FLORIDA HEALTHY KIDS CORPORATION Invitation to Negotiate : Health Benefits Coverage Underwriting and Services (Draft)

Transcription

1 FLORIDA HEALTHY KIDS CORPORATION Invitation to Negotiate : Health Benefits Coverage Underwriting and Services (Draft) The Florida Healthy Kids Corporation (Corporation) s and Answers Posting Date: January 9, 2015 s provided below include all questions received by the questions deadline of January 6, s to Public Comments Upon Approval of the Board, comments will be incorporated into the final ITN ITN Page, Section, 1 2 Section I (page 3) References to Respondents and Insurers refer to those Parties that will respond or intend to respond to this ITN. Section II (page 3) For Section I and for other sections that ask for experience serving similar populations, please confirm that the experiences of affiliate companies are included in the definition of Respondent and Insurer. Will FHKC provide additional information on what other providers of healthcare services other than licensed insurers may meet FHKC standards? No, the experience of affiliate companies will not be taken into consideration. Section (5)(b)10, F.S. requires that FHKC contract with authorized insurers or any provider of health care services, meeting standards established by the corporation Section III.A (page 5) Section III.H. (page 9) Tab A, Tab 1 (page 13) Tab G, Tab 2 (page 21) How will the evaluation assure the review of HEDIS scores for comparable FHK (CHIP like) populations? Please describe the methodology that will be used for tying quality ratings to preferred auto assignments. Does FHKC have a minimum or maximum number of plans targeted for each Region that can be shared with plans? Please confirm that the experiences of affiliate companies are included in the definition of Respondent and Insurer, and references of affiliate companies may be included. Please confirm that plans are not required to submit specific dollar amounts or percentages in this section; rather, Therefore, authorized insurers, HMOs, PSNs, PPOs, etc., are eligible. HEDIS scores will be a weighted component of the evaluation scoring tool. The minimum will be two (2) plans per region, and the FHKC Purchasing and Contracting Committee will be recommending the maximum number of plans at a future meeting. See response to 1. References from affiliated companies are not acceptable. Yes, we confirm. Page 1 of 19

2 ITN Page, Section, Tab G, Tab 5 (page 22) Volume Two, (page 26) Volume Three, Condition #5 (page 32) Volume Three, Condition #5 (page 32) Volume Three, Condition #5 (page 32) Appendix I, Section I (page 37) template reimbursement schedules that identify the methodology (e.g. flat dollar amount, percentage of a defined fee schedule, etc.) is acceptable. For behavioral health and substance abuse services, respondents are strongly encouraged to contract with providers who are accredited by JCAHO or CARF. Please clarify that this refers to accredited facilities and not individual providers. If a provider has two offices and their practice is open at the same time (same hours) with providers working from both offices, can both offices be listed? For example, the provider MD is working in one office and another MD is working in the other office. Is FHKC able to provide any additional detail regarding the experience adjustment in advance of the proposed Contract release? Does this imply that the rates and resulting experience for the full pay program does not need to meet the statutory minimum loss ratio? Is there a different minimum loss ratio requirement for the full pay program? The second to last paragraph of this section says: Applicants and Enrollees who meet the eligibility criteria described above for Medicaid or the CMSN, as determined by the responsible state agency, are not eligible for the Healthy Kids program. The following paragraph says Insurers should be aware that some Enrollees in the Healthy Kids program may meet the financial and clinical requirements for the CMSN program but have elected to enroll in the Healthy Kids program instead. It appears that this language conflicts. The first reference identifies that individuals who meet eligibility requirements for Medicaid and CMSN are not eligible for the Healthy Kids programs, but then the second paragraph seems to contradict this. This refers to accredited facilities, and not individual providers. See, Chapter 934, Part IV, Florida Statutes. Yes, if separate providers are listed and working at each facility. The statute, ITN and the contract will clarify the experience adjustment, all of which will be posted to the procurement library on or about February 1, Section (5)(b)10, F.S requires that all FHKC health plan contracts must meet the 85% minimum loss ratio. That also includes the full pay program. The ITN will be revised accordingly. Children that qualify for Medicaid must enroll in Medicaid, but families with special needs may opt out of the CMS network as allowed by Chapter 409, Florida Statutes. Page 2 of 19

