Minnesota Department of Human Services Health Care Administration

Transcription

1 Minnesota Department of Human Services Health Care Administration Request for Proposals for Qualified Grantee(s) to Provide Health Care Services to Medical Assistance and MinnesotaCare Enrollees Under Alternative Payment Arrangements Through the Integrated Health Partnerships (IHP) Demonstration Date of Publication: April 27, 2015 Americans with Disabilities Act (ADA) Statement: This information is available in accessible formats for people with disabilities by calling or by using your preferred relay service. For other information on disability rights and protections, contact your agency s Americans with Disabilities Act (ADA) coordinator. IHP RFP Revised - July 13,

2 Table of Contents I. Introduction... 4 A. Purpose of Request... 4 B. Objective of this RFP... 4 C. Background General: Eligible Populations: Excluded Populations: Other Information... 6 II. Scope of Work... 6 A. Overview System Requirements Overview of Payment Models and Risk Definitions of Total Cost of Care Attribution Methodology Quality Measures Interaction with Medicaid Managed Care Organizations (MCOs) Data Feedback to Providers B. Tasks/Deliverables III. Proposal Format A. Required Proposal Contents B. Proposal Requirements Executive Summary: Description of the Applicant Delivery System: Description of MHCP Population Served by the Delivery System: Proposed Payment Arrangement: Quality Measures: D. Required Statements IV. RFP Process A. Timeline B. Optional Individual Question and Answer Sessions C. Responders Questions IHP RFP Revised - July 13,

3 D. Proposal Submission V. Proposal Evaluation and Selection A. Overview of Evaluation Methodology B. Evaluation Team C. Evaluation Phases Phase I Required Statements Review Phase II - Evaluation of Technical Requirements of Proposals Phase III - Selection of the Successful Responder(s) D. Contract Negotiations and Unsuccessful Responder Notice VI. Required Contract Terms and Conditions VII. State s Rights Reserved Appendix A, IHP Provider Reports Reference Documentation...33 Appendix B, Model IHP Contract IHP RFP Revised - July 13,

4 I. Introduction The goal of the Integrated Health Partnerships demonstration Request for Proposal (RFP) is to improve the quality and value of the care provided to the citizens served by public health care programs. This program creates an Integrated Health Partnership (IHP) structure for provider organizations to voluntarily contract with the Minnesota Department of Humans Services (DHS) to care for Minnesota Health Care Programs (MHCP) patients in both fee for service (FFS) and managed care under a payment model that holds these organizations accountable for the total cost of care and quality of services provided to this population. Within this structure, DHS plans to implement demonstration projects in different geographic regions of the state and across different models of care delivery that will integrate health care with chemical and mental health services, safety net providers, and social service agencies. The projects will include clear incentives for quality of care and targeted savings, and will result in increased competition in the marketplace through direct contracting with providers. A. Purpose of Request The Minnesota Department of Human Services, through its Health Care Administration (State), is seeking Proposals from qualified Responders to test alternative and innovative health care delivery systems serving MHCP patients. Minnesota Statutes 256B.0755 directs the State to solicit proposals to test alternative and innovative health care delivery systems that provide services to a specified patient population for an agreed upon total cost of care or risk/gain sharing payment arrangement. It also states that the request for proposals should be developed in consultation with hospitals, primary care providers, health plans, and other key stakeholders. To this end DHS released an RFI on March 28, 2011 and held three stakeholder meetings (April 7, 8, and 15, 2011). The RFI closed on April 15, The State received 40 responses and used the information to inform the development of the IHP model. B. Objective of this RFP The objective of this RFP is to contract with qualified Responders to perform the tasks and services set forth in this RFP. It is anticipated that any contract awarded under this RFP will have a start date of January 1, 2016, and an initial term of one year. Thereafter, the Commissioner of Human Services may choose to renew any contract awarded under this RFP annually over a three year period. Proposals must be submitted by 4:00 p.m. Central Time on August 24, This RFP does not obligate the State to award a contract or complete the project, and the State reserves the right to cancel the solicitation if it is considered to be in its best interest. All costs incurred in responding to this RFP will be borne by the Responder. C. Background 1. General: Under the authority of Minnesota Statutes 256B.0755, the State is soliciting IHP RFP Revised July 13,

