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ATTACHMENT E TECHNICAL PROPOSAL INSTRUCTIONS

AHCA ITN 024-12/13, Attachment E, of 14

The purpose of this document is to provide respondents with instructions for completing the Technical Proposal required in Attachment C, Section I.B.7.e., Technical Response. This document includes sections applicable for Standard MMA Plans and Specialty Plans. Respondents to this ITN shall utilize Attachment E, Exhibits E-1 through E-5, as applicable. RESPONDENTS SHALL SIGN AND RETURN THE ATTESTATION PROVIDED IN EXHIBIT E-6, RESPONDENT ATTESTATION FOR RESPONSE SUBMISSION WITH THEIR TECHNICAL PROPOSAL SUBMISSION OR THE RESPONSE WILL BE REJECTED. Standard MMA Plan Technical Proposal Instructions Respondents to this ITN shall utilize Attachment E, Exhibits E-1 through E-5, as applicable. All respondents bidding on a Standard MMA Plan shall complete the following Exhibits to Attachment E: Exhibit E-1, Standard Submission Requirements and Evaluation Criteria; Exhibit E-2, Standard Quality Measurement Tool; and Exhibit E-3, Provider Network Assessment Tool. Exhibit E-1, Standard Submission Requirements and Evaluation Criteria Respondents must respond to all Submission Requirements and Evaluation Components (SRCs) and submit a narrative response to each SRC contained in Exhibit E-1, Standard Submission Requirements and Evaluation Criteria. SRCs are included under each of the headings below:

• Qualifications and Experience (SRC #1 – SRC #10); • Eligibility and Enrollment (SRC #11 – SRC #12); • Enrollee Services and Grievance (SRC #13 – SRC #17); • Covered Services (SRC #18 – SRC #24); • Provider Network (SRC #25 – SRC #33); • Quality and Utilization Management (SRC #34 – SRC #41); and • Administration and Management (SRC #42 – SRC #56).

Each SRC in Exhibit E-1, Standard Submission Requirements and Evaluation Criteria, contains form fields with unlimited character spaces. Respondents shall name and label attachments to refer back to the number identifier for the respective SRC, as outlined in Exhibit E-1. Respondents are responsible for drafting and monitoring their text entry and use of attachments to ensure each SRC is answered completely and to the best of the respondent’s ability while adhering to the binder limitations outlined in Attachment C, Section I.B.6, Response Submission Requirements. Respondents shall not include website links, embedded links and/or cross references between response SRCs to circumvent the Agency’s prescribed response instructions. Exhibit E-2, Standard Quality Measurement Tool The respondent shall enter Healthcare Effectiveness Data and Information Set (HEDIS) performance measure data from three different states in which it operates for each performance measure included in SRC #10. For each measure, the respondent shall enter the name of the state, the state’s standard or goal rate, the national mean for the year being reported for each line being reported, and the rate that the plan achieved for the measure in the year being reported. The respondent shall use the following indicators for the Medicaid, Medicare or Commercial Indicator column: “MC” for reporting a Medicaid performance measure; “MA” for reporting a Medicare performance measure; and “CM” for reporting a Commercial performance



measure. For SRC #10, Year 1 refers to Calendar Year 2010 (HEDIS 2010) and Year 2 refers to Calendar Year 2011 (HEDIS 2011). Exhibit E-3, Provider Network File The respondent shall submit a Provider Network File that contains a comprehensive listing of the respondent’s proposed provider network. Respondents shall submit both a printed hard copy and electronic version of the Provider Network File saved to CD. The electronic version of the Provider Network File shall be an Excel spreadsheet, and should adhere to the data specifications outlined below. The Agency will evaluate the Provider Network File using a Provider Network Assessment Tool, as specified in Exhibit E-1, Standard Submission Requirements and Evaluation Criteria, SRC #29 and SRC #30. An example of a Provider Network File is located in Exhibit E-3, Provider Network File. TABLE 1: Provider Network File Field Formats and General Instructions The data specifications for the Excel Provider Network File are summarized in TABLE 1. The first row of the file should contain header names as described in the "Column Header" field of TABLE 1. All columns in the Excel spreadsheet should be formatted as TEXT, with the exception of AGREE_DATE, which should be formatted as a DATE. The number in parentheses (#) in the “Format” field is the maximum length accepted for this field. If no max is specified then there is no restriction on the length of the field. Note: This is a maximum length and data that is less than the maximum should not be padded in any way to make it equal to the maximum length.

TABLE 1: Provider Network File Field Formats

Short Description Column Header

Format (Length, if Applicable) Required Note

Provider ID /Registration Number

PROV_ID TEXT (9) If Applicable

If known, the 9 digit Medicaid ID number provided by FMMIS when a provider is either enrolled or registered with Florida Medicaid.

Provider Name PROV_NAME TEXT Required

Business name of provider, or for individuals, Lastname, Firstname.

Group Name GROUP_NAME TEXT If Applicable Name of group association.

License Number LICENSE TEXT If Applicable

The license number for this provider if the licensure is required for the identified provider.






SSN /FEIN FEIN TEXT (9) Required

Social Security Number (no dashes) or Federal Employer Identification Number for the individual practitioner, facility, or group practice.

NPI Number NPI TEXT (10) If Applicable

National Provider Identifier number for the Provider or Group if NPI is required.

City CITY TEXT Required

The city where the provider service location is physically located.

Zip Code ZIP TEXT (5) Required

The 5-digit zip code where the provider service location is physically located.

County Code COUNTY_CODE TEXT (2) Required Select values from Table 2: County Codes

Agreement Type AGREE_TYPE TEXT (1) Required

Select values from Table 3: Agreement Type

Agreement Date AGREE_DATE DATE

(mm/dd/yyyy) Required

The date of the agreement with provider. If a written contract, it must match the effective date of the contract.

Provider Type PROV_TYPE TEXT (2) Required Select values from Table 4: Provider Type Codes

Specialty Type PROV_SPEC TEXT (3) Required Select values from Table 4: Provider Type Codes

PCP Indicator PCP_IND TEXT (1) Required Is this provider or group a Primary Care Provider? Y or N.






Electronic Health Records Indicator

EHR_IND TEXT (1) Required Does this provider use Electronic Health records? Y or N.

Mail Order Indicator MAIL_IND TEXT (1) Conditional:

See Note

Is this pharmacy a mail-order pharmacy? Y or N. This field only applies to PROV_TYPE = 20, Pharmacy. If non-pharmacy, leave NULL.

Bed Count BED_COUNT TEXT Conditional: See Note

The number of beds the health plan is contracted for at this facility. This field only applies to hospitals and crisis stabilization units. If no contracted beds, leave NULL.

Statewide Essential Provider

ESS_PROV TEXT (1) Required

Is this provider a statewide essential provider, as defined in the resulting Contract? Y or N.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK



TABLE 2: County Codes Include the COUNTY_CODE corresponding to the name of the county where the provider service location is physically located.

TABLE 2: County Codes County Name County Code County Name County Codes Alachua 01 Leon 37 Baker 02 Levy 38 Bay 03 Liberty 39 Bradford 04 Madison 40 Brevard 05 Manatee 41 Broward 06 Marion 42 Calhoun 07 Martin 43 Charlotte 08 Monroe 44 Citrus 09 Nassau 45 Clay 10 Okaloosa 46 Collier 11 Okeechobee 47 Columbia 12 Orange 48 Dade 13 Osceola 49 Desoto 14 Palm Beach 50 Dixie 15 Pasco 51 Duval 16 Pinellas 52 Escambia 17 Polk 53 Flagler 18 Putnam 54 Franklin 19 St. Johns 55 Gadsden 20 St. Lucie 56 Gilchrist 21 Santa Rosa 57 Glades 22 Sarasota 58 Gulf 23 Seminole 59 Hamilton 24 Sumter 60 Hardee 25 Suwannee 61 Hendry 26 Taylor 62 Hernando 27 Union 63 Highlands 28 Volusia 64 Hillsborough 29 Wakulla 65 Holmes 30 Walton 66 Indian River 31 Washington 67 Jackson 32 Georgia 68 Jefferson 33 Alabama 69 Lafayette 34 Other State 70 Lake 35 Dade 85 71 Lee 36 Unknown 72



TABLE 3: Agreement Type For each provider in network, include the AGREE_TYPE corresponding to the type of agreement shared with that provider.

TABLE 3: Agreement Type Agreement Type with Provider AGREE_TYPE Letter of Intent I Letter of Agreement A Contract C

TABLE 4: Provider Type Codes For each provider in network, select the PROV_TYPE and PROV_SPEC based on the appropriate Provider Type Description. If a provider has more than one specialty, enter that provider as separate records for each known specialty. Only use provider types and specialty codes that are associated with each other as specified in TABLE 4.

TABLE 4: Provider Type Codes

Provider Type Description PROV_TYPE PROV_SPEC Family Practice 25 009 General Practice 25 011 Pediatrics 25 035 Internal Medicine 25 018 Advanced Registered Nurse Practitioner (ARNP) 30 930 Physician Assistant 29 929 Hospital (acute care) 01 901 Hospital with birth/delivery services 01 200 Emergency Services 01 201 Home Health 65 965 Adult Family Care Home 14 125 Assisted Living Facility (ALF) 14 121 Birthing Center 69 969 Hospice 15 915 Durable Medical Equipment (DME) 90 990 Pharmacy 20 150 24- hour Pharmacy 20 203 Adolescent Medicine 25 001 Allergies 25 002 Anesthesiology 25 003 Cardiology 25 004 Cardiology (PEDS) 25 037 Cardiovascular Surgery 25 053



TABLE 4: Provider Type Codes Provider Type Description PROV_TYPE PROV_SPEC

Cardiovascular Surgery (PEDS) 25 204 Chiropractic 25 928 Dermatology 25 005 Endocrinology 25 008 Endocrinology (PEDS) 25 205 Gastroenterology 25 010 General Dentist 35 071 General Surgery 25 055 Infectious Diseases 25 017 Midwife 34 934 Nephrology 25 021 Nephrology (PEDS) 25 039 Neurology 25 022 Neurology (PEDS) 25 023 Neurosurgery 25 057 Obstetrics/Gynecology 25 027 Oncology 25 029 Ophthalmology 25 030 Optometry 62 962 Oral Surgery 35 072 Orthodontist 35 088 Orthopedics 25 206 Orthopedics (PEDS) 25 207 Orthopedic Surgery 25 058 Orthopedic Surgery (PEDS) 25 208 Otolaryngology 25 031 Pathology 25 032 Podiatry 27 927 Pedodontist 30 078 Pulmonology 25 046 Rheumatology 25 051 Therapist (Occupational) 83 090 Therapist (Speech) 83 092 Therapist (Physical) 83 091 Therapist (Respiratory) 83 093 Urology 25 209 Board Certified or Board Eligible Adult Psychiatrists 25 042 Board Certified or Board Eligible Child Psychiatrists 25 043



TABLE 4: Provider Type Codes Provider Type Description PROV_TYPE PROV_SPEC

Licensed Practitioners of the Healing Arts 07 907 Licensed Community Substance Abuse Treatment Centers 05 905 Inpatient Substance Abuse Detoxification Units 01 901 Fully Accredited Psychiatric Community Hospital or Crisis Stabilization Unit (CSU) ADULT 01 210 Fully Accredited Psychiatric Community Hospital or CSU CHILD 01 211

Specialty Plan Technical Proposal Instructions Respondents to this ITN shall utilize Attachment E, Exhibits E-1 through E-5, as applicable. All respondents bidding on a Specialty Plan shall complete the following Exhibits to Attachment E: Exhibit E-1, Standard Submission Requirements and Evaluation Criteria; Exhibit E-2, Standard Quality Measurement Tool; Exhibit E-3, Provider Network Assessment Tool; Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria; and Exhibit E-5, Specialty Quality Measurement Tool. Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria Respondents must respond to all SRCs and submit a narrative response to each SRC contained in Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria. SRCs which must be addressed are described below. Unless otherwise indicated, the Agency is not requiring minimum requirements but encourages respondents to exceed the minimum requirements for MMA Plans. While providing substantial flexibility in order to accommodate innovation from respondents for various specialty populations, the Agency is providing examples below of potential responses to specific SRCs for the purpose of illustration only. The examples provided by the Agency do not represent the Agency’s ideal response to the SRCs. Each SRC in Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria, contains form fields with unlimited character spaces. Respondents shall name and label attachments to refer back to the number identifier for the respective SRC, as outlined in Exhibit E-4. Respondents are responsible for drafting and monitoring their text entry and use of attachments to ensure each SRC is answered completely and to the best of the respondent’s ability while adhering to the binder limitations outlined in Attachment C, Section I.B.6, Response Submission Requirements. Respondents shall not include website links, embedded links and/or cross references between response SRCs to circumvent the Agency’s prescribed response instructions.

