L.A. Care Duals Demonstration Participating Physical Group (PPG) Subcontracting Application

L.A. Care Duals Demonstration Participating Physical Group (PPG) Subcontracting Application

Please submit responses to with “Duals PPG Application” in the subject line. Attachments should be submitted separately in the same file format as the original file.

This application does not constitute a contract or a binding obligation on the part of L.A. Care or the submitting health plan. Any request for information or use of that information by L.A. Care shall not be construed as a legal obligation to proceed with or enter into a transaction or agreement with the submitting plan. Submitting plans shall be notified in writing regarding their status as it is determined by L.A. Care.

As part of this application, L.A. Care intends to enter into a Confidentiality and Nondisclosure Agreement with the applicant, on a form provided by L.A. Care (see Attachment 10.1), to protect the applicant’s confidential and proprietary information to the extent permitted by applicable laws, including without limitation, the California Public Records Act.

Section 1: PPG Information

PPG Name:
Address:
Telephone:
Website:
Primary Contact:
Primary Contact Email:
Primary Contact Telephone:
Please provide a profile of your company (e.g. an overview of your organization; an organizational chart; relevant business and market experience; ownership). Please limit responses to 500 words or less.
Please identify your management company (MSO).
Is your organization independently or publicly owned? When and in what state is your company incorporated?
If your organization is a closely held company, please list all shareholders/owners with more than 5% interest.
Please provide a discussion of your corporate structure, including your organizational relationship to other entities, including but not limited to a parent organization, a subsidiary or any other affiliated organization or entity. Include the following information:
Taxpayer Identification Number (TIN)
Type of organization (e.g., sole proprietorship, partnership, corporate entity (not tax-exempt), corporate entity-not for profit (tax-exempt), government entity (Federal, State, or local), or other type of organization)
Whether you are owned or controlled by a common parent. A common parent is defined as a corporate entity that owns or controls an affiliated group of corporations that files its Federal income tax returns on a consolidated basis, and of which you are a member.
a.  Name of common parent, or if you are the common parent
b.  Any subsidiaries or affiliates and describe the relationship
Are you listed on the DMHC website as a risk bearing organization (RBO)? / Yes
No
Please complete the following certification.
Offeror and/or any of its Principals:
a.  Are are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency or from participating in any Federal healthcare programs;
b.  Have have not , within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) contract or subcontract; violation of Federal or State antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, violating Federal criminal tax laws, or receiving stolen property;
c.  Are are not presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in paragraph b; and
d.  Have have not , within a three-year period preceding this offer, been notified of any delinquent Federal taxes in an amount that exceeds $3,000 for which the liability remains unsatisfied.
For purposes of this certification, “Principal” means an officer, director, owner, partner, or a person having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a division or business segment; and similar positions).
The Offeror shall provide immediate written notice to L.A. Care if, at any time prior to award of any subcontract, the Offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

Section 2: General Information

Are you currently contracted with a Medicare plan(s) in Los Angeles County? / Yes
No
If yes, please list each plan and indicate the number of years contracted.
Please provide current Duals enrollment in Los Angeles County (indicate D-SNP, MAPD, or other).
Please list excluded zip codes, if any, in Los Angeles County.
Please list other counties in California in which you contract with a Medicare plan.
CY 2010-2012 D-SNP Risk Adjustment Factor (RAF) Data
Please provide the percentage of providers in your Medicare network that fall under each RAF score category below.
RAF Score / 2010 / 2011 / 2012
Q1 / Q2 / Q3 / Q4 / Q1 / Q2 / Q3 / Q4 / Q1 / Q2 / Q3 / Q4
1.0 / % / % / % / % / % / % / % / % / % / % / % / %
0.9-1.0 / % / % / % / % / % / % / % / % / % / % / % / %
0.8-0.89 / % / % / % / % / % / % / % / % / % / % / % / %
<0.8 / % / % / % / % / % / % / % / % / % / % / % / %
Please (1) indicate your 2011 D-SNP HEDIS scores and (2) certify your capability to meet HEDIS measurements at the 25th percentile in the following categories:
(1) Current Score / (2) Certification
Breast Cancer Screening- Ages 40-69 (Stars C01)
Cholesterol Management- LDL Screening (Stars C03)
Diabetes Care- LDL Screening (Stars C04)
Adults’ Access to Preventive/Ambulatory Health Services (Stars C11)
Adult BMI Assessment (Stars C12)
Care for Older Adults- Medication Review (Stars C13)
Annual Monitoring of Patients on Persistent Medications- Combined Rate
Diabetes Care- HbA1c Poor Control > 9.0% (Stars C19)
Diabetes Care- LDL < 100 (Stars C20)

