Texas Health and Human Services Commission HHSC

1
Texas Health and Human Services Commission (HHSC)

• Medicaid / Children with Special Health Care
  Needs Claims Processing, Primary Care Case
  Management and Pharmacy Claims and Rebate
  AdministrationRequest for Proposals
  529-08-0159
• Vendor Conference September 23, 2008

2

• Welcome
• Introductions
• Lyn Peters, Enterprise Contract and Procurement
  Services (ECPS)
• David Brown, Assistant General Counsel
• Tim Seelig, Deputy Director, Medicaid/CHIP
  Procurement and Contract Services
• Robert Hall, Director/HUB Coordinator,
  Administrative Services Development (ASD)
• Larry Fisher, Senior Financial Analyst,
• HHS System Budget and Fiscal Policy
• Housekeeping Items

3
HHSC Procurement Roles

• ECPS- Responsible for procurement activity
• HUB- Responsible for HUB activity
• Program- Responsible for project scope,
  requirements, performance, results, contract
  management/monitoring
• Legal- Questions/answers and legal activity

4
Vendor Conference Overview

• Procurement Activities
• RFP Overview
• Break
• HUB Items
• Questions Submittal
• Lunch
• Notary Public
• Preliminary Responses to Questions
• Closing Comments

5

• Procurement Activities
• Questions Answers
• Sole Contact, Lyn Peters, ECPS
• Procurement Schedule
• Solicitation Access- http//www.hhsc.state.tx.us/
  about_hhsc/BusOpp/contracts.asp
• Submission Requirements
• Solicitation Changes
• Screening Evaluation
• Award Information

6
HHSC Point of Contact
Lyn Peters, Contract Administrator Enterprise
Contract and Procurement Services (ECPS)
Division 4405 N. Lamar Blvd. Austin, Texas
78756-3422 [phone] Fax (512)
206-5475 lyn.peters_at_hhsc.state.tx.us All
communications relating to this RFP must be
directed to the HHSC contact person. All
communications between respondents and other HHSC
staff members concerning this RFP are strictly
prohibited. Failure to comply with these
requirements may result in proposal
disqualification.
7
Medicaid / Children with Special Health Care
Needs Claims Processing, Primary Care Case
Management and Pharmacy Claims and Rebate
Administration
8
Medicaid / Children with Special Health Care
Needs Claims Processing, Primary Care Case
Management and Pharmacy Claims and Rebate
Administration

• RFP Overview
• Background
• Mission
• Scope of Work
• Performance Goals
• Performance Measures
• Compensation

9
Background

• Since 1991, HHSC has overseen and coordinated the
  planning and delivery of health and human service
  programs in Texas. HHSC is established in
  accordance with Texas Government Code Chapter 531
  and is responsible for the oversight of all Texas
  health and human service agencies (HHS Agencies).
  HHSCs chief executive officer is Albert Hawkins,
  Executive Commissioner of the Health and Human
  Services Commission.

10
Background

• Current Contracts
• The current contracts for administering the
  operations of the Texas Medicaid Management
  Information System (TMMIS) are set to terminate
  in August 2009. The contracts may be extended up
  to one additional year, expiring no later than
  August 31, 2010.

11
Background

• HHSC is seeking a vendor(s) who can
• 1) Take over operations of the current TMMIS,
  including the processing of MTP claims
• 2) Manage the Pharmacy Claims and Rebate
  Administration functions and
• 3) Provide a CHIP PCCM option.
• To accomplish the above, HHSC is seeking vendors
  who can perform the following business functions

12
Background

• General Operational Requirements Primary
  Care Case Management (PCCM) Administration
• Integrated Care Management (ICM) Provider
  Services
• Client Services Call Centers
• Administrative Cost Containment Health Care
  Cost Containment
• Medical/Dental Policy Program Policy
• Prior Authorization (PA) Fair Hearings
• Surveillance/Utilization Review (SUR) Third
  Party Resources (TPR)
• Claims Processing Health Insurance Premium
  Payments (HIPP) Insurance
• Reference Data Maintenance Premium Payment
  Assistance (IPPA)
• Financial Management Recipient Eligibility
  Maintenance and Eligibility Verification
• Provider Reimbursement Management and
  Administrative Reporting
• Ad Hoc Reporting System Maintenance and
  Modification
• System Operations, Disaster Recovery, Long
  Term Care Online Portal
• and Integrated Test Facility Long Term Care
  (LTC) Programs
• Medical Transportation Program (MTP)
  Children with Special Health Care Needs (CSHCN)
  Services
• Family Planning (FP) Program
• County Indigent Health Care Program (CIHCP)
  Medically Needy Program (MNP) and
• Pharmacy Claims and Drug Rebate
  Administration (PCRA)