3 ITN Page, Section, Will FHKC please provide further detail on the distinction? Appendix I, Section II (page 38) On occasion, FHKC may request that Insurer also accept a second (2nd) supplemental file of Enrollees retroactive to the first (1st) of the coverage for month. In the referenced situation, would the Yes, the child would receive retroactive coverage to the 1 st of the month. All out of network claims are handled the same regardless of which enrollment file the child was reported on. 13 Insurer be responsible for retroactive coverage of any claims received during the period of the 1st of the month through the receipt of the 2 nd supplemental file, inclusive of any out of network claims that may have been received? Appendix I, Section IV.F (page 43) Please confirm that existing provider contracts for the Healthy Kids program 14 may remain in effect as long as they are amended (if required) to comply with any new requirements. Appendix IV (page 48) Entire Appendix. Please confirm that references of affiliate companies are allowed. Since many Respondents are No, references from affiliated entities are not acceptable. 15 organizations solely dedicated to Florida programs, most Respondents will be limited to providing Florida based references. 16 Section III. A, page 4 For Full Pay, can cost sharing be different? 17 Section III. A, page 4 Under an essential plan there are deductibles, co insurance, is this permissible? 18 Tab F, 17 Are CHIP benefits subject to the elimination of the lifetime max? 19 Tab F, 18 Can a plan be selected for subsidized and not full pay? 20 How will full pay be regulated? Full pay will be regulated the same as the subsidized population. 21 Will OIR review and approve rates for full pay? Tab F-3 Prescription Formularies, page The Medicaid Formulary utilized by the Agency for Health Care Administration required an eighteen percent (18%) increase to the monthly PMPMs to meet actuarial soundness. The FAHP has since provided information that the actual costs experienced by the health plans is costing 5 to 13 percentage points more than this anticipated increase. Managed Care plans have experience developing high quality, comprehensive, cost effective formularies. All rates must be actuarially sound. All respondents should include any factors that they deem relevant, accompanied by an actuarial memorandum, to support the provided rates, both full pay and subsidized. Page 3 of 19

4 ITN Page, Section, Tab A, Primary Care Providers, Example Region 1 Table, page 27 Appendix I, I. Program Eligibility, page 36 V. Member Services, page 44 Appendix II. Utilization Data, page 46 Is it the intention of the FHK corporation to factor in the 23-30% increase in pharmacy cost to both the CHIP ("subsidized") membership and the "full pay" membership? Providing the actual office hours is often outdated immediately after the ITN is completed, creates an unnecessary administrative cost that provides little value to the members as provider office hours are determined by the provider and are subject to change often times without notice. Would the Florida Healthy Kids Corporation consider an identification protocol that would indicate whether a provider has evening/weekend hours instead of providing the actual office hours? Consistent with Medicaid policy, if it is determined that there was fraud or an eligibility error that led to someone's enrollment will there be a retroactive disenrollment, such that FHK recoups premiums paid to the Plan and in turn, the Plans are able to recoup monies paid for claims incurred? To enhance members' access to plan materials, will the plans be permitted to distribute member materials electronically, with hard copies made available upon request? Will separate data books be available for full pay and subsidized members? If so, when will they be available? Costs associated with eligibility errors not involving fraud, where FHKC is not responsible, are the responsibility of FHKC s Third Party Administrator. Section (10)&(11), Florida Statutes, govern the remedies available in the instance of fraud. The FHKC contract with insurers also has subrogation provisions. Yes, but families must opt into an electronic distribution. Yes, on or about February 1, Procurement Process: Evaluation of Proposals, page 4 Appendix VI (A&B): Premium Rate Proposal Forms, pages Appendix VI (A&B): Premium Rate Proposal Forms, pages Tab F: Benefits and Cost Sharing, page 17 Will you describe the scoring criteria and evaluation process with available points for each criteria? As part of the rate proposal should rates be submitted with or without the Health Insurer Fee? How many contracts will FHKC award by region? Is there an explicit minimum medical loss ratio (MLR) for the full pay program? Scoring materials will be made available after the contracts are awarded. See response to 22. See response to 4. See response to No reference provided in ITN Can a Florida Medicaid Provider Service Network (PSN) currently under contract Page 4 of 19

5 ITN Page, Section, with the Agency for Health Care Administration bid in those regions in which they are currently serving Medicaid members? No reference provided in ITN If the PSN is partially owned (minority 32 interest) by a current FHK contractor would both entities by allowed to bid? Section III-A, Procurement Does the reference to "such person" in the Process/Evaluation of phrase "The notification will inform "such Proposals, page 6 person" refer to the party requesting disclosure or the party whose information is being requested? In other words, is it the party requesting disclosure or the party 33 whose information is being requested that "has 30 days following the receipt of such notice to file an action in Circuit Court in Leon County seeking a determination whether the document or information or in question contains trade secrets and an order barring FHKC from disclosing the document"? Section III-A, Procurement FHKC may disclose a trade secret, Process/Evaluation of together with the claim that it is a trade Proposals, page 6 secret, to an officer or employee of any governmental agency, state or federal, whose use of the trade secret is within the scope of his or her employment. To the 34 extent FHKC discloses information designated as a trade secret to an officer or employee of a governmental agency, what means are in place to insure that the officers or employees of the governmental agency will protect the information from disclosure to other persons or entities? Section III-G, Procurement G. Amendment of the ITN Process/Amendment of the FHKC reserves the right to amend any ITN, page 9 portion of the ITN at any time prior to the announcement of Contract award. In any such event, all Respondents will be afforded an opportunity to revise their 35 proposals to address ONLY the amendment, if in FHKC s sole discretion, it determines such an amendment is necessary. Please confirm once a proposed ITN amendment is released the Respondent will necessarily have the opportunity to revise its proposal to address only that amendment. 36 Section III-G, Procurement G. Amendment of the ITN FHKC reserves Yes, but affiliates will not be awarded contracts for the same region. We will clarify in the final ITN that the party whose trade secrets are being requested has the burden of filing a court action within 30 days to prevent disclosure. Otherwise, any claim of trade secret is waived. This provision mirrors that found in section (3), Florida Statutes, in connection with trade secrets filed with the Florida Office of Insurance Regulation, and is contained in many other exemptions to Florida s public records laws. Page 5 of 19