5 proposals for Responders to participate in alternative payment arrangements for health care services on a statewide basis as an IHP. The proposed IHP will serve the population of non-dually eligible adults and children in Medical Assistance and MinnesotaCare enrolled under both fee-for-service and managed care programs. 2. Eligible Populations: The following persons who are recipients of Medical Assistance and MinnesotaCare are eligible for attribution to the IHP: a. Medical Assistance Enrollees Including pregnant women, children under 21, adults without children, and state-funded Medical Assistance. b. MinnesotaCare Enrollees Including pregnant women, children under 21, and adults without children. Individuals must belong to an eligible group under Minnesota Statutes, chapter 256L, meet income criteria, satisfy all other eligibility requirements, and pay a premium to the State. c. Recipients receiving Medical Assistance due to blindness or disability, as determined by the U.S. Social Security Administration or the State Medical Review Team, who are not dually eligible for Medicare. 3. Excluded Populations: The following persons are excluded from attribution to the IHP: a. Recipients receiving Medical Assistance due to age, blindness or disability who are dually eligible for Medicare. b. Recipients for whom DHS receives incomplete claims data due to third-party liability coverage. c. Recipients receiving Medical Assistance under the Refugee Assistance Program pursuant to 8 U.S.C. 1522(e). d. Individuals who are Qualified Medicare Beneficiaries (QMB), as defined in Section 1905(p) of the Social Security Act, 42 U.S.C. 1396d (p), who are not otherwise receiving Medical Assistance. e. Individuals who are Service Limited Medicare Beneficiaries (SLMB), as defined in Section 1905(p) of the Social Security Act, 42 U.S.C. 1396a(a)(10)(E)(iii) and 1396d(p), and who are not otherwise receiving Medical Assistance. f. Non-citizen recipients who only receive emergency Medical Assistance under Minnesota Statutes, section 256B.06, subd. 4. g. Recipients receiving Medical Assistance on a medical spend down basis. h. Medical Assistance recipients with cost-effective employer-sponsored private health care coverage, or who are enrolled in a non-medicare individual health plan determined to be cost-effective according to Minnesota Statutes, section 256B.69, subd. 4(b)(9). IHP RFP Revised - July 13,

6 i. Medical Assistance recipients with private health care coverage through a Health Maintenance Organization (HMO) licensed under Minnesota Statutes, chapter 62D. j. Medical Assistance recipients enrolled with Metropolitan Health Plan d/b/a Hennepin Health under the Hennepin County Medicaid demonstration project for single nondisabled adults under age sixty-five. k. MinnesotaCare recipients who are enrolled in the Healthy Minnesota Contribution Program. l. The commissioner may exclude recipients enrolled in Minnesota Senior Care Plus (MSC+), other than those in (a) above. 4. Other Information Minnesota Health Care Programs Fact Sheet Center for Medicare and Medicaid Innovation Models IHP website and RFI Responses Minnesota Health Reform Initiative Attachments Included DHS IHP Provider Reports Reference Documentation (Appendix A of this document) Integrated Health Partnerships (IHP) Model Base Contract and Attachments (Appendix B of this document) II. Scope of Work A. Overview This RFP provides background information and describes the services desired by the State. It delineates the requirements for this procurement and specifies the contractual conditions required by the State. Although this RFP establishes the basis for Responder Proposals, the detailed obligations and additional measures of performance will be defined in the final negotiated contract. The purpose of the IHP demonstration is to provide opportunities for providers and other organizations to develop innovative forms of care delivery under shared savings and loss payment arrangements that reduce the cost of care, improve health outcomes, and improve patient experience. The demonstration IHP RFP Revised - July 13,

7 will be conducted over a three-year period with annual performance periods. The demonstration will be conducted statewide and is not limited to providers or MHCP participants in a specified geographic area. MHCP participants included in the demonstration are non-dually eligible Medical Assistance and MinnesotaCare enrollees attributed to the IHP for the performance period. 1. System Requirements To be considered eligible to participate as an IHP for the purposes of responding to this RFP, a successful Responder must meet the following criteria: a. Provide the full scope of primary care, and adopt methods of care delivery so that the full scope of primary care is provided and care is coordinated across the spectrum of services provided. b. All providers included in the IHP demonstration payment model must be enrolled MHCP providers. c. Demonstrate, through the care delivery model, how the IHP will affect the total cost of care of its MHCP participants regardless of whether the services are delivered by the IHP. d. Demonstrate how formal and informal partnerships with community-based organizations, social service agencies, counties, public health resources, etc. are included in the care delivery model. Responders are encouraged to propose mechanisms to incorporate these organizations directly into the payment model. e. Demonstrate how the IHP will engage and coordinate with other providers, counties, and organizations, including county-based purchasing plans, that provide services to the IHP s patients on issues related to local population health, including applicable local needs, priorities, and public health goals. Responders should describe how local providers, counties, organizations, county-based purchasing plans, and other relevant purchasers were consulted in developing the application to participate in the demonstration project. f. Demonstrate how the IHP will meaningfully engage patients and families as partners in the care they receive, as well as in organizational quality improvement activities and leadership roles. g. Demonstrate established processes to monitor and ensure the quality of care provided. Participate in quality measurement activities as required by the State and engage in quality improvement activities. h. Demonstrate the capacity to receive data from the State via secure electronic processes and use it to identify opportunities for patient engagement and to stratify its population to determine the care model strategies needed to improve outcomes. i. Nothing in the contract agreement will obviate all providers included in the IHP from meeting all MHCP fee-for-service and/or managed care organization (MCO) IHP RFP Revised - July 13,

