RFP MEDICAID SHARED SAVINGS PROGRAM FOR ACCOUNTABLE CARE ORGANIZATIONS 10/25/

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1 RFP Section Reference: General Questions Question 1: Will the types of organizations described below need to receive an ID from DVHA? Can you articulate the process for disclosing these relationships to DVHA and getting approval for these subcontracts? One is an association that will provide technical assistance and infrastructure to the ACO. One is a consulting firm that is working on our internal policies and procedures. The final is a healthcare analytics firm affiliated with a major university. Answer: Only providers considered ACO Participants and ACO Provider/Suppliers would need a Medicaid provider ID from DVHA. DVHA would expect that the ACO include information related to its subcontracts as part of its technical proposal and in Appendix B, Form 3 under ACO Other Entities. If warranted, DVHA will work with the selected ACOs to ensure disclosure of conflicts of interest or other relevant reporting requirements related to sub-contracts. Question 2: Are there page and/or character limit requirements for the responses? Answer: There are no page or character limit requirements. However, DVHA is more interested in the quality of response over quantity of information. Question 3: Will DVHA be open on Monday, November 11, 2013 to receive hand carried copies of proposals and a receipt for delivery of the same? Answer: No. The RFP has been amended because it is an official State holiday. The new closing date is Tuesday, November 12 th, 2013, 3:00pm EST. Question 4: Regarding professional liability, the limits for this coverage are left blank in the RFP (page 13), what are the intended coverage requirements? Answer: The standard limits for this are $1,000,000/occurrence $3,000,000 in aggregate, however these limits may be further negotiated as necessary. Question 5: Regarding Sub-Agreements (page 15), the standard terms restrict sub-agreements, yet for the ACO agreements with providers are an integral element of the program of which the State is aware. Please confirm that ACO provider agreements do not fall within the scope of subagreements as contemplated by this provision. Page 1 of 7

2 Answer: The State would be willing to appropriately negotiate this clause as not to restrict the project. Question 6: Will DVHA accept more than one ACO fully-compliant proposal in response to this RFP? Answer: Yes. There are no limitations to how many ACO proposal s DVHA will accept. It is possible for DVHA to contract with more than one ACO. Question 7: Will the State accept proposals for a grant, an advance payment model, or a permember per-month payment to provide for ACO infrastructure development/costs during the first year? Answer: The state is looking into launching a grant program using SIM funds to assist participants in payment model pilots being tested under the SIM grant. The State is aiming to update the SIM Steering Committee with more details on the grant program at the November 20 th meeting. Moreover, there are considerable technical assistance resources provided under all SIM related programs and activities that will also indirectly support the ACOs. DVHA is not able to support supplemental funding in support of ACO development. Implementation of an advanced payment model is still under consideration; however, DVHA is still assessing what additional programmatic requirements would be needed in order to support introduction of an advanced payment model. Should there be continued interest, DVHA would continue to work through the requirements and consider phasing in the model should it be feasible and mutually amendable to both DVHA and the ACO(s). Question 8: What other support will the state provide? Answer: See response above. Question 9: Can DVHA assist bidders in getting non-medicaid-enrolled providers enrolled in Medicaid? Answer: DVHA s provider member relations (PMR) can provide the ACO with guidance on the process for Medicaid provider enrollment if requested. Question 10: What is the state s view on competition v. collaboration in this process? Answer: In short, we are open to innovation and multiple participants. To the extent that ACOs share information and approaches that lead to improved quality of care and patient experience of Page 2 of 7