6 ITN Page, Section, Process/Amendment of the ITN, page 9 Section III-H, Procurement Process/Special Note - Disclosure Statement, ITN, page 9 RESPONSE, Tab A: Profile of Respondent, Tab 1, page 13 RESPONSE, Tab A: Profile of Respondent, Tab 1, page 13 RESPONSE, Tab A: Profile of Respondent, Tab 1, 13 RESPONSE, Tab A: Profile of Respondent, Tab 1, 13 the right to amend any portion of the ITN at any time prior to the announcement of Contract award. In any such event, all Respondents will be afforded an opportunity to revise their proposals to address ONLY the amendment, if in FHKC s sole discretion, it determines such an amendment is necessary. Does this provision also apply in the event there is an amendment to the proposed Contract prior to contract award? FHKC intends to award Contracts to more than one Respondent in a Region or a program site. How many awards will be made in each region? Background information and corporate profile of Respondent, including any experience Respondent may have with providing comprehensive health insurance coverage to children through Medicaid, Title XXI (state Children s Health Insurance Programs ( CHIP )) or similar initiatives. Please confirm our response can include experience managing both risk and non-risk administrative plans. Please confirm our response can include experience from both owned and administered plans. Please confirm that the Respondent may include the experience of its affiliates in offering or administering health plans that provide comprehensive health insurance coverage to children through Medicaid, Title XXI (state Children s Health Insurance Programs ( CHIP )) or similar initiatives. For purposes of this question, "affiliates" are entities that conduct Medicaid and/or CHIP business and are related to the Respondent by virtue of the fact that Respondent and the related entities are all owned or controlled by a common entity. Background information and corporate profile of Respondent, including any experience Respondent may have with providing comprehensive health insurance coverage to children through Medicaid, See response to 4. The response can include such non-risk administrative management experience, but that experience may be given less weight in the scoring process. Please see response to 38. To the extent this is asking a different question, we are unsure what it refers to. We suggest attending the bidder s conference for further clarification. See response to 1. There is no specific time period. Page 6 of 19

7 ITN Page, Section, RESPONSE, Tab A: Profile of Respondent Title XXI (state Children s Health Insurance Programs ( CHIP )) or similar initiatives. Is there a specific time period or "look-back" period Respondent should cover when answering this question? Tab 4: Information regarding the location of where services will be provided if Respondent is awarded a Contract, and what percentage of the total Contract such services represents. Please use any methodology you deem relevant, including percentage of employees/contractors at a specific location, etc RESPONSE, Tab A: Profile of Respondent RESPONSE, Tab A: Profile of Respondent, Tab 6, page 14 RESPONSE, Tab A: Profile of Respondent, Tab 7, page 14 RESPONSE, Tab A: Profile of Respondent, Tab 8, page 14 How should Respondent calculate the percentage of the total Contract the provided services represent? Should the calculation of that percentage be based on the anticipated amount of compensation paid to the vendor versus the anticipated amount of capitation received by the Plan or some other formula? Please clarify. Does the question ask where administrative service centers will be located or which geographic regions will be served? Tab 6: Conflict of Interest Statement and Disclosure FHKC has a Code of Ethics which is included in the ITN. The Respondent must review that Code of Ethics and disclose any relationships with any members of FHKC s Board of Directors or its employees Respondent could not locate FHKC's Code of Ethics in the draft ITN. When will the Code of Ethics be available for review by Respondents? Please confirm that Respondent will have an opportunity to review any Amendment prior to attesting to agreement with its terms. Please confirm that Respondent may include the experience of its affiliates in offering or administering contracts of comparable population, size or annual premium volume. For purposes of this question, "affiliates" are entities that conduct Medicaid and/or CHIP business and are related to the Respondent by Where the service centers will be located. This document will be included in the Please see response to 1. Page 7 of 19

