there any other program or policy changes that have impacted (or are expected) to impact the SMMC LTC program between July 2008 and the end of the rating period for each region? Has there been any change in the criteria for the CARES assessment or the number of "slots" available for the legacy waiver programs? Please also identify any assumptions made in the final rates for participant directed services.

Please refer to Sections 2, 3 and 4, as well as Appendix A of Attachment N-2. The criteria for the CARES assessment has not changed. Waiver slots and capacity are based on annual appropriations from the Legislature. Participant Directed Care applicable to the LTC program is included in the base data for rate setting. See Addendum No. 2, Item #3 and Item #16.

311



7 - Developing Actuarially Sound Contract Rates / Risk Adjustment

MPA Please discuss why the CARES assessment information will not be used for purposes of risk adjustment.

The necessary statistical analyses and comprehensive testing of a newly developed model of risk adjustment based on the CARES assessment was not possible prior to the implementation of the SMMC LTC program. AHCA may consider implementing such a model in future years of the SMMC LTC program.



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7 - Developing Actuarially Sound Contract Rates / Risk Adjustment

MPA

The risk adjustment process requires clarification and additional details. Please explain how adjustments will be made for plans that achieve more HCBS penetration than assumed in the rates. Will they receive less capitation revenue as a result of the successful movement of individuals to a more efficient setting of care?

Please refer to Section 5 of Attachment N-2. See Addendum No. 2, Item #3 and Item #16.

313



7 - Developing Actuarially Sound Contract Rates / SMMC LTC Plan Administration Costs

MPA

Are the case management costs included in the Data Book inclusive of all historical case management costs for the legacy waiver programs? Are there missing items for plans that may have subcontracted the case management function to providers? Do the NHD plans report case management as service costs?

The Data Book case management costs represent the historical expenditure for the populations included in the Data Book.The NHD plans report case management as service costs.

314



7 - Developing Actuarially Sound Contract Rates / SMMC LTC Plan Administration Costs

MPAAre there any state taxes or fees that will be assessed as part of the SMMC LTC program? If so, how will this amount be included in the administrative component of the capitation rate?

No taxes or premium taxes are levied under the SMMC LTC program.

315



7 - Developing Actuarially Sound Contract Rates / Trend

MPA

Please provide the detailed assumptions (e.g. trend, admin, program changes, managed care factors, etc.) used in the development of the capitation rate ranges by service, population, and region along with the specific rate ranges.

Please refer to Attachment N-2. There are various sections detailing all the assumptions. See Addendum No. 2, Item #3 and Item #16.

316



Appendix A - Medicaid Services Included in this Data Book

MPA

The note at the bottom of this exhibit indicates that certain state plan services will be included in the SMMC LTC program. Please confirm that these additional covered services are included as part of the base data.

The state plan costs associated with the covered services listed are already included as part of the Data Book detail.

317



Attachment 1: Data Summaries by Region

MPAPlease provide additional summaries that segment the HCBS category into subcohort populations based on the HCBS approach (i.e. assisted living, consumer's home, etc.)

The data provided in the Data Book (Attachment M of the ITN) are the only data that will be provided.



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Attachment 1: Data Summaries by Region

MPA Please provide information related to the primary drivers of the higher HCBS penetration in Regions 10 and 11.

The primary drivers of higher HCBS penetration in Regions 10 and 11 are the availability of more waiver programs and more service providers.

319


ATTACHMENT M - DataBook na General MPA

In the capitation rate ranges to be published on or before 7/18 please provide the logic and calculations that bridge from the data book reconciliations to the final rate ranges including all assumptions.

Attachment N-2, includes a description of the adjustments and methodology used to develop the rate ranges. See Addendum No. 2, Item #3 and Item #16.

320


ATTACHMENT M - DataBook Table 1 3 - Covered

Service Area MPA

Table 1 of the Data Book indicates the projected effective dates by region for the SMMC LTC program. What adjustments to capitation rates will be included should the resulting effective dates not align with the projected timeline?

The rates would be adjusted by trend to the appropriate program period midpoint based on the beginning and ending date.

321


ATTACHMENT M - DataBook Table 3

6- Adjustments Reflected in this Data Book

MPA

Table 3 of the Data Book provides the statewide adjustments applied to the encounter data for each SFY. Please provide the details for each region, rate cell, and service type applied to the encounter data.

There were no variations by rate cell or region when these factors were applied. As indicated in the Data Book Attachment M of the ITN, these adjustments were applied across all categories of service.

322


ATTACHMENT M - DataBook Tables 4 and 5 8 - Data

Reconciliation MPA

Note 6d discusses the removal of the difference between the capitation rate and encounter experience for NHD. This value is significant. Please confirm if this amount includes a reduction for services that will not be covered by the SMMC LTC program (e.g. acute care benefits). The encounter to capitation ratio suggested by this value is approximately 73%. The concern is that there may additional under-reporting in the encounter data that is not being captured.

The amount includes reduction for services not otherwise covered under SMMC LTC including acute care services and other services not identified in the list of covered SMMC LTC services. Also, historical administrative costs and margin associated with this program and part of the capitation expenses would be included in this number since the comparison point in the reconciliation is service costs. Please refer to Attachment M of the ITN, section 6.

323


ATTACHMENT D-II Page 39 of 168

Section 2. C. Responsibilities of the State of Florida (state) (See Attachment D-II, Exhibit 2) 15.

MPA

If the Managed Care Plan is capitated by the Agency for a covered service, then the Managed Care Plan shall register all participating providers for such services who are not verified as Medicaid-enrolled providers with the Agency’s fiscal agent, in the manner and format determined by the Agency. What format and manner shall the Managed Care Plan follow to comply with this requirement?

Plans need to follow the mass registration process outlined in the Managed Care Organization (MCO) Provider Mass Registration Enrollment Guide . The guide for registration is found on this site: http://portal.flmmis.com/FLPublic/Provider_ManagedCare/tabId/126/Default.aspx

324 Humana ATTACHMENT J-5 NA Capitation

Rate Ranges MPA Please confirm when the state plans to release the Capitation Rate Ranges.

See Attachment N-2. See Addendum No. 2, Item #3 and Item #16.



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ATTACHMENT J Pg.1 MPA Will the Agency entertain questions regarding the ranges of the rate cells, when published?

Questions will be accepted in writing at the vendor conference scheduled for 7/19/12.

326


ATTACHMENT M Data Book MPA Will a capitation amount for services for which no historical data is available be added to the respondents bid rates?

Please refer to Attachment N-2. See Addendum No. 2, Item #3 and Item #16.

327

Molina Healthcare of Florida Attachment J-5 MPA

When the state publishes the rate cell ranges for Attachment J-5, will the Agency entertain questions on that document? Questions will be accepted in writing at the vendor

conference scheduled for 7/19/12.

328 SIMPLY ATTACHMENT D-II NA Section F.7 MPA Will there be a process or provision for the health plan to

dispute the results of the achieved savings rebate audit?The achieved savings rebate methodology will be reflected in a rule to be developed by the Agency.

329

UnitedHealthcare of Florida, Inc. ATTACHMENT C

Attachment J-5Capitation Rate Ranges

N/A MPA When will the actuarially sound rate ranges be published for each region to complete section J-5?

Please refer to Attachment N-2. See Addendum No. 2, Item #3 and Item #16.

330

UnitedHealthcare of Florida, Inc.

ATTACHMENT M Statewide Medicaid Managed Care Long-Term Care Managed Care Data Book

N/A

7. Developing Actuarially Sound Contract Rates

MPA Can you provide more details on risk adjustment methodology? Please refer to Section 5 of Attachment N-2. See Addendum No. 2, Item #3 and Item #16.

331


Attachment M Statewide Medicaid Managed Care Long-Term Care Managed Care Data Book

N/A N/A MPA Will the Databook be made available in Excel format? If so, when?

An Excel version of the Data Book is currently available at http://ahca.myflorida.com/Procurements/index.shtml

332


ATTACHMENT M Statewide Medicaid Managed Care Long-Term Care Managed Care Data Book

N/A N/A MPA Will the patient responsibility cost be included in the base rate? Please refer to Attachment N-2. See Addendum No. 2, Item #3 and Item #16.



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333WellCare of Florida ATTACHMENT C N/A Section C.45.d MPA

What is the Agency's assumption of administrative load and profit margin in the development of the actuarially sound rate range?

Please refer to Appendix A, Tables 6 and 7, Attachment N-2. See Addendum No. 2, Item #3 and Item #16.

334


Section V, Item A, 5, m & n

MPA

This item states that Intermittent and Skilled Nursing, as well as DME services include the benefit available under the Medicaid state plan, in addition to the expanded services under the waiver. Can you please explain how the utilization and costs for these services were incorporated into the data book?

Costs and utilization for state plan services (including DME) associated with individuals identified as part of existing waivers and/or residing in nursing homes who are expected to enroll in the SMMC LTC program were included in the appropriate service categories offered under the SMMC LTC program. For example, all state plan related costs and utilization associated with DME services for the universe of SMMC LTC recipients were included in the "Medical equipment and supplies" category of service.

335

WellCare of Florida ATTACHMENT M Appendix A N/A MPA

Footnote at the bottom, in reference to Behavioral Management, Medication Administration and Medication Management, "No historical FFS experience data are available for these services. These are new services that will be available in the SMMC LTC program. The intent is that these services will be made available to SMMC LTC enrollees; however no additional funding is available for these services and coverage of these services is expected to be funded by offsets to other services." Does this mean the rate ranges will not include a provision for these services? This seems different than what footnote 1 of the data book summaries says (pg 31 of 183): "Historical data are not available for these services. The services will be incorporated as a programmatic adjustment in the rate development process" and also different from what we were told at the last databook meeting.

Please refer to Sections 2 and 4 of Attachment N-2. See Addendum No. 2, Item #3 and Item #16.

336

WellCare of Florida ATTACHMENT M Attachment 1 Data Summaries MPA

In HB7107 409.983, the law states that "The Agency shall establish nursing facility payment rates for each licensed nursing home based on facility costs adjusted for inflation and other facets as authorized by the GAA. Payments to long-term care managed care plans shall be reconciled to reimburse actual payments to nursing facilities." Can you explain the timing and process by which this adjustment would take place to ensure managed care plans are made whole for the adjustment?

Please refer to Sections 2, 3 and 4, as well as Appendix A of Attachment N-2. See Addendum No. 2, Item #3 and Item #16.



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Will the plans be provided with updated distributions of waiver populations (as shown on page 22 of Attachment M) prior to the ITN due date. Also, will AHCA adjust the revenue for the MLTC providers based on their distribution of waiver populations? Is this being taken care of through risk adjustment?

AHCA does not plan to issue additional member month distributions beyond those already provided in Attachment N-2. See Addendum No. 2, Item #3 and Item #16.

338


What are the causes of variation in membership and cost between the old databook and the new databook? Please describe the methodology changes that took place in creating the revised databook vs. the original one.

Please refer to Attachment M, Section 2, related to how the populations were selected and assigned their setting of care. The changes in the selection and assignment process contribute to the largest difference. Another difference is that only certain types of Hospice users are included in the June 21, 2012 version, based on design element changes.

339


Section 6 states that data for non-mandatory populations have been excluded. Will the bidders be provided with some cost information on the non-mandatory populations, as well as their current population?

The DataBook includes data for only the mandatory LTC populations. Excluded populations are not allowed to enroll into the SMMC LTC program and therefore no data will be provided. We anticipate the cost for the voluntary populations will not differ significantly from the cost of the mandatory populations.

340


In HB7107 409.983, the law states that "The Agency shall establish nursing facility payment rates for each licensed nursing home based on facility costs adjusted for inflation and other facts as authorized by the GAA. Payments to long-term care managed care plans shall be reconciled to reimburse actual payments to nursing facilities." Can you explain the timing and process by which this adjustment would take place to ensure managed care plans are made whole for the adjustment?


341

WellCare of Florida ATTACHMENT M Attachment 1 Data Summaries MPA Will there be an annual adjustment to rates to reflect changes in

mix, acuity, nursing facility rates and other trend factors?

The Agency will determine internally how future capitation rates will be developed (e.g., rebase rates annually, trend forward existing rates and adjust for additional anticipated transitions from NF to HCBS).



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WellCare of Florida ATTACHMENT M N/ASection VII. Risk Adjustment

MPA

Please provide an example of how the risk adjustment methodology will work assuming a simple two plans in a region situation. Will plans who do a better job of moving people from institution to home and community based care be penalized under the risk adjustment methodology? Is there going to be a difference in risk adjustment methodology for capitated plans versus fee-for-service plans?

An example of the risk adjustment methodology is provided in Appendix C of Attachment N-2. Plans that move more individuals from Nursing Facilities to HCBS settings will not be penalized under the risk adjustment methodology. See Addendum No. 2, Item #3 and Item #16.

343WellCare of Florida General N/A N/A MPA

Can the Agency please clarify the accounting methodology you will use to classify expenses in the achieved savings rebate calculation?


344

WellCare of Florida General N/A N/A MPA

While the law describes the Achieved Savings Rebate that is reflected in the current ITN, response to the Medicaid waiver has indicated that CMS may prefer a medical loss ratio. Please advise how AHCA will reconcile CMS feedback with the current Achieved Savings Rebate.

There has been no communications with CMS relating to MLR for the 1915(b) and (c) waivers that govern the LTC managed care program.

345


The legislation clearly established a competitive price bid process, but it is unclear how a respondent's price bid is evaluated in the scoring mechanism (other than that it is within the actuarially sound range). Is that the extent to which the bids are evaluated?

Plan cost proposals are not being scored. Cost proposals must be within the LTC rate range to be considered for negotiations. The Agency will negotiate with eligible respondents to achieve cost savings as required by Section 409.966, F.S. and will consider the quality selection criteria for eligible plans based on the requirements of Sections 409.966 and 409.981, F.S., in order to obtain the best value to the state. Specific negotiation points will be made available to respondents who are invited to negotiations through the provision of an Agency developed agenda prior to entering into the negotiation process.

346

WellCare of Florida General N/A N/A MPA Will the Actuaries consider a rate of uncollectibiilty for cost share for consideration in the competitive price bid?

The historical data represents the patient responsibility amounts and is used to develop the prospective capitation rates. The rate paid to SMMC LTC MCOs and PSNs will be net of patient responsibility.



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How will the Agency make a comparison of rates (PMPM) from the prior year for purposes of calculating savings if there has not been a comparable rate (benefit to benefit comparison)? For example, neither Nursing Home Diversion or the Medicaid waiver programs individually are comparable to the current MLTC program. How would the 5% savings be calculated?

The development of actuarially sound capitation rates is described in the rate addendum to the ITN. AHCA will measure savings by comparing the estimated cost of delivering LTC services under the SMMC LTC program and the estimated cost of delivering LTC services had the existing waiver and FFS programs continued.

348


How will the Agency guarantee that the 5% savings consideration does not compromise the actuarial soundness of the rates? How will the actuaries reconcile competitively bid rates and the 5% savings requirement?


349


Section X Item D Encounters Data

MPAFor services that are capitated, is the Agency requesting capitated dollar amounts to be included in the encounter transaction submissions?

Health plans are required to submit encounters for all services rendered to plan enrollees, regardless of whether these services were provided as a fee-for-service or capitated arrangement between health plan and provider. For capitated encounters, plans should be prepared to submit either the capitated amount or the amount the plan would have paid on a fee-for-service basis. Further instructions will be provided by the Agency.

350



MPA

Our internal process deems a claim complete upon payment. As such, is it acceptable to utilize paid date versus adjudication date to start the measurement of the seven day turnaround time for encounter submission?

Yes

351



MPA For capitated encounter's paid amount, how does the State define the paid amount in this field (i.e. PMPM)?

The capitation amount is the amount a plan pays a provider to be responsible for a defined set of services for a plan member in given period, such as a month. A common example is a per member per month payment for case management.

352



MPACurrently we can register in and out-of state providers once a week, will we be able to register more often (i.e. daily) in order to meet the 7 days SLA?

Yes. Plans can register providers more often than weekly. The Agency can handle a “Mass Enrollment” file more frequently than weekly, and Plans also have the option/tool available to use the 2 page registration form at any time.



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Section X, Item D.7.a Encounter Data

MPA

What is the required timeline to submit encounter data? Section X, Item D, 7, a states: "For all non-pharmacy typical and atypical services, the Managed Care Plan shall submit encounter data no later than seven (7) calendar days following the date on which the Managed Care Plan adjudicated the claims." However, the section also references the AHCA companion guides for information on submission, and this resource indicates a timeline of "within 60 days following the end of the month in which the payment was made." Will the plans be able to submit encounters on a daily basis?

With the LTC ITN, the Agency is seeking to establish new timing standards for encounter submissions. Companion guides will be adjusted to reflect these new standards.

354


ATTACHMENT D-II Exhibit 13 Capitated LTC

Plans, C.4 MPA

What is impact of budget adjustments on plan participation? What will plans be allowed to do if a rate decrease occurs and is unacceptable? Or does this affect slots and, if so, how will it work?

(1) The Agency cannot anticipate the reaction of plans to budget adjustments. (2) If a plan perceives a rate to be unacceptable, the plan may withdraw from the region. In doing so, it should be noted that the plan will be subject to the penalty provisions specified in s. 409.967(2)(h), F.S. (3) The question relating to slots is unclear.

355


ATTACHMENT D-II Exhibit 13

Capitated LTC Plans, F. Achieved Savings Rebate

MPA NOI margin adjustment- at region or plan level? Net Operating Income is at the plan level.

356WorldNet Services Corp.

ATTACHMENT D-II Exhibit 13 FFS LTC

PSNs, A.2 MPA PCCB adjustments- are they at region or plan level? Depending on the type of PCCB adjustment, these are made at both the plan and region level.

357

WorldNet Services Corp. ATTACHMENT J NA NA MPA

The footer of Attachment J (Cost Proposal) indicates there are 2 pages to the attachment, but only page 1 is included. Please confirm Page 2 is identical to Exhibit 1 (Sample General Narrative – Long-Term Care Rate-Setting Methodology) included in Part 3 of the ITN or, if not, can Page 2 be made available?

This is simply an example page so there is no second page.

358

WorldNet Services Corp. ATTACHMENT M NA 7- Risk

Adjustment MPAIf risk adjustment is to actual mix between NF and HCBS settings how will savings be recognized by the plan for shifts from NF to HCBS settings of care?




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WorldNet Services Corp. ATTACHMENT M NA Base Data

Page 15 of 183 MPA

In the ITN, the state indicates that it may decide to aggregate regions and/or rate cells for rate making purposes and may provide additional information on or before July 18. Will the state make a final decision regarding aggregation on or before July 18? Will details regarding how aggregation was used in the rate development process be included with the rate ranges?


360


ATTACHMENT M Data Book NA Detailed

Exhibits MPA

Please confirm that the amounts shown in the data book under “Services Covered Under the Current Waiver Programs that Will Not be Covered Under the SMMC LTC Program” are NOT included in the Category of Service detail above.

The costs for the services labeled as "Services Covered Under the Current Waiver Programs that Will Not be Covered Under the SMMC LTC Program" are not included in the Category of Service detail in the Data Book.

361


ATTACHMENT M Data Book NA Detailed

Exhibits MPA

The data book indicates that adjustments will be made for behavioral management, medication administration, and medication management in the state’s rate development process. Will the details behind these adjustments be released with the rate capitation rates in mid-July?

Please refer to Sections 2 and 4 of Attachment N-2. See Addendum No. 2, Item #3 and Item #16.

362


ATTACHMENT M Data Book NA Section 6 MPA

Section 6 of the data book indicates that crossover NF claims have been included in the data. Please confirm that only the Medicaid portion of the liability is included in the data and that the Medicare portion of the liability has been excluded.

Only the Medicaid liability is included and SMMC LTC plans are responsible for only the Medicaid liability for LTC services.

363


ATTACHMENT M Data Book NA Section 6 MPA

The data book indicates that no adjustments have been made for historical fee changes made to NF and hospice but that adjustments will be included as a program change in the rate development process to restate experience based on the July 2012 fee schedule. Will the state release the details of this adjustment (e.g. by year, service category, and/or rate cell) with the capitation rate ranges to be published in mid-July?


364

WorldNet Services Corp. General NA NA MPA Will bidders be required to submit an actuarial rate certification

on behalf of the plan?

The bidders are required to complete the cost development documents including the narrative. No actuarially sound attestation is required from the vendor.

365


ATTACHMENT D-II Exh 3

Medicaid Pending for HCBS

MPA / DOEA

What is the historical volume of Medicaid Pending by region and setting? Also, please provide the proportion of Medicaid Pending individuals that are ultimately Medicaid eligible vs. those that are denied Medicaid. Please provide this by HCBS and Facility.




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N/A

Core, 10. Qualifications and Experience.

MQM

Please identify the source for the reference to "contract-required" measures in the following: "The respondent shall describe its experience in achieving quality standards with populations similar to the target population for the long-term care component of the Statewide Medicaid Managed Care program. Include experience with standardized measures, such as HEDIS and contract-required measures." Does "contract-required" denote the Core Contract provided via the ITN documents, Attachment D-II, Core Contract Provisions? If not, please provide the applicable contract reference.

The respondent should describe its experience and performance with standardized or other contractually required performance measures that have been used to assess the respondent's performance under current and previous contracts. In particular, the respondent should describe its performance on measures related to the scope of services and target population for the long-term care component of the Statewide Medicaid Managed Care program.

367


Qualifications and Experience #1

MQM

If a plan is in the process of getting accredited by NCQA, and has received corporate certifications for multiple NCQA standards, can the plan receive evaluation credit for this certification?

If a health plan has certifications for subsets of accreditation standards from an accrediting organization, they may receive partial credit for this in the evaluation. If a plan is in the process of getting accredited but does not have such certifications, that plan will not receive evaluation credit for this submission requirement.

368

WellCare of Florida ATTACHMENT E Exhibits 1, 2, and 3

Network Spreadsheets MS

The spreadsheet that is provided allows only for two providers per specialty per county. Many bidders may have more than two providers per specialty per county. Will you permit bidders to modify the spreadsheet to show all contracted providers in a category?

“The Regional Network Contracts and Agreements tool is designed to provide Managed Care Plans with credit for establishing signed contracts or written agreements per 409.966(3)(a)7., F.S. During the plan readiness phase, as outlined in Attachment C, Exhibit 6, Managed Care Plans will be required to provide their complete provider network.

369


ATTACHMENT D-II 7

TABLE 1, Assisted Living Facility, Adult Family Care Home (AFCH), and Nursing Facility Care, pages 60 and 65 of 114

MS

Are the bed count requirements rolled up to the region or is it by county? The max enrollment is at the region level but the network requirement is on a county level on Table 1. In addition, many of the members may be living in their homes and not a facility. Should the full max enrollment be used when calculating needed bed days?

AHCA will issue an ITN addendum removing the bed count requirement for Assisted Living Facilities, (ALFs), and Skilled Nursing Facilities (SNFs) listed in Attachment D-II, Table 1 on pages 60-67. Please see Addendum No. 2, Item #9.