13
Mission

• HHSCs mission for this procurement is to provide
  quality and necessary health care services to the
  segment of the Texas population with health
  benefits covered by the Texas Medicaid Program,
  Primary Care Case Management (PCCM), Department
  of State Health Services Family Planning (DSHS
  Family Planning), Texas Health Steps Programs
  (THSteps), the Children with Special Health Care
  Needs (CSHCN) Services Program and the Vendor
  Drug Program.

14
Scope of Work
Requirements Overview Section 7 General
Contract and Turnover Requirements Section 8
Operations Requirements General Operational
Requirements Primary Care Case Management
(PCCM) Administration Integrated Care
Management Provider Services Client Services
Call Centers Administrative Cost
Containment Health Care Cost Containment Medical
/Dental Policy Program Policy Prior
Authorization (PA) Fair Hearings

15
Scope of Work

• Requirements Overview
• Section 8 Operations Requirements
• Surveillance and Utilization Review
• Third Party Resources (TPR)
• Health Insurance Premium Payment (HIPP) System
  and Insurance Premium Payment Assistance (IPPA)
• Claims Processing
• Financial Management
• Provider Reimbursement
• Management and Administrative Reporting (MAR)
• Ad Hoc Reporting
• Reference Data Maintenance
• Recipient Eligibility Maintenance

16
Scope of Work

• Requirements Overview
• Section 8 Operations Requirements
• Eligibility Verification
• System Maintenance and Modification
• System Operations, Disaster Recovery, and
  Integrated Test Facility
• Long Term Care (LTC) Online Portal
• Long Term Care (LTC) Programs
• Children with Special Health Care Needs (CSHCN)
  Services Program
• Family Planning (FP)
• County Indigent Health Care Program (CIHCP)
• Medically Needy Program (MNP)
• Medical Transportation Program (MTP) and
• Pharmacy Claims and Drug Rebate Administration
  (PCRA).
• Section 9 Transition Phase Scope of Work

17
Performance Goals
HHSC will monitor the performance of the
contract(s) issued under this RFP. All services
and deliverables under the contract shall be
provided at an acceptable quality level and in a
manner consistent with acceptable industry
standards, customs and practices. Failure to
produce deliverables in such a manner could
result in remedies as outlined in Appendix D.
18
Compensation

• The State has chosen to use a Fixed Price
  approach related to the administrative services
  and a Fiscal Agent approach related to the
  medical benefit costs / pharmacy benefit costs
  included in the Contract or Contract(s) resulting
  from this RFP. Normally, the medical benefit
  costs for Medicaid recipients enrolled in a
  Medicaid Managed Care Health Maintenance
  Organization (HMO) will not be included with the
  Fiscal Agent medical benefit funds. The pharmacy
  benefit costs for Medicaid recipients enrolled in
  a Medicaid HMO will be included with the Fiscal
  Agent pharmacy benefit funds.
• The RFP is comprised of two specific component
  service areas for which the Vendor may propose
  solutions
• Medicaid/CSHCN Services Program Claims/PCCM
  Administrator
• Pharmacy Claims/Pharmacy Rebate Administrator.

19
Compensation Financial Approach

• The various program types included in the
  Medicaid/CSHCN Services Program Claims/PCCM
  Administrator component service area are as
  follows
• (1) Core Title XIX -
• (includes all services not otherwise covered by
  programs below)
• (2) Children with Special Health Care Needs
  (CSHCN) Services Program
• (3) Family Planning (FP) Title V, X, and XX
• (4) Long Term Care (LTC) and
• (5) Medical Transportation Program (MTP).
• The various program types included in the
  Pharmacy Claims/Pharmacy Rebate Administrator
  component service area are as follows
• (1) Core Title XIX
• (including pharmacy claims for Medicaid managed
  care clients)
• (2) Childrens Health Insurance Program (CHIP)
• (3) CSHCN Services Program and
• (4) Kidney Health Care Program (KHC).

20
Compensation Financial Approach

• A Vendor may choose to propose a solution for one
  or both of the RFP components.
• A Vendor that proposes solutions for more than
  one RFP component must submit pricing proposals
  for each component type separately and a pricing
  proposal for both components together (3 separate
  proposals in total).