Qualifications and Experience (SRC #1) In contrast to the qualifications and experience provided in response to SRC #1 in Exhibit E-1, Standard Submission Requirements and Evaluation Criteria SRC #1 in Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria should reflect only Contracts applicable to the specialty population proposed by the respondent.



Eligibility and Enrollment (SRC #2) In addition to meeting the eligibility requirements listed in Attachment D, Section III, Eligibility and Enrollment, A., Eligibility, and notwithstanding Attachment II, Section III, Eligibility and Enrollment, B., Enrollment, the respondent should identify the specialty population as clearly as possible in order for the Agency to adequately identify the population proposed to be enrolled by the Specialty Plan. For examples: HIV/AIDS Specialty Plan – Recipients may be HIV positive but asymptomatic, individuals with symptomatic HIV disease and individuals with CDC-defined AIDS as identified through diagnostic, procedure code and prescription drug information available through administrative claims data. Child Welfare Specialty Plan – Recipients may be less than 18 years old and on file with the Department of Children and Family Services’ Florida Safe Families Network (FSFN). Covered Services – Expanded Benefits (SRC #3) Expanded benefits proposed to be provided by the Specialty Plan are provided via SRC #19 in Exhibit E-1, Standard Submission Requirements and Evaluation Criteria. In response to SRC #3 of Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria, the respondent should address its experience providing any expanded benefits specified in response to SRC #19 in Exhibit E-1, Standard Submission Requirements and Evaluation Criteria, to the specialty population proposed. It is also important for the respondent to articulate a rationale for the expanded benefits proposed by addressing how these benefits are relevant to the proposed specialty populations. For examples: HIV/AIDS Specialty Plan – The Managed Care Plan may provide adult dental services in accordance with Clinical Guidelines for HIV/AIDS because people with weakened immune systems such as those living with HIV and AIDS are especially at risk. Child Welfare Specialty Plan – The Managed Care Plan may provide additional behavioral health services because children and adolescents involved in the child welfare system can be at greater risk for mental health issues than children in the general population because of histories of child abuse and neglect, separation from biological parents, or placement instability. Covered Services – Care Coordination/Care Management (SRC #4) Care coordination and care management interventions are essential for specialty populations. In proposing care coordination/care management activities for specialty populations, the respondent should be as detailed as possible regarding staffing composition and qualifications, assessment and interventions proposed to be conducted. The respondent should also describe entities and mechanisms involved in coordination



of care, as well as specific clinical criteria for care coordination and care management activities proposed. For examples: HIV/AIDS Specialty Plan – The Managed Care Plan shall provide care coordination/case management in which it assigns, to each enrollee, one (1) lead care coordination/case manager with demonstrated experience in medical, behavioral health, and home and community-based services for persons living with HIV/AIDS and shall coordinate with the appropriate entities for the provision of these services for their patients. The Managed Care Plan may establish reasonable caseload maximums for case managers. The Managed Care Plan may develop and use a plan of treatment for chronic disease follow-up care that is tailored to the individual enrollee and is in agreement with clinical guidelines for HIV/AIDS Care. The Managed Care Plan’s care coordination/case management may assist the enrollee in achieving quality health outcomes by: • Coordinating care through all levels of practitioner care (primary care to specialist); • Assessing the acuity level and service needs of each enrollee; • Assuring that the enrollee is assigned to an appropriate primary care provider; • Assuring that the enrollee is assigned to a specialist physician unless the enrollee’s

primary care provider is a specialist physician; • Offering twenty four (24) hour triage services to avoid unnecessary emergency room

and other acute care services; • Coordination with and referrals to providers of behavioral health services for

enrollees with co-occurring mental health and/or substance abuse disorders; • Providing patient education to assist enrollees in better management of their

disease, as well as transmission prevention, risk-reduction services, and secondary prevention of associated conditions and illnesses;

• Providing outreach programs that make a reasonable effort to locate and/or re-engage enrollees who have been lost to follow-up care for one hundred eighty (180) calendar days or more; and

• Coordinating support services with Project AIDS Care (PAC) Waiver case managers/agencies as well as other public or private organizations that provide services to HIV/AIDS clients, their families and caregivers.

Child Welfare Specialty Plan – The Managed Care Plan may provide care coordination/case management for children in out-of-home settings and that evaluates for the level of care coordination necessary for children living at home and receiving services.

The Managed Care Plan may have a detailed memorandum of agreement with the Community Based Care (CBC) Lead Agencies in their geographic area prior to initiation of services. These agreements may address coordination of service provision to children enrolled in the Managed Care Plan.

The Managed Care Plan may establish and maintain standard operating procedures for the appropriate sharing of health care information. The Managed Care Plan may collaborate with the Department of Children and Families (DCF) Regional Office and the local CBC Lead Agency to establish such procedures to address:



• Obtaining medical information at the time of removal; • Obtaining pertinent medical information from any Child Protection Team evaluations; • Results of all screenings, assessments, referrals to all health care providers; • Outcomes and progress on all services provided by health care providers; and • Case plan status and disposition.

The Managed Care Plan’s care coordination/case management program may include policies and procedures for coordinating with the local CBC Lead Agency and DCF Regional Office to determine the level of care coordination necessary for children receiving services in their own home and provision of that level of enhanced care coordination. Such determinations level of care coordination necessary under the Managed Care Plan’s care coordination/case management program may be based upon at least the following factors:

• Child’s health condition; • History of receiving appropriate health care when living at home with parents; • Parental need for assistance in locating and arranging for health care services; and • Parental need for developmental guidance and assistance in meeting the health care

needs of the child.

The Managed Care Plan may provide enhanced care coordination and management for enrollees at risk for inpatient hospitalization. Such enrollees may include at a minimum enrollees that meet the following conditions:

• Reside in the community and have had two (2) or more admissions to a mental

treatment facility in the past thirty six (36) months; • Reside in the community and have had three (3) or more admissions to a crisis

stabilization unit, short-term treatment facility, inpatient psychiatric unit, or any combination of these facilities within the past twelve (12) months; or

• Have been diagnosed with a behavioral health disorder in conjunction with a complex medical condition and have been prescribed numerous prescription medications.

Provider Network (SRC #5) The respondent’s proposed provider network must be documented through Exhibit E-3, Provider Network Assessment Tool required under SRC #29 in Exhibit E-1, Standard Submission Requirements and Evaluation Criteria. Specialty Plans must meet the minimum requirements regarding network capacity standards as MMA Plans as specified in Attachment D, Section VI, Provider Network and Exhibit D-1, Section VI, Provider Network, A., Network Capacity and Geographic Access Standards. Specialty Plans are required to exceed these standards by providing greater access to specific provider types relevant to the specialty population proposed. In response to SRC #3 of Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria, respondents should provide regional provider access ratios and other applicable requirements for the provider network it proposes to serve the specialty population proposed.



For examples: HIV/AIDS Specialty Plan – The Managed Care Plan may select and approve its Primary Care Providers (PCPs) that practice in one of the following areas: general practice, family practice, pediatrics, internal medicine, infectious disease, hematology, obstetrics, or gynecology. The Managed Care Plan may ensure that HIV specialists with training and demonstrated experience in treating HIV/AIDS patients are members of the provider network and can be designated as PCPs with a ratio of at least one (1) PCP per five hundred (500) enrollees HIV/AIDS identified enrollees. The Managed Care Plan's credentialing and recredentialing files may document the education, experience, prior training and ongoing service training regarding HIV/AIDS for each staff member or provider rendering medical or behavioral health services. The Managed Care Plan may require formal training or verification of completed training for network providers in the use of these assessment instruments and in techniques for identifying individuals with unmet behavioral health needs. The Managed Care Plan may include the following information in its provider handbooks regarding proposed policies and procedures, to include:

• Provider education requirements; • Provider responsibility for HIV primary and secondary prevention activities and risk

reduction education; • Requirements for care in accordance with the most recent clinical practice guidelines

for HIV/AIDS treatment; • Treatment adherence services available from the Managed Care Plan; • HIV Specialist PCP criteria including procedures for required use of approved

assessment instruments for behavioral health and substance abuse; • Case Management policies and procedures including role of the provider in the

Managed Care Plan’s medical case management/care coordination services; • Referral to services including services outside of the Managed Care Plan’s covered

services and services provided through interagency agreements; • Quality measurement standards for providers and requirements for exchange of

data; • Policies and procedures for enrollee access to clinical trials, including coverage of

costs for an enrollee's participation in clinical trials and provider notification of patient participation in clinical trials.

Child Welfare Specialty Plan – The provider network may have staff available that can provide evidence based practices in at least one of the following areas:

• Attachment and Behavioral Health Catch-up; • Incredible Years; • Functional Family Therapy; • Trauma Based Cognitive Behavioral Therapy; • Multi-systemic Therapy; and • Child and Parent Psychotherapy.



Behavioral practitioners may be available with sufficient training to appropriately service children with the following characteristics:

• Children from birth through age five with history of child abuse and/or neglect; • Child and Parent treatment needs; • Children with dual diagnosis of a behavioral health disorder and developmental

disabilities; • Children exposed to acute or chronic trauma; • Children with serious therapeutic needs that have been involved in violent criminal

acts; • Children involved in human trafficking; • Children with pre adoption or post adoption needs; • Children with at risk or have a traumatic brain injury; • Infants exposed prenatally to substances and neonatal abstinence syndrome; • Children who have been exposed to chronic and/or acute trauma; and/or • Children who have been exposed to human trafficking. Quality and Utilization Management (SRC #6)

Specialty Plans must meet the minimum requirements for quality management activities as MMA Plans as specified in Attachment D, Section VII, Quality and Utilization Management and Exhibit D-1, Section VII, Quality and Utilization Management, A., Performance Measures. Additional quality management activities relevant to the specialty population proposed are required by the Agency. This includes additional performance measures. In response to SRC #6 in Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria, the respondent shall address any additional proposed activity, program, or other proposal that it believes may improve the quality of care to the specialty population proposed. For examples: HIV/AIDS Specialty Plan – The Managed Care Plan’s Quality Improvement (QI) Plan shall include measurement of adherence to clinical and preventive health guidelines consistent with prevailing standards of professional medical practice and with standards regarding the most recent clinical practice guidelines for HIV/AIDS treatment. Additional measures may include national HIV/AIDS performance measures developed by the National Committee for Quality Assurance, American Medical Association & AMA-Convened Physician Consortium for Performance®; the Health Resources and Services Administration and the Infectious Diseases Society of America/HIV Medicine Association; or other source. Child Welfare Specialty Plan – The Managed Care Plan shall designate a staff member employed by the Managed Care Plan with a behavioral health-related license to maintain oversight responsibility for behavioral health services and to act as liaison to DCF. The staff member must have experience in systems of care for children in the child welfare system and/or integration of behavioral health and physical health care services.



Additional measures may include performance measures related to the Child and Family Service Reviews conducted by the Administration on Children and Families, or other sources.

Documented experience relative to the achievement of standard performance measures are provided via SRC #10 in Exhibit E-1, Standard Submission Requirements and Evaluation Criteria and Exhibit E-2, Standard Quality Measurement Tool. In response to SRC #6 of Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria, the respondent should address its experience providing any performance measures specific to the specialty population proposed. Additionally, Exhibit E-5, Specialty Quality Measurement Tool, must be completed to also indicate those proposed measures for which the respondent has prior experience.

Exhibit E-5, Specialty Quality Measurement Tool The respondent shall enter HEDIS or other performance measure data from three different states in which it operates for each performance measure the respondent has prior experience, as specified by the respondent in Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria. For each measure, the respondent shall enter the name of the state, the state’s standard or goal rate, the national mean for the year being reported for each line being reported, and the rate that the plan achieved for the measure in the year being reported. The respondent shall use the following indicators for the Medicaid, Medicare or Commercial Indicator column: “MC” for reporting a Medicaid performance measure; “MA” for reporting a Medicare performance measure; and “CM” for reporting a Commercial performance measure. In Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria, Year 1 refers to Calendar Year 2010 (HEDIS 2010) and Year 2 refers to Calendar Year 2011 (HEDIS 2011). For non-HEDIS measures, the respondent shall enter the name of the state, the state’s standard or goal rate, and the national mean, if there is one available, in addition to the rate that the plan achieved for the measure in the year being reported.

EXHIBIT E-1 STANDARD SUBMISSION REQUIREMENTS AND

EVALUATION CRITERIA

AHCA ITN 024-12/13, Exhibit E-1, Page 1 of 38

Vendor’s Name:

Category: Qualifications and Experience SRC #1 [CORE]: The respondent shall provide a list of all current and/or recent (within five (5) years of the issue date of this ITN) Contracts for managed care (medical care and/or integrated medical and behavioral health services) for each Medicaid population served (Temporary Assistance for Needy Families (TANF), Aged, Blind and Disabled (ABD), dual eligibles). If the respondent does not have experience with managed care, please include any relevant Contracts. The respondent shall provide the following information for each identified Contract: a. The Medicaid population served (TANF, ABD, duals); b. The name and address of the client; c. The name of the Contract; d. The time period of the Contract; e. A brief narrative describing the role of the respondent and scope of the work

performed, including covered populations and covered services; f. The annual Contract amount (payment to the respondent) and annual claims

payment amount; g. The scheduled and actual completion dates for Contract implementation; h. The barriers encountered that hindered implementation (if applicable) and the

resolutions; i. Accomplishments and achievements; j. Number of enrollees, by health plan type (e.g., commercial, Medicare, Medicaid); and k. Whether the Contract was capitated, fee-for-service or other payment method. Vendor Response: SRC #1 Evaluation Criteria: 1. The Medicaid population served by the managed care Contracts.

2. The number and size of managed care Contracts active in the last five (5) years.

3. The extent to which managed care Contracts, or other Contracts, active in the last five

years, provided relevant experience.

4. The extent to which listed accomplishments and achievements are significant and relevant to this ITN.

Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each.


EVALUATION CRITERIA


SRC #2 [CORE]: The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies) shall describe its experience (i.e., number of years, number of enrollees, and number of Contracts) in delivering managed care services (i.e., medical and integrated medical and behavioral health, dental, and/or transportation services), to Medicaid populations similar to the target population (TANF, ABD, dual eligibles) of this ITN. The respondent shall describe all relevant experience it has gained prior to responding to this ITN by each relevant Medicaid population. The respondent may include experience regarding services provided by subcontractors for which the respondent was contractually responsible. Vendor Response: SRC #2 Evaluation Criteria: 1. The extent to which the respondent identifies experience in delivering services to

populations similar to the target population.

2. The extent to which the respondent describes its experience managing or delivering services to populations similar to the target population through medical and behavioral health services.

3. The extent to which the respondent describes its experience managing or delivering

services to the TANF population.

4. The extent to which the respondent describes its experience managing or delivering services to the ABD population.

5. The extent to which the respondent describes its experience managing or delivering

services to the dual eligible population.

Score: This section is worth a maximum of 25 raw points with the above components being worth a maximum of 5 points each. SRC #3 [CORE]: The respondent (including respondents’ parent, affiliate(s) or sudsidiary(ies)) shall describe any lessons learned from its managed care or other relevant experience and how the lessons learned will be applied to this ITN for each Medicaid population served (TANF, ABD, dual eligibles). This shall include, but not be limited to, lessons learned regarding enrollee services, provider network, and helping enrollees live successfully and safely in the community. Vendor Response:


EVALUATION CRITERIA


SRC #3 Evaluation Criteria: 1. The degree to which the lessons learned for enrollee services and managing the provider

network are relevant and significant to this ITN for each population served. 2. The extent to which the respondent implemented innovative or best practices in response to

the lessons learned for each population served. Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. SRC #4 [CORE]: The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience with helping providers unfamiliar with managed care transition to successfully provide services in a managed care setting, including lessons learned, and shall propose how it will help providers unfamiliar with managed care transition to successfully provide services in a managed care environment in relation to this ITN. Vendor Response: SRC #4 Evaluation Criteria: 1. The extent to which the respondent demonstrates success in transitioning providers to

managed care.

2. The extent to which the lessons learned are applicable to and likely to be effective with providers associated with this ITN.

3. The extent to which the respondent’s proposed approach is applicable and likely to be

effective with providers associated with this ITN. Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. SRC #5 [CORE]: The respondent shall describe any sanctions levied against it or its affiliates and subsidiaries or its parent company, or its affiliates subsidiaries and subcontractors (whose sub-contracts are paid at $250,000 or more annually), within the last seven (7) years, that have been imposed by the Agency, a Medicaid program in another state, Medicare or any federal government or state regulatory body in any state. Include a description of the Contracts for which the sanction was levied (if the sanction was contractual), a description of the sanction, the specific reason for the sanction and the timeline to resolve or correct the deficiency for which the sanction was levied. Indicate any sanctions that are currently in dispute. Sanctions are defined as any monetary (e.g., penalties and withholds) and non-monetary (e.g., letters of non-compliance and involuntary enrollment freezes) punitive actions taken by regulatory bodies. If there have been no sanctions that meet the criteria described, the respondent


EVALUATION CRITERIA


must so state. Failure to provide any item of information requested under this paragraph shall result in a score of zero for this section. Vendor Response: SRC #5 Evaluation Criteria: 1. The extent to which sanctions were due to issues with patient care, including quality and

access, versus administrative issues.

2. The extent to which sanctions were significant (e.g., high dollar amounts (above $10,000), lengthy, involuntary enrollment freezes) or numerous (e.g., multiple Contracts with similar sanctions).

3. The extent to which sanctions were imposed multiple times for the same issue prior to

resolution. Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. For Item 1: (a) 5 points if no sanctions or other adverse actions; (b) 4 points if sanctions related only to administrative issues; (c) 3 points if non-administrative sanctions were all minor (less than $10,000) and there were

fewer than four (4) incidents; (d) 2 points if non-administrative sanctions were all minor but four (4) or more incidents; (e) 1 point if any major ($10,000 or above) administrative sanction; (f) 0 points if any major non-administrative sanction. For Item 2: (a) 5 points if no sanctions; (b) 4 points if sanctions were minor and there were fewer than four (4) incidents; (c) 3 points if sanctions were all minor (less than $10,000) but four (4) or more incidents; (d) 2 points if up to two (2) high-dollar amounts or lengthy (longer than 90 days) freezes or more

than two (2) Contracts with multiple sanctions; (e) 1 point if more than two (2) but fewer than five (5) high-dollar amounts or lengthy (longer

than 90 days) freezes and/or more than two (2) but fewer than five (5) Contracts with multiple sanctions;

(f) 0 points if performance falls below above limits. For Item 3: (a) 5 points if no sanctions; (b) 4 points if sanction imposed twice for same issue; (c) 3 points if sanction imposed twice for the same issue and involved such actions for multiple

incidences of same action; (d) 2 points if sanction imposed twice for multiple incidences of same action across multiple

Contracts;


EVALUATION CRITERIA


(e) 1 point if sanctions imposed more than twice but fewer than five (5) times for the same issue(s);

(f) 0 points if performance falls below above limits. SRC #6 [CORE]: The respondent shall state whether, in the past seven (7) years, it has voluntarily terminated all or part of a Contract (other than a provider Contract) to provide health care services; has had such a Contract partially or fully terminated before the Contract end date (with or without cause); has withdrawn from a contracted service area; or has requested a reduction of enrollment levels. If so, describe the Contract; the month and year of the Contract action; the reason(s) for the termination, withdrawal, or enrollment level reduction; the parties involved; and provide the address and telephone number of the client/other party. If the Contract was terminated based on the respondent’s performance, describe any corrective action taken to prevent any future occurrence of the problem leading to the termination. Include information for the respondent as well as the respondent’s affiliates and subsidiaries and its parent organization and that organizations’ affiliates and subsidiaries. Vendor Response: SRC #6 Evaluation Criteria: 1. The extent to which the respondent or parent or subsidiary or affiliates has voluntarily

terminated all or part of a Contract.

2. The extent to which the respondent or parent or subsidiary or affiliates has had Contracts terminated due to performance.

3. The extent to which the respondent or parent or subsidiary or affiliates had terminations for

performance issues related to patient care rather than administrative concerns (e.g., reporting timeliness).

Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. For Item 1: (a) 5 points for no voluntary termination of all or part of a Contract and no service area

withdrawals; (b) 0 points for any voluntary terminations/withdrawals. For Item 2: (a) 5 points for no involuntary terminations; (b) 0 points for any involuntary termination based on performance. For Item 3: (a) 5 points for no Contract terminations; (b) 0 points if termination related to patient care or claims payment.


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SRC #7 [CORE]: The respondent shall state whether there is any pending or recent (within the past seven (7) years) civil, criminal or administrative litigation against the respondent, (to include respondent’s affiliates and subsidiaries and its parent organization and that organizations’ affiliates and subsidiaries) including by a state or federal agency. If there is pending or recent litigation against the respondent, describe the Contract that is being litigated (if applicable); the damages being sought or awarded; and the extent to which adverse judgment is/would be covered by insurance or reserves set aside for this purpose. Include any outcomes; deferred prosecution agreements (or agreements whose effect is the same); and settlement agreements. Also include any Securities and Exchange Commission (SEC) filings, discussing any pending or recent litigation. Respondent does not need to divulge workers’ compensation litigation, real estate litigation, or employment litigation if no Equal Employment Opportunity Commission (EEOC) cause finding (or state/local agency equivalent of cause finding). If there has been no litigation that meets the criteria described, the respondent must so state. Failure to provide any item of information requested under this paragraph shall result in a score of zero for this section. Vendor Response: SRC #7 Evaluation Criteria: 1. The number of Contracts in which litigation occurred, that resulted in adverse outcome (e.g.

money damages, findings of liability, settlement payment, deferred prosecution agreements, etc.).

2. The number of lawsuits pending against the respondent. 3. The extent to which actual and anticipated judgments are not covered by insurance or

reserves. 4. The extent to which actual and anticipated litigation involves allegations of criminal

misconduct (defined as a dereliction of duty); or unlawful or improper behavior) as described in the complaint or other documents filed in the case.

Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. For Item 1: (a) 5 points if no litigation, or if litigation did not result in any adverse outcomes; (b) 4 points if one (1) case (to include equitable, legal or administrative) with an adverse

outcome; (c) 3 points if two (2) cases with an adverse outcome each; (d) 2 points if five (5) or fewer cases with an adverse outcome; (e) 1 point if more than five (5) but fewer than eight (8) cases with an adverse outcome(to

include equitable, legal or administrative) with more than two (2) Contracts; (f) 0 points if multiple litigation with multiple Contracts.


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For Item 2: (a) 5 points if no pending cases; (b) 3 points if fewer than five (5) pending cases; (c) 0 points if more than five (5) pending cases. For Item 3: (a) 5 points if no litigation; (b) 4 points if sought or awarded damages covered by insurance or reserves; (c) 0 if not covered.

For Item 4: (a) 5 points if no criminal litigation that resulted in adverse outcome; (b) 0 if completed litigation involved criminal or intentional misconduct that resulted in an

adverse outcome. SRC #8 [CORE]: The respondent shall describe its organizational commitment to quality improvement, including active involvement by respondent’s medical and administrative leadership, and document its achievements with two (2) examples of quality improvement projects and their results. At least one of the examples shall address well child visits/child health checkup improvement projects. Vendor Response: SRC #8 Evaluation Criteria: 1. The extent to which the respondent describes how it ensures that quality improvement is

incorporated into operations throughout the health plan.

2. The extent to which the respondent provides examples of quality improvement projects that include data-based root cause analysis, measurement of the intervention and re-evaluation.

3. The extent to which the respondent’s description demonstrates that the medical director has substantial oversight in the assessment and enhancement of quality improvement activities, and the Chief Executive Officer (CEO) is actively involved in quality management.

4. The extent to which the quality improvement project methodology and study SRCs have been reviewed by the respondent’s medical director and quality management staff.



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SRC #9 [REGIONAL]: The respondent shall provide documentation that it has experience operating as a Florida Medicaid health plan in the Region in which it plans to provide MMA services or in any other Region in the State of Florida. If applicable, the respondent shall provide the Agency Contract number and the county(ies) of operation to show it has experience providing managed care services in Florida. This includes Medicare Advantage Special Needs Plans that have a Standard Contract with the Agency. Vendor Response: SRC #9 Evaluation Criteria: For the Managed Care Plan that is proposing to provide services under this ITN, whether the respondent has an: • Existing Florida Medicaid health plan Contract in that Region; • Existing Florida Medicaid health plan Contract in another Region in the State of Florida; or • Medicare Advantage Special Needs Plan Standard Contract with the Agency.

Score: This section is worth a maximum of 20 raw points as outlined below. (a) 20 points if the respondent already has a Florida Medicaid health plan Contract in any

county in the Region that it plans to provide medical assistance services or if the plan has a Medicare Advantage Special Needs Plan Standard Contract in any county in the Region that it plans to provide medical assistance services;

(b) 10 points if the respondent does not have a Florida Medicaid health plan Contract in the Region, but does have a Contract and is operating as a Florida Medicaid health plan in another Region of the state or if the plan does not have a Medicare Advantage Special Needs Plan Standard Contract in the Region, but does have a Contract and is operating as a Medicare Advantage Special Needs Plan Standard Contract in another Region of the state;

(c) 0 points if the plan does not have a Florida Medicaid health plan Contract or a Medicare

Advantage Special Needs Plan Standard Contract with the Agency. SRC #10 [CORE]: The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience in achieving quality standards with populations similar to the target population for this ITN. Include in table format, the target population (TANF, ABD, dual eligibles), the respondent’s results for the HEDIS measures specified below for each of the last two (2) years (CY 2010 and CY 2011) as compared to the Medicaid national average for the respondent’s three (3) largest Medicaid Contracts (measured by number of enrollees). If the respondent does not have Medicaid HEDIS results for at least (3) three states, the respondent shall provide commercial HEDIS measures for the respondent’s largest Contracts compared to the commercial national average. Describe any instances of failure to meet HEDIS or Contract-required quality standards and actions taken to improve performance. Describe actions taken to improve quality performance when HEDIS or Contract required


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standards were met, but improvement was desirable. Respondents shall provide the data requested in Attachment E-2, Standard Quality Measurement Tool to provide results for the following HEDIS measures:

• Annual Dental Visits; • Antidepressant Medication Management; • Adolescent Well-Care Visit; • Breast Cancer Screening; • Controlling High Blood Pressure; • Timeliness of Pre-natal care; • Post-Partum Care; • Well-Child Visit in the 1st 15 months of life; and • Childhood Immunizations.

Vendor Response: SRC #10 Evaluation Criteria: 1. The extent of experience (e.g., number of Contracts, enrollees or years) in achieving quality

standards with similar target populations, including HEDIS or Contract-required measures.

2. The extent to which the described experience demonstrates the ability to improve quality in a meaningful way and to successfully remediate all failures.

3. The extent to which the respondent exceeded State standards or goal rates and the national

mean for each quality measure reported.

Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. For Item 3, a total of 5 points are available.

Exhibit E-2, Standard Quality Measurement Tool, provides for fifty four (54) opportunities for a respondent to report prior experience in meeting a state quality standard (nine (9) measures, three (3) states each, two (2) years each). For each of the nine (9) measures a total of 6 points is available. The respondent will be awarded 1 point if their reported plan rate exceeded both the State standard or goal rate and the national mean, for each available year, for each available state. An aggregate score will be calculated and respondents will receive a final score of 0 through 5 corresponding to the number of points received out of the total available points, as described below:

a. 5 points if total aggregate score is between 40 and 54 points; b. 4 points if total aggregate score is between 30 and 39; c. 3 points if total aggregate score is between 10 and 29; d. 2 points if total aggregate score is between 5 and 9; e. 1 points if total aggregate score is between 1 and 4; and f. 0 points if total aggregate score is 0.


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Category: Eligibility and Enrollment SRC #11 [CORE]: The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience (i.e., number of years, number of enrollees, and number of Contracts) collecting premiums from populations similar to the target population for this ITN. The respondent shall describe any lessons learned from its managed care or other relevant experience and how the lessons learned will be applied to this ITN for the Medically Needy population served. Vendor Response: SRC #11 Evaluation Criteria: 1. The extent to which the respondent has experience collecting premiums from populations

similar to the target population. 2. The extent to which the respondent plans to implement innovative or best practices in

response to the lessons learned for a similar population served. Score: This section is worth a maximum of 10 raw points with the above components being worth a maximum of 5 points each. SRC #12 [CORE]: The respondent shall describe how it will use community outreach/marketing and how it will educate its community outreach/marketing representatives and providers about prohibited and permitted activities. Vendor Response: SRC #12 Evaluation Criteria: 1. The appropriateness of the respondent’s approach to community outreach and marketing

based on the TANF population. 2. The appropriateness of the respondent’s approach to community outreach and marketing

based on the ABD population. 3. The appropriateness of the respondent’s approach to community outreach and marketing

based on the dual eligibles population. 4. The adequacy of the respondent’s approach to educating its community outreach /marketing

representatives about prohibited and permitted activities. 5. The adequacy of the respondent’s process for capturing acknowledgement from community

outreach/marketing representatives regarding prohibited and permitted outreach activities.


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6. The adequacy of the respondent’s training approach for educating providers about permitted and prohibited activities.

Score: This section is worth a maximum of 30 raw points with each of the above components being worth a maximum of 5 points each. Category: Enrollee Services and Grievance Procedures SRC #13 [CORE]: The respondent shall describe how it will ensure that covered services are provided in an appropriate manner to enrollees with limited English proficiency, and to enrollees who are hearing impaired, including the provision of interpreter services when receiving covered services, and to ensure provider compliance with Americans with Disabilities (ADA) requirements. Vendor Response: SRC #13 Evaluation Criteria: 1. The adequacy and availability of interpreters and sign language interpreters for

appointments.

2. The adequacy of training of staff regarding how to assist enrollees with limited English proficiency and enrollees who are hearing impaired in obtaining an interpreter for appointments.

3. The adequacy of the respondent’s approach to contracting with providers who speak a language other than English and providing that information to enrollees.

4. The adequacy of the respondent’s description for provider training regarding how to provide covered services in an appropriate manner to enrollees with limited English proficiency and enrollees who are hearing impaired.

5. The adequacy of the respondent’s approach to ensuring compliance with ADA requirements.

Score: This section is worth a maximum of 25 raw points with each of the above components being worth a maximum of 5 points each. SRC #14 [CORE]: The respondent shall describe its experience with enrollee help lines, specifically the average speed of answer, staffing ratios and other relevant help line metrics for a Contract similar to this ITN. The respondent shall describe, in detail, its training program for the enrollee help line staff, including the respondent’s standards for help line staffing ratios and help line metrics. The respondent shall describe how it will assist an enrollee with urgent needs (e.g., enrollee is out of necessary medication or supplies) who calls the respondent’s enrollee help line and how it will ensure staff is trained appropriately and consistently to handle these situations.


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Vendor Response: SRC #14 Evaluation Criteria:

1. The extent of the respondent’s experience in achieving successful enrollee help line metrics.

2. The adequacy of the respondent’s training program for help line staff (both initial and

ongoing).

3. The adequacy of the respondent’s approach for ensuring adherence to staffing ratios and help line metrics or statistics.

4. The adequacy of the respondent’s procedures or work flows identifying the steps or

questions that the help line staff are to ask to determine timeframe and urgency of the situation, including whether the situation is an emergency and how to respond.

5. The completeness of the respondent’s process and level of involvement of supervisory and clinical staff for oversight and triage.

Score: This section is worth a maximum of 25 raw points with each of the above components being worth a maximum of 5 points each. SRC #15 [CORE]: The respondent shall submit a sample of a hard copy enrollee handbook created for populations similar to those covered in the resulting Contract. The respondent shall describe the process and frequency of updating the hard copy enrollee handbook. Vendor Response: SRC #15 Evaluation Criteria: 1. The extent to which the hard copy enrollee handbook is at or near the fourth grade reading

level.

2. The extent to which the enrollee handbook contains all required information.

3. The frequency of hard copy enrollee handbook updates.



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SRC #16 [CORE]: The respondent shall describe the provider search function for the online provider directory, including the parameters upon which enrollees may search. The respondent shall also describe how it will include performance indicators in its provider directory. Vendor Response: SRC #16 Evaluation Criteria: 1. The extent of the respondent’s search functions for the online directory.

2. The extent of the performance indicators available in the provider directory.

Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. SRC #17 [CORE]: The respondent shall provide a flowchart and written description of how it will execute its enrollee grievance system, including identifying, tracking and analysis of enrollee complaints, grievances and appeal reports. The respondent shall include in the description how data resulting from the grievance system are used to improve the operational performance of the respondent. Vendor Response: SRC #17 Evaluation Criteria: 1. The extent to which the grievance system flowchart reflects ease of access for individuals

with complaints, grievances and appeals.

2. The extent to which the timelines for acknowledging and responding to complaints, grievances and appeals comply with requirements.

3. The extent to which complaint, grievance and appeal data are aggregated so that results are actionable, protect enrollee privacy and are reviewed by a quality committee for analysis and prioritization of corrective action and/or improvement initiatives.

4. The extent to which the complaint, grievance and appeal process imposes deadlines on completion of corrective action plans implemented as a result of verified complaints, grievances or appeals.



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Category: Covered Services SRC #18 [CORE]: The respondent shall describe the following components of its care coordination/case management program: a. Process used to assign enrollees to case managers; b. Process to inform enrollees of assigned case manager and how to change case

managers; c. Process of case manager coordination and follow-up of ambulatory and inpatient

care/services needs; and d. Process to ensure case managers share pertinent information and interface with the

enrollee, the enrollee’s PCP and other relevant providers. Vendor Response: SRC #18 Evaluation Criteria: 1. The extent to which respondent’s description addresses the process for enrollee assignment

to a case manager.

2. The adequacy of the process of informing enrollees regarding assigned case manager, including how enrollees can change to another case manager.

3. The adequacy of the process of coordination and follow-up of ambulatory and inpatient

care/services needs. 4. The adequacy of the respondent’s process for ensuring case managers are sharing and

interfacing with the appropriate providers. Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. SRC #19 [CORE]: The respondent shall describe each of the expanded benefits it proposes to offer its enrollees, if approved by the Agency. The respondent shall document each expanded benefit and list which specific services are included, as well as any limitations on those services. This documentation shall include the calculations used to determine the per-member-per-month (PMPM) cost. The submitted PMPM cost must be developed on a “total member” basis, rather than a “per user” or “per benefit eligible” basis (e.g., if the benefit is for adults only, do not submit the expected monthly cost per adult but rather the expected cost per member; or, if the benefit is for the household, its expected monthly cost must be converted to the expected cost per member). Any co-payments that apply to expanded benefits must be accounted for in the calculation of the PMPM cost. In addition the respondent shall provide each procedure/Current Procedural Terminology (CPTs)/standard billing codes used for tracking the proposed expanded benefits.


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Vendor Response: SRC #19 Evaluation Criteria: 1. The extent to which the respondent identifies the expanded benefits it will provide, the

rationale for providing each expanded benefit and the extent that the rationale supports the overall purpose of the ITN.

2. The extent to which the respondent includes expanded benefit standards, such as: a) Benefit (e.g. co-pay waiver) or service definitions; b) Procedure/CPT/standard billing codes; and c) PMPM cost.

Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. Zero (0) points will be awarded to plans offering no expanded benefits. SRC #20 [CORE]: The respondent shall describe how it will provide dental services to the target population. Vendor Response: SRC #20 Evaluation Criteria: 1. The extent to which the respondent’s description includes the process to request dental

services; identification of any review process to ensure the appropriateness of the service; and how dental service utilization will be tracked and monitored.

2. The extent to which the respondent’s description encourages the use of appropriate access to dental services.

3. The adequacy of the respondent's description of how it will contract for the provision of

dental services to the target population. 4. The adequacy of the respondent’s description regarding how access to dental services will

be ensured and the service provision standards that will be employed (e.g., enrollee outreach, provider availability).



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SRC #21 [CORE]: The respondent shall describe how it will provide non-emergency transportation services to the target population. Vendor Response: SRC #21 Evaluation Criteria: 1. The extent to which the respondent’s description includes the process to request

transportation services; identification of any review process to ensure the appropriateness of the service; and how transportation service utilization will be tracked and monitored.

2. The extent to which the respondent’s description encourages the use of alternative modalities of transportation when appropriate for a given enrollee but assures against underutilization.

3. The adequacy of the respondent's description of how it will contract for the provision of

transportation services to the target population. 4. The adequacy of the respondent’s description regarding how access to transportation

services will be ensured and the service provision standards that will be employed (e.g., responsiveness, availability).

Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. SRC #22 [CORE]: The respondent shall describe how it will screen for behavioral health issues and the process for referral and coordination with behavioral health providers or other health plans. Vendor Response: SRC #22 Evaluation Criteria: 1. The extent to which the respondent describes how screenings for behavioral health issues

will occur (e.g. as part of disease management programs, PCP visits, nurse line and customer service), including the use of standardized screening tools; the designation of staff conducting screenings that possess appropriate qualifications and competencies; and examples of events that will trigger the need to complete a behavioral health screening.

2. The extent to which the respondent describes how it will ensure timely referrals for behavioral health services when indicated by the behavioral health screening and the process to ensure appropriate follow-up to support enrollees in accessing needed care.

3. The adequacy of the respondent's description of how it will coordinate care among

behavioral health providers, medical specialists, and other health plans for enrollees


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receiving behavioral health services. The respondent’s description should include examples of the types and frequency of clinical information that will be shared.

4. The extent to which the respondent describes how it will ensure that plan staff are trained

and educated regarding the identification of behavioral health issues, referral processes, confidentiality issues and expectations regarding coordinating care with behavioral health providers.

Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. SRC #23 [CORE]: The respondent shall describe how its care coordination/case management policies and procedures for behavioral health conditions, will differ from care coordination/case management policies and procedures for medical conditions, including post-partum and prenatal care. Vendor Response: SRC #23 Evaluation Criteria: 1. The extent to which the respondent addresses behavioral health-specific strategies for self-

management and treatment adherence, especially as it relates to medication (e.g., motivational interviewing, special pill containers, visual reminders).

2. The extent to which the respondent addresses the importance of identification of a co-occurring substance abuse problem, how it complicates certain treatments and how to refer for additional treatment.

3. The extent to which the respondent’s care coordination/case management policies and procedures address the need for increased outreach and additional assistance facilitating medical treatment when the individual has a serious behavioral health condition.

4. The extent to which the respondent has care coordination/case management policies and

procedures that delineate requirements when enrollees refuse care coordination/case management services.



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SRC #24 [CORE]: The respondent shall describe its expected approach to effectively treating individuals with co-occurring disorders. Address treatment planning, care coordination/case management and outcome measurement for children and adults. Vendor Response: SRC #24 Evaluation Criteria: 1. The extent to which the respondent incorporates evidence-based practices for co-occurring

disorders into utilization review, care coordination/case management training protocols and outcome measurement.

2. The extent to which the respondent’s treatment planning, care coordination/case management and outcome measurement practices are sufficiently flexible to accommodate factors associated with both (all) disorders.

3. The extent to which the respondent addresses how it assures that employees and contractors (e.g., participating providers) continually update their professional knowledge and skills to include evidence-based practices for individuals with co-occurring disorders.

4. The extent to which treatment planning and outcome measurement are targeted to both (all) disorders.

Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. Category: Provider Network SRC #25 [CORE]: The respondent shall describe its experience with and proposed approach to recognizing patient centered medical homes (PCMHs). Vendor Response: SRC #25 Evaluation Criteria: 1. The extent to which the respondent’s description demonstrates experience in using patient

centered medical homes for populations similar to the target population of this ITN.

2. The extent to which the respondent’s description of recognizing PCMHs addresses the following PCMH criteria: (a) each enrollee has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care; (b) whole person orientation; (c) enhanced access; (d) coordinated and/or integrated care; and (e) quality and safety.


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Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. SRC #26 [CORE]: The respondent shall describe its proposed approach to incentivizing and compensating patient centered medical homes (PCMHs). Vendor Response: SRC #26 Evaluation Criteria: 1. The extent to which the respondent will provide financial and non-financial support to

providers to become PCMHs.

2. The extent to which respondent describes Contract incentives and other performance-based payments it will offer to recognized PCMHs.

Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. SRC #27 [CORE]: The respondent shall describe its proposed process to credential and recredential providers. Vendor Response: SRC #27 Evaluation Criteria: 1. The extent to which the respondent’s credentialing and recredentialing criteria and

processes exceed Contract requirements.

2. The extent to which the respondent’s criteria for processing credentialing applications is more expeditious than the industry standard processing timeline of one hundred eighty (180) days.

3. The extent to which the respondent uses information from ongoing monitoring, including recommendations from its Quality Improvement Committee in its recredentialing process.

Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. SRC #28 [CORE]: The respondent shall submit its proposed training plan and schedule for network providers. Vendor Response:


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SRC #28 Evaluation Criteria: 1. The adequacy of the respondent’s approach to initial education and training of network

providers regarding claims submission and payment processes, including the type, location and frequency of training.

2. The extent to which the respondent will provide ongoing education and training, including problem resolution, responding to provider requests for training and how the respondent will evaluate the effectiveness of its education and training activities.

3. The extent to which the respondent will provide training to providers on Florida Medicaid’s

medical necessity definition and Early and Periodic Screening, Diagnostic and Treatment (EPSDT).

Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. SRC #29 [REGIONAL]: The respondent shall describe progress made towards establishing a provider network and towards establishing adequate network capacity to meet the minimum access standards for each provider type required. The respondent is required to submit a Provider Network File, as specified in Attachment E, Technical Proposal Instructions. An example of a Provider Network File is located in Exhibit E-3. Vendor Response: SRC #29 Evaluation Criteria: 1. The extent to which the respondent has made substantial progress in establishing

relationships with providers in sufficient numbers to meet the provider access ratios specified in the resulting Contract.

2. The extent to which the respondent has written agreements (letters of intent or letters of agreement) or signed Contracts with providers in sufficient numbers to meet the provider access ratios specified in the resulting Contract.

3. The extent to which the respondent has signed contracts with primary and specialty

physicians in sufficient numbers to meet the provider access ratios specified in the resulting Contract.

4. The extent to which the respondent has signed Contracts with statewide essential providers,

as specified in the resulting Contract.

Score: This section is worth a maximum of 65 raw points as outlined below.


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For Item 1, a total of 25 points are available:

(a) 25 points if the Provider Network Assessment Tool indicates the respondent has made

some progress (letter of intent, letter of agreement or Contract) towards contracting with 81-100% of required providers;

(b) 20 points if the Provider Network Assessment Tool indicates the respondent has made some progress (letter of intent, letter of agreement or Contract) towards contracting with 61-80% of required providers;

(c) 15 points if the Provider Network Assessment Tool indicates the respondent has made some progress (letter of intent, letter of agreement or Contract) towards contracting with 41-60% of required providers;

(d) 10 points if the Provider Network Assessment Tool indicates the respondent has made some progress (letter of intent, letter of agreement or Contract) towards contracting with 21-40% of required providers;

(e) 5 points if the Provider Network Assessment Tool indicates the respondent has made some progress (letter of intent, letter of agreement or Contract) towards contracting with 1- 20% of required providers;

(f) 0 points if the Provider Network Assessment Tool indicates the respondent has made no progress (letter of intent, letter of agreement or Contract) towards contracting with required providers.

For Item 2, a total of 15 points are available: (a) For each provider type required, the respondent will receive 1 point for indicating a letter of

intent, 2 points for indicating a letter of agreement, 3 points for indicating a provider network Contract. All points will be summed for aggregate total points.

(b) Based on that aggregate total as a percentage of three times the number of required providers (total available points), the Provider Network Assessment Tool will award points as follows:

a. 15 points if score represents 81-100% of total available points; b. 12 points if score represents 61-80% of total available points; c. 9 points if score represents 41-60% of total available points; d. 6 points if score represents 21-40% of total available points; e. 3 points if score represents 1-20% of total available points; f. 0 points if score represents 0% of total available points.


(a) 20 points if the respondent has signed Contracts with 75-100% of the required number of primary care providers and specialty providers;

(b) 10 points if the respondent has signed Contracts with 50-74% of the required number of primary care providers and specialty providers;

(c) 5 points if the respondent has signed Contracts with 25-49% of the required number of primary care providers or specialty providers;

(d) 0 points if the respondent has signed Contracts with less than 25% of the required number of primary care providers or specialty providers.


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(a) 5 points if the respondent has signed Contracts with 75-100% of all statewide essential providers;

(b) 3 points if the respondent has signed Contracts with 50-74% of all statewide essential providers;

(c) 1 point if the respondent has signed Contracts with 25- 49% of all statewide essential providers;

(d) 0 points if the respondent has signed Contracts with less than 25% of all statewide essential providers.

SRC #30 [REGIONAL]: The respondent shall describe its plan to encourage and promote the use of electronic health records and electronic exchange of health information, including its proposed plan to encourage providers to connect to the Florida Health Information Exchange (HIE) and how it will promote provider use of the HIE, including educating providers on the benefits of using the HIE and the availability of outreach funding. The respondent shall identify the number and percent of its participating providers that use electronic health records, as defined in Section 408.051, Florida Statutes. Respondents must indicate each provider who they attest uses electronic health records on their Provider Network File, as specified in Attachment E, Technical Proposal Instructions. Vendor Response: SRC #30 Evaluation Criteria: 1. The adequacy of the respondent’s plan to identify providers that do not currently use

electronic health records.

2. The adequacy of the respondent's plan to encourage providers to use electronic health records and connect to the HIE.

3. The adequacy of the respondent’s description of how it will support providers in the use of electronic health records and the HIE.

4. The adequacy of the respondent’s proposed plan to educate providers on the availability of

outreach funding for the HIE.

5. The percentage of the required number of providers who use electronic health records. Score: This section is worth a maximum of 30 raw points with Items 1-4 being worth a maximum of 5 points each and Item 5 being worth a maximum of 10 points. For Item 5 a total of 10 points are available: (a) 10 points if more than 10% of the required number of providers use electronic health

records;


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(b) 8 points if more than 7% but less than 10% of the required number of providers use electronic health records;

(c) 6 points if more than 4% but less than 7% of the required number of providers use electronic health records;

(d) 4 points if more than 2% but less than 4% of the required number of providers use electronic health records;

(e) 2 points if more than 0% but less than 2% of the required number of providers use electronic health records;

(f) 0 points if none of the required providers use electronic health records. SRC #31 [CORE]: The respondent shall submit a summary of its draft network development and management plan. Vendor Response: SRC #31 Evaluation Criteria:

1. The adequacy of the respondent’s methodology for identifying and resolving barriers and

network gaps.

2. The adequacy of the respondent’s plan to meet the needs of enrollees if it is unable to provide the service within its provider network.

Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. SRC #32 [CORE]: The respondent shall describe how it will establish community partnerships with providers that create opportunities for reinvestment in community-based services. Reinvestment in community-based services is defined as initiatives undertaken by the Managed Care Plan that foster accountability to, and reinvestment in local communities. Vendor Response: SRC #32 Evaluation Criteria: 1. The extent to which the partnerships will create opportunities for reinvestment in community-

based services. Score: This section is worth a maximum of 5 raw points. SRC #33 [CORE]: The respondent shall describe how it will monitor the quality and performance of participating providers, including the use of performance measures, and how it will address provider performance issues, up to and including Contract termination and any incentives to providers for good performance. If the respondent subcontracts its network management, also describe how the respondent performs monitoring of the subcontractor.


EVALUATION CRITERIA


Vendor Response: SRC #33 Evaluation Criteria: 1. The adequacy of the respondent’s approach to monitoring the quality and performance of

participating providers, including the frequency and type of monitoring.

2. The extent to which the respondent uses performance measures in monitoring the quality and performance of participating providers.

3. The adequacy of the respondent’s processes for addressing performance issues, including the triggers for increased monitoring activities, interventions and Contract termination.

Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. Category: Quality and Utilization Management SRC #34 [CORE]: The respondent shall provide documentation of current accreditation by a nationally recognized accrediting body of the Managed Care Plan that will be providing services outlined in this ITN. This shall include the name of the accrediting body, proof of accreditation (i.e. certificate), the type and/or level of accreditation, a copy of the most recent site visit report and the status of accreditation. Vendor Response: SRC #34 Evaluation Criteria: 1. For the Managed Care Plan that will provide services under this ITN, whether the

respondent has: a. full accreditation by a nationally recognized accrediting body e.g., accredited for the

National Committee for Quality Assurance (NCQA), full two (2) year accreditation for URAC, or three (3) year accreditation for Accreditation Association for Ambulatory Health Care, Inc. (AAAHC); or

b. partial/conditional health accreditation (e.g., provisional for NCQA, conditional or provisional for URAC, or one (1) year or six (6) months for AAAHC; or

c. no accreditation or denied accreditation.


EVALUATION CRITERIA


Score: This section is worth a maximum of 10 raw points using the scoring scale outlined below: (a) 5 points for full accreditation; (b) 3 points for partial/conditional accreditation; (c) 0 points if accreditation denied or no accreditation; (d) 5 additional points for full accreditation with NCQA. SRC #35 [CORE]: The respondent shall provide a description of the process it will employ to audit medical/case records and describe how the results of the audit will be used to improve performance and verify service provision. Vendor Response: SRC #35 Evaluation Criteria: 1. The extent to which the respondent’s medical record audit process indicates it meets or

exceeds nationally recognized accrediting body medical record review standards including at a minimum the NCQA core element guidelines and recognizes how behavioral health records may require special protections.

2. The extent to which the respondent’s description includes a process to ensure the reliability and validity of data, including inter-rater reliability activities.

3. The extent to which the respondent’s description includes: (a) designated staff to perform the function; (b) the method of case selection; (c) the anticipated number of reviews by practice site; and (d) review tools that the respondent will utilize at each site.

4. The adequacy of the respondent’s description of how medical record review results will be

utilized to: (a) identify relevant provider training needs; (b) support the provision of technical assistance to providers; (c) implement corrective action plans; and (d) support other managed care functions (e.g., credentialing, peer review).



EVALUATION CRITERIA


SRC #36 [CORE]: The respondent shall describe its utilization management (UM) program to be implemented under the resulting Contract, if awarded. The narrative shall include: a. A description of UM guidelines/review criteria, including how they are developed and

updated; b. A description of how and what resources the respondent will use to ensure that

services are medically necessary; c. A description of the different roles of case management and utilization management

staff and how case management and utilization management staff interact; d. A description of the utilization management process for enrollees requiring out-of-

network services; e. A description of how the respondent will ensure consistent application of the review

criteria for authorization decisions; f. A description of how the respondent will ensure that the UM guidelines and review

criteria are designed so that the process is completed efficiently and with the minimum impact on network providers and enrollees; and

g. A description of how the respondent will detect, monitor and evaluate under-utilization, over-utilization and inappropriate utilization as well as processes to identify and address opportunities for improvement.

Vendor Response: SRC #36 Evaluation Criteria: 1. The extent to which the respondent describes UM guidelines and review criteria that are

evidence-based and specific to the characteristics of the population served.

2. The extent to which the respondent describes how it will ensure that services are medically necessary.

3. The extent to which the respondent describes and differentiates the role of the case

manager and utilization management staff.

4. The adequacy of the respondent's description of how it will ensure the consistent application of review criteria for authorization decisions (e.g., inter-rater reliability studies, and training for plan staff and network provider).

5. The adequacy of the respondent’s description of how it will ensure that the UM guidelines

and review criteria are designed so that the process is completed efficiently and with the minimum impact on network providers and enrollees.

6. The extent to which the respondent describes how utilization management and case management staff will communicate and collaborate with hospital staff to ensure active and effective transition planning.


EVALUATION CRITERIA


7. The extent to which the respondent addresses procedures for identifying patterns of over-utilization and under-utilization of covered services, including the use of claims and encounter data for identification.

8. The extent to which the respondent describes the process to address potential problems identified as a result of an analysis of under-, over- and inappropriate utilization of services.

9. The extent to which the respondent describes the structures and processes it will implement

to ensure the regular review of under- and over -utilization data reports. Score: This section is worth a maximum of 45 raw points with each of the above components being worth a maximum of 5 points each. SRC #37 [CORE]: The respondent shall describe its plan redirecting costs to ensure physician compensation rates are equal or exceed Medicare rates for services similar to MMA covered services within two (2) years of the respondent’s contracting to provide MMA services. Vendor Response: SRC #37 Evaluation Criteria:

1. The adequacy of the respondent’s plan for redirecting costs to increase physician compensations rates.

2. The extent to which the respondent incorporates outcomes and enrollee satisfaction rates into the compensation approach.

Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. SRC #38 [CORE]: The respondent shall describe how it will ensure that enrollees transitioning into the Managed Care Plan from fee-for-service (FFS) receive appropriate care, including how it will honor prior authorizations from the FFS program and other health plans. Vendor Response: SRC #38 Evaluation Criteria: 1. The extent to which the respondent identifies how it will coordinate care with other health

plans and service providers for new enrollees transitioning into the Managed Care Plan.

2. The extent to which the respondent describes the transition of new enrollees into the Managed Care Plan and how it will ensure that enrollees seamlessly transition into the Managed Care Plan.


EVALUATION CRITERIA


3. The adequacy of the respondent’s description in addressing the need for service

authorization and the continuation of services by participating and non-participating providers for enrollees transitioning from the FFS program and other health plans.

Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. SRC #39 [CORE]: The respondent shall describe how it will ensure continuity of care when enrollees transition out of the Managed Care Plan, including coordination and supporting transition to care and services with the new health plan or delivery system. Vendor Response: SRC #39 Evaluation Criteria: 1. The extent to which the respondent describes the process for coordinating care and

assisting other Managed Care Plans obtain enrollees’ medical/case records when transitioning to another Managed Care Plan or delivery system.

2. The extent to which the respondent’s description addresses transitioning enrollees with special circumstances or medical conditions; enrollees with ongoing needs; and enrollees who at the time of their transition have existing prior authorization or approval for covered services.

Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. SRC #40 [CORE]: The respondent shall describe how it will address the transition of care between service settings. Identify populations and transition types (e.g., hospital to home) that require a transition plan. Provide an example of an effective transition plan. Vendor Response: SRC #40 Evaluation Criteria: 1. The extent to which the respondent’s example addresses the following transition of care

requirements: (a) assessment criteria for making sure the enrollee can be served safely in the community; (b) collaboration with hospital discharge planning staff; (c) referral and scheduling assistance; (d) coordination with PCP and specialists as appropriate to the enrollee’s needs, and (e) processes to reduce unnecessary hospital readmissions.

2. The extent to which the respondent’s example ensures the protection of the enrollee’s

privacy consistent with confidentiality requirements.


EVALUATION CRITERIA


Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. SRC #41 [CORE]: The respondent shall describe the program the respondent will implement to demonstrate innovative approaches to disease management for enrollees with cancer, diabetes, asthma, congestive heart failure or hypertension with a proven record of increasing clinical efficiencies and cost savings. Vendor Response: SRC #41 Evaluation Criteria: 1. The extent to which the respondent’s description addresses education and support for

enrollees with cancer, diabetes, asthma, congestive heart failure or hypertension.

2. The adequacy of the respondent's description in identification of enrollees with cancer and education and support needs to be addressed through a disease management program.

3. The adequacy of the respondent’s description of the program’s capability to address:

(a) symptom management; (b) medication support; (c) emotional support; (d) behavior change; (e) safety concerns; and (f) communication with providers.

4. The extent to which the respondent’s description represents an innovative approach to

disease management for enrollees with cancer, diabetes, asthma, congestive heart failure or hypertension, relevant to the population served under the resulting Contract.

5. The extent to which the respondent described a methodology for evaluating the impact of

the disease management program for enrollees with cancer, diabetes, asthma, congestive heart failure or hypertension.

Score: This section is worth a maximum of 25 raw points with each of the above components being worth a maximum of 5 points each. Category: Administration and Management SRC #42 [CORE]: The respondent shall describe its organizational background and history. The description shall include, at a minimum: a. A description of the respondent’s organizational structure, history, legal structure,

ownership, affiliations, and locations(s); and b. A copy of the respondent’s organizational chart, including the total number of

employees dedicated to the resulting Contract.


EVALUATION CRITERIA


Vendor Response: SRC #42 Evaluation Criteria: 1. The completeness of the respondent's description of its organizational structure, history,

legal structure, ownership, affiliations and locations; and whether it includes parent companies and affiliates so it is clear where organizational responsibility resides.

2. The extent to which respondent’s organizational history is consistent with successful development and implementation of an MMA program.

3. The adequacy of the range of positions in the organizational chart and the likelihood that

the organization could take on the Contract within expected time frames with the staff dedicated to the resulting Contract.

Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. SRC #43 [CORE]: For the organization chart included for SRC #42 above, the respondent shall provide a brief narrative explaining how responsibilities and reporting relationships will function for all Regions, if applicable, in providing services outlined in this ITN. The expanded organizational chart and brief narrative shall include: a. Reporting relationships showing clear lines of authority within the Managed Care Plan

and its subcontractors; b. Number and type of full time equivalent positions (both existing and projected for

start date of service delivery) per functional area; c. Location of staff (city and state); and d. Use of administrative or service subcontractors. Vendor Response: SRC #43 Evaluation Criteria: 1. The extent to which reporting relationships demonstrate clear lines of authority within the

Managed Care Plan.

2. The extent to which reporting relationships demonstrate clear lines of authority over its administrative or service subcontractors.

3. The adequacy of the number and type of positions in all functional areas. Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. 5 additional points will be awarded if the respondent scores a 5 on Item 3 above.


EVALUATION CRITERIA


SRC #44 [CORE]: The respondent shall provide information regarding whether each operational function, as defined in Section 409.966(3)(c)3, Florida Statutes, will be based in the State of Florida, and the extent to which operational functions will be conducted by staff, in-house or through contracted arrangements, located in the State of Florida. This includes: a. Specifying the location of where the respondent’s corporate headquarters will be

located (as defined by Section 409.966(3)(c)3, Florida Statutes); b. Indicating whether the respondent is a subsidiary of, or a joint venture with, any other

entity whose principal office will not be located in the State of Florida; and c. Identifying the number of full-time staff, by operational function (as defined in Section

409.966(3)(c)3, Florida Statutes), that will be located in the State of Florida and out of state.

Vendor Response: SRC #44 Evaluation Criteria: 1. Whether the respondent’s corporate headquarters will be located in Florida (it is not a

subsidiary of or a joint venture with any other entity whose principal office will not be located in Florida).

2. The extent to which operational functions (claims processing, enrollee/member services,

provider relations, utilization and prior authorization, case management, disease and quality functions, and finance and administration) will be performed in the State of Florida.

Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. 5 additional points will be awarded if respondent meets Items 1(a) and 2(a) below. For Item 1: (a) 5 points for corporate headquarters in Florida and no parent or joint venture organization

outside Florida; (b) 4 points if corporate headquarters in Florida but parent or joint venture organization outside

Florida depending on extent of non-Florida presence; (c) 0 points if no relevant corporate headquarters in Florida.

For Item 2: (a) 5 points if all functions will be performed in Florida; (b) 4 points for 6-7 functions will be performed in Florida; (c) 3 points for 4-5 functions will be performed in Florida; (d) 2 points for 2-3 functions will be performed in Florida; (e) 1 point for 1 function will be performed in Florida; (f) 0 points for no functions will be performed in Florida; (g) 0 points if only community outreach, medical director and state administrative functions will

be performed in Florida.


EVALUATION CRITERIA


SRC #45 [CORE]: The respondent shall provide position descriptions for the following key staff that includes the percentage of time dedicated to the resulting Contract: a. Contract Manager; b. Medical Director; c. Data Processing and Data Reporting Coordinator; d. Utilization Management (UM) Professional; e. Grievance System Coordinator; f. Compliance Officer; g. Claims/Encounter Manager; and h. Fraud Investigative Unit (Special Investigative Unit) Manager. Vendor Response: SRC #45 Evaluation Criteria: 1. The extent to which each position (a-h) description demonstrates an appropriate amount of

training, experience and/or licensure.

2. The extent to which the position description requirements for each position (a-h) match the requirements listed in this ITN for the corresponding position.

Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. SRC #46 [CORE]: The respondent shall identify any anticipated administrative subcontractors, service subcontractors, managed behavioral health organization subcontractor, prepaid dental organization subcontractor or other prepaid health services subcontractor, or any transportation broker subcontractor it will use to provide services outlined in this ITN. This shall include the name of the subcontractor, ownership information, the services to be provided by the subcontractor (including an estimated percentage of total services), the qualifications of the subcontractor, and how the respondent will manage the subcontractor to ensure compliance with all requirements. The respondent may limit this response to subcontractors to which it expects to make payments of $100,000 or more in one year. Vendor Response: SRC #46 Evaluation Criteria: 1. The extent to which subcontractors are qualified to provide the identified services.

2. The extent to which the respondent’s plan to manage the subcontractors is likely to ensure

compliance with requirements.


EVALUATION CRITERIA


Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 5 points each. SRC #47 [CORE]: The respondent shall submit detailed flowcharts and a narrative description of its claims processing and payment process, addressing both paper and electronic claims submissions. The respondent shall include the following in its narrative: monitoring process for accurate and timely claim adjudication, including performance metrics; how deficiencies are identified and resolved; the process for development and implementation of interventions for improved claims processing and payment; and cost avoidance/third party liability (TPL) activities. Vendor Response: SRC #47 Evaluation Criteria: 1. The ability of the respondent to ensure timely and accurate adjudication and payment of

both paper and electronic claims.

2. The ability of the respondent to process Medicare cross-over and bad debt claims.

3. The completeness of the respondent’s flowcharts describing its claims processing and payment processes.

4. The adequacy of the respondent’s monitoring process (frequency and type of activities), including performance metrics.

5. The adequacy of the respondent's process for developing and implementing interventions to improve the timeliness and accuracy of its claims processing.

6. The extent to which the respondent’s timeframes for claims processing are consistent with this ITN’s requirements.

7. The adequacy of the respondent’s cost avoidance/TPL process.

Score: This section is worth a maximum of 35 raw points with each of the above components being worth a maximum of 5 points each. SRC # 48 [CORE]: The respondent shall submit a flow chart and narrative description of its encounter data submission process including, but not limited to, how accuracy, timeliness and completeness are ensured. The description should include tracking, trending, reporting, process improvement, and monitoring of encounter submissions and encounter revisions. The respondent shall include any feedback mechanisms to improve encounter accuracy, timeliness and completeness. Vendor Response:


EVALUATION CRITERIA


SRC #48 Evaluation Criteria: 1. The adequacy of the respondent’s process to ensure accurate, timely, and complete

encounter data.

2. The completeness of the respondent’s flowcharts describing its encounter data submission process.

3. The adequacy of the respondent’s mechanisms for tracking, trending, and monitoring encounter submissions and revisions, including the type and frequency of activities.

4. The adequacy of the respondent’s process for converting paper claims to electronic encounter data.

5. The adequacy of the respondent’s approach to identifying specific processing/systems issues that could result in invalid data being submitted to the State.

Score: This section is worth a maximum of 25 raw points with each of the above components being worth a maximum of 5 points each. SRC #49 [CORE]: The respondent shall describe how it will work with providers, particularly subcapitated providers, subcontractors, atypical providers, and non-participating providers to ensure the accuracy, timeliness and completeness of encounter data. Vendor Response: SRC #49 Evaluation Criteria: 1. The adequacy of the respondent’s approach to ensure that all network providers, including

subcapitated providers, are registered with the Florida Medicaid Management Information System (FMMIS) for the purposes of encounter data submission.

2. The adequacy of the respondent’s approach to educating and supporting providers who submit paper claims.

3. The adequacy of the respondent’s approach to encouraging providers, particularly subcapitated providers, subcontractors, atypical providers, and non-participating providers to submit accurate, timely, and complete encounter data, including the type and frequency of activities and any incentives/penalties.

4. The adequacy of the respondent's description of how it will connect with providers to revise encounter submissions in a timely manner.



EVALUATION CRITERIA


SRC #50 [CORE]: The respondent shall describe its compliance program including the compliance officer’s level of authority and reporting relationships. Include an organizational chart of staff involved in compliance, along with staff levels of authority. Vendor Response: SRC #50 Evaluation Criteria: 1. The extent to which the compliance program complies with all state and federal

requirements.

2. The extent to which the respondent has identified a qualified individual with sufficient authority and adequate corporate governance reporting relationships to effectively implement the compliance program.

3. The extent to which there are sufficient staff to implement the compliance program.

4. The extent to which the respondent has experience identifying contractor fraud and internal fraud and abuse in managed care programs.

Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. SRC #51 [CORE]: The respondent shall describe its Special Investigations Unit (SIU) program and its controls for prevention and detection of potential or suspected fraud and abuse and overpayment, including the use of biometric technology to ensure that services are provided to the correct enrollee, including verification of home-based visits and services, to ensure those services are being appropriately provided and that services billed were received by the correct enrollee. Vendor Response: SRC #51 Evaluation Criteria: 1. The extent to which the respondent uses various types of controls and automated

approaches as part of a comprehensive approach to prevent and detect potential or suspected fraud and abuse and overpayment.

2. The extent to which the respondent uses biometric technology at the point of service delivery to prevent and detect potential or suspected fraud and abuse and overpayment.

3. The extent to which the respondent conducts clinical reviews and SIU investigations to detect potential or suspected fraud and abuse and overpayment.

4. The level of technology the respondent proposes to use in verifying home-based visits and

services.


EVALUATION CRITERIA


Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. SRC #52 [CORE]: The respondent shall describe its reporting and data analytic capabilities to utilize for reporting, analysis and evaluation including: a. Capability to generate reports automatically versus manually; b. Generation and provision of reports to the Agency on request; c. Staffing levels, skills and team structure available for data collection, reporting,

analysis and application of problem solving and process improvement; and d. Monitoring and evaluation completed by the respondent to ensure accuracy and

timeliness. Vendor Response: SRC #52 Evaluation Criteria: 1. The adequacy of the respondent’s staffing levels and team structure, organizational charts

or work flows identifying staffing levels and team structure to support data collection, data analysis and reporting functions necessary under the resulting Contract.

2. The extent to which the respondent’s description addresses the following: a) automated reporting; b) ad hoc report development; and c) team member skills to support data collection, reporting, analysis, problem solving and process improvement.

3. The accuracy of the respondent’s ability to monitor and ensure that reports are accurate, complete, valid and reliable.

Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. SRC #53: [CORE] The respondent shall describe how it will implement information systems in support of the resulting Contract: a. Capability and capacity assessment to determine if new or upgraded systems,

enhanced systems functionality and/or additional systems capacity are required to meet Contract requirements;

b. Configuration of systems (e.g., business rules, valid values for critical data, data exchanges/interfaces) to accommodate Contract requirements;

c. System setup for intake, processing and acceptance of one-time data feeds from the State and other sources (e.g., initial set of enrollees, claims/service utilization history for the initial set of enrollees, active/open service authorizations for the initial set of enrollees, etc.); and

d. Internal and joint (Managed Care Plan and State) testing of one-time and ongoing exchanges of eligibility/enrollment, provider network, claims and other data.

Vendor Response:


EVALUATION CRITERIA


SRC #53 Evaluation Criteria: 1. The adequacy of the respondent’s system and subsystem capabilities and functions.

2. The adequacy of the respondent’s approach to assessing its system to determine if

upgrades are necessary.

3. The adequacy of the respondent’s plan for making necessary changes to its system in a timely manner in order to comply with Contract requirements.

4. The adequacy of the respondent's approach to test one-time and ongoing data feeds. Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. SRC #54 [CORE]: The respondent shall describe how it will store and use electronic indexed images of documents sent to enrollees and providers, including correspondence and enrollee materials. Vendor Response: SRC #54 Evaluation Criteria: 1. The adequacy of the respondent’s process for retrieving electronic indexed images from the

system.

2. The adequacy of the respondent's approach to developing and maintaining electronic index.

3. The extent of the respondent’s experience with electronic indexed images.

4. The extent to which staff in relevant departments have access to electronic indexed images. Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. SRC #55 [CORE]: The respondent shall describe how it will initiate a change in a system including how employees and Agency staff and providers (if applicable) are notified about system changes. The description shall address testing and production control operations. Vendor Response: SRC #55 Evaluation Criteria: 1. The adequacy of the respondent’s notification process prior to launching a change in the

system, including notice to all impacted parties.


EVALUATION CRITERIA


2. The adequacy of the respondent's approach to testing to ensure system changes are accurate.

3. The adequacy of the respondent’s approach to determining how a change in one system impacts other systems.

Score: This section is worth a maximum of 15 raw points with each of the above components being worth a maximum of 5 points each. SRC #56 [CORE]: The respondent shall explain how its system will be integrated across departments (e.g., case management is able to access claims data or information in the system entered by enrollee services) and what limitations exist regarding integration among systems. In the response, the respondent shall explain how key systems are designed to interoperate (e.g., data field elements, refresh cycles, manual vs. automatic data exchange). Vendor Response: SRC #56 Evaluation Criteria: 1. The respondent’s capability to integrate systems across departments.

2. The extent of the respondent's system integration limitations.

3. The adequacy of the respondent’s description of users’ permission to edit

records/information.

4. The extent to which changes in one system are reflected in other systems (automatically vs. manual).


EXHIBIT E-2 STANDARD QUALITY MEASUREMENT TOOL


Year 1 Year 2

Annual Dental Visits

State

Medicaid, Medicare or Commercial

Indicator State Standard/

Goal National

Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

Example Florida 50.60% 42.50% 40.10% Example Florida 50.60% 42.70% 43.00%

State 1 State 1

State 2

State 2

State 3

State 3

Year 1 Year 2

Antidepressant Medication Management

State


Indicator State

Standard/Goal National

Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

Example Florida 48.30% 42.80% 63.50% Example Florida 48.30% 43.00% 64.00%

State 1 State 1

State 2 State 2

State 3 State 3

Year 1 Year 2

Adolescent Well-Care Visit

State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1 State 1

State 2 State 2

State 3 State 3



Year 1 Year 2

Breast Cancer Screening

State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1 State 1

State 2 State 2

State 3 State 3

Year 1 Year 2

Controlling High Blood-Pressure

State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1 State 1

State 2 State 2

State 3 State 3

Year 1 Year 2

Timeliness of Pre-natal Care

State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1 State 1

State 2 State 2

State 3 State 3



Year 1 Year 2

Post-Partum Care

State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1 State 1

State 2 State 2

State 3 State 3

Year 1 Year 2

Well-Child Visit in the 1st 15 months of life

State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1 State 1

State 2 State 2

State 3 State 3

Year 1 Year 2

Childhood Immunizations State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1 State 1

State 2 State 2

State 3 State 3

EXHIBIT E-3PROVIDER NETWORK FILE


PROV_ID PROV_NAME GROUP_NAME LICENSE FEIN NPI CITY ZIP COUNTY_CODE AGREE_TYPE AGREE_DATE PROV_TYPE PROV_SPEC PCP_IND EHR_IND MAIL_IND BED_COUNT ESS_PROV

123456789 LEDGERWOOD, DARRYL OS10046 431920294 1659543379 CORAL GABLES 33146 13 I 12/20/2012 26 102 N N N

123456790 DEPENDABLE NIGHTINGALES AGENCY 22007096 223979311 1992980874 ALTAMONTE SPRINGS 32714 59 I 12/6/2012 65 090 N N N

123456790 DEPENDABLE NIGHTINGALES AGENCY 22007096 215655795 1992980874 ALTAMONTE SPRINGS 32714 59 A 11/22/2012 65 091 N N N

123456813 ICONIQUE PLASTIC SURGERY OS8521 262683307 1700113040 BELLEAIR 33756 52 I 11/8/2012 26 060 N N N

TALLANT, CLARE OS8134 592441934 1548220064 BRADENTON 34208 41 I 10/25/2012 26 047 N Y N

123456815 HEMINGER, ALLAN 215922750 ALACHUA 32615 01 C 10/11/2012 67 096 N Y N

123456816 DOBROWOLSKI, JAVIER AA110 042783152 1205112513 AVENTURA 33180 13 C 9/27/2012 36 130 N Y N

123456817 SOUTHLAND EMS AT WEEMS, PL 274447119 1124302443 APALACHICOLA 32320 19 C 9/13/2012 25 035 Y N N

123456819 ADVANCED BEHAVIORAL CONSULTING 300624312 1235459199 GAINESVILLE 32606 01 A 8/30/2012 91 174 N Y N

123456819 ADVANCED BEHAVIORAL CONSULTING EMERG & ACUTE CARE MEDICAL CO, S.E 381860692 1235459199 GAINESVILLE 32606 01 A 8/16/2012 91 175 N Y 200 N

123456820 FORCIER, NELSON D ADVENTIST HEALTH SYS./SUNBELT, INC. ARNP637562 267632452 1295727097 CHATTAHOOCHEE 32324 20 A 8/2/2012 31 173 N Y N

123456821 ABILITY HEALTH SERVICES INC ALLERGY ASTHMA SPEC. PT14926 407641517 1952392854 ALTAMONTE SPRINGS 32714 59 A 7/19/2012 83 983 N Y N

123456822 DURGAN, ALANA CELEBRATION HEALTH MEDICAL GROUP 584764063 1205891934 MELBOURNE 32901 05 A 10/16/2012 97 803 N Y N

KINGS PHARMACY FL DEPT OF HEALTH,SEMINOLE CO H.D PH18847 589020215 1700824885 BOYNTON BEACH 33437 50 A 10/2/2012 20 203 N Y Y N

123456824 PALEN, DARRYL CORAL SPRINGS MED. CTR. ME81386 264940976 1528014313 BROOKSVILLE 34601 27 I 9/18/2012 25 100 N N N

123456825 LACH, SELENA NORTH TAMPA ANESTHESIA CONSULTANTS OS7906 144729931 1982604856 ALTAMONTE SPRINGS 32701 59 I 9/4/2012 26 017 N N N

123456826 AMERIGROUP 062383500 BOCA RATON 33487 50 A 8/21/2012 70 970 N N N

123456827 ESCOTO, KELLY P BELLE GLADE EMERGENCY PHYSICIANS OS5993 231715208 1750493177 ARCADIA 34266 14 C 8/7/2012 26 007 N N N

CHILDREN'S MEDICAL SRVC #4B 416405288 DAYTONA BEACH 32014 64 A 7/24/2012 78 978 N Y N

123456829 WALBORN, CARLENE OS1833 769059205 1619910734 SEMINOLE 33772 52 I 10/21/2012 26 067 N Y N

123456830 SNELGROVE, ESMERALDA ME59526 593318959 1265441026 ALTAMONTE SPRINGS 32714 59 I 10/7/2012 25 022 N Y N

MCANULTY, SAUNDRA OS6136 036287757 1962428219 BARTOW 33830 53 C 9/23/2012 26 003 N N N

123456832 MALLEN, KATHRINE ME60102 593688943 1386646461 ALTAMONTE SPRINGS 32701 64 C 9/9/2012 25 050 N Y N

123456833 ZEPP, LORAINE AMERIPATH HOSPITAL SERVICES FL LLC OS6191 294380364 1316909278 BOCA RATON 33428 50 C 8/26/2012 26 053 N Y Y

123456833 ZEPP, LORAINE OS6191 261617825 1316909278 BOCA RATON 33428 50 C 8/12/2012 26 061 N Y N

123456835 BORGEN, ROSLYN E ME29981 591355883 1891744512 ALTAMONTE SPRINGS 32714 59 C 9/6/2012 25 011 Y Y N

123456835 BORGEN, ROSLYN E FL DEPT OF HEALTH,SEMINOLE CO H.D ME29981 204583206 1891744512 ALTAMONTE SPRINGS 32714 59 C 8/23/2012 25 012 N Y N

FELTZ, MELISA CORAL SPRINGS MED. CTR. ME57670 593425191 1427035120 ALTAMONTE SPRINGS 32701 59 C 8/9/2012 25 009 Y Y N

GENERAL HOPITAL 000009002 030394176 1669431219 CAMBRIDGE 21613 99 I 7/26/2012 1 901 N Y 60 N

123456839 HETH, MARICELA ME41800 591313320 1417923962 ALTAMONTE SPRINGS 32701 59 I 7/12/2012 25 036 N Y N

123456840 TULEY, DARREN ME35836 582335994 1003872607 FT LAUDERDALE 33316 06 I 6/28/2012 25 024 N N N

123456841 SCOLA, KURT OS4250 261429970 1871516476 WINTER PARK 32792 59 C 7/23/2012 26 052 N N N

DURRELL, HUGH ME39822 108805737 1760461610 CAPE CORAL 33990 36 A 7/9/2012 25 034 N Y N

123456843 TOWSEND, HARRIETT ME42232 390700676 1205817632 ALTAMONTE SPGS. 32714 59 A 6/25/2012 25 058 N N N

123456844 KLAHN, ALLAN MAGELLAN BEHAVIORAL HEALTH OF FL DN8121 254556761 1073723003 ALTAMONTE SPRINGS 32714 59 A 6/11/2012 35 088 N N N

123456845 RAMSAY YOUTH SERVICES OF FLORIDA PH0016205 319340099 1417094160 BRADENTON 34210 41 I 5/28/2012 16 916 N N N

MARRO, MAX SHERIDAN HEALTHCORP, INC. OPC1543 096403196 1770593295 ALACHUA 32615 01 I 7/20/2012 62 962 N N N

123456847 CROOM'S, INC 000000077 512560418 APALACHICOLA 32320 19 C 7/6/2012 41 941 N N N

123456848 HOSPICE OF THE COMFORTER, INC. 5030096 639948810 1275553018 ALTAMONTE SPRINGS 32714 59 C 6/22/2012 15 915 N N N

123456849 AMERICAN HOME PATIENT HM0000490 592227075 1588635213 ALTAMONTE SPRINGS 32714 59 C 6/8/2012 90 069 N N N

SAMPLE

EXHIBIT E-4 SPECIALTY SUBMISSION REQUIREMENTS AND EVALUATION

CRITERIA


Category: Qualifications and Experience SRC #1 [CORE]: The respondent shall provide a list of all current and/or recent (within five (5) years of the issue date of this ITN) Contracts for managed care for the proposed specialty population. If the respondent does not have experience with the provision of managed care to the proposed specialty population, please include any relevant Contracts. The respondent shall provide the following information for each identified Contract: a. The specialty population served; b. The name and address of the client; c. The name of the Contract; d. The time period of the Contract; e. A brief narrative describing the role of the respondent and scope of the work

performed, including covered populations and covered services; f. The annual Contract amount (payment to the respondent) and annual claims

payment amount; g. The scheduled and actual completion dates for Contract implementation; h. The barriers encountered that hindered implementation (if applicable) and the

resolutions; i. Accomplishments and achievements; j. Number of enrollees, by health plan type (e.g., commercial, Medicare, Medicaid); and k. Whether the Contract was capitated, FFS or other payment method. Vendor Response: SRC #1 Evaluation Criteria: 1. The extent the Medicaid population served by the Managed Care Contracts is similar to the

specialty population proposed.

2. The number and size of Managed Care Contracts active in the last five (5) years.

3. The extent to which Managed Care Contracts, or other Contracts, active in the last five (5) years, provided relevant experience.

4. The extent to which listed accomplishments and achievements are significant and relevant to the specialty population proposed.

Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. Category: Eligibility and Enrollment SRC #2 [CORE]: The respondent shall propose detailed and specific criteria (age, medical condition and/or diagnoses) for the specialty population proposed in response to this ITN. The respondent shall include proposed methods for identifying the specialty population proposed, including any data sources/system, specific medical codes for


CRITERIA


procedures (e.g. CPT, Healthcare Common Procedure Coding System (HCPC), International Classification of Diseases (ICD-9)) or diagnoses (e.g. ICD-9, Diagnosis Related Groups (DRG), American College of Gastroenterology (ACG)) associated with the population, clinical assessment and/or referral protocols required. The respondent shall identify the estimated number of recipients meeting the criteria for the specialty population proposed, along with the source or methodology for such an estimate. Vendor Response: SRC #3 Evaluation Criteria: 1. The extent to which the proposed criterion produces a clearly defined and readily identifiable

target population.

2. The extent to which the proposed criterion results in a specialty population that does not exceed ten (10) percent of the total population of MMA eligible recipients.

Score: This section is worth a maximum of 40 raw points as indicated below. For Item 1: (a) 20 points if the proposed criterion produces a clear target population that is data driven and

not dependent on assessment or referral; (b) 10 points if the proposed criterion produces a clear target population that is in any way

dependent on assessment or referral; (c) 0 points if the proposed criterion does not produce a clear target population that can readily

be identified. For Item 2: (a) 20 points if the estimated size of the specialty population does not exceed ten percent (10%)

of the estimated total population of MMA recipients; (b) 10 points if the estimated size of the specialty population exceeds ten percent (10%) of the

estimated total population of MMA recipients. Category: Covered Services - Expanded Benefits SRC #3 [CORE]: The respondent may propose expanded benefits to meet the unique needs of the specialty population being proposed for this ITN. The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience in providing expanded services proposed to populations similar to the specialty population being proposed for this ITN. The respondent shall provide the rationale for each expanded service proposed, including the evidence-base and expected outcomes of such services related to the specialty population proposed. Vendor Response:


CRITERIA


SRC #3 Evaluation Criteria: 1. The extent of experience (e.g., number of Contracts, enrollees or years) in proving proposed

services to similar target populations are relevant to the specialty population proposed based on available evidence, and extent to which the described experience demonstrates the ability to achieve appropriate outcomes for the specialty population proposed.

Score: This section is worth a maximum of 5 raw points with the above component being worth a maximum of 5 points. Category: Covered Services - Care Coordination/ Case Management SRC #4 [CORE]: The respondent shall propose care coordination and/or case management activities to meet the unique needs of the specialty population being proposed for this ITN, including specific disease management interventions or special condition management relevant to the specialty population. The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience in providing care coordination/case management for populations similar to the specialty population being proposed, including experience with disease management or other special condition management. The respondent shall describe proposed interventions, evidence-based risk assessment tools, self-management practices, practice guidelines, etc., relevant to the specialty population proposed. The respondent shall identify specific staff qualifications, training and/or experience for case management personnel related to the specialty population proposed. The respondent shall describe any other care coordination/case management activities the respondent proposes to meet the needs of the specialty population proposed. Vendor Response: SRC #4 Evaluation Criteria: 1. The extent of experience (e.g., number of Contracts, enrollees or years) in providing care

coordination/case management to similar target populations, including disease or special condition management.

2. The extent to which the described experience demonstrates the ability to effectively provide care coordination/case management to the population proposed.

3. The extent to which the care/coordination activities proposed are relevant to the specialty population proposed.

Score: This section is worth a maximum of 30 raw points with each of the above components being worth a maximum of 10 points each as described below: (a) 10 points if the component is excellent; (b) 8 points if the component is above average; (c) 6 points if the component is average;


CRITERIA


(d) 4 points if the component is below average; (e) 2 points if the component contained significant deficiencies; (f) 0 points if the component was not addressed. Category: Provider Network SRC #5 [REGIONAL]: The respondent shall propose provider network standards that meet the needs of the specialty population being proposed for this ITN, including specific provider access ratios that exceed MMA standards for provider types relevant to the specialty population. The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience in managing provider networks for populations similar to the specialty population being proposed for this ITN, including experience with provider contracting and performance measurement relevant to the specialty population proposed. Identify specific requirements for provider Contracts, credentialing, provider handbooks, etc., the respondent proposes for network providers serving to the specialty population proposed. Describe any other provider services the respondent proposes to make available to the provider network serving to the specialty population. Vendor Response: SRC #5 Evaluation Criteria: 1. The extent of experience (e.g., number of Contracts, enrollees or years) managing a

provider network serving similar target populations.

2. The extent to which the described experience demonstrates the ability to manage a provider network relevant to the specialty population proposed.

3. The extent to which the provider capacity ratios proposed ensure the adequacy of a provider network relevant to the specialty population proposed.

4. The extent to which the provider requirements proposed are relevant to the provider network

serving the specialty population proposed. 5. The extent to which the provider services proposed are relevant to the provider network

serving the specialty population proposed. Score: This section is worth a maximum of 25 raw points with each of the above components being worth a maximum of 5 points each. Category: Quality Management SRC #6 [CORE]: The respondent shall propose quality management activities to address the needs of the specialty population being proposed for this ITN, including specific quality measures relevant to the specialty population. The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience in quality


CRITERIA


management for populations similar to the specialty population being proposed for this ITN. Include experience with standardized measures, such as HEDIS and Contract-required measures, relevant to the specialty population proposed by completing Exhibit E-5, Specialty Quality Measurement Tool. Identify specific quality measures relevant to the specialty population the respondent proposes to collect and report to the Agency. Describe any other quality management activities the respondent proposes to improve performance. Describe any instances of failure to meet HEDIS or Contract-required quality standards and actions taken to improve performance. Describe actions taken to improve quality performance when HEDIS or Contract required standards were met, but improvement was desirable. Vendor Response: SRC #6 Evaluation Criteria: 1. The extent of experience (e.g., number of Contracts, enrollees or years) in achieving quality

standards with similar target populations, including HEDIS or Contract required measures.

2. The extent to which the quality measures proposed are relevant to the specialty population being proposed for this ITN.

3. The extent to which the quality management activities proposed demonstrates the ability to

improve quality for the population proposed in a meaningful way. 4. The extent to which the respondent met all quality measures, successfully remediated all

failures or achieved overall improvement to overall performance. Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each. For Item 4, at total of 5 points are available. Exhibit E-5, Specialty Quality Measurement Tool provides for opportunities for a vendor to report prior experience in meeting a state quality standard on quality measures specific to the intended specialty population. The respondent will be awarded ¼ point, up to a maximum of 5 points, if their reported plan rate exceeded both the state standard or goal rate and the national mean, for each available year, for each available state.

EXHIBIT E-5 SPECIALTY QUALITY MEASUREMENT TOOL


Specialty Population Measures

Year 1 Year 2

State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1

State 2

State 3

Year 1 Year 2

State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1

State 2

State 3

Year 1 Year 2

State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1

State 2

State 3

Year 1 Year 2

State


Indicator State


Mean Plan Rate

State

State Standard/Goal

National Mean

Plan Rate

State 1

State 2

State 3

EXHIBIT E-6 RESPONDENT ATTESTATION FOR RESPONSE SUBMISSION


• I hereby certify that any submission in this response to Exhibit E-1, Standard Submission Requirements and Evaluation, or Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria, marked as “Core” is identical for every Region in which my company submitted a response.

• I hereby certify that any submission in this response to Exhibit E-1, Standard

Submission Requirements and Evaluation, or Exhibit E-4, Specialty Submission Requirements and Evaluation Criteria, marked as “Regional” applies only to the Region identified in the ITN to which this response applies.

• I hereby certify that any submission in this response to Exhibit E-2, Standard

Quality Measurement Tool or Exhibit E-5, Specialty Quality Measurement Tool, is true and accurate as submitted.

• I hereby certify that any submission in this response to Exhibit E-3, Provider Network File, is true and accurate as submitted.

Signature of Authorized Official

Date

Respondent Company Name

IN THE EVENT THE AGENCY DETERMINES THE RESPONDENT HAS FALSIFIED INFORMATION SUBMITTED ON ANY EXHIBIT TO ATTACHMENT E, INCLUDING THIS ATTESTATION, THE AGENCY WILL REJECT THE RESPONSE.

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