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ATTACHMENT D-II

Exhibit 7, Page 60 of 114, Table 1

Table 1 Provider qualifications re Services provided in assisted living facilities

MS

Can Adult Family Care Home (AFCH) and Nursing Facility be added as Qualified providers in that they meet 429.02 Definition- (5) “Assisted living facility” means any building or buildings, section or distinct part of a building, private home, boarding home, home for the aged, or other residential facility, whether operated for profit or not, which undertakes through its ownership or management to provide housing, meals, and one or more personal services for a period exceeding 24 hours to one or more adults who are not relatives of the owner or administrator.

Qualified providers of assisted living facility services are assisted living facilities licensed per Chapter 429, Part I, Florida Statutes.

371


ATTACHMENT D-II

Exhibits, Page 60 of 114, Table 1

Table 1 Provider qualifications re Services provided in assisted living facilities

MS

Can Adult Family Care Home (AFCH) and Nursing Facility be added as Qualified providers in that they meet 429.02 Definition- (5) “Assisted living facility” means any building or buildings, section or distinct part of a building, private home, boarding home, home for the aged, or other residential facility, whether operated for profit or not, which undertakes through its ownership or management to provide housing, meals, and one or more personal services for a period exceeding 24 hours to one or more adults who are not relatives of the owner or administrator.

Qualified providers of assisted living facility services are assisted living facilities licensed per Chapter 429, Part I, Florida Statutes.

372


ATTACHMENT D-II


Table 1 Provider qualifications re Adult Day Care (Adult Day Health Care)

MS

Can Adult Family Care Home (AFCH) and Nursing Facility be added as Qualified providers in that they meet these definitions as part of their licensed services: 429.901 Definitions.—As used in this part, the term:(1) “Adult day care center” or “center” means any building, buildings, or part of a building, whether operated for profit or not, in which is provided through its ownership or management, for a part of a day, basic services to three or more persons who are 18 years of age or older, who are not related to the owner or operator by blood or marriage, and who require such services.(3) “Basic services” include, but are not limited to, providing a protective setting that is as non institutional as possible; therapeutic programs of social and health activities and services; leisure activities; self-care training; rest; nutritional services; and respite care.

Qualified providers of adult day care under the LTC MC program are Assisted Living Facilities and Adult Day Care Centers.



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ATTACHMENT D-II


Table 1 Provider qualifications re Adult Day Care (Adult Day Health Care)

MS

Can Adult Family Care Home (AFCH) and Nursing Facility be added as Qualified providers in that they meet these definitions as part of their licensed services: 429.901 Definitions.—As used in this part, the term:(1) “Adult day care center” or “center” means any building, buildings, or part of a building, whether operated for profit or not, in which is provided through its ownership or management, for a part of a day, basic services to three or more persons who are 18 years of age or older, who are not related to the owner or operator by blood or marriage, and who require such services.(3) “Basic services” include, but are not limited to, providing a protective setting that is as non institutional as possible; therapeutic programs of social and health activities and services; leisure activities; self-care training; rest; nutritional services; and respite care.


374


ATTACHMENT D-II


Table 1 Provider qualifications re Respite

MS

Can Adult Family Care Home be added as qualified provider as it meets ITN definition for Respite (Attachment D-II, Exhibits, Page 18 of 114) which refers to home/place of residence and assisted living facility (429.02 Definition- (5) “Assisted living facility”)?

Qualified providers for Respite are: Community Care for the Elderly providers; nurse registry; adult day care center; assisted living facility; nursing facility; Center for Independent Living; home health agency and homemaker/companion agency.

375


ATTACHMENT D-II


Table 1 Provider qualifications re Respite

MS

Can Adult Family Care Home be added as qualified provider as it meets ITN definition for Respite (Attachment D-II, Exhibits, Page 18 of 114) which refers to home/place of residence and assisted living facility (429.02 Definition- (5) “Assisted living facility”)?

Qualified providers for Respite are: Community Care for the Elderly providers; nurse registry; adult day care center; assisted living facility; nursing facility; Center for Independent Living; home health agency and homemaker/companion agency.

376


ATTACHMENT D-II

Table 1 Provider Qualifications, Page 60 of 114

Table 1 Services in Adult Day Care

MS Can Adult Family Care Homes be deemed as a qualified provider under 429.901?




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Humana ATTACHMENT D-II, Exhibits Table 1

LTC Provider Qualifications & Minimum Network Adequacy Requirements Table

MS Can Adult Family Care Homes be deemed as a qualified provider under 429.901?

Section 429.901, F. S., defines various terms used in adult day care enter licensure. The only Long-Term Care Managed Care service offered in adult day care centers is Adult Day Health Care. Adult Family Care Homes cannot satisfylicensure requirements for an adult day care center and are not exempt from licensure as an adult day care center when offering adult day care or adult day health care. As result, Adult Family Care Homes cannot be deemed a qualified provider of adult day health care services under Chapter 429, F. S.

378


ATTACHMENT D-II


Table 1 Provider qualifications re Medical Equipment & Supplies

MS

Can AHCA please further break out the "Medical Equipment and Supplies" qualifications to include Consumable Medical Supplies provider qualifications? This would allow the "supplies only" qualified providers to match those in the Nursing Home Diversion Waiver thus improving continuity and price competition.

Specific provider qualifications do not exist for supplies only providers, however, supplies only providers could be included in the MCP provider networks to satisfy the overall Medical Equipment and Supplies provider network requirement as long as they meet the MES provider qualifications.

379

WorldNet Services Corp. ATTACHMENT C Exhibit 5 NA MS Can AHCA please provide this listing in Microsoft Excel or

compatible format?

The list of Aging Network Service Providers will be provided in an Excel format. The file includes county, city, state, zip code and phone number where available. Providers can utilize on-line tools such as FloridaHealthFinder.com to identify additional address information if needed. The excel document can be found through the following link: http://ahca.myflorida.com/Procurements/index.shtml.

380



MSCan ALFs and Nursing Facilities be deemed as a qualified provider under the ITN definition of Assistive Care Services in Attachment D-11, Page 6 of 168?

Assisted living facilities are a provider of Assistive Care Services. Nursing facilities are not qualified providers for assistive care services under the LTC MC program or the Medicaid state plan program.

381


ATTACHMENT D-II

Table 1 Provider Qualifications, Page 60 of 114

Table 1 Assisted Living Services

MSCan ALFs and Nursing Facilities be deemed as a qualified provider under the ITN definition of Assistive Care Services in Attachment D-11, Page 6 of 168?




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ATTACHMENT D-II


Table 1 Provider qualifications re Assistive Care Services

MS

Can Assisted Living Facility (ALF) and Nursing Facility be added as Qualified providers in that they meet ITN definition (from Attachment D-II, Page 6 of 168)- Assistive Care Services — An integrated set of 24-hour services only for Medicaid-eligible residents in assisted living facilities (see 429.02(5)F.S.), adult family care homes and residential treatment facilities?


383


ATTACHMENT D-II


Table 1 Provider qualifications re Assistive Care Services

MS

Can Assisted Living Facility (ALF) and Nursing Facility be added as Qualified providers in that they meet ITN definition (from Attachment D-II, Page 6 of 168)- Assistive Care Services — An integrated set of 24-hour services only for Medicaid-eligible residents in assisted living facilities (see 429.02(5)F.S.), adult family care homes and residential treatment facilities?


384


ATTACHMENT D-II

Exhibit 7, Page 60 to 66 of 114, Table 1

Table 1 Provider qualifications re multiple service types

MS

Can Community Health Centers (FQHC) be added as qualified providers for all SMMC LTC services they are licensed to provide in support of rural options, continuity of care, and potentially comprehensive SMMC approach.

Community Health Centers are not a qualified provider for the LTC MC program.

385


ATTACHMENT C 5

Aging Network Service Provider List, page 38 of 165

MS Can EXHIBIT 5 be provided electronically in Excel with complete mailing addresses for each provider?


386


ATTACHMENT D-II


Table 1 Provider qualifications re Behavior Management

MSCan Home Health Agency and Nurse Registry be added as qualified provider to help maintain continuity of care since other services include all 3 provider types (Nurse, HHA, and NR)?

Home health agencies and nurse registries will be allowed as qualified provider types for Behavior Management. Individuals providing service through the Home Health Agency or Nurse Registry must be a clinical social worker, mental health counselor, psychologist, or registered nurse.



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ATTACHMENT D-II


Table 1 Provider qualifications re Behavior Management

MSCan Home Health Agency and Nurse Registry be added as qualified provider to help maintain continuity of care since other services include all 3 provider types (Nurse, HHA, and NR)?

Home health agencies and nurse registries will be allowed as qualified provider types for Behavior Management. Individuals providing service through the Home Health Agency or Nurse Registry must be a clinical social worker, mental health counselor, psychologist, or registered nurse. Please see Addendum No. 2, Item #9.

388


ATTACHMENT D-II


Table 1 Provider qualifications re Personal Care services

MSCan Individuals and/or Centers of Independent Living be added as qualified provider to help maintain continuity of care for Participant Directed care?

1) Individuals are already included in the qualified provider list.2) CILs will not be added as a qualified provider.

389


ATTACHMENT D-II

Exhibits 7, Page 65 of 114, Table 1

Table 1 Provider qualifications re Personal Care services

MSCan Individuals and/or Centers of Independent Living be added as qualified providers to help maintain continuity of care for Participant Directed care?

1) Individuals are already included in the qualified provider list.2) CILs will not be added as a qualified provider.

390


ATTACHMENT D-II


Table 1 Provider qualifications re Medication Management services

MS

Can Nurse (RN), Nurse Registry, and Home Health Agency be added as qualified provider types to help maintain continuity of care since other services include all 3 provider types (Nurse, HHA, and NR)?

Registered Nurse is already included in the qualified provider list.Nurse Registries and Home Health Agencies will be allowed as qualified provider types for Medication Management services. Individuals providing service through the Nurse Registry or Home Health Agency must be a Registered Nurse or Licensed Practical Nurse.

391


ATTACHMENT D-II


Table 1 Provider qualifications re Medication Administration services

MSCan Nurse Registry and Home Health Agency be added as qualified provider to help maintain continuity of care since other services include all 3 provider types (Nurse, HHA, and NR)?

Nurse Registries and Home Health Agencies will be allowed as qualified provider types for Medication Administration services. Individuals providing service through the Nurse Registry or Home Health Agency must be a Registered Nurse or Licensed Practical Nurse. Please see Addendum No. 2, Item #9.

392


ATTACHMENT D-II


Table 1 Provider qualifications re Nutritional Assessment and Risk Reduction


Qualified providers for Nutritional Assessment and Risk Reduction services are: Community Care for the Elderly provider; dietician/nutritionalist or nutrition counselor or other health care professional practicing within the legal scope of their practice. These providers meet the standards designated under the LTC MC program.



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ATTACHMENT D-II


Table 1 Provider qualifications re Medication Administration services


Nurse Registries and Home Health Agencies will be allowed as qualified provider types for Medication Administration services. Individuals providing service through the Nurse Registry or Home Health Agency must be a Registered Nurse or Licensed Practical Nurse. Please see Addendum No. 2, Item #9.

394


ATTACHMENT D-II


Table 1 Provider qualifications re Nutritional Assessment and Risk Reduction


Qualified providers for Nutritional Assessment and Risk Reduction services are: Community Care for the Elderly provider; dietician/nutritionalist or nutrition counselor or other health care professional practicing within the legal scope of their practice. These providers meet the standards designated under the LTC MC program.

395


ATTACHMENT D-II


Table 1 Provider qualifications re Intermittent and Skilled Nursing services

MSCan Nurse Registry and Nurse be added as qualified provider to help maintain continuity of care since other services include all 3 provider types (Nurse, HHA, and NR)?

Nurse Registry and Nurse will not be added as qualified provider types for the purpose of this ITN. Nurse Registries and Nurses may be allowed by the State on a case by case basis during the plan readiness phase and subsequent to contract execution.

396


ATTACHMENT D-II


Table 1 Provider qualifications re Intermittent and Skilled Nursing services

MSCan Nurse Registry and Nurse be added as qualified provider to help maintain continuity of care since other services include all 3 provider types (Nurse, HHA, and NR)?

Nurse Registry and Nurse will not be added as qualified provider types for the purpose of this ITN. Nurse Registries and Nurses may be allowed by the State on a case by case basis during the plan readiness phase and subsequent to contract execution.

397


ATTACHMENT D-II


Table 1 Provider qualifications re Caregiver Training services

MSCan Nurse Registry be added as qualified provider to help maintain continuity of care since other services include all 3 provider types (Nurse, HHA, and NR)?

Qualified providers for Caregiver Training services are: Community Care for the Elderly provider; clinical social worker; mental health counselor; registered nurse; licensed practical nurse or a home health agency. These providers meet the standards designated under the LTC MC program.

398


ATTACHMENT D-II


Table 1 Provider qualifications re Caregiver Training services

MSCan Nurse Registry be added as qualified provider to help maintain continuity of care since other services include all 3 provider types (Nurse, HHA, and NR)?

Qualified providers for Caregiver Training services are: Community Care for the Elderly provider; clinical social worker; mental health counselor; registered nurse; licensed practical nurse or a home health agency. These providers meet the standards designated under the LTC MC program.



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ATTACHMENT D-II


Table 1 Provider qualifications re all Therapies (Occupational, Physical, Respiratory, Speech)

MSCan Nurse Registry, Adult Day Care Center, and Skilled Nursing Facility be added in of the patient centered approach and continuity of care?

Nurse Registries, Adult Day Health Care Centers, and Skilled Nursing Facilities will not be added as qualified provider types.

400


ATTACHMENT D-II


Table 1 Provider qualifications re all Therapies (Occupational, Physical, Respiratory, Speech)

MSCan Nurse Registry, Adult Day Care Center, and Skilled Nursing Facility provider types be added to the patient centered approach to promote continuity of care?


401


ATTACHMENT D-II


Table 1 Provider qualifications re Medication Management services

MS

Can Nurse(RN), Nurse Registry, and Home Health Agency be added as qualified provider to help maintain continuity of care since other services include all 3 provider types (Nurse, HHA, and NR)?

Registered Nurse is already included in the qualified provider list.Nurse Registries and Home Health Agencies will be allowed as qualified provider types for Medication Management services. Individuals providing service through the Nurse Registry or Home Health Agency must be a Registered Nurse or Licensed Practical Nurse.

402



MS Can Nursing Homes and Adult Family Home be deemed as qualified providers under 429.02?

Section 429.02, F.S., defines general terms used in the assisted living facility licensure program. For the Long-Term Care Managed Care program, Chapter 409, Part IV, F. S., and the waiver program application details provider qualifications for each service. Nursing Homes and Adult Family Homes are listed as qualified providers for various services in the waiver application.



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403


ATTACHMENT D-II

Page 66 of 114 Table 1

Table 1 Provider Qualifications Occupational, Physical, Respiratory and Speech Therapies

MS Can Skilled Nursing and Adult Day Care be deemed a qualified provider for these services?


404

WellCare of Florida ATTACHMENT D-II Exhibit 5 N/A MS

Can the health plan require that the participant/direct service worker incur the cost of the background screen prior to employment?

The MCP can require that the direct service worker incur the cost of the background screening prior to employment. However, the MCP cannot require the participant to incur the cost of the background screening for the direct service workers or representative.

405

WellCare of Florida ATTACHMENT C Exhibit 5Aging Network Service Provider List

MSCan you please provide the Aging Network Service Provider List to in Excel format with the Medicaid # and address (including city, state, and zip) added for each facility?


406


Section IV. Item A.6.d Provider Directory

MS

Could you please provide more detail about what is expected related to the statement “The online provider directory shall also have the capability to compare the availability of providers to network adequacy standards and accept and display feedback from each provider’s patients” For example, how would we compare the availability of providers to network adequacy standards? What is the expectation around the display of feedback from each provider's patients? When will the detailed requirements of the web portal be available?

The Respondent may use its discretion and this will be reviewed by the Agency as a part of plan readiness.



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407

WellCare of Florida ATTACHMENT D-II Exhibit 7 Table 1 MS

Do support coordination agencies currently certified to provide support coordination services to individuals in the Developmental Disabilities Home and Community Based Services Waivers meet standards to provide case management as a Case Management Agency if all of their employees providing case management services meet the education, training and experience requirements for case managers employed or contracted by a LTC plan? What are the standards that DOEA will use in determining which case management agencies meet 'comparable standards' to be qualified to provide services as a case management agency?

Any entity providing case management must employ case management supervisors and case managers who meet the qualifications listed in the ITN. This is the standard by which all case management agencies will be evaluated. The case managers must meet all qualifications as specified in Attachment D-II, Exhibit 5, Section V, Covered Services, Item I., Care Coordination/Case Management.

408


Section III Item A.3 Excluded Populations

MS

Do the excluded 'recipients residing in residential commitment facilities operated by DJJ or mental health facilities' include those residing in Residential Treatment Facilities licensed under Section 408, F.S., who would otherwise meet eligibility requirements for the LTC component of the SMMC?

Since individuals residing in residential treatment facilities operated through other agencies or programs are not excluded from mandatory enrollment in Section 409.972, F. S., these residents would be mandatory for enrollment provided the residents were otherwise qualified for the program.

409

WellCare of Florida ATTACHMENT D-II Exhibit 5 5.D Assisted

Living MSDoes AHCA ever license ALFs that do not have home-like characteristics as defined within this ITN? Should we defer contracting with these ALFs for purposes of this program?

Currently, Florida’s Assisted Living Facilities (ALFs) licensure requirements do not specifically require facilities to meet all of home-like characteristics required by the Centers for Medicare and Medicaid Services. Managed Care Plans (MCPs) will need to contract with ALFs that agree to meet these home-like characteristics initially and continuously throughout the contract period. Failure to adhere to these requirements will subject the MCP to sanctions.

410


Qualifications and Experience #1

MS

Evaluation Criteria for Qualifications and Experience require disclosure of any instances of failure to meet HEDIS or contract-required quality standards. Does this only refer to HEDIS measures applicable to the eligible population?

For the purpose of this procurement, respondents must submit information related to all current or previous contracts. Responses should not be restricted to a specific contract for a particular population.



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411


ATTACHMENT D-II 5

Section V. Covered Services, Item I, Care Coordination/Case Management, 5.b.(1), 33 of 114; and Table I, Case Management, 62 of 114

MS

First reference says "The Managed Care Plan shall ensure that case manager caseloads do not exceed a ratio of 60 enrollees to one case manager for enrollees that reside in the community and no more than a ratio of 100 enrollees to one case manager for enrollees that reside in a nursing facility. " Second reference says "Each case manager's caseload may not exceed 60." There appears to be a discrepancy. Please confirm that the second reference should also reflect the different ratio for enrollees residing in a nursing facility (1:100).

The first reference is correct. The second reference refers to Urban Counties and Rural Counties in the table and is not referencing nursing facilities.

412

Amerigroup Florida GENERAL MS

Florida statute 409.978 provides that the program should include incentives for the delivery of services in the most appropriate setting. Where have these incentives been included in the ITN and how will respondents be evaluated relative to these requirements?

Section 409.978, F. S., does not reference incentives for delivery of services in the most appropriate setting.

Section 409.983, F.S., specifies adjustments that must be made in the capitated rates to provide incentives for and encouragement to increase utilization of home and community based services and reduce institutional placement. See Addendum #1, Item #2 for information on the rate setting methodology.



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413


Section VII, Item B.5 Network Standards

MS

For HCBS services, the following statement is made: "Unless otherwise provided in this Contract or authorized by the Agency, the Managed Care Plan shall ensure that each county in a region has at least two (2) providers available to deliver each covered HCBS. For HCBS provided in an enrollee’s place of residence, the provider does not need to be located in the county of the enrollee’s residence but must be willing and able to serve residents of that county. For adult day health care, the service provider does not have to be located in the enrollee’s county of residence, but must meet the access standards for adult day health care specified in Item G. below." However, in Table 1 that outlines the requirements for each HCBS service, it indicates that we must have two providers serving each county. Therefore, can you please clarify whether the two required providers must be in the county or if they can be willing to serve the county?

Providers do not have to be located within the county being served as long as they are willing (and authorized by license or network contract and other required documents as applicable) to serve the county in question, with the exception of Assisted Living, Assistive Care, and Nursing Facility services. These providers must be located within the county. Table 1 states the waiver authority minimum requirement of two providers per county. However, the b/c waiver authority may allow for exceptions when proposed by respondents and evaluated by the state on a regional level on a case by case basis, depending on the availability of service providers unique to each region.

414


Section VII, Item G Appointment Waiting Times and Geographic Standards

MSFor network development purposes, during the response period is there a process that we should follow to document the need for contiguous counties or a "no available provider" exception?

No. The process will be provided as a part of plan readiness. The minimum federal requirement for choice of providers according to the Centers for Medicare and Medicaid Services is for two providers per specialty per county. The Agency will require that Managed Care Plans submit their full listing of network service providers to be evaluated during the pre-implementation plan readiness review process.

415

WellCare of Florida ATTACHMENT D-II

Exhibit 6 - Behavioral Health N/A MS

Given that there may be multiple plans for similar providers in any one county, which could create redundancy in training, can there be a shared responsibility and/or can training requirements be met by providing webinars?

Collaborative training for community service providers is beneficial for supporting the provision of quality services. However, for purposes of responding to this ITN, the respondent must be able to describe and demonstrate how it will develop and provide behavioral health procedures training to applicable service providers.

416

Allied Health Care Solutions ATTACHMENT C NA Qualification of

Plan Eligibility MS

HELLO, WE RECEIVED THIS OFFER TO BID IN OUR INBOX, I WOULD LIKE TO KNOW IF THIS IS MEANT FOR MANGED CARE COMPANIES LIKE AMERIGROUP/TANGO ETC OR IS THIS FOE END SERVICE PROVIDERS SUCH AS MYSELF. WE ARE A NURSE REGISTRY, AND PROVIDE IN HOME CARE TO MEDICAID WAIVER CLIENTS.

This procurement is intended for managed care plans as defined in Attachment D-I, Scope of Services, Long-Term Care (LTC) Managed Care Plans.



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417

Humana ATTACHMENT D-II C.2

Satisfaction and Experience Surveys

MS

Historically the State has provided contractors with the methodology and a template of a survey that we could use or expand upon, will the State continue to provide a tool/methodology based on the new requirements, or will each contractor have to develop the tool and the methodology?

Please see Attachment D-II, Section VIII, A, p. 90

418

Amerigroup Florida ATTACHMENT C MS

How will AHCA evaluate the provider network for vendors who win one region and are awarded additional regions where they are not operational? Will contracted providers and letters of intent be valued equally?

As specified in Attachment C.19, the Agency shall award one (1) additional region to each Vendor who receives a Region 1 or Region 2 contract award. The Vendor shall submit its region preference for the additional award. The Agency shall award the additional contract in the Vendor's highest desired region of preference in which the Vendor submitted a responsive reply and negotiates a rate acceptable to the Agency. For the Network Contracts and Agreements Exhibit found in Attachment E-I Contracted providers and letters of intent will be valued equally during the evaluation of responses.

