Answers
Questions and Answers: adultBasic Request for Proposal
 

In the prior RFP the administrative expense was 10% - it appears this is now being scaled back to 7.5%. Is that an accurate assessment?
No. Part II-5 (Page 22) states that the Department's goal is to contain any annual PMPM cost increases to the level of annual medical inflation or 7.5%, whichever is lower. Part II-5 (4) Administrative Expenses (Page 32) allows Administrative Expenses up to ten percent of the total rate, but requires expenses to be fully described and justified.

 

In the prior RFP under Benefits - Transplant Services including immunosuppressants were specifically listed as a benefit. In this RFP there is no specific mention of that benefit. Does this mean that we should no longer include that as a benefit?
The Department's requirement is that enrollees requiring transplant services be identified and evaluated for potential eligibility for Medicaid, thereby eliminating the need to provide transplant services or the subsequent treatments through the adultBasic Program. Page 46 of the RFP requires each contractor to have protocols in place that identify such persons and others who may be eligible for Medicaid categories of coverage for which Federal funds are available (e.g. disability). In cases where it is determined that the transplant is necessary, but the person is not eligible for MA, transplant services and immunosuppresants will be provided through adultBasic as in the past.

 

To assist us with our proposal and an ongoing analysis of our operations we need some data from CAPS. Specific to our plan the total individuals processed (i.e. apps renewals redetermined eligibility) for the last year (Oct '03 - Sept '04). We need the totals provided separately for CHIP and aB. It would also be helpful to have the totals broken out by category. But we do not absolutely need this part of the request especially if it adds an additional level of complexity.

The questioner may contact Deloitte (the Department’s IT contractor) directly to obtain the requested information. The contact at Deloitte for this action is Sarji Ramanathan. Mr. Ramanathan can be reached by email at saramanathan@dc.com or by phone at (717) 526-0430 ext 5305.   

 

In section G.1.c.3 of Appendix D: Are the questions in this section referring to the plan's processes surrounding the initial review of a request for service/care or the processes followed after the service/care has been denied and a grievance had been filed?

The question refers to the plan’s processes when a grievance is filed as a result of a denial of service.

 

In working through the response template and the work plan it appears that there are some sections in the work plan that are not on the template. Does this mean that those sections not specifically listed on the template should not or do not need responses? For instance page 59 of the RFP which would be D.12 Medical Necessity states that each contractor must provide in its response to this RFP the definition of medical necessity it will utilize; however this section is not included in the template. There are numerous sections as listed below that are not on the template. In reviewing these sections there are not specific questions within those sections in Part II of the RFP it states that the technical proposal should provide evidence of the offeror's ability to meet the work statement described in Part IV of the RFP. I would assume this means we should respond to the work plan in it's entirety. Please clarify. If there is any way to receive a response to this question before November 2 because in order to meet the 11/19 deadline the draft of our response will need to be completed before that time.
There are sections within the Work Plan that state the requirements under the contract. As such, these statements require no response in the proposal unless direction for doing so is provided in the response template. Therefore, if the offeror answers all the questions in the template, their response is complete.

The specific area questioned above, Medical Necessity, is addressed in Appendix E, fifth statement from the end. If the offer deviates from the definition provided in the RFP, annotate the deviate column and attach the definition to be used by the offeror to the Appendix E submission.

There is an error in the response template. D.3 should, in fact, be PCP/Medical Home Responsibility and provides requirements, but has no specific response required. D.4 is CRNP as a PCP/Medical Home.

 

On your request for the prescription drug benefit with a $5 generic and $10 branded copay we assume that you are referring to a full prescription drug program and not only for the mandated supplies such as the diabetic supplies. Can you confirm.
The assumption is correct.

 

The Cost Proposal section of the RFP states that "...the Department's goal is to contain costs to the level of annual medical inflation or seven and one-half percent (7.5%) whichever is lower". Does the lesser of 7.5% or "medical inflation" requirement apply to the upcoming contract year (3/1/05-6/30/06) only or to the length of the entire contract (3 years)? If the "7.5% requirement" applies to future years also can we make provisions in the initial rates to account for the rate increase limitations in the second and third years of the contract?
The goal of containing costs to the level of annual medical inflation or seven and one-half percent, whichever is lower is a per annum goal for each of the years of the contract. (e.g. no more than 7.5% increase over current costs for the first year of the contract and no more than 7.5% increase for each of the succeeding two years).