3 care that are not in violation of any federal or state statutes, the State encourages this kind of collaboration. Furthermore, we encourage ACOs to include a more detailed description of their efforts towards collaboration in their written proposal. Question 11: Would DVHA consider amending the charge of the consumer to that of an existing advisory group such as the Medicaid Advisory Board? Answer: The design of this standard was approved by the SIM work group, steering committee, and core team process and is consistent with standards pending approval from the Green Mountain Care Board. These same decision making bodies would need to approve any proposed changes to this standard and would expect to, at minimum, engage stakeholders in this change or clarification. If amending the charge of the consumer advisory board is desired by the ACO, then the ACO should submit a proposed change for consideration in its RFP response. Question 12: Is DVHA limiting bidder s to participation in only the Medicaid ACO SSP (ie prohibiting participation in Medicare or commercial shared savings programs?) Answer: No. Medicaid encourages ACOs to participate in as many shared savings programs as desired by the ACO for which they are eligible. RFP Section Reference: Attachment F, Agency of Human Services Customary Contract Provisions, section 3 reads: Encounter Data: Any Contractor accessing payments for services through the Global Commitment to Health Waiver and Vermont Medicaid programs must provide encounter data to the Agency of Human Services and/or its departments and ensure that it can be linked to enrollee eligibility files maintained by the State. Question 13: What encounter data would AHS require of a successful bidder? (page 22) Answer: Related to this clause, all ACO Participants and Provider Suppliers must submit encounter data for payment as they normally would for services provided. This clause does not apply to payments of shared savings under the program. Question 14: Regarding Attachment F, "Agency of Human Services' Customary Contract Provisions" contains a standard provision entitled "Intellectual Property/Work Product Ownership" that purports to assign to the State of Vermont certain intellectual property rights in data, reports, software programs among other works. The vendor, both in activities conducted directly by its personnel and in activities conducted by its technology and data warehousing and analysis vendors (VITL and NNEACC), will likely develop databases, data models, data analysis systems and tools and related technology solutions that would not be unique to the Medicaid SSP Page 3 of 7

4 activities. The vendor and its sub-vendors would expect to retain rights in these works. Please confirm that the "Intellectual Property/Work Product Ownership" provision may be limited in the final agreement in a manner consistent with the vendor and its sub-vendors retaining ownership of works developed for the vendor s accountable care activities. Answer: DVHA suggests that the Bidder propose amended contract language to DVHA to mitigate any concern they have about this particular issue. DVHA will take this under consideration. RFP Section Reference: Technical proposal section a page 42 reads Provide the full scope of Core Services identified in Section in Year 1 and the full scope of additional services as well as Core Services in Year 3 (or Year 2 if this option is selected). Question 15: As ACOs are groups of providers who have agreed to become accountable for care, the ACO itself does not provide care; rather Medicaid beneficiaries can obtain care at providers of their choice. Could you explain what is meant in Section in light of the nature and character of ACOs? DVHA has referred to a "network model" ACO, can you define this term? Answer: DVHA intends to amend a on page 42 of the RFP to read: a. Agree to have savings measured based on a Total Cost of Care (TCOC) calculation that includes Core Services identified in Section in Year 1 and the full scope of additional services plus Core Services in Year 3 (or Year 2 if this option is selected). Question 16: This section is ambiguous in that no single network is likely to provide all core services but instead will maintain formal and informal referral relationships. Can you please clarify that the intent of this section is to indicate that the ACO is financially accountable for the full scope of the Core Services and does not need to add services provided they can ensure that their patients will have access to them? Answer: See response above. DVHA understands that the ACO entity itself will not be delivering services but rather managing the coordination of services among ACO participants and provider/suppliers with which it will establish relationships. Question 17: The RFP is silent on the issue of Medicaid ACO participant exclusivity. The Medicare SSP program has specific restrictions on a participant's engagement with more than Page 4 of 7

5 one MSSP ACO. Are there similar or other restrictions now or anticipated on a participant's engagement with more than one Medicaid SSP ACO? Answer: DVHA is expecting some ACO participants will be exclusive to an ACO to ensure no duplication in attribution much like they are in the Medicare SSP model. That said, DVHA is making some exceptions related to exclusivity compared to the Medicare program policy. ACO Participants that are themselves, or include Provider/Suppliers considered primary care providers, must be exclusive to an ACO. Primary care providers in this context would be those included in the attribution methodology, identified by enrolled provider specialty codes, described in the RFP. This is because the SSP model will roll-up patient attribution at the ACO Participant level. The ID that will be used to identify an ACO Participant is the provider s DVHA Provider Billing ID. This means the ID could represent an individual doctor, a group practice, an FQHC, a hospital, or some other entity. o In the situation where the ACO Participant is a group physician practice, the doctors that are a part of that practice will also have a DVHA provider ID. For example, their ID may be used to indicate that they are the rendering provider even if the group practice ID is this billing provider. In this case, however, the individual doctors are considered ACO Providers/Suppliers. o If an ACO Provider/Supplier assigns their billings to an ACO Participant that includes primary care providers, then they (the ACO Provider/Supplier) too must be exclusive to an ACO. o However, if an ACO participant, and the associated providers/suppliers who assign their billings to this ACO Participant, do not contain primary care providers and therefore would not be eligible for patient attribution then these providers would not need to be exclusive to the ACO. One example of this is specialist physicians. In DVHA s SSP, specialists may contract with more than one ACO. Medicare does not allow this because Medicare may attribute beneficiaries to specialists. DVHA is considering adding an additional data element to the analytic file that would allow the potential ACO to identify which providers would be considered exclusive. DVHA expects to compare provider lists among all bidders to this RFP that are submitted as part of their RFP response to ensure there is no duplication in attribution. Page 5 of 7