419

Universal Health Care ATTACHMENT C Exhibit 5 NA MS

I work in the Medicaid Department at Universal Health Care. I have been reviewing all of the Region documents and was wondering if you all had a spreadsheet of all of the providers listed in the Statewide Medicaid Managed Care (SMMC) – Long Term Care (LTC) – Regions 4 through 11. I look forward to hearing from you.


420

WellCare of Florida ATTACHMENT E Exhibit 1 N/A MS

If providers are on existing plan contracts, and will need to be updated for long term care regulatory contract requirements, will they be accepted in the ITN response for network adequacy, under the condition that they will be updated by readiness review if a contract award is received?


421

UnitedHealthcare of Florida, Inc. General N/A Network MS

If the Health Plan has a Provider Network Agreement Template that needs review and approval in an effort to contract the network in advance of the ITN submission, who should the template be submitted to and what will the turn around time be for review and approval?

This question is out of the scope of this ITN. The Agency will not be reviewing or approving templates prior to the ITN award.



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422

SIMPLY ATTACHMENT C NASection C.19 Number of Awards

MS If there is no LTC PSN provider awarded in a region, will the Agency award an additional plan?

As specified in s. 409.981(2), F.S., if no provider service network submits a responsive bid in a region other than Region 1 or Region 2, the agency shall procure no more than one less than the maximum number of eligible plans permitted in that region. Within 12 months after the initial invitation to negotiate, the agency shall attempt to procure a provider service network.

423


ATTACHMENT C 5

Aging Network Service Provider List, page 38 of 165

MS

If we are offering expanded benefits (i.e., dental and vision), and these are provided through a contracted benefit manager, please confirm that we do not need to offer contracts to the dentists and optometrists in the exhibit since they would be for expanded and not covered services?

If a Managed Care Plan offers expanded benefits, there must be a contracted network provider available to support those extra benefits

424

Humana ATTACHMENT C C.46

Other Required Documentation - Exhibit 4

MS

In regards to Statutorily Required Providers, we understand the listing provided in Exhibit #4, Aging Network Service Providers, contains a list of providers who may not be qualified for the new SMMLTC program or existing waiver program. Can the State please provide:

1. A listing of provider qualification criteria for the previous program and2. How that criteria has changed for the new program.

The list of Aging Network Service Providers was obtained from the Florida Medicaid Management Information System (FMMIS) and from the Nursing Home Diversion plans, who provided their current list of network service providers. Provider criteria for existing waivers are available in waiver coverage and limitations handbook or in the contracts for the Nursing Home Diversion and Channeling waiver programs. All service providers must be in good standing with the Florida Medicaid program.

425


In the ITN SNF, AFCH, and ALF provider categories are required to have one licensed bed for each enrollee in applicable max enrollment. This many licensed beds may not exist in a region, and we would not expect 100% of the max enrollment of members to require a bed at any given time. Can you please clarify the requirement? Would the Agency be open to a reduction in the requirement based on a more realistic estimate of enrollees needing licensed nursing facility beds as reflected in the data book?




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426

WellCare of Florida General N/A N/A MS

In the Managed Long Term Care technical advisory panel meetings earlier this year, it was undetermined whether plans would be responsible for Medicaid-pending individuals residing in a nursing home. Has the Agency made a determination or decision regarding Medicaid-pending status of those individuals versus those in the community?

Based on the recommendation of the long-term care managed care technical advisory workgroup, the Agency for Health Care Administration in cooperation with the Department of Elder Affairs agreed to implement Medicaid Pending for individuals in the community. These are individuals who would be at risk of institutionalization if they were unable to receive home and community-based services during the Medicaid financial eligibility process. Medicaid Pending will not be implemented in the nursing facility setting, because these individuals are already receiving necessary care during the Medicaid eligibility determination process.

427WellCare of Florida ATTACHMENT D-

II Exhibit 5 E. MS Is it permissible for the health plan to use one standard fee schedule for all participant-delivered services?

Yes, it is permissible for the MCP to use one standard fee schedule for all Participant Directed Option services.

428

SIMPLY ATTACHMENT C Exhibit 4Aging Network Service Provider List

MSIs the Agency's expectation that where appropriate, the respondent should "offer" a contract with the providers on this list? How is "offered demonstrated?

Section 409.982(1) provides that while plans selected to participate in the LTC component of the SMMC program may limit the providers in their networks based on credentials, quality indicators, and price, they are required to offer network contracts to certain providers in their region for the period of October 1, 2013 through September 30, 2014. Offers may be demonstrated by the submission of written correspondence from the MCP to aging network service providers.

429


ATTACHMENT D-II 7

TABLE 1, Assisted Living Facility, Adult Family Care Home (AFCH), and Nursing Facility Care, pages 60 and 65 of 114

MSIs the bed count requirement rolled up to a single number of beds as a total for all facility types or does each type have the bed requirement at the max enrollment?

This requirement is being amended. Please see Addendum No. 2, Item #9.



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Question #4: Qualifications and Experience

MS

Is the State interested only in direct care experience, etc. for executive managers, or is management and program administration experience considered of equal relevance in evaluation?

Experience to be considered includes both direct care experience and administrative management experience related to serving this population.

431


It appears that the ITN requirements are based on the current CDC+ program requirements. Will the recommendations from the Consumer-Directed Care Plans Program Evaluation, 2011, be incorporated into manual & procedures?

Yes, the recommendations from the Consumer-Directed Care Plus Program Evaluation, 2011 are being considered to be incorporated into the Manuals and procedures for the Participant Directed Option.

432


ATTACHMENT D-II and M

Exh 3 and Data Book

Medicaid Pending for HCBS

MS

Medicaid Pending is listed as a mandatory enrollment group. Furthermore, the language in this section states that the "Managed Care Plan shall authorize and provide services". Section 6 of the Data Book states that plans are not required to provide services prior to enrollment in the plan. It further states that, "SMMC LTC plans that choose to render services to a potential member prior to enrollment will receive capitation payments for this individual for the retroactive enrollment period after the recipient is determined to be eligible".

Please clarify the difference and the process for determining someone Medicaid Pending for HCBS compared to someone Medicaid Pending NF. Who is responsible for the recipients Medicaid Pending in a NF?

Please clarify if this is a mandatory or optional population.

Please provide historical cost and utilization data for the Medicaid Pending population in the Data Book format.

Will there be a different rate for the Medicaid Pending population that reflects their true experience?

Managed Care LTC plans will be required to offer Medicaid Pending to potential members. It is optional for the member, but not the plan. 1) The procedures for Medicaid eligibility for nursing facility services will follow processes in the Medicaid Nursing Facility Services Handbook, which provides for retroactive Medicaid eligibility which is currently, and will continue to be, separate and apart from Medicaid pending as described in the ITN. Medicaid pending as described in this ITN does not currently, nor will it apply to the nursing facility services. Therefore, there is no responsible party for Medicaid Pending in a NF. 2) Please see Attachment D-II, Exhibit 3. 3) Historical cost and utilization data for the Medicaid Pending population is unavailable. 4) There will not be a different rate for the Medicaid pending population.



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American Eldercare, Inc.

ATTACHMENT E-1 2

Network Contracts and Agreements Facility Services

MS

On this chart it requests Medicaid Provider Number, but does not say 'If applicable'. As AHCA is aware, there are numerous providers that do not currently have a Medicaid provider number due to problems with the non-Medicaid provider process of obtaining a Medicaid Provider Number. Furthermore, as a MCO program, providers are not required to be a Medicaid Provider in order to participate as part of a MCO's network. If a provider in our network does not yet have a Medicaid Provider Number do we simply leave the section blank and, if so, will they still be properly accounted for?

If the provider does not have a Medicaid number, it is acceptable to leave this section blank.

434


Section 6 Participant Direction Option

MSPayment for Self-Direction appeared to be required to be direct deposit. If a Provider requests, will paper checks be allowed? If so, does the member receive the check or the provider?

No, paper checks will not be allowed.

435


Section III Item A.2.g. Voluntary Populations

MS

Please clarify eligibility for the voluntary enrollment of individuals who meet nursing facility level of care and are MEDS-AD eligible and enrolled in the DD waiver as well as those on the DD HCBS waitlist. Also, please clarify conflict between voluntary enrollment of MEDS-AD eligible DD waiver clients as required in D-II, Exhibit 3 A.2.g. and (1) the following excluded populations listed in Exhibit 3; I budget waiver (developmental disabilities waiver) and Developmental Disabilities (DD) waivers (Tiers 1-4), and (2) Appendix C in Attachment M which lists MEDS-AD DD waiver clients as an excluded population.

The Agency states that there is no conflict. For clarification see below: As specified in s. 409.972, F.S., certain Medicaid-eligible persons are exempt from mandatory managed care enrollment, but may voluntarily choose to participate. Individuals in other waivers who meet nursing facility level of care, including individuals designated as Medicaid for the Aged and Disabled (MEDS AD) category who are enrolled in the Developmental Disabilities (DD) waiver can voluntarily choose to disenroll from their current waiver to enroll in the Managed Long-Term Care Program. Medicaid eligibles on the DD HCBS waiting list can also choose to voluntarily enroll in the Managed Long-Term Care Program if they meet nursing facility level of care. Attachment M, Appendix C is consistent with the Attachment D-II, Exhibit 3 eligibility categories.



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Humana ATTACHMENT D-II NA

Section V, Covered Services, Item B, Expanded Benefits Page 29 of 114

MSPlease clarify if $15 is the total for all expanded benefits combined or a maximum of $15 per expanded benefit. Is the $15 plan cost or retail?

In Exhibit D-11, Section V, Covered Services, Item B, Expanded Benefits, the benefits offered by the MCP have no overall limits. However, if the MCP offers over the counter benefits, then this benefit is limited to $15.00 (retail) per member per month based upon plan costs for the service.

437


Please clarify requirements and timing for 'written approval from local AHCA office' for Assisted Living Facilities to provide Adult Day Care services under the LTC component of the SMMC. Although this requirement for 'written approval' applies to Adult Day Care services under the Nursing Home Diversion program, the Agency does not currently provide approval, but rather acknowledgement of ALF notification that Adult Day Care services will be provided by the ALF. Specifically, how must LTC plans demonstrate minimum network adequacy for Adult Day Care services for purposes of bid submission when these services will be provided by ALFs under the LTC component of the SMMC? When Assisted Living Facilities submit request "for letter to provide Adult Day Services" to AHCA there is approximately a 30 day turn around time for the provider to receive the confirmation letter. Are we able to accept a statement/attestation from an Assisted Living Facility stating they do Adult Day Care Services, in the event the Assisted Living Facility does not receive the letter back from the AHCA prior to the ITN submission?

Managed Care Plans (MCPs demonstrate minimum network adequacy for Adult Day Health Care services by requiring the assisted living facilities (ALFs) to contact the AHCA licensing office by email at [email protected] to request approval to offer adult day health care services. If the facility does not receive the requested approval letter within 5 business days, the facility should contact the Agency at (850) 412-4304 to speak with the program analyst assigned to the request. For the ITN response, a notarized statement from the assisted living facility attesting that adult day health care services are provided and AHCA approval is pending is sufficient. For successful bidders, the ALF approval letter must be provided along with the provider network during the plan readiness phase of program implementation.

438


Attachment E-1 Exhibits 2-3 Network Adequacy

Exhibit 3 - Network Contracts and Agreements Non-Facility Services

MS Please clarify the license requirements for an Assistive Care facility.

Assistive Care Services are provided in an assisted living facility licensed under Chapter 429, Part I, Florida Statutes, in an adult family care home licensed under Chapter 429, Part II, F.S., or under the Medicaid State Plan in residential treatment facilities licensed under Chapter 394, F.S. To be considered a qualified provider, all statutory and contractual requirements must be met.



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WellCare of Florida ATTACHMENT D-II N/A Section I.A

Definitions MSPlease explain the exclusion of Residential Treatment Facilities licensed under Chapter 408, F.S. from the definition of Residential Facility.

Although residential treatment facilities are licensed under Chapter 408, Florida’s Medicaid Managed Care program statute in Section 409.982(4), F. S., does not list residential treatment facilities as a required provider type to be included in the Long-Term Care Managed Care Plan’s provider network. Also in Section 409.972 (b), F. S., residents of residential treatment facilities operated by DJJ are exempt from mandatory enrollment in the Long-term Care Managed Care program.

440


ATTACHMENT D-II, Exhibits, Page 61 of 114

Attachment D-II, Exhibits, Page 61 of 114

MS Please provide a definition of the activities in the service "behavior management"

Behavior Management is defined as maximizing reduction of the enrollee’s disability and restoration to the best possible functional level and may include, but is not limited to: an evaluation of the origin and trigger of the presenting behavior; development of strategies to address the behavior; implementation of an intervention by the provider; and assistance for the caregiver in being able to intervene and maintain the improved behavior.

441 SIMPLY ATTACHMENT D-II NA Section II.D.12 MS Please provide an example of information or data that might be

requested under this provision of the contract.See Attachment D-II, Exhibit 12, Reporting Requirements, p. 80/114.

442

SIMPLY ATTACHMENT D-II NA Section

IV.A.2.a MS Please provide by region the languages that comprise more 5% or more of the language spoken in the region

Information on the languages spoken by the population in a county can be found at the following website:

http://www.city-data.com/states/Florida-Languages.html

443



Question 56 - XII Reporting Requirements

MSPlease specify the requirements (if any) for the attachment for this item.

There are no requirements for an attachment for this item. The respondent may use the attachment to provide additional responses at its discretion. Narrative response is limited to the size allotted.



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Question 35 - Section VIII Quality Management

MSPlease specify the requirements, if any, for the attachment for this item.

There are no requirements for an attachment for this item. The respondent may use the attachment to provide additional responses at its discretion. Narrative response is limited to the size allotted.

445

UnitedHealthcare of Florida, Inc. General N/A Network MS

Pursuant to Section 409.982(1), in order to offer a contract to all current aging network service providers, please provide the provider file in Excel with Provider and Tax ID numbers, and Medicaid ID numbers.


446


Section VIII, Question #38: Quality Management

MS

Question #38, of Attachment E-1, Section VIII references utilization management for long-term care. In general, we are accustomed to seeing references to utilization management relative to acute care services or medical benefits. Does the term "utilization management" as used in this context refer to the assessment of members needs for services and supports and the concurrent process to match member's needs to services or something else?

Utilization management of all Medicaid services is a requirement for LTC Plans. An effective UM program ensures that each enrollee receives all medically necessary services in the appropriate scope, amount, frequency and duration.

447

Sunshine State Health Plan

ATTACHMENT D-II NA

Section X, C.d.(2) Administration and Management, pages 106 of 168

MS

Regarding the phrase: "2) Within forty (40) calendar days after receipt of the claim, pay the claim …" Would AHCA please clarify that this standard applies to clean claims only per the definition of CLEAN CLAIM on page 8 of 168 in Attachment D-II (Section I)?

This sentence applies to all claims (not just clean claims): claims are either paid or the managed care plan must notify the provider that the claim is denied. Specifically, (2) relates to non-electronically submitted claims (section 641.3155 does not include clean claim but uses "all claims").

448


ATTACHMENT D-II NA

Section X, C.c.(3,) Administration and Management, pages 106-168

MS

Regarding the phrase: "3) Within twenty (20) calendar days after receipt of a non-nursing facility/non hospice claim, pay the claim or notify the provider …". Would AHCA please clarify that this standard applies to clean claims only per the definition of CLEAN CLAIM on page 8 of 168 in Attachment D-II (Section I)?

This sentence applies to all claims (not just clean claims): claims are either paid or the managed care plan must notify the provider that the claim is denied. Specifically, (3) relates to electronically submitted claims (section 641.3155 does not include clean claim but uses "all claims").



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X.C.2.d (2-3) MS

Section (2) speaks to paying the claim or notifying the provider that the claim is denied or contested within 40 days. Section (3) speaks to paying or denying the claim within 120 days after receipt. Please clarify the difference between section (2) and (3).

Attachment D-II, Section X, C.2.d., of this procurement provides claims processing specifications for all claims non-electronically submitted to the managed care plan. Section X, C.2.d.(2) provides that for all non-electronically submitted claims for services, the Managed Care Plan shall: (2) Within forty (40) calendar days after receipt of the claim, pay the claim or notify the provider or designee that the claim is denied or contested. The notification to the provider of a contested claim shall include an itemized list of additional information or documents necessary to process the claim.

450



X.C.2.c (3-4) MS

Section (3) speaks to paying the claim or notifying the provider that the claim or denied or contested within 20 days. Section (4) speaks to paying or denying the claim within 90 days after receipt. Please clarify the difference between section (3) and (4).

Attachment D-II, Section X, C.2.d., of this procurement provides claims processing specifications for all claims non-electronically submitted to the managed care plan. Section X, C.2.d.(2) provides that for all non-electronically submitted claims for services, the Managed Care Plan shall: (3) Pay or deny the claim within one hundred twenty (120) calendar days after receipt of the claim. Failure to pay or deny the claim within one hundred forty (140) calendar days after receipt of the claim creates an uncontestable obligation for the Managed Care Plan to pay the claim.

451

WellCare of Florida ATTACHMENT D-II Exhibit 5 C. MS

Since some of the members transitioned will be participating in CDC+ with budget authority and they will now be moved to more restrictive "employer authority"; how will the Agency account for negative feedback in the annual participant satisfaction survey related to that dissatisfaction?

The Agency may provide technical assistance in response to survey feedback and/or may implement policy changes.



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452


ATTACHMENT D-II Page 35 of 168

Section 2. C. Responsibilities of the State of Florida (state) (See Attachment D-II, Exhibit 2) 9.

MS

The Agency or its fiscal agent shall also reimburse non-participating FFS MMA and FFS LTC PSN providers on a FFS basis for authorized services. What fee schedule does the Agency or its fiscal agent use for this purpose? Are there reimbursement limitations?

The Agency uses the fee schedules and provider handbooks it uses for all Medicaid fee-for-service claims. There are no separate fee schedules or handbooks specifically for medical assistance or long-term care fee-for-service provider service networks.

453


The application to CMS contained a service definition for "financial management services" which was the mechanism to reimburse for the services required from the F/EA. Since financial management services appears to have been deleted from the ITN, please confirm that since the responsibility falls for implementation of PDO falls to care management that F/EA becomes a care management cost? Have the administrative costs incurred by the Department of Elder Affairs to administer the F/EA portion of the CDC+ Waiver been incorporated into the data book calculations?

Financial management services (FMS) is not a service offered in the Participant Directed Option (PDO), but an administrative activity. The costs for providing the F/EA service to participants will be incurred by the managed care plans. Administrative costs incurred by the Department of Elder Affairs were not included in the data book calculations.

454

WellCare of Florida ATTACHMENT D-II Exhibit 5 6.B. MS

The application to CMS contains both the Fiscal Employer Agent (F/EA) model and Employer of Choice option for PDO. Can you confirm that based on this section the only allowable option is the F/EA model for PDO?

Yes, the only allowable option for the Participant Directed Option (PDO) is the F/EA model.

455

WellCare of Florida ATTACHMENT D-II Exhibit 5 6.B. MS

The application to CMS contains both the Fiscal Employer Agent (F/EA) model and Employer of Choice option for PDO. Can you confirm that based on this section the only allowable option is the F/EA model for PDO?

Yes, the only allowable option for the PDO is the F/EA model.

456


Section V. Item A.5.c Assistive Care Services

MS

The definition for residential facility doesn't reference residential treatment facilities. Attachment D-II, Exhibit 5, Item C references residential treatment facilities. Can you please clarify?

The facility type was listed under Assistive Care Services because these services are provided in residential treatment facilities under the Medicaid state plan program. Residential treatment facilities are not part of LTC Medicaid Managed Care.



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N/ACore, 31. Provider Network.

MS

The evaluation criteria for this SRC/question provides "1. The extent to which the respondent's credentialing and recredentialing criteria and processes meet Contract requirements." and "2. The extent to which the respondent's criteria reflect NCQA standards, where applicable or standards of other relevant accrediting organizations." We do not understand the "NOTE" referencing "Elements of NCQA" contained in this credentialing section. Please provide clarification around the information in this "NOTE".

“The “Note” contained NCQA elements for the evaluator to use in reviewing ITN responses to this question, where applicable.”

458



N/ACore, 23. Covered Services.

MS

The evaluation criteria for this SRC/question provides "1. The extent to which the respondent's description addresses: (a) documentation requirements." Note that one of the documentation requirements is the inclusion of the CARES assessment in the plan of care. We are unable to ascertain how the Agency and/or the DOEA will ensure that health plans receive CARES assessment documentation. Please clarify and describe the process/method for ensuring that plans receive this documentation and in a timeframe that supports any underlying activities required of the health plan.

“The “Note” contained NCQA elements for the evaluator to use in reviewing ITN responses to this question, where applicable.”

459

WellCare of Florida ATTACHMENT E-1 N/A Qualifications/

Experience #2 MSThe evaluation scores plans on awards and certifications. Please describe relevant industry awards and certifications that would be considered applicable for Long Term Care.

Examples of awards and certifications include, but are not limited to, acknowledgements such as health care industry leadership awards, long term care management course completion/certification, long term care community service awards, professional education awards, health care association awards or quality management certifications.



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460

Amerigroup Florida GENERAL MS

The ITN appears to contemplate a medical model for the MLTC program and uses terminology consistent with acute care benefits such as "care plan" and management of services by medical need. It is our understanding that a substantial portion of the population will be eligible and will need services and supports to maintain their independence, but may not require medical management. Please clarify how bidders should respond to these distinctly different, but important elements of care and service planning. These populations may need more HCBS services in conjunction with acute care services. Does AHCA contemplate that there are separate tools for each of these components of care and service delivery? Typically, in the case of members needing HCBS we would develop a service plan versus a care plan to determine goals and supports to meet their objectives.

The plan of care for LTC MC recipients is an all-encompassing plan that includes all goals and supports to meet the individual's needs.

461


Section 6 Item J.3.m Care Planning Standard

MS

The ITN describes having to have the member sign the care plan each time a service changes. Can the Agency confirm if member signature is required for ad-hoc changes in hours related to acute illness or a change in natural support systems?

If the recipient is unable to sign the plan of care due to acute illness or a change in natural support systems, it may be possible for the caregiver to provide the authorization. If the recipient becomes able to sign at a later date, the plan may be signed after the change in services.

462

Humana ATTACHMENT D-I NA

C. Covered Services, #2 Approved Expanded Benefits

MSThe ITN mentions preventive dental and OTC as examples of expanded services. The table cited for Attachment D-1 does not include other services. Please clarify.

Attachment D-I, Table 1 will include the expanded services a LTC MCP submits as a part of their ITN response and that are approved by the Agency to provide to their enrollees once the contract is executed.

463

WellCare of Florida ATTACHMENT D-II Exhibit 5 W. MS

The ITN states "The Agency reserves the right to require subcontracting with a particular F/EA". When can we expect to be notified of this decision? When do you expect the health plan to be able to negotiate with the vendor for this service?

The Agency will not require subcontracting with a particular F/EA at this time. Therefore, the MCPs can negotiate with the vendors of their choice.