Section 3: Model of Care

Please describe your experience managing a Medicare product under a D-SNP model of care.
Are you fully delegated to conduct Utilization Management concurrent review? / Yes
No
Are you fully delegated to conduct complex case management? / Yes
No

Section 4: Access

Please indicate your experience meeting Medi-Cal access standards.
Please describe your experience meeting Medicare access standards.
Please describe your group’s experience meeting access to care through the CAHPS survey or other health plan and/or industry surveys.

Section 5: Financial Information

Please certify you are in compliance with DMHC financial solvency standards, including but not limited to the following:
a.  Tangible Net Equity
b.  Cash-to-Claims Ratio
c.  Claims Payment Timeliness
Please indicate your Medicare encounters PMPY:
2010 / 2011
E&M Encounters
Total Encounters

Section 6: Provider Network

Attachment 6.1: Provider and Facility Table Instructions
Attachment 6.2: Provider Table (.xls)
Attachment 6.3: Facility Table (.xls)
Please attach evidence of contracted provider network for benefits currently provided under the Medicare program the following by completing Attachments 6.2-6.3. Specific instructions can be found in Attachment 6.1: Provider and Facility Table Instructions.
Please describe the nature of your relationship with hospital partners.
Please identify the top three hospitals your group intends to work with as part of the Duals Pilot.
Are you in dual risk arrangements with any of these facilities for Duals products? / Yes
No

Section 7: Long Term Care, Long Term Support Services, and Home and Community Based Services (Section 7 not to exceed 4 pages in length)

Are you currently at risk for any LTC, LTSS, and/or HCBS? / Yes
No
Please describe your experience, if any, with skilled nursing facility (SNFist) programs.
Please describe your experience assessing, coordinating and referring eligible beneficiaries to long-term care supports and services, specifically In-Home Support Services, Community-Based Adult Services and the Multi-Purposes Senior Services Program.
Please describe your ability and/or experience connecting beneficiaries to community social programs such as CalFresh, Meals on Wheels and others.

Section 8: Regulatory Compliance

Please list all sanctions, penalties and corrective action plans issued by Centers for Medicare and Medicaid Services (CMS) or ANY state of California government entity taken in the last three years, including the reason for the corrective action plan and the resolution.
Please certify you are not under sanction by any regulatory agency.
Please certify you are not under sanction by any MAPD or D-SNP within California.

Section 9: Other (Section 9 not to exceed 4 pages in length)

Do you have any Medicare provider incentive programs? / Yes
No
If yes, please describe the incentive programs (attach additional program materials if needed).
Do you have any quality-based incentive programs? / Yes
No
If yes, please describe the incentive programs (attach additional program materials if needed).
Do you have safety net providers in your contracted network (FQHCs, community clinics, etc.)? / Yes
No
If yes, what percentage of your network is comprised of safety net providers?
Please describe your reimbursement model for downstream providers (PCP, specialty, ancillary) and any payment or program offered that incentivizes care delivery in the most clinically appropriate/cost effective setting.
Please describe your experience referring and tracking beneficiaries’ access to County’s behavioral health programs.
Please provide any other relevant information for L.A. Care’s consideration (e.g. unique value added).

Section 10: Non-Disclosure and Confidentiality Agreement

Attachment 10.1: Non-Disclosure and Confidentiality Agreement
Please complete Attachment 10.1.

______

Name Title Signature Date

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