8 ITN Page, Section, RESPONSE, Tab B: Copy of Letter of Intent, page 14 RESPONSE, Tab F: Benefits and Cost Sharing, page 17 RESPONSE, Tab F, page 17 RESPONSE, Tab F, page 17 RESPONSE, Tab H: Implementation Period and Transition Process, page 23 RESPONSE, Tab H: Implementation Period and Transition Process, page 23 VOLUME TWO: PROVIDER NETWORKS, BY REGION, Special Notes, pages virtue of the fact that Respondent and the related entities are all owned or controlled by a common entity. The LOI and identification of Regions is non-binding and may be withdrawn or modified at any time by the Respondent. Please confirm that identification of regions in the letter of intent is non-binding and a final and different set of regions can be submitted with the final proposal. The Full Pay program is not a Title XXI CHIP program, and benefits must therefore comply with the relevant portions of the Patient Protection and Affordable Care Act ( ACA ). Please confirm that the PPACA requirements we will be required to comply with are limited to benefits. Respondents shall submit separate rates under Volume III of this ITN for both the subsidized and full pay populations. Can FHKC provide identification of full pay members for the current population so that health plans can produce actuarially sound rates for full pay and subsidized populations separately? If the changes to the benefit package result in a material, adverse impact to Respondent, will the Respondent have the opportunity to consent to such changes prior to their implementation? Respondents must include a detailed timeline that would ensure the successful implementation of the Contract by October 1, For the purposes of the ITN response, would a high level sequence of major tasks listed chronologically be acceptable? Those awarded Contracts under this ITN will be required to submit a more detailed transition plan for FHKC approval within ten (10) days of Contract execution. Will further details regarding the requirements of the transition plan be made available during Contract negotiation or at some other time prior to Contract execution? Please confirm that if Respondent is an incumbent contractor with FKHC, and already has an executed contract under which the contracted party has agreed to Minimum Essential Benefits must be provided to full pay enrollees. See response to 134. This document will be included in the No, however Respondents will have the opportunity to file amended rates per the contract. No, please follow the specific instructions in the ITN. More detail will be provided to those Respondents awarded contracts. See response to 14. Page 8 of 19

9 ITN Page, Section, VOLUME TWO: PROVIDER NETWORKS, BY REGION, Tab F, page 30 VOLUME TWO: PROVIDER NETWORKS, BY REGION, Tab H, page 32 VOLUME TWO: PROVIDER NETWORKS, BY REGION, Tab H, page 32 VOLUME THREE: PREMIUM RATE PROPOSALS, Item 3, page 32 VOLUME THREE: PREMIUM RATE PROPOSALS, Tab I, Option 4, page 34 VOLUME THREE: PREMIUM RATE PROPOSALS, Tab I, Option 4, page 34 APPENDIX I: BACKGROUND INFORMATION, Section II, page 37 APPENDIX I: IV Delivery of Services, D Geographic specifically participate with Respondent under its incumbent Healthy Kids program contract (and that contract by its terms would not require any amendment if Respondent is awarded a new Healthy Kids Contract), no further amendment, letter of agreement or re-execution of the incumbent contract is necessary to meet this ITN requirement. Would FHKC be willing to provide a definition and examples of "non-physician providers"? Please confirm that the response should include proposed subcontract templates for the FHKC s review, but need not be signed until the Respondent is awarded a Contract. May the subcontracts (other than proposed network provider contracts) leave the proposed compensation blank or to be determined until the Respondent is awarded a Contract? The statutorily required minimum medical loss ratio is 85%. Can FHKC clarify how MBR (sic) is defined? Specifically how HIF (including FIT gross up), expense for care initiatives are handled in the calculation. Can FKHC clarify how "a range of rates" works, and how it is different from the other options? The trade secret provisions of this ITN do not apply to Respondent s Volume III submissions. Does this mean that the Volume III submissions will not be subject to disclosure at all, even if not identified as a trade secret? Or that the Volume III submissions will automatically be subject to disclosure, notwithstanding being identified as a trade secret? What is the auto-assignment methodology? The methodology used by ACHA for the state-wide Medicaid Managed Care rollout was sound though it needs to be thoroughly tested during implementation. The ITN describes certain responsibilities for the dental vendor but then seems to Examples are listed on Appendix, Vol. II, Tab F, of the ITN. The FHKC Board has previously adopted the MLR definition formulated by the National Association of Insurance Commissioners. Respondents have the option to bid by region, statewide, or any combination thereof. See response to 33. Equal ratio the first year, allocation in future years based on the plans HEDIS performance. Other factors may be taken into consideration, at FHKC s discretion. Information was provided for purposes of coordination of benefits only. Page 9 of 19