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464


Exhibit 5 - Aging Network Service Provider List

MSThe listing of Aging Network Service Providers does not contain street addresses. Can the Agency provide these addresses?


465

Amerigroup Florida ATTACHMENT D-II Exhibit 5

Section V.5: Caseload and Contact Management

MS

The requirements in Section V.5.b.1 stipulate case management caseload ratios. For example, some case managers will have some members in the community receiving HCBS services while others may have members in nursing facilities. We recommend that the case management ratio requirements reflect the levels of care and setting. Will AHCA allow a blended ratio consisted with blended caseloads to meet the requirements? Also, please clarify if AHCA will consider allowing the use of the interdisciplinary team to meet the case management caseload requirements?

The caseload for case management and case manager qualifications have been set out in the referenced section of the contract. An interdisciplinary team may be used if the lead case manager meets the qualifications and the team meets the caseload ratios.

466


ATTACHMENT D-II 7

TABLE 1, 66 AND 67 OF 114, Occupational Therapy, Physical Therapy, Respiratory Therapy, Speech Therapy

MS

These services are typically provided in the patient's facility or home. How should this be accounted for in the Geonetwork analysis? Should the SNFs or ALFs be listed as well as the home health agency if provided in a home setting?

If therapy services are provided in the enrollee's home of the facility in which the recipient resides, travel times are not required.

467

WellCare of Florida ATTACHMENT D-II Exhibit 5 Section V,

Item J, 4, d MS

This item states: “The case manager must ensure that the enrollee or representative understands that some long-term care services (such as home health nurse, home health aide or durable medical equipment (DME) must be prescribed by the PCP.” Could you please provide a comprehensive list of which covered services require a PCP prescription?

Medicaid state plan programs have provider handbooks describing the policy and procedures for state plan programs. Any listing would be very extensive. These handbooks may be found at: www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support and then Provider Handbooks.



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468

Humana ATTACHMENT D-II

Section II, C, 11-12

Responsibilities of the State of Florida(state),"

MS

This sections refers to a "lock-in period of twelve (12) consecutive months." Please clarify how the State impose a lock-in period on dual eligibles who, according to Federal law, have a continuous SEP?

Florida Medicaid is authorized by the Legislature to mandatorily assign and lock-in all populations eligible to enroll in the Managed Long-Term Care Program. Mandatorily enrolled Medicaid recipients are subject to lock-in requirements. SEP is applicable to Medicare enrollment, rather than Medicaid. Nothing in the Managed Long-Term Care Program will impact Medicare plan choice options.

469


We have been told that CCE Leads are current providers of Home Accessibility Adaptation Services under other Medicaid waiver programs. Is there a reason why CCE Leads are not an acceptable license type to provide Home Accessibility Adaptations under MLTC?

Home accessibility adaptations provider qualifications under the LTC MC waiver are independent contractors licensed by local city and/or county occupational license boards for the type of work performed or general contractors licensed under Section 489.131, Florida Statutes.

470

WorldNet Services Corp. General NA NA MS

What are you estimating the number of new qualified enrollees, by region, for the first year of the program who have been waiting for more than three (3) months for services?

This data is unavailable for consideration in ITN responses.

471WorldNet Services Corp.

ATTACHMENT D-II Exhibit 3 2. Voluntary

Populations MS What is historical data on number of voluntary participants by region?


472SIMPLY ATTACHMENT C NA

Section C.20 Transition Population

MS What percent of (total) by Region of LTC recipients are enrolled with a Health Plan today?


473


ATTACHMENT D-II


Table 1 Provider qualifications re homemaker and/or adult companion services

MSWhat section of Chapter 400, Part IX, F. S. is the authority for "Health Care Service Pools" to offer Homemaker and/or Adult Companion services to members?

Section 400.980 (1) (b), F. S., defines Health Care Service Pools as "…firms…or associations engaged for hire in the business of providing temporary employment …and agencies for… trained health care personnel ..without limitation, nursing assistants, nurse’s aides, and orderlies…".No specific statute authorizes Health Care Service Pools to provide homemaker and adult companion services.



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474


ATTACHMENT D-II


Table 1 Provider qualifications re homemaker and/or adult companion services

MSWhat section of Chapter 400, Part IX, F. S. is the authority for "Health Care Service Pools" to offer Homemaker and/or Adult Companion services to members?

Section 400.980 (1) (b), F. S., defines Health Care Service Pools as "…firms…or associations engaged for hire in the business of providing temporary employment …and agencies for… trained health care personnel ..without limitation, nursing assistants, nurse’s aides, and orderlies…".No specific statute authorizes Health Care Service Pools to provide homemaker and adult companion services.

475


ATTACHMENT D-II NA

Section XII Reporting Reqs, A. Managed Care Plan Reporting Requirements, 2. LTC Mgd Care Plan Report Guide

MSWhen will the actual LTC Report Guide be available? In the event that it has already been made available, please advise where Respondent's may locate it.

The Agency anticipates that the Long-Term Care Managed Care Report Guide will be available by February, 2013. The Agency's current Health Plan Report Guide can be found at the following link: http://ahca.myflorida.com/MCHQ/Managed_Health_Care/MHMO/med_prov_0912.shtml

476 WellCare of Florida General N/A N/A MS When will the Medicaid Long Term Care fee schedule be published and available for plan use?

The Medicaid fee schedule will be available prior to implementation of the LTC managed care program.

477WellCare of Florida ATTACHMENT E Exhibits 1, 2, and

3

Provider Network Spreadsheets

MS Where within the network adequacy report would you like for us to report number of beds? Please see Addendum No. 2, Item #9.

478

Amerigroup Florida ATTACHMENT C

Section C.20, Item 3: Enrollment Levels

MSWill AHCA please define the anticipated population by provider type as the capacity needs will be driven by the level of care needs of the enrollees.

The population to be served will include Medicaid recipients ages 18 and older residing in nursing facilities and in the home and community-based waiver programs specified in s. 409.979, F.S. The Long-Term Care Managed Care Data Book provides information on historical enrollment and Medicaid payment for this population.

479


Section III Item A.2.g. Voluntary Populations

MS

Will an individual on the DD HCBS waitlist who voluntarily enrolls in the SMMC and meets nursing facility level of care be placed on the SMMC LTC HCBS waitlist before being eligible to receive HCBS services?

As specified in s. 409.979(3), F.S., the Department of Elder Affairs shall make offers for enrollment to eligible individuals based on a wait-list prioritization and subject to availability of funds. This would also include individuals on the DD HCBS waitlist who wish to voluntarily enroll in the Long-Term Care Managed Care waiver program.



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480

WellCare of Florida General N/A N/A MS Will the bidders be provided with the State's fee schedules for HCBS services from 2008 - 2012?

Current fee schedules are available on-line through the following link: http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/Provider_ProviderSupport_FeeSchedules/tabId/44/Default.aspx

481WellCare of Florida ATTACHMENT D-

II Exhibit 5 Section VI MS Will the materials on the CDC+ website be revised for MLTC and when will they be available?

No. The materials which will be provided by the State are listed in the Contract. The MCPs are responsible for all other materials.

482

Freedom Health Plan

ATTACHMENT D-II Page 29 - 30

Section V Covered Services

MSWill the Plan have to pay for the services listed in the ITN and no other traditional Medicaid benefits? What about dental - vision or pharmacy or DME covered by traditional Medicaid

Managed Long-Term Care Plans will be responsible for providing all services specified in Attachment D-II, Exhibit 5, Covered Services - LTC Plans.

483

WellCare of Florida General N/A N/A MS

Would the Agency consider a process by which the plan would solicit bids for Home Accessibility Adaptation providers and subsequently pay the invoiced amount as an alternative to contracting?

Respondents must ensure that, for each service required by the ITN, there is a contracted network adequate to meet the needs of enrollees and that recipients have a choice of provider for each service. As long as successful bidders satisfy these requirements, MCPs may develop their own separate invoicing process for this service as a part of their service provider reimbursement process.

484


ATTACHMENT D-II NA

B. Community Outreach & Mktg 1. General Provisions

MS / DOEA Approximately how many community outreach events are expected per year?

This is at the discretion of the individual managed care plans.

485

Amerigroup Florida ATTACHMENT D-II Section II.D.4 MS / DOEA

Attachment D-II Section II.D.4 requires that the plan submit “all policies and procedures…and all other materials related to this Contract to the Agency for approval before implementation.” As the requirement for “all policies and procedures” and “all other materials” is very broad, and would span across hundreds of policies and other materials, will the Agency provide more specific guidance on the intent of this requirement? Is this limited to those materials and policies specifically related to provider and subcontractor agreements?

This requirement is for all documents as specified and is required to ensure the Agency and the Centers for Medicare and Medicaid Services that the vendor’s policies and procedures, standard letters and model contracts, etc., relative to the resulting contract have been reviewed for compliance with contract requirements prior to implementation.



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486

Amerigroup Florida ATTACHMENT D-II

Section VII.J.4.d MS / DOEA

Attachment D-II, Section VII.J.4.d requires the plan’s call center to have the capability to track call management metrics as defined for the plan’s Enrollee Services help line. Please confirm that the State’s intent is for the plans to calculate and report these metrics separately for the Provider Services line.

Managed care plans are required to collect and report these measures separately for the Provider Services line.

487


Section V. Item I.5.c Initial Contact

MS / DOEA

Based on the high volume of members expected during the launch of each region, how long will the Agency allow for completion of the initial face-to-face assessment? Will the Agency allow for the prioritization of non-facility based members in that process?

"An onsite visit to develop an individualized plan of care must be completed by the Managed Care Plan within five (5) business days of the enrollee’s effective date of enrollment for enrollees in the community (including ALFs) and within seven (7) business days of the effective date of enrollment for those enrolled in a nursing facility."

MCPs must develop an individualized plan of care within five business days of the enrollee's effective date of enrollment for enrollees in the community (including ALFs) and within seven business days of the effective date of enrollment for those enrolled in a nursing facility. MCPs may prioritize completing the initial face-to-face visits in any manner they see fit, as long as they are completed within the timeframes expressed in contract and above.

488

Coventry Health Care of Florida General na na MS / DOEA

Can AHCA make available CARES data for the current population in order to understand at a region level the specific ADL and other clinical deficits?

There is limited data available on this topic for the purpose of ITN responses. Available data may be found at http://elderaffairs.state.fl.us/doea/needs_assessment.php

489


ATTACHMENT D-II


Table 1 Provider qualifications re Medical Equipment & Supplies

MS / DOEA

Can you break out Consumable Medical Supplies provider qualification so that the "supplies only" qualified providers would match those in the Nursing Home Diversion Waiver so as to improve continuity and price competition?

Qualified providers for Medical Equipment and Supplies are: pharmacy; home health agency; and home medical equipment company. These providers meet the standard designated under the long-term care managed care program.

490

WorldNet Services Corp. General NA NA MS / DOEA

Can you explain planned claims transition from current status to MLTC program? Does MLTC plan liability begin with services incurred on or after plan enrollment date?

If a Managed Care Plan incurred claims pursuant to another Medicaid program/contract or line of business, the claims liability does not end on the MLTC enrollment date. Any claims received for authorized services provided during the span of a past Medicaid program shall be paid, assuming they were received in a timely fashion, as defined by law, contract, or applicable Rule. LTC MCP liability begins on the effective date of enrollment.



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491

Amerigroup Florida GENERAL MS / DOEA

Currently the Department of Elder Affairs (DOEA) operates the consumer direction program for certain populations who will be enrolled in the Managed Long-term Care (MLTC) program. Will the DOEA program continue to function as it does currently under the new program? Are plans expected to contract and/or collaborate with the DOEA program or is the expectoration that plans will deliver this service directly or contract directly for the services?

Plans are expected to deliver this service directly or contract with a fiscal employer agent.

492


ATTACHMENT E-1 3

Network Contracts and Agreements Non-Facility Services, 1 of 4

MS / DOEAFor Transportation, if we have a single vendor with multiple service providers, would this satisfy the two provider minimum count?

A single transportation vendor is acceptable, as long as the multiple individual service providers meet the provider qualifications specified in contract, and all are listed separately on the network report and provider directory.

493


General MS / DOEA How do plans demonstrate proof that contracts have been offered to existing aging service providers in a given region?

Offers may be demonstrated by the submission of written correspondence from the MCP to aging network service providers. This will be handled during Plan Readiness.

494


Section V, Item I.5.C Initial Contact

MS / DOEAIn response to the care management aspects of the ITN, can you tell us how the Agency Assessment Form will be provided to plans when we receive a new member?

The Department of Elder Affairs is developing a transfer process for the Agency Assessment Form.Successful bidders will receive this information during the plan readiness phase of the implementation of the program.

495


Section VII. Item I Credentialing and Recredentialing

MS / DOEA In terms of credentialing and recredentialing, is there a standard attestation the Agency would like for us to use?

No. The contract stipulates that specific elements must be included in the credentialing and recredentialing process. See Attachment D-II, Section VII, Provider Network, Item I., Credentialing and Recredentialing, p. 76/168; and Attachment D-II, Exhibits, Section VII, Provider Network, Item I., Credentialing and Recredentialing, p. 58/114.

496


Section V Item B Expanded Benefits

MS / DOEA Is there any limit for enhanced benefits offered? Will encounters for those enhanced benefits be allowed for submission?

Expanded benefit limits will be determined based on the particular expanded benefits offered by the managed care plan. For instance, the over-the counter drug expanded benefit is limited to $15 per enrollee, per month. Encounter data may be required for expanded benefits provided to enrollees.



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497

WellCare of Florida ATTACHMENT D-II Exhibit 2 4.E MS / DOEA

Paragraph E states the Agency will notify the plan if and when Medicaid-pending enrollees are determined eligible via the 834. Does this mean that the plans are not responsible for obtaining the NOA from DCF and sending it to the State?

Managed Care Plans (MCPs) are not responsible for sending the Notice of Case Action (NOCA) to the State. However, MCPs are responsible for obtaining the NOCA and retaining it in their records in order to track their enrollees ongoing Medicaid eligibility

498


section V. Item N.1 Monitoring of Care Coordination and Services

MS / DOEA

Please provide additional information regarding elements required by the Managed Care Plan to demonstrate inter-agency coordination (e.g., DOEA, AHCA) as it relates to the Case Management Program.

Examples of inter-agency interfacing shall include electronic and written reports and verbal communication required for coordination of care planning activities. See Attachment D-II, Exhibits, Item N.1, p. 46/114; Attachment D-II, Exhibits, Exhibit 12, Reporting Requirements.

499

Aetna Better Health of Florida General N/A N/A MS / DOEA

Presently, CARES are conducted through the DOEA and PASSRs conducted through DCF, Agency for Persons with Disability, or through a hospitals discharge planners or other staff, etc. The LTMC authorization legislation seems to indicate that these functions will continue through DOEA, but the ITN and its accompanying exhibits/attachments do not make solid references that CARES assessments will continue to be conducted by DOEA. Moreover, the legislation and the ITN and its accompanying exhibits/attachments are silent on who will be conducting PASSRs, i.e. existing agencies/hospitals or other vendors. Please provide clarification.

CARES will conduct all initial assessments for level of care determinations. No changes are anticipated for the PASRR processes currently in place.

500


Section V. Item J.5 Reassessment Standard

MS / DOEA

Reassessment standards here indicate that managed care plan quarterly reports must include 'enrollees requesting a fair hearing related to their level of care'. Please clarify the role of the LTC Managed Care Plan in completing level of care determinations, including enrollee requests for fair hearings related to State eligibility determinations.

If an enrollee makes a request for a fair hearing related to level of care or any matter known to the MCP, the MCP shall assist the enrollee in submitting the fair hearing request to the appropriate entity. The quarterly reports must document these instances related to level of care determinations. The LTC Managed Care Program does not complete level of care determinations, they complete assessments to be submitted to CARES which completes LOC determinations.



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501

SIMPLY General NA NA MS / DOEARegarding provider networks in rural counties, will the applicant be able to use providers of adjacent counties in the event a provider of a required type is not available in the county?

Attachment E, Regional Network Contracts and Agreements tool, states the minimum requirement of two providers per provider type per county. The Regional Network Contracts and Agreements tool is designed to provide Managed Care Plans with credit for establishing signed contracts or written agreements per 409.966(3)(a)7., F.S. During the plan readiness phase, as outlined in Attachment C, Exhibit 6, Managed Care Plans will be required to provide their complete provider network for evaluation by the Agency. Any exceptions to the two provider per county minimum requirement will be considered during the plan readiness phase.

502

WellCare of Florida ATTACHMENT D-II Exhibit 5 Section V,

Item J, 2 MS / DOEA

The requirement states: “The case manager must review and utilize Agency-required forms when completing the initial assessment of the enrollee and developing the initial plan of care.” Could you please provide a copy of the Agency-required forms for the initial assessment of the enrollee and developing the initial plan of care? Or is this item referencing an existing form like, the 701B?

The current state approved assessment form is the 701B. The 701B assessment form is available for reference at http://elderaffairs.state.fl.us/doea/forms/doea701b_sep08.pdf. The Agency reserves the right to change the assessment form in the future.



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503



N/A

Core, 20. Enrollee Services, Community Outreach and Marketing.

MS / DOEA

The SRC/questions provides that "The responded shall describe the resources it will dedicate to maintaining current on-line information about its provider network and providing hard copy information to enrollees in the timelines established by this ITN. This also includes how it will include performance indicators in its provider directory pursuant to s. 409.967(2)(c), F.S." Section 409.967(2)(c), F.S. provides that "(2) The agency shall establish such contract requirements as are necessary for the operation of the statewide managed care program. In addition to any other provisions the agency may deem necessary, the contract must require: (c) Access.—1. The agency shall establish specific standards for the number, type, and regional distribution of providers in managed care plan networks to ensure access to care for both adults and children. Each plan must maintain a region wide network of providers in sufficient numbers to meet the access standards for specific medical services for all recipients enrolled in the plan. The exclusive use of mail-order pharmacies may not be sufficient to meet network access standards. Consistent with the standards established by the agency, provider networks may include providers located outside the region. A plan may contract with a new hospital facility before the date the hospital becomes operational if the hospital has commenced construction, will be licensed and operational by January 1, 2013, and a final order has issued in any civil or administrative challenge. Each plan shall establish and maintain an accurate and complete electronic database of contracted providers, including information about licensure or registration, locations and hours of operation, specialty credentials and other certifications, specific performance indicators, and such other information as the agency deems necessary. The database must be available online to both the

Section 409.967 (2) (c), F. S. states in the third sentence the following “ Each plan shall establish and maintain an accurate and complete electronic database of contracted provider, including information about licensure, or registration, locations, and hours of operation, specialty credentials and other certifications, specific performance indicators and such other information as the agency deems necessary.



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504



Question 67 - Section VII - Provider Network

MS / DOEA

The submission requirements state that "the respondent shall provide a list of currently contracted network providers and copies of letters of agreement or letters of intent from providers who intend to join the network". Please confirm that no documents (such as first/last page of contract) are required to be submitted if the respondent has a contract with the provider.

The Regional Network Contracts and Agreements tool is designed to provide Managed Care Plans with credit for establishing signed contracts or written agreements per 409.966(3)(a)7., F.S. During the plan readiness phase, as outlined in Attachment C, Exhibit 6, Managed Care Plans will be required to provide their complete provider network. Details on what should be provided in order for the Agency to give credit for the contracts or agreements as part of the ITN, the instructions located in Attachment E-I, Exhibit 1 should be followed. For contracts, the instructions state to provide the signature page.

505


ATTACHMENT D-II NA

Section IV. A. Enrollee Services 2. Written Materials b.

MS / DOEA

This section requires the vendor to make materials available to foreign language speakers that make up at least 5% of the total population. 1) Does the total population refer to the region, county or entire state, and 2) Where can responding vendors obtain the inventory of the 5% foreign language speakers by total population?

1) By region. 2) Information on the languages spoken by the population in a county can be found at the following website:

http://www.city-data.com/states/Florida-Languages.html

506


Section VII, Item G.2 Appointment Waiting Times and Geographic Standards

MS / DOEA

What is an "other preferred location" as described in the statement "Therapy, facility-based hospice, and adult day health care services must be available within an average of thirty minutes from an enrollee's residence or other preferred location within the region."

The "other preferred location" describes a preference the enrollee may have for provision of these services, if available in another location. This location may be more convenient for the enrollee.

507


ATTACHMENT D-II Exhibit 3 4.e MS / DOEA

What is historical data on the number of participants in the Medicaid pending program not meeting Medicaid eligibility by region?


508

Coventry Health Care of Florida General na na MS / DOEA

What, if any, is the process around distributing slots? Are slots a constraint on placing and maintaining someone in the community or is the Plan allowed to construct the most appropriate benefit regardless of legacy waiver slots?

Managed Care Plans (MCPs) will be able to transition appropriate plan members residing in nursing facilities into the HCBS setting by notifying AHCA on their monthly Nursing Facility Transfer Report without being constrained by legacy waiver slots.



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509


Section VIII, Item C. Transition of Care

MS / DOEA

Will AHCA be providing historical member authorization or patient care information to assist with the transition of membership? What form will that take, and what would the timing be for that information?

The state will require existing providers to share information regarding an enrollee's care to ensure a smooth transition and effective coordination and continuity of care.

510


Section VIII, Item C. Transition of Care

MS / DOEA

Will the AHCA be providing historical member authorization or patient care information to assist with the transition of members into the plan? What form will that take, and what would the timing be for that information?

DUPLICATE QUESTION

511

Amerigroup Florida ATTACHMENT D-II Exhibit 5

Section H. Quality Enhancements

MS / DOEA Will vendors be allowed the flexibility to develop or refine the noted quality enhancements for enrollees?

Vendors may refine or expand on the Quality Enhancements with the approval and guidance of the Agency.

512


ATTACHMENT D-II 5

Section V, Covered Services, Item A., Covered Services, 6.b. Participant Direction Option, 19 of 114

MS / LegalCan AHCA provide a list of approved fiscal intermediary vendors? Would AHCA also allow plans to use the state portal similar to the CDC+ program?

AHCA will not provide a list of F/EA vendors. All F/EA vendors must meet the requirements outlined in the Contract. The current portal established by the Department of Elder Affairs (DOEA) is used by current Consumer Directed Care Plus program participants to report their service provider time for reimbursement purposes. Under the Long-Term Care Managed Care program, Managed Care Plans (MCPs) will be responsible for establishing their own reimbursement reporting system completely separate from the current state program portal.

513


Section V, Question #57: Covered Services

MS / Legal

Please clarify the following regarding Question #57: •Please define administrative contract vs. service contract as used in question #57. •Please clarify if only direct subcontractors of the respondent are to be reported for this requirement.

(a) Service contracts reference the contracts a health plan has with service providers that are responsible for providing direct services to enrollees. Administrative contracts reference the contracts a health plan has with entities that are not responsible for providing direct services to enrollees, such as a fiscal employer agent, claims processing agent, or risk management company. (b) Question #57 clarifies how the Respondent may limit its response. Respondent may limit this response to subcontractors to which it expects to make payments of $25,000 or more in one year.