8 requirements including, but not limited to enrollment, reporting, claims submission, and quality measures. IHPs will not administer the MHCP benefit set or pay claims under the demonstration or be required to contract for additional services outside of the services delivered by the IHP. An IHP may include an organizing entity and agreement of shared governance. This may include but is not limited to a non-profit or a county or group of counties; however any IHP payments must be provided to and/or received from an MHCP enrolled provider identified in section III.B.4.b of this RFP by the IHP. 2. Overview of Payment Models and Risk Organizations that meet the system requirements described above are eligible to participate in either a Virtual or Integrated payment mode as described below. Eligibility for each payment model will be determined by the integration and scope of services provided by the IHP as described below. The payment models outlined are based on IHP performance against a risk-adjusted total cost of care target for all qualifying MHCP participants attributed to the IHP for the performance period. The total cost of care target will be calculated using risk-adjusted MHCP fee-for-service claims and encounter claims submitted by managed care organizations (MCOs) under contract with the State. IHP financial incentives under the demonstration related to reducing total costs will be contingent on performance on quality and patient experience outcomes. All shared savings and losses payments under the models described below will be calculated and disbursed annually via a reconciliation payment. Providers will continue to receive the current MHCP fee-for-service or MCO contracted payment during the performance period. Responders are encouraged to involve community organizations, local public health, behavioral health or long term care service providers in the distribution of shared savings and losses payments as defined in Sections III and IV, and bonus points are available for such arrangements. DHS is committed to developing a credible and fair risk-sharing and performance measurement process. In developing the initial IHP model analytics, DHS compiled a significant amount of stakeholder and expert feedback and performed a variety of analyses to develop the initial proposed payment model. During previous IHP negotiation and contract development processes, the payment model was refined based on additional research, actuarial analyses and feedback, and is described below and in the supplementary documentation. To assure the credibility of the process during the three years of the Demonstration Project, the payment models and process as described below may be subject to mutually agreed-upon modifications based on additional DHS research, emerging findings or feedback from the participating IHPs. a. Type of Models Model 1: Virtual IHP i. Provider organizations eligible for the Virtual IHP payment model include primary care providers and/or multi-specialty provider groups that are not formally integrated with a hospital or integrated system via aligned financial arrangements and common clinical and information systems. Provider organizations with an MHCP population between IHP RFP Revised - July 13,

9 1,000-1,999 attributed participants are eligible only for the Virtual IHP model, regardless of their level of formal integration. ii. The payment model is a shared savings model that will distribute the difference between annual expected and actual realized total cost of care if savings are achieved, a portion of which is contingent on quality and patient experience outcomes. Model 2: Integrated IHP i. Provider organizations eligible for the Integrated IHP include an integrated delivery system that provides a broad spectrum of outpatient and inpatient care as a common financial and organizational entity. Provider organizations must serve an MHCP population of 2,000 attributed participants or greater in order to be eligible for the integrated model. ii. iii. The payment model incorporates shared risk over time and builds toward a two-way risk sharing model that distributes the difference between the annual expected and actual realized total cost of care whether savings are achieved or not, a portion of which is contingent on quality and patient experience measures. Responders are required to propose the amount of risk for the MHCP population attributed to the IHP for the purposes of this RFP. The basic terms of the risk sharing agreement are outlined below. In responding to this RFP, IHPs will be required to propose their risk sharing arrangement within these parameters. b. Total Cost of Care (TCOC) Performance Assessment Process IHP performance assessment is based on a comparison of the observed TCOC for each performance period (Calendar Year (CY) 2016, CY2017, and CY2018) to a TCOC Target. The TCOC Target is based on a base period TCOC (CY2015) after adjusting for expected trend and changes in attributed population size and relative risk from the base period to the performance periods. The Base Period Attributed Population will be developed for each IHP using 2015 claims, MCO encounter data, and the attribution process as described in this RFP. Using this attributed population, the Base Period Total Cost of Care (Base TCOC) will be developed using the services as outlined in Section II.A.3 in this RFP. Claims for an individual member that fall outside of pre-determined thresholds will be capped to adjust the per member per month (PMPM) results for catastrophic cases. In addition, the Base Period Risk Score will be assessed for the assigned members, using the Johns Hopkins ACG risk adjustment tool to determine the relative risk of the base population. In addition to developing weights based exclusively on the services included in the Base TCOC, the weights used to assess the risk of the population will be calculated using the pre-determined claim caps to adjust the weights and reduce the impact of catastrophic cases. Early in each performance period, DHS will develop an Expected Trend rate for the total cost of care based on the trend rates used to develop the annual expected cost increases for the aggregate MHCP population, with appropriate adjustments for services excluded from the Base TCOC or other factors that are applicable to the total cost of care and goals of the program. An initial TCOC Target for the IHP RFP Revised - July 13,