10 ITN Page, Section, Access, b. Dental, page 42 include dental requirements for the health plan, such as ensuring an appropriate dental network, access & appointment standards, etc. (i.e. p. 42). Please describe the expected health plan responsibilities for dental services Appendix II, Page 46, Utilization Data Appendix III, Page 47, Enrollee Demographic Information Appendix V, Volume Two, Tab B, Page 51, Specialty Care Providers Summary Sheet Appendix V, Volume Two, Tab B, Page 51, Specialty Care Providers Summary Sheet Appendix V, Volume Two, Tab F, Page 55, Specialty Care Providers Summary Sheet Appendix V, Volume Two, Tab F, Page 55, Non- Physician Services Summary Sheet III.A: Evaluation of Proposals, page 5 III.A: Evaluation of Proposals, page 6 When will the data be released? On or about February 1, When will the data be released? On or about February 1, Are there any parameters or ratio requirements as to the number of providers that are suggested or required for each of the specialty types and facility types in the filing? The Specialty Care Provider Summary Sheet currently has a requirement labeled Locations to show towns that have each provider type in it. Now that the filings are regional this requirement would have in some cases several dozen towns listed in the column. Could this requirement be moved to listing counties where the providers are located in as the largest region still has 16 counties, but is easier to manage than upwards of 100 towns being listed? The birthing centers we have dealt with consider pregnant women under 18 years of age a high risk and do not handle their deliveries at their birthing centers. is for the need of birthing centers to be part of the network. There are very few SNFs with Adolescent or Pediatric Experience in Florida. What is the suggested course of action and requirements for number of facilities or beds per region? How will past performance under HEDIS standards be evaluated for incumbents and non-incumbents? For trade secrets, is it acceptable to submit two electronic versions of the proposal, one containing all pages and a second with the pages marked "trade secret" redacted? Page 10 of 19 Respondents must meet the network adequacy requirements as described in the ITN. We will clarify in the final ITN. Birthing Centers are not required to be included in any network, but lack of same could negatively affect scoring. FHKC declines to make such suggestions or recommendations. Scoring methodology will be released after the ITN process. No, please follow the instructions of the ITN. 70 III.A: Evaluation of Please clarify who FHKC will notify in the See response to 33.

11 ITN Page, Section, Proposals, last bullet, page 6 III.D: s Regarding the ITN, page 8 V.B: Submission Requirements, Specific Contents, page 11 Respondent, Tab A, page 13 Respondent, Tab A.4, page 13 Respondent, Tab F, page 17 Respondent, Tab F, page 17 event a third party makes a request for a document that has been submitted as a trade secret, and who has the burden of filing a motion with respect to the document. The ITN states FHKC will notify "the requesting entity" that the document is a trade secret and that such person has 30 days to seek an order "barring FHKC from disclosing the document". The interest of the requesting party would be for an order directing FHKC to disclose the document, not barring it from doing so. Please clarify the procedure in this paragraph. We conduct business unrelated to FHK with board members such as Beth Kidder, Elizabeth Dudek and Dr. Schechtman. Please confirm that this does not constitute a violation of the Single Point of Contact/blackout period restriction. Please confirm that Respondents should submit one Administrative Proposal that covers all bid Regions, as opposed to distinct proposals for each Region. In 2012, FHKC permitted documents created in software other than Word or Excel to be submitted in PDF format. This included all Volume One attachments (e.g., audited financial statements), as well as GEOAccess maps and tables. Please clarify whether these materials can again be submitted in PDF. Please confirm that the requirement to submit information regarding where services will be provided applies to administrative activities and does not include medical providers (e.g., crossborder providers in neighboring states). Please clarify whether the bullets beginning on the bottom of page 17 and continuing to page 18 apply in their entirety to both the Subsidized (CHIP) and Full Pay program components. The ITN states that the Full Pay program is not a Title XXI CHIP program and must comply with relevant portions of the Patient Protection and Affordable Care Act (ACA). Does that specifically include the following regulations: 1) Medical Loss Ratio Yes, this is not a problem so long as the ITN or related issues are not discussed. Yes, as long as the document has a search capability. Yes, administrative services. Yes, applicable to both subsidized and full pay components. See response to 10. Page 11 of 19

12 ITN Page, Section, Respondent, Tab F, page 17 Respondent, Tab F, page 17 Respondent, Tab F, page 17 Respondent, Tab G, Tab 2, second bullet, page 20 Respondent, Tab G, Tab 2, third bullet, page 21 Respondent, Tab I, page 24 Respondent, Tab J, page 25 Regulations as defined in Section 2718 of the Public Health Service Act, which sets a minimum loss ratio for certain types of n insurance plans; and 2) the Transitional Reinsurance Program as defined in Section 1341 of the ACA, which requires certain insurance plan types to contribute to a reinsurance program established under the ACA. CHIP populations have certain protections and rights provided under federal regulations (i.e., specific requirements and processes related to grievances, appeals, UM, claims payment, network, access, quality, etc.). However, we understand these requirements would not automatically apply to Full Pay enrollees. Could FHKC please provide the operational and service requirements that will apply to Full Pay populations, to the extent they will differ from the CHIP population? Could FHKC also please document any ACA requirements that will apply to the Full Pay population and provide a detailed benefit package for the Full Pay population, along with cost-sharing structure and actuarial value. Please confirm that, consistent with the 2012 ITN, you are requesting submission of provider contract templates and not the actual contracts held with individual providers. Please confirm that, consistent with the 2012 ITN, it is acceptable to submit a description of the types of payment arrangements we have by provider type (fee-for-service, capitation). What additional or revised reporting requirements, if any, does FHKC anticipate as the result of adopting regional service areas and Does FHKC anticipate changes to reporting and claims submissions, or other operational processes, as a result of changes to the service areas (adoption of MMA regions) and treatment of the Full Pay population? The ITN states that, "FHKC may make awards without proposed revisions being FHKC declines to opine on this issue, and suggests obtaining legal advice on the issue. For all purposes except some benefits, these populations will be treated equally. See response to 134. There are no anticipated changes to the reporting requirements. Page 12 of 19

