Specialty Submission Requirements

EXHIBIT A-4-d

SPECIALTY SUBMISSION REQUIREMENTS

AND EVALUATION CRITERIA

RESPONDENT NAME:

A. RESPONDENT BACKGROUND/EXPERIENCE

SPECIALTY SRC #1 – Specialty Experience (Statewide):

The respondent, including respondent’s parent, affiliate(s) or subsidiary(ies), shall provide a list of all current and/or recent (within five (5) years of the issue date of this solicitation [since July 14, 2012]) 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, the respondent shall not submit a response to this SRC. 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 specific start and end dates 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 use of administrative and/or delegated subcontractor(s), their scope of work;

g. The annual contract amount (payment to the respondent) and annual claims payment amount;

h. The scheduled and actual completion dates for contract implementation;

i. The barriers encountered that hindered implementation (if applicable) and the resolutions;

j. Accomplishments and achievements;

k. Number of enrollees, by health plan type (e.g., commercial, Medicare, Medicaid); and

l. Whether the contract was capitated, fee-for-service or other payment method.

For this SRC the respondent shall not include subcontractor experience.

Response:

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.

B. AGENCY GOALS

Specialty SRC# 2 - Care Coordination and/or Case Management (Statewide):

The respondent shall propose care coordination and/or case management activities to meet the unique needs of the specialty population being proposed for this solicitation, 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.

Response:

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/case management 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;

(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.

Specialty SRC #3 – Quality Measures (Statewide):

The respondent shall propose quality management activities to address the needs of the specialty population(s) being proposed for this solicitation, including specific quality measures relevant to the specialty population(s). The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience in quality management for population(s) similar to the specialty population(s) being proposed for this solicitation. Include experience with standardized measures, such as HEDIS and Contract-required measures, relevant to the specialty population(s) proposed. Identify specific quality measures relevant to the specialty population(s) 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.

Response:

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(s) being proposed for this solicitation.

3. The extent to which the quality management activities proposed demonstrate the ability to improve quality for the population(s) proposed in a meaningful way.

4. The extent to which the respondent met quality measure targets, successfully remediated all failures or achieved 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.

C. RECIPIENT EXPERIENCE

Specialty SRC #4 Eligibility and Enrollment (Statewide):

The respondent shall propose detailed and specific criteria (age, medical condition and/or diagnoses) for the specialty population proposed in response to this solicitation. The respondent shall include proposed methods for identifying the specialty population proposed, including any data sources/system, specific medical codes for procedures (e.g. Current Procedural Technology (CPT), Healthcare Common Procedure Coding System (HCPC), International Classification of Diseases (ICD-10)) or diagnoses (e.g. ICD-10, 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.

Response:

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 percent (10%) 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;

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

D. PROVIDER EXPERIENCE

No SRCs in this Category for Specialty.

E. DELIVERY SYSTEM COORDINATION

Specialty SRC# 5 - PROVIDER NETWORK (Regional):

The respondent shall propose provider network standards that meet the needs of the specialty population(s) being proposed for this solicitation, including specific provider access ratios that exceed MMA standards for provider types relevant to the specialty population(s). The respondent (including respondents’ parent, affiliate(s) or subsidiary(ies)) shall describe its experience in managing provider networks for population(s) similar to the specialty population(s) being proposed for this solicitation, including experience with provider contracting and performance measurement relevant to the specialty population(s) proposed. Identify specific requirements for provider contracts, credentialing, provider handbooks, etc., the respondent proposes for network providers serving the specialty population(s) proposed. Describe any additional provider services the respondent proposes to make available to the provider network serving the specialty population(s).

Response:

Evaluation Criteria:

1. The extent of experience (e.g., number of Contracts, enrollees or years) managing a provider network serving the proposed population(s).

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

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

4. The extent to which the provider requirements proposed are relevant to the provider network serving the specialty population(s) proposed.

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

F. OVERSIGHT AND ACCOUNTABILITY

No SRCs in this Category for Specialty.

G. STATUTORY REQUIREMENTS

No SRCs in this Category for Specialty.

AHCA ITN 005-17/18, Attachment A, Exhibit A-4-d, Page 2 of 8