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514


ATTACHMENT D-II Exh 5

Caseload and Contact Management

MS / MPA

Please confirm that the case manager caseloads of 60:1 and 100:1 for HCBS and NF respectively are consistent with historical practice and the full cost of these caseloads is reflected in the data book. If this is not the case, please confirm the adjustment to be made in the rate ranges to be published.

This data is unavailable for consideration in ITN responses. Rate changes are not anticipated.

515

WellCare of Florida ATTACHMENT C N/A C.46 MS/DOEAIs there any "other documentation" that the Agency will need on record that the MCO has offered contracts to the statutorily required providers?

Offers may be demonstrated by the submission of written correspondence from the MCP to aging network service providers. This will be handled during Plan Readiness

516


ATTACHMENT D-II 15 SECTION

XV.G.2.d Operations

This section speaks to liens against the proceeds of a third party resource and prorating the amount due to Medicaid to satisfy the lien. How will the Agency will prorate funds to due to the Managed Care Plan? Will the state be receiving all funds from the liable third party and then disbursing funds or allowing the liable third party to disburse funds directly to the Managed Care Plan?


517

Aetna Better Health of Florida General NA NA Procureme

nt

The hyperlink http://devahca/Procurements/index.shtml provided throughout the ITN is not an active link. Could the AHCA please provide an active link to the additional documentation mentioned throughout the ITN?

The corrected link is: http://ahca.myflorida.com/Procurements/index.shtml. See addendum No. 1, Item #1



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

CITE REFERENCE


518

Amerigroup Florida ATTACHMENT E

Section E.2: Review of Provider Comments

Procurement

Please clarify the following regarding Attachment E, Section E.2: Review of Provider Comments:

•Please describe the process for the review and scoring of provider comments received during the comment period. How will providers be identified -- for example, will they be rolled up to the Provider ID# or Employer ID# or some other mechanism? •Will comments be viewed in aggregate or parsed by provider type or service? •How long will providers have to post comments after AHCA publishes the list of respondents? •Please clarify if health plan are permitted to reach out to providers to request they submit comments regarding the health plan, as part of the procurement process?

While we understand the objective to incorporate provider comments into the consideration of awards per FSA 7107 , we believe the process defined could lead to unintended consequences or significant adverse comments without achieving a balanced and effective view of the health plan or organization.

Utilizing the formula published in Attachment E, Evaluation Criteria, the Agency will assign a score to each respondent based on the provider comments received.

Providers will be required to include their Medicaid Provider ID#, the Respondent's name for which their comment addresses, and the region in which their comments should be assigned in order for their comments to be considered. Providers may only make comments in relation to Respondents in their own region.

The Agency anticipates allowing at least ten (10) days for providers to comment. Comments will be scored in aggregate.

While the Agency does not encourage respondents to solicit comments from providers, the Agency can not prohibit this action.

519


Table of Contents

Procurement

Because there is not a way to create separate formats for headings and subheadings in the form fields provided, please indicate how the State would like respondents to satisfy this requirement.

Respondents must respond within the Agency allowed fields.

520Amerigroup Florida GENERAL Procureme

ntHow are the technical proposal scores weighted in the final assessment of whether the vendor will be invited to negotiate?

The weight factors are provided in Attachment E, Evaluation Criteria. There is no further weighting of the technical proposal scores.

521Humana ATTACHMENT E-

1 NA NA Procurement

Please provide Attachment E-1 in an editable format such as Microsoft Word or Excel.

The Agency has provided the version of the document which respondents are to utilize. See http://ahca.myflorida.com/Procurements/index.shtml.

522SIMPLY General NA NA Procureme

nt

Links to document (for example questions template and Cost Proposal Rate Sheets) appear not to link to a valid page/document

The corrected link is: http://ahca.myflorida.com/Procurements/index.shtml. See addendum No. 1, Item #1



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

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523


General Procurement

The requirement to provide client references doesn’t allow the listing of AHCA and DOEA which seems to favor multi-state HMOs, will any preference be given to plans with specific Florida experience?

The Agency has allowed for respondents to provide information regarding their past performance with AHCA and DOEA. See Attachment F, Past Performance – Client Reference Form, pages 5 through 8. No additional preference will be given to plans with specific Florida experience, unless otherwise identified in the ITN.

524


General Procurement

Many areas of the ITN require responses to be listed in the boxes provided, however, the format doesn’t allow data entry, are plans required to reproduce the document or will AHCA provide the ITN in a format that can be edited?

The working documents are provided for respondents to utilize at the following link: http://ahca.myflorida.com/Procurements/index.shtml

525

WellCare of Florida ATTACHMENT E N/A Section E.6 Procurement

Can the Agency provide any clarification or further guidance as to how evaluators will objectively determine a technical response on the Financials that is below average, average, above average and excellent?

The Agency utilizes a Certified Public Accountant to analyze the financial information submitted to determine if a company is financially stable based on several factors including a financial ratio analysis.

526

WellCare of Florida ATTACHMENT E-1 N/A N/A Procureme

nt

We have begun documenting in the Agency-provided response forms. The formatting appears to create challenges when trying to match the response with the evaluation criteria because the column spacing is not locked. Will the Agency consider alternative submission formats?

No.

527

WellCare of Florida ATTACHMENT E-1 N/A N/A Procureme

nt

Can you please confirm that one standard evaluation tool should be used for all Regions being submitted, and that an incremental evaluation tool should be submitted for each Region with only those questions that are different being addressed? For example, if qualifications and experience questions are all the same for eleven regions, but community outreach is different, than the community outreach questions would be the only questions answered in the Regional version.

Respondents must complete Attachment E-1, Submission Requirements and Evaluation Criteria Components in its entirety for each region that it is responding to. Respondents must include identical answers for all core submission requirements for each region.

528

Aetna Better Health of Florida ATTACHMENT A NA 16 Procureme

nt

We understand that any irregularity, technicality, or omission that materially, adversely impacts Respondent's compensation or scope of work would not be deemed "minor" under this Section 16. Is this correct?

Yes.

529

Aetna Better Health of Florida ATTACHMENT A NA 17 Procureme

nt

We understand that no contract shall be formed between respondent and Buyer until Buyer and respondent both sign the final Contract. Is this correct?

Yes



VENDOR NAMEITN


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530

Aetna Better Health of Florida ATTACHMENT A NA 9, 13th solid

bullet pointProcurement

We understand the possibility of punishment under law to be limited to intentional misrepresentations, rather than accidental oversights. Would it therefore be acceptable to insert the word "intentional" before the word "misstatement" in this bullet point?

No. This is not an Agency form. This form is maintained and required by the Florida Department of Management Services.

531

Aetna Better Health of Florida ATTACHMENT B NA 10 - Literature Procureme

nt Will AHCA provide an inventory of literature that is anticipated to be required, including format, languages, etc.?

This provision does not apply to this ITN. The Agency has described all literature requirements of the Vendor in the ITN.

532

Aetna Better Health of Florida ATTACHMENT C N/A C.45 Procureme

nt

The ITN indicates "A “Submission Requirements and Evaluation Criteria Components” (SRC) outlined in Attachment E-1, Submission Requirements and Evaluation Criteria Components, marked as “Core” must be identical for each Region in which the respondent submitted a reply. For timeliness of response evaluation, the Agency will evaluate each “Core” SRC once and transfer the score to each applicable Region’s evaluation score sheet(s). The SRC marked as “Regional” will be specific to each region and only apply to the Region identified in the ITN. The evaluation score will not be transferred to each Region’s score sheet(s).

In regard to the questions in Attachment E-1, would AHCA consider allowing Respondents to submit the responses to the CORE questions only once (i.e. with the ITN Response to Region 1) and for any other Regions it may be bidding submit only responses to the REGIONAL questions?

Respondents must complete Attachment E-1, Submission Requirements and Evaluation Criteria Components in its entirety for each region for which a response is provided. Respondents must include identical answers for all core submission requirements for each region.

533

Aetna Better Health of Florida ATTACHMENT C N/A

C.45.B - Financial Information

Procurement

This section calls for the submission of a Respondent's most recent 2 years of audited Financial Statements, etc. As we are a publicly traded company, 2 years of Financial Statements equate to over 350 pages. Given the limitation that Respondents' ITN Responses be contained within 2 Binders, would AHCA consider allowing Respondents to submit these required Financial Statements via CD-ROM only, rather than providing hard copies as well?

Yes, a respondent may include its audited financial statements on a CD. The response must clearly indicate that the financial statements are included on a CD as part of the submission. See Addendum No. 2, Item #2.

534


ATTACHMENT D-II General General Procureme

nt

Certain Exhibits in this Attachment state "N/A." Does this mean the exhibit is not applicable or does this mean that the exhibit is presently not available? If the latter, when does the Agency expect to provide the those exhibits presently marked with "N/A."

N/A indicates that the exhibit is not applicable.



VENDOR NAMEITN


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SECTION/SUBSECTION

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535

Amerigroup Florida ATTACHMENT B, Attachment H

Section 26, Section I.M.4

Procurement

Attachment B, Section 26 and Attachment H Section I.M.4 identify that the contract may be renewed, however Attachment C, Section C.21 identifies that the contract may not be renewed. Please confirm that per the order of preference in Attachment A, the contract is not subject to renewal.

The contract(s) may not be renewed, pursuant to 409.967(1), F.S.

536

Amerigroup Florida ATTACHMENT C Various

Section C.16 (Proposal Guarantees), C.24 (Performance Bonds, C.25 (Fidelity Bond)

Procurement

The ITN includes several requirements related to "guarantees" and other financial commitments that are "payable" to the State of Florida. Please explain how these guarantees should be accounted for and to what extent the funds will be returned to the bidders should they not be successful in the bid. Given that they are to be “payable” to the state of Florida seems to suggest that they involve actual cash / checks and not simply a “guarantee” of some sort. Please explain further.

Proposal guarantees must be submitted in either a cashier's check or bond made payable to the State of Florida. The Agency will return the proposal guarantee to the unsuccessful respondents upon execution of a legal contract with the successful respondents. See Attachment C, Special Conditions, Section C.16, Proposal Guarantee, third paragraph.

The Agency will return the proposal guarantees to the successful respondents upon the Agency receipt and approval of the respondents' performance bond(s).

537

Amerigroup Florida ATTACHMENT CSection B. Financial Information

Procurement

In several cases, the requirements under Section B require that the respondent "describe" or "demonstrate" such items as funding the insolvency protection account or surplus start up or surplus account. Where should Respondents include this material in the response?

The required documents may be submitted with the original copy and tabbed accordingly as an attachment.

538


Section C.45: General Instructions for Response Preparation and Submission

Procurement

Respondents are required to submit a total of 18 paper copies for each Region of interest. We recommend reducing the total number of paper copies as part of the submission requirements or allowing electronic submission, as this is the more environmentally responsible approach. This approach also decreases AHCA’s administrative burden; under the current requirement, AHCA will receive at least 198 total binders from every Respondent that chooses to bid on all 11 Regions.

Respondents must submit one paper original and 15 copies. See Addendum No. 2, Item #1



VENDOR NAMEITN


ATTACHMENT EXHIBIT


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539


Section C.45: General Instructions for Response Preparation and Submission

Procurement

ITN Attachment C, Section C.45 General Instructions for Response Preparation and Submission states that "any portion of the submitted response which is asserted to be exempt from disclosure under Chapter 119, Florida Statutes, shall be set forth on a page or pages separate from the rest of the submission." The requirement also states "The respondent shall also submit both a hard and an electronic redacted copy of the response suitable for release to the public in addition to the original and seventeen (17) copies." Are Respondents expected to separate pages marked as exempt from the rest of the response in un-redacted copies, and how should Respondents properly present this information (For example, include exempt pages in an envelope within the same binder as the rest of the response or a separate binder containing only exempt pages, etc.)?

The redacted version should not include any trade secret and/or proprietary information. This information should be omitted from the submission in its entirety in the redacted hard and electronic copies. The redacted version must be suitable for public release.

540

Amerigroup Florida ATTACHMENT C Section C.8 Procurement

Section C.8 prohibits any communication between the Agency and the respondents until 72 hours after the intent to award posting. Will the State consider clarifying that respondents with existing business obligations to the Agency are permitted to have communications with the Agency in the ordinary course of existing business?

The restriction on communications relates only to the procurement. Vendors with current business relationships are not prohibited from contacting the Agency regarding existing business relationship issues.

541

Coventry Health Care of Florida ATTACHMENT C C.24 Performance

BondProcurement

The ITN states if a vendor is awarded more than one region they will need to supply "one" performance bond for a total of $1M for each region. Please confirm that this performance bond can be adjusted for different enrollment start dates as well as different contract end dates.

Yes, awarded vendors may adjust the period of the performance bonds to be respective to their awarded regions.

542

Humana ATTACHMENT C C.

Past Performance - Client Reference

Procurement

The link provided to download Attachment F, Past Performance Client Reference Form, does not appear to be valid. Please provide an updated link.

The corrected link is: http://ahca.myflorida.com/Procurements/index.shtml. See Addendum No. 1, Item #1

543


ATTACHMENT C Pg. 19 C.45 Procurement

Are the 17 electronic copies in addition to the 17 manual copies?

Respondents must submit one original and 15 copies. See Addendum No. 2, Item #1



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

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544



In the event that an applicant is not awarded the contract, is the "Proposal Guarantee" returned to the applicant?

The Agency will return the proposal guarantee to the unsuccessful respondents upon execution of a legal contract with the successful respondents. See Attachment C, Special Conditions, Section C.16, Proposal Guarantee, third paragraph.

545


ATTACHMENT E Formatted Submission

Procurement What is the character limit for the responses of each question?

See Addendum No. 2, Item #18, Submission Requirement Component Character Space Allowance, attached hereto.

546



Procurement

For questions that require an attachment, such as the accreditation documentation required for question 1. Qualifications and Experience, should bidders place the tabbed, labeled attachments at the end of the response? Should attachments be placed in a separate binder?

Attachments to each response submission should be tabbed and labeled to correspond to each section and placed collectively in an “Attachments” section of their response. Responses are limited to two (2) binders. Respondents must work within that response submission allowance. See Addendum No. 2, Item #14.

547


C.45 General Instructions for Response Preparation and Submission

Procurement

When exempt, confidential or trade secret information consists of only a portion of a page, are bidder's required to identify specific text that is exempt, confidential or a trade secret? If so, how would that information be identified?

Any portion of the submitted response which is asserted to be exempt from disclosure under Chapter 119, Florida Statutes, shall be set forth on a page or pages separate from the rest of the submission. Each page of the portion(s) asserted to be exempt shall be clearly marked “exempt”, “confidential”, or “trade secret” (as applicable) and shall also contain the statutory basis for such claim on every page. Pages containing trade secrets shall be marked “trade secret as defined in Section 812.081, Florida Statutes”. Failure to segregate and identify such portions shall constitute a waiver of any claimed exemption and the Agency will provide such records in response to public records requests without notifying the respondent. Designating material simply as “proprietary” will not necessarily protect it from disclosure under Chapter 119, Florida Statutes.



VENDOR NAMEITN


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SECTION/SUBSECTION

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548



Procurement

Since the Attachment E-1 template provided has locked headers and white space, and the only areas that can be populated are inside specific cells, how should bidders include the proprietary indicator and the statutory basis for such claim on every page?

Any portion of the submitted response which is asserted to be exempt from disclosure under Chapter 119, Florida Statutes, shall be set forth on a page or pages separate from the rest of the submission. Each page of the portion(s) asserted to be exempt shall be clearly marked “exempt”, “confidential”, or “trade secret” (as applicable) and shall also contain the statutory basis for such claim on every page. Pages containing trade secrets shall be marked “trade secret as defined in Section 812.081, Florida Statutes”. Failure to segregate and identify such portions shall constitute a waiver of any claimed exemption and the Agency will provide such records in response to public records requests without notifying the respondent. Designating material simply as “proprietary” will not necessarily protect it from disclosure under Chapter 119, Florida Statutes.

549


C.45 General Instructions for Response Preparation and Submission, B. Financial Information

Procurement

For the mandatory items listed in 1 through 5, there are no related questions within Attachment E-1. Should bidders supply the documents requested as a separate attachment included at the end of the response, or is there another method the state would prefer bidder's use?

The required documents may be submitted with the original copy and tabbed accordingly as an attachment. Attachments to each response submission should be tabbed and labeled to correspond to each section and placed collectively in an “Attachments” section of their response. Responses are limited to two (2) binders. Respondents must work within that response submission allowance.

550

SIMPLY ATTACHMENT C NASection C.47 Provider Comments

Procurement In what way will the Agency consider provider comments?

Utilizing the formula published in Attachment E, Evaluation Criteria, the Agency will assign a score to each respondent based on the provider comments received.

551


ATTACHMENT D-II NA

Section X, E.5.c.(13), Administration and Management, pages 112 of 168

Procurement

CONSIDER - The URL listed at: http://apps.ahca.myflorida.com/dm_web/%20(S(xrohgczyhedzok1lq2bntiov))/default.aspx does not appear to exist or is not accessible on the web. Can AHCA provide correct URL or otherwise advise? Thank you!

The corrected link is: http://ahca.myflorida.com/Procurements/index.shtml. See Addendum 1, Item #1.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

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552


ATTACHMENT C NAC.15, Required Certifications

Procurement

The URL listed at the bottom of C.15: http://devahca/Procurements/index.shtml, does not appear to exist or is not accessible on the web. Can AHCA provide correct URL or otherwise advise?

The corrected link is: http://ahca.myflorida.com/Procurements/index.shtml. See Addendum No. 1, Item #1

553


ATTACHMENT C NA


Procurement

The ITN requires that responses be in 11 pt Arial font. Is it acceptable to use 8-10 pt font in tables, charts, and diagrams - for example, 11 point font in organizational charts, and various types of flowcharts and diagrams is fairly uncommon. In addition, tables that include numbers or that are structured to compare or group certain types of information in text are often more readable in 8-10 point Arial font.

Font no less than 8 pt is allowable for tables, charts, and diagrams in the attachments.

554


ATTACHMENT C and E-1 NA

Attachment C, ITN Response, page 19 of 165; C.45, General Instructions for Response Preparation and Submission; and E-1, VII - Provider Network, #67

Procurement

The ITN states that the response may not exceed 2 binders in length. The ITN also requires the most recent audited financial statements for the past 2 years; proforma financial statements for the first 3 years of the contract; and copies of provider lists for and LOIs obtained from all targeted providers. Given the potential volume associated with these submission requirements, would AHCA consider allowing bidders to submit these documents electronically on CD and outside of the two binder limit?

Yes, a respondent may include its audited financial statements on a CD. The response must clearly indicate that the financial statements are included on a CD as part of the submission.

No, LOIs may not be submitted on a CD.

555


ATTACHMENT D-1 Scope of Services

N/A 1. Plan Type Procurement

Are we required to complete TABLE 1 - LTC Plan Type? If so, where should it appear in our proposal response?

No. The Agency will complete this table upon contract award.

556

WellCare of Florida ATTACHMENT C N/A


Procurement

To the extent that there is content in the document that is trade secret is it correct to read that only one redacted copy should be submitted or should bidders also submit and original and 17 copies of the redacted version of the submission?

No. Only one hard copy and one electronic copy of the redacted response is required.

557WellCare of Florida ATTACHMENT C N/A Section C.16 Procureme

nt

Proposal Guarantee: Will one bid bond representing total number of regions we are applying be accepted or are individual bid bonds per region required?

Individual bid bonds per region are required.



VENDOR NAMEITN


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558

WellCare of Florida ATTACHMENT C N/A Section C.44 Procurement

Please confirm whether the following listed objectives are applicable to the services covered by the ITN: 2. (Environmental Considerations); 4. (Products Available from the Blind or Other Handicapped (RESPECT)); and 6. (Prison Rehabilitative Industries and Diversified Enterprises, Inc. (PRIDE)).

Yes, the are required.

559


ITN states the responses per Region should include an original and seventeen (17) duplicate paper copies and a redacted copy with the original set clearly marked and indicated as such. Further, the ITN states that plans may mark components which are core and others which are regional. The Core Components must be identical for each region in which the plan submits a reply. The Agency will only review the Core Components once and apply the corresponding score to each applicable region. Question: Must the Core Components (original and 17 copies) be submitted for each region in which the plan submits a reply?

Respondents must complete Attachment E-1, Submission Requirements and Evaluation Criteria Components in its entirety for each region for which it is responding. Respondents must include identical answers for all core submission requirements for each region.

560


Deadline for questions to AHCA is 7/6/12 to be sent electronically in required template as indicated in ITN to Issuing Officer (Barbara Vaughn); However, Voluntary Vendor’s Conference is scheduled for July 19, 2012 in Tallahassee. It is possible that additional, unanswered questions may arise as a result of information given to plans at the Vendor’s Conference. Will there be another opportunity for plans to submit written questions after the July 19th Vendor’s Conference?

Vendors may submit verbal and written questions during the vendor's conference; however, the Agency will only provide formal response to written questions.

561

WellCare of Florida ATTACHMENT CSection C.47 Provider Comments

Procurement

ITN indicates provider comments shall be submitted in writing by the Date/Time indicated in Section C.6 Solicitation Timeline and as outlined on the SMMC website. Please provide this Date/Time.

The Agency anticipates allowing at least ten (10) days for providers to comment.

562


Section XV, Item K. Performance Bond

Procurement

Performance Bond: Per attachment $1MM worth of bond is required per region in which HMO has been awarded contract. Can performance bonds be consolidated into a single bond for whichever regions are awarded?

Yes.

563

WorldNet Services Corp. ATTACHMENT C NA C.16 Procureme

nt Does the state have a standard proposal guarantee bond form?No. Proposal guarantees must be submitted in either a cashier's check or bond made payable to the State of Florida.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


SECTION/SUBSECTION

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564

WorldNet Services Corp. ATTACHMENT C NA C.45 Procureme

nt

In consideration of the number of binders – 1 original, 17 copies, 1 redacted copy – and environmental concerns, would AHCA consider making the response two-sided?

No.

565


ATTACHMENT D-II NA Section 7,

E.2.ffProcurement

Reference to Attachment D-II, Section X, Administration and Management, Item D. Encounter Data. Section 10 does not contain an item D?

Attachment D-11, Section X, Administration and Management does include Item D, on page 107.

566



N/A

Core, 2. Qualifications and Experience, c. and corresponding Evaluation Criteria 4.

Procurement / Legal

Certain SRCs/questions ask for the "Respondent" to describe certain "Qualifications and Experience" it possesses. In some of these circumstances it is appropriate for the vendor to provide a response/support for Qualifications/Experience that specifically address the Respondent's Qualifications/Experience; however, in other circumstances, it may be appropriate to reference the corresponding Qualifications/Experience of a primary subcontractor. The Evaluation Criteria for these types of questions seem to allow reference to parent companies and affiliates but reference to subcontractors is limited. Are Respondent's permitted to include information relative to Subcontractors in response to these Qualifications/Experience questions?

This submission requirement is referring the Respondent's experience and qualifications.

567

Aetna Better Health of Florida ATTACHMENT H 1 Section III.C Procureme

nt / Legal

Would any retroactive adjustment that materially, adversely impacts the Respondent be subject to the Respondent's written consent?