13 ITN Page, Section, 84 Volume Two: Provider Networks by Region, page 26 Volume Three: Premium Rate Proposals, page 32 accepted." Please confirm that if a Respondent requests changes to the Contract that are not accepted the Respondent will have the option to decline a Contract award. The ITN states that, "Providers that have multiple office hours may be listed more than once; however, the office hours may not overlap." Please confirm that, consistent with our 2012 response, we will be permitted to comply with this requirement by doing the following: 1) when a solo practitioner has multiple offices and rotates his/her location on a weekly basis, showing the office hours in each location based on when the provider is present (e.g., M - F, 8-5); and 2) when a provider is part of a group/clinic and has coverage when in a different location, showing office hours in each location for the entire clinic. This section notes that 1) The statutorily required minimum medical loss ratio is 85% and 2) The statutorily required maximum administrative component is 15%. The new ACA Health Insurance Providers Fee is expected to be over 3% for the 2015/2016 plan year and, given that it increases each year, could be over 4% by This is a new tax that was not contemplated when the 15% administration load was developed. See response to 8. FHKC declines to further define provisions already contained in law. Please seek appropriate legal or accounting advice. 85 We request that FLHK define the ACA Health Insurance Providers Fee in the ITN and subsequent contract as a tax that is outside of the administration costs and note that the tax will be netted from the premium before the calculation to determine the medical loss ratio and before determining the administrative component of the rate. This will allow plans to include the Fee in the premium rates at the appropriate level without being arbitrarily impacted by the two requirements above. This can be accomplished in the templates in Appendix VIA and VIB by adding two Page 13 of 19

14 ITN Page, Section, Volume Three: Premium Rate Proposals, seventh bullet, page 32 Volume Three: Premium Rate Proposals, page 32 Volume Three: Premium Rate Proposals, fifth bullet, page 32 Appendix I.III: Benefits, page 39 more lines below the medical loss ratio line. One titled ACA Health Insurance Providers Fee and the other titled Grand Total with Tax. The ITN states that bonus points may be awarded for submission of a single statewide rate. Will the same bonus points be awarded for Option 4: Combination Statewide Rate? Can FHKC please provide as soon as possible a list of Full Pay members enrolled in our plan since July 1, 2012? We will need this information to develop separate Full Pay and Subsidized rates. Please clarify whether an MLR requirement also applies to the Full Pay population and, if so, the percentage (e.g., 85% or 80%). If yes, also please clarify whether the ACA methodology or FHK methodology for the Subsidized population will be applied. The Draft ITN states: The Insurer must have a system for tracking each Enrollee's out-of-pocket costs so as to ensure that no Enrollee exceeds the federal cost sharing maximums. Healthy Kids will make the final determination as to whether a family has reached its maximum, and therefore, no additional co-payments can be collected from the Enrollee for the remainder of the designated year. Can FHKC clarify the expected action on the part of the Plan if the Plan's records indicate the member has met cost share maximums, but the 834 does not indicate the member has met the maximum? We will not identify any full pay member previously or currently enrolled by a particular plan. See response to 49. See response to 10. The MLR methodology for the full pay program is not anticipated to change from current practice. No, it is the Respondent s responsibility to track out of pocket costs and notify FHKC of any discrepancies. 90 Appendix I.IV: Delivery of Services, D.1.b., page 42 Please confirm that dental (other than oral surgery) will continue to be carved-out in the new contract period and that the dental standards shown for informational purposes on page 42 will not apply to Respondents. 91 Intro / 2nd para. Page 3 FHKC currently contracts with a TPA to determine eligibility, collect premium payments and provider certain customer services functions. Will the Respondent be required to collect and track premiums? Page 14 of 19