 

For what timeframe should statistics be provided? The last 12 months (10/03-9/04)? Calendar year 2003? Other? Also is the reference to admissions only and not activity upon concurrent review?
We are uncertain to what exactly you might be referring. If "statistics" refers to the Experience Data to develop the rate in the RCS Form in Appendix H, it is the most current consecutive 12 months data - it need not be calendar year. However, the Historical Experience Data (page 34 and 36 - item 6) must be provided by calendar year in the format included in Appendix I.

 

Assuming we capture our administrative expense data differently than the proposed format can we submit administrative expense information in the format which we utilize currently to capture and analyze expenses?
Please provide the administrative expenses in the required Department format. You may, in addition, provide the format used by you to capture and analyze data.

 

Is an RCS for "Full Cost" members required?
An RCS for “Full Cost” enrollees is not required for the purpose of the RFP. However, the Department reserves the right to request that data in the future.

 

For the benefit packages relative to the medical PMPMs of $150 $200 and $280 do these packages need to include all the PA state mandated benefits?
It is unclear what the questioner means by the phrase “state mandated benefits”.

If the questioner means the benefits required to be provided by all insurers in their commercial products (in accordance with the Insurance Company Law as amended), the answer is No.  However, if the questioner is referring to the benefits specified in 35 P.S. Section 5701.1303(f)(2) for the adultBasic program, the answer is a qualified Yes.

The intent of Benefit Package 3 is to seek from offerors “what it would take” to provide all benefits prescribed by the statute at the three specified price points.  For example, we are interested in the degree to which cost shifting to consumers would be required, what limitations of services might be necessary, etc. The offeror may choose to offer a benefit package with fewer benefits but also must explain the rationale for doing so and how it could be done without adversely affecting consumers.

 

On page 1, fourth paragraph, you mention "service areas", but do not further define the term in the definitions. For the purpose of this RFP, what is the definition of service area that is to be used?
For the purposes of this RFP, "service area" is defined as a county or group of counties (contiguous or non-contiguous) in which the offeror proposes to provide adultBasic Coverage.  In order to propose coverage in a county or group of counties, the offeror must be properly approved by the Department of Health (in the case of an HMO) to do business in the area selected as a condition for issuance of an HMO certificate of authority by the Insurance Department and the Department of Health.  Offerors who operate subject to the provisions of 40 Pa. C.S. Ch. 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations) or both are reminded that their offer must include all counties or areas in the Commonwealth as identified in their licensing agreement through the BlueCross BlueShield Association.

 

On page 1 paragraph 4 last 2 sentences give the impression that only one contractor per service area will be selected - yet on page 3 it states that the Department intends to award multiple contracts and does not specify per service area. Can you please clarify?
It is the intent of the Department to have a single contractor provide coverage to individuals in a service area (as service area is defined above). Multiple contracts means that we will be awarding more than one contract (just as we now have four) as a result of this RFP.

 

Is the Department willing to accept the exclusion of major categories of care (e.g. Outpatient Services) in order to meet the premium levels as outlined in Package 3? If no can the Department please provide guidance on what modification to benefits can be made to achieve the suggested rates?
See the response to the prior question relating to modifications to the benefit package.

 

The value of these component benefits is dependent upon the overall medical plan to which it applies. Is it acceptable to price these components assuming the current plan of benefits?
Yes

 

Relative to Section G.1.c.3 The last two questions. We are not sure of the intent of the questions. The next question after this asks for the same information. Are you asking for the % of initial cases denied? If so what types of cases: non-par precerts etc.? We do not believe that you are referring to initial determinations is that correct?
G.1.c.3 does not refer to initial determinations. We are interested in the percentage of cases denied in the grievance process and then the percentage of those denials that are maintained upon appeal. This is regardless of category (pre-certs, non-par precerts, etc.). Question G.1.c.4 is different as it requests the description of the process, not the data resulting from the process.

 

Regarding Section G.1.b.8 Please clarify if you are asking for how many patients were admitted after being seen in the ER or how many people were seen in the ER and the case was denied. We do not review ER visits because of ACT 68 and the prudent lay person definition. Claims are only denied if there is a benefit or eligibility issue. We have complaints on these but they are not classified as grievances.
Question G.1.b.8 does not request a number of patients admitted or denied, but is more targeted at the offeror's process for monitoring  / controlling emergency room admissions. The bulleted items are to help fully describe the process. (If reviews are conducted, what is the percentage of the reviews that are referred to a staff physician or specialist consultant? What criteria does the offeror use for referring a case to a physician for review?)