10 upcoming performance period can be established using the Base TCOC and Expected Trend. The target will ultimately be adjusted for the relative risk of the actual population attributed to the IHP in the performance period. At the end of each performance period, DHS will determine the Performance Period Attributed Population using retrospective claims data and the attribution process as described in this RFP. In addition, the Performance Period Total Cost of Care (Performance TCOC) will be developed, adjusting for any claims for an individual member that fall outside of pre-determined catastrophic case thresholds. The risk score for the measurement period s attributed population will be used to calculate the change in relative risk from the base period to the performance period. Using the change in relative risk, the Target TCOC will be adjusted based on the increase or decrease in the risk of the attributed populations. The Adjusted Target TCOC will be compared to the Performance TCOC for purposes of determining the performance results and the basis for the calculation of shared savings and losses. c. Total Cost of Care Performance Measurement Specifications and Requirements To assure that a participating IHP does not have the measurement of their performance inappropriately impacted by changes in the risk status of the membership, DHS will perform risk adjustment on the attributed populations in the base period and performance period and adjust the Target TCOC (the Adj. Target TCOC ) to reflect the changes in risk. To further refine the measurement process and reduce the potential variability inherent in any risk score methodology, DHS has developed the following specifications and requirements: 1. Population sizes: Successful Responders must meet a minimum attributed MHCP population size of 1,000 members. For purposes of developing the risk arrangements, DHS is defining the following MHCP sizes: a. Small Population 1,000 to 1,999 attributed patients (Virtual model only) b. Medium Population 2,000 to 4,999 attributed patients c. Large Population more than 5,000 attributed patients 2. Claim cap levels: To reduce the potential variability of the risk assessment process and the financial results, DHS will develop the risk scores and total cost of care PMPM by removing the claim costs for individual members that fall above specific thresholds. Because of the greater impact of large claimants on the results for smaller populations, DHS developed the following general guidelines for managing catastrophic risk: a. Small Population $50,000 maximum annual claims per patient (Virtual model only) b. Medium Population $100,000 maximum annual claims per patient c. Large Population $200,000 maximum annual claims per patient 3. Minimum Performance Thresholds: DHS has established a 2% minimum performance threshold that must be met prior to the distribution of any shared savings or losses payments between the State (including its contracted MCOs, as applicable) and the IHP. Specifically, the Performance TCOC must be above 102% or below 98% of the Adj. Target TCOC in the Integrated IHP for shared savings and losses payments to occur. A Virtual IHP will not receive any shared savings unless their Performance TCOC is below 98% of the Adj. Target TCOC. Once the performance IHP RFP Revised - July 13,

11 target is met, shared savings or shared losses payments are calculated back to the first dollar, i.e., any amount above or below the TCOC target. 4. Shared Savings and Shared Losses Payment Distributions: DHS is requiring Integrated IHP Responders to propose their preferred performance thresholds for shared savings or shared losses between DHS and the IHP, within some specified parameters. The performance threshold parameters gradually incorporate two-way risk sharing and increased flexibility for IHPs over the three years of the demonstration. The parameters for each year are as follows: a. Performance Period 1: IHP shares any savings equally (50/50) with the State/MCOs provided the 2% minimum performance threshold has been achieved. The maximum threshold for shared savings in Performance Period 1 must be the same in Performance Period 3 and is limited to a maximum of 85% of the TCOC Target. b. Performance Period 2: IHP assumes some downside risk, but it need not be symmetrical to the proposed shared savings threshold. The IHP has some discretion around the amount of risk it is willing to bear, but the ratio of shared savings thresholds to shared loss thresholds must be 2:1. For example, if the IHP wishes to avoid risk for claims above 106% of the TCOC Target, the maximum threshold for shared savings is 88% (6 percentage points x 2 = 12) below the TCOC Target. All shared savings and shared losses are distributed equally (50/50) with the State/MCOs. c. Performance Period 3: IHP assumes two-way risk with symmetrical risk sharing thresholds. For example, if an IHP wishes to avoid risk at 115% of the TCOC Target, the maximum threshold for shared savings must be 85%. An IHP may elect different distributions of shared savings and shared losses within the proposed thresholds. The maximum threshold for shared savings in Performance Period 3 must be the same as in Performance Period 1 and is limited to a maximum of 85% of the TCOC Target (see section 1.3 of Attachment D of the model contract in Appendix B of this document, for specific requirements and additional detail). A Virtual IHP does not have the option of proposing a schedule and will be required to share any savings (once the 2% minimum performance threshold is met) equally (50/50) with the State for all three years of the demonstration. 3. Definitions of Total Cost of Care The two payment models will use the same methodology and categories of service to calculate the riskadjusted Total Cost of Care (TCOC) target. TCOC will be calculated by the State for all MHCP patients in both fee-for-service and managed care attributed to the IHP for the performance period. Further detail on the categories of service included and the specific procedure codes included in each category is provided in Attachment E: Core Services of the IHP model contract included as an attachment to this RFP. The State reserves the right to modify the services included in the total cost of care calculation under this RFP. The Responder may propose additional Medicaid covered services for inclusion in the TCOC target. The Responder should detail in their proposal any additional services beyond the core set by major category of service and procedure code. 4. Attribution Methodology IHP RFP Revised - July 13,