15 ITN Page, Section, Intro / 3rd para. Page 3 Background / Info I. Program Eligibility, page 36 Background / Info I. Program Eligibility Florida KidCare has four components: FHKC, CMSN, XXI, CHIP. Will Children with special needs still be eligible and assigned to CMSN? Child must be a citizen or qualified alien. Enrollment of non-qualified non-citizen children was closed several years ago, however, some children were grandfathered-in and remain enrolled in the program. Are the enrollees that were grandfathered due to lack of citizenship, identified in the 820 or 834 file? Some Enrollees who meet the eligibility financial and clinical criteria for CMSN may opt out and elect to enroll in Healthy Kids. Yes, however CMSN children may opt out of the CMS program as allowed by Florida Statute Background / Info I. Program Eligibility / 2nd Para, page 36 Background / Info I. Program Eligibility / 2nd Para, page 36 Background / Info I. Program Eligibility, page 39 Background / III Benefits (INFO), page 39 Background / IV Delivery of Services, page 40 Are the enrollees that opt out of CMSN, identified in the 820 or 834 file? Program eligibility and premium calculations are not the responsibility of the Insurer. Except for "full pay" enrollees, FHKC will not identify subsidy levels of its Enrollees to Insurers. Can FHKC provide additional information regarding the "Full Pay" program? Can FHKC elaborate on the statement "FHKC will not identify subsidy levels"? Comprehensive dental benefits pursuant to section (2(q) F.S. are currently being provided to Enrollees under separate contracts. Who are your current Dental providers? Respondent must agree to coordinate dental services with contracted dental plan including hospitalization, surgeries, and prescription by dental providers. To assist with coordination of care, will FHKC provide a listing of enrollees receiving dental services at the time of implementation? No credit is given for internal Medicine Physicians or General Practice physicians as PCPs. Additionally, only those Internal Medicine or General Practice physicians that have received a specific exemption from FHKC will be counted. Will FHKC provide a listing of providers that have See response to 134. FHKC will identify full pay and subsidy enrollees. What sub-category of subsidy a particular enrollee belongs to is irrelevant, and will not be provided. Argus DentaQuest MCNA This may be clarified in the final ITN. Any available information will be posted in the Page 15 of 19

16 ITN Page, Section, been given an exemption by Regions? Background-IV.D.1b Geographic Access: Primary Care Dental Geographic Access, page 41 provider 20 minutes from Enrollee's home. Will FHKC provide a listing of dental providers? II. Scope of ITN, 1st para, ITN solicits proposals to assume the page 3 underwriting risk of the health benefits coverage provided by FHKC. Will FHKC confirm that the Respondent will be at full risk for all medical services provided? II. Scope of ITN, 1st para, ITN solicits proposals to assume the page 3 underwriting risk of the health benefits coverage provided by FHKC. Will FHKC consider a risking sharing or cost saving arrangement? Tab F, page 17 Certain enrollees may be prohibited from participating in cost sharing (if costs exceeds 5% of family income or if an American Indian or Alaskan Native). Will the 820 or 834 file identify the American Indian or Alaskan Native and will the income level of the family be provided to the plan? III. Procurement H, page 9 FHKC intends to contract in the same regions as AHCA. More than one contract per regions. Is there a set limit of contracts/plans per Region? Tab A-5, page 14 Organizational Chart with Key Staff. Are there any contract required positions? If so, what are those positions? Tab A-6, page 14 Conflict of Interest Statement and Disclosure. Can FHKC provide the names Tab A-6, page 14 Tab A-7, page 14 Tab E, page 16 Tab F, page 17 Tab F, page 17 of the members of their board? Conflict of Interest Statement and Disclosure. When will the Code of Ethics document be available for review? Affirmation of agreement to all ITN terms and not de-barred or other prohibited from or eligible to receive federal or state funds. When will the Contract be available for review? Eligibility and Enrollment Process. When will FHKC start testing the 820 & 834 file exchange? Benefits and Cost Sharing. Can we obtain sample certificate of coverage or benefit outline for a Full Program member? Benefits and Cost Sharing. Can FHKC provide more information on the Full Pay No, the dental network is the responsibility of the dental plan. Yes, the Respondent will be at full risk for all medical services provided, subject to any statutory limitations. Yes, the 834 file identifies American Indians and Alaskan Natives. FHKC will not provide the income level of the family. See response to 4. Yes, this information will be included in the Yes, this information will be included in the Yes, this information will be included in the A specific date will be included in the final ITN. See section , Florida Statutes. See response to 134. See response to s 10, 75, 79, 87, 88, 99 and 134. Page 16 of 19