21
Compensation Financial Approach

• The Vendors accounting records and procedures
  are subject to State approval. Accruals of
  expenses or liabilities are subject to State
  review and approval. The State will not recognize
  as valid costs, any accruals that it deems
  inappropriate. For example, lease agreement costs
  beyond the effective date of termination or
  completion of the Contract, or lease cancellation
  expenses resulting from termination or completion
  of the Contract, will not represent valid
  allowable costs.

22
Compensation Financial Approach

• A Vendor must keep separate financial records
  for each of the two (2) component service areas
  administered under the Contract or Contracts
  resulting from the RFP
• (1) Medicaid/CSHCN Services Program Claims/PCCM
  Administrator and
• (2) Pharmacy Claims / Pharmacy Rebate
  Administrator.
• A Vendor must keep separate financial records
  for the following Medicaid/CSHCN Services Program
  Claims/PCCM Administrator sub-component program
  types
• Core Title XIX
• CSHCN Services Program
• Family Planning Title V, X, and XX (FP)
• Long Term Care (DADS-LTC) and
• Medical Transportation Program (MTP).
• A Vendor must keep separate financial records
  for the following Pharmacy Claims/Pharmacy Rebate
  Administrator sub-component program types
• Pharmacy Claims Administration and
• Pharmacy Rebate Administration.

23
Compensation Financial Approach

• A Vendor must provide monthly financial
  statements depicting the Vendors operation under
  this Contract or Contracts resulting from this
  RFP no later than the twenty-fifth (25th)
  calendar day following the end of the previous
  month. HHSC reserves the right to request
  financial information in a format that will allow
  the State to most efficiently comply with its
  State and Federal financial reporting
  requirements.
• A Vendor must provide a monthly report that shows
  daily cash balances in each of the bank accounts
  described in this Request for Proposal.
• A Vendor must provide a monthly report that
  details all of the types of deposits made by the
  Vendor into each applicable bank account.

24
Compensation Financial Approach

• A Vendor must establish and maintain three (3)
  bank accounts in a bank located within the State
  of Texas. The accounts are identified as follows
  
• (1) Core Title XIX Medical Benefits Disbursement
  Account,
• (2) Core Title XIX Refund Account, and
• (3) CSHCN Services Program Medical Benefits
  Disbursement Account.

25
Compensation Financial Approach

• The Medicaid/CSHCN Services Program Claims/PCCM
  Administrator Vendor will receive funds weekly
  from the State to pay medical benefit claims the
  Vendor has determined are ready for payment. The
  Vendor will receive payments monthly as
  compensation for the applicable administrative
  services required in the RFP.

26
Compensation Financial Approach

• Costs for administrative services provided by the
  Medicaid/CSHCN Services Program Claims/PCCM
  Administrator Vendor will be based on fixed fee
  (s) and variable fee formulas for two (2) of the
  program types. The costs for administrative
  services for three (3) program types will be
  based on fixed fee (s) only.

27
Compensation Financial Approach

• HHSC requires that no more than 50 of the
  administrative fees for the DADS Long Term Care
  services will be paid utilizing fixed fees and a
  minimum of 50 of the administrative fees for the
  DADS Long Term Care services will be paid
  utilizing variable fees. HHSC reserves the right
  to determine the final percentage of fixed fees
  and variable fees in the contract for the DADS
  Long Term Care services.
• HHSC requires that no more than 65 of the
  administrative fees for the Core Title XIX
  services will be paid utilizing fixed fees and a
  minimum of 35 of the administrative fees for the
  Core Title XIX services will be paid utilizing
  variable fees. HHSC reserves the right to
  determine the final percentage of fixed fees and
  variable fees in the contract for the Core Title
  XIX services.

28
Compensation Financial Approach

• Transition costs to meet the requirements of the
  RFP will be paid on a fixed fee basis. Transition
  costs in excess of the final fixed price
  amount(s) included in the Contract(s) will not be
  paid by the State. Any expenses incurred by a
  vendor after the commencement of the operational
  phase of the contract(s) to complete transition
  activities or correct any defects from the
  Transition Phase must not be recorded as an
  operational expense and will not be considered an
  allowable expense for the Retrospective Cost
  Settlement provision of the Contract.

29
Compensation Financial Approach

• Separate transition costs will be proposed,
  negotiated, and paid for the following program
  types of the Medicaid/CSHCN Services Program
  Claims/PCCM Administrator component service area
• Core Title XIX services
• CSHCN Services Program services
• Family Planning Title V, X, and XX services
• Long Term Care Program services
• Medical Transportation Program services and
• Childrens Health Insurance Program (CHIP)
  for
• CHIP PCCM option.