No.

568

Amerigroup Florida ATTACHMENT H Section III.A Procurement / Legal

Attachment H, Section III.A identifies the Agency’s termination rights under the contract, however, there are no termination rights identified for the Contractor. There are multiple sections throughout the ITN that reference events or actions that will occur if a Contract terminates the contract, including Attachment D-II, Section XVI.P, but there does not appear that there are any provisions that outline the Contractor’s termination rights. Will the Agency please provide clarification on the Contractors termination rights?

See Attachment D-II, Section XVI.P., Termination Procedures.

569


ATTACHMENT F Procurement / Legal

Please expand on the definition of the word Client. Is it the Payor under government contract, a provider under contract with a payor, or a recipient of services?

The “Client” would be the entity with which the Vendor (Respondent) entered into contract to provide agreed upon services to the client and/or the client’s customers (recipients/providers) and from which payment was received.



VENDOR NAMEITN


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570


Attachment H - Agency Standard Contract

Exhibit 1 - Business Associate Agreement

Procurement / Legal

Under HIPAA, health plans are considered "covered entities" as opposed to "business associates" and as such must comply with HIPAA's requirements for covered entities. Why is AHCA requiring each selected health plan under this ITN to sign a HIPAA Business Associate Agreement?

All entities who enter into Contract with the Agency and encounter Protected Health Information are required to sign the Agency's Business Associate Agreement.

571


ATTACHMENT F NA

Past Performance - Client Reference Form

Procurement / Legal

The ITN states that . .. "If a respondent cannot provide a maximum of three (3) Non-AHCA/DOEA client references, the respondent shall list DOEA and AHCA contracts (with names of applicable AHCA or DOEA Contract Managers). . ." The ITN further states that "The Agency will not use client references who are evaluators or negotiators for the ITN’s issued pursuant to s. 409.981, F.S. (2011). In the event AHCA cannot, after a reasonable effort, contact a contract manager or immediate supervisor of that contract manager for a listed contract where the respondent was a prime vendor for AHCA or DOEA and who is not an evaluator or negotiator as listed above, then the respondent will receive a score of zero (0) for that reference evaluation." We would appreciate AHCA considering an alternative that does not penalize bidders for matters beyond their control, such as not knowing which references are evaluators or negotiators, or due to the prohibition against discussing the ITN with Agency staff, not being able to confirm the contact's availability during the period of being contacted as a reference.

The Agency's approach will remain as stated in the ITN.

572

WellCare of Florida ATTACHMENT E N/AE.4 Past Performance Evaluation

Procurement / Legal

The ITN requires the submission of 3 references. Please confirm that these may include references related to the performance of a corporate parent, affiliate or subsidiary company.

No. Client references must be for the respondent and not their corporate parent, affiliate or subsidiary.



VENDOR NAMEITN


ATTACHMENT EXHIBIT


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573

Amerigroup Florida ATTACHMENT E-1 Question #5 Procureme

nt / MS

Question 5 includes an extensive amount of data required for each contract and yet, the maximum character count is the equivalent of 1 page. Is the character limit applied to each contract, or is it possible that additional space can be allocated to allow respondents to be fully responsive to the question?

The Agency's intent was not to limit the character space in each cell to describe one contract per cell. This particular submission requirement allows ten (10) text field cells which is the equivalent of ten (10) pages. The Agency has determined that one page equals 3,881 character spaces based on a page allowance of 8.5 x 11, Arial point 11 size font with 1 inch margins. The entire submission requirement allows for 38,810 character spaces combined.

574

Coventry Health Care of Florida ATTACHMENT C C.20 Enrollment

Levels

Please explain in detail how the initial auto assignment logic will work? Is the intent of the logic to initially hit equitable distribution of membership by plan? Will the ongoing auto assignment language be different from the initial? If so, how?

If the recipient does not make an active choice to enroll in a managed care plan, the Agency will assign the recipient to a managed care plan based on the criteria outlined in s. 409.984(2), F.S.

575Prestige Health Choice LLC ATTACHMENT C NA Section c.46

576 Duane Morris What region is Miami-Dade located in? Region 11

577



In the event that an applicant is not awarded the contract, is the "Proposal Guarantee" returned to the applicant?

The Agency will return the proposal guarantee to the unsuccessful respondents upon execution of a legal contract with the successful respondents. See Attachment C, Special Conditions, Section C.16, Proposal Guarantee, third paragraph.

578WellCare of Florida ATTACHMENT C N/A Section C.16 Procureme

nt

Proposal Guarantee: Will one bid bond representing total number of regions we are applying be accepted or are individual bid bonds per region required?

Individual bid bonds per region are required.

579


Section XV, Item K. Performance Bond

Procurement

Performance Bond: Per attachment $1MM worth of bond is required per region in which HMO has been awarded contract. Can performance bonds be consolidated into a single bond for whichever regions are awarded?

Yes.

580WorldNet Services Corp. ATTACHMENT C NA C.16 Procureme

nt Does the state have a standard proposal guarantee bond form?No. Proposal guarantees must be submitted in either a cashier's check or bond made payable to the State of Florida.

EXHIBIT 4 Vendor Conference Sign-In Sheets


EXHIBIT 5


TABLE 1-A

LTC Provider Qualifications & Minimum Network Adequacy Requirements Table Effective 08/01/2013 - 08/31/2018

Long-Term Care Plan Benefit

Qualified Service Provider Types Provider Qualifications

Network Adequacy Requirements Urban Counties Rural Counties

Adult Companion

Community Care for the Elderly (CCE) Provider As defined in Ch. 410 or 430, F.S.

At least two (2) providers serving each county of the

region.


region.

Center for Independent Living As defined under 413.371, F. S.

Homemaker/Companion Agency

Registration in accordance with 400.509, F.S.

Home Health Agency Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.

Nurse Registries Licensed per Chapter 400.506, F. S.

Health Care Service Pools Licensed per Chapter 400, Part IX, F. S.

Adult Day Care (Adult Day Health

Care)

Assisted Living Facility (ALF)

Licensed per Ch. 429, Part I, F.S. with a written approval from 768 AHCA’s HQA office to provide services under 429.905(2) F.S.


region AND at least (1) provider within 30 minutes

travel time.



travel time. Adult Day Care Center Licensed per Ch. 429, Part III, F.S.

Assisted Living Facility Services Assisted Living Facility

Licensed per Ch. 429, Part I, F.S. and ALF must agree to offer facility services with home-like characteristics*


region.

At least two (2) providers serving each county of the.

Assistive Care Services*

Adult Family Care Home (AFCH)

Licensed per Ch. 429, Part II, F.S. and Adult Family Care Home (AFCH) must agree to offer facility services with home-like characteristics* At least two (2) providers

serving each county of the region.


region.

Assisted Living Facilities

Licensed per Ch. 429, Part I, F.S. and ALF must agree to offer facility services with home-like characteristics*





Attendant Care

Home Health Agency Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484. At least two (2) providers


At least two (2) providers serving each county of the region.

Registered Nurse (RN), Licensed Practical Nurse (LPN)

Licensed per Ch. 464, F.S.

Nurse Registry Licensed per 400.506, F.S.

Behavior Management

Clinical Social Worker, Mental Health Counselor



region.


Community Mental Health Center Licensed per Ch. 394, F.S.

Home Health Agencies Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484

Nurse Registries Licensed per 400.506, F.S. Psychologist Licensed per Ch. 490, F.S.

Registered Nurse

Licensed per Ch. 464, Part I "Nurse Practice Act", F.S. and Ch. 64B9 "Board of Nursing", F.A.C.; Minimum of 2 years direct experience working with adult populations diagnosed with Alzheimer's disease, other dementias or persistent behavioral problems.

Caregiver Training

CCE Provider As defined in Ch. 410 or 430, F.S.


region.


Clinical Social Worker, Mental Health

Counselor


RN, LPN Licensed per Ch. 400, Part III, F.S.

Home Health Agency

Optional to meet Federal Conditions of Participation under 42 CFR 484.





Case Management

Case Managers employed or contracted by LTC plans

Either (1) BA or BS in Social Work, Sociology, Psychology, (2) RN licensed in FL, (3) BA or BS in unrelated field and 2+ yrs. experience, (4) LPN with 4 yrs. of relevant experience. All must have at least 2 yrs. relevant experience and 4 hrs. of in-service training in identifying and reporting Abuse, Neglect and Exploitation.

Each case manager's caseload may not exceed 60 for plan members in HCBS

settings or 100 for plan members in nursing

facilities.

Each case manager's caseload may not exceed 60 for plan members in HCBS settings or 100 for plan members in nursing facilities. Center for Independent

Living

Case managers must have either (1) BA or BS in Social Work, Sociology, Psychology; (2) RN licensed in Florida; (3) BA or BS in unrelated field and 2+ yrs. experience; (4) LPN with 4 years of relevant experience. All must have at least 2 yrs. of relevant experience and 4 hrs. of in-service training in identifying and reporting Abuse , Neglect and Exploitation

Case Management Agency

Designated a CCE Lead Agency by DOEA (per Ch. 430 F.S.) or other agency meeting comparable standards as determined by DOEA.

Home Accessibility Adaptation

Independent Provider

Licensed per state and local building codes or other licensure appropriate to tasks performed. Ch. 205, F.S.; Licensed by local city and/or county occupational license boards for the type of work being performed. Required to furnish proof of current insurance.


region.


Center for Independent Living

As defined under 413.371, F. S. and licensed under Ch. 205, F. S.

General Contractor Licensed per 459.131, F.S.



Qualified Service Provider Types Provider Qualifications Network Adequacy Requirements

Urban Counties Rural Counties

Home Delivered Meals

Food Establishment Permit under 500.12, F.S.

At least two (2) providers



region.

Older American’s Act (OAA) Provider As defined in Rule 58A-1, F.A.C. CCE Provider As defined in Ch. 410 or 430, F.S. Food Service Establishment Licensed per S.509.241, F.S.

Homemaker



region.


region.


CCE Provider As defined in Ch. 410 or 430, F.S. Center for Independent Living As defined under 413.371, F. S.

Homemaker/Companion Agency

Registration in accordance with Ch. 400.509, F.S.

Health Care Service Pools Licensed per Chapter 400, Part IX, F. S.

Hospice Hospice Organizations

Hospice providers must be licensed under Chapter 400, Part IV, F. S. and meet Medicaid and Medicare conditions of participation annually.


region.


region.

Intermittent and Skilled Nursing Home Health Agency

Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.


region.


region.

Medication Administration

RN, LPN Licensed per Ch. 464, F.S.


region.


region.





Qualified Service Provider Types Provider Qualifications Network Adequacy Requirements

Urban Counties Rural Counties

Unlicensed Staff Member Trained per 58A-5.0191(5), F.A.C.

Trained per 58A-5.0191(5), F.A.C.; demonstrate ability to accurately read and interpret a prescription label.

Home Health Agencies Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.

Medication Management

Nurse Registries Licensed per 400.506, F.S. At least two (2) providers



region. Licensed Nurse, LPN Licensed per Ch. 464, F.S.

Medical Equipment & Supplies

Pharmacy Licensed per Ch. 465, F.S.; Permitted per Ch. 465, F.S.


region.


region. Home Health Agency


Home Medical Equipment Company Licensed per Ch. 400, Part VII, F.S.





Nutritional Assessment and Risk Reduction



region.




Other Health Care Professional

Must practice within the legal scope of their practice.

Dietician/Nutritionist or Nutrition Counselor Licensed per Ch. 468, Part X, F.S.

Nursing Facility Care

See State Plan Requirements. See State Plan Requirements.


region.


Personal Care

Nurse Registry Licensed per 400.506, F.S. At least two (2) providers


At least two (2) providers serving each county of the region. Home Health Agency



Personal Emergency Response System

Alarm System Contractor Certified per Ch. 489, Part II, F.S.

At least two (2) providers. Serving each county of the

Region.


Low-Voltage Contractors and Electrical Contractors

Exempt from licensure in accordance with 489.503(15)(a-d), F.S. and 489.503(16), F.S.





Respite Care



region.


region.


Adult Day Care Center Licensed per Ch. 429, Part III, F.S. Assisted Living Facility Licensed per Ch. 429, Part I, F.S. Nursing Facility Licensed per Ch. 400, Part II, F.S.

Center for Independent Living* As defined under 413.371, F. S.


Homemaker/ Companion Agency

Registration in accordance with 400.509, F.S.

Transportation

Independent (private auto, wheelchair van, bus, taxi)

Licensed per Ch. 322, F.S.; Residential facility providers that comply with requirements of Ch. 427, F.S. At least two (2) providers



region. Community Transportation Coordinator

Licensed per Chapter 316 and 322, F. S., in accordance with Chapter 41-2, F. A. C

Occupational Therapy




travel time.



travel time.

Occupational Therapist Assistant Licensed per Ch. 468, Part III, F.S.

Occupational Therapist Assistant Licensed per Ch. 468, Part III, F.S.

Physical Therapy

Physical Therapist Licensed per Ch. 486, F.S. At least two (2) providers

serving each county of the region AND at least (1)

provider within 30 minutes travel time.



travel time.

Physical Therapist Assistant Licensed per Ch. 486, F.S.






Respiratory Therapy

Home Health Agency

Home Health Agencies licensed per Chapter 400, Part III,F. S, employing certified respiratory therapists licensed under Chapter 468, F. S and may meet Federal conditions of Participation under 42 CFR 484 or individuals licensed per Chapter 468, F. S. as certified respiratory therapists.



travel time.



travel time.

Respiratory Therapist Licensed per Ch. 468, F.S.

Speech Therapy

Speech-Language Pathologist Licensed per Ch. 468, Part I, F.S. At least two (2) providers

serving each county of the region AND at least (1)

provider within 30 minutes travel time.



travel time. Home Health Agency


*Additional qualifications: ALF or AFCH must offer facility services to Long-Term Care Managed Care plan members with the following home-like characteristics: a) access to typical facilities in a home such as a kitchen with cooking facilities; (b) provide privacy options in the living unit; (c) access to resources and activities in the community; (d) provide individuals with the option to assist in choosing what activities ALFs or AFCHs will be conducting and (f) ensure individuals are allowed to conduct/hold unscheduled activities of their choosing.


AHCA ITN 001-12/13, Attachment D-II, Exhibits, Exhibit 17, Page 1 of 12

ATTACHMENT D-II EXHIBIT 17

Liquidated Damages — LTC Plans

NOTE: This exhibit provides Long-Term Care Plan requirements in addition to Attachment D-II of this Contract, unless otherwise specified. B. Issues and Amounts

Liquidate Damages – Effective 8/01/2013 – 8/01/2018

PROGRAM ISSUES DAMAGE

1 Failure to comply with claims processing as described in Attachment D-II Section X and Exhibit 10 of this Contract.

$10,000 per month, for each month that the Agency determines that the Managed Care Plan is not in compliance with the requirements as described in Section X and Exhibit 10 of this Contract.

2 Failure by the Managed Care Plan to ensure that all data containing protected health information (PHI), as defined by HIPAA, is secured through commercially reasonable methodology in compliance with HITECH, such that it is rendered unusable, unreadable and indecipherable to unauthorized individuals through encryption or destruction, that compromises the security or privacy of the Agency enrollee’s PHI (See also ancillary business associate agreement requirements between the parties) as specified in Attachment D-II, in Sections XI and XVI and Attachment H, Exhibit 1 (Business Associate Agreement) of the Contract.

$1,000 per enrollee per occurrence, AND if the State determines credit monitoring and/or identity theft safeguards are needed to protect those enrollees whose PHI was placed at risk by Managed Care plan’s failure to comply with the terms of this Contract, the Managed Care Plan shall be liable for all costs associated with the provision of such monitoring and/or safeguard services.


3 Failure by the Managed Care Plan to execute the appropriate agreements to effectuate transfer and exchange of enrollee PHI confidential information including, but not limited to, a data use agreement, trading partner agreement, business associate agreement or qualified protective order prior to the use or disclosure of PHI to a third party (See ancillary business associate agreement between the parties) pursuant to Attachment D-II, Sections XI and XVI and Attachment H, Exhibit 1 of the Contract.

$500 per enrollee per occurrence

4 Failure by the Managed Care Plan to timely report violations in the access, use and disclosure of PHI or timely report a security incident or timely make a notification of breach or notification of provisional breach (See also ancillary business associate agreement between the parties) as described in Attachment D-II, Sections XI and XVI and Attachment H, Exhibit 1 of the Contract.

$500 per enrollee per occurrence, not to exceed $10,000,000.

5 Failure to timely submit audited annual and quarterly unaudited financial statements as described in Attachment D-II, Section XV of the Contract.

$500 per calendar day for each day that reporting requirements as described in Section XV are not met.

6 Failure to comply in any way with encounter data submission requirements as described in Attachment D-II, Section X and Section II of the Contract (excluding the failure to address or resolve problems with individual encounter records in a timely manner as required by the Agency).

$25,000 per occurrence.


7 Failure to address or resolve problems with individual encounter records in a timely manner as required by the Agency and described in Attachment D-II, Section X of the Contract.

$500 per calendar day, per occurrence

8 Failure to provide continuation of services during the pendency of a Medicaid fair hearing and/ or the Managed Care Plan’s grievance process where the enrollee has challenged a reduction or elimination of services as required by Attachment D-II, Section IX of the Contract, applicable state or federal law, and all court orders governing appeal procedures as they become effective.

The liquidated damages accessed for this failure to continue services during the pendency of a Medicaid fair hearing and/or the Managed Care Plan’s (MCP’s) grievance process where the enrollee has challenged the MCP’s action shall equal the value of the reduced or eliminated services as determined by the Agency for the timeframe specified by the Agency and $500 per day for each calendar day the MCP fails to provide continuation or restoration as required by the Agency.

9 Failure to provide restoration of services after the Plan receives an adverse determination as a result of a Medicaid fair hearing or the Managed Care Plan’s grievance process as required by Attachment D-II, Section IX of the Contract, applicable state or federal law and all court orders governing appeal procedures as they become effective.

The liquidated damages accessed for this failure to provide program services and promptly reimbursing the enrollee for any costs incurred for obtaining the services at the enrollee’s expense in a timeframe specified by the Agency shall equal the value of the reduced or eliminated services as determined by the Agency and $500 per day for each calendar day the MCP fails to provide continuation or restoration as required by the Agency.

10 Failure to acknowledge or act timely upon a request for prior authorization in accordance with Attachment D-II, Section IV, VII, VIII, and Exhibit 5 of the Contract.

$1,000 per occurrence, plus $1,000 for each day that it is determined the Managed Care Plan failed to acknowledge or act timely upon a request for prior authorization in accordance with Attachment D-II, Section VIII of the Contract.

11 Failure to comply with the timeframes for developing and approving a plan of care for transitioning or initiating home and community-based services as described in Attachment D-II, Sections V and VIII of the Contract and

$500 per day, per occurrence.


Attachment D-II, Exhibits 5, 7, and 8 of the Contract.

12 Failure to complete in a timely manner minimum care coordination contacts required for persons transitioned from a nursing facility to a community placement as described in Attachment D-II, Exhibit 5 of the Contract.


13 Failure to meet the performance standards established by the Agency regarding missed visits for personal care, attendant care, homemaker, or home- delivered meals for enrollees (referred to herein as “specified HCBS”). Pursuant to Attachment D-II, Exhibits 5 and 8 of the Contract.


14 Failure to provide continuity of care and a seamless transition consistent with the services in place prior to the individual’s enrollment in the Managed Care Plan for a person transferring from another MCO as described in Attachment D-II, Sections XVI and Exhibits 6 and 8 of the Contract.

$500 per day beginning on the next calendar day after default by the Managed Care Plan in addition to the cost of the services not provided These amounts shall be multiplied by two (2) when the Managed Care Plan has not complied with the case management requirements as described in Section VI and VIII or the Contract.

15 Failure to complete a comprehensive assessment, develop a plan of care, and authorize and initiate all long-term care services specified in the plan of care for an enrollee within specified timelines as described in Attachment D-II, Exhibit 5 and 8 of the Contract.

$500 per day for each service not initiated timely beginning on the next calendar day after default by the Managed Care Plan in addition to the cost of the services not provided. These amounts shall be multiplied by two (2) when the Managed Care Plan has not complied with the case management requirements as described in the Contract.

16 Failure to develop a person-centered plan of care for an enrollee that includes all of the required elements, and which has been reviewed with and signed and dated by the member or authorized

$500 per deficient plan of care. These amounts shall be multiplied by two (2) when the Managed Care Plan has not complied with the caseload and staffing requirements specified in the Contract.


representative, unless the member/representative refuses to sign, which shall be documented in writing as described in Attachment D-II, Exhibit 5 of the Contract.

17 Failure to facilitate transfers between health care settings as described in Attachment D-II, Section XVI and Attachment D-II Exhibits 5 and 8 of the Contract.

$1,000 per occurrence. These amounts shall be multiplied by two (2) when the Managed Care Plan has not complied with the case management requirements as described in Section V and VIII and Exhibits 5 and 8 of the Contract.

18 Imposing arbitrary utilization guidelines or other quantitative coverage limits as prohibited in Attachment D-II, Sections II, VII, and VIII and Exhibits VIII of the Contract.


19 Failure to meet any timeframe regarding care coordination for members as described in Attachment D-II, Sections V and VIII and Exhibit 5 of the Contract.

$250 per calendar day, per occurrence.

20 Failure to comply in any way with staffing requirements as described in Attachment D-II, Sections IV, VII, VIII and X of the Contract and Exhibits 4, 5, 7, 8 and 10 of the Contract.

$250 per calendar day for each day that staffing requirements are not met

21

Failure to comply with the medical/case records documentation requirements pursuant to Attachment D-II, Sections V, VII, and VIII and Exhibits 5 and 8 of the Contract.

$500 per plan of care for members in Group 2 or 3 that does not include all of the required elements. $500 per member file that does not include all of the required elements. $500 per face-to-face visit where the care coordinator fails to document the specified observations. These amounts shall be multiplied by two (2) when the Managed Care Plan has not complied with the caseload and staffing requirements

22 Failure to have a face-to-face contact between the Managed Care Plan case manager and each enrollee at least every ninety (90) days or following a significant change as described in

$5,000 for each occurrence


Attachment D-II, Exhibit 5 of the Contract.

23 Failure to follow-up within seven (7) days of service authorization for the initial care plan to ensure that services are in place as described in Attachment D-II, Exhibit 5 of the Contract


24 Failure to notify enrollees of denials, reductions, or terminations of services within the timeframes specified in the Contract as described in Attachment D-II, Sections IV and IX of the Contract

$1,000 per occurrence plus a per calendar day assessment in increasing increments of $500 ($500 for the first day, $1,000 for the second day, $1,500 for the third day, etc.) for each day the notice is late.

25 Failure to provide a copy of the Care Plan to each enrollee's PCP and residential facility in the timeframes as described in Attachment D-II, Exhibit 5 of the Contract

$500 per calendar day.

26 Failure to report enrollees that do not receive any long-term care services listed in the approved care plan for a month, failure to report the occurrence to the Agency as described in Attachment D-II, Exhibit 5 of the Contract.