 

Is Question G.1.b.8 referencing emergency room inpatient admissions only?
Yes

 

In section A.2.a reference is made to "live answer" and "incomplete calls". Definitions of these terms would be helpful. It is possible that we analyze our call activity similarly to how the Commonwealth requests but we just refer to the categories differently.
"Live answer" calls are those calls directly answered by a person (customer service representative) during the established hours of operation.

"Incomplete calls" are calls in which no contact occurs between the caller and the Member Helpline due to a busy signal, recorded message, no answer or caller initiated disconnect prior to connection (during established hours of operation).

 

In section G.2.a the fifth bullet indicates that we are to provide "summary case management information on a quarterly basis". There is no other mention of this requirement in the RFP; it is even absent under the Quarterly Reports section on page 69. Please provide detail on the format and what specific information is required. Without further clarification we cannot confirm that the information can be submitted.
The reports noted in Part IV-7, D(1)(a) are reports that are currently required by the program and as noted in the last paragraph of subsection (c), "The above list of reports is subject to change as deemed appropriate by the Department."  The case management summary reports noted in G.2 will be reports that we eventually expect to develop and require sometime after the new contracts are in place.  At this time, there is no specific format.   The summary reports will be developed and formatted based partly on information received via this RFP which will give us a better sense of what offerors can provide generally. In the event that the Department determines that reporting this type of information is not feasible, we may reconsider the requirement all together.  The point of the requested confirmation is to determine whether offerors have the capability of reporting out case management information.

 

Can you advise if any specific attachments are being requested. Our review did not seem to indicate that attachments such as QM UM DM plans are mandated only optional. Also regarding page numbering does the page numbering apply at the tab level or the document level. That is if Tab 1 has 5 pages and then Tab 2 has ten pages would page numbering for Tab 2 begin with 6 or should it be numbered 2-1 etc.
Page 18 of the RFP cautions offerors to not provide more documentation than necessary to demonstrate their ability to meet the work statement; however, the RFP allows for the submission of addenda that further explains or augments a response to a requirement (page 16 II-2). Attachments such as those identified in the offeror's question need not to be included for evaluation as part of the proposal. However, a successful offeror may be asked to supply such documents at a later date for the Department's review.

The RFP requires that the pages be numbered for easy reference. The Department has no preference on the method used to number the pages.

 

According to the RFP offerors are to cover a disease management program for obesity. Are we to also cover medical and surgical costs related to a diagnosis of obesity? Currently such services are not cover and in actuality were specifically excluded according to the Q&A (#65) of the 2001 RFP.
The requirement to offer Disease Management for obesity relates only to non-surgical methods of managing obesity.  These may include such activities as proactive identification of at-risk individuals, telephonic counseling, education and ongoing support, incentives and rewards, discounts on gym memberships, resource identification, provider education, diet and nutrition counseling, tool identification and the like.

 

When responding would you prefer to see the question you posed in the template and then response or does it not matter if the question is included as long as all parts are answered?
The Department would prefer to have the question followed by the offeror's response. Appendix D, RFP Response Template was placed on the web site as a Word document to facilitate downloading and cutting and pasting responses directly into the template.

 

Is the Department requiring Offerors to provide the Prescription Drug Discount Program to adultBasic eligibles on the wait list (even if they are not purchasing At Cost Coverage)?
No. Part IV-4.B.1.n (Benefit Plan - Prescription Drugs) requires that if the contractor has a prescription drug discount plan currently available in Pennsylvania, the contractor shall provide such a plan at no cost to enrollees as an additional benefit of this program.
Eligible adults on the wait list purchasing at full cost would get the same benefits as those we are subsidizing through the adultBasic program - they would be considered enrollees at full cost. adultBasic eligibles on the wait list who are not purchasing at full cost are not enrollees.

 

In the text of the RFP page 50 (item i) you refer to a prior authorization chart for Specialist Services in Appendix D. Is there a chart we must complete that was not included?
The Offeror is not required to submit a prior authorization chart.   It was the intention of the Department to remove reference to the prior authorization chart on page 50 of the RFP.  However, it was inadvertently retained in the text.