12 MHCP participants will be attributed by the State to an IHP using retrospective claims data for the purposes of determining the TCOC Target and actual Performance TCOC. Participants will be attributed to one IHP at a time. All of the attributed participants care as provided in the total cost of care definition will be attributed to the IHP, regardless of whether the IHP delivered the services. An interim attributed population will be determined early in the performance period and shared with the IHP. The final attributed population for the performance period will be re-calculated following 12 months of claims run-out for purposes of accountability under the payment models. Attribution will be done using a hierarchical process that incents active outreach and retention of patients by the IHP under the following general methodology: 1 st Participants actively enrolled in care coordination through a certified Health Care Home (HCH) submitting a monthly care coordination claim. 2 nd Participants that cannot be attributed based on HCH enrollment may be attributed to the IHP based on the number of Evaluation and Management (E&M) visits (i.e., encounters) with provider who specializes in primary care. 3 rd Participants that cannot be attributed through primary care visits may be attributed to the IHP based on their E&M visits with non-primary care (specialty) providers. Because the results of the attribution method will impact the size of the population included in each IHP s demonstration payment model, the State and Responder will define contract terms based on subsequent analysis of which participants are actually attributable. 5. Quality Measures 1. Shared savings under the payment models for IHPs will be contingent in part on clinical quality and patient experience measure results. The State will align quality measures across demonstrations and with existing measures and data collection under the Statewide Quality Reporting and Measurement System (Minnesota Statutes 62U.02), and Health Care Home Outcomes (Minnesota Statutes 256B.0751, subd. 6). The core set of quality measures, reporting specifications, and the benchmarking and scoring methodology are provided in detail in Attachment F: Quality and Patient Experience Measures of the IHP model contract included as Appendix B to this RFP. Performance on quality measures will impact the amount of shared savings (if any) achieved by each IHP and is phased in over the three year demonstration as follows: a. Performance Period 1: 25% of IHP portion of shared savings based on reporting measures. b. Performance Period 2: 25% of IHP portion of shared savings based on performance (overall quality score). c. Performance Period 3: 50% of IHP portion of shared savings based on performance (overall quality score). 2. The State will determine preliminary minimum and maximum attainment thresholds for each measure for all IHPs under the demonstration before the beginning of Performance Periods 2 and 3 and will post them on the DHS website. The State will notify the IHP of final thresholds upon final calculation using the data based on the most recent quality measurement periods. IHP RFP Revised - July 13,

13 3. In addition to the core set of measures defined by the State, successful Responders are encouraged to propose additional measures and to demonstrate how the additional measures apply to the specific communities and/or population served by the IHP. These measures can include specific health outcomes measures, patient experience measures, or measures of overall population health. Proposed additional measures are subject to approval by the State. Guidelines for additional measures include: a. Utilize a state or nationally recognized quality measure specification. b. The data must be able to be collected by a third-party using an existing data collection mechanism. c. The data must be validated and audited by a third-party. d. Not be a measure that is impacted by high variability due to coding changes. e. Ensure needed appropriate care is not negatively impacted. 6. Interaction with Medicaid Managed Care Organizations (MCOs) The IHP demonstration will be implemented consistently at the delivery system level and for MHCP participants currently enrolled in either fee-for-service and managed care. The State will implement and execute the IHP payment model, quality measures and methodology, patient attribution for both MHCP enrollees in fee-for-service and in MCOs under contract with the State to provide services to non-dually eligible Medical Assistance and MinnesotaCare enrollees. The MCOs will participate as a payer in the IHP payment process via their contract requirement with the State. The MHCP participants will be attributed to an IHP regardless of whether they are enrolled in fee-forservice or in an MCO. All attributed participants will be calculated together at the delivery system level for the purposes of the Total Cost of Care and the payment model. The State will calculate the total cost of care targets and the shared savings or losses payment across both fee-for-service and managed care using retrospective claims and encounter data. The State will also calculate the quality measures and overall score using data applicable to each measure. The State (and its contracted MCOs, as applicable) will each pay its portion of the shared savings payments to the IHP (or the State and its contracted MCOs will receive shared losses payments from the IHP). MCOs (licensed health plans or County-Based Purchasing Organizations) may not participate as principal Respondents in the IHP demonstration. 7. Data Feedback to Providers DHS will make utilization and risk information for its attributed population available to IHP providers via DHS IHP and MN-ITS data portals. The data will be populated by a monthly set of risk adjustment (Johns Hopkins Adjusted Clinical Groups [ACG ]) output in the DHS data warehouse, and will include both feefor-service and MCO encounter claim data. Data will be as timely as possible given standard claims lag, and will be available via risk adjustment software output or standardized reports. Key variables available to delivery systems will be primarily from ACG output, and will include population-level data (such as the total cost of care and rates of inpatient and emergency department utilization) and participant-level data (such as medical and pharmacy utilization histories, predictive risk information, and indices of care coordination). Reference documentation to IHP provider feedback reports can be found in Appendix A. IHP RFP Revised - July 13,

14 B. Tasks/Deliverables Successful Responders will: 1. Demonstrate innovative care models and community coordination, integration or linkages. 2. Describe the care model, programs and strategies and demonstrate how they will impact the total cost of care, clinical quality, and patient experience outcomes. 3. Agree to the requirements and structure defined in the RFP and the Model Contract in Appendix B of this document. 4. Agree to enter into a three-year demonstration with DHS, with at least annual opportunities to re-negotiate key contract provisions. 5. Propose the nature of the shared savings and/or losses arrangement, including the amount and distribution of shared savings and losses, within the guidelines laid out in the RFP. 6. Provide an estimated population size included in IHP to verify minimum population participation requirements. III. Proposal Format Proposals must conform to all instructions, conditions, and requirements included in the RFP. Responders are expected to examine all documentation and other requirements. Failure to observe the terms and conditions in completion of the Proposal are at the Responder s risk and may, at the discretion of the State, result in disqualification of the Proposal for non-responsiveness. Acceptable Proposals must offer all services identified in Section II - Scope of Work and agree to the contract conditions specified throughout the RFP. A. Required Proposal Contents Within the guidelines laid out in the Scope of Work above, Responders must describe their care model capabilities and propose specific elements of the demonstration payment model. Proposals should adhere to the following format: 1. Table of Contents 2. Proposal Requirements a. Executive Summary b. Description of the Applicant Delivery System c. Description of Care Models d. Description of Community Partnerships e. Description of Patient and Family Engagement f. Description of MHCP Population Served by Delivery System g. Proposed Payment Arrangement i. Selected Payment Model and Justification IHP RFP Revised - July 13,