17 ITN Page, Section, Tab F, page 17 Tab F, page 17 Tab F-2, page, page 18 Tab F-3, page 19 Tab G-1, page 20 Tab G-3, page 21 Tab G-4, page 21 Tab G-5, page 21 Tab G-5, page 22 Tab I, page 24 Tab I program? Benefits and Cost Sharing. When will historical utilization data be available for review? Benefits and Cost Sharing. What enhanced benefits are currently offered? Benefits and Cost Sharing / Coordination of Benefits include Dental provider. Who is FHKC's Dental provider(s)? Benefits and Cost Sharing / Prescription Formularies. Who is FHKC's contracted PBM? What is the current formulary? Member Services / Retention efforts for renewing enrollees. Can FHKC provide the current renewal process? Quality Assurance / Audits & Contract Requirements. When will the Contract be available for review? Medical Case Management. Will FHKC provide a listing of enrollees currently in treatment to assist in the transition and coordination of care? Behavioral Health and Substance Abuse Services. Who is currently providing behavioral health services to these enrollees? Behavioral Health and Substance Abuse Services. Would FHKC accept the plan sub delegating these services to an MBHO accredited by NCQA, AAAHC or URAC? Reporting Requirements. Will FHKC provide a report guide outlining the reporting requirements? If so, when will it be available for review? Reporting Requirements This information will be included in the This depends on the particular plan. FHKC maintains no list of enhanced benefits that may be offered by any participating plan. See response to 97. FHKC does not have a PBM. The current formulary is based on the current Medicaid formulary. This information will be included in the On or about February 1, This information will be included during the transition from the outgoing plan to the new plan. Plans contract directly with Behavioral Health and Substance Abuse providers. Yes, as long as the MBHO meets the requirements in section , Florida Statutes, and Rule 59A , F.A.C. This information will be posted in the A specific date will be included in the final ITN Volume II, page 25 Volume II, Tab A, page 25 When will FHKC start testing file exchanges with ICHP? Provider Networks, By Region. Will FHKC provide a listing of the current provider network? Submit a list of providers alphabetically by region as described in ITN (Appendix X). How should the plan list providers within a group or facility contract? They should be listed individually by region following the format in the ITN. If the provider has multiple locations, please list their name once, and then complete as many address lines as Page 17 of 19

18 ITN Page, Section, needed. 125 Volume II, Tab A, page 27 Respondents may not imply to any provider, during the ITN process that the plan is already a Healthy Kids provider, has a contract or is about to receive a Healthy Kids contract unless they are an incumbent in that specific county. What language would be appropriate for Plan to use for network development/recruitment? Can the plan inform providers that an ITN was be submitted to provide services to the children covered under the healthy Kids program? PCP Geo-Access Maps are not required but strongly encouraged. When will FHKC provide a membership zip code file for the GeoAcess Maps? Yes, you may inform the provider that you are responding to an ITN for Healthy Kids enrollees. 126 Volume II, Tab A, page 26 This information will be posted in the 127 Volume II, Tab E, page 30 Pharmacy Network. Who is FHKC's current PBM vendor? Will the Plan be at risk for pharmacy cost? Public Providers (i.e. County Health Departments, FQHC, Rural Health clinics, etc.). Does FHKC deem the county Safety Net Hospital(s) as Public Provider(s)? FHKC has no PBM, and the Plans are at risk for all pharmacy costs. 128 Volume II, Tab G, page 31 FHKC governing statutes do not include Safety Net Hospitals as public providers. We will review this and attempt to clarify this point in the final ITN. Appendix VI A and VI B As provided for past invitations to negotiate, will FHKC provide historical information regarding utilization and cost of services for the FHK program? a) It would be helpful if these data were provided separately for the subsidized rate and full pay rate populations; b) It would be helpful if these data were provided in the same level of detail as the premium rate proposal forms provided in Appendix VI A and VI B. This information will be posted in the Appendix VI A and VI B Will FHKC provide the current premium rates by county for each of the subsidized rate and full pay rate populations? For the subsidized rate population, we are interested in knowing the entire rate for The county by county rate information will be posted in the Procurement Library on or about February 1, Insurers will contract on a single PMPM basis by Region. Subsidy in this context refers to the Title XXI CHIP Page 18 of 19

19 ITN Page, Section, these members, not just the subsidized amount. program enrollees (not full pay) whose premiums are subsidized by the state and federal government. The PMPM rate is the entire rate. 131 Appendix VI A and VI B Will FHK provide enrollment by region for both the subsidized rate and full pay rate populations? How many plans will be awarded per region? How will membership be assigned to each awarded plan? This information will be posted in the See response to 4 and Appendix VI A and VI B Appendix VI A and VI B Appendix VI A and VI B Can FHKC segment the requested eligibility and claims data by those members who terminated FHK coverage due to Medicaid expansion versus those who remain enrolled in FHK? Since benefits must comply with the relevant portions of the Patient Protection and Affordable Care Act ( ACA ) for full pay members, can you please itemize the required enhancements to the benefits over the standard FHKC benefits? Claims data will only be provided for current FHKC enrollees. 1. No lifetime or annual limits. 2. Habilitative benefits as necessary to achieve age-appropriate development, including but not limited to speech and occupational therapy; 3. Outpatient physical therapy not to exceed 35 sessions per year; 4. One pair of standard eyeglass lenses or contact lenses per calendar year. 135 Appendix II Utilization Data When will the Utilization Data be released? Will it contain all services delivered including dental, transportation, etc.? This information will be posted in the Page 19 of 19