 

In the text of the RFP page 51 under Disease Management you list target diseases for management under adultBasic. Must Offerors propose to offer disease management for all of these listed? What if a current disease management program is not available for one of the targeted diseases?
The Department's intent is to have disease management programs for each of the targeted diseases as an additional tool used to control costs of health care. If an offeror does not currently have a disease management program for one or more of the targeted diseases, please describe the approach that would be taken to institute the disease management program. Also complete the respective charts in IV-5.C of Appendix D (data sources for identifying candidates, components of the program, and measuring of the process and outcomes) proposed for that specific disease.

 

In the event an offeror would like to submit a proposal for two Contracted Service Areas (one using a PPO model and the other using an HMO model) how should the questions concerning provider networks provider services appointment standards QM and UM be answered in Appendix D? Should we break out each response into the coverage types being proposed? (e.g. answer each question for HMO and then again for PPO).
Yes, either question by question or a section for the HMO response and a separate section for the PPO response. Either method is acceptable as long as the answer is clearly marked.

 

In the event two contractors bid on the same county will the PID select only one contractor or will multiple contractors be permitted? In counties with multiple contractors will selected contractors be required to match the highest ranked Offeror rate?
The Department's intent is to have one contractor per county.

 

Are plans required to collect adultBasic specific HEDIS and CAHPS or are plan wide results acceptable?
The Department will not require adultBasic specific HEDIS or CAHPS for at least the first year of the contract.  However, depending on internal Departmental factors, the Department may require contractors to undergo either the HEDIS/CAHPS process or an alternative external review process yet to be determined
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Under Tab 5A.2 do you want us to respond with information about all of the member service and enrollment/eligibility service units that would service this account in each region? For instance there is an HMO service unit that handles all insurance related calls; there is a similar unit set up for the PPO service; and a dedicated eligibility/enrollment/outreach service unit. Do you want an answer for all three under each bullet/question?
The Department is interested in the overall process and the level of service provided to potential callers, not necessarily the individual units that would provide the response. If processes differ for each of the units, the differences should be explained (e.g. standards for rates of response may vary between the dedicated eligibility service unit and the general insurance related units). Your response should not be limited to the bulleted items; these were provided as a guide in the preparation of the response. The most complete response would include the process from the time an individual initiated a call to any component of the contractor through the resolution of the reason for the call and the processes utilized by the contractor to measure the service and satisfaction level of the help line.

 

In Section IV-4 B.1.n of the RFP it states: "Does not include prescription drugs other than those specifically mentioned above." There does not seem to be a reference to immunosuppressants even though this drug category is currently included in the adultBasic benefit package? Should immunosuppressants no longer be included?
The Department's requirement is that enrollees requiring transplant services be identified and evaluated for potential eligibility for Medicaid, thereby eliminating the need to provide transplant services or the subsequent treatments through the adultBasic Program. Page 46 of the RFP requires each contractor to have protocols in place that identify such persons and others who may be eligible for Medicaid categories of coverage for which Federal funds are available (e.g. disability). In cases where it is determined that the transplant is necessary, but the person is not eligible for MA, transplant services and immunosuppresants will be provided through adultBasic as in the past.

 

Please define “relevant” as it used in Appendix D Tab 3 item k. Are you interested in government clients adult populations being administered for clients special income programs etc.?
The Department is interested in ensuring that the offeror has the corporate experience and background to undertake this project. Relevant clients should mirror the relevant experience described in Appendix D, Tab 3, item a. This would include any program administered by the offeror that is similar to the adultBasic program in that it is administered on behalf of another entity, it includes a limited Benefit package, the enrollees must meet specific eligibility requirements, and the offeror is responsible for managing the application, eligibility determination, and enrollment and renewal processes.