6 RFP Section Reference: Appendix B, ACO Participant Form 1 ACO Participant Form, instructions reads: Bidders are required to complete a table like the one shown below. A formatted Excel file is provided as an attachment to this RFP to use in completing Appendix B, Form 1. For any provider agreeing to participate in the Bidder's submission as an ACO Participant, a copy of their signed agreement must also be included with the Bidder's submission. Question 18: As a statewide Medicare SSP ACO, OneCare Vermont has over 100 participation agreements in place and about 2,200 providers. Each of our agreements is about 40 pages long. Copies of all our participation agreements could comprise over 4,000 pages. The application process for the Medicare SSP had a similar requirement but called for including only the first "parties' page "and the "parties' signature page" of each agreement. May we follow that "first and last page" convention for our Medicaid SSP application? A: Medicaid is agreeable to the proposed arrangement but would also request at least one full copy of every unique arrangement as part of the RFP response. Question 19: It is unlikely that each of our Medicare SSP ACO participants will have time to consider and sign new separate agreements for the OneCare Medicaid ACO within the limited time prior to completion and submission of our proposal. May we list participants labeled as "signed" and "pending" on Form 1? What will be the process for adding additional participants that sign their agreement following November 11, 2013 and prior to January 1, 2014? Answer: Medicaid is agreeable to the inclusion of pending providers on the provider participation list, given that there is a reasonable expectation that said provider is interested in participation in the program. Please indicate clearly on the list which providers are pending and which providers are signed. DVHA would expect that all ACO Participants for whom they plan to have beneficiaries assigned to have a signed agreement in place prior to the DVHA/ACO contract execution, i.e. mid December. DVHA suggests submitting additional participants and related documentation and/or updating the status of participants weekly through December. If no changes occurred, no submission would be required. Question 20: In calculating our estimated proposed number of attributed lives in Year 1 of the Medicaid Shared Savings Program (for the "Rate Sheet"), are we restricted to the participants we have signed at the time of our submittal or may we include additional pending but unsigned participants in that calculation? If we are restricted to actual executed agreements, may we also include an expected number of attributed lives as of January 1, 2014 on our Rate Sheet? Answer: Please see response to above question and clearly identify how the numbers were derived. Page 6 of 7

7 Question 21: If OneCare Vermont is a successful bidder, we assume our minimum savings rate and other elements of our relationship with DVHA will reflect all participants that have signed agreements in place before the start of the first performance year on January 1, 2014 and their attributed lives. Is that a correct assumption? Answer: No, the MSR and other patient-related calculations will be based on actual attributed lives during the performance year determined retrospectively during the reconciliation process. Question 22: Regarding the inclusion of Federally Qualified Health Centers in our submission, we would like clarity from the State on which billing numbers to include in our ACO Participant forms. Is it correct to assume that we should have records on the form for each corporate entity, site or location, and also for the individual providers who work within the FQHCs? Do we understand that Appendix B, Form 2 must list each FQHC provider by Provider ID? Answer: Attribution and exclusivity will be based generally on DVHA provider IDs and their associated DVHA billing ID. If warranted, DVHA would consider rolling up some billing IDs to a more aggregated level across FQHC sites or location or other entities. DVHA recommends the respondents propose different methods for aggregation as part of the response to the proposal. It would be helpful to include an excel based crosswalk in addition to a written description of the proposed aggregation. RFP Section Reference: Program Specifications section page 41 reads for years two and three, there must be a plan in place to ensure that the ACO activities follow waiver population individual care plans and guidelines provided by the State departments responsible for the specific populations (i.e., CFC, CRT, SED, DS, and TBI). Question 23: Does the ACO have audit responsibility to ensure that individual providers have to follow individual care plans? Answer: No, the ACO does not have audit responsibility to ensure that individual providers are following individual care plans. The intent of the language at the bottom of page 41 is that the ACO is actively working in concert with any state departments that have lead responsibility for a case management function of a beneficiary as it pertains to waiver services. CMS has specific requirements related to waiver services that should not be violated under this program. DVHA recommends the ACO seek specific guidance from DVHA and/or any AHS department on specific questions related to honoring these requirements and following individual care plans. Page 7 of 7