For each enrollee , an amount equal to the capitation rate for the month in which the enrollee did not receive long- term care services.

27 Failure to comply with obligations and time frames in the delivery of annual face-to-face reassessments for Level of Care as described in Attachment D-II, Exhibit 5 of the Contract.


28 Failure to provide proof of compliance to the Agency within five (5) calendar days of a directive from the Agency or within a longer period of time which has been approved by the Agency upon a Attachment D-II, Section XVI demonstration of good cause.

$500 per day beginning on the next calendar day after default by the Managed Care Plan


29 Failure to comply with conflict of interest or lobbying requirements as described in Attachment D-II, Section XVI of the Contract

$10,000 per occurrence

30 Failure to disclose lobbying activities and/or conflict of interest as required by the Contract, including Attachment D-IV

$1,000 per day that disclosure is late

31 Failure to obtain approval of member and Provider materials, and provider agreements, as required by Attachment D-II, Sections IV and VII and Exhibit 5 of the Contract.

$500 per day for each calendar day that the Agency determines the Managed Care Plan has provided member or provider material, or provider agreements that had not been approved by the Agency

32 Failure to comply with time frames for providing Member Handbooks, I.D. cards, Provider Directories, as required in Attachment D-II, Sections IV and VII and Exhibit 4


33 Failure to achieve and/or maintain financial requirements as described in Attachment D-II, Section XV and Exhibit 15 of the Contract.

$1,000 per calendar day for each day Contract requirements are not met.

34 Failure to require and ensure compliance with Ownership and Disclosure requirements as required in Attachment D-II, Sections IV, VII and XVI.

$5,000 per provider disclosure/attestation for each disclosure/attestation that is not received timely as described in Sections VII and XVI or is not in compliance with the requirements outlined in 42 CFR 455, Subpart B.

35 Failure to maintain required insurance as required in Attachment D-II, Section XVI of this Contract

$500 per calendar day

36 Failure to submit a Provider Network File that meets the Agency’s specifications as described in Attachment D-II, Section VII and Exhibit 12 of the Contract.

$250 per day after the due date that the Provider Enrollment File fails to meet the Agency’s specifications.

37 Failure to comply with marketing requirements as described in Attachment D-II,

$500 per recipient, per verified incident of promotion or marketing of Managed Care Plan.


Section IV of the Contract.

38 Failure to timely file required reports as described in Attachment D-II, Section XI and Exhibit 12 of the Contract.

$500 per day beyond the due date until submitted.

39 Failure to file accurate reports as described in Attachment D-II, Section XI and Exhibit 12 of the Contract


40 Submission of inappropriate report certifications as described in Attachment D-II, Section XII of the Contract.

$250 per occurrence.

41 Failure to respond to an Agency communication within the time prescribed by the Agency as described in Attachment D-II, Section II and XI of the Contract.

$500 for each calendar day beyond the due date until provided to the Agency. However, after three (3) instances during the Contract period, the liquidated damage amount is increased by $1,000 per day.

42 Failure to respond to an Agency request or ad-hoc report for documentation (such as medical records, complaint logs, or Contract checklists) within the time prescribed by the Agency as described in Section II of the Contract.

$500 per day for each calendar day beyond the due date until provided to the Agency. However, after three (3) instances during the Contract period, the liquidated damage amount is increased by $1,000 per day.

43 Failure to update online provider directory in accordance with Contract requirements as described in Attachment D-II, Section IV of the Contract.


44 Failure to timely report staff or community outreach representative violations as described in Attachment D-II, Section IV and Exhibit 4 of the Contract.


45 Failure to timely report significant network changes as described in Section VII and Exhibit 7 of the Contract.


46 Failure to timely report changes in staffing as described in Attachment D-II, Section X of the Contract.



47 The Managed Care Plan shall ensure that for each enrollee all necessary paperwork is submitted to DCF within the timeframes included in Attachment D-II, Exhibits 4 and 5 of the Contract.

$100 assessed for each enrollee who temporarily loses eligibility (for less than 60 days) pursuant to a redetermination.

48 Failure to achieve and/or maintain insolvency requirements in accordance with Attachment D-II, Exhibit 15 of the Contract.

$500 per calendar day for each day that financial requirements are not met

49

Failure to comply with the notice requirements as described in Attachment D-II, Sections XIV and XVI of the Contract, the Agency rules and regulations, and all court orders governing appeal procedures, as they become effective.

$500 per occurrence in addition to $500 per calendar day for each calendar day required notices are late or deficient or for each calendar day beyond the required time frame that the appeal is unanswered in each and every aspect and/or day beyond the required time frame that the appeal is unanswered in each and every aspect and/or each day the appeal is not handled according to the provisions set forth by this Contract or required by the Agency. $1,000 per occurrence if the Agency notice remains defective plus a per calendar day assessment in increasing increments of $500 ($500 for the first day, $1,000 for the second day, $1,500 for the third day, etc.) for each day the notice is late and/or remains defective.

50 Failure to submit a timely notice of involuntary disenrollment to the enrollee as described in Attachment D-II, Section III of the Contract.

$1,000 per occurrence if the enrollee notice remains defective plus a per calendar day assessment in increasing increments of $500 ($500 for the first day, $1,000 for the second day, $1,500 for the third day, etc.) for each day the notice is late and/or remains defective.

51 Failure to comply with member notice requirements as described in Attachment D-II, Sections III, IV, VII, VIII and IX and Exhibits 5, 7, 8 and 9 of the Contract.

$1,000 per occurrence if the enrollee notice remains defective plus a per calendar day assessment in increasing increments of $500 ($500 for the first day, $1,000 for the second day, $1,500 for the third day, etc.) for each day the notice is late and/or remains defective $500 per calendar day.

52 Failure to comply with licensure and background

$5,000 per calendar day that staff/provider/driver/agent/subcontractor


check requirements in Attachment D-II, Sections V, VII and XVI and Exhibit 7 of the Contract.

is not licensed or qualified as required by applicable state or local law plus the amount paid to the staff/provider/driver/agent/subcontractor during that period

53 Failure to comply with fraud and abuse provisions as described in Attachment D-II, Section X of this Contract.

$500 per calendar day

54 Failure to report provider notice of termination of participation in the Managed Care Plan as described in Attachment D-II, Sections VII and XII and Exhibit 12 of the Contract.

$500 per day, per occurrence

55 Failure to cooperate fully with the Agency and/or state during an investigation of fraud or abuse, complaint, or grievances as described in Attachment D-II, Sections II, VII, X, XV, and XVI.

$500 per incident for failure to fully cooperate during an investigation.

56 Failure to timely report notice of terminated providers due to imminent danger/impairment as described in Attachment D-II, Section VII and Exhibit 12 of the Contract.


57 Failure to timely report termination or suspension of providers; for “for cause” terminations, including reasons for termination as described in Attachment D-II, Section VII of the Contract.

$250 per occurrence

58 Failure to timely submit fingerprints of newly hired principals as described in Attachment D-II, Section XVI of the Contract.

$ 500 per occurrence

59 Failure to timely report information about offenses listed in s. 435.04, F.S. as described in Attachment D-II, Section XVI of the Contract.

$500 per occurrence

60 Failure to timely report changes in ownership and control as described in Attachment D-II, Section XVI



of the Contract.

61 Failure to complete or comply with corrective action plans as described in Attachment D-II, Section XIV of the Contract.

$500 per calendar day for each day the corrective action is not completed or complied with as required by Section XIV

62 Failure to submit audited HEDIS, CAHPS, Agency-Defined Measures results annually by July 1 as described in Attachment D-II, Section VIII

$250 per day for every calendar day reports are late

63 Failure to obtain and/or maintain national accreditation as described in Attachment D-II, Section XVI of the Contract.

$500 per day for every calendar day beyond the day accreditation status must be in place as described in Section XVI of the Contract.

64 Failure to have a rate at or above the 25th percentile for the HEDIS measures as described in Attachment D-II, Exhibit 14 of the Contract

$500 per each case in the denominator not present in the numerator for the measure.

65

Performance Measure: Care for Older Adults and Call Answer Timeliness (Exhibit 14)

Failure to achieve a rate at the 25th percentile (per the NCQA National Means and Percentiles, Medicare for the Care for Older Adults measure and Medicaid for the Call Answer Timeliness measure) or higher will result in liquidated damages of $500 per each case in the denominator not present in the numerator for the measure. If the Managed Care Plan’s rate remains below the 25th percentile in subsequent years, damages will be $1,000 per case.

66

Performance Measure: Failure to have a Call Abandonment rate of 5% or less, per the HEDIS measure specifications. (Exhibit 14)

Failure to have a Call Abandonment rate of 5% or less, per the HEDIS measure specifications, will result in liquidated damages of $500 per each case in the denominator not present in the numerator for the measure. If the Managed Care Plan’s rate remains above 5% in subsequent years, damages will be $1,000 per case.

67 Performance Measure: Required Record Documentation – numerators 1-4. (Exhibit 14)

Failure to achieve a rate of 90% or higher for each of these measures will result in liquidated damages of $500 per each case in the denominator not


present in the numerator for the measure. If the Managed Care Plan’s rate remains below 90% in subsequent years, damages will be $1,000 per case.

68

Performance Measure: Face-to-Face Encounters (Exhibit 14)

Failure to achieve a rate of 90% or higher for each of these measures will result in liquidated damages of $500 per each case in the denominator not present in the numerator for the measure. If the Managed Care Plan’s rate remains below 90% in subsequent years, damages will be $1,000 per case.

69

Performance Measure: Care Manager Training as required in (Exhibit 14)


70

Performance Measure: Timeliness of Service (Exhibit 14)


71 Performance Measure: Satisfaction with Care Manager (Exhibit 14)


72

Performance Measure: Rating of Quality of Services (Exhibit 14)



ATTACHMENT N COST PROPOSAL

AHCA ITN 001-12/13, Attachment N, Page 1 of 2

A. The Respondent shall propose a monthly capitation rate for each of the HCBS and Non-HCBS rate components as outlined below in Table 1, Capitation Rates, and in accordance with Attachment C, Section C.45, Item D., Cost Proposal.

B. The final capitation rate will be a blended rate of the HCBS and the Non-HCBS

capitation rate components. The blending will be based on an Agency prescribed case mix to address, at a minimum, incentive adjustments as referenced in s. 409.983, F.S.

TABLE 1

CAPITATION RATES

ELIGIBILITY GROUP

HCBS

CAPITATION RATE

(Total from Line 32D)

NON-HCBS

CAPITATION RATE

(Total from Line 32G)

All Eligibility Groups $ per month $ per month

C. The respondent must include Attachment N-1, Cost Proposal Rate Sheet, to

demonstrate the calculation of the proposed monthly capitation rates above.

NOTES:

1) The intent of the Cost Proposal is for the respondent to provide prospectively determined monthly capitation rates for each of the two rate components, outlined above.

2) The respondent’s proposed capitation rates must be within the capitation rate ranges

individually for each of the HCBS and Non-HCBS rate components, as identified in Attachment N-2, Capitation Rate Ranges, or THE RESPONSE WILL BE REJECTED.

Name of Respondent Name and Title of Respondent Representative

Respondent Representative’s Signature Date

AHCA ITN 001-12/13, Attachment N, Page 2 of 2

EXHIBIT 1 SAMPLE GENERAL NARRATIVE

LONG-TERM CARE RATE-SETTING METHODOLOGY

1. Data Used

The respondent shall describe the source data used to develop the proposed capitated rates. For example, the respondent shall explain how the Data Book data from State Fiscal Years 2008-2009, 2009-2010 and 2010-2011 and any data from other sources were used in developing the proposed capitation rates.

2. Population and Service Changes Incorporated

The respondent shall include any increases/decreases applied to any categories of service, by rate cell.

3. Trend Rate Applied

The respondent shall include a detailed description of trend development. For example:

• Is this a combined utilization and unit cost trend? If not, supply the information for both. • Overall annual trend: _____% • Does trend differ by COS? If so, provide assumptions. • List data sources used to develop trend estimates. • Are there specific COS concerns/trends? If so, explain.

4. Administrative Charge/Margin Charge

The respondent shall explain how the administrative and margin charge amounts in the proposed capitated rates were developed. If the administrative and/or margin assumptions differ by HCBS and non-HCBS populations, the respondent shall provide an explanation of the differences.

5. Other Adjustments Applied

The respondent shall explain any other adjustments included in the proposed capitated rates.

Item Description Rate Cell Categories of Service

(COS) Value

ATTACHMENT N-1Long-Term Care Managed Care Program

Cost Proposal Rate Sheet

State of Florida

AHCA ITN 001-12/13, Attachment N-1, Page 1 of 1

Vendor Name:

Rating Period: Eligibility Group: All SFY 10-11 Member Months 7,737 SFY 10-11 Member Months 26,366

Region: 1 Current Mix 23% Current Mix 77%

(B) (C) (D) (E) (F) (G) (H)

Utilization per 1,000* Average Unit Cost Per Member Per Month Utilization per 1,000* Average Unit Cost Per Member Per

Month Additional Information may be

provided if necessary

HCBS Population Non-HCBS Population1 $ - $ -

2 $ - $ -

3 $ - $ -

4 $ - $ -

5 $ - $ -

6 $ - $ -

7 $ - $ -

8 $ - $ -

9 $ - $ -

10 $ - $ -

11 $ - $ -

12 $ - $ -

13 $ - $ -

14 $ - $ -

15 $ - $ -

16 $ - $ -

17 $ - $ -

18 $ - $ -

19 $ - $ -

20 $ - $ -

21 $ - $ -

22 $ - $ -

23 $ - $ -

24 $ - $ -

25 $ - $ -

26 $ - $ -

27 $ - $ -

28 $ - $ -

29 $ - $ - 30 Administrative Charge $ - $ -

31 Margin Charge $ - $ -

32 HCBS/Non-HCBS Capitation Rate $ - $ -

33 HCBS/Non-HCBS Mix*** 24% 76%

34 Total Blended Capitation Rate $ -

* Utilization per 1,000 for HCBS should be calculated on the HCBS MM. Non-HCBS utilization per 1,000 should be calculated on the non-HCBS MM.

** State Plan Covered Service*** The assumed mix in line 33 reflects a 2% transition as outlined in statute, adjusted for the enrollment period in the implementation year. The assumed mix is subject to change.

Net Medical PMPMTransportation

Respite care (facility-based)

Respiratory therapy

Physical therapy

Respite care (in-home)

Assisted living

Adult day health care

Speech therapy

Personal emergency response system

(A)

Category of Service

Assistive Care Services

Adult companion

Attendant care

Home delivered meals

Caregiver training

Case management

Home accessibility adaptations

Behavior management

Personal care

Medication administration

Medication management

Home Health Services **

Hospice **

Intermittent & Skilled Nursing

Medical Equipment & Supplies**

Nursing facility services **

Homemaker

Nutritional assessment & risk reduction

Occupational therapy

ATTACHMENT N-2

CAPITATION RATE RANGES


CONTENTS

1. Capitation Rate Range Development Overview ......................................................... 2

2. Base Data and Base Data Adjustments..................................................................... 3 • Base Data ........................................................................................................... 3 • Base Programmatic Changes .............................................................................. 3 • Services Not Covered Under SMMC LTC ............................................................ 4 • Services Included in the Data Book without Historical Utilization and Expenditure

Information ......................................................................................................... 4 • Non-Emergency Transportation Services ............................................................ 4 • Regional Grouping............................................................................................... 5

3. Prospective Adjustments ........................................................................................... 6 • Prospective Trend ............................................................................................... 6 • Prospective Programmatic Changes ................................................................... 6 • Hospice and Nursing Facility Fee Changes ......................................................... 6 • Administration and Margin ................................................................................... 7 • Transition from Nursing Facilities to HCBS .......................................................... 7

4. Prospective Program Changes that Impact SMMC LTC Bids and Negotiated Rates . 9 • SMMC LTC ITN Bid Process ............................................................................... 9

5. Risk Adjustment Approach ...................................................................................... 11 • Operational Plan ................................................................................................ 12

6. Certification of Final Rate Ranges ........................................................................... 13

Appendix A: Adjustment Tables .................................................................................. 14

Appendix B: Rate Ranges ........................................................................................... 19

Appendix C: Risk Adjustment Example Calculation ..................................................... 21


1 Capitation Rate Range Development Overview This document presents an overview of the process used to develop the capitation rate ranges in which the Agency for Health Care Administration (AHCA) is willing to contract for the first contract year of Florida’s Statewide Medicaid Managed Care Long Term Care (SMMC LTC) Program (September 1, 2013 – August 31, 2014). These rate ranges are provided in Appendix B. Please note the rate ranges presented in Appendix B are applicable only to capitated Long-Term Care Plans (LTC Plans) and are not applicable to Fee-for-Service Long-Term Care Provider Service Networks (FFS LTC PSNs). AHCA will release FFS LTC PSN benchmarks at a later date. The following sections provide prospective bidders with the following information: • Base Data and Base Data Adjustments • Prospective Adjustments • Prospective Program Changes that Impact SMMC LTC Bids and Negotiated Rates • Risk Adjustment Approach


2 Base Data and Base Data Adjustments Base Data The base data from the Data Book that were used to determine the rate ranges in Appendix B included the State Fiscal Year (SFY) 2009/2010 and SFY 2010/2011 data periods. The adjusted base data for SFY 2009/2010 were trended to the SFY 2010/2011 period and blended with the adjusted SFY 2010/2011 data. A weighting of 40% was applied to the adjusted and trended SFY 2009/2010 data and a weighting of 60% was applied to the adjusted SFY 2010/2011 data. The weighting of the blended base data utilizes the SFY 2010/2011 historical member months. Data for SFY 2008/2009 were considered but not included in the adjusted base data. Base Programmatic Changes The base period programmatic changes reflect adjustments that occurred after the base data periods and that need to be reflected in the development of the rate ranges. The following programmatic changes were applied to the base data as base data adjustments: • Nursing Facility fee changes (effective January 1, 2012) • Hospice fee changes (effective January 1, 2012) • Telephonic Home Health Services Delivery Monitoring and Verification (DMV) and Care

Coordination Programs Hospice and Nursing Facility Rate Changes AHCA updates the Hospice and Nursing Facility fee schedules on a semi-annual basis (January and July). Per Section 409.982(5), Florida Statutes (F.S.), all SMMC LTC contractors are required to contract with Hospice and Nursing Facility providers at rates no less than those set by AHCA. The SFYs 2008/2009, 2009/2010, and 2010/2011 base data represent expenditures based on the fees that existed during the dates of service included in each data period. The base data were adjusted for each year to reflect the Hospice and Nursing Facility fees effective January 1, 2012 to June 30, 2012. The data presented in the Data Book are net of patient responsibility. The fee changes were analyzed inclusive of patient responsibility and the impact measured both on a gross basis (with patient responsibility) and on a net basis (without patient responsibility). The fee change impact was developed by analyzing the historical data by provider and measuring the difference between the historical unit cost represented by the data and the January 1, 2012 – June 30, 2012 AHCA-set fees. The gross and net impacts for each data


period (SFYs 2008/2009, 2009/2010, and 2010/2011) are outlined in Appendix A – Tables 1 and 2.

The fee changes for July 1, 2012 – December 31, 2012 have not been included in the base data adjustments and rate range development due to the timing of the Invitation to Negotiate (ITN) release. AHCA will update the rate ranges to reflect the effective fee changes after the award of contracts. This process and potential future rate adjustments related to the fee changes for Hospice and Nursing Facility services are outlined in Section 4 of this document. Telephonic Home Health Services (DMV) and Care Coordination Programs AHCA implemented a telephony requirement and a care coordination program in Region 11 (Miami-Dade County only) during the SFY 2010/2011 data period. This change reduced the utilization for home health services by approximately 45%. Since this change is reflected in the SFY 2010/2011 data for Region 11, the SFYs 2008/2009 and 2009/2010 home health services utilization for Region 11 were adjusted downward by 45% to reflect this impact. AHCA intends to implement this program in additional regions covered under the SMMC LTC program, but expects a decrease in utilization of only 10%. As such, a downward adjustment to the home health services utilization in Regions 1 through 10 are included as a prospective change since the historical base data do not include the impact of this change. Please refer to Section 3 of this document. Services Not Covered Under SMMC LTC Certain services were provided under the predecessor waiver programs but will no longer be offered under the SMMC LTC program. (Costs for those services are separately identified in the Data Book.) Because these services will not be included under the SMMC LTC program, their costs were not included in the capitation rate range development. Services Included in the Data Book without Historical Utilization and Expenditure Information With the implementation of the SMMC LTC program, contracted plans will be responsible for providing Behavioral Management, Medication Management and Medication Administration services, which were not provided as distinct services under the predecessor waiver programs. The approach for including this adjustment in the capitation rate ranges is outlined in Section 4. Non-Emergency Transportation Services Contracted plans will be responsible for providing non-emergency transportation to and from services covered under the SMMC LTC program as a separate service, so long as that transportation is not the responsibility of the provider of the LTC service. AHCA estimates the total cost of this non-emergency transportation to be $0.04 per member per month (PMPM). An adjustment of $0.04 PMPM is added to the rate ranges for each region.


Regional Grouping The historical home- and community-based services (HCBS) and Non-HCBS Data Book data were analyzed to determine the optimal groupings for developing rate ranges for the SMMC LTC program. The optimal groupings should collapse data into similar cost categories while taking into account the size of each group for credibility purposes. Initially, data in the Data Book were stratified by: • Medicare eligibility status (Duals and non-Duals) • Age (18 – 64 and 65+) and Gender (Male and Female) • Region Because the SMMC LTC program covers only LTC services, there is not a notable difference between the services that are covered by Medicare and Medicaid for the populations who will enroll. Thus, combining the Dual and non-Dual populations is appropriate. The Dual Eligible 65+ population is by far the largest population category. Given the very few member months in the other categories, collapsing the population categories provides additional credibility for rate-setting purposes. Small cell sizes (such as those for the Dual 18 – 64 and the non-Duals) can lead to variation in historical costs that would not be predictive of future costs. Collapsing the cells helps to mitigate the impact of small cell size and enhances the credibility of the data used in projecting future costs. Given the populations and services covered under the SMMC LTC program, it is appropriate to collapse each region’s population into a single cell that includes all eligible recipients, regardless of age or Medicare eligibility. The regional groupings for HCBS and Non-HCBS are outlined in the following table. Regional Base Data Groupings Data Grouping HCBS Regions Non-HCBS Regions

01 01, 03, 04 01, 02, 03, 04, 06 02 02 05, 07 03 05, 06, 07 08, 09 04 08, 10, 11 10, 11 05 09 Not Applicable

As illustrated above, the HCBS population for Regions 01, 03, and 04 from the Data Book were aggregated and serve as the base data for the development of rate ranges for Regions 01, 03, and 04.