 

May an offeror that meets the criteria in the Instructions section of the RFP submit a proposal with a co-offeror that qualifies as a charitable organization under Section 501(c)(3) of the Internal Revenue Code? The RFP provides that an offeror "must be" one of the following entities: a health plan corporation a health maintenance organization a risk-assuming preferred provider organization or a life or health insurance corporation that meets the licensing requirements of the Pennsylvania Insurance Department and Department of Health. Although the adultBasic statute requires that a "contractor" be one of the entities described above the statutory language does not preclude the Commonwealth from permitting co-offerors as is done with the CHIP program. As the Commonwealth is aware most of the current adultBasic contractors sub-contract with their non-profit foundations to provide some administrative services for the adultBasic program including the following! services expressly set
It was the Department's intent to utilize the electronic contracting process (“SAP”) and the appropriate Standard Terms and Conditions for that process were made part of the RFP (Appendix A). However, the “SAP” process does not allow for co-contractors. Therefore, to allow for co-contractors, based on the request in the above question, we will not utilize the “SAP” Contract. This will require a different set of Contract Standard Terms and Conditions. The revised Standard Terms and Conditions are on the web site at Appendix A - revised. Offerors are reminded, requirements of this RFP and commitments made in the proposals of selected offerors will become part of each contract and are not subject to negotiation.

 

Please clarify "complaints" and "appeals" as listed in G.1.c.1 and G.1.c.2 in Appendix D. In order to adequately reply we need greater specificity. Is complaint referring to an informal complaint process such as through Member Services whereas appeals is meant to encompass the formal complaint and grievance process?
The inadvertent omission of the word "grievance" from the question in G.1.c.1 may have caused some confusion. The question should read "Describe how the offeror handles complaints and grievances".  The reference here is in relationship to Act 68, Article XXI Quality Health Care Accountability and Protection, Section 2141, and how the offeror's appeal process is structured to comply with state law.  G.1.c.2 also relates to Act 68.

 

The following benefits were included in the 2001 RFP as covered services but are not even mentioned in this RFP: Rehab Therapies Home Health Care in lieu of inpatient hospital stay Blood and blood products furnished in connection with covered surgery or inpatient hospital services Are these services to be covered for this RFP?
Under the cost proposal section of this RPF, Part II-5, package 1 requires offerors to price a package of services as noted on the RCS form, Appendix H.  The RCS form specifically lists rehab therapies.  We also note on the RCS sheet categories for miscellaneous services under "hospital", "physician", and "other".  Please refer back to Part II-5(A) "Rating Information by Contracted Area - Instructions for Completing the Rate Calculation Sheet".  Offerors should list/spell out such services as, but not limited to, home health care in lieu of inpatient hospital, enteral formulas, transplant services, and other covered services which are not specifically listed on the RCS form. Also refer to Part IV-3, subsection B(1) - Benefit Package.

 

The 2001 RFP included a list of excluded services this RFP does not. Can the Department provide a list of excluded services?
The Department elected not to list exclusions in this RFP due to the confusion it generated in the last RFP process.  Instead, under the cost proposal section of this RPF, Part II-5, package 1 and 2, the Department is basically requiring offerors to price a package of core services as noted on the RCS, Appendix H.  The RCS sheet also lists categories for miscellaneous services under "hospital", "physician" and "other".  Offerors should list such services as, but not limited to, home health care in lieu of inpatient hospital, enteral formulas, transplant services, and other covered services which are not specifically listed on the RCS form.  Offerors should also refer to Part IV-3, subsection B(1) - Benefit Package.  Subsection (j) includes a reference to "Inpatient Hospitalization and Skilled Nursing Facility (in lieu of inpatient hospitalization)" as part of the overall benefit package.

 

Shall Offerors rate for: Home Health Care (in lieu of inpatient hospitalization); Hospice Care; Enteral Formula under PKU Mandated benefits; Transplants; and/or immunosuppressants for transplant surgeries under covered drugs? We did not see these things specifically listed in the Benefits section.
Under the cost proposal section of this RPF, Part II-5, package 1 requires offerors to price a package of services as noted on the RCS form, Appendix H.  The RCS form specifically lists rehab therapies.  We also note on the RCS sheet categories for miscellaneous services under "hospital", "physician", and "other".  Please refer back to Part II-5(A) "Rating Information by Contracted Area - Instructions for Completing the Rate Calculation Sheet".  Offerors should list/spell out such services as, but not limited to, home health care in lieu of inpatient hospital, enteral formulas, transplant services, and other covered services which are not specifically listed on the RCS form. Also refer to Part IV-3, subsection B(1) - Benefit Package.  

 

 

 

 

 

 

 

 

 
02/05/2004 07:33 AM 11/02/2004 11:15 AM 11/02/2004 11:15 AM 11/02/2007 12:15 PM "Melissa Fox"