30
Compensation Financial Approach

• Payment to the Pharmacy Claims/ Pharmacy Rebate
  Administrator Vendor for administrative services
  will be based on a fixed administrative fee
  basis.
• Separate fixed administrative fees will be paid
  for
• Pharmacy Claims Administration and
• Pharmacy Rebate Administration.

31
Compensation Financial Approach

• Transition costs to meet the requirements of the
  RFP will be paid on a fixed fee basis. Transition
  costs in excess of the final fixed price
  amount(s) included in the Contract will not be
  paid by the State.
• Transition costs will be proposed to allow the
  Pharmacy Claims/Pharmacy Rebate Administrator
  Vendor to assume the responsibilities of the RFP
  effective no later than September 1, 2010.
• Transition costs will not be paid as an element
  of operational administrative costs. Transition
  costs will be paid to the Vendor retrospectively.

32
Compensation Financial Approach

• Ownership of all nonexpendable capital items
  FUNDED by the contract resulting from this RFP
  will pass to the State at the expiration of the
  contract.
• Actual expenditures for Pass-Through Items made
  on the States behalf will be paid without
  allocation of any indirect charges (general
  administrative expenses, overhead, etc.) or
  profit.
• A complete listing of expenditures designated as
  Pass-Through Items is documented at Section
  6.8.3.2 of the RFP.

33
Compensation Financial Approach

• Administrative fees paid to the Vendor during
  each Operational Contract Year will consist of
• Fixed Administrative Fees
• Variable Administrative Fees
• Administrative Fees for the Additional Periodic
  Activities
• Administrative Fees for Additional Recurring
  Activities
• The sum of the four Fee components will be
  referred to as the Fee Ceiling.

34
Compensation Financial Approach

• The total maximum cost of the Services and
  Deliverables supplied by the Vendor to HHSC
  during each Operational Contract Year will not
  exceed the lesser of
• (a) the Vendors Fees (Fee Ceiling) or
• (b) the sum of the Allowable Costs incurred by
  the Vendor plus the allowable administrative
  service fee during the subject Operational
  Contract Year.

35
Compensation Financial Approach

• Forms substantially similar to those described in
  the RFP must provide the component costs of the
  Firm Fixed Prices quoted for providing the
  services and deliverables set forth in the RFP.
• Attachment A, Appendix A-1 contains Transitional
  Pricing Schedules
• Attachment A, Appendix A-2 contains Operational
  Pricing Schedules
• Attachment A, Appendix A-3 contains formal Price
  Summary Sheets

36
Compensation Financial Approach

• The potential Vendor must structure its pricing
  quotation to allow HHSC a method to map the
  proposed costs for the cost proposal submitted
  back to the Vendors Detailed Work Plan for the
  initial term of the Contract.
• The Vendor must provide separate Transitional
  Costs through the proposed transition period.
• The Vendor must provide the required projected
  monthly costs for the entire operations period.
• The pricing quotations for each specific
  component must agree with the Firm Fixed Prices
  proposed by the Vendor (Fixed and Variable
  Prices).

37
Compensation Financial Approach

• Transition Pricing Schedules
• The potential Vendors transitional cost proposal
  sheets for this RFP must identify the proposed
  Key Milestones the Vendor will accomplish
  during the Transitional period (Appendix A-1).
• The State is requesting each prospective Vendor
  to identify the Key Milestones the Vendor
  believes would be pertinent and appropriate as a
  Key Milestone during the Transition period.
• The State reserves the option to add, delete
  and/or modify Key Milestones included in the
  Vendors transitional cost proposal sheets.

38
Compensation Financial Approach

• The potential Vendors operational cost proposal
  sheets (Appendix A-2) for each of the operational
  components must be delineated by the primary
  business functions (functional areas) documented
  in the RFP for each component.

39
Compensation Financial Approach

• Instructions for completing each schedule are
  included in the RFP.
• Summary forms should be supported by the detailed
  information contained on monthly schedules.
• Amounts shown on the monthly schedules must agree
  with the cumulative amounts shown on the summary
  forms.
• In addition to paper copies of the Vendors Cost
  Proposal and Price Summary sheets, Vendors must
  submit electronic versions in an MS Excel format.
  