15 ii. Defined Provider Population and Accountable Fiscal Entity iii. Additional Service Categories Included in Total Cost of Care (if applicable) iv. MHCP Population Size v. Proposed Amount of Assumed Risk vi. Mechanism for Distributing Shared Savings and Losses Payments vii. Quality Measures h. Additional Proposed Measures (if applicable) i. Description and data of Applicability of Measures to the Population Served 3. Required Statements a. Responder Information and Declarations b. Exceptions to Terms and Conditions c. Affidavit of Non-collusion d. Trade Secret/Confidential Data Notification e. Submission of Certified Financial Audit, IRS Form 990, or Most Recent Board-Reviewed Financial Statements f. Disclosure of Funding Form g. Human Rights Compliance i. Affirmative Action Certification ii. Equal Pay Certificate h. Certification and Restriction on Lobbying 4. Appendix (If Applicable) Any additional information thought to be relevant, but not applicable to the prescribed format, may be included in an Appendix of the Responder s Proposal. Please use letter K for this Appendix and attach it at the end of the Responder s Proposal. B. Proposal Requirements The following will be considered minimum requirements of the proposal. Emphasis should be on completeness and clarity of content. 1. Executive Summary: This component of the proposal should demonstrate the Responder's understanding of the requirements in this RFP and any problems anticipated in accomplishing the work. The Executive Summary should also show the Responder s overall design of the project in response to achieving the deliverables as defined in this RFP. Specifically, the proposal should demonstrate the Responder's familiarity with the project elements, its solutions to the problems presented and knowledge of the requested services. 2. Description of the Applicant Delivery System: This section must include information on the programs and activities of the delivery system, the number of people served, geographic area served, staff experience, and/or programmatic accomplishments. Include reasons why your organization is capable to effectively complete the services outlined in the RFP. Include a brief history of your organization and all strengths that you consider are an asset to your program. The Responder should demonstrate the length, depth, and applicability of all prior experience in IHP RFP Revised - July 13,

16 providing the requested services. The Responder should also verify that the delivery system provides the full scope of primary care services (defined as overall and ongoing medical responsibility for comprehensive care for preventive care and a full range of acute and chronic conditions). The Responder should also demonstrate the skill and experience of lead staff and designate a project manager with experience in planning and providing the proposed services. a. Description of Care Models: This section should detail how the IHP expects to lower the total cost of care and maintain or improve clinical quality and patient experience through innovative care delivery models, such as health care home certification or other national certifications, community-based or collaborative initiatives (e.g., DIAMOND, RARE, etc.). Include information on approaches and methods to coordinate care across the spectrum of services included in the payment model; encourage prevention and health promotion to create healthier communities; and use of data to target care interventions, stratify patients by complexity and conduct quality improvement activities. The Responder should provide examples and summaries of experience with similar performance or risk-sharing arrangements including percentages of total patient population and primary payer break out included in these arrangements between the Responder and Medicare or other payers, if applicable. b. Description of Community Partnerships: This section should describe any existing or planned partnerships between the IHP and community-based organizations and public health resources, such as disability and aging services, social services, transportation services, and school-based services. Describe the expected impact of these partnerships on key outcomes of interest. The Responder should describe how the IHP will engage and coordinate with other providers, counties, and organizations, including county-based purchasing plans, that provide services to the IHP s patients on issues related to local population health, including applicable local needs, priorities, and public health goals. Describe how the IHP consulted with local providers, counties, organizations, county-based purchasing plans, and other relevant purchasers in developing the application to participate in the demonstration project. c. Description of Patient and Family Partnerships: This section should demonstrate the ways in which patients (and their families where appropriate) are meaningfully engaged as partners in the care they receive, as well as in organizational quality improvement activities and leadership roles. 3. Description of MHCP Population Served by the Delivery System: This section must describe the entire MHCP population currently served by the IHP, including the total number of MHCP enrollees served, the overall proportion of the payer mix represented by MHCP enrollees, and key descriptive information such as age, gender, race/ethnicity, and the diagnoses/conditions of highest prevalence. As described above, the population served must include all MHCP enrollees not specifically excluded from the demonstration payment model. 4. Proposed Payment Arrangement: IHP RFP Revised - July 13,