3 Prospective Adjustments This section describes the adjustments applied to the base data, which have already been adjusted and blended, as described in Section 2 of this document. Prospective Trend Historical Data Book data were analyzed and utilized to determine trends on a utilization and unit cost basis. In addition to analyzing the historical Data Book data, supplemental trend data supplied by AHCA were reviewed. The average annual trend factors were applied from the midpoint of the blended base data period (January 1, 2011) to the midpoint of the contract payment period for each region. The contract payment period for each region is detailed in Appendix A – Table 3. The contract payment period varies by region and, therefore, the midpoint varies depending on the region. Appendix A outlines the following information: • Table 3: Contract payment period, midpoints, trend months • Table 4: Mapping of the Data Book service categories to the consolidated service categories • Table 5: Average annual range of utilization/1,000 and unit cost trend factors Prospective Programmatic Changes Prospective program changes recognize the impact of benefit, eligibility or State reimbursement changes that take place between the base data period and the projection period. For the SMMC LTC program, the following prospective program changes were applied: • Telephonic Home Health Services DMV and Care Coordination Programs As discussed in the base data adjustments section, AHCA will implement the Telephonic Home Health Services DMV and Care Coordination programs for Regions 01 through 10 on October 1, 2012. For these regions, a downward adjustment of 10% was applied to the home health service category for each SFY. Note that Region 11 was adjusted as part of the base programmatic change, as described in Section 2. Hospice and Nursing Facility Fee Changes As previously discussed, AHCA updates Hospice and Nursing Facility fees on a semi-annual basis (January and July). The rate ranges presented in this document are based on the fees effective for January 1, 2012 – June 30, 2012. No assumptions or projections have been made


to estimate the impact of the fees effective for July 1, 2012 – December 31, 2012 or for periods beyond December 31, 2012. The rate ranges presented in Appendix B are based on the Nursing Facility and Hospice fees in effect January 1, 2012 to June 30, 2012. For SMMC LTC offerors who are awarded contracts, negotiated rates may be adjusted to reflect the impact of future fee changes. Please refer to Section 4 of this document. Administration and Margin The rate ranges were developed including administrative cost and margin allowances. Case management services are included in the adjusted base data as covered services and through the Nursing Facility per diem, and are therefore not included in the administrative loadings. The range of administration and margin loadings are outlined in the Appendix A – Tables 6 and 7. Transition from Nursing Facilities to HCBS As part of the SMMC LTC program, contracted LTC Plans are expected to transition and divert recipients from the Nursing Facility setting to the HCBS setting. The Agency-required transition percentages included in the rate range development process are outlined in Appendix A – Table 8. An example of how these percentages are applied is below. In this example, the transition percentage is 2%. This example is for illustrative purposes only. The figures below do not tie to the development of the rate ranges provided in this document. Population Plan 1 Population

Mix (Actual) Plan 2 Population Mix (Actual)

Plan 1 Population Mix (with Agency-required Transition)

Plan 2 Population Mix (with Agency-required Transition)

HCBS 32.5% 39.5% 34.5% 41.5% Non-HCBS 67.5% 60.5% 65.5% 58.5% Total 100.0% 100.0% 100.0% 100.0% For purposes of this illustration, the following rates are assumed. Population Example PMPM

Rate

HCBS $1,000 Non-HCBS $4,000


The rates for Plans 1 and 2 with the example Agency-required transition percentage of 2% would be calculated as follows: Plan 1 HCBS 34.5% * $1,000 = $ 345.00 Non-HCBS 65.5% * $4,000 = $2,620.00 Total = $2,965.00 Plan 2 HCBS 41.5% * $1,000 = $ 415.00 Non-HCBS 58.5% * $4,000 = $2,340.00 Total = $2,755.00


4 Prospective Program Changes that Impact SMMC LTC Bids and Negotiated Rates AHCA intends to recalculate the capitation rate ranges to reflect two prospective program changes that are not reflected in the capitation rate ranges presented in Appendix B. • AHCA implements updates to the Hospice and Nursing Facility fees on a semi-annual basis

(January and July). Per Section 409.982(5), F.S., SMMC LTC contractors are required to pay Hospice and Nursing Facilities at rates no lower than those set by AHCA.

• With the implementation of the SMMC LTC program, contractors will be responsible for providing Behavioral Management, Medication Management and Medication Administration services, which were not provided as distinct services under the predecessor waiver programs.

SMMC LTC ITN Bid Process The following outlines the process AHCA will utilize to reflect the future impact of Hospice and Nursing Facility fee changes, as well as the addition of Behavioral Management, Medication Management and Medication Administration services. • SMMC LTC offerors will submit bids for the HCBS and Non-HCBS components for each

region. The rate ranges the offerors bid must fall within the rate ranges outlined in Appendix B. These rate ranges are within the actuarially sound rate range for each region.

• The rate bids submitted by the SMMC LTC offerors will be negotiated by AHCA and final agreed-upon rates are binding. The rate ranges will be updated to reflect the Hospice and Nursing Facility fee changes effective prior to the implementation of the program for each region. They will also be adjusted to reflect the addition of Behavioral Management, Medication Management and Medication Administration services. If a rate negotiated with an LTC Plan in the initial contract year is within the updated rate range (i.e., the range that reflects the inclusion of the above program changes), AHCA will not change the LTC Plan’s rate. If the rate negotiated with an LTC Plan in the initial contract year falls below the updated rate range, AHCA will contract with the LTC Plan at the lower bound of the new rate range. If the rate negotiated with an LTC Plan in the initial contract year falls above the updated rate range, AHCA will contract with the LTC Plan at the upper bound of the new rate range. If the updated rate ranges decrease as a result of legislated changes, a corresponding decrease will be applied to the negotiated rate.

• No other adjustments beyond those outlined above, legislatively mandated changes or AHCA-implemented changes will be considered. The capitation rate(s) paid to the SMMC


LTC Plans will be the rates bid under this procurement, adjusted, if necessary, as described above.

Nursing Facility and Hospice Fee Change Updates Prior to September 1, 2013, AHCA will update the rate ranges in all regions to reflect the Nursing Facility and Hospice fees that will be in effect from July 1, 2013 to December 31, 2013. If necessary, LTC Plan rates will be adjusted as described above. No further updates to the rate ranges or LTC Plan rates will be made during the September 1, 2013 to August 31, 2014 period related to the Nursing Facility and Hospice fee changes. AHCA will perform a reconciliation to account for the fee changes that impacted Nursing Facility and Hospice services during the September 1, 2013 to August 31, 2014 period. Adjustments for the Addition of New Services Prior to August 1, 2013, AHCA will recalculate rate ranges to include an adjustment for the addition of Behavioral Management, Medication Management and Medication Administration services. As noted above, if the rates negotiated with LTC Plans in the initial year are within the rate ranges that include this adjustment (and the fee change adjustments described above), the LTC Plans’ rates will not change. If the negotiated rates fall below the updated rate range, the LTC Plans’ rates will be set at the lower bound of the rate range.


5 Risk Adjustment Approach This section describes the methodology for AHCA to prospectively adjust the negotiated SMMC LTC capitation rates for differences in actual selection risk related to recipients residing in a Nursing Facility and those in HCBS settings. Under this methodology, the actual payment rate to each contracted LTC Plan may not be the negotiated capitation rate, but instead may be the risk-adjusted rate, if an adjustment is required by this methodology. Under this approach, the contracted LTC Plan and the State agree to accept the final payment rates that result from this risk adjustment methodology (RAM), including any retroactive adjustments related to this RAM and any program changes outlined in Section 4 of this document, without further rate or contract negotiations. AHCA will ensure that the final risk-adjusted payment rates are budget neutral to the State on a regional basis. In other words, the PMPM cost (i.e., federal and State funds combined) of the respective managed care capitation payments in each region must be the same before and after application of the RAM. The approach is outlined below. AHCA will analyze 12 months of historical data 3 months prior to the beginning of enrollment in each region. The enrollment distribution will be calculated using the same population segmentation logic that was used in the SMMC LTC Data Book and the recipient’s latest setting of care will be utilized. A pre-enrollment benchmark rate will be calculated based on this mix. Once the likely eligible recipients are identified, AHCA will begin the enrollment process by notifying eligible recipients. Eligible recipients will be offered the opportunity to select a plan; if they do not choose one, they will automatically be assigned a plan. For new LTC enrollees after the enrollment begin date: • The enrollee will be classified as Nursing Facility (Non-HCBS) if he/she had a Medicaid paid

Nursing Facility claim. • HCBS enrollees will be determined through the Department of Elder Affairs. For rate purposes, for both the transitional and new enrollees, the recipient’s initial classification will remain valid through the contract year.


Operational Plan Month 1 In each region, AHCA will pay each plan a blended capitation rate that reflects the region-wide Nursing Facility/HCBS mix, adjusted for the Agency-required transition percentage for all LTC Plans in the region. AHCA will later perform a reconciliation based on month 1 actual enrollment and case mix for each plan. Subsequent Months For the second month and each subsequent month of the contract payment period, AHCA will develop a blended capitation rate for each LTC Plan, adjusted for the new enrollments and disenrollments that occurred in the previous month (i.e., the second month payment will be based on the first month of enrollment, etc.) and adjusted for the Agency-required transition from the Nursing Facility to the HCBS setting. Once 95% of regional eligible recipients are enrolled in LTC Plans, AHCA will ensure that the recalibrated rates are budget neutral to the State on a PMPM basis. The benchmark against which budget neutrality will be measured is the region-wide rate based on the pre-enrollment mix with the Agency-required transition percentage. AHCA will compute the total PMPM rate for each LTC Plan and if the resulting rates for all plans do not result in a PMPM equal to the benchmark amount to be paid by the State, AHCA will make an adjustment (downward or upward) to compute the recalibrated final payment rates that are budget neutral. An example of the RAM is provided in Appendix C. The figures in Appendix C are for illustrative purposes only and do not tie to the development of the capitation rate ranges in this document.


6 Certification of Final Rate Ranges In preparing the rate ranges for the SMMC LTC program, AHCA’s contracted actuary used and relied upon enrollment, eligibility, claim, reimbursement level, benefit design, financial data and information supplied by AHCA. The State is responsible for the validity and completeness of this supplied data and information. AHCA’s contracted actuary reviewed the data and information for internal consistency and reasonableness but did not audit them. In the opinion of AHCA’s contracted actuary, the data are appropriate for the intended purposes. If the data and information are incomplete or inaccurate, the values shown in this report may need to be revised accordingly. AHCA’s contracted actuary certifies that the rate ranges developed for the SMMC LTC program were developed in accordance with generally accepted actuarial practices and principles, and are appropriate for the Medicaid-covered populations and services under the SMMC LTC program. The actuary certifying these rates is a member of the American Academy of Actuaries and meets its qualification standards to certify to the actuarial soundness of Medicaid managed care capitation rates. Rate ranges developed by AHCA’s contracted actuary are actuarial projections of future contingent events. Actual LTC Plan costs will differ from these projections. AHCA’s contracted actuary has developed these rate ranges on behalf of the State to demonstrate compliance with the CMS requirements under 42 CFR 438.6(c) and accordance with applicable law and regulations. Use of these rate ranges for any purpose beyond that stated may not be appropriate. LTC Plans are advised that the use of these rate ranges may not be appropriate for their particular circumstance, and AHCA’s contracted actuary disclaims any responsibility for the use of these rate ranges by LTC Plans for any purpose. AHCA’s contracted actuary recommends that any LTC Plan considering contracting with the State should analyze its own projected medical expense, administrative expense and any other premium needs for comparison to these rate ranges before deciding whether to contract with the State. This document assumes the reader is familiar with the SMMC LTC program, Medicaid eligibility rules and actuarial rating techniques. Readers should seek the advice of actuaries or other qualified professionals competent in the area of actuarial rate projections to understand the technical nature of these results.


APPENDIX A

Adjustment Tables Appendix A provides the value of certain adjustments used to calculate the rate ranges shown in Appendix B. Tables 1 and 2: Hospice and Nursing Facility Fee Impact – January 1, 2012 – June 30, 2012 Table 1: Hospice Services SFY 2008/2009 SFY 2009/2010 SFY 2010/2011 Region Gross Net Gross Net Gross Net

01 15.0% 17.7% 2.7% 3.1% -0.6% -0.8% 02 14.8% 18.0% 1.6% 1.9% -1.4% -1.7% 03 13.2% 15.6% 0.4% 0.5% -2.2% -2.7% 04 12.1% 14.7% -0.5% -0.6% -2.7% -3.2% 05 14.0% 16.5% 0.6% 0.7% -3.1% -3.8% 06 13.7% 16.1% 0.6% 0.8% -2.5% -3.0% 07 20.3% 22.9% 2.7% 3.2% -1.9% -2.2% 08 11.4% 13.7% -1.8% -2.1% -3.1% -3.7% 09 14.0% 16.1% 0.0% 0.0% -2.8% -3.4% 10 19.6% 21.7% 1.8% 2.1% -2.5% -2.9% 11 14.4% 15.3% -0.1% -0.1% -1.9% -2.1%


Table 2: Nursing Facility Services SFY 2008/2009 SFY 2009/2010 SFY 2010/2011 Region Gross Net Gross Net Gross Net

01 14.1% 17.0% 1.3% 1.5% -0.5% -0.6% 02 10.7% 12.7% -0.3% -0.4% -1.4% -1.7% 03 9.7% 11.6% -0.7% -0.8% -1.7% -2.0% 04 10.7% 12.9% 0.7% 0.8% -1.6% -1.9% 05 10.0% 12.1% 0.0% 0.0% -1.8% -2.1% 06 9.8% 11.7% -0.6% -0.7% -2.3% -2.7% 07 10.2% 12.1% 0.0% 0.0% -2.1% -2.5% 08 8.6% 10.3% -0.9% -1.0% -1.5% -1.7% 09 7.6% 9.0% -0.8% -0.9% -2.0% -2.3% 10 12.0% 13.9% 1.2% 1.4% -1.4% -1.5% 11 8.0% 8.8% -0.2% -0.2% -1.8% -1.9%

Table 3: Contract Payment Period / Midpoints / Trend Months Region Contract Payment Period Midpoint Trend Months*

01 November 1, 2013 – August 31, 2014 April 1, 2014 39.0 02 November 1, 2013 – August 31, 2014 April 1, 2014 39.0 03 March 1, 2014 – August 31, 2014 June 1, 2014 41.0 04 March 1, 2014 – August 31, 2014 June 1, 2014 41.0 05 February 1, 2014 – August 31, 2014 May 17, 2014 40.6 06 February 1, 2014 – August 31, 2014 May 17, 2014 40.6 07 August 1, 2013 – August 31, 2014 February 14, 2014 37.5 08 September 1, 2013 – August 31, 2014 March 1, 2014 38.0 09 September 1, 2013 – August 31, 2014 March 1, 2014 38.0 10 November 1, 2013 – August 31, 2014 April 1, 2014 39.0 11 December 1, 2013 – August 31, 2014 April 16, 2014 39.5

*From the midpoint of the 2010/2011 data period to the midpoint of the contract payment period


Table 4: Mapping of the Data Book Service Categories to the Consolidated Service Categories Consolidated Service Category Data Book Service Category

Assisted Living Assisted Living Case Management Case Management HCBS Adult Companion

Adult Day Health Care Assistive Care Services Attendant Care Caregiver Training Home Accessibility Adaptations Home Health Services Home Delivered Meals Homemaker Intermittent and Skilled Nursing Medical Equipment and Supplies Nutritional Assessment and Risk Reduction Occupational Therapy Physical Therapy Speech Therapy Personal Care Personal Emergency Response System Respiratory Therapy Respite - facility Respite - in-home

Hospice Hospice Nursing Facility Services Nursing Facility Services


Table 5: Average Annual Range of Utilization/1,000 and Unit Cost Trend Consolidated Service Category Trend Type Bottom of the Range Top of the Range

Assisted Living Utilization 0.5% 0.5% Unit Cost 2.5% 4.0%

Case Management Utilization 0.5% 1.0% Unit Cost 0.0% 0.0%

HCBS Utilization 1.5% 2.0% Unit Cost 0.0% 0.0%

Hospice Utilization 0.0% 0.5% Unit Cost 0.0% 0.0%

Nursing Facility Utilization 0.0% 0.5% Unit Cost 0.0% 0.0%

Patient Responsibility* Annual Event 3.6% 3.6% * Patient responsibility is trended according to the Cost of Living Adjustment and is not applied as a compounded trend factor. Table 6: Administration Loading (PMPM) Population Bottom of the Range Top of the Range

HCBS $105.00 $108.50 Non-HCBS $96.00 $98.00

Table 7: Margin Loading (Percentage) Population Bottom of the Range Top of the Range

HCBS 1.50% 1.75% Non-HCBS 1.50% 1.75%


Table 8: Agency-required Transition Percentages

Region Contract Payment Period Transition Percentage

01 November 1, 2013 – August 31, 2014 1.67% 02 November 1, 2013 – August 31, 2014 1.67% 03 March 1, 2014 – August 31, 2014 1.00% 04 March 1, 2014 – August 31, 2014 1.00% 05 February 1, 2014 – August 31, 2014 1.17% 06 February 1, 2014 – August 31, 2014 1.17% 07 August 1, 2013 – August 31, 2014 2.00% 08 September 1, 2013 – August 31, 2014 2.00% 09 September 1, 2013 – August 31, 2014 2.00% 10 November 1, 2013 – August 31, 2014 1.67% 11 December 1, 2013 – August 31, 2014 1.50%


APPENDIX B

Rate Ranges The rate ranges presented in this appendix are within the actuarially sound rate ranges and represent the rate ranges in which AHCA is willing to contract. Please note that these rate ranges are applicable to capitated LTC Plans only and are not applicable to FFS LTC PSNs. Table 9: HCBS Population* Region Contract Payment Period Bottom of the Range Top of the Range

01 November 1, 2013 – August 31, 2014 $1,095.71 $1,129.50 02 November 1, 2013 – August 31, 2014 $760.27 $780.01 03 March 1, 2014 – August 31, 2014 $1,098.74 $1,134.09 04 March 1, 2014 – August 31, 2014 $1,098.74 $1,134.09 05 February 1, 2014 – August 31, 2014 $1,234.72 $1,277.66 06 February 1, 2014 – August 31, 2014 $1,234.72 $1,277.66 07 August 1, 2013 – August 31, 2014 $1,228.95 $1,268.85 08 September 1, 2013 – August 31, 2014 $1,358.17 $1,401.37 09 September 1, 2013 – August 31, 2014 $1,454.57 $1,500.28 10 November 1, 2013 – August 31, 2014 $1,360.24 $1,404.49 11 December 1, 2013 – August 31, 2014 $1,361.28 $1,406.06

*Rates are net of patient responsibility


Table 10: Non-HCBS Population* Region Contract Payment Period Bottom of the Range Top of the Range

01 November 1, 2013 – August 31, 2014 $4,619.89 $4,721.61 02 November 1, 2013 – August 31, 2014 $4,619.89 $4,721.61 03 March 1, 2014 – August 31, 2014 $4,619.90 $4,726.18 04 March 1, 2014 – August 31, 2014 $4,619.90 $4,726.18 05 February 1, 2014 – August 31, 2014 $4,714.38 $4,821.87 06 February 1, 2014 – August 31, 2014 $4,619.90 $4,725.27 07 August 1, 2013 – August 31, 2014 $4,714.35 $4,814.65 08 September 1, 2013 – August 31, 2014 $4,948.21 $5,054.68 09 September 1, 2013 – August 31, 2014 $4,948.21 $5,054.68 10 November 1, 2013 – August 31, 2014 $5,166.61 $5,273.67 11 December 1, 2013 – August 31, 2014 $5,166.61 $5,274.95

*Rates are net of patient responsibility


APPENDIX C

Risk Adjustment Example Calculation The following example is for illustrative purposes only. The figures in thisexample do not tie to the rate ranges outlined in this report.

AssumptionsAgency-required Transition

2%

RatesHCBS 1,000$ Non-HCBS 4,000$

Pre-enrollment The pre-enrollment membership is measured 3 months in advanceof the enrollment date in each region, analyzing 12 months of dataand using the segmentation logic applied in the Data Book.

Pre-enrollment MembershipPlan A Plan B Total

HCBS N/A N/A 1,800 Non-HCBS N/A N/A 5,900 Total N/A N/A 7,700

Pre-enrollment Membership MixPlan A Plan B Total

HCBS N/A N/A 23.4%Non-HCBS N/A N/A 76.6%Total N/A N/A 100.0%

Pre-enrollment Membership Mix with Agency-required TransitionPlan A Plan B Total

HCBS N/A N/A 25.4%Non-HCBS N/A N/A 74.6%Total N/A N/A 100.0%

Month 1Month 1 - Payment to Plans*

Plan A Plan B TotalTotal 3,239$ 3,239$ 3,239$ *This amount is later reconciled to actual plan enrollment. Reconciliation not shown here. This PMPM is also the benchmark PMPM for the Budget Neutrality calculation.


Month 2 Measure Actual Enrollment in Month 1

Plan A Plan B TotalHCBS 1,050 820 1,870 Non-HCBS 3,020 2,850 5,870 Total 4,070 3,670 7,740

Actual Enrollment Percentage (Based on Month 1)Plan A Plan B Total

HCBS 25.8% 22.3% 24.2%Non-HCBS 74.2% 77.7% 75.8%Total 100.0% 100.0% 100.0%

Enrollment Percentage (Based on Month 1) with Agency-required TransitionPlan A Plan B Total


Month 2 - Payment to Plans before Budget NeutralityPlan A Plan B Total

Total 3,166$ 3,270$ 3,215$

Budget Neutrality Factor*1.0073

* The Budget Neutrality adjustment would not be triggered until 95% of of regional eligible recipients are enrolled in LTC Plans. The Budget NeutralityFactor is displayed here for illustrative purposes only.

Month 2 - Payment to Plans After Budget NeutralityPlan A Plan B Total

Total 3,189$ 3,294$ 3,239$


Month 3

New Enrollment / DisenrollmentsPlan A Plan B Total

HCBS 5 5 10 Non-HCBS - (5) (5) Total 5 - 5

Enrollment for Rate PurposesPlan A Plan B Total

HCBS 1,055 825 1,880 Non-HCBS 3,020 2,845 5,865 Total 4,075 3,670 7,745

Percentage Enrollment for Rate PurposesPlan A Plan B Total


Percentage Enrollment for Rate Purposes with Agency-required TransitionPlan A Plan B Total


Month 3 - Payment to Plans Before Budget NeutralityPlan A Plan B Total

Total 3,163$ 3,266$ 3,212$

Budget Neutrality Factor*1.0084

* The Budget Neutrality adjustment would not be triggered until 95% of of regional eligible recipients are enrolled in LTC Plans. The Budget NeutralityFactor is displayed here for illustrative purposes only.

Month 3 - Payment to Plans After Budget NeutralityPlan A Plan B Total

Total 3,190$ 3,293$ 3,239$

In Month 2, Plan A transitioned 10 people from NF to HCBS and enrolled 5 additional HCBS recipients.

In Month 2, Plan B transitioned 5 people from NF to HCBS, enrolled 5 additional HCBS recipients and disenrolled 5 NF recipients.

Barbara B. Vaughan - myflorida.com · Barbara B. Vaughan Barbara B. Vaughan, SMA Procurement Office...

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