40
Compensation Financial Approach

• The State will be providing prospective Vendors
  with an electronic version of the required Cost
  Proposal and Price Summary sheets in an MS Excel
  format on or before October 6, 2008 (when answers
  to questions are posted to the website). The file
  will posted in the procurement library.
• Any electronic version of the pricing forms must
  contain any and all formulas used to calculate
  pricing information contained on the forms and
  include any and all links to other worksheets /
  forms included in the Vendors Cost Proposal.

41
Compensation Financial Approach

• Vendors must separately identify value-added
  benefits, cost-savings and cost-avoidance methods
  and measures, and the effect of such methods on
  the Cost Proposal and Scope of Work.
• The cost proposal should include any business,
  economic, legal, programmatic, or practical
  assumptions that underlie the Cost Proposal. HHSC
  reserves the right to accept or reject any
  assumptions.

42
15 Minute Break
43
HUB Subcontracting Plan(HSP) Requirements
44
Agenda Topics

• RFP Section 4.0 Historically Underutilized
  Business
• Participation Requirements
• HUB Subcontracting Plan for the RFP is required
• Self Performance HSP
• HSP Prime Contractor Progress Assessment Report

45
RFP Section 4.0 - Historically Underutilized
Business Participation Requirements

• HUB Participation Goals
• Potential Subcontracting Opportunities
• Vendor Intends to Subcontract
• Minority or Women Trade Organizations
• Self Performance
• HSP Changes After Contract Award
• Reporting and Compliance with the HSP

46
If HSP is inadequate, response will be rejected
HUB GOALS
47
Special Language
Section 1 Company Information
Section 2 Subcontracting Intentions
If Yes Enter subcontracting opportunities If
No skip to Sections 9 and 10
48
One page for each area subcontracted (listed in
Section 2)
HSP Information Page
49
Section 3 List Line and Subcontracting
Opportunity
50
Section 4 Protégé performing the work
Section 5 Professional Services Category
51
HSP Information Page
Section 6(a) Good Faith Efforts to find/include
Texas Certified HUB Vendors
52
HSP Information Page
Section 6(b) Contact HUB Trade Organization
53
HSP Information Page
Section 6(c) Written Notification Requirements
54
HSP Information Page
Section 7 List 3 HUBs Contacted for this
Subcontracting Opportunity
Section 8 List Subs Selected (HUBs Non-HUBs)
for this Subcontracting Opportunity
55
HSP Information Page
Section 8 Reason why HUB was not selected for
this Subcontracting Opportunity
56
Section 9 Self Performance Explanation
Section 10 Signature Affirms that True and
Correct Information is Provided
57
HSP Prime Contractor Progress Assessment Report
ATTACHMENT E

• Required with
• ALL Pay Requests

• List ALL Sub payments
• (HUBs Non-HUBs)

58
HSP ASSISTANCE FROM TPASS
HUB Subcontracting Plan (HSP) Forms Step-by-step
instructions and an audio on How to Complete an
HSP is located on the Texas Building and
Procurement Commissions (TBPCs) website at
http//www.cpa.state.tx.us/procurement/prog/hub/h
ub-forms/HUBSubcontractingPlan.pdf How to
Complete an HSP Play Windows Media Version (7.7
MB) Play QuickTime (mp4) version (24 MB) Play
Macromedia Flash version (10.8 MB) Read Video
Transcript (.rtf file, 160K)
59
Administrative Services Development HUB Program
Office

• Robert L. Hall, C.P.M.
• Director of Administrative Services
  Development
• - [phone]
• - robert.hall_at_hhsc.state.tx.us
• Carlos A. Balderas
• ASD HUB Administrator
• - [phone]
• - carlos.balderas_at_hhsc.state.tx.us
• Sherice Williams-Patty
• ASD HUB Administrator
• - [phone]
• - sherice.williams-patty_at_hhsc.state.tx.us
• Segundo Sanchez
• ASD Procurement/HUB Team Lead
• - [phone]
• - segundo.sanchez_at_hhsc.state.tx.us

60

• Submit Questions
• Lunch Break Noon - 200 p.m.
• Lonestar Conference Room
• 100 p.m. - 200 p.m. Notary Public Available to
  Sign Non-Disclosure Statements.
• 200 p.m. 300 p.m. Non-Binding Answers to
  Vendor Questions.

61
Questions and Answers

• Non-binding verbal answers to vendor questions.
• Binding responses will be posted on the
  procurement website by October 17, 2008.
• http//www.hhsc.state.tx.us/about_hhsc/BusOpp/cont
  racts.asp

62
Closing Comments

• Office of General Counsel
• Collusion
• Conflict of Interest
• Permissible contacts