17 a. Selected Payment Model and Justification: This section will indicate whether the delivery system qualifies for the Virtual IHP or the Integrated IHP payment model described in Section II above. If the Responder identifies the Virtual IHP model, it must describe the organizational structure of the delivery system and demonstrate that it either does not operate within a formally integrated care system, or serves an MHCP population of 1,000 1,999 participants, or both. Features of such integration include, but are not limited to, common clinical and information systems, shared financial structure and a common parent organization. This section will also indicate the catastrophic claim cap level to be used in the payment model based on the number of qualifying MHCP participants served, as illustrated in Section II. b. Defined Provider Population and Accountable Financial Entity: This section must identify the care for which the IHP will be accountable by identifying the involved providers. This must be done in a way that allows DHS to link claims data to a defined fiscal entity or group of providers. o The Responder must specify the Group National Provider Identifiers (NPI) (type 2) for the entities participating in the IHP, and o o A complete list of individual provider NPIs participating in the IHP. Further, the Respondent must specify the billing provider NPI or Tax Identification Number (TIN) that it wishes to be the locus of accountability for the delivery system and contracting partner with the State. This will be the identified entity for the shared savings and loss payments to be transmitted to and from DHS. c. Additional Service Categories Included in Total Cost of Care (if applicable): Attachment E: Core Services of the IHP model contract included as an attachment to this RFP lists the minimum services included in the Total Cost of Care (TCOC) for all demonstration payment models. Responders are encouraged to include additional services in the TCOC in their proposal. This section should identify any additional service categories that the IHP proposes to be accountable for through their inclusion in the TCOC calculation. Responders need not complete this section if they do not wish to add services to the defined TCOC model. d. MHCP Population Size: This section should provide an estimate of the population size that the IHP expects to serve under the demonstration project, and a confirmation of the corresponding catastrophic claim cap laid out in Section II. In addition to the estimate, the methodology, assumptions and information (e.g. plan provided data, payment analysis) used by the IHP to estimate the population size should be briefly described in the response. e. Proposed Amount of Assumed Risk: This section must contain a proposal for the amount and distribution of the shared savings and/or losses payments in the model in each of the three years of the demonstration. (The Virtual Model contains a standard 50/50 split of shared savings.) Within the guidelines described in Section II above, the Respondent must propose the amount of shared savings and losses. In the Integrated IHP model, the amount of shared savings and shared loss must adhere to the following guidelines: Performance Period 1: IHP shares any savings equally (50/50) with the State/MCOs provided the 2% minimum performance threshold has been achieved. The IHP RFP Revised - July 13,

18 maximum threshold for shared savings in Performance Period 1 must be the same in Performance Period 3 and is limited to a maximum of 85% of the TCOC Target. Performance Period 2 (Integrated only): IHP assumes some downside risk, but it need not be symmetrical to the proposed shared savings threshold. The IHP has some discretion around the amount of risk it is willing to bear, but the ratio of shared savings thresholds to shared loss thresholds must be 2:1. For example, if the IHP wishes to avoid risk for claims above 106% of the TCOC Target, the maximum threshold for shared savings is 88% (6 percentage points x 2 = 12) below the TCOC Target. All shared savings and losses are distributed equally (50/50) with the State/MCOs. Performance Period 3 (Integrated only): IHP assumes two-way risk with symmetrical risk sharing thresholds. For example, if an IHP wishes to avoid risk at 115% of the TCOC Target, the maximum threshold for shared savings must be 85%. An IHP may elect different distributions of shared savings and losses within the proposed thresholds. The maximum threshold for shared savings in Performance Period 3 must be the same as the maximum threshold in Performance Period 1 and is limited to a maximum of 85% of the TCOC Target. (See section 1.3 of Attachment D of the model contract in Appendix B of this document, for additional detail on the settlement process). The table below provides a hypothetical example of a permissible 3-year risk sharing agreement under the integrated model, along with a suggested format for developing your response. Performance Period 1 Performance Period 2 Performance Period 3 Shared Savings Only Example Responder to Complete Example Responder to Complete Threshold % of Adj. Target TCOC IHP/DHS Distribution % of Adj. Target TCOC IHP/DHS Distribution % of Adj. Target TCOC IHP/DHS Distribution % of Adj. Target TCOC IHP/DHS Distribution % of Adj. Target TCOC IHP/DHS Distribution 1 112% - 115% None 110% - 115% None 112% - 115% 40% / 60% 2 110% - 112% None 110% - 112% None 110% - 112% 50% / 50% 3 106% - 110% None 106% - 110% None 106% - 110% 60% / 40% 4 102% - 106% None 102% - 106% 50% / 50% 102% - 106% 70% / 30% 5 100% - 102% None 100% - 102% 50% / 50% 100% - 102% 70% / 30% 6 98% - 100% 50% / 50% 98% - 100% 50% / 50% 98% - 100% 70% / 30% 7 94% - 98% 50% / 50% 94% - 98% 50% / 50% 94% - 98% 70% / 30% 8 90% - 94% 50% / 50% 90% - 94% 50% / 50% 90% - 94% 60% / 40% 9 88% - 90% 50% / 50% 88% - 90% 50% / 50% 88% - 90% 50% / 50% 10 85% - 88% 50% / 50% 85% - 88% None 85% - 88% 40% / 60% The % thresholds for the second and third year of the Demonstration can be modified based on the preferences of the bidding IHP. The selected shared savings/losses distributions must follow the guidelines described below. For Performance Period 2, the IHP is expected to accept downside risk, which can be capped at a threshold specified by the IHP. However, if the IHP chooses to cap the loss threshold, the amount of shared savings must be capped at a 2:1 percentage of the loss cap. For Performance Period 3, the thresholds and distribution percentages may differ from the example and can vary by year. However, the IHP/State distribution must be the same for savings and losses at the symmetric thresholds (e.g., 90 to 94% gain share distribution must equal the 106 to 110% loss share distribution). Additionally, the shared savings thresholds in Performance Period 3 must be the same as Performance Period 1. IHP RFP Revised - July 13,

19 The State may consider deviations from the threshold and distribution percentage requirements described above for Responders that include community providers or organizations or additional service beyond the core set for TCOC in the IHP payment model. The Responder should follow the requirements above for completing the financial template but include details of how they propose to include community providers or organizations and/or additional services in their proposal. Deviations from the current requirements may need further federal approval. f. Mechanism for Distributing Shared Savings and Losses Payments: This section must describe the manner in which the IHP will distribute potential shared savings payments among its component parts or entities, as well as the nature of shared responsibility for potential shared losses payments penalties in the Integrated Model. If applicable, the IHP should highlight the direct inclusion of community organizations in the payment model structure. 5. Quality Measures: As described in Section II above, a portion of shared savings that accrue to the IHP are contingent on clinical quality and patient experience measure reporting in Performance Period 1 and performance in Performance Periods 2 and 3. The core set of outcome measures for all IHPs in the demonstration are measures included in the Statewide Quality Reporting and Measurement System pursuant to Minnesota Statutes 62U.02. An IHP may propose measures in addition to the core set in accordance with the guidelines described below. a. Additional Proposed Measures (if applicable): If desired, the Responder may identify additional quality and patient experience measures to incorporate into the payment model. These additional measures do not replace the core measure set identified above. Describe how the measures are defined and collected, how they have been validated and endorsed by state and/or national organizations, and otherwise meet the guidelines described is section II.A.5. of this RFP. b. Description of Applicability of Measures to the Population Served: This section must describe how the clinical quality and patient experience measures (both the core set and any additional measures proposed) apply to the specific populations and communities served by the Respondent, as well as how the care models, community partnerships, and patient and family partnerships are expected to improve these outcomes. D. Required Statements Complete the correlating forms found in edocs by right clicking on the links below (in blue), select Copy Hyperlink and paste into your web browser and click Enter. These forms must be submitted as the Required Statements section of your proposal. You must use the current forms found in edocs. Failure to use the most current forms found in edocs in completion of the proposal are at the responder s risk and may, at the discretion of the State, result in disqualification of the proposal for nonresponsiveness. IHP RFP Revised - July 13,

20 1. Responder Information and Declarations (Responder Information/Declarations Form DHS ENG): Complete and submit the attached Responder Information and Declarations form. If you are required to submit additional information as a result of the declarations, include the additional information as part of this form. 2. Exceptions to RFP Terms (Exceptions to Terms and Conditions Form- DHS-7019-ENG): The contents of this RFP and the proposal(s) of the successful responder(s) may become part of the final contract if a contract is awarded. Each responder's proposal must include a statement of acceptance of all terms and conditions stated within this RFP or provide a detailed statement of exception for each item excepted by the responder. Responders who object to any condition of this RFP must note the objection on the attached Exceptions to RFP Terms form. If a responder has no objections to any terms or conditions, the responder should write None on the form. Responder should be aware of the State s standard contract terms and conditions in preparing its response. A sample State of Minnesota, Department of Human Services, Grant Contract is attached in the Appendix for your reference. Much of the language reflected in the contract is required by statute. If you take exception to any of the terms, conditions or language in the contract, you must indicate those exceptions in your response to the RFP. Only those exceptions indicated in your response to the RFP will be available for discussion or negotiation. Responders are cautioned that any exceptions to the terms of the standard State contract which give the responder a material advantage over other responders may result in the responder s proposal being declared nonresponsive. Proposals being declared nonresponsive will receive no further consideration for award of the Contract. Also, proposals that take blanket exception to all or substantially all boilerplate contract provisions will be considered nonresponsive proposals and rejected from further consideration for contract award. 3. Affidavit of Noncollusion (Affidavit of Noncollusion Form- DHS-7021) : Each responder must complete and submit the attached Affidavit of Noncollusion form. 4. Trade Secret/Confidential Data Notification (Trade Secret/Confidential Data Notice Form- DHS ENG): All materials submitted in response to this RFP will become property of the State and will become public record in accordance with Minnesota Statutes, section , after the evaluation process is completed. Pursuant to the statute, completion of the evaluation process occurs when the government entity has completed negotiating the contract with the successful responder. If a contract is awarded to the Responder, the State must have the right to use or disclose the trade secret data to the extent otherwise provided in the grant contract or by law. If the responder submits information in response to this RFP that it believes to be trade secret/confidential materials, as defined by the Minnesota Government Data Practices Act, Minnesota Statutes, section 13.37, and the responder does not want such data used or disclosed for any purpose other than the evaluation of this proposal, the responder must: a. clearly mark every page of trade secret materials in its proposal at the time the proposal is submitted with the words TRADE SECRET or CONFIDENTIAL in capitalized, underlined and bolded type that is at least 20 pt.; the State does not assume liability for the use or disclosure of unmarked or unclearly marked trade secret/confidential data; IHP RFP